-NK-cells, CD8
- and CD3
-T-cells, tryptase
) and
tumor necrosis factor-alpha
-cells (TNF-
) by immunohistochemistry (IHC).
All biopsies were fixed in 5% formalin and embedded in paraffin. We
H. FLIEGE et al.
80 Psychosomatic Medicine 67:7888 (2005)
examined two to four different sections of tissue for each patient. To make
sure the trophoblast had been in contact with maternal immunocompetent cells
and could have been a target of rejection, we stained the tissue with a monoclonal
antibody against pancytokeratin (CK) to test for invasive fetal cells. Consecutive
slides were stained with monoclonal antibody against mast cell tryptase, CD3,
CD8, or CD56, respectively. Probes for human TNF- mRNA were stored at
70C until use. Five-micron paraffin sections were dewaxed and rehydrated,
washed in DEPC-treated water, and immersed in 0.1N HCl followed by 2SSC
at RT. Sections were exposed to 10 g/ml proteinase K and postfixed in 0.4%
paraformaldehyde at 4C. Hybridization was carried out at 59C using S
35
UTP-labeled cRNA. Afterward, sections were washed in 4 SSC and treated
with RNase A (20 l/ml). The slides were desalted, dehydrated, air dried, dipped
into autoradiography emulsion, and developed. The sections were counterstained
with hemalaun. Microscopic investigators were blinded to the patients stress
scores. The number of positive cells per square millimeter tissue was evaluated by
two independent observers.
To examine sensitivity, we tested patient samples, pregnant women, and
healthy adults for differences in their stress levels. All differences between
samples were investigated by analysis of variance and secured by post-hoc t tests.
RESULTS
Dimensional Structure
Exploration and Item Reduction
The Kaiser-Meyer-Olkin measure of the quality of the
correlation matrix was high (KMO 0.96). A significant
Bartlett test of sphericity justified a dimension reducing pro-
cedure such as the factor analysis. The measure of sampling
adequacy was over 0.80, so the items could be considered apt
for factor analyses.
Exploratory analyses of all 30 items yielded a different
solution from the original one (14). A forced 7-factor solution
TABLE 1. Exploratory Factor Analysis With Promax-Rotation of the Original 30 PSQ Items From Sample 1 (n 650)
Items No.
Primary Components (all 30 items)
Item parameters
(20 selected items)
Loadings
h2 r
i(ti)
I II III IV M sd p
Factor I: 41.6% explained variance (rotated solution)scale
worries
x You are afraid for the future 22 .789 .028 .054 .200 .61 .69 2.08 1.01 .36
x You have many worries 18 .766 .100 .028 .061 .63 .73 2.23 0.98 .41
x Your problems seem to be piling up 15 .745 .136 .067 .083 .71 .77 2.10 0.96 .36
You feel lonely or isolated 05 .710 .073 .210 .231 .55 .63
x You fear you may not manage to attain
your goals
09 .700 .138 .004 .115 .57 .69 2.18 0.94 .39
You find yourself in situations of conflict 06 .697 .031 .081 .080 .51 .63
You are under pressure from other people 19 .689 .258 .124 .285 .59 .64
You feel discouraged 20 .670 .134 .190 .230 .67 .63
You feel criticized or judged 24 .620 .368 .287 .197 .50 .56
x You feel frustrated 12 .560 .213 .138 .077 .59 .69 1.97 0.89 .32
You feel youre doing things because you
have to not because you want to
23 .528 .185 .378 .139 .55 .64
You feel loaded down with responsibility 28 .505 .132 .058 .341 .59 .63
You have too many decisions to make 11 .453 .128 .259 .349 .45 .47
Factor II: 8.0% explained variancescale tension
You feel tired 08 .168 .758 .067 .117 .55 .58
x You feel tense 14 .211 .691 .139 .047 .63 .68 2.45 0.81 .48
x You feel rested 01 .231 .688 .309 .179 .66 .66 2.69 0.89 .56
x You feel mentally exhausted 26 .173 .589 .151 .012 .63 .68 2.18 0.88 .39
x You have trouble relaxing 27 .246 .543 .047 .002 .56 .66 2.28 1.00 .43
x You feel calm 10 .109 .501 .187 .150 .57 .67 2.64 0.99 .55
You are irritable or grouchy 03 .175 .232 .169 .109 .28 .46
Factor III: 5.0% explained variancescale joy
x You feel youre doing things you really like 07 .064 .003 .737 .069 .63 .61 2.31 0.89 .44
x You enjoy yourself 21 .201 .214 .597 .109 .70 .75 2.34 0.87 .45
x You are lighthearted 25 .082 .191 .552 .022 .52 .64 2.71 0.95 .57
x You are full of energy 13 .001 .391 .538 .181 .59 .60 2.63 0.90 .54
x You feel safe and protected 17 .400 .097 .410 .022 .58 .63 2.35 1.04 .45
Factor IV: 3.4% explained variancescale demands
x You have too many things to do 04 .185 .091 .042 .841 .66 .61 2.42 0.91 .47
x You have enough time for yourself 29 .330 .015 .380 .792 .65 .51 2.59 1.01 .53
x You feel under pressure from deadlines 30 .084 .130 .197 .692 .57 .59 2.17 0.93 .39
x You feel youre in a hurry 16 .357 .161 .052 .455 .58 .58 2.06 0.87 .35
x You feel that too many demands are being
made on you
02 .360 .072 .038 .447 .54 .58 2.17 0.79 .39
h
2
communality; M mean (before transformation); sd standard deviation; r
i(ti)
corrected item-scale correlation; p item difficulty.
Note: Remaining items are marked with an X.
PERCEIVED STRESS QUESTIONNAIRE
81 Psychosomatic Medicine 67:7888 (2005)
did not yield the original structure. Four factors were extracted
with eigenvalues greater than 1. The eigenvalues course was
12.5, 2.4, 1.5, and 1.0, then 0.9, 0.8, and 0.8, indicating a
strong primary factor with 1 to 3 additional factors. We tested
solutions with 4, 3 and 2 factors, respectively.
The 4-factor solution accounted for 58% of the variance.
Item 03 (You are irritable or grouchy) did not load distinctly
and item 11 (You have too many decisions to make) had a
low communality (0.50). They were therefore excluded.
Item 17 (you feel safe and protected) loaded on factor III
(0.410) but also on factor I (0.400). Still, we decided to
accept this flaw and keep the item with a view to keeping
scales of even length and in light of its satisfactory commu-
nality (0.58).
All remaining factor loadings were greater than 0.50 and
the items share of communality concerning one factor was at
least 20% higher than its share of communality concerning
any other factor. Communality varied between 0.50 and 0.71
around a mean of 0.60. See Table 1 for factorial solution,
loadings, and item parameters.
The 3-factorial solution conformed to a simple factor struc-
ture except for items 03 and 17. It replicated factor I and factor
IV of the 4-factorial solution, but factor II and factor III of the
4-factorial solution fell together on one factor. In the 2-facto-
rial solution, the second factor replicated factor IV of the
4-factorial solution with only the addition of item 28. All other
items loaded on a strong first factor.
We considered the 4-factorial solution the most informative
one. The 3-factorial solution would have meant abandoning a
consistently positively worded scale (factor III of the 4-facto-
rial solution). As regards content, we considered a positively
worded scale as advantageous, so we wanted to keep it, given
sufficient structural stability. The 2-factorial solution seemed
to replicate a theoretical distinction of the stress construct into
perceived stressor (factor II) and stress reaction (factor I). We
ultimately decided to investigate the 4-factorial solution more
thoroughly and to include all three solutions in the confirma-
tory analyses.
TABLE 2. Confirmatory Factor Analyses (CFA) of 2-, 3-, and 4-Factorial Solutions and Multi-Sample Analyses (MSA) of the 4-Factorial Solution
of 20 PSQ Items From Sample 2 (n 1,808)
Model
Model-test Fit Statistics
a
2
df Cmin/df GFI AGFI RMR TLI CFI RMSEA
2
/df
b
CFA
2 factors 2,834.6 169 16.77 .83 .78 .007 .85 .86 .090
3 factors 2,310.0 167 13.83 .86 .83 .007 .87 .89 .087 524.6/2
4 factors 1,921.8 166 11.58 .89 .86 .006 .90 .91 .079 388.2/1
MSA 3 groups
c
Restricted 4,302.7 538 8.00 .92 .93 .064
Unrestricted 3,381.6 500 6.76 .93 .95 .058 921.1/38
MSA 4 groups
d
Restricted 4,424.8 723 6.12 .92 .93 .055
Unrestricted 4,306.5 685 6.29 .92 .93 .056 118.3/38
MSA 5 groups
e
Restricted 4,615.5 908 5.08 .92 .93 .049
Unrestricted 4,443.9 870 5.11 .92 .94 .049 171.6/38
a
Fit statistics: GFI goodness of fit index; AGFI adjusted goodness of fit; RMR root mean squared residual; TFI Tucker-Lewis Index; CFI
comparative fit index; RMSEA root mean standard error of approximation.
b
2
df difference in chi-square by df (all p .001).
c
Ill (mental/behavioral, tinnitus, IBD) vs. pregnant vs. healthy.
d
Somatically ill (tinnitus, IBD) vs. mentally/behaviorally ill vs. pregnant vs. healthy.
e
Suffering from tinnitus vs. IBD vs. mental/behavioral illness vs. healthy vs. pregnant.
Figure 1. Linear structural equation model of a 4-factor solution based on
one latent construct of perceived stress
H. FLIEGE et al.
82 Psychosomatic Medicine 67:7888 (2005)
We then selected those 5 items of each scale that showed
the highest corrected item-scale-correlation (Table 1). Thus, a
20-item questionnaire of 4 scales with 5 items each resulted.
Scale 1 (worries) covers worries, anxious concern for the
future, and feelings of desperation and frustration.
Scale 2 (tension) explores tense disquietude, exhaustion,
and the lack of relaxation.
Scale 3 (joy) is concerned with positive feelings of chal-
lenge, joy, energy, and security. Because all items of this scale
are positively worded, we opted for a positive name.
Scale 4 (demands) covers perceived environmental de-
mands, such as lack of time, pressure, and overload.
An overall index score is calculated from all items, and
linearly transformed to values between 0 and 1. For this purpose,
the scale joy, which is positively coded, will be inversed. A
high overall PSQ score means a high level of perceived stress.
Although all PSQ scales intercorrelate fairly highly, demands,
which focuses on external stressors, shows the lowest correlations to
the other three scales, which focus on the stress reaction (Table 3).
Confirmatory analyses, validation, and usability testing
were all performed on the resulting 20-item questionnaire.
Confirmation
Following the above cited theoretical concepts (2), SEM
was constructed as shown in Figure 1. Thus, the tested 4-fac-
tor solution specifies an additional latent variable stress re-
action loading on the first 3 factors (worries, tension, joy)
and covarying with demands. This resulted in a significant
likelihood-ratio
2
test (Table 2) with a global fit index (GFI)
below 0.95 and an adjusted GFI below 0.90. However, be-
cause Hoelters critical number (here 176) is considerably
smaller than the sample size, any model would inevitably have
been rejected applying those indices. Thus, we followed a
recommendation to judge a model by a number of different
criteria (25). The root mean squared residual below 0.05 is a
criterion in favor of the model fit. Furthermore, the Tucker-
Lewis index (TLI) and the comparative fit index (CFI)
reached good values (0.90). Both are independent of sample
size and either take into account model complexity (TLI) or
model misspecification (CFI). Finally, a value of about 0.08 or
less for the root mean standard error of approximation is
considered to indicate a reasonable fit (26). This index allows
for discrepancies between sample and population. Taking all
this into account, we consider the model fit satisfactory.
Only the path weight between item 29 and demands fails
to satisfy (0.47). This might be due to a positive item wording.
A tentative exclusion of the item does not result in a closer
model fit. The lowest path weight results for the overall
sample, whereas in the subgroups this weight varies between
0.54 and 0.60. Because this item had a high loading in the
original exploratory factor solution (0.72) and seems unprob-
lematic as to content, we decided to keep it.
Multisample analyses yield that there is no appreciable gain
in model fit by omitting the restriction of structural equality
between groups. In sum, they confirm the assumption of a
comparable dimensional structure in different samples.
Reliability
Cronbachs alpha and split-half reliability values of the
scales in the subgroups are all at least 0.70, in half the cases
at least 0.80. Cronbachs alpha of the overall score is at least
0.85 and reliability at least 0.80 (Table 4).
TABLE 3. PSQ Scale Intercorrelations and Correlations Between PSQ and WHOQOL-Bref (n 650) and PSQ and TICS (Trier Inventory of
Chronic Stress) (n 559)
PSQ Scales
Worries Tension Joy Demands Overall Score
PSQ
Worries .67 .61 .51 .86
Tension .63 .57 .87
Joy .36 .78
Demands .76
WHOQOL-Bref
Physical domain .58 .64 .62 .24 .62
Psychological domain .78 .69 .79 .33 .79
Social domain .56 .50 .63 .25 .59
Environmental domain .60 .48 .55 .23 .57
Global QoL score .58 .56 .63 .17 .58
TICS
Work overload .61 .61 .44 .83 .77
Work discontent .51 .45 .49 .42 .57
Social stress .52 .39 .32 .45 .52
Lack of social recognition .51 .37 .46 .36 .52
Worries .80 .67 .61 .55 .81
Intrusive memories .66 .51 .45 .37 .61
Notes: Joy values are positively coded (except for the overall score). All Pearson correlations p .001. WHOQOLs Cronbachs alpha: physical 0.81;
psychological 0.88; social 0.70; environmental 0.79; global QOL score 0.62. TICS Cronbachs alpha: work overload .88, work discontent .76, social stress .76,
lack of social recognition .85, worries .88, intrusive memories .91.
PERCEIVED STRESS QUESTIONNAIRE
83 Psychosomatic Medicine 67:7888 (2005)
Construct Validity
Stress scales and overall score are negatively correlated,
and the joy scale is positively correlated with quality of life
(QoL) dimensions (p .001) (Table 3). All PSQ scales
correlate more highly with the psychological domain of the
WHO-QOL than with other WHO-QOL domains. The corre-
lational pattern with the TICS is altogether consistent with
expectation. Five of the 6 TICS subscales are most highly
TABLE 4. Mean Values and Consistency Values in Different Subgroups of Sample 1 (n
1
650) and Sample 2 (n
2
1,808), n
overall
2,458
Samples
PSQ Scales
Overall
Worries Tension Joy Demands
Sample 1
Psychosomatic in-patients n 246
M .53 .48 .37 .44 .52
SD .26 .12 .23 .16 .18
Crohnbachs alpha .83 .80 .83 .79 .85
r Spearman-Brown .84 .79 .82 .79 .87
Females after spontan. abortion n 81
M .34 .44 .56 .41 .41
SD .25 .23 .22 .21 .19
Crohnbachs alpha .83 .83 .75 .79 .92
r Spearman-Brown .88 .78 .77 .83 .88
Females after regular delivery n 74
M .23 .36 .65 .38 .33
SD .19 .22 .21 .21 .17
Crohnbachs alpha .79 .82 .77 .77 .91
r Spearman-Brown .76 .76 .77 .71 .85
Students n 249
M .26 .40 .60 .43 .37
SD .18 .21 .21 .23 .17
Crohnbachs alpha .77 .83 .82 .81 .92
r Spearman-Brown .76 .83 .85 .73 .84
Sample 2
Psychosomatic out-patients n 559
M .60 .66 .37 .47 .59
SD .27 .23 .21 .25 .19
Crohnbachs alpha .86 .81 .77 .82 .92
r Spearman-Brown .86 .75 .80 .77 .83
Tinnitus patients n 184
M .41 .54 .47 .44 .48
SD .25 .23 .24 .24 .21
Crohnbachs alpha .89 .84 .87 .81 .94
r Spearman-Brown .88 .82 .87 .79 .87
IBD patients n 144
M .35 .47 .51 .40 .43
SD .21 .20 .22 .22 .17
Crohnbachs alpha .79 .77 .79 .82 .90
r Spearman-Brown .80 .70 .76 .79 .80
Pregnant females 8
th
week n 587
M .23 .37 .64 .37 .33
SD .18 .20 .20 .19 .16
Crohnbachs alpha .81 .79 .76 .76 .90
r Spearman-Brown .78 .73 .81 .73 .85
Healthy adults n 334
M .26 .34 .62 .36 .33
SD .20 .21 .21 .21 .17
Crohnbachs alpha .83 .81 .79 .80 .92
r Spearman-Brown .81 .77 .79 .77 .86
ANOVA
df 8;2,393 8;2,389 8;2,381 8;2,392 8;2,329
F value 136.5 101.3 90.2 11.8 102.1
Explained variance
2
31% 25% 23% 4% 26%
p .001 .001 .001 .001 .001
Note: Scale values are linearly transformed from 14 to 01. Joy is inverted when computing the overall PSQ score.
H. FLIEGE et al.
84 Psychosomatic Medicine 67:7888 (2005)
correlated with the same PSQ scale (worries), whereas the
TICS work overload scale is most strongly related to the PSQ
demands scale.
Comparison to the Original
In the 650 subjects who completed the full questionnaire,
the correlation between the 30-item overall score and the
20-item overall score was high (r 0.95, p .001). To
examine whether the level of the overall score and its mea-
surement consistency were maintained in spite of the item
reduction, we compared the gastroenterological sample of the
original study (including many ulcerative colitis patients) with
the inflammatory bowel disease (IBD) sample of the present
study. Internal consistency of the original and the revised
version is identical ( 0.90). Mean values and distribution
of the overall stress score of the original (0.42 0.15, range
0.110.83) and the revised questionnaire (0.43 0.17, range
0.020.87) do not differ. Mean values and distribution of the
overall stress score of healthy adults in a Spanish validation
(16) of the 30-item PSQ (0.35 0.14, range 0.080.86) and
the healthy adults in the German revision (0.33 0.17, range
0.000.85) also do not differ.
Group Differences
Values are listed in Table 4, and differences are roughly
summarized in Figure 2 (see Table 5 for details). All scales
differed between patients and healthy adults. The extent of the
differences varies with the scale and the group in question.
The most severe stress values are obtained from Psychoso-
matic Medicine patients, especially outpatients, followed by
tinnitus patients. Both groups have higher stress levels than
IBD patients and women after spontaneous abortion, who
report the second highest. Next in line are students, pregnant
women, and women after regular delivery. Consistently low
stress levels are reported by healthy adults. Students selec-
tively report high levels of demands. Pregnant women and
women after regular delivery show the highest levels of joy
and the lowest levels of worries. When controlled for age, they
even have significantly better values than healthy controls.
Sociodemographic Variables
Sociodemographic differences were tested on the healthy
adults sample (n 334). All scales are significantly associ-
ated with age (worries r 0.14*, tension r 0.25**, joy
r 0.14**, demands r 0.31**, overall score r
0.28**), but not with gender. Figure 3 presents differences
between age groups. Perceived stress is diminished and joy is
raised in age groups over 60 years. Only worries are slightly
lessened in the 60s group but no longer significantly in the 70s
and older. Demands are selectively elevated in the 30- to
39-year-olds.
Criterion Validity
To test for immunological differences, women after mis-
carriage were divided in two stress groups by median-split.
Decidual tissue for immunohistochemistry could be obtained
in 50 cases. Women with a higher stress score had a signifi-
cantly higher rate of tryptase
), of CD8
T-cells. In
sum, higher perceived stress scores are associated with some
of the relevant indicators of a supposed immunological im-
balance in women who have had a miscarriage (22).
Sensitivity of Change
Psychosomatic Medicine inpatients under treatment show
significant improvements for three of the stress scales and the
overall score, but no change for joy. Tinnitus patients after 10
weeks of relaxation training (27) show a significant decrease
of tension and an increase of joy, whereas worries and de-
mands remain unchanged (Figure 5).
Usability
It took respondents on average 4.9 minutes to complete the
revised 20-item questionnaire. The time median was 3.3 minutes.
Only 5% of the patients took longer than 10 minutes; a few of
those took up to an hour. We could not find any differences
between diagnostic groups. There also was not any indication of
a language effect in non-German-born participants. Age was
significantly correlated with time-to-complete (r 0.28). The
stress scores themselves were slightly negatively (!) correlated
with time (between r 0.05 and 0.06), the less stressed
patients taking more time to complete, yet when controlling for
age, this association disappeared.
Figure 2. Tentative summary of the PSQ mean differences between samples
by post hoc t tests (p .05). (Note: a complete overview of the comparisons
can be requested from the authors.)
Figure 3. Mean differences between age groups for different dimensions of
perceived stress (PSQ scales)
PERCEIVED STRESS QUESTIONNAIRE
85 Psychosomatic Medicine 67:7888 (2005)
DISCUSSION
The PSQ by Levenstein et al. (14) was revised and tested for
its dimensional structure on a large sample. We reduced the
length of the questionnaire from 30 to 20 items and explored a
meaningful and widely stable structure. The scales are balanced
in the sense of comprising of the same number of items. Reli-
ability values and construct validity are satisfactory.
Exploratory analyses were performed on one sample, con-
firmatory analyses on a second and separate sample. The
original 7-factor solution was not replicated when the com-
plete 30-item scale was analyzed. Instead, a 4-factor solution
emerges. SEM analyses confirm this structure. Multisample
analyses yield a sufficiently stable dimensional structure
across different subgroups of patients and healthy adults. On
the whole, the structure appears statistically robust and satis-
factory as regards content. Consequently, in our opinion, the
problem concerning the path weight between item 29 and the
demands factor can be considered of minor importance and
does not justify a modification. A trend toward comparably
lower path weightsas can also be observed in items 01 and
10might arise from positive item wordings. However, con-
sidering that mixed item wordings have advantages of their
own, such as representing various facets of the latent construct
or keeping subjects attentive, we do not endorse abandoning
the positively worded items.
The dimensional structure is meaningful. Three factors
(worries, tension, and joy) represent the dimension of stress
reactions. In our opinion, the positively coded joy scale could
assess a positive challenge or a personal resource component.
The fourth factor (demands) represents a specific aspect of
perceived environmental stressors. That the demands scale has
a different focus than the three other scales is also proven by
lower correlations of demands with the remaining scales. To
regard the demands scale as focusing on an environmental
dimension of perceived stress and the other scales as focusing
on perceived stress reactions would be in line with findings
from earlier studies in which the persons perception of stress
was best represented by the two global dimensions of external
stressor and stress reaction (2). Differential validity of the
demands scale is supported by two findings: Students report
higher levels and older adults report lower levels of demands.
Demands can be considered external stressors (8,21). How-
ever, the scale does not claim to cover all possible external
stressors. Item topics are confined to the perception of basic
demands on ones performance, like having too many things
to do or being under time pressure. We do not know what
specific demands a person who scores high on that scale has
in mind. Specific hassles or life events are not included in this
questionnaire.
Furthermore, an explicitly social component of environ-
mental stressors is not included. For instance, out of the
original harassment scale, which had dealt specifically with
interpersonal tensions, only one of four items remained (You
feel that too many demands are being made on you). The
harassment scale had originally explained the greatest share of
variance (15%) and it had strongly correlated with physical
outcome. This is a possible limitation of the briefer PSQ. In
sum, construct validity results point out that the psychological
component of perceived stress is well represented by the
20-item PSQ, whereas the social component is not. Therefore,
studies that strongly focus on social stress issues should prefer
the use of the original 30-item questionnaire.
Future research could endeavor to strengthen and differen-
tiate the stressor side of the questionnaire and to economize
the stress reaction side with the aim to assess both sides of the
coin accurately and economically. The relative merits of pre-
senting a specific time frame, as in the original PSQ, or
leaving it open-ended, as in the instructions for this revision,
Figure 4. Immunological differences between women with high versus low
stress scores after miscarriage (median-split; t tests, ES effect size d)
Figure 5. Changes of perceived stress of Psychosomatic Medicine in patients
after psychotherapeutic treatment (left) and of tinnitus patients after relaxation
training (right) (t tests for dependent measures, ES effect size d)
H. FLIEGE et al.
86 Psychosomatic Medicine 67:7888 (2005)
also remain to be assessed. As the time-frame depends on the
specific research question, future research should specify and
compare different time-frames.
Comparisons of PSQ index values between gastroenter-
ological samples of the study by Levenstein et al. (14) and the
present study yield no differences in measurement precision or
respondents scoring. This indicates thatconcerning the in-
dex scorethe revised German version of the questionnaire
reaches the same precision as the English original, with com-
parable results. In the original study, Levenstein et al. (14)
observed higher values for Italian than for English respon-
dents. Considering our own results, we do not expect great
deviations between German and English-speaking samples,
yet we consider a confirmation of the revised questionnaire
with an English-speaking sample desirable. Only if structural
invariance between samples from different cultural or lingual
backgrounds was substantiated could we confidently use the
instrument for studies across cultures.
Similar to the original questionnaire, the revised instrument
does not significantly vary with respect to gender. This is not
consistent with other research, which yields higher perceived
stress scores for women (17,20). An explanation for this could be
TABLE 5. Comparisons Between Samples by Post-hoc t Tests (p < .05)
Post Hoc Comparisons
p t i a g d s h
Worries
Psychosomatic patients p
Tinnitus t
Inflammatory bowel dis. i
Spontaneous abortion a
Gravidity 8th week g
Delivery d
Students s
Healthy adults h
Tension
Psychosomatic patients p
Tinnitus t
Inflammatory bowel dis. i
Spontaneous abortion a
Gravidity 8th week g
Delivery d
Students s
Healthy adults h
Joy
Psychosomatic patients p
Tinnitus t
Inflammatory bowel dis. i
Spontaneous abortion a
Gravidity 8th week g
Delivery d
Students s
Healthy adults h
Demands
Psychosomatic patients p
Tinnitus t
Inflammatory bowel dis. i
Spontaneous abortion a
Gravidity 8th week g
Delivery d
Students s
Healthy adults h
Overall score
Psychosomatic patients p
Tinnitus t
Inflammatory bowel dis. i
Spontaneous abortion a
Gravidity 8th week g
Delivery d
Students s
Healthy adults h
Note: greater, smaller, no significant difference (left column compares to right).
PERCEIVED STRESS QUESTIONNAIRE
87 Psychosomatic Medicine 67:7888 (2005)
that the original PSQ was specifically designed and developed to
ensure that men and women would have similar scores (14).
As to age, the original study yielded a relatively small
correlation between the overall score and age (r 0.22). In
the present study, the association with age is reversed (r
0.28). This might be due to the fact that among the former
sample, older age groups were underrepresented (mean age
was 32), whereas the sample of the present study covers all
age groups. Here, group differences suggest that the demands
values are slightly higher for the 30- to 39-year-olds compared
with the 20- to 29-year-olds. This would be in line with the
former findings. However, the overall stress score is appre-
ciably lowest for the age groups above 60 years. Those groups
were hardly represented in the original study.
Reference values for healthy adults and different disease
groups were attained. We found particularly high stress levels
in Psychosomatic Medicine patients, followed by patients with
tinnitus and IBD and women after spontaneous abortion.
Women in pregnancy or after regular delivery and healthy
adults report the lowest stress levels. The data prove differ-
ential validity. Decreased levels of perceived stress after dif-
ferent forms of treatment in different settings sufficiently
substantiate sensitivity to change.
In sum, our revision of the PSQ arrived at an economic,
reliable, structurally stable and valid instrument that enables
us to assess perceived stress in healthy adults and different
disease groups. It measures three dimensions of a stress reac-
tion (worries, tension, joy/reversed) and one stressor dimen-
sion. Because the stressors are generic, the questionnaire can
be administered to different clinical and healthy adult samples
in different settings. Results can be compared with the refer-
ence values at hand and across studies. The overall score is
comparable to results from earlier studies with the original
instrument (14,16). The original 30-item questionnaires
structure was not replicable, whereas the 20-item versions
structure proved reasonably robust. Taking this advantage and
respondent burden into account, we suggest that the 20-item
version is preferable. However, it means that notably the
social stressor domain is not sufficiently represented. Further-
more, future research should also investigate how a corre-
sponding 20-item English version of the PSQ would perform.
We wish to thank Ingrid Wittmann, Urania Berlin, and Jan Schwen-
dowius for their assistance in raising the healthy adult sample, and
especially Dr. Susan Levenstein for her many helpful comments on
the paper.
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