Stress Measurement By Self-Report And Interview Research Paper

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The term ‘stress’ is used in a variety of different ways. Sometimes it is employed to refer to an experience of physical tension or distress stimulated by the environment and sometimes to the occurrence of events or experiences that are assumed to involve significant adaptive demands. In this latter case, the focus is on stressors, measured in terms of the occurrence of events and circumstances of stress-evoking potential. Even though it is useful to distinguish stressors from stress, the two terms are often used interchangeably. Despite varying characterizations of stress, Cohen et al. (1995, p. 3) have argued that all perspectives share a concern with the process in which ‘environmental demands tax or exceed the adaptive capacity of an organism, resulting in psychological and biological changes that may place persons at risk for disease.’

This research paper is focused on stress measurement in social as opposed to laboratory contexts. For that reason, strategies for assessing the environmental activation of physiological systems are not covered. Initial consideration will be given to measures of eventful stressors, which fall into two categories— those using a checklist approach and those that rely on data obtained in detailed interviews. This will be followed by brief discussions on the measurement of chronic stress and of exposure to major, potentially traumatic events.

1. Life Event Checklists

By far the largest amount of available evidence linking stress exposure to physical and mental health has come from studies employing checklist measures of social stress. Stimulated by Adolf Meyer’s life chart procedure, Hawkins et al. (1957) developed the Schedule of Recent Experiences (SRE). This 42-item questionnaire covered events in areas such as marital problems, relationship changes, work and residential changes, and family relationships. A decade later Holmes and Rahe (1967), elaborating on the SRE, developed the Social Readjustment Rating Scale (SRRS) by employing a panel of judges to rate the amount of adjustment each event would typically require. Although research has not supported the expectation that the weights derived from these ratings would improve estimates of stress exposure, their contribution to the face validity of event checklists was evidently substantial. Following the publication of the SRRS there was a huge outpouring of research on stressful life events and it was, for a considerable period, the best-known and most widely used instrument.

The conceptualization that initially informed the checklist approach was that an individual’s level of experienced stress was embodied in the cumulative amount of change or readjustment brought about by personal events occurring in the recent past (Holmes and Rahe 1967). This idea that the amount of change is the event property responsible for the stressful impact of life events seems to have been based on Selye’s (1956) contention that stress is comprised of nonspecific biological change elicited in response to environmental events and that even relatively small changes occurring in close succession can influence susceptibility and thus disease.

Over the years since the publication of the Social Readjustment Rating Scale (SRRS) there has been an active debate over its adequacy and about alternative approaches to measuring life events and to evaluating their stress-engendering properties. Indeed, at least 20 critical reviews of stressful life event methodology have been published since 1975 (Turner and Wheaton 1995). However, the checklist method has evolved in response to criticism, and a substantial array of different life event scales have been developed. Turner and Wheaton (1995) provide a nonexhaustive list of 47 different life event inventories—many targeted to specific age groups.

Despite several clearly justified criticisms and associated questions about the reliability and validity of resulting scores, the various published and unpublished life event inventories collectively represent the traditional, and still dominant, research procedure for estimating variations in stress exposure. A substantial preponderance of the now massive literature assessing the linkage between social stress and health is based on checklist measures of life stress. This literature has indicated a reliable association between life stress and the occurrence of both psychological distress and risk for physical health problems (e.g., Thoits 1983, Jemmot and Locke 1984).

A conclusion that seems to follow from the consistency with which these relationships have been observed is that, whatever the shortcomings of the method, event inventories yield meaningful estimates of stress exposure. However, there are two major challenges to this conclusion. One is the possibility that observed associations are an artifact of operational confounding arising from the fact the many checklists, perhaps the majority historically, have included items that are arguably symptoms of physical or mental health problems, or the consequences of such problems. Although evidence on this possibility has not been entirely consistent, the majority of studies have found that the relationships at issue persist, and are little attenuated, when potentially confounding items are removed from consideration (e.g., Tausig 1982).

The second challenge involves the hypothesis of reverse causality. Concern that illness or distress also produces either real or artifactually higher numbers of reported events has been a prominent theme within the life events literature. A crucial point in this regard is that the possibility that illness also causes stress exposure does not question the causal status of life event scores with respect to illness; it simply complicates the proper estimation of this causal impact (Turner and Wheaton 1995). In this connection, longitudinal studies consistently suggest that if one controls for prior or baseline distress or mental health, life events have a net impact on change in distress or mental health over time. Thus, at least with respect to mental health, where the causal direction debate has been most intense, the literature supports two essential criteria of causality: (a) statistical association, and (b) temporal precedence.

The primary remaining issue is the possibility of spuriousness in the apparent effect of life events on health outcomes. Although this explanatory hypothesis cannot be entirely set aside, the literature is filled with examples of studies that have attempted to control for confounding factors, and almost none that have claimed to explain away the life events—illness relationship (e.g., Kessler et al. 1985, Turner and Lloyd 1999).

1.1 Change Events Versus Negative Change Events

As previously noted, the conceptualization that guided developers of earlier event checklists was that change per se, whether positive or negative in nature, required adaptation and can have a stressful impact. Although this perspective continues to be represented among a number of prominent investigators, the majority of life event researchers have come to focus upon undesirable change assessed with lists containing only putatively negative events. The debate about whether it is change or undesirability that is relevant to the experience of stress is difficult to resolve because there is no wholly satisfactory criterion measure—at least not one that can be applied in field settings. However, a number of researchers have argued that power to predict distress or illness represents a reasonable criterion (e.g., Turner and Wheaton 1995). From this perspective, considerable evidence on the change versus undesirability issue has accumulated. Zautra and Reich (1983) published a review of 17 studies that examined the relationships of desirable and undesirable events to measures of psychological distress. They observed a consistent pattern of clear positive relationships with negative events in contrast to weak and contradictory findings with respect to positive events. Results suggesting the dominant significance of negative compared to positive events as risk factors for distress and illness have been quite consistent across a range of study populations, dependent variables, and life event inventories (Turner and Wheaton 1995). However, the conclusion that ostensibly positive life changes play no role in either elevating or conditioning stress experiences cannot be made with confidence. The mechanisms involved may simply be more complex than research has so far been able to reveal. The data do support the recommendation that, in the context of the limited time or space that characterizes most questionnaires, event checklists be restricted to events that are presumptively undesirable in nature.

1.2 Event Timing And Duration

Most checklist studies on the health effects of social stress have employed a one-year time frame for inquiring about experienced events. This time frame appears to be favored because it is regarded as long enough to obtain a reasonable estimate of variations in exposure to recent life events, and short enough to avoid the substantial decline in the ability of respondents to recall events that appears to occur beyond one year. In contrast, studies employing two-to five-year time frames have sometimes reported higher correlations than those that have considered shorter periods. In general, the choice of an appropriate time frame must involve consideration of the nature of the outcome of interest and the estimated or assumed causal lag of event effects for that outcome. When relatively long time periods are selected, group decline in event reporting can be investigated as a function of months prior to interview and cut-points for the time frame established based on the results.

In this connection, it should be recognized that the problem of reliability of reporting or of remembering, and the contention that stressors may be time limited in their effects, cannot be applied equally to all events that may be experienced. For example, it would rarely be the case that a subject would not remember, or fail to report in response to specific questions, that his or her parent had died, or child had died, or parents had divorced that he or she had served in combat, or had been physically or sexually assaulted. Evidence that a number of major events or circumstances are relevant to mental health and that the duration of their effects is closer to a lifetime than to one year suggests the utility of considering such events within efforts to index a person’s burden of stressful experience. The measurement of major, potentially traumatic events is discussed briefly below.

It is widely recognized that both discrete life events and relatively enduring problems are relevant to distress and illness. The experience of eventful stress may alter the meanings of existing strains, generate new strains, or magnify existing strains (Pearlin 1983). Alternatively, the impact of recent events may be amplified in the presence of chronic stress (Brown and Harris 1978). To test the idea that eventful and chronic stressors act synergistically requires the capacity to distinguish stressors within the two categories. Although life event checklists aim to assess discrete events, it is clear that some occurrences of a given event are time-limited in nature, whereas other occurrences of the same event may represent the beginning of a long-term difficulty.

In a large-scale community study (n 1561), Avison and Turner (1988) obtained information for each reported event on when it ended as well as when it had occurred. Analyses confirmed that event checklists routinely reflect differences in exposure to relatively enduring as well as discrete stressors. Moreover, none of the 31 negative events assembled by these investigators from established lists were found to be uniformly experienced as either discrete or chronic stressors. This research thus indicates that enduring or chronic stress is part of what is reflected in associations of checklist scores with health outcomes and that it is possible to distinguish its contribution. However, the enduring stressors that might be indexed within an event checklist are likely to be too limited and narrow to yield adequate estimates of variations in exposure to chronic stress. This issue is discussed further below.

1.3 Event Weighting

Considerable attention has been given to differential weighting of life events, presumably because the idea that there are no differences in impact potential across events is counterintuitive. There are several types of weighting, but the two most common are ‘objective’ ratings of change, or importance, or seriousness, of events by ‘judges,’ selected in random samples of defined populations, in purposive samples of individuals who have experienced the event being weighted, or by expert panels, and ‘subjective’ ratings assigned by individuals to their own events and considered only at the individual level. A primary difference between these two is the level of aggregation of the weight: objective weights reflect an average assigned by a group of raters; subjective weights involve self-reporting by the individual on how serious or stressful the event was for them.

Thus, ‘objective’ weights are attempts to capture differences in event characteristics that imply differences in impact potential that are applicable across individuals, whereas ‘subjective’ weights attempt to capture differences in impact potential associated with variations in the meaning of an event for individuals themselves. As noted above, despite numerous attempts to demonstrate otherwise, research has failed to yield evidence for the effectiveness of the ‘objective’ weighting of events. Nevertheless, some researchers have called for additional efforts, arguing that the issue is not yet settled (Turner and Wheaton 1995).

Concern about subjective weights most often revolves around the issue of confounding estimates of stress exposure with measures of outcome. Reports of illness or distress and of the seriousness or stressfulness of reported events may reflect the same domain of experience. This problem is arguably less serious when the outcome of interest is physical health status and, with longitudinal data, bias can be substantially reduced by partialling out the effects of events on later health. However, subjective weights are problematic in another respect: they tend to confound differential stress exposure with differential vulnerability to stress. The weight attached by a respondent to an event will be substantially a function of his or her capacity, real or perceived, to handle that event emotionally and/or practically. This capacity is largely determined by the individual’s coping skills and the availability of social and personal resources. Thus, subjective ratings confound the effects of stress mediators moderators with those of stress exposure and should therefore be avoided even in prospective studies and studies on physical health status.

2. Interview Measures Of Life Events

Interview measures are distinguished from the checklist approaches by their use of qualitative probes. These probes are employed to more precisely specify the characteristics of life events that might be stressful. The approach avoids the violence to logic implicit in assuming that widely differing events have equivalent stress-evoking potential by specifically attempting to establish the degree of severity of each event exposure (Wethington et al. 1995). Other major strengths of intensive interview measures include achievement of greater comprehensiveness of event coverage through flexible domain-specific elicitation and self-nomination of events not evoked by direct questioning, and the ability to establish the time ordering of stress exposure and health outcomes with greater confidence. The major disadvantage of interview measures is that they are extremely time-consuming and expensive relative to checklist methods.

2.1 Life Events And Difficulties Schedule (LEDS)

The Life Events and Difficulties Schedule (LEDS) is the most widely used personal interview method and has produced perhaps the most compelling evidence available for the role of stress in psychiatric disorder (Brown and Harris 1978). This semistructured instrument yields a narrative story of each experienced event that is used by investigators to rate the importance of events. These investigator-based ratings attempt to estimate what the impact would be in a specific context for the average person. It is the experience of a ‘severely’ threatening event or of a severe chronic difficulty that is hypothesized to increase risk for the occurrence of physical or psychiatric disorder. Severity is established through ratings of ‘long-term contextual threat,’ aided by the use of ‘dictionaries’ of examples of rated events and difficulties, the use of which requires a formal training course (see Wethington et al. 1995).

The considerable strengths of this approach are offset by the very high cost noted earlier. This fact, along with the extensive amount of time required to complete the rating process, may make the method unsuitable for large-scale community studies. From certain points of view, a second disadvantage is that the method, in evaluating social context within the severity rating process, ends up aggregating stress exposure with factors that may amplify or moderate its impact. That is, what has been described as the stress process is substantially represented in the ratings of contextual threat. Although this results in powerful predictions of health outcomes, information that is crucial to interventionists is obscured when the effects of stress exposure and of differential vulnerability are confounded. As Wethington et al. (1995) have noted, Brown and his colleagues continue to refine the measure to address this criticism, at least to some extent.

2.2 The Standardized Event Rating System

The Standardized Event Rating System (SEPRATE) utilizes a structured interview format to develop descriptions of each event or difficulty reported (Dohrenwend et al. 1993). In addition to the narrative description, the probes allow a standardized assessment of separate aspects of events and situations thought to condition level of stress experienced. A major difference from the LEDS interview is that material that might infer differences in stress vulnerability is stripped from narratives to avoid the inclusion of vulnerability estimates within event ratings.

This interview measure is relatively new and has not been as widely tested as the LEDS. Like the LEDS it is relatively expensive to use, is lengthy to administer, and requires specialized training from the authors.

3. Chronic Stress

Despite growing evidence that chronic stressors affect physical and psychological health, there have been few attempts toward comprehensive measurement of such stressors. The relative lack of attention in this area may arise from concern that reports of enduring role related or other stressors may be more a consequence or reflection, than a cause of disorder. A promising 51 item inventory has recently been offered by Wheaton (1997) who has presented evidence contrary to this concern about causal confounding. The inclusion of this measure, along with a life events checklist, has been shown to account for about 2.5 times as much variance in depressive symptomatology as typically reported in the literature (Turner et al. 1995). This measure assesses a wide range of role-related and role unrelated chronic stressors and the observation that it is unique association with depression suggests the need in future research for including a separate sampling of items addressed to the general domain of chronic stress. There is also a variety of less comprehensive questionnaires that deal with specific domains such as work or relationship strains. These have been enumerated and critiqued by Lapore (1995) and Herbert and Cohen (1995).

4. Lifetime Exposure To Major Traumatic Events

There is evidence that traumatic events or circumstances, individually or cumulatively, are relevant to mental health (Rutter 1989, Kessler and Magee 1993, Turner and Lloyd 1995). There appears to be a range of events that, presumably, can be reliably measured and that can have significant mental health consequences despite their occurrence years, or even decades, earlier. This argues strongly for the systematic inclusion of lifetime experience of such events as part of the effort to assess difference in stress exposure. Analyses should consider both the direct individual and cumulative effects of lifetime traumas and the extent to which they may condition the impact of more contemporaneous stressors. Brief inventories of major traumatic events are presented in Kessler and Magee (1993) and Turner and Lloyd (1995). However, because the nature of traumatic experience varies across populations and age cohorts, event selection and coverage should be specific to each study population.

It is important to understand that the health significance of social stress has never been effectively tested because we have yet to adequately measure differences in stress exposure. The conceptual consequences of this inadequate measurement can be profound. This is so because unmeasured group differences in stress exposure masquerade within research findings as group differences in vulnerability. Failure to take account of differences in traumatic stress or in the stress of discrimination can inappropriately suggest group differences in coping skills or other personal attributes relevant to adaptation. It seems clear that efforts to measure stress exposure should be as comprehensive as possible and take account of eventful stressors, more enduring strains, lifetime occurrence of traumatic events, and stress associated with discrimination and acculturation.

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