Special Article

Psychother Psychosom 2016;85:337–345 Received: February 19, 2016

Accepted after revision: June 22, 2016
DOI: 10.1159/000447760
Published online: October 15, 2016

Use of the Psychosocial Index:

A Sensitive Tool in Research and Practice
Antonio Piolanti a Emanuela Offidani c Jenny Guidi a Sara Gostoli a
Giovanni A. Fava a, d Nicoletta Sonino b, d
a
Department of Psychology, University of Bologna, Bologna, and b Department of Statistical Sciences, University
of Padova, Padova, Italy; c Center for Integrative Medicine, Weill Cornell Medical College, New York, N.Y., and
d
Department of Psychiatry, University at Buffalo, Buffalo, N.Y., USA

Key Words in different populations. When subjects were identified by

Psychosocial Index · Stress · Allostatic load · Well-being · categorical criteria (presence of allostatic overload, psycho-
Anxiety · Depression · Illness behavior · Quality of life · somatic syndromes, psychiatric disorders), the PSI scores
Clinimetrics · Patient-reported outcomes were significantly different across subgroups. Conclusions:
In clinical practice, scanning the list of symptoms allows cli-
nicians to assess rapidly which symptoms and problems are
Abstract perceived as most troublesome. In research settings, the use
Background: The Psychosocial Index (PSI) is a self-rating of scores makes the PSI a valid and sensitive tool in differen-
scale based on clinimetric principles that is simple to use in tiating levels of psychosocial variables among groups.
a busy clinical setting. It can be integrated by observer-rated © 2016 S. Karger AG, Basel
clinical judgment, providing a first-line, comprehensive as-
sessment of stress, well-being, distress, illness behavior, and
quality of life. By calculation of scores, it can be used for con- Introduction
ventional psychological measurements. Its clinical applica-
tions and clinimetric properties are reviewed. The present The Psychosocial Index (PSI) was introduced by Soni-
version of the PSI has been slightly revised. In addition, a no and Fava [1] in 1998 mainly to provide clinicians with
modified version for use in adolescents and young adults a simple screening tool for stress and other psychosocial
(PSI-Young; PSI-Y) is also included. Methods: Articles that in- dimensions in a busy clinical practice. By the evaluation
volved the use of the PSI were identified by searching the of scores, it can be employed in research settings as well.
Web of Science database from 1998 to February 2016 and by It was developed according to clinimetric principles. The
a manual search of the literature. Results: A total of 20 stud- domain of clinimetrics is concerned with quantitative
ies reporting results from the use of PSI were included. The methods in the collection and analysis of clinical phe-
PSI has been employed in various clinical populations in dif- nomena, such as type, severity and sequence of symp-
ferent countries and showed high sensitivity. It significantly toms, problems of functional capacity, and reason for
discriminated varying degrees of psychosocial impairment medical decisions, with emphasis on clinical judgment

© 2016 S. Karger AG, Basel Nicoletta Sonino, MD

0033–3190/16/0856–0337$39.50/0 Department of Statistical Sciences, University of Padova
Via Battisti 241
E-Mail karger@karger.com
IT–35121 Padova (Italy)
www.karger.com/pps
E-Mail nicoletta.sonino @ unipd.it
[2–8]. The clinimetric criteria for evaluating the clinical (b) Stress: this section (items 13–20 and 22–30) is an
validity of a scale differ from those of the standard psy- integration of both perceived and objective stress, life
chometric analyses [4, 9]. An essential difference is con- events and chronic stress. It consists of 17 questions with
cerned with the discrimination properties (responsive- a total score ranging from 0 to 17. These questions con-
ness/sensitivity) of an index, defined as the ability to dif- tain essential information for case identification of allo-
ferentiate between patients and controls. Unlike in static overload [16].
psychometrics, homogeneity of components is not re- (c) Well-being: this section (items 31–36) covers dif-
quested and single items may be weighed in different ferent areas of well-being, i.e., positive relations with oth-
ways. What matters is the capacity of an index to discrim- ers (items 31, 32), environmental mastery (items 33, 34)
inate between different groups of subjects and to reflect and autonomy (items 35, 36), with a score ranging from
changes in experimental settings such as drug trials. In 0 to 6.
psychometrics, the same properties that give a scale a high (d) Psychological distress: this section (items 37–51)
score for homogeneity may obscure its ability to detect consists of a checklist of symptoms addressing sleep dis-
change, and redundant scale items may increase homo- turbances, somatization, anxiety, depression and irrita-
geneity but decrease sensitivity [4]. A high correlation is bility. The total score may range from 0 to 45. Questions
often regarded as evidence that the two scales measure the 37–40 refer to sleep disturbances (range 0–12) and may
same factor. However, a high correlation does not indi- also be scored separately from the other questions.
cate similar sensitivity: a common content of two scales (e) Abnormal illness behavior: it allows the assessment
may insure a high positive correlation between them, but of hypochondriacal beliefs and bodily preoccupations
the items they do not share may be important in deter- (items 52–54). The total score may range from 0 to 9.
mining their sensitivity [4]. A test of sensitivity is pro- (f) Quality of life (item 55): a simple direct question
vided by the capacity of an index to discriminate between on quality of life is included, following the recommenda-
subgroups of subjects with the same disease (e.g., inpa- tion of Gill and Feinstein [17]. The score ranges from 0 to
tients and outpatients with depression) [10]. 4. The scores concerned with psychological well-being
Based on insights derived from studies performed in (0–6) and quality of life (0–4) can be added for obtaining
the past two decades, we here report a slightly modified a global well-being score (0–10).
version of the PSI and review the available data concern- The self-rating questionnaire (Appendix 1) provides a
ing its clinimetric properties and clinical applications. dimensional assessment of psychosocial features. Some
questions involve specific responses, most require a yes/
Description of the PSI no answer, while others are rated on a Likert scale (0–3,
This self-rating questionnaire (Appendix 1) includes from ‘not at all’ to ‘a great deal’); 1 item, quality of life, has
55 items, most of which are derived from previously vali- 5 possible choices, from excellent to awful. For detailed
dated instruments. Thirty-five items (1–20 and 37–51) scoring instructions, see Appendix 3. The PSI is not de-
were selected from the 118 of Kellner’s Screening List for signed to calculate a total score.
Psychosocial Problems [11], eliminating all sources of re- A 51-item modified version of the PSI has recently
dundancy. They constitute the sociodemographic and been developed for assessing psychosocial factors among
clinical data section, the psychological distress scale and adolescents and young adults up to 21 years of age (PSI-
part of the stress scale. The latter has been integrated with Young; PSI-Y), with particular reference to studying ac-
10 items (21–30) derived from the Wheatley Stress Profile tivities, educational setting, peer relationships, and fam-
[12]. Six questions (31–36) were derived from Ryff’s Psy- ily environment (see online suppl. table  1, 2; see www.
chological Well-Being scales [13] and constitute the well- karger.com/doi/10.1159/000447760 for all online suppl.
being section. Three questions (52–54) were selected material). It has been used in a study aimed at providing
from Kellner’s Illness Attitude Scales [14, 15] and com- a psychological characterization of hyperandrogenic
pose the abnormal illness behavior scale. states among late adolescent and young women [18].
The following domains are covered: The observer rating of the PSI (Appendix 2), by visu-
(a) Sociodemographic and clinical data: this part ally scanning the patient self-rated responses, allows the
(items 1–12) includes largely routine information about clinician to evaluate the PSI subscales directly on a 5-point
medical and psychiatric history, the patient’s family, em- Likert scale. Observer-rating scores may range from high-
ployment and habits. It may alert clinicians to some ly stressful life to nonstressful life for stress; from excel-
threats to health, such as alcohol or drug use. lent to absent for well-being; from incapacitating to ab-

338 Psychother Psychosom 2016;85:337–345 Piolanti/Offidani/Guidi/Gostoli/Fava/

DOI: 10.1159/000447760 Sonino
sent for psychological distress and abnormal illness be- ic overload were found to report significantly more
havior. Observer rating does not provide a total score. psychological distress than subjects without allostatic
Question 55 on quality of life is self-rated by the patient, overload. In another investigation [22], the determina-
with no need for external judgment by the observer. tion of allostatic overload in healthy subjects was based
on the responses to the PSI in conjunction with addi-
tional self-rated measures. This study showed that in-
Methods dividuals with an allostatic overload differed from
those without it in levels of some biological parameters
Data Source
[22].
Articles citing the original PSI reference [1] were identified by
searching the Web of Science database, from 1998 to February – The PSI has been administered as a screening tool for
2016. In addition, potentially relevant papers were searched man- psychosocial factors in a psychoneuroendocrinology
ually. clinic [23]. Data gathered from the PSI were used to
evaluate the need of patients for further psychological
Study Selection
assessments and to plan therapeutic strategies.
Two investigators (A.P. and E.O.) carried out the search inde-
pendently; disagreements were resolved by consensus among rat-
ers and one senior investigator (N.S.). Articles were considered to Use of Self-Rating Scores
be eligible if they reported research data with regard to administra- The PSI consists of items of validated scales and its sec-
tion of the PSI. tions can thus be used for conventional psychological
measurements.
Data Extraction
Data were independently extracted with the use of a precoded – In clinical endocrinology, it detected significantly
form. The following data were extracted from the included studies: higher levels of stress and psychological distress, im-
purpose of the study, number of subjects, design, tools adminis- paired well-being and maladaptive illness behavior in
tered and findings (online suppl. table 3). patients with pituitary disease compared to healthy
controls [24]. The sensitivity of the PSI was also con-
firmed when a population suffering from a wide range
Results of endocrine conditions [25] was analyzed as to the
presence of psychiatric disorders according to the
Characteristics of Included Studies DSM-IV [26] and/or psychosomatic syndromes ac-
The literature search identified 37 relevant articles. Of cording to the Diagnostic Criteria for Psychosomatic
these, 17 were excluded: 15 studies only cited the PSI and Research (DCPR) [27–29]. Psychological distress
2 were duplicates. A total of 20 investigations were in- identified by semistructured research interviews was
cluded in the review (for a flow diagram of the search, see confirmed by PSI self-rated scores. Such findings were
online suppl. fig. 1). Details of the 20 studies are summa- similar to those obtained in a community sample [30],
rized in online supplementary table 3 and the main find- where significantly higher scores in the scales of stress
ings are outlined here. and psychological distress and significantly lower
scores in well-being were found in subjects with DCPR
Use for Clinical Assessment syndromes compared to those without. In another
– The interrater reliability of the observer-rating part of study [31], hypertensive subjects with primary aldo-
the PSI (Appendix 2) was assessed in subjects with steronism showed significantly higher levels of stress
functional medical disorders evaluated by an internist and psychological distress and lower levels of well-be-
and a psychiatrist. The PSI observer-rating part showed ing as compared to normotensive controls. Further-
high interrater reliability, with intraclass correlation more, patients with primary aldosteronism displayed
coefficients of 0.88 for rating stress, 0.94 for well-be- significantly higher scores on PSI stress compared to
ing, 0.89 for psychosocial distress, and 0.90 for illness patients with essential hypertension. Finally, in a re-
behavior [1]. cent study [18], adolescent females affected by isolated
– The PSI was used to aid the clinical interview in three clinical hyperandrogenism (i.e., hirsutism) reported
investigations concerned with the assessment of allo- significantly lower levels of PSI-Y well-being and qual-
static overload in the general population [19], in atrial ity of life compared to their healthy counterparts.
fibrillation [20], and in congestive heart failure [21]. In – As to blood pressure, the PSI was used to evaluate the
these three studies, individuals who displayed allostat- influence of psychosocial factors on changes in day-

Psychosocial Index Psychother Psychosom 2016;85:337–345 339

DOI: 10.1159/000447760
 time/nighttime blood pressure rhythm in normoten- indicates positive changes in many life domains as a
sive and hypertensive subjects [32]. In this investiga- result of the personal, cognitive and emotional efforts
tion, the items concerned with sleep disturbances were in dealing with traumatic events [42].
analyzed separately from the section of psychological – In the setting of a highly pathogenic avian influenza in
distress. Patients with essential hypertension who had Nigeria, people whose farms had suffered avian influ-
no nocturnal fall in blood pressure had a significantly enza H5N1 outbreaks had significantly higher PSI
worse quality of sleep compared to those who had the scores of abnormal illness behavior and stress than
blood pressure physiological decline. Further, there those whose farms had not been affected by the out-
were significant correlations between the amount of break epidemics in poultry [43].
stress and nocturnal blood pressure levels in subjects
with normal blood pressure [32]. In another study on
hypertensive subjects [33], participants were classified Discussion
into three subgroups (affective disturbances, alexi-
thymia, and somatization) according to a cluster anal- The self-rating PSI may be employed in different
ysis based on DSM-IV [26] and DCPR [27–29] diag- ways: (a) as a screening tool in the setting of medical eval-
noses. The combined PSI score of stress and psycho- uation and interviewing; (b) it can be integrated with
logical distress discriminated among these subgroups. clinical judgment by applying a simple observer-rated
Patients in the somatization group reported the high- score, and (c) by calculation of scores, it can be used for
est combined score and those in the alexithymia group conventional psychological measurements [1]. In the
showed the lowest score. studies that we have reviewed, all these modalities have
Subjects with medically unexplained syncope been used.
showed significantly higher levels of PSI psychological In clinical assessment, using the PSI allows to scan the
distress and lower levels of psychological well-being, list rapidly to determine which psychological and social
as compared to individuals with vasovagal syncope problems, and/or psychiatric symptoms the patient finds
[34]. This finding is consistent with previous studies distressing. By simply scanning the answers, the clinician
[35, 36]. may understand the degree of stress, well-being, psycho-
– In cardiology, a longitudinal study [37] evaluated the logical distress, illness behavior and quality of life. It may
psychological status of patients who underwent coro- provide preliminary ground for specific questions as to
nary artery bypass grafting at 1 month and at 6–8 years psychological distress during medical examination and
after surgery. The PSI section of abnormal illness be- interviewing, leading to diagnostic and therapeutic deci-
havior sensitively detected a decrease in worry about sions or specialist referral [1, 23].
physical conditions when the acute phase of the illness The simple observer-rating score, which emphasizes
abated. In patients with recent myocardial infarction clinical judgment [4], may result particularly useful for
who participated in a cardiac rehabilitation program clinical practice, due to the short time that is requested for
[38], combined PSI scores did not predict subsequent this rating. These issues are all of considerable impor-
coronary events (death, myocardial infarction, or an- tance for primary care, where psychological distress is
gina pectoris). Among patients with congestive heart common but often remains undetected and inadequately
failure [39], participants with DCPR diagnoses had sig- managed [44].
nificantly higher scores on the PSI sections of stress and The PSI has some unique properties compared to oth-
psychological distress compared to those with no diag- er scales that are available [3]. According to clinimetric
noses. In patients with an implantable cardioverter de- principles, items that were included were selected on the
fibrillator [40], the PSI was used to monitor psycho- basis of the amount of clinical information they carried.
logical variables up to 1 year of follow-up. For instance, as to psychological distress, there are 4
– Breast cancer survivors showed significantly higher items concerned with sleep (items 37–40, Appendix 1),
levels of PSI psychological distress as compared to that cover difficulties falling asleep, restless sleep, early
healthy controls reporting negative events other than morning awakening and feeling tired on waking up.
cancer [41]. In addition, breast cancer survivors with These are 4 key areas in the determination of sleep qual-
a high posttraumatic growth score reported signifi- ity [45, 46].
cantly less psychological distress compared to those The specific contribution of the PSI as to main clinical
with a low score. Posttraumatic growth is a feature that domains deserves to be discussed.

340 Psychother Psychosom 2016;85:337–345 Piolanti/Offidani/Guidi/Gostoli/Fava/

DOI: 10.1159/000447760 Sonino
 Allostatic Load the evaluation of disease outcomes by the clinician be in-
Due to its ability to provide a quick but comprehensive tegrated with appraisal of health and quality of life by the
evaluation of stress, the PSI is a very suitable instrument patient [56, 57]. A related aspect concerns patient-report-
for the screening of allostatic overload, especially in med- ed outcomes, any report coming directly from patients
ical settings [20–22, 47]. Clinimetric criteria for the deter- without interpretation by physicians or others about how
mination of allostatic overload include: (a) the presence they function or feel in relation to a health condition or
of a stressor exceeding individual coping skills, and (b) its therapy [58, 59]. The PSI provides a global measure of
clinical manifestations of distress, which may range from well-being integrated with that of quality of life. The evi-
psychiatric to psychosomatic/subclinical symptoms, and dence from the studies included in this review suggests
from impairment in social and occupational functioning that well-being and quality of life are compromised in
to decrease in well-being [16]. patients with cardiovascular and endocrine disorders [18,
24, 31, 32, 34].
Well-Being Calculation of scores provides conventional psycho-
Stress, psychological distress and illness behavior may logical measurements. The findings suggest a high sensi-
be linked to the individual’s potential for coping and so- tivity of the PSI self-rating questionnaire. In all studies,
cial support (well-being). Several studies have suggested the PSI displayed good sensitivity in discriminating be-
that psychological well-being plays a buffering role in tween patients and controls. In particular, there were sig-
coping with stress and has a favorable impact on disease nificant differences in stress, psychological distress and
course [13, 45, 48, 49]. well-being between patients affected by endocrine dis-
ease, cardiovascular disorders, breast cancer and their
Psychological Distress matched healthy controls. In addition, the PSI discrimi-
Psychological distress is strongly associated with med- nated between subjects with and without allostatic over-
ical conditions. Depression, in particular, may affect load [19–22].
functioning, quality of life and health care utilization [50, Another important clinimetric characteristic is in-
51]. However, there is emerging awareness that also psy- cremental validity [4, 60]: each distinct aspect of mea-
chological symptoms that do not reach the threshold of a surement should deliver a unique increase in informa-
psychiatric disorder may affect quality of life and entail tion in order to qualify for inclusion. Often a number
pathophysiological and therapeutic implications [29]. of scales are used under the misguided assumption that
nothing will be missed. On the contrary, violation of the
Illness Behavior concept of incremental validity leads to conflicting re-
The concept of illness behavior was introduced to in- sults [4]. Each of the five PSI sections yields an incre-
dicate the ways in which given symptoms may be per- mental increase in information that provides a compre-
ceived, evaluated and acted upon at an individual level hensive assessment of the main psychosomatic domains
[52]. Illness behavior may greatly vary according to ill- [16, 50, 61], where elements of redundancy were elimi-
ness-related, patient-related and doctor-related variables nated.
and their complex interactions. In the past decades, im- In conclusion, the PSI constitutes a clinimetric tool of
portant lines of research have been concerned with ill- high clinical utility and allows a comprehensive, sensitive
ness perception, frequent attendance of medical facili- appraisal of psychosomatic domains in different popula-
ties, health-care-seeking behavior, treatment-seeking be- tions.
havior, delay in seeking treatment, and treatment
adherence [53–55]. According to this review, the ques-
tions on abnormal illness behavior helped to discrimi- Disclosure Statement
nate between subgroups [24, 43]. They might show high
None of the authors has any conflicts of interest to declare.
sensitivity in populations where hypochondriasis or
functional medical disorders are predominant aspects
[15].

Quality of Life
Since measures of disease status alone are insufficient
to describe the burden of illness, it has been proposed that

Psychosocial Index Psychother Psychosom 2016;85:337–345 341

DOI: 10.1159/000447760
 Appendix 1. PSI, revised version (modified from Sonino and Fava [1])

Self-rating items

NAME____________________________SURNAME_________________________

1. Date of birth:________day________month__________year__________
2. Sex: Male □
Female □
3. Marital status: Single □
Married □
Divorced □
Separated □
Widowed □
4. Occupation_________________________________________________
How many hours do you work per week?_________________________
Occupation of spouse:________________________________________
5. Have you ever been hospitalized? YES NO
6. Please list illnesses, surgical operations and other treatments and give dates
____________________________________________________________
7. Are you allergic to any drug or substances? YES NO
If yes, specify_________________________________________________
8. What medication are you taking at present?_________________________
9. Do you drink alcohol? YES NO
10. Do you smoke? YES NO
11. Do you take recreational drugs? YES NO
12. Do you drink coffee or tea? YES NO
If yes, how many per day?________________________________________
Did any of the following happen to you in the past year? (YES/NO)
13. Death of a family member YES NO
14. Separation from spouse or long-time partner YES NO
15. Recent change of job YES NO
16. Financial difficulties YES NO
17. Moving within the same city YES NO
18. Moving to another city YES NO
19. Legal problems YES NO
20. Beginning of a new relationship YES NO
Please answer the following questions (YES/NO)
21 Do you have a job? YES NO
If you have a job:
22. Are you satisfied with your work? YES NO
23. Do you feel under pressure at work? YES NO
24. Do you have problems with your colleagues at work? YES NO
If you do not have a job:
22. Are you retired or student? YES NO
23. Do you feel under pressure during the day? YES NO
24. Are you unable to find a job? YES NO
25. Do you have serious arguments with close relatives? YES NO
26. Do you have serious arguments with other people? YES NO
27. Has any close relative been seriously ill in the past year? YES NO
If yes, specify:_________________________________________________
28. Do you feel tension at home? YES NO

342 Psychother Psychosom 2016;85:337–345 Piolanti/Offidani/Guidi/Gostoli/Fava/

DOI: 10.1159/000447760 Sonino
29. Do you live by yourself? YES NO
30. Do you feel lonely? YES NO
31. Do you have anyone whom you can trust and confide in? YES NO
32. Do you get along well with people? YES NO
33. Do you often feel overwhelmed by the demands of everyday life? YES NO
34. Do you often feel you cannot make it? YES NO
35. Do you tend to be influenced by people with strong opinions? YES NO
36. Do you tend to worry about what other people think of you? YES NO
Please describe any problems or difficulties you have had recently and indicate how much they have troubled you by marking the
appropriate column
Not at all Only a Some- A great
little what deal
37. It takes a long time to fall asleep □ □ □ □
38. Restless sleep □ □ □ □
39. Waking too early and not being able to fall asleep again □ □ □ □
40. Feeling tired on waking up □ □ □ □
41. Stomach, bowel pains □ □ □ □
42. Heart beating quickly or strongly without a reason □ □ □ □
43. Feeling dizzy or faint □ □ □ □
44. Feelings of pressure or tightness in head or body □ □ □ □
45. Breathing difficulties or feeling of not having enough air □ □ □ □
46. Feeling tired or lack of energy □ □ □ □
47. Irritable □ □ □ □
48. Sad or depressed □ □ □ □
49. Feeling tense or ‘wound up’ □ □ □ □
50. Lost interests in most things □ □ □ □
51. Attacks of panic □ □ □ □
52. Do you believe you have a physical disease but that doctors have not □ □ □ □
diagnosed it correctly?
53. When you read or hear about an illness, do you get similar symptoms? □ □ □ □
54. When you notice a sensation in your body, do you find it difficult to think of □ □ □ □
something else?
55. How do you rate the quality of your life? Excellent Good Fair Poor Awful

Appendix 2. PSI, revised version (modified by Sonino and Fava [1])

Observer-rating scores
Highly stressful life Stressful life Non-stressful life
Stress 5 4 3 2 1
Excellent Good Fair Poor Absent
Well-being 5 4 3 2 1
Incapacitating Severe Moderate Slight Absent
Psychological distress 5 4 3 2 1
Incapacitating Severe Moderate Slight Absent
Abnormal illness behavior 5 4 3 2 1

Psychosocial Index Psychother Psychosom 2016;85:337–345 343

DOI: 10.1159/000447760
 Appendix 3. PSI, revised version (modified by Sonino and Fava [1])

How to score the PSI

Stress: the scale includes 17 questions (13 – 20; 22 – 30) with yes/no answers. In questions 13 – 20 and 23 – 30, ‘yes’ corresponds to a
score of 1, indicating presence of stress, while ‘no’ corresponds to a score of 0, i.e., absence of stress. For question 22, answer ‘yes’
corresponds to a score of 0, while ‘no’ to a score of 1 (reverse score). Total scale score may range from 0 (absence of stress) to 17
(maximum stress).
Well-being: this scale is made of 6 questions (31 – 36), which have two possible choices (yes/no). In questions 31 and 32, ‘yes’
corresponds to a score of 1, while ‘no’ corresponds to a score of 0; for questions 33 – 36, the answer ‘yes’ corresponds to a 0 score,
while ‘no’ to 1 (reverse score). Total score may range from 0 to 6.
Psychological distress: the scale consists of 15 questions (37 – 51), with four possible choices ranging from no psychological distress to
high psychological distress (‘not at all’, ‘a little’, ‘somewhat’, ‘a great deal’). The attributable score to single items ranges from 0 to 3,
with higher scores indicating greater distress. Total score may vary from 0 to 45. Questions 37 – 40 indicate sleep disturbances and
may be scored separately (range: 0 – 12) from other questions on psychological distress (range: 0 – 33).
Abnormal illness behavior: the scale consists of 3 questions (52 – 54), with four possible choices ranging from absent abnormal illness
behavior to maximum (‘not at all’, ‘a little’, ‘somewhat’, ‘a great deal’). The attributable score to single items range from 0 to 3. Total
score may vary from 0 to 9.
Quality of life: question 55 ‘How do you rate the quality of your life?’ has 5 possible answers (‘excellent’, ‘good’, ‘fair’, ‘poor’, ‘awful’).
Its attributable score ranges from 4 to 0, where 4 corresponds to ‘excellent’ and 0 to ‘awful’. Total score may range from 0 (awful
quality of life) to 4 (excellent quality of life). The scores concerned with psychological well-being (0 – 6) and quality of life (0 – 4) can
also be added for obtaining a global well-being score (0 – 10).

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