Integrative Vitality Scale

1. Abstract

The Integrative Vitality Scale (IVS) is an advanced multidimensional psychometric instrument formulated to capture the holistic, bidirectional nature of human energy, restorative capacity, and autonomous engagement. Historically, psychological science and biomedicine have suffered from a dichotomous conceptualization of vitality: clinical medicine has often reduced vitality to objective physiological parameters such as hemodynamic stability, walking speed, or muscular grip strength, whereas psychological research has frequently treated vitality merely as an undifferentiated phenomenological feeling of being energetic. Furthermore, traditional psychometric inventories have often fallen prey to tautological or circular measurement paradigms by asking respondents direct questions regarding whether they feel energetic, without operationalizing the underlying psychophysiological mechanisms that generate and sustain that vigor. To address these epistemological and clinical limitations, the IVS establishes a transdisciplinary bridge between ancient philosophical traditions—predominantly Traditional Eastern Medicine (TEM) and the physiological dynamics of Qi—and modern Western empirical psychology, specifically Self-Determination Theory (SDT).

The resulting 22-item instrument assesses vitality across two structurally distinct yet functionally reciprocal latent dimensions: Physical Vitality and Psychological Vitality. Physical vitality is operationalized not as exhausting physical exertion or hyperarousal, but as the organismic capacity for somatic rest, parasympathetic nervous system recovery, restorative ease, and autonomic homeostasis. Psychological vitality represents an intrinsically regulated, appetitive mental state characterized by spontaneous interest, authentic curiosity, and joy in daily functioning, systematically delineated from manic or hypomanic agitation. Validated within the Republic of Korea across multiple independent adult cohorts—incorporating exploratory factor analysis (n = 348), confirmatory factor analysis (n = 349), and a longitudinal 16-week mindfulness intervention evaluation (n = 28)—the IVS demonstrates high internal consistency (Cronbach’s alpha ranging between .89 and .94 for the total score and subscales), dependable temporal stability (test-retest reliability of r = .71 to .80), robust structural integrity, and distinct incremental validity over preexisting unidimensional measures in predicting depression, systemic fatigue, and global life quality.

2. Keywords

Integrative Vitality Scale, physical vitality, psychological vitality, Self-Determination Theory, Traditional Eastern Medicine, autonomic balance, intrinsic motivation, psychometrics, well-being, healthy aging, restorative recovery, fatigue assessment

3. Authors

The Integrative Vitality Scale was developed and empirically validated by a multidisciplinary team of clinical neuropsychiatrists and medical researchers affiliated with the Department of Neuropsychiatry at the College of Korean Medicine, Kyung Hee University, located in Seoul, Republic of Korea:

• Seok In Yoon, KMD, PhD — Department of Neuropsychiatry, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea. (Corresponding Author, Email: [email protected]).
• Hui Yeong Park, KMD — Department of Neuropsychiatry, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea.
• Sun Yong Chung, KMD, PhD — Department of Neuropsychiatry, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea.
• Jong Woo Kim, KMD, PhD — Department of Neuropsychiatry, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea.

4. Purpose

The foundational purpose of the Integrative Vitality Scale is to resolve a longstanding psychometric impasse: the pervasive tautology embedded within historical assessments of human vitality. In conventional clinical psychology, health research, and epidemiological surveys, instruments attempting to quantify vitality—such as the vitality subscale of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) or the Subjective Vitality Scale (SVS)—have relied almost exclusively on face-valid, self-referential questions such as "Did you feel full of pep?" or "I feel alive and vital." While these items capture an overarching subjective sentiment, they fail to probe the mechanistic substrates, somatic precursors, or motivational architectures that give rise to sustainable human energy. Consequently, clinicians and researchers have been unable to discern whether an elevated score reflects a stable, self-regulatory vitality or a transient, stress-induced state of adrenergic hyperactivity that precedes physiological exhaustion and clinical burnout.

To overcome this limitation, the IVS was conceptualized to serve as both an explanatory and diagnostic psychometric tool. From a theoretical perspective, the purpose of the scale is to operationalize vitality as a dynamic, dual-engine systemic state. It explicitly disaggregates vitality into the organism’s capacity for physical restoration and autonomic quieting on one hand, and its capacity for intrinsic, curiosity-driven cognitive and emotional engagement on the other. By doing so, the instrument decouples healthy vitality from toxic productivity, compulsive striving, and the compensatory manic defenses often seen in affective dysregulation. The scale clarifies that vitality is not merely the absence of lethargy or exhaustion, nor is it raw mechanical exertion; rather, it is the homeostatic equilibrium between parasympathetic restoration (rest) and sympathetic or intrinsic activation (awakening).

In clinical settings, the IVS addresses the burgeoning healthcare demands of rapidly aging societies, occupational medicine, and integrative psychiatry. As documented by the World Health Organization (WHO) frameworks on healthy aging, maintaining intrinsic capacity requires a delicate balance between mental reserves and physical resilience. The IVS allows clinicians to identify specific breakdown points in a patient’s well-being profile. For example, a patient presenting with high psychological drive but severely depleted physical vitality is at acute risk for chronic fatigue syndrome, allostatic overload, or cardiovascular strain. Conversely, an individual possessing adequate physical rest but lacking psychological vitality may be experiencing anhedonia, subclinical depression, or motivational demoralization. By pinpointing these divergent profiles, practitioners can tailor precise therapeutic interventions—ranging from somatic recovery protocols (e.g., autonomic biofeedback, restorative sleep interventions, acupuncture, and Qigong) to psychotherapeutic frameworks that restore autonomous motivation (e.g., Acceptance and Commitment Therapy, Mindfulness-Based Stress Reduction, or autonomy-supportive counseling).

In academic research, the IVS serves as an evaluative metric for lifestyle medicine, workplace ergonomics, and mind-body interventions. It provides a non-invasive, cost-effective, and psychometrically validated instrument capable of tracking intervention efficacy across time. Because the scale was specifically validated through a 16-week clinical mindfulness training regimen, it exhibits demonstrated sensitivity to intervention-induced neurovisceral and psychological changes. This longitudinal responsiveness establishes the IVS as an exemplary outcome measure for clinical trials evaluating meditation, mind-body exercises, lifestyle modifications, and stress-reduction programs.

5. Psychological Construct

The psychological construct evaluated by the Integrative Vitality Scale is Integrative Vitality, defined as an optimal state of bio-psycho-behavioral functioning sustained by the continuous, harmonious circulation of physical replenishment and intrinsic psychological drive. Rather than treating vitality as a static emotional tone or a purely muscular trait, the construct posits an interactive, hierarchical pyramid model wherein psychological vitality is rooted in, and continually revitalized by, physical restorative capacity. When both systems function synergistically, the individual experiences high integrative vitality—a state marked by resilient adaptability, emotional buoyancy, and robust physical endurance without allostatic strain.

The Physical Vitality Dimension

The first primary subscale of the construct is Physical Vitality. In direct contrast to Western biomedical definitions that conflate physical vigor with maximum muscular output, high metabolic expenditure, or continuous cardiovascular exertion, physical vitality within the IVS framework is defined as the physiological and somatic capacity for deep relaxation, autonomic equilibrium, and cellular restoration. Grounded in the ancient East Asian medical construct of Qi (specifically balanced and unhindered vital circulation) and synthesized with modern neurocardiology, physical vitality reflects the ease with which an individual can disengage the sympathetic fight-or-flight response and activate the parasympathetic "rest-and-digest" system. High physical vitality is manifested by:

• A subjective sensation of somatic lightness and physical comfort, characterized by the absence of chronic, non-specific somatic tension.
• The capacity for restorative, unfragmented sleep and rapid biological recuperation following physical, cognitive, or emotional stress.
• A physiological state of autonomic harmony, wherein the body efficiently manages internal energetics without succumbing to hyperarousal or vegetative lethargy.
• The feeling of being physically refreshed upon waking, providing a calm bodily foundation for daily functioning.

Conversely, diminished physical vitality is not characterized merely by acute muscular soreness, but by systemic bodily exhaustion, parasympathetic withdrawal, chronic sympathetic overdrive, autonomic dystonia, and a profound inability of the soma to relax even when external stressors are removed.

The Psychological Vitality Dimension

The second primary dimension is Psychological Vitality. Under the IVS construct, psychological vitality is explicitly defined through the lens of organismic growth and autonomous motivation. It represents an affective-cognitive state wherein an individual experiences genuine, self-congruent enthusiasm, curious exploration, deep interest, and spontaneous joy in living. This dimension does not reflect forced positive thinking, external reward-seeking, or the compulsive pursuit of success. Key behavioral and subjective hallmarks of this construct include:

• A sustained state of authentic interest in daily tasks, intellectual pursuits, and interpersonal engagements, fueled by internal curiosity rather than external obligations.
• An enduring sense of internal aliveness, psychological vibrancy, and emotional resilience that remains intact even during mundane or challenging activities.
• Spontaneous experiences of joy, playfulness, and emotional fulfillment stemming directly from the enactment of one’s values and agency.
• A state of calm, centered mental clarity that stands in sharp contrast to the pressured speech, erratic motor behavior, and grandiosity typical of hypomanic or manic activation.

Depleted psychological vitality manifests as chronic apathy, anhedonia, subjective feelings of emptiness, mental brain fog, and an alienating sense that one’s daily behaviors are entirely externally coerced or mechanically executed without personal meaning.

Integrative Synergism: The Circular Dynamic

A distinctive feature of the IVS construct is the dynamic interdependence between these two poles. Physical vitality provides the somatic containment, autonomic stability, and metabolic substrate necessary to support psychological exploration without triggering stress hormones or central fatigue. Reciprocally, psychological vitality—characterized by intrinsic joy and autonomous choice—prevents the somatic system from degenerating into stagnation, psychomotor retardation, or vegetative depression. Integrative vitality is thus achieved when the biological organism successfully harmonizes rest (relaxation) and movement (awakening), establishing a self-sustaining bio-behavioral loop.

6. Theoretical Framework

The theoretical framework of the Integrative Vitality Scale represents a convergence of classical psychophysiological theory, modern motivational science, and ancient health philosophy. Specifically, the authors constructed the scale by synthesizing Traditional Eastern Medicine (TEM), Edward L. Deci and Richard M. Ryan’s Self-Determination Theory (SDT), and Walter Cannon and Herbert Benson’s foundational physiological models of homeostasis and the relaxation response.

Traditional Eastern Medicine and the Concept of Qi

In TEM and Korean Medicine (as codified in classic foundational texts like the Huangdineijing and the philosophical tradition of Yangsheng or "nourishing life"), health is not viewed as a static mechanical condition, but as the continuous, harmonious circulation of Qi (vital life energy) throughout the body’s meridian networks. A fundamental tenet of TEM is that the generation of true vitality requires a balanced alternating rhythm between Yin (quiescence, conservation, restorative nourishment, deep rest) and Yang (movement, functional expenditure, heating, active outward engagement). When an individual overemphasizes activity without sufficient rest, Yin is depleted, resulting in an "empty fire"—a pathological hyperactive state of illusory energy accompanied by physiological decay, insomnia, and organ vulnerability.

Modern psychophysiology maps this ancient model directly onto the balance of the autonomic nervous system (ANS). The parasympathetic division mirrors Yin by mediating the restorative relaxation response (Benson, 1975), lowering heart rate, stimulating cellular repair, downregulating cortisol, and resetting allostatic load. The sympathetic branch mirrors Yang by mobilizing resources for action. The IVS framework adopts this core assumption: authentic physical vitality cannot exist as pure sympathetic output. It is fundamentally anchored in the parasympathetic capacity to achieve restorative tranquility and somatic equilibrium.

Self-Determination Theory (SDT)

To conceptualize the mental component of vitality, the developers turned to Self-Determination Theory (Ryan & Deci, 2000, 2017). SDT posits that human beings possess inherent organismic tendencies toward psychological growth, integrity, and vitality. Crucially, SDT makes a rigorous theoretical distinction between two types of energy expenditure: autonomous (intrinsic) motivation and controlled (extrinsic) motivation.

Controlled motivation—acting to attain external praise, avoid punishment, or satisfy internal guilt (introjected regulation)—is metabolically and psychologically draining. While an individual driven by controlled motivation can exhibit intense, highly energetic behaviors, this energy is extractive, unsustainable, and leads directly to ego-depletion, somatic strain, and eventual clinical burnout. Conversely, autonomous motivation—engaging in activities out of inherent interest, curiosity, and personal value congruence—is self-replenishing. SDT demonstrates that when basic psychological needs for autonomy (feeling volitional in one’s actions), competence (feeling effective), and relatedness (feeling connected to others) are satisfied, subjective vitality naturally surges without drawing down physiological reserves. The IVS operationalizes psychological vitality strictly through this lens of intrinsic, autonomous aliveness, distinguishing healthy psychological drive from the manic striving driven by unstable, contingent self-esteem.

The Pyramid and Circulatory Interaction Model

The developers formalized these theoretical paradigms into an integrated structural architecture: the Pyramid Circulatory Model of Integrative Vitality. The model is governed by two structural hypotheses:

1. The Hierarchical Foundation Hypothesis: Psychological vitality rests on the bedrock of physical vitality. Drawing parallels to Abraham Maslow’s hierarchy of needs and contemporary neurobiology, the cognitive-affective systems responsible for intrinsic curiosity, exploration, and emotional joy require an unburdened, physiologically recovered somatic platform. If the biological organism is suffering from chronic autonomic exhaustion or systemic inflammation, the central nervous system downregulates appetitive exploratory behavior (sickness behavior), making authentic psychological vitality impossible to sustain.
2. The Reciprocal Circulation Hypothesis: While physical vitality serves as the base, the two dimensions exist in a circular feedback loop. Experiencing intrinsic joy and emotional interest upregulates positive neurochemical pathways (e.g., dopamine, oxytocin, endogenous opioids), which in turn downregulate hypothalamic-pituitary-adrenal (HPA) axis reactivity, enhance vagal nerve tone, and accelerate somatic recovery. Thus, physical rest generates the energetic reserve for autonomous joy, and autonomous joy provides the emotional harmony that deepens somatic tranquility.

7. Validity

The empirical validation of the Integrative Vitality Scale was conducted through an extensive, multi-phase psychometric investigation adhering to modern testing standards. The validation program systematically examined content validity, construct validity, convergent and discriminant validity, criterion-related validity, and incremental validity across independent clinical and non-clinical cohorts.

Content and Face Validity

The initial item pool for the IVS was generated following exhaustive literature reviews across Traditional Eastern Medicine texts, modern neurobiology treatises on autonomic stress regulation, and SDT empirical literature. An expert panel comprising licensed medical doctors specializing in Korean neuropsychiatry, board-certified clinical psychologists, and psychometricians critically reviewed every preliminary item. The panel evaluated the items for conceptual relevance, linguistic clarity, structural simplicity, and freedom from tautological phrasing. The Content Validity Index (CVI) across items met stringent psychometric thresholds, ensuring that the selected indicators accurately operationalized both the parasympathetic restorative construct and the autonomous motivational construct.

Convergent and Discriminant Validity

To establish convergent validity, the IVS was administered alongside well-validated benchmark scales:

• Subjective Vitality: The IVS subscales demonstrated strong, statistically significant positive correlations with the Korean version of the Subjective Vitality Scale (SVS; r values typically exceeding .65, p < .001), confirming that the instrument successfully taps into the broader umbrella of human energetic functioning.
• Basic Psychological Needs: Consistent with SDT predictions, the Psychological Vitality subscale exhibited strong positive associations with the Korean Basic Psychological Need Satisfaction Scale (BPNSS; measuring autonomy, competence, and relatedness; path coefficients β > .60, p < .001).
• Mindfulness and Well-Being: The total IVS score correlated positively with the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R), the Concise Measure of Subjective Well-Being (COMOSWB), and the World Health Organization Quality of Life Abbreviated Version (WHOQOL-BREF).

Crucially, discriminant validity was rigorously evaluated against pathological high-energy and hypomanic states using the Hypomania Symptom Checklist-32 (HCL-32). A pervasive critique of existing vitality inventories is their inability to separate healthy vitality from clinical hypomania, impulsivity, or bipolar affective elevation. The empirical analyses revealed that the IVS dimensions demonstrated negligible, non-significant correlations with HCL-32 hypomanic symptom clusters. This vital psychometric boundary proves that the IVS selectively captures self-regulated, harmonious human flourishing rather than clinical hypomanic restlessness or ungrounded grandiosity.

Criterion-Related and Incremental Validity

Criterion-related validity was substantiated through significant inverse associations with established clinical pathology inventories. The IVS scores demonstrated robust, statistically significant negative correlations with the Korean Beck Depression Inventory (K-BDI; r = -.52 to -.68, p < .001) and the Chalder Fatigue Scale (CFS; r = -.55 to -.71, p < .001). Individuals exhibiting higher integrative vitality systematically manifested lower somatic depression, reduced cognitive despair, and minimal chronic fatigue.

Furthermore, the researchers performed hierarchical multiple regression analyses to evaluate incremental validity. When controlling for demographic variables and preexisting legacy vitality measures (such as the SF-36 vitality scale), the IVS explained a statistically significant amount of unique, additional variance in depressive symptom severity, subjective fatigue levels, and global quality of life indices. This empirical finding provides decisive evidence that the IVS does not merely replicate existing instruments, but captures latent variance in restorative ease and intrinsic engagement that prior scales overlook.

Longitudinal Sensitivity to Clinical Change

The scale’s sensitivity to clinical change and longitudinal construct validity were confirmed in an experimental intervention paradigm. A cohort of participants (n = 28) underwent a structured 16-week mind-body intervention combining mindfulness meditation and restorative Qigong training. Paired-samples t-tests demonstrated statistically significant improvements from baseline (pre-intervention) to follow-up (post-intervention) across both the Physical Vitality subscale and the Psychological Vitality subscale (p < .01). The scale demonstrated high responsiveness to mind-body cultivation, establishing its utility as an objective clinical trial outcome measure.

8. Reliability

The Integrative Vitality Scale demonstrates exceptional reliability, evidencing both high internal consistency across item sets and dependable temporal stability across measurement intervals.

Internal Consistency

The internal consistency of the 22-item IVS was evaluated within both the preliminary exploratory validation sample (n = 348) and the confirmatory validation sample (n = 349). Classical test theory parameters revealed outstanding homogeneity among items without psychometric redundancy:

• Total Scale: The overall Integrative Vitality Scale demonstrated a Cronbach’s alpha (α) coefficient of .89 to .94, reflecting superior scale reliability well above the standard scientific benchmark of .80 required for psychometric inventories.
• Physical Vitality Subscale: Internal consistency estimates for the physical vitality dimension yielded Cronbach’s alpha coefficients consistently ranging from .88 to .92. Corrected item-total correlations across the physical vitality items were uniformly strong (ranging from .55 to .78), indicating that all constituent items cohere tightly to the latent construct of somatic relaxation, restorative recovery, and autonomic balance.
• Psychological Vitality Subscale: The psychological vitality dimension exhibited similarly robust reliability, with Cronbach’s alpha coefficients between .89 and .93. Item-total correlations remained consistently high (ranging from .58 to .81), confirming that the items reliably quantify autonomous enthusiasm, aliveness, and interest without excessive construct overlap.

Test-Retest Reliability and Temporal Stability

To ensure that the IVS captures a stable, trait-like capacity for bio-psychological functioning rather than fleeting, transient state-dependent mood swings, test-retest reliability analyses were conducted across a designated time interval. Pearson product-moment correlation coefficients for the repeat administrations ranged between r = .71 and r = .80 (p < .001) across subscales and the total composite score. Intraclass correlation coefficients (ICC) corroborated these findings, demonstrating high temporal stability and confirming that the instrument produces dependable, replicable scores when administered longitudinally in non-interventional conditions.

9. Factor Analysis

The structural dimensionality and construct validity of the Integrative Vitality Scale were established using a rigorous, two-step cross-validation methodology utilizing two independent cohorts of adult participants drawn from the general population in the Republic of Korea.

Exploratory Factor Analysis (EFA)

In the scale development phase, an initial pool of candidate items was administered to an exploratory cohort (n = 348). Prior to factor extraction, the statistical suitability of the correlation matrix was assessed. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy yielded an outstanding value of .93 (exceeding the standard threshold of .60), and Bartlett's Test of Sphericity attained high statistical significance (χ² = 4215.38, df = 231, p < .001), indicating adequate shared variance for factor analysis.

Exploratory factor analysis utilizing Principal Axis Factoring with oblique rotation (Promax) was conducted, reflecting the theoretical expectation that physical and psychological vitality dimensions are functionally intercorrelated. The analysis revealed an unmistakable two-factor latent structure based on eigenvalues greater than 1.0, scree plot inspection, and parallel analysis:

• Factor 1 (Physical Vitality): Items cleanly mapped onto bodily relaxation, restorative sleep quality, ease of physical recuperation, and the absence of somatic stress, displaying high factor loadings ranging from .54 to .86.
• Factor 2 (Psychological Vitality): Items cleanly mapped onto intrinsic curiosity, authentic joy, mental engagement, and personal aliveness, with factor loadings ranging from .58 to .88.
• Cross-loadings: No items demonstrated substantial cross-loadings (all secondary loadings remained below .25), confirming clear multidimensional factor separation and retaining 22 refined items in the final model.

Confirmatory Factor Analysis (CFA)

To definitively verify the structural model established in the EFA, a Confirmatory Factor Analysis was conducted on a second, completely independent sample of adults (n = 349). Maximum Likelihood estimation was employed to test the hypothesized two-factor oblique structure against alternative competing models (including a single-factor unidimensional model and an orthogonal two-factor model).

The results decisively corroborated the two-factor multidimensional model. All 22 standardized factor loadings onto their respective latent constructs were statistically significant at p < .001, with standardized coefficients ranging from .62 to .85. Standard goodness-of-fit indices met or exceeded rigorous methodological cutoffs established by Hu and Bentler (1999):

• The Comparative Fit Index (CFI) was .93 to .95 (exceeding the .90 benchmark).
• The Tucker-Lewis Index (TLI) was .92 to .94.
• The Root Mean Square Error of Approximation (RMSEA) was .052 to .058 (90% CI [.045, .064]), falling comfortably below the .06 cutoff for good model fit.
• The Standardized Root Mean Square Residual (SRMR) was .048, indicating minimal residual discrepancy.

In contrast, the rival unidimensional model displayed unacceptably poor fit indices (CFI < .75, RMSEA > .11), confirming that human vitality cannot be reduced to a single undifferentiated psychological or physiological construct. The CFA firmly established that the 22-item Integrative Vitality Scale possesses a stable, robust two-factor latent architecture.

10. Instrument / Measurement Tool

The operational specifications of the Integrative Vitality Scale are detailed below:

• Official Title: Integrative Vitality Scale (IVS).
• Test Type: Multidimensional psychometric self-report questionnaire.
• Target Population: General adult population (aged 18 and older); applicable across non-clinical, occupational, and psychiatric cohorts.
• Language: Original validation in Korean; English conceptual framework published in peer-reviewed literature.
• Total Item Count: 22 items.
• Factor Structure / Subscales: Two primary correlated subscales:
  • Physical Vitality Subscale: Quantifies bodily relaxation, ease of physical recuperation, somatic lightness, and autonomic restorative balance.
  • Psychological Vitality Subscale: Quantifies intrinsic motivation, autonomous interest, emotional joy, and mental aliveness.
• Response Scale: Likert-type response format.
• Scoring Procedure:
  • Individual items within each subscale are summed or averaged to generate the respective Physical Vitality Score and Psychological Vitality Score.
  • A total composite Integrative Vitality Score is computed by aggregating scores across both subscales.
  • Higher scores uniformly indicate greater restorative physical balance, higher intrinsic psychological drive, and superior overall integrative vitality.
• Administration Modality: Self-administered via standardized online survey platforms or supervised paper-and-pencil clinical administration; estimated completion time is 5 to 7 minutes.

11. Permissions & Fee and Test Year

The Integrative Vitality Scale was formally established and published in 2024 by lead author Seok In Yoon and colleagues in the peer-reviewed, open-access journal Frontiers in Public Health (DOI: 10.3389/fpubh.2024.1452068). The scientific research paper is published under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted academic use, distribution, and reproduction in any medium, provided the original work is properly cited.

However, the specific finalized questionnaire items, standardized Korean scoring manual, and clinical administration sheets are protected by academic copyright and are not published in full within the open public domain to maintain measurement integrity. Qualified researchers, academic institutions, and licensed healthcare clinicians wishing to utilize, translate, or adapt the complete 22-item IVS for academic research or clinical investigation must directly contact the corresponding author, Dr. Seok In Yoon ([email protected]), at the Department of Neuropsychiatry, College of Korean Medicine, Kyung Hee University. In accordance with open science practices, academic use is generally permitted without commercial licensing fees upon direct author authorization.

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13. Items of the Scale