The Perceived Stress Questionnaire (PSQ) Reconsidered: Validation and

Reference Values From Different Clinical and Healthy Adult Samples

HERBERT FLIEGE, PHD, MATTHIAS ROSE, MD, PETRA ARCK, MD, OTTO B. WALTER, MD,
RUEYA-DANIELA KOCALEVENT, MA, CORA WEBER, MD, AND BURGHARD F. KLAPP, MD, PHD
Objective: The aim was to translate, revise, and standardize the Perceived Stress Questionnaire (PSQ) by Levenstein et al. (1993) in
German. The instrument assesses subjectively experienced stress independent of a specific and objective occasion. Methods: Exploratory
factor analyses and a revision of the scale content were carried out on a sample of 650 subjects (Psychosomatic Medicine patients, women
after delivery, women after miscarriage, and students). Confirmatory analyses and examination of structural stability across subgroups
were carried out on a second sample of 1,808 subjects (psychosomatic, tinnitus, inflammatory bowel disease patients, pregnant women,
healthy adults) using linear structural equation modeling and multisample analyses. External validation included immunological measures
in women who had suffered a miscarriage. Results: Four factors (worries, tension, joy, demands) emerged, with 5 items each, as
compared with the 30 items of the original PSQ. The factor structure was confirmed on the second sample. Multisample analyses yielded
a fair structural stability across groups. Reliability values were satisfactory. Findings suggest that three scales represent internal stress
reactions, whereas the scale demands relates to perceived external stressors. Significant and meaningful differences between groups
indicate differential validity. A higher degree of certain immunological imbalances after miscarriage (presumably linked to pregnancy
loss) was found in those women who had a higher stress score. Sensitivity to change was demonstrated in two different treatment samples.
Conclusion: We propose the revised PSQ as a valid and economic tool for stress research. The overall score permits comparison with
results from earlier studies using the original instrument. Key words: stress perception, stress measurement, tinnitus, inflammatory bowel
diseases, pregnancy, immunology.
PSQ Perceived Stress Questionnaire; ICD International Classification of Diseases; QoL quality of life; IBD inflammatory
bowel disease; SEM structural equation modeling; MSA multisample analysis; TLI Tucker-Lewis index; CFI comparative
fit index.

INTRODUCTION
tress is a key concept in health research (1). Definitions
have basically focused on two major components of stress:
a) stressors in terms of environmental conditions, and b) the
persons reaction to stress. Stress reactions have been further
differentiated theoretically, for example, into perceptional
processing and emotional response. An empirical study based
on structural equation modeling techniques found that the
experience of stress was best represented by a two-factorial
construct of stress (2). Environmental conditions were one
factor; stress appraisal and emotional response in combination
comprised the second.
With regard to the measurement of stress, it has been much
debated whether or not we should limit ourselves to measuring
stressors in terms of objective conditions, such as major life
events or cumulative minor stressors (eg, daily hassles), or if
we should rather concentrate on the persons stress reactions,
in terms of their stress appraisal or emotional response (3).
Stress research has shown an inconsistent picture of the effects
of life events or daily hassles on health. Empirical studies have
shown many instances in which an experience of accumulated

From the Department of Psychosomatic Medicine, Charite-University Hospital Berlin, Berlin, Germany.
Address correspondence and reprint requests to Dr. Herbert Fliege,
Department of Psychosomatic Medicine, Charite - University Hospital
Berlin, Luisenstrasse 13 a, D-10117 Berlin, Germany. E-mail: herbert.
fliege@charite.de
Received for publication December 1, 2003; revision received August 19,
2004.
Financial aid was granted by the Humboldt-University Medical Faculty
Research Fund (UFF-N. 99 648/99 652). The ethics committee approved
of the study design (N 209/98/107/99).
DOI: 10.1097/01.psy.0000151491.80178.78
78
0033-3174/05/6701-0078
Copyright 2005 by the American Psychosomatic Society

or chronic stress led to physical health problems, whereas

more severe but acute and temporally more contained life
events could not predict illness to the same extent (4 6).
Obviously, the personal impact of life events cannot be determined before the event has actually occurred (7). Other approaches have shifted the focus from specific objective stressors to more chronic and subjective stress experience (8).
Stress definitions have become more strongly focused on
the subjective reactions to external events or demands (9). In
the revised stress measure Hassles and Uplifts Scale (10),
for example, we see both an environmental and an appraisal
measure of stress, because it assesses not only whether a
hassle occurs but also the perception of its severity or intensity. Nevertheless, many researchers have gone further and
called for the development of instruments for the assessment
of stress focused primarily on the subjective perception of the
individual (3,1113).
Against this background, Levenstein et al. (14) published
the Perceived Stress Questionnaire (PSQ) 10 years ago. It
had been their aim to overcome some of the difficulties
concerning the definition and measurement of stress by putting the focus on the individuals subjective perception and
emotional response. With this aim in mind, item wordings
were designed to represent the subjective perspective of the
individual (You feel. . . ). The presented stress experiences
were intended to be abstract enough to be applicable to adults
of any age, stage of life, sex, or occupation, but at the same
time interpretable as specific to a variety of real-life situations.
For example, you feel under pressure from deadlines could
refer to anything from a payment, to an oncoming birthday
party, or to a grant proposal. Factorial analyses resulted in 7
dimensions (harassment, irritability, lack of joy, fatigue, worries, tension, and overload). The authors made no a priori
distinction between presumed stressor and stress response
items. Although stress reactions certainly predominate the
content of the scales, the overload subscale (too many things
Psychosomatic Medicine 67:78 88 (2005)

PERCEIVED STRESS QUESTIONNAIRE

to do, too many decisions to make, etc) seemed at least to
reflect the perception of stressful environmental conditions.
Psychometric characteristics proved to be favorable. PSQ
scores correlated moderately with Cohens Perceived Stress
Scale (described later in this section), anxiety (State-TraitAnxiety Inventory), and depression (CES-D Depression
Scale). As far as external validity was concerned, PSQ values
were higher in asymptomatic ulcerative colitis patients with an
inflamed rectal mucosa than in those with a normal-appearing
rectum. By choosing only patients in clinical remission, confounds resulting from the distressing effects of symptoms
were eliminated. Furthermore, the authors were able to predict
adverse health outcomes by means of PSQ values in a prospective study (15).
It seemed, therefore, that the instrument was properly qualified for research on stress and illness. However, there were
certain flaws that suggested to us that reconsideration and
further development of the questionnaire should take place.
First, the original validation study relied on relatively small
samples. The overall sample comprised 230 subjects. Another
point of concern is the number of scales. Although the pattern
of item loadings could be satisfactorily interpreted, a total of
7 scales drawn from the original 36 items, tested on 230
subjects, seems fairly high from a statistical point of view. In
4 of the 7 scales, all item loadings scored below 0.50. This
might indicate that a 7-factor solution does not rely on a
sufficiently robust statistical basis. Finally, the clinical samples originally consisted only of patients with gastroenterological diseases. In a Spanish study, the PSQ was administered to psychiatric patients, nursing students, and healthy
adults (16). Another study yielded moderate overall PSQ
scores for a Swedish population sample (17). There was some
evidence for external validity in a Thai sample of patients with
peptic ulcer disease (18). In our opinion, the PSQs dimensional structure should be investigated in different clinical
groups and further reference values should be established.
Because there are some alternative stress questionnaires
available that are also based on a concept of stress as a
subjective experience, we will briefly point out what distinguishes them from the PSQ.
The Perceived Stress Scale (PSS) (11) is probably the most
widely accepted of these measurements of stress. This 14-item
questionnaire asks the respondent how often certain experiences of stress occurred in the last month. Stressas opposed
to challengeis believed to result from experienced overload
with further emphasis on experienced unpredictability and
uncontrollability of events. This implies that the existence of
stress in a person is partly inferred from information on the
persons experience of lack of control. The content of the
items is nonspecific. Two items directly address stress or
hassles, three refer to situations of overload, whereas nine
items refer to uncontrollable, unmanageable, or unpredictable
situations. Thus, the PSS focuses on a more cognitive appraisal of stress and the respondents perceived control and
coping capability. A total score is provided. No subscales are
reported.
Psychosomatic Medicine 67:78 88 (2005)

The Index of Clinical Stress (ICS) (19) consists of 25

items. These items are designed to indicate affective states
involved in the stress reaction. Cognitive appraisals, physical
signs, or behavioral reactions are not considered. The ICS
consists of one homogeneous scale. Subscales are not provided. The questionnaire lacks external validation.
The recently published Stress Response Inventory (SRI)
(20) consists of 39 items that comprehensively focus on cognitive, emotional, behavioral, and somatic stress responses. In
addition to a total score, its subscales differentiate between
depression, frustration, anger, aggression, tension, and somatization. It does not cover the individuals perception of external stressors or demands.
The Trier Inventory for the Assessment of Chronic Stress
(TICS) (21) is a validated German questionnaire focusing on
chronic stress. The 39 items are factor-analytically assigned to
6 scales: work overload, work discontent, social stress, lack of
social recognition, worries, and intrusive memories. The emphasis is on work-related and other socially stressful environmental conditions. To our knowledge, no English version has
been published.
In comparison to the aforementioned instruments, we suggest that the PSQ is most useful
1. when, from a conceptual point of view, perceived stress
should be asked as directly as possible, without inferring it
from control or coping appraisals;
2. when, in addition to an overall score, different facets of
perceived stress are of interest;
3. when information is wanted, not only concerning the
persons stress response, but also concerning the perception of
external stressors.
The first aim of our study was to investigate the dimensional structure of the questionnaire on a larger sample drawn
from a different cultural context. Because questionnaires that
might be included in routine use should keep respondent
burden as small as possible, we aimed to reduce the length of
the PSQ. In the course of item reduction, the explanatory
power of different scales was to be balanced. Finally, we
wanted to provide normative values for different clinical
groups and healthy adults.
Concerning external validation, we expected that a higher
perceived stress level in women who had experienced a spontaneous abortion would be associated with a higher concentration of certain immune parameters considered to be mediating factors in triggering spontaneous abortions (22). With
regard to the instruments sensitivity, we expected higher
stress levels in women after miscarriage and inpatient groups,
especially those who were treated with somatoform and depressive symptoms, and lower stress levels in pregnant women
and healthy adults.
METHODS
Study Design
We administered the original 30-item questionnaire to one sample of
participants (N 650) in order to explore the factorial structure and to reduce
the length of the questionnaire on one set of data. We then administered only
79

H. FLIEGE et al.
the resulting item-reduced version of the questionnaire with 20 items to
another sample (N 1808) to test for structural stability on a completely
separate set of data.

Samples
The study included two samples that involved a total of 2,458 participants.
1. The first sample (N 650) is composed of the following:
246 patients hospitalized in the Psychosomatic Medicine ward, that is,
patients with mental or behavioral disorders associated with at least one
complex of somatic complaints or illness (included are somatoform,
affective, eating disorders, other neurotic disorders, and personality
disorders, all according to ICD-10 F3 to F6; excluded are organic,
addictive, or psychotic disorders according to ICD-10 F0 to F2) (77.6%
female, 22.4% male; age 38.9 15.4 years, range 1779),
81 female patients after miscarriages of unexplained origin (age 30.2
7.7, range 17 41),
74 women after regular delivery (age 30.2 5.0, range 19 43), and
249 medical students in the 4th year (51.1% female, 48.9% male; age
24.6 2.9, range 20 41).
Initial results from this sample have been published in German (23).
2. The second sample (n 1808) is composed of the following:
559 Psychosomatic Medicine outpatients (diagnoses as above) (63.9%
female, 36.1% male; age 37.8 15.3, range 18 72),
184 outpatients with tinnitus (46.6% female, 53.4% male; age 42.1
12.7, range 28 70),
144 outpatients with inflammatory bowel diseases (54.7% female,
45.3% male; age 39.6 14.2, range 22 67),
587 women in routine care at week 8 of pregnancy (age 29.6 5.3,
range 17 44), and
334 healthy adults (61.6% female, 38.4% male; age 45.3 15.6, range
18 88) who were visitors to a well-frequented institution for public
education. (We defined only those participants as healthy who declared that they did not have any chronic or acute disease, were not in
constant medical treatment, and were not in permanent need of medication).
3. Sensitivity to change was tested in the following:
in 91 of the abovementioned sample of 246 Psychosomatic Medicine
inpatients who were treated 5 weeks or more, so that we could measure
at admission and after 5 weeks; treatment included a combination of
single and group psychotherapy, relaxation training, sports, and in
some cases antidepressants; and
in 46 tinnitus outpatients who were assessed before and after 10 weekly
sessions of progressive muscle relaxation training (27).
All patient groups were recruited in routine care. The students were
recruited at the end of a course. The healthy adults were recruited before or
at some time during the event that they visited. All participants were told
about the aims of the study and gave their informed consent to participate.

Instruments
Levenstein et al. (14) developed the PSQ to assess perceived stressful
situations and stress reactions on a mainly cognitive and to some degree
emotional level. With regard to stressors, the aim was to assess the subjective
experience of their quality as stressful.
The scale construction was based on classical test theory and was carried
out by factor analyses. The final instrument comprises 30 items that fell on
factor analysis into 7 scales (harassment, overload, irritability, lack of joy,
fatigue, worries, tension). Respondents rate how often an item applies to them
on a 4-point scale (1: almost never, 2: sometimes, 3: often, and 4: usually). The
general form of the instruction asks in general, in the last two years, the
recent form asks during the last month (both in (14)). The PSQ Index and
the scale values are mean values that are calculated from the raw item scores
and linearly transformed to values between 0 and 1. The instrument was
originally validated in English-speaking and Italian-speaking samples of
80

gastroenterological inpatients, outpatients, hospital employees, and students

(overall N 230).
We translated the questionnaire into German. A clinical psychologist and
English native speaker who had no prior knowledge of the instrument translated it back into English. Deviations from the original were examined, and
the German translation was optimized accordingly.
On the samples presented here, we applied the general form of the questionnaire. According to the authors, it integrates an individuals stress in the
long run, [and] may be a superior predictor of health status (Levenstein et al.,
1993, p. 30). To avoid problems resulting from varying or insufficient memory
recall, we omitted the time span of the last year or two. So the respondent was
only asked to rate how often an item applied in general.
For purposes of validation, we administered the short measure of quality of
life by the World Health Organization (WHOQOL-Bref (24)) and the abovementioned Trier Inventory of Chronic Stress (TICS (21)) to part of the sample.
The time needed to complete the questionnaire was recorded for the
sample of 559 Psychosomatic Medicine outpatients.

Statistical Procedures
Exploration
An exploratory principal component factor analysis of the 30-item questionnaire was performed on the data from the first sample using SPSS.
Because it could be expected that factors were correlated, an oblique rotation
(promax, power coefficient 4) was conducted. The factors were defined and
interpreted based on the factor pattern matrix. We also tested whether the
original 7-factor solution could be replicated on the German samples.

Item Reduction
The first rationale for item selection was to balance the explanatory power
between the scales by attaining scales of (approximately) equal length. The
second rationale was to maximize reliability of the resulting scales by selecting
those items that showed the highest corrected item-scale-correlation (Table 1).

Confirmation
We tested for structural stability on the data from the second sample,
where subjects were administered only those 20 items that had resulted from
the item selection. We tested a structure of 4 factors by means of linear
structural equation modeling (SEM, Program AmosTM 4.0), allowing for one
latent stress construct to underlie all 4 factors (Figure 1). In addition, we tested
a 3-factorial and a 2-factorial structure, also allowing for correlations between
the factors. We tested the 4-factorial structure for dimensional stability across
groups by multisample analyses (MSA) using SEM. We performed several
different comparisons between ill and healthy samples, combined and separate (Table 2). Because we expected mean values to differ across groups, we
added a mean structure to the MSA model. To examine whether the factors
can be defined the same way in all groups, cross-group equality constraints
were imposed on the factor loadings (one loading was fixed to 1 in all groups).
The mean of the factor was fixed to 0 in one group and estimated freely in the
other groups (one indicator intercept per factor was fixed to 1 in all groups).
Because this analysis did not aim to test hypotheses about means, no other
equality constraints across groups were imposed.
For purposes of the MSA, all factor loadings of the observed variables
(items) on latent traits (factors) and all loadings of the primary factors on the
superordinate factor (stress reaction) and the correlation between demands and stress reaction were assumed to be constant across groups.

Validation
To corroborate construct validity, we performed comparisons with a
measure of quality of life (WHOQOL-Bref (24)) and with a questionnaire of
chronic stress (TICS (21)) that had been applied in two partial samples.
To determine criterion validity, we tested for associations between stress
scores and immunological parameters in women suffering from a spontaneous
abortion (22). We took decidual tissue biopsies and determined the occurrence of
CD56-NK-cells, CD8- and CD3-T-cells, tryptase-mast cells (TMC) and
tumor necrosis factor-alpha-cells (TNF-) by immunohistochemistry (IHC).
All biopsies were fixed in 5% formalin and embedded in paraffin. We
Psychosomatic Medicine 67:78 88 (2005)

PERCEIVED STRESS QUESTIONNAIRE

TABLE 1.

Exploratory Factor Analysis With Promax-Rotation of the Original 30 PSQ Items From Sample 1 (n 650)
Primary Components (all 30 items)
Items

No.

h2
I
Factor I: 41.6% explained variance (rotated solution)scale
worries
x
You are afraid for the future
22
x
You have many worries
18
x
Your problems seem to be piling up
15
You feel lonely or isolated
05
x
You fear you may not manage to attain
09
your goals
You find yourself in situations of conflict
06
You are under pressure from other people
19
You feel discouraged
20
You feel criticized or judged
24
x
You feel frustrated
12
You feel youre doing things because you
23
have to not because you want to
You feel loaded down with responsibility
28
You have too many decisions to make
11
Factor II: 8.0% explained variancescale tension
You feel tired
08
x
You feel tense
14
x
You feel rested
01
x
You feel mentally exhausted
26
x
You have trouble relaxing
27
x
You feel calm
10
You are irritable or grouchy
03
Factor III: 5.0% explained variancescale joy
x
You feel youre doing things you really like
07
x
You enjoy yourself
21
x
You are lighthearted
25
x
You are full of energy
13
x
You feel safe and protected
17
Factor IV: 3.4% explained variancescale demands
x
You have too many things to do
04
x
You have enough time for yourself
29
x
You feel under pressure from deadlines
30
x
You feel youre in a hurry
16
x
You feel that too many demands are being
02
made on you

Item parameters
(20 selected items)

Loadings
ri(ti)

II

III

IV

sd

.789
.766
.745
.710
.700

.028
.100
.136
.073
.138

.054
.028
.067
.210
.004

.200
.061
.083
.231
.115

.61
.63
.71
.55
.57

.69
.73
.77
.63
.69

2.08
2.23
2.10

1.01
0.98
0.96

.36
.41
.36

2.18

0.94

.39

.697
.689
.670
.620
.560
.528

.031
.258
.134
.368
.213
.185

.081
.124
.190
.287
.138
.378

.080
.285
.230
.197
.077
.139

.51
.59
.67
.50
.59
.55

.63
.64
.63
.56
.69
.64

1.97

0.89

.32

.505
.453

.132
.128

.058
.259

.341
.349

.59
.45

.63
.47

.168
.211
.231
.173
.246
.109
.175

.758
.691
.688
.589
.543
.501
.232

.067
.139
.309
.151
.047
.187
.169

.117
.047
.179
.012
.002
.150
.109

.55
.63
.66
.63
.56
.57
.28

.58
.68
.66
.68
.66
.67
.46

2.45
2.69
2.18
2.28
2.64

0.81
0.89
0.88
1.00
0.99

.48
.56
.39
.43
.55

.064
.201
.082
.001
.400

.003
.214
.191
.391
.097

.737
.597
.552
.538
.410

.069
.109
.022
.181
.022

.63
.70
.52
.59
.58

.61
.75
.64
.60
.63

2.31
2.34
2.71
2.63
2.35

0.89
0.87
0.95
0.90
1.04

.44
.45
.57
.54
.45

.185
.330
.084
.357
.360

.091
.015
.130
.161
.072

.042
.380
.197
.052
.038

.841
.792
.692
.455
.447

.66
.65
.57
.58
.54

.61
.51
.59
.58
.58

2.42
2.59
2.17
2.06
2.17

0.91
1.01
0.93
0.87
0.79

.47
.53
.39
.35
.39

h2 communality; M mean (before transformation); sd standard deviation; ri(ti) corrected item-scale correlation; p item difficulty.
Note: Remaining items are marked with an X.
examined two to four different sections of tissue for each patient. To make
sure the trophoblast had been in contact with maternal immunocompetent cells
and could have been a target of rejection, we stained the tissue with a monoclonal
antibody against pancytokeratin (CK) to test for invasive fetal cells. Consecutive
slides were stained with monoclonal antibody against mast cell tryptase, CD3,
CD8, or CD56, respectively. Probes for human TNF- mRNA were stored at
70C until use. Five-micron paraffin sections were dewaxed and rehydrated,
washed in DEPC-treated water, and immersed in 0.1N HCl followed by 2 SSC
at RT. Sections were exposed to 10 g/ml proteinase K and postfixed in 0.4%
paraformaldehyde at 4C. Hybridization was carried out at 59C using S35
UTP-labeled cRNA. Afterward, sections were washed in 4 SSC and treated
with RNase A (20 l/ml). The slides were desalted, dehydrated, air dried, dipped
into autoradiography emulsion, and developed. The sections were counterstained
with hemalaun. Microscopic investigators were blinded to the patients stress
scores. The number of positive cells per square millimeter tissue was evaluated by
two independent observers.
To examine sensitivity, we tested patient samples, pregnant women, and
Psychosomatic Medicine 67:78 88 (2005)

healthy adults for differences in their stress levels. All differences between
samples were investigated by analysis of variance and secured by post-hoc t tests.

RESULTS
Dimensional Structure
Exploration and Item Reduction
The Kaiser-Meyer-Olkin measure of the quality of the
correlation matrix was high (KMO 0.96). A significant
Bartlett test of sphericity justified a dimension reducing procedure such as the factor analysis. The measure of sampling
adequacy was over 0.80, so the items could be considered apt
for factor analyses.
Exploratory analyses of all 30 items yielded a different
solution from the original one (14). A forced 7-factor solution
81

H. FLIEGE et al.

Figure 1. Linear structural equation model of a 4-factor solution based on

one latent construct of perceived stress

did not yield the original structure. Four factors were extracted
with eigenvalues greater than 1. The eigenvalues course was
12.5, 2.4, 1.5, and 1.0, then 0.9, 0.8, and 0.8, indicating a
strong primary factor with 1 to 3 additional factors. We tested
solutions with 4, 3 and 2 factors, respectively.
The 4-factor solution accounted for 58% of the variance.
TABLE 2.

Item 03 (You are irritable or grouchy) did not load distinctly

and item 11 (You have too many decisions to make) had a
low communality (0.50). They were therefore excluded.
Item 17 (you feel safe and protected) loaded on factor III
(0.410) but also on factor I (0.400). Still, we decided to
accept this flaw and keep the item with a view to keeping
scales of even length and in light of its satisfactory communality (0.58).
All remaining factor loadings were greater than 0.50 and
the items share of communality concerning one factor was at
least 20% higher than its share of communality concerning
any other factor. Communality varied between 0.50 and 0.71
around a mean of 0.60. See Table 1 for factorial solution,
loadings, and item parameters.
The 3-factorial solution conformed to a simple factor structure except for items 03 and 17. It replicated factor I and factor
IV of the 4-factorial solution, but factor II and factor III of the
4-factorial solution fell together on one factor. In the 2-factorial solution, the second factor replicated factor IV of the
4-factorial solution with only the addition of item 28. All other
items loaded on a strong first factor.
We considered the 4-factorial solution the most informative
one. The 3-factorial solution would have meant abandoning a
consistently positively worded scale (factor III of the 4-factorial solution). As regards content, we considered a positively
worded scale as advantageous, so we wanted to keep it, given
sufficient structural stability. The 2-factorial solution seemed
to replicate a theoretical distinction of the stress construct into
perceived stressor (factor II) and stress reaction (factor I). We
ultimately decided to investigate the 4-factorial solution more
thoroughly and to include all three solutions in the confirmatory analyses.

Confirmatory Factor Analyses (CFA) of 2-, 3-, and 4-Factorial Solutions and Multi-Sample Analyses (MSA) of the 4-Factorial Solution
of 20 PSQ Items From Sample 2 (n 1,808)
Fit Statisticsa

Model-test
Model

CFA
2 factors
3 factors
4 factors
MSA 3 groupsc
Restricted
Unrestricted
MSA 4 groupsd
Restricted
Unrestricted
MSA 5 groupse
Restricted
Unrestricted

df

Cmin/df

GFI

AGFI

RMR

TLI

CFI

RMSEA

2/df b

2,834.6
2,310.0
1,921.8

169
167
166

16.77
13.83
11.58

.83
.86
.89

.78
.83
.86

.007
.007
.006

.85
.87
.90

.86
.89
.91

.090
.087
.079

524.6/2
388.2/1

4,302.7
3,381.6

538
500

8.00
6.76

.92
.93

.93
.95

.064
.058

921.1/38

4,424.8
4,306.5

723
685

6.12
6.29

.92
.92

.93
.93

.055
.056

118.3/38

4,615.5
4,443.9

908
870

5.08
5.11

.92
.92

.93
.94

.049
.049

171.6/38

Fit statistics: GFI goodness of fit index; AGFI adjusted goodness of fit; RMR root mean squared residual; TFI Tucker-Lewis Index; CFI
comparative fit index; RMSEA root mean standard error of approximation.
b
2 df difference in chi-square by df (all p .001).
c
Ill (mental/behavioral, tinnitus, IBD) vs. pregnant vs. healthy.
d
Somatically ill (tinnitus, IBD) vs. mentally/behaviorally ill vs. pregnant vs. healthy.
e
Suffering from tinnitus vs. IBD vs. mental/behavioral illness vs. healthy vs. pregnant.
a

82

Psychosomatic Medicine 67:78 88 (2005)

PERCEIVED STRESS QUESTIONNAIRE

TABLE 3.

PSQ Scale Intercorrelations and Correlations Between PSQ and WHOQOL-Bref (n 650) and PSQ and TICS (Trier Inventory of
Chronic Stress) (n 559)
PSQ Scales
Worries

PSQ
Worries
Tension
Joy
Demands
WHOQOL-Bref
Physical domain
Psychological domain
Social domain
Environmental domain
Global QoL score
TICS
Work overload
Work discontent
Social stress
Lack of social recognition
Worries
Intrusive memories

Tension

Joy

Demands

Overall Score

.67

.61
.63

.51
.57
.36

.86
.87
.78
.76

.58
.78
.56
.60
.58

.64
.69
.50
.48
.56

.62
.79
.63
.55
.63

.24
.33
.25
.23
.17

.62
.79
.59
.57
.58

.61
.51
.52
.51
.80
.66

.61
.45
.39
.37
.67
.51

.44
.49
.32
.46
.61
.45

.83
.42
.45
.36
.55
.37

.77
.57
.52
.52
.81
.61

Notes: Joy values are positively coded (except for the overall score). All Pearson correlations p .001. WHOQOLs Cronbachs alpha: physical 0.81;
psychological 0.88; social 0.70; environmental 0.79; global QOL score 0.62. TICS Cronbachs alpha: work overload .88, work discontent .76, social stress .76,
lack of social recognition .85, worries .88, intrusive memories .91.

We then selected those 5 items of each scale that showed

the highest corrected item-scale-correlation (Table 1). Thus, a
20-item questionnaire of 4 scales with 5 items each resulted.
Scale 1 (worries) covers worries, anxious concern for the
future, and feelings of desperation and frustration.
Scale 2 (tension) explores tense disquietude, exhaustion,
and the lack of relaxation.
Scale 3 (joy) is concerned with positive feelings of challenge, joy, energy, and security. Because all items of this scale
are positively worded, we opted for a positive name.
Scale 4 (demands) covers perceived environmental demands, such as lack of time, pressure, and overload.
An overall index score is calculated from all items, and
linearly transformed to values between 0 and 1. For this purpose,
the scale joy, which is positively coded, will be inversed. A
high overall PSQ score means a high level of perceived stress.
Although all PSQ scales intercorrelate fairly highly, demands,
which focuses on external stressors, shows the lowest correlations to
the other three scales, which focus on the stress reaction (Table 3).
Confirmatory analyses, validation, and usability testing
were all performed on the resulting 20-item questionnaire.
Confirmation
Following the above cited theoretical concepts (2), SEM
was constructed as shown in Figure 1. Thus, the tested 4-factor solution specifies an additional latent variable stress reaction loading on the first 3 factors (worries, tension, joy)
and covarying with demands. This resulted in a significant
likelihood-ratio 2 test (Table 2) with a global fit index (GFI)
below 0.95 and an adjusted GFI below 0.90. However, because Hoelters critical number (here 176) is considerably
Psychosomatic Medicine 67:78 88 (2005)

smaller than the sample size, any model would inevitably have
been rejected applying those indices. Thus, we followed a
recommendation to judge a model by a number of different
criteria (25). The root mean squared residual below 0.05 is a
criterion in favor of the model fit. Furthermore, the TuckerLewis index (TLI) and the comparative fit index (CFI)
reached good values (0.90). Both are independent of sample
size and either take into account model complexity (TLI) or
model misspecification (CFI). Finally, a value of about 0.08 or
less for the root mean standard error of approximation is
considered to indicate a reasonable fit (26). This index allows
for discrepancies between sample and population. Taking all
this into account, we consider the model fit satisfactory.
Only the path weight between item 29 and demands fails
to satisfy (0.47). This might be due to a positive item wording.
A tentative exclusion of the item does not result in a closer
model fit. The lowest path weight results for the overall
sample, whereas in the subgroups this weight varies between
0.54 and 0.60. Because this item had a high loading in the
original exploratory factor solution (0.72) and seems unproblematic as to content, we decided to keep it.
Multisample analyses yield that there is no appreciable gain
in model fit by omitting the restriction of structural equality
between groups. In sum, they confirm the assumption of a
comparable dimensional structure in different samples.
Reliability
Cronbachs alpha and split-half reliability values of the
scales in the subgroups are all at least 0.70, in half the cases
at least 0.80. Cronbachs alpha of the overall score is at least
0.85 and reliability at least 0.80 (Table 4).
83

H. FLIEGE et al.
TABLE 4.

Mean Values and Consistency Values in Different Subgroups of Sample 1 (n1 650) and Sample 2 (n2 1,808), noverall 2,458
PSQ Scales
Samples

Sample 1
Psychosomatic in-patients
M
SD
Crohnbachs alpha
r Spearman-Brown
Females after spontan. abortion
M
SD
Crohnbachs alpha
r Spearman-Brown
Females after regular delivery
M
SD
Crohnbachs alpha
r Spearman-Brown
Students
M
SD
Crohnbachs alpha
r Spearman-Brown
Sample 2
Psychosomatic out-patients
M
SD
Crohnbachs alpha
r Spearman-Brown
Tinnitus patients
M
SD
Crohnbachs alpha
r Spearman-Brown
IBD patients
M
SD
Crohnbachs alpha
r Spearman-Brown
Pregnant females 8th week
M
SD
Crohnbachs alpha
r Spearman-Brown
Healthy adults
M
SD
Crohnbachs alpha
r Spearman-Brown
ANOVA
df
F value
Explained variance 2
p

Overall
Worries

Tension

Joy

Demands

.53
.26
.83
.84

.48
.12
.80
.79

.37
.23
.83
.82

.44
.16
.79
.79

.52
.18
.85
.87

.34
.25
.83
.88

.44
.23
.83
.78

.56
.22
.75
.77

.41
.21
.79
.83

.41
.19
.92
.88

.23
.19
.79
.76

.36
.22
.82
.76

.65
.21
.77
.77

.38
.21
.77
.71

.33
.17
.91
.85

.26
.18
.77
.76

.40
.21
.83
.83

.60
.21
.82
.85

.43
.23
.81
.73

.37
.17
.92
.84

.60
.27
.86
.86

.66
.23
.81
.75

.37
.21
.77
.80

.47
.25
.82
.77

.59
.19
.92
.83

.41
.25
.89
.88

.54
.23
.84
.82

.47
.24
.87
.87

.44
.24
.81
.79

.48
.21
.94
.87

.35
.21
.79
.80

.47
.20
.77
.70

.51
.22
.79
.76

.40
.22
.82
.79

.43
.17
.90
.80

.23
.18
.81
.78

.37
.20
.79
.73

.64
.20
.76
.81

.37
.19
.76
.73

.33
.16
.90
.85

.26
.20
.83
.81

.34
.21
.81
.77

.62
.21
.79
.79

.36
.21
.80
.77

.33
.17
.92
.86

8;2,393
136.5
31%
.001

8;2,389
101.3
25%
.001

8;2,381
90.2
23%
.001

8;2,392
11.8
4%
.001

8;2,329
102.1
26%
.001

n 246

n 81

n 74

n 249

n 559

n 184

n 144

n 587

n 334

Note: Scale values are linearly transformed from 1 4 to 0 1. Joy is inverted when computing the overall PSQ score.

Construct Validity
Stress scales and overall score are negatively correlated,
and the joy scale is positively correlated with quality of life
(QoL) dimensions (p .001) (Table 3). All PSQ scales
84

correlate more highly with the psychological domain of the

WHO-QOL than with other WHO-QOL domains. The correlational pattern with the TICS is altogether consistent with
expectation. Five of the 6 TICS subscales are most highly
Psychosomatic Medicine 67:78 88 (2005)

PERCEIVED STRESS QUESTIONNAIRE

correlated with the same PSQ scale (worries), whereas the
TICS work overload scale is most strongly related to the PSQ
demands scale.
Comparison to the Original
In the 650 subjects who completed the full questionnaire,
the correlation between the 30-item overall score and the
20-item overall score was high (r 0.95, p .001). To
examine whether the level of the overall score and its measurement consistency were maintained in spite of the item
reduction, we compared the gastroenterological sample of the
original study (including many ulcerative colitis patients) with
the inflammatory bowel disease (IBD) sample of the present
study. Internal consistency of the original and the revised
version is identical ( 0.90). Mean values and distribution
of the overall stress score of the original (0.42 0.15, range
0.11 0.83) and the revised questionnaire (0.43 0.17, range
0.02 0.87) do not differ. Mean values and distribution of the
overall stress score of healthy adults in a Spanish validation
(16) of the 30-item PSQ (0.35 0.14, range 0.08 0.86) and
the healthy adults in the German revision (0.33 0.17, range
0.00 0.85) also do not differ.
Group Differences
Values are listed in Table 4, and differences are roughly
summarized in Figure 2 (see Table 5 for details). All scales
differed between patients and healthy adults. The extent of the
differences varies with the scale and the group in question.
The most severe stress values are obtained from Psychosomatic Medicine patients, especially outpatients, followed by
tinnitus patients. Both groups have higher stress levels than
IBD patients and women after spontaneous abortion, who
report the second highest. Next in line are students, pregnant
women, and women after regular delivery. Consistently low
stress levels are reported by healthy adults. Students selectively report high levels of demands. Pregnant women and
women after regular delivery show the highest levels of joy
and the lowest levels of worries. When controlled for age, they
even have significantly better values than healthy controls.

between age groups. Perceived stress is diminished and joy is

raised in age groups over 60 years. Only worries are slightly
lessened in the 60s group but no longer significantly in the 70s
and older. Demands are selectively elevated in the 30- to
39-year-olds.
Criterion Validity
To test for immunological differences, women after miscarriage were divided in two stress groups by median-split.
Decidual tissue for immunohistochemistry could be obtained
in 50 cases. Women with a higher stress score had a significantly higher rate of tryptase mast cells (TMC), of CD8
T-cells, and of TNF- cells (Figure 4). No differences resulted with regard to CD56 NK-cells and CD3 T-cells. In
sum, higher perceived stress scores are associated with some
of the relevant indicators of a supposed immunological imbalance in women who have had a miscarriage (22).
Sensitivity of Change
Psychosomatic Medicine inpatients under treatment show
significant improvements for three of the stress scales and the
overall score, but no change for joy. Tinnitus patients after 10
weeks of relaxation training (27) show a significant decrease
of tension and an increase of joy, whereas worries and demands remain unchanged (Figure 5).
Usability
It took respondents on average 4.9 minutes to complete the
revised 20-item questionnaire. The time median was 3.3 minutes.
Only 5% of the patients took longer than 10 minutes; a few of
those took up to an hour. We could not find any differences
between diagnostic groups. There also was not any indication of
a language effect in non-German-born participants. Age was
significantly correlated with time-to-complete (r 0.28). The
stress scores themselves were slightly negatively (!) correlated
with time (between r 0.05 and 0.06), the less stressed
patients taking more time to complete, yet when controlling for
age, this association disappeared.

Sociodemographic Variables
Sociodemographic differences were tested on the healthy
adults sample (n 334). All scales are significantly associated with age (worries r 0.14*, tension r 0.25**, joy
r 0.14**, demands r 0.31**, overall score r
0.28**), but not with gender. Figure 3 presents differences

Figure 2. Tentative summary of the PSQ mean differences between samples

by post hoc t tests (p .05). (Note: a complete overview of the comparisons
can be requested from the authors.)
Psychosomatic Medicine 67:78 88 (2005)

Figure 3. Mean differences between age groups for different dimensions of

perceived stress (PSQ scales)
85

H. FLIEGE et al.

Figure 4. Immunological differences between women with high versus low

stress scores after miscarriage (median-split; t tests, ES effect size d)

DISCUSSION
The PSQ by Levenstein et al. (14) was revised and tested for
its dimensional structure on a large sample. We reduced the
length of the questionnaire from 30 to 20 items and explored a
meaningful and widely stable structure. The scales are balanced
in the sense of comprising of the same number of items. Reliability values and construct validity are satisfactory.
Exploratory analyses were performed on one sample, confirmatory analyses on a second and separate sample. The
original 7-factor solution was not replicated when the complete 30-item scale was analyzed. Instead, a 4-factor solution
emerges. SEM analyses confirm this structure. Multisample

Figure 5. Changes of perceived stress of Psychosomatic Medicine in patients

after psychotherapeutic treatment (left) and of tinnitus patients after relaxation
training (right) (t tests for dependent measures, ES effect size d)
86

analyses yield a sufficiently stable dimensional structure

across different subgroups of patients and healthy adults. On
the whole, the structure appears statistically robust and satisfactory as regards content. Consequently, in our opinion, the
problem concerning the path weight between item 29 and the
demands factor can be considered of minor importance and
does not justify a modification. A trend toward comparably
lower path weightsas can also be observed in items 01 and
10 might arise from positive item wordings. However, considering that mixed item wordings have advantages of their
own, such as representing various facets of the latent construct
or keeping subjects attentive, we do not endorse abandoning
the positively worded items.
The dimensional structure is meaningful. Three factors
(worries, tension, and joy) represent the dimension of stress
reactions. In our opinion, the positively coded joy scale could
assess a positive challenge or a personal resource component.
The fourth factor (demands) represents a specific aspect of
perceived environmental stressors. That the demands scale has
a different focus than the three other scales is also proven by
lower correlations of demands with the remaining scales. To
regard the demands scale as focusing on an environmental
dimension of perceived stress and the other scales as focusing
on perceived stress reactions would be in line with findings
from earlier studies in which the persons perception of stress
was best represented by the two global dimensions of external
stressor and stress reaction (2). Differential validity of the
demands scale is supported by two findings: Students report
higher levels and older adults report lower levels of demands.
Demands can be considered external stressors (8,21). However, the scale does not claim to cover all possible external
stressors. Item topics are confined to the perception of basic
demands on ones performance, like having too many things
to do or being under time pressure. We do not know what
specific demands a person who scores high on that scale has
in mind. Specific hassles or life events are not included in this
questionnaire.
Furthermore, an explicitly social component of environmental stressors is not included. For instance, out of the
original harassment scale, which had dealt specifically with
interpersonal tensions, only one of four items remained (You
feel that too many demands are being made on you). The
harassment scale had originally explained the greatest share of
variance (15%) and it had strongly correlated with physical
outcome. This is a possible limitation of the briefer PSQ. In
sum, construct validity results point out that the psychological
component of perceived stress is well represented by the
20-item PSQ, whereas the social component is not. Therefore,
studies that strongly focus on social stress issues should prefer
the use of the original 30-item questionnaire.
Future research could endeavor to strengthen and differentiate the stressor side of the questionnaire and to economize
the stress reaction side with the aim to assess both sides of the
coin accurately and economically. The relative merits of presenting a specific time frame, as in the original PSQ, or
leaving it open-ended, as in the instructions for this revision,
Psychosomatic Medicine 67:78 88 (2005)

PERCEIVED STRESS QUESTIONNAIRE

TABLE 5.

Comparisons Between Samples by Post-hoc t Tests (p < .05)

Post Hoc Comparisons

Worries
Psychosomatic patients
Tinnitus
Inflammatory bowel dis.
Spontaneous abortion
Gravidity 8th week
Delivery
Students
Healthy adults
Tension
Psychosomatic patients
Tinnitus
Inflammatory bowel dis.
Spontaneous abortion
Gravidity 8th week
Delivery
Students
Healthy adults
Joy
Psychosomatic patients
Tinnitus
Inflammatory bowel dis.
Spontaneous abortion
Gravidity 8th week
Delivery
Students
Healthy adults
Demands
Psychosomatic patients
Tinnitus
Inflammatory bowel dis.
Spontaneous abortion
Gravidity 8th week
Delivery
Students
Healthy adults
Overall score
Psychosomatic patients
Tinnitus
Inflammatory bowel dis.
Spontaneous abortion
Gravidity 8th week
Delivery
Students
Healthy adults

p
t
i
a
g
d
s
h

p
t
i
a
g
d
s
h

p
t
i
a
g
d
s
h

p
t
i
a
g
d
s
h

p
t
i
a
g
d
s
h

Note: greater, smaller, no significant difference (left column compares to right).

also remain to be assessed. As the time-frame depends on the

specific research question, future research should specify and
compare different time-frames.
Comparisons of PSQ index values between gastroenterological samples of the study by Levenstein et al. (14) and the
present study yield no differences in measurement precision or
respondents scoring. This indicates that concerning the index scorethe revised German version of the questionnaire
reaches the same precision as the English original, with comparable results. In the original study, Levenstein et al. (14)
observed higher values for Italian than for English responPsychosomatic Medicine 67:78 88 (2005)

dents. Considering our own results, we do not expect great

deviations between German and English-speaking samples,
yet we consider a confirmation of the revised questionnaire
with an English-speaking sample desirable. Only if structural
invariance between samples from different cultural or lingual
backgrounds was substantiated could we confidently use the
instrument for studies across cultures.
Similar to the original questionnaire, the revised instrument
does not significantly vary with respect to gender. This is not
consistent with other research, which yields higher perceived
stress scores for women (17,20). An explanation for this could be
87

H. FLIEGE et al.
that the original PSQ was specifically designed and developed to
ensure that men and women would have similar scores (14).
As to age, the original study yielded a relatively small
correlation between the overall score and age (r 0.22). In
the present study, the association with age is reversed (r
0.28). This might be due to the fact that among the former
sample, older age groups were underrepresented (mean age
was 32), whereas the sample of the present study covers all
age groups. Here, group differences suggest that the demands
values are slightly higher for the 30- to 39-year-olds compared
with the 20- to 29-year-olds. This would be in line with the
former findings. However, the overall stress score is appreciably lowest for the age groups above 60 years. Those groups
were hardly represented in the original study.
Reference values for healthy adults and different disease
groups were attained. We found particularly high stress levels
in Psychosomatic Medicine patients, followed by patients with
tinnitus and IBD and women after spontaneous abortion.
Women in pregnancy or after regular delivery and healthy
adults report the lowest stress levels. The data prove differential validity. Decreased levels of perceived stress after different forms of treatment in different settings sufficiently
substantiate sensitivity to change.
In sum, our revision of the PSQ arrived at an economic,
reliable, structurally stable and valid instrument that enables
us to assess perceived stress in healthy adults and different
disease groups. It measures three dimensions of a stress reaction (worries, tension, joy/reversed) and one stressor dimension. Because the stressors are generic, the questionnaire can
be administered to different clinical and healthy adult samples
in different settings. Results can be compared with the reference values at hand and across studies. The overall score is
comparable to results from earlier studies with the original
instrument (14,16). The original 30-item questionnaires
structure was not replicable, whereas the 20-item versions
structure proved reasonably robust. Taking this advantage and
respondent burden into account, we suggest that the 20-item
version is preferable. However, it means that notably the
social stressor domain is not sufficiently represented. Furthermore, future research should also investigate how a corresponding 20-item English version of the PSQ would perform.
We wish to thank Ingrid Wittmann, Urania Berlin, and Jan Schwendowius for their assistance in raising the healthy adult sample, and
especially Dr. Susan Levenstein for her many helpful comments on
the paper.

4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

16.
17.
18.

19.
20.
21.
22.
23.
24.
25.

REFERENCES
1. Kenny DT, Carlson JG, McGuigan FJ, Sheppard JL. Stress and health:
research and clinical applications. Amsterdam: Harwood Academic; 2000.
2. Lobel M, Dunkel-Schetter C. Conceptualizing stress to study effects on
health: environmental, perceptual, and emotional components. Anxiety
Res 1990;3:21330.
3. Cohen S, Kessler RC, Gordon GL. Strategies for measuring stress. In:

88

26.
27.

Cohen S, Kessler RC, Gordon LU, editors. Studies of psychiatric and

physical disorders in measuring stress. New York: Oxford University
Press; 1995. p. 326.
Adler CM, Hillhouse JJ. Stress, health, and immunity: a review of the
literature. In: Miller T, editor. Theory and assessment of stressful life
events. Madison: International Universities Press; 1996. p. 109 38.
Critelli J, Ee J. Stress and physical illness: development of an integrative
model. In: Miller T, editor. Theory and assessment of stressful life events.
Madison: International Universities Press; 1996. p. 139 59.
Searle A, Bennett P. Psychological factors and inflammatory bowel disease:
a review of a decade of literature. Psychol Health Med 2001;6:12135.
Dohrenwend BS, Dohrenwend BP. Socioenvironmental factors, stress,
and psychopathology. Am J Comm Psychol 1981;9:128 59.
DeLongis A, Coyne JC, Dakof G, Folkman S, Lazarus RS. Relationship
of daily hassles, uplifts, and major life events to health status. Health
Psychol 1982;1:119 36.
Lazarus RS, Folkman S: Stress, appraisal, and coping. New York:
Springer; 1984.
DeLongis A, Folkman S, Lazarus RS. The impact of daily stress on health
and mood: psychological and social resources as mediators. J Pers Soc
Psychol 1988;54:486 95.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived
stress. J Health Soc Behav 1983;1983:38596.
Derogatis LR, Coons HL: Self-report measures of stress. In: Goldberger
L, Breznitz S, editors. Handbook of stress: theoretical and clinical aspects. New York: The Free Press; 1993. p. 200 33.
OKeefe MK, Baum A. Conceptual and methodological issues in the
study of chronic stress. Stress Med 1990;6:10515.
Levenstein S, Prantera C, Varvo V, Scribano ML, Berto E, Luzi C,
Andreoli A. Development of the Perceived Stress Questionnaire: a new
tool for psychosomatic research. J Psychosom Res 1993;37:19 32.
Levenstein S, Prantera C, Varvo V, Scribano ML, Andreoli A, Luzi C,
Arca` M, Berto E, Milite G, Marcheggiano A. Stress and exacerbation in
ulcerative colitis: a prospective study of patients enrolled in remission.
Am J Gastroenterol 2000;95:1213220.
Sanz-Carrillo C, Garcia-Campayo J, Rubio A, Santed M, Montoro M.
Validation of the Spanish version of the Perceived Stress Questionnaire
(PSQ). J Psychosom Res 2002;52:16772.
Bergdahl J, Bergdahl M. Perceived stress in adults: prevalence and
association of depression, anxiety and medication in a Swedish population. Stress Health 2002;18:235 41.
Wachirawat W, Hanucharurnkul S, Suriyawongpaisal P, Boonyapisit S,
Levenstein S, Jearanaisilavong J, Atisook K, Boontong T, Theerabutr C.
Stress, but not Helicobacter pylori, is associated with peptic ulcer disease
in a Thai population. J Med Assoc Thai 2003;86:672 85.
Abell N. The Index of Clinical Stress: a brief measure of subjective stress
for practice and research. Soc Work Res Abstracts 1991;27:12 6.
Koh KB, Park JK, Kim CH, Cho S. Development of the Stress Response
Inventory and its application in clinical practice. Psychosom Med 2001;
63:668 78.
Schulz P, Schlotz W. Trierer Inventar zur Erfassung von chronischem
Stre (TICS). Diagnostica 1999;45:8 19.
Arck P, Rose M, Hertwig K, Hagen E, Hildebrandt M, Klapp BF. Stress
and immune mediators in miscarriage. Human Reprod 2001;16:150511.
Fliege H, Rose M, Arck P, Levenstein S, Klapp BF. Validierung des
Perceived Stress Questionnaire (PSQ) an einer deutschen Stichprobe.
Diagnostica 2001;47:14252.
Angermeyer MC, Kilian R, Matschinger H: WHOQOL-100 und WHOQOL-BREF. Gottingen: Hogrefe; 1999.
Breivik E, Olsson U. Adding variables to improve fit: the effect of model
size on fit assessment in LISREL. In: Cudeck R, du Toit S, Sorbom D,
editors. Structural equation modeling. Lincolnwood: Scientific Software
International; 2001. p. 169 194.
Browne M, Cudeck R: Alternative ways of assessing model fit. In: Bollen
K, Long J, editors. Testing structural equation models. Newbury Park:
Sage; 1993. p. 136 162.
Weber C, Arck P, Mazurek B, Klapp BF. Impact of a relaxation training
on psychometric and immunologic parameters in tinnitus sufferers. J Psychosom Res 2002;52:29 33.

Psychosomatic Medicine 67:78 88 (2005)