CODE-UD in psychiatric education.
Morra & Ban
PATIENT SELF-ASSESSMENT FORM
Mark “True” or “False” to the following statements as they apply to you at the time that you complete the questionnaire. In case that you cannot decide or that you don’t know the answer please mark “False.” Mark each question before moving to the next.
BEFORE RETURNING THE QUESTIONNAIRE, ALL STATEMENTS SHOULD BE MARKED EITHER TRUE OR FALSE
2. I don’t have enough will to do anything
True____ False____
3. I have been depressed at least for 4 weeks
True____ False____
4. I have aches and pains which cannot be attributed to medical illness or trauma
True____ False____
5. My depression started suddenly It’s time of onset can be clearly defined and
determined within a specific 2-week period
True____ False____
6. I have rapid and extreme changes in my mood
True____ False____
7. I have to move all the time and cannot stand still for a moment
True____ False____
8. I am so angry that I feel ready to explode
True____ False____
10. I feel tightness in my chest
True____ False____
11. I feel that I lost my ability to experience pleasure
True____ False____
13. I feel nervous and anxious
True____ False____
14. I feel so scared that something might happen that I have at least 1 of the following 7 symptoms: goose bumps, moist skin, bulging eyes, dilated pupils, vascular throbbing, tremor, rapid breathing
True____ False____
15. I don't care about anything any longer
True____ False____
17. I feel weak and tired even without doing anything
True____ False____
20. I have strange feelings in my body
True____ False____
21. I have been depressed for less than 2 weeks
True____ False____
23. I just gave birth to a baby
True____ False____
24. I spend much more time in bed than before
True____ False____
25. I am complaining all the time
True____ False____
26. I can't stop carrying out some of my senseless thoughts
True____ False____
28. I am a conscientious, responsible and reliable person
True____ False____
29. I feel that my emotions are limited to one or a few feeling(s)
True____ False____
30. I feel ill, but I know that I don't have a physical illness
True____ False____
31. I have a tendency to be overcritical and an inclination to judge others too harshly
True____ False____
32. I lost my appetite and eat less than before
True____ False____
33. I have less desire for sex than before
True____ False____
34. I have been talking less than before
True____ False____
36. I was diagnosed with delusional disorder
True____ False____
38. I have beliefs which people around me think are false
True____ False____
39. I believe that my world has been destroyed and no one from my family is left alive
True____ False____
40. I feel strange, changed, unreal and unidentifiable
True____ False____
41. I feel depressed and sad
True____ False____
42. I had just delivered a baby when my current depression began
True____ False____
43. My depression started within 2 months that someone dear to me passed away
True____ False____
44. My depression started within 3 months after that I was diagnosed with a medical illness
True____ False____
45. In the month my current depression started I was taking at least one of the following drugs: cimetidine, clonidine, corticosteroids, cytotoxic agents, guanethidine, oral contraceptives, methyldopa, propranolol, reserpine
True____ False____
46. My depression started within 1 month after I was diagnosed with a neurological illness
True____ False____
47. My depression started within 3 months after I was diagnosed with one of the following illnesses: anxiety disorder, dissociative disorder, factitious disorder, somatoform disorder
True____ False____
48. My depression started within 3 months after I was diagnosed with one of the following illnesses: schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, shared psychotic disorder
True____ False____
49. My depression started within 3 months after a very emotionally painful event occurred in my life
True____ False____
50. In the month before my current depression started I was taking at least one of the following: alcohol in excess, amphetamines, cannabis, cocaine, hallucinogens, inhalants, ketamine, opioids, phencyclidine and related drugs and/or sympathomimetics
True____ False____
51. I have nothing good in my life, I have no happy memories and I have nothing to look for in the future
True____ False____
52. I feel that the world around me has changed and become strange and unreal
True____ False____
53. I wish I was dead
True____ False____
54. I am displeased with myself and with my current situation
True____ False____
55. I have problems concentrating
True____ False____
56. I awake already exhausted in the mornings
True____ False____
57. The severity of my depression is different at different times of the day
True____ False____
58. I keep on complaining about the same things
True____ False____
59. I have indigestion with belching, nausea and vomiting
True____ False____
60. I feel bitter, resentful and grumpy
True____ False____
61. Since I was diagnosed with dysthymia I have never felt well again
True____ False____
62. I have difficulty falling asleep at night
True____ False____
63. I was younger than 22 when I had to see a doctor because of my depression
True____ False____
64. I was diagnosed with epilepsy
True____ False____
65. My appetite has increased and I eat more than before
True____ False____
66. I have been depressed for longer than 6 months, but less than 2 years
True____ False____
68. I feel that I am physically controlled by outside forces
True____ False____
69. I feel that I am losing control
True____ False____
70. I feel overwhelmed with my problems
True____ False____
71. I feel completely empty
True____ False____
72. I feel that I am unable to manage my affairs on my own
True____ False____
73. I feel that nothing in the future could improve my situation
True____ False____
74. I feel inferior to others
True____ False____
75. I feel that I cannot experience emotions any longer
True____ False____
76. I have lost my vitality and I am less lively and vigorous
True____ False____
77. I feel unlucky and unfortunate
True____ False____
78. I feel that I am good for nothing
True____ False____
79. I feel guilty about things I have or have not done, but should have done
True____ False____
80. I feel that I am losing everything I have and poverty is inevitable
True____ False____
81. I am a woman
True____ False____
82. This is my first depressive episode for which I am seeing a physician
True____ False____
83. I have had short, less than 2 weeks duration, depressive episodes for at least a year
True____ False____
84. I have always completely recovered from my depression
True____ False____
85. I have problems with my bowels and I have at least one of the following symptoms: abdominal pain, abdominal discomfort, bloating, flatulence, constipation and diarrhea
True____ False____
86. I have a family history of mood disorder
True____ False____
87. I have a family history of mental illness, but not of mood disorder
True____ False____
88. At least 1 of the following applies to me: I hear voices that others cannot hear; I see things others cannot see; I smell things others cannot smell; and I feel like I am being touched when no one is around.
True____ False____
91. I am theatrical and have a tendency to exaggerate my problems
True____ False____
92. I killed or tried to kill someone recently
True____ False____
93. I have recurrent thoughts of killing someone
True____ False____
96. I am hostile, unfriendly to people
True____ False____
97. I have been sleeping more than usual lately
True____ False____
99. I am very concerned about having a serious physical illness
True____ False____
100. In the past I have had one or more episode(s) with elevated or irritable mood which affected my judgment to the extent that I was doing things I would not do otherwise
True____ False____
101. I was diagnosed with hysteria
True____ False____
102. I pick up cues which indicate to me that people are observing me and/or are talking about matters related to me
True____ False____
104. I act and talk without considering the possible consequences of what I am doing and saying
True____ False____
105. I cannot cope with my family and with my responsibilities at home
True____ False____
106. I cannot cope with my colleagues and with my responsibilities at work
True____ False____
108. I have had difficulties at work and with people all through my life
True____ False____
109. My emotional responses are often inappropriate
True____ False____
111. I have difficulty in making decisions
True____ False____
112. I feel that there is an external force physically interfering with the flow of my
thoughts that I cannot remove however hard I try
True____ False____
116. I am irritable, I get annoyed by trivial matters
True____ False____
117. I don’t have the energy to start with any new activity
True____ False____
118. All my difficulties are real and they have nothing to do with my mood state
True____ False____
119. I have lost interest in everything
True____ False____
120. I have no joy in my life
True____ False____
121. I have no play in my life
True____ False____
122. I wake up earlier in the mornings than before
True____ False____
123. I was at least 45 years old when I became so depressed that I had to see a doctor
True____ False____
124. I feel my arms and legs are heavy
True____ False____
125. I have been continuously depressed all my life
True____ False____
126. I have been depressed longer than 2 weeks, but less than 6 months currently
True____ False____
127. I have lost my desire to live
True____ False____
128. Someone dear to me passed away recently
True____ False____
129. I had one or more episode(s) with an elevated or irritable mood that affected my judgment to the extent that I had to be hospitalized
True____ False____
130. I was diagnosed with a non-psychiatric and non-neurological medical illness
True____ False____
133. I wake up many times during the night
True____ False____
134. I have been depressed currently at least for 2 weeks
True____ False____
136. I despise people and hate mankind
True____ False____
138. I have been treated with one or more of the following drugs: cimetidine, clonidine, corticosteroids, cytotoxic agents, guanethidine, oral contraceptives, methyldopa, propranolol, reserpine
True____ False____
139. I am restless
True____ False____
140. I move slower than before
True____ False____
141. My symptoms keep changing
True____ False____
143. I was diagnosed with a neurological illness
True____ False____
144. I believe that I don't exist
True____ False____
146. I was diagnosed with one of the following illnesses: anxiety disorder, somatoform disorder, factitious disorder, dissociative disorder
True____ False____
147. I was diagnosed with one of the following illnesses: schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, shared psychotic disorder
True____ False____
149. I am a perfectionist and cannot tolerate uncertainties in my life
True____ False____
150. I am bothered by persistently recurring senseless thoughts which I cannot ignore however hard I try
True____ False____
151. I have had panic attacks
True____ False____
152. I am argumentative and hard to please
True____ False____
153. I have been depressed for less than 6 months
True____ False____
154. I feel befuddled by events, and cannot figure out what is going on
True____ False____
155. I am a pessimist; I see the negative side of everything
True____ False____
156. In certain situations and in the presence of certain objects I am overcome by fear that, even if I know that it is unwarranted, is so overwhelming that I try to avoid the triggering situations and objects
True____ False____
157. I recently had an emotionally painful event in my life
True____ False____
158. Almost every month I am depressed before my menstruation starts
True____ False____
159. I have been depressed for at least 2 years
True____ False____
160. If something good or bad happens to me my mood changes
True____ False____
160. If something good or bad happens to me my mood changes
True____ False____
161. I had to see a doctor before because another depressive episode
True____ False____
163. I am always afraid of being rejected
True____ False____
164. My depression responded favorably to medication or electroconvulsive treatment
True____ False____
166. My thinking is restricted to a handful of themes and I have difficulty switching from one topic to another
True____ False____
169. My thinking is slow and when I talk there are increasing delays
True____ False____
170. I am endlessly preoccupied with thoughts of unpleasant events in my past
True____ False____
171. I was diagnosed with schizophrenia
True____ False____
172. I am a transvestite
True____ False____
173. I become depressed every year in the same season
True____ False____
174. I cannot stop thinking about myself
True____ False____
175. I accuse and denigrate myself
True____ False____
176. I feel sorry for myself
True____ False____
179. I have been depressed for less than 1 week
True____ False____
190. The beginning of my depression was gradual; it’s time of onset can be approximated within a specific 3-month period but not clearly defined within a 2-week period
True____ False____
191. I have used recurrently one or more of the following: alcohol in excess, amphetamines, cannabis, cocaine, hallucinogens, inhalants, ketamine, opioids, phencyclidine and related drugs and/or sympathomimetics
True____ False____
192. I have been depressed less than 2 months
True____ False____
193. I have tried to kill myself
True____ False____
194. I have frequent thoughts of killing myself
True____ False____
197. I believe in magic and the supernatural
True____ False____
200. I feel suspicious and distrust people
True____ False____
202. I cry easily and frequently
True____ False____
203. I feel tense and unable to relax
True____ False____
204. People know what I think; everybody knows what goes on in my head
True____ False____
205. People have introduced thoughts into my head which are not mine
True____ False____
206. People have removed thoughts from my head
True____ False____
207. Time passes slowly than before
True____ False____
208. I have been depressed for less than 1 month
True____ False____
209. I cannot understand or explain why I am depressed
True____ False____
210. I cannot understand or explain why I am so bitter
True____ False____
212. I have one or more of the following symptoms: dry mouth, excessive perspiration, hyperventilation, pounding heart
True____ False____
214. I have put on at least 5% of my original weight without dieting
True____ False____
215. I have lost at least 5% of my original weight, without dieting
True____ False____
216. I have withdrawn from people
True____ False____
217. I feel worse in the evenings than in the mornings
True____ False____
218. I feel worse in the mornings than in the evenings
True____ False____