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Article

The Role of Adverse Childhood Experiences and Protective Factors in the Co-Occurrence of Somatization and Post-Traumatic Stress Symptoms

by
Rubing Ma
,
Sizhe Chen
and
Jinjing Xiang
*
School of Humanities and Social Sciences, Beijing Forestry University, Beijing 100083, China
*
Author to whom correspondence should be addressed.
J. Mind Med. Sci. 2025, 12(1), 9; https://doi.org/10.3390/jmms12010009
Submission received: 12 February 2025 / Revised: 6 March 2025 / Accepted: 12 March 2025 / Published: 14 March 2025
Review Reports Versions Notes

Abstract

:
Objectives: Adverse childhood experiences (ACEs) pose a significant public health concern, negatively impacting children’s physical and mental health. This study examines the association between ACEs and the co-occurrence of somatization and post-traumatic stress symptoms (PTSSs) among Chinese college students. Additionally, it explores the roles of both internal (psychological resilience) and external (social support) protective factors in this relationship. Methods: A sample of 701 students were analyzed using the Adverse Childhood Experiences International Questionnaire, the Somatization subscale from the Symptom Checklist-90, the PTSD Checklist from the DSM-5, the Connor–Davidson Resilience Scale, and the Multidimensional Scale of Perceived Social Support. A four-level outcome variable was created based on measures of somatization and PTSSs: no symptoms, somatization-only, post-traumatic stress symptoms-only (PTSSs-only), and co-occurring symptoms. Data analysis was conducted using multiple logistic regression. Results: Among Chinese college students, the prevalence of ACEs was 62.9%, while the prevalence of co-occurring somatization and PTSSs was 13.7%. The results of the multiple logistic regression analysis indicated a positive association between ACEs and the co-occurrence of somatization and PTSSs compared to no symptoms (OR = 2.28, p < 0.001). Furthermore, social support (OR = 0.26, p < 0.001) and psychological resilience (OR = 0.48, p = 0.049) were negatively associated with the co-occurrence. Conclusions: ACEs are risk factors for the co-occurrence of somatization and PTSSs among college students, while social support and psychological resilience serve as effective protective factors against this risk.

1. Introduction

Adverse childhood experiences (ACEs) refer to a range of traumatic events of varying severity that individuals may encounter in adverse familial or social environments during childhood. These experiences are associated with detrimental effects on physical and mental health, as well as developmental outcomes [1]. Epidemiological studies reveal a 50% prevalence of at least one ACE across global populations [2,3,4,5], contrasting sharply with the 82.6% reported among Chinese college students [6]. This discrepancy highlights the urgency of examining ACE impacts within China’s higher education context. The university period constitutes a neurodevelopmentally critical window, characterized by simultaneous psychosocial transitions (identity formation) and prefrontal cortex maturation (ages 18–25) [7,8,9]. During this phase, ACE-induced maladaptive schemas may interact with heightened neuroplasticity, creating dual vulnerability and remediation potential. Emerging evidence suggests that protective psychosocial factors may enhance prefrontal–limbic integration, facilitating emotional regulation and traumatic memory reprocessing [10]. This neurobiological mechanism positions early adulthood as a strategic intervention window for ACE-related impairments. Investigating ACE–mental health dynamics in college populations therefore serves dual purposes: 1) informing developmentally timed interventions leveraging neuroplasticity, and 2) establishing evidence-based targets for campus mental health services. Such research addresses both individual remediation needs and systemic prevention strategies within educational frameworks.
ACEs elevate lifetime risks for psychosomatic disorders through toxic stress mechanisms—the persistent activation of stress response systems without adequate buffering resources causes neurophysiological dysregulation [11,12,13]. This dysregulation manifests clinically as depression, anxiety, and, notably, the co-occurrence of somatization (physical expressions of psychological distress) and post-traumatic stress symptoms (PTSSs) [14,15,16,17]. Rather than distinct entities, these symptom clusters represent interactive trauma responses: somatization serves as a somatic adaptation to unprocessed distress, while PTSSs reflect cognitive–emotional hypervigilance [18,19]. Empirical evidence underscores their interconnectedness across populations—chronic pain patients with PTSSs exhibit heightened trauma exposure [20], and combat veterans frequently demonstrate overlapping somatic–PTSS profiles that amplify symptom severity [21,22]. This bidirectional relationship suggests a shared pathophysiological pathway rooted in ACE-related stress system alterations.
Current ACE research exhibits critical limitations in addressing symptom co-occurrence, predominantly examining somatization and PTSSs in isolation [14,15]. This reductionist approach neglects their synergistic interactions mediated by shared neurobiological substrates—particularly HPA axis dysregulation and prefrontal–limbic circuit abnormalities that concurrently drive both symptom clusters [23,24]. The resultant clinical “symptom fragmentation” predisposes clinicians to imprecise or incomplete diagnoses, which in turn result in suboptimal therapeutic interventions that fail to address underlying pathophysiological mechanisms, ultimately elevating the risk of symptom recurrence [25,26]. Our study addresses this gap by systematically investigating the dual impact of ACEs on somatization–PTSS comorbidity, proposing that integrated neurobiopsychosocial frameworks could circumvent current diagnostic and therapeutic shortcomings.
The Reciprocal Maintenance Theory proposed by Sharp and Harvey provides a critical framework for understanding the mechanisms underlying the comorbidity of somatization and PTSSs. This theory suggests that the cognitive, emotional, and behavioral components of chronic pain may sustain or exacerbate PTSD symptoms, while, conversely, the physiological hyperarousal and avoidance behaviors in PTSD may intensify the perception of pain [27]. Although this theory was initially focused on chronic pain and PTSD, its core mechanisms—such as hypervigilance amplifying the perception of somatic discomfort and avoidance behaviors limiting functional rehabilitation—can be applied to explain the comorbidity of ACE-related somatization and PTSSs, as both involve the amplification of somatic symptoms due to central sensitization and failures in emotional regulation [28]. Empirical studies further demonstrate that the interaction between somatization and trauma-related stress symptoms results in significantly greater symptom severity in comorbid groups compared to those with a single symptom [29], along with an increased treatment dropout rate [30]. This may primarily stem from somatization symptoms activating the trauma memory networks related to ACEs through interoceptive conditioning [31], while intrusive recollections and hypervigilance in PTSSs exacerbate the perception of somatic discomfort through sympathetic nervous system activation, thereby forming a vicious cycle that increases the risk of chronicity and heightens the symptom burden [32]. Based on these mechanisms, this study posits that the co-occurrence of somatization and PTSSs represents a complex and significant phenomenon following traumatic events, reflecting the dynamic interplay between psychological and physiological processes. Elucidating the comorbidity of somatization and PTSSs not only aids in the development of integrated assessment tools but also promotes the design of multimodal intervention programs, ultimately improving prognosis and reducing annual healthcare costs.
Despite the ubiquity of ACEs, not all exposed individuals develop adverse health outcomes in adulthood [33,34]. This observation implies that ACEs alone are insufficient predictors of individual health trajectories, suggesting the critical role of protective factors in modulating the magnitude and likelihood of long-term health consequences [33]. Protective factors are broadly defined as conditions or resources capable of mitigating the negative impacts of ACEs through direct or indirect pathways [35]. Empirical evidence confirms that these factors can effectively buffer against childhood adversity via both compensatory and moderating mechanisms [36]. The resilience compensation model specifically posits that protective factors exert direct compensatory effects when they counterbalance risk factors [37].
Building on Grych et al.’s conceptualization [38], we operationalize protective factors as comprising both intrinsic (e.g., individual characteristics conducive to healthy development) and extrinsic (e.g., social support systems) resources. It is worth noting that the theory of post-traumatic growth provides a new perspective for understanding such protective mechanisms. Tedeschi and Calhoun point out that cognitive reappraisal and social interaction after trauma can promote positive psychological changes, such as increased personal strength or deepened interpersonal relationships [39]. Connor and Davidson [40] characterize resilience as personal attributes that foster growth amid adversity. Complementing these internal resources, social support encompasses the emotional and material assistance derived from social networks [10]. Guided by these theoretical frameworks, the present study selects psychological resilience (as an internal protective factor) and social support (as an external protective factor) to investigate their potential compensatory effects on the co-occurrence of somatization and PTSSs in ACE-exposed populations.
In summary, we hypothesize that (1) ACEs significantly predict the co-occurrence of somatization and PTSSs among college students; and (2) psychological resilience and social support exert compensatory effects on this co-occurrence, even in the presence of ACEs. This research not only deepens the understanding of the multidimensional expressions of ACEs but also provides a practical intervention framework for mental health services in higher education institutions. Its core value lies in the embodiment of “repairing hope”—indicating that even in the presence of ACEs, through activating an individual’s psychological resilience and social resources, it is still possible to achieve post-traumatic growth during critical periods of neuroplasticity. This has profound social significance for improving the mental health of college students and reducing the long-term burden of disease.

2. Materials and Methods

2.1. Participants and Procedures

Questionnaires were designed on the Wenjuanxing platform. Subsequently, through multiple online social channels, these questionnaires were distributed and administered online to undergraduate and postgraduate students enrolled in Chinese universities. The samples were primarily sourced from Beijing, Xinjiang, and Shandong. A total of 858 questionnaires were collected, and after screening, 701 valid questionnaires were obtained, with an effective rate of 81.7%. Among the participants, 431 were female and 270 were male. There were 285 only-children and 416 non-only-children. Their ages ranged from 17 to 26 years old, with an average age of 21.24 ± 1.74 years.
This study was approved by the Ethics Review Form for Human Studies of Beijing Forestry University (BJFUPSY-2024-074). An online anonymous survey format was adopted, and participants read and agreed to the online informed consent form prior to participation, contributing to the survey voluntarily.

2.2. Measures

2.2.1. Adverse Childhood Experience International Questionnaire (ACE-IQ)

This questionnaire consists of 29 items and assesses 13 types of ACEs across three dimensions: childhood abuse, family dysfunction, and community violence. This study employed the Chinese version revised by Professor HO and colleagues, which has demonstrated good reliability and validity in China [41,42]. The scale can be scored using either a dichotomous scoring method or a frequency scoring method, with the latter being more aligned with international standards; therefore, this study adopted the frequency scoring method. The total score ranged from 0 to 13, with higher scores indicating a greater number of ACEs experienced during childhood. In this study, the Cronbach’s alpha coefficient for this questionnaire was 0.91.

2.2.2. Outcome (Co-Occurrence of Somatization and Post-Traumatic Stress Symptoms)

The Somatization subscale from the Symptom Checklist-90 (SCL-90) was selected to measure somatic symptoms, consisting of 12 items [43]. A 5-point scoring system was used, ranging from 1 (not at all) to 5 (extremely severe), with a maximum score of 60. A score of 24 or above indicates the presence of positive somatic symptoms. In this study, the Cronbach’s alpha coefficient for this subscale was 0.94.
The PTSD Checklist from the DSM-5 (PCL-5) was used to measure PTSSs, comprising 20 items corresponding to four symptom clusters as defined in the DSM-5: intrusion symptoms (Criterion B), avoidance symptoms (Criterion C), negative alterations in cognition and mood (Criterion D), and arousal and reactivity symptoms (Criterion E) [44]. A 5-point scoring system was employed, ranging from 0 (not at all) to (extremely), with a maximum score of 80. A score of 33 or above indicates the presence of positive PTSSs. In this study, the Cronbach’s alpha coefficient for this questionnaire was 0.96.
The co-occurrence outcome variable was derived by combining scores from the Somatization subscale and the PCL-5. Participants were categorized into four mutually exclusive groups based on validated clinical cutoffs [43,44]. (1) No symptoms: Somatization subscale ≤ 24 and PCL-5 < 33; (2) somatization-only: Somatization subscale > 24 and PCL-5 < 33; (3) post-traumatic stress symptoms-only (PTSSs-only): Somatization subscale ≤ 24 and PCL-5 ≥ 33; and (4) co-occurring symptoms: Somatization subscale > 24 and PCL-5 ≥ 33.

2.2.3. Protective Factors (Internal Psychological Resilience and External Social Support)

The Connor–Davidson Resilience Scale (CD-RISC) consists of 25 items that encompass three dimensions: strength, toughness, and optimism [45]. A 5-point scoring system is employed, ranging from 1 (not at all) to 5 (almost always), where higher scores indicate a higher level of psychological resilience. In this study, the optimal threshold for converting this continuous variable into a binary variable was determined to be 97.5 based on the receiver operating characteristic (ROC) curve and the maximum Youden index. Scores above 97.5 are classified as high resilience, while scores below are classified as low resilience. The Cronbach’s alpha coefficient for this questionnaire in this study was 0.96.
The Perceived Social Support Scale (PSSS) consists of 12 items that measure three dimensions: support from friends, family support, and support from others [46]. A 7-point scoring system is used, ranging from 1 (strongly disagree) to 7 (strongly agree), where higher scores indicate a stronger perception of social support. In this study, the optimal threshold for converting this continuous variable into a binary variable was determined to be 66.5 based on the receiver operating characteristic (ROC) curve and the maximum Youden index. Scores above 66.5 are classified as high social support, while scores below are classified as low social support. The Cronbach’s alpha coefficient for this questionnaire in this study was 0.95.

2.3. Data Analysis

Statistical analysis was conducted using SPSS version 27.0. First, the detection rates of ACEs, internal and external protective factors, and the co-occurrence of somatization and PTSSs were statistically analyzed. Second, differences in demographic variables, ACEs, and internal and external protective factors across the four-level co-occurrence outcome were compared: ACE scores did not conform to a normal distribution, so the Kruskal–Wallis H test was used; age was analyzed using one-way analysis of variance (ANOVA); and gender, grade, family region, only-child status, psychological resilience, and social support were all categorical variables, analyzed using chi-square tests. Finally, the four-level co-occurrence outcome, which conforms to a multinomial distribution, was assessed using a generalized linear model to evaluate the predictive effects of ACEs and both internal and external protective factors on this co-occurrence. Two multiple logistic regression models were tested: Model 1 included only the predictive effect of ACE scores on co-occurring symptoms, and Model 2, in the presence of ACEs, added psychological resilience and social support, treating these two protective factors as dummy variables: low psychological resilience and low social support were assigned a value of 0, while high psychological resilience and high social support were assigned a value of 1 to create the dummy variables. The predictive effects of all three factors on co-occurring symptoms were evaluated, with a significance level set at α = 0.05.
The results of the common method bias test indicated that 15 factors with eigenvalues greater than 1 were extracted in this study, with the largest common factor explaining 28.13% of the variance, which is below the critical threshold of 40% [47]. This suggests that there is no significant issue with common method bias in this study.

3. Results

3.1. Detection Rates of ACEs, Protective Factors, and Four-Level Co-Occurrence Outcome

Among the 701 university students, 441 had ACEs, resulting in a detection rate of 62.9%. The detection rates for somatization and PTSSs were 21 and 23.7%, respectively. The rate of comorbidity between these two symptoms was 13.7%. Additionally, 270 university students had high psychological resilience, representing 38.5%, while 343 students had high social support, accounting for 48.9%.

3.2. Comparison of ACEs, Protective Factors, and Demographic Variables Across Four-Level Co-Occurrence Outcomes

The Kruskal–Wallis H test revealed significant differences in ACE scores across the four-level co-occurring outcomes of somatization and PTSSs [H (3) = 142.3, p < 0.001] (see Table 1). Post hoc pairwise comparisons indicated (1) significantly higher ACE scores in somatization-only, PTSSs-only, and co-occurring symptoms compared to no symptoms; (2) no significant difference in ACE scores between somatization-only and PTSSs-only; and (3) that the co-occurring symptoms demonstrated significantly higher ACE scores than both somatization-only and PTSSs-only.
The chi-square tests revealed no significant differences across four-level co-occurring outcomes for gender (χ2(3) = 0.85, p = 0.837), family geographic region (χ2(6) = 5.12, p = 0.528), or only-child status (χ2(3) = 7.39, p = 0.06). By contrast, significant differences were observed for academic year (χ2(12) = 29.76, p = 0.003), psychological resilience (χ2(3) = 45.46, p < 0.001), and social support (χ2(3) = 97.58, p < 0.001) (Table 1). One-way ANOVA indicated no significant age differences across the four-level co-occurring outcomes (F (9) = 1.7, p = 0.087) (Table 2).

3.3. Prediction of ACEs and Protective Factors on the Four-Level Co-Occurrence Outcome

After controlling for grade, multinomial logistic regression analyses were conducted with the four-level co-occurring outcomes of somatization and PTSSs as the dependent variable (coded as follows: 0 = no symptoms, 1 = somatization-only, 2 = PTSSs-only, 3 = co-occurring symptoms). Model 1 included ACEs as the independent variable, while Model 2 incorporated ACEs, high psychological resilience, and high social support as independent variables.
The results (Table 3) demonstrated that ACEs, as a risk factor, significantly increased the odds of symptom outcomes compared to the asymptomatic group. For each unit increase in ACEs, the odds of somatization-only increased by 1.51 times (OR = 1.51), the odds of PTSSs-only increased by 1.63 times (OR = 1.63), and the odds of co-occurring symptoms increased by 2.28 times (OR = 2.28).
When protective factors were added to the model, ACEs remained significantly associated with all four-level co-occurring outcomes. Compared to the asymptomatic group, high psychological resilience showed a marginally significant protective effect only for co-occurring symptoms, reducing the odds by 52% (OR = 0.48, p = 0.049), but did not significantly reduce the odds of somatization-only (OR = 0.88, p = 0.718) or PTSSs-only (OR = 0.53, p = 0.061); high social support, however, significantly reduced the odds of all three symptom outcomes: somatization-only by 65% (OR = 0.35, p = 0.003), PTSSs-only by 69% (OR = 0.31, p < 0.001), and co-occurring symptoms by 74% (OR = 0.26, p < 0.001).

4. Discussion

The findings of this study suggest that university students with co-occurring somatization and PTSSs are associated with a higher number of ACEs compared to those with only somatization or PTSSs alone. This aligns with prior research indicating that the detrimental effects of ACEs often persist into adulthood and exhibit a dose–response relationship with adverse outcomes—where greater cumulative ACE exposure during childhood leads to more pronounced negative impacts on physical and mental health in later life [48,49,50]. Furthermore, this study identified a robust association between ACEs and the co-occurrence of somatization and PTSSs, supporting Hypothesis 1, which underscores that ACEs are a critical risk factor for the dual burden of somatic and trauma-related symptoms among university students. This magnitude of association is strongly aligned with the toxic stress model—wherein early adversity induces multisystem dysregulation (e.g., HPA-axis hyperactivity, neuroinflammation)—amplifying vulnerability to both somatic and trauma-related outcomes [13]. The observed synergism further corroborates the mutual maintenance theory: somatic symptoms (e.g., chronic pain) may act as trauma reminders that reactivate PTSS-related hypervigilance, while PTSS-driven avoidance behaviors exacerbate somatic distress by reducing physical activity and social engagement [27]. This bidirectional interplay creates a self-perpetuating cycle, explaining why co-occurrence risk escalates disproportionately with ACE accumulation.
These findings underscore the importance of bidirectionally integrating psychological and somatic assessments—both evaluating the impact of ACEs beyond psychological dimensions to screen for somatization and incorporating ACE screening into routine somatic care. This integrated approach could redirect patients from fragmented specialty consultations to trauma-informed multidisciplinary clinics, thereby reducing diagnostic times and lowering healthcare costs. Furthermore, research on Chinese youth reveals culturally distinct manifestations of ACE-related mental health challenges [51]. Unlike Western counterparts who often exhibit emotional dysregulation, Chinese youth tend to suppress internal distress and somatize psychological disorders due to cultural stigma surrounding psychological disclosure [52,53]. This divergence highlights the necessity for culturally resonant interventions—for instance, integrating somatization narratives into trauma therapy in cultures where somatic expression predominates over psychological disclosure.
Although ACEs are widespread, this study found that both internal psychological resilience and external social support can effectively reduce the risk of co-occurring somatization and PTSSs compared to asymptomatic individuals, validating Hypothesis 2. This aligns with existing neurobiological research on early adversity and resilience, indicating that protective factors can buffer against mental health risks by modulating the limbic system and providing recovery opportunities during sensitive developmental periods [11]. However, the study revealed that in single-symptom presentations (either somatization or PTSSs alone), only social support demonstrated protective effects, while psychological resilience showed no significant protection. This discrepancy suggests distinct protective pathways for psychological resilience and social support in addressing ACE-related health consequences.
As an intrinsic resource for coping with stress, psychological resilience plays a crucial protective role in co-occurring symptoms typically associated with severe ACEs. These co-occurring symptoms often reflect deeper psychological trauma and allostatic overload—where cumulative physiological stress exceeds individual compensatory thresholds [54], necessitating resilient adaptation. By contrast, single symptoms may indicate lower stress levels where resilience mechanisms are less critical. A review suggests that moderate ACEs may foster psychological immunization, while severe ACEs require protective factors to mitigate mental health damage [36]. On the contrary, social support, as an external protective factor, depends on environmental stability rather than individual psychological states. Effective social support provides safety and resources to reduce threat perception and enhance trauma coping capacities [10,55,56].
At the systemic level, our findings advocate for policy reforms prioritizing ACE prevention programs (e.g., parenting support, poverty reduction) as a cost-effective strategy to reduce downstream healthcare burdens. However, existing research indicates that most individuals have been exposed to adverse childhood experiences, underscoring the need to focus on interventions targeting ACE-related adverse health outcomes. Building on prior studies of single symptoms, this research identifies ACEs as predictors of the co-occurrence of somatization and PTSSs, suggesting that proactive intervention programs may be particularly beneficial for college students experiencing comorbid somatization and PTSSs. Seligman, the father of positive psychology, posits that effective clinical interventions require dual efforts—alleviating suffering while enhancing well-being—viewing positive interventions as complementary to traditional symptom-focused treatments [57]. Accordingly, based on our findings, we recommend implementing a tiered positive intervention strategy: for individuals with single symptoms, prioritize social support interventions through family system therapy and peer support programs; for those with comorbid symptoms, implement integrated interventions targeting psychological resilience (e.g., cognitive restructuring training, mindfulness-based stress reduction) and social support enhancement (e.g., community support network development). Concurrently, neuroscience-informed approaches such as neurofeedback technology could strengthen the formation of protective neural circuits. Studies demonstrate that social support activates the ventral striatum (reward system), while psychological resilience enhances resting-state functional connectivity within the salience network [58,59].
This study has several limitations. First, the assessment of ACEs in this study relied on retrospective self-reports. While this method has been validated, it may lead to over- or under-reporting [60]. Future research could collect more objective and comprehensive information through longitudinal investigations. Second, this study only examined the direct effects of two protective factors—psychological resilience and social support—on comorbid symptoms. However, the social ecological model emphasizes that understanding positive development requires considering interactions among individuals, processes, environments, and time across four levels: individual, relational, community, and societal [61]. Thus, future studies should incorporate a broader range of multilevel protective factors and explore their interrelationships, as well as their interactions with ACEs. Third, the use of a college student sample may limit the generalizability of the findings. University students typically possess higher socioeconomic status and cognitive resources compared to the general population, which may result in an underestimation of the observed associations between ACEs and adverse outcomes. Future work should validate these findings in more diverse samples. Finally, although we measured and controlled for key demographic variables, unmeasured confounding factors might still influence the results. Despite these limitations, this study advances our understanding of the impact of ACEs on the co-occurrence of somatization and PTSSs. Raising awareness of this comorbidity could improve clinical identification and facilitate the development of personalized treatment plans targeting these co-occurring symptoms [62]. Additionally, psychological resilience and social support may serve as critical intervention targets to mitigate the effects of comorbid conditions.

5. Conclusions

In conclusion, our findings demonstrate that ACEs act as a risk factor for the co-occurrence of somatization and PTSSs. This underscores the necessity for families and clinical practitioners to recognize the multifaceted and severe consequences of ACEs for children’s development. Furthermore, we identified psychological resilience and social support as effective protective factors that mitigate ACE-related comorbid symptoms. These insights highlight the critical importance of designing personalized intervention plans and targeted therapeutic strategies to foster healthy development among college students affected by ACEs.

Author Contributions

Conceptualization, R.M. and J.X.; methodology, R.M.; validation, S.C. and J.X.; investigation, R.M.; data curation, R.M. and S.C.; writing—original draft preparation, R.M.; writing—review and editing, S.C. and J.X.; supervision, J.X. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the Fundamental Research Founds for the Central Universities, grant number 2021SRY09.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Review Form for Human Studies of Beijing Forestry University. The approval code is BJFUPSY-2024-074 and the date of approval is 9 December 2024.

Informed Consent Statement

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

Data Availability Statement

The original data presented in the study are openly available in Open Science Framework at DOI 10.17605/OSF.IO/8BFUQ.

Acknowledgments

The authors thank all participants involved in this study.

Conflicts of Interest

The authors declare no conflicts of interest.

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Table 1. Differences in Adverse childhood experiences (ACEs), demographic variables, and protective factors across four-level co-occurrence outcomes (n (%)).
Table 1. Differences in Adverse childhood experiences (ACEs), demographic variables, and protective factors across four-level co-occurrence outcomes (n (%)).
No SymptomsSomatization-OnlyPTSSs-Only dCo-Occurring SymptomsH/χ2(df)p
ACE Scores
(Median (IQR))		1(0,1)1(0,2) a1.5(1,3) a4(1,6.75) abc142.3(3)<0.001
GenderMale184(26.25)19(2.71)26(3.71)41(5.85)0.85(3)0.837
Female300(42.8)32(4.56)44(6.28)55(7.84)
Grade1st106(15.12)11(1.57)5(0.71)18(2.57)29.76(12)0.003
2nd87(12.41)14(2.0)5(0.71)19(2.71)
3rd109(15.55)10(1.43)18(2.57)16(2.28)
4th145(20.68)15(2.14)36(5.14)31(4.42)
Grad.37(5.28)1(0.14)6(0.86)12(1.71)
Family regionCity198(28.24)19(2.71)23(3.28)37(5.28)5.12(6)0.528
Town124(17.69)10(1.43)16(2.28)22(3.14)
Rural162(23.11)22(3.14)31(4.42)37(5.28)
Only childYes191(27.25)15(2.14)30(4.28)49(6.99)7.39(3)0.06
No293(41.8)36(5.13)40(5.71)47(6.7)
ResilienceHigh225(32.1)16(2.28)14(2.0)15(2.14)45.46(3)<0.001
Low259(36.95)35(4.99)56(7.99)81(11.55)
Social supportHigh296(42.23)16(2.28)17(2.42)14(2.0)97.58(3)<0.001
Low188(26.82)35(4.99)53(7.56)82(11.7)
a Compared to no symptoms, p < 0.05; b Compared to somatization-only, p < 0.001; c Compared to PTSSs-only, p < 0.05;d PTSSs-only=post-traumatic stress symptoms-only.
Table 2. One-way analysis of variance (ANOVA) for age and four-level co-occurrence outcomes.
Table 2. One-way analysis of variance (ANOVA) for age and four-level co-occurrence outcomes.
Sum of SquaresdfMean SquareFp
Between groups18.7492.081.70.087
Within groups848.966911.23
Total867.7700
Table 3. Prediction of Adverse childhood experiences (ACEs) and protective factors on the four-level co-occurrence outcome.
Table 3. Prediction of Adverse childhood experiences (ACEs) and protective factors on the four-level co-occurrence outcome.
Somatization-Only aPTSSs-Only abCo-Occurring Symptoms a
βpOR
(95% CI)		βpOR
(95% CI)		βpOR
(95% CI)
Model 1: ACE score0.41<0.0011.51
(1.25–1.81)		0.49<0.0011.63
(1.39–1.91)		0.82<0.0012.28
(1.96–2.65)
Model 2: ACE score0.30.0021.35
(1.12–1.62)		0.36<0.0011.44
(1.22–1.69)		0.7<0.0012.02
(1.74–2.34)
High psychological resilience−0.130.7180.88
(0.44–1.77)		−0.640.0610.53
(0.27–1.03)		−0.740.0490.48
(0.23–0.997)
High social support−1.050.0030.35
(0.17–0.71)		−1.16<0.0010.31
(0.17–0.6)		−1.36<0.0010.26
(0.12–0.53)
a Referent group = no symptoms; b PTSSs-only=post-traumatic stress symptoms-only.
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Ma, R.; Chen, S.; Xiang, J. The Role of Adverse Childhood Experiences and Protective Factors in the Co-Occurrence of Somatization and Post-Traumatic Stress Symptoms. J. Mind Med. Sci. 2025, 12, 9. https://doi.org/10.3390/jmms12010009

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Ma R, Chen S, Xiang J. The Role of Adverse Childhood Experiences and Protective Factors in the Co-Occurrence of Somatization and Post-Traumatic Stress Symptoms. Journal of Mind and Medical Sciences. 2025; 12(1):9. https://doi.org/10.3390/jmms12010009

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Ma, Rubing, Sizhe Chen, and Jinjing Xiang. 2025. "The Role of Adverse Childhood Experiences and Protective Factors in the Co-Occurrence of Somatization and Post-Traumatic Stress Symptoms" Journal of Mind and Medical Sciences 12, no. 1: 9. https://doi.org/10.3390/jmms12010009

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Ma, R., Chen, S., & Xiang, J. (2025). The Role of Adverse Childhood Experiences and Protective Factors in the Co-Occurrence of Somatization and Post-Traumatic Stress Symptoms. Journal of Mind and Medical Sciences, 12(1), 9. https://doi.org/10.3390/jmms12010009

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