Perseverative thoughts and subjective health complaints in adolescence: Mediating effects of perceived stress and negative affects.

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Perseverative thoughts and subjective health complaints in adolescence: Mediating effects of perceived stress and negative affects a

ab

c

Gyöngyi Kökönyei , Anna Józan , Antony Morgan , Eszter ab

a

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Szemenyei , Róbert Urbán , Melinda Reinhardt

& Zsolt

a

Demetrovics a

Institute of Psychology, Eötvös Loránd University, Budapest, Hungary b

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Doctoral School of Psychology, Eötvös Loránd University, Budapest, Hungary c

School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK d

Institute of Psychology, Károli Gáspár University of the Reformed Church, Budapest, Hungary Accepted author version posted online: 20 Jan 2015.Published online: 09 Feb 2015.

To cite this article: Gyöngyi Kökönyei, Anna Józan, Antony Morgan, Eszter Szemenyei, Róbert Urbán, Melinda Reinhardt & Zsolt Demetrovics (2015): Perseverative thoughts and subjective health complaints in adolescence: Mediating effects of perceived stress and negative affects, Psychology & Health, DOI: 10.1080/08870446.2015.1007982 To link to this article: http://dx.doi.org/10.1080/08870446.2015.1007982

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Psychology & Health, 2015 http://dx.doi.org/10.1080/08870446.2015.1007982

Perseverative thoughts and subjective health complaints in adolescence: Mediating effects of perceived stress and negative affects Gyöngyi Kökönyeia*, Anna Józana,b, Antony Morganc, Eszter Szemenyeia,b, Róbert Urbána, Melinda Reinhardtb,d and Zsolt Demetrovicsa


a

Institute of Psychology, Eötvös Loránd University, Budapest, Hungary; bDoctoral School of Psychology, Eötvös Loránd University, Budapest, Hungary; cSchool of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; dInstitute of Psychology, Károli Gáspár University of the Reformed Church, Budapest, Hungary (Received 16 July 2014; accepted 8 January 2015) Stable tendency to perseverative thoughts such as trait rumination and worry can influence somatic health. The purpose of the study was to investigate the relationship between perseverative thoughts and somatic complaints, and the possible mediating effects of perceived stress, negative and positive affectivity in adolescence. Having an acute or a chronic condition was also assessed to be controlled for and to reveal their effects on symptom reporting. Three hundred and six adolescents from 7th to 12th grade with mean age of 16.33 (SD = 1.29) participated in the study. Mediation analysis suggested that impact of trait-like perseverative thoughts on complaints were mediated by perceived stress and negative affectivity. Having an acute condition had also an effect on symptom reporting through increased negative affectivity. Our results highlight that ruminations or worry as stable intrapersonal characteristics are relevant processes in health and can be potential targets in prevention programmes in adolescence. Keywords: perseverative thoughts; subjective health complaints; perceived stress; negative affectivity; acute condition

Introduction Subjective health complaints (SHC) refer to a set of somatic and psychological symptoms experienced by the individual with or without a defined diagnosis (Eriksen & Ursin, 2004). Both somatic complaints such as fatigue (Jellesma, Rieffe, & Terwogt, 2007), headache, abdominal pain (Saps et al., 2009) and psychological symptoms such as irritability or nervousness (Hagquist & Andrich, 2004) are common even in otherwise healthy adolescents. Co-occurrence of symptoms is not rare, and warrants special attention, because it is associated with poor general health, low life satisfaction (Ravens-Sieberer et al., 2009) and more medicine used (Gobina et al., 2011). SHC have been theorised to be at least partly related to psychosocial stress. Frequent or sustained stress and the related emotional and physiological arousal may *Corresponding author. Email: [email protected] © 2015 Taylor & Francis


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G. Kökönyei et al.

have an etiological role in the development of frequent complaints (Brosschot, 2002; Dantzer, 2005; Ursin & Eriksen, 2004). During adolescence, school and peer-related stressors are reliable predictors of SHC. For example, failures in school (Hurrelmann, Engel, Holler, & Nordlohne, 1988), lack of support from teachers (Ghandour, Overpeck, Huang, Kogan, & Scheidt, 2004) being bullied or non-acceptance by peers (Jellesma, Rieffe, Terwogt, & Kneepkens, 2006; Natvig, Albrektsen, Anderssen, & Qvarnstrom, 1999; Nixon, Linkie, Coleman, & Fitch, 2011), all have a direct effect on the frequency of complaints. Family related stress, such as communication problems (Moreno et al., 2009) and conflicts with parents (Hurrelmann et al., 1988) are also strongly correlated with symptoms. However, previous studies rarely provide information about the mechanisms of symptom perception and symptom reporting. According to the perseverative cognition hypothesis, it is not stress itself or reactivity to stressors that are the most predictive of chronic SHC. Instead it is the prolonged consequence (such as prolonged cardiovascular activity) that remain beyond the presence of the stressor that are more potent factors for predicting somatic health (Brosschot, 2002; Brosschot, Gerin, & Thayer, 2006; Brosschot, Pieper, & Thayer, 2005). According to this perspective, stressful events can only lead to SHC if repeated or sustained stress-related cognition prolongs the physiological stress-related activity (Brosschot et al., 2006). Perseverative cognitions such as rumination, worry or anticipated stress are capable of maintaining stress-related physiological and psychological arousal, and thus contribute to the development of SHC (Brosschot et al., 2005, 2006). Stress-related prolonged cardiovascular reactivity and cortisol response have been considered to be the physiological pathways that might mediate between perseverative thoughts and somatic health. In a recent review Zoccola and Dickerson (2012) concluded that in experimental laboratory studies stress-related state rumination measures were associated with greater cortisol response to the stressor. A daily life study applying ecological momentary assessment has revealed that mean daily ruminative self-focus predicted higher cortisol level (Huffziger et al., 2013). After cognitive stress delayed heart rate recovery has been found among high-trait worriers (Verkuil, Brosschot, de Beurs, & Thayer, 2009), and delayed blood pressure has been detected if the person ruminated about their task after finishing it (Radstaak, Geurts, Brosschot, Cillessen, & Kompier, 2011). Studies using momentary assessments show increased cardiovascular reactivity in worry episodes (Brosschot, Van Dijk, & Thayer, 2007; Pieper, Brosschot, van der Leeden, & Thayer, 2010), and worry episodes had an effect on heart rate and heart rate variability 2 h later (Pieper et al., 2010) or even predicted lowered heart rate variability during the subsequent night (Brosschot et al., 2007), all providing ecologically valid evidences for the relationship between perseverative thoughts and cardiovascular health. The latter results also indicate that worry episodes have prolonged effect on physiological functioning. Adaptation (habituation) to repeated stressors can decrease the allostatic load on the body (McEwen, 1998), and some recent studies have suggested that perseverative cognitions after stressors prevent this adaptive response. Post-stress rumination, for example, predicted non-habituation of HPA-axis (cortisol) response to the repeated Trier Social Stress Test on a subsequent day (Gianferante et al., 2014), and ruminators failed to adapt their cardiac responses (blood pressure and heart rate) to a repeated 5-min emotional recall task (Johnson, Lavoie, Bacon, Carlson, & Campbell, 2012). These results might implicate that not only prolonged activation of stress-related responses but


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the lack of habituation to repeated stressors also contribute to the adverse effect of rumination on somatic health. Perseverative cognitions such as rumination or worry are cognitive factors in psychological symptoms or disorders (e.g. in depression or anxiety) both in adults (Borkovec, 1994; Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008) and in adolescents (e.g. Legerstee, Garnefski, Verhulst, & Utens, 2011). Some studies have provided support for the relationship between perseverative cognition and somatic health complaints in adults (Borkovec, 1994), in adolescents (Brosschot & van der Doef, 2006; Lohaus et al., 2013) and in children (Jellesma, Rieffe, & Terwogt, 2006). Rumination and worry represent a recurrent negative thinking about events that happened in the past, or may happen in the future, respectively (Nolen-Hoeksema et al., 2008). Both rumination and worry are self-focused thoughts on negative and/or threatening materials or events (McLaughlin, Borkovec, & Sibrava, 2007) and are difficult to control (Ehring & Watkins, 2008). Furthermore, concerning problem-solving, perseverative thinking seems to be unproductive (Lyubomirsky, Tucker, Caldwell, & Berg, 1999). People differ in the extent they tend to engage in perseverative thoughts (trait-like perseverative thinking). People who are high on trait rumination tend to focus on negative aspect of self or events frequently, especially in times of sad moods (Nolen-Hoeksema, 1991) or in case of failures (Martin, Tesser, & McIntosh, 1993). Nevertheless, perseverative thoughts can be induced by certain instructions in experimental studies (McLaughlin et al., 2007). Both trait-like perseverative thinking and induced perseverative thinking are associated with increased occurrence of negative affects (NA) and decreased occurrence of positive affects (PA) (McLaughlin et al., 2007). Similarly, real life rumination assessed by dairies or experience sampling is associated with increased NA and decreased PA (Brans, Koval, Verduyn, Lim, & Kuppens, 2013; Genet & Siemer, 2012). According to both the experimental and real-life studies, rumination precedes the development of increased NA. Similarly, the stress reactivity model of rumination (Alloy et al., 2000) emphasises that rumination makes the perceived stress more intense, disturbing and uncontrollable which in turn increases NAs. Sustained psychological arousal is accompanied with physiological arousal that may be perceived as somatic symptoms. Namely, Eriksen and Ursin (2004) suggest that SHC are based on sensations associated with normal physiological processes such as sympathetic activation during stress. For some individuals, these ‘normal’ sensations (such as butterflies in the stomach during stress) capture attention, and they might perceive and report them as complaints (stomach ache) if the stress is prolonged. According to the results of a prospective study, these non-productive perseverative cognitions (e.g. worry and rumination) preceded the development of complaints, but complaints did not cause perseverative cognition in adolescence (Jellesma et al., 2006). The primary aim of this study was to test the relationship between perseverative thoughts and somatic complaints in adolescents. Based on previous theoretical and empirical work described above, the perceived stress, NA and PA were expected to be mediators between perseverative thoughts and complaints. This study also hypothesised that perceived stress would increase NA and decrease PA (Figure 1). The existence of a chronic condition might have an effect on the symptoms experienced, because physical well-being of a child with a chronic condition is usually lower when compared to that of a healthy peer (Tzavara et al., 2012). Furthermore, having a chronic condition might have an impact even on the stress experienced (see Sentenac et al., 2012). Similarly, an

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G. Kökönyei et al. Negative Affects

Perseverative thoughts

Perceived stress

Somatic complaints


Positive Affects

Figure 1. The theoretical model of the mediating effect of perceived stress, negative and PA between trait perseverative thoughts and somatic complaints.

acute condition, e.g. a viral infection, is also associated with certain physical symptoms (including fatigue, headache, hyperalgesia) and with psychological symptoms such as depressive mood (Dantzer, Bluthe, Laye, et al., 1998; Maier & Watkins, 1998). Having an acute condition may influence symptom reporting if the time interval assessing symptoms is short (e.g. one or two weeks). Therefore, we included questions about chronic and acute conditions, and controlled for their effects in the analyses. Methods Participants and procedure Three hundred and six adolescents (134 boys and 172 girls) between the ages of 13 and 18; from 7th to 12th grade with mean age of 16.33 (SD = 1.29) participated in the study. The adolescents were invited from nine secondary grammar schools (using a convenience sampling method), the response rate are above 90% (94.5%). Twenty-three per cent of the participants lived in the capital, 53% had their residence in other town and 24% of the respondents lived in villages. The majority of the participants (63.7%) reported that their mothers having college or university degree, 22% reported secondary school education of their mothers, while 10.5% reported lower education, and some students (3.6%) did not know their mothers’ highest education. The study was approved by the Institutional Review Board of Eötvös Loránd University. Informed consent was received from parents prior to the implementation of the study. All adolescents answered the questionnaires in their own classrooms. Measures Non-productive Thought Questionnaire for Kids (Jellesma, Meerum Terwogt, Reijntjes, Rieffe, & Stegge, 2005). The scale contains 10 items that capture trait-like perseverative thoughts – such as ‘I often worry’ or ‘When I have a problem, I cannot stop thinking about it’. The items are

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answered on a three-point scale (0 = not true, 1 = sometimes true, 2 = often true). The internal consistency of the scale was good (Cronbach’s alpha = 0.80) similarly to earlier results (Garnefski, Koopman, Kraaij, & ten Cate, 2009; Jellesma, Verkuil, & Brosschot, 2009; Miers, Rieffe, Terwogt, Cowan, & Linden, 2007). The validity of the scale was supported with positive correlations with other maladaptive emotion regulation scales, such as catastrophising (Garnefski, Rieffe, Jellesma, Terwogt, & Kraaij, 2007).


Positive and Negative Affectivity Schedule (Watson, Clark, & Tellegen, 1988) The PANAS includes ten positive (e.g. proud, interested) and ten negative (e.g. nervous, distressed) affects rated on a five-point Likert-type scale (from 1 = very slightly or not at all to 5 = very much) and covered a 2-week period in our study. Both the negative affectivity and positive affectivity subscales had good internal consistency with an earlier study (Gyollai, Simor, Koteles, & Demetrovics, 2011) and in this study (Cronbach’s alpha = 0.84 and 0.83, respectively). Somatic Complaints List (Jellesma et al., 2007) SCL is an 11-item scale measuring the occurrence of somatic complaints. Two items of 11 are reverse scored and their content refers to being healthy. Participants were asked to indicate on a five-point Likert-type scale how often the items apply to themselves, with 1 = almost never to 5 = quite often. In our study SCL covered the last two weeks, and similarly to earlier results (Jellesma, Rieffe, Terwogt, & Westenberg, 2008, 2011) the internal consistency of the scale was good (Cronbach’s alpha = 0.81). Perceived Stress Scale-4 (PSS-4, Cohen, Kamarck, & Mermelstein, 1983) We used a four item measure to assess subjective stress for the last month (e.g. ‘In the past month, how often have you felt that difficulties were piling up so high that you could not overcome them?’). Each item was rated on a five-point Likert-type scale ranging from never (0) to almost always (4). The Hungarian version has good psychometric properties (Stauder & Konkoly Thege, 2006) and in our study the reliability of the scale was good (Cronbach’s alpha = 0.74). Data regarding acute conditions in the last two weeks (e.g. flu, viral or bacterial infection) and chronic conditions requiring regular medical investigation (e.g. asthma, heart-related problems) were collected. Seventy-nine students (25.8%) reported having one or more acute condition in the last two weeks, and 40 students reported having a chronic condition (13.1%). Chronic conditions such as asthma, allergy, heart diseases and kidney diseases were reported. Statistical analysis SPSS 19.0 and Mplus 6.01 statistical software packages were used for statistical analyses. The proposed mediation model (see Figure 1) was tested with path analysis within structural equation modelling (SEM). Due to sampling method (class as a unit) and deviation from normal distribution, in SEM analysis maximum likelihood estimation robust to non-normality (MLR) was used (Muthén & Muthén, 1998–2007) and cluster

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effect was controlled. To evaluate the overall model fit, absolute fit index (chi-square value), comparative fit index (CFI), Tucker–Lewis fit index or non-normed fit index (TLI or NNFI) and root mean square error approximation (RMSEA) were inspected. CFI and TLI are related to the total variance accounted by the model, values higher than 0.95 indicate a good-fit. RMSEA is related to the variance of residuals, values below 0.05 indicate a good-fit (Browne & Cudeck, 1993).


Results Descriptive analyses were carried out and gender differences were examined (Table 1). Statistically significant differences were found across all scales. Girls had higher scores than boys on the scales measuring non-productive thoughts, somatic complaints, negative affectivity and perceived stress, but had lower scores on positive affectivity. The effect sizes (Cohen d) were small for positive affectivity, and medium for all other scales (Table 1). Age was associated positively with non-productive thoughts, complaints, perceived stress and negative affectivity significantly (Table 2). Having an acute condition and having a chronic condition are linked with more complaints, as we expected (see Table 2). Adolescents with an acute condition in the last two weeks scored higher on both the perseverative thoughts and negative affectivity scales (Table 2). We hypothesised that the relationship between perseverative thoughts and complaints would be mediated by negative and PA and perceived stress (see Figure 1). The degree of fit of the proposed mediational model was tested by the means of SEM. An initial model was created controlling for gender, age, acute and chronic condition. The absolute and relative fit indices indicated only an acceptable fit (χ2 = 35.433, df = 12, p < 0.001; RMSEA = 0.081 [0.051–0.113], CFI = 0.947, TLI = 0.884). Further examination of modification indices showed that having an acute condition in the last two weeks had an effect on NA. As a result we modified our model (see Figure 2), and after that all the indices indicated a good-fit (χ2 = 14.974, df = 11, p = 0.184; RMSEA = 0.035 [0.000–0.075], CFI = 0.991, TLI = 0.979). The final model (see Figure 2) showed that perseverative thoughts had no direct effect on complaints, and on PA, but did have a direct effect on perceived stress and NA. Perceived stress had a significant direct effect on both negative and PA and on

Table 1. Mean, standard deviations (SD) and effect sizes (Cohen d) by gender. Mean (SD) (total sample) Perseverative thoughts (NPTQ) Somatic complaints (SCL) Positive affects (PA) Negative affects (NA) Perceived stress (PSS-4)

Cohen d

Boys

Girls

t/d

9.23 (4.21)

7.53 (3.77)

10.54 (4.07)

6.58***

0.77

21.19 (6.36) 33.23 (4.21) 19.98 (6.65) 5.97 (2.86)

19.34 (6.08) 34.31 (6.61) 18.37 (6.01) 5.11 (2.44)

22.59 (6.22) 32.41 (7.32) 21.19 (6.87) 6.63 (2.99)

4.56*** 2.31** 3.67*** 4.85***

0.53 0.27 0.44 0.56

Notes: NPTQ: non-productive thought questionnaire, SCL: somatic complaints list, PA: positive affects, NA: negative affects, PSS-4: perceived stress scale. **p < 0.01; ***p < 0.001.

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Table 2. Scale, age (acute and chronic) condition correlation. 2


1. Perseverative thoughts (NPTQ) 2. Somatic complaints (SCL) 3. Positive affects (PA) 4. Negative affects (NA) 5. Perceived stress (PSS-4)

3

4

5

Age

Acute cond.+

.33*** −.26***

.50***

.58***

.16** −.14*

−.47***

.57***

.52***

.15*

−.23***

−.23*** −.47*** −.11 −.04 .60*** .20** −.25*** .18** −.06

Chronic cond.++ .07 .12* −.06 .05 .08

Notes: NPTQ: non-productive thought questionnaire, SCL: somatic complaints list, PA: positive affects, NA: negative affects, PSS-4: perceived stress scale. *p < 0.05; **p < 0.01; ***p < 0.001; +point biserial correlation, (1): had acute condition, (2): did not have acute condition; ++point biserial correlation, (1): has a chronic condition, (2): does not have a chronic condition; The coefficients with *** are significant according to Bonferroni correction (p < 0.002).

Negative Affects

0.20

0.07

0.47

Perseverative thoughts

0.57

Perceived stress

0.23

-0.21

0.41

Acute condition

-0.11

Somatic complaints

-0.49 -0.08

0.04 Positive Affects

-0.10

Figure 2. The final mediation model and standardised path coefficients. Notes: Dash arrows: non-significant path coefficients. Double arrow: covariance between the errors of negative and positive affectivity measures. Acute condition is coded: (1): having any acute condition, (2): not having acute condition.

somatic complaints. While NA had a significant effect on complaints, PA lacked this association with complaints. No significant direct path associate was found between acute condition and complaints. However, acute condition had a significant direct effect on NA. Examination of possible indirect effects showed four mediated pathways to be significant: ‘perseverative thoughts→NA→Complaints’ (standardised indirect effect was 0.08, p < 0.001), ‘perseverative thoughts→perceived stress→NA→Complaints’ (standardised indirect effect was 0.11, p < 0.001), and ‘perseverative thoughts→perceived stress→complaints’ (standardised indirect effect was 0.08, p < 0.001), and ‘acute condition→NA→complaints (standardised indirect effect was −0.09, p < 0.001).


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Therefore, perseverative thoughts had an effect via both perceived stress and via NA on complaints, and via perceived stress→NA pathway. Pathways from perseverative thoughts to complaints via PA were non-significant partly due to lack of significant relationship between PA and complaints. The final model explained 41% of the total variance of somatic complaints among adolescents. Since our study has a cross-sectional design, multiple equivalent/competing alternative models can be produced. In our model (see Figure 1) NA explains the variance of complaints. Though we would have formulated our theoretical model differently in which complaints explained the variance of NA. If the relationship between complaints and NA is simply reversed (SHC→NA), all the indices indicated good-fit as the fit indices of our original model did: χ2 = 15.588, df = 11, p = 0.157; RMSEA = 0.037 [0.000–0.077], CFI = 0.990, TLI = 0.975. Similarly, relationship between perseverative thoughts and NA can be reversed or even bidirectional (Brans et al., 2013; Moberly & Watkins, 2008a). If we reversed the relationship between PC and NA (NA→Perseverative thoughts), all the fit statistics indicated a poor-fit: χ2 = 65.092, df = 15, p = 0.000; RMSEA = 0.105 [0.080–0.132], CFI = 0.897, TLI = 0.794. Discussion In our cross-sectional study perseverative thoughts were connected to SHC, and this association was fully mediated by NA and perceived stress. Our results therefore indicate that rumination exerts its effects on SHC not directly, but through perceived stress and negative affectivity. We argue that rumination represents a cognitive-emotional sensitisation process (Brosschot, 2002), because it is associated with higher perceived stress and increased NA. Those who are prone to ruminating or worrying elongate their state of stress resulting in their recovery psychologically and physiologically being hampered or delayed (O’Connor, Walker, Hendrickx, Talbot, & Schaefer, 2013; McCullough, Orsulak, Brandon, & Akers, 2007; Zoccola & Dickerson, 2012; Zoccola, Figueroa, Rabideau, Woody, & Benencia, 2014). Unlike other studies (Pressman & Cohen, 2005) no evidence was found between the occurrence of frequent somatic complaints and the protective role of PA. Our cross-sectional study did find, however, experiencing NA had a much stronger effect on complaints than experiencing PA. This is contrast to (Cohen, Alper, Doyle, Treanor, & Turner, 2006; Cohen, Doyle, Turner, Alper, & Skoner, 2003) experimental studies and Pettit, Kline, Gencoz, Gencoz, and Joiner (2001) prospective study. Though the relationship between PA and physical health is inconsistent as Pressman and Cohen’s (2005) review summarised. For example, in a recent cross-sectional study found a positive relationship between trait PA and physical health (Nath & Pradhan, 2012) but in a prospective study with undergraduates found that state PA did not predict physical health, while physical health predicted subsequent PA (Finch, Baranik, Liu, & West, 2012). It is worth noting that in our cross-sectional study state positive affectivity was assessed instead of trait one and the PANAS we used did not differentiate between selfgenerated and passively experienced PA. Some recent longitudinal field experiment found that self-generate positive emotions were associated with less SHC (Fredrickson,


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Cohn, Coffey, Pek, & Finkel, 2008) and increased vagal tone as an index of objective marker of physical health (Kok et al., 2013). Self-reported NA had a direct effect on complaints, and mediated the relationship between perseverative thoughts and complaints. It is worth mentioning that this result indirectly contradicts classic alexithymia theory (see Nemiah, 1996; Sifneos, 1973; Taylor, Bagby, & Parker, 1991), which emphasised that unawareness of emotion was a potent factor in developing somatic complaints or even somatic diseases and conceptualised alexithymia as a tendency to express psychological distress in somatic rather than emotional way. Though we could not exclude the possibility that deficits in identifying emotions as a key aspects of alexithymia might contribute to the development of SHC (De Gucht & Heiser, 2003) via undifferentiated emotional responses (Taylor et al., 1991) or via increased physiological stress responses (Friedlander, Lumley, Farchione, & Doyal, 1997; Wehmer, Brejnak, Lumley, & Stettner, 1995). Furthermore, alexithymia has been demonstrated to be related to maladaptive (abstract-analytical) rumination (Di Schiena, Luminet, & Philippot, 2011). Further studies need to explore the possible relationship between perseverative thoughts and alexithymia and reveal whether they exert their effects on somatic or even on psychological symptoms through distinct pathways. In our study, perceived stress had a negative effect on PA. According to the dynamic model of affect (Zautra, Smith, Affleck, & Tennen, 2001) the relative independence of positive and negative affect is context-dependent. During calm states or times without stress amount of NA and PA can be independent, but during stress this affective complexity – described as a relative independence of NA and PA – may decrease, resulting increased NA and decreased PA. Our results concord with previous research which has shown that the prevalence of somatic and psychological symptoms increases with age, and girls report more complaints than boys (Hagquist, 2009). In our study, girls were also found to report more frequent perseverative thoughts, negative affect and evaluated perceived stress higher than boys, while boys reported more PA in the last two weeks than girls. Gender differences in cognitive vulnerabilities such as rumination are well-documented in the literature (Johnson & Whisman, 2013) and thought to contribute the well-known gender differences in mood (Weissman et al., 1993) and anxiety disorders (McLean, Asnaani, Litz, & Hofmann, 2011). Our study highlights that gender differences in perseverative thoughts may contribute the well-known gender differences in syndromes characterised by medically unexplained symptoms (Kroenke & Spitzer, 1998). Perseverative thoughts – such as worry and rumination – have been consistently linked to depressive and/or anxious symptoms or psychopathology in adults (see Aldao, Nolen-Hoeksema, & Schweizer, 2010; Nolen-Hoeksema et al., 2008) and in adolescents (e.g. Calvete, Orue, & Hankin, 2013; Michl, McLaughlin, Shepherd, & Nolen-Hoeksema, 2013) as well. There are small numbers of studies that have investigated the effect of perseverative thoughts on somatic health during adolescence. Our study demonstrated that individual differences in perseverative thoughts were important in explaining the variance of health complaints among school-aged youth and pointed out that trait perseverative thoughts made the perceived stress stronger. During adolescence social approval is a major concern, and one may argue that stressors relating to social evaluative threat might be more frequent and salient. Occurrence of the stressors is not totally under the control of the individual, but response to them could be modified, as a simple worry intervention demonstrated: postponing worry to a daily 30- min worry episode reduced health


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complaints (Brosschot & van der Doef, 2006; Jellesma et al., 2009). Large-scale international studies on youth’s health should consider including variables that might mediate or even moderate the relationship between stressors (e.g. bullying) and complaints. Perseverative thoughts are, therefore, warranted when investigating the relationship between stressors and health (Verkuil, Brosschot, Gebhardt, & Thayer, 2010). Having an acute condition was found to have an effect on symptom reporting. Those who had experienced an acute condition reported more symptoms, and according to the path analysis this was due to the increased NA. The body’s first response to infection has been called acute phase response or ‘sickness’ characterised by complex physiological and behavioural adjustment mediated by innate or non-specific immunity (Dantzer, Bluthe, Laye, et al., 1998). Acute viral illnesses are accompanied by non-specific symptoms, just like fever, somnolence, hyperalgesia, headache, fatigue, nausea, depressed mood and are attributable to cytokine production in central nervous system during infection (Chrousos, 2000; Dantzer, Bluthe, Gheusi, et al., 1998; Maier & Watkins, 1998). The list of symptoms typically contains items about headache, fatigue, pain in arms and legs, dizziness, shaky and shivery. If someone has just recovered from a viral infection, she/he will report frequent complaints for the last weeks. Our study therefore suggests that assessing acute conditions is important to take account of the fact that people are more likely to report symptoms following an acute episode. Based on earlier studies investigation well-being of adolescents with chronic condition (e.g. Tzavara et al., 2012), it was hypothesised that having a chronic condition would have an effect on symptom reporting. We did not find a relationship between chronic condition and rumination, though only a minority of students reported having a chronic condition. Other studies investigating relationship between cognitive emotion regulation strategies and emotional health have reported that rumination seem to be an important factor in depressive symptoms (Kraaij & Garnefski, 2012) and in lower level of health-related quality of life (Garnefski et al., 2009). In our study the proportion of adolescents reporting chronic condition was 13%, which is very similar to that found in a national representative sample (14.9%, Költő & Kökönyei, 2011). In our study, only a weak association between chronic condition and symptoms was found. If a list of symptoms captures a longer period, e.g. last six months, perhaps enquiring about chronic condition is advisable, though according to our results having a chronic condition did not affect the reported negative and positive affectivity and perceived stress. Limitations This study has some limitations. The cross-sectional study design used does not allow us to exclude the possibilities that perceived stress, NA and complaints had an effect on perseverative thought. However, a previous prospective study supports the findings that the relationship between rumination and symptoms was unidirectional (Jellesma et al., 2006). Only self-report measures were used in our study that could have resulted in an overestimation of the effects detected. Besides subjective perceived stress objective physiological indices (such as heart rate or heart rate variability) could have strengthened our results. For the other variables, other measures would not really have been better as internal states are subjective. Another limitation is that the measure of perseverative thinking did not distinguish between the two facets: rumination and worry. Though the two concepts have overlapping features, they might be uniquely associated


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with somatic symptoms, as has been demonstrated in relation to depressive and anxious symptoms and coping behaviour in adolescents (Hong, 2007). Retrieving a past or imagining a possible future event characterised by negative affectivity should have been differentiated from the way of thinking about or analysing them (Kross, Gard, Deldin, Clifton, & Ayduk, 2012). Both rumination and worry refer to a special way of dealing with materials associated with NA. In this study we treated them as unproductive and maladaptive processes, though certain type of rumination called self-reflection or self-distancing could be fruitful to elaborate events with negative emotions (Kross, Ayduk, & Mischel, 2005; Kross, Duckworth, Ayduk, Tsukayama, & Mischel, 2011). Further studies are needed to explore the possible role of adaptive and maladaptive self-reflection in developing SHC. One could argue that no perseverative thoughts that lead to higher perceived stress, but it is perceived stress that induces that kind of thinking. We cannot exclude this possibility, but in our study trait-like perseverative thoughts were measured, that explains the direction of process illustrated in the path analysis. Similarly, relationship between perseverative thoughts and NA can be reversed or even bidirectional, as it has been demonstrated by momentary assessment studies (Brans et al., 2013; Moberly & Watkins, 2008a). Therefore, we tested the reversed relationship between PC and NA (NA→Perseverative thoughts), but all the fit statistics of this alternative model indicated a poor-fit, though this result might be due to our cross-sectional design. However, when not just rumination but other regulation strategies (e.g. reappraisal, distraction, social sharing, suppression) are measured simultaneously with experience sampling method those who experienced NA applied different strategies – e.g. suppression, distraction, rumination, reappraisal – to regulate negative feelings (Brans et al., 2013). This result shows that when experiencing NA a person is likely to use different strategies, so NA → rumination is not a specific relationship. It is worth noting that in a momentary study, Moberly and Watkins (2008b) found that trait ruminators reported greater negative affect after a negative event which is in line with our model that suggests that those who are tend to use perseverative thoughts will report increased level of NA. From a theoretical point of view, symptom perception model (Watson & Pennebaker, 1989) states that both trait and state negative affectivity or any general psychological distress lead to symptom perception through increased self-focus and attentional and interpretational biases. Concerning the relationship between (state) negative affectivity and complaints, therefore, we hypothesised that NA would explain the variance of SHC. Though we would have formulated our theoretical model differently in which complaints explained the variance of NA. For instance, in a study with a short prospective daily diary design, there was a cross-lagged association between state NA and pain symptoms among adults (Charles & Almeida, 2006). In line with their results our alternative model proved to be as good as our suggested model. From a statistical point of view, producing and comparing equivalent cross-sectional SEM models has both the advantage and disadvantage. SEM approach allows the test of competing equivalent models but there are some drawbacks of producing many equivalents models as well. If more than one model is supported by fit indices, the only way how we can decide is the theoretical position. Since our purpose was to test the possible indirect effects of perseverative thoughts on complaints, therefore, we chose NA → SHC direction. Nonetheless, the equivalence of the ‘original’ model (NA → SHC) and the alternative one (SHC → NA) suggests a

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bidirectional relationship between emotional and physical distress. Further studies need to reveal when and how general distress and/or specific emotional states affect physical health, and vice versa, when and how general physical distress and/or specific complaints affect emotional life. Another limitation of the study was that known protective factors such as secure attachments to peer and family (Tremblay & Sullivan, 2010) or school-related sense of coherence (Modin, Ostberg, Toivanen, & Sundell, 2011) were not included. Effortful control as a temperament factor would have moderated the mediation between rumination and complaints, as it has been demonstrated for depressive symptoms in a followup study in a sample of 7th through 10th grades adolescents (Verstraeten, Vasey, Raes, & Bijttebier, 2009). Conclusions The health of adolescents has been demonstrated to be influenced by a range of social determinants, both structural (e.g. social inequality) and the dynamic features of the social environment (e.g. school environment) (Viner et al., 2012). Our results indicate that besides interpersonal factors (e.g. peer and family related functioning) and static factor (gender and age), interindividual differences of health in adolescence are determined by intrapersonal functioning as well. The main aims of this paper were to shed light on how perseverative thoughts could influence symptom reporting and experiencing. Cognitive and emotional intrapersonal mechanisms have been overlooked because of the attention given to addressing social determinants of health, but should have been studied in relation to health, because they may be modifiable much easier than disadvantaged social circumstances of the individual. Our results draw attention to intra-individual characteristics, namely cognitive and emotional processes in health. Previous research has mainly focused on rumination and worry as cognitive vulnerabilities in the development of depressive and anxiety symptoms and disorders and associated with attentional and interpretational biases concerning events, symptoms and distress (NolenHoeksema et al., 2008). However, our results highlight the possible role of perseverative thoughts in frequent somatic complaints in adolescence. Future works need to reveal how these processes are related to other aspects of health, and whether they are gender-dependent. Funding Gyöngyi Kökönyei and Zsolt Demetrovics acknowledge financial support of the János Bolyai Research Fellowship awarded by the Hungarian Academy of Sciences. This work was supported by the Hungarian Scientific Research Fund [grant number: 83884].

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The mediating roles of perceived stress and health behaviors in the relation between objective, subjective, and neighborhood socioeconomic status and perceived health.

The association between bullying-related behaviours and subjective health complaints in late adolescence: cross-sectional study in Greece.

Mindfulness, perceived stress, and subjective well-being: a correlational study in primary care health professionals.

The relationship between memory complaints, activity and perceived health status.

Participation in organized sport and self-esteem across adolescence: the mediating role of perceived sport competence.

GPs' negotiation strategies regarding sick leave for subjective health complaints.

Subjective health complaints predict functional outcome six months after stroke.

Work and Mental Complaints: Are Response Outcome Expectancies More Important Than Work Conditions and Number of Subjective Health Complaints?

Are students' symptoms and health complaints associated with perceived stress at university? Perspectives from the United Kingdom and Egypt.

Socioeconomic Status, Subjective Social Status, and Perceived Stress: Associations with Stress Physiology and Executive Functioning.

Interactive effects of subjective memory complaints and hypertension on learning and memory performance in the elderly.

Dimensions of Emotional Intelligence and Online Gaming Addiction in Adolescence: The Indirect Effects of Two Facets of Perceived Stress.

Associations between long commutes and subjective health complaints among railway workers in Norway.

Perfectionism, anxiety, and depressive distress: evidence for the mediating role of negative automatic thoughts and anxiety sensitivity.

Comparison of Subjective Health Complaints between Chinese and German University Students: A Cross-Sectional Study.

Symptoms and health complaints and their association with perceived stressors among students at nine Libyan universities.

Subjective underemployment and psychosocial stress: the role of perceived social and supervisor support.

Prevalence and Profile of Poststroke Subjective Cognitive Complaints.

Incident subjective memory complaints and the risk of subsequent dementia.

The (perceived) meaning of spontaneous thoughts.

Subjective Health Complaints Among Workers in the Aftermath of an Oil Tank Explosion.

Subjective complaints after cataract surgery: common causes and management strategies.

Social reactions to sexual assault disclosure and problem drinking: mediating effects of perceived control and PTSD.

Mild eczema affects self-perceived health among pre-adolescent girls.