Validation of the Spanish version of the Perceived Stress Questionnaire

C. Sanz-Carrilloa, J. Garcıa-Campayob,c,*, A. Rubiod, M.A. Santede, M. Montorof

aDepartment of Psychiatry, San Jorge Hospital, Huesca, SpainbDepartment of Psychiatry, Miguel Servet University Hospital, Zaragoza, Spain

cUniversity of Zaragoza, Zaragoza, SpaindDepartment of Family Medicine, San Jorge Hospital, Huesca, Spain

eDepartment of Psychology of Personality and Psychological Assessment and Treatment,

Universidad Nacional de Educacion a Distancia, Madrid, SpainfDepartment of Gastroenterology, San Jorge Hospital, Huesca, Spain

Received 5 March 2001; accepted 28 June 2001

Abstract

Objective: To validate in Spanish the Perceived Stress

Questionnaire (PSQ), a questionnaire to assess stress for research

purposes in psychosomatic patients. Method: The test was

administered to a healthy population (N= 174) of nursing students

and health workers and to a clinical sample (N= 80) of patients

attending a psychiatric outpatient consultation. Results: Con-

current validity: General and Recent PSQ scores correlated high

with trait anxiety (r= .65), moderate with depression (r= .46) and

psychological disturbance (r = .51) and poor with state anxiety

(r = .22). Predictive validity: PSQ scores were higher in

‘‘psychiatric cases’’ than in ‘‘psychiatric noncases’’ (P < .01),

and correlated highly with somatic symptoms of psychological

origin (r= .62) in the clinical subsample. Internal consistency was

0.9 for the General and 0.87 for the Recent PSQ. Test– retest

reliability of the General PSQ was 0.80. Discussion: The Spanish

version of PSQ presents good psychometric properties and it

seems to be a valuable instrument for psychosomatic researchers.

D 2002 Elsevier Science Inc. All rights reserved.

Keywords: Questionnaire; Perceived stress; Validation; Psychosomatics; Spanish

Introduction

The relationship between stress and the onset of med-

ical and psychiatric disorders has been widely studied in

psychiatric literature [1], however, there is no clear con-

sensus on how to measure stress [2,3]. Some of the

approaches used by researchers has been to evaluate

different aspects of this construct such as: (a) external

stressors in the form of ‘‘life events’’ [4], (b) the cumu-

lative minor stresses or hassles [5,6] and (c) the coping,

i.e., the individual’s sense of control [7]. All of these

systems of evaluation present important drawbacks that

limit their usefulness in research.

The Perceived Stress Questionnaire (PSQ) of Levenstein

et al. [8] is specifically designed to measure stress in clinical

psychosomatic research. It consists of 30 items developed

by experienced clinicians and has been validated in Italian

and English languages in a population (N = 230) of psychi-

atric inpatients, outpatients, students and health workers.

The validation study showed excellent psychometric prop-

erties [8], and it has been used in research, demonstrating

good predictive value in stress-related diseases such as

ulcerative colitis [9,10].

In the context of a high-scale study of somatization and

somatoform disorders [11–14], we needed to use a scale to

measure stress in psychosomatic disorders so we selected

PSQ. The objective of this paper is to translate into Spanish

and validate the PSQ.

Method

The questionnaire was translated from English into

Spanish by two native Spanish-speaking psychiatrists

working independently of each other and, in a second

step, they agreed on a final common translation. After that,

0022-3999/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved.

PII: S0022 -3999 (01 )00275 -6

* Corresponding author. Avda. Cesareo Alierta 47, 2� B, 50.008

Zaragoza, Spain. Fax: +34-976-254006.

E-mail address: jgarcamp@arrakis.es (J. Garcıa-Campayo).

Journal of Psychosomatic Research 52 (2002) 167–172

the Spanish version of PSQ was back-translated into

English by unaware native English-speaking people, and

differences between the original test and the Spanish

version were resolved. Finally, the questionnaire was

administered to bilingual persons in English and Spanish

versions to detect possible differences.

The Spanish version of PSQ was validated in two

different populations: (1) A healthy sample of 176 persons,

of which 128 were first and second year nursing students at

the University of Huesca, Spain, and 48 were health

professionals (doctors and nurses) working in San Jorge

Hospital in Huesca. The sociodemographic characteristics

of the sample were the following: In relation to sex, females

clearly predominated (N = 133, 75.6%) over males (N = 43,

24.4%), and the mean age was 27.9 years (standard devi-

ation: 12.4 years, range:18–65). (2) A clinical sample

(N = 80) of first-time patients attending the outpatient psy-

chiatric consultations of Miguel Servet University Hospital

in Zaragoza, Spain. The SPPI psychiatric interview clas-

sified the sample into two subgroups: 49 psychiatric cases

and 31 psychiatric noncases. The sociodemographic char-

acteristics of the whole sample were the following: pre-

dominance of women (N = 51, 63.7%) and middle-aged

patients (mean: 45.8 years; standard deviation: 18.8 years;

range: 18–66). Psychiatric cases were primarily depressive

and anxiety disorders, while nonpsychiatric cases were

subthresold minor psychiatric disorders and couple distur-

bances. In both samples, all the participants were Cauca-

sian, and their native language was Spanish.

Construct validity was performed through comparison

with other measures of stress. The most specific question-

naire for comparison, Cohen et al.’s Perceived Stress Scale

[15], has not been validated in Spanish, so it had to be

rejected. We used three scales validated in our country: (1)

the State–Trait Anxiety Inventory (STAI) [16,17] also

used in the original paper; (2) the Beck Depression

Inventory [18,19] and (3) the General Health Question-

naire-28 items (GHQ-28) [20,21], a patient-rated question-

naire of psychological distress.

Predictive validity was assessed by two different meth-

ods, based on the paper by Levenstein et al.: (1) Compar-

ison of PSQ scores in first time patients attending a

psychiatric outpatient consultation divided into two sub-

groups: ‘‘psychiatric cases’’, as defined by the psychiatric

interview SPPI [22], an interview widely used by our group

[11–14] that allows DSM-IV and ICD-10 psychiatric dia-

gnosis. These patients were compared with ‘‘psychiatric

noncases’’, as defined by the same interview. (2) In the

population of ‘‘psychiatric noncases’’, correlation of the

PSQ scores with the section of somatic symptoms of

psychological origin of the psychiatric interview SPPI

[22], a section that allows scores ranging from 0 to 35,

which can be used as a scale. The reason to reject the

subsample of ‘‘psychiatric cases’’ was to avoid confusing

somatic symptoms produced by stress with those produced

by the psychiatric disorder itself [23].

In addition, internal consistency analysis, analysis by

demographic characteristics, test–retest reliability and fac-

tor analysis were also carried out.

Data analyses were performed using SPSS 9th version

for Windows. Whole-scale reliability (internal consist-

ency) was estimated using coefficient alpha [24], test–

retest reliability and analysis by demographic character-

istics were tested using the Spearman r, and factor

analysis of PSQ was performed using principal compon-

ent analysis with the Varimax transformation, in its

oblique solution.

Results

PSQ index was obtained according to Levenstein et al.’s

[10] indications, i.e., PSQ= (raw score� 30) / 90. Overall

mean scores were 0.35 (S.D. = 0.14) for the General and 0.37

(S.D. = 0.15) for the Recent form, with scores ranging from

0.08 to 0.86 and from 0.01 to 0.93, respectively. Table 1

shows PSQ scores (General form) by age and sex distri-

bution. Scores of � 0.25 fell into the lowest quartile for the

validation sample as a whole, 0.25–0.34 in the second

quartile, 0.35–0.44 in the third quartile and � 0.45 in the

upper quartile for both forms.

We studied correlation between age and PSQ and we

found a Spearman r of � .04 (P = .55) for the General and

Table 1

Age and sex distributions of the PSQ scores (General form) in healthy

population (N= 176)

Mean Standard deviation

Sex

Male (N= 43) 0.3366 0.1353

Female (N= 133) 0.3604 0.1418

Age

18–24 years (N= 110) 0.3681 0.1485

25–39 years (N= 33) 0.3384 0.1230

> 39 years (N= 33) 0.3259 0.1251

Entire sample (N= 176) 0.3546 0.1403

Table 2

Specific items varying at a P < .05 level with age or sex (N = 176)

Age

(7) You feel you are doing things you really like.

(9) You fear you may not manage to attain your goals.

(17) You feel safe and protected.

(20) You feel discouraged.

(21) You enjoy yourself.

(22) You are afraid for the future.

(30) You feel under pressure from deadlines.

Sex

(23) You feel you are doing things because you have to not because you

want to.

C. Sanz-Carrillo et al. / Journal of Psychosomatic Research 52 (2002) 167–172168

.11 (P = .12) for the Recent form. PSQ index did not vary

by gender, and t test yielded t (174) =� 0.96 (P = .33) for

the General form, and t (174) =� 1.23 (P = .22) for the Re-

cent form. Table 2 summarizes specific items varying at a

P < .05 level with age or sex.

All individual items in both the General and the Recent

PSQ correlated in the predicted direction with their cor-

responding PSQ index, i.e., all items showed a positive

correlation except items 1, 7, 10, 13, 17, 21, 25 and 29,

which showed a negative correlation with PSQ index. The

highest correlation of any item with any other single item

was r= .59. The mean for each item was between 1.35 and

2.93 in all cases, and the standard deviation always

exceeded 0.6.

Table 3 summarises concurrent validity of the General

and the Recent PSQ in relation with other questionnaires.

Both correlate highly with trait anxiety and somatic symp-

toms of psychological origin, moderately with depression

and psychological disturbance in general, and poorly with

state anxiety.

In relation to predictive validity, the General Index was

significantly higher (P < .01) in psychiatric cases than in

psychiatric noncases. In addition, in the ‘‘nonpsychiatric’’

clinical sample, correlation between PSQ and the somatic

section of the SPPI was good as can be seen in Table 3.

Internal consistency, as measured by coefficient alpha,

was 0.9 for the General and 0.87 for the Recent PSQ. Test–

retest reliability of the General PSQ, after an interval of

13.12 ± 2.05 days (mean ± S.D.), was 0.80.

Table 4 summarises principal component analysis, with

the Varimax transformation in its oblique solution, of the

General PSQ scores of the healthy sample (N = 174). The

analysis yielded seven factors with eigenvalues greater

than 1. Factor names were assigned appropriate to the

contributing items: tension– fatigue, conflict – social

acceptance, overload–harrassment, energy–joy, self-real-

isation–satisfaction, fear–anxiety and Factor 7. This

solution explained 58% of the variance. According to

empirical criteria, we have grouped in the same subscale

those items that presented the highest loading in the

same factor. The only exception was Item 29, which

showed the highest loading in Factor 7. However, as in

this factor, no other item presented its highest loading,

the subscale has been deleted, and Item 29 has been

included into Factor 4 (energy–joy) in which loading

was .3.

The Spanish version of the questionnaire is attached as

an annex at the end of the paper. The approximate time

needed for administration of the Spanish version of the PSQ

ranges from 10 to 15 min.

Discussion

The present data demonstrate the favourable psychomet-

ric characteristics of the Spanish version of the PSQ in

relation to the different psychometric properties that should

define a valid and reliable test. In addition, the patients,

health professionals and students evaluated confirm that the

Spanish version of the questionnaire is easy to understand

and quick to administer, supporting the feasibility of the test

in the everyday clinical practice.

Concurrent validity demonstrates good correlation with

trait anxiety and somatic symptoms of psychological origin,

moderate correlation with depression and psychological

disturbance in general, and poor correlation with state

anxiety. These data, quite similar to those found by Leven-

stein et al. [8], were expected.

Predictive value has been assessed by confirming that in

people without psychiatric disorders, as evaluated by SPPI

psychiatric interview, PSQ is well correlated with minor

physical symptomatology. In addition, PSQ scores are

significantly higher in ‘‘psychiatric cases’’ compared with

‘‘psychiatric noncases’’ from a sample of people attending

psychiatric outpatient consultations. These data are coherent

with those described by Levenstein et al. [8]. Further data

confirming the predictive value of the PSQ will be obtained

from the research on somatoform disorders in progress.

Other psychometric measures such as internal consist-

ency (Cohen’s a coefficient = 0.9) and test–retest reliability

(0.80) were also satisfactory and similar to the original study.

One of the expectations of a stress questionnaire is a

minimal correlation with sex and age. In fact, the PSQ

Spanish version seems to be more independent than the

original version from these sociodemographic character-

istics: In our study, we found no correlation in either

variable, while Levenstein et al. did not find a correlation

with sex but they did with age (Spearman r=.22, P < .001

for the General form). In addition, the specific PSQ items

that showed P < .05 in relation with sex and age were less

numerous in our study compared with the study by

Levenstein et al. Therefore, Spanish validation shows

better psychometric properties related to the specific aspect

of correlation with sex and age. In general, PSQ scores are

lower in our sample than in the original sample by

Levenstein et al. We think the explanation is the predom-

inance in our study of students in which stress is supposed

to be lower.

Table 3

Concurrent validity of the PSQ with other measures

General PSQ Recent PSQ

State anxiety (STAI) (N = 80) 0.22 0.28

Trait Anxiety (STAI) (N= 80) 0.65*** 0.69***

Depression (BDI) (N= 80) 0.46** 0.49**

Psychological disturbance

(GHQ-28) (N= 80)

0.51** 0.55**

Somatic symptoms (SPPI

somatic section) (N= 31)

0.62*** 0.67***

** P < .01 by Spearman’s r.

*** P < .001 by Spearman’s r.

C. Sanz-Carrillo et al. / Journal of Psychosomatic Research 52 (2002) 167–172 169

Table 4

Factor analysis of the Spanish version of PSQ

Item

Tension–

irritability– fatigue

Conflict–

social acceptance

Factor

overload

Energy–

joy

Self– realization

satisfaction

Fear–

anxiety

Factor 7 (deleted

and included in

energy– joy)

(3) You are irritable or grouchy .60

(8) You feel tired .51 .36 .44

(10) You feel calm .63

(14) You feel tense .73

(15) Your problems seem to be pilling up .48 .32 .42

(16) You feel you’re in a hurry .53 .45

(26) You feel mentally exhausted .38 .32 .31

(27) You have trouble relaxing .67

(30) You feel under pressure from deadlines .52 .35

(5) You feel lonely or isolated .65

(6) You find yourself in situations of conflict .55 .30

(12) You feel frustrated .54

(17) You feel safe and protected .58 .39

(19) You are under pressure from other people .57 .36

(20) You feel discouraged .55

(24) You feel criticized or judged .53

(2) You feel that too many demands are being

made on you

.66

(4) You have too many things to do .33 .58 .37 .37

(11) You have too many decisions to make .73

(18) You have many worries .57 .31

(1) You feel rested .35 .34 .60

(13) You are full of energy .68

(21) You enjoy yourself .64 .30

(25) You are lighthearted .56

(29) You have enough time for yourself .30 .60

(7) You feel you’re doing things you really like .75 .35

(9) You fear you may not manage to attain your goals .30 .56

(23) You feel you’re doing things because you have to

not because you want to

.72

(22) You are afraid for the future .75

(28) You feel loaded down with responsibility .61

Eigenvalue 7.89 2.71 1.83 1.38 1.27 1.15 1.14

Percent of total variance explained by factor 12.27 9.75 9.42 8.96 6.35 6.05 5.17

Percent cummulated variance 12.27 22.03 31.46 40.43 46.78 52.84 58.01

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

C.Sanz-C

arrillo

etal./JournalofPsych

osomatic

Resea

rch52(2002)167–172

170

The main difference between the Spanish and the

original English version of the PSQ is the factorial

structure, which can be seen in Table 5. In the Spanish

version, only six factors have been obtained, one less

than in the original. In addition, in the Spanish version

the number of items in each subscale is quite variable

(range 2–10) compared to the English version (range of

items in each subscale: 2–7), but the variance explained

for each subscale is rather more balanced in the Spanish

version (range 5–12%) compared with the original ver-

sion (range 2–15%).

Differences in factor analysis between different valida-

tion studies is frequent. The six subscales we have

obtained from the analysis show great conceptual coher-

ence (in addition to empirical coherence) and respond to

the name used. We have included all the items in each

subscale with loadings equal or higher than .3. Levenstein

et al.’s original validation [10] had included several items

in subscales with loadings as low as � .15 (Item 7), .18

(Item 18) or .19 (Items 11 and 12). For this reason,

factorial structure of the Spanish version seems coherent

from a psychometric point of view.

In summary, the Spanish version of PSQ seems to be an

accurate instrument to assess stress in psychosomatic

research and deserve to be used in clinical practice.

Acknowledgments

The authors want to thank Dr. Susan Levenstein, San

Camillo-Forlanini Hospital, Rome, Italy, for her valuable

comments on a draft of the paper. This research was carried

out with the support of grants 98/1017 and 00/0991 from

the Spanish ‘‘fondo de investigaciones sanitarias de la

seguridad social’’ (FISSS).

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Table 5

Factors and items according to factor analysis in the original English

version and the Spanish version

Original english version Spanish version

Harrassment (2, 6, 19, 24) Harrassment– social acceptance

(5, 6, 12, 17, 19, 20, 24)

Overload (4, 11, 28, 29) Overload (2, 4, 11, 18)

Irritability (3, 10) Irritability– tension– fatigue

(1, 3, 8, 10, 14, 15, 16, 26, 27, 30)

Lack of joy (5, 7, 16, 17,

21, 23, 25)

Energy– joy (1, 13, 21, 25, 29)

Fatigue (1, 8, 13, 15) –

Worries (9, 18, 20, 22, 30) Fear–anxiety (22, 28)

Tension (12, 14, 26, 27) –

– Self-realisation–satisfaction (7, 9, 23)

C. Sanz-Carrillo et al. / Journal of Psychosomatic Research 52 (2002) 167–172 171

Appendix A. Cuestionario de estres percibido

A.1. Instrucciones para la forma general

En cada pregunta marque un cırculo en el numero que mejor describa con que frecuencia se aplica esta cuestion a su vida en

general durante los ultimos uno o dos anos. Responda rapidamente, sin intentar comprobar las respuestas y teniendo cuidado

en describir lo ocurrido en un perıodo largo de tiempo.

A.2. Instrucciones para la forma reciente

En cada pregunta marque un cırculo en el numero que mejor describa con que frecuencia se aplica esta cuestion a su

vida en general durante el ultimo mes. Responda rapidamente, sin intentar comprobar las respuestas y teniendo cuidado en

describir lo ocurrido exclusivamente en el ultimo mes.

Casi

nunca

A

veces

A

menudo

Casi

siempre

(1) Se siente descansado 1 2 3 4

(2) Siente que se le hacen demasiadas peticiones 1 2 3 4

(3) Esta irritable o malhumorado 1 2 3 4

(4) Tiene demasiadas cosas que hacer 1 2 3 4

(5) Se siente solo o aislado 1 2 3 4

(6) Se encuentra sometido a situaciones conflictivas 1 2 3 4

(7) Siente que esta haciendo cosas que realmente le gustan 1 2 3 4

(8) Se siente cansado 1 2 3 4

(9) Teme que no pueda alcanzar todas sus metas 1 2 3 4

(10) Se siente tranquilo 1 2 3 4

(11) Tiene que tomar demasiadas decisiones 1 2 3 4

(12) Se siente frustrado 1 2 3 4

(13) Se siente lleno de energıa 1 2 3 4

(14) Se siente tenso 1 2 3 4

(15) Sus problemas parecen multiplicarse 1 2 3 4

(16) Siente que tiene prisa 1 2 3 4

(17) Se siente seguro y protegido 1 2 3 4

(18) Tiene muchas preocupaciones 1 2 3 4

(19) Esta bajo la presion de otras personas 1 2 3 4

(20) Se siente desanimado 1 2 3 4

(21) Se divierte 1 2 3 4

(22) Tiene miedo del futuro 1 2 3 4

(23) Siente que hace cosas por obligacion, no porque quiera hacerlas 1 2 3 4

(24) Se siente criticado o juzgado 1 2 3 4

(25) Se siente alegre 1 2 3 4

(26) Se siente agotado mentalmente 1 2 3 4

(27) Tiene problemas para relajarse 1 2 3 4

(28) Se siente agobiado por la responsabilidad 1 2 3 4

(29) Tiene tiempo suficiente para usted 1 2 3 4

(30) Se siente presionado por los plazos de tiempo 1 2 3 4

C. Sanz-Carrillo et al. / Journal of Psychosomatic Research 52 (2002) 167–172172