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Article

Association between Negative Life Events and Somatic Symptoms: A Mediation Model through Self-Esteem and Depression

by
Sijia Lv
1,
Tong Chang
2,
Siyu Na
2,
Lei Lu
3 and
Erying Zhao
2,4,*
1
Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin 150081, China
2
Psychological Science and Health Management Center, Harbin Medical University, Harbin 150081, China
3
Department of Engineering Science, University of Oxford, Oxford OX1 3PJ, UK
4
Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK
*
Author to whom correspondence should be addressed.
Behav. Sci. 2023, 13(3), 243; https://doi.org/10.3390/bs13030243
Submission received: 27 December 2022 / Revised: 19 February 2023 / Accepted: 5 March 2023 / Published: 10 March 2023
(This article belongs to the Section Social Psychology)
Browse Figure
Versions Notes

Abstract

:
The purpose of this study was to investigate the serial multiple mediation of self-esteem and depression in the relationship between negative life events and somatic symptoms in Chinese medical students. We recruited a total of 3383 medical students for this study, and used the Patient Health Questionnaire-15 to assess the somatic symptoms of subjects; the Adolescent Self-Rating Life Events Check List to assess negative life events; the Rosenberg Self-Esteem Scale to assess self-esteem; and the Patient Health Questionnaire for depression. Descriptive analysis and statistical tests were then performed on the collected data. We showed that 39.17% of the medical students had mild somatic symptoms, 24.14% had moderate somatic symptoms, and 5.66% had severe somatic symptoms; we observed significant differences in somatic symptoms among genders, living expenses, and one-child. For negative life events, interpersonal stress was the most important predictor of somatization during the regression analysis. In addition, we observed significance for both the direct and part of the indirect paths from negative life events to somatic symptoms using mediation model analysis. However, we noted that there was no significance for the path through negative life events and self-esteem to somatic symptoms. This study revealed a high prevalence of somatic symptoms among Chinese medical students, and the findings suggested that interventions aimed at reducing somatization in this population should consider the impact of negative life events, particularly those related to interpersonal stress. One potential approach to mitigating the effects of negative life events on somatization is to enhance self-esteem and decrease the level of depression among medical students.

1. Introduction

Somatic symptom disorder is characterized by an extreme focus of a person on physical symptoms, such as pain, headaches, weakness, or shortness of breath, which causes significant distress and/or impairment in daily functioning [1]. These symptoms are commonly observed among adolescents [2,3]; for example, a previous study found that the prevalence of somatic symptoms was 22.7% among 15–16-year-old adolescents in a cross-sectional study in Sweden [4]. Although somatic symptoms are typically not life-threatening, they can affect individuals’ daily lives, such as sleep, psychological well-being, and social activities, which can reduce their quality of life and interfere with learning and work abilities. In addition, somatic symptoms often result in repeated and prolonged medical treatments, which can impose a significant economic burden on society [5,6].
The pathogenesis of somatic symptoms is unclear, i.e., medically unexplained symptoms (MUSs) [7]. However, previous studies have suggested that negative life events may play a significant role in the development and course of somatic symptoms [8]. Negative life events are often described as sudden and dramatic experiences, which have the potential to significantly alter an individual’s social world (e.g., unemployment, discrimination, or financial hardship) [9,10]. Proposed mechanisms for the association between negative life events and somatic symptoms involve physiological and emotional stress responses [8]. These negative events often elicit unpleasant emotional experiences, such as unease, helplessness, negativity, anxiety, and so on, which can lead to the development of negative emotional states in individuals. For example, children or adolescents in their early stages of psychological development are particularly susceptible to the impact of negative life events and are at a higher risk of developing somatic symptoms [11]. Additionally, previous research showed that the college students who have experienced high levels of childhood trauma reported more somatic symptoms, likely due to the stress associated with the transition period from adolescence to adulthood [12]. In particular, the college students face a range of academic and social demands and need to adapt to various psychological changes in preparation for their working lives, which can make this period one of the most stressful periods of an individual’s life.
In addition to the impact of negative life events, research suggests that somatic symptoms are closely associated with depression [13,14]. A study found positive correlations between depression and somatic symptoms, including headache, stomach ache, constipation, diarrhea, backache, and fatigue [14]. A cross-cultural study confirmed this link in both Japanese and American undergraduates, with significant correlations found between depression and somatic symptoms for both men and women [15]. Notably, depression and depressive symptoms are prevalent among medical students, with a rate of 27.2% among 122,356 individuals across 43 countries [16]. Studies have suggested that Chinese medical students with a mean prevalence of 32.74% in particular suffer from more severe depression [17].
Negative life events can be significant stressors that contribute to the development of depressive symptoms in adolescents [18]. Prolonged exposure to such events can lead to feelings of hopelessness and helplessness, which may, in turn, result in the development of depressive symptoms. Common stressors experienced by college students often pertain to school life, such as academic failure, and interpersonal relationships, including conflicts with roommates. Medical students, in particular, may face higher levels of stress due to the length of their schooling and clinical practice. These acute stressors can significantly disrupt mental well-being and potentially lead to the emergence of depressive episodes [19]. Maladaptive emotion regulation strategies mediate the relationship between relational stress and challenging life events and depressive symptoms [20]. On the basis of these factors, we propose our first hypothesis that depression may serve as an intermediary variable between negative life events faced by medical students and somatic symptoms.
To investigate the relationship between negative life events and somatic symptoms, we propose another potential pathway that is mediated by self-esteem. This is because self-esteem is a crucial aspect of an individual’s self-concept, which involves their overall assessment of their positive or negative value [21]. People with low self-esteem often have a negative self-evaluation, leading to reduced confidence and courage in dealing with life’s challenges [22]. Previous research has explored the mediating role of self-esteem and its impact on social life in different adolescent groups, including left-behind children [23], college students [24], and medical students [25]. Negative life events can cause a decline in self-esteem, as reported in previous studies, while higher self-esteem has been associated with better social adaptation and increased peer trust and perceived social support [26,27]. Self-esteem has been shown to influence individual cognition, motivation, emotion, and behavior [27]. Therefore, we propose our second hypothesis that self-esteem may mediate the relationship between negative life events faced by medical students and somatic symptoms.
According to the susceptibility model of depression, negative self-evaluation is considered a risk factor for depression [28]. Since self-esteem is a core component of an individual’s self-evaluation, it may also have a negative predictive effect on depression. Previous research found that higher self-esteem can decrease the likelihood of an individual experiencing depression [29]. Negative life events may cause low self-esteem [26], which may exacerbate or even trigger depression, ultimately leading to somatic symptoms. Therefore, self-esteem and depression may have a chain relationship as mediators for negative life events leading to somatic symptoms.
The multiple mediation model is an approach that involves two or more mediation variables between independent and dependent variables. It has been widely used for analyzing the relationships in mental health [30] and social behavior [31]. This model has been shown promising performance in exploring the underlying mechanisms of the relationship between the independent and dependent variables. However, there are limited studies that have examined the association between negative life events and somatic symptoms while considering the self-esteem and depression of medical students, particularly among Chinese medical students. Therefore, this study investigates the serial multiple mediation of self-esteem and depression in the relationship between negative life events and somatic symptoms, with the aim of revealing how negative life events, as an external social factor, may act on somatization through internal cognitive and emotional psychological factors. Ultimately, this study will provide evidence for potential interventions that could alleviate somatic symptoms experienced by medical students.

2. Methods

2.1. Study Design and Participants

A cross-sectional study was conducted to collect data for this research at Harbin Medical University, China. A total of 3383 clinical medical students were invited to participate in the experiment. Participants were first informed about the objective of the study, and they were assured that no personal identities would be disseminated. Each subject was then asked to complete a voluntary and anonymous questionnaire, which included sociodemographic information, such as age, gender, living expenses, and whether the subject was the only child in their family (i.e., one-child). Four standard scales were used to assess somatic symptoms, negative life events, self-esteem, and depression for each participant. The details of these scales can be found in the following sections. After distributing the scales to all 3383 students, we collected the responses and excluded incomplete scales, resulting in 3219 effective responses, with a response rate of 95.16%. Of the participants with effective scales, 1399 were male (43.46%) and 1820 were female (56.54%), with an average age of 20.92 ± 0.94 years old. The study was approved by the Ethics Committee of Harbin Medical University.

2.2. Measurement of Somatic Symptoms

The Patient Health Questionnaire-15 (PHQ-15) was used to assess the somatic symptoms of the subjects in this study [32]. This self-rating scale is a suitable tool to measure the severity of somatization disorders and somatic symptoms. The PHQ-15 consists of 15 items distributed in three dimensions, including cardiothoracic, gastrointestinal, and general discomfort. Each item is rated on a 3-point scale (0 = not bothered at all, 1 = bothered a little, 2 = bothered a lot). The total score ranges from 0 to 30, and higher scores indicate greater severity of somatic symptoms. Somatic symptom severity is categorized into four levels: non or minimal (0–4), low level (5–9), medium level (10–14), and high level (≥15).

2.3. Measurement of Negative Life Events

The Adolescent Self-Rating Life Events Check List (ASLEC) was used to assess the negative life events experienced by the participants [33]. This questionnaire was designed to evaluate the occurrence and impact of negative life events in five dimensions, including interpersonal stress (such as being misunderstood or blamed by others), academic pressure (such as having a heavy academic burden), punishment (such as criticism or corporal punishment), personal loss (such as the death of friends or relatives), and adaptation (such as a deterioration in living habits). The scale consists of 27 items, and participants were asked to report whether the listed events had occurred in the past 12 months and to rate the degree of their impact using a 6-point scale ranging from 0 (never experienced) to 5 (experienced and very strongly impacted). A higher score indicates more negative life events experienced. The ASLEC has previously been shown to have good reliability (Cronbach’s α = 0.91) and validity in the Chinese population [34].

2.4. Measurement of Self-Esteem

The situation of self-esteem of subjects was assessed by the Self-Esteem Scale (SES) [35]. This questionnaire is a commonly used self-report tool for evaluating an individual’s self-esteem. Participants were presented withasked to answer 10 items, such as “I feel that I have a number of good qualities”, and all items in SES were rated on a 4-point scale ranging from “strongly agree” to “strongly disagree”. Five of the items, such as “I feel I do not have much to be proud of”, were reverse scored. The average score was then calculated and used as a measure of self-esteem, with higher scores indicating higher levels of self-esteem.

2.5. Measurement of Depression

The depression of subjects was assessed by the Patient Health Questionnaire (PHQ-9). The PHQ-9 is a widely used screening, diagnostic, and monitoring tool for measuring the severity of depression, as recommended by the American Psychiatric Association [1]. Participants are asked to evaluate the presence of 9 symptoms over the previous two-week period, including depressed mood, anhedonia, sleep problems, fatigue, changes in appetite or weight, feelings of guilt or worthlessness, difficulty concentrating, feelings of sluggishness or agitation, and suicidal ideation. Responses are rated on a 4-point scale ranging from 0 (not at all) to 3 (nearly every day). The total score can range from 0 to 27, with higher scores indicating greater severity of depression. Severity is categorized into five levels: none-minimal (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe (20–27).

2.6. Statistical Methods

Descriptive analysis was used to describe the summary of the demographic characteristics of the participants. The independent samples t-test and one-way analysis of variance (ANOVA) were utilized to compare demographic variables, such as gender, living expenses, and one-child, as well as the distribution of somatic symptoms. Spearman correlation analysis was performed to examine the relationships between four variables: negative life events, self-esteem, depression, and somatic symptoms. Statistical software SPSS version 24.0 was used to conduct these analyses. To evaluate the significance of the multiple mediator model, we employed Model 6 of the PROCESS macro for SPSS. This method is based on ordinary least-squares regression and the bootstrap method. The 1000 bootstrap bias-corrected 95% confidence intervals (BC cIs) were used for mediation analyses in the test from the Serial Multiple Mediation Model 6. Statistical significance was defined as p < 0.05.

3. Results

3.1. Somatic Symptoms of Medical Students

The statistical results of somatic symptoms experienced by medical students are presented in Table 1. Out of the 3219 medical students, only 999 (31.03%) did not suffer somatic symptoms, 1261 (39.17%) reported mild somatic symptoms, 777 (24.14%) had moderate somatic symptoms, and 182 (5.66%) had severe somatic symptoms. There are 15 types of somatic symptom selections in the questionnaire PHQ-15, and Table 2 presents the statistics of the medical students with somatic symptoms. The numbers of people suffering these symptoms from the most to the least are constipation, loose bowels, or diarrhea, 1875 (84.46%); feeling tired or having low energy, 1819 (81.94%); nausea, gas, or indigestion, 1732 (78.02%); headaches, 1637 (73.74%); stomach pain, 1440 (64.86%); feeling heart pound or race, 1417 (63.83%); back pain, 1306 (58.83%); pain in arms, legs, or joints, 1289 (58.06%); trouble sleeping, 1276 (57.48%); menstrual cramps with periods, 1210 (54.5%); chest pain, 899 (40.5%); dizziness, 899 (40.5%); shortness of breath, 672 (30.27%); fainting spells, 208 (9.37%); and pain or problems during sexual intercourse, 172 (7.75%).

3.2. Statistical Analysis

The statistical test results of somatic symptoms in different groups are presented in Table 3. The table shows that there are significant differences in somatic symptoms between genders (p < 0.05), with females having a significantly higher degree of somatic symptoms (8.37 ± 4.52) than males (5.44 ± 4.15). The ANOVA results reveal significant differences in somatic symptoms among medical students with different living expenses and one-child (p = 0.005). In particular, medical students who had higher living expenses or were not the only child in the family experienced more severe somatic symptoms. However, no significant differences were found in somatic symptoms among different emotional statuses and religious beliefs.

3.3. Correlation Analysis

The results of the correlation analysis between negative life events, self-esteem, depression, and somatic symptoms are presented in Table 4. As shown in the table, there were positive relationships between negative life events and self-esteem, depression, and somatic symptoms. Furthermore, self-esteem was positively correlated with depression and somatic symptoms, and depression was positively related to somatic symptoms. These correlation analysis findings provide the necessary basis for the subsequent mediating effect test.

3.4. Regression Analysis

We conducted regression analysis to further examine the predictive effect of different types of negative life events on the somatization scores. As shown in Table 5, the regression results indicate that punishment, loss, interpersonal relationship pressure, and learning pressure were positively associated with somatization. In particular, interpersonal stress had the most significant predictive effect on somatization. However, adaptive life events showed negative predictive effects on somatization.

3.5. Mediation Analysis

We established a mediating model with negative life events as the independent variable, somatic symptoms as the dependent variable, and self-esteem and depression as mediating variables. As shown in Figure 1, the results of the mediating effect test indicate that negative life events of adolescents not only had direct effects on somatic symptoms but also had indirect effects on somatic symptoms through self-esteem and depression. The significant pathways include negative life events → somatic symptoms; negative life events → depression → somatic symptoms; and negative life events → self-esteem → depression → somatic symptoms. All mediation models were partial mediation models.
The Bootstrap method was used to determine the serial multiple mediation of self-esteem and depression between the four variables. As shown in Table 6, the results of the mediation test demonstrate that the following paths were statistically significant: the path through negative life events to somatic symptoms (point estimate = 0.0310; 95% BC CI [0.0229, 0.0391]), the path through negative life events → self-esteem → depression → somatic symptoms (point estimate = 0.0101; 95% BC CI [0.0079, 0.0125]), and the path through negative life events → depression → somatic symptoms (point estimate = 0.0414; 95% BC CI [0.0363, 0.0467]). However, the path through negative life events → self-esteem → somatic symptoms (point estimate = −0.0012; 95% BC CI [−0.0030, 0.0006]) was observed as not significant. The results indicate that self-esteem and depression may play a sequential mediating role between negative life events and somatic symptoms. Therefore, this model does not conform to the characteristics of the composite multiple mediation model.

4. Discussion

Somatic symptoms have received considerable attention among adolescents in recent years. Our study is the first to examine whether depression and self-esteem can moderate the relationship between negative life events and somatic symptoms among medical students in the north of China. The study yielded three important findings: First, the prevalence of somatic symptoms was high among medical students in China, and a significant correlation was found among negative life events, self-esteem, depression, and somatic symptoms. Second, different types of negative life events had varying predictive effects on somatic symptoms, with negative life events about interpersonal pressure having the most significant influence. Third, self-esteem and depression played roles to mediate negative life events and somatic symptoms, but only partially.
The study found that 68.97% of medical students experience somatic symptoms, underscoring the need for greater attention to the prevention and intervention of somatization in this population. The most commonly reported symptoms were general discomfort (including headache, dizziness, fatigue, and insomnia), consistent with previous findings [36]. The questionnaire PHQ-15 involved 15 typical somatic symptoms and revealed that constipation, loose bowels, or diarrhea; feeling tired or having low energy; and nausea, gas, or indigestion were the top three symptoms reported. These symptoms may be attributed to the prolonged years of study, heavier academic burden, and the high-level requirements of medical education that medical students face in comparison to their peers. Additionally, medical students are a vulnerable population, as they must manage multiple stressors, which may contribute to the development of somatic distress [37].
This study found that female medical students scored higher than male students in somatic symptom problems, which is consistent with the results in previous studies [38,39]. This gender difference may be attributed to females being more sensitive, vulnerable, and influenced by their surroundings, leading to a deeper perception of negative life events. Moreover, medical students who were not the only child faced more severe somatic symptoms, potentially due to the lack of parental support. Being the only one child in the family, the student may enjoy more resources and less life pressure, which can reduce the likelihood of developing somatic symptoms. Interestingly, medical students with higher living expenses experienced more severe somatic symptoms. However, the relationship between living expenses and somatic symptoms remains unclear, and further research is needed to explore potential influences, such as life experiences, eating habits, and school environment.
This study demonstrates a direct relationship between negative life events and somatic symptoms in medical students. The greater the number of negative life events experienced by medical students, the higher the likelihood of somatic symptoms. Additionally, the results indicate a significant correlation between depression and self-esteem with negative life events and somatic symptoms. Medical students with higher levels of depression reported more negative life events, more somatic symptoms, and lower self-esteem, while those with lower self-esteem showed more negative life events, somatic symptoms, and depression. These findings align with previous research; for example, a study on suicidality in Chinese medical students found a positive correlation between adverse life events, depressive symptoms, and somatic symptoms [40]. Other studies have also demonstrated that individuals who grow up in environments with poor family harmony and support may be more susceptible to somatic disorders [41,42]. Furthermore, different levels of self-esteem are strongly associated with the development of depression, with self-esteem considered a risk factor for depression in young adults [43]. Therefore, the correlations between negative life events, self-esteem, depression, and somatic symptoms are supported by extensive evidence.
To further examine the relationship between negative life events and somatic symptoms, we conducted regression analysis to test the predictive effect of different types of negative life events on somatic scores. The results showed that punishment, personal loss, interpersonal relationship pressure, and learning pressure had a positive predictive effect on somatization, while adaptive life events had a negative predictive effect. Of these, interpersonal stress had the most significant predictive effect on somatization. This finding is supported by previous research demonstrating that interpersonal factors are important predictors of somatic symptoms in the general population [44]. Previous research found that interpersonal stress was significantly related to both psychological distress and somatic symptoms, both directly and indirectly through pathways mediated by loneliness [45]. It is acknowledged that experiencing discrimination can be detrimental to one’s relationships, and research has shown that even ethnic microaggressions can lead to an increase in depression and somatic symptoms in adolescents [46]. As college students mature, they become increasingly aware of the importance of interpersonal relationships, and the influence of interpersonal relationship pressure becomes more powerful. It is interesting to note that negative life events classified as academic stress were found to have the least predictive effect on somatic symptoms among medical students. It is understood that college students with many years of learning experience are more strongly influenced by psychological and social factors, such as interpersonal relationships, personal loss, punishment, and social adaptation. These results suggest the need to pay more attention to the different types of negative experiences that medical students face to decrease the level of somatic symptoms.
The primary objective of this study was to examine the moderating role of depression and self-esteem in the relationship between negative life events and somatic symptoms. By utilizing the Bootstrap method, we analyzed the chain-mediating model, and the results suggest that self-esteem and depression may play sequential and mediating roles between negative life events and somatic symptoms. All paths in the model were significant, with the exception of the association between self-esteem and somatic symptoms. Negative life events were found to have a direct effect on somatic symptoms and can be modulated by depression alone. Moreover, the sequence of negative events was found to first affect self-esteem, then depression, and, finally, somatic symptoms, as demonstrated by the chain of events.
Negative life events have been found to have a direct effect on depression, which is consistent with previous research demonstrating that negative life events can increase depression levels [47]. Prior studies have also investigated the relationship between life events, depression, and somatic symptoms, with depression being identified as one of the primary factors contributing to the development of somatic complaints [48]. According to symptom perception theory, bodily cues interact with psychological and environmental factors to produce perceived somatic symptoms, emphasizing the importance of examining these dimensions (negative life events, depression, and somatic symptoms) together [45].
It is worth noting that the multiple mediating model of self-esteem and depression was a chain model rather than a parallel model, which does not show the characteristics of the composite multiple mediating model. Self-esteem and depression are strongly related [49]. Two models tried to explain their nature of relation: the scar model stated that depression erodes self-esteem, while the vulnerability model stated that low self-esteem contributes to depression [50]. A meta-analysis of longitudinal studies provided evidence for supporting the vulnerability model and indicated that the effect of self-esteem on depression was significantly stronger than the effect of depression on self-esteem [50]. This finding can explain why the path of our multiple mediating model is from self-esteem to depression. It has been demonstrated that people with low self-esteem have more negative thoughts and memories when in a negative mood, whereas people with high self-esteem engage more in positive emotional thinking in order to alleviate their negative mood [51]. This indicates that high self-esteem can be a kind of protector with the ability to adequately cope with these feelings, no longer developing into depression [52]. Although there is a significant correlation between self-esteem and somatic symptoms, self-esteem cannot predict somatic symptoms directly. Based on this model, self-esteem shows its modulating effect on depression, and then, its function is transferred by depression to somatic symptoms. Previous studies have pointed out that the accumulation of negative life events can impair an individual’s cognitive function, leading to more depressive symptoms [53]. External social factors may expand the influence through self-cognition, indicating that self-esteem will be affected by negative life events to some extent, and the decrease in self-esteem will increase the individual’s susceptibility to depression. The chain model between self-esteem and depression further proves that the interaction between both has an important effect on the development of somatic symptoms.

5. Conclusions

In this study, we observed a high prevalence of somatic symptoms existing in medical students, and we found that different types of negative life events have distinct predictive effects on somatic symptoms, as well as on self-esteem and depression, forming an intermediary variable chain consisting of a multiple mediation model. The results indicate that external social factors, such as negative life events, can affect somatic symptoms through internal psychological factors, such as cognition and mood. Our findings suggest that attention should be paid to the effects of negative life events on the self-esteem and depression status of medical students. Support and help from friends, families, schools, and all sectors of society can help to reduce the incidence and susceptibility of negative life events among medical students. By improving the self-esteem of medical students, it may be possible to further reduce their depression levels, which, in turn, may help to alleviate their somatic symptoms, thereby contributing to their overall physical and mental well-being.

6. Limitations

The present study has several limitations that should be acknowledged. Firstly, although the study included more than 3000 participants, all the samples were collected from a single medical university in the north of China. Therefore, the generalizability of the study findings to other populations may be limited, and follow-up research should aim to broaden the scope of investigation. Secondly, this is a cross-sectional study, which only allows for the observation of correlations rather than causation. Therefore, in future research, a longitudinal design should be employed to establish causal relationships. Finally, the study only examined the mediating relationship between several variables and did not conduct a detailed analysis of the influence of potential moderating variables, such as anxiety, coping, and social support. Future research could conduct an in-depth analysis of certain demographic variables that may influence the two mediators of cognitive style and emotion.

Author Contributions

Experiments, T.C., S.N., S.L. and E.Z.; data analysis, S.L.; writing and original draft, S.L. and E.Z.; revision, L.L. and E.Z. All authors have read and agreed to the published version of the manuscript.

Funding

This research was supported by Heilongjiang Provincial Natural Science Foundation of China (QC2017019), and in part by the National Natural Science Foundation of China (81903397).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data supporting the conclusions of this article will be made available by the authors upon request.

Acknowledgments

All the authors thank the participants and research assistants from Harbin Medical University. E. Zhao is a visiting researcher at the University of Oxford, UK, and part of the work was finished during her visiting research.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5; American Psychiatric Association: Washington, DC, USA, 2013. [Google Scholar]
  2. Kozlowska, K. Functional somatic symptoms in childhood and adolescence. Curr. Opin. Psychiatry 2013, 26, 485–492. [Google Scholar] [CrossRef]
  3. Ginsburg, G.S.; Riddle, M.A.; Davies, M. Somatic symptoms in children and adolescents with anxiety disorders. J. Am. Acad. Child Adolesc. Psychiatry 2006, 45, 1179–1187. [Google Scholar] [CrossRef]
  4. van Geelen, S.M.; Rydelius, P.A.; Hagquist, C. Somatic symptoms and psychological concerns in a general adolescent population: Exploring the relevance of DSM-5 somatic symptom disorder. J. Psychosom. Res. 2015, 79, 251–258. [Google Scholar] [CrossRef]
  5. Zonneveld, L.N.; Sprangers, M.A.; Kooiman, C.G.; van’t Spijker, A.; Busschbach, J.J. Patients with unexplained physical symptoms have poorer quality of life and higher costs than other patient groups: A cross-sectional study on burden. BMC Health Serv. Res. 2013, 13, 1–11. [Google Scholar] [CrossRef] [Green Version]
  6. Joustra, M.L.; Janssens, K.A.; Bültmann, U.; Rosmalen, J.G. Functional limitations in functional somatic syndromes and well-defined medical diseases. Results from the general population cohort LifeLines. J. Psychosom. Res. 2015, 79, 94–99. [Google Scholar] [CrossRef] [Green Version]
  7. Dimsdale, J.E.; Creed, F.; Escobar, J.; Sharpe, M.; Wulsin, L.; Barsky, A.; Lee, S.; Irwin, M.R.; Levenson, J. Somatic symptom disorder: An important change in DSM. J. Psychosom. Res. 2013, 75, 223–228. [Google Scholar] [CrossRef]
  8. Bonvanie, I.J.; Janssens, K.A.; Rosmalen, J.G.; Oldehinkel, A.J. Life events and functional somatic symptoms: A population study in older adolescents. Br. J. Psychol. 2017, 108, 318–333. [Google Scholar] [CrossRef]
  9. Cairney, J.; Krause, N. Negative life events and age-related decline in mastery: Are older adults more vulnerable to the control-eroding effect of stress? J. Gerontol. Ser. B Psychol. Sci. Soc. Sci. 2008, 63, S162–S170. [Google Scholar] [CrossRef]
  10. Avison, W.; Gotlib, I.H. Stress and Mental Health: Contemporary Issues and Prospects for the Future; Springer Science & Business Media: Berlin/Heidelberg, Germany, 1994. [Google Scholar]
  11. Zhang, Y.; Zhang, J.; Zhu, S.; Du, C.; Zhang, W. Prevalence and predictors of somatic symptoms among child and adolescents with probable posttraumatic stress disorder: A cross-sectional study conducted in 21 primary and secondary schools after an earthquake. PLoS ONE 2015, 10, e0137101. [Google Scholar] [CrossRef]
  12. Heshmati, R.; Azmoodeh, S.; Caltabiano, M.L. Pathway linking different types of childhood trauma to somatic symptoms in a subclinical sample of female college students: The mediating role of experiential avoidance. J. Nerv. Ment. Dis. 2021, 209, 497–504. [Google Scholar] [CrossRef]
  13. Haug, T.T.; Mykletun, A.; Dahl, A.A. The association between anxiety, depression, and somatic symptoms in a large population: The HUNT-II study. Psychosom. Med. 2004, 66, 845–851. [Google Scholar] [CrossRef]
  14. Konno, C.; Suzuki, M.; Osaki, K.A.; Furihata, R.; Takahashi, S.; Kaneita, Y.; Ohida, T.; Uchiyama, M. Depressive symptoms and somatic complaints in Japanese adults. J. Jpn. Soc. Psychosom. Obstet. Gynecol. 2010, 15, 136–228. [Google Scholar]
  15. Hamamura, T.; Mearns, J. Depression and somatic symptoms in Japanese and American college students: Negative mood regulation expectancies as a personality correlate. Int. J. Psychol. 2019, 54, 351–359. [Google Scholar] [CrossRef]
  16. Rotenstein, L.S.; Ramos, M.A.; Torre, M.; Segal, J.B.; Peluso, M.J.; Guille, C.; Sen, S.; Mata, D.A. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA 2016, 316, 2214–2236. [Google Scholar] [CrossRef] [Green Version]
  17. Mao, Y.; Zhang, N.; Liu, J.; Zhu, B.; He, R.; Wang, X. A systematic review of depression and anxiety in medical students in China. BMC Med. Educ. 2019, 19, 1–13. [Google Scholar] [CrossRef] [Green Version]
  18. Rauschenberg, C.; Schulte-Strathaus, J.C.; van Os, J.; Goedhart, M.; Schieveld, J.N.; Reininghaus, U. Negative life events and stress sensitivity in youth’s daily life: An ecological momentary assessment study. Soc. Psychiatry Psychiatr. Epidemiol. 2022, 57, 1641–1657. [Google Scholar] [CrossRef]
  19. Wong, Y.S.; Zulkefly, N.S.; Tan, K.A. Stressful life events and depressive symptoms among adolescents in Malaysia: The mediating role of maladaptive cognitive schema. Int. J. Adolesc. Med. Health 2020, 33, 493–500. [Google Scholar] [CrossRef]
  20. Stikkelbroek, Y.; Bodden, D.H.; Kleinjan, M.; Reijnders, M.; van Baar, A.L. Adolescent depression and negative life events, the mediating role of cognitive emotion regulation. PLoS ONE 2016, 11, e0161062. [Google Scholar] [CrossRef] [Green Version]
  21. Harter, S.; Leahy, R.L. The Construction of the Self: A Developmental Perspective. J. Cogn. Psychother. 2001, 15, 383–384. [Google Scholar] [CrossRef]
  22. Branden, N. The Power of Self-Esteem; Health Communications, Inc.: Deerfield Beach, FL, USA, 2021. [Google Scholar]
  23. Gao, F.; Yao, Y.; Yao, C.; Xiong, Y.; Ma, H.; Liu, H. The mediating role of resilience and self-esteem between negative life events and positive social adjustment among left-behind adolescents in China: A cross-sectional study. BMC Psychiatry 2019, 19, 1–10. [Google Scholar] [CrossRef] [Green Version]
  24. Li, W.; Zhang, L.; Liu, B.; Cao, H. The impact of negative interpersonal life events on social adaptation of Chinese college students: Mediator effect of self-esteem. Soc. Behav. Personal. Int. J. 2013, 41, 705–714. [Google Scholar] [CrossRef]
  25. Aboalshamat, K.; Jawhari, A.; Alotibi, S.; Alzahrani, K.; Al-Mohimeed, H.; Alzahrani, M.; Rashedi, H. Relationship of self-esteem with depression, anxiety, and stress among dental and medical students in Jeddah, Saudi Arabia. J. Int. Med. Dent. 2017, 4, 61–68. [Google Scholar] [CrossRef]
  26. Wan, Y.; Chen, R.; Wang, S.; Orton, S.; Wang, D.; Zhang, S.; Sun, Y.; Tao, F. Effects of self-esteem on the association between negative life events and suicidal ideation in adolescents. Int. J. Environ. Res. Public Health 2019, 16, 2846. [Google Scholar] [CrossRef] [Green Version]
  27. Xin, Y.; Li, Q.; Liu, C. Adolescent self-esteem and social adaptation: Chain mediation of peer trust and perceived social support. Soc. Behav. Personal. Int. J. 2019, 47, 1–9. [Google Scholar] [CrossRef]
  28. Masselink, M.; Van Roekel, E.; Hankin, B.L.; Keijsers, L.; Lodder, G.M.A.; Vanhalst, J.; Verhagen, M.; Young, J.F.; Oldehinkel, A.J. The Longitudinal Association between Self-esteem and Depressive Symptoms in Adolescents: Separating Between-Person Effects from Within-Person Effects. Eur. J. Pers. 2018, 32, 653–671. [Google Scholar] [CrossRef] [Green Version]
  29. Ranøyen, I.; Stenseng, F.; Klöckner, C.A.; Wallander, J.; Jozefiak, T. Familial aggregation of anxiety and depression in the community: The role of adolescents’ self-esteem and physical activity level (the HUNT Study). BMC Public Health 2015, 15, 1–16. [Google Scholar] [CrossRef] [Green Version]
  30. Saricali, M.; Satici, S.A.; Satici, B.; Gocet-Tekin, E.; Griffiths, M.D. Fear of COVID-19, mindfulness, humor, and hopelessness: A multiple mediation analysis. Int. J. Ment. Health Addict. 2022, 20, 2151–2164. [Google Scholar] [CrossRef]
  31. Moroney, E.; Lee, S.S.; Ebbert, A.M.; Luthar, S.S. Digital media use frequency, online behaviors, and risk for negative mental health in adolescents in high-achieving schools. Clin. Child Psychol. Psychiatry 2023, 28, 237–254. [Google Scholar] [CrossRef]
  32. Spitzer, R.L.; Kroenke, K.; Williams, J.B.; Patient Health Questionnaire Primary Care Study Group and Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. JAMA 1999, 282, 1737–1744. [Google Scholar] [CrossRef] [Green Version]
  33. Yan, W.; Li, Y.; Sui, N. The relationship between recent stressful life events, personality traits, perceived family functioning and internet addiction among college students. Stress Health 2014, 30, 3–11. [Google Scholar] [CrossRef]
  34. Tang, J.; Yang, W.; Ahmed, N.I.; Ma, Y.; Liu, H.Y.; Wang, J.J.; Wang, P.X.; Du, Y.K.; Yu, Y.Z. Stressful Life Events as a Predictor for Nonsuicidal Self-Injury in Southern Chinese Adolescence. Medicine 2016, 95, e2637. [Google Scholar] [CrossRef]
  35. Rosenberg, M. Society and the Adolescent Self-Image; Princeton University Press: Princeton, NJ, USA, 2015. [Google Scholar]
  36. Rhee, H.; Miles, M.S.; Halpern, C.T.; Holditch-Davis, D. Prevalence of recurrent physical symptoms in US adolescents. Pediatr. Nurs. 2005, 31, 314. [Google Scholar]
  37. Ibrayeva, Z.; Aldyngurov, D.; Myssayev, A.; Meirmanov, S.; Zhanaspayev, M.; Khismetova, Z.; Muzdubayeva, Z.; Smail, E.; Yurkovskaya, O.; Pivina, L.; et al. Depression, anxiety and somatic distress in domestic and international undergraduate medical students in Kazakhstan. Iran. J. Public Health 2018, 47, 919. [Google Scholar]
  38. Kapfhammer, H.P. Somatic symptoms in depression. Dialogues Clin. Neurosci. 2022, 8, 227–239. [Google Scholar] [CrossRef]
  39. Silverstein, B. Gender differences in the prevalence of somatic versus pure depression: A replication. Am. J. Psychiatry 2002, 159, 1051–1052. [Google Scholar] [CrossRef]
  40. Tang, W.; Kang, Y.; Xu, J.; Li, T. Associations of suicidality with adverse life events, psychological distress and somatic complaints in a Chinese medical student sample. Community Ment. Health J. 2020, 56, 635–644. [Google Scholar] [CrossRef]
  41. Won, S.-D.; Lee, S.H.; Kim, S.; Jun, J.Y.; Shin, S.-S. Somatic symptoms as mediating factors between the perceived social support and the health-related quality of life in North Korean defectors. Psychiatry Investig. 2017, 14, 407. [Google Scholar] [CrossRef] [Green Version]
  42. Horwitz, B.N.; Marceau, K.; Narusyte, J.; Ganiban, J.; Spotts, E.L.; Reiss, D.; Lichtenstein, P.; Neiderhiser, J.M. Parental criticism is an environmental influence on adolescent somatic symptoms. J. Fam. Psychol. 2015, 29, 283. [Google Scholar] [CrossRef]
  43. Choi, Y.; Choi, S.H.; Yun, J.Y.; Lim, J.A.; Kwon, Y.; Lee, H.Y.; Jang, J.H. The relationship between levels of self-esteem and the development of depression in young adults with mild depressive symptoms. Medicine 2019, 98, e17518. [Google Scholar] [CrossRef]
  44. Kitselaar, W.M.; Van Der Vaart, R.; Perschl, J.; Numans, M.E.; Evers, A.W. Predictors of Persistent Somatic Symptoms in the General Population: A systematic review of cohort studies. Psychosom. Med. 2023, 85, 71–78. [Google Scholar] [CrossRef]
  45. Aanes, M.M.; Mittelmark, M.B.; Hetland, J. Interpersonal stress and poor health. Eur. Psychol. 2010, 15, 3–11. [Google Scholar] [CrossRef]
  46. Huynh, V.W. Ethnic microaggressions and the depressive and somatic symptoms of Latino and Asian American adolescents. J. Youth Adolesc. 2012, 41, 831–846. [Google Scholar] [CrossRef] [PubMed]
  47. Bernaras, E.; Jaureguizar, J.; Garaigordobil, M. Child and Adolescent Depression: A Review of Theories, Evaluation Instruments, Prevention Programs, and Treatments. Front. Psychol. 2019, 10, 543. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  48. Kern, M.L.; Waters, L.E.; Adler, A.; White, M.A. A multidimensional approach to measuring well-being in students: Application of the PERMA framework. J. Posit. Psychol. 2015, 10, 262–271. [Google Scholar] [CrossRef] [Green Version]
  49. Orth, U.; Robins, R.W. Understanding the link between low self-esteem and depression. Curr. Dir. Psychol. Sci. 2013, 22, 455–460. [Google Scholar] [CrossRef] [Green Version]
  50. Sowislo, J.F.; Orth, U. Does low self-esteem predict depression and anxiety? A meta-analysis of longitudinal studies. Psychol. Bull. 2013, 139, 213. [Google Scholar] [CrossRef] [Green Version]
  51. Heimpel, S.A.; Wood, J.V.; Marshall, M.A.; Brown, J.D. Do people with low self-esteem really want to feel better? Self-esteem differences in motivation to repair negative moods. J. Personal. Soc. Psychol. 2002, 82, 128. [Google Scholar] [CrossRef]
  52. LEE, M.S.; Choi, Y.; YOU, J.S. The relationship of somatic symptoms and self-esteem in adolescence. J. Korean NeuroPsychiatric Assoc. 2000, 39, 323–333. [Google Scholar]
  53. Gao, B.; Zhao, M.; Feng, Z.; Xu, C. The chain mediating role of cognitive styles and alienation between life events and depression among rural left-behind children in poor areas in Southwest China. J. Affect. Disord. 2022, 306, 215–222. [Google Scholar] [CrossRef]
Behavsci 13 00243 g001 550
Figure 1. Serial multiple mediation of self-esteem and depression in the relationships between negative life events and somatic symptoms with non-standardized beta values and standard errors. Note: *** p < 0.001.
Figure 1. Serial multiple mediation of self-esteem and depression in the relationships between negative life events and somatic symptoms with non-standardized beta values and standard errors. Note: *** p < 0.001.
Behavsci 13 00243 g001
Table
Table 1. Somatic symptoms of medical students.
Table 1. Somatic symptoms of medical students.
Somatic Symptoms LevelNumberPercentage (%)
No somatic symptoms99931.03
Mild somatic symptoms126139.17
Moderate somatic symptoms77724.14
Severe somatic symptoms1825.66
Table
Table 2. Individual symptom conditions among medical students with somatic symptoms.
Table 2. Individual symptom conditions among medical students with somatic symptoms.
Somatic SymptomNumberPercentage (%)
1. Stomach pain144064.86
2. Back pain130658.83
3. Pain in arms, legs, or joints (knees, hips, etc.)128958.06
4. Menstrual cramps with periods (females only)121054.50
5. Headaches163773.74
6. Chest pain89940.50
7. Nausea, gas, or indigestion173278.02
8. Constipation, loose bowels, or diarrhea187584.46
9. Shortness of breath67230.27
10. Dizziness89940.50
11. Fainting spells2089.37
12. Feeling tired or having low energy181981.94
13. Trouble sleeping127657.48
14. Feeling heart pound or race141763.83
15. Pain or problems during sexual intercourse1727.75
Table
Table 3. Descriptive statistics and the distribution of somatic symptoms.
Table 3. Descriptive statistics and the distribution of somatic symptoms.
CategorySubcategoryNumber (%)Somatic Symptoms ± SDt/Fp
GenderMale1399 (43.46%)5.44 ± 4.15−19.6180.000 *
Female1820 (56.54%)8.37 ± 4.52
Emotional statusSingle2275 (70.67%)7.13 ± 4.420.6990.485
Not single944 (29.33%)7.01 ± 4.51
Living expenses<1000294 (9.13%)6.52 ± 4.383.0200.049 *
1000–20002280 (70.83%)7.12 ± 4.36
>2000645 (20.04%)7.28 ± 4.76
One-childYes2068 (64.24%)6.93 ± 4.50−2.7950.005 *
No1151 (35.76%)7.39 ± 4.34
Religious beliefYes129 (4.01%)7.71 ± 4.361.5890.112
No3090 (95.99%)7.07 ± 4.45
Note: * p < 0.05.
Table
Table 4. Correlations between negative life events, self-esteem, depression, and somatic symptoms.
Table 4. Correlations between negative life events, self-esteem, depression, and somatic symptoms.
1234
1. Negative life events1.000
2. Self-esteem−0.215 **1.000
3. Depression0.389 **−0.421 **1.000
4. Somatic symptoms0.314 **−0.218 **0.548 **1.000
Mean28.35029.6903.7207.100
SD17.1164.5704.2984.450
Note: ** p < 0.01.
Table
Table 5. Regression analysis of negative life events and somatization scores.
Table 5. Regression analysis of negative life events and somatization scores.
Negative Life EventsBSEβtp
Punishment0.1940.0290.1576.596<0.001
Personal loss0.2310.0280.1898.225<0.001
Interpersonal pressure0.2860.0290.2569.991<0.001
Learning pressure0.0520.0260.0531.9650.05
Health adaptation−0.2630.025−0.271−10.559<0.001
Table
Table 6. Mediating effects in the mediation model.
Table 6. Mediating effects in the mediation model.
EffectProduct of CoefficientsBoot 95% CI
Point EstimateBoot SELower CIUpper CI
Direct effect: X→Y0.03100.00410.02290.0391
Indirect effect 1: X→M1→Y−0.00120.0009−0.00300.0006
Indirect effect 2: X→M1→M2→Y0.01010.00120.00790.0125
Indirect effect 3: X→M2→Y0.04140.00270.03630.0467
Total effect0.08130.00440.07270.0898
Note: X: negative life events, M1: self-esteem, M2: depression, and Y: somatic symptoms.
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Lv, S.; Chang, T.; Na, S.; Lu, L.; Zhao, E. Association between Negative Life Events and Somatic Symptoms: A Mediation Model through Self-Esteem and Depression. Behav. Sci. 2023, 13, 243. https://doi.org/10.3390/bs13030243

AMA Style

Lv S, Chang T, Na S, Lu L, Zhao E. Association between Negative Life Events and Somatic Symptoms: A Mediation Model through Self-Esteem and Depression. Behavioral Sciences. 2023; 13(3):243. https://doi.org/10.3390/bs13030243

Chicago/Turabian Style

Lv, Sijia, Tong Chang, Siyu Na, Lei Lu, and Erying Zhao. 2023. "Association between Negative Life Events and Somatic Symptoms: A Mediation Model through Self-Esteem and Depression" Behavioral Sciences 13, no. 3: 243. https://doi.org/10.3390/bs13030243

APA Style

Lv, S., Chang, T., Na, S., Lu, L., & Zhao, E. (2023). Association between Negative Life Events and Somatic Symptoms: A Mediation Model through Self-Esteem and Depression. Behavioral Sciences, 13(3), 243. https://doi.org/10.3390/bs13030243

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