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Limitations of adjustment for reporting tendency in observational studies of stress and self reported coronary heart disease
  1. J Macleod1,
  2. G Davey Smith2,
  3. P Heslop2,
  4. C Metcalfe2,
  5. D Carroll3,
  6. C Hart4
  1. 1Department of Primary Care and General Practice, University of Birmingham, UK
  2. 2Department of Social Medicine, University of Bristol, UK
  3. 3School of Sport and Exercise Sciences, University of Birmingham
  4. 4Department of Public Health, University of Glasgow, UK
  1. Correspondence to:
 Dr J Macleod, Department of Primary Care and General Practice, Division of Primary Care Public and Occupational Health, The Medical School, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK;

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Recently, observational evidence has been suggested to show a causal association between various “psychosocial” exposures, including psychological stress, and heart disease.1,2 Much of this evidence derives from studies in which a self reported psychosocial exposure is related to an outcome dependent on the subjective experience of coronary heart disease (CHD) symptoms. Such outcomes may be measured using standard symptom questionnaires (like the Rose angina schedule). Alternatively they may use diagnoses of disease from medical records, which depend on an individual perceiving symptoms and reporting them to a health worker. In these situations, reporting bias may generate spurious exposure-outcome associations.3 For example if people who perceive and report their life as most stressful also over-report symptoms of cardiovascular disease then an artefactual association between stress and heart disease will result.


We investigated this phenomenon among 5577 middle aged men recruited from 27 Scottish workplaces in 1970–73. Measurements at recruitment included psychological stress (Reeder Stress Inventory (RSI)), questions on the experience of a range of physical symptoms, “Rose” angina and six lead, resting electrocardiograph. There is good evidence of construct and concurrent validity of …

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