Four-Dimensional Symptom Questionnaire (4DSQ)


Many health care problems in primary care are stress-related (distress) and do not represent true psychiatric disorder (irrespective of whether DSM-IV criteria for depressive or anxiety disorders are fulfilled). Indiscriminate application of DSM-IV criteria in the primary care setting produces many false positive diagnoses confusing patients and misleading professionals.
In health care practice the 4DSQ can be used to:
– help patients acknowledge mental health issues when presenting with physical complaints,
– assess the overall severity of the mental health problems,
– detect depressive and anxiety disorders severe enough to require specific treatment (antidepressants or cognitive behavioral therapy),
– monitor patients’ progress under treatment.


The 4DSQ has been extensively tested for reliability and validity. Reliability is high (coefficients generally >.80). Factorial, critirion and concurrant validity has been confirmed.

Author of Tool:

Berend Terluin

Key references:

Terluin B, Van Rhenen W, Schaufeli WB, De Haan M. The Four-Dimensional Symptom Questionnaire (4DSQ): measuring distress and other mental health problems in a working population. Work and Stress 2004; 18(3): 187-207.

Terluin B, Van Marwijk HWJ, Adèr HJ, De Vet HCW, Penninx BWJH, Hermens MLM, Van Boeijen CA, Van Balkom AJLM, Van der Klink JJL, Stalman WAB. The Four-Dimensional Symptom Questionnaire (4DSQ): a validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization. BMC Psychiatry 2006; 6:34.

Terluin B, Brouwers EPM, van Marwijk HWJ, Verhaak PFM, van der Horst HE. Detecting depressive and anxiety disorders in distressed patients in primary care; comparative diagnostic accuracy of the Four-Dimensional Symptom Questionnaire (4DSQ) and the Hospital Anxiety and Depression Scale (HADS). BMC Fam Pract 2009; 10:58.

Primary use / Purpose:

The 4DSQ is a self-report questionnaire to assess distress, depression, anxiety and somatization. It is mainly used in primary care. The 4DSQ helps to differentiate between normal distress and psychiatric disorder.

Other Information:

The 4DSQ is free for non-commercial use. Available language versions: English, Dutch, French, German, Polish, Turkish

Four-Dimensional Symptom Questionnaire (4DSQ)

  • no
  • sometimes
  • regularly
  • often very often or constantly

During the past week, did you suffer from:

  • 1. dizziness or feeling light-headed?
  • 2. painful muscles?
  • 3. fainting?
  • 4. neck pain?
  • 5. back pain?
  • 6. excessive sweating?
  • 7. palpitations?
  • 8. headache?
  • 9. a bloated feeling in the abdomen?
  • 10. blurred vision or spots in front of your eyes?
  • 11. shortness of breath?
  • 12. nausea or an upset stomach?

During the past week, did you suffer from:

  • 13. pain in the abdomen or stomach area?
  • 14. tingling in the fingers?
  • 15. pressure or a tight feeling in the chest?
  • 16. pain in the chest?
  • 17. feeling down or depressed?
  • 18. sudden fright for no reason?
  • 19. worry?
  • 20. disturbed sleep?
  • 21. a vague feeling of fear?
  • 22. lack of energy?
  • 23. trembling when with other people?
  • 24. anxiety or panic attacks?

During the past week, did you feel:

  • 25. tense?
  • 26. easily irritated?
  • 27. frightened?

During the past week, did you feel:

  • 28. that everything is meaningless?
  • 29. that you just can’t do anything anymore?
  • 30. that life is not worth while?
  • 31. that you can no longer take any interest in the people and things around you?
  • 32. that you can’t cope anymore?
  • 33. that you would be better off if you were dead?
  • 34. that you can’t enjoy anything anymore?
  • 35. that there is no escape from your situation?
  • 36. that you can’t face it anymore?

During the past week, did you:

  • 37. no longer feel like doing anything?
  • 38. have difficulty in thinking clearly?
  • 39. have difficulty in getting to sleep?
  • 40. have any fear of going out of the house alone?

During the past week:

  • 41. did you easily become emotional?
  • 42. were you afraid of anything when there was really no need for you to be afraid? (for instance animals, heights, small rooms)
  • 43. were you afraid to travel on buses, streetcars/ trams, subways or trains?
  • 44. were you afraid of becoming embarrassed when with other people?
  • 45. did you ever feel as if you were being threatened by unknown danger?
  • 46. did you ever think “I wish I was dead”?
  • 47. did you ever have fleeting images of any upsetting event(s) that you have experienced?
  • 48. did you ever have to do your best to put aside thoughts about any upsetting event(s)?
  • 49. did you have to avoid certain places because they frightened you?
  • 50. did you have to repeat some actions a number of times before you could do something else?

4DSQ scoring form

  • ‘no’ = score 0 ‘sometimes’ = score 1
  • ‘regularly’ or more often = score 2

Distress Depression Anxiety Somatisation

  • Interpretation:
  • moderately elevated: > 10 > 2 > 8 > 10
  • strongly elevated: > 20 > 5 > 12 > 20