1 – Strongly disagree
2 – Disagree
3 – Neither agree nor disagree
4 – Agree
5 – Strongly agree
¹
1
2
3
4
5
1
I struggle with the feeling that I am separate from other people.
2
I feel like I am ultimately alone in life.
3
I feel an upsetting distance between myself and other people.
4
I struggle with the feeling that I cannot connect fully with others.
5
I have an upsetting feeling that I am disconnected from everyone else.
6
I feel utterly alone in the world.
The presented answer sheet is not an original form and is not intended for printing or use as a handout.
The answer numbers are used only to label response columns. They are NOT scores and should not be used for calculating results.