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Agoraphobic cognitions questionnaire

آخرین به روز رسانی یکشنبه, 23 آذر 1393 16:06

Agoraphobic cognitions questionnaire

Below are some thought or ideas that may pass through your mind when you are nervous or frightened. Please indicate how often each thought occurs when you are nervous. Rate from 1-5 using the scale below:

 

1

Thought

Never

Occurs

2

Thought

Rarely

occurs

3

Thought occurs

During half of the times

4

Thought

Usually

Occurs

5

Thought

Always

occurs

When I am nervous ….

1. I am going to throw up

1

2

3

4

5

2. I am going to pass out

         

3. I must have a brain tumor

         

4. I will have a heart attack

         

5. I will chock to death

         

6. I am going to act foolish

         

7. I am going blind

         

8. I will not be able to control my self

         

9. I will lose control of my bladder or bowels

         

10. I will hurt someone

         

11. I am going to have stroke

         

12. I am going crazy

         

13. I am going to scream

         

14. I am going to babble or talk funny

         

15. I will be paralysed with fear

         

16. I am about to die

         

17. I am seriously ill

         

18. I am going to suffocate

         

other ideas not listed (please describe and rate them)

         

. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .

         

. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .

         

. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .

         

Copy right 1984‚ Dianne L. Chambless

When you have the symptoms of panic‚ how much would you believe each of these thoughts to be true. Go back and rate each thought by choosing a number from the scale below‚ and put the number which applies on the dotted line on the RIGHT hand side of the form.

0

I do not believe this thought at all

10

20

30

40

50

60

70

80

90

100

I am completely convinced this thought is true

Finally‚ please rate the item below in the way you have done for the individual thoughts above; remember that the harm might include one or more of the thoughts listed above.

19. in panic attack‚ I will suffer serious physical or mental harm

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