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The 4DSQ scales correlated with most other questionnaires measuring corresponding constructs.

Characteristic distress symptoms are worry, irritability, tension, listlessness, poor concentration, sleeping problems and demoralisation.

Mild distress states, which do not interfere much with normal social functioning, can be considered to be part of normal daily life.

The aim of this paper is to investigate the 4DSQ's validity.

Validity refers to the degree to which an instrument measures what it purports to measure.

Conclusion: The 4DSQ seems to be a valid self-report questionnaire to measure distress, depression, anxiety and somatization in primary care patients.

However, the 4DSQ Distress scale appeared to correlate with some other depression scales more than the 4DSQ Depression scale. life events, psychosocial problems, and work stress) were mainly associated with Distress, while Distress, in turn, was mainly associated with psychosocial dysfunctioning, including sick leave. Results: Regarding criterion validity, the Distress scale was associated with any psychosocial diagnosis (area under the ROC curve [AUC] 0.79), the Depression scale was associated with major depression (AUC = 0.83), the Anxiety scale was associated with anxiety disorder (AUC = 0.66), and the Somatization scale was associated with the GPs' suspicion of somatization (AUC = 0.65). The associations with other questionnaires were assessed with Pearson correlations and regression analyses.However, severe distress states (as in NB) force a patient to give up and withdraw from major social roles, especially the occupational role.We conceptualize distress as the direct manifestation of the effort people must exert to maintain their psychosocial homeostasis and social functioning when confronted with taxing life stress.The 4DSQ is free for non-commercial use in health care and research and it is available as a Dutch and an English version.