OBJECTIVES: The objective of this study is to assess the translatability of “distressed” and to explore conceptually equivalent alternatives. The term has been observed to cause difficulties during translation of Clinical Outcomes Assessments (COAs), thus warranting further investigation. METHODS: Using Qualtrics, a web-based survey distribution service, a questionnaire was sent to 52 linguists who recently translated “distressed” in a questionnaire. They were asked if they faced difficulties in translating the term, to elaborate on these difficulties if applicable and provide conceptually equivalent alternatives. Additionally, cognitive debriefing results of “distressed” were analyzed. RESULTS: Out of 52 linguists, 29 responded to the questionnaire. Sixty-two percent (62%) of respondents (18 /29) stated that “distressed” was difficult to translate. Synonyms presented by all sample members show that “distressed” lacks conceptual equivalency across languages. The most common synonyms provided were “suffering,” “affliction,” and “sorrow,” showing variation in the way respondents interpret emotional pain associated with “distress.” Four respondents indicated that “distressed” could refer to physical or emotional pain in their language. Two respondents reported that their language had multiple terms which correspond to “distressed.” Nine languages were available for cognitive debriefing analysis. “Distressed” appeared to be problematic for four out of the nine languages. Although minimal issues were found with the term during debriefing, some subjects claim the term to be ambiguous or inappropriate for use in patient questionnaires, which is concordant with linguist feedback. CONCLUSIONS: Results show that “distressed” can be difficult to translate, due to its ambiguity in describing adverse effects.  When developing a source item measuring distress, it is recommended that multiple alternatives such as “despair,” “mental suffering,” and “anxiety” be measured in lieu of a single item on “distress,” as the suggested alternatives can neither be ambiguous nor misconstrued.