The sample consisted of 465 18-to-65-year-old adults from a general population sample (mean age 45.5; SD = 13.0) recruited from a general practitioner’s (GP) practice in The Netherlands. Of the respondents, 81.5% was female, 50.0% was married or living together with a partner, 83.4% had received higher education.
Three GP practices in The Netherlands were approached to ask for permission to recruit patients who might be willing to participate in this research study. One GP practice agreed to participate. Although no formal data is available concerning the representativeness of this GP’s patient population compared with the general population in The Netherlands, the location of the practice is in a neighbourhood where the majority of people can be characterized by high education, high income, and a Dutch ethnic identity. All patients of the GP’s practice that met the following inclusion criteria were eligible for participation: Being between 18 and 65 years of age, being able to read and understand Dutch, and having shared an e-mail address with the GP. In total, 1850 persons met these criteria. Potential participants were contacted by an e-mail message that contained a link to an online self-report questionnaire. To preserve patients’ anonymity, i.e., to keep the researchers, the GP, and the practice staff blind with respect to the identity of both participants and non-participants, the e-mail was sent by the GP practice, and the questionnaire did not request the participant’s name. The e-mail message explained Leiden University was conducting a research project in cooperation with the GP practice, and that the project was focused on the relationships between the experience of negative life events, physical health, and psychological problems. It was explained that filling in the questionnaire would take about 25-min and that participation was voluntary. No compensation was offered for participation. Participants also filled out an informed consent as part of the questionnaire. Ethical approval had been obtained from the ethics committee of the University. A total of 465 persons completed the on-line questionnaires, which was 25.1% of the total number of e-mail messages that were sent to potential participants. There was no opportunity to gather data from those individuals who did not respond to the e-mail message.
Cognitive Emotion Regulation Strategies
To measure the cognitive strategies that participants used in response to negative life events, the Cognitive Emotion Regulation Questionnaire (CERQ) was used (Garnefski, Kraaij, & Spinhoven, 2001, 2002). The CERQ is a 36-item questionnaire, consisting of the following nine conceptually distinct subscales, each consisting of four items referring to what someone thinks after the experience of threatening or stressful life events:
Self-blame, referring to thoughts of blaming oneself for what one has experienced. Typical subscale items are: “I feel that I am the one to blame for it” and “I feel that I am the one who is responsible for what happened.”
Acceptance, referring to thoughts of accepting what one has experienced and resigning oneself to what has happened. Typical subscale items are: “I think that I have to accept that this has happened” and “I think that I cannot change anything about it.”
Rumination or focus on thought, referring to thinking about the feelings and thoughts associated with negative events. Typical subscale items are: “I often think about how I feel about what I have experienced” and “I dwell upon the feelings the situation has evoked in me.”
Positive refocusing, referring to thinking about joyful and pleasant issues instead of thinking about the actual events. Typical subscale items are: “I think of pleasant things that have nothing to do with it” and “I think of something nice instead of what has happened.”
Refocus on planning, referring to thinking about what steps to take and how to handle the negative events. It is the cognitive part of action-focused coping, which does not automatically imply that actual behavior will follow. Typical subscale items are: “I think about how to change the situation” and “I think about a plan of what I can do best.”
Positive reappraisal, referring to thoughts of attaching a positive meaning to the events in terms of personal growth. Typical subscale items are: “I think I can learn something from the situation” and “I look for the positive sides to the matter.”
Putting into perspective, referring to thoughts of playing down the seriousness of the events or emphasizing its relativity when compared to other events. Typical subscale items are: “I think that it all could have been much worse” and “I tell myself that there are worse things in life.”
Catastrophizing, referring to thoughts of explicitly emphasizing the terror of the experiences. Typical subscale items are: “I keep thinking about how terrible it was what I have experienced” and “I continually think how horrible the situation has been.”
Blaming others, referring to thoughts of putting the blame of what one has experienced on others. Typical subscale items are: “I feel that others are to blame for it” and “I feel that others are responsible for what has happened.”
The following instruction was provided: “Everyone gets confronted with negative or unpleasant events now and then and everyone responds to them in his or her own way. By the following questions you are asked to indicate what you generally think, when you experience negative or unpleasant events.” Response scales of the items ranged from: 1 = (almost) never to 5 = (almost) always. Individual subscale scores were obtained by summing up the scores belonging to the particular subscale (possible range per subscale: 4–20). Higher scores refer to higher use of the specific strategy.
Research on cognitive emotion regulation strategies, as measured by the CERQ, has shown that the subscales have good internal consistencies, with alphas ranging from 0.67 to 0.81 (Garnefski et al., 2001, 2002). In the present study alpha reliabilities of the subscales were the following: 0.83 for Self-blame, 0.76 for Acceptance, 0.83 for Rumination, 0.86 for Positive refocusing, 0.84 for Planning, 0.84 for Positive reappraisal, 0.83 for Putting into Perspective, 0.63 for catastrophizing, and 0.84 for Other-blame.
To measure somatic complaints, one of the subscales of the SCL-90 was used, i.e., the Somatization subscale (Symptom Check List: Derogatis & Cleary, 1977; Dutch translation and adaptation by; Arrindell & Ettema, 1986). The following 12 somatic complaints were assessed: painful muscles, painful joints, painful limbs, difficulty breathing, abdominal complaints, stomach complaints, body weakness, fatigue complaints, heart complaints, and chest complaints. The following instruction was provided: “Below is a list of complaints that people sometimes have. Please read each one carefully. After you have done so, please indicate to what extent that specific complaint has bothered or distressed you during the past week, including today.”
Response scales of the items ranged from: 1 = not at all to 5 = very much. An individual scale score was obtained by summing up the responses (possible range: 4–20). Higher scores refer to a higher amount of somatic complaints.
Previous studies of the SCL-90 Somatization scale have reported alpha-coefficients ranging from 0.74 to 0.89. In addition, test–retest reliabilities are found to be good and both subscales have been found to show strong convergent validity with other conceptually related scales (Arrindell & Ettema, 1986). In the present study, a Cronbach’s alpha of 0.82 was found.
Traumatic Life Event with Current Impact
To assess whether participants have experienced a traumatic life event, they were asked to indicate whether there is a past negative life event that still produces strong and negative feelings in the present. The following instruction was provided: “Did you experience one or more negative life events in your life that still produce strong and negative feelings in the present?” Possible answers were: yes and no. If the answer was yes, participants were asked to describe the life event with the strongest negative feelings in the present. In the present study, this variable was included as a dichotomous variable (yes/no traumatic event).
Total Number of Lifetime Negative Life Events
The total number of lifetime negative life events was assessed. A checklist was used to collect data on the experience of negative life events (provided at http://www.cerq.leidenuniv.nl). The instruction was: “Did you experience one of the following events in your life, before the age of 16, between 16 and 1 year ago, and/or in the past year? If you did not experience a particular event in any of the three periods, please check the box no. If you experienced a particular event in a particular period, please check the box concerning the period in which the event occurred. If an event occurred in several periods, please check the event for all these periods.” Life events that were assessed were: sexual abuse (self), physical abuse (self), victim of crime (self), victim of bullying (self), violence within home situation, alcohol or drug abuse within home situation, suicide attempt by close relative, divorce (parents/self), death of close relative. If the no was checked (did not experience this life event in any of the periods), the response was scored as 0. If the yes box was checked for a specific period, the response was scored as 1. An individual total number of negative events score was obtained by summing up the responses (possible range: 0–27). Higher scores refer to a higher amount of negative life events.
Means, standard deviations and ranges of the study variables (cognitive emotion regulation strategies, somatic complaint score, total number of negative life events) were calculated. In addition, the number of participants that reported a traumatic life event with current impact was determined. Subsequently, associations between somatic complaints scores and background variables (gender, age, and number of life events) were calculated. The relationships between somatic complaints scores and gender were tested by t tests, the relationships between somatic complaints and age were tested by a Pearson correlation. Likewise, a Pearson correlation was calculated between somatic complaints and total number of negative life events. On basis of these analyses, it was decided that gender, age, and number of life events were to be included in the main multiple regression analysis.
Next, Pearson correlations between the experience of a traumatic life event, cognitive strategies, and somatic complaints were calculated. Finally, hierarchical multiple regression was used to answer questions about whether specific cognitive strategies explain variation in somatic complaints over and above the effect of the number of negative life events, and whether the relationship between traumatic life events and somatic complaints is moderated by specific cognitive strategies. This method makes it possible to determine the extent to which the specific blocks of predictor variables make a unique contribution to the prediction of somatic complaints after the contribution of preceding blocks of variables has been taken into account. Somatic complaints was the dependent variable.
As gender, age, and number of number of negative life events proved to be significantly related to somatic complaints, these variables were entered respectively in the first (gender and age) and second step (life events). In the third step, traumatic life event was entered. In the fourth step the nine cognitive strategies were entered. In the fifth step, the nine interactions between traumatic life event and cognitive emotion regulation strategies were entered. Because the interaction terms were included, all variables were centered before being entered into the regression equation.