Coping with psychosomatic symptoms: The buffering role of psychological flexibility and impact on quality of life

Abstract

Individual differences in avoidant coping were hypothesized to exacerbate quality of life impairment associated with somatization and illness anxiety symptoms; psychological flexibility was expected to moderate this impairment. Individuals from a random community sample (N = 298; 182 females), who met screening criteria for somatization and illness anxiety, reported lower quality of life and psychological flexibility and greater avoidant coping compared to controls. Psychological flexibility significantly moderated the impact of somatization and illness anxiety on quality of life domains. Findings suggest that decreasing avoidant coping through therapy may be promising in mitigating the negative impact of these symptom categories.

Keywords

coping psychological flexibility experiential avoidance psychosomatic symptoms health anxiety

Somatic symptom disorder (somatization in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV); American Psychiatric Association (APA), 1994) and illness anxiety disorder (DSM-IV hypochondriasis; health anxiety in previous literature) compromise quality of life (QoL) in the psychological, social and professional domains. Unexplained physical symptoms are related to psychological distress, poverty, low education (Mai, 2004), interpersonal difficulties and unemployment (Terluin et al., 2011) and high healthcare costs due to frequent healthcare visits (Barsky et al., 2005; Burton, 2003; Grabe et al., 2009; Kroenke, 2003; Shaw and Creed, 1991; So, 2008). Individuals with such disorders avoid engaging in valued activities because of discomfort and fear of their symptoms worsening (Chaturvedi et al., 2006; Woolfolk and Allen, 2010). Medical interventions offer little comfort, whereas both traditional cognitive behavioural therapy and third-wave therapies such as acceptance and commitment (ACT) have shown promising effects (Eilenberg et al., 2013; Lovas and Barsky, 2010). Understanding the behavioural changes that may decrease the cost of these disorders on individuals and society represents an important research endeavour, which is the goal of this study.

Clinical conceptualizations of these conditions highlight their similarities with anxiety disorders (e.g. Rachman, 2012; Van De Heuvel et al., 2014), emphasizing the role of reassurance seeking and symptom avoidance in maintaining pathology. These coping styles are emotion focused and aim to avoid contact with undesirable emotions of anxiety and fear, unpleasant thoughts about the potential meaning of symptoms and discomfort of symptoms themselves. Avoidance of this sort has been identified as a general psychological vulnerability (Kashdan et al., 2006), called experiential avoidance, which was found to hinder psychological wellbeing in samples with depression, anxiety, somatization and post-traumatic stress (Hayes et al., 2006; Tull et al., 2004).

Avoidance of internal experiences is in stark contrast to problem-focused coping, acceptance of symptoms and psychological flexibility (PF). The latter construct is derived from ACT and represents the ability to consciously and fully experience the moment, without defence, behaving in accordance with chosen values (Hayes et al., 2012) and adapting to changing situational demands by reconfiguring mental resources, perspectives and competing needs and values (Kashdan and Rottenberg, 2010). Relying flexibly on effective ways of coping can be critical in whether symptoms are alleviated or perpetuated, and understanding the role of coping in somatic symptoms can inform mechanisms of therapeutic change.

Findings on the coping mechanisms in somatic symptom disorders substantiate the claim that emotion-focused and avoidant coping represent dominant strategies, similar to other anxiety disorders (Panayiotou et al., 2014a), forming a mechanism that maintains symptoms. Positive associations have been established between disease conviction and health anxiety with cognitive avoidance (Fergus and Valentiner, 2010), rumination, catastrophizing (Bailey and Wells, 2015; Görgen et al., 2013; Marcus et al., 2008), self-blame, other blame and expressive suppression (Görgen et al., 2013; Hall et al., 2011; Rasmussen et al., 2010), all of which focus primarily on decreasing negative experiences rather than on actively resolving the source of stress (Penley et al., 2002). The conflict-avoidant style of emotion regulation used by individuals with such symptoms has been linked to their difficulties in differentiating emotions from bodily sensations (Panayiotou et al., 2015; Waller and Scheidt, 2004). Such coping may decrease distress momentarily, but in the long term leads to more psychological symptoms, worse functioning and lower life satisfaction (Eftekhari et al., 2009; Gross and John, 2003; Saxena et al., 2011; Sempertegui et al., 2017).

In contrast to these coping styles, accumulating evidence indicates that more functional approaches may be pivotal in improved wellbeing. Reappraisal, planning and active coping are well documented for their beneficial effects including in individuals with health anxiety and medically unexplained symptoms (e.g. Fergus and Valentiner, 2010; Görgen et al., 2013; Sempertegui et al., 2017). Recent studies have suggested that PF, which encompasses the capacity to use coping strategies flexibly depending on the context (Bonanno et al., 2004; Karekla and Panayiotou, 2011; Panayiotou et al., 2014a; Thompson, 1994), is also beneficial. Coping flexibility has been associated with more adaptive functioning, better mental and physical health, life satisfaction and positive affect (Eftekhari et al., 2009; Haga et al., 2009; Hu et al., 2014), while it reduces negative emotions, anxiety and somatization (Masuda and Tully, 2012). For these reasons, it was hypothesized that PF may play a buffering role, moderating the effects of somatization and illness anxiety on QoL.

Supportive evidence for this hypothesis comes from effective third-wave cognitive behavioural therapy (CBT) interventions for illness anxiety (e.g. Eilenberg et al., 2013; Lovas and Barsky, 2010) and medically unexplained symptoms (Van Ravesteijn and Fjorback, 2016), which emphasize acceptance, mindfulness and PF: this study examines factors that may be central to the treatment of somatization and illness anxiety, including increases in PF and decreases in ineffective avoidance, which may explain why these treatments have been effective.

Current study

This study (1) evaluates the impact of somatization and illness anxiety on four domains of QoL (physical, psychological, social and environmental), (2) compares the coping strategies typically utilized by individuals who meet screening criteria for somatization or illness anxiety and those with comorbid symptoms, in comparison to controls and (3) examines the potential role of PF in reducing the impact of these symptoms on QoL, that is, as a buffering mechanism. It was predicted that psychosomatic symptoms would be associated with poorer QoL across domains, but mostly in the physical domain according to the previous literature. On the basis of prior findings, it was expected that avoidant coping would be reported more and PF would be reported less by individuals with such symptoms compared to controls. It was finally predicted that higher PF would moderate the effect of psychosomatic symptoms on QoL.

Methods

Participants

The sample included 298 community adults (182 females, 113 males, 3 gender not reported) recruited for the purposes of a larger project on anxiety symptoms, using stratified random sampling. Participants were selected from phone directories of all districts of the Republic of Cyprus, so that geographic areas and age ranges were equally represented. Research assistants contacted potential participants via telephone. A packet of questionnaires and stamped return envelope were sent by post to those who volunteered to participate. A 27.1 per cent return rate was achieved.

In all, 36 participants (12.1%) met screening criteria for somatization and 50 (16.8%) for illness anxiety, and 18 participants (6%) met criteria for both disorders and were placed in a comorbid group. The final groups included in analyses were as follows: illness anxiety N = 32 (18 females, 18 males), somatization N = 18 (14 females, 4 males) and comorbid N = 18 (12 females, 6 males). The control group consisted of 32 individuals (age-matched, 18 females, 18 males), who did not meet screening criteria for these two disorders, or for depression, panic, paranoia, agoraphobia, social anxiety and generalized anxiety.

Measures

All measures had previously been translated and standardized into Greek. A demographic questionnaire was included, which in addition to sociodemographics inquired about the presence of medical diagnoses. This was used to derive a severity score of the medical conditions reported by each participant (for psychometric properties and description, see Panayiotou and Karekla, 2013). This medical conditions index was added as a covariate in the analyses to control for the effects of medical problems.

The Psychiatric Diagnostic Screening Questionnaire (PDSQ; Zimmerman and Mattia, 1999, 2001), a self-report instrument on which participants respond with yes/no regarding their experience of a series of symptoms, screens for DSM-IV Axis I disorders (APA, 1994), providing clinical cutoffs and critical items for each symptom category. It was used to screen for illness anxiety, somatization (possible score range for both = 0–5), generalized anxiety disorder (range = 0–10), panic disorder (range = 0–8), agoraphobia (range = 0–11), social anxiety (range = 0–15), paranoia (range = 0–6) and major depression (range = 0–21). Although the PDSQ was developed based on DSM-IV, the questions referring to somatization (e.g. ‘Do you get ill more often than other people?’) and hypochondriasis (e.g. ‘During the last 6 months, was it difficult for you to stop worrying that you had a severe somatic illness?’) overlap with DSM-5 criteria and were used in the absence of more updated measures. It demonstrates good psychometric properties including high reliability (Cronbach’s α = .66–.94). The Greek version showed similar subscale reliabilities to the initial standardization (α = .60–.90; Theodorou and Panayiotou, 2013). Participants were included in the respective illness anxiety and somatization symptom groups if they met PDSQ clinical cutoffs and endorsed at least one critical item.

PF was assessed with the Greek version of the Acceptance and Action Questionnaire II (AAQ-II; Karekla and Michaelides, submitted), a 7-item tool measuring psychological inflexibility (e.g. ‘I am afraid of my feelings’) on a 7-point Likert scale (never–always applies to me; score range = 7–49). Items were reversed so that higher scores showed enhanced PF. The instrument has shown good psychometric properties in previous studies, with Cronbach’s α > .80 in all language translations and α = .84 in Greek (Monestes et al., 2009).

Coping strategies were measured using the Greek Brief-COPE (Kapsou et al., 2010), a 28-item questionnaire that assesses the use of 14 dispositional coping styles (e.g. ‘I deny believing that this happens’, ‘I look for something positive in what is happening’) using a 4-point scale (I do not do this at all–I do this very much; subscale score range = 1–4). In its Greek adaptation, the tool showed good internal consistencies for most subscales (α = .50–.93), similar to those reported by Carver (1997). Coping styles can be factorized into eight broad dimensions (Kapsou et al., 2010), used in this study, namely, active–positive coping (which includes active coping, positive reframing, acceptance and planning; in this study, Cronbach’s α = .77), support seeking (emotional and instrumental, α = .87), avoidance (denial and distraction, α = .71), negative affect expression (venting and self-blame, α = .56), substance use (α = .78), behavioural disengagement (α = .71), humour (α = .47) and religion (α = .75).

The World Health Organization’s QoL instrument (WHOQOL-BREF; WHOQOL Group, 1998) is a 26-item tool that measures QoL during the last 2 weeks in four domains: physical capacity (e.g. ‘Do you need medical treatment to function in your daily life?’), psychological health (e.g. ‘Do you feel that your life has meaning?’), social relationships (e.g. ‘How satisfied are you with the support you receive from your friends?) and environment (e.g. ‘How safe is your physical environment?’). The answers are given in a 5-point scale (not at all–extremely) and higher scores indicate better QoL (domain score range: 0–100). WHOQOL-BREF showed adequate internal consistencies in Greek (α = .67–.81; Ginieri-Coccossis et al., 2012). In this study, physical domain α = .72, psychological domain α = .77, social domain α = .64 and environmental domain α = .75.

Results

Correlations between measures

Bivariate correlations on all included variables (Table 1) and using Bonferroni correction for multiple correlations (all p < .00048) indicated negative associations of somatization and illness anxiety symptoms with QoL and PF and positive associations with avoidant coping (avoidance and behavioural disengagement). QoL was negatively associated with these two coping factors and positively with PF, supporting previous findings that it is a healthy way of approaching difficulties. Correlation coefficients were all below .80, suggesting no multicollinearity.

Table 1.

Pearson correlations between the measures (N = 298).

	2	3	4	5	6	7	8	9	10	11	12	13	14	15
1. Somatization severity	.38*	−.53*	−.45*	−.36*	−.35*	.05	.14	.28*	.12	.08	.23*	−.03	.06	−.34*
2. Illness anxiety severity		−.27*	−.21*	−.15	−.24*	.01	.04	.21*	.11	.01	.18	.06	.11	−.21
3. Physical QoL			.58*	.48*	.54*	−.03	−.16	−.22*	−.14	−.11	−.29*	.08	−.13	.44*
4. Psychological QoL				.64*	.54*	.06	−.20	−.31*	−.20	−.19	−.32*	−.01	−.05	.66*
5. Social QoL					.44*	.01	−.13	−.17	−.09	−.14	−.26*	−.01	−.04	.50*
6. Environmental QoL						.05	−.03	−.11	−.06	−.16	−.20*	.05	−.07	.33*
7. Active–positive coping							.34*	.37*	.49*	−.12	−.05	.31*	.27*	−.10
8. Support seeking								.36*	.48*	−.06	.21*	.22*	.24*	−.32*
9. Avoidance									.46*	.01	.33*	.30*	.15	−.41*
10. Negative affect expression										−.03	.20	.30*	.21*	−.42*
11. Substance use											.08	.05	−.12	−.10
12. Behavioural disengagement												.02	.05	−.39*
13. Humour													−.01	−.03
14. Religion														−.13
15. Psychological flexibility

QoL: quality of life.

p < .00048; the correlation between illness anxiety and psychological flexibility was marginally significant, p = .00052.

Group differences in QoL

A multivariate analysis of covariance (MANCOVA), with medical conditions as a covariate, examined group differences in QoL (Table 2). Pillai’s trace multivariate test indicated significant group effects, F(12, 282) = 2.70, p < .01, with a medium to large effect size, $η_{p}^{2} = . 10$ (small effect size: $η_{p}^{2} = . 01$ , medium effect size: $η_{p}^{2} = . 06$ and large effect size: $η_{p}^{2} = . 14$ ; Kirk, 1996). Group differences were significant for physical QoL, F(3, 95) = 4.64, p < .01, $η_{p}^{2} = . 13$ , and post hoc univariate analyses with Bonferroni adjustment for multiple comparisons indicated that the difference was significant between the control group and the illness anxiety group (p < .05), with a medium to large effect size, Cohen’s d = .71 (small effect size: d = .20, medium effect size: d = .50 and large effect size: d = .80; Cohen, 1992), and between the control and somatization group (p < .01, Cohen’s d = 1.14), with the illness anxiety and somatization groups scoring lower on physical QoL than controls. Differences between the control and comorbid group were not significant, p > .05.

Table 2.

Adjusted means and confidence intervals of quality of life domains, coping strategies and psychological flexibility.

	Illness anxiety symptoms (N = 32)M (95% CI)	Somatization symptoms (N = 18)M (95% CI)	Comorbid symptoms (N = 18)M (95% CI)	Control group (N = 32)M (95% CI)
Quality of life
Physical	70.47 (65.20, 75.74)	64.23 (57.12, 71.35)	70.67 (62.89, 78.44)	80.88 (75.23, 86.54)
Psychological	65.80 (60.45, 71.14)	57.94 (50.72, 65.17)	55.90 (48.01, 63.80)	73.32 (67.58, 79.05)
Social	67.68 (61.09, 74.27)	65.39 (56.48, 74.30)	72.45 (62.72, 82.19)	73.76 (66.69, 80.84)
Environmental	63.03 (58.18, 67.89)	61.55 (54.99, 68.11)	60.89 (53.72, 68.06)	72.91 (67.70, 78.12)
Coping strategies
Avoidant coping	2.40 (2.18, 2.62)	2.50 (2.21, 2.80)	2.64 (2.32, 2.97)	1.91 (1.67, 2.15)
Behavioural disengagement	1.62 (1.42, 1.81)	1.68 (1.41, 1.95)	1.72 (1.42, 2.01)	1.22 (1.01, 1.44)
Substance use	1.20 (1.01, 1.39)	1.43 (1.17, 1.68)	1.02 (.74,1.30)	.99 (.79, 1.19)
Psychological flexibility	36.15 (33.39, 38.91)	35.52 (31.79, 39.25)	30.04 (25.97, 34.12)	40.91 (37.95, 43,87)

CI: confidence interval.

Groups also differed in psychological QoL, F(3, 95) = 4.74, p < .01, $η_{p}^{2} = . 13$ ; post hoc analyses showed significant differences between the control and somatization groups (p < .05, Cohen’s d = 1.04) and control and comorbid groups (p < .01, Cohen’s d = 1.17); the somatization and comorbid groups scored lower on psychological QoL. Differences between control and illness anxiety groups were non-significant, p > .05.

Additionally, there were significant differences in environmental QoL, F(3, 95) = 3.63, p < .05, $η_{p}^{2} = . 10$ . Post hoc analyses indicated that the difference was significant between the control and illness anxiety group (p < .05, Cohen’s d = .73), with the latter reporting lower environmental QoL. Differences between the control and somatization or comorbid groups did not reach significance.

Group differences in social QoL (control group: M = 73.76 (66.69, 80.84), illness anxiety group: M = 67.68 (61.09, 74.27), somatization group: M = 65.39 (56.48, 74.30), comorbid group: M = 72.45 (62.72, 82.19)) were not significant, F(3, 95) = 1.04, p > .05. Mean differences on all four QoL domains between the three groups meeting screening criteria were not significant, indicative of the similarities in these conditions.

Group differences in coping and PF

Another MANCOVA examined group differences in coping and PF with medical conditions as covariate (Table 2). Pillai’s trace multivariate test indicated significant group differences, F(27, 267) = 1.89, p < .01, with a large effect size, $η_{p}^{2} = . 16$ . Significant differences were found in avoidant coping, F(3, 95) = 5.17, p < .01, $η_{p}^{2} = . 14$ . Post hoc tests indicated a significant difference between control and each of the three groups: somatization (p < .05, Cohen’s d = 1.00), illness anxiety (p < .05, Cohen’s d = .80) and comorbid symptoms (p < .01, Cohen’s d = 1.19), with individuals in the latter groups scoring higher in avoidance. There were no significant differences between the three groups meeting screening criteria, indicating that individuals with any of these symptoms utilize avoidance to a similar degree.

Significant group differences were also found in substance use for coping, F(3, 95)= 3.00, p < .05, $η_{p}^{2} = . 09$ , although post hoc tests did not reach significance. Group differences in behavioural disengagement were significant, F(3, 95) = 3.48, p < .05, $η_{p}^{2} = . 10$ , and post hoc tests indicated differences between the control and illness anxiety groups (M p < .05, Cohen’s d = .72). All other group differences were not significant.

For PF, F(3, 95) = 5.41, p < .01, $η_{p}^{2} = . 15$ , however, post hoc tests indicated significant differences only between the control and comorbid group (p < .01, Cohen’s d = 1.42), with the latter reporting significantly lower PF. Differences between the control and illness anxiety or somatization groups and among the three groups meeting screening criteria were not significant.

The moderating role of PF between psychosomatic symptoms and QoL

Based on the above findings of generally lower PF in the symptom groups compared to controls, we next examined the hypothesis that PF moderates the effects of the severity of somatization or illness anxiety symptoms on QoL. Somatization and illness anxiety were treated as continuous variables, using the entire sample (N = 298), with medical conditions as covariate. We examined the moderating role of PF on each of the four QoL domains through eight separate moderating models, four for each type of symptom (illness anxiety, somatization; see Figure 1). Moderation analyses were conducted in PROCESS, a versatile modelling tool for observed variable moderation. It is considered as an advancement over previous methods as it provides conditional effects (Hayes, 2013) and increases reliability through multiple iterations. As predicted, results showed that PF significantly moderated the relationship between somatization and physical QoL: F(4, 293) = 51.18, p < .01, R² = .41; main effect of PF on physical QoL: B = .55 (95% confidence interval (CI): .38, .72), t = 6.27, p < .01; main effect of somatization on physical QoL: B = −4.13 (−5.51, −2.75), t = −5.90, p < .01; interaction effect of PF × somatization on physical QoL: B = −.14 (−.27, −.02), t = −2.35, p < .05). This showed that mean and especially high levels of PF were associated with higher levels of physical QoL, compared to when PF was low.

Figure 1.

The moderating role of PF on the effect of somatization severity on physical QoL.

Second, PF significantly moderated the relationship between somatization and environmental QoL: F(4, 293) = 17.17, p < .01, R² = .19; main effect of PF on environmental QoL: B = .45 (.26, .64), t = 4.72, p < .01; main effect of somatization on environmental QoL: B = −3.87 (−5.37, −2.36), t = −5.06, p < .01; interaction effect of PF × somatization on environmental QoL: B = −.14 (−.27, −.01), t = −2.12, p < .05. Mean and high PF were associated with higher levels of environmental QoL moderating the effect of somatization, compared to when PF was low. In contrast, PF was not a significant moderator in the relationship between somatization and psychological (interaction effect of PF × somatization on psychological QoL: B = −.04 (−.16, .07), t = −.74, p > .05) or social QoL (PF × somatization interaction on social QoL: B = −.14 (−.31, .04), t = −1.53, p > .05).

PF also moderated the effects of illness anxiety on QoL, and, more specifically, the association between illness anxiety and social QoL: F(4, 293) = 30.34, p < .01, R² = .29; main effect of PF on social QoL: B = 1.13 (.89, 1.38), t = 9.21, p < .01; main effect of illness anxiety on social QoL: B = −.32 (−1.92, 1.28), t = −.40, p > .05; interaction effect of PF × illness anxiety on social QoL: B = −.23 (−.41, −.05), t = −2.57, p < .05. At low and mean levels of illness anxiety, having high PF was associated with better social QoL, whereas at high levels of illness anxiety, social QoL seems to decline irrespective of PF, although remaining at higher levels compared to when PF was low. Further analyses of the moderation role of PF in the relationship between illness anxiety and other domains of QoL were non-significant.

Discussion

Somatization and illness anxiety impact individuals’ functionality in most domains, especially physical QoL (e.g. Hyphantis et al., 2009; Terluin et al., 2011). Individuals with symptoms of these disorders frequently employ dysfunctional, emotion-focused coping strategies, characterized by avoidance in order to deal with psychological distress (e.g. Fergus and Valentiner, 2010; Görgen et al., 2013; Marcus et al., 2008), which however may perpetuate their symptoms. This investigation examined differences in QoL and coping between community individuals meeting screening criteria for illness anxiety and/or somatization disorder and addressed the hypothesis that having higher levels of PF, a well-documented effective approach to coping, may buffer individuals from experiencing detriments in their QoL. The study contributes three main findings, which extend the current understanding of these symptom categories.

First, the study supports the hypothesis that increased PF buffers individuals from the negative impact of somatization symptoms on QoL, verifying that this individual difference variable is important for mental health and wellbeing. Moderation by PF was significant between somatization and physical and environmental QoL, as well as between illness anxiety and social QoL. When PF was high, individuals with somatization maintained their physical and environmental QoL at higher levels than when PF is lower. This may be because PF allows one to remain engaged with one’s life, values and goals in spite of somatization symptoms and potential distress over these symptoms. The level of distress itself may not be what changes with increases in PF; instead, the individual may perceive oneself as more capable and efficient when one accepts what cannot change and continues to remain active in important daily activities (Ciarrochi et al., 2010; Kashdan and Rottenberg, 2010; Masuda and Tully, 2012), utilizing available environmental resources so as to promote wellbeing. Precisely because the effect of PF may not be on lowering distress as such, the moderation effect on psychological QoL was not significant.

PF also moderates the association between illness anxiety and social QoL. It appears that when illness anxiety is at low or moderate levels, being psychologically flexible may enhance QoL, as the person can better utilize resources such as social support, to improve wellbeing and may not allow symptoms to compromise their social relationships. At very high levels of anxiety, the influence of PF was less important: when the person experiences high distress, it may be difficult to actively engage in social life and/or their social relationships may become burdened by the unrelenting anxiety. Although seeking social support represents adaptive coping (Panayiotou and Karekla, 2013), when such support-seeking is done compulsively, it may produce paradoxical effects of burdening social relations, as others may tire or even become aggressive towards the perpetual complaining and reassurance seeking. This hypothesis is in accord with the previous literature showing social impairments in psychosomatic patients (Lind et al., 2014; Neumann et al., 2015). Investigation of additional variables such as levels of depression and/or isolation may be needed to fully understand why the effects of PF are dependent on levels of illness anxiety. Current findings, however, point to a beneficial and buffering role of PF, which is a coping approach that can be taught in the context of therapy to improve QoL.

The study also extends the literature on QoL in somatic symptom disorders. Consistent with past research (Hyphantis et al., 2009), physical QoL mainly suffers among these individuals. This may suggest that having somatization or illness anxiety influences one’s perception that something is physically wrong, which in turn probably limits one’s physical activity, increasing perceptions of being unwell. Because of the parallel high levels of distress, psychological wellbeing also suffers. This is also supported by the associations between depression and anxiety with negative outcomes in the functional status of patients with medically unexplained symptoms (Sempertegui et al., 2017). Considering environmental QoL, rarely examined in relation to these disorders, it appears that individuals with increased levels of illness anxiety, perceive this to be poorer. One hypothesis is that because individuals high in illness anxiety perceive themselves as threatened by serious illness but find no adequate medical treatments to mitigate their concerns and at times little understanding by others, their perceptions regarding environmental resources are negative. Because of their symptom persistence in spite of frequent healthcare and reassurance seeking (Rachman, 2012; Warwick and Salkovskis, 1990), they may see that domains such as living in a safe and healthy environment, access to health-related information and to healthcare facilities do not address their needs. Also, people who perceive themselves as seriously ill may feel helpless and unable to utilize environmental resources, even if these are seen as available. Assisting illness anxiety patients in the better use of resources may be an appropriate therapeutic target. In contrast, low to medium levels of somatic symptoms may not hinder social wellbeing and, in fact, may enhance the perception of receiving support, perhaps because such support is actively sought (e.g. the comorbid group, which should be most impaired, scored equally high in social QoL to controls).

The third contribution of this study pertains to coping in individuals with somatization symptoms. Evidence was consistent with conceptualizations, which draw similarities between these conditions and anxiety disorders in that avoidance represents a preferred coping approach. Groups high in these symptoms were primarily characterized by avoidance, behavioural disengagement and substance use, all of which focus on alleviating negative experiences rather than actively resolving the problem (Haaga et al., 2004; Penley et al., 2002; Ottenbreit and Domson, 2004). Avoidance, especially of unwanted experiences, is a well-established predictor of psychopathology, including anxiety disorders (Glick and Orsillo, 2011; Kashdan and Rottenberg, 2010; Pickett et al., 2011). Current findings suggest that somatic disorders share similar coping styles, supporting that both anxiety and somatic disorders are perpetuated by similar mechanisms (e.g. Forsyth et al., 2003; Karekla et al., 2004; McCracken and Zhao-O’Brien, 2010; Marx and Sloan, 2005; Panayiotou et al., 2014b; Sempertegui et al., 2017). Individuals meeting screening criteria, compared to controls, also reported significantly lower PF, which was negatively related to emotion-focused coping and positively to QoL. It appears that individuals high in these symptoms show inflexibility in their coping approaches, consistently relying on avoidance of symptoms and distress.

The study’s results have clinical implications regarding maintenance mechanisms of these disorders and potential interventions to hamper the impact of these mechanisms. PF and coping can be modified through CBT and therapies like ACT, aiming to improve QoL and daily adjustment and reduce psychological distress. Promising findings demonstrate the effectiveness of such interventions for somatic symptom disorders (e.g. Eilenberg et al., 2013; Lovas and Barsky, 2010; Van Ravesteijn and Fjorback, 2016). This study contributes towards understanding potential mechanisms that explain the effectiveness of such therapies.

Study limitations include the small sample sizes of groups meeting screening criteria. To counteract this issue, regression analyses, using the whole sample verified for the most part the same patterns observed in group comparisons. The cross-sectional nature of the study is another limitation, as the way that variables such as PF, coping and QoL change over time cannot be addressed. Longitudinal studies are needed to identify if these characteristics are actually causes or effects of having psychosomatic symptoms. For these reasons, the study avoids causal claims about the proposed associations. Strengths of the study include the random community sample and efforts to control for the severity of medical problems in a standardized manner, a safeguard against confounds rarely applied in previous studies. Also, the use of PROCESS to assess moderation provides more stable results than traditional regression approaches. Future studies should replicate the proposed moderation models in clinical samples to establish if findings generalize to higher levels of symptom severity.

In sum, present findings highlight the importance of PF and coping in psychosomatic symptomatology and its influence on QoL. Results suggest potential maintenance mechanisms, highlighting domains of intervention with the aim to increase wellbeing among individuals with somatization and illness anxiety symptoms.

Footnotes

Acknowledgements

C.L. and G.P. contributed equally to this work.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was in part funded by a grant from the Cyprus Research Promotion Foundation and EU structural funds to Georgia Panayiotou and Maria Karekla. The funding organizations had no role in the design or execution of the study or in the preparation of this manuscript

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