Methods of Life Stress Assessment

Introduction Investigator-Based Methods vs. Respondent-Based Methods Assessment Methods Covered in this Review References

This review was authored by Barbara Anderson.

Introduction
Life stress has been posited as a key mechanism in the etiology and course of both psychological and physical health outcomes. The extant evidence to date has been inconsistent and as such has lead some researchers to suggest that stress per se does not play a major role in determining health outcome. Other researchers, however, have argued that different results across studies emerge from the use of different measurement strategies. In this respect, two research traditions of paradigmatic status are associated with the assessment and measurement of life stress: 1. Respondent-based assessment, based on the use of self-report checklists in which respondents are ask to identify the events they have experienced from a standard list of options. 2. Investigator-based assessment, typically involves the use of a semi-structured interview to elicit descriptions of occurrences. These descriptions are then presented to a panel of raters who define events and chronic difficulties as well as ratings along various theoretical dimensions. Hence, an important distinction between these two methods lies in the notion that for investigator-based approaches the primary responsibility for defining and categorizing life stress resides with the investigator not with the respondent. In other words, the final interpretation of an occurrence as a life event or chronic difficulty as well as the ratings assigned to that occurrence (e.g., severity or threatfulness, independence, etc.) are made by trained researchers in conjunction with the respondents self-report, omitting any information about the respondents actual reaction to the occurrence. These ratings are referred to contextual and/or objective ratings as opposed to subjective ratings that are the product of respondent-based or self-report checklists. In fact, a consensus is emerging in the literature that the assessment of contextual or objective factorsthe personal and psychosocial setting in which a stressor occursis a key consideration in understanding the relationship between that stressor and outcome (Thoits, 1995). In this respect, the definition of stress as well as its effects can be viewed as a process through which environmental events are interpreted by people, in relation to own values and resources and responded to psychologically, behaviorally, and biologically, (Herbert & Cohen, p. 295, 1996). Thus, a focus on contextual factors (e.g., biographical circumstances, chronic difficulties, etc) that elucidate the meaning of a particular stressor to a particular person within a process framework may help to account for the variability in response to that particular stressor.

The reliance on self-report checklists makes it exceedingly difficult to evaluate context or objective features of a particular occurrence. For example, a checklist item such as pregnancy may be associated with a different level of stressfulness for an unmarried woman with little financial or emotional support than for a happily married woman who has planned for the event in a stable financial position. In contrast, investigator-based methods attempt to provide a more accurate index of the objective severity of an occurrence by examining the context for each occurrence. In general, though researchers need to choose measures that most likely assess their conceptualization of life stress.

Investigator-Based Methods vs. Respondent-Based Approaches

1. Data Collection Parameter Method of data collection Definition of stressor Data recoding Training necessary Respondent burden Researcher burden Cost of implementation Respondent-based Self-report questionnaire Respondent Paper/computer-assisted NO Low Low Low Investigator-Based Interview Investigator Audio recorder YES High High High

2. Standardization/ Precision of Measurement Parameter Number of possible events Standardization of Probes Precise criteria for defining events and/or difficulties Distinguish acute from chronic occurrences Distinguish events/difficulties from dependent variable Establish independence of event/difficulty Establish dating of events/difficulties Establish temporal relations between events and/or difficulties and outcome measures Respondent-based Usually fixed Fully standardized No Investigator-Based Open Flexible Yes

No

Yes

No

Yes

No

Yes

Not fully

Yes

No

Yes

Advantages of Investigator-Based Measures of Life Stress Assessment The magnitude of association between life stress and illness has been modest when employing self-report measures. However, in a broad range of studies, the LEDS has achieved substantially stronger effects sizes than self-administered measures have (see Brown & Harris, 1989). Investigator based methods are better suited for assessing objective features of life circumstances, which is consistent with the stimulus-based model of psychological stress. Checklists have demonstrated poor inter-rater reliability, low test-retest reliability, and limited validity (see Gorman, 1995 for a review). Investigator-based methods have developed several strategies to control for measurement errors and biases in the identification, dating, and evaluation (e.g., severity) of life events and chronic difficulties. Investigator-based methods allow for greater precision in the definition of the types of stressors (e.g., acute versus chronic, life domain, etc.) as well as precision in dating relative to the timing of exposure and outcome.

Disadvantages of Investigator-Based Measures of Life Stress Assessment The cost of implementation is significantly more than that cost involved in the administration of a self-report measure: o o o Training is necessary. Respondent/investigator burden in terms of time and effort for administration is considerable. Rating and independent review of ratings can take considerable effort and time.

There are other research considerations to take into account: o o Investigator based methods are not widely used in the literature because of cost and training considerations so comparisons across studies remain problematic. Extant evidence supporting their use in terms of predictive validity is limited. Given respondent/investigator burden they may not be suitable for large-scaled studies.

Assessment Methods Covered in this Review

This review will be divided into three sections. In the first section, we have started with a brief review of the LEDS since it is considered to be the gold standard of the investigator-based methods of life stress assessment. A brief description of other investigator-based methods is provided at the end of this first section. Forthcoming in the second section will be a review of respondent-based questionnaires of life events as well as the questionnaire assessment of daily hassles. The third section will review the instruments available to assess the respondents perception or feelings of stress. LEDS and Investigator-Based Methods Respondent-Based Questionnaires (forthcoming) Available Instruments (forthcoming)

References
Cohen S, Kessler RC, Underwood Gordon L: Measuring stress: A guide for health and social scientists. New York: Oxford University Press, 1995. Dougall AL, Baum A: Stress, health, and illness. In: A Baum, TA Revenson, JE Singer (Eds.), Handbook of health psychology. Mahwah, NJ: Lawrence Erlbaum Associates, 2001. Brown GW, Harris TO: Life events and illness. New York: The Guilford Press, 1989. Cohen S, Kessler RC, Underwood Gordon L: Measuring stress: A guide for health and social scientists. New York: Oxford University Press, 1995.

Gorman DM: A review of studies comparing checklist and interview methods of data collection in life event research. Behav Med 9(2):66-73, 1993. Katschnig H: Life events and psychiatric disorders: Controversial issues. Cambridge: Cambridge University Press, 1986. Kessler RC: The effects of stressful life events on depression. Annu Rev Psychol 48:191214, 1997. McQuaid JR, Monroe SM, Roberts JE, Johnson SL, et al: Toward the standardization of life stress assessment: Definitional discrepancies and inconsistencies in methods. Stress Med 8(1):47-56, 1992. McQuaid JR, Monroe SM, Roberts JE, Kupfer DJ, Frank E: A comparison of two life stress assessment approaches: Prospective prediction of treatment outcome in recurrent depression. J Abnorm Psychol 109(4): 787-791, 2000. Wethington E, Almeida D, Brown GW, Frank E, Kessler RC: The assessment of stressor exposure. In: A Vingerhoets (Ed.), Assessment in Behavioral Medicine (pp. 113-134). New York: Taylor & Francis Inc., 2001. Zimmerman M: Methodological issues in the assessment of life events: A review of issues and research. Clin Psychol Rev 3:339-370, 1989.

Investigator-Based Methods of Life Stress Assessment

An Example of Contextual Assessment: Life Events and Difficulties Schedule (LEDS) LEDS (Life Events and Difficulty Schedule) SEPARATE (The Standardized Event Rating System) DAS-C (The Detroit Couples Study Life Events Methods) Munich Events List Paykel Brief Life Events List List of Recent Experiences SLI (Structured Life Events Inventory) Hammen Life Stress Interview Kendler Life Stress Interview SLEDS (Stressful Life Events and Difficulties Interview

An Example of Contextual Assessment: Life Events and Difficulties Schedule (LEDS)

The most comprehensive and well-documented example of an investigator-based assessment of life stress is embodied in the methodology developed by Brown and Harris (1979, 1989). In fact, many of the variations of investigator-based methods that have emerged in the literature

attempt to include some of the conceptual features of contextual assessment defined by Brown and Harris. Briefly, the Life Events and Difficulties Schedule (LEDS) consists of a three part process: 1. Interview The LEDS is a semi-structured interview used to gather as full and coherent an account as possible in 10 domains (e.g., work, finance, relationships, etc.) or broad categories of life stress. It takes into account a persons biographical circumstances. Once the occurrence of an acute or chronic stressor is established, a second level of probing allows the interviewer to specify various aspects of the event or difficultys meaning for the individual by establishing the life circumstances of the individual at the time the event or difficulty occurs. Several strategies have been developed to ensure the accurate dating of occurrences aw well as their temporal relationship to each other over the period of observation.

2. Rating Procedure The LEDS is rated with respect to severity of threat and a variety of other dimensions (e.g., independence, focus, etc.). By assessing the level of threat associated with an event or difficulty, the rater makes a judgment as what most persons in such circumstances would be likely to experience. In doing so, the rater takes into account what is known of the persons plans, purposes, and commitments to their role areas as reflected in his or her biographical circumstances. The LEDS relies on a system of measurement particularly concerned with controlling respondent biases often overlooked by other methods and protecting equally well against various interviewer/rater biases. The LEDS manuals provide standard criteria for 1) defining whether an occurrence is an event or chronic difficulty and 2) for rating core dimensions (e.g., threat or severity, independence, etc.). Precedent examples in the manuals, organized by domain, are used to calibrate the ratings. These standard rating procedures prevent interviewers and raters from allowing the respondents symptoms or reported emotional responses to influence these ratings.

3. The Consensus/Expert Rater Process The manuals are also used in the consensus process (a panel of two or more trained rater) to ensure standardization of ratings as well as to provide a check on interviewer bias (an attempt to reduce the interviewers subjective reaction to the narrative provided by the respondent). The consensus process provides a final product or life stress profile consisting of a temporal sequence of events and difficulties.

LEDS (Life Events and Difficulty Schedule)

Brown GW, Harris TO: Social Origins of Depression: A Study of Depressive Disorder in Women. New York: Free Press, 1978. Description: The LEDS is the most widely used investigator-based life stress assessment measure (see above for details). The LEDS has been used in studies involving both physical and mental health outcomes in community-based as well as patient-based populations. In its present form, the LEDS requires significant investigator and/or research personnel training. The rating procedures are manualized, that is, manuals are available that for rating both events and difficulties as well as providing dictionaries of precedent examples that serve to standardize ratings across several dimensions. Limited data is available that indicates that it appears to be very reliable especially with comparisons to respondent-based measures.

SEPRATE (The Standardized Event Rating System)

Dohrenwend BP, Raphael KG, Schwartz S, Stueve A, Skodol A: The structured event probe and narrative rating method for measuring stressful life events. In: L Goldberger, S Breznitz (Eds.), Handbook of Stress: Theoretical and Clinical Aspects (pp. 174-199). New York: Free Press, 1993. Description: The SEPRATE is derived from the PERI (Psychiatric Epidemiology Research Interview) life events checklist and consists of 84 individual items for which a respondent endorses as occurring (yes) or not occurring (no). For those items that are endorsed as occurring, an interviewer uses a number of structured probes to provide a narrative description of each occurrence and to produce a standardized assessment of several rating dimensions including magnitude of change brought about by the occurrence, desirability of the occurrence, disruptiveness to daily routines, independence from the respondents behavior, etc. Unlike the LEDS, the SEPRATE does not appear to differentiate between acute occurrences and chronic difficulties. However, similar to the LEDS, the SEPRATE has manualized interview and rating procedures such that extensive training is required for the investigator and/or research staff. Primarily, the SEPRATE has been used with adult community and patient samples; it does not appear to have been widely used in studies of physical health outcomes. Limited data is available with respect to reliability.

DAS-C (The Detroit Couples Study Life Events Methods)

Kessler RC, Wethington E: The reliability of life event reports in a community survey. Psychol Med 21:723-738, 1991. Description: Similar to the SEPRATE, this interview uses a checklist to ascertain the occurrence of a particular life event. Then, a series of standard domain-specific queries along with semi-structured probes (these probes are used to assess meaning) are used to make objective ratings of stress severity. Similar to the LEDS, acute life events are differentiated from chronic stressors (difficulties). The authors note that even with the probes used to assess

meaning not enough contextual information is collected to approximate the contextual severity ratings made in the LEDS. An important feature of this measure is the development of techniques to improve recall and accurate dating of life events. The measure appears to have acceptable psychometric properties overall. Use of this instrument requires training but the authors indicate a significant reduction in training time, interviewing time, and coding time when compared to the LEDS. This measure was designed to be used in large-scale community surveys.

Munich Events List

Wittchen H, Essau CA, Hecht H, Teder W, Pfister H: Reliability of life event assessments: Testretest reliability and fall-off effects of the Munich Interview for the Assessment of Life Events and Conditions. J Affect Disord 16:77-91, 1989. Description: This interview measure consists of 85 concretely specified event descriptions for which the respondent indicates whether the event has occurred in the timeframe of interest. For those event descriptions endorsed as occurring, the respondent is queried for relevant context. Subjective (respondent-based) and objective (interviewer-based) ratings of severity are made on several dimensions (gain or loss, positive or negative impact, independence from respondents behavior) for each event endorsed. Limited data on its psychometric properties is provided by the authors but it appears to be adequate. No information is provided with respect to the time (and costs) involved in training, interviewing, and rating the interviews.

Paykel Brief Life Event List

Paykel ES: The interview for recent life events. Psychol Med 27:301-310, 1997. Description: This interview measure consists of 63 life event and difficulty questions. Each endorsement by the respondent is followed by a series of semi-structured probes used to ascertain objective features of the occurrence. Two independent raters rate each occurrence along several dimensions including independence, negative or positive impact, and objective severity of impact based on context. Training is required (three weeks) for rating the interview. Some reliability data is available and appears to be adequate. The interview has been used in a number of studies with adult community samples and patient samples.

List of Recent Experiences

Henderson S, Byrne DG, Duncan-Jones P: Neurosis and the Social Environment. New York: Academic Press, 1981. Description: This interview measure is based on a life events scale developed by Tennant and Andrews (1976). Again, once one of the enumerated life events is endorsed by the respondent, probes are used to ascertain dating, to obtain a brief description of the occurrence, and to obtain a respondents rating regarding the severity of impact. The method distinguishes

between discrete life events and ongoing chronic difficulties. Independent raters are used to objective ratings of severity. The authors report on test-retest reliability which appears to be more than adequate. No information is provided with respect to the time (and costs) involved in training, interviewing, and rating the interviews. The method has been used with adult community samples and patient samples.

SLI (Structured Life Events Inventory)

Wethington E, Kessler RC, Brown GW: Training Manual and Technical Report for the Structured Life Events Inventory. Ithaca, NY: Life Course Institute, Cornell University, 1993. Description: The SLI was designed to be a more structured version of the LEDS (more consistent with standard survey techniques) with the purpose of reducing the amount of time required for training as well as for producing contextual ratings similar to those available from the LEDS. The method consists of two sets of probes for each life domain: 1) probes sequences are designed to filter out events that are determined not to reach threshold for severity, and 2) for those events deemed to be above threshold, additional probe sequences are administered that attempt to clarify the circumstances surrounding the event. In addition, the interviewer has the option of probing further in a less structured fashion to ascertain any other information thought to be needed to make the contextual ratings. For each event, ratings are made by interviewers for contextual severity, event type, independence, and focus which are similar in concept to the LEDS ratings. The method is manualized and requires training. Importantly, the authors provide some preliminary data from a study designed to examine the reliability and validity of the structured version, in comparison to the LEDS. Most noteworthy is the considerable reduction in time for training, interviewing, and rating of the SLI in comparison to the LEDS. SLI interviewers were able to reliably distinguish severe events from non-severe events, however, the LEDS appears to be superior in eliciting and rating chronic difficulties. The LEDS and SLI appeared to compare favorably with estimating the risk of depression onset. This method has only been used with adults.

Hammen Life Stress Interview

Hammen C, Mayol A, DeMayo R, Marks T: Initial symptom levels and the life event-depression relationship. J Abnorm Psychol 95:14-112, 1986. Description: This interview schedule is based on an events list developed by Paykel and Mangen (1980) and modeled after the contextual threat approach used in the LEDS. Similar to the LEDS, once an enumerated event has occurred, the respondent is queried regarding the date and details surrounding the occurrence including duration of the occurrence, expectedness of the occurrence, previous exposure to similar occurrences, available resources and support, consequences of the occurrence, and any other relevant background. An independent rating team then rates each of the narratives prepared by the interviewer for each occurrence. As with LEDS event and difficulty descriptions, any specific information about how the respondent felt or reacted to the event is omitted from the narrative. Objective ratings for threat and independence are made by the rating team and not the respondent or interviewer. This method has been used extensively by Hammen and her colleagues in studies of unipolar depression

that have included non-depressed samples as well as respondents with medical conditions. Inter-rater reliability appears to be adequate for both the independence and threat ratings.

Kendler Life Stress Interview

Kendler KS, Karkowski L, Prescott CA: Stressful life events and major depression: risk period, long-term contextual threat and diagnostic specificity. J Nerv Ment Disord 186:661-669, 1998. Description: This interview schedule consists of probes designed to collect information on the occurrence of 11 event types occurring primarily to the respondent as well as four classes of events that occurred primarily to, or in interaction, an individual in the respondents social network. Similar to the LEDS, once an event has occurred, the respondent is queried regarding the date and details surrounding the occurrence. Interviewers make objective ratings of longterm contextual threat and independence. This method has been used extensively by Kendler and his colleagues in numerous studies involving both face-to-face interviewing as well as telephone interviewing.

SLEDS: (Stressful Life Events and Difficulties Interview)

Leserman J: Stressful Life Events and Difficulties (SLED) Interview: Training and Rating Manual for the PREDICT Study. Chapel Hill, NC: Department of Psychiatry, University of North Carolina at Chapel Hill, 2003. Description: This interview method is based on a modification of the PERI and includes 111 items. Once an enumerated event or difficulty has been reported, trainer interviewers use semistructured probes designed for each life domain to ascertain the dating and contextual circumstances surrounding the occurrence. Most noteworthy, is that the author(s) has developed a stress rating manual containing a detailed set of rating rules, norms, and vignettes for rating each of the 111 stresses that is conceptually-based on the LEDS ratings of contextual severity. Although, subjective ratings of stress are obtained from respondents for each event and difficulty endorsed, the contextual ratings of stress are made by raters independent of the respondents rating of threat as well as the respondents way of coping with the occurrence. The manual provides the standardization for these ratings. In this respect, the author reports that interrater reliability is good. Leserman and her colleagues have used the method in several studies examining the relationship between stress and disease progression in HIV infection.