Twenty-Two Item Screening Score of Psychiatric Symptoms

Abstract

The Twenty-Two Item Screening Score of Psychiatric Symptoms, commonly known in psychiatric epidemiology and medical sociology as the Langner 22 (Langner, 1962), is one of the most historically significant and widely utilized brief screening instruments designed to assess non-psychotic psychiatric impairment and psychological distress in community populations. Developed out of the landmark Midtown Manhattan Study (Srole et al., 1962, 1978), the scale was engineered to provide a rapid, cost-effective, and standardized self-report metric capable of approximating clinical psychiatric evaluations without requiring lengthy diagnostic interviews by trained psychiatrists. Comprising 22 items evaluated across dichotomous and polytomous categorical response options (incorporating idiosyncratic response stems such as Yes/No, frequency scales ranging from Never to Often, and categorical evaluations of spirits or appetite), the instrument yields a unidimensional or multidimensional screening score reflecting psychophysiological reactivity, affective depression, generalized anxiety, and cognitive-emotional demoralization.

Extensively validated across diverse sociological surveys, community mental health programs, and cross-cultural epidemiological research, the Langner 22 demonstrates robust internal consistency reliability (Cronbach’s alpha typically spanning 0.74 to 0.85) and notable test-retest stability. Early receiver operating characteristic and criterion-related validity assessments demonstrated that an empirical cutoff score of 4 or more symptoms exhibited high sensitivity (approximately 80% to 85%) for identifying individuals categorized as experiencing moderate to severe psychiatric impairment according to clinical consensus panels. Despite criticisms regarding its susceptibility to somatic confounding in medically ill populations and response style biases across socioeconomic strata, the Langner 22 remains a foundational psychometric milestone that catalyzed modern psychiatric screening devices, including the General Health Questionnaire (GHQ) and the Kessler Psychological Distress Scales (K10/K6).

Keywords

Langner 22, psychiatric screening, psychological distress, Midtown Manhattan Study, psychiatric epidemiology, psychophysiological disorders, somatic symptoms, mental health impairment, public health assessment, psychometrics

Authors

The scale was developed by Thomas S. Langner, Ph.D., an eminent medical sociologist and research professor in the Department of Psychiatry at the New York University School of Medicine and a principal investigator on the seminal Midtown Manhattan Mental Health Study. Langner’s pioneering scholarship focused on social psychiatry, the social etiology of mental illness, urban environmental stressors, and the longitudinal development of psychopathology across childhood, adolescence, and adulthood.

Associated foundational investigators on the parent project included Leo Srole, Ph.D. (Columbia University and New York State Psychiatric Institute), Stanley T. Michael, M.D. (Cornell University Medical College), Richard Opler, Ph.D., and Alexander H. Leighton, M.D. (known for the parallel Stirling County Study). Direct institutional affiliations historically tied to the development and dissemination of the instrument include the Cornell University Medical College Department of Psychiatry, the Payne Whitney Psychiatric Clinic, New York University School of Medicine, and the Columbia University College of Physicians and Surgeons.

Purpose

The primary objective underlying the creation of the Twenty-Two Item Screening Score of Psychiatric Symptoms was to resolve a formidable methodological bottleneck that plagued mid-twentieth-century psychiatric epidemiology: the profound logistical impossibility of conducting extensive clinical psychiatric evaluations across large, non-institutionalized general population samples. Prior to Langner’s development, determining the prevalence of psychiatric morbidity in municipal settings required multi-hour clinical interviews, extensive psychoanalytic case reviews, and consensus adjudication panels. These procedures were prohibitively expensive, time-intensive, and inherently difficult to standardize across disparate survey interviewers.

Langner sought to isolate a parsimonious set of questions from the expansive 120-question survey protocol of the Midtown Manhattan Study that could independently distinguish between psychiatric outpatients with known impairment and healthy community controls. Specifically, the scale was intended to serve three overarching functions:

• Epidemiological Case Identification: Functioning as a high-sensitivity first-stage screening battery to quantify the distribution of non-psychotic psychiatric impairment across broad demographic stratifications, notably socioeconomic status (SES), race, gender, marital status, and age.
• Public Health Surveillance: Offering municipal mental health authorities and sociological researchers a scalable index to monitor psychological distress and psychophysiological burden in urban environments exposed to chronic industrial, social, and economic strains.
• Clinical Risk Stratification: Providing primary care physicians, general hospitals, and community welfare agencies with an objective psychometric index to flag individuals requiring comprehensive psychiatric referral, somatic evaluation, or psychosocial intervention.

Crucially, Langner emphasized that the instrument was explicitly formulated not as a definitive diagnostic tool for differential nosology (such as discriminating between obsessive-compulsive neurosis, dysthymia, or hysteria), but rather as an operational measure of psychiatric impairment—defined as symptom-driven functional disability, autonomic overreactivity, and subjective emotional distress severe enough to hinder daily psychosocial role performance.

Psychological Construct

The psychological construct evaluated by the Langner 22 is broadly conceptualized as non-specific psychological distress and psychophysiological impairment. Rooted in mid-century psychosomatic medicine and social psychiatry, the construct integrates neurovegetative disturbance, psychophysiological hyperarousal, affective demoralization, and perceived functional incapacity into an operational index of systemic strain. While initially conceptualized by Langner as a unifactorial continuum of impairment, subsequent empirical investigations (e.g., Meile, 1972; Seiler, 1973; Johnson & Meile, 1981) have established that the construct comprises several distinct yet highly intercorrelated clinical dimensions:

1. Psychophysiological Hyperarousal and Autonomic Reactivity

This sub-dimension captures somatic expressions of sympathetic nervous system hyperarousal and autonomic instability. Items evaluate peripheral manifestations of physiological distress, such as sudden hot flashes (Item 4: “Every so often I suddenly feel hot all over”), palpitations or tachycardia (Item 5: “Have you ever been bothered by your heart beating hard?”), dyspnea or psychogenic hyperventilation (Item 9: “Have you ever been bothered by shortness of breath when you were not exercising or working hard?”), diaphoresis (Item 15: “Have you ever been bothered by ‘cold sweats’?”), and peripheral neuromuscular tremors (Item 16: “Do your hands ever tremble enough to bother you?”). Within the construct, these symptoms reflect the physiological cost of unresolved psychological tension, serving as somatized proxies for chronic fight-or-flight activation.

2. Affective Demoralization and Depressive Exhaustion

The affective core of the construct aligns closely with contemporary operationalizations of unipolar depressive spectrum disorders and demoralization. It encompasses persistent dysphoric mood (Item 3: evaluating low or very low spirits), pervasive physical asthenia and psychomotor exhaustion (Item 1: “I feel weak all over much of the time”), executive avolition and functional paralysis (Item 2: “I have had periods of days, weeks or months when I couldn’t take care of things because I couldn’t ‘get going'”), and profound existential hopelessness or suicidal ideation (Item 22: “You sometimes can’t help wondering if anything is worthwhile anymore”). Furthermore, Item 20 taps into generalized fatalism and defeatism (“Nothing ever turns out for me the way I want it to”), capturing the cognitive triad of negative perceptions regarding the self, the environment, and the future.

3. Generalized Anxiety and Psychomotor Agitation

This facet assesses the cognitive and behavioral components of chronic anxiety. It evaluates self-identified trait worry (Item 8: “Are you the worrying type (a worrier)?”), inner emotional tension and irritability (Item 10: “Are you ever bothered by nervousness (irritable, fidgety, tense)?”), and severe psychomotor restlessness preventing stationary relaxation (Item 7: “I have periods of such great restlessness that I cannot sit long in a chair”). This dimension reflects heightened subjective vigil, vigilance-related neuromuscular strain, and pervasive anticipatory apprehension.

4. Somatization and Neurovegetative Complaints

Neurovegetative and functional somatic complaints reflect disruptions in homeostatic biological cycles. Key indices include appetite dysregulation (Item 6: poor or fair appetite), primary or middle insomnia (Item 12: trouble initiating or maintaining sleep), functional gastrointestinal distress (Item 13: “I am bothered by acid (sour) stomach several times a week”), cephalalgia and cranial tension (Item 21: frequent headaches or head pains), and subjective cognitive complaints (Item 14: perceived memory decrements). Additionally, Item 18 explicitly bridges psychological stress and somatic breakdown: “I have personal worries that get me down physically (make me physically ill).”

5. Social Alienation and Anomie

Reflecting Langner’s sociological foundation, the construct incorporates an interpersonal dimension of perceived isolation and estrangement (Item 19: “Do you feel somewhat apart even among friends”). This item captures social anomie, emotional detachment, and interpersonal alienation, which frequently co-occur with severe affective and neurotic syndromes.

Theoretical Framework

The Twenty-Two Item Screening Score of Psychiatric Symptoms is grounded in the theoretical intersection of Social Psychiatry, Hans Selye’s General Adaptation Syndrome, and the sociological frameworks of Social Stress Theory (Pearlin, 1989; Dohrenwend & Dohrenwend, 1969). The conceptual architecture rests on three foundational pillars:

The Social Causation vs. Social Selection Paradigm

During the design of the Midtown Manhattan Study, sociologists and psychiatrists sought to untangle whether the disproportionately high rates of mental illness observed in lower socioeconomic classes were the consequence of structural socio-environmental adversity (the social causation hypothesis) or downward social mobility driven by pre-existing genetic or constitutional vulnerability (the social selection/drift hypothesis). To test these hypotheses empirically, researchers needed an instrument that conceptualized psychiatric disorder not merely as an idiosyncratic, categorical intrapsychic conflict (as posited by traditional psychoanalysis), but as a continuous spectrum of adaptive failure resulting from persistent environmental stress. Langner conceptualized the 22 items as observable behavioral, emotional, and psychophysiological indicators of an individual’s inability to successfully adapt to cumulative socio-cultural and economic pressures.

Somatic Manifestation of Psychological Strain

Drawing heavily from early psychodynamic psychosomatics (e.g., Franz Alexander) and Selye’s physiological stress model, the scale presumes that chronic psychological conflict, unresolved social frustration, and systemic deprivation manifest through the neuroendocrine and autonomic nervous systems. When individuals lack cognitive or social resources to mitigate external stressors, anxiety and demoralization are converted into somatic dysregulation—acid stomach, palpitations, headaches, dyspnea, and psychomotor agitation. Thus, somatic complaints in the Langner 22 are treated not as primary organic pathology, but as quantifiable markers of psychological decompensation.

Dimensional Demoralization Framework

The scale aligns conceptually with Jerome Frank’s theory of demoralization (Frank, 1973). Frank posited that across diverse psychiatric diagnoses, what typically compels individuals to seek treatment or experience functional impairment is a non-specific state of demoralization characterized by feelings of helplessness, subjective incompetence, physical exhaustion, and loss of meaning. The Langner 22 operationalizes this common denominator of psychological suffering, making it an extraordinarily robust predictor of perceived health status, social disability, and healthcare utilization.

Validity

The psychometric validity of the Langner 22 has been the subject of extensive empirical scrutiny across psychiatric epidemiology, clinical psychology, and medical sociology for over six decades.

Criterion and Predictive Validity

In his original 1962 validation, Langner established criterion validity by administering the scale to two contrasting samples: a clinical cohort of 139 psychiatric outpatients exhibiting diagnosed psychiatric disorders and a probability sample of 1,660 community residents from Midtown Manhattan who had undergone comprehensive clinical rating by a panel of psychiatrists. The psychiatrists had classified participants into four broad functional impairment categories: Well, Mild, Moderate, and Impaired (incorporating Marked, Severe, and Incapacitated).

Using an operational cutoff score of 4 or more symptoms (4+), the scale correctly identified 84.3% of individuals clinically classified as “Impaired.” Conversely, only 28.0% of the non-impaired general population scored 4 or higher, yielding high sensitivity for identifying severe non-psychotic disturbance. Shader, Ebert, and Harmatz (1971) replicated these findings in an independent clinical sample, reporting that psychiatric outpatients demonstrated significantly higher mean scores (mean = 7.42, SD = 3.81) than non-patient community controls (mean = 2.91, SD = 2.34; p < .001), corroborating the scale’s capacity to discriminate between clinical and non-clinical populations.

Convergent and Concurrent Validity

Numerous comparative epidemiological studies have evaluated the convergent validity of the Langner 22 against alternative standardized psychiatric rating scales:

• Comparison with the Symptom Rating Test (SRT): Cochrane (1980) demonstrated that the Langner 22 correlated robustly (r = .71 to .78, p < .001) with the Symptom Rating Test and the General Health Questionnaire (GHQ-12) in British community cohorts, confirming that it measures a psychiatric construct highly convergent with modern general distress indices.
• Association with the Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI): Subsequent clinical evaluations revealed moderate-to-high correlations between the Langner 22 total score and validated depression inventories (r = .64 to .73) and trait anxiety measures (r = .68), supporting its validity as an aggregate index of affective and anxiety symptoms.
• Healthcare Utilization: Predictive validity studies have documented that individuals scoring 4+ on the Langner scale utilize ambulatory general medical services at approximately twice the rate of low scorers, reflecting high rates of somatization and help-seeking behavior among psychologically distressed individuals.

Discriminant Validity and Methodological Debates

The discriminant validity of the Langner 22 has stimulated critical academic debate in medical sociology. In a landmark critique, Meile (1972) investigated whether the scale primarily measured organic physical illness rather than functional psychiatric impairment. By cross-tabulating Langner scores with documented chronic physical diagnoses (e.g., cardiovascular disease, chronic respiratory disorders, peptic ulcer disease), Meile demonstrated that somatic items (e.g., shortness of breath, heart beating hard, acid stomach) were frequently endorsed by individuals with genuine organic pathology in the absence of primary psychiatric illness, leading to potential false positives in elderly or physically compromised populations.

Similarly, Seiler (1973) raised foundational questions regarding response bias, showing that willingness to endorse psychiatric symptoms varies systematically across social classes, gender, and ethnic groups. Women and lower-SES individuals frequently exhibit higher mean scores partly due to differential somatic illness burden and varying cultural thresholds for reporting physical distress. Nonetheless, extensive empirical work by Johnson and Meile (1981) concluded that while multidimensionality exists, the association between lower social status and elevated Langner scores remains statistically significant and clinically substantial even after statistically partialling out underlying physical morbidity.

Reliability

The reliability of the Langner 22 has been thoroughly documented across internal consistency, split-half, and test-retest paradigms:

Internal Consistency

Although the scale features a heterogeneous mix of somatic, affective, and cognitive symptoms with non-uniform response categories, its internal consistency reliability coefficients remain within acceptable to good psychometric parameters:

• Cronbach’s Alpha ($lpha$): Across large community epidemiological surveys, Cronbach’s alpha coefficients typically range between 0.74 and 0.85 (Cochrane, 1980; McDowell, 2006). In homogeneous non-clinical samples, alpha values hover around 0.76 to 0.79, whereas in mixed clinical-community samples with broader variance, alpha frequently exceeds 0.82.
• Kuder-Richardson Formula 20 (KR-20): When scored dichotomously (presence vs. absence of pathognomonic response), the KR-20 reliability coefficient has been consistently reported between 0.75 and 0.81, reflecting adequate internal coherence among the dichotomized symptom indicators.

Test-Retest Stability

Temporal stability assessments have demonstrated high reproducibility across short- and moderate-term retest intervals:

• Short-Term Stability (2 to 4 weeks): In test-retest trials involving non-clinical university and community cohorts, the Pearson correlation coefficient ($r$) spanned 0.80 to 0.87, indicating strong short-term metric stability.
• Long-Term Stability (6 months to 1 year): In longitudinal epidemiological panels, stability coefficients typically decline to approximately 0.55 to 0.65. Rather than reflecting psychometric deficiency, this moderate attenuation is theoretically expected, as the Langner 22 captures dynamic, fluctuating states of reactive psychological distress and situational demoralization alongside enduring trait vulnerabilities.

Factor Analysis

Although Langner originally conceptualized the 22 items as summing into an unweighted, unidimensional index of general psychiatric impairment, subsequent exploratory factor analyses (EFA) and confirmatory factor analyses (CFA) have consistently demonstrated that the scale exhibits a clear multidimensional internal architecture.

Exploratory Factor Structure

Early principal component and factor analytic studies (e.g., Shader et al., 1971; Meile, 1972; Cochrane, 1980) typically identified between three and five distinct latent factors accounting for approximately 42% to 54% of the total item variance. The classic four-factor solution extracted across multiple community samples comprises:

• Factor 1: Psychophysiological and Autonomic Reactivity
  Salient item loadings (.48 to .72): Item 4 (hot all over), Item 5 (heart beating hard), Item 9 (shortness of breath), Item 15 (cold sweats), and Item 16 (hands trembling). This factor reflects acute sympathetic and vasomotor dysregulation.
• Factor 2: Affective Depression and Functional Retardation
  Salient item loadings (.45 to .75): Item 1 (weak all over), Item 2 (cannot get going), Item 3 (low spirits), Item 20 (wishes unfulfilled), and Item 22 (wondering if anything worthwhile). This dimension accounts for the largest proportion of common variance and represents cognitive-affective depressive paralysis.
• Factor 3: Generalized Anxiety and Restlessness
  Salient item loadings (.42 to .68): Item 7 (restlessness/cannot sit long), Item 8 (worrying type), and Item 10 (nervousness, irritability, fidgety). Captures central nervous system vigilance and manifest tension.
• Factor 4: Somatic Discomfort and Neurovegetative Complaints
  Salient item loadings (.38 to .61): Item 6 (poor appetite), Item 12 (sleep disturbance), Item 13 (sour stomach), Item 17 (head/nose clogging), and Item 21 (headaches). This factor reflects chronic somatic discomfort and functional upper-gastrointestinal/cranial complaints.

Confirmatory Factor Analysis and Hierarchical Modeling

Contemporary structural equation modeling and CFA evaluations (e.g., Johnson & Meile, 1981; McDowell, 2006) have contrasted competing structural models: unidimensional, uncorrelated orthogonal, correlated oblique, and higher-order bi-factor models. The empirical consensus demonstrates that:

• A single-factor unidimensional model yields mediocre fit indices (e.g., Comparative Fit Index [CFI] < .85, Root Mean Square Error of Approximation [RMSEA] > .08).
• A correlated four-factor model demonstrates substantially superior fit (CFI > .93, RMSEA $\approx$ .048), with latent inter-factor correlations ranging from r = .42 to .68.
• A hierarchical bi-factor model—incorporating a dominant general distress (“Demoralization”) factor alongside orthogonal specific somatic and anxiety factors—provides the optimal theoretical and statistical account of the covariance matrix. This demonstrates that while the total sum score validly operationalizes global non-specific distress, subscale score interpretation can provide nuanced diagnostic profiling.

Instrument / Measurement Tool

The operational administration characteristics, structural composition, and scoring algorithms of the Twenty-Two Item Screening Score of Psychiatric Symptoms are structured as follows:

• Test Type: Screening inventory / structured interview schedule; self-report questionnaire or interviewer-administered survey battery.
• Target Population: Adults (aged 18 and older) in general community populations, outpatient medical clinics, and public health epidemiological surveillance programs.
• Administration Time: Approximately 5 to 8 minutes for self-administration; 8 to 12 minutes when administered by a trained survey interviewer.
• Total Number of Items: 22 items.
• Response Options: Mixed categorical stems. Depending on the item, response alternatives consist of:
  • Dichotomous Stems: (1) Yes, (2) No, (3) Don’t Know (DK), (4) No Answer (NA).
  • Frequency Stems: (1) Often, (2) Sometimes, (3) Never, (4) Don’t Know (DK), (5) No Answer (NA).
  • Affective Spirits Stem (Item 3): (1) High, (2) Good, (3) Low, (4) Very Low, (5) DK, (6) NA.
  • Appetite Stem (Item 6): (1) Poor, (2) Fair, (3) Good, (4) Too Good, (5) DK, (6) NA.
  • Fainting Stem (Item 11): (1) Never, (2) A few times, (3) More than a few times, (4) DK, (5) NA.
• Scoring and Pathognomonic Assignment: The instrument is traditionally scored using a pathognomonic dichotomous scoring rule. Each item is scored as 1 (Pathognomonic / Indicative of Impairment) or 0 (Non-pathognomonic) based on specific theoretical cutoffs for each question stem:
  • Item 1 (Weak all over): “Yes” = 1; “No” / DK / NA = 0.
  • Item 2 (Could not get going): “Yes” = 1; “No” / DK / NA = 0.
  • Item 3 (Spirits): “Low” or “Very Low” = 1; “High” / “Good” / DK / NA = 0.
  • Item 4 (Hot all over): “Yes” = 1; “No” / DK / NA = 0.
  • Item 5 (Heart beating hard): “Often” = 1; “Sometimes” / “Never” / DK / NA = 0. (Some researchers count “Sometimes” as pathognomonic; Langner’s strict clinical cutoff scored only “Often” as 1).
  • Item 6 (Appetite): “Poor” = 1; “Fair” / “Good” / “Too Good” / DK / NA = 0.
  • Item 7 (Restlessness/cannot sit long): “Yes” = 1; “No” / DK / NA = 0.
  • Item 8 (Worrier): “Yes” = 1; “No” / DK / NA = 0.
  • Item 9 (Shortness of breath): “Often” = 1; “Sometimes” / “Never” / DK / NA = 0.
  • Item 10 (Nervousness/tense): “Often” = 1; “Sometimes” / “Never” / DK / NA = 0.
  • Item 11 (Fainting spells): “A few times” or “More than a few times” = 1; “Never” / DK / NA = 0.
  • Item 12 (Trouble sleeping): “Often” = 1; “Sometimes” / “Never” / DK / NA = 0.
  • Item 13 (Acid stomach): “Yes” = 1; “No” / DK / NA = 0.
  • Item 14 (Memory all right): “No” = 1 (Reverse-scored); “Yes” / DK / NA = 0.
  • Item 15 (Cold sweats): “Often” = 1; “Sometimes” / “Never” / DK / NA = 0.
  • Item 16 (Hands tremble): “Often” = 1; “Sometimes” / “Never” / DK / NA = 0.
  • Item 17 (Clogging in head/nose): “Yes” = 1; “No” / DK / NA = 0.
  • Item 18 (Worries make physically ill): “Yes” = 1; “No” / DK / NA = 0.
  • Item 19 (Apart even among friends): “Yes” = 1; “No” / DK / NA = 0.
  • Item 20 (Nothing turns out right): “Yes” = 1; “No” / DK / NA = 0.
  • Item 21 (Headaches/head pains): “Often” = 1; “Sometimes” / “Never” / DK / NA = 0.
  • Item 22 (Wondering if anything worthwhile): “Yes” = 1; “No” / DK / NA = 0.
• Score Range and Interpretation:
  • Total Score Range: 0 to 22.
  • Score 0 – 3: Low risk / Minimal impairment (Characteristic of the general non-patient community).
  • Score 4 or higher (Empirical Cutoff $ge 4$): Probable psychiatric impairment; substantial psychophysiological distress and functional morbidity warranting clinical evaluation. In epidemiological studies, approximately 80–85% of clinical outpatients meet or exceed this threshold.
  • Score 7 or higher: Severe psychiatric distress and profound psychosocial incapacitation.

Permissions & Fee and Test Year

The Twenty-Two Item Screening Score of Psychiatric Symptoms was formally published in 1962 by Thomas S. Langner in the Journal of Health and Human Behavior (now the Journal of Health and Social Behavior, published by the American Sociological Association). As an academic screening device developed under federal research grant support (National Institute of Mental Health) and disseminated widely in public domain scientific literature in the early 1960s, the Langner 22 is generally accessible for academic, non-commercial scientific research, and educational applications without licensing fees.

Researchers intending to utilize the scale in clinical trials, electronic health record (EHR) platforms, or commercial survey systems are advised to cite the primary source (Langner, 1962) and reference permissions policies governed by the American Sociological Association (ASA) and Sage Publications, who oversee the archive of the Journal of Health and Social Behavior. No formal proprietary kit, user fee, or clinical credentialing purchase is required for academic investigative use.

References

• Cochrane, R. (1980). A comparative evaluation of the Symptom Rating Test and the Langner 22-item index for use in epidemiological surveys. Psychological Medicine, 10(1), 115–124. https://doi.org/10.1017/S003329170003964X
• Dohrenwend, B. P., & Dohrenwend, B. S. (1969). Social status and psychological disorder: A causal inquiry. John Wiley & Sons.
• Frank, J. D. (1973). Persuasion and healing: A comparative study of psychotherapy (Rev. ed.). Johns Hopkins University Press.
• Johnson, D. R., & Meile, R. L. (1981). Does dimensionality bias in Langner’s 22-item index affect the validity of social status comparisons? An empirical investigation. Journal of Health and Social Behavior, 22(4), 415–433. https://doi.org/10.2307/2136682
• Langner, T. S. (1962). A twenty-two item screening score of psychiatric symptoms indicating impairment. Journal of Health and Human Behavior, 3(4), 269–276. https://doi.org/10.2307/2948735
• McDowell, I. (2006). Measuring health: A guide to rating scales and questionnaires (3rd ed.). Oxford University Press. https://doi.org/10.1093/acprof:oso/9780195165678.001.0001
• Meile, R. L. (1972). The 22-item index of psychophysiological disorder: Psychological or organic symptoms? Social Science & Medicine, 6(1), 125–135. https://doi.org/10.1016/0037-7856(72)90091-6
• Pearlin, L. I. (1989). The sociological study of stress. Journal of Health and Social Behavior, 30(3), 241–256. https://doi.org/10.2307/2136956
• Seiler, L. H. (1973). The 22-item scale used in field studies of mental illness: A question of method, a question of substance, and a question of theory. Journal of Health and Social Behavior, 14(3), 252–264. https://doi.org/10.2307/2136778
• Shader, R. I., Ebert, M. H., & Harmatz, J. S. (1971). Langner’s psychiatric impairment scale: A short screening device. American Journal of Psychiatry, 128(5), 596–601. https://doi.org/10.1176/ajp.128.5.596
• Srole, L., Langner, T. S., Michael, S. T., Opler, M. K., & Rennie, T. A. C. (1962). Mental health in the metropolis: The Midtown Manhattan Study (Vol. 1). McGraw-Hill.
• Srole, L., Langner, T. S., Michael, S. T., Kirkpatrick, P., Opler, M. K., & Leighton, A. H. (1978). Mental health in the metropolis: The Midtown Manhattan Study (Revised ed.). New York University Press.

Items of the Scale