The purpose of the study was to develop and validate a self-report scale to measure

depression in both clinical and non-clinical Pakistanipopulations. The 72 items

obtained from university students were judged for their relevance to depression
by psychiatrists and clinical psychologists. An approximate 50% consensus
among judges was taken as the selection criterion. The 36 items so obtained were
split into two equivalent halves and tested on clinical as well as non-clinical
populations. The split half reliabilities of the scale with Spearman-Brown correc-
tion were r 0. 79 and r 0.84 for the clinical and r 0.80 and r 0.89 for the
= = = =

non-clinical samples respectively. The Alpha coefficients for the clinical and
non-clinical samples were 0.91 and 0.89 respectively. The scale correlated sig-
nificantly with Zung’s Depression Scale, r 0.55 (p < .001) and psychiatrists’ rat-
=

ings of depression r 0.40 (p < .05). The scale showed a significant correlation
=

with subjective mood ratings for the clinical group r 0.64 (p < . .001) as com-
=

pared to the non-clinical group r = 0.14 (p: n.s.). The scale also demonstrated
high sensitivity and specificity. The percentiles and cut-off scores for the clinical
as well as non-clinical groups have been determined.

Siddiqui-Shah Depression
Scale (SSDS): Development
and Validation

SALMA SIDDIQUI
Quaid-i-Azam University
Islamabad

SYED ASHIQ ALI SHAH*

International Islamic University
Malaysia

The psychological concept of depression has been variously

described as having the blues, feeling sad, guilty, hopeless, help-

* Address all correspondence to Dr Syed Ashiq Ali Shah, International Islamic

University, Selangor, Malaysia.
246 /

less and melancholy and as reacting to the grief of losing some

loved object. It is also described as a feeling state or symptom, a
syndrome or reaction, a characteristic or lifestyle, and/or an ill-
ness (Schuyler, 1974). Some researchers have adopted an opera-
tional approach to the definition and subsequent classification of
depression (Depue & Monroe, 1978; Spitzer, Sheehy, & Endicott,
1977). The most prevalent definition is that of a dysphoric
(chronic) feeling of illness and discontented mood and/or a per-
vasive loss of interest which is characterised by certain symptoms
(Spitzer, Sheehy, & Endicott, 1977). These and other similar defi-
nitions of depression are the result of work on the conceptualisa-
tion of depression and the development of instruments for its
assessment primarily carried out in the West. Assuming the uni-
versality of psychological disorders, such as depression, these in-
struments can be used in other cultures, which have a different
outlook than the Western one. However, one cannot ignore er-
rors in assessment stemming from the total disregard for local
values and norms. One way of overcoming such errors is to
adapt and standardise the instrument before using it in cultures
other than where it was developed. Such attempts, too, have
their limitation as cultures differ not only with respect to their
norms and values but also in terms of their lexical categories for
emotions (Russell, 1991). Emotional experiences and their ex-
pressions are determined to a great extent by the words available
in a particular language. The basic categories of emotion may be
pan-cultural but the expression varies with the degree of permis-
siveness in a culture along with the available distinct lexical cate-
gories. For instance, Muslim societies impose religious restrictions
on the expression of sexual desires. The lack of sexual experi-

ences, therefore, in the case of unmarried persons, especially

women, renders the items attempting to measure a decrease in
libido or sexual feelings as an indicator of depression, irrelevant.
Cross-cultural research has yet to emphasise the peculiarity and
complexity of cultural meanings associated with psychological
disorders by lay persons. There appears overwhelming concern
to adapt Western models :of psychological disorders while dis-
regarding the more local nuances of emotional and other experi-
ences. Such an approach poses both methodological problems as
well as problems of validity due to difficulties in linguistic and con-
ceptual translation in representing illness episodes as meaningful
 247

social Therefore, to make the analysis and conceptualisa-

events.
tion of a disorder
more universal, credence must be given to the

conceptual organisation of cultural knowledge of that disorder.

That is, to discover how a lay person talks about his illness in a
social as well as a personal context. This emphasis becomes criti-
cal with reference to the assessment of depression. Despite its
universality, the manifestation of depression may vary across dif-
ferent cultures as the expression of emotion is determined both
by the language and conceptual organisation of the disorder. For
instance, psychological and mental symptoms are reported to be
less prominent (and/or less differentiated) in certain non-Western
societies than somatic symptoms (Marsella & White, 1984). In
non-Western cultures, there is a tendency among depressives to
somatise their illness (Nijdam, 1986; Sethi, 1986) either due to il-
literacy or lack of awareness as well as lower acceptability of psy-
chological disorders in these cultures (Shah, 1993). In addition to
this, a difference in value orientation may determine specific pre-
dictors of depression as well (Aldwin & Greenberger, 1987). For
instance, due to differences in intrinsic cultural values Japanese
university students obtained higher scores on self-report of de-
pression as compared to their American counterparts (Baron &
Matsuyama, 1987). With regard to traditional Muslim societies
one significant difference is in terms of suicide ideation, which is

generally regarded as a taboo (Shah, 1993) and, therefore, may

not be an appropriate measure of depression.
Moreover, the suicidal ideation of depressives may have no
correspondence with the actual proportion of suicides commit-
ted (Venkoba Rao, 1978) which may be a mere desire to be dead.
Such differences in value structure across cultures and the docu-
mentation of culture specific contents of emotion have high-
lighted the need to develop indigenous norms and culture
relevant operational definitions of psychopathology.
The present study was carried out to realise this need in the
context of Pakistani culture, which is rather unique in its compo-
sition. The complex intermingling of religious dictates and social
values influences the individual’s attitude and thought pattern to-
ward distressing situations. Often religious considerations come
into conflict with the more pressing social values. In a culture
where long-standing values are giving way to more materialistic
pursuits, the class structure has been undergoing rapid change.
248/

The majority of women still perform their traditional roles, fend-

ing and feeding the family, though they are aware of the chang-
ing society through television and other media. This often results
in conflicts and helplessness. The conflicting value structure
leads to emotional distress but its expression is handicapped be::
cause of low literacy levels, authoritarian family set-up and
scarce psychiatric help. In Pakistani villages, men and women
still seek the services of faith healers when they are depressed
fearing it to be a possession by evil spirits. Rapid urbanisation
and the non-availability of basic amenities in villages lead to a
widespread feeling of deprivation and frustration in their effort to
improve their lot which in turn gives rise to a feeling of lack of
control. The authoritarian structure of society inculcates an atti-
tude of self-blame. In such a cultural context, if an instrument
measuring depression, developed in the West, is administered, it
is possible that individuals may obtain spuriously higher scores,
whereas many cultural peculiarities may not be assessed. There-
fore, in the absence of local empirical data the development of a
scale which is based upon the experiential definition of depres-
sion is relevant.

Method

The development of an indigenous depression scale was car-

ried out in three phases, comprising generation of items for the
scale, assessment of the relevance of items, and estimation of its
reliability and validity. Three different samples were taken for
each phase according to the specific purpose entailed.

Phase I

The purpose of phase I was to generate items’for the depres-

sion scale.

Sample. The sample consisted of 80 (40 males and 40 females)

students from the University of Punjab, Lahore and Quaid-i-Azam
University, Islamabad. Their ages ranged from 20 to 25 years and
 249

they were all enrolled in postgraduate courses. The sample could

be regarded as representative of university students in Pakistan
as the respondents belonged to different geographical regions of
the country.

Procedure. The subjects were administered a semi-structured

questionnaire, which consisted of three steps.

Subjects were given instructions to recall and enlist those situ-

atians when they felt depressed. They could list as many situ-
ations they believed to be relevant.
When the subjects had completed listing the situations the
researcher, citing specific examples, explained to them the re-
lation of cognition, feelings and behaviour to a depressing
situation.
They were then asked to describe their cognitions, feelings ’

and behaviour regarding the situations listed earlier.

Individual protocols (comprising situations, cognitions, feel-

ings and behaviour associated with them) were compiled and
statements were drawn from them. This resulted in 72 constructs
pertaining depression. These were then selected for the sec-
to
ond phase of the study. The statements extracted from the proto-
cols helped generate the item pool for the selection of items for
the scale. Most of the subjects expressed themselves in Urdu,
therefore, the remaining protocols were translated from English
to Urdu. Excluding the repetitive statements, 72 of the most rep-
resentative constructs were selected which pertained to either
cognitions, feelings or behaviour related to depression. Of these,
48 constructs were, related to cognitions, 16 described feelings,
and 8 constructs were related to behaviour, more specifically to
somatic complaints. In phase II of the study these 72 constructs
were ranked to determine the intensity of each item with regard
to depression.

Phase II

As the items for the scale were generated by the student sam-
ple,it was considered necessary to estimate the intensity of the
 250/

items with regard to their relevance to the clinically depressed

; group. Therefore, consensus among the judges was obtained to
select the most representative items.

Sample. A sample of 42 psychiatrists and clinical psychologists

judged the items to assess their relevance. These judges had
practical clinical experience and were working in different psy-
chiatric settings in hospitals and other institutions in Rawalpindi,
Lahore and Peshawar.

Procedure. Judges were asked to rate the 72 items in the light of

their clinical experience, keeping in mind the actual incidence of
these cognitions, feelings and behaviours in the clinical sample.
They were asked to rate the items on a 3-point scale, where &dquo;1&dquo;
&dquo;

denoted normal sadness, &dquo;2&dquo; mild depression, and &dquo;3&dquo; severe de-
pression. If an item appeared more characteristic of normal sad-
ness, it was rated as &dquo;1&dquo;, if it was found to be reported more
frequently by mildly depressed persons, the item was given a rat-
ing of &dquo;2&dquo;, and if the item was considered as characteristic of se-
verely depressed patients, it was rated as &dquo;3&dquo;. This helped
determine the classification of items as characteristic of normal
sadness, mild depression or severe depression. On the basis of
this pilot study, the items for the final scale were selected. Fre-
quencies and percentages were obtained forwach item, which in-
dicated the judges’ consensus for assigning items to one of the
three categories (see Table 1). Items which had above 50% con-
sensus among the judges were selected for the final scale. How-
ever, in the categories of normal sadness and &dquo;severe depression&dquo;
the criterion had to be lowered to 47% for a few items so as to
have an equal number of items in each category. In all, 36 items
were retained, 12 in each category, that is, normal sadness, mild

depression, and severe depression.

Phase III

In phaseIII of the study the validity and reliability of the scale

were determined for the psychiatric and non-psychiatric groups.

Sample. The non-clinical sample for this phase of the study

comprised 206 male and female university students from five
universities in major cities of the country. They were: Quaid-i-
 251

Azam University, Islamabad; Punjab University, Lahore; Karachi

University, Karachi; University of Peshawar, Peshawar; and
Balochistan University, Quetta. An attempt was made to ensure
approximate representation of the non-clinical group. The sub-
jectswere enrolled in postgraduate courses and their ages were
in the range of 22 to 28 years.
The clinical sample for this phase, which comprised 60 patients
(23 male and 37 female), was selected from two major hospitals
of Rawalpindi and Islamabad. They were largely tested at the
psychiatric outpatient department of the hospitals, though a few
of them were contacted in the psychiatric wards as well.

Instruments. The non-clinical group was assess~d :on the fol-

lowing measures:

A self-rating 7-point mood scale (the subjects judged their cur-

rent mood by selecting any number from -3 to +3 on this scale;
+3 indicated &dquo;very pleasant&dquo; and -3 &dquo;very unpleasant&dquo;; ’zero’
indicated a mood which is neither pleasant nor unpleasani ).
The 36 items selected from phase II of the study which were
characteristic of varying degrees of depression.
Zung’s Depression Scale (Zung, 1965), which has been de-
signed for use with the general population, is brief and can be
self-administered. Moreover, it covers affective, psychological
and somatic symptoms and has been used in cross-cultural re-
search (Marsella, 1980).
A questionnaire to elicit personal information such as age
and occupation.

The clinical group was also assessed on these instruments, with

the exception of Zung’s Depression Scale as it was in English and
hence it could not be administered to them. Instead, psychiatrists
making the referral of the patient for the study were asked to
evaluate the clinically depressed on an assessment form based
on ICD-10. There were 30 such patients in the total sample of 60
who were diagnosed by psychiatrists before being assessed on
the 36-item scale.

Procedure. The non-clinical sample was studied in smaller groups

and instructions were given after the introduction of each measure,
whereas the clinical group was studied individually in a one-to-
252,

one situation. Individuals diagnosed by psychiatrists as depressed

and capable of communication were selected for the study.

Results

The data obtained in phase III of the study provided the differ-
ential analysis of the 36-item scale between the clinical and
non-clinical groups. The clinical group had a higher mean and
SD (mean: 51.93, SD: 18.33) than the non-clinical group (mean:
27.93, SD: 12.7).

Item Analysis

Item analysis was done to determine the relationship of the in-

dividual items with the scale. The results revealed that all the
item-total correlations were significant at the 0.05 level and above.

Split-half Reliability
As the items of the scales were randomly ordered (in terms of
the relevance of the items) into two equal halves, split-half reli-

Table 1
Item-total Score Correlation for Indigenous Depression Scale

Table 1 continued
 / 253

Table 1 continued

*
p < 0.05, ** p < 0.01.

ability was computed, which indicated a high significant value of

r: 0.79, p < .001 (Spearman-Brown correction r: 0.84, p < .001) for
the clinical group and an equally high significant value of r: 0.80
(p < .001) for the non-clinical group (Spearman-Brown correc-
tion r: 0.89, p < .001).

Table 2
Correlation Coefficients for Split-half Reliability and Spearman-Brown
Correction of the Scale for Clinical and Non-clinical Groups
 254 /

Internal Consistency Reliability .

Alpha coefficient was computed to determine the internal con-

sistency of the scale. The value obtained for the clinical group
was 0.91 (p < .001) and for the non-clinical group 0.89 (p < .001).
Table 3
Internal Consistency of the Scale for Clinical and Non-clinical Groups

Construct Validity
The correlation between the scores of the non-clinical group
on the 36-item scale and Zung’s Depression Scale indicated a
value of r: 0.55 (p < .001). The scores of the clinical group were
significantly correlated with the psychiatrists’ ratings for depres-
sion (r: 0.4, p < .05). The scores of the clinical group on the scale
correlated significantly with their self-reported mood (r: -0.64, p
< .001), whereas the correlation of the scores of the non-clinical

group with their subjective mood ratings was not significant (r:
0.14, p>.05).

Table 4
Construct and Concurrent Validity of Indigenous Depression Scale
 255

Factorial Validity

Principal component analysis was performed to determine the

factor structureof the scale. The majority of items except nos 4,
5, 12 and 35 had factor loadings of 0.35 and above on the first
factor. The first factor had an eigen value of 8.4 and explained
23.3% of the total variance. All the items were positively loaded
on the first factor, which is regarded as a depression-related fac-
tor. The obtained one factor solution explaining the major pro-
portion of variance points to the unidimensionality of the scale.
All other factors had eigen values less than 2 and explained 5% or
less of the total variance.

Table 5
Eigen Values and Percentage of Variance Explained by the
Extracted Factors

Sensitivity and Specificity

Sensitivity and specificity were determined for the three differ-

ent categories of affect-normal sadness, mild depression, and
severe depression. The sensitivity of the scale, that is, correct
identification of depressives was quite high for normal sadness
and mild depression, 95% and 77% respectively, whereas it was
50% for severe depression. The specificity of the scale, that is,.correct
identification of non-depressed was 55% for normal sadness,
84% for mild depression, and 94% for severe depression. In our
opinion a 50% sensitivity of the scale was due to the inclusion of
 256

a large proportion of non-depressed in the sample and the inclu-

sion of items pertaining to normal sadness, which added to the
score of depression. Moreover, the clinical group included individu-
als with varying degrees of depression as indicated by a high SD.

Cut-off Scores
As the scale measures the frequency of the indicators of depres-
sion, the subject’s score is determined by the category of en-
dorsement of his/her responses. The frequency distribution of
the computed for both the clinical and non-clinical
score was

groups separately to determine the cut-off points for the scale.

The two frequency distributions were used to locate an optimal
cutting score that would minimise the sum of false positives and
false negatives. This procedure has been used by other re-
searchers as well (Westhuis & Thyer, 1989). A score of 26 indi-
cated that 56% of the non-clinical sample was not depressed,
whereas at the same score less than 5% were diagnosed as
non-cases in the clinical sample. Taking a score of 26 as the
lower limit and a score of 36 as the upper limit indicative of &dquo;mild
depression&dquo;, yields the first range of clinical cut-off scores: The
frequency distribution of the scores revealed that 83% of the
non-clinical group scored below 36, whereas in the clinical
group 21.7% cases were diagnosed as mildly depressed. Further,
93.7% cases of the non-clinical group scored below 49, whereas
in the clinical group this percentage was 46.71. This provides an-
other set of clinical cut-off scores ranging from 37-49, interpret-
able as &dquo;rryoderate depression&dquo;, whereas a score of 50 and above
denoted the presence of &dquo;severe depression&dquo;. The classification
of scores can further be facilitated with the help of given percen-
tile ranks for the clinical and non-clinical groups.

Discriminant Validity
A discriminant index for each cut-off score (26, 37 and 50) was
obtained by dichotomising the frequencies of false positives and
’alse negatives around each cut-off score. This resulted in 3 2 x 2
:ontingency tables (Tables 6, 7 and 8). It can be seen from Table
 / 257

Table 6
Discriminant Validity of the Sccsle for tbe Cutting Score oJ below and
above, 26 for Depressed and Non-depressed Groups

Table 7
Discriminant Validity of tbe Scale for the Cutting Score of below and
above, 37 for Depressed and Non-depressed Groups

Table 8
’

Discriminant Validity of the Scale for the Cutting Score of, below and
above, 50 for Depressed and Non-depressed Groups

6 that below the cut-off score of 26, the frequency of non-cases in

the non-clinical sample was 113, whereas 93 individuals in the
non-clinical group were classified as false positive at this cut-off
point. In comparison, only 3 cases in the clinical group were la-
belled as non-cases and 57 were diagnosed as depressives at the
same cut-off score. The phi-coefficient indicated a significantly

high discriminant validity for the cut-off score of 26 (phi: 0.42; chi
square: 46.9, df: 1, p < .0001).
It can be seen from Table 7 that below the cut-off score of 37,
the frequency of non-cases in the non-clinical sample was 173,
whereas 33 individuals in the non-clinical group were classified
as false positive at this cut-off point. In comparison, only 14 cases
in the clinical group were labelled as non-cases and 46 were
258 /

diagnosed as depressives at this cut-off score. The phi-coefficient

revealed a significantly high discriminant validity for the cut-off
score of 36 (phi: 0.55; chi square: 81.8, df: 1, p < .0001).

Further, Table 8 shows that below the cut-off score of 50, the
frequency of non-cases in the non-clinical sample was 193,
whereas 13 individuals in the non-clinical group were classified
as false positive at this cut-off point. In comparison, 30 cases of
the clinical group were labelled as non-cases and 30 were diag-
nosed as depressives at this cut-off score. The phi-coefficient
demonstrated a significantly high discriminant validity for the
cut-off score of 50 (phi: 0.48; chi square: 60.45, df: 1, p < .0001).

Discussion

The indigenously developed scale, henceforth called Sid-

diqui-Shah Depression Scale (SSDS), has been subjected to
different measures of validity. The scale has demonstrated signifi-
cantly high split-half reliability and internal consistency. It has
also shown a significant relationship with Zung’s Depression
Scale, which indicates that it is an appropriate measure of depres-
sion. The significant correlation of the scale with psychiatric
ratings reveals that the scale is sensitive to the clinical manifesta-
tions of depression. The cut-off scores with separate frequency
distribution tables for the clinical and non-clinical groups permit
evaluation of an individual’s score in a differential manner. De-
pression here is taken as a continuous construct, normally dis-
tributed in the population, therefore, the non-clinical group can
be considered an appropriate reference group for the normal
population. This assumption of continuity of depression is sub-
stantiated by the phenomenological evidence of many who feel
depressed on different occasions in their lives. However, caution
must be exercised in using the cut-off points as classifying indica-
tors. They are not to be interpreted as a precise estimate of a true
cut-off score. Such a definitive diagnostic status requires further ,.

validation studies to establish the stability of cut-off scores, which

depends heavily on the size of the sample. Therefore,- a larger
sample would ensure greater stability of the cut-off scores as
diagnostic indicators. Moreover, the scale has been designed to
 259

assess the severity of a respondent’s self-reported depression and

not to provide definitive diagnostic judgment. Therefore, cor-
roborative data from other key sources would still be needed for
a diagnostic or treatment decision. This is one kind of interpreta-

tion, which may be correct. However, the findings here suggest

(nonsignificant correlation) that in the case of normal persons
the subjective mood (which is assumed to be pleasant) has no re-
lationship with any measure of depression. In fact, one would
have expected a negative correlation but as it is not the case, then
the above interpretation may be true.
SSDS attempts to quantify and assess depression in Pakistan. As
the scale depends on the cultural interpretation of depression, it
will be useful both for a theoretical study of depression as well as
an assessment tool in the clinical set-up. A perusal of the items of
the~scale indicates that most of the items pertain to the hopeless-
ness aspect of depression (items 1, 3, 5, 9, 10, 16, and 25). This is
consistent with the prevalent conceptualisation of the depressive
disorder that views hopelessness as one of the chief components
of depression. Interpersonal conflicts with friends, parents and
other family members also constitute a significant component of
depression (items 6, 17, 24, 30, and 34) indicating that in Pakistan
significant others influence the life of an individual in a psycho-
logically significant manner. The component of guilt is mani-
fested in terms of being punished for some deed (item 10) and
prayers not being answered (item 5). This is different from the
expression of guilt as measured by depression scales developed
in the West. Guilt here is more in relation to perceived transgres-
sion of religious laws than social mores. The cognition that one’s
prayers are not answered also refers to the same where the per-
son thinks that God has stopped listening to him. Thus, in con-
trast to other scales of depression SSDS explicitly relates the
feelings of guilt to perceived or actual transgression of divine
laws emphasising the religious orientation of people in Pakistan.
Punishment has a divine connotation. Feelings of personal
worthlessness and incompetence, similar to Western features of
depression, are also reported (items 9, 15, 16, 22, 23, and 27).
The fact that no item pertaining to sex was obtained substantiates
the assumption that due to cultural restrictions in this regard such
complaints would not come up as an index of depression. Com-
plaints regarding bodily functions constitute a significant portion
260/

of the scale (items 4, 11, 21,

and 32). It is generally accepted that
depression is expressed insimilar terms more in non-Western
cultures than in Western ones (Marsella & White, 1984). Dearth
wish has also been reported (items 13 and 36). This is in contrast
with the suicidal wish generally measured by scales developed in
the West. This again may be a reflection of the religious orienta-
tion of Pakistani people as their religion, Islam, forbids suicide. It
is generally believed that in the hereafter those who commit suicide
shall be deprived of Allah’s blessings. Moreover, one who commits
suicide is believed to be going through a perpetual torture till the
day of judgment. Therefore, the depressives in the sample ver-
balise a passive wish for death desiring relief from their miseries.
Such a content that is truly indigenous would not have emerged
had any adaptation been opted for the development of the scale.
SSDS will be useful both in clinical assessment and research.
Being a measure of depression based on culture relevant expres-
sion of depression may help assess the very features missed out,
thus facilitating clinicians in making more accurate diagnosis.
Nevertheless, SSDS is in the primary stage of development. Many
more validation studies are in order to accord it the status of a
definitive diagnostic instrument. The focus in this study was on
ensuring that the items were relevant to the culture where it is be-
ing developed. Therefore, for ~quivalence of its classification
with Western standard diagnostic .categories calls for a new series
of research which may attract the attention of some future re-
searchers.

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DEPUE, R.A., & MONROE, S.M. (1978). Learned helplessness in the perspective of
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MARSELLA, A.J., & WHITE, G.M. (Eds). (1984). Cultural conceptions of mental
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English Translation of Siddiqui-Shah Depression

.
Scale (SSDS)

This questionnaire describes the thoughts and feelings of an in-

dividual. The four columns against each statement reflect the
various degrees of these thoughts and feelings. You are re-
quested to read each statement carefully and indicate how much
they apply to you with the help of given columns. For instance,
if a statement ’never’ applies to you indicate it by putting a (/)
correct sign in the first column. If the statement stands true for
you ’all the times’, put a mark in the last column. Likewise use
other columns as well.

Never Sometimes Often All the times

1. I have become very hopeless.
2. I feel myself confused.
3. I am very unfortunate.
262,

4. I have almost lost my appetite.

5. My prayers do not get answered. ’

6. I have differences with my parents.

7. People always criticise me.
8. I feel like crying aloud.
9. I cannot do anything properly.
’

10. I am being punished for my deeds.

11. My heart starts pounding suddenly.
12. Success and failure depends upon kismat (luck).
13. My life is reaching its end.
14. I am haunted by the feeling of having lost something.
15. I lack something.
16. I feel myself as worthless.
17. Others always dominate me.
18. I get anxious easily.
19. I hate my life.
20. I feel lonely.
21. My body seems tired.
22. I am a useless person.
23. I have many flaws.
24. Friends do not understand my feelings.
25. I lose heart very quickly.
26. I am incapable.
27. I am inferior to others.
28. I have lost zeal of life.
29. I detestable person.
am a

30. My friendsseem selfish to me.

31. The memories from the past make me sad.
32. My sleep is disturbed. ’

33. I am very hopeless about my future.

’

34. I do not come up to my parents’ image of an ideal child.

35. Most of the people are not trustworthy.
36. I intensely wish for death.

Salma Siddiqui is at the National Institute of Psychology, Quaid-i-Azam Univer-

sity, Islamabad, Pakistan.

Syed Ashiq Ali Shah is Associate Professor of Psychology at the International Is-
lamic University, Selangor, Malaysia. His research interests are in the areas of
culture and psychopathology.