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July, 2001 >>

Hopkins Symptoms Checklist 25(HSCL-25) Urdu Translation: An Instrument for detecting Anxiety and Depression in Torture and Trauma Victims

A.A. Halepota, S.A. Wasif  ( Deparlment Psychiatry, Dow Medical College and Civil Hospital, Karachi. )


Introduction and Backgrpund: The two major psychiatric illnesses associated with trauma and torture are major depression and post-traumatic stress disorder. Obtaining accurate knowledge of traumatic event and symptoms and properly classifying them into a diagnostic system is fundamental for providing effective treatment and good therapeutic intervention.The Harvard Trauma Questionnaire (HTQ) measures symptoms associated with diagnostic criteria for post-traumatic stress disorder as defined by DSMIII R manual and symptoms. Therefore an attempt is made to translate the HTQ, the only cross-culturally validated screening instrument for the assessment of trauma and torture related to mass violence and their sequelae.
Methodology: The Havard Trauma Questionnaire (HTQ) was translated into Urdu by a team of psychiatrists and linguistic experts proficient in national languages belonging to different ethnic backgrounds. Each member translated HTQ independently and subsequently a work shop was arranged to develop the standard translation and finally it was approved. Subsequently back translation of the approved questionnaire was carried out by independent multilingual psychiatrist to test the accuracy of the approved translation and was formally accepted (JPMA 51:255;2001).


Trauma and torture leaves a permanent scar on the survivor with physical. psychological and social sequelae. The two major psychiatric illnesses associated with trauma and torture are major depression and post-traumatic stress disorder. There are no recognized tools to measure the extent of trauma or the resulting emotional disability.
Hopkins Symptoms Checklist-25 are intended to provide primary care physicians. mental health practitioners and other health care providers with an instrument for detecting anxiety and depression in torture and trauma victims. Clinicians have noticed that patients with psychiatric illness first present themselves to outpatient medical settings1,2. Studies have also shown that the psychiatric problems of primary care patients are often overlooked due to lack of familiarity with symptoms of psychiatric disorders and mental health diagnosis3,4. Mental health problems present an even greater threat, both because they contribute to difficulties in coping with resettlement in normal life and because the admission of mental illness makes the person a source of humiliation and potential ridicule5,6. In torture and trauma survivors there may be a reluctance to discuss trauma related events or symptoms with a health care practitioner because there are painful feelings which the patients often would rather put behind them.
The Hopkins Symptom Checklist
The Hopkins symptoms checklist (HSCL) is a well known and widely used screening instrument that dates from the 1950s. It was originally developed by Parloff, Kelman and Frank at John Hopkins University as a self-reporing symptom invventory used for measuring change in the clinical status of psychotherapy patients2. The carliest version called hte discomfort scale comprised of 41 sympom questions most of which were taken from the Cornell Medical Index (CMR). developed in 1949. These were supplemented by 12 items from a psychiatric outpatient relating scale developed by Lorr6. The sacale was rewritten to include four categories of responses ("Not at all"."A little", Quite a bit", "Extremely"), in keeping with its primary use as a measure of improvement. Since its inception, the HSCL has undergone continuing are now in use ranging in lenth from 25 to 90 items (including 31-,35-, 58-, 64- and 71- item versions). This version screens and depression.

The HSCL has been employed in several kinds of research. It has been used as a screening instrument to elicit information on sympotms of anxiety and depression in medical patients, psychiatrice patients and in normal population. It has been used to assess outcome to psychotherapy, espcially in combination with psychopharmacologic agents (2-pp126132)7,8. Uhlenhuth, Llipman and Balter used the HSCL in an epideniological study of life stress in the city.
The HSCL-25 uses ten items from the HSCL-58 anxiety cluster (suddenly scared for no reason; feeling fearful; faintness, dizziness, or weakness; nervousness or shakiness inside; heart pounding or racing; tremblind; feeling tense or keyed up: headaches; spells of terror or panic; restlessness, cant sit still), and thirteen itmes from the depression cluster (feeling low in energy, slowed down: blaming yourself for things; crying easily; loss of sexual interest or pleasure; feeling lonely; thoughts of ending your life; feeling of being trapped or caught; worrying too much about things; feeling no interest in things; feeling everything is an effort; feeling of worthlessness). It also includes two additional somatic symptoms (poor appetite;) difficulty in falling asleep or staying asleep)9.
The HSCL-25 has several advantages as a screening instrument. The questionnaire is brief, simple in its language and may be self-administered by literate patients. It can be understood by people of all levels of educational attainment. While the HSCL does not supply a diagnosis, it allows the clinician to recognize symptoms universally associated with anxiety and depression10 The four categories of response. ranging from “Not at All” to “E:xtreniely”. provide a safeguard against simple “Yes” and “No” answers as (toes the tact that the items are neither questions nor true-false statements. This structure is helpful in determining severity of psychiatric disorder as well as in documenting change in the patients condition.
Some questionnaires are so assaultive that they are capable of triggering a flash back. in contrast. the HSCL does not strip up feelings; it is not a provocative instrument. It puts words around feelings. Many people feel overwhelmed: unable to articulate and tend to say they are “just not feeling right”. The H SCL differentiates the components of feelings, which is necessary for treatment11.


Our procedure began with the translation of the HSCI-25 from English into Urdu by three experienced clinicians (psychiatrists) and two expert linguistics, fluent in English. This version was then back-translated blind into English by a multi-linguistic psychiatrist. Discrepancies were discussed and resolved by each pair of translators.
In the preparation of the present version we consulted several cultural experts who combined native fluency and knowledge of mental health issues. The final version incorporated some of the suggested word changes while maintaining terminology.
Instructions for the use for the HSCL-25
The instructions3 for the HSCL-25 are printed on the instrument. Patients who are literate can be asked to fill out the checklist themselves. Responses are summed and divided by the number of answered items to generate three scores: Total (25 items), anxiety (10 items) and depression (15 items). Patients with scores of greater than 1.75 on anxiety and/or depression are considered symptomatic. These patients are most likely experiencing significant eniotional distress and should be referred to a psychiatrist or mental health clinic for additional screening and diagnostic evaluation.


Many thanks to Dr. Inge Geneike, Secretary General, IRCT, International Rehabilitation Council for Torture Victims, IRCT, Copenhagen, Denmark, Ms. Siddiqa Begum, Editor in Chief, Adab-e-Latif. Lahore, Mrs. Masooma Raza, Mrs. Fauzia Habib and Dr. Farhan Hameed, Karachi, for all their help and pains taking cooperation.


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