DSM-5 Self-Rated Cross-Cutting Symptom Measure—Adult

Name:   Age:   Date:

If this questionnaire is completed by an informant, what is your relationship with the individual?

In a typical week, approximately how much time do you spend with the individual? hours/week

Instructions: The questions below ask about things that might have bothered you. For each question, select the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?

1. Little interest or pleasure in doing things?
   0; None - Not at all
   1; Slight - Rare, less than a day or two
   2; Mild - Several days
   3; Moderate - More than half the days
   4; Severe - Nearly every day
2. Feeling down, depressed, or hopeless?
   0; None – Not at all
   1; Slight – Rare, less than a day or two
   2; Mild – Several days
   3; Moderate – More than half the days
   4; Severe – Nearly every day
3. Feeling more irritated, grouchy, or angry than usual?
   0; None – Not at all
   1; Slight – Rare, less than a day or two
   2; Mild – Several days
   3; Moderate – More than half the days
   4; Severe – Nearly every day
4. Sleeping less than usual, but still have a lot of energy?
   0; None – Not at all
   1; Slight – Rare, less than a day or two
   2; Mild – Several days
   3; Moderate – More than half the days
   4; Severe – Nearly every day
5. Starting lots more projects than usual or doing more risky things than usual?
   0; None – Not at all
   1; Slight – Rare, less than a day or two
   2; Mild – Several days
   3; Moderate – More than half the days
   4; Severe – Nearly every day
6. Feeling nervous, anxious, frightened, worried, or on edge?
   0; None – Not at all
   1; Slight – Rare, less than a day or two
   2; Mild – Several days
   3; Moderate – More than half the days
   4; Severe – Nearly every day
7. Feeling panic or being frightened?
   0; None – Not at all
   1; Slight – Rare, less than a day or two
   2; Mild – Several days
   3; Moderate – More than half the days
   4; Severe – Nearly every day
8. Avoiding situations that make you anxious?
   0; None – Not at all
   1; Slight – Rare, less than a day or two
   2; Mild – Several days
   3; Moderate – More than half the days
   4; Severe – Nearly every day
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?
   0; None – Not at all
   1; Slight – Rare, less than a day or two
   2; Mild – Several days
   3; Moderate – More than half the days
   4; Severe – Nearly every day
10. Feeling that your illnesses are not being taken seriously enough?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
11. Thoughts of actually hurting yourself?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
12. Hearing things other people couldn’t hear, such as voices even when no one was around?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
14. Problems with sleep that affected your sleep quality over all?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
17. Feeling driven to perform certain behaviors or mental acts over and over again?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
19. Not knowing who you really are or what you want out of life?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
20. Not feeling close to other people or enjoying your relationships with them?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
21. Drinking at least 4 drinks of any kind of alcohol in a single day?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day
23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed ?
    0; None – Not at all
    1; Slight – Rare, less than a day or two
    2; Mild – Several days
    3; Moderate – More than half the days
    4; Severe – Nearly every day