Name:______________________________________

Amen Brain System Checklist

Please rate yourself on each of the symptoms listed below using the following scale. If possible, to give us the most complete picture,
have another person who knows you well (such as a spouse, partner or parent) rate you as well. List other _____________________
0 1 2 3 4 NA
Never Rarely Occasionally Frequently Very Frequently Not Applicable/Not Known
Other Self
____ ___ 1. Fails to give close attention to details or makes careless mistakes
____ ___ 2. Trouble sustaining attention in routine situations (i.e., homework, chores, paperwork)
____ ___ 3. Trouble listening
____ ___ 4. Fails to finish things
____ ___ 5. Poor organization for time or space (such as backpack, room, desk, paperwork)
____ ___ 6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
____ ___ 7. Loses things
____ ___ 8. Easily distracted
____ ___ 9. Forgetful
____ ___10. Poor planning skills
____ ___11. Lack clear goals or forward thinking
____ ___12. Difficulty expressing feelings
____ ___13. Difficulty expressing empathy for others
____ ___14. Excessive daydreaming
____ ___15. Feeling bored
____ ___16. Feeling apathetic or unmotivated
____ ___17. Feeling tired, sluggish or slow moving
____ ___18. Feeling spacey or “in a fog”
____ ___19. Fidgety, restless or trouble sitting still
____ ___20. Difficulty remaining seated in situations where remaining seated is expected
____ ___21. Runs about or climbs excessively in situations in which it is inappropriate
____ ___22. Difficulty playing quietly
____ ___23. "On the go" or acts as if "driven by a motor"
____ ___24. Talks excessively
____ ___25. Blurts out answers before questions have been completed
____ ___26. Difficulty waiting turn
____ ___27. Interrupts or intrudes on others (e.g., butts into conversations or games)
____ ___28. Impulsive (saying or doing things without thinking first)
____ ___29. Excessive or senseless worrying
____ ___30. Upset when things do not go your way
____ ___31. Upset when things are out of place
____ ___32. Tendency to be oppositional or argumentative
____ ___33. Tendency to have repetitive negative thoughts
____ ___34. Tendency toward compulsive behaviors
____ ___35. Intense dislike for change
____ ___36. Tendency to hold grudges
____ ___37. Trouble shifting attention from subject to subject
____ ___38. Trouble shifting behavior from task to task
____ ___39. Difficulties seeing options in situations
____ ___40. Tendency to hold on to own opinion and not listen to others
____ ___41. Tendency to get locked into a course of action, whether or not it is good
____ ___42. Needing to have things done a certain way or you become very upset
____ ___43. Others complain that you worry too much
____ ___44. Tend to say no without first thinking about question
____ ___45. Tendency to predict fear
____ ___46. Frequent feelings of sadness
____ ___47. Moodiness
____ ___48. Negativity
____ ___49. Low energy
____ ___50. Irritability
____ ___51. Decreased interest in others
____ ___52. Decreased interest in things that are usually fun or pleasurable
____ ___53. Feelings of hopelessness about the future
____ ___54. Feelings of helplessness or powerlessness
____ ___55. Feeling dissatisfied or bored
____ ___56. Excessive guilt
____ ___57. Suicidal feelings
____ ___58. Crying spells
____ ___59. Lowered interest in things usually considered fun
____ ___60. Sleep changes (too much or too little)
____ ___61. Appetite changes (too much or too little)
____ ___62. Chronic low self-esteem
____ ___63. Negative sensitivity to smells/odors
____ ___64. Frequent feelings of nervousness or anxiety
____ ___65. Panic attacks
____ ___66. Symptoms of heightened muscle tension (headaches, sore muscles, hand tremor)
____ ___67. Periods of heart pounding, rapid heart rate or chest pain
____ ___68. Periods of trouble breathing or feeling smothered
____ ___69. Periods of feeling dizzy, faint or unsteady on your feet
____ ___70. Periods of nausea or abdominal upset
____ ___71. Periods of sweating, hot or cold flashes
____ ___72. Tendency to predict the worst
____ ___73. Fear of dying or doing something crazy
____ ___74. Avoid places for fear of having an anxiety attack
____ ___75. Conflict avoidance
____ ___76. Excessive fear of being judged or scrutinized by others
____ ___77. Persistent phobias
____ ___78. Low motivation
____ ___79. Excessive motivation
____ ___80. Tics (motor or vocal)
____ ___81. Poor handwriting
____ ___82. Quick startle
____ ___83. Tendency to freeze in anxiety provoking situations
____ ___84. Lacks confidence in their abilities
____ ___85. Seems shy or timid
____ ___86. Easily embarrassed
____ ___87. Sensitive to criticism
____ ___88. Bites fingernails or picks skin
____ ___89. Short fuse or periods of extreme irritability
____ ___90. Periods of rage with little provocation
____ ___91. Often misinterprets comments as negative when they are not
____ ___92. Irritability tends to build, then explodes, then recedes, often tired after a rage
____ ___93. Periods of spaciness or confusion
____ ___94. Periods of panic and/or fear for no specific reason
____ ___95. Visual or auditory changes, such as seeing shadows or hearing muffled sounds
____ ___96. Frequent periods of deja vu (feelings of being somewhere you have never been)
____ ___97. Sensitivity or mild paranoia
____ ___98. Headaches or abdominal pain of uncertain origin
____ ___99. History of a head injury
____ ___100. Dark thoughts, may involve suicidal or homicidal thoughts
____ ___101. Periods of forgetfulness or memory problems
 Amen Brain System Checklist Answer Key
Prefrontal Cortex Symptoms (PFC)
Inattention Symptoms, 1-18
Hyperactivity-Impulsivity Symptoms, 19-28
Anterior Cingulate System (ACS) Symptoms, 29-45
Deep Limbic System (DLS) Symptoms, 46-63
Basal Ganglia (BGS) Symptoms, 64-88
Temporal Lobe (TLS) Symptoms, 89-101

Add up all of the questions answered as 3 or 4 in each section.

PFC

ADD, combined type if both 1-18, and 19-28 score (in each area)
Highly probable 8 questions with 3 or 4
Probable 6 questions with 3 or 4
May be possible 4 questions with 3 or 4

ADD, inattentive subtype if 1-18 has X questions with 3 or 4 but

19-28 has less than 3 questions with 3 or 4
Highly probable 8 questions with 3 or 4
Probable 6 questions with 3 or 4
May be possible 4 questions with 3 or 4

Anterior Cingulate System Hyperactivity, questions 29-45

Highly probable 10 questions with 3 or 4
Probable 7 questions with 3 or 4
May be possible 4 questions with 3 or 4

Deep Limbic System Hyperactivity, questions 46-63

Highly probable 10 questions with 3 or 4
Probable 7 questions with 3 or 4
May be possible 4 questions with 3 or 4

Basal Ganglia Hyperactivity, questions 64-88

Highly probable 10 questions with 3 or 4
Probable 7 questions with 3 or 4
May be possible 4 questions with 3 or 4

Temporal Lobe System, questions 89-101

Highly probable 8 questions with 3 or 4
Probable 6 questions with 3 or 4
May be possible 4 questions with 3 or 4
 How To Use The Amen Brain Systems Checklist in Daily Clinical Practice

Daniel Amen, M.D. developed the ABSC (Amen Brain System Checklist) to provide a way of assessing the
need for SPECT brain imaging and to utilize as an assessment tool to measure the effectiveness of medication.
The ABSC can be used as a one time assessment to measure whether or not referral for a SPECT Scan is
needed, and to be used periodically to provide objective feedback to the prescribing physician to help titrate
medications/supplements or to know when medication/supplements may need to be changed.

Ways to Administer:
The checklist can be self administered, or given verbally to the patient by the therapist. When the checklist is
administered verbally it gives you the opportunity to question the patient about their responses to gain further
information about the severity of their symptoms. As an example with question #99, “History of a head injury
or family history of violence or explosiveness”. It is helpful to ask if they have experienced a blow to the head
by asking the following questions. Note their responses, with approximate dates, and age at the time of the
traumatic incident.

• Have you ever experienced a blow to the head where you saw “stars”, felt confused or shaken up?
• Have you been in a car accident? Can you describe what happened?
• Ever played football? Soccer? Have you ever been surfing?
• Any times when you had periods of high fever?
• Ever been in a fist fight?
• Drug or alcohol experiences where you passed out, or got into a fight?
• Did your father, or mother rage? Did they or any family members when they were angry throw things?
Kick ? Did they become so angry they punched holes in the walls?
• Did your parents or family members have mood swings? Periods of sleeplessness? Times of mania?

The Importance of “Other”.

The ABSC has a column that can be used for self report, and a column to have their spouse, parent, or close
friend rate them. Generally speaking unless the patient is in a time of high stress or desperately needing help
“self report” can yield highly inaccurate results. At the beginning of therapy it is not unusual for patients to
see themselves as functioning quite normally. In situations where it is clear that verbal abuse and rage are
frequent and common occurrences it is not unusual for the volatile spouse to rate themselves quite “normal”.
I usually find that the “other” rating will be closer to SPECT Scan results than self – report. I usually have
both people fill out the ABSC for themselves, and on their spouse. The results will yield interesting data on
how each person is coming across to the other person.