modern approaches to conceptualizing and measuring human ... · chobiological costs and...

ANRV339-CP04-02 ARI 22 February 2008 16:17

Modern Approaches toConceptualizing andMeasuring HumanLife StressScott M. MonroeDepartment of Psychology, University of Notre Dame, Notre Dame,Indiana 46556; email: [email protected]

Annu. Rev. Clin. Psychol. 2008. 4:33–52

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

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

This article’s 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 axis,allostasis, allostatic load

AbstractThe idea that adverse life circumstances and negative life eventscontribute to disorder and disease has long been held. Advances inconceptualizing and defining these conditions under the commonlabel of life stress have led to progress in measuring both the envi-ronmental and individual response characteristics that may promotedisorder and disease. In general, a substantial and growing researchliterature supports the basic premise that life stress plays an impor-tant role in the development of many psychological and physicalproblems. Recent research, too, strongly suggests that interest inlife stress in relation to health and disease will accelerate over thecoming years. Yet debates and controversies remain concerning howto best conceptualize and measure life stress, which presents distinc-tive challenges for advancing the field. The present review examinesthe major issues pertaining to these debates, controversies, and chal-lenges, for they will be crucial to resolve if progress is to be made inunderstanding ways in which life stress may or may not contributeto psychological and physical disorders.

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Contents

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

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

STRESS . . . . . . . . . . . . . . . . . . . . . . . . . 35Defining Stress . . . . . . . . . . . . . . . . . . . 35Allostasis and Allostatic Load . . . . . 36Perception, Cognition, and

Psychological Appraisal . . . . . . . . 37MEASURING LIFE STRESS. . . . . . . 38

Stressful Life Events andDifficulties Measures . . . . . . . . . . 38

Perceived Stress Measures . . . . . . . . 42The Psychobiology of Stress . . . . . . 43

CURRENT STATUS,CONTROVERSIES,AND DEBATES . . . . . . . . . . . . . . . . . 44Subjectivity, Individuality,

and Measurement . . . . . . . . . . . . . 45Costs, Requirements,

and Compromises . . . . . . . . . . . . . 46Stress as a Self-Contained

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

FUTURE DIRECTIONS. . . . . . . . 48

INTRODUCTION

The concept of stress is inherently about anorganism’s adaptation to challenging environ-mental conditions over time. Since the earlyorigins 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 byenvironmental events, and (b) what the psy-chobiological costs and consequences are ofthese dynamic regulatory processes. It wasappreciated 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 im-mediate fight-or-flight physical action, thestress response recruits a larger network ofcentral nervous system activities involvingarousal, vigilance, cognitive processing, andmemory (de Kloet et al. 2005, Gunnar &Quevedo 2007) and influences an extensiverange of other metabolic and immune activ-ities (Sapolsky et al. 2000). Broadly consid-ered, stress encompasses adaptive demandsfrom the molecular through the molar, fromgene expression through social interaction.

Recognition of the different psychobiolog-ical levels participating in the stress responseconsiderably enlarges the scope of inquiry.Contributions to understanding stress comefrom basic neuroscience and biology throughpsychology, epidemiology, sociology, and an-thropology. Given such a broad and multilevelmandate for stress research, there have beendiverse approaches to, and debates over, themost appropriate ways to define, conceptual-ize, and measure life stress. Noteworthy, too,is that interest in life stress has not been re-stricted to the research laboratory or to ob-scure scientific circles. Stress terminology inits many colloquial forms underpins and per-meates popular explanations for diverse prob-lems in health and well-being.

In this review, historical and backgroundinformation pertinent to understanding cur-rent ideas about stress theory and measure-ment are presented first. Next, definitions of,and conceptual approaches to, life stress arediscussed. Examining the relative merits of al-ternative views about stress assists in the sub-sequent task of evaluating current theoreti-cal and measurement issues for studying lifestress. Given the large range of approachesto measuring life stress, the review focusesupon the most common and the most promis-ing methods employed in human field studies.As the reader will see, although progress hasbeen made in theory and measurement of lifestress, there are concerns about how well theseadvances are being incorporated into stan-dard practices. Finally, although concepts and

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findings from animal laboratory and humanexperimental and field research are drawnupon, the objective is to focus the reviewon theory and measurement of human lifestress.

BACKGROUNDCONSIDERATIONS

Many believe that stress is a problem ofrelatively recent origins, endemic to modernsociety and unrelentingly on the rise. Thereis a sense that, as a result of acceleratingprogress 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 infuseseveryday 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, and that stress is not necessarily animportant cause of many disorders or diseases.People are very prone to mistakenly attributeproblems of unknown origins to general andnonspecific concepts akin to life stress. Thecultural practice of invoking stress as an ex-planation for disorders whose causes remaina mystery represents a serious challenge toprogress in research on human life stress. Bothinvestigators and research participants can beeasily misled by unsubstantiated beliefs aboutlife 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,” whereas“disease” was initially meant to reflect “dis-ease” or dis-comfort (not illness), a form of distress. The terms remainrich with interconnected meanings, which likely contributeto many of the problems in research with regard to keepingconcepts and measures separate and distinct.

CONCEPTUALIZINGLIFE STRESS

Defining Stress

A variety of definitions have been proposedfor stress. Despite numerous attempts, thereremains no universally accepted characteri-zation of the term. Separate research tradi-tions have emphasized different facets of thegeneral topic of stress. For example, humanfield studies and clinical observations haveviewed 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, thatstress 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 thatchange over time. In other words, the stimu-lus and response viewpoints incompletely andonly indirectly capture these three featuresof 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 termsof an ongoing relationship between organismand environment (Weiner 1992) or as the suc-cessive transactions between 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, thestress process is thought of in terms of externalchallenges and perceptions of the challenges,coping resources and perceptions of copingresources, and the dynamic interplay of theseover time (Cohen et al. 1995b, Gunnar &Quevedo 2007).

There have been other attempts to capturethe breadth, complexity, and spirit of “stress”over 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 stressresearch, psychobiology versus psychology ofstress), they provide useful complements forone another. They remind us that stress in-volves adaptation from the most basic biolog-ical functions through the highest cognitiveprocesses.

Allostasis and Allostatic Load

From animal laboratory research on psy-chobiological regulatory systems involvingthe 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 thebody’s internal milieu, and in particular to theregulatory concept of homeostasis, have beena prominent underlying principles of stress.In response to environmental changes andchallenges, 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 thistradition, stress has been viewed as exter-nal challenges that disrupt or impair\breakhomeostasis.

The concepts of stress and homeostasis,however, often have been used in ambiguousways that have obscured possible psychobio-

logical implications for health and well-being(McEwen 2000, McEwen & Wingfield 2003).The concept of allostasis was introduced tobring greater clarity to these matters as wellas to broaden and differentiate the range ofpsychobiological activities recruited in serviceof homeostasis and adaptation under stress.Theoretically, the concept of homeostasis hasreferred to the regulation of a limited num-ber of core physiological systems that sus-tain life, systems that must be kept withintight limits (e.g., body temperature, pH bal-ance). Allostasis, in turn, refers to how theorganism achieves stability (or homeostasis)through continual change. It is a more en-compassing concept, intended to incorporatean extensive range of whole-organism mech-anisms recruited to meet environmental de-mands, all of which have more flexible setpoints designed to accommodate constantlychanging environments and regulatory chal-lenges (McEwen & Wingfield 2003, Sterling& Eyer 1988).

Allostatic load, in turn, refers to the con-sequences of sustained activation of primaryregulatory systems serving allostasis overtime, to the cumulative burden on bodily sys-tems (i.e., wear and tear) that is believed tocontribute to disorder and disease. The con-cepts of allostasis and allostatic load underpina more comprehensive model of stress pro-cesses that may be useful for explaining whyactivation of these systems is adaptive overthe short run and maladaptive over more pro-longed periods of time. These concepts pro-vide a richer and more differentiated frame-work of ideas to shed light on how stressresponse mechanisms are involved with theexigencies of the immediate flight-fight de-mands, in the short-term self-regulation andfine-tuning of these systems, as well as in theirlonger-term role in restoration and repair(de Kloet et al. 2005, McEwen & Wingfield2003). The concepts of allostasis and allo-static load hold the potential to shed light ona range of current mental and physical pro-cesses conditions, some of which have onlyrecently begun to be considered as potentially

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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 and recog-nition that psychological processes intervenebetween the environmental event and theorganism’s response (Somerfield & McCrae2000). Instead of stress involving reflexive re-sponses to specific environmental challenges,the stress process expanded to accommodatea host of factors involving individual differ-ences in perceptual processes and cognition.Increasingly complex and elegant theoriesevolved. These theories depict longitudinaltransactions between the external demands ofthe environment, appraisal of the environ-mental demands, assessment of resources tohandle the external demands, coping efforts tochange the environmental, and so on (Cohenet al. 1995b, Lazarus & Folkman 1984).

As a result of these fertile ideas, individualdifferences in psychological processes were el-evated to key positions as intervening vari-ables. Specifically, the appraisal of stressful sit-uations and coping resources were accordedcentral significance for moderating how envi-ronmental challenges could affect psyche andsoma. The hypothetical influence of appraisalcould cut two ways: the impact of very stress-ful events could be attenuated, and the impactof more minor stressful events could be ampli-fied (Kanner et al. 1981). Formulations suchas these helped to explain why some peoplesuccumb more readily under stress than oth-ers. They also assuage underlying anxietiesabout the apparently random and relentlessexposure to stress (i.e., if one can gain controlover the consequences, one can control andperhaps eventually conquer the most noxiouspiece of the problem).

How pivotal and influential are appraisalprocesses for moderating stress impact? Ar-guably, this matter represents one of the mostpressing considerations in contemporary re-

search on life stress. At one extreme, thereis 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 dependupon a reasonable correspondence betweenthe external demands of the environment andan organism’s perceptions of those demands.Psychological factors and appraisal in partic-ular remain relevant within this perspective,but the exigencies of the external environmentlargely contour and constrain psychologicalfactors.

At the other extreme, there is a relativelyloose linkage between environmental chal-lenges and perceived demands. This extremerepresents a strong psychological perspec-tive, one in which cognition and appraisaldominate 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 thephilosopher Epictetus averred, “Men are dis-turbed not by things, but by the view whichthey take of them”). Psychological factorsand 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 thatstress appraisal and cognitive processes areimportant 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 regardto the measurement of stress (Monroe &Kelley 1995).

MEASURING LIFE STRESS

Given the breadth of the stress conceptand the differing views as to its nature, itis 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 transactionsof stress). However, many if not most mea-surement systems in practice blur these the-oretical boundaries. For example, self-reportlife event checklists appear to fit most read-ily with an environmental definition of lifestress. But when the study participant makesthe decisions about which events qualify, orhow stressful the events are, these measuresinherently incorporate response componentsas well. Interview-based procedures for assess-ing life events, too, often estimate the likelyimpact of the life event on the participant orfor the average person and thus include ap-proximations of the person’s response in themeasure (Brown & Harris 1978, Dohrenwendet al. 1993).

A similar situation exists with response-oriented measures of human life stress. It istypically not possible to determine the degreeto which variation in the particular responseis due to external environmental conditionsper se versus other individual difference vari-ables that contribute to the stress process. Forexample, measures of perceived stress or cor-tisol levels may be a consequence of environ-mental stress but also may be moderated bysuch factors as personality or social support.Particularly of 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 mayreport high stress or evidence elevated corti-

sol due to being depressed, not external stres-sors). Thus, response-based measures of stresspose significant challenges for separating theinfluences of stress from other factors, includ-ing the confounding with manifest disorder orpsychopathology (Monroe & Kelley 1995).

Finally, the transactional definitions ofstress have been more appealing in theorythan evident in practice. There are few in-stances of empirical work in the literaturebased on such models (Folkman & Moskowitz2004; cf. Stroebe et al. 2006). Keeping in mindthese limitations for the different definitionalperspectives on life stress, the following re-view of stress measures is organized aroundthe most common practices used in the hu-man literature on life stress.

Stressful Life Events andDifficulties Measures

The vast majority of studies of human lifestress have assessed people’s recent major lifeevents. Since the idea of measuring life stressas discrete life events took operational formin the Schedule of Recent Experiences (SRE;Hawkins et al. 1957, Rahe et al. 1964), andwith the addition of specific weightings for theSRE in the Social Readjustment Rating Scale(SRRS) (Holmes & Rahe 1967), attention tothe topic has grown yearly. At present, over10,000 publications beginning in 1967 havepertained to the topics of stressful life eventsor life stress (Dohrenwend 2006). Given thetremendous presence and influence of thisgeneral approach to the measurement of hu-man life stress, as well as the ongoing de-bates about different measurement practicesthat have been spawned, the subject is cov-ered in some depth.

The early procedures for measuring lifeevents were based upon the precedent pro-vided by the innovative SRE and SRRS. Theseand derivative self-report checklists included arange of life experiences that were consideredto be relatively common in most people’s livesand were assumed to require varying degreesof readjustment or, implicitly, stress. A clear

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attraction of these measures was the ease withwhich one could apparently capture an ob-jective index of something as complex as lifestress. As in any area of scientific development,problems were soon uncovered with the firstgeneration 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 lifeevent checklists, however, suggested that theproblems with these measures were morebasic, that they represented fundamentaland possibly incorrigible limitations of theself-report checklist method itself (Brown1974, 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 andwidely used system for assessing, defining,and rating life stress is the Life Events andDifficulties Schedule (LEDS), developed byGeorge Brown and Tirril Harris (Brown &Harris 1978). The LEDS system includesan extensive manual that provides explicitrules and operational criteria for defining bothacute and chronic forms of stress, for distin-guishing between complex constellations ofthese forms of stress, and for rating these expe-riences using a comprehensive manual. Thesesources of information help guide decisionsand enhance standardization of measurement.The unique biographical circumstances of theindividual are taken into account when ratingeach 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 5000case exemplars are provided in the manual toalso help anchor the assessment decisions andstandardize the ratings. The LEDS informa-tion can be presented in a separate meeting toraters who are blind to the subjective reactionsof the particular individual, in order to avoidconfounding of the study participant’s 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; Katschnig1986; Lewinsohn et al. 2003; McQuaid et al.1992, 2000; Oei & Zwart 1986; Simons et al.1993; Zimmerman et al. 1986). Although theprocedures across these different studies varywith regard to the specific life event check-list and interview method used, the consistentfinding is that there are significant differencesin 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 withlife events defined by the LEDS (Brown &Harris 1978). Lewinsohn et al. (2003) recentlyperformed a similar comparison between self-report and follow-up interview methods. Forlife events primarily involving the subject,they found that 67.5% of events indicatedon the checklist met the criteria for eventsaccording to their stress interview. For lifeevents primarily involving other people, thecorrespondence 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 areconsistent with those of Duggal et al. (2000),who concluded that a checklist measure of lifeevents captured only 32% of severe events oc-curring prior to depression onset.

These studies indicate that, even under themost optimistic circumstances, self-reported


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life events are consistent with the type oflife event envisioned by the investigator lessthan half of the time. To be perfectly clearabout this central matter, the likelihood of alife event reported by the study participanton a self-report checklist matching the lifeevent defined according to interview-basedcriteria is generously, at best, even odds. Asdescribed below, these discrepancies do notreflect merely different opinions about thematter or alternative views; they typically re-flect outright errors in the self-reporting oflife 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 methodsrepresent the current gold standard for assess-ing life stress (Dohrenwend 2006, Gorman1993, 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 mightexpect people to be relatively accurate andconsistent in reporting exposure to a trau-matic incident. Yet researchers investigatingtrauma have grappled with assessment prob-lems essentially identical to those of life eventsresearchers, and several reports have docu-mented problems with self-report checklistsfor trauma exposure similar to those foundwith self-report life events checklists (Heppet al. 2006, Roemer et al. 1998, Southwicket al. 1997). Different age groups experiencedifferent 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 adultlife event measures (Grant et al. 2004). Finally,for many years survey research methodologyhas been dedicated to understanding factorsaffecting the subject’s interpretation of ques-tionnaire items and recall, factors that haveeffects that are often subtle, yet effects that

can substantially compromise the reliabilityand validity of the data obtained (see Schwarz2007).

Three common themes cut across these re-lated literatures that can help inform debateabout appropriate methods for life stress mea-surement. The first theme concerns memoryand recall of the essential information, the lifeevents. How accurately can people rememberpast experiences and report on them? Some-what surprisingly, with proper assistance andstructuring of the questioning, people can ac-complish this reasonably well. For severe lifeevents using the LEDS system, it has beenestimated that people can reliably report onsuch experiences for up to ten years (Neilsonet al. 1989). Less severe events and more mi-nor stressors, however, may be less reliablyrecalled (Brewin et al. 1993, Hardt & Rutter2004). Current research on autobiographicalmemory provides clues on how to enhancethe ability of individuals to recall life stressinformation reliably over extended periods oftime (Belli 1998, Schwarz 2007). In principle,it would seem that these enhancements couldimprove both interview-based and self-reportchecklist methods for assessing life stress. Dis-crepancies between self-report and interview-based measures, then, are not likely to beexplained by differences between the two ap-proaches with respect to memory per se.3

The second and third themes are both re-lated to the issue of recall, but more subtly so.And these two themes point to a critical di-vide between self-report and interview-basedmethods for measuring life stress. The firstof these themes concerns the definition of,and decision about, what formally constitutesa life event. As Dohrenwend (2006) has re-cently systematically addressed, a major prob-lem with self-report checklists is that peoplequite often interpret the life event descrip-tors in highly personal and idiosyncratic ways.

3It should be noted that when precise timing of event oc-currences and onset of the disorder under study is required,more intensive questioning and assistance are needed.

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Depending upon how the particular personinterprets the question, the same life event de-scriptor can reflect a range of life events, fromthe trivial through the catastrophic. For ex-ample, serious illness and injury events can beendorsed for experiences involving a bad coldor minor sprain through heart attacks and ma-jor crippling accidents. This means that whatthe 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% ofthe time). There is no common understandingof the spirit of the event between subject andinvestigator. This major shortcoming with lifeevent checklists unfortunately has been re-peatedly overlooked, minimized, or simplyignored.

Research on cognitive aspects of surveymethodologies converges on this identicalproblem. As Schwarz (2007) notes regard-ing behavioral reports, “memory processes areonly one of the determinants of their accu-racy . . . respondents may report on a behav-ior that does not match what the researcherhad in mind” (p. 283). This is where mem-ory melds with the participant’s current im-perfect and evolving understanding of the taskat hand. The participant’s recall is structuredby his or her own interpretation about what tosearch for. If the life event item is interpreteddifferently from the way in which the inves-tigator intended, there will be a mismatchin understanding, error intrinsic to the datacollected.

The third theme of relevance to this topicacknowledges that research participants drawupon a number of additional sources of in-formation, background and contextual, toframe the task requirements, infer the in-vestigator’s intentions, interpret the informa-tion provided, and eventually come up witha response. Recognition of these multiple in-fluences raises awareness about how readilystress measures are contaminated by extrane-ous information or confounded by subjectivebias. Two major domains of influence are ofparticular concern (see sidebar). First, most

people who complete self-report checklistsreadily 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 participant’s general views aboutlife stress and specific inferences about thepresent research needs. This is one mech-anism via which the cultural biases aboutstress can intrude and contaminate stress mea-surement, introducing random error. Second,people who have already developed problems,disorders, or illnesses may seek explanationsfor their maladies and be more prone to en-dorse life events that only vaguely resemblewhat happened to them (Brown 1974). Viathis mechanism, awareness of the problem un-der study may confound stress measurement,resulting in systematic errors, which in turnpromote spurious associations between lifeevents and disorder. More generally, relianceon these uncontrolled background sources ofinformation becomes most pronounced whenthere is no means for the participant to clarifythe 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 eventschecklists (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 ahandful of studies with data bearing upon thematter. In general, the interview-based meth-ods have been found to be superior in termsof associations with depression or depression-related phenomena (e.g., predicting greaterdepressive 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 aboutlife 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 happenedto them, but with further information recognized that the ex-perience did not qualify). First, there were people who hadvery 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 thatthe endorsed items were not quite right, but they indicatedthat endorsed items were the closest they could come up withto 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 orto 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 inquiredabout 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 wasn’t stressful. As a result of his heart attack, herhusband had quit smoking and perhaps become more patient,and they were getting along much better than previously. Shewas so strongly influenced by her assumptions about our in-terest in stress that she was able to override the rather clearand 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 aretruly stressful versus trivial (Gorman 1993).It should be noted that self-report measuresof life events on occasion have yielded asso-

ciations when compared with interview-basedmeasures (e.g., McQuaid et al. 2000; see alsoWagner et al. 2006). However, given the higherror rate of event identification, concernsabout the timing between stressors and dis-order onset, and the problem of confound-ing between stress and disorder with suchmethods, the implications for stress-disorderrelations are tenuous. Indeed, recommenda-tions for the use of self-report checklists maybe limited to a summary index of “overalllevel of subjectively experienced stress,” withinterview-based methods suggested for re-search on etiology (Duggal et al. 2000, p. 451).

In summary, research has repeatedlydemonstrated serious shortcomings of self-report checklists of life events and chronicstressors as reliable and valid measures oflife stress. Most of these problems can beaddressed satisfactorily with semistructuredinterview-based approaches that utilize oper-ational rules and guidelines for defining lifeevents. There is an abiding faith in self-reportchecklists, however, as sufficient measures forsome, or even many, research needs (e.g., anearly life event scale, the SRRS, recently wasdeclared to be “a robust instrument for iden-tifying the potential for the occurrence ofstress-related outcomes”; Scully et al. 2000,p. 875). And life event checklists continue,by far, to be the most common approach toassessing stressful life events. This indicatesthat other factors beyond empirical evidenceinfluencing opinions in this crucial debate de-serve greater attention. We return to this topicbelow in the Current Status, Controversies,and Debates section.

Perceived Stress Measures

In comparison with the literature on stressfullife events, relatively few attempts have beenmade to measure perceptions or appraisals ofstress (Monroe & Kelley 1995). The mostcommon instrument of this kind in the liter-ature, however, is the Perceived Stress Scale(PSS; Cohen et al. 1983). The PSS was devel-oped based upon appraisal theory (Lazarus &

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Folkman 1984) and was designed to “ . . . tapthe 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 [yetCohen & Williamson (1988) recommend therelatively superior 10-item version]. The PSSis widely cited, used in diverse studies of lifestress, and has been translated into several lan-guages. Second to the generic life event check-list approach, the PSS is probably the mostcommonly used measure of stress in the re-search literature.

The PSS has been found to predict manyadverse outcomes. Importantly, the PSS hasshown discriminant validity with regard to lifeevent measures of stress (i.e., each measureof stress predicts different stress-related pro-cesses or outcomes). For example, Cohen et al.(1993) reported that both perceived stressand 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 thatperceived stress and stressful life events mea-sure different components of stress. Impor-tantly, this suggests that measures of stressbased 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 ordiseases.

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 thePSS. Cohen et al. (1983) note this matter, re-porting correlations of 0.76 and 0.65 acrosstwo samples with depressive symptoms. Yet in

other research, these investigators have shownthe PSS to prospectively predict health out-comes independent of psychological symp-toms (Cohen & Williamson 1988; Cohenet al. 1983, 1993), supporting the discrimi-nant validity of the PSS with regard to psycho-logical symptoms (Monroe & Kelley 1995).Overall, despite limitations inherent to stressresponse measures and cautionary concernsabout confounding with psychological symp-toms, the PSS possesses good psychometricqualities and a respectable record of validitystudies (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 provideda strong focal theme (Selye 1936, Weiner1992). Animal laboratory and human exper-imental stress studies commonly incorporatebiological indicators of stress responses; suchmeasures 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 resilienceover the past decade (Dickerson & Kemeny2004, Gunnar & Quevedo 2007, Hammen2005, Sapolsky 2005, Southwick et al. 2005).In particular, the developmental neurobiologyof the hypothalamic-pituitary-adrenal corti-cal (HPA) axis and the regulation of corti-sol have become a major focus of interest forunderstanding individual differences in stressreactivity (Heim & Nemeroff 2002, Meaney2001).

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 toHPA axis functioning (Heim & Nemeroff2002). Alterations in these systems have beenhypothesized to lead to greater sensitivity toenvironmental stress, and thereby to a greaterlikelihood of developing psychopathology, aswell as other possible disorders (Gunnar &


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Quevedo 2007). These sources of informationnicely 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 inlater life (Felitti et al. 1998).

There are important implications of theserelated research literatures for human lifestress research. Theoretical frameworks andmeasurement practices can be expanded toincorporate early developmental abuses andadversities, along with their implications forpsychobiological functioning and stress regu-lation. Recent advances in noninvasive mea-surement techniques, too, have fueled in-terest in the neurobiology of developmentalstress research and provide the groundworkfor shedding light on how environmental andpsychological stress are biologically medi-ated (Gunnar & Quevedo 2007). However,the number of biological systems affected bystressful conditions is tremendous (Charney2004, Southwick et al. 2005), and measure-ment issues are at least as paramount as arethose encountered with other levels of stressresearch.

For example, studies on the HPA axisand regulation of cortisol are useful forunderstanding challenges to be considered(Dickerson & Kemeny 2004, Gunnar &Quevedo 2007, Miller et al. 2007). Althoughcortisol represents a logical indicator of stressimpact involving key biological regulatorysystems, standardized, consensually acceptedmethods for assessing the hormone do not yetexist. Significant obstacles to progress includebasic questions about the nature of cortisol re-lease (Young et al. 2004) as well as questionsinvolving 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 cerebrospinalfluid), which in turn vary in the amount of bi-ologically active cortisol (unbound by carrierproteins) and in the temporal window duringwhich 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 et al.2004). Finally, cortisol may not signify a non-specific indicator of stress responsivity, butrather may be recruited in reaction to partic-ular classes of environmental challenges (e.g.,social or physical threat; Dickerson & Ke-meny 2004, Miller et al. 2007). These caution-ary points are raised not to dissuade efforts torelate psychological stress to biological corre-lates, but rather to acknowledge that other ar-eas of stress research face difficult challengesin measuring indicators of the construct.

Overall, progress along these lines reaf-firms stress as a whole-organism phenome-non. These ideas, too, are in keeping with re-cent recommendations for bridging the gapsbetween distal genes and proximal environ-mental factors through a systems approachthat incorporates intermediate psychobiolog-ical processes (Caspi & Moffitt 2006, Gottes-man & Hanson 2005). Although such workwill no doubt add complexities for modelingand measuring the multiple components, suchefforts will provide opportunities to anchorideas about psychological stress more securelywithin a broadened and biologically plausiblenomological network.

CURRENT STATUS,CONTROVERSIES,AND DEBATES

Scientific interest in life stress and its impli-cations for health and well-being perhaps hasnever been greater (Cohen et al. 2007, Milleret al. 2007). In terms of neuroscience under-pinnings, the concepts of allostasis and allo-static load are reinvigorating thinking abouthow adversity contributes to a host of men-tal and medical conditions. The range of bi-ological processes involving stress is expand-ing, stretching toward physical conditions notpreviously viewed within a stress framework(e.g., metabolic syndrome, the aging process)(Miller et al. 2007, Sapolsky 2004). Advancesin mapping the human genome and in de-veloping molecular genetics techniques haveset the stage for long-awaited breakthroughs

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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 canpredict with confidence that even more at-tention will be devoted to life stress and itsmeasurement over the next several years asinvestigators expand their efforts to under-stand the causes of diverse mental and medicalproblems.

Unfortunately, there are fewer reasons tobe confident that the potential of life stressmeasurement to make meaningful contribu-tions to these efforts will be fully realized. Al-though advances have been made in conceptu-alizing and measuring human life stress, theseadvances have not become part of establishedmeasurement practices. Despite the clear ad-vantages of interview-based approaches tomeasuring 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-basedprocedures. Most of what is accepted as sat-isfactory measurement of stress is simply notin keeping with what is now well documentedabout scientifically sound measurement prac-tices, or with what is recommended by ex-perts in careful reviews of the literature. Asbiomedical fields develop increasingly sophis-ticated and cutting-edge assessment technolo-gies, progress on life stress measurement hasat best plateaued (or flatlined).

When it comes to conceptualizing andmeasuring life stress, a curiously casual anduncritical attitude characterizes much of theresearch literature. Oftentimes stress mea-sures are improvised for the immediateundertaking, with little regard for the largerliterature on assessing life stress or even for re-porting basic psychometric information. Themanner in which the final stress score is op-erationalized, too, is highly inconsistent, andoften unique, across studies (e.g., total lifeevents, total negative life events, subjectivelyweighted life events, events selected from a

particular life domain). The lack of attentionto standardized practices, despite their avail-ability, has resulted in setbacks along severallines. Replication is not possible when primi-tive and diverse methods are used across stud-ies. Falsification of hypotheses based on lifestress is a problem when there are few con-straints upon what passes for “stress,” whenthere is a smorgasbord of seemingly endlessoperational 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 guidancefor developing better ideas and stronger mea-sures. This may be the most incapacitating re-sult of these problems. The gold standard forassessing life stress is the LEDS, and this ven-erable measure is now over three decades old(Brown & Harris 1978). The PSS, too, hasnow been in existence for a quarter century(Cohen et al. 1983). These represent very longperiods of time within the continually evolv-ing world of science. New developments areneeded to advance the field and to meet theanticipated 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 lifestress? In the following section, we specu-late on several factors that may explain thiscurrent state of affairs in human life stressresearch. Through bringing these issues tothe forefront of discussion, it is hoped thatthe standards for stress measurement can beraised, and new approaches may be developed,in pursuit of clarifying the role(s) stress mayor may not play in disorder and disease.

Subjectivity, Individuality,and Measurement

Many theorists and researchers have a stronginclination to view the participant’s percep-tions as the deepest and most meaningfultruth about the stressfulness of the situation.


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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 theperson experiencing the event can ever speakto, or appraise, how stressful it was? By notallowing the participant to express his or herfeelings about the issue, the uniqueness of theindividual is not honored or respected, andthe 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 thatinsidiously undermines the credibility ofinvestigator-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 ofthe truth about stress to emerge. Many simplybelieve what is central is the view the persontakes 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 alreadydiscussed for not naıvely relying only on whatthe respondent has to say casually about his orher recent life experiences.

When the questioning is properly struc-tured, when there is ample opportunity for“collaborative cognition,” and when clarifi-cation about the information can be sought(Schwarz 2007), study participants can pro-vide reasonably reliable information about thelife 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 necessarytask of eliciting essential personal information

from the respondent with the equally neces-sary and separate task of making standardizedjudgments about the information so obtained.

Costs, Requirements,and Compromises

One point of agreement across all perspectiveson stress measurement is that interview-basedprocedures are more costly and time consum-ing and thereby less suitable for investigationsrequiring large samples (Dohrenwend 2006,Hammen 2005). Although these are impor-tant limitations of the method, they do not defacto legitimate the use of self-report checklistmethods. These are quite separate matters.

Often life stress is one factor among manyin a multifactorial design, with stress rangingin importance from a primary cause througha trigger, a contributor, or only a complica-tion. When stress is only part, or a relativelyminor part, of the working model, even themost conscientious investigator may feel pres-sure to adopt methods that are more expedi-ent. But does measuring stress poorly makesense, even if other factors in the model aremeasured with fidelity? Alternatively, the re-search agenda may require very large numbersof individuals, and resources are insufficientto support interview-based measures of lifestress. But measuring stress with large num-bers of people doesn’t make poor measure-ment any better, and it doesn’t translate intogood science in any obvious way (especiallywith serious concerns about confoundingfactors). Worthy of mention, too, is the largeincrease in statistical power afforded by pre-cise and reliable measurement; employingthe best measures of life stress can thus re-duce the required sample size (Moffitt et al.2005).

More generally, the concern is that theseexpedient precedents build upon themselves,and the literature proliferates with measuresthat then provide perceived credibility forthe inferior approach. Recall that as little as2% of the research literature may be basedon preferred measurement approaches (Grant

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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 andtime-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 andresources are limited and to avoid self-reportlife event checklists altogether. As notedabove, the PSS and similar measures havetheir limitations, yet proper control proce-dures and research designs can help offsetmany of these concerns. For example, con-trolling for psychological symptoms increasesconfidence that associations with perceivedstress are not attributable to confoundingwith existing symptoms. By also employingprospective designs, the investigator can helpassure 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 andof having an extensive research record forcomparative purposes (see also Cohen et al.1995a). Self-report life event checklists aretoo 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 lifestress. The idea of stress possesses such com-pelling face validity and cultural reificationthat investigators may be blinded to thinkingmore critically about its measurement. Twoaspects of this admittedly speculative idea areworth considering.

Quite commonly, studies that report stressfor some adverse outcome do not take thelogical next step to question what it mightbe about stress that accounts for the find-ings. There tends to be a lack of curiosityabout what it “is” about stress that leads toharm. 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 situationinvolves 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 stressprocess can be accounted for by the objec-tive environmental versus subjective appraisalis seldom considered. In a strange and circularway, stress seems to stand on its own as a plau-sible, complete, self-contained explanation.

The face validity of stress not only deflectsattention away from the inner elements of thestress concept, it also allows attention to bedrawn to tangentially related factors. Life cir-cumstances that can be connected in someway with the generic idea of stress are readilyentertained, 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 notedabove, the need for further explanation thenceases.

Recent research on life stress and the sero-tonin transporter gene in depression pro-vides a good example of this loose mode oftransitive thinking. The original report byCaspi 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 acomposite including a questionnaire on so-cial problem solving, parental education, and


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total life events (Eley et al. 2004). Although12 replication studies had been conducted atthe time this review was written, investigators(Monroe & Reid 2007) had identified onlyone that employed interview-based life eventmethods (Kendler et al. 2005). Once again,the intuitive appeal and face validity of lifestress helps to understand how such diversephenomena are uncritically united and in-terchangeably employed under the commonstress rubric. The field needs to move awayfrom this misleading mode of thought andadopt 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 thepast 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., the common cold) through chronicmedical 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 anddisorder to address increasingly specific ques-tions about what acute or chronic forms ofstress, 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 increasedrigor in the measurement of stressful lifeevents, a wide recognition of the limitationsof self-report checklists, and the availabilityof 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 identifystress measures that can provide reliability and

specificity and that are able to illuminate par-ticular dimensions of stress and their implica-tions for health. For example, acute forms ofstress such as stressful life events may be rel-evant for the onset of certain conditions (e.g.,major depression), whereas chronic forms ofstress may be informative for diseases thathave a more protracted and insidious onset(e.g., coronary heart disease). More gener-ally, measurement systems for future researchshould be capable of distinguishing betweendifferent qualities of life stress to permit morefine-grained analysis in relation to differentdisorders (see examples in Brown & Harris1989).

Research on life stress and physical disease,too, raises the intriguing possibility that ef-fects for objective indicators of environmen-tal stress and subjective indicators of stressappraisal operate via different mechanismsand possibly contribute to different outcomes(e.g., Cohen et al. 1993). In addition to thesemain effect distinctions worthy of further ex-amination, the interaction between the ob-jective demands of the external environmentand the subjective perceptions of the personsrequires greater research attention (Monroe& Kelley 1995). For instance, individual dif-ferences in stress sensitivity may explain whysome people break down under high stressconditions and others do not, as well as whyother people develop disorders under appar-ently minimal environmental provocation. In-tegrating these two perspectives on objectiveand subjective stress measures will again re-quire methods capable of reliably measuringthe two facets of stress and making such dis-tinctions. Finally, given that life stress rep-resents a whole-organism response, the in-clusion of genetic information and biologicalindicators will afford a framework of inquiryallowing investigators to probe the ways inwhich external and perceptual stress processesaffect key biological processes and systems,which in turn create the vulnerable conditionsthat can lead to disorder and disease.

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DISCLOSURE STATEMENT

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

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AR339-FM ARI 5 March 2008 23:50

Annual Review ofClinical Psychology

Volume 4, 2008Contents

Ecological Momentary AssessmentSaul Shiffman, Arthur A. Stone, and Michael R. Hufford � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1

Modern Approaches to Conceptualizing and Measuring HumanLife StressScott M. Monroe � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 33

Pharmacotherapy of Mood DisordersMichael E. Thase and Timothey Denko � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 53

The Empirical Status of Psychodynamic TherapiesMary Beth Connolly Gibbons, Paul Crits-Christoph, and Bridget Hearon � � � � � � � � � � � � � 93

Cost-Effective Early Childhood Development Programs fromPreschool to Third GradeArthur J. Reynolds and Judy A. Temple � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �109

Neuropsychological RehabilitationBarbara A. Wilson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �141

Pediatric Bipolar DisorderEllen Leibenluft and Brendan A. Rich � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �163

Stress and the Hypothalamic Pituitary Adrenal Axis in theDevelopmental Course of SchizophreniaElaine Walker, Vijay Mittal, and Kevin Tessner � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �189

Psychopathy as a Clinical and Empirical ConstructRobert D. Hare and Craig S. Neumann � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �217

The Behavioral Genetics of Personality DisorderW. John Livesley and Kerry L. Jang � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �247

Disorders of Childhood and Adolescence: Gender andPsychopathologyCarolyn Zahn-Waxler, Elizabeth A. Shirtcliff, and Kristine Marceau � � � � � � � � � � � � � � � �275

vii

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AR339-FM ARI 5 March 2008 23:50

Should Binge Eating Disorder be Included in the DSM-V? A CriticalReview of the State of the EvidenceRuth H. Striegel-Moore and Debra L. Franko � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �305

Behavioral Disinhibition and the Development of Early-OnsetAddiction: Common and Specific InfluencesWilliam G. Iacono, Stephen M. Malone, and Matt McGue � � � � � � � � � � � � � � � � � � � � � � � � � � �325

Psychosocial and Biobehavioral Factors and Their Interplayin Coronary Heart DiseaseRedford B. Williams � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �349

Stigma as Related to Mental DisordersStephen P. Hinshaw and Andrea Stier � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �367

Indexes

Cumulative Index of Contributing Authors, Volumes 1–4 � � � � � � � � � � � � � � � � � � � � � � � � � � �395

Cumulative Index of Chapter Titles, Volumes 1–4 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �397

Errata

An online log of corrections to Annual Review of Clinical Psychology chapters (if any)may be found at http://clinpsy.AnnualReviews.org

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