Mild Behavioral Impairment Checklist (MBI-C) Date: __________________________ Rated by: ! Clinician ! Informant Location: ! Clinic ! Research Label ! Subject Circle “Yes” only if the behavior has been present for at least 6 months (continuously, or on and off) and is a change from her/his longstanding pattern of behavior. Otherwise, circle “No”. Please rate severity: 1 = Mild (noticeable, but not a significant change); 2 = Moderate (significant, but not a dramatic change); 3 = Severe (very marked or prominent, a dramatic change). If more than 1 item in a question, rate the most severe. This domain describes interest, motivation, and drive Has the person lost interest in friends, family, or home activities? Does the person lack curiosity in topics that would usually have attracted her/his interest? Has the person become less spontaneous and active – for example, is she/he less likely to initiate or maintain conversation? Has the person lost the motivation to act on their obligations or interests? Is the person less affectionate and/or lacking in emotions when compared to her/his usual self? Does she/he no longer care about anything? This domain describes mood or anxiety symptoms Has the person developed sadness or appear to be in low spirits? Does she/she have episodes of tearfulness? Has the person become less able to experience pleasure? Has the person become discouraged about their future or feel that she/he is a failure? Does the person view herself/himself as a burden to family? Has the person become more anxious or worried about things that are routine (e.g. events, visits, etc.)? Does the person feel very tense, having developed an inability to relax, or shakiness, or symptoms of panic? This domain describes the ability to delay gratification and control behavior, impulses, oral intake and/or changes in reward Has the person become agitated, aggressive, irritable, or temperamental? Has she/he become unreasonably or uncharacteristically argumentative? Has the person become more impulsive, seeming to act without considering things? Does the person display sexually disinhibited or intrusive behaviour, such as touching (themselves/others), hugging, groping, etc., in a manner that is out of character or may cause offence? YES NO SEVERITY Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes Yes No No 1 1 2 2 3 3 Yes No 1 2 3 Yes No 1 2 3 Based on the ISTAART-AA Research Diagnostic Criteria for Mild Behavioral Impairment © 2016 For more information contact Zahinoor Ismail MD email: MBIchecklist@gmail.com Has the person become more easily frustrated or impatient? Does she/he have troubles coping with delays, or waiting for events or for their turn? Does the person display a new recklessness or lack of judgement when driving (e.g. speeding, erratic swerving, abrupt lane changes, etc.)? Has the person become more stubborn or rigid, i.e., uncharacteristically insistent on having their way, or unwilling/unable to see/hear other views? Is there a change in eating behaviors (e.g., overeating, cramming the mouth, insistent on eating only specific foods, or eating the food in exactly the same order)? Does the person no longer find food tasteful or enjoyable? Are they eating less? Does the person hoard objects when she/he did not do so before? Has the person developed simple repetitive behaviors or compulsions? Has the person recently developed trouble regulating smoking, alcohol, drug intake or gambling, or started shoplifting? This domain describes following societal norms and having social graces, tact, and empathy Has the person become less concerned about how her/his words or actions affect others? Has she/he become insensitive to others’ feelings? Has the person started talking openly about very personal or private matters not usually discussed in public? Does the person say rude or crude things or make lewd sexual remarks that she/he would not have said before? Does the person seem to lack the social judgement she/he previously had about what to say or how to behave in public or private? Does the person now talk to strangers as if familiar, or intrude on their activities? This domain describes strongly held beliefs and sensory experiences Has the person developed beliefs that they are in danger, or that others are planning to harm them or steal their belongings? Has the person developed suspiciousness about the intentions or motives of other people? Does she/he have unrealistic beliefs about her/his power, wealth or skills? Does the person describe hearing voices or does she/he talk to imaginary people or “spirits”? Does the person report or complain about, or act as if seeing things (e.g. people, animals or insects) that are not there, i.e., that are imaginary to others? Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Yes No 1 2 3 Based on the ISTAART-AA Research Diagnostic Criteria for Mild Behavioral Impairment © 2016 For more information contact Zahinoor Ismail MD email: MBIchecklist@gmail.com