Acute Stress Response Essay

SOCIAL BEHAVIOR AND PERSONALITY, 2011, 39(5), 713-720
© Society for Personality Research
DOI 10.2224/sbp.2011.39.5.713

DEVELOPMENT OF THE ACUTE STRESS RESPONSE SCALE
YEBING YANG, JINGJING TANG, YUAN JIANG, XUFENG LIU, YUNFENG SUN,
XIA ZHU, AND DANMIN MIAO
Fourth Military Medical University, Xi’an, People’s Republic of China
In this study we developed a scale to provide a tool for accurate assessment of acute stress response (ASR). We determined the dimensions and symptom clusters of ASR according to a review of the literature and through interviews with psychologists, and then compiled corresponding items, using these to compose the Acute Stress Response Scale (ASRS). We also investigated the construct validity, concurrent validity, test-retest reliability, and internal
consistency reliability of this scale. The final version of the scale included 6 dimensions and 25 symptom clusters with comparatively satisfactory indices of validity and reliability, indicating that the ASRS can lay the foundation for the detection and objective and accurate assessment of ASR.
Keywords: acute stress response, stress symptoms, stress dimensions.

In recent years, the psychological impact on people of traumatic events has been extensively investigated, particularly in relation to psychological changes in survivors and rescue personnel, who have experienced traumatic events such as disasters (Breslau et al., 1998). However, the different domains of stress-related research have developed unevenly. Research into posttraumatic stress disorder (PTSD) has been relatively comprehensive, such as investigations into symptoms, influencing factors, and methods of treatment (Brewin, Andrews,
& Valentine, 2000), but there have been fewer studies of acute stress response

Yebing Yang, Jingjing Tang, Yuan Jiang, Xufeng Liu, Yunfeng Sun, Xia Zhu, and Danmin Miao,
Department of Psychology, School of Aerospace Medicine, Fourth Military Medical University,
Xi’an, People’s Republic of China.
Appreciation is due to anonymous reviewers.
Please address correspondence and reprint requests to: Xia Zhu or Danmin Miao, Department of
Psychology, School of Aerospace Medicine, Fourth Military Medical University, Chang Le Western
Street No. 17, Xi’an, Shannxi, CO. 710032, People’s Republic of China. Email: [e-mail] or [e-mail]

713

714

THE ACUTE STRESS RESPONSE SCALE

(ASR) occurring in the early period after stressful events (Brewin, Andrews,
Rose, & Kirk, 1999).
Acute stress response refers to a series of physiological and psychological responses generated after stressful events, that are manifested mainly by cognitive, emotional, and behavioral changes as well as somatic symptoms.
Severe ASR may even lead to symptoms of mental illness (Shalev, 2002).
Numerous researchers have found close correlations between the occurrence and severity of ASR and the occurrence risk of PTSD (see e.g., Brewin et al.,
1999). Yitzhaki, Solomon, and Kotler (1991) found that ASR can manifest after the occurrence of traumatic events and its symptoms are quite complicated and unstable. ASR symptoms can lessen in severity over time, but this is not always the case. People who are already suffering from the severe symptoms associated with ASR are more vulnerable to PTSD when encountering stressful events.
This is in contrast to the comparatively lower risk of PTSD in individuals who have also experienced traumatic events but who have no or mild manifestations of ASR (Shalev, 2002). Therefore, timely assessment of ASR and dynamic monitoring of its progress are of great practical significance for prompt detection of people suffering from PTSD and rational allocation of resources for psychological services.
Many factors limit the development of ASR-related research, one of which is the lack of professional tools for measurement. To investigate the presence of
ASR as a factor in predicting the occurrence of PTSD, an objective and rational
ASR scale needs to be developed. To achieve this, in the present study, the construct of ASR was determined and an initial of items thought to be relevant for the scale was compiled. The initial version of the scale was then developed following two rounds of expert discussion and modification. On this basis, the initial version of the scale was administered to rescue personnel who had participated in relief work after the earthquake in Sichuan, China on 12 May
2008 (“5.12” earthquake), along with students enrolled at a military academy, to test for reliability and validity testing, so as to establish the final version of the scale. METHOD
PARTICIPANTS
Participants comprised two groups: one group consisted of rescue personnel who had participated in the “5.12” earthquake relief work and the other group consisted of students enrolled at the Fourth Military Medical Academy in China.
In the rescue personnel group there were 983 males from three provinces, with an average age of 20.5 years (SD = 2.1), of whom 940 returned valid questionnaires.
There were 391 males with an average age of 19.1 years (SD = 1.9), and 39

THE ACUTE STRESS RESPONSE SCALE

715

females with an average age of 18.2 years (SD = 2.1) in the student group (n =
430). The students completed the questionnaires on both the third and the seventh days, during military training, in the first month after admission to the academy and we received 410 valid questionnaires.
RESEARCH METHODS AND TOOLS
The initial version of the ASRS Literature reviews were conducted by six graduate students majoring in psychology, who extracted and classified all the psychological and physiological responses caused by acute stress, to form the initial dimensions and symptom clusters of the ASRS. Interviews were conducted by one associate professor specializing in psychology and five graduate students majoring in psychology, with psychologists who had provided psychological services during the “5.12” earthquake relief efforts to evaluate and determine the construct summarized from the review of literature. Another six graduate students majoring in psychology then sorted the items based on scale dimensions and symptom clusters and two associate professors specializing in psychology reviewed and modified this work to form the initial version of the scale.
Validity testing The initial ASRS was administered to rescue personnel who had participated in 5.12 earthquake relief, along with the Symptom Checklist 90
(SCL-90; Derogatis, 1975), the State-Trait Anxiety Inventory (STAI; Spielberger,
1983), the Generalized Self-efficacy Scale (GSES; Schwarzer & Jerusalem,
1995), and the Perceived Social Support Scale (PSSS; Xiao & Yang, 1987).
The SCL-90 includes 90 items, reflecting symptoms associated with mental health, assessed with a 5-point Likert scale including none, mild, moderate, severe, and very severe which are scored as 0, 1, 2, 3, and 4, respectively. The
STAI, which was developed by Spielberger and colleagues has 40 items scored on a 4-point scale (none = 1, some = 2, moderate = 3, and very obvious = 4). In the STAI 20 items scoring the state (S-form) and 20 scoring the trait (T-form).
The S-form was used in this study. The GSES scoring 10 items and has a 4-point scoring scale (totally wrong = 1, partly wrong = 2, partly right = 3, and totally right = 4). The PSSS is made up of 12 items and scores are assessed on a 7-point scale (strongly disagree = 1, moderately disagree = 2, slightly disagree = 3, neutral = 4, slightly agree = 5, moderately agree = 6, and strongly agree = 7), to measure individuals’ degree of self-perceived social support. The total score is obtained by summing these scores.
Unidimensional testing was conducted on items in the same dimension according to findings gained during construction of the ASRS, and items were abridged based on factor loadings. Confirmatory factor analysis was used to test the construct validity. Correlation analyses for the total score for the ASRS and scores for different dimensions, compared with the SCL-90, S-form of the
STAI, GSES, and PSSS scores, were conducted to test the concurrent validity.

716

THE ACUTE STRESS RESPONSE SCALE

Confirmatory factor analysis was conducted using LISREL version 8.50 and all other analyses were conducted using SPSS version 13.0.
RELIABILITY TESTING
Correlation analysis was conducted to calculate the test-retest reliability of the ASRS, using the results from the questionnaires completed on two separate occasions by students during their military training. Analysis of the results for rescue personnel was conducted to calculate the internal consistency reliability of the scale. All analyses were carried out using SPSS version 13.0.
RESULTS
CONSTRUCTION OF THE ASRS
Construction of the ASRS was ultimately determined through reviews of related literatures and interviews, and revealed six dimensions and 25 symptom clusters (see Table 1).
TABLE 1
SCALE CONSTRUCTION
Dimensions

Cognitive changes Emotional responses Behavioral changes Physiological Psychiatric Reduced responses symptoms work efficiency Symptom clusters Nightmares
Memory loss
Disorientation
Indecision
Uncertainty
Hypoprosexia

Grief
Frustration
Anger
Anxiety
Despair
Apathy
Guilt
Helplessness
Depression

Less attention Somatic paid to symptoms personal hygiene Communicates less with others Panic attacks
Obsessive
compulsive behaviors Changes of sleeping behaviors
Changes in eating habits
Isolated from others

Psychiatric Reduced symptoms work efficiency VALIDITY TESTING
Construct validity Testing revealed that the unidimensionality of all six dimensions met the requirement in that the amount of variability explained by the first factor was more than three times that of the second factor, and the inflexion point of the first factor was obvious. The items with factor loadings below 0.3 for the first dimension were discarded (see Table 2).

717

THE ACUTE STRESS RESPONSE SCALE
TABLE 2
PRINCIPAL FACTOR LOADINGS FOR THE SIX DIMENSIONS
Dimension

First loading

Second loading

First/second loading

7.49
9.23
5.32
6.47
2.64
1.53

1.76
1.90
1.75
1.89
0.84
0.48

4.26
4.86
3.04
3.43
3.14
3.19

Cognitive changes
Emotional responses
Behavioral changes
Physiological responses
Psychiatric symptoms
Reduced work efficiency

On this basis, confirmatory factor analysis was conducted using LISREL version 8.50. Since original entries were comparatively abundant, symptom cluster scores were first calculated based on original entries, followed by confirmatory factor analysis. It was found that the fit indices were comparatively good (see Table 3).
TABLE 3
FIT INDICES FOR CONFIRMATORY FACTOR ANALYSIS OF THE FIRST-ORDER MODEL

Model

2

df

RMSEA

NFI

NNFI

CFI

3274.16

328

0.084

0.90

0.89

0.91

However, the correlation coefficients for the six factors were all above
0.80, indicating that the fit of the second-order model would be better. Thus, a second-order factor, named ASR, was put forward on the basis of the first-order model to undergo confirmatory factor analysis. The results showed that the fit indices of the second-order model were superior to those of the first-order model
(see Table 4).
TABLE 4
FIT INDICES FOR CONFIRMATORY FACTOR ANALYSIS OF THE SECOND-ORDER MODEL

Model

2

df

RMSEA

NFI

NNFI

CFI

2678.84

319

0.078

0.92

0.91

0.93

The above results indicate that the construct validity of the ASRS is favorable, and the data fit the second-order model better, indicating that this scale can be applied not only for calculations based on dimensions, but also for calculations based on total scores, which reflect the degree of severity of ASR.
Concurrent validity This scale measures the major symptoms and severity of
ASR occurring in individuals who have experienced traumatic events, which in turn reflects the state of mental health of individuals experiencing response to

718

THE ACUTE STRESS RESPONSE SCALE

an acutely stressful event. Anxiety in those experiencing ASR is very obvious and significant, so theoretically, scores gained on the ASRS should correlate positively with scores gained on the SCL-90 and STAI. Moreover, a search of the literature revealed that generalized self-efficacy and perceived social support are important protective factors, so that scores on the ASRS should be negatively correlated with these (Langley & Jones, 2005).
All dimensions and the total score for the ASRS were found to be significantly positively correlated with the total scores for the SCL-90 and STAI S-form, among which the maximum correlation coefficient represented the correlation between the total score for the ASRS and the total score for the SCL-90
(r = 0.67, p < 0.01) and the minimum correlation coefficient represented the correlation between psychiatric symptoms and the STAI S-form score (r = 0.14, p < 0.01). Moreover, scores for the majority of dimensions of the ASRS were significantly negatively correlated with the total scores of general self-efficacy and perceived social support, among which the maximum correlation coefficient represented the correlation between cognitive changes and the total score for generalized self-efficacy (r = -0.37, p < 0.01) and the minimum correlation coefficient represented the correlation between physiological responses and the total score of perceived social support (r = 0.12, p < 0.05). The correlation of the psychiatric symptom score with the total scores for generalized self-efficacy and perceived social support was not significant (see Table 5). The results showed that the ASRS had favorable concurrent validity.
TABLE 5
CONCURRENT VALIDITY ANALYSIS OF ASRS

Cognitive changes
Emotional responses
Behavioral changes
Physiological responses
Psychiatric symptoms
Reduced work efficiency
Total scale
*

Total score for SCL-90

STAI S-form

Generalized self-efficacy Perceived social support

0.66*
0.63*
0.64*
0.61*
0.36*
0.43*
0.67*

0.59*
0.55*
0.53*
0.46*
0.14*
0.38*
0.55*

-0.37**
-0.21**
-0.23**
-0.23**
-0.04
-0.23**
-0.27**

-0.22**
-0.25**
-0.14**
-0.12*
-0.02
-0.13**
-0.19**

p < 0.05, ** p < 0.01

RELIABILITY TESTING
Test-retest reliability Correlation analysis showed that correlation coefficients of the two questionnaires filled in by each of the students on separate occasions gave scores for all dimensions of between 0.78 and 0.86, among which the maximum represented that of psychiatric symptoms and the minimum represented that of physiological responses; the test-retest reliability of the total scale was 0.80, indicating that the scale has favorable stability.

THE ACUTE STRESS RESPONSE SCALE

719

Internal consistency reliability Calculation of the internal consistency reliability for different dimensions revealed that the Cronbach’s alpha coefficients for cognitive changes, emotional response, behavioral changes, physiological responses, psychiatric symptoms, reduced work efficiency, and total scale internal consistency reliability were, respectively, 0.89, 0.89, 0.84, 0.88, 0.74,
0.79, and 0.85, indicating that the scale has acceptable internal consistency reliability. DISCUSSION
Everybody experiences stressful events. After having experienced stressful events, individuals display ASR in complicated and different ways that reflect individual physiological and psychological states. These individual responses to stress have an important role in understanding the impact of stressful events and the coping strategies that each person adopts. To evaluate ASR more accurately and lay the foundation for future investigation, we developed a scale with six dimensions and achieved acceptable construct and concurrent validity. The results of test-retest reliability and internal consistency reliability were also favorable, indicating that the ASRS is an objective and effective tool that can accurately assess ASR, and which can provide the foundation for related research.
The scope of application for the ASR scale includes three main aspects. Firstly, the ASRS can be used for ASR evaluation for individuals who have experienced traumatic events, including survivors and their relatives, and rescue personnel, laying the foundation for targeted psychological intervention (Hammond &
Brooks, 2001). The resources of psychological services could be rationally allocated according to the degree of ASR among different individuals and populations, so as to improve the effectiveness and efficiency of psychological intervention. Another use could be in situations where individuals are faced with significant pressure events because events are about to happen (for example, when students are about to sit an examination). This type of stress can also be evaluated with the ASR scale. This information could be used by the students to improve their performance and by others to help students maintain their psychological health by providing relevant psychological advice and assistance for them according to the degree and types of their symptoms.
The second application is providing tools for correlation analysis of ASR with PTSD and resilience. The risk of PTSD can be predicted by monitoring the severity and course of ASR for individuals who have experienced traumatic events; in addition, the psychological model of ASR can be established via comprehensive research on psychosocial factors like psychological resilience
(Levine, 2001), which can lay the theoretical foundation for studying the impact of psychosocial factors on reaction to stress and provide reference for effective psychological education.

720

THE ACUTE STRESS RESPONSE SCALE

The third application is combining the ASR scale with physiological and biochemical indicators, including changes in hormone secretions, immunologic functions, and neural activities (Antelman, 1988), to further investigate the physiological mechanism of stress reaction and elucidate the neuroendocrine foundation for stress reaction, thereby laying the theoretical foundation for physiological function training and intervention with medication for stress reactions. This study has some limitations, predominantly in the following three aspects.
Firstly, the scale norm is imperfect. The scale has been tested with only two populations: rescue personnel who participated in earthquake relief and students newly enrolled at a military academy. The criteria for norms, without further investigation into other stressful events and individuals of other ages are not generalizable. Secondly, this scale was developed based on the classical test theory (also known as item response theory), which is comparatively limited for dynamic monitoring of stress states. Thirdly, the validity verification of this scale still lacks support of objective criteria and needs further testing and research.
REFERENCES
Antelman, S. M. (1988). Time-dependent sensitization as the cornerstone for a new approach to pharmacotherapy: Drugs as foreign/stressful stimuli. Drug Development Research, 14(1), 1-30.
Breslau, N., Kessler, R. C., Chilcoat, H., Schultz, L., Davis, G., & Andreski, P. (1998). Trauma and posttraumatic stress disorder in the community: The 1996 Detroit area survey of trauma. Archives of General Psychiatry, 55(7), 626-632.
Brewin, C. R., Andrews, B., Rose, S., & Kirk, M. (1999). Acute stress disorder and posttraumatic stress disorder in victims of violent crime. American Journal of Psychiaty, 156, 360-365.
Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68,
748-766.
Derogatis, L.
R. (1975). How to use the Symptom Distress Checklist (SCL-90) in clinical evaluations
(Vol. 3). Nutley, NJ: Hoffmann-La Roche.
Hammond, J., & Brooks, J. (2001). The World Trade Center attack. Helping the helpers: The role of critical incident stress management. Critical Care, 5, 315-317.
Langley, A., & Jones, R. (2005). Coping efforts and efficacy, acculturation, and post-traumatic symptomatology in adolescents following wildfire. Fire Technology, 41, 125-143.
Levine, S. (2001). Primary social relationships influence the development of the hypothalamic– pituitary–adrenal axis in the rat. Physiology and Behavior, 73, 255-260.
Schwarzer, R., & Jerusalem, M. (1995). Generalized Self-efficacy Scale. In J. Weinman, S. Wright,
& M. Johnston (Eds.), Measures in health psychology: A user’s portfolio (pp. 35-37). Windsor,
UK: NFER-Nelson.
Shalev, A. Y. (2002). Acute stress reactions in adults. Biological Psychiatry, 51, 532-543.
Spielberger, C. D. (1983). State-Trait Anxiety Inventory: Comprehensive bibliography. Palo Alto,
CA: Consulting Psychologists Press.
Xiao, S., & Yang, D. (1987). The influence of social support on psychological health. Chinese Mental
Health Journal, 1,
184-187.
Yitzhaki, T., Solomon, Z., & Kotler, M. (1991). The clinical picture of acute combat stress reaction among Israeli soldiers in the 1982 Lebanon war. Military Medicine, 156, 193-197.

Copyright of Social Behavior & Personality: An International Journal is the property of Society for Personality
Research and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder 's express written permission. However, users may print, download, or email articles for individual use.