Four-Dimensional Symptom Questionnaire (4DSQ)


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.


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.



PDF iconEnglish version 4DSQPDF iconScorings instructions for the 4DSQ

Web link to tool: 

Four-Dimensional Symptom Questionnaire (4DSQ)

Other Information: 

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

Digital Object Identifier (DOI):


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