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First, we shall describe the 4DSQ and its conceptual background. The 4DSQ is a self-report questionnaire comprising 50 items distributed over four scales.The items are worded as questions similar to those that can be asked in everyday primary care practice. For example, item 26 reads "During the past week, did you feel easily irritated? The 4DSQ does not contain any positive affect questions, nor any other "reversed" worded questions. Regarding the construct validity, the 4DSQ scales appeared to have considerable inter-correlations (r = 0.35-0.71). 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).Dutch general practitioners (GPs) use the label "nervous breakdown" (NB, or "overstressed"/"overburdened", in Dutch "overspanning") as a proper diagnosis to denote a syndrome that is associated with overwhelming life stress to the extent that the patient cannot cope anymore.In our study, it appeared that NB patients typically showed a syndrome of non-specific symptoms that we have called "distress". The associations with other questionnaires were assessed with Pearson correlations and regression analyses. The factorial structure of the 4DSQ was assessed through confirmatory factor analysis (CFA).

The 4DSQ is free for non-commercial use in health care and research and it is available as a Dutch and an English version.

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.

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

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

However, severe distress states (as in NB) force a patient to give up and withdraw from major social roles, especially the occupational role.