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Health and Quality of Life Outcomes
Published in: Health and Quality of Life Outcomes 1/2016

Open Access 01-12-2016 | Research

The Four-Dimensional Symptom Questionnaire (4DSQ) in the general population: scale structure, reliability, measurement invariance and normative data: a cross-sectional survey

Authors: Berend Terluin, Niels Smits, Evelien P. M. Brouwers, Henrica C. W. de Vet

Published in: Health and Quality of Life Outcomes | Issue 1/2016

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Abstract

Background

The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire measuring distress, depression, anxiety and somatization with separate scales. The 4DSQ has extensively been validated in clinical samples, especially from primary care settings. Information about measurement properties and normative data in the general population was lacking. In a Dutch general population sample we examined the 4DSQ scales’ structure, the scales’ reliability and measurement invariance with respect to gender, age and education, the scales’ score distributions across demographic categories, and normative data.

Methods

4DSQ data were collected in a representative Dutch Internet panel. Confirmatory factor analysis was used to examine the scales’ structure. Reliability was examined by Cronbach’s alpha, and coefficients omega-total and omega-hierarchical. Differential item functioning (DIF) analysis was used to evaluate measurement invariance across gender, age and education.

Results

The total response rate was 82.4 % (n = 5273/6399). The depression scale proved to be unidimensional. The other scales were best represented as bifactor models consisting of a large general factor and one or more smaller specific factors. The general factors accounted for more than 95 % of the reliable variance of the scales. Reliability was high (≥0.85) by all estimates. The distress-, depression- and anxiety scales were invariant across gender, age and education. The somatization scale demonstrated some lack of measurement invariance as a result of decreased thresholds for some of the items in young people (16–24 years) and increased thresholds in elderly people (65+ years). The somatization scale was invariant regarding gender and education. The 4DSQ scores varied significantly across demographic categories, but the explained variance was small (<6 %). Normative data were generated for gender and age categories. Approximately 17 % of the participants scored above average on de distress scale, whereas 12 % scored above average on de somatization scale. Percentages of people scoring high enough on depression or anxiety as to suspect the presence of depressive or anxiety disorder were 4.1 and 2.5 respectively.

Conclusions

Evidence supports reliability and measurement invariance of the 4DSQ in the general Dutch population. The normative data provided in this study can be used to compare a subject’s 4DSQ scores with a general population reference group.
Appendix
Available only for authorised users
Footnotes
1
In July 2013 the 4DSQ was presented to all available panel members of 16 years and older in two forms, the standard present tense form and an alternative past tense form. The purpose was to examine whether these forms produced different responses. It was the original plan to present the standard form to the larger part of the panel and the alternative form to a relatively small subsample. Unfortunately, however, the forms were swapped so that the smaller subsample was presented with the standard form and the greater subsample with the alternative form. As it was suspected that the form could have an effect on the way people respond to the 4DSQ (which was later partly confirmed [51]), it was decided to present the standard form of the 4DSQ again in October to those panel members who had not completed a standard 4DSQ in July. The present study includes the responders who completed the standard present tense form of the 4DSQ, either in July or in October.
 
2
The relationship between distress and depression/anxiety is characterized by a non-reciprocal hierarchy [1]: when depression or anxiety are high, distress is also high, but the reverse is not true. Distress is invariably a part of depression and anxiety, but depression and anxiety are not invariable part of distress. The explanation is twofold. First, it is hard to cope with depressive and anxiety disorders. Therefore, understandably, these disorders are associated with much distress. Second, depressive and anxiety disorders can be triggered in vulnerable people when they experience severe distress from external stressors.
 
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Metadata
Title
The Four-Dimensional Symptom Questionnaire (4DSQ) in the general population: scale structure, reliability, measurement invariance and normative data: a cross-sectional survey
Authors
Berend Terluin
Niels Smits
Evelien P. M. Brouwers
Henrica C. W. de Vet
Publication date
01-12-2016
Publisher
BioMed Central
Published in
Health and Quality of Life Outcomes / Issue 1/2016
Electronic ISSN: 1477-7525
DOI
https://doi.org/10.1186/s12955-016-0533-4

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