Brief reportPerceived stress in anxiety disorders and the general population: A study of the Sheehan stress vulnerability scale
Introduction
Perception of stress is one determinant of physiologic and psychological responses to stressful events (Ryff and Singer, 1998). These perceptions vary widely between individuals, as does the magnitude and duration of the stress response over time. How stress is perceived is a matter of considerable importance and perhaps should be considered as an outcome measure in clinical trials, where the emphasis has generally been placed upon assessing treatment effects on symptoms, functioning, and quality of life. Relatively little attention has been given to the possible effect of treatment upon the perceived effects of daily setbacks or upon the ability to cope with stress. The related concept of resilience has been largely overlooked, although there has been some interest in this area. Understanding patients' perception of stress may reflect how resilient they are the in the face of adversity.
We contend that perceptions of stress and vulnerability to its effects may be areas of psychopharmacology which deserve more attention. This contention is supported by the following evidence: (1) anxiety disorders are characterized by poor tolerance to the effects of stress (Van Praag, 1996, Parker et al., 2000); (2) one common anxiety disorder, posttraumatic stress disorder (PTSD), is specifically defined as a condition brought about by exposure to extreme stress, with worsening upon exposure to reminders of the stressor among its diagnostic features (APA, 1994); (3) significant improvement in resilience was found in individuals with PTSD treated with fluoxetine (Connor and Davidson, 2003); and (4) serotonin selective reuptake inhibitor (SSRI) antidepressants appear to modulate the response to everyday stress and daily hassles in depression (Ravindran et al., 1995, Ravindran et al., 1999), dysthymia (Haykal and Akiskal, 1999), and PTSD (Connor et al., 1999), and to reduce hostility and negative affect, while improving affiliative behavior, in healthy controls (Knutson et al., 1998). Besides the question of possible treatment effects upon perceptions of and reactions to stress, virtually nothing is known about the extent to which different anxiety disorders differ from one another in their perceived vulnerability to the effects of stress.
Physicians often assess psychosocial stressors. Several self-rated scales may help in this assessment, e.g., the Daily Hassles Scale (Delongis et al., 1988), the Derogatis Stress Profile (Derogatis, 1987), the Life Experiences Survey (Sarason et al., 1978), and the Recent Life Changes Questionnaire (Miller and Rahe, 1997). The utility of these instruments is limited, however, in some cases by their length and in others by their difficulty in distinguishing between stressful life events and distress. For example, the 77-item Derogatis Stress Profile takes approximately 12–15 min to complete (Derogatis, 1987), while the Recent Life Changes Questionnaire contains between 43 and 87 items, takes 10–15 min to complete, and assesses life events, but not the individual's response to them.
Other self-rated measures focus on how stress is perceived rather than on the events themselves, e.g., the Perceived Stress Scale (PSS) (Cohen et al., 1983) and the Stress Vulnerability Scale (SVS) (Sheehan et al., 1990). The PSS was developed to assess the stress domains of unpredictability, lack of control, burden overload, and stressful life circumstances, with items scored on a 5-point scale. The SVS is a one-item global assessment which rates perceived stress over the last week on a 0–10 point visual analogue scale, with a higher score reflecting greater disturbance from stress. Changes on the SVS indicating improved stress vulnerability have been observed in subjects with PTSD treated with fluoxetine (Connor et al., 1999), while in panic disorder, neither buspirone nor alprazolam resulted in changes on this measure (Sheehan et al., 1990). To date, validity and reliability measurements for the SVS have not been established; nor do population norms exist for the scale. These measurements for the SVS are useful as its innate simplicity may lend itself to widespread use.
In this report, we present data on the reliability, validity, and population norms of the SVS as a self-rated global measure of the perceived effects of stress. Using the SVS, we then utilize datasets for two anxiety disorders which were readily available to us, namely social phobia and posttraumatic stress disorder, to assess whether individuals with these disorders are more upset by stress than general population controls.
Section snippets
Methods
A sample of 630 adult subjects age 18 years and older was drawn from the general US population, by means of a random digit dialed telephone survey evaluating the prevalence of PTSD in the community (group 1) (Connor and Davidson, 2001). All subjects were asked a series of questions regarding overall health status and past trauma. Respondents who reported a lifetime history of trauma were asked additional questions assessing posttraumatic symptomatology. Of 630 respondents, 439 (70%) reported a
Reliability and validity of the SVS
One hundred three subjects who exhibited either no change or minimal change on the CGI-I at two consecutive visits were available from groups 2 and 4. The intraclass correlation coefficient was 0.86 (P < 0.0001), indicating acceptable test–retest reliability.
Convergent validity following treatment was examined by comparing the SVS scores at endpoint with the PSS-10 total in subjects from group 3. The scales were highly correlated (r = 0.83, P < 0.0001; n = 19). Convergence was also assessed by
Discussion
The purpose of this study was: (1) to provide information on the psychometric properties and to establish normative values for the SVS, a measure of vulnerability to perceived stress; and (2) to examine differences in levels of vulnerability to perceived stress in two anxiety disorders relative to the general population. We found that the SVS demonstrates acceptable psychometric properties as a measure of vulnerability to perceived stress, correlating very strongly with the PSS-10, a scale
Acknowledgements
Data came from studies which were supported by grants from Hoffman La Roche, Upjohn, Smith Kline Beecham, and NIMH grants 1R01-MH44740-01 and 1R01-56656-01A1 to Dr. Davidson. Statistical support from Erik Churchill and Larry Tupler is acknowledged.
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