comment sheet paper

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Modern Approaches toConceptualizing andMeasuring HumanLife Stress

Scott M. Monroe

Department of Psychology, University of Notre Dame, Notre Dame,Indiana 46556; email: [email protected]

Annu. Rev. Clin. Psychol. 2008. 4:3352

First published online as a Review in Advance onJanuary 31, 2008

The Annual Review of Clinical Psychology is onlineat http://clinpsy.annualreviews.org

This articles doi:10.1146/annurev.clinpsy.4.022007.141207

Copyright c 2008 by Annual Reviews.All rights reserved

1548-5943/08/0427-0033$20.00

Key Words

stressful life events, perceived stress, stress reactivity, HPA axisallostasis, allostatic load

Abstract

The idea that adverse life circumstances and negative life ev

contribute to disorder and disease has long been held. Advancconceptualizing and defining these conditions under the com

label of life stress have led to progress in measuring both the eronmental and individual response characteristics that may prom

disorder and disease. In general, a substantial and growing reseliterature supports the basic premise that life stress plays an im

tant role in the development of many psychological and phyproblems. Recent research, too, strongly suggests that intere

life stress in relation to health and disease will accelerate ovecoming years. Yet debates and controversies remain concerningto best conceptualize and measure life stress, which presents dis

tive challenges for advancing the field. The present review examthe major issues pertaining to these debates, controversies, and

lenges, for they will be crucial to resolve if progress is to be maunderstanding ways in which life stress may or may not contri

to psychological and physical disorders.

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Contents

INTRODUCTION . . . . . . . . . . . . . . . . . 34BACKGROUND

CONSIDERATIONS. . . . . . . . . . . . 35CONCEPTUALIZING LIFE

STRESS . . . . . . . . . . . . . . . . . . . . . . . . . 35Defining Stress . . . . . . . . . . . . . . . . . . . 35

Allostasis and Allostatic Load . . . . . 36Perception, Cognition, and

Psychological Appraisal. . . . . . . . 37

MEASURING LIFE STRESS. . . . . . . 38Stressful Life Events and

Difficulties Measures . . . . . . . . . . 38Perceived Stress Measures . . . . . . . . 42

The Psychobiology of Stress . . . . . . 43CURRENT STATUS,

CONTROVERSIES,AND DEBATES . . . . . . . . . . . . . . . . . 44

Subjectivity, Individuality,and Measurement . . . . . . . . . . . . . 45

Costs, Requirements,and Compromises . . . . . . . . . . . . . 46

Stress as a Self-Contained

Nonspecific Explanation . . . . . . . 47CONCLUSIONS AND

FUTURE DIRECTIONS. . . . . . . . 48

INTRODUCTION

The concept of stress is inherently about an

organisms adaptation to challenging environ-mental conditions over time. Since the early

origins in research on animal and humanphysiology, stress concepts have sought to ex-

plain how the body (a) maintains core regula-tory functions despite the continual, and of-

tentimes extreme, perturbations imposed by

environmental events, and (b) what the psy-chobiological costs and consequences are ofthese dynamic regulatory processes. It was

appreciated early on that stress involved di-

verse responses that were orchestrated acrossseveral levels of psychobiological function-

ing, an integrated whole organism reac-tion (Weiner 1992). In addition to the rapid

mobilization of energy substrates for

mediate fight-or-flight physical action,stress response recruits a larger networ

central nervous system activities invoarousal, vigilance, cognitive processing,

memory (de Kloet et al. 2005, Gunna

Quevedo 2007) and influences an extenrange of other metabolic and immune a

ities (Sapolsky et al. 2000). Broadly conered, stress encompasses adaptive dem

from the molecular through the molar, fgene expression through social interactio

Recognitionof the different psychobioical levels participating in the stress resp

considerably enlarges the scope of inquContributions to understanding stress c

from basic neuroscience and biology thro

psychology, epidemiology, sociology, andthropology. Given such a broad andmultimandate for stress research, there have b

diverse approaches to, and debates over

most appropriate ways to define, concepize, and measure life stress. Noteworthy,

is that interest in life stress has not beenstricted to the research laboratory or to

scure scientific circles. Stress terminologits many colloquial forms underpins and

meates popular explanations for diverse p

lems in health and well-being.In this review, historical and backgro

information pertinent to understanding

rent ideas about stress theory and measment are presented first. Next, definition

and conceptual approaches to, life stres

discussed. Examining the relative merits oternative views about stress assists in the

sequent task of evaluating current theocal and measurement issues for studying

stress. Given the large range of approa

to measuring life stress, the review focupon the most common and the most proing methods employed in human field stu

As the reader will see, although progresbeen made in theory and measurement o

stress,thereareconcerns about howwell tadvances are being incorporated into s

dard practices. Finally, although concepts

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findings from animal laboratory and human

experimental and field research are drawnupon, the objective is to focus the review

on theory and measurement of human lifestress.

BACKGROUNDCONSIDERATIONS

Many believe that stress is a problem ofrelatively recent origins, endemic to modern

society and unrelentingly on the rise. Thereis a sense that, as a result of accelerating

progress in science and society, life is inex-orably moving forward at too rapid a pace,

with a diminishing sense of personal securityand control. The vocabulary of stress infuses

everyday conversations, providing an idiomwith rich subtexts to help explain away innu-

merable problems, ailments, and illnesses ofunknown origins (Pohlman & Becker 2006).

It is important to recognize that this fore-

boding sense of stress is not a very recent de-velopment, andthat stress is not necessarily an

important cause of many disordersor diseases.People are very prone to mistakenly attribute

problems of unknown origins to general andnonspecific concepts akin to life stress. The

cultural practice of invoking stress as an ex-planation for disorders whose causes remain

a mystery represents a serious challenge toprogress in research on human lifestress. Both

investigators and research participants can beeasily misled by unsubstantiated beliefs about

life stress and its consequences (Monroe &

Slavich 2007, Sontag 1978).1

1As Rees (1976) noted, the terms stress, distress, and

disease appear on the surface to be simple and discrete.But as one traces their derivations and changing mean-ings over time, they flow into each other and are closelyconnected (p. 3). For example, stress was used in the fif-teenth century as a shortened form of distress, whereasdisease was initially meant to reflect dis-ease or dis-comfort (not illness), a form of distress. The terms remainrich withinterconnected meanings, whichlikely contributeto many of theproblemsin research with regardto keepingconcepts and measures separate and distinct.

CONCEPTUALIZINGLIFE STRESS

Defining Stress

A variety of definitions have been proposedfor stress. Despite numerous attempts, there

remains no universally accepted characteri-zation of the term. Separate research tradi-

tions have emphasized different facets of the

general topic of stress. For example, humanfield studies and clinical observations have

viewed stress as originating in the externalenvironment (Dohrenwend 2000, Monroe &

Roberts 1990). This stimulus perspectivefor defining stress typically assumes that en-

vironmental conditions are more or less likelyto be stressful for the average individual, that

stress is a probabilistic feature of particularenvironmental conditions. In contrast, ani-

mal laboratory research has frequently viewedstress as a particular psychobiological re-

sponse of the organism to differing environ-

mental challenges (e.g., the general adapta-tions syndrome, the fight-or-flight response)

(Selye 1936, 1976; Weiner 1992). Within thisresponse-based tradition, the environmen-

tal conditions eliciting the stress have beentermed stressors (Selye 1976).

Although each of these approaches pos-sesses merit, neither fully addresses a core fea-

ture of stress: the adaptation of the partic-ular organism to specific circumstances that

change over time. In other words, the stimu-lus and response viewpoints incompletely and

only indirectly capture these three features

of the construct (i.e., environment, organism,time). As others have explicitly recognized,

stress is an intrinsically interactive and dy-namic concept (Lazarus & Folkman 1984,

Weiner 1992). The particulars of the organ-ism, the environment, and time are all key el-

ements of the concept. Consequently, it hasbeen suggested that stress be defined in terms

of an ongoing relationship between organismand environment (Weiner 1992) or as the suc-

cessive transactionsbetween the organism andenvironment over time (Lazarus & Folkman

www.annualreviews.org Conceptualizing and Measuring Human Life Stress 35


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1984). From this expanded viewpoint, the

stress process is thought of in terms of externalchallenges and perceptions of the challenges,

coping resources and perceptions of copingresources, and the dynamic interplay of these

over time (Cohen et al. 1995b, Gunnar &

Quevedo 2007).There have been other attempts to capture

the breadth, complexity, and spirit of stressover the years, and two conceptual develop-

ments have become influential in thinkingabout stress. These are (a) allostasis and al-

lostatic load, and (b) psychological appraisal.Although these two topics derive from sep-

arate research traditions and levels of anal-ysis (animal laboratory versus human stress

research, psychobiology versus psychology of

stress), they provide useful complements forone another. They remind us that stress in-

volves adaptation from the most basic biolog-ical functions through the highest cognitive

processes.

Allostasis and Allostatic Load

From animal laboratory research on psy-chobiological regulatory systems involving

the stress response, there has been an increas-

ing interest in how the stress response is or-chestrated over time in service of adaptation.Since at least the work of Claude Bernard,

ideas pertaining to the maintenance of the

bodys internal milieu, and in particular to theregulatory concept of homeostasis, have been

a prominent underlying principles of stress.In response to environmental changes and

challenges, the organism maintained stabil-ity of key biological functions through home-

ostatic regulatory mechanisms. For example,

set points for many vital bodily functions aremaintained in balance and within strict lim-its through homeostatic controls. Within this

tradition, stress has been viewed as exter-nal challenges that disrupt or impair\break

homeostasis.

The concepts of stress and homeostasis,however, often have been used in ambiguous

ways that have obscured possible psychobio-

logical implications for health and well-b

(McEwen 2000, McEwen & Wingfield 20The concept of allostasis was introduce

bring greater clarity to these matters as as to broaden and differentiate the rang

psychobiological activities recruited in se

of homeostasis and adaptation under stTheoretically, the concept of homeostasi

referred to the regulation of a limited nber of core physiological systems that

tain life, systems that must be kept witight limits (e.g., body temperature, pH

ance). Allostasis, in turn, refers to howorganism achieves stability (or homeost

through continual change. It is a morecompassing concept, intended to incorpo

an extensive range of whole-organism m

anisms recruited to meet environmentamands, all of which have more flexiblepoints designed to accommodate consta

changing environments and regulatory c

lenges (McEwen & Wingfield 2003, Ster& Eyer 1988).

Allostatic load, in turn, refers to the sequences of sustained activation of prim

regulatory systems serving allostasis time, to the cumulative burden on bodily

tems (i.e., wear and tear) that is believe

contribute to disorder and disease. The cepts of allostasis and allostatic load undea more comprehensive model of stress

cesses that may be useful for explaining activation of these systems is adaptive

the short run and maladaptive over more

longed periods of time. These concepts vide a richer and more differentiated fra

work of ideas to shed light on how sresponse mechanisms are involved with

exigencies of the immediate flight-fight

mands, in the short-term self-regulationfine-tuning of these systems, as well as inlonger-term role in restoration and re

(de Kloet et al. 2005, McEwen & Wing2003). The concepts of allostasis and a

static load hold the potential to shed ligha range of current mental and physical

cesses conditions, some of which have

recently begun to be considered as poten

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stress-related (including key cellular biomark-

ers of aging; Epel et al. 2004, Sapolsky 2004).

Perception, Cognition, andPsychological Appraisal

A second major influence on stress theorycame with the cognitive revolution andrecog-

nition that psychological processes intervenebetween the environmental event and the

organisms response (Somerfield & McCrae2000). Instead of stress involving reflexive re-

sponses to specific environmental challenges,the stress process expanded to accommodate

a host of factors involving individual differ-ences in perceptual processes and cognition.

Increasingly complex and elegant theories

evolved. These theories depict longitudinaltransactions between the external demands of

the environment, appraisal of the environ-mental demands, assessment of resources to

handlethe external demands, copingefforts tochange the environmental, and so on (Cohen

et al. 1995b, Lazarus & Folkman 1984).As a result of these fertile ideas, individual

differencesin psychological processes were el-evated to key positions as intervening vari-

ables. Specifically, the appraisalof stressful sit-

uations and coping resources were accordedcentral significance for moderating how envi-ronmental challenges could affect psyche and

soma. The hypothetical influence of appraisal

could cut two ways: the impact of very stress-ful events could be attenuated, and the impact

of more minor stressful events could be ampli-fied (Kanner et al. 1981). Formulations such

as these helped to explain why some peoplesuccumb more readily under stress than oth-

ers. They also assuage underlying anxieties

about the apparently random and relentlessexposure to stress (i.e., if one can gain controlover the consequences, one can control and

perhaps eventually conquer the most noxiouspiece of the problem).

How pivotal and influential are appraisal

processes for moderating stress impact? Ar-guably, this matter represents one of the most

pressing considerations in contemporary re-

search on life stress. At one extreme, there

is a relatively tight linkage between objectiveenvironmental stress and perceived stress. In-

deed, it would seem obvious that perceptionsare derived from the objective characteris-

tics of the environmental context, the circum-

stances that lend themselves to perception(Monroe & Kelley 1995). From the broad-ened adaptive perspective of evolutionary the-

ory, too, one would expect survival to depend

upon a reasonable correspondence betweenthe external demands of the environment and

an organisms perceptions of those demands.Psychological factors and appraisal in partic-

ular remain relevant within this perspective,buttheexigenciesof theexternal environment

largely contour and constrain psychological

factors.At the other extreme, there is a relatively

loose linkage between environmental chal-

lenges and perceived demands. This extremerepresents a strong psychological perspec-

tive, one in which cognition and appraisal

dominate and significantly alter, override, oreven reverse the influence of external circum-

stances. This perspective, too, is bolstered bypopular motifs in cognitively oriented psy-

chological science and practice (e.g., as the

philosopher Epictetus averred, Men are dis-turbed not by things, but by the view whichthey take of them). Psychological factors

and appraisal within this perspective are onlypartially constrained by the existing environ-

mental exigencies. There are strong sympa-thies for this theoretical position, particu-

larly in human life stress research (Lazarus &

Folkman 1984, Lazarus et al. 1985).The preceding discussion establishes that

stress appraisal and cognitive processes are

important additions to defining and concep-tualizing life stress. The degree to which en-vironmental challenges, the perception of en-

vironmental challenges, or the conjunction ofthe two contribute to stress and produce sus-

ceptibility to breakdown is presently unknownand is a pivotal topic for future research.

The inclusion of cognition and appraisal tothe stress model also poses challenges for



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conducting research, particularly with regard

to the measurement of stress (Monroe &Kelley 1995).

MEASURING LIFE STRESS

Given the breadth of the stress conceptand the differing views as to its nature, it

is no surprise that a variety of measure-ment approaches exist (see Cohen et al.

1995a). At a very general level, current ap-proaches to measuring stress appear consis-

tent with the three conceptual perspectivesoutlined above (the environmental compo-

nent of stress, the response component ofstress, and environment-person transactions

of stress). However, many if not most mea-

surement systems in practice blur these the-oretical boundaries. For example, self-report

life event checklists appear to fit most read-ily with an environmental definition of life

stress. But when the study participant makesthe decisions about which events qualify, or

how stressful the events are, these measuresinherently incorporate response components

as well.Interview-based proceduresfor assess-ing life events, too, often estimate the likely

impact of the life event on the participant or

for the average person and thus include ap-proximations of the persons response in themeasure (Brown & Harris1978, Dohrenwend

et al. 1993).

A similar situation exists with response-oriented measures of human life stress. It is

typically not possible to determine the degreeto which variation in the particular response

is due to external environmental conditionsper se versus other individual difference vari-

ables that contribute to the stress process. For

example, measures of perceived stress or cor-tisol levels may be a consequence of environ-mental stress but also may be moderated by

such factors as personality or social support.Particularlyof concern for response measures,

too, is the degree to which the measure is ac-

tively confounded with the problem or disor-der under study (e.g., depressed persons may

report high stress or evidence elevated corti-

sol due to being depressed, not external s

sors). Thus, response-based measures of spose significant challenges for separating

influences of stress from other factors, incing the confounding with manifest disord

psychopathology (Monroe & Kelley 199

Finally, the transactional definitionstress have been more appealing in ththan evident in practice. There are few

stances of empirical work in the litera

based on such models (Folkman & Mosko2004; cf. Stroebe et al. 2006). Keeping in m

these limitations for the different definitiperspectives on life stress, the following

view of stress measures is organized arothe most common practices used in the

man literature on life stress.

Stressful Life Events andDifficulties Measures

The vast majority of studies of humanstress have assessed peoples recent majo

events. Since the idea of measuring life sas discrete life events took operational f

in the Schedule of Recent Experiences (SHawkins et al. 1957, Rahe et al. 1964),

with theaddition of specific weightings fo

SRE in the Social Readjustment Rating S(SRRS) (Holmes & Rahe 1967), attentiothe topic has grown yearly. At present,

10,000 publications beginning in 1967

pertained to the topics of stressful life evor life stress (Dohrenwend 2006). Given

tremendous presence and influence ofgeneral approach to the measurement of

man life stress, as well as the ongoingbates about different measurement prac

that have been spawned, the subject is

ered in some depth. The early procedures for measuringevents were based upon the precedent

videdbytheinnovativeSREandSRRS.Tand derivative self-reportchecklists includ

range of life experiences that were consid

to be relatively common in most peoplesand were assumed to require varying deg

of readjustment or, implicitly, stress. A

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attraction of these measures was the ease with

which one could apparently capture an ob-jective index of something as complex as life

stress.Asinanyareaofscientificdevelopment,problems were soon uncovered with the first

generation of self-report checklists, modifica-

tions were suggested, and a host of next gener-ation measures were, and continue to be, de-

veloped (Brown & Harris 1978, Dohrenwend& Dohrenwend 1974, Dohrenwend et al.

1978, Monroe 1982, Paykel 2001). Many early critics of self-report life

event checklists, however, suggested that theproblems with these measures were more

basic, that they represented fundamentaland possibly incorrigible limitations of the

self-report checklist method itself (Brown

1974, Dohrenwend 2006).2

Alternative sys-tems for assessing life stress were developed,

typically based upon information gleanedfrom structured or semistructured interviews

(Dohrenwend et al. 1993, Hammen 1991,Paykel 2001). Perhaps the most elaborate and

widely used system for assessing, defining,and rating life stress is the Life Events and

Difficulties Schedule (LEDS), developed byGeorge Brown and Tirril Harris (Brown &

Harris 1978). The LEDS system includes

an extensive manual that provides explicitrules andoperational criteria for defining bothacute and chronic forms of stress, for distin-

guishing between complex constellations of

theseformsofstress,andforratingtheseexpe-riences using a comprehensive manual. These

sources of information help guide decisionsand enhance standardization of measurement.

The unique biographical circumstances of theindividual are taken into account when rating

each life event; this helps to place the experi-

ence in context for that person, increasing thelikelihood that the meaning of the event will

2Much has been written on recent topics in life stress the-ory and research, so we only provide an overview of theissues that have been well detailed elsewhere. For morethorough expositions, we refer the reader to several ex-cellent sources (Brown 1989, Dohrenwend 2006, Paykel2001).

be captured in the rating. Approximately 5000

case exemplars are provided in the manual toalso help anchor the assessment decisions and

standardize the ratings. The LEDS informa-tion can be presented in a separate meeting to

raters whoare blind to the subjective reactions

of the particular individual, in order to avoidconfounding of the study participants reac-

tion with depression status (e.g., depressed in-dividuals may evidence greater upset initially,

or may report greater upset retrospectively tohelp justify or explain their depression).

A considerable body of research has nowdirectly compared life event checklist mea-

sures with interview-based measures (e.g.,Duggal et al. 2000; Gorman 1993; Katschnig

1986; Lewinsohn et al. 2003; McQuaid et al.

1992, 2000; Oei & Zwart 1986; Simons et al.1993; Zimmerman et al. 1986). Although the

procedures across these different studies varywith regard to the specific life event check-

list and interview method used, the consistentfinding is that there are significant differences

in the information obtained between the twomethods. For example, McQuaid et al. (1992)

found that only 38.5% of life events reportedwith a self-report checklist corresponded with

life events defined by the LEDS (Brown &

Harris 1978). Lewinsohnet al. (2003)recentlyperformed a similar comparison between self-report and follow-up interview methods. For

life events primarily involving the subject,

they found that 67.5% of events indicatedon the checklist met the criteria for events

according to their stress interview. For lifeevents primarily involving other people, the

correspondence rate was only 19.7%. Sincelife events primarily involving others were re-

ported twice as often as events primarily in-

volving the subject, the overall percentage ofvalid events as defined by the interview crite-rion was well below 50%. These findings are

consistent with those of Duggal et al. (2000),who concluded that a checklist measure of life

events captured only 32% of severe events oc-

curring prior to depression onset.These studies indicate that, even under the

most optimistic circumstances, self-reported



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life events are consistent with the type of

life event envisioned by the investigator lessthan half of the time. To be perfectly clear

about this central matter, the likelihood of alife event reported by the study participant

on a self-report checklist matching the life

event defined according to interview-basedcriteria is generously, at best, even odds. As

described below, these discrepancies do notreflect merely different opinions about the

matter or alternative views; they typically re-flect outright errors in the self-reporting of

life events. The basic point is quite clear: Self-report checklist methods are very prone to er-

rors in identifying life events. More generally,reviews of the life events literature are basi-

cally unanimous in concluding that interview-

based measures are superior to self-reportchecklists, and that interview-based methods

represent the current gold standard for assess-ing life stress (Dohrenwend 2006, Gorman

1993, Hammen 2005, Kessler 1997, Mazure1998, Paykel 2001).

Many of the concerns about life eventsmeasurement echo across other research lit-

eratures. For example, trauma appears tobe self-evident. On the surface, one might

expect people to be relatively accurate and

consistent in reporting exposure to a trau-matic incident. Yet researchers investigatingtrauma have grappled with assessment prob-

lems essentially identical to those of lifeevents

researchers, and several reports have docu-mented problems with self-report checklists

for trauma exposure similar to those foundwith self-report life events checklists (Hepp

et al. 2006, Roemer et al. 1998, Southwicket al. 1997). Different age groups experience

different life events, too, and sundry self-

report checklists of life events for children andadolescents have been developed that are sus-ceptible to the same limitations as the adult

lifeevent measures (Grantet al. 2004). Finally,for many years survey research methodology

has been dedicated to understanding factors

affecting the subjects interpretation of ques-tionnaire items and recall, factors that have

effects that are often subtle, yet effects that

can substantially compromise the reliab

and validity of the data obtained (see Schw2007).

Threecommonthemes cutacross theslated literatures that can help inform de

about appropriate methods for life stress m

surement. The first theme concerns memand recall of the essential information, thevents. How accurately can people remem

past experiences and report on them? So

what surprisingly, with proper assistancestructuring of the questioning, people can

complish this reasonably well. For severeevents using the LEDS system, it has b

estimated that people can reliably reporsuch experiences for up to ten years (Ne

et al. 1989). Less severe events and more

nor stressors, however, may be less relirecalled (Brewin et al. 1993, Hardt & Ru2004). Current research on autobiograp

memory provides clues on how to enhthe ability of individuals to recall life s

information reliably over extended perio

time (Belli 1998, Schwarz 2007). In princit would seem that these enhancements c

improve both interview-based and self-rechecklist methods for assessing life stress.

crepancies between self-report and interv

based measures, then, are not likely texplained by differences between the twoproaches with respect to memory per se.

The second and third themes are bot

lated to the issue of recall, but more subtlAnd these two themes point to a critica

vide between self-report and interview-bmethods for measuring life stress. The

of these themes concerns the definitionand decision about, what formally constit

a life event. As Dohrenwend (2006) ha

cently systematically addressed, a major plem with self-report checklists is that pequite often interpret the life event desc

tors in highly personal and idiosyncratic w

3It should be noted that when precise timing of evencurrencesand onset of thedisorderunderstudyis reqmore intensive questioning and assistance are neede

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Depending upon how the particular person

interprets the question, the same life event de-scriptor can reflect a range of life events, from

the trivial through the catastrophic. For ex-ample, serious illness and injury events can be

endorsed for experiences involving a bad cold

or minor sprain through heart attacks andma-jor crippling accidents. This means that what

the investigator intends to measure frequentlydoes not correspond with what the subject ac-

tually infers and endorses (i.e., as noted above,correspondence is likely to be below 50% of

thetime). There is no commonunderstandingof the spirit of the event between subject and

investigator. This majorshortcoming with lifeevent checklists unfortunately has been re-

peatedly overlooked, minimized, or simply

ignored.Research on cognitive aspects of survey

methodologies converges on this identicalproblem. As Schwarz (2007) notes regard-

ing behavioralreports, memory processes areonly one of the determinants of their accu-

racy. . . respondents may report on a behav-ior that does not match what the researcher

had in mind (p. 283). This is where mem-ory melds with the participants current im-

perfect and evolving understanding of the task

at hand. The participants recall is structuredby his or her own interpretation about what tosearch for. If the life event item is interpreted

differently from the way in which the inves-

tigator intended, there will be a mismatchin understanding, error intrinsic to the data

collected.The third theme of relevance to this topic

acknowledges that research participants drawupon a number of additional sources of in-

formation, background and contextual, to

frame the task requirements, infer the in-vestigators intentions, interpret the informa-tion provided, and eventually come up with

a response. Recognition of these multiple in-fluences raises awareness about how readily

stress measures are contaminated by extrane-

ous information or confounded by subjectivebias. Two major domains of influence are of

particular concern (see sidebar). First, most

people who complete self-report checklists

readily recognize that stress is of relevanceto the study. Decisions about whether to en-

dorse any of the listed life events are influ-enced by the participants general views about

life stress and specific inferences about the

present research needs. This is one mech-anism via which the cultural biases aboutstress canintrude andcontaminate stress mea-

surement, introducing random error. Second,

people who have already developed problems,disorders, or illnesses may seek explanations

for their maladies and be more prone to en-dorse life events that only vaguely resemble

what happened to them (Brown 1974). Viathis mechanism, awareness of theproblem un-

der study may confound stress measurement,

resulting in systematic errors, which in turnpromote spurious associations between lifeevents and disorder. More generally, reliance

on these uncontrolled background sources ofinformation becomes most pronounced when

there is no means for the participant to clarify

the question, or to secure a better understand-ing, through discussion with a knowledge-

able individual (Schwarz 2007). Thus, one ofthe main attractions of self-report life events

checklists (i.e., expediency and minimal inves-

tigator burden) represents a fundamental lim-itation of the method.

The reliability data from the life stress re-

search and information from related litera-tures consistently point to the serious short-

comings of self-report life event checklists.Given an estimated error rate for basic iden-

tification of life events with self-report pro-

cedures exceeding 50%, one can question theneed for, or incremental value of, compara-

tive validity studies. Nonetheless, there is a

handful of studies with data bearing upon thematter. In general, the interview-based meth-ods have been found to be superior in terms

of associations with depression or depression-related phenomena (e.g., predicting greater

depressive symptoms or lower probability ofremission, McQuaid et al. 2000; detecting se-

vere events typically found to precede depres-sion onset, Duggal et al. 2000). In particular,



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STRESS MEASUREMENT ERRORSRESULTING FROM MISINTERPRETATIONSBY RESPONDENTS

In previous research, we routinely interviewed people about

life events they endorsed on a self-report checklist (McQuaidet al. 1992). Many times when we asked about what had actu-

ally happened, participants reversed themselves and indicatedthat it was probably an error (Monroe & McQuaid 1994).

Interestingly, two types of false positive endorsements com-monly occurred (people who indicated an event had happened

to them, but with further information recognized that the ex-perience did not qualify). First, there were people who had

very few events but knew we were studying stress and felt thatthey should provide some relevant information on the topic.

Upon questioning, these individuals quickly recognized that

the endorsed items were not quite right, but they indicatedthat endorsed items were the closest they could come up with

to provide us with some indicator of stress in their lives. Sec-ond, there were people who also had very few if any events,

but upon questioning rather sheepishly and spontaneously in-dicated they did not want us to think their lives were boring.

Both types of respondents stretched the definitions of partic-ular events to satisfy the perceived needs of the research or

to preserve respect in the eyes of the interviewer. The de-gree to which there may be a mismatch between the infor-

mation sought by the investigator and the interpretation bythe respondent can be astonishing. In these interviews follow-

ing the completion of a life event checklist, we also inquired

about events that may have happened but were not listed. Inresponse to this query, one woman volunteered that her hus-

band had recently suffered a heart attack. When probed asto why she might not have endorsed the life event item as

Serious illness in close family member, she indicated thatthe event wasnt stressful. As a result of his heart attack, her

husband had quit smoking and perhaps become more patient,and they were getting along much better than previously. She

was so strongly influenced by her assumptions about our in-terest in stress that she was able to override the rather clear

and explicit question at hand and modify her response in linewith what she thought we wanted.

interview-based measures are better suited fordistinguishing between life events that are

truly stressful versus trivial (Gorman 1993).It should be noted that self-report measures

of life events on occasion have yielded asso-

ciations when compared with interview-b

measures (e.g., McQuaid et al. 2000; seeWagner et al. 2006). However, given the

error rate of event identification, concabout the timing between stressors and

order onset, and the problem of confou

ing between stress and disorder with methods, the implications for stress-diso

relations are tenuous. Indeed, recommetions for the use of self-report checklists

be limited to a summary index of ovlevel of subjectively experienced stress,

interview-based methods suggested forsearch on etiology (Duggal et al. 2000, p. 4

In summary, research has repeatdemonstrated serious shortcomings of

report checklists of life events and chr

stressors as reliable and valid measurelife stress. Most of these problems caaddressed satisfactorily with semistruct

interview-based approaches that utilize oational rules and guidelines for defining

events. There is an abiding faith in self-re

checklists, however, as sufficient measuresome, or even many, research needs (e.g

early life event scale, the SRRS, recentlydeclared to be a robust instrument for i

tifying the potential for the occurrenc

stress-related outcomes; Scully et al. 2p. 875). And life event checklists contiby far, to be the most common approac

assessing stressful life events. This indicthat other factors beyond empirical evid

influencing opinions in this crucial debatserve greater attention. We returnto this t

below in the Current Status, Controver

and Debates section.

Perceived Stress Measures

In comparison with the literature on strelife events, relatively few attempts have

made to measure perceptions or appraisa

stress (Monroe & Kelley 1995). The mcommon instrument of this kind in the l

ature, however, is the Perceived Stress S(PSS; Cohen et al. 1983). The PSS was de

oped based upon appraisal theory (Lazar

42 Monroe


11/22

Folkman 1984) and was designed to . . . tap

the degree to which respondents found theirlives unpredictable, uncontrollable, and over-

loading (Cohen et al. 1983, p. 387). Theoriginal scale includes 14 items, and addi-

tional versions have been developed for 10-

and 4-item subsets of the scale. All three ver-sions possess good psychometric qualities [yet

Cohen & Williamson (1988) recommend therelatively superior 10-item version]. The PSS

is widely cited, used in diverse studies of lifestress,and hasbeen translatedinto several lan-

guages.Secondtothegenericlifeeventcheck-list approach, the PSS is probably the most

commonly used measure of stress in the re-search literature.

The PSS has been found to predict many

adverse outcomes. Importantly, the PSS hasshown discriminant validity with regard to life

event measures of stress (i.e., each measureof stress predicts different stress-related pro-

cessesor outcomes). Forexample, Cohen et al.(1993) reported that both perceived stress

and stressful life events predicted greater riskfor developing the common cold. However,

these two measures produced different rela-tions with illness and were mediated by dif-

ferent biological processes, suggesting that

perceived stress and stressful life events mea-sure different components of stress. Impor-tantly, this suggests that measures of stress

based upon the objective environment ver-

sus those based upon subjective appraisal re-late to different underlying mechanisms, pre-

dict different aspects of illness, and in theorymay be associated with different disorders or

diseases. As a general response measure of per-

ceived stress, the PSS possesses the limita-

tions previously discussed with response mea-sures (i.e., the scale is influenced by a rangeof factors aside from environmental stres-

sors). More specific and critical, too, is theobvious concern about overlap in item con-

tent between psychological symptoms and the

PSS. Cohen et al. (1983) note this matter, re-porting correlations of 0.76 and 0.65 across

two samples with depressive symptoms. Yet in

otherresearch, these investigators haveshown

the PSS to prospectively predict health out-comes independent of psychological symp-

toms (Cohen & Williamson 1988; Cohenet al. 1983, 1993), supporting the discrimi-

nantvalidityofthePSSwithregardtopsycho-

logical symptoms (Monroe & Kelley 1995).Overall, despite limitations inherent to stressresponse measures and cautionary concerns

about confounding with psychological symp-

toms, the PSS possesses good psychometricqualities and a respectable record of validity

studies (including noteworthy biological cor-relates; Epel et al. 2004, Gianaros et al. 2007).

The Psychobiology of Stress

Ever since early interest emerged in stressfulphenomena, biological factors have provided

a strong focal theme (Selye 1936, Weiner1992). Animal laboratory and human exper-

imental stress studies commonly incorporatebiological indicators of stress responses; such

measures have been employed far less fre-quently in human field studies of life stress.

Yet there has been a steady growth of interestin the psychobiology of stress and resilience

over the past decade (Dickerson & Kemeny

2004, Gunnar & Quevedo 2007, Hammen2005, Sapolsky 2005, Southwick et al. 2005).In particular, the developmental neurobiology

of the hypothalamic-pituitary-adrenal corti-

cal (HPA) axis and the regulation of corti-sol have become a major focus of interest for

understanding individual differences in stressreactivity (Heim & Nemeroff 2002, Meaney

2001).Considerable evidence across the animal,

experimental human, and clinical human lit-

eratures suggests that early adversity con-tributes to alterations in neurobiological sys-tems regulating stress, and in particular to

HPA axis functioning (Heim & Nemeroff2002). Alterations in these systems have been

hypothesized to lead to greater sensitivity to

environmental stress, and thereby to a greaterlikelihood of developing psychopathology, as

well as other possible disorders (Gunnar &



12/22

Quevedo2007). These sources of information

nicely complement other areas of recent re-search, which have found strong general link-

ages between early abuse in childhood anda wide variety of adverse health outcomes in

later life (Felitti et al. 1998).

There are important implications of theserelated research literatures for human life

stress research. Theoretical frameworks andmeasurement practices can be expanded to

incorporate early developmental abuses andadversities, along with their implications for

psychobiological functioning and stress regu-lation. Recent advances in noninvasive mea-

surement techniques, too, have fueled in-terest in the neurobiology of developmental

stress research and provide the groundwork

for shedding light on how environmental andpsychological stress are biologically medi-

ated (Gunnar & Quevedo 2007). However,the number of biological systems affected by

stressful conditions is tremendous (Charney2004, Southwick et al. 2005), and measure-

ment issues are at least as paramount as arethose encountered with other levels of stress

research.For example, studies on the HPA axis

and regulation of cortisol are useful for

understanding challenges to be considered(Dickerson & Kemeny 2004, Gunnar &Quevedo 2007, Miller et al. 2007). Although

cortisol represents a logical indicator of stress

impact involving key biological regulatorysystems, standardized, consensually accepted

methods for assessing the hormone do not yetexist. Significant obstacles to progress include

basic questions about the nature of cortisol re-lease (Young et al. 2004) as well as questions

involving the particular methods of measure-

ment. For instance, cortisol output can be as-sessed in different fluid systems of the body(e.g., saliva, blood, urine, or cerebrospinal

fluid), which in turn vary in the amount of bi-ologically active cortisol (unbound by carrier

proteins) and in the temporal window during

which cortisol is released (Miller et al. 2007).The circadian and ultradian rhythms of cor-

tisol activity, too, further complicate optimal

measurement of the hormone (Young e

2004). Finally, cortisol may not signify a specific indicator of stress responsivity,

rather may be recruited in reaction to paular classes of environmental challenges (

social or physical threat; Dickerson &

meny 2004, Miller et al. 2007). These cautary points are raised not to dissuade efforrelate psychological stress to biological co

lates, but rather to acknowledge that othe

eas of stress research face difficult challein measuring indicators of the construct.

Overall, progress along these lines rfirms stress as a whole-organism pheno

non. These ideas, too, are in keeping withcent recommendations for bridging the

between distal genes and proximal envi

mental factors through a systems approthat incorporates intermediate psychobioical processes (Caspi & Moffitt 2006, Go

man & Hanson 2005). Although such wwill no doubt add complexities for mode

andmeasuring the multiple components,

efforts will provide opportunities to anideas about psychological stress more secu

within a broadened and biologically plaunomological network.

CURRENT STATUS,CONTROVERSIES,

AND DEBATES

Scientific interest in life stress and its imcations for health and well-being perhap

never been greater (Cohen et al. 2007, Met al. 2007). In terms of neuroscience un

pinnings, the concepts of allostasis and static load are reinvigorating thinking a

how adversity contributes to a host of m

tal and medical conditions. The range oological processes involving stress is exping, stretching toward physical condition

previously viewed within a stress framew

(e.g., metabolic syndrome, the aging pro(Miller et al. 2007, Sapolsky 2004). Adva

in mapping the human genome and inveloping molecular genetics techniques

set the stage for long-awaited breakthro

44 Monroe


13/22

in understanding gene-environment interac-

tions (Moffitt et al. 2005), with groundbreak-ing findings recently reported for an inter-

action between major life events and theserotonin transporter gene in clinical depres-

sion (Caspi et al. 2003). Overall, one can

predict with confidence that even more at-tention will be devoted to life stress and its

measurement over the next several years asinvestigators expand their efforts to under-

stand the causes of diverse mental andmedicalproblems.

Unfortunately, there are fewer reasons tobe confident that the potential of life stress

measurement to make meaningful contribu-tions to these efforts will be fully realized. Al-

thoughadvanceshave beenmade in conceptu-

alizing and measuring human life stress, theseadvances have not become part of established

measurement practices. Despite the clear advantages of interview-based approaches to

measuring life stress, Grant and colleagues(2004) recently estimated that fewer than 2%

of 500 studies they reviewed on stress in chil-dren and adolescents used interview-based

procedures. Most of what is accepted as sat-isfactory measurement of stress is simply not

in keeping with what is now well documented

about scientifically sound measurement prac-tices, or with what is recommended by ex-perts in careful reviews of the literature. As

biomedical fields develop increasingly sophis-

ticatedand cutting-edge assessment technolo-gies, progress on life stress measurement has

at best plateaued (or flatlined). When it comes to conceptualizing and

measuring life stress, a curiously casual anduncritical attitude characterizes much of the

research literature. Oftentimes stress mea-

sures are improvised for the immediateundertaking, with little regard for the largerliteratureon assessing lifestressor even for re-

porting basic psychometric information. Themanner in which the final stress score is op-

erationalized, too, is highly inconsistent, and

often unique, across studies (e.g., total lifeevents, total negative life events, subjectively

weighted life events, events selected from a

particular life domain). The lack of attention

to standardized practices, despite their avail-ability, has resulted in setbacks along several

lines. Replication is not possible when primi-tive and diverse methods are used across stud-

ies. Falsification of hypotheses based on life

stress is a problem when there are few con-straints upon what passes for stress, whenthere is a smorgasbord of seemingly endless

operational opportunities from which to draw

(Monroe & Reid 2007).Finally, without reliable means of estab-

lishing replication or refutation of stress hy-potheses, there is little direction or guidance

for developing better ideas and stronger mea-sures. This may be the most incapacitating re-

sult of these problems. The gold standard for

assessing life stress is the LEDS, and this ven-erable measure is now over three decades old(Brown & Harris 1978). The PSS, too, has

now been in existence for a quarter century(Cohenet al. 1983). These representvery long

periods of time within the continually evolv-

ing world of science. New developments areneeded to advance the field and to meet the

anticipated demands of the next decade andbeyond for stress research.

One way forward is to gain a better un-

derstanding of the reasons for the presentimpasse. Why is there such a permissiveand uncritical attitude toward measuring life

stress? In the following section, we specu-late on several factors that may explain this

current state of affairs in human life stressresearch. Through bringing these issues to

the forefront of discussion, it is hoped that

the standards for stress measurement can beraised,and newapproaches maybe developed,

in pursuit of clarifying the role(s) stress may

or may not play in disorder and disease.

Subjectivity, Individuality,and Measurement

Many theorists and researchers have a strong

inclination to view the participants percep-tions as the deepest and most meaningful

truth about the stressfulness of the situation.



14/22

Without this level of phenomenological in-

sight into the experience, it is believed thatmeasurement will be stripped of individual-

ity and thereby stripped of what likely con-stitutes the essence of stress. Whom but the

person experiencing the event can ever speak

to, or appraise, how stressful it was? By notallowing the participant to express his or her

feelings about the issue, the uniqueness of theindividual is not honored or respected, and

the most insightful source of information isignored.

Admittedly, this is a caricature of the is-sue, intended to magnify a subtle, but pos-

sibly substantial, source of prejudice. Thepoint touches on a sympathetic chord that

insidiously undermines the credibility of

investigator-based approaches to assessinglife stress, of approaches trying to standard-

ize measurement of the environmental con-ditions characterizing stressful encounters.

Somehow having the respondent supply hisor her own subjective views, untainted by in-

vestigator interference, is assumed by manyto permit a more profound understanding of

the truth about stress to emerge. Many simplybelieve what is central is the view the person

takes of the situation, not the situation itself

(which, as noted, remains an important em-pirical question). These attempts at preserv-ing the sanctity of the subjective self, how-

ever, ignore the inescapable reasons already

discussed for not navely relying only on whatthe respondent has to say casually about his or

her recent life experiences.When the questioning is properly struc-

tured, when there is ample opportunity forcollaborative cognition, and when clarifi-

cation about the information can be sought

(Schwarz 2007), study participants can pro-vide reasonably reliable informationaboutthelife experiences involved. Details of the ex-

perience that are of importance for estimat-ing the likely personal meaning of the event,

too, can be obtained (i.e., the contextual rat-

ings of the LEDS system; Brown & Harris1978). One should not confuse the necessary

taskof eliciting essential personal information

from the respondent with the equally ne

sary and separate task of making standardjudgments about the information so obtai

Costs, Requirements,and Compromises

Onepointofagreementacrossallperspec

on stress measurement is that interview-bprocedures are more costly and time cons

ing and thereby less suitable for investigatrequiring large samples (Dohrenwend 2

Hammen 2005). Although these are imtant limitations of the method, they do no

facto legitimate theuse of self-report checmethods. These are quite separate matte

Often life stress is one factor among m

in a multifactorial design, with stress ranin importance from a primary cause thro

a trigger, a contributor, or only a comption. When stress is only part, or a relati

minor part, of the working model, evenmost conscientiousinvestigator may feel p

sure to adopt methods that are more expent. But does measuring stress poorly m

sense, even if other factors in the modemeasured with fidelity? Alternatively, th

searchagenda may require very large num

of individuals, and resources are insufficto support interview-based measures ofstress. But measuring stress with large n

bers of people doesnt make poor meas

ment any better, and it doesnt translate good science in any obvious way (espec

with serious concerns about confounfactors). Worthy of mention, too, is the l

increase in statistical power afforded by cise and reliable measurement; emplo

the best measures of life stress can thu

duce the required sample size (Moffitt e2005).More generally, the concern is that t

expedient precedents build upon themseand the literature proliferates with meas

that then provide perceived credibility

the inferior approach. Recall that as litt2% of the research literature may be b

on preferred measurement approaches(G

46 Monroe


15/22

et al. 2004). As Gorman (1993) pointed out,

in other areas of scientific inquiry, the choiceof method would probably be made accord-

ing to which technique seemed most promis-ing in terms of advancing knowledge (p. 72).

Many areas of psychology require costly and

time-consuming assessment procedures butdo not suffer from the same begrudging at-

titude about the time, expense, and technicalrequirements entailed.

A compromise position might be to adoptmeasures of perceived stress when time and

resources are limited and to avoid self-reportlife event checklists altogether. As noted

above, the PSS and similar measures havetheir limitations, yet proper control proce-

dures and research designs can help offset

many of these concerns. For example, con-trolling for psychological symptoms increases

confidence that associations with perceivedstress are not attributable to confounding

with existing symptoms. By also employingprospective designs, the investigator can help

assure that variation in stress precedes andpredicts the later-occurring outcome of in-

terest. The PSS, too, has the added attrac-tion of being relatively transparent with re-

spect to its advantages and disadvantages and

of having an extensive research record forcomparative purposes (see also Cohen et al.1995a). Self-report life event checklists are

too easily overvalued and misleading, provid-

ing an illusion of accurate stress measurementdespite extensively documented unreliability

(Dohrenwend 2006).

Stress as a Self-ContainedNonspecific Explanation

It is worth considering whether somethingabout the concept itself contributes to theuncritical attitude about how to measure life

stress. The idea of stress possesses such com-

pelling face validity and cultural reificationthat investigators may be blinded to thinking

more critically about its measurement. Twoaspects of this admittedly speculative idea are

worth considering.

Quite commonly, studies that report stress

for some adverse outcome do not take thelogical next step to question what it might

be about stress that accounts for the find-ings. There tends to be a lack of curiosity

about what it is about stress that leads to

harm. After one accepts the basic premise thatstress is associated with some negative out-

come, attention shifts to other aspects of theresearch or elements of the causal model. Re-

searchers rarely probe the inner workings ofstress (e.g., questioning whether the situation

involves physical threat, loss, danger, or hu-miliation) or the possible underlying mech-

anisms (e.g., negative affect, rumination, orneuroendocrine dysregulation). Even the crit-

ical question of what proportion of the stress

process can be accounted for by the objec-tive environmental versus subjective appraisalis seldom considered. In a strange and circular

way, stress seems to stand on its own as a plau-

sible, complete, self-contained explanation.The face validity of stress not only deflects

attention away from the inner elements of thestress concept, it also allows attention to be

drawn to tangentially related factors. Life cir-cumstances that can be connected in some

way with the generic idea of stress are readily

entertained, easily accepted, and uncriticallyincorporated into the nonspecific construct.Once these remotely related factors are some-

how connected to stress, they then snap to thedefining grid of the construct. And, as noted

above, the need for further explanation then

ceases.Recent research on life stress and the sero-

tonin transporter gene in depression pro-vides a good example of this loose mode of

transitive thinking. The original report by

Caspi et al. (2003) used preferred interview-based methods to assess life events. Studiesattempting to replicate the original findings,

however, have used stress measures rangingfrom indices composed of chronic diseases,

unemployment, and physical distress (withno life events; Grabe et al. 2005) through a

composite including a questionnaire on so-

cial problem solving, parental education, and



16/22

total life events (Eley et al. 2004). Although

12 replication studies had been conducted atthe time this review was written, investigators

(Monroe & Reid 2007) had identified onlyone that employed interview-based life event

methods (Kendler et al. 2005). Once again,

the intuitive appeal and face validity of lifestress helps to understand how such diverse

phenomena are uncritically united and in-terchangeably employed under the common

stress rubric. The field needs to move awayfrom this misleading mode of thought and

adopt a more critical attitude about what qual-ifies as life stress and how it is to be measured.

CONCLUSIONS ANDFUTURE DIRECTIONS

Theory and research on life stress and its im-

plications for health and well-being have pro-duced a wealth of promising findings over the

past several years. In one form or another, lifestress has been found to predict a wide va-

riety of psychological problems and medicalconditions, ranging from acute infectious dis-

eases (e.g., thecommon cold) through chronic

medical disorders (e.g., coronary heart dis-ease) (Cohen et al. 2007, Miller et al. 2007).

Future studies will need to move beyondgeneric associations between life stress and

disorder to address increasingly specific ques-tions about what acute or chronic forms of

stress, under what circumstances, lead to par-ticular disorders or diseases.

Controversy and debate, however, havesurrounded the optimal ways to conceptual-

ize, and in particular to measure, human lifestress. Despite repeated calls for increased

rigor in the measurement of stressful life

events, a wide recognition of the limitationsof self-report checklists, and the availability

of better measures (e.g., the LEDS or PSS),the self-report checklists continue to predom-

inate (Brown 1989, Dohrenwend 2006, Grantet al. 2004). Studies are needed to identify

stress measures that canprovide reliability and

specificity and that are able to illuminate

ticular dimensions of stress and their imptions for health. For example, acute form

stress such as stressful life events may be

evant for the onset of certain conditions (major depression), whereas chronic form

stress may be informative for diseases have a more protracted and insidious o

(e.g., coronary heart disease). More geally, measurement systems for future rese

should be capable of distinguishing betwdifferent qualities of life stress to permit m

fine-grained analysis in relation to diffedisorders (see examples in Brown & H

1989).Research on life stress andphysical dis

too, raises the intriguing possibility tha

fects for objective indicators of environmtal stress and subjective indicators of s

appraisal operate via different mechanand possibly contribute to different outco

(e.g., Cohen et al. 1993). In addition to tmain effect distinctions worthy of furthe

amination, the interaction between the jective demands of the external environm

and the subjective perceptions of the perrequires greater research attention (Mo

& Kelley 1995). For instance, individual

ferences in stress sensitivity may explain some people break down under high s

conditions and others do not, as well as other people develop disorders under ap

entlyminimal environmental provocationtegrating these two perspectives on obje

and subjective stress measures will againquire methods capable of reliably measu

the two facets of stress and making suchtinctions. Finally, given that life stress

resents a whole-organism response, the

clusion of genetic information and bioloindicators will afford a framework of inqallowing investigators to probe the way

which external and perceptual stress proc

affect key biological processes and systwhich in turn create the vulnerable condi

that can lead to disorder and disease.

48 Monroe


17/22

DISCLOSURE STATEMENT

The author is not aware of any biases that might be perceived as affecting the objectivity ofthis review.

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