Development and Psychometric Evaluation of the Reactions to Somatic Stress Questionnaire (RSSQ)
Abstract
Abstract.Background: Stress is a ubiquitous phenomenon in modern societies and is often accompanied by somatic sensations and symptoms, such as tension and nausea. Despite the inherent somatic component of stress, research on coping with stress has previously neglected to consider how somatic stress responses (i.e., somatic stress) may affect stress-coping behavior. Aim: To address this gap in the literature, this study introduces the concept of reactions to somatic stress (RSS). It also provides the first psychometric evaluation of the Reactions to Somatic Stress Questionnaire (RSSQ), a novel 16-item questionnaire that assesses hampering and facilitating RSS. Method: The RSSQ and a battery of questionnaires on related constructs were administered via an online survey to N = 265 participants from the general population. Results: Exploratory (n = 133) and confirmatory (n = 132) factor analyses yielded two dimensions of the RSSQ: Hampering RSS (RSS-H) and facilitating RSS (RSS-F). Both subscales showed good internal consistency (α = .81–.89). Correlations with body awareness, emotion regulation skills, and beliefs about stress indicated medium to high convergent and discriminant validity. The RSS-H and RSS-F scores significantly predicted maladaptive and adaptive coping behavior, respectively. This association remained stable after controlling for subjective stress and related measures. Limitations: Generalization of the obtained results is limited to healthy individuals. Conclusion: The study supports the theoretical assumptions underlying the RSS concept. The RSSQ suggests a promising way to assess reactions to somatic stress as they relate to coping with stress. The RSSQ could be used for clinical and health psychological testing or interdisciplinary research.
Stress is a common and recurring phenomenon in everyone’s life. From a scientific point of view, stress occurs whenever a situation is perceived as challenging or threatening, and one’s resources for dealing with it are deemed insufficient (Lazarus & Folkman, 1984). While the experience of stress has been linked to positive health correlates (see, e.g., Aschbacher et al., 2013; Crum et al., 2020; Nelson & Cooper, 2005), previous and current research predominantly focus on the potentially detrimental health impact of stress. As such, stress has been associated with numerous negative health outcomes, including some of the most prevalent mental disorders and somatic diseases worldwide (Chrousos, 2009). The extent to which stress can lead to detrimental health conditions is largely influenced by various coping strategies (e.g., Penley et al., 2002; Schneidermann et al., 2005; Taylor & Stanton, 2007). These strategies are adaptive or maladaptive, depending on whether they are useful in resolving a stressful situation or not. Coping strategies include cognitive (e.g., distancing, denial), emotional (e.g., emotion regulation strategies), and behavioral (e.g., social support, sport) aspects (e.g., Folkman & Moskowitz, 2004). Given the key role of coping behavior in translating stress into ill-health, it is pivotal to learn more about its determinants.
One so far rather neglected determinant of stress coping is the stress response itself, and in particular, the various somatic sensations (e.g., restlessness and tension) and somatic symptoms (e.g., nausea and headache) that accompany this response (see, e.g., Glise et al., 2014; Kozlowska, 2013; Morina et al., 2018; Schlinkert et al., 2020). Two existing research lines have previously supported the notion of a relation between somatic stress responses (i.e., somatic stress) and the subsequent coping behavior. The first line of research has found that somatic symptoms (e.g., abdominal pain, back pain) can map onto maladaptive coping (e.g., Matud, 2004; Wilpart et al., 2017). For example, Garnefski and colleagues (2017) have found empirical evidence that (stress-related) somatic symptoms are significantly associated with catastrophizing and blaming (correlations varied between r = .16–.31). By contrast, the second line of research has shown that somatic sensations (e.g., heart beating, warmth) can be followed by adaptive coping (e.g., Benecke et al., 2008a, 2008b; Berking & Znoj, 2008; Craig, 2015; Price & Hooven, 2018). For instance, in a mixed-methods study, Zamariola and colleagues (2019) have illustrated that the perception of somatic sensations is related to an improved verbalization of feelings. It thus appears as if somatic stress can both hamper and facilitate coping with stress. However, the mechanisms underlying this association remain unknown.
A potential explanation for the differential role of somatic stress in governing the choice of coping strategies could be that individuals differ in their reactions to somatic stress. There is indeed evidence from various research areas that the experience of somatic sensations and symptoms can evoke strong reactions. On the one hand, psychosomatic research suggests that somatic stress could trigger negative reactions, such as negative thoughts, behaviors, and emotions. For instance, studies on the diagnostic framework of somatic symptom disorder show that somatic symptoms can lead to catastrophizing and feelings of helplessness (Dimsdale & Levenson, 2013). This, in turn, has a high probability of fostering maladaptive coping (e.g., social withdrawal). On the other hand, mind-body research and research on emotion regulation have conceptualized that somatic sensations can prompt positive reactions. For instance, research on the concept of body awareness shows that somatic sensations can serve as a means to identify (underlying) emotional states (e.g., shallow breathing and anxiety; Price & Thompson, 2007). Additionally, research on emotion regulation proposes that somatic sensations may be applied to support the regulation of emotions. As such, it is assumed that somatic sensations can be used to express emotions (e.g., tears to express sadness) and as a source of information to understand personal feelings, desires, and needs (e.g., Body shaking to understand the need for a rest to calm down; Benecke et al., 2008a, 2008b; Berking & Znoj, 2008). Therefore, it is likely that these reactions facilitate adaptive coping (e.g., engaging in self-care). However, there is a lack of research that specifically investigates such negative and positive reactions in the context of somatic stress, which can partly be explained by the fact that the above-mentioned conceptual frameworks (i.e., somatic symptom disorder, body awareness, emotion regulation) include somatic symptoms and sensations in general.
Taken together, the current state of research purports that somatic stress facilitates both adaptive and maladaptive stress coping and that this may be mediated by negative and positive reactions to somatic stress. Given the fact that both somatic sensations/symptoms and coping are inevitably linked to stress and given their essential role in health and disease, it is highly relevant to extend the current knowledge about their interrelation. To this date, no theoretical models on this subject have been developed, and no empirical studies have been undertaken. To address this gap in the literature, this article (a) introduces the theoretical concept of reactions to somatic stress (RSS) and (b) describes the development and validation of the Reactions to Somatic Stress Questionnaire (RSSQ).
The Concept of Reactions to Somatic Stress
The concept of RSS integrates existing knowledge on reactions to somatic sensations and symptoms into a theoretical concept and both applies and refines this knowledge to the context of somatic stress (i.e., stress-related somatic sensations and symptoms) and stress coping. It is the main assumption of the RSS concept that reactions to somatic stress impact coping with stress (see Figure 1). The RSS concept thus builds the conceptual bridge between the experience of somatic responses to stress and coping behavior.
The RSS further assumes that reactions to somatic stress can facilitate both maladaptive and adaptive coping with stress (see Figure 1). Examples of hampering reactions to somatic stress would be to give in to feelings of helplessness and/or be left feeling paralyzed. In such cases, the RSS assumes that somatic stress does not support coping and may contribute to stress proliferation (see Ward, 2014). In contrast, examples of facilitating reactions to somatic stress would be to use somatic stress as an encouragement to reflect one’s stress levels and/or to use it as a source of information regarding the origins of stress. In such cases, the RSS assumes that somatic stress represents a helpful source of coping. In order to test these assumptions, this study aims to validate the outlined RSS concept with the use of the newly developed RSSQ.
Methods
Study Design
Standardized questionnaires were used to collect information on stress and coping measures (e.g., perceived stress and coping behavior), body-related measures (e.g., body connection and body responsiveness), current health and well-being, and psychosocial resources via an online survey. The study was conducted by the Department of Psychopathology and Clinical Intervention at the University of Zurich. All procedures were in accordance with ethical standards laid down in the Declaration of Helsinki and were approved by the Ethics Committee of the Faculty of Arts and Social Sciences at University of Zurich.
Participants and Procedure
Participants were recruited through different channels, including websites, advertisements, posts on social media platforms, and flyers. To extend the age range of participants, various age-specific locations of daily living (e.g., medical and health services, grocery shops, pharmacies, leisure services, and community centers) were included. Criteria of inclusion were a minimum of 18 years of age and good knowledge of the German language. Interested participants could access the online survey directly via a provided link. The survey was programmed online using Unipark software (Unipark & Questback, 2016) and was conducted in German. After the start of the online survey, information on the purpose and procedure of the study was provided, followed by the informed consent form. Participants who provided informed consent were directed to the first questionnaire. On a superordinate level, the survey followed the same sequence for each participant, namely, health and well-being aspects were followed by stress and stress-related aspects, body-related measures, and resources. However, to avoid sequence and order effects, measurement instruments within these categories were randomized. To increase response rates (Edwards et al., 2009), participants who completed the survey were entered into a draw for 10 grocery store vouchers.
The total sample of N = 265 was randomly split into two almost equally sized subsamples. The first half (n = 133) was used to explore the factorial structure of reactions to somatic stress (exploratory factor analysis [EFA] subsample). The second half (n = 132) was used to confirm the factorial structure using confirmatory factor analysis (confirmatory factor analysis [CFA] subsample).
Measures
Reactions to Somatic Stress
The preliminary item pool for the development of the RSSQ was generated by two strategies: An extended panel of master level and doctoral students, as well as senior researchers and clinical psychotherapists, was asked to think about possible (hampering and facilitating) ways of how stress-related somatic sensations and symptoms may affect coping with stress, including cognitive, behavioral, and emotional reactions to somatic stress. Instruments used in previous research on emotion regulation were screened for items or phrasings addressing the link between somatic sensations and emotion regulation. To the best of our knowledge, the only questionnaire addressing this link was the Questionnaire for the Assessment of Emotion Experience and Emotion Regulation (EER), based on the theoretical concept by Benecke and colleagues (2008a, 2008b). This questionnaire was screened for additional items. These two strategies resulted in an item pool of 26 items. All items were subjective statements about reactions to somatic stress with regard to coping with stress and started with “somatic responses to stress, …”. To keep the RSSQ as simple as possible for laypeople, stress-related somatic sensations and symptoms were summarized under the above-mentioned umbrella term “somatic responses to stress” and was explained as part of the questionnaire’s instruction as follows: “Being stressed might manifest in various ways, such as somatic responses, feelings, and thoughts. These reactions can vary from person to person and relate to a usual stress answer. Somatic responses to stress can include a broad range of phenomena, from more diffuse somatic sensations (e.g., restlessness, tension, heart beating) to specific somatic symptoms (e.g., headache, nausea, diarrhea, back pain). The following questions refer to somatic responses to stress in general. Please consider what applies to you personally when you feel stressed (i.e., regardless of a specific stressful situation)”.
In the next step, the item pool was tested in a pre-study with a convenience sample of N = 24 (age M = 35.80 years; range = 25–68). The answering format was a 4-point Likert scale (1 = completely disagree, 2 = mostly disagree, 3 = somewhat agree, and 4 = definitely agree), and items were ordered using a random number generator. The item pool was reduced stepwise based on the following criteria: To evaluate item comprehensibility, participants were asked to choose the additional answer option “I don’t know” in case of difficulties in understanding. Items that were rated on this additional answer option more than once were removed from the item pool (one item). All remaining items were evaluated in terms of answer variability, and items that were not used on all response options were removed (one item). Finally, in the case of items covering the same thought, the more specific items (e.g., to trigger helplessness) were preferred over the more general items (e.g., to trigger negative feelings) (four items). To ensure that participants understood the basic intention of the questionnaire (i.e., to assess the effect of somatic stress responses on coping with stress) as well as the provided definition of somatic stress, participants’ answers were tested with a manipulation check, asking to which stressor and somatic stress response their answers refer to. This manipulation check was successful for all participants and backed up the good validity of the RSSQ. At the end of the pre-study, participants were asked if there were other possible effects of somatic stress responses on coping that were not yet included in the set of items. This was not the case, and an item pool of 20 items following the same answering format as tested was included in the validation study. An English translation of this item pool can be found in Table A1 in the Appendix. The translation was performed using a forward-backward translation procedure.
Current Subjective Stress
The Perceived Stress Questionnaire (PSQ; Fliege et al., 2001; Levenstein et al., 1993) is a 20-item measure to assess stressful situations and stress reactions within the past four weeks on a mainly cognitive and, to some degree, emotional level. Items are rated on a 4-point Likert scale (1 = almost never, 2 = sometimes, 3 = often, and 4 = usually). All items were summed up to a PSQ Index score and linearly transformed to values between zero and one. The German version showed good internal consistency (α = .85; Fliege et al., 2001, 2005). This measure was used as a control variable and for descriptive purposes.
General Health Condition
The Short-Form Health Survey (SF-12; Morfeld et al., 2011; Ware et al., 1995) has been designed to assess eight dimensions of the subjective health perception, such as, e.g., physical functioning, bodily pain, vitality, and mental health. In the present study, the dimension of general health condition was assessed through the corresponding single item. The item is rated on a 5-point Likert scale (1 = excellent to 5 = bad). Lower values indicate the perception of a better general health condition. In previous studies using the German version, satisfying reliability was shown for this item (α = .71–.89; Bullinger et al., 2003; Wirtz et al., 2018). This measure was used only for descriptive purposes.
Well-Being
The World Health Organization-5 index (WHO-5; Bech et al., 2003; Brähler et al., 2007) is a one-dimensional 5-item self-assessment measure of general well-being, referring to the past two weeks. Items are answered on a 6-point Likert scale (1 = all of the time to 6 = at no time). Appropriate psychometric properties for the German version were documented in various samples (Brähler et al., 2007). This measure was used only for descriptive purposes.
Validating Measures
The following measures were used to validate the RSSQ. Below, a description of each measure, as well as hypotheses about their relationships with the RSSQ, can be found.
Beliefs About Stress
The Beliefs about Stress Scale (BASS; Laferton et al., 2018) comprises a total of 15 items that assess negative and positive stress beliefs and the controllability of stress. Items are rated on a 4-point Likert scale (1 = completely disagree, 2 = mostly disagree, 3 = somewhat agree, and 4 = definitely agree). The German version showed good internal consistency for the subscales negative stress beliefs (α = .80) and positive stress beliefs (α = .87) and satisfying results for the subscale controllability (α = .73; Laferton et al., 2018). As an indicator of the individual attitude to stress (and potentially also to somatic stress), positive beliefs about stress were assumed to be positively associated with facilitating reactions to somatic stress (i.e., RSS-F). Conversely, negative beliefs about stress were assumed to be positively associated with hampering reactions to somatic stress (i.e., RSS-H).
Coping Strategies
The Questionnaire for Individual Coping (Incope; Bodenmann, 2000) is a questionnaire to assess maladaptive (e.g., rumination, self-blame, social withdrawal) and adaptive (e.g., reappraisal, positive self-verbalization, activity, relaxation) coping strategies, with 10 and 11 items, respectively. All items are rated on a 5-point Likert scale (1 = never to 5 = usually). The German version showed acceptable internal consistency for both subscales: Maladaptive coping (α = .70) and adaptive coping (α = .70; Bodenmann, 2000). Following the notion of the RSS concept, it was assumed that facilitating reactions to somatic stress (i.e., RSS-F) are positively associated with adaptive coping strategies. Conversely, hampering reactions to somatic stress (i.e., RSS-H) are assumed to be positively associated with maladaptive coping strategies.
Emotion Regulation
The questionnaire for Self-Assessment of Emotion Regulation Skills (SEK-27; Berking & Znoj, 2008) is a self-report measure that includes nine dimensions of adaptive ways to deal with negative emotions, such as acceptance, resilience, regulation, and clarity. Twenty-seven items are assessed on a 5-point Likert scale (0 = not at all to 4 = (almost)always) and refer to the previous week. Appropriate psychometric properties for the German version were documented in various samples (Berking & Znoj, 2008). Given the strong connection between emotions and somatic experiencing, emotion regulations skills were assumed to be positively associated with facilitating reactions to somatic stress (i.e., RSS-F) and negatively with hampering reactions to somatic stress (i.e., RSS-H).
Body Connection
The Scale of Body Connection (SBC; Price & Thompson, 2007) is a 20-item measure with two distinct dimensions of body connection, namely body awareness (BA) and body dissociation (BD), with 12 and 8 items, respectively. The BA refers to the ability to experience inner somatic sensations, identify links between somatic sensation and emotion, and listen to the body guide self-care. The BD is characterized by the avoidance or disregard of internal experience that interferes with health and self-care. Items are rated on a 5-point Likert scale (0 = not at all to 4 = all of the time). Measures of reliability and validity for the SBC were considered to be acceptable (Price & Thompson, 2007). The awareness of one’s body was assumed to be positively associated with facilitating reactions to somatic stress (i.e., RSS-F). Conversely, the tendency to avoid or disregard somatic signals was assumed to be positively associated with hampering reactions to somatic stress (i.e., RSS-H).
Body Responsiveness
The Body Responsiveness Questionnaire (BRQ; Cramer et al., 2018; Daubenmier, 2005) is a 7-item instrument measuring responsiveness to somatic sensations on a 7-point Likert scale ranging from 1 = not at all true about me to 7 = very true about me. Body responsiveness is the tendency to integrate body sensations into conscious awareness to guide decision-making and behavior and not suppress or react impulsively to them (Daubenmier, 2005). The German version of the BRQ showed acceptable internal consistency (α = .75; Cramer et al., 2018). As a kind of a somatic indicator, the responsiveness to somatic sensations was assumed to be positively associated with facilitating reactions to somatic stress (i.e., RSS-F) and negatively with hampering reactions to somatic stress (i.e., RSS-H).
Mindfulness
The Southampton Mindfulness Questionnaire (SMQ; Böge et al., 2020; Chadwick et al., 2008) is a 16-item measure for mindful awareness of distressing thoughts and images. The SMQ is particularly suited to focus on the effects of a mindful attitude toward distressing inner experiences (Bergomi et al., 2013). Items are rated on a 7-point Likert scale (0 = not at all to 6 = at all). The German version showed good reliability (α = .89; Böge et al., 2020). A mindful attitude toward somatic experiencing was assumed to be positively associated with facilitating reactions to somatic stress (i.e., RSS-F) and negatively with hampering reactions to somatic stress (i.e., RSS-H).
Self-Efficacy
The General Self-Efficacy Scale (GSE; Schwarzer & Jerusalem, 1995) measures the general conviction that difficult situations in life can be mastered successfully by one’s own means. The GSE is a one-dimensional inventory consisting of 10 items that are rated on a 4-point Likert scale (1 = not at all true to 4 = exactly true). For the German version, good psychometric properties (α = .80–.90) were documented in various samples (e.g., Schwarzer et al., 1999). As another indicator of how an individual might approach stressful situations, self-efficacy was assumed to be positively associated with facilitating reactions to somatic stress (i.e., RSS-F) and negatively with hampering reactions to somatic stress (i.e., RSS-H).
Affectivity
The Positive and Negative Affect Schedule (PANAS; Watson et al., 1988) measures positive and negative affect and consists of 20 items referring to the past months. Items are rated on a 5-point Likert scale ranging from 1 = not at all to 5 = very much. For the German version, high internal consistency for both subscales (positive affect α = .84; negative affect α = .86) was documented (Krohne et al., 1996). Given that affectivity is likely to impact the handling of a stressful situation (and potentially also somatic stress), it was assumed that positive affectivity was positively associated with facilitating reactions to somatic stress (i.e., RSS-F). Conversely, negative affectivity was assumed to be positively associated with hampering reactions to somatic stress (i.e., RSS-H).
Data Analysis
Regarding missing values, there were less than 1% of such in the whole data set. Little’s missing completely at random (MCAR) test indicated that the values were not completely missing at random. Given the low amount of missings, values were replaced using the expectation-maximization algorithm (Dempster et al., 1977). Frequency distribution, means, and standard deviations were assessed for each variable. Participants’ eligibility for the validation of the RSSQ was reviewed using a control question (“How strongly does your body react to stress?”) which was rated on a 10-point Likert scale. All participants rated the question with a number higher than 1 (i.e., no reactions), meaning that all participants were aware of any form of somatic reactions to stress (also assessed in an open-end follow-up question “What kind of stress reaction do you notice in your body?”). For the RSSQ item pool validation, item difficulties were assessed, and items with a lack of discriminatory values (above p = .80 and below p = .20) were excluded from further analysis. Item intercorrelations were assessed to identify and exclude items without any intercorrelation larger than r = .30 and also items with intercorrelations higher than r = .80 (to avoid multicollinearity).
To investigate the latent factor structure of the RSSQ, an EFA (principal axis factoring, PAF; Field, 2013; Tabachnik & Fidell, 2007) was conducted using IBM Statistical Package for Social Sciences (SPSS) version 26 (IBM Corp, 2020) on the randomly generated EFA subsample. PAF was chosen over principal component analysis as it estimates factor loadings and factor correlations more realistically while recognizing the existence of random error introduced by measurement (Baglin, 2014). Consequently, PAF is less likely to produce inflated factor loadings or to underestimate factor correlations (Fabrigar et al., 1999). Kaisers’ criteria (eigenvalue > 1), visual inspection of the scree plot, and parallel analysis (Horn, 1965; Ledesma & Valero-Mora, 2007) were used to determine the number of factors to extract. These three criteria were combined in deciding the number of factors to retain. An oblique rotation method (OBLIMIN) was chosen because interrelations between different underlying latent factors of the RSSQ seemed to be conceivable. In the rotated factor solution, items were directly assigned to one factor if their main loadings were ≥ .40 and no side loadings were > .30. In the case of an item being a limited case, theoretical consideration was decisive for factor allocation. Items that did not meet these criteria were not included in the final item version.
To further evaluate the factor structure of the new scale derived from the EFA, CFA with the remaining CFA subsample was modeled using the package lavaan (Rosseel, 2012) in R version 3.5 (R Core Team, 2020). To minimize parameter estimation bias, a Maximum Likelihood estimation procedure with bootstrapping was used. The following fit indices indicated good fit (Brown, 2006; Schweizer, 2010): root mean square error of approximation (RMSEA) ≤ .08; standardized root mean square residual (SRMR) ≤ .08; and a comparative fit index (CFI) ≥ .95.
The reliability and validity of the RSSQ were evaluated using the total sample. Internal consistency of the RSSQ subscales was assessed using Cronbach’s alpha (α), with α coefficients of ≥ .70 considered acceptable (Cronbach, 1951). To test for convergent and discriminant validity, bivariate Pearson’s correlation between the RSSQ subscales and various related psychological concepts was evaluated. The test-specific criteria, namely metric scaling, linearity, and approximately normal distribution were satisfied. Correlations of .10 were considered small, .30 moderate, and .50 large (Cohen, 1988). The predictive validity of the RSSQ was assessed using blockwise linear multiple regression analysis. The dependent variable was the functionality of coping strategies (maladaptive/adaptive). Block I assessed the association of the RSSQ subscales with the corresponding subscale of the Incope (maladaptive/adaptive coping). In block II, it was further controlled for those psychological concepts that have shown the highest correlation with the corresponding RSSQ subscale when investigating the discriminant validity of the RSSQ. Post hoc power calculations (N = 265, α = .05, effect size = .30) for the statistical analysis directed to evaluate the validity of the RSSQ suggested high levels of statistical power (1 − β > .99). T-tests for independent samples, Pearson correlation, and Kruskal-Wallis tests were used to test for differences in RSS-H and RSS-F.
Results
Sample
The total sample consisted of N = 265 participants with an age range of 18–83 years and a mean age of M = 34.06 years (SD = 14.73). The sample comprised n = 205 females (77.4%) and n = 60 males. The majority of the participants (53.2%; n = 141) indicated that a university or applied science university degree was their highest level of education, followed by 34.3% (n = 91) with a higher entrance qualification and 12.5% (n = 33) who had completed at least nine years of school or professional training. Regarding employment status, the majority of the participants were professionals (50.9%; n = 135), others were students or professional trainees (41.5%; n = 110), retirees (3.8%; n = 10), homemakers (2.6%; n = 7), or unemployed (1.1%; n = 3). On average, participants reported a general health condition that was rated as very good and well-being that was rated as good. During the four weeks preceding the time of data collection, participants experienced, on average, a small to moderate amount of stress. In general, participants showed a well-balanced coping behavior. Detailed sample characteristics on stress, coping, well-being, and health are shown in Table 1. The two subsamples used to conduct exploratory and confirmatory factor analyses did not differ concerning sample characteristics (see Table 1).
Item Reduction
Item difficulties of the whole item pool can be found in Table A1 in the Appendix. Three items (9, 12, 18) were deleted due to low difficulty. All remaining items had intercorrelations above r = .30. There was no intercorrelation higher than r = .80, indicating the absence of multicollinearity.
Exploratory Factor Analysis
To investigate the dimensionality of the RSSQ, an EFA with all remaining RSSQ items was conducted within the EFA subsample. The Kaiser-Meyer-Olkin (KMO) measure of .85 confirmed great sampling adequacy. Bartlett’s test of sphericity indicated that correlations between items were sufficiently large for PAF (χ2(136) = 902.798, p < .001). The Eigenvalue criterion suggested a four-factor solution (first four Eigenvalues: F1 = 4.707, F2 = 3.653, F3 = 1.222, F4 = 1.127), though the 3rd and 4th Eigenvalues were just slightly larger than 1. The scree plot suggested a two-factor solution (see Figure 2).
Moreover, the parallel analysis also suggested the extraction of two factors. Given the indications of the scree plot and the parallel analysis, a factor model with two factors was chosen for EFA. In the rotated two-factor solution, 15 out of 17 items could be uniquely assigned to a specific factor with all main loading > .40 and no side loadings > .30. Item 17 showed loadings below .30 on both factors and was therefore omitted from further analysis. One item represented a limited case and was retained in the final RSSQ item pool based on theoretical considerations: Item 14 showed the main loading of .45 on factor two and a side loading of .40 on factor one. Given the not negligible communality of h2 = .35, this item was allocated to the factor with the higher factor loading, namely factor two. Factor loadings and communalities (h2) of the 16 final RSSQ items can be seen in Table 2.
The final factor solution after oblique rotation accounted for 44.61% of the cumulative variance in the model. Factor 1 accounted for 26.69%, and factor 2 for 17.92% of the total variance. Factor 1 represents different ways how reactions to stress-related somatic sensations and symptoms can hamper coping with stress and was therefore labeled as “hampering reactions to somatic stress (RSS-H).” Factor 2 includes items representing different ways in how reactions to stress-related somatic sensations and symptoms could facilitate coping with stress and was termed “facilitating reactions to somatic stress (RSS-F).” Both subscale scores reflect the sum of their corresponding items. The correlation between the two factors was small, confirming the choice of an oblique rotation method (r = .04, p = .49).
Confirmatory Factor Analysis
To find further evidence for the two-dimensionality of the RSSQ, the final factor structure obtained from the EFA was cross-validated with a CFA using the remaining CFA subsample. Therefore, a model with two correlated factors (see Figure 3) was modeled and compared to a one-factor solution. All models terminated normally. The two-factor model yielded an acceptable (to good) model fit (RMSEA = .08; 90% CI [.07, .10], SRMR = .11, CFI = .88). The chi-square χ2(104) = 196.85 was statistically significant (p < .01). As expected, the alternative model with one latent factor showed an unsatisfactory model fit (RMSEA = .16; 90% CI [.14, .17], SRMR = .18, CFI = .60).
Furthermore, a modified two-factor model where the item with the lowest factor loading was deleted for both latent factors (item 5 for RSS-H and item 16 for RSS-F) was tested. This modified two-factor model showed a model fit that was only marginally better than that of the two-factor model (RMSEA = .08; 90% CI [.06, .11], SRMR = .11, CFI = .91), emphasizing the coherence of the two-factor structure obtained from the EFA. No further modifications substantially improved the model.
Reliability Analyses
Internal consistency was assessed by Cronbach’s α coefficient. Both subscales of the RSSQ showed a satisfactory internal consistency (RSS-H: α = .89; RSS-F: α = .81). Internal consistency could not be substantially increased by the elimination of any item, confirming a coherent factor solution. Stability over time has not yet been tested.
Convergent and Discriminant Validity
Convergent validity was tested by correlations of the RSSQ subscales RSS-H and RSS-F with body-regulation measures (i.e., body awareness, body dissociation, and body responsiveness) and stress-related measures (i.e., mindfulness and emotion regulation skills). Significant correlations with up to moderate effect sizes were considered as evidence for high convergent validity. Correlations are shown in Table 3. For RSS-H, correlations were between −.56 and ∓.42, indicating a medium convergent validity. Evidence for medium to high convergent validity of RSS-F was further demonstrated by mostly small to moderately significant associations between this subscale and the tested measures. As expected, RSS-F showed the highest association with the subscale body awareness, as both concepts focus on facilitating (i.e., functional) reactions to somatic sensations and symptoms.
Discriminant validity was tested by correlations of the two RSSQ subscales, RSS-H and RSS-F, with stress-related measures (i.e., positive and negative stress beliefs and self-efficacy) and affectivity measures (i.e., positive and negative affect). Correlations below or around r = .30 were considered an indicator of high discriminant validity. Correlations are shown in Table 3. For RSS-H, correlations were between −.13 and ∓.43, indicating medium discriminant validity. Evidence for high discriminant validity was further demonstrated by small significant associations between RSS-F and measures of positive and negative stress beliefs, self-efficacy, and positive affect (all r between .07 and .16).
Predictive Validity
To assess predictive validity, we investigated whether the RSSQ subscales would predict the subjective level of coping behavior functionality/adaptivity (Incope) using multiple linear regression analysis. Results are shown in Tables 4 and 5. Controlling for levels of subjective stress over the four weeks before data collection and negative affectivity, RSS-H significantly predicted a higher level of maladaptive coping behavior (Block 1; see Table 4). The same result was found for RSS-F predicting adaptive coping behavior (Block 1; see Table 5).
Additionally, RSS-H and RSS-F remained significant predictors for maladaptive and adaptive coping behavior (p = .02 and p < .001, respectively), when controlling for different measures of stress regulation, such as emotion regulation skills and mindfulness (Block 2; see Tables 4 and 5). This indicates that RSS has a significant effect on coping with stress beyond existing stress-regulating measures.
Descriptive Analysis of the Final Items
The final 16 items were evaluated for skewness, kurtosis, bimodality, and ceiling and floor effects. Scores from only a few items were normally distributed, and most items showed a moderate extent of positive skewness (see Table A2 in the Appendix). There was no evidence of bimodality or ceiling or floor effects, as all response options were utilized for all items.
Demographic Variables Analyses
Gender-related differences in both subscales of the RSSQ were found. Women had significantly higher values of hampering and facilitating RSS than men (RSS-H: t(263) = 2.618, p = .01; RSS-F: t(263) = 2.419, p = .02), showing small to slightly moderate effect sizes (rRSS-H = .16; rRSS-F = .15). No significant age-related difference was identified for RSS-F, whereas RSS-H was significantly negatively correlated with age (r = −.20; p = .001). Results showed significant differences in RSS-H between education levels (χ2(4) = 21.749, p ≤ .001) and employment status (χ2(4) = 30.547, p ≤ .001). For education, post hoc tests showed a significant difference between people with a university degree (M = 15.12, SD = 4.68) and people with a higher entrance qualification as the highest education (M = 17.99, SD = 4.83; z = 4.315, p ≤ .001). For employment, post hoc tests showed significant differences between retirees (M = 13.35, SD = 4.13) and students or professional trainees (M = 18.00, SD = 4.78; z = 2.842, p = .05) as well as between professionals (M = 15.01, SD = 4.94) and students or professional trainees (M = 18.00, SD = 4.78; z = −4.843, p ≤ .001). Results showed no significant differences in RSS-F between education levels (χ2(4) = 6.844, p = .28), or employment status (χ2(4) = 4.723, p = .32).
Discussion
This study introduces the reactions to somatic stress concept and provides the first psychometric evaluation of the proposed Reactions to Somatic Stress Questionnaire. The investigation of dimensionality revealed that the RSS concept is two-dimensional and includes hampering and facilitating reactions to somatic stress. Both dimensions of the RSS concept are co-existent and are not mutually exclusive. The two-factor structure reached an acceptable (to good) fit in the confirmatory factor analysis. As such, this study could confirm the theoretical assumptions of the RSS concept.
The findings reported here provide initial support for the reliability and for the convergent, discriminant, and predictive validity of the RSSQ. With regard to the reliability, the findings suggest that the RSSQ is internally consistent, with high and almost equal α-coefficient values for both the hampering and facilitating subscales. This indicates that both dimensions of RSSQ are described with reliable and coherent items. However, a more detailed evaluation of the RSSQ reliability is missing data on its retest stability. This is of particular interest as it could be further evaluated whether or not RSS is a construct that is generally stable across the lifespan or whether it shows intra-individual change over time, such as in response to major life events or therapeutic interventions.
Concerning convergent and discriminant validity, results for the RSSQ were favorable. Both subscales were moderately (to strongly) correlated with body-related measures, such as body awareness, body dissociation, body responsiveness, and stress-related measures, such as mindfulness and emotion regulation skills. These medium effect sizes suggest that RSS combines both body-related and stress-related aspects, as was theoretically assumed, and is distinguishable from related concepts. Furthermore, both dimensions of the RSSQ seem to (only) partly overlap with how people think about stress (beliefs about stress), what people think about their mastery skills (general self-efficacy), and how people feel (affectivity). Altogether, these findings indicate that RSS is a construct that differentiates from established constructs in stress research.
Interestingly, both RSSQ subscales showed low to moderate associations with beliefs about stress – an emergent concept in stress research (Laferton et al., 2018). While the RSS-F subscale was positively associated, the RSS-H subscale was negatively associated with both negative and positive stress beliefs. As such, it seems reasonable that higher levels of RSS-F are associated with more positive beliefs about stress, and higher levels of RSS-H are associated with less positive beliefs about stress. However, the remaining associations, particularly the negative association between RSS-H and negative beliefs about stress, remain unclear and need further investigation. In this context, it would also be interesting to pair this kind of future research with the concept of health beliefs, as there is research showing a link between health beliefs and coping with stress (e.g., Ayaz-Alkaya et al., 2020; Wethinghton et al., 2015).
The results of this study provide initial evidence of the predictive validity of the RSSQ. Apart from the subjective stress level and the level of negative affectivity, higher scores on each of the RSSQ subscales seemed to predict the functionality of the used coping strategies. This means that higher levels of RSS-H predicted the use of more maladaptive coping strategies, and higher levels of RSS-F predicted the use of more adaptive coping strategies. This association remained stable even after controlling for other psychological constructs affecting coping with stress, such as mindfulness (see Böge et al., 2020) and emotion regulation skills (see Berking & Znoj, 2008). While preliminary, these findings suggest that hampering and facilitating RSS can predict coping behavior beyond the established psychological constructs. In order to better understand this mechanism, more research on RSS and the relationship with different forms of stress and coping mechanisms is needed.
Preliminary demographic analysis of the RSSQ showed mixed results. Both hampering and facilitating RSS was significantly higher in women than in men. Also, hampering RSS was significantly negatively correlated with age, indicating that stress-related somatic sensations and symptoms might be less hampering for coping with stress in older people. Moreover, significant differences in RSS-H were found for different levels of education and employment status, implying that somatic stress might be more hampering for coping with stress for people with higher education and for those who are either entering or leaving the working world. However, these results need to be interpreted with caution, as the sample consisted of a greater proportion of female than male participants, a greater proportion of people under 50 years of age, as well as a greater proportion of highly educated and working people, which might have led to a bias. Future research should replicate our findings in samples with an equal distribution of gender, age, education level, and employment status to clarify the extent to which RSS might vary.
As a multidimensional concept, the RSS per se, as well as the use of the RSSQ, could contribute to a gain in knowledge in several areas of psychological research. Using a somatic approach to coping, the RSSQ could be used to identify people at risk of disadvantageous coping behavior from a previously neglected perspective and could thereby also help prevent the development of psychological disorders (e.g., somatic symptom disorder) after experiencing stressful life events. Additionally, by identifying people with high facilitating RSS, the RSSQ might also represent an instrument that could be interesting for researchers and clinicians focusing on salutogenic processes. Furthermore, as the RSS includes all kinds of potential somatic stress responses, it is a construct that considers the great interindividual variety in somatic stress responses and is thereby also applicable to different types of stress, including acute and chronic stress. Finally, the RSS concept might be of clinical relevance as it renews the notion of stress interventions, such as mindfulness-based stress reduction (e.g., Chiesa & Serretti, 2009; Grossman et al., 2004), somatic experiencing (e.g., Levine, 2010; Payne et al., 2015), progressive muscle relaxation (e.g., Dolbier & Rush, 2012; Rausch et al., 2006), or biofeedback (e.g., De Witte et al., 2019) that somatic stress responses can serve as a helpful feedback resource to reduce stress.
A number of limitations provide directions for future research. First, participants reported a comparatively low level of stress at the time of data collection. To provide stronger evidence for the generalizability of the results, future studies should apply the RSSQ in samples currently affected by various significant life events. This would allow the investigation of a potential dose-response relationship between RSS and the magnitude/severity of experienced stressors. In doing so, future studies could examine the impact of traumatic stressors, as it is well documented that traumata can lead to altered body access (e.g., Levine, 2010; Tsur et al., 2018; van der Kolk, 2014). Second, the present convenience sample showed good health conditions. Future studies should apply the RSSQ to samples with different health conditions to give insight into potential differences in RSS. This would ideally include the collection of norm data among different populations. Finally, more detailed studies on the association of the RSSQ and established constructs in stress research, such as stress reactivity, self-compassion, and particularly somatic stress, are needed to understand RSS’s relevance better.
The present study provides the first theoretical concept and questionnaire that deliberately address the role of stress-related somatic sensations and symptoms in coping with stress. As a conceptual bridge between the experience of somatic responses to stress and stress coping, the RSS addresses both negative and positive characteristics of somatic stress responses. By demonstrating the potential functional characteristic of somatic stress responses, the present study proposes an approach to somatic sensations and symptoms that is scarce in current psychological stress research. As such, it also aims to contribute to a de-pathologizing of somatic stress responses. Given that many people regularly experience somatic stress and are required to cope with stress, it opens up a relevant area of research that has previously been neglected. The presented findings provide initial support for the RSSQ as a valid and reliable measure to assess the role of stress-related somatic sensations and symptoms in coping with stress. The use of this standardized questionnaire has the potential to facilitate interdisciplinary research on RSS as a promising new construct in psychological stress research.
We gratefully acknowledge Romana Bednar’s help in conducting the surveys.
The idea for this questionnaire and a preliminary item pool has been presented at the 7th annual scientific conference of the European Association of Psychosomatic Medicine (EAPM), 2019, Rotterdam, The Netherlands.
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