The Holmes and Rahe Social Readjustment Rating Scale (SRRS)
The Holmes and Rahe stress scale is a list of 43 stressful life events that can contribute to illness. John Sarno, MD devotes almost 2 pages to the stress scale in his third book, The Mindbody Prescription.
The Holmes and Rahe Stress Scale and TMS, by Eric Sherman, Psy.D.
The following introduction to how the Holmes and Rahe Stress Scale is used in TMS treatment was donated by Eric Sherman, PsyD. Dr. Sherman is a co-author of Pathways to Pain Relief, with Frances Sommer Anderson, PhD, SEP. He completed his clinical psychology internship at The Rusk Institute of the Langone Medical Center in New York where he rotated through the Psychophysiological Pain Service, under the direction of John E. Sarno, MD, and Arlene Feinblatt, PhD. He worked with Dr. Sarno for 29 years, providing psychotherapy to Dr. Sarno's patients.
As part of Dr. Sarno’s psycho-educational approach to treating TMS/PPD, he introduces patients to the Holmes and Rahe Stress Scale. The scale predicts a person’s chances of developing a physical or emotional condition, based on cumulative exposure to stressful external events in the preceding year. Events range from mundane nuisances like getting a parking ticket to catastrophic events like the death of a spouse or the diagnosis of a life-threatening illness. The events are weighted: The parking ticket receives l point, the death of a spouse is assigned 50 points. Research indicates that when an individual accumulates more than 200 points in a year, he or she is at much greater risk of developing serious physical, emotional, or psychophysiologic conditions.
Although constitutional factors and personality variables play a role in an individual’s vulnerability and resistance to stress, no one can imagine an individual entirely unaffected by experiencing one or more of the following in the same year: the loss of a spouse, the amputation of a limb, an adult child’s bitter divorce, or a hefty assessment by the co-op board. However, the specific nature and magnitude of these effects vary greatly because of the highly subjective ways in which different people experience the same situation.
Personality variables, childhood experiences, and external stressors all contribute to the development of TMS/PPD. Holmes and Rahe Stress Scale is predicated upon the idea that individuals react in typical and therefore predictable ways to life events. Although this observation is largely true, there are no events that are intrinsically stressful, or benign. The experience of stress is always the co-creation of the event and how a particular individual subjectively perceives it. Let me illustrate this concept with an example from my own life. During a brief break in between appointments with patients, I dashed across the street to the bank to deposit a Canadian check. I live in New York City. The check had been declined for deposit by the ATM earlier that same day and I was advised to visit my branch manager. Upon my arrival, I encountered a line with 6 people ahead of me. In my impatient and pressured state of mind, it seemed that the customers couldn’t have been processed more slowly if the tellers had all been corpses. Then, much to my surprise and fascination, a young man, probably no more than 19 or 20 arrives 3 places behind me in line; he couldn’t be happier. I briefly entertained the possibility that he was one of those preternaturally cheerful people before I realized the long line represented a cherished escape from his job. The boss had sent him to make a deposit and the longer and slower the line, the more time he spent away from the office, a place he detested. That same line that tormented me in my hurried attempts to accomplish yet one more task in an already over-scheduled day was the answer to this young man’s prayers.
Therefore, the Holmes and Rahe Stress Scale should never be used either as the basis for diagnosing TMS/PPD, or excluding a diagnosis of TMS/PPD. The Holmes and Rahe Scale is an adjunct to a thorough examination by a physician experienced in diagnosing and treating TMS/PPD and a carefully conducted clinical inquiry by a mental health professional familiar with the varied presentations of TMS/PPD. Because of the highly subjective nature of the experience of stress, the Holmes and Rahe Stress Scale is not to be viewed as Gospel. However, it is a valuable tool for generating hypotheses about a person’s condition and guiding introspection in individuals who have already received a diagnosis of TMS/PPD.
The Holmes and Rahe Stress Scale can be viewed as a portal into an individual’s psychological interior. If an individual is appropriately diagnosed with TMS/PPD and his or her score on the Holmes and Rahe Stress Scale says “tilt”, one’s understanding of that person is far from complete and has only just begun. If the person is mourning the loss of a significant relationship, is the patient bereft or guilt-ridden because now there are no longer any obstacles standing in the way of an outside relationship? Or, does the death of the person force the individual to confront his or her own ambivalence about formalizing this outside relationship? Also, many people with TMS/PPD are so estranged from their own needs and feelings that they are genuinely surprised when they recognize the cumulative toll of their suffering. These people are often highly adept at rationalizing why their own needs and feelings should go unmet. The discrepancy between their own self-experience and the Holmes and Rahe Stress Scale illuminates how disconnected they are from recognizing the impact of events on their emotional state. The scores do not tell the story; they are footprints that can lead you to the heart of the matter when used correctly.
Similarly, when someone with a score that is “off the charts” doesn’t manifest any significant physical, emotional, or mindbody symptomatology, it doesn’t necessarily mean the Holmes and Rahe Stress Scale is no longer useful. Instead, several intriguing possibilities are raised. Is this individual someone who is genetically resistant to stress, as demonstrated by his or her history? Or, does this person have extraordinary coping resources and/or an extensive support network? Another possibility is that this individual cannot report distress that he or she is oblivious to. When this situation occurs, it suggests other lines of inquiry, for example: is the individual cognitively impaired; is the person deliberately providing an inaccurate account; is this behavior symptomatic of a personality disorder characterized by dissociative tendencies; is this person soothing him or herself with drugs and alcohol, thereby averting any experience of distress?
When the Holmes and Rahe Stress Scale is not used mechanically, another layer of understanding about an individual’s inner world is often revealed. If the person reports, for example, a bankruptcy or serious health problem in the past year, a history of financial recklessness or self-destructive habits might emerge. This same approach can also identify resources which mitigate the impact of stressful events. And of course, not all divorces are created equally. Some represent liberation and a new beginning; others are experienced as grievous losses and shameful failures.
Never should a high score on the Holmes and Rahe Stress Scale be used to blame anyone for his or her TMS/PPD symptomatology. As mentioned earlier, TMS/PPD symptomatology is a multifactorial phenomenon involving genetic resistance or vulnerability to stress, personality variables, the effects of childhood experiences, and the impact of external stressors. TMS/PPD can be likened to a perfect storm; no single contributing factor in and of itself ever leads to the development of this condition. Therefore, the Holmes and Rahe Stress Scale should never be misused to establish, confirm, or refute the diagnosis of a mindbody disorder. However, the Holmes and Rahe Stress Scale is a valuable tool to examine and understand an individual’s history and psychodynamics with respect to the development of TMS/PPD.
In 1967, psychiatrists Thomas Holmes and Richard Rahe examined the medical records of over 5,000 medical patients as a way to determine whether stressful events might cause illnesses. Patients were asked to tally a list of 43 life events based on a relative score. A positive correlation of 0.118 was found between their life events and their illnesses.
Their results were published as the Social Readjustment Rating Scale (SRRS), known more commonly as the Holmes and Rahe Stress Scale. Subsequent validation has supported the links between stress and illness.
Rahe carried out a study in 1970 testing the reliability of the stress scale as a predictor of illness. The scale was given to 2,500 US sailors and they were asked to rate scores of 'life events' over the previous six months. Over the next six months, detailed records were kept of the sailors' health. There was a +0.118 correlation between stress scale scores and illness, which was sufficient to support the hypothesis of a link between life events and illness.
In conjunction with the Cornell medical index assessing, the stress scale correlated with visits to medical dispensaries, and the H&R stress scale's scores also correlated independently with individuals dropping out of stressful underwater demolitions training due to medical problems. The scale was also assessed against different populations within the United States (with African American|African, Hispanic and White American groups). The scale was also tested cross-culturally, comparing Japanese and Malaysian groups with American populations.
In The Mindbody Prescription
In the chapter on "The Psychology of Mindbody Disorders" in The Mindbody Prescription, Dr. Sarno identified three sources of rage: "Trauma in Infancy and Childhood," "Personality Traits," and "The World Around Us." For the section on "The World Around Us," he reviewed how Holmes and Rahe constructed the list of life events in the stress scale and he also reproduced the entire list of 42 life events. Commenting on the list, he wrote: “We postulate that these events produce 'disease' through the mechanism of internal rage. ... Both positive and negative stress generate unconscious anger, whether or not one is consciously angry. Accumulated anger is rage, and frightening, unconscious rage leads to the development of physical symptoms.” He noted that the list, while it contains negative events, as might be expected, also contains positive events that could be socially desirable and “consonant with the American values of achievement, success, materialism, practicality, efficiency, future orientation, conformism, and self-reliance.”
This arguably suggests that even positive events, because they lead to change, can be stressful to our unconscious minds.
To measure stress according to the Holmes and Rahe Stress Scale, the number of "Life Change Units" that apply to events in the past year of an individual's life are added and the final score will give a rough estimate of how stress affects health.
|Life event||Life change units|
|Death of a spouse||100|
|Death of a close family member||63|
|Personal injury or illness||53|
|Dismissal from work||47|
|Change in health of family member||44|
|Gain a new family member||39|
|Change in financial state||38|
|Death of a close friend||37|
|Change to different line of work||36|
|Change in frequency of arguments||35|
|Foreclosure of mortgage or loan||30|
|Change in responsibilities at work||29|
|Child leaving home||29|
|Trouble with in-laws||29|
|Outstanding personal achievement||28|
|Spouse starts or stops work||26|
|Begin or end school||26|
|Change in living conditions||25|
|Revision of personal habits||24|
|Trouble with boss||23|
|Change in working hours or conditions||20|
|Change in residence||20|
|Change in schools||20|
|Change in recreation||19|
|Change in church activities||19|
|Change in social activities||18|
|Minor mortgage or loan||17|
|Change in sleeping habits||16|
|Change in number of family reunions||15|
|Change in eating habits||15|
|Minor violation of law||11|
Score of 300+: At risk of illness.
Score of 150-299: Risk of illness is moderate (reduced by 30% from the above risk).
Score <150: Only have a slight risk of illness.
A modified scale has also been developed for non-adults. Similar to the adult scale, stress points for life events in the past year are added and compared to the rough estimate of how stress affects health.
|Life Event||Life Change Units|
|Death of parent||100|
|Divorce of parents||90|
|Acquiring a visible deformity||80|
|Fathering a child||70|
|Jail sentence of parent for over one year||70|
|Marital separation of parents||69|
|Death of a brother or sister||68|
|Change in acceptance by peers||67|
|Unplanned pregnancy of sister||64|
|Discovery of being an adopted child||63|
|Marriage of parent to stepparent||63|
|Death of a close friend||63|
|Having a visible congenital deformity||62|
|Serious illness requiring hospitalization||58|
|Failure of a grade in school||56|
|Not making an extracurricular activity||55|
|Hospitalization of a parent||55|
|Jail sentence of parent for over 30 days||53|
|Breaking up with boyfriend or girlfriend||53|
|Beginning to date||51|
|Suspension from school||50|
|Becoming involved with drugs or alcohol||50|
|Birth of a brother or sister||50|
|Increase in arguments between parents||47|
|Loss of job by parent||46|
|Outstanding personal achievement||46|
|Change in parent's financial status||45|
|Accepted at college of choice||43|
|Being a senior in high school||42|
|Hospitalization of a sibling||41|
|Increased absence of parent from home||38|
|Brother or sister leaving home||37|
|Addition of third adult to family||34|
|Becoming a full fledged member of a church||31|
|Decrease in arguments between parents||27|
|Decrease in arguments with parents||26|
|Mother or father beginning work||26|
Score of 300+: At risk of illness.
Score of 150-299: Risk of illness is moderate. (reduced by || 30% from the above risk)
Score <150: Slight risk of illness.
- Holmes TH, Rahe RH (1967). "The Social Readjustment Rating Scale". J Psychosom Res 11 (2): 213–8. doi:10.1016/0022-3999(67)90010-4. PMID 6059863
- Rahe RH, Arthur RJ (1978). "Life change and illness studies: past history and future directions". J Human Stress 4 (1): 3–15. doi:10.1080/0097840X.1978.9934972. PMID 346993
- Rahe RH, Mahan JL, Arthur RJ (1970). "Prediction of near-future health change from subjects' preceding life changes". J Psychosom Res 14 (4): 401–6. doi:10.1016/0022-3999(70)90008-5. PMID 5495261
- Rahe RH, Biersner RJ, Ryman DH, Arthur RJ (1972). "Psychosocial predictors of illness behavior and failure in stressful training". J Health Soc Behav 13 (4): 393–7. doi:10.2307/2136831. JSTOR 2136831. PMID 4648894
- Komaroff AL, Masuda M, Holmes TH (1968). "The social readjustment rating scale: a comparative study of Negro, Mexican and white Americans". J Psychosom Res 12 (2): 121–8. doi:10.1016/0022-3999(68)90018-4. PMID 5685294
- Masuda M, Holmes TH (1967). "The Social Readjustment Rating Scale: a cross-cultural study of Japanese and Americans". J Psychosom Res 11 (2): 227–37. doi:10.1016/0022-3999(67)90012-8. PMID 6059865
- Woon, T.H.; Masuda, M.; Wagner, N.N.; Holmes, T.H. (1971). "The Social Readjustment Rating Scale: A Cross-Cultural Study of Malaysians and Americans". Journal of Cross-Cultural Psychology 2 (4): 373. doi:10.1177/002202217100200407. Retrieved 2008-04-10.
- Rahe RH et al. (2000). The stress and coping inventory: an educational and research instrument. Stress Medicine 16: 199-208.
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