Journal of Psychosomatic Research 52 (2002) 167 172

Validation of the Spanish version of the Perceived Stress Questionnaire

a-Campayob,c,*, A. Rubiod, M.A. Santede, M. Montorof C. Sanz-Carrilloa, J. Garc
Department of Psychiatry, San Jorge Hospital, Huesca, Spain Department of Psychiatry, Miguel Servet University Hospital, Zaragoza, Spain c University of Zaragoza, Zaragoza, Spain d Department of Family Medicine, San Jorge Hospital, Huesca, Spain e Department of Psychology of Personality and Psychological Assessment and Treatment, n a Distancia, Madrid, Spain Universidad Nacional de Educacio f Department of Gastroenterology, San Jorge Hospital, Huesca, Spain
b a

Received 5 March 2001; accepted 28 June 2001

Abstract Objective: To validate in Spanish the Perceived Stress Questionnaire (PSQ), a questionnaire to assess stress for research purposes in psychosomatic patients. Method: The test was administered to a healthy population (N = 174) of nursing students and health workers and to a clinical sample (N = 80) of patients attending a psychiatric outpatient consultation. Results: Concurrent validity: General and Recent PSQ scores correlated high with trait anxiety ( r = .65), moderate with depression ( r = .46) and psychological disturbance ( r = .51) and poor with state anxiety
Keywords: Questionnaire; Perceived stress; Validation; Psychosomatics; Spanish

( r = .22). Predictive validity: PSQ scores were higher in psychiatric cases than in psychiatric noncases ( P < .01), and correlated highly with somatic symptoms of psychological origin ( r = .62) in the clinical subsample. Internal consistency was 0.9 for the General and 0.87 for the Recent PSQ. Test retest reliability of the General PSQ was 0.80. Discussion: The Spanish version of PSQ presents good psychometric properties and it seems to be a valuable instrument for psychosomatic researchers. D 2002 Elsevier Science Inc. All rights reserved.

Introduction The relationship between stress and the onset of medical and psychiatric disorders has been widely studied in psychiatric literature [1], however, there is no clear consensus on how to measure stress [2,3]. Some of the approaches used by researchers has been to evaluate different aspects of this construct such as: (a) external stressors in the form of life events [4], (b) the cumulative minor stresses or hassles [5,6] and (c) the coping, i.e., the individuals sense of control [7]. All of these systems of evaluation present important drawbacks that limit their usefulness in research. The Perceived Stress Questionnaire (PSQ) of Levenstein et al. [8] is specifically designed to measure stress in clinical psychosomatic research. It consists of 30 items developed

by experienced clinicians and has been validated in Italian and English languages in a population (N = 230) of psychiatric inpatients, outpatients, students and health workers. The validation study showed excellent psychometric properties [8], and it has been used in research, demonstrating good predictive value in stress-related diseases such as ulcerative colitis [9,10]. In the context of a high-scale study of somatization and somatoform disorders [11 14], we needed to use a scale to measure stress in psychosomatic disorders so we selected PSQ. The objective of this paper is to translate into Spanish and validate the PSQ.

Method The questionnaire was translated from English into Spanish by two native Spanish-speaking psychiatrists working independently of each other and, in a second step, they agreed on a final common translation. After that,

reo Alierta 47, 2 B, 50.008 * Corresponding author. Avda. Cesa Zaragoza, Spain. Fax: +34-976-254006. a-Campayo). E-mail address: jgarcamp@arrakis.es (J. Garc

0022-3999/02/$ see front matter D 2002 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 0 1 ) 0 0 2 7 5 - 6

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Table 1 Age and sex distributions of the PSQ scores (General form) in healthy population (N = 176) Mean Sex Male (N = 43) Female (N = 133) Age 18 24 years (N = 110) 25 39 years (N = 33) > 39 years (N = 33) Entire sample (N = 176) 0.3366 0.3604 Standard deviation 0.1353 0.1418

0.3681 0.3384 0.3259 0.3546

0.1485 0.1230 0.1251 0.1403

the Spanish version of PSQ was back-translated into English by unaware native English-speaking people, and differences between the original test and the Spanish version were resolved. Finally, the questionnaire was administered to bilingual persons in English and Spanish versions to detect possible differences. The Spanish version of PSQ was validated in two different populations: (1) A healthy sample of 176 persons, of which 128 were first and second year nursing students at the University of Huesca, Spain, and 48 were health professionals (doctors and nurses) working in San Jorge Hospital in Huesca. The sociodemographic characteristics of the sample were the following: In relation to sex, females clearly predominated (N = 133, 75.6%) over males (N = 43, 24.4%), and the mean age was 27.9 years (standard deviation: 12.4 years, range:18 65). (2) A clinical sample (N = 80) of first-time patients attending the outpatient psychiatric consultations of Miguel Servet University Hospital in Zaragoza, Spain. The SPPI psychiatric interview classified the sample into two subgroups: 49 psychiatric cases and 31 psychiatric noncases. The sociodemographic characteristics of the whole sample were the following: predominance of women (N = 51, 63.7%) and middle-aged patients (mean: 45.8 years; standard deviation: 18.8 years; range: 18 66). Psychiatric cases were primarily depressive and anxiety disorders, while nonpsychiatric cases were subthresold minor psychiatric disorders and couple disturbances. In both samples, all the participants were Caucasian, and their native language was Spanish. Construct validity was performed through comparison with other measures of stress. The most specific questionnaire for comparison, Cohen et al.s Perceived Stress Scale [15], has not been validated in Spanish, so it had to be rejected. We used three scales validated in our country: (1) the State Trait Anxiety Inventory (STAI) [16,17] also used in the original paper; (2) the Beck Depression Inventory [18,19] and (3) the General Health Questionnaire-28 items (GHQ-28) [20,21], a patient-rated questionnaire of psychological distress. Predictive validity was assessed by two different methods, based on the paper by Levenstein et al.: (1) Comparison of PSQ scores in first time patients attending a

psychiatric outpatient consultation divided into two subgroups: psychiatric cases, as defined by the psychiatric interview SPPI [22], an interview widely used by our group [11 14] that allows DSM-IV and ICD-10 psychiatric diagnosis. These patients were compared with psychiatric noncases, as defined by the same interview. (2) In the population of psychiatric noncases, correlation of the PSQ scores with the section of somatic symptoms of psychological origin of the psychiatric interview SPPI [22], a section that allows scores ranging from 0 to 35, which can be used as a scale. The reason to reject the subsample of psychiatric cases was to avoid confusing somatic symptoms produced by stress with those produced by the psychiatric disorder itself [23]. In addition, internal consistency analysis, analysis by demographic characteristics, test retest reliability and factor analysis were also carried out. Data analyses were performed using SPSS 9th version for Windows. Whole-scale reliability (internal consistency) was estimated using coefficient alpha [24], test retest reliability and analysis by demographic characteristics were tested using the Spearman r, and factor analysis of PSQ was performed using principal component analysis with the Varimax transformation, in its oblique solution.

Results PSQ index was obtained according to Levenstein et al.s [10] indications, i.e., PSQ = (raw score 30) / 90. Overall mean scores were 0.35 (S.D. = 0.14) for the General and 0.37 (S.D. = 0.15) for the Recent form, with scores ranging from 0.08 to 0.86 and from 0.01 to 0.93, respectively. Table 1 shows PSQ scores (General form) by age and sex distribution. Scores of 0.25 fell into the lowest quartile for the validation sample as a whole, 0.25 0.34 in the second quartile, 0.35 0.44 in the third quartile and ! 0.45 in the upper quartile for both forms. We studied correlation between age and PSQ and we found a Spearman r of .04 ( P = .55) for the General and

Table 2 Specific items varying at a P < .05 level with age or sex (N = 176) Age (7) You feel you are doing things you really like. (9) You fear you may not manage to attain your goals. (17) You feel safe and protected. (20) You feel discouraged. (21) You enjoy yourself. (22) You are afraid for the future. (30) You feel under pressure from deadlines. Sex (23) You feel you are doing things because you have to not because you want to.

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.11 ( P = .12) for the Recent form. PSQ index did not vary by gender, and t test yielded t (174) = 0.96 ( P = .33) for the General form, and t (174) = 1.23 ( P = .22) for the Recent form. Table 2 summarizes specific items varying at a P < .05 level with age or sex. All individual items in both the General and the Recent PSQ correlated in the predicted direction with their corresponding PSQ index, i.e., all items showed a positive correlation except items 1, 7, 10, 13, 17, 21, 25 and 29, which showed a negative correlation with PSQ index. The highest correlation of any item with any other single item was r = .59. The mean for each item was between 1.35 and 2.93 in all cases, and the standard deviation always exceeded 0.6. Table 3 summarises concurrent validity of the General and the Recent PSQ in relation with other questionnaires. Both correlate highly with trait anxiety and somatic symptoms of psychological origin, moderately with depression and psychological disturbance in general, and poorly with state anxiety. In relation to predictive validity, the General Index was significantly higher ( P < .01) in psychiatric cases than in psychiatric noncases. In addition, in the nonpsychiatric clinical sample, correlation between PSQ and the somatic section of the SPPI was good as can be seen in Table 3. Internal consistency, as measured by coefficient alpha, was 0.9 for the General and 0.87 for the Recent PSQ. Test retest reliability of the General PSQ, after an interval of 13.12 2.05 days (mean S.D.), was 0.80. Table 4 summarises principal component analysis, with the Varimax transformation in its oblique solution, of the General PSQ scores of the healthy sample (N = 174). The analysis yielded seven factors with eigenvalues greater than 1. Factor names were assigned appropriate to the contributing items: tension fatigue, conflict social acceptance, overload harrassment, energy joy, self-realisation satisfaction, fear anxiety and Factor 7. This solution explained 58% of the variance. According to empirical criteria, we have grouped in the same subscale those items that presented the highest loading in the same factor. The only exception was Item 29, which showed the highest loading in Factor 7. However, as in

this factor, no other item presented its highest loading, the subscale has been deleted, and Item 29 has been included into Factor 4 (energy joy) in which loading was .3. The Spanish version of the questionnaire is attached as an annex at the end of the paper. The approximate time needed for administration of the Spanish version of the PSQ ranges from 10 to 15 min.

Discussion The present data demonstrate the favourable psychometric characteristics of the Spanish version of the PSQ in relation to the different psychometric properties that should define a valid and reliable test. In addition, the patients, health professionals and students evaluated confirm that the Spanish version of the questionnaire is easy to understand and quick to administer, supporting the feasibility of the test in the everyday clinical practice. Concurrent validity demonstrates good correlation with trait anxiety and somatic symptoms of psychological origin, moderate correlation with depression and psychological disturbance in general, and poor correlation with state anxiety. These data, quite similar to those found by Levenstein et al. [8], were expected. Predictive value has been assessed by confirming that in people without psychiatric disorders, as evaluated by SPPI psychiatric interview, PSQ is well correlated with minor physical symptomatology. In addition, PSQ scores are significantly higher in psychiatric cases compared with psychiatric noncases from a sample of people attending psychiatric outpatient consultations. These data are coherent with those described by Levenstein et al. [8]. Further data confirming the predictive value of the PSQ will be obtained from the research on somatoform disorders in progress. Other psychometric measures such as internal consistency (Cohens a coefficient = 0.9) and test retest reliability (0.80) were also satisfactory and similar to the original study. One of the expectations of a stress questionnaire is a minimal correlation with sex and age. In fact, the PSQ Spanish version seems to be more independent than the original version from these sociodemographic characteristics: In our study, we found no correlation in either variable, while Levenstein et al. did not find a correlation with sex but they did with age (Spearman r =.22, P < .001 for the General form). In addition, the specific PSQ items that showed P < .05 in relation with sex and age were less numerous in our study compared with the study by Levenstein et al. Therefore, Spanish validation shows better psychometric properties related to the specific aspect of correlation with sex and age. In general, PSQ scores are lower in our sample than in the original sample by Levenstein et al. We think the explanation is the predominance in our study of students in which stress is supposed to be lower.

Table 3 Concurrent validity of the PSQ with other measures General PSQ State anxiety (STAI) (N = 80) Trait Anxiety (STAI) (N = 80) Depression (BDI) (N = 80) Psychological disturbance (GHQ-28) (N = 80) Somatic symptoms (SPPI somatic section) (N = 31) ** P < .01 by Spearmans r. *** P < .001 by Spearmans r. 0.22 0.65*** 0.46** 0.51** 0.62*** Recent PSQ 0.28 0.69*** 0.49** 0.55** 0.67***

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Table 4 Factor analysis of the Spanish version of PSQ Tension irritability fatigue .60 .51 .63 .73 .48 .53 .38 .67 .52 Conflict social acceptance Factor overload .36 Energy joy .44 C. Sanz-Carrillo et al. / Journal of Psychosomatic Research 52 (2002) 167172 Self realization satisfaction Fear anxiety Factor 7 (deleted and included in energy joy)

Item (3) (8) (10) (14) (15) (16) (26) (27) (30) (5) (6) (12) (17) (19) (20) (24) (2) You are irritable or grouchy You feel tired You feel calm You feel tense Your problems seem to be pilling up You feel youre in a hurry You feel mentally exhausted You have trouble relaxing You feel under pressure from deadlines You feel lonely or isolated You find yourself in situations of conflict You feel frustrated You feel safe and protected You are under pressure from other people You feel discouraged You feel criticized or judged You feel that too many demands are being made on you (4) You have too many things to do (11) You have too many decisions to make (18) You have many worries (1) You feel rested (13) You are full of energy (21) You enjoy yourself (25) You are lighthearted (29) You have enough time for yourself (7) You feel youre doing things you really like (9) You fear you may not manage to attain your goals (23) You feel youre doing things because you have to not because you want to (22) You are afraid for the future (28) You feel loaded down with responsibility Eigenvalue Percent of total variance explained by factor Percent cummulated variance

.32

.42 .32 .35 .45 .31

.65 .55 .54 .58 .57 .55 .53

.30 .39 .36

.66 .33 .58 .73 .57 .34 .37 .31 .60 .68 .64 .56 .30 .37

.35

.30 .60 .75 .56 .72 .35

.30

.75 .61 7.89 12.27 12.27 2.71 9.75 22.03 1.83 9.42 31.46 1.38 8.96 40.43 1.27 6.35 46.78 1.15 6.05 52.84 1.14 5.17 58.01

The highest loading for each item is included. Loading < .3 have been omitted.

C. Sanz-Carrillo et al. / Journal of Psychosomatic Research 52 (2002) 167172 Table 5 Factors and items according to factor analysis in the original English version and the Spanish version Original english version Harrassment (2, 6, 19, 24) Overload (4, 11, 28, 29) Irritability (3, 10) Lack of joy (5, 7, 16, 17, 21, 23, 25) Fatigue (1, 8, 13, 15) Worries (9, 18, 20, 22, 30) Tension (12, 14, 26, 27) Spanish version Harrassment social acceptance (5, 6, 12, 17, 19, 20, 24) Overload (2, 4, 11, 18) Irritability tension fatigue (1, 3, 8, 10, 14, 15, 16, 26, 27, 30) Energy joy (1, 13, 21, 25, 29) Fear anxiety (22, 28) Self-realisation satisfaction (7, 9, 23)

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The main difference between the Spanish and the original English version of the PSQ is the factorial structure, which can be seen in Table 5. In the Spanish version, only six factors have been obtained, one less than in the original. In addition, in the Spanish version the number of items in each subscale is quite variable (range 2 10) compared to the English version (range of items in each subscale: 2 7), but the variance explained for each subscale is rather more balanced in the Spanish version (range 5 12%) compared with the original version (range 2 15%). Differences in factor analysis between different validation studies is frequent. The six subscales we have obtained from the analysis show great conceptual coherence (in addition to empirical coherence) and respond to the name used. We have included all the items in each subscale with loadings equal or higher than .3. Levenstein et al.s original validation [10] had included several items in subscales with loadings as low as .15 (Item 7), .18 (Item 18) or .19 (Items 11 and 12). For this reason, factorial structure of the Spanish version seems coherent from a psychometric point of view. In summary, the Spanish version of PSQ seems to be an accurate instrument to assess stress in psychosomatic research and deserve to be used in clinical practice.

Acknowledgments The authors want to thank Dr. Susan Levenstein, San Camillo-Forlanini Hospital, Rome, Italy, for her valuable comments on a draft of the paper. This research was carried out with the support of grants 98/1017 and 00/0991 from the Spanish fondo de investigaciones sanitarias de la seguridad social (FISSS).

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