SCID Baseline/Lifetime Data Entry Form

Transcription

1 SCID Baseline/Lifetime Data Entry Form Study of Women s Health Across the Nation SECTION A. GENERAL INFORMATION A1. RESPONDENT ID: AFFIX ID LABEL HERE A2. SWAN STUDY VISIT#: 12 A3. SCID INTERVIEW FORM VERSION: / / M M D D Y Y Y Y A4. DATA ENTRY FORM VERSION: 07/01/2010 A5. DATE INTERVIEW COMPLETED: / / M M D D Y Y Y Y A6. INTERVIEWER S INITIALS: A7. TRANSCRIBER S INITIALS: A8. RESPONDENT S DOB: / / M M D D Y Y Y Y VERIFY WITH RESPONDENT A9. INTERVIEW COMPLETED IN: RESPONDENT'S HOME...1 CLINIC/OFFICE...2 RESPONDENT'S HOME BY PROXY...3 CLINIC/OFFICE BY PROXY...4 TELEPHONE...5 TELEPHONE BY PROXY...6 Begin transcription with SCID page SWAN-12. SCID Version /01/2010 Annual Follow-up 12 SCID Baseline/Lifetime Data Entry Form

2 SCID SUMMARY SCORE SHEET NP8 NP10 SWAN-3 Diagnosis Lifetime Meets Symptomatic Prevalence DX Criteria Past Month (DX Inade- Sub- Code) quate Ab- thresh- Thresh- Info. sent old old Absent Present MOOD DISORDERS (01) Bipolar I? > 1 3 Disorder Current Episode Single manic episode 1 Manic 1 Recurrent episode 2 Mixed 2 NP9 NP11 Hypomanic 3 Major depressive 4 Unspecified 5 NP8_A Not post-partum (4 not circled) 0 Post-partum (4 circled) 1 NP15 (only if not current) In partial remission 6 In full remission 7 SWAN Core Lifetime Data Entry Form 1 07/01/2010

3 NP17 SWAN-4 Diagnosis Lifetime Meets Symptomatic Prevalence DX Criteria Past Month MOOD DISORDERS (continued) (DX Inade- Sub- Code) quate Ab- thresh- Thresh- Info. sent old old Absent Present (02) Bipolar II? > 1 3 Disorder Current Episode NP18 Hypomanic 1 NP19 Major 2 depressive NP17_A Not post-partum (4 not circled) 0 Post-partum (4 circled) 1 NP23 (only if not current) In partial remission 6 In full remission 7 NP (03) Other Bipolar? > 1 3 Disorder NP26 NP27 Cyclothymic disorder 1 Intermittent hypomanic episodes 2 Manic or hypomanic episode 3 superimposed on psychotic disorder Other 4 SWAN Core Lifetime Data Entry Form 2 07/01/2010

4 NP28 NP30 SWAN-5 Diagnosis Lifetime Meets Symptomatic Prevalence Dx Criteria Past Month MOOD DISORDERS (continued) (Dx Inade- Code) quate Ab- Thresh- Info. sent old Absent Present (04) Major Depres-? > 1 3 sive Disorder Current Episode Single episode 1 Neither melan- 0 cholic, atypical, Recurrent 2 or catatonic Melancholic 1 Atypical 2 NP29 NP31 NP28_A Not post-partum (4 not circled) 0 Post-partum (4 circled) 1 NP33 (only if not current) In partial remission 6 In full remission 7 Subthreshold recurrence 8 NP35 NP Subthreshold (05) Dysthymic? Disorder (current only) Early onset 1 Late onset SWAN Core Lifetime Data Entry Form 3 07/01/2010

5 NP37 NP38-A SWAN-6 Diagnosis Lifetime Meets Symptomatic Prevalence Dx Criteria Past Month MOOD DISORDERS (continued) Dx Inade- Code quate Ab- Thresh- Info sent old Absent Present (06) Depressive? > 1 3 Disorder Not Otherwise Spec. 0 Not Postpartum 0 1 Postpartum 1 NP38 NP38_B NP39 NP40 NP42 NP43 NP45 NP46 3a Possible premenstrual dysphoric disorder 3b 4a Minor Depressive disorder 4b 6a Other 6b (07) Mood Disorder? > 1 3 due to a General Medical Condition Specify GMC NP40A With major depressive-like episode 1 With depressive features 2 With manic features 3 With mixed features (08) Substance-In-? > 1 3 duced Mood Disorder Specify Substance NP43A With depressive-like episode 1 With manic features 2 With mixed features (9) Psychotic? > 1 3 Symptoms Primary Psychotic Symptoms (not part of Mood Disorder) NP39_A NP41 NP44 NP47 SWAN Core Lifetime Data Entry Form 4 07/01/2010

6 NP66 NP71 NP77 NP79 NP80 NP82 SWAN-7 Diagnosis Lifetime Meets Symptomatic Prevalence Dx Criteria Past Month ANXIETY DISORDERS Dx Inade- Panic Code quate Ab- Panic Thresh- Attacks Info sent Attacks old Absent Disorder Present (26) Panic? > Disorder/Attacks without Agoraphobia 1 with Agoraphobia (28) Social Phobia? > Refused Sub-threshold (31) Posttraumatic -7? > 1 3 Stress (32) Generalized? 1 3 Anxiety (current only) (33) Anxiety? > 1 3 Disorder Due To a General Medical Condition Specify GMC: NP80A with Panic Attacks 1 with Generalized Anxiety 2 Social Phobia 3 Anxiety NOS NP67 NP68 NP72 NP78 NP81 SWAN Core Lifetime Data Entry Form 5 07/01/2010

7 NP86 SWAN-8 Diagnosis Lifetime Meets Symptomatic Prevalence Dx Criteria Past Month ANXIETY DISORDERS (Continued) Dx Inade- Code quate Ab- Thresh- Info sent old Absent Present (35) Anxiety-? > 1 3 Disorder NOS NP87 SWAN Core Lifetime Data Entry Form 6 07/01/2010

8 SWAN-9 Diagnosis Lifetime Meets Symptomatic Prevalence Dx Criteria Past Month (Dx Inade- Sub- Code) quate Ab- thresh- Thresh- Info. sent old old Absent Present NP99 (44)ADJUSTMENT 1 3 DISORDER (current only) CODE SUBTYPE BASED ON PREDOMINANT SYMPTOMS NP99_A 1 WITH DEPRESSED MOOD (e.g., depressed mood, tearfulness, feelings of hopelessness) NP100 NP101_A 2 WITH ANXIETY (e.g., nervousness, worry, jitteriness, or in children, fears of separation from major attachment figures) 3 WITH MIXED ANXIETY AND DEPRESSED MOOD (e.g., a combination of depression and anxiety) ) OTHER SELF-? > 1 3 REPORTED DSM IV AXIS I DISORDER: NP100A Specify: (46) OTHER NON-? > 1 3 DMS IV AXIS I DISORDER: NP101 NP101_B SWAN Core Lifetime Data Entry Form 7 07/01/2010

9 SWAN-10 DSM-IV Axis V: Global Assessment of Functioning (GAF) Scale Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations. Indicate appropriate code for the LOWEST level of functioning during the week of POOREST functioning in past month. (Use intermediate level when appropriate, e.g., 45, 68, 72.) Note: Make a rating of 0 (zero) if inadequate information NP Superior functioning in a wide range of activities, life s problems never seem to get out of 91 hand, is sought out by others because of his or her many positive qualities. No symptoms. 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional 81 argument with family members). 80 If symptoms are present, they are transient and expectable reactions to psychosocial stress-ors (e.g., difficulty concentrating after family argument), no more than slight impairment in 71 social, occupational, or school functioning (e.g., temporarily falling behind in school or work). 70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or absences from work), but 61 generally functioning pretty well, has some meaningful interpersonal relationships. 60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, 51 conflicts with co-workers). 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, 41 unable to keep a job). 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is 31 failing at school). 30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, 21 home, or friends). 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death, frequently violent, manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication 11 (e.g., largely incoherent or mute). 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicide act with clear expectations 1 of death. SWAN Core Lifetime Data Entry Form 8 07/01/2010

10 SWAN-11 Baseline Core Assessment Date: 1. SCID Interview conducted more than 1 month after the Baseline Core Assessment: 1 = No (STOP) 2 = Yes (go to #2) 2. Is there a current episode or disorder in partial remission? 1 = No (go to #3) 2 = Yes, and episode onset after baseline core (go to #3) 3 = Yes, and episode onset before baseline core (STOP) 3. Was there another episode in year prior to SCID? 1 = No (STOP) 2 = Yes (go to #4) 4. At Baseline Core Assessment, episode was 1 = full remission 2 = Current or in partial remission (go to #5) 5. List diagnosis and diagnostic code(s) of episode(s): Code Diagnosis a. b. c. SWAN Core Lifetime Data Entry Form 9 07/01/2010

11 SWAN-12 OVERVIEW DEMOGRAPHIC DATA NP106 NP108 Age: Marital Status: 1 married or living with someone as if married 2 widowed 3 divorced or annulled 4 separated 5 never married Any children? (What are their ages?) NP108_A NP108_B NP108_C How many?: Age of youngest child?: Age of oldest child?: NP109 Education Level: 1 grade 6 or less 2 grade 7 to 12 (without graduating high school) 3 graduated high school or high school equivalent 4 part college 5 graduated 2 year college 6. graduated 4 year college 7 part graduate/professional school 8 completed graduate/professional school SWAN-13 NP109_A Are you working now? 1 No 2 Yes SWAN Core Lifetime Data Entry Form 10 07/01/2010

12 SWAN-13 PAST PERIODS OF PSYCHOPATHOLOGY LIFETIME NP110 NP110_A NP110_B NP110_C Treatment for emotional problems with 1 No a physician or mental health professional 2 Yes Treated with psychotherapy? 1 No 2 Yes Treated with medication? 1 No 2 Yes If Yes, what drug code number (s)?,,,,. (May code up to 5 drugs) CURRENT NP110_D NP110_E NP110_F Treated with psychotherapy? 1 No 2 Yes Treated with medication? 1 No 2 Yes If Yes, what drug code number (s)?,,,,. (May code up to 5 drugs) LIFETIME NP110_G Treatment for drugs/alcohol? 1 No 2 Yes SWAN-14 Have you ever been a patient in a psychiatric hospital? NP111 NP111_A If Yes: How many times? (or more) Have you ever been hospitalized for drugs or alcohol? 1 No 2 Yes SWAN Core Lifetime Data Entry Form 11 07/01/2010

13 SWAN-18 A. MOOD EPISODES - CURRENT MAJOR DEPRESSIVE EPISODE A1 Depressed mood? A1 A2 Markedly diminished interest or pleasure? A2 if either A1 or A2 above is coded 2 or 3, continue; otherwise go to SWAN-28 (Q.A52) SWAN-19 A3 Weight/appetite change? A3 A4 Weight loss or decreased appetite (1) Checked (2) Not Checked A4 A5 Weight gain or increased appetite (1) Checked (2) Not Checked A5 A6 Insomnia or hypersomnia? A6 A7 Insomnia (1) Checked (2) Not Checked A7 A8 Hypersomnia (1) Checked (2) Not Checked A8 A9 Psychomotor agitation or retardation? A9 A10 Psychomotor retardation (1) Checked (2) Not Checked A10 A11 Psychomotor agitation (1) Checked (2) Not Checked A11 A12 Fatigue or loss of energy? A12 SWAN-20 A13 Feelings of worthlessness or excessive? A13 or inappropriate guilt A14 Worthlessness (1) Checked (2) Not Checked A14 A15 Inappropriate guilt (1) Checked (2) Not Checked A15 A16 Diminished ability to think or concentrate, or indecisiveness? A16 A17 Diminished ability to think (1) Checked (2) Not Checked A17 A18 Indecisiveness (1) Checked (2) Not Checked A18 A19 Recurrent thoughts of death, recurrent suicidal? A19 A20 Thoughts of own death (1) Checked (2) Not Checked A20 A21 Suicidal ideation (1) Checked (2) Not Checked A21 A22 Specific plan (1) Checked (2) Not Checked A22 A23 Suicide attempt (1) Checked (2) Not Checked A23 If not current MDE, go to SWAN-28 (Q.A52); otherwise, continue? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/

14 SWAN-22 (if Current MDE D criterion is coded 1, go to SWAN-28, Q.A52; otherwise, continue) A28_A Change in your life? A28_A 0=NO 1=YES 2=UNSURE A28_B If yes, event #,,,, A28_B A28_B1 If 9, Specify: A28_B1 A28_C (Events) had anything to do with your becoming sick, depressed, etc.? A28_C 0=NO 1=YES 2=UNSURE 3=NA A28_D Treatment for this episode? A28_D 0=NO 1=YES 2=UNSURE A29 Number of Major Depressive Episodes A29 A29_A Episodes since SWAN started 1 3 A29_A SWAN-24 MELANCHOLIC FEATURES A38 Lack of reactivity? A38 (if either criterion A(1) or A(2) are coded 3, continue; otherwise, go to SWAN-26, Q.A46) A39 Distinct quality of depressed mood? A39 A40 Depression is regularly worse in the morning? A40 SWAN-25 A41 Early morning awakening? A41 SWAN-26 ATYPICAL FEATURES (if not checked, continue; if checked go to SWAN-35, CME) A46 Mood reactivity? A46 (if coded 1, go to SWAN-35 CME; otherwise, continue) Go to SWAN-35 A49 Leaden paralysis? A49 A50 Long-standing pattern of interpersonal? A50 rejection sensitivity SWAN-28 PAST MAJOR DEPRESSIVE EPISODE A52 Depressed mood? A52 A53 Markedly diminished interest/pleasure? A53 (if either A52 or A53 above are coded 2 or 3, continue; otherwise, go to SWAN-35, CME) SWAN-29 A54 Weight/appetite change? A54 A55 Weight loss or decreased appetite (1) Checked (2) Not checked A55 A56 Weight gain or increased appetite (1) Checked (2) Not checked A56 A57 Insomnia or hypersomnia? A57 A58 Insomnia (1) Checked (2) Not checked A58 A59 Hypersomnia (1) Checked (2) Not checked A59? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/

15 SWAN-29 A60 Psychomotor agitation or retardation? A60 A61 Psychomotor agitation (1) Checked (2) Not checked A61 A62 Psychomotor retardation (1) Checked (2) Not checked A62 A63 Fatigue or loss of energy? A63 SWAN-30 A64 Feelings of worthlessness or excessive? A64 or inappropriate guilt A65 Worthlessness (1) Checked (2) Not checked A65 A66 Inappropriate guilt (1) Checked (2) Not checked A66 A67 Diminished ability to think or concentrate,? A67 or indecisiveness A68 Diminished ability to think (1) Checked (2) Not checked A68 A69 Indecisiveness (1) Checked (2) Not checked A69 A70 Recurrent thoughts of death, recurrent suicidal? A70 A71 Thoughts of own death (1) Checked (2) Not checked A71 A72 Suicidal ideation (1) Checked (2) Not checked A72 A73 Specific plan (1) Checked (2) Not checked A73 A74 Suicide attempt (1) Checked (2) Not checked A74 SWAN-31 (if at least 5 sx are coded 3, continue; otherwise, go to SWAN-35, CME) SWAN-32 (if Criterion D coded 3, continue; otherwise, go to SWAN-35, CME) SWAN-33 A79_A Change in your life A79_A 0=NO 1=YES 2=UNSURE A79_B If yes, event #,,,,. A79_B A79_B1 If 9, Specify:. A79_B1 A79_C (Events) had anything to do with your becoming sick, depressed, etc.? A79_C 0=NO 1=YES 2=UNSURE 3=NA A79_D Treatment for this episode? A79_D 0=NO 1=YES 2=UNSURE SWAN-34 A80 Age at onset of Past Major Depressive Episode A80 A81 Total number of Major Depressive Episodes A81 A81_A Episodes since SWAN started 1 3 A81_A? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/

16 SWAN-35 CURRENT MANIC (if checked, go to SWAN-44; if not checked and criterion A, irritable/expansive mood is coded 1, go to SWAN-44; if criterion A, lasting at least 1 week is coded 1 or 2, go to SWAN-40; otherwise, continue) SWAN-39 A100 Number of Manic Episodes, including current A100 SWAN-40 CURRENT HYPOMANIC EPISODE (if checked, go to SWAN-62; otherwise, continue) A108 Period of persistently elevated expansive,? A108 or irritable mood go SWAN-44 A109 Elevated, expansive mood (1) Checked (2) Not checked A109 A110 Irritable mood (1) Checked (2) Not checked A110 A111 Inflated self-esteem or grandiosity? A111 A112 Decreased need for sleep? A112 A113 More talkative? A113 A114 Flight of ideas, thoughts are racing? A114 SWAN-41 A115 Distractibility? A115 A116 Increased in goal-directed activity or psychomotor? A116 agitation A117 Increase in activity (1) Checked (2) Not checked A117 A118 Psychomotor agitation (1) Checked (2) Not checked A118 A119 Excessive involvement, a high potential for? A119 painful consequences SWAN-44 (if criterion A, irritable/expansive mood is coded 1, go to SWAN-54; if criterion A, lasting at least 1 week, is coded 1 or 2, go to SWAN-49; otherwise, continue) SWAN-46 (if at least three B symptoms are coded 3 continue, otherwise, go to SWAN-54) SWAN-48 (if MANIC EPISODE is coded 1, go to SWAN-54 - Q.A163; otherwise, continue) A143 Age at onset - Past Manic Episode A143 A144 Number of Manic Episodes A144 (go to SWAN-66)? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/

17 SWAN-49 PAST HYPOMANIC EPISODE A145 Period of sustained elevated, expansive,? A145 or irritable mood go to SWAN-54 A146 Elevated, expansive mood (1) Checked (2) Not checked A146 A147 Irritable mood (1) Checked (2) Not checked A147 A148 Inflated self esteem or grandiosity? A148 A149 Decreased need for sleep? A149 A150 More talkative? A150 A151 Flight of ideas, thoughts racing? A151 SWAN-50 A152 Distractibility? A152 A153 Increase in goal-directed activity or psychomotor? A153 agitation A153_A Increase in activity (1) Checked (2) Not checked A153_A A153_B Psychomotor agitation (1) Checked (2) Not checked A153_B A154 Excessive involvement, painful consequences? A154 SWAN-53 (if past hypomanic episode criteria coded 3, continue; otherwise, go to SWAN-54) A161 Age at onset of Past Hypomanic Episode A161 A162 Total number of Hypomanic Episodes A162 SWAN-54 DYSTHYMIC DISORDER (if checked, go to SWAN-66; otherwise, continue) A163 Depressed mood? A163 go to SWAN-66 SWAN-55 A164 Poor appetite or overeating? A164 A165 Insomnia or hypersomnia? A165 A166 Low energy or fatigue? A166 A167 Low self-esteem? A167 A168 Poor concentration or difficulty making decisions? A168 A169 Feelings of hopelessness? A169? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/

18 SWAN-56 (if criterion D is coded 3, continue; otherwise, go to SWAN-66) A173 Age at onset of current Dysthymic Disorder A173 SWAN-57 (if DYSTHYMIC DISORDER coded 3, continue: otherwise, go to SWAN-66) A Early Onset: Onset before age 21 A Late Onset: Onset age 21 or older SWAN-66 MOOD DISORDERS (if checked, otherwise, continue) go to SWAN-76, F. Anxiety Disorders; SWAN-68 OTHER BIPOLAR DISORDERS (If diagnosis made, code D20 and then go to SWAN-76; if diagnosis not made, go to SWAN-72) SWAN-69 D20 Age at onset of disorder D20 SWAN-71 DEPRESSIVE DISORDER NOS (If diagnosis is made, continue; otherwise, go to SWAN-74) SWAN-72 D31_A Change in your life D31_A 0=NO 1=YES 2=UNSURE D31_B If yes, list event #,,,, D31_B D31_B1 If 9, Specify: D31_B1 D31_C (Events) had anything to do with your becoming sick, depressed, etc.? D31_C 0=NO 1=YES 2=UNSURE 3=NA D31_D Treatment for this episode? D31_D 0=NO 1=YES 2=UNSURE SWAN-73 D33_A Age at first onset of disorder D33_A go to SWAN-76 if only 1 episode, otherwise, continue D33_B Episodes since SWAN started 1 3 D33_B SWAN-74 MOOD CHRONOLOGY (if past month is coded 3, go to D37) D35 Number of months last had depressed, or D35 euphoric or irritable mood (episode) D37 Age at onset of first Manic, Mixed, or Major or NA D37 Depressive Episode (for Bipolar Disorder) (if not Bi-polar Disorder) D39 Age at onset of first Major Depressive Episode or NA D39 (for Major Depressive Disorder) (if not MDD)? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/

19 SWAN-76 ANXIETY DISORDERS - PANIC DISORDER/ATTACKS (if criterion A1 is coded 1, go to SWAN-82; otherwise, continue) SWAN-77 (if criterion B is coded 1, go to SWAN-82; otherwise, continue) F4 Palpitations, pounding heart? F4 F5 Sweating? F5 F6 Trembling or shaking? F6 F7 Shortness of breath or smothering? F7 F8 Feeling of choking? F8 F9 Chest pain or discomfort? F9 F10 Nausea or abdominal distress? F10 F11 Dizzy, unsteady, light-headed or faint? F11 F12 Derealization? F12 F13 Fear of losing control/going crazy? F13 F14 Fear of dying? F14 SWAN-78 F15 Numbness or tingling? F15 F16 Chills or hot flushes? F16 (if Panic Disorder criterion D is coded 1, go to SWAN-82; otherwise, continue) SWAN-81 F Partial Remission F Full Remission 6 - Prior History NA - i.e., past month coded 3 ; Go to F28 F27 Number of months ago last had a symptom F27 of Panic Disorder/Attacks F28 Age at onset of Panic Disorder/Attacks F28 F28_A Episodes since SWAN started 1 3 F28_A? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/

20 SWAN-82 SOCIAL PHOBIA (if criterion A is coded 3, continue; otherwise, go to SWAN-88) F48 Public speaking (1) Checked (2) Not checked F48 F49 Eating in front of others (1) Checked (2) Not checked F49 F50 Writing in front of others (1) Checked (2) Not checked F50 F51 Generalized (1) Checked (2) Not checked F51 F52 Other (1) Checked (2) Not checked F52 F52_1 Specify: F52_1 SWAN-85 If Social Phobia criteria A-H are met (i.e., coded 3 ), continue; otherwise, go to SWAN-88) SWAN-86 F Partial Remission F Full Remission 6 - Prior History NA - i.e., past month coded 3 ; Go to F66 F65 Number of months last had a symptom F65 of Social Phobia F66 Age at onset of Social Phobia F66 SWAN-87 POSTTRAUMATIC STRESS DISORDER (if F103 is checked, go to SWAN-93, GAD; otherwise, continue) Event Age when first How long did this Event assessed Code event occurred last (# months) (y/n) F103b F103c F103d F103e F103g F103h F103i F103j F103l F103m F103n F103o F103q F103r F103s F103t F103v F103w F103x F103y (if F104 is checked, go to SWAN-93, GAD; otherwise, continue) SWAN-88 F105 Threatening event? F105 Go to GAD SWAN-93 F106 Intense fear, helplessness? F106 Go to GAD SWAN-93 F107 Recurrent, intrusive recollections? F107 F108 Recurrent distressing dreams? F108 F109 Feel like event recurring, reliving experience? F109 F110 Intense psychological distress? F110? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/

21 SWAN-89 F111 Physiological reactivity? F111 F112 AT LEAST ONE B SX IS CODED 3? 1 3 F112 F113 Avoid thoughts associated with trauma? F113 F114 Avoid activities that remind of trauma? F114 F115 Unable to recall aspects of trauma? F115 F116 Diminished interest in activities? F116 F117 Feeling detached from others? F117 F118 Restricted range of affect? F118 SWAN-90 F119 Foreshortened future? F119 F120 AT LEAST THREE C SXS ARE CODED F120 F121 Difficulty sleeping? F121 F122 Irritable or angry? F122 F123 Difficulty concentrating? F123 F124 Hypervigilance? F124 F125 Exaggerated startle response? F125 F126 AT LEAST TWO D SXS ARE CODED F126 If either criterion C or D = 3, continue. SWAN-91 F127 Duration greater than 1 month? F127 SWAN-92 Go to GAD SWAN-93 Go to GAD SWAN-93 F128 Disturbance causes clinically significant distress? F128 Go to GAD SWAN-93 F129 PTSD CRITERIA A, B,C,D,E AND F ARE CODED F129 Go to GAD SWAN-93 POSTTRAUMATIC STRESS DISORDER CHRONOLOGY F130 PTSD threshold/subthreshold current in past month?? 1 3 F130 (if past month is coded 3, go to F134; otherwise continue) F In Partial Remission 5 - In Full Remission 6 - Prior History NA - i.e., past month coded 3, Go to F134 F132 F133 Number of months last had a symptom F133 of Posttraumatic Stress Disorder F134 Age at onset of Posttraumatic Stress Disorder F134? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/

22 SWAN-93 GENERALIZED ANXIETY DISORDER (GAD) F135 Excessive anxiety or worry? F135 Go to SWAN-102 (if GAD criteria A, B, and F coded 2 or 3, continue; otherwise, go to SWAN-102) SWAN-94 F138 Restlessness or feeling keyed up or on edge? F138 F139 Being easily fatigued? F139 F140 Difficulty concentrating or mind going blank? F140 F141 Irritability? F141 F142 Muscle tension? F142 F143 Sleep disturbance? F143 SWAN-97 F149 Age at onset of Generalized Anxiety Disorder F149 SWAN-102 ANXIETY DISORDER NOS (If diagnosis made, i.e., coded 3, continue; otherwise, go to SWAN-104) SWAN-103 F158 Experienced a number of these symptoms (1) Checked (2) Not Checked F158 the past month F158_A Age at first onset F158_A F159 1 Social Phobia Subthreshold F159 2 Panic Disorder/Attacks Subthreshold 3 Multiple Anxiety SX that didn t meet criteria for a specific diagnosis 4 GAD Subthreshold SWAN-104 ADJUSTMENT DISORDER (if checked, end of interview) I2 Symptoms in response to an identifiable stressor? I2 NOTES:? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true 21