Several of the following questions refer to panic attacks and 'limited symptom attacks'. For this questionnaire, a panic attack is defined as "A sudden rush of fear or discomfort" accompanied by at least four of the symptoms listed below. To qualify as 'a sudden rush' the symptoms must peak within 10 minutes. Episodes like panic attacks but having fewer than four of the listed symptoms are called 'limited symptom attacks'.
Symptoms:
Rapid or pounding heartbeat
Sweating
Trembling or shaking
Breathlessness
Feeling of choking
Chest pain or discomfort
Nausea
Dizziness or faintness
Feelings of unreality
Numbness or tingling
Chills or hot flushes
Fear of losing control or going crazy
Fear of dying
How many panic and limited symptom attacks did you have during the week?
Please select your answer
No panic or limited symptom episodes
Mild: No full panic attacks and no more than one limited symptom attack per day
Moderate: One or two full panic attacks and/or multiple limited symptom attacks per day
Severe: More than two full attacks but not more than one per day on average
Extreme: Full panic attacks occurred more than once a day, more days than not
If you had any panic attacks during the past week, how distressing (uncomfortable, frightening) were they while they were happening?
Please select your answer
Not at all distressing, or no panic or limited symptom attacks during the past week
Mildly distressing (not too intense)
Moderately distressing (intense, but still manageable)
Severely distressing (very intense)
Extremely distressing (extreme distress during all attacks)
During the past week, how much have you worried or felt anxious about when your next panic attack would occur or about fears related to the attacks?
Please select your answer
Not at all
Occasionally or only mildly
Frequently or moderately
Very often or to a very disturbing degree
Nearly constantly and to a disabling extent
During the past week were there any places or situations you avoided or felt afraid of because of fear of having a panic attack?
Please select your answer
None: No fear or avoidance
Mild: Occasional fear and/or avoidance but I could usually confront or endure the situation. There was little or no modification of my lifestyle due to this.
Moderate: Noticeable fear and/or avoidance but still manageable. I avoided some situations, but I could confront them with a companion. There was some modification of my lifestyle because of this, but my overall function was not impaired.
Severe: Extensive avoidance. Substantial modification of my lifestyle was required to accommodate the avoidance making it difficult to manage usual activities.
Extreme: Pervasive disabling fear and/or avoidance. Extensive modification in my lifestyle was required such that important tasks were not performed.
During the past week, were there any activities that you avoided or felt afraid of because they caused physical sensations like those you feel during panic attacks or that you were afraid might trigger a panic attack?
Please select your answer
No fear or avoidance of situations because of distressing physical sensations
Mild: Occasional fear and/or avoidance, but usually I could confront or endure with little distress those activities that cause physical sensations. There was little modification of my lifestyle due to this.
Moderate: Noticeable avoidance but still manageable. There was definite, but limited, modification of my lifestyle such that my overall functioning was not impaired.
Severe: Extensive avoidance. There was substantial modification of my lifestyle or interference in my functioning.
Extreme: Pervasive and disabling avoidance. There was extensive modification in my lifestyle due to this such that important tasks or activities were not performed.
During the past week, how much did the above symptoms altogether interfere with your ability to work or carry out your responsibilities at home?
Please select your answer
No interference with work or home responsibilities
Slight interference with work or home responsibilities, but I could do nearly everything I could if I didn't have these problems
Significant interference with work or home responsibilities, but I could manage to do the things I needed to do
Substantial impairment in work or home responsibilities; there were many important things I couldn't do because of these problems
Extreme, incapacitating impairment such that I was essentially unable to manage any work or home responsibilities
During the past week, how much did panic and limited symptom attacks or worry about attacks interfere with your social life?
Please select your answer
No interference
Slight interference with social activities, but I could do nearly everything I could if I didn't have these problems
Significant interference with social activities but I could manage to do most things if I made the effort
Substantial impairment in social activities. There are many social things I couldn't do because of these problems
Extreme, incapacitating impairment, such that there was hardly anything social I could do
