Journal of Abnormal Psychology
The Assessment and Measurement of Adult Life Stress:
Basic Premises, Operational Principles, and Design
Requirements
Kate L. Harkness and Scott M. Monroe
Online First Publication, June 2, 2016. http://dx.doi.org/10.1037/abn0000178
CITATION
Harkness, K. L., & Monroe, S. M. (2016, June 2). The Assessment and Measurement of Adult Life
Stress: Basic Premises, Operational Principles, and Design Requirements. Journal of Abnormal
Psychology. Advance online publication. http://dx.doi.org/10.1037/abn0000178
Journal of Abnormal Psychology
2016, Vol. 124, No. 4, 000
© 2016 American Psychological Association
0021-843X/16/$12.00 http://dx.doi.org/10.1037/abn0000178
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The Assessment and Measurement of Adult Life Stress: Basic Premises,
Operational Principles, and Design Requirements
Kate L. Harkness
Scott M. Monroe
Queen’s University
University of Notre Dame
Life stress is a central factor in the onset and course of a wide range of medical and psychiatric
conditions. Determining the precise etiological and pathological consequences of stress, though, has been
hindered by weaknesses in prevailing definitional and measurement practices. The purpose of the current
paper is to evaluate the primary strategies for defining and measuring major and minor acute life events,
chronic stressors, and daily hassles as informed by 3 basic scientific premises. The first premise concerns
the manner in which stress is conceptualized and operationally defined, and specifically we assert that
stress measures must not conflate the stress exposure with the stress response. The second premise
concerns how stress exposures are measured, and we provide guidelines for optimizing standardized and
sensitive indicators of life stress. The third premise addresses the consequences of variations in the
procedures for life event measurement with regard to the validity of the research designs employed. We
show that life stress measures are susceptible to several sources of bias, and if these potential sources of
bias are not controlled in the design of the research, spurious findings may result. Our goal is to provide
a useful guide for researchers who consider life stress to be an important factor in their theoretical models
of disease, wish to incorporate measures of life stress in their research, and seek to avoid the common
pitfalls of past measurement practices.
General Scientific Summary
Life stress is a key factor in causing disease. However, many of the most commonly used measures
for assessing life stress lack adequate reliability and validity. This paper critically reviews stress
measurement strategies and provides practical recommendations for incorporating the best stress
measures into research designs.
Keywords: chronic stress, daily hassles, measurement, stressful life events
medical conditions, including cardiovascular disease, diabetes, and
Alzheimer’s disease (e.g., Kershaw et al., 2014; Renzaho et al.,
2014). Despite the promise of life stress for understanding the
etiology and course of disease, research advances have been hindered by weaknesses in prevailing definitional and measurement
practices. Today’s research agendas increasingly are being shaped
by the groundbreaking scientific advances being made in the
identification and assessment of biomarkers for many diseases
(e.g., neuroimaging technologies, sophisticated epigenetic and proteomic assays). The environment crucially shapes biology and,
thus, research examining their integration is poised to make enormous contributions to the understanding of disease etiology. However, the measurement of life stress today relies largely upon
research practices that are insufficient for addressing contemporary research questions in a scientifically sound and sensitive
manner.
The purpose of the current paper is to evaluate existing practices
for defining and measuring life stress. We start by introducing
three premises based on scientifically sound principles intended to
help guide measurement practices and research in this domain. The
first premise concerns the manner in which stress is conceptualized
and operationally defined. Broadly considered, stress can be
viewed as involving the environmental challenges to which an
Theories pertaining to the origins of mental disorders, dating
back centuries, commonly include a strong causal role for stress.
Modern studies, using sophisticated prospective designs strongly
support etiological effects of stress for many of these disorders
(e.g., Brown & Harris, 1989; Cohen, Janicki-Deverts, & Miller,
2007; Kendler, Karkowski, & Prescott, 1999). Further, stress is an
important contributing factor in the onset and course of many
Editor’s Note. Constance Hammen served as the Guest Editor for this
article.—SHG
Kate L. Harkness, Department of Psychology, Queen’s University; Scott
M. Monroe, Department of Psychology, University of Notre Dame.
Preparation of this review was supported by a grant from the Social
Sciences and Humanities Research Council (435-2012-1536) awarded to
K. Harkness, and a Fellowship from the John Simon Guggenheim Foundation awarded to S. Monroe. We thank Katrina Milani for help in the
preparation of this manuscript.
Correspondence concerning this article should be addressed to Kate L.
Harkness, Department of Psychology, Queen’s University, Kingston, Ontario, Canada, K7L 3N6. E-mail: [email protected]
1
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HARKNESS AND MONROE
individual is exposed (i.e., stress exposure), or as the response to
these environmental challenges (i.e., stress response). We show
that these two different ways of assessing stress often have been
conflated and confused in theory and measures, leading to misunderstandings throughout the literature. The second premise concerns how stress exposures are measured. We provide guidelines
based on definitional procedures and operational principles that
have the potential to yield standardized and sensitive indicators of
life stress. The final premise addresses the consequences of variations in the procedures used in life stress measurement for the
validity of research designs. In particular, we show that life stress
measures are susceptible to several sources of bias, and that if
these sources of bias are not controlled in the design of the
research, spurious associations and misleading findings may result.
After initially expanding on the above three premises, we evaluate the primary approaches for assessing and measuring stress: (a)
major and minor acute life events and chronic stressors, and (b)
daily hassles. Within each of these domains we describe the types
of instruments commonly included, discuss their advantages and
disadvantages as informed by the three premises, and make recommendations. Our goal is to provide a valuable guide for researchers who consider life stress to be an important factor in their
theoretical models of disease, wish to incorporate measures of life
stress in their research, and seek to avoid the common pitfalls of
past measurement practices.
Premise One: Conceptualizing and Defining Stress
The first priority for research on the relation of stress to disease
is to provide a clear and consistent reference point for measurement. The term ‘stress,’ however, has two distinct components.
The measurement of stress can focus on the external environmental stressors to which individuals are exposed (e.g., Dohrenwend &
Dohrenwend, 1974). Alternatively, the measurement of stress can
focus on the responses to the external environmental exposures
(Selye, 1955).1 These responses include the psychological (e.g.,
feelings of psychic and somatic anxiety, depression) and physiological (e.g., sympathetic nervous system and hypothalamicpituitary adrenal cortical activation) reaction states of stress.
Within individuals over time, periods of higher stressful life event
exposure commonly are associated with higher stress responses
(e.g., anxiety, arousal, hypercortisolemia; McEwen, 2006), and
very chronic and high stress exposure may be associated with a
dampening of the stress response (e.g., anhedonia, hypocortisolemia; Harkness, Stewart, & Wynne-Edwards, 2011; Pizzagalli,
2014). Importantly, however, stress responses encompass a broad
collection of psychological and/or biological reactions that are
multidetermined. Although influenced by environmental exposures, stress responses are also influenced by a variety of other
factors (e.g., personality, behavior, cognitive style, genetic vulnerability and other trait biomarkers, early stress exposure, concurrent
chronic stress, and so on; see Figure 1).
There are significant consequences of the multidetermined nature of stress responses. First, one factor influencing stress responses is broad and enduring individual differences in peoples’
propensity to be stress reactive in the face of adverse environmental conditions (e.g., Ellis, Boyce, Belsky, Bakermans-Kranenburg,
& van IJzendoorn, 2011). This poses challenges for evaluating the
causal status of “stress.” Second, stress responses also can be
Figure 1. Stress exposure and the multi-determined nature of the stress
response. See the online article for the color version of this figure.
contaminated by precursors, concomitants, or consequences of the
disorder in question. In general, these concerns raise potentially
serious problems and threats to validity when focusing solely on
measuring stress responses.
Some examples of these points help to illustrate the relevance of
these concerns (see Figure 1). First, individuals high in Neuroticism show increased reactivity to identical stress exposures compared to those low in trait Neuroticism (Bolger & Schilling, 1991).
However, trait Neuroticism is also a strong risk factor for many
adverse outcomes, including depression (Bagby, Joffe, Parker,
Kalemba, & Harkness, 1995). Measuring only the stress response
may confound stress exposure with Neuroticism, rendering it impossible to determine whether stress exposures cause the depression onset, or whether Neuroticism accounts for the relation between stress responses and depression onset.
Extending this example into the realm of molecular psychiatry,
much has been made over the past decade about the reliability of
findings regarding the interaction of the 5-HTTLPR polymorphism
of the serotonin transporter gene with stress in depression (e.g.,
Karg, Burmeister, Shedden, and Sen, 2011). As documented by
Hariri et al. (2005), the short (s) allele of the 5-HTTLPR influences
amygdala hyperreactivity to stress. Therefore, similar to individuals high in Neuroticism, individuals with the s-allele of the
5-HTTLPR may show heightened reactivity to the same stress
exposure compared to those heterozygous for the long (l) allele.
Once again, potentially spurious relations with depression may
plague gene-by-environment research if genetic susceptibility (or
other biomarker) is allowed to ‘bleed into’ the measure of stress.
This is a crucial point that is rarely considered in the new realm of
biomarker research (Monroe & Reid, 2008).
Finally, measures used to assess the stress response may be
contaminated by the disease outcome under study. For example,
one common index of the stress response is output of the stress
1
Stress responses may also be viewed as a mismatch between the
environmental demands and the individual’s psychological and biological
resources to cope with those demands (Cohen, Evans, Stokols, & Krantz,
1986).
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LIFE STRESS MEASUREMENT
hormone cortisol in the face of laboratory stress exposure. Hyperor hypocortisolemia in the face of stress is well established in
depression (Burke, Davis, Otte, & Mohr, 2005), and dysregulation
of the hypothalamic-pituitary-adrenal (HPA) axis response to
stress may also represent a precursor in the development of depression (Waugh, Muhtadie, Thompson, Joormann, & Gotlib,
2012). If the research on the etiological role of “stress” in depression focuses solely on the measurement of psychological or biological stress responses, it becomes quite apparent how these
precursors or concomitants of depression could contaminate the
stress response measures, thereby spuriously influencing any association between the stress response and disorder.
Intractable problems arise when stress exposures and stress
responses are confused with one another or used interchangeably.
For example, a widely used measure of the psychological stress
response is the Perceived Stress Scale (PSS), which is a “measure
of the degree to which situations in one’s life are appraised as
stressful” (Cohen, Kamarck, & Mermelstein, 1983). The PSS
includes items such as, “how often have you found that you could
not cope with all the things that you had to do?,” and “how often
have you felt nervous and ‘stressed’?” (over the last month). The
PSS was designed to quantify subjective reaction states of stress.
However, the PSS often has been used mistakenly as a proxy for
environmental exposures. For example, many otherwise strong
studies present hypotheses or background information about the
relation of “external stressors” or “stressful events” to specific
outcomes, yet these studies measure “stress” with the PSS (e.g.,
Otte, McCaffery, Ali, & Whooley, 2007; Rosengren et al., 2015;
Treadway et al., 2015). As such, the construct of theoretical
interest (stress exposure) does not match the construct that is
measured (stress response, or ‘perceived stress’). Despite the
stated objective of these studies, the findings are not informative
for understanding stress exposures.
In contrast, it is appropriate to focus on the construct of stress
response for other research questions, as assessed by instruments
such as the PSS. Some examples from the recent literature include
studies investigating whether an online stress management program improves individuals’ levels of subjective stress and coping
(Hintz, Frazier, & Meredith, 2015), whether sleep deprivation
increases feelings of stress (Loft & Cameron, 2014), and whether
high levels of psychological stress predict particular outcomes
(e.g., do women who feel high levels of stress during pregnancy
have negative child outcomes? [Slykerman et al., 2015]). The
focus in these studies is on the individual’s trait/state of psychological stress, with no specific assumptions about how that maps
onto environmental exposures.
There are also research questions for which it is appropriate to
assess both stress exposure and stress response, and in many ways
this is the ideal design. For example, recent studies have sought to
understand individual differences in the correspondence between
objectively defined stress exposure and the neuroendocrine (e.g.,
Mazurka, Wynne-Edwards, & Harkness, 2015) and psychophysiological (e.g., Lampert, Tuit, & Sinha, 2011) stress response. In
general, the first priority for research on stress is to be clear and
consistent about the stress component under study, and to choose
a measurement strategy that is appropriate and does not confound
one with the other.
We focus specifically in the current review on stress exposures
and argue for the primacy of this component for several reasons.
3
First, theoretical models of stress-disorder relations are predicated
on the assumption that stress exposures precede and promote stress
responses that, in turn, have potentially pathogenic implications
for disease. Without the exposures, there are no responses. Second,
stress response systems evolved to enhance adaptation to diverse
environmental exposures and demands. It follows that stress responses have no meaning independent of stress exposures; they are
consequent to, and thereby a function of, variation in stress exposures. This directly implies that stress responses are meaningful
only when understood in the context of the different exposures
(i.e., adaptive demands) placed upon the organism. Indeed the
interaction between stress exposures and stress responses lies at
the conceptual heart of stress research (e.g., Hankin, Abramson,
Miller, & Haeffel, 2004; Monroe & Simons, 1991). Third, a
prerequisite for research on stress responses is the preliminary
demonstration of an association between some kind of stress
exposure and disease outcome. Otherwise, research on stress responses has no exposure effects to explain.2 Finally, the nature of
diverse exposures necessarily constrains the range of conceivable
responses, and thereby conceptually informs which kinds of responses are most likely to merit study. Overall, studying stress
responses without due attention to their hypothetical origins (i.e.,
what they are responses to) places the empirical cart before the
theoretical horse.
Premise Two: Operational Procedures and Guidelines
for Measuring Stress
Life events are defined as environmental changes that have a
definable beginning point in time and that would be expected to be
associated with at least some degree of psychological threat, unpleasantness, or behavioral demands. Examples of acute life events
include beginning or ending a romantic relationship, starting or
ending a job, being diagnosed with a serious illness, and so on.
Acute life events can vary in severity, or threat. Some acute events
are major and severe, such as getting fired from a job or finding out
that one’s child has been diagnosed with a terminal illness. Others
are more minor and less threatening, but still have some impact,
such as moving to a new apartment or spraining one’s ankle.
Chronic stressors are distinct from acute life events in terms of
their ongoing and enduring nature. Examples include prolonged
marital strife, dealing with a chronic illness, persistent financial
difficulties, or trouble finding employment. These, too, can vary
greatly in severity. In contrast, daily hassles are defined as quotidian incidents that are bothersome, annoying, inconvenient, and
expected to produce only a mild degree of negative emotion.
Although not necessarily occurring on a daily basis, hassles represent the annoying vicissitudes of daily life as opposed to major
2
An alternative position would be to focus on individual differences in
stress response, and to minimize or disregard the importance of variation in
exposures. From this perspective, a main effect of exposures on health
outcomes may not be readily evident, owing to the effect occurring only
within individuals who are highly stress reactive. However, even these
highly stress reactive people must be reacting to something, not just
anything. Without recognition of the types of exposures that elicit the
potentially pathogenic stress responses within these people, there are no
initiating or anchoring reference points for informing and circumscribing
the range of stress responses to be considered, and ultimately no interaction
between exposure and response for detecting adverse health outcomes.
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HARKNESS AND MONROE
or minor life events, which occur much more rarely. Examples of
hassles include “having to wait,” “preparing meals,” “wasting
time,” or “filling out forms” (Kanner, Coyne, Schaefer, & Lazarus,
1981).
Life events, chronic stressors, and hassles are intuitively appealing types of environmental exposures that possess considerable
face validity as indicators of life stress. Yet their apparent validity
undermines attention to the significant challenges they pose for
sound measurement practices. Given the ongoing stream of experiences in life, at what point does an acute or chronic exposure
become of sufficient magnitude to merit definition as a ‘life event’
or ‘chronic stressor’? For example, under what circumstances does
a recent illness or accident qualify as a ‘life event’ versus a ‘hassle’
(e.g., a heart attack or broken leg vs. a minor cold or stubbed toe)?
When does the recent loss of a relationship merit designation as a
‘break-up’ (e.g., a mutual decision to stop casual dating vs. breaking off of an engagement)? Similarly, stress exposures are often
inextricably intertwined (e.g., a loved one is in a car crash, and dies
a few days later; an infidelity is discovered, and a breakup follows
14 days later). Whether and under what circumstances these sequentially related events are defined as one, two, or more also
represent important operational decisions that need to be rendered
consistently.
Further, acute and chronic stressors possess distinct theoretical
implications for stress and illness (e.g., Hammen, Kim, Eberhart,
& Brennan, 2009; Monroe, Slavich, Torres, & Gotlib, 2007) and,
thus, each should be assessed. But this does not mean that they are
always entirely independent of one another (e.g., chronic financial
stressors may involve repeated financial problems or crises). Measurement practices need to avoid ‘double-dipping’ and potentially
confounding acute life events and chronic stressors. For example,
guidelines are required to determine when to collapse repeated
exposures into an overarching chronic stressor (e.g., marital disputes occurring on a regular basis factor into the rating of chronic
stress, but are not also each rated as separate acute life events). At
the same time, measurement practices need to reliably assess acute
life events that may be related to a chronic stressor, but that
represent a substantive increase in the stressful exposure (e.g.,
physical violence for the first time within an ongoing marital
difficulty). To assess stress exposures reliably, operational criteria
and severity thresholds are required and must be applied consistently across individuals. Sorting out these measurement premises
represents a substantial prerequisite task for the researcher.
When decisions regarding what experiences ‘count’ as stress
exposures are not defined a priori, and particularly when such
decisions are left up to the individual respondent, the problem of
‘intracategory variability’ becomes a major concern (Dohrenwend,
2006). That is, a variety of disparate experiences—major or minor
life events, chronic stressors, and hassles— can be assigned to the
same life event category by different respondents. For example,
one respondent might endorse the item ‘major personal injury or
illness’ in the case of a major heart attack, another respondent
might endorse the same item in the case of a minor cold, and yet
another respondent in reference to chronic asthma. In such circumstances, it is impossible to determine whether the experiences
endorsed by the respondent reflect what the investigator intends
them to mean, thus severely threatening the validity of the measure
and associated findings.
Premise Three: Research Design Requirements
Much as stress exposures and stress responses need to be kept
conceptually separate, exposures and responses need to be kept
methodologically separate. The concern is that information about
one component can bias the measurement of the other, resulting in
spurious associations and invalid inferences. For example, a researcher who learns that a study participant who recently lost his
job was highly distressed by the event may be inclined to rate the
exposure as highly stressful. In contrast, the researcher may rate
the exact same life event as less stressful for a different participant
if aware that this second participant was unfazed by the event.3 If
the stress exposure measure is biased by information regarding
stress responses, it is impossible to determine whether any relation
of the stress measure to disease outcome is due to the stress
exposure or to the psychological perceptions of, and responses to,
the stress exposure (Brown, 1974). The same logic mandates that
information about stress exposures needs to be kept separate from
information about the disease outcomes or risks. For instance,
researchers may be biased in rating the severity of chronic work
stress if aware that the participant had a recent heart attack or is a
heavy drinker, again resulting in potentially spurious associations
between stress exposure and disease outcome.
Overall, optimal measurement practices mandate independent
and blind assessments of exposures, responses, and outcomes. If
such precautions are not observed, the burden of scientific proof
falls upon the investigator to demonstrate that a parsimonious
alternative explanation (i.e., confounding of measures) does not
account for the observed associations.
Assessing Acute Life Events and Chronic Stressors
In this section we evaluate three general approaches for measuring major and minor acute life events and chronic stressors: (a)
Self-report checklists; (b) interview-derived systems in which the
interviewer performs the ratings; and (c) interview-derived systems in which independent coders perform the ratings. These
approaches for assessing life stress are summarized and compared
in Table 1.
To maintain a clear and consistent focus on recent stressful
exposures, we do not evaluate childhood or lifetime stress exposure measures (see Vanaelst, De Vriendt, Huybrechts, Rinaldi, &
De Henauw, 2012 for a review). There are many unique and
important considerations associated with measurement of distal
stress that go beyond the scope of the current review and that
require separate consideration (e.g., lengthy recall periods, use of
third-party informants, developmental considerations, etc.). We
also do not cover proxy measures of stress exposures (e.g., socioeconomic status; e.g., Winkleby, Jatulis, Frank, & Fortmann,
1992), traumatic stress measures (see Norris & Hamblen, 2004 for
a review), or laboratory paradigms of stress exposure (see Dickerson & Kemeny, 2004 for a review). A final topic that is beyond
the scope of the current paper, yet is worthy of more empirical
attention, is the use of ‘objective’ or group-based stress exposures;
that is, studies in which all participants have been exposed to the
3
This is a symmetrical methodological concern. For investigators interested in stress responses, awareness of the ratings of stressful exposures
can bias ratings of the responses.
LIFE STRESS MEASUREMENT
5
Table 1
Comparison of Methods for Assessing Life Stress
Acute life events and chronic stressors
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Measure feature
Training required
Participant burden
Researcher burden
Cost
Who defines the stressor?
Who rates the stressor?
Are ratings of stress exposure independent
of stress response?
Are ratings of stress exposure independent
of disease state?
Allows for precise dating?
Distinguishes acute events from chronic
stressors?
Distinguishes major from minor stressors?
Provides guidelines for sequential and
complex events?
Provides anchoring examples for
standardization of rating
Daily hassles
Self-report
checklists
Interviewer-rated
contextual
interviews
Blind-rater
contextual
interviews
Self-report
checklists
Investigator-based
interview
Experience sampling
with independent
ratings
NO
LOW
LOW
LOW
Respondent
Respondent
YES
HIGH
MEDIUM
MEDIUM
Investigator
Interviewer
YES
HIGH
HIGH
HIGH
Investigator
Raters
NO
LOW
LOW
LOW
Respondent
Respondent
YES
HIGH
HIGH
HIGH
Investigator
Raters
YES
HIGH
HIGH
HIGH
Respondent
Respondent/Raters
NO
NOT ASSURED
YES
NO
YES
YES
NO
NO
NOT ASSURED
YES
YES
YES
NO
YES
YES
YES
YES
YES
NO
NO
Variable
YES
YES
YES
NO
NO
YES
YES
YES
YES
NO
YES
YES
NO
YES
YES
NO
Variablea
Variable
NO
YES
YES
a
Some systems, such as the LEDS, SLEDS, and DISE, anchor ratings to exemplars to ensure standardization of ratings across participants and research
groups. Other systems, such as the UCLA LSI, utilize a manual with rating rules, but the manual does not include anchored exemplars.
same specific stressor (e.g., chronic caregiving, Epel et al., 2004;
hip fracture, Lenze et al., 2005; midterm examination, La Rocque,
Lee, & Harkness, 2016).
Self-Report Life Event Checklist Measures
The earliest and still most commonly used method for assessing
life events is the self-report checklist. Checklists are easy to
administer and score, and are inexpensive in terms of researcher
and participant time. But these expediencies come at serious scientific costs. We first describe three of the most common instruments, highlighting some of their distinctive attributes. We then
evaluate the approach in light of the three basic premises outlined
above.
Checklists and defining stress. Probably the most widely
recognized self-report life event checklist is Holmes and Rahe’s
(1967) Social Readjustment and Rating Scale (SRRS; or the life
change incidence version, the Schedule of Recent Experience
[SRE]; see Rahe, 1978). The SRRS comprises 42 life events (plus
‘Christmas’), each of which has been assigned an a priori ‘life
change unit’ (LCU). These LCUs were based upon ratings from a
“sample of convenience” of 394 healthy people who provided
estimates of the average degree of life change for each event (e.g.,
divorce–73; pregnancy– 40; fired at work– 47; etc.; Holmes &
Rahe, 1967). The LCUs for each endorsed event are summed for
a total score.
The use of a priori ‘objective’ weights in the SRRS was designed to avoid the problem of individual differences in stress
perception biasing respondents’ ratings of the severity of their
stress exposure (Rahe, 1978). However, it presents a complementary concern by assuming that all events within a certain category
are equally stressful across all individuals. In reality, the same
general category of life event can have widely different features
due to differences in biographical circumstances or “context.” For
example, “pregnancy” in the SRRS is always scored ‘40,’ whether
the respondent is in a secure relationship and planning a family, or
whether she is on social assistance and the pregnancy was not
planned. Important individual differences in context are not taken
into consideration in the SRRS scoring, compromising the ability
of the measure to sensitively assess stress exposures.
The Life Experiences Survey (LES; Sarason et al., 1976) is a
checklist of up to 60 life events. The LES includes 34 items similar
to those on the SRRS, but worded more specifically (e.g., the
‘pregnancy’ item is further specified as ‘male: wife’s/girlfriend’s
pregnancy’ and ‘female: pregnancy’). The measure also provides
some criteria to help respondents decide whether or not an experience ‘counts’ as a life event (e.g., “Trouble with employer [in
danger of losing job, being suspended, demoted]”). Further, instead of having a priori weights assigned to each event, participants provide a 7-point subjective rating of how much of an impact
they perceived each event had on them (from ⫺3 [extremely
negative] to 3 [extremely positive]). These ratings are summed
across all endorsed events for a total score. In some respects the
LES represents an improvement on the SRRS (e.g., more events,
some definitional criteria). However, the addition of self-reported
severity ratings introduces new concerns. Specifically, subjective
ratings of life event severity can be biased by state symptoms or
factors that are known to predispose to psychological conditions
(e.g., personality, cognitive schemas, genetic vulnerabilities; see
Simons, Angell, Monroe, & Thase, 1993), or by knowledge of
existing disorder (and ‘explaining away’ the disorder because of
stress). As a result, it is not possible to determine whether high
scores on the LES are a reflection of exposure to life events that
are objectively highly stressful, or represent heightened subjective
responses to relatively minor life events. The problem of con-
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HARKNESS AND MONROE
founding stress exposures and stress responses undermines the
validity of measures such as the LES.
The concerns with measures such as the SRRS and LES were
considered carefully in the development of the List of Threatening
Experiences (LTE; Brugha & Cragg, 1990), a checklist of 12 life
events that respondents endorse ‘yes’ or ‘no.’ In the original
sample on which the LTE was developed, respondents were queried in a detailed contextual interview about biographic details
regarding 67 life events. For example, in addition to simply finding
out whether a respondent had lost a job, the interviewer queried
about the life circumstances surrounding the termination, social
and financial implications, and so on. Second, the endorsed events,
as informed by their associated biographic context, were rated for
severity by a team of raters who were unaware of the respondents’
subjective responses to the events using a standardized manual.
The 12 life events selected for inclusion in the resulting LTE were
those that consistently received ratings of ‘moderate’ or ‘marked’
in terms of their psychological threat and probable impact by the
independent rating team. According to Brugha and Cragg (1990),
the LTE is a measure of life events that possess “considerable
objectively-defined long-term threat.”
Given that the LTE does not use respondent subjective severity
ratings and focuses specifically on events that were originally rated
as ‘objectively’ highly threatening, this measure would appear to
be a significant advance over the LES and SRRS. However,
although detailed personal information was available for the original interview from which the LTE was derived, such information
is not available for new respondents. This means that although the
12 events listed in the LTE are likely to have high objective threat,
there are no assurances for any new respondent that this is indeed
the case. As with the problems outlined with the SRRS, items on
the LTE are subject to potentially significant individual differences
in biographical circumstances, which can alter the threat associated
with the exposure. For example, while the item ‘terminated from
job’ is very threatening for a respondent in a financially distressed
context, it may contain little to no threat in a financially stable and
readily reemployable context. Overall, it is not possible to determine if items endorsed on the LTE reflect life event exposures for
new respondents that investigators would define as having “considerable objectively defined long-term threat.”
Checklists and basic measurement practices. A number of
limitations are apparent when evaluating self-report life event
checklists in light of basic measurement premises. A very important concern is that self-report checklists do not provide common
criteria or rules for defining and assessing life events in a standardized manner. No formal guidance is given to respondents
regarding how to interpret items beyond the brief description of
each life event. Instead, decisions are based entirely on each
participant’s idiosyncratic interpretation of what constitutes a life
event. This problem is compounded by further relying on each
respondent’s informal guesswork about how to handle events that
are sequentially related, part of a chronic stressor, or one facet of
a multievent experience. As introduced above, these procedures
inevitably result in extensive intracategory variability (see Dohrenwend, 2006). Fundamentally different life events can be included
within the same category, and the same life events can be included
in different categories, depending on how the respondent interprets
the information provided (Monroe, 2008). In general, there are no
assurances that participants interpret the instructions and individ-
ual checklist items in keeping with the intended meanings of the
researcher for measuring stress exposures.4
Indeed, when comparing respondent-defined life events with
events defined by the investigator (using a priori designated operational criteria and standardized procedures), the correspondence
between the two is surprisingly low (e.g., less than 40% of the
time; Gorman, 1993; Lewinsohn, Rohde, & Gau, 2003; McQuaid
et al., 1992; Monroe, 2008). This problem even extends to highly
significant life events. For instance, Duggal et al. (2000) reported
that only 32% of severe events occurring prior to major depression
onset (defined by an interview-derived measure) were endorsed on
a self-report checklist. This failure of checklists to detect even
severely stressful events may be due to limitations imposed by the
number of items included on the checklist. For example, checklists
often do not allow for the reporting of more than one of the listed
events in the time period (e.g., ‘major personal illness or injury’ on
the LES or SRRS can only be endorsed once even if the respondent
had both a major illness and a major injury, or more than one of
either). Self-report checklists also do not provide a basis for
distinguishing between acute life events and chronic stressors. For
instance, McQuaid et al. (1992) concluded that almost one-quarter
(22.2%) of events endorsed on the 110-item self-report Psychiatric
Epidemiology Research Interview (PERI) Life Events Scale
(Dohrenwend, Askenasy, Krasnoff, & Dohrenwend, 1978) were,
upon follow-up probing, more appropriately defined as long-term
chronic stressors.
More generally, self-report checklists typically combine a heterogeneous array of life events into one overall score. However,
not all types and timings of life events are equally relevant for all
disorders, or for all etiological or pathological processes within a
disorder. This procedure of general additivity, wherein only some
of the events contributing to the summed score are relevant,
reduces the power of the research design. For example, a prominent model of life stress in depression is Hammen’s (1991, 2006)
stress generation hypothesis. This model makes an important distinction between life events that are in part ‘dependent’ on the
individual’s behavior (e.g., terminated from job because of poor
performance, break-up of a romantic relationship) and those that
are ‘independent’ life events (e.g., terminated from job because of
factory closure, grandmother diagnosed with cancer). This distinction is crucial for testing research questions about the role of
disease in generating life events; for example, individuals with a
depression history report high cross-sectional and prospective rates
of dependent life events than nondepressed individuals, but the two
groups do not differ in rates of independent life events (see
Hammen, 2006, for a review). Self-report checklists do not draw
on sufficient information to determine which events are indepen4
As Dohrenwend (2006) explains: “When positive responses to event
categories [on a self-report checklist] were probed [in an interview] for
details of what actually occurred, it became evident, for example, that some
deaths of close friends turned out to involve deaths of long absent,
childhood friends to whom the respondents were no longer close; that
serious illness and injury events ranged from episodes of flu and sprained
arms to severe heart attacks; and that ‘laid off,’ intended to encompass
economic failure of the employer, was sometimes a euphemism for being
fired for cause. Clearly, a positive response for the same item on the
checklist could, and did, in fact, represent very different types of actual
experience” (p. 479).
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LIFE STRESS MEASUREMENT
dent versus dependent, and thus these measures cannot address
these important questions.
A related, and very important, problem with self-report checklists is that they typically do not allow for precise dating of events
and instead cover one very broad time period (e.g., life events in
the past year). However, life events that precede disease onset are
obviously the only ones of etiological relevance. Similarly, life
events that follow onset are the primary events for questions about
the role of stress in maintaining disease, and/or the role of disease
in generating stress. Further, even within the preonset and postonset periods, only limited timeframes are relevant. For example,
using rigorous interview methods, research on major depression
consistently has shown that severely threatening life events within
1 to 3 months before onset are of central etiological significance
(e.g., Brown & Harris, 1978; Kendler et al., 1999). Collapsing
events occurring across a broad, nonspecific timeframe into one
overall score reduces power, as many irrelevant events will be
included in, and thus dilute, the resulting stress measure.
Basic research design requirements. Inevitably, study participants are aware of their stress responses and health status.
Consequently the requirement for maintaining measurement independence of stress exposures, responses, and outcomes inherently
is breached with self-report checklists. In fact, these measures
commonly include as life events items that are even symptoms of
disease (e.g., change in sleeping habits, sex difficulties). Simply
put, confounding cannot be ruled out between stress exposures and
biases related to the participant’s knowledge about stress responses
or illness outcomes.
Psychometric data. Examining recent publications from Web
of Science searches, we found that self-report checklists of life
events continue to dominate in the measurement of stress exposures. These studies rarely report essential psychometric statistics.
Instead, a number of ‘cosmetic psychometric’ practices sidestep
disclosure of such basic information and thereby elude critical
attention. A common practice, especially in large-scale epidemiological studies, is simply to omit psychometric information altogether, apparently relying on the face validity or tradition of
employing checklists such as the SRRS (e.g., Määttänen et al.,
2015; Masters Pedersen et al., 2015; Tamers et al., 2015). Another
strategy is to claim “good reliability and validity,” either with no
evidentiary basis provided or by referring to studies that do not
furnish strong psychometric support (e.g., Kindt, Kleinjan, Janssens, & Scholte, 2015). More specifically, early psychometric
studies of the major self-report checklists reported poor test-retest
correlations (e.g., .30 –.60 in Neugebauer, 1984; see also Paykel,
1983; Rabkin & Struening, 1976; Thoits, 1983), low within-person
longitudinal/retrospective agreement (e.g., 25% for the PERI;
Monroe, 1982; see also Raphael, Cloitre, & Dohrenwend, 1991),
and very low coinformant agreement (e.g., 33% for the SRRS;
Yager, Grant, Sweetwood, & Gerst, 1981; see also Neugebauer,
1983). There is no substantive reason to presume such measures in
contemporary research fare any better in terms of reliability and
validity.
Another common but misleading psychometric practice is to
report internal consistency statistics (Cronbach’s or coefficient
alpha; e.g., Carter, Dellucci, Turek, & Mir, 2015; Zhao et al.,
2015). Internal consistency, though, is not an appropriate statistical
criterion for these types of measures (Cleary, 1981; Monroe, 1982)
because there is no presumption or expectation that individual life
7
events (a spouse’s serious illness, a traffic accident, a flood, etc.)
should correlate with one another (which is the basis for internal
consistency measures). Of course, life events can correlate with
one another. But when they do, it must be determined whether this
reflects a valid association (e.g., engagement and marriage several
months later), or is a result of measurement errors (e.g., problems
related to ‘intracategory variation,’ such as redundancies in reporting events and a lack of consistent handling of complex events).
Ironically, it could be argued that moderate to high levels of
internal consistency provide evidence against the psychometric
credibility of self-report checklists.
Other cosmetic psychometric practices include claims for the
validity of life event checklists based on statistically significant,
though very modest, correlations with interview-derived measures
of life events (e.g., ⬍20% shared variance). Given that both types
of measures purportedly quantify the same recent life experiences,
it again seems reasonable to suggest that such modest associations
provide prima facie evidence against the psychometric credibility
of the self-report checklist (see, e.g., Duggal et al., 2000; McQuaid
et al., 1992 reviewed above). Indeed, other studies demonstrate
poor validity of self-report checklists. For example, McQuaid,
Monroe, Roberts, Kupfer, and Frank (2000) reported that scores on
the self-report PERI did not significantly predict treatment outcome in major depression, whereas life events defined with an
investigator-based interview measure showed robust associations
with depression outcomes. Similarly, a meta-analysis by Karg et
al. (2011) determined that the effect of the interaction between the
serotonin transporter gene and life events on depression outcomes
was significant and large (p ⫽ .0002) in studies using interviewderived methods to assess life events, whereas it was not significant in studies using checklist measures of life events (p ⫽ .096).5
Summary. Self-report event checklists fail across all three
basic premises for defining, measuring, and designing research on
stress exposures. We enjoin researchers to critically consider the
psychometric credentials of life stress checklists. We also issue a
challenge to the field to provide a single example of a self-report
life event checklist that meets minimal scientific standards for
acceptable reliability and validity. Most generally, reviews of the
life events literature are unanimous in concluding that self-report
checklists do not meet conventional standards for scientific acceptability (e.g., Dohrenwend, 2006; Hammen, 2006; Monroe, 2008),
and are inferior to interview-derived measures of life events.
Interview-Derived Measures of Life Events and
Chronic Stressors
Interview-derived life stress measurement systems were developed to address the limitations of self-report life event checklists.
A number of systems exist, which are similar with respect to (a)
employing interviews to solicit the initial information from the
5
A more recent meta-analysis of 81 studies examining the 5-HTTLPR
by stress interaction in depression found a significant moderation effect in
studies using self-report checklist measures of stress, although this effect
was smaller than that reported in studies using objective and interviewbased stress assessments (Sharpley, Palanisamy, Glyde, Dillingham, &
Agnew, 2014). Further, studies using self-report checklist assessments on
stressful life events were particularly compromised in their ability to detect
a significant 5-HTTLPR by stress interaction when the depression outcome
was defined using valid diagnostic interview criteria.
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8
HARKNESS AND MONROE
respondent, and (b) defining and scoring environmental exposures
based on prespecified procedural guidelines and operational criteria. Accordingly, these systems comply with the first premise by
formally separating the stress exposures from stress responses. In
the following, we examine these major approaches in light of the
other two premises: measurement practices and research requirements.
Interviews and basic measurement practices. Interviewderived systems begin with a semistructured interview that covers
a broad and open-ended range of stressors, allowing multiple
opportunities for respondents to talk about their experiences,
thereby stimulating autobiographical memory. A calendar typically is used to enhance recall and accurate dating. Because a date
is obtained for each event, the temporal ordering of stress exposure
and disorder onset can be readily determined. A semistructured
interview also provides opportunities for respondents and interviewers to engage in “collaborative cognition,” through discussion, ensuring that the experiences the respondents report are
consistent with the a priori defined exposures the researcher intends to assess (Belli, 1998; Schwarz, 2007). For example, in
response to the question “have any relatives or close friends died?”
the respondent might indicate that a cousin died. But the qualifiers
‘relative’ and ‘close’ contain ambiguities; interviewers are trained
to probe further to determine if this exposure is personally meaningful enough to warrant rating (“How often had you seen this
cousin before she died? Did you attend the funeral? Were you
close growing up?”). If the respondent had never met the cousin
and had only heard about the death through a relative, the interviewer might determine that this event would not meet criteria
within the measurement system and would not probe any further.
Interview-derived approaches for assessing stressful exposures
also are instrumental for obtaining detailed information about the
person’s biographic circumstances (Brown & Harris, 1989; Hammen, 2006). Using this information allows the researcher to evaluate the exposure within the particular life ‘context’ of that person,
permitting an individually tailored and fine-grained rating of the
likely meaning and probable impact of the exposure for that
person. For example, rating of a ‘pregnancy’ depends upon the
woman’s biographical circumstances. If she is in a stable relationship, desires another child, and has adequate financial means, it
will be rated as less severe than a woman without a partner, on
social assistance, and responsible for four other children. (For
other examples, see Table 2.) In essence, raters estimate the
meaning and impact of the exposure for the average person in a
similar life situation, but without compromising the independence
of measurement of exposures and responses. In theory, contextual
ratings allow the investigator more precision in specifying the
nature of the objective exposure, thereby providing a more sensitive measure of the construct.
With interview-derived systems the basic measurement steps are
codified in manuals, which provide explicit operational definitions
and, sometimes, rating exemplars to enhance fidelity of scoring
across participants and research groups. Complex decisions regarding sequences of exposures, multifaceted or compound exposures, and relations between acute events and chronic stressors are
handled with prespecified rules and guidelines. Standard rules also
guide the rating of stressors on a number of dimensions that enable
a fine-grained examination of the relation of life events to disease
(e.g., severity, independence, etc.). This is important as it allows
investigators to focus on the aspects of environmental exposures
that are most theoretically pertinent for the specific disorder under
study. For example, the odds of developing depression increase
dramatically as more discerning distinctions are made for the
specific types, severities, and qualities of stressful exposures (see
Bebbington, Sturt, Tennant, & Hurry, 1984; Campbell, Cope, &
Teasdale, 1983; Costello, 1982; Kendler, Hettema, Butera, Gardner, & Prescott, 2003; Parry & Shapiro, 1986). For other pathological outcomes, different types or qualities of exposures may be
of theoretical interest. More generally, although interview-derived
systems share these basic premises, they can vary in terms of how
the premises are implemented, and the degree of detail provided to
help standardize the scoring process.
Basic research design requirements. A major distinction
within interview-derived systems is who defines and scores the
exposures. In the ‘interviewer-scored’ system, the interviewer determines which exposures qualify, and then rates the severity of the
qualifying exposures (sometimes in real time). Examples of such
an approach include the Kendler Life Stress Interview (LSI; Kendler et al., 1995), the Brief Life Event List (ISEL; Paykel, 1997),
the Structured Life Events Inventory (SLI; Wethington, Kessler, &
Brown, 1993), and the UCLA Chronic Stress Interview (Hammen,
1991). Alternatively, with the ‘blind rater–scored’ system, information on exposures is presented to an independent panel of blind
raters. Importantly, this means that the information about exposures has been stripped of clues or details regarding the respondent’s personal reactions and disease status. Examples include the
Life Events and Difficulties Schedule (LEDS; Brown & Harris,
1978), the UCLA Episodic Life Event Interview (Hammen, 1991),
the Standardized Event Rating System (SEPARATE; Dohrenwend, Raphael, Schwartz, Stueve, & Skodol, 1993), and the
Stressful Life Events and Difficulties Interview (SLEDS; Leserman, 2003).
Interviewers inevitably are aware of respondents’ subjective
responses to the stress exposures through nonverbal (e.g., crying,
appearing distressed or, alternatively appearing stoic) or verbal
(e.g., “this event really upset me”) behavior during the interview.
This information can bias ratings of stress exposure. Interviewerscored ratings also are susceptible to bias because of the interviewer’s potential knowledge about the participant’s health status.
Even if the interviewer has no prior knowledge of the participant’s
health status and avoids directly querying about such information,
health status clues can easily ‘leak’ into the interview (e.g., when
answering questions about a recent marital separation the respondent might comment that “my husband got sick of dealing with my
MS”; or, when answering questions about changes in employment,
the respondent might quip “after I had my last heart attack I
decided to resign as Director”). From a strict methodological
perspective, interviewer-scored systems do not incorporate the
safeguards for preventing contamination and possible confounding
of the measures of exposures, responses, and outcomes. As with
research using self-report checklists, the burden of scientific proof
rests with researchers employing interviewer-scored approaches to
countermand plausible and parsimonious alternative explanations
based on the confounding of exposure, response, and outcome
measures.
Two studies have directly compared the reliability of interviewerscored versus blind rater–scored measurement systems of life events.
LIFE STRESS MEASUREMENT
9
Table 2
Examples of Contextual Ratings
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Event domain
SRE
score
Marital/romantic
relationship
separation
65
Fired at work
47
Change in
financial state
38
Spouse begins
or stops work
26
Vignettes and associated contextual threat rating (LEDS system)
‘Marked’
‘Moderate’
‘Some’
S found out that husband had been sexually S and her husband of 1 year S had been seeing her
interfering with daughter. He refused to
decide to separate
first boyfriend for 6
seek psychiatric help and she found out
because of difficulties
months. It was not
he had done it again. She packed up and
maintaining a longa sexual
left him 3 weeks later, taking the
distance relationship. The
relationship. She
children with her.
decision is mutual and
finished the
amicable. They have no
relationship. There
children or mutual
was no particular
property.
evidence of
closeness. They
had seen each other
weekly and had
never talked of
marriage or
cohabiting.
S is fired from her job as a cashier for
S, an actor who has not had S is fired from his job
failing to come to work for two days the
acting work for a year, is
as a delivery man
week before as she had to care for her
fired from his job as a
at a pizza
son who has ADHD and was suspended
medical assistant in an
restaurant for
from school. S has no savings and lives
alternative medicine
delivering too
month to month on her cashier salary
clinic. He is told he is
many late pizzas. S
and alimony payments. She does not
“no longer needed” yet
does not find other
have another job to go to and will not be
someone else is taken on.
work within two
able to receive a reference from this one.
S does not know what he
weeks as the job
can have done to justify
market is tight in
dismissal, though he has
his town at the
very occasionally
moment, but he
miscalculated a fee. S
lives with his
does not find other work
parents and, thus,
within two weeks. S has
this does not have
no dependents
financial
implications.
S’s husband’s firm went bankrupt. He was S and husband were told
S had to borrow
one of the chief partners. The event has
that $4500 they had given
$3000 from her
grave financial implications because the
to a man to put new
grandmother to pay
firm had been operating on a bank loan
electric fixtures in their
her utility bill,
secured on the deeds of the cottage his
apartment was not
which was
mother lived in. Even before the
recoverable. The man
threatening to go to
bankruptcy money had been tight—S’s
absconded with half of
collection. S is
husband said this was because he
their savings.
currently working
gambled but in retrospect S thinks he
and has a plan to
was paying out to the other woman. S
repay her
has 3 teenage children and herself has
grandmother over
only a clerical job. S’s husband will
the next several
probably have great difficulty in finding
months.
another source of income.
S’s wife, who is the primary wage earner
S’s husband starts a job in
S’s husband is laid
as S is on disability, loses her job when
Hong Kong on a 2-year
off from his job as
the company she works for goes
contract. He will be away
an engineer. He
bankrupt. S and his wife have significant
for 6-week periods
decides not to
debts relating to medical bills that have
interspersed with 1
pursue employment
accumulated since S’s disability. Jobs in
week’s leave.
so that he can
S’s wife’s field are scarce and she may
devote time to his
need to look for a significantly lowerwriting. This will
status and lower-paying job just to make
put pressure on S
ends meet.
to be the primary
wage earner.
‘Little/none’
No examples
S is told that the
restaurant at which
she works as a hostess
is closing and, thus,
she is let go. S is
given a good
reference and finds a
new hostess job at a
similar restaurant
within two weeks.
There are no financial
implications.
S receives an inheritance
sum of $5000 from
his great-aunt who
recently passed away.
S was not close with
his aunt and was
surprised at this news.
S’s wife is offered a
full-time teaching
position in her field at
a local University.
This means that they
will be able to start
thinking about buying
a house.
(table continues)
HARKNESS AND MONROE
10
Table 2 (continued)
Event domain
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Change in
residence
SRE
score
20
Vignettes and associated contextual threat rating (LEDS system)
‘Marked’
‘Moderate’
S’s house is destroyed in a landslide and,
S and her husband move
thus, he and his family must move into a
from an apartment to
temporary disaster shelter. It is not clear
their first house. The
whether S will recover any money from
house requires significant
the insurance company, and S is
repairs and upgrades and,
currently unemployed. As such, the
thus, for the first several
family’s future housing prospects are
weeks they are unable to
uncertain.
use the kitchen or main
bathroom and, thus, must
shower at the gym and
eat out.
When two interviewers independently interviewed and rated the
stressors from 191 respondents (i.e., interviewer-scored approach),
Kendler et al. (1995) reported that the LSI yielded modest reliability for event threat (k ⫽ .41) and slightly higher reliability for
event independence (k ⫽ .63). However, when these investigators
assessed interrater reliability by having two blind raters code the
same interviews (i.e., blind rater-scored approach), higher reliabilities for both threat (k ⫽ .67) and independence (k ⫽ .79) were
achieved. Similarly, Cooke (1985) reported with the IRLE that
when two interviewers conducted separate interviews and ratings
of the same groups of patients (i.e., interviewer-scored), reliabilities were in the modest range (threat k ⫽ .58 and independence k ⫽
.62). However, reliability values were much higher when one
person interviewed the patients, and two independent people rated
the information (i.e., blind rater-scored): long-term threat k ⫽ .76,
independence k ⫽ .87 (Paykel, 1983). Interrater reliabilities for
severity are also high for the LEDS (k ranging from .76-.90; e.g.,
Harkness, Bruce, & Lumley, 2006; Muscatell, Slavich, Monroe, &
Gotlib, 2009), and the UCLA Episodic Life Event Interview (intraclass correlations for severity range from .91–.95; Davila, Hammen, Burge, Paley, & Daley, 1995; Conway, Hammen, & Brennan, 2012). Overall, these data suggest that superior reliability
estimates for the severity of life events are achieved when event
summaries are presented to a panel of raters who are blind to the
respondent’s subjective perceptions of events and health status.6
The special case of chronic stress. Interview-derived measures of stress exposures also differ with respect to how they
approach chronic stress. Several of the interview-based systems
described above either do not assess chronic stressors at all, or do
not distinguish them in the ratings from acute life events (e.g., the
SEPARATE, Kendler LSI, ISEL, and SLI). As noted previously,
this is problematic because acute and chronic stress are distinct
constructs and may be differentially relevant to the onset and
pathology of particular diseases over others. The SLEDS, LEDS,
and UCLA Chronic Stress Interview all assess chronic stress, but
take different approaches to the conceptualization and measurement of this construct. In the SLEDS and LEDS, chronic “difficulties” are defined as ongoing stress exposures lasting at least
four weeks (e.g., financial problems, chronic migraines, persistent
arguments and/or tension with spouse, etc.). Similar to the procedure for acute life events, respondents are queried about the
contextual details of these difficulties, and severity ratings are
made with reference to standardized criteria and examples from
‘Some’
S moves from his
family home to his
college dorm. This
is S’s first move
away from home.
The move goes
smoothly.
‘Little/none’
S moves with two
roommates from one
apartment to a new
apartment in a better
neighborhood. The
move goes smoothly
the manuals by blind raters As with acute life events, chronic
difficulties can vary in severity from “very mild” issues (e.g.,
Respondent’s husband has had asthma since he was a child. He
still takes medication but it has not changed his routine) to “high
marked” difficulties (e.g., Marriage involves constant tension and
frequent fights with injuries to both partners). Dates are provided
for onsets and offsets of difficulties, as well as any change points
in the difficulties, to allow for clear timing of chronic stress
exposures to the onset and course of illness. In this way, the
assessment of chronic stress mirrors that of acute life events, and
thus satisfies the measurement and design requirements outlined
above.
In contrast, the chronic stress scale in the UCLA LSI is not a
measure of chronic stress exposure, but alternatively is a measure
of the level of adjustment or functioning in each role or domain
assessed by the interview. For example, in the ‘intimate relationship’ domain, every participant receives a score, ranging from 1
(exceptional on all “quality” factors [stability, supportive, mutual,
good conflict resolution ability]) to 5 (abusive [physically and/or
emotionally], negative conditions, inability to trust, lack of communication, not reciprocal). It could be assumed that individuals
scoring a ‘1’ or ‘2’ in any domain do not have chronic stress
exposure in that domain, and that those scoring 3 through 5 are
exposed to chronic stress; however, for some domains the construct of stress exposure is difficult to separate from the response
and also may be difficult to disentangle from the disease outcome.
For example, the anchor for ‘5’ in the work domain is “changing
jobs often because unable to hold down job; not working; impaired, overwhelmed, not functional in nonworking role.” That is,
a score of ‘5’ in this instance represents the extent to which the
individual is responding to the environmental demands (although
based on behavioral, not subjective, indicators), but is not necessarily a measure of the environmental demands themselves. Indeed, in the UCLA manual Hammen (1991) explicitly states that a
high score on any particular domain “represents both a presumed
ongoing source of strain and a statement of that person’s functional
6
It is worth noting that the interview-scored reliability data are a
function both of different interviewers and raters, whereas the independent
and blind scored reliability data are a function of only different raters.
Consequently, the higher reliability of the latter could be in part a function
of the invariant information derived from one interview. To our knowledge
no research to date has addressed this consideration.
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LIFE STRESS MEASUREMENT
attainment (which may be due to symptoms but could also be due
to other circumstances or characteristics of the situation).”
To date there has been no research directly comparing the LEDS
versus UCLA methods of defining and assessing chronic stress,
and thus the choice between the two will depend on the research
question. It would be very interesting to determine whether, for
example, these two systems are tapping the same fundamental
construct of chronic ‘stress,’ and whether they possess differential
predictive power in terms of particular disease outcomes. An
important way in which they are similar is that in both cases the
interview does not query the participants’ subjective distress in
response to their circumstances. Further, ratings are based on the
behavioral and contextual features of the circumstances and not on
the individual’s feelings about his or her circumstances.
Recommendations
We have provided theoretical justification, and psychometric
evidence, supporting the claim, first, that interview-derived measures of stress exposures are superior to self-report life event
checklists. We assert that it is preferable not to assess stress
exposures at all than to assess them with psychometrically flawed
measures that have the potential to produce misleading results
(Karg et al., 2011). To be very clear about this matter, based on all
available evidence we cannot envision any circumstances under
which self-report checklists of life events, in good scientific conscience, can be recommended or justified.
Second, we have provided theoretical justification, and some
preliminary evidence, that blind rater–scored interview methods
are superior to interviewer-rated systems, and represent the best
available practices for measuring life stress exposures (see Table
1). There is as yet no empirical information to support preference
for one blind rater-scored system over another and, thus, such
decisions may be based on personal preference or experience with
a particular system, as well as the research question. Particularly in
the case of the assessment of acute life events, the distinctions
between the various systems are minor and unlikely to have
substantial effects on the resulting stress variable for analysis
(although this is an empirical question worthy of study). However,
given the importance of distinguishing between acute and chronic
stress exposure, a system that allows for clear distinction of these
constructs in the measurement would be preferable, particularly for
research questions involving diseases in which chronic stress features prominently in theories of etiology (e.g., cardiovascular
disease). Relatedly, some research questions may require a measure of the presence and severity of chronic stress exposure that is
not influenced by the respondent’s symptoms and functioning
(e.g., “Does exposure to chronic difficulties contribute to the onset
and/or ongoing course of disease?” “What is the threshold of
severity of difficulties necessary to trigger onsets and/or recurrences of disease?” “Do acute life events differ in their relation to
disease outcomes when occurring in the context of chronic difficulty exposure?”). In this case, the LEDS or SLEDS would be
appropriate measures. Other research questions may be more appropriately addressed by a measure of chronic stress that represents role functioning (e.g., “What domains of chronic role impairment are most strongly associated with particular diseases and
disease outcomes?” “How does chronic role impairment contribute
to the longitudinal course of disease?” “Does chronic role impair-
11
ment contribute to the generation of acute life events [and is there
a match in terms of domain]?”). In these cases, the UCLA Chronic
Stress Interview would be more appropriate. The most important
point here is that the research question should inform the choice of
measure, and the interpretation of results should be clearly (and
accurately) tied back to the construct measured.
Despite the clear superiority of interview-based measures of
stress exposure, many investigators may be hesitant to incorporate
such time- and cost-intensive instruments into their research. It is
simply not feasible to use such an approach in a Genome-Wide
Association study or in a national epidemiological survey of several thousand participants. But, too, it is not feasible to conduct
functional MRI, or detailed behavioral coding, in such large-scale
designs, and this is not the purpose of these designs. Specifically
in the realm of genetics, the purpose of very large polygenic
studies is to identify the genetic markers of prime relevance to
disease. From these huge samples, high and low genetic risk
individuals can then be selected for more detailed phenotyping
using rigorous measures of environmental exposure (Uher, Keers,
& Harkness, 2016). Indeed, blind rater-scored interview systems
such as the LEDS or UCLA LSI are feasible in studies with several
hundred or a few thousand participants (e.g., Hammen, Hazel,
Brennan, & Najman, 2012; Harkness et al., 2015; Uliaszek et al.,
2012), and the use of these instruments can be expanded through
collaboration. Further, the power gained with sensitive, reliable,
and valid measures helps offset limitations in sample size (see
Caspi, Hariri, Holmes, Uher, & Moffitt, 2010; Karg et al., 2011;
Monroe & Reid, 2008). Further suggestions for stress measurement given the above feasibility concerns include the following:
1.
Consider how important the need is to assess stress
exposures. Is life stress a crucial variable in the model, or
is it a peripheral one (including life stress ‘just in case’?).
If life stress is not a primary variable, then consider
leaving it out.
2.
Consider whether the stress construct of interest is the
stress exposure or the stress response. If the construct of
theoretical import in the proposed study is within- or
between-groups differences in how individuals perceive
stress, then a self-report measure such as the Perceived
Stress Scale (PSS) may be acceptable (Cohen et al.,
1983). The main concern to keep in mind, as emphasized
above, is that the stress construct should be clearly and
consistently operationalized. Further, the research design
still should ensure that the measure of stress perception is
not confounded with either the outcome or the other
independent variable(s). This may be difficult to ensure
with the PSS as scores on this measure are necessarily
very highly correlated with, for example, state and trait
levels of symptoms, personality, cognitive biases, and so
on. Procedures that help with this confounding are prospective, multiwave designs that examine changes in
levels of stress and associated trait/state markers over
time, or designs that examine the relation of PSS scores
and disease or other pathological response outcomes,
controlling for state/trait symptoms.
HARKNESS AND MONROE
12
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3.
Consider using a hybrid approach that first assesses life
event exposures with a self-report checklist and then
follows up on the endorsed events using an interview that
is then rated contextually by blind raters according to
standardized guidelines as described above. For example,
some studies have administered the PERI checklist, followed up with LEDS-based interviewing and scoring of
the endorsed events (e.g., Monroe, Kupfer, & Frank,
1992). Similarly, Alloy, Abramson, and colleagues developed the Life Events Scale (LES), a checklist of 134
major and minor events and chronic stressors, which is
followed up with the Stress Interview (SI) and contextual
ratings based on the LEDS system (Alloy & Clements,
1992; Needles & Abramson, 1990). Hybrid systems cut
down on interview time, as only exposures that have
previously been endorsed by respondents are further queried (see Gleason, Powers, & Oltmanns, 2012, for a
similar approach using the LTE). However, trained raters
are still required. It should be noted, too, that it is currently unclear whether or not hybrid systems are subject
to underreporting (e.g., less sensitive for stimulating recall and detecting initially relevant stress exposures).
We can also envision a role for a hybrid system that
utilizes a self-report checklist followed up by an
interviewer-rated interview. This approach, although suffering from the limitations outlined above in terms of
potential interviewer bias, may be useful in the early
stages of piloting and hypothesis generation for a particular disorder or pathological process. Nevertheless, we
would strongly advise moving to an independent rater–
based system once firm research questions and hypotheses have been developed.
4.
Finally, and this is our preferred recommendation, consider collaborating or contracting out for the life stress
assessment. There are several excellent research teams
with expertise in blind rater-coded contextual methods,
many of who are open to collaborative arrangements.
These collaborative arrangements may include, for example, training on-site interviewers and raters and providing remote supervision; training on-site interviewers
who then forward interviews to the expert site for rating;
or conducting all interviews (e.g., by telephone or Skypelike interface) and ratings from the expert site. In our
experience, these arrangements often have developed
into fruitful and long-lasting multidisciplinary collaborations that have enriched all parties, and have resulted in
methodologically rigorous designs at all levels of analysis. One example of this approach is the Canadian Biomarker Integration Network for Depression (CANBIND), a multisite, pan-Canadian network of studies
investigating genetic, epigenetic, proteomic, inflammatory, and neuroimaging biomarkers of pharmacotherapy
and cognitive– behavioral therapy response, as moderated
by stress (Lam et al., 2016). A priority for this network is
rigorous, state-of-the-art assessment at all levels of analysis. Therefore, lead investigators who are experts in
each specific technology, including stress, have been
recruited to collaborate at all stages of the research design
and implementation. Acute and chronic stress exposures
are being assessed with the LEDS, and early childhood
stress exposure is being assessed with a similar contextual interview, the Childhood Experience of Care and
Abuse scale (CECA; Bifulco, Brown, & Harris, 1994).
This project is a model for how the rigorous assessment
of stress can be incorporated into large-scale psychiatric
and neuroscience research.
Finally, there are many research questions that are not appropriate for interview-based measures. Most notably, there has recently been increasing interest in the cumulative impact of daily
hassles on disease onset and neurobiological and psychological
pathology. Life event and chronic stress interviews are poorly
suited to assess such types of experiences and typically explicitly
exclude them from rating. Further, life event interviews cover too
broad of a time span for accurate recollection of hassles (e.g.,
several months). To assess hassles, different measures are needed
that capture individuals’ daily experience. We turn to such approaches next.
Daily Hassles and Experience Sampling Procedures
Research on hassles and daily experiences is concerned with the
intriguing questions of day-to-day, and even hour-to-hour, fluctuations in (a) exposure to hassles, as well as (b) emotional, cognitive, and physiological responses to hassles. These are novel
questions that allow researchers to examine in a fine-grained
manner the ways in which daily stress exposures and responses
influence each other over time. These microlongitudinal stress
processes are intriguing on their own, and they also potentially
inform the mechanisms that translate major stressors to disease
outcomes. Because these studies take such a fine-grained approach
to the temporal dynamics of stress processes they also may inform
hypotheses regarding the threshold of stress required to trigger and
maintain disease, and how these thresholds may change over time
in the face of other moderating influences.
Research on hassles and daily experiences also requires novel
and creative methods. As recall of hassles has been found to decay
after only a few hours (Stone, Kessler, & Haythomthwatte, 1991),
an interview covering the hassles that have occurred to the participant over the past year is obviously not appropriate. Indeed,
questions of, for example, stress exposure–stress response relations across the circadian cycle of stress hormones, mood, energy,
and so on, may require multiple assessments throughout the day.
Creative experience sampling methods have been developed for
this purpose, and these are described in detail below. It is very
important for researchers adopting these novel approaches to
studying hassles to abide by the same basic premises outlined
above for major life events. Indeed, given the potential of these
designs to clarify in detail the relation between stress exposure and
stress response, methodological and scientific rigor in assessment
is crucial.
Consistent with our previous discussion, it is necessary to meet
the first basic premise that the construct of hassles clearly distinguishes the exposure from the response. This first premise is
violated in many studies of hassles. For example, “daily stress” is
often operationalized as the respondent’s “overall stress level”
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LIFE STRESS MEASUREMENT
rated on a Likert-type scale (e.g., 1 [no stress] to 7 [very stressed]),
which is assessed at a number of points throughout the day. This
approach provides a measure of individuals’ daily state of feeling
stressed or hassled, but does little to clarify whether the individual
was actually exposed to hassles that would be objectively considered stressful. The problem, again, is that exposure and response
are conflated.
Similarly, the Hassles and Uplifts scale (DeLongis, Folkman, &
Lazarus, 1988) provides a list of 53 life domains (e.g., your
child[ren], your job security, your physical appearance, legal matters, etc.) and asks the participant to indicate to what extent each
has been a hassle (or uplift) that day from 0 (none or not applicable) to 3 (a great deal). Ratings for each item are summed to
create a total hassle (or uplift) ‘score.’ Theoretically this measure
is very similar to the Perceived Stress Scale (PSS) described earlier
in that it assesses the psychological state of feeling ‘hassled’ (or
‘uplifted’), not the presence of actual objectively defined exposure
to hassles (or uplifts). Individuals with a trait tendency to feel
stressed and upset in response to life’s daily struggles, or individuals who feel stressed for other reasons (e.g., due to exposure to
major life events or chronic stressors) are likely to score high on
this scale, regardless of whether their objective circumstances are
actually characterized by many hassles. Because our focus is on
stress exposure, below we address three strategies for assessing
exposure to hassles: (a) self-report checklists, (b) interviewderived measures, and (c) daily diary experience sampling approaches.
Self-Report Hassles Checklists
In terms of premise one (defining and measuring stress exposures), self-report checklists of hassles fail for the same reasons
reviewed in relation to self-report checklists of life events. We will
not reiterate all of these concerns here with regard to this premise,
but move on to focus on premises two and three. In terms of the
second premise, self-report checklists of hassles also have problems with intracategory variability. This is because of the inclusion
of items that are vague and open to interpretation, given the
absence of objective referents and contextual modifiers. The specific concern here is an inability to determine if the endorsed item
truly reflects a hassle or if, for some participants, the exposure
reflects a major life event or is part of a chronic stressor. For
instance, the item “property was damaged” on the 60-item Daily
Stress Inventory (DSI; Brantley, Waggoner, Jones, & Rappaport,
1987) would be a hassle for someone whose car was dinged in the
parking lot, but a major life event for someone whose home roof
blew off in a hurricane. Similarly, the item “money problems”
would not distinguish someone with chronic financial problems
involving bankruptcy versus someone who on the particular day in
question lost $20 out of her wallet. These problems do not allow
the researcher to determine whether a positive association between
the DSI and disease outcome is attributable to a valid effect of
hassles, or whether the effect is spurious, driven by other more
severe life events or chronic stressors.
In terms of the third premise, self-report checklists of hassles are
subject to bias by trait and state factors that are correlated with the
stress response and the disease outcome. For example, the Daily
Events Survey (DES; Butler, Hokanson, & Flynn, 1994) is a
checklist of daily events that are rated on a scale from 0 (did not
13
happen) to 4 (very meaningful). Sample items include, “did poorly
on schoolwork task,” “a friend, family member, or romantic partner insulted me,” and “did something awkward or embarrassing in
a social situation or in public.” It is very likely that individuals who
are upset or have psychological problems are more likely to
endorse these items, and to find them more ‘meaningful,’ than
those without. Therefore, this scale also confounds the presence
and objective threat associated with daily hassles with the disorder
outcome(s) and/or psychological trait tendencies under study.7
Therefore, we cannot recommend the use of self-report checklists
as measures of daily hassle exposure.
Interview-Derived Hassles Measures
To address concerns with self-report checklists of daily hassles,
the Daily Inventory of Stress Events (DISE; Almeida, Wethington,
& Kessler, 2002) was developed as part of the National Study of
Daily Experiences (NSDE; Almeida, McGonagle, & King, 2009).
To our knowledge, the DISE is the only contextual interview and
rating system of daily hassles. To address memory decay, the
DISE is administered nightly to cover the hassles experienced that
day. The DISE consists of a series of stem questions that ask
whether particular exposures have occurred and then there are
guidelines for additional probes to gather sufficient contextual
information to rate these experiences. Independent raters then rate
each hassle using a manual containing rating rules and more than
4,000 anchored exemplars. One of the main goals of this
investigator-based, blind rater-coded system is to distinguish those
exposures that are truly hassles from exposures that are major
stressful events (thus fulfilling premise 2). Interrater reliability for
severity is k ⫽ .72, and other threat dimensions (e.g., loss, danger,
disappointment) have a mean k of .88 (Almeida et al., 2002).
Similar to comparisons between interview-based and self-report
assessments of major life events, severity ratings in the DISE
correlate only moderately with subjective ratings (r ⫽ .36, p ⬍ .05;
Almeida, Stawski, & Cichy, 2010). The subjective ratings in this
study were higher than the objective ratings, and this difference
was statistically significant for women (subjective threat M ⫽ 2.9
vs. objective threat M ⫽ 1.9, p ⬍ .01). This latter result suggests
that gender-related differences in event perception (e.g., higher
levels of depression, anxiety, or trait negative affect) bias the
subjective ratings. Therefore, although subjective ratings may be
interesting as correlates of disease or pathological processes (e.g.,
Schilling & Diehl, 2014), the issue of confounding with the state
or trait phenomena under study is still great, even for minor events.
Therefore, we maintain that blind rater–scored interview methods
are superior to self-report checklists for measuring exposure to
daily events and hassles. That is, they satisfy premise 3 by ensur7
Some research using the DES has focused simply on frequencies of
daily hassles instead of the subjective impact scores. On the surface this
may be justified given that the events on the DES are supposed to be very
minor and, thus, there should not be great variability in their objective
threat. However, this point does not obviate the concerns above regarding
the role of biases in determining individual differences in whether or not
particular stressors are endorsed at all. Not surprisingly, in this particular
study results did not differ whether frequency counts or impact scores were
used—those who believe that certain events are more meaningful than
others will also be more likely to endorse those events in the first place.
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14
HARKNESS AND MONROE
ing that the resulting stress measure is not biased by individual
differences in stress responses or disease.
Another advantage of the DISE is that when major life events or
chronic stressors turn up, they can be clearly distinguished in the
ratings from daily hassles and accounted for in analyses. As a result,
this measure provides more valid information about whether the
relation of daily hassles to disease outcome is, indeed, attributable to
the effects of daily hassles and not to spurious and unrecognized
contributions of more impactful life events or chronic stressors. A
related and very important advantage of contextual approaches for
assessing hassles is that the researcher is able to investigate different
potential thresholds of stress severity required to trigger illness. As
noted above, the general life event landscape consists of exposures
that vary in objective severity from very ubiquitous hassles (e.g., “
preparing meals”) to exposures that are less common and minor, but
still captured by life event systems such as the LEDS (e.g., “confidant
engaged”) to infrequent major, potentially severely threatening, life
events (e.g., “fired from job”). Is a particular disease outcome triggered by an accumulation of daily hassles? Or is onset only apparent
when the threshold of stress exposure involves minor life events? Or
is the etiological role of stress reserved for the major, severely threatening life events? Only measures that allow for independent, unbiased, indicators of severity across the spectrum of stress exposure are
able to provide answers to these questions. However, these questions
are crucial for allowing future research to hone in on the stress
exposures most directly relevant for the outcome under study.
Experience Sampling Assessments
Interest has grown over recent years in fluctuations of micro
event exposure and response throughout the day. This question is
often assessed with experience sampling (ES) procedures that use
palm pilots or cell phones to prompt participants every 2 to 4 hours
per day over a particular period of time (e.g., one week). Participants typically report on life events, hassles, mood, and other
variables of interest. Obviously it is not feasible to use a contextual
interview in an experience sampling study in which participants
are interrupted several times throughout their day. Even a 60-item
self-report checklist would be inefficient, given that the modal
number of life events and hassles respondents would be expected
to endorse at any one sample point is zero. Instead, participants are
typically asked to describe the “most significant” negative or
positive event that occurred since the last prompt and to rate its
severity on a Likert-type scale.
In general, ES methods do not satisfy the premises outlined above.
They do not clearly distinguish the stress exposure from the stress
response, either in terms of the construct or in terms of its measurement. Specifically, the participant alone decides what constitutes a
“most significant event,” the severity rating is entirely subjective and,
hence, both defining and rating “a most significant event” is susceptible to bias. In terms of the second premise, these measures also
suffer from the problem of intracategory variability. That is, this most
significant ‘event’ could be a hassle, or simply by chance the person
could have been exposed to a minor, or even a major life event.
Without an objective determination of the stress exposure it is unclear
how to interpret the individual’s perceived response; high scores on
perceived severity could reflect a response that matches the objective
threat of the stress exposure for some people, but also could reflect a
heightened response to an objectively mild exposure for others. Fi-
nally, ES methods cannot assure independence with regard to the
health outcome under consideration.
Despite the above limitations, the point of these studies often is
to investigate individual differences in the perceived stressfulness
of events and hassles that occur throughout the day. For example,
in an experience sampling study of adults with MDD and/or
generalized anxiety disorder (GAD), Ruscio et al. (2015) prompted
145 participants eight times per day for one week to rate the
‘stressfulness’ of the most significant event they had experienced
since the last signal, as well as the extent to which they ruminated
immediately after the event. The purpose of this study was to
examine the extent to which individuals with MDD and/or GAD
ruminate in response to events that they perceive as “important in
their daily lives,” and then whether that rumination prospectively
predicts changes in symptoms. Therefore, the exposure and objective severity of the events is not relevant, as the phenomenon of
interest is the perceived stressfulness of these events, a point about
which the investigators are clear and consistent.
In addition, a series of studies by Myin-Germeys and colleagues
used experience sampling to examine mood reactivity to stressors
assessed on a daily basis in individuals with psychotic disorders (e.g.,
Collip et al., 2013; Hernaus et al., 2015). For example, Collip et al.
(2013) found that greater self-reported negative affect in response to
negative events (defined as “the most important event” that happened
since the last beep) was associated with smaller left hippocampal
volume in patients with schizophrenia and larger total hippocampal
volume in healthy controls. Importantly, in this study and other
studies by this group, no difference between the patient and control
group were found in the subjective ratings of events. That is, it is not
simply that the patient group shows lower hippocampal volume than
the control group because patients with schizophrenia are more likely
to feel stress in response to daily events than controls. Instead, these
results show a differential relation of reactivity to events that are
perceived similarly in terms of their relation with hippocampal volume in patients versus controls.
What studies such as those reviewed above cannot examine using
the ES methods are intriguing questions pertaining to daily and hourly
fluctuations in stress exposure, stress response, and the relation between the two to disease outcomes. We suggest that the ES method
could be adapted, however, to permit objective ratings of daily stress
exposure. Specifically, individuals could be given a brief follow-up
interview along the lines of the DISE during which the “most important event” is probed in greater detail. The objective severity of these
events then could be independently rated by a blind rating team using
a manual such as the DISE. The addition of a follow-up interview and
contextual ratings would add some time and cost, but likely not as
much as using the full DISE interview on a nightly basis. The
potential explanatory power afforded by such an addition would
increase the scope of the ES method substantially in terms of the
questions that could be addressed.
Recommendations
For research questions concerned with exposure to hassles,
self-report checklist measures suffer from all of the same problems
as checklist measures of major and minor life events. First, it is
impossible to determine whether the events endorsed represent
hassles, minor life events, major life events, or chronic stressors.
Lack of specificity at this most basic level prevents researchers
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LIFE STRESS MEASUREMENT
from making conclusions regarding the nature of the exposure they
are purporting to measure. Second, by leaving it up to the individual to rate his or her experience, these measures are subject to
biases that may be confounded with the responses or outcomes
under study. Therefore, we recommend that studies addressing the
question of exposure to hassles employ a contextual interview and
rating system such as the DISE.
Alternatively, if the construct of interest is the extent to which
individuals feel hassled in their daily lives, a measure like the
Hassles-Uplifts scale may be appropriate. However, it must be
recalled that these measures are very limited and subject to interpretive abuses. They only provide information about the psychological state of the individual, and proportionately little information about how this state arises (see Figure 1). There is a tendency
to infer that these states are attributable to external exposures, but
they may not be. Studies using such scales also do not control for
biases in measurement of the responses and the outcomes of
interest.
Studies using ES procedures to date have focused on daily and
hourly stress responses and this is entirely appropriate as long as
certain conditions are met. First, it must be clear that the question
under investigation is variability in response to daily events that
individuals perceive as stressful. Second, in designs examining
group differences in responses to daily events, if groups are found
to differ in terms of the event impact ratings (which would be
likely in designs comparing patients with MDD to controls, e.g.),
then the event impact ratings should be accounted for in the
statistical models.
The exciting promise of ES procedures, however, is their ability
to examine how stress exposure and stress response interact over
time to predict outcomes. Without a distinct, reliable, and valid
assessment of both components, empirical assessment of this question is severely limited. As discussed above, objective ratings
based on contextual indicators of events are needed to provide an
unbiased account of event exposure. We suggest that this could be
accomplished even within an intensive experience sampling design
with minimal added time cost by adding brief follow-up interviews
regarding participants’ daily events that would then be rated by
independent raters using a standardized rating system.
General Discussion and Conclusions
We have provided detailed theoretical reasoning and empirical
data documenting that interview-derived systems are superior to
checklist approaches for measuring life stress. Further, we suggest
that the rigor of independent, contextualized ratings can be incorporated into intensive experience sampling methods of assessing
daily hassles to increase the power of such methods to address
questions of stress exposure and stress response. Most important is
their ability to address the problem intracategory variation, and
thereby to ensure that the exposures reported by the respondent
correspond in kind, quality, and spirit with the investigator’s
intended purposes. Assuring that the respondent’s exposure
matches the investigator’s definition of an exposure represents a
bedrock principle upon which modifications in procedures across
different interview-derived systems can vary.
There are, however, important differences between the
interview-derived systems when it comes to validity considerations. To avoid measurement bias, there simply is no scientific
15
substitute for independent and uncontaminated ratings of exposures, responses, and outcomes. On these grounds alone, blind
rater–scored measurement represents the current ‘gold standard’ of
the field. Given the time and labor required with such systems,
however, interview-scored systems and hybrid systems may be
useful ‘first steps’ in developing an understanding of stress effects
on different health outcomes. These approaches can assure reasonable fidelity between respondents’ exposures and investigators’
definitions of life events and chronic stressors, and can enhance the
likelihood of discovering potentially important relations. But investigators need to be mindful that the ‘enhanced’ likelihood of
detecting relations also may be a spurious artifact of measurement
bias. The discovery of new relations needs to be responsibly
evaluated and interrogated by subsequent research to more securely validate the preliminary findings.
There are other differences between the alternative interviewderived systems that can influence the choice of measure. For
example, the UCLA Chronic Stress Interview and the LEDS/
SLEDS differ in the operationalization of chronic stress (Brown &
Harris, 1989; Hammen, 1991). This is important to keep in mind
when evaluating the literature on the relation of chronic stress to
disease outcomes using these two very distinct measures. It is also
important for researchers to be aware of when choosing a measure
of chronic stress. Broadly considered, the choice of measure, and
the choice of stress construct, will depend on theoretical models
for the health outcomes of interest. Environmental exposures vary
in qualities, degrees, and durations, and these variations in stress
exposure have differential implications for particular disease outcomes. For example, coronary heart disease typically develops
over the course of many years, suggesting a chronic or cumulative
role for stress exposures over time; however, acute exposures also
are recognized as triggers for heart attacks in vulnerable individuals, indicating a complementary role for life events. Life events
involving targeted social rejection preferentially predict depression
through their effects on the immune system and inflammation
(e.g., Slavich & Irwin, 2014), whereas life events with themes of
physical threat preferentially predict anxiety, potentially through
their effects on amygdala-anterior cingulate-prefrontal cortical fear
circuitry (e.g., Shin et al., 2005). These distinctions in the operationalization of stress require a comprehensive and flexible system
that gathers enough contextual information to make these finegrained judgments, and does so in a way that is not biased by
knowledge of the outcome under study. This is yet another reason
why blind rater-scored interview systems are to be recommended.
We fully recognize that the ‘gold standard’ contextual interview
and independent rating of stress is a labor-intensive method in
terms of time and cost. As a result, this approach will not be
feasible for some designs (e.g., studies with sample sizes in the
thousands or studies with an already very demanding protocol).
However, it makes no sense to simply substitute an expedient
checklist that does not measure the theorized construct and/or
lacks adequate reliability and validity. Indeed, it is difficult to
imagine any other scientific field in which this option would
represent an acceptable research strategy; practices such as these
without doubt contribute to widespread concerns about the lack of
replication in psychological research (Open Science Collaboration,
2015). The past 30 years have seen tremendous advances in the
rigorous assessment of life stress, which have led to exciting new
knowledge on the relation of stress to a wide array of diseases and
HARKNESS AND MONROE
16
disease processes. Through creativity, consultation, and collaboration we believe that these scientifically sound methods can be
applied in almost any research design in which investigators value
the theoretical importance of stress exposure.
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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Received January 9, 2016
Revision received April 29, 2016
Accepted May 4, 2016 䡲