| 1. I feel psychological pain. | 1 | 2 | 3 | 4 | 5 |
| 2. I seem to ache inside. | 1 | 2 | 3 | 4 | 5 |
| 3. My psychological pain seems worse than any physical pain. | 1 | 2 | 3 | 4 | 5 |
| 4. My pain makes me want to scream. | 1 | 2 | 3 | 4 | 5 |
| 5. My pain makes my life seem dark. | 1 | 2 | 3 | 4 | 5 |
| 6. I can’t understand why I suffer. | 1 | 2 | 3 | 4 | 5 |
| 7. Psychologically, I feel terrible. | 1 | 2 | 3 | 4 | 5 |
| 8. I hurt because I feel empty. | 1 | 2 | 3 | 4 | 5 |
| 9. My soul aches. | 1 | 2 | 3 | 4 | 5 |