Abstract
Behavioral symptoms are a class of behavior that is observable, clinically significant, and taken as a sign of an underlying mental or neurological disorder. In cognitive neuropsychiatry the term is dominated by the behavioral and psychological symptoms of dementia, a syndrome of agitation, aggression, depression, apathy, delusions, and disinhibition that affects the large majority of patients over the course of the illness. This article develops the concept as a classification problem, surveys the standardized instruments that measure it, reviews the prevalence and course of neuropsychiatric symptoms across dementia, and sets out the structured, nonpharmacologic-first approach to management that now defines best practice. A worked example and three interactive demonstrations accompany the text.
Keywords: behavioral symptoms, neuropsychiatric symptoms, dementia, BPSD, symptom classification
Behavioral symptoms are the observable, measurable manifestations of a disordered mental state: not the inner experience itself but the agitation, withdrawal, aggression, or disinhibition through which it is expressed and by which a clinician recognizes it (Finkel et al., 1996). The category is broad by design, spanning child psychiatry, neurology, and geriatrics, because its organizing question is the same everywhere: how to turn a heterogeneous mass of observed conduct into a reliable, countable set of signs that research and treatment can act on.
In the dementias the problem is acute and the stakes high. Reisberg and colleagues first systematized the behavioral disturbances of Alzheimer's disease as a distinct clinical target, separable from the memory loss that defines the diagnosis (Reisberg et al., 1987). The consensus term that followed, the *behavioral and psychological symptoms of dementia*, named a syndrome that drives caregiver burden, institutionalization, and cost more powerfully than cognitive decline alone (Finkel et al., 1996). The sections below treat behavioral symptoms as that measurement and management problem: how they are classified, counted, and contained.
Key Takeaways
- Behavioral symptoms are observable signs of a mental or neurological disorder, classified in MeSH as a kind of behavior.
- The term is dominated clinically by the behavioral and psychological symptoms of dementia, which affect the large majority of patients at some point in the illness.
- Standardized instruments such as the Neuropsychiatric Inventory and the BEHAVE-AD turn observed conduct into reliable, countable domain scores.
- Neuropsychiatric symptoms predict caregiver burden, institutionalization, and mortality more strongly than cognitive decline alone.
- Current best practice puts structured nonpharmacologic approaches first, reserving medication for danger or failure of behavioral measures.
What Behavioral Symptoms Are
Behavioral symptoms are clinically significant disturbances of conduct, mood, perception, or thought that are observable in a person's behavior and are taken to indicate an underlying mental or neurological disorder. The Medical Subject Headings vocabulary classifies them under behavior, in tree position F01.145.126, a placement that reflects the term's role as an indexing umbrella for a large family of specific disturbances rather than a single construct. The defining feature is observability: a behavioral symptom is a *sign* a clinician or caregiver can see and, with the right instrument, count, as distinct from a purely subjective complaint.
The concept has a long history in the measurement of psychopathology. Achenbach's factor-analytic study of children's psychiatric symptoms was an early demonstration that the apparent chaos of clinical presentation resolves, statistically, into a small number of recurring dimensions, the internalizing and externalizing broad-band factors that still organize child psychopathology (Achenbach, 1966). That finding established the working assumption behind every symptom inventory since: that behavioral symptoms co-occur in structured ways, and that naming those structures is what makes them tractable. The same logic later drove the Research Domain Criteria initiative, which proposed to anchor symptom dimensions to underlying neural and behavioral systems rather than to diagnostic categories (Insel et al., 2010).
Types of Behavioral Symptoms
The Medical Subject Headings vocabulary files *Behavioral Symptoms* (D001526) beneath its parent descriptor Behavior (D001519) in tree F01.145.126, and lists twenty-two narrower descriptors directly under it, shown in Table 1. These subtypes are not mutually exclusive: a single patient may show several at once, and several of them (depression, aggression, delusions) are themselves large clinical topics indexed in other MeSH trees as well. The list is an *indexing classification*, a controlled vocabulary for retrieving literature, not a theory-of-the-mind taxonomy that claims to carve behavior at its natural joints. It records how the published literature is organized, not what the true kinds of disordered behavior are. Subtypes that have their own article on this site are linked; the remainder are glossed in plain text from their ordinary clinical meaning.
| Subtype | In brief |
|---|---|
| Aberrant Motor Behavior in Dementia | Repetitive, purposeless motor activity such as pacing, rummaging, or wandering in a person with dementia. |
| Affective Symptoms | Disturbances of mood and emotion, from depressed or anxious states to lability and blunting. |
| Aggression | Behavior intended or liable to cause harm, directed at people, objects, or self. |
| Catatonia | A syndrome of motor dysregulation, from mutism and rigidity to excited stereotypy, cutting across diagnoses. |
| Child Reactive Disorders | Behavioral and emotional reactions in childhood that arise in response to identifiable stress or adversity. |
| Delusions | Fixed false beliefs held against evidence, such as beliefs of theft or persecution common in dementia. |
| Depersonalization | A sense of detachment from one's own body, thoughts, or actions, as if observing oneself from outside. |
| Depression | Persistently low mood with loss of interest, a common and treatable symptom across neuropsychiatric disorders. |
| Encopresis | Repeated passage of feces in inappropriate places past the age of expected continence. |
| Enuresis | Repeated involuntary voiding of urine past the age of expected bladder control. |
| Functional Hearing Loss | Apparent hearing loss with no organic auditory cause, attributed to psychological factors. |
| Human Coprophagia | Ingestion of feces, seen in some severe psychiatric and neurodevelopmental conditions. |
| Malingering | Deliberate feigning or exaggeration of symptoms for an external incentive, distinct from genuine illness. |
| Mental Fatigue | A state of reduced cognitive efficiency and motivation following sustained mental effort. |
| Obsessive Behavior | Persistent, repetitive acts the person feels compelled to perform, often to reduce anxiety. |
| Paranoid Behavior | Conduct driven by unwarranted suspicion and mistrust of others' motives. |
| Psychogenic Polydipsia | Excessive, compulsive water drinking in the absence of a physiological cause for thirst. |
| Problem Behavior | Conduct that is disruptive or harmful in a given setting, a broad term used across education and clinical care. |
| Schizophrenic Language | Disordered, loosely associated speech characteristic of the thought disturbance in schizophrenia. |
| Self-Injurious Behavior | Deliberate harm to one's own body without suicidal intent, seen in several psychiatric and developmental conditions. |
| Psychological Stress | The strain of demands that tax or exceed a person's adaptive resources, with behavioral and physiological signs. |
| Wandering Behavior | Aimless or disoriented locomotion in dementia, carrying risk of falls, exit-seeking, and getting lost. |
Figure 1
The Twelve Domains of the Neuropsychiatric Inventory
Measuring Behavioral Symptoms
A behavioral symptom becomes a research object only once it can be rated reliably, and the history of the field is in large part the history of its instruments. The Neuropsychiatric Inventory, developed by Cummings and colleagues, is the most widely used: it rates twelve behavioral domains through a structured interview with a caregiver, scoring each as the product of frequency and severity and adding a separate measure of the distress the symptom causes the caregiver (Cummings et al., 1994). Its frequency-times-severity design, worked through below, is what lets a diffuse clinical impression become a number that can be tracked over time and compared across patients.
The NPI was not the first such scale. The BEHAVE-AD, introduced by Reisberg and colleagues, rated the behavioral symptoms of Alzheimer's disease specifically, grouping them into paranoid and delusional ideation, hallucinations, activity disturbances, aggressiveness, diurnal rhythm disturbance, affective disturbance, and anxiety (Reisberg et al., 1987). The move from these scales to a shared vocabulary was deliberate: the Finkel consensus statement proposed the single umbrella term *behavioral and psychological symptoms of dementia* precisely so that studies using different instruments could be compared and a common research and treatment agenda set (Finkel et al., 1996). Lyketsos and colleagues later argued for treating neuropsychiatric symptoms as a core feature of Alzheimer's disease in their own right, not an incidental complication, which raised the standard for how carefully they are measured (Lyketsos et al., 2011).
Neuropsychiatric Inventory profiler: frequency × severity
Set each domain's frequency (1–4) and severity (1–3). Each domain score is their product (0–12); the total is their sum.
Structure after the Neuropsychiatric Inventory (Cummings et al., 1994). The starting values reproduce the Worked Example total of 33. Values are illustrative of the scoring rule, not measured from any patient; computed locally, not stored.
Prevalence and Course in Dementia
Behavioral and psychological symptoms are not an occasional feature of dementia but close to a defining one. In the population-based Cardiovascular Health Study, Lyketsos and colleagues found that a clear majority of people with dementia had exhibited at least one neuropsychiatric symptom in the preceding month, with apathy, depression, and agitation the most common, and that even mild cognitive impairment carried a substantial symptom burden (Lyketsos et al., 2002). A systematic review and meta-analysis by Zhao and colleagues put the pooled prevalence of any neuropsychiatric symptom in Alzheimer's disease at roughly four in five patients, with apathy the single most frequent (Zhao et al., 2016). The symptoms are the rule, not the exception.
They are also persistent and consequential. Selbaek and colleagues, reviewing nursing-home cohorts, found that neuropsychiatric symptoms are highly prevalent and, for many patients, run a chronic or fluctuating course rather than resolving (Selbæk et al., 2013). Cerejeira and colleagues set out the neurobiological substrates, linking particular symptom clusters to degeneration in specific frontal-subcortical and neurotransmitter systems, which is part of why the symptoms track the disease rather than appearing at random (Cerejeira et al., 2012). The clinical weight of this is large: behavioral symptoms predict caregiver distress, earlier institutionalization, and worse outcomes more strongly than the degree of cognitive impairment, which is why they, rather than memory loss, are often the proximate reason a family can no longer cope.
Managing Behavioral Symptoms
The management of behavioral symptoms has shifted decisively toward nonpharmacologic approaches as first-line treatment. Gitlin and colleagues laid out the evidence that structured caregiver-focused and environmental interventions can reduce behavioral symptoms with none of the risks that attend medication (Gitlin et al., 2012). The caution about drugs is well founded: Ballard and Corbett summarized the evidence that antipsychotics, long used to control agitation and psychosis in dementia, carry a raised risk of stroke and death and offer only modest benefit, so their use must be weighed carefully and time-limited (Ballard & Corbett, 2010).
The field's synthesis of this is the structured clinical approach set out by Kales, Gitlin, and Lyketsos, built around assessing and treating symptoms systematically rather than reaching reflexively for a sedative (Kales et al., 2015). Their DICE framework names four steps that recur in every behavioral episode: *Describe* the behavior and its context precisely, *Investigate* possible causes from pain to environment to unmet need, *Create* a tailored plan that is tried first, and *Evaluate* whether it worked. Tible and colleagues translated the same principles into a best-practice sequence, emphasizing that a reversible cause, such as pain, infection, or an overstimulating environment, should be sought and corrected before any symptomatic drug is considered (Tible et al., 2017). The worked example and the demonstrations below make the frequency-times-severity scoring and the DICE cycle concrete.
BPSD prevalence across the course of dementia
An illustrative model of the prevalence pattern reported across the dementia literature (e.g. Lyketsos et al., 2002; Zhao et al., 2016); the curves are representative shapes, not pooled estimates. Computed locally, not stored.
Worked Example
The Neuropsychiatric Inventory scores each behavioral domain as the product of two caregiver-rated judgments: how *often* the behavior occurs, on a frequency scale of 1 (occasionally) to 4 (very often), and how *severe* it is when it occurs, on a severity scale of 1 (mild) to 3 (severe). The domain score is their product, running from 1 to 12, and the total NPI score is the sum across the rated domains. This multiplicative design is deliberate: a behavior that is frequent but mild and one that is rare but severe can reach the same score, and a behavior that is both frequent and severe dominates the profile.
Consider an illustrative patient rated on five domains:
| Domain | Frequency (1–4) | Severity (1–3) | Domain score |
|---|---|---|---|
| Agitation / Aggression | 4 | 3 | 12 |
| Apathy / Indifference | 4 | 2 | 8 |
| Depression / Dysphoria | 3 | 2 | 6 |
| Anxiety | 2 | 2 | 4 |
| Delusions | 1 | 3 | 3 |
Summing the five domain scores gives a total of 12 + 8 + 6 + 4 + 3 = 33, out of a possible 60 for five domains rated at the maximum of 12 each. The profile's shape matters as much as its total. Agitation reaches the ceiling because it is both frequent and severe; the single delusion, though severe, is rare and so contributes little; apathy, frequent but moderate, contributes more than the more alarming delusion. A clinician reading this profile would target the agitation first, exactly the prioritization the frequency-times-severity product is designed to surface. The NpiProfileDemo lets the reader set frequency and severity for each domain and watch the total and the dominant symptom update; the values are illustrative of the scoring rule, not measured from any patient.
Discussion
The study of behavioral symptoms is, at bottom, a sustained attempt to make disordered conduct countable. Achenbach's demonstration that children's symptoms resolve into a few recurring dimensions, and the inventories that followed for dementia, share a single premise: that the way to act on behavior clinically is first to measure it reliably (Achenbach, 1966; Cummings et al., 1994). The behavioral and psychological symptoms of dementia are the field's central case because they are nearly universal in the illness, because they drive its human and economic cost, and because they are, unlike the underlying neurodegeneration, often modifiable (Lyketsos et al., 2002; Finkel et al., 1996).
What has changed most is the treatment logic. The default was once pharmacologic, and the recognition that antipsychotics raise mortality for limited benefit forced a reckoning (Ballard & Corbett, 2010). The structured, nonpharmacologic-first approach that replaced it treats a behavioral symptom not as noise to be suppressed but as a communication of an unmet need to be investigated, a reframing with both ethical and practical force (Gitlin et al., 2012; Kales et al., 2015). The open problems are the reliability of symptom clusters across instruments and cultures, the neurobiological specificity of those clusters, and the scaling of nonpharmacologic interventions into routine care, where expertise and time are scarce.
Current Directions
The active research front is sharpest on the management side. The strongest recent evidence on nonpharmacologic treatment comes from a systematic review and network meta-analysis by Watt and colleagues, which compared interventions for aggression and agitation in dementia and found several nonpharmacologic approaches, including multidisciplinary care and massage or touch therapy, to be as effective as or more effective than drugs, strengthening the case for trying behavioral measures first (Watt et al., 2019). The result matters because it puts a quantitative ranking under a recommendation that had rested largely on the risks of the alternative.
In parallel, the field has worked to standardize practice. Kales and colleagues conducted an international Delphi consensus that produced explicit, expert-agreed algorithms for assessing and managing the behavioral and psychological symptoms of Alzheimer's disease, operationalizing the describe-investigate-create-evaluate logic into steps a non-specialist can follow (Kales et al., 2019). Tible and colleagues similarly distilled best practice into a sequence that foregrounds the search for reversible causes before symptomatic treatment (Tible et al., 2017). Together these lines are moving the field from establishing that nonpharmacologic approaches work toward specifying, in transferable detail, how to deliver them at scale. The DICE cycle in the demonstration below traces that logic step by step.
The DICE cycle for behavioral symptoms
The DICE approach (Describe, Investigate, Create, Evaluate) after Kales et al. (2015). The cycle repeats rather than terminating, foregrounding reversible causes and nonpharmacologic plans. Illustrative; computed locally, not stored.
Common Misconceptions
- Behavioral symptoms in dementia are an inevitable, untreatable part of the decline.
- Unlike the underlying neurodegeneration, these symptoms are often modifiable; structured nonpharmacologic interventions reduce them and are now recommended as first-line treatment (Gitlin et al., 2012).
- Antipsychotic medication is the standard treatment for agitation in dementia.
- Antipsychotics raise the risk of stroke and death and offer only modest benefit, so they are reserved for danger or failure of behavioral measures, not used as a default (Ballard & Corbett, 2010).
- A behavioral symptom is just unwanted behavior to be stopped.
- In structured approaches a symptom is treated as a sign of an unmet need, pain, or an environmental trigger to be investigated and corrected, not merely suppressed (Kales et al., 2015).
Glossary
- Affective Symptoms.
- Disturbances of mood and emotion, such as depression, anxiety, or lability, forming one subtype of behavioral symptoms.
- Apathy.
- Loss of motivation, interest, and emotional responsiveness; the single most frequent neuropsychiatric symptom in dementia.
- BEHAVE-AD.
- A rating scale for the behavioral symptoms of Alzheimer's disease, grouping them into seven categories from delusions to anxiety.
- Behavior.
- The observable actions of an organism; the parent MeSH category under which behavioral symptoms are classified.
- Behavioral and psychological symptoms of dementia.
- The consensus umbrella term for the agitation, mood, psychotic, and other noncognitive symptoms that accompany dementia.
- Behavioral symptom.
- An observable, clinically significant disturbance of conduct, mood, perception, or thought taken as a sign of an underlying disorder.
- Caregiver distress.
- The strain a behavioral symptom places on the person caring for the patient, rated separately on the Neuropsychiatric Inventory.
- DICE approach.
- A structured method for behavioral symptoms: Describe the behavior, Investigate causes, Create a plan, and Evaluate its effect.
- Externalizing symptoms.
- An outward-directed broad-band factor of child psychopathology, including aggression and rule-breaking, identified by factor analysis.
- Internalizing symptoms.
- An inward-directed broad-band factor of child psychopathology, including anxiety and depression, identified by factor analysis.
- Neuropsychiatric Inventory.
- A caregiver-based instrument rating twelve behavioral domains of dementia as frequency times severity, with a distress score.
- Neuropsychiatric symptoms.
- The behavioral and psychological symptoms accompanying a neurological disorder; used interchangeably with BPSD in dementia.
- Nonpharmacologic intervention.
- A caregiver, behavioral, or environmental treatment for behavioral symptoms, now recommended ahead of medication.
- Research Domain Criteria.
- A framework proposing to anchor symptom dimensions to neural and behavioral systems rather than to diagnostic categories.
- Severity rating.
- On the Neuropsychiatric Inventory, how intense a behavioral symptom is when present, scored 1 (mild) to 3 (severe).
Key Researchers
Clive Ballard
(University of Exeter Medical School). Professor of age-related diseases whose trials, including DART-AD, established the mortality and stroke risks of antipsychotics in dementia and advanced nonpharmacologic alternatives.
Wikipedia - Faculty Page
Jeffrey L. Cummings
(University of Nevada, Las Vegas). Behavioral neurologist who created the Neuropsychiatric Inventory, the most widely used instrument for rating the behavioral symptoms of dementia, and a leader in Alzheimer's drug development.
ORCID - Faculty Page
Laura N. Gitlin
(Drexel University). Applied researcher on aging and caregiving whose work established the efficacy of nonpharmacologic, caregiver-focused interventions for behavioral symptoms in dementia.
ORCID - Wikipedia
Helen C. Kales
(University of California, Davis). Chair of psychiatry whose DICE approach gave clinicians a structured, nonpharmacologic-first framework for assessing and managing behavioral symptoms in dementia.
ORCID - Wikipedia
Constantine G. Lyketsos
(Johns Hopkins University). Psychiatrist whose epidemiological work established the prevalence and prognostic weight of neuropsychiatric symptoms in dementia and mild cognitive impairment.
ORCID - Wikipedia
Barry Reisberg
(New York University Grossman School of Medicine). Psychiatrist who systematized the behavioral symptoms of Alzheimer's disease, created the BEHAVE-AD scale, and coined the term mild cognitive impairment.
Google Scholar - Wikidata
Frequently Asked Questions
What are behavioral symptoms?
Behavioral symptoms are observable, clinically significant disturbances of conduct, mood, perception, or thought that are taken as signs of an underlying mental or neurological disorder. In MeSH they are classified as a kind of behavior (Finkel et al., 1996).
What are the behavioral and psychological symptoms of dementia?
They are the noncognitive symptoms that accompany dementia, including agitation, aggression, depression, apathy, anxiety, delusions, and disinhibition, grouped under a consensus umbrella term so that research and treatment can address them together (Finkel et al., 1996).
How common are neuropsychiatric symptoms in dementia?
Very common. A meta-analysis found that roughly four in five people with Alzheimer's disease show at least one neuropsychiatric symptom, with apathy the most frequent (Zhao et al., 2016).
How are behavioral symptoms measured?
Through standardized rating scales such as the Neuropsychiatric Inventory, which rates twelve behavioral domains as the product of frequency and severity from a structured caregiver interview (Cummings et al., 1994).
Are behavioral symptoms in dementia treatable?
Yes. Structured nonpharmacologic interventions reduce behavioral symptoms and are recommended as first-line treatment, reserving medication for danger or failure of those measures (Gitlin et al., 2012).
Why are antipsychotics used cautiously in dementia?
Because they raise the risk of stroke and death while offering only modest benefit for agitation and psychosis, so their use is weighed carefully and kept time-limited (Ballard & Corbett, 2010).
What is the DICE approach?
DICE is a structured method for behavioral symptoms with four steps: Describe the behavior and its context, Investigate possible causes, Create a tailored plan, and Evaluate whether it worked (Kales et al., 2015).
How do behavioral symptoms relate to cognitive decline?
They predict caregiver burden, institutionalization, and poor outcomes more strongly than the degree of cognitive impairment, which is why they are often the proximate reason a family can no longer manage care at home (Lyketsos et al., 2002).
References
Achenbach, T. M. (1966). The classification of children's psychiatric symptoms: A factor-analytic study. Psychological Monographs: General and Applied, 80(7), 1–37. https://doi.org/10.1037/h0093906
Ballard, C., & Corbett, A. (2010). Management of neuropsychiatric symptoms in people with dementia. CNS Drugs, 24(9), 729–739. https://doi.org/10.2165/11319240-000000000-00000
Cerejeira, J., Lagarto, L., & Mukaetova-Ladinska, E. B. (2012). Behavioral and psychological symptoms of dementia. Frontiers in Neurology, 3, 73. https://doi.org/10.3389/fneur.2012.00073
Cummings, J. L., Mega, M., Gray, K., Rosenberg-Thompson, S., Carusi, D. A., & Gornbein, J. (1994). The Neuropsychiatric Inventory: Comprehensive assessment of psychopathology in dementia. Neurology, 44(12), 2308–2314. https://doi.org/10.1212/wnl.44.12.2308
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Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., Sanislow, C., & Wang, P. (2010). Research domain criteria (RDoC): Toward a new classification framework for research on mental disorders. American Journal of Psychiatry, 167(7), 748–751. https://doi.org/10.1176/appi.ajp.2010.09091379
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Reisberg, B., Borenstein, J., Salob, S. P., Ferris, S. H., Franssen, E., & Georgotas, A. (1987). Behavioral symptoms in Alzheimer's disease: Phenomenology and treatment. Journal of Clinical Psychiatry, 48(5, Suppl), 9–15.
Selbæk, G., Engedal, K., & Bergh, S. (2013). The prevalence and course of neuropsychiatric symptoms in nursing home patients with dementia: A systematic review. Journal of the American Medical Directors Association, 14(3), 161–169. https://doi.org/10.1016/j.jamda.2012.09.027
Tible, O. P., Riese, F., Savaskan, E., & von Gunten, A. (2017). Best practice in the management of behavioural and psychological symptoms of dementia. Therapeutic Advances in Neurological Disorders, 10(8), 297–309. https://doi.org/10.1177/1756285617712979
Watt, J. A., Goodarzi, Z., Veroniki, A. A., Nincic, V., Khan, P. A., Ghassemi, M., Thompson, Y., Tricco, A. C., Straus, S. E., & Seitz, D. P. (2019). Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: A systematic review and network meta-analysis. Annals of Internal Medicine, 171(9), 633–642. https://doi.org/10.7326/M19-0993
Zhao, Q. F., Tan, L., Wang, H. F., Jiang, T., Tan, M. S., Tan, L., Xu, W., Li, J. Q., Wang, J., Lai, T. J., & Yu, J. T. (2016). The prevalence of neuropsychiatric symptoms in Alzheimer's disease: Systematic review and meta-analysis. Journal of Affective Disorders, 190, 264–271. https://doi.org/10.1016/j.jad.2015.09.069