Psychology
2011. Vol.2, No.4, 283-290
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.24045
The Self-Assessment Perceived Global Distress Scale—Reliability
and Construct Validity*
—Perceived Global Distress Scale
Bo Ivarsson1, Leif Lindström2, Ulf Malm3, Torsten Norlander1
1Department of Psychology, Karlstad University, Karlstad, Sweden;
2 Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden;
3Institute for clinical neuropsychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden.
Received March 8th, 2011; revised April 16th, 2011; accepted May 17th, 2011.
Objective: the aim was to study psychometric properties of the Perceived Global Distress Scale (PGD) for peo-
ple with severe mental illness, mainly with schizophrenia disorders. Methods: PGD is a Visual Analogue Scale
included in “The Quality Star”, a minimal platform for clinical follow-up and efficiency documentation of men-
tal health services in eight dimensions used in Sweden. Naturalistic data was used. Validating instruments in-
cluded Quality of Life-100, Symptom Check List-90, Consumer Satisfaction Rating Scale—self-rating version,
Manchester Short Assessment of Quality of Life (MANSA), Global Quality of Life scale, Care Burden Scale for
Relatives, Perceived Global Burden, Brief Psychiatric Rating Scale (BPRS), Side Effect Rating Scale (SERS),
and Global Assessment of Functioning (GAF)—the split-GAF version. Concurrent validity with corresponding
item in MANSA was explored. Test-retest reliability of the GQL was examined. Results: the content validity
was clarified by associations with validating measures from several contexts in three studies, supporting con-
struct validity. Concurrent validity with the last item MANSA, “How satisfied are you with your mental health?”,
was demonstrated. Test-retest reliability was indicated. Conclusion: the Perceived Global Distress Scale (PGD)
was shown to have acceptable psychometric properties and valid for serious mental ill persons with schizophre-
nia disorders. Its use as an easy-to-use instrument for the screening of perceived global mental distress was sup-
ported.
Keywords: Schizophrenia, Severe Mental Illness, Distress, Visual Analogue Scale, Perceived Global Distress
Scale
Introduction
To support continuous improvement for the quality of care, a
concept was developed for regular (i.e., at least yearly) fol-
low-up together with the user and his or her next of kin. The
concept called ”The Quality Star” (Erdner & Ivarsson, 2002;
Ivarsson, Erdner, & Malm, 2006), aimed to be a minimal plat-
form for the follow-up of psychiatric care in a multi-dimen-
onal, holistic perspective using simple measures of generic
nature. Instruments should be handy in clinical praxis. They
should fill the function to be a point of departure for a dialogue
with users with an under-lying question “Where do we stand
now and how do we improve?” The aspects chosen for regular
review include professional ratings of present syndrome sever-
ity and psychosocial functioning as well as user ratings of per-
ceived complaints, satisfaction with services, subjective quality
of life, and also the burden to an important relative. The inclu-
sion of patients’ and relatives’ subjective measures was
strongly motivated by the desire to secure that user perspective
is in focus. With this perspective the choice of global instru-
ments was made, illustrated in Figure 1.
Figure 1.
Graphic representation of global instruments in “The Quality Star”
concept. Measures used for each dimension in parentheses. In addition
to chosen quality dimensions, a representation of resource use is in-
cluded in the bottom of the “star” by number of “days in care”, later to
be specified by national treatment content codes.
*The research plan has been evaluated and approved by the Regional Ethi-
cal Vetting Board in Uppsala and the study followed the ethical standards
of the World Medical Association declaration of Helsinki concerning
Ethical Principles of Medical Research Involving Human Subjects.

B. IVARSSON ET AL. 284
It was understood that more detailed instruments have to be
used in addition to the global measures in clinical work and
research, in varying degree depending upon focus and tasks.
However, the basic, simple instruments desired should be good
enough to be useful in benchmarking between the clinical cen-
ters participating in the Quality Star Network.
Regarding global mental distress or complaints, a minimal
instrument for rating the subjective, perceived dimension of the
phenomenon was sought. The network chose to use a single
visual analogue scale (Bech, 1993; Everitt & Wykes, 1999), the
Perceived Global Distress Scale (PGD), constructed for the
purpose by the network (GGG-group, 2009). It is an adaptation
for stand-alone use of the last item “How satisfied are you with
your mental health?” in Manchester Short Assessment of Qual-
ity of Life (MANSA) (Priebe, Huxley, Knight, & Evans, 1999).
However, the focus was narrowed by changing the introductory
question to “How much have you been bothered by your psy-
chiatric problems during the last month?”. The phenomenon
sought to capture by the scale is the degree of feeling mentally
distressed and/or having complaints regarding mental health,
irrespective of how the respondent arrived to an opinion. De-
grees of positive mental health are not focused, which is a dif-
ference to the MANSA. Thus, the PGD scale assumes that most
psychiatric patients experience degrees of mental health distress,
and if not, the scale does not give room for expressing degrees
of satisfaction with mental health. The intention with this re-
striction was to guide the respondent to focus on the issue if
mental health problems existed at all. In this sense, the PGD is
intended to support problem identification in the mental health
area together with the patient. A following dialogue should
clarify the precise nature of the problems that the patient ex-
periences. This was deemed advantageous compared to using
any of numerous available short form instruments with similar
aims, for instance the WHO Self Reporting Questionnaire 20
(Harpham et al., 2003), General Health Questionnaire (Gold-
berg & Williams, 1988), Kessler Psychological Distress Scale
(Andrews & Slade, 2001), Psycho-Social Well-Being Scale
(O’Hare et al., 2003). Though they are well-proven to detect
mental health problems, the more open question alternative
based on the MANSA item was preferred. More syndrome
directed self-assessments, for instance Hopkins Symptom
Check List (Derogatis, 2000) would not be alternatives because
of the inclination to professional concepts, being syndrome
oriented or because too lengthy.
The Quality Star Concept has been adopted by a number of
services in Sweden. Though the measures used have generally
been seen as useful in the clinic, there has also been criticism
that some of the instruments have not been properly investi-
gated regarding their psychometric properties. The initial as-
sumption that the new single item scales, like the PGB, derived
from established item in MANSA with relatively small adjust-
ments did not necessarily need thorough investigations before
being used was questioned. Therefore several studies have re-
cently been launched dedicated to investigate the validity and
reliability of instruments included in the Quality Star Test Bat-
tery, as the material available in the National Network Database
now permits basic studies. The aim of the present study was to
investigate the psychometric properties of the Perceived Global
Distress Scale (PGD) for seriously mentally ill (SMI) persons
with predominantly schizophrenia disorders.
Methods
Participants
Participants in this study were 1670 patients, 937 men and
733 women, where the Quality Star has been used on one or
more occasions during a ten year period at psychiatric centers
in 13 areas throughout Sweden, and where data was complete
regarding professional and patient instruments. At the first re-
corded use, their mean age was 43.77 years (SD = 12.15). The
majority, 87.87 %, had schizophrenia spectrum disorders (ICD
codes F20-F29). The remaining patients had representations in
particular from depressive and anxiety states (F30-F49). They
were, by large, SMI patients in long-term treatment and support
and rehabilitation schemes. Their reported mean duration of
illness was in the order of 17 years (SD about 11).
Some of the analyses were done on sub-samples with op-
tional use of instruments. The sub-samples were judged to be
similar enough regarding age, sex and diagnosis composition to
allow their uses in this study. Details are mentioned at the end
of the respective instruments presentations below.
Instruments
Perceived Global Distress Scale (PGD). The instrument is a
visual analogue scale (GGG-group, 2009). The introductory
question has the wording “How much have you been bothered
by your psychiatric problems during the last month?” and the
anchor-points of the VAS line is marked “I have not experi-
enced any psychiatric problems at all” and “My psychiatric
problems have troubled me extremely much”. The scale is a 10
cm line, thus giving a scale 0 - 100 mm. Rating 0 represents the
worst possible situation and 100 represents no problems. Pre-
sently, only two validation studies are available on limited pa-
tient materials by Bergman (2003) and Söderberg (2007).
Healthy adult population data for the PGD, was studied in a
separate work (Ivarsson, Andersson, Malmström, Carlsson, &
Johansson, 2010) and found to be mean 89.55 (SD = 19.18)
which may be compared with the mean value for patients in the
present study (M = 62.74, SD =27.90).
Quality of Life-100 (QOL-100). The Quality of Life-100
scale was constructed primarily to support working together
with patients regarding problem finding and solving (Skantze,
Malm, Dencker, May, & Corrigan, 1992). The inventory con-
tains 100 items in 14 dimensions (subscales) including Housing,
Household and Self-Care, Leisure, Housing Environment,
Community Services, Knowledge and Education, Contacts,
Physical Health, Mental Health, Work, Finances/Savings, Inner
Experience, Dependence, and anything else unsatisfactory. The
number of items in each domain differs. The patient is in-
structed to encircle items that are perceived as unsatisfactory in
life at the moment. This gives the value 1 and no mark gives the
value 0. The values on the subscales are calculated through
simple averaging the scores and expressing the percentage of
items rated unsatisfactory. Total score is obtained by expressing
the percentage of total number of items encircled. Test-retest
reliability was found good (r = 0.88 over 7 - 10 days). Correla-
tions between subscales and total sum were between r = 0.48 to
0.87. The total sum is also considered as a quality of life mea-
sure (Skantze & Malm, 1994). The mean value for QOL-100 in
the present study was 13.51 (SD = 11.42) for those patients (N
= 179) who used this optional instrument. Their background

B. IVARSSON ET AL. 285
characteristics were close to the total subset values.
Symptom Check List-90 (SCL90). The SCL-90 is a psy-
chiatric self-report inventory with 90 items scored on a five-
point Likert Scale of Distress with anchor points 0: none; 1: a
little bit; 2: moderately; 3:quite a bit; and 4: extremely, indi-
cating the rate of occurrence of the symptom during the last
week (Derogatis, Lipman, & Covi, 1973). The SCL-90 is
well-suited for measuring general mental health and changes in
symptoms (Bech, et al., 1993; Derogatis, 1994). The SCL-90
has been used as a central outcome measure in numerous clini-
cal trials, as an outcome measure, as a measure of mental status,
and as a screening instrument. It has been shown to have a good
reliability with high internal consistency. It discriminates pa-
tients from normal controls well and there is support for its
validity as a measure of general symptom severity, but there
less support for its suggested dimensionality and the nine sub-
scales should thus be treated with some caution. (Fridell, Ce-
sarec, Johansson, & Malling Andersen, 2002; Holi, 2003).
Validation of Swedish versions in use, have been done by
Fridell et al. (2002). The mean value for SCL-90 in the present
study was 1.11 (SD = 0.77). This instrument, for optional use,
was used in part of the material (N = 45). Background charac-
teristics were similar to the total subset values, though some-
what younger (mean 35 years), with shorter illness duration
(mean = 11.72 years), and more homogenous regarding diagno-
sis (98 % schizophrenia).
Consumer Satisfaction Rating Scale—Self-Rating Version
(ConSat-P). This self rating scale has questions in 6 process
quality domains (availability, atmosphere, treatment modalities,
information, drug treatment and psychosocial interventions) and
two out-come related domains (usefulness of treatment/care and
general well-being) (GGG-group, 2009). The ConSat-P scale
has been shown to have acceptable psychometric proper- ties
including acceptable internal consistency. Its use has been vali-
dated for schizophrenia spectrum disorders as well as for affec-
tive, anxiety and substance abuse syndromes (Ivarsson & Malm,
2007). In this study, the first 11 items was used as the 12th item,
regarding general well-being, was used as a specific instrument
(the GQL—see below). These items were rated on a seven point
scale with the format in principle +3 full satisfaction, +2 satis-
fied but with minor dissatisfaction, +1 More satisfaction than
dissatisfaction, 0 equally satisfaction/dissatisfaction or indeci-
sive, −1 to –3 formulated in a reciprocal fashion. The summary
score thus, ranges from –33 - +33. The Mean Value for patients
in the present study was 16.60 (SD = 9.78).
Manchester Short Assessment of Quality of Life (MANSA).
The MANSA (Priebe et al.,1999) contains 12 subjective quality
of life items (Life as a whole, Work satisfaction, Economy,
Satisfaction with friends, Leisure activities, Housing, Personal
safety, Satisfied with people you live with/living alone, Sex life
satisfaction, Satisfaction with family relations, Satisfaction with
physical health, Satisfaction with mental health). Items are
rated on a 7-point rating scale (1 = Couldn’t be worse, 7 =
Couldn’t be better). Cronbach’s alpha for the satisfaction rat-
ings was 0.74. The mean score of all satisfaction ratings was
used as the total measure for subjective quality of life
(MANSA-tot). The MANSA was validated in Sweden for seri-
ous mental ill (SMI) persons by Björkman and Svensson
(Björkman & Svensson, 2005) in regard to social network as-
pects and to beliefs of devaluation/discrimination. They also
found internal consistency adequate (Cronbach’s alpha = 0.81).
The mean value for MANSA-tot in the present study was 4.51
(SD = 0.95). This instrument was optionally used at some
places (N = 27). Background characteristics were similar to the
total subset values; though males were more common (male/
female 66.7/33.3%) and duration of illness somewhat longer
(mean 20.6 years).
Global Quality of Life Scale (GQL). The instrument is a
Visual Analogue Scale (GGG-group, 2009). The introductory
question has the wording” How do you find your life situation
right now?” and the anchor-points of the VAS line are marked
“Best possible life situation” and “Worst possible life situation”.
The scale is a 10 cm line, thus giving a scale 0 - 100 mm. Rat-
ing 0 represents the worst possible quality of life and 100 the
best possible. The GQL has been found valid for serious mental
ill persons with acceptable psychometric properties (Ivarsson,
Malm, Lindström, & Norlander, 2010). Test-retest reliability
was found satisfactory. Concurrent validity with the initial item
of life satisfaction scale of MANSA, “How satisfied are you
with your life as a whole today”, was good (r = 0.85 and rho =
0.86). Content validity was clarified by associations with a
number of validating measures. The Mean Value for GQL in
the present study was 60.39 (SD = 25.05).
Care Burden Scale for Relatives (CBS-R). This compre-
hensive scale was developed to describe the burden of relatives
and its change after interventions (Bergmark, Durling, Boström,
& Wistedt, 1990). Six areas are covered with a total of 92 items.
Items are constructed as 4-point scales using anchors of 1: No;
2: Sometimes; 3: Often and 4: All the time. The six areas are:
emotional burden, day-to-day aspects of burden, effects on
health, work, and siblings, and, finally, views of medication
and psychiatry. Psychometric properties of the CBS-R were
studied by Hjärthag, Helldin, and Norlander ( 2008), who found
internal consistency of the scale (Cronbach’s alpha 0.96).
Concurrent validity, tested by total score correlations with the
Clinical Global Impression scale, GAF, Camberwell Assesse-
ment of Needs, was plausible (rs = .28 to .44). Content validity
was further clarified by step-wise regression of all CBR-S items
using the PGB as criterion variable. The mean value for total
CBS-R in the present study was 38.67 (SD = 44.32). This in-
strument for optional use was used at some places (N=49). The
background characteristics for those participants were similar to
the total subset values, though sex distribution was more equal
(male/female 49/51%) and duration of illness was shorter
(mean 12.5).
Perceived Global Burden (PGB). This is a Visual Analogue
Scale constructed in a similar way as the GQL (GGG-group,
2009). The introductory question has the wording ”How big a
burden have you experienced (felt) the last month due to your
next of kin’s psychiatric problems?” and the anchor-points of
the VAS line are marked “No burdening feeling” and “The
greatest possible feeling of burden”. The scale is a 10 cm line,
thus giving a scale 0 - 100 mm. Rating 0 represents the worst
possible situation and 100 no burden. The PGB manual [4]
suggests that the respondent finally was asked what kind of
burden made him/her put the cross at the actual place. The PGB
has been validated in two studies (Erdner & Eiman, 2003;
Hjärthag et al., 2008) using the Care Burden Scale for Relatives
(Bergmark et al., 1990) indicating strong associations to several
subscales. The mean value for PGB in the present study was
66.76 (SD = 28.45). The instructions for use of this instrument

B. IVARSSON ET AL. 286
includes a recommendation to use it with some caution and first
consider if there is a present functioning contact with next of
kins before using it. This, and the absence of relevant next of
kins, resulted in less respondents (N = 744). Their background
characteristics were however similar to the total material.
Brief Psychiatric Rating Scale (BPRS). The 24 item BPRS,
version 4.0 was constructed to follow psychotic and affective
symptoms in serious mentally ill persons (Ventura et al., 1993).
Ratings are based on semi-structured interview (14 items)
and observations (10 items). A detailed manual contains inter-
view questions, symptom definitions and specific anchor points
for the 1 - 7 rating levels. The use required training, and with
trained raters good inter-rater reliability was reported (ICC in
the range of 0.8) (Ventura, Lukoff, Nuechterlein, Subotnik, &
Gilbert, 1995). The mean value for BPRS in the present study
was 39.00 (SD = 13.23). Background characteristics for those
patients where this optional instrument was used (N = 124)
were similar to the total subset values, except diagnosis was
more homogenous (96.6 % schizophrenia).
Health Screening, Using the Side Effect Rating Scale
(SERS). The SER comprises in its first part an inventory of 48
symptoms (45 for women and 42 for men) with well-defined
items and scale steps clustered into psychic, neurological,
autonomic and other symptoms areas (Lingjaerde, Ahlfors,
Bech, Dencker, & Elgen, 1987). Although it was primarily
constructed for monitoring side effects in drug treatment, its
broad content allows it to be used as a screening devise for
health problems, regardless if they are side effects, part of a
parallel disorder or part of a psychiatric syndrome. The scoring
pattern is: 1. Not present; 2. Possible presence or discrete; 3.
Clearly present; 4. Prominent. Only this first part, the “health
screening” is used in this study. In the second part of SERS a
judgment was made if the symptom present is or is not a medi-
cation side effect, which was not important when, (as in this
study), validation of the PGD is the aim. The summary index
used consisted of the sum of ratings on all items, i.e. if no
symptom was observed the sum is 45 or 42 for woman and men
respectively. The rating in percentage of maximum possible
rating for each sex is used for calculating a Sex Neutral Index
(SERS Index, 0 - 100). The Mean Value for the SERS Index in
the present study was 35.59 (SD = 7.73).
Global Assessment of Functioning (GAF). The instrument
measures global mental health from the perspective of psychic,
social, and functional ability (American Psychiatric Association,
2000). The scale has ten vignettes exemplifying symptom se-
verity and psychosocial functioning to be used as reference in
rating, each vignette representing successive 10-point intervals
in the semi-quantifying in the total scale range 1 - 100. Rating 1
represents the maximum dysfunction and 100 the best possi-
ble function. In each vignette, the first part exemplifies syn-
drome severity and the last part psycho-social functioning.
GAF is a much used scale and its psychometric properties are
documented in several studies, e.g. by Patterson & Lee (1995),
Söderberg (2007), Söderberg & Tungström (2007), and Ya-
mauchi, Ono, Baba, and Ikegami (2001). The split-GAF ver-
sion is used, with separate ratings of symptom severity (GAF-S)
and psychosocial functioning (GAF-F) (Pedersen, Hagtvet, &
Karterud, 2007). The mean value for GAF-S in the present
study was 50.44 (SD = 11.96) and for GAF-F it was 50.53 (SD
= 11.39).
Design
Content validity of the PGD scale for SMI patients was stud-
ied using a dataset from the Quality Star Database where Regis-
tration was completed for all patients and professional instru-
ments (N=1670). In addition, ratings on the PGB done by im-
portant others were used when completed, as well as a smaller
number of ratings on optional instruments. Correlations be-
tween PGD and the other instruments were analyzed. Since data
usually did not meet the demands for normal distribution, nei-
ther regarding kurtosis nor skewness, non-parametric statistics
were chosen for the analyses (Spearman’s rho). In analyses
using instruments that were not used for all patients in the sub-
set, patient background data was studied regarding representa-
tiveness. The smaller number of patients available in some of
the analyses was due to the naturalistic nature of the data, as
services use the instruments when locally considered useful in
the specific clinical situation only. Also, because of the study
being based on naturalistic data, no formal test-retest study was
staged. Instead, available patient data with three consecutive
yearly ratings were analyzed to address the issue.
Procedure
Decision to participate in the Quality Star Network by the
psychiatric departments include ethical considerations regard-
ing clinical follow up by using data from routine care and qua-
lity systems. The data software was not delivered to any site
unless such declaration was given. The personal were trained in
use of the instruments following the manual (GGG-group,
2009). Instructions include that GPD, as well as the other sub-
jective instruments, should be used in a most neutral situation
as possible, for instance not directly after focus on topics that
may influence the rating. Subjective instruments should not be
used immediately following each other, for the same reason.
Participants were introduced to the Quality Star at routine vis-
its by their Case Manager (CM) and given written information.
Right to withdraw without further motivation, and right to get
extracts from the data-base was part of the information. If they
chose to participate, this is noted in the clinical case notes. The
CM went through the instruments with the patient at one or two
ordinary appointments with the primary purpose to review the
situation, to further the document findings in the patient’s record,
and in the Quality Star data-base. The CM prepared the first
contact by reviewing notes to enter background data regarding
history and sociodemographic questions. Recommended order to
use the instrument is to start with GQL and then ConSat-P. Next
the CM turned to the question if the participant would be willing
to let a next of kin or an “important other” tell if he/she is trou-
bled by burden in order to—if so—discuss how the situation
might be improved. Written information of the Quality Star
Method and the instrument PGB is presented. The next instru-
ment presented is the PGD, followed by the SERS. Finally, the
CM presented his rating of the GAF.
Additional instruments used locally to penetrate further the
areas covered by the global measures mentioned above, such as
using the BPRS to expand information of symptom severity
beyond GAF-symptom rating, were presented after the global
measures. Concluding, a summary presentation (Figure 1) of all
ratings was done and discussed with the user what needs were
to be taken care of in the following review of the personal

B. IVARSSON ET AL. 287
treatment plan. Entries to the local Quality Star software are
transferred to the national data-base at intervals where partici-
pant identification was replaced by random identification.
Results
Correlations between the PGD scale and used validation in-
struments are reported in three sections: Correlations with other
self-report instruments (part 1), instruments used by important
others (part 2) and professionally used instruments (part 3).
Finally, the analyses regarding test-retest properties of the PGD
are reported (part 4). Note that negative correlations reported
are due to construct differences where high scores in some in-
struments represent the positive situation and in others the most
problematic situation. Thus, all correlations are showing vari-
ous degrees of convergent validity. Distinct divergent results
did not appear in the analyses, though significant low correla-
tions may be indicative.
Results Part 1—PGD Correlations with Other
Self-Report Instruments
Spearman’s correlation between PGD and the quality of life
inventory QLS-100 total sum was rho = −0.39 and in about the
same level with items covering perceived problems with Mental
Health, Felling understood by others, Shopping, and Inner
Harmony (See Table 1 for further details here and in the fol-
-lowing results). The correlation with the Total Index of the
Self-Report Symptom Inventory SCL-90 was rho = −0.54, and
in the same order with indices for interpersonal difficulties and
anxiety. Correlation with the Depression Index was stronger
(rho = −0.64). The correlation with the Consumer Satisfaction
Scale ConSat-P total sum was low, though rho = 0.27 for one
of the items (Perceived results of treatment). No significant
correlation was found for the MANSA mean, but two of the
items, “Mental health” and “Life as a whole” had stronger cor-
relations (rho = 0.59 and rho = 0.54). Similarly, the correlation
with the Global Quality of Life Scale GQL was rho = 0.55.
Results Part 2—PGD Correlations with Instruments
Used by Important Others
No significant correlation was found with the CBS-R total
score, and most notable correlation was found with the item
“Problem understanding what happens” (rho = −0.28). Correla-
tion with the Global Burden Scale PGB was rho = 0.32. For
details see Table 1.
Results part 3—PGD Correlations with Professional
Instruments
Correlations between PGD and the total scores of the two
symptom rating scales BPRS and SERS were in the same order
(rho = −0.41 and rho = −0.45 respectively). Several items had
similar or near similar correlations, as can be seen in Table 1.
The symptom severity rating with GAF-S had lower correlation
(rho = 0.24)
Results Part 4—Clinical Test-Retest Reliability
Properties
As a measure for test-retest reliability of the PGD scale
Spearman’s correlations between a 2nd and 3rd consecutive
year ratings was studied for patients in the Quality Star Data-
base, who had previous years, i.e. 1st and 2nd recorded year,
rated PGD on a equal level, not exceeding +/− 9 points between
years. This was chosen as indicating a subjective near equal
perception of distress the two years. As a control for that the
mental situation for the patients were reasonably equal also for
year’s 2 and 3, the professional GAF-symptom ratings was
used. For the analysis only patients that did not differ more than
+/− 9 points on the GAF-symptom scale was used, assuming
that this professional judgment indicated that symptom severity
was near equal both years for this subgroup. Patients having
used the Quality Star Ratings for three consecutive years were
numbering 404. This subgroup with stable meeting the inclu-
sion criteria as described above consisted of 118 persons (60
men and, 58 women. aged mean 46.28 and mean duration of
illness 19.34 years. Diagnosis was in 95.59% schizophrenia
spectrum disorders, ICD codes F20-F29. Spearman correlation
between year 2 and year 3 PGD ratings for this group was rho =
0.75 (p < 0.001).
Discussion
The main results in this validation study regarding the PGD
scale were: 1) content validity was clarified by associations
with a number of validating measures and strengthened by the
fact that findings were based on multi-site data. The findings
were also supportive for construct validity; 2) concurrent valid-
ity with the last item of life satisfaction scale MANSA, “How
satisfied are you with your mental health”, was demonstrated; 3)
clinical test-retest reliability was indicated.
The findings regarding content validity were suggested valid
for seriously mental ill (SMI) persons, mainly in the schizo-
phrenia spectrum of diseases, in supportive and/or rehabilitation
phases in a Swedish context, given the comparatively large,
naturalistic material from more than 13 hospital organizations
including about 60 specific units with various service objectives
for SMI patients ranging from intensive treatment and rehabili-
tation to supportive programs. The concurrent validity of the
PGD with the last item of MANSA was found reasonably good
(Spearman´s correlation rho = 0.59), considering the differ-
ences in construction pointed out in the Instruments section.
Associations found considered supporting content validity
are summarized in Table 1. Associations with features of de-
pression and anxiety as well as perceptions of interpersonal
aspects were indicated by notable correlations between partici-
pants’ PGD ratings and ratings on the subjective SCL90 (rho’s
about 0.5 - 0.6). Correlations with QLS-100 sum and several
items (rhos between –0.36 - 0.39) were also indicating that the
respondents’ interpretation of the PGD construct includes, apart
from mental health, interpersonal as well as autonomy and sa-
tisfaction elements. There was also an association to the dy-
namics of improvement shown by correlation with the specific
item in the satisfaction scale ConSat-P (rho = 0.27). The strong
association between the PGD rating and perception of mental
health and a quality of life dimension were further underlined
by correlations to the relevant MANSA items (rhos about 0.5 -
0.6) and total sum, along with regarding quality of life, the
correlation to the Global Quality of Life Scale GQL (rho =
0.55). The inclusion of an interpersonal element in patients’

B. IVARSSON ET AL. 288
Table 1.
Correlations between PGD scal e a nd t ot al s of va li da tion instruments a s well as most prominent indices/items of the respective instruments.
Perceived Global Distress scale
Spearman’s rho p-values n
Self-report i nstruments
QOL-100
Total sum
Mental health
Feeling understood by others
Shopping
Inner harmony
−0.39
−0.37
−0.37
−0.37
−0.36
<0.001
<0.001
<0.001
<0.001
<0.001
179
SCL90
Total index
Depression index
Interpersonal index
Anxiety index
−0.54
−0.64
−0.51
−0.50
<0.001
<0.001
<0.001
<0.001
45
ConSat-P
Total sum
Item “Perceived result of treatment”
0.19
0.27
<0.001
<0.001
1670
MANSA
MANSA mean
Item “Mental health”
Item “Life as a whole”
0.35
0.59
0.54
0.077
0.001
0.003
27
GQL 0.55 <0.001 1670
Instruments for important others
CBS-R
CBRS-R total sum
Item “Problem understanding what happens”
−0.17
−0.28
0.232
0.048
49
PGB 0.32 <0.001 744
Professional ratings instr uments
BPRS
BPRS total sum
Item ”Anxiety”
Item “Depression”
Item ”Hallucinations”
Item “Guilt”
−0.41
−0.43
−0.39
-0.33
-0.32
<0.001
<0.001
<0.001
<0.001
<0.001
124
SERS
SERS total index
Item “Tension/Inner unrest”
Item ”Depression”
Item ”Concentration difficulties”
Item “Asthenia/Lassitude/Increased fatigability”
−0.45
−0.48
−0.47
−0.39
−0.34
<0.001
<0.001
<0.001
<0.001
<0.001
1670
GAF-S 0.24 <0.001 1670
Significance level p < 0.001.
perception of mental health as rated with the PGD was further
supported by the fact that the only item in the comprehensive
next-of-kin burden scale CBS-R that showed notable correla-
tion (rho = −0.28), was an item about understanding the situa-
tion and correlation with the “important other´s” global burden
scale PGB (rho = 0.32). The correlations with professional
ratings on the BPRS and SERS scales provided some external
validation to the patient construct of the PGD. Items concerned
with anxiety and depression features were notably correlated to
the PGD (rhos about –0.4 - –0.5). Also, the interpersonal aspect
was supported (BPRS item “Guilt” rho = –0.32). Interestingly,
there may also be an indication that patients do also de facto
consider psychosis specific elements, as there was notable cor-
relation noted to the item “Hallucinations” in the BPRS, and
there may also have been a connection to the negative symp-
toms of psychosis as SERS items for “Concentration Difficul-
ties” and “Asthenia” showed correlations (rho –0.39 and –0.34
respectively”. On the other hand the severity of symptoms did
not seem to be similarly judged by patients and professionals as
correlation to GAF-S was lower, rho = 0.24. These findings
were in support of views expressed by Lindström, Jedenius, and
Levander (2009), who pointed out that: “patients appear to

B. IVARSSON ET AL. 289
construct their appreciation of degree of illness differently than
clinicians. Much of the feelings of being ill seems to be chan-
neled via affective symptoms.”
Regarding the importance of using patient subjective illness
ratings in the clinical work Lindström et al. (2009) also suggest:
“This may open an alternative way to communicate with
(schizophrenia, authors’ remark) patients about their illness.
Rather than confronting them with respect to the psychotic
symptoms …… we should focus on their affective reaction to
the actual situation”. This view is very much coinciding with
the intended construct of the PGD scale and its rationale for use,
as was described in the Introduction: ‘The PGD is intended to
support problem identification in the mental health area to-
gether with the patient, and a following dialogue should clarify
the precise nature of the problems that the patient experiences’.
It was important that the question has an open character to fa-
cilitate that the patient’s perception is expressed. The findings
reported do support that the intended construct was achieved in
a satisfactory way.
The successful use of clients’ subjective ratings in alliance
building to enhance recovery has also been suggested in terms
of “Client-Directed Outcome-Informed (CDOI)” work (Duncan,
Miller, Wampold, & Hubble, 2010) The theory behind the
Quality Star Concept fits well with the CDOI concept, relating
the user and professional dimensions.
The study has weaknesses. The test-retest properties study
reported in Results Section 4, was done in order to shed some
light on the matter using the data available however, studies
with a stricter design are necessary to verify the findings. Ne-
vertheless, the present results were considered as a fairly robust
indication that the test-retest properties were sufficiently reli-
able. The study was further hampered by the limited data
available for some of validation instruments for instance re-
garding the concurrent validity study (N = 27). Another weak-
ness of the study was that participant background data was
limited regarding for instance, sociodemographic data due to
the naturalistic data sources, and we were thus not in the posi-
tion to describe the possible influence of such external valida-
tion circumstances.
Also, as the PGD was constructed with the purpose to be a
generic instrument regardless of diagnosis, the study was lim-
ited in clarifying these matters only for SMI persons in the
schizophrenia spectrum. Although other diagnostic groups were
also represented in the material, they were insufficient in num-
bers to allow detailed presentation. Further studies should also
take in account the properties of PGD as a measure of change,
which was not covered by this study. Finally, it should be
pointed out that the question if VAS scales, like PGD, are suit-
able for obtaining correct categorical or numerical values for
subjective phenomena is discussed, but the problem area was
out of the scope for this paper.
In conclusion, it is suggested that the PGD in regard to seri-
ous mental ill persons with schizophrenia disorders was shown
to have acceptable psychometric properties. It is deemed justi-
fied to use this easy to use instrument for screening perceived
global distress in individual cases. Unsatisfactory level and
change in PGD on repeated administration could be a signal to
explore the problem closer by interview and/or specific instru-
ments. On a group level, with aggregated data, it will be rea-
sonable to foresee that the self-assessment Global Quality of
Life Scale can be used in a similar fashion as for instance the
GAF scale, aiming at adding a user subjective view to the pro-
fessional global severity rating.
Acknowledgements
Authors acknowledge the excellent technical assistance of
Göran Eiman, RN, Ass. Head Psychiatric dept., Kungälv Hos-
pital, Kungälv in preparing the database used. Our gratitude is
also expressed to all users of the Quality Star method and their
willingness to make their data available for this study. Our
thanks goes also to Ms Carol Schultheis for her careful english
language improvements suggest to us.
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