Psychological Symptoms Checklist

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Circle the number, from 0 (never) to 4 (frequently), that represents the degree to which the following thoughts, feelings, and behaviors have bothered you during the past month.

0 = Never
1 = Rarely
2 = Sometimes
3 = Often
4 = Frequently

THOUGHTS

1. Awfulizing (fantasizing the worst possible outcome) 0 1 2 3 4
2. Blaming myself 0 1 2 3 4
3. Blaming others 0 1 2 3 4
4. Difficulty concentrating 0 1 2 3 4
5. Holding grudges 0 1 2 3 4
6. Thinking and rethinking the same situation 0 1 2 3 4
7. Wishing I could “turn my mind off” 0 1 2 3 4
8. Constantly criticizing other people or situations 0 1 2 3 4
9. Worrying 0 1 2 3 4
10. Thinking something is wrong with my mind 0 1 2 3 4
11. Needing to be right 0 1 2 3 4
12. Feeling out of control 0 1 2 3 4

EMOTIONS

1. Afraid of specific places or circumstances 0 1 2 3 4
2. Feeling like a victim 0 1 2 3 4
3. Anxious 0 1 2 3 4
4. Blue 0 1 2 3 4
5. Lonely 0 1 2 3 4
6. Irritable 0 1 2 3 4
7. Wanting to throw things or hit people 0 1 2 3 4
8. Guilty 0 1 2 3 4
9. Feeling unfriendly 0 1 2 3 4
10. Uptight 0 1 2 3 4
11. Hopeless about the future 0 1 2 3 4
12. Wanting to “pull the covers over my head” 0 1 2 3 4
13. Feeling that other people don’t like me 0 1 2 3 4
14. Upset over criticism 0 1 2 3 4

BEHAVIORS

1. Nail or cuticle biting 0 1 2 3 4
2. Using tobacco in any form 0 1 2 3 4
3. Taking tranquilizers or “street” drugs to change mood 0 1 2 3 4
4. Drinking alcoholic beverages 0 1 2 3 4
5. Chewing gum or sucking candies 0 1 2 3 4
6. Talking a lot 0 1 2 3 4
7. Crying a lot 0 1 2 3 4
8. Sleeping problems (too much or too little) 0 1 2 3 4
9. Eating problems (too much or too little) 0 1 2 3 4
10. Trouble communicating 0 1 2 3 4
11. Avoiding responsibilities 0 1 2 3 4
12. Too much caffeine 0 1 2 3 4

Copyright © Jane Leserman, Ph.D., and Claudia Dorrington, 1986.

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