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. Author manuscript; available in PMC: 2021 Oct 1.
Published in final edited form as: Arthritis Care Res (Hoboken). 2020 Oct;72(Suppl 10):676–685. doi: 10.1002/acr.24228

Measures of Psychosocial Stress and Stressful Exposures

Sarah L Patterson 1,2, Sara Sagui-Henson 2, Aric A Prather 3
PMCID: PMC8063511  NIHMSID: NIHMS1597622  PMID: 33091267

INTRODUCTION

This article presents a summary of selected self-report measures that are considered to be most relevant to the assessment of psychological stress among adult patients and research participants in the context of rheumatology clinical and/or research practice. Measures that accurately capture stress exposures and perceptions are relevant to the rheumatology community for several reasons. First, patients with rheumatic conditions frequently identify stressful events as triggers for disease flares or worse symptoms burden [1]. Second, there is growing evidence that psychosocial stress may confer increased risk of developing autoimmune conditions or more severe/active disease among patients who have already been diagnosed. For example, prior studies have shown an association of daily stressors and stress vulnerability with changes in stress hormones and worse disease severity among patients with rheumatoid arthritis [2–6]. There is also data from large national cohort studies that demonstrate independent associations of prior trauma and trauma-related disorders such as post-traumatic stress disorder (PTSD) with subsequent incident rheumatoid arthritis and systemic lupus erythematosus, even after adjusting for important covariates such as race, socioeconomic status, and health-related behaviors [7–9]. Third, there is biologic plausibility to support a link between stress and autoimmune conditions given the known effects of physiologic stress response systems such as the hypothalamic-pituitary-adrenal (HPA) axis on inflammatory pathways [10].

In order to capture its multi-dimensional nature, a thorough assessment of psychological stress is best captured with multiple validated instruments that collectively measure both stressful exposures and stress perceptions. This review therefore addresses measures designed to capture exposure to specific stressful events as well as the individual’s appraisal of them, and it includes the following instruments: Adverse Childhood Experiences Questionnaire (ACE); Trauma history questionnaire (THQ); the Life Events List (LEL), and the Perceived Stress Scale (PSS). Instruments included in this review were selected to cover four major types of stress: stress experienced during childhood, prior exposure to trauma, exposure to general (non-traumatic) life events, and the respondents’ appraisal of the degree to which their life circumstances are stressful. For each of the four types of stress, we selected the instrument that would be most reliable and useful based on several criteria including whether prior studies have demonstrated adequate psychometric performance, prior use in clinical research, availability of normative data, associated burden to respondents (time to complete), and ease of scoring/interpretation. In most cases we were not able to identify a single instrument that performs well on all criteria considered, in which case we selected instruments with favorable performance across most of the criteria.

This review is not intended to be exhaustive; it focuses on self-report measures and does not include measures of physiologic stress or stress biomarkers. Though two of the instruments we reviewed query respondents regarding prior exposure to trauma, they are not intended to diagnose or treat trauma-related conditions such as PTSD. The decision to diagnose a psychiatric illness should be made by trained mental health professionals and is beyond the scope of this review. Finally, given the sensitive nature of the questions included in several of the instruments, some respondents may experience and express an emotional response while answering them. Therefore, if used as part of a research study, we recommend that investigators provide study interviewers with a protocol and script to reference in the event that respondents express emotional distress while answering questions, including contact information for appropriate mental health resources.

PERCEIVED STRESS SCALE

Description

  • Purpose: To measure general stress perceptions and the degree to which situations in one’s life are appraised as stressful.

  • Content or domains: Items assess the respondent’s global level of perceived stress over the last month, including the degree to which they find life unpredictable, uncontrollable, and overloading [11].

  • Number of items: The original version includes 14 items. There are two validated iterations with 10-items and 4-items.

  • Response options/scale: Scale. 5-point scale, where 0 = never, 1 = almost never, 2 = sometimes, 3 = fairly often, and 4 = very often.

    Score range. Scores for the 14-item form range from 0 to 56, for the 10-item form the range is 0 to 40, and for the 4-item form the range is 0 to 16.

  • Recall period for items: The past month.

  • Cost to use: Free. Permission for use is not necessary when use is for nonprofit academic research or nonprofit educational purposes.

  • How to obtain: The 14-item scale can be found in Appendix A of the original publication by Cohen et al [11]. The 4-item (PSS-4) and 10-item (PSS-10) iterations are available for download at the following URL: https://www.cmu.edu/dietrich/psychology/stress-immunity-disease-lab/scales/index.html

Practical application

  • Method of administration (written, paper and pencil, computer): Easily self-administered or administered by interviewer. Can be administered in-person, by written or interview format, by telephone interview, or by mail.

  • Scoring. PSS scores are obtained by reversing the scores on the positive items (0=4, 1=3, 2=2, 3=1, and 4=0) and then summing across all items. For the 14-item form, items 4–7, 9–10, and 13 are the positively stated items.

  • Score interpretation (include whether normative data/scoring are available): Higher scores indicate greater perceived stress. The PSS was not developed to be used as a diagnostic instrument and there are no score cut-offs, only comparisons within the study sample. Normative data exists for the PSS-4, PSS-10, and PSS-14 from 2,387 respondents in a United States probability sample collected by the Harris Poll in 1983, including mean and standard deviation scores by gender, occupation, income, race, and ethnic background [12]. The mean (SD) scores for the PSS-14 by sex were 18.8 (6.9) for men and 20.2 (7.8) for women; the PSS-10 mean scores were 12.1 (5.9) for men compared to 13.7 (6.6) for women. More recent national normative data for the PSS-10 is available from questionnaires administered in 2006 and 2009, which showed greater reported stress among women, younger adults, and those of lower socioeconomic status [13].

  • Respondent time to complete: ~5 minutes.

  • Administrative burden: Training to administer. Minimal.

    Equipment needed. When self-administered, a pencil or pen to complete.

    Time to score. <= 5 minutes

  • Translations/adaptations: There are two abbreviated adaptations that were developed and validated by Dr. Sheldon Cohen: The 10-item scale [12, 13] has become the most commonly used adaptation and the 4-item scale [11] can be made from questions 2, 4, 5, and 10 of the PSS-10 item scale. The questionnaire has been translated in at least 25 languages, many of which are available for download: https://www.cmu.edu/dietrich/psychology/stress-immunity-disease-lab/scales/index.html

Psychometric information

  • Floor and ceiling effects: Not pre-tested during original development, but subsequent studies of other samples have indicated negligible ceiling or floor effects [14].

  • Reliability (internal consistency, test-test): Internal consistency: Cronbach’s alpha correlations for the PSS-14 from samples tested in the original publication were high (r = 0.84–0.86) [11]. A meta-analysis of PSS psychometric properties found that Cronbach’s alpha was greater than 0.70 (established cut-off for minimum measure of internal consistency) for both PSS-14 and PSS-10 in all studies in which it was evaluated. In contrast, the reported Cronbach’s alpha was below the acceptable cut-off in half of the six studies in which the PSS-4 was evaluated [15].

    Test-retest reliability: Correlations over two days (r = 0.85) and 4 weeks suggest that PSS scores reflect stable individual differences during short time intervals, whereas the test-retest reliability was not satisfactory when studied over an interval of six weeks (r = 0.55).

  • Validity (content/face, criterion, construct): There is no established gold standard for PSS, which complicates the ability to assess validity. The PSS was strongly correlated with the mental component of health status as measured by the Medical Outcomes Study-Short Form 36 [16]. In the original publication Cohen et al reported that the PSS-14 “correlated in the expected manner with a range of self-report and behavioral criteria.”

  • Responsiveness: The PSS-10 has been found to correctly classify patients as improved or unchanged according to the patient’s own judgement [17].

  • Minimally important differences: In a study of the Danish version of the PSS-10 tested among Danish people with work-related stress, the estimates for minimal clinically important change were 11 points for the absolute change score and 28% for the relative change score [17].

  • Use in clinical trials: The PSS has been used to measure changes in self-report stress in a variety of non-pharmacologic stress reduction interventions, such as mindfulness interventions for caregivers [18–20], and as a secondary outcome in a physical activity intervention for fibromyalgia [21].

Critical appraisal of overall value to the rheumatology community

  • Strengths: The PSS is easy to use and requires relatively minimal time from respondents. It has established acceptable psychometric properties and normative data from large samples of US residents.

  • Caveats and cautions: May not be generalizable to certain patient populations such as those with less education (less than a high school degree) and under-represented racial/ethnic groups. Though the psychometric properties were favorable for the 14-item and 10-item scales, the internal consistency of the PSS-4 was only marginally acceptable.

  • Clinical usability: Unclear application in clinical practice as no established cut-offs have been developed to predict subsequent development of clinical psychiatric disorders or differential health outcomes.

  • Research usability: Useful for research studies that aim to measure appraised stress in relationship to treatments and/or clinical outcomes among patients with rheumatic conditions. Given the widespread use of the PSS in prior stress research and the presence of normative date, there is an ability to compare scores observed in future studies to data from a variety of clinical and healthy populations.

ADVERSE CHILDHOOD EXPERIENCES (ACE) QUESTIONNAIRE

Description

  • Purpose: To measure the incidence of different types of traumatic exposure during childhood (first 18 years of life).

  • Content or domains: The items assess prior history of physical, emotional, and sexual abuse; neglect; domestic violence; and dimensions of household dysfunction ranging from exposure to substance abuse and mental illness to parental separation and divorce.

  • Number of items: The most common version of the ACEs tool is 10-items; however, several other versions exist. For example, in 2018, the World Health Organization (WHO) created the ACE-International Questionnaire (IQ) to better capture exposures that occur in low- and middle-income countries, including community violence. The ACE-IQ includes 29 items [22].

  • Response options/scale: Dichotomous (yes/no).

  • Recall period for items: Varies by version. For the adult version, individual self-report of exposures during the first 18 years of life. However, versions that utilize parent/caregiver report also exist to assess exposure among minors; those version query caregivers regarding the period from birth until the present in the dependent’s life.

  • Cost to use: Free

  • How to obtain (include online link to measure if available): We recommend the current Adverse Childhood Events Revised Questionnaire found here: https://www.acesaware.org/screen/screening-tools/.

Practical application

  • Method of administration (written, paper and pencil, computer): Written, paper and pencil, interviewer, and computer-based administration.

  • Scoring. Original/long form: Scores range from 0 to 10 on the standard ACE questionnaire.

  • Score interpretation (include whether normative data/scoring are available): Higher scores indicate more exposure to different adverse events in the first 18 years of life.

  • Respondent time to complete: ~5 minutes, possibly faster depending on population and burden of exposures.

  • Administrative burden: Low burden outside of health care setting. If administered to parents/caregivers of a child within a health care setting, burden may increase if exposures trigger services.

  • Translations: The ACEs questionnaire has been translated into multiple languages, including Spanish, German, French, Norwegian, and Swedish.

  • Adaptations: There is a validated short-form ACEs screener that shows strong convergent validity with the full ACE measure and was similarly related to the health outcomes. The short-form ACE screener is made up of two items assessing exposure to household alcohol abuse and emotional abuse. Several other versions of the ACEs exist, including the ACE-IQ, the ACE from the Center for Youth Wellness, Philadelphia ACEs, National Survey of Child and Adolescent Well-being (NSCAW), National Survey of Children’s Health-ACEs, and the Behavioral Risk Factor Surveillance System (BRFSS)-ACEs. They range in content but generally incorporate the standard CDC/Kaiser ACEs questions, utilize similar methodology, and demonstrate consistent associations with worse health outcomes [23].

Psychometric information

  • Floor and ceiling effects: Floor and ceiling effects have not been explicitly investigated, though because ACEs occur more frequently in certain populations, such low SES populations, such effects are possible.

  • Reliability (internal consistency, test-test): Several studies report modest to good test-retest reliability period [24, 25]. Similarly, internal consistency of the ACE items are generally moderate to high [26].

  • Validity (content/face, criterion, construct): The ACEs measure shows good construct validity as it shows strong correlations with other childhood trauma measures [27].

  • Responsiveness: This is a measure of childhood exposures and not appropriate for responsiveness psychometrics.

  • Minimally important differences: This is a measure of exposure and not response.

  • Generalizability (special populations for which measure is relevant or not relevant): This measure appears to be generalizable though cultural considerations are warranted when using this measure to predict future health outcomes. Similarly, there may be sensitive periods in development when exposures are more meaningful, which is not traditionally captured in the standard ACEs measure, possibility limiting its generalizability.

  • Use in clinical trials: Several clinical trials have been conducted in which participants report ACEs, or in which the ACEs score is hypothesized as a moderator. However, ACEs have not been tested as a primary outcome in a clinical trials setting.

Critical appraisal of overall value to the rheumatology community

  • Strengths: Can be easily administered quickly and at low cost. The ACEs score is predictive of future mental and physical health problems, and can theoretically be administered in childhood, adolescence, and in adulthood. Of note, administration in childhood typically relies on responses from parent/caregiver.

  • Caveats and cautions: The primary concern has historically been around recall bias of trauma in childhood. However, a recent study demonstrated modest correlation (r=0.47) and convergent associations with health outcomes, the caveat being that data from the study suggested that personality characteristics (e.g., neuroticism) may bias retrospective reports [28].

  • Clinical and Research usability: This measure appears to be useful in predicting disease risk, and has been linked with inflammatory responses relevant to rheumatic disease [29, 30]. As such, ACE scores may be useful in stratifying risk of disease incidence and progression; however, this is yet to be empirically tested.

TRAUMA HISTORY QUESTIONNAIRE (THQ)

Description

  • Purpose: To measure lifetime exposure to stressful and potentially traumatic events in general, community, and clinical populations.

  • Content or domains: The THQ covers a broad range of stressors and potentially traumatic events that meet Criterion A of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Criterion A includes situations in which a person experienced, witnessed, or was confronted with an event involving a threat to the physical integrity of the self or others. Criterion A does not include symptoms or responses related to the event. THQ items ask respondents about 24 different and prevalent types of stressful and traumatic experiences, including crime, general disaster, and physical and sexual assault [31].

  • Number of items: This is a 24-item self-report measure.

  • Response options/scale: Response options. Respondents are asked whether each event ever happened to them (Yes/No). For each event endorsed, respondents are asked to provide qualitative details about the event, the frequency of the event, as well as their approximate age at the time of the event.

  • Recall period for items: Entire lifetime.

  • Cost to use: Free. Permission for use is not necessary when use is for nonprofit academic research or nonprofit educational purposes.

  • How to obtain: All language versions are available for download at: https://ctc.georgetown.edu/toolkit/

Practical application

  • Method of administration (written, paper and pencil, computer): The THQ can be easily administered as a self-report instrument or in an interview format. Can be administered in-person, by written or interview format, by telephone interview, by mail, or electronically.

  • Scoring. The THQ is a data collection instrument, not a test, so there is no standard scoring method. However, the most common scoring convention is to generate a total score representing the numbers and types of events endorsed by summing all items [32, 33], which can range from 0–24. A researcher or clinician can also generate subscale scores, calculated by summing items associated with crime-related events (4 items; range 0–4), general disaster and traumatic events (13 items; range: 0–13), and physical and sexual experiences (6 items; range: 0–6). The final item allows for reports of traumatic experiences not covered in the other statements and is not usually scored unless the provided response contains relevant information not pertaining to the other items. Other researchers have dichotomized the total trauma score to classify participants as “low” or “high” trauma [34, 35]. For example, Spertus et al. (1999) grouped participants who reported no traumatic events or only one kind of event as “low trauma” and participants who reported two or more kinds of traumatic events as “high trauma.”

  • Score interpretation (include whether normative data/scoring are available): Higher scores on the total trauma score and subscale scores indicate greater exposure to stressful and traumatic events[31]. Consistent with other trauma history instruments, there is no standard scoring system; thus, no normative data have been published.

  • Respondent time to complete: The self-report paper-and-pencil format takes approximately 10 to 15 minutes to complete. Administering it as an interview takes approximately 15–20 minutes, depending on the number and types of trauma-exposed events the person endorses.

  • Administrative burden: Training to administer. Minimal. Equipment needed. When self-administered, a pencil, pen, or electronic report form. Time to score. Minimal training time to score; approximately 5–10 minutes.

  • Translations/adaptations: The THQ has been culturally adapted and translated into Portuguese [36], Spanish [37], Hebrew [38], and Kurdish [39], as well as French, Danish, Urdu, Icelandic, Japanese, and Vietnamese. Many of these translated versions are available for download at the link provided above.

Psychometric information

  • Floor and ceiling effects: Researchers have not evaluated floor or ceiling effects for the total trauma or subscale scores of the THQ.

  • Reliability (internal consistency, test-test): Test-retest reliability. In the original study testing the psychometric properties of the THQ [40], stability coefficients over 2–3 months ranged from .47 to .91 for the reporting of specific traumatic events (Yes/No). The correlation for the number of items endorsed across administrations was r=0.70, indicating adequate reliability. In a study administering the THQ as an interview with a small sample of psychiatric outpatients, researchers found kappa coefficients ranging from 0.57 to 0.89 across 7 days for events endorsed by at least 20% of the sample [41]. Interrater reliability. Mueser et al. also found excellent consistency among three interviewers rating audiotaped interviews, with kappa coefficients ranging from .76 to 1.00 for events endorsed by at least 20% of participants [41].

  • Validity (content/face, criterion, construct): Face and content validity were established in the development of the THQ by including items that correspond with DSM examples of Criterion A stressors. Construct validity. In a small sample, items on the THQ were compared to those on the Stressful Life Events Screening Questionnaire. The authors found high variability in kappa coefficients (ranging from 0.13 to 1.00), indicating adequate convergent validity for several items [42]. Scores on the THQ were also significantly positively correlated with scores on the Conflict Tactics Scale (r=0.46), which measures intrafamily conflict and violence [43]. Criterion-related validity. THQ scores for the total number of traumas and the type of trauma have been significant predictors of rates of Post-Traumatic Stress Disorder (PTSD) and PTSD symptomatology [44]. THQ scores have also been significantly positively related to depression and personality disorders and inversely related to resilience and mental health functioning [45].

  • Responsiveness and minimally important differences: This instrument is a checklist of stressful and traumatic event exposure and not a measure of symptom severity following exposure that would change over time. Thus, there have been no studies that sought to determine the responsiveness or minimally important differences of the THQ.

  • Generalizability (special populations for which measure is relevant or not relevant): The THQ has been used in samples of college students, people with severe mental illness, pregnant women, individuals with substance dependence, police officers, people with epilepsy, and people with lower income, among many others. It has been used by researchers in the United States and internationally to assess trauma and stressor exposure. Thus, results derived from use of the THQ are generalizable to several demographic groups and cultures. It may not be generalizable to specific clinical groups for which it has not yet been validated.

  • Use in clinical trials: The THQ, similar to other stressful life event inventories, is not intended to measure change over time in the context of a randomized controlled trial. Thus, it has mostly been administered at baseline in clinical trials to classify the proportion of the sample that has experienced certain trauma or meets criteria for PTSD [46].

Critical appraisal of overall value to the rheumatology community

  • Strengths: The THQ is easy to administer and requires minimal time from respondents. Across a range of both national and international studies, the THQ appears to be a reliable and valid questionnaire for assessing trauma and stress exposure in clinical and nonclinical samples.

  • Caveats and cautions: Findings about the psychometric properties of this measure are preliminary; most of the studies assessing reliability and validity were in small samples that may not be generalizable (e.g., primarily white, patients with severe mental illness). Further, the test-retest reliability ranges from fair to excellent across different types of events with higher reliability for the total number of events endorsed compared to individual items.

  • Clinical usability: This instrument is potentially useful to mental health providers to screen for prior trauma exposure that could impact mental and/or physical health. However, it is not endorsed as a tool to diagnose or treat clinical conditions such as PTSD and has low direct clinical usability to practicing rheumatologists.

  • Research usability: Useful for research studies that aim to assess lifetime exposure to events that are considered stressful and potentially traumatic in relationship to physiological stress reactivity, health behaviors, and clinical outcomes such as onset of autoimmune conditions and/or autoimmune disease severity.

LIFE EVENTS LIST

Description

  • Purpose: To assess the occurrence of major life events in the past 12 months

  • Content or domains: The measure is composed of major life events, both positive and negative, experienced by the person completing the questionnaire or (i.e., self), and/or someone with whom they are close. These events include a broad spectrum of experiences including relocation, interpersonal loss (e.g., romantic break-up), job loss or gain, marriage, new baby, death of a loved one, and significant change in finances.

  • Number of items: 26 event items (23 specified events and 3 optional events). For items that are endorsed as occurring, there are follow up questions to determine whether the event was perceived as positive or negative, who experienced the event (self vs. close other), and additional contextual information.

  • Response options/scale: Events are assessed as yes/no if occurred. Follow up question response scales are specific to the particular event.

  • Recall period for items: Past 12 months

  • Cost to use: Free. Permission for use is not necessary when use is for nonprofit academic research or nonprofit educational purposes.

  • How to obtain (include online link to measure if available): Available on the author’s university website: https://www.cmu.edu/dietrich/psychology/stress-immunity-disease-lab/scales/index.html

Practical application

  • Method of administration (written, paper and pencil, computer): Can be administered by interview, paper and pencil, or by computer.

  • Scoring. Items are scored based on whether they occurred, the perceived impact of the event (positive vs. negative), and whether the event occurred to the respondent or a close other. Specific scoring for each item is available here: https://www.cmu.edu/dietrich/psychology/stress-immunity-disease-lab/scales/pdf/lel_scoring_revised.pdf.

  • Score interpretation. Higher scores indicate more exposure to life events in the past 12 months (range 0–61). Subscales also include Total Negative Self-Events; Total Positive Self-Events; Total Negative Other Events; Total Positive Other Events; Total Negative Events; Total Positive Events.

  • Respondent time to complete. The time to complete will vary based on number of items endorsed with a mean range of 5–10 minutes.

  • Administrative burden: Training to administer. Minimal. Equipment needed. When self-administered, a pencil, pen, or electronic report form. Time to score. Minimal training time to score; approximately 5–10 minutes.

  • Translations/adaptations: English-only, but can be translated. However, when generating translated versions, care should be taken to include culturally relevant events.

Psychometric information

  • Floor and ceiling effects: Researchers have not evaluated floor or ceiling effects for total life events or subscale of events (e.g., positive vs. negative; self vs. close other).

  • Reliability (internal consistency, test-test). This is a checklist of major life events. As such it does not make sense to assess internal consistency as endorsement of one event is unlikely to increase the chances of endorsing another event. Test-retest reliability of this measure has not been reported.

  • Validity (content/face, criterion, construct): The events were a subset of those appearing in the List of Recent Experiences[47] and were chosen for their potential impact and their relatively high frequency of occurrence in population studies[48].

  • Responsiveness and minimally important differences: This instrument is a checklist of exposure to major life events and not a measure of severity following exposure that would change over time. Studies of responsiveness have not been conducted.

  • Generalizability: This scale has largely been used in healthy community samples. The events included in this measure likely reflect events that happen more commonly among adults, especially among those from Western cultures. It is not intended for use in children.

  • Use in clinical trials: This scale has not been used in clinical trials.

Critical appraisal of overall value to the rheumatology community

  • Strengths: Can be easily administered quickly and at low cost. It provides an assessment of both positive and negative life events that may affect progression of rheumatic disease. This measure also goes beyond self-relevant events to obtain information on events that affect close others.

  • Caveats and cautions: This measure has not been rigorously evaluated with psychometric testing. This is particularly relevant when it comes to the stability of subjective rating of an event (e.g., how one feels about a romantic break up is likely to change over time). Moreover, some events may be more relevant to some populations than others. For example, job loss is not appropriate for a largely retired population.

  • Clinical and Research usability: This measure may be useful in understanding triggers of disease; however, it has not been used in clinical or research contexts in those with rheumatologic conditions to date. Higher scores have been predictive of greater susceptibility to infectious illness in a healthy population using experimental paradigms (Cohen et al.,1993), which may be relevant to patients with rheumatic conditions who are taking immunosuppressing medications as those treatments also confer elevated risk of infection.

Table 1.

Practical Applications

Measure Number of Items Content & Domains Method of Administration Recall Period Response Format Range of Scores Score Interpretation Availability of Normative Data Cross-cultural Validation
Perceived Stress Scale (PSS) 14 (there are also 10-item and 4-item scales) global perceived stress written or interview format 4 weeks 5-point scale 14-item: 0–56; 10-item: 0–40; 4-item: 0–16 higher scores indicated greater perceived stress available from large samples of US residents Many non-English translations have been validated in other cultures by independent research groups
Adverse Childhood Experiences (ACE) 10 Trauma exposure written or interview First 18 months of life Occurrence (yes/no) 0 to 10 higher score indicates more trauma exposure available from population samples Many non-English translations have been validated in other cultures by independent research groups
Trauma History Questionnaire (THQ) 24 Lifetime exposure to traumatic events: crime-related, general disaster, and physical and sexual experiences Written or interview format Lifetime Occurrence (yes/no), frequency, approximate age 0–24 (total score); 0–4 (crime-related events); 0–13 (general disaster and traumatic events); 0–6 (physical and sexual experiences) Higher scores indicate greater stressor and trauma exposure No normative data Culturally adapted and translated into Portuguese, Spanish, Hebrew, Kurdish, French, Danish, Urdu, Icelandic, Japanese, Vietnamese
Life Events List (LEL) 23 specific events and 3 optional events Exposure to positive and negative life events written or interview Past 12 months Occurrence (yes/no); follow-up questions specify contextual information (self vs. other; positive vs. negative) 0–61 (Total score) Higher scores indicate more exposures in past year No normative data No known cross-sectional validation
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Table 2:

Psychometrics

Measure Floor & Ceiling Effects Reliability Validity Responsiveness Minimally Important Differences Generalizability Used in RCTs
Perceived Stress Scale (PSS) negligible Good for PSS-14 and PSS-10; marginally acceptable for PSS-4 Good Adequate PSS-10: 11 points for absolute change score adults with education through high school or beyond Yes
Adverse Childhood Experiences (ACE) unknown moderate to good Good N/A N/A Likely generalizable across populations. ACE-International Questionnaire has also been created to be used in low- and middle-income countries At baseline to classify sample trauma exposure
Trauma History Questionnaire (THQ) N/A Good Good N/A N/A Several demographic and clinical groups and cultures At baseline to classify sample trauma exposure
Life Events List (LEL) N/A Unknown Good N/A N/A Adult community samples No
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