1.
Have you been repeatedly hopeless and helpless during the last 10 years of your life, either because of the withdrawal of persons who were very important to you and/or your failure to achieve particularly important aims in life? This hopelessness and depression was caused because these events made it impossible for you to satisfy your most important emotional needs, such as those for love, nearness, understanding and recognition. The cause might be the death of or separation from some particularly important person, causing disappointment and difficulties. How closely does this description fit you own case?
2.
Have you been repeatedly excited, annoyed and resigned in the last 10 years because people disturbed you and interfered with your plans? This excitement and annoyance was caused by your failure, in spite of constant effort to change the situation, allowing some person or persons to prevent the satisfaction of your all-important goal, such as happiness with a sexual partner or advancement at work. How closely does this description fit your own case?
3.
Considering the past 10 years, particularly your relations with people who were particularly important to you from an emotional point of view (either positively or negatively), which of the four reactions described below would be most descriptive of you and to what extent?
3A.
I seek and long for closeness and emotional contact with a person or persons who are at the moment too distant from me because of a death, separation, lack of understanding on the part of my partner, or some shocking or too-demanding events. I would be willing to do anything to diminish this distance, but I do not succeed in reaching the wished-for intimacy. How closely does this description fit your own case?
3B.
I seek distance or separation from one person or persons whose closeness to me (as a partner, in work or other situation) I experience as crushing. In spite of my efforts I fail to achieve this distancing or separation, largely because of fear of the consequences, such as fear of financial difficulties. How closely does this description fit your case?
3C.
I alternate between great emotional closeness to a person who is important to me and great emotional distancing and separation. My actions only achieve a regular alteration of too-great closeness and too-great distance interspersed with moments in which distance and nearness are optimal. How closely does this description fit your own case?
3D.
My relations with people who are important to me are neither crushingly close nor too-distant emotionally. Nearness and distance are for the most part optimal and regulated appropriately. I increase the distance from people who annoy me and decrease the distance to people with whom I interact positively. How closely does this description fit your own case?
4.
During the past 10 years, have you always been in a position to enjoy relaxation in various bodily activities, such as sports, work and sex, using these activities as a pleasant alternative to mental relaxation and activity?
If the answer to the above question is No, were you prevented from doing so:
5.
In the past 10 years, have you repeatedly acted in such a way that emotionally negative (undesirable) consequences occurred? Were you unable to find ways of acting that led to more positive and desirable consequences, such as better interaction between you and emotionally important persons? How closely does this description fit your own case?
6.
Do you have frequent feelings of fear and anxiety (a general state of anxiety, a syndrome of anxiety, periods during which you suffer from anxiety, fears of being threatened or persecuted, fear of specific situations)? these fears should be relatively unrealistic, in the sense that you are in the position to avoid them if need be. How strong is this anxiety?
