Occupational Medicine 2012;62:600605

Advance Access publication 10 September 2012 doi:10.1093/occmed/kqs140

Clinical stress assessment using a visual

analoguescale
F.-X.Lesage1, S.Berjot1 and F.Deschamps2
Cognition, Health and Socialization, Psychology Department, Reims, France, 2Occupational Health Department, Faculty of
1

Medicine, Reims, France.

Correspondence to: F.-X. Lesage, Occupational Health Department, Faculty of Medicine, UF de pathologie professionnelle et
sant au travail, Hpital Sbastopol, 48, rue de Sbastopol, 1092 Reims Cedex, France. Tel:+33 326788933;
fax: +33 326784356; e-mail: fxlesage@chu-reims.fr

Background Clinicians increasingly require short, efficient methods for assessing distress, both in applied research
and clinical settings. Most of the available questionnaires are unsuitable for busy clinical settings.

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The visual analogue scale (VAS) is widely but empirically used to assess perceived stress.
Aims To provide evidence on two of the psychometric properties of the VAS: its discriminative sensitivity
(capacity to highlight a difference between groups) and its interconcept validity (the relationship
between VAS stress assessment and the assessment of different, but similar concepts).
Methods Employees attending occupational health centres were randomly selected and completed the VAS
and also either the Perceived Stress Scale (PSS) or the Hospital Anxiety and Depression Scale
(HADS). Analyses of variance were performed to study group effects (age, sex, marital status, paren-
tal status, occupational status) on stress scores (PSS and VAS).
Results In total, 763 employees participated of whom 501 completed the PSS and 262 the HADS. P-values
obtained for the effects of sex, age and occupational status were lower with the VAS than with the
PSS. Correlations between the VAS and the anxiety subscale, depression subscale and total score of
the HADS were 0.66, 0.45 and 0.65, respectively. Other tools used to assess aspects of psychological
distress are known to have similar correlations.
Conclusions Our findings provide evidence that the VAS is at least as discriminating as a questionnaire when it
comes to highlighting differences in stress levels between two groups, and the observed correlations
with related constructs support its construct validity.
Keywords Occupational mental health; stress; validation; well-being; work stress.

Introduction
The assessment of stress is an important component
of medical assessments, particularly in occupational or
clinical medicine and areas such as oncology or chronic
disease management. One way of assessing stress is to
administer a questionnaire, which has the benefit of
allowing a rapid quantitative assessment, which is par-
ticularly useful both in clinical and research settings.
A number of questionnaires are currently available for
assessing stress, such as Cohens Perceived Stress Scale
(PSS). However, these are often too long and compli-
cated to use in routine clinical practice.
Mitchell recommends the utilization of a single ques-
tion which asks participants to rate their perceived stress
on a 10-point scale designed for use in both clinical and
research settings, such as the visual analogue scale (VAS)
[1]. This scale is particularly well suited for the clini-
cal assessment of self-reported stress. Numerous recent
studies (we identified 28 since 2008 in the Medline and
PsycInfo databases) have used the VAS to assess per-
ceived psychologicalstress.
Several subjective qualities favour the use of the
VAS. First of all, it offers a quick and simple means of
assessment of perceived stress within doctorpatient
consultations, enabling patients to express their
distress without using an impersonal questionnaire.
Furthermore, it avoids misunderstandings that may
occur during questionnaire-based assessments due to
difficulty in communication (e.g. literacy or language
problems).

The Author 2012. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
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Regardless of the qualitative properties of the VAS,
it is vital to assess its psychometric properties. Several
employee-based surveys have indicated some interest-
ing psychometric properties, such as satisfactory stability
and high inter-rater reliability [24]. Moreover, there are
good correlations between the stress VAS and other tools
used to assess stress, such as the 14-item PSS (Lins con-
cordance correlation coefficient=0.66) [2,5].
Experimental studies have also pointed to good sen-
sitivity for acutely distressing events, and significant
relationships with cardiovascular parameters (heart rate,
blood pressure) [6] and salivary cortisol levels [7].
However, numerous parameters still need to be eval-
uated in order to assess the limitations of the VAS and
its efficiency in assessing stress. The aim of this study
was therefore to provide evidence of its discriminative
sensitivity (i.e. the capacity to highlight a difference in
stress between two groups) and its interconcept valid-
ity (the relationship between VAS assessments of stress
and assessments of different but similar concepts such as
anxiety or depression).
Methods
We randomly selected employees attending five occu-
pational health centres in the Champagne-Ardenne,
Haute-Normandie, and Ile-de-France dpartements in
Northern France in 2010. In France, every employee
must undergo a thorough medical examination either
annually or biennially. On their arrival at the centre and
before their actual examination, participants were told
about the aim of the study and asked by the authors to
take part on a voluntary and anonymous basis. They were
assured that they could withdraw at any time. Both oral
and written instructions were given to ensure informed
participation, and participants were guaranteed confi-
dentiality. Under prevailing French legislation, the study
design did not require ethics committee approval since
the participants were not patients.
During the medical consultation, a practitioner
assessed the stress of all participants with theVAS.
The French version of the PSS-14 was used to assess
perceived stress during the previous month [8]. Items are
rated on a 5-point Likert scale (0 = never, 1 = almost participants, and s its variance. Mwomen and Mmen are
never, 2=once in a while, 3=often and 4=very often). the average stress scores for women and men, respec-
The scores of Items 4, 5, 6, 7, 9, 10 and 13 are reversed
(4 = never, 3 = almost never, 2 = once in a while, The number n of women and men (n=nwomen=nmen)
1=often, 0=very often). Atotal score can be obtained needed to highlight a statistical difference in stress
by summing the scores for the 14 items, following the
guidelines set out by the original authors, and scores
therefore range from 0 to 56. The higher the score, the
higher the level of stress. We also calculated the PSS-10
(Items 1, 2, 3, 6, 7, 8, 9, 10, and 11; range [040]) and
PSS-4 (Items 2, 6, 7 and 14; range [016]) scores. Each
score (PSS-14, 10, 4)was converted to a 010scale.
F.-X. LESAGE ET AL.: CLINICAL STRESS ASSESSMENT 601
The PSS is a unidimensional scale that assesses per-
ceived stress by asking respondents to report whether
their lives seem to be unpredictable or uncontrol
lable, or if they feel overburdened. This questionnaire
is based on Lazarus transactional model of stress. It
assesses the cognitively mediated emotional response
to an objective event, rather than the objective event
itself, as a checklist of stressful events would do. This
scale is used worldwide, and it has satisfactory psycho-
metric properties.
We used the French version of the HADS to assess
depression and anxiety [9,10]. The HADS is a 14-item
self-report measure that was specifically developed to
assess anxiety and depression. It is considered to be
an effective means of screening for anxiety and depres-
sion and is widely used [11]. It has two subscales, one
assessing anxiety (HAD-A) and the other assessing
depression (HAD-D). The scores for each subscale
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range from 0 to21.
We chose this scale for two reasons. Firstly, the HADS
is a rapid and widely used scale, measuring a different
concept from stress. Secondly, the literature contains
several recent validation studies (since 2006) compar-
ing different stress assessment methods with the HADS
(i.e. interconcept validity). These methods are the PSS
[13,14], the Psychological Distress Scale (PDS) [15] and
the Distress Thermometer (DT) [16]. We could there-
fore compare the relationship between the VAS and the
HADS with these differenttools.
The Stress VAS consists of a small, unmarked 100mm
ruler with endpoints labelled none and as bad as it
could be.
The scale was introduced to participants by the
practitioner during the consultation, with the following
instruction: Indicate how stressed you feel on the small
ruler. The scale therefore yielded a single subjective
stress score between 0 and100.
Analyses of variance (ANOVA) were performed to
analyse the main effects of the different variables (age,
sex, marital status, parental status, occupational status)
on stress scores (PSS scales and StressVAS).
We compared the discriminative sensitivity of
the VAS and the PSS-14, 10 and 4 with the follow-
ing formula, where M is the mean stress score of the
tively, and is the difference between Mwomen and Mmen.
levels between the women and men is indicated by
the formula:
( )
2
n=2 s 2
2
is a constant:
602 OCCUPATIONAL MEDICINE
( )
= Z Z1 to yield a significant stress difference for three reasons.
2 First, the calculation required two categories and con-
The comparison of two different methods (here, the PSS
and the VAS) allows a mathematical simplification:
nPSS s2 s2 Third and the last, the numbers in each group have to be
= PSS 2 VAS equal (n1=n2).
nVAS PSS 2
VAS
We compared the capacity of the PSS and the VAS
to highlight the statistical difference in stress accord-
ing to sex. The ratio nPSS/nVAS was computed for each
version of the PSS (14, 10 and 4 items). Interconcept
validity was tested using two types of statistical analysis:
Pearsons correlation coefficient and analysis of variance
(ANOVA). Pearson correlations between the VAS and
HADS scores (HAD-A, HAD-D and total score) were
computed. This type of analysis does not require a large
sample to provide reliable correlations. We estimated that
half of our sample would be enough and therefore aimed
to include 250 participants.
Results
A total of 501 participants completed the PSS-14, and
262 completed the Hospital Anxiety and Depression
Scale (HADS), giving 763 participants in total. The
mean age of those completing the PSS was 40.4 years
(95% confidence interval [39.4, 41.4]) (Table1). There
were 249 women and 252 men. As a large number of
occupations were represented in this sample, they were
divided into four categories, according to the French
occupational statusindex.
We analysed the response rate for the first 100 par-
ticipants. Only five workers declined to participate, the
main reason being illiteracy. Given the high response rate
(95%), we stopped collecting data for non-respondents.
All the scales showed significant differences in stress
according to age and parental status. The effect of sex
was only statistically significant for the 10-item version
of the PSS and for the VAS (P < 0.05 and P < 0.01, low confidence intervals. In this sense, questionnaires
respectively).
There were no differences in stress levels according to
marital and occupational status. The P-values obtained
for the effects of sex, age and occupational status were
lower with the VAS than with thePSS.
Results showed that the ratios of numbers (assum-
ing that numbers were equal in both groups) required to
obtain a significant difference in stress levels according
to sex, for each PSS version versus the VAS (nPSS14/nVAS,
nPSS10/nVAS, and nPSS4/nVAS ) were 3.9, 2.26 and 6.7 for the
PSS-14, 10 and 4, respectively. For the most efficient
version of the PSS (10 items), the sample size needed to
be twice as high (2.26) as that of the VAS to highlight a
significant difference in stress levels according to sex. We
chose the sex effect to compute the numbers required
sequently could not be done with age or occupational
status. Second, the difference in stress responses between
women and men is well documented in the literature.
The Pearson correlations between the VAS, HAD-
A, HAD-D and HADS were r = 0.66, 0.45, and 0.65,
respectively. These interconcept correlations were very
close to those found with the PSS, the ODS and the
DT (Table2). Two recent studies reported similar cor-
relations between the PSS and the HADS [13,14], while
Grassi found a similar relationship between the DT
(used in an oncology setting) and the HADS [15]. Lastly,
Dolbeaut found the same relationship between the PDS
and the HADS [16].
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The ANOVA was run on the VAS scores after the
anxiety and depression scores had been categorized as
low, average or high. The cut-offs were determined using
the lower third, middle third, and upper third of the
normative distribution of each score from this sample.
Results showed significant differences in stress levels
(P-values < 0.001) according to anxiety and depression
levels.
Discussion
This study showed that the VAS is at least as discriminat-
ing as the PSS. Moreover, the links with other related
variables showed that the VAS does indeed measure what
it is intended to measure, namely perceived stress, as we
found similar links to those reported in the literature.
More specifically, we found that the size of the sample
required to yield a statistical difference in stress accord-
ing to sex was twice as high for the PSS-10 as it was
for the VAS. This finding can be explained firstly by the
fact that questionnaires are intrinsically designed to have
a parametric distribution and a low variance. This kind
of distribution allows for parametric statistical tests, and
can be considered to be a statistically adequate measure
of aconcept.
However, low variance does not necessarily equate
with a powerful method, and while the confidence inter-
val will be lower, the scale will not be any more powerful
as aresult.
A weak variance of observations within a group leads
to a low difference between two subgroups (e.g. male
and female). We explained in the methods section that
the discriminative sensibility of a scale is related to the
s/ ratio. This ratio was lower with the VAS than with
the PSS for all subgroups except parental status (the
P-value is another expression of this ratio). We believe
that this finding can be interpreted as indicating the
 F.-X. LESAGE ET AL.: CLINICAL STRESS ASSESSMENT 603

Table1. Means of total scores on the PSS-14, 10 and 4 and VAS by age, sex, marital status, parental status, and occupational status.

Categories Sample (n=501) PSS-14 [010] PSS-10 [0-10] PSS-4 [0-10] VAS [0-10]

Overall P-valuea Overall P-valuea Overall P-valuea Overall P-valuea

score score score score
(SD) (SD) (SD) (SD)

Age (years) Overall mean 40.4 [39.4; 41.4] 3.8 3.8 3.4 4.0
[95% CI] (1.36) (1.55) (1.78) (2.41)
30 n=125 3.5 <0.05 3.4 <0.01 3.0 <0.01 3.3 <0.001
(1.38) (1.59) (1.87) (2.23)
3140 n=133 3.7 3.8 3.3 4.0
(1.29) (1.46) (1.62) (2.46)
4150 n=129 4.0 4.0 3.7 4.4
(1.52) (1.74) (2.00) (2.53)
51 n = 114 3.9 4.1 3.5 4.4
(1.16) (1.28) (1.53) (2.28)
Sex Female n=252 3.9 NS 4.0 <0.05 3.5 NS 4.4 <0.01

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(1.50) (1.68) (2.00) (2.54)
Male n=249 3.7 3.7 3.3 3.7
(1.20) (1.39) (1.54) (2.23)
Marital status Couple n=337 3.8 NS 3.8 NS 3.3 NS 4.0 NS
(1.32) (1.49) (1.66) (2.40)
Single n=162 3.8 3.8 3.4 4.1
(1.42) (1.63) (1.98) (2.45)
Parental status Children n=335 3.9 <0.01 4.0 <0.01 3.5 <0.01 4.2 <0.05
(1.37) (1.54) (1.75) (2.47)
No children n=166 3.6 3.5 3.1 3.7
(1.33) (1.55) (1.83) (2.26)
Occupational Managers/Engineers n=123 3.7 NS 3.8 NS 3.2 NS 4.4 NS
status (1.19) (1.37) (1.61) (2.11)
Technical workers n=53 3.8 3.8 3.4 3.5
(1.11) (1.27) (1.44) (2.20)
Administrative n=149 3.7 3.7 3.2 4.0
workers, Secretaries (1.49) (1.68) (1.95) (2.38)
Blue-collar workers n=176 3.9 3.9 3.6 3.9
(1.42) (1.63) (1.83) (2.66)

ANOVA used to compare intergroup means (age, sex, marital status, parental status, occupational status).
a

SD, standard deviation; CI, confidence interval; NS, not significant.

Table2. Correlations between the HADS scores and other tools of this analysis was thus to indicate the impact of dis-
used to assess stress or psychological distress criminative sensitivity for clinical research.
The results of our study showed that the VAS is a rela-
VAS PSSSpanisha PSSb PDSc DTd tively efficient tool for assessing stress. However, it is not
a case-finding tool for anxiety or depression. Stress is not
HAD-A 0.66 0.64 0.67 0.61
a mood disorder; high chronic stress levels are certainly a
HAD-D 0.45 0.52 0.39 major risk factor, and can be a primary marker of a mood
HAD-Total 0.65 0.71 0.64 0.66 disorder, but they do not constitute pathology. There is,
nonetheless, a clear relationship between stress, anxiety
Remor [14]; bSpada [13]; cDolbeaut [15]; dGrassi [16].
a
and depression, which we found to be similar to that
PSS, perceived stress scale; PDS, psychological distress scale; DT, distress reported for other tools used to assess different aspects
thermometer.
of psychological distress.
It was not possible in this study to administer both
greater discriminative sensibility of the VAS. The VAS the PSS and the HADS to the same participants, as
highlighted a difference in stress levels with half as many this would have required too much time and effort both
participants as the PSS. This finding must, however, be for them and for the occupational physicians. Hence,
interpreted with caution. This was a univariate analysis, the correlations between the HADS and the PSS were
and some other factors may have intervened, such as age, extracted from the literature. It would have been better
occupational stress and parental status. The sole purpose to base our assessment of the interconcept validity of the
604 OCCUPATIONAL MEDICINE
Table3. Mean VAS scores according to levels (low, average, high) of anxiety and depression
HADS-Anxiety scale
Low anxiety
VAS stress (mean (SD)) 2.21 (1.59)
HADS-Depression scale
Low depression
VAS stress (mean (SD)) 2.63 (1.86)
VAS on our own data. This limitation provides further
evidence that a comprehensive questionnaire battery is
poorly suited to a busy clinicalsetting.
Although the present study had several limitations
other earlier validity studies have also highlighted the
psychometric properties of the VAS in stress assessment:
its inter-rater reliability [3], its stability [4] and its good
concordance (which is different from the Pearson corre-
lation) [17] with the PSS (Lins concordance correlation
coefficient=0.66) [2].
Experimental studies of acute stress responses
have highlighted the sensitivity of the VAS [6,1820].
Unfortunately, to our knowledge, there are no pub-
lished assessments of its reproducibility. Even if this is an
important issue and constitutes a weakness in our studys
design, it would have been difficult to carry this out in
the present study, or in a worker-based study. This is a
possible focus for futurestudies.
Overall, numerous surveys have shown the psycho-
metric properties of the VAS for the assessment of stress
to be very satisfactory. Its main weakness is its simpli
city. Ashort tool may be perceived as ineffective, by both
patients and practitioners, with complex stress assess-
ments or biological markers being perceived as a more
effective way of measuringstress.
Mitchell claimed that no screening tool should be seen
as an alternative to careful clinical assessment [12]. The
particularity of the VAS is that it is a clinical tool used by
clinicians during consultations. Hence, it is (and should
be) only part of the clinical stress assessment, forming
just the starting point of an interview. The VAS extends
the doctorpatient relationship more than a questionnaire
given in a waiting room would and is eminently suited to
a busy clinical setting. This has been confirmed by our
own personal experience, extending over several years,
with patients spontaneously adding comments after their
self-assessment on the VAS. Feedback from practitioners
using the VAS on a daily basis is also very positive.
Clinicians are increasingly looking for efficient methods
of assessing distress, both in applied research and clinical
settings. Perceived stress measures are often administered
on top of broader evaluations and medical examinations.
Consequently, most questionnaires are not suitable for
busy clinical settings. Clinicians, undertaking routine
Average anxiety High anxiety P-value
3.62 (1.82) 5.32 (2.32) < 0.001
Average depression High depression P-value
3.42 (2.17) 5.13 (2.24) < 0.001
clinical work, clinical research, medical examinations or
occupational health, may be interested in a very short
clinical tool for the assessment ofstress.
Numerous psychometricians consider that a psycholog-
ical dimension cannot be measured with fewer than three
items. We agree that a complex psychological dimension
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such as self-esteem cannot be assessed with a single ques-
tion. Besides, when there are several items, specific statistical
analyses can be conducted to assess internal validity, such
as internal consistency and factor analysis. Putting aside
ideological considerations, numerous studies of stress or
distress assessment have shown that some concepts or feel-
ings can be evaluated with a short tool. This was confirmed
by a recent meta-analysis concerning short screening tools
used for the assessment of cancer-related distress, which
identified 45 short and ultra-short tools [12]. Very few of
these tools have been validated, but the author concluded
that the overall accuracy of these single-item approaches
seems comparable to that of the 14-item HADS (total
score), whereas their efficiency is superior.
Key points
Clinicians undertaking routine clinical work, clin-
ical research, medical examinations or occupa-
tional health, may value a very short clinical tool
for the assessment of stress.
The visual analogue scale is widely but empirically
used to assess perceived stress.
Our study suggests that the visual analogue scale
is at least as discriminating as a questionnaire
when it comes to highlighting differences in stress
levels between two groups.
Conflicts of interest
None declared.
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