Repetitive Negative Thinking and Somatic Symptoms as Mediators of the Relationship between Childhood Abuse and Depression Severity in Major Depressive Disorder
-
Narzikulova Dilnoza
,
Qilichev Rajab
,
Komilov Kamol
,
Shakhlo Mirzaeva
,
Ernazarova Rano
,
Jonibek Khayitov
Abstract
Objective: Major depressive disorder (MDD) is highly heterogeneous, and adverse childhood experiences (ACEs) contribute significantly to its variability. While abuse-type ACEs are linked to worse outcomes, the specific mechanisms remain poorly understood. This study tests a novel model in which abuse-specific ACEs, compared to neglect or household dysfunction, exert a stronger influence on depression severity by increasing repetitive negative thinking (RNT), which in turn amplifies somatic symptom burden.
Method: In a cross-sectional study, 435 adults with a confirmed DSM-5 diagnosis of MDD were recruited from psychiatric clinics. Participants completed the Childhood Trauma Questionnaire (CTQ), the RNT Questionnaire (RNTQ), the Patient Health Questionnaire-15 (PHQ-15) for somatic symptoms, and the Beck Depression Inventory-II (BDI-II). Using structural equation modeling (SEM), we tested a dual mediation model where abuse, neglect, and household dysfunction ACEs predicted BDI-II scores via direct and indirect pathways, with a focus on the sequential path through RNT and somatic symptoms.
Results: The model demonstrated excellent fit (CFI = 0.96, RMSEA = 0.04) and accounted for 54% of the variance in depression severity (R² = 0.54). Abuse ACEs had a significantly stronger total effect on depression severity than other ACE types (β = 0.41 versus ≤ 0.18, P < 0.01) and also exerted a significant direct effect on depression severity (β = 0.22, P = 0.012). The specific indirect pathway from abuse ACEs to RNT to somatic symptoms to depression was also significant (β = 0.19, 95% CI [0.13, 0.26]), accounting for 46% of the total effect of abuse on depression (total effect β = 0.41, P < 0.001). This pathway was significantly stronger (P < 0.001) than analogous pathways from neglect or household dysfunction ACEs.
Conclusion: The path from childhood abuse to severe depression is characterized by a cognitive-somatic cascade: abuse fuels persistent negative thinking, which exacerbates the perception and burden of physical symptoms, ultimately deepening depressive severity. This identifies a specific phenotypic profile (high RNT + high somatic burden) associated with abuse histories, highlighting essential targets for tailored intervention in trauma-informed depression care.
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12. Lippard ETC, Nemeroff CB. The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders. Am J Psychiatry. 2023;180(8):548-64.
13. Mattioni L, Nikčević AV, Ferri F, Spada MM, Sestieri C. An integrative model of perseverative thinking. Dialogues Clin Neurosci. 2025;27(1):34-54.
14. Brosschot JF, Gerin W, Thayer JF. The perseverative cognition hypothesis: a review of worry, prolonged stress-related physiological activation, and health. J Psychosom Res. 2006;60(2):113-24.
15. Zagaria A, Ottaviani C, Lombardo C, Ballesio A. Perseverative Cognition as a Mediator Between Perceived Stress and Sleep Disturbance: A Structural Equation Modeling Meta-analysis (meta-SEM). Ann Behav Med. 2023;57(6):463-71.
16. Lopez JM, Lohmann S, Mekawi Y, Hughes C, Sunderrajan A, Tengshe C, et al. Perseverative Negative Thinking, Self-Control, and Executive Functioning in Symptoms of Depression and Anxiety: A Comprehensive Meta-Analysis of Competing Models. Clin Psychol Sci. 2025;14(1):24-40.
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20. Appel JE, Vrijsen JN, Marchetti I, Becker ES, Collard RM, van Eijndhoven P, et al. The Role of Perseverative Cognition for Both Mental and Somatic Disorders in a Naturalistic Psychiatric Patient Sample. Psychosom Med. 2021;83(9):1058-66.
21. Mattioni L, Spada MM, Ferri F, Sestieri C. The relationship between perseverative thinking, proactive control, and inhibition in psychological distress: a study in a women's cohort. Sci Rep. 2023;13(1):19319.
22. Park H, Sanchez SM, Kuplicki R, Tsuchiyagaito A, Khalsa SS, Paulus MP, et al. Attenuated interoceptive processing in individuals with major depressive disorder and high repetitive negative thinking. J Psychiatr Res. 2022;156:237-44.
23. Everaert J, Joormann J. Emotion regulation difficulties related to depression and anxiety: A network approach to model relations among symptoms, positive reappraisal, and repetitive negative thinking. Clin Psychol Sci. 2019;7(6):1304-18.
24. Everaert J, Benisty H, Gadassi Polack R, Joormann J, Mishne G. Which features of repetitive negative thinking and positive reappraisal predict depression? An in-depth investigation using artificial neural networks with feature selection. J Psychopathol Clin Sci. 2022;131(7):754-68.
25. Hsu KJ, Mullarkey M, Dobias M, Beevers CG, Björgvinsson T. Symptom-level network analysis distinguishes unique associations of repetitive negative thinking and experiential avoidance with depression and anxiety in a transdiagnostic clinical sample. Cognit Ther Res. 2022;46(6):1062-74.
26. Strine TW, Edwards VJ, Dube SR, Wagenfeld M, Dhingra S, Prehn AW, et al. The mediating sex-specific effect of psychological distress on the relationship between adverse childhood experiences and current smoking among adults. Subst Abuse Treat Prev Policy. 2012;7:30.
27. Zashchirinskaia O, Isagulova E. Childhood Trauma as a Risk Factor for High Risk Behaviors in Adolescents with Borderline Personality Disorder. Iran J Psychiatry. 2023;18(1):65-71.
28. Mahoney AE, McEvoy PM, Moulds ML. Psychometric properties of the Repetitive Thinking Questionnaire in a clinical sample. J Anxiety Disord. 2012;26(2):359-67.
29. McEvoy PM, Salmon K, Hyett MP, Jose PE, Gutenbrunner C, Bryson K, et al. Repetitive Negative Thinking as a Transdiagnostic Predictor of Depression and Anxiety Symptoms in Adolescents. Assessment. 2019;26(2):324-35.
30. Hybelius J, Kosic A, Salomonsson S, Wachtler C, Wallert J, Nordin S, et al. Measurement Properties of the Patient Health Questionnaire-15 and Somatic Symptom Scale-8: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2024;7(11):e2446603.
31. von Glischinski M, von Brachel R, Hirschfeld G. How depressed is "depressed"? A systematic review and diagnostic meta-analysis of optimal cut points for the Beck Depression Inventory revised (BDI-II). Qual Life Res. 2019;28(5):1111-8.
32. Wilson-Genderson M, Heid AR, Cartwright F, Pruchno R. Adverse childhood experiences, adult trauma, and depressive symptom trajectories. Aging Ment Health. 2022;26(11):2170-8.
33. Giampetruzzi E, Tan AC, LoPilato A, Kitay B, Riva Posse P, McDonald WM, et al. The impact of adverse childhood experiences on adult depression severity and treatment outcomes. J Affect Disord. 2023;333:233-9.
34. McCarrick D, Prestwich A, O'Connor DB. Perseverative cognition and health behaviours: exploring the role of intentions and perceived behavioural control. Psychol Health. 2024;39(9):1183-99.
35. Ciobotaru D, Jones CJ, Cohen Kadosh R, Violante IR, Cropley M. "Too much of a burden": Lived experiences of depressive rumination in early adulthood. J Couns Psychol. 2024;71(4):255-67.
36. Denovan A, Dagnall N, Lofthouse G. Neuroticism and Somatic Complaints: Concomitant Effects of Rumination and Worry. Behav Cogn Psychother. 2019;47(4):431-45.
37. Jopling E, Tracy A, LeMoult J. Childhood Maltreatment, Negative Self-Referential Processing, and Depressive Symptoms During Stress. Psychol Res Behav Manag. 2020;13:79-87.
38. Tjoelker FM, Jeuring HW, Aprahamian I, Naarding P, Marijnissen RM, Hendriks GJ, et al. The impact of a history of child abuse on cognitive performance: a cross-sectional study in older patients with a depressive, anxiety, or somatic symptom disorder. BMC Geriatr. 2022;22(1):377.
39. Bell IH, Marx W, Nguyen K, Grace S, Gleeson J, Alvarez-Jimenez M. The effect of psychological treatment on repetitive negative thinking in youth depression and anxiety: a meta-analysis and meta-regression. Psychol Med. 2023;53(1):6-16.
40. Khaleghi A, Samiei H, Zarafshan H, Baloochi SA, Mohammadi MR. Effectiveness of fMRI-based Neurofeedback Therapy on Depression: A Systematic Review. Clin Psychopharmacol Neurosci. 2025;23(3):337-55.
41. Ajluni V. Integrating psychiatry and family medicine in the management of somatic symptom disorders: Diagnosis, collaboration, and communication strategies. J Gen Fam Med. 2025;26(1):12-8.
42. Tabasi M, Mostafavi SA, Oreyzi H, Mohammadi MR, Khaleghi A. The Effectiveness of Transcranial Direct Current Stimulation (tDCS) and Omega-3 on Food Craving, Executive Functions, Weight, and Depressive Symptoms in Patients with Depression and Overweight: A Randomized Controlled Trial. Iran J Psychiatry. 2024;19(2):158-73.
2. Mohammadi MR, Khaleghi A, Mostafavi SA, Ahmadi N, Kamali K, Hooshyari Z, et al. Gender Determines the Pattern of Correlation between Body Mass Index and Major Depressive Disorder among Children and Adolescents: Results from Iranian Children and Adolescents' Psychiatric Disorders Study. Child Obes. 2019;15(5):331-7
3. Remes O, Mendes JF, Templeton P. Biological, Psychological, and Social Determinants of Depression: A Review of Recent Literature. Brain Sci. 2021;11(12).
4. Mohammadi MR, Alavi SS, Ahmadi N, Khaleghi A, Kamali K, Ahmadi A, et al. The prevalence, comorbidity and socio-demographic factors of depressive disorder among Iranian children and adolescents: To identify the main predictors of depression. J Affect Disord. 2019;247:1-10.
5. Abate BB, Sendekie AK, Merchaw A, Abebe GK, Azmeraw M, Alamaw AW, et al. Adverse Childhood Experiences Are Associated with Mental Health Problems Later in Life: An Umbrella Review of Systematic Review and Meta-Analysis. Neuropsychobiology. 2025;84(1):48-64.
6. Fitzgerald M, Gallus KL. Conceptualizing and measuring childhood adversity: A comprehensive critique of the adverse childhood experiences measure and offering a new conceptualization of childhood adversity. Am J Orthopsychiatry. 2025;95(3):274-87.
7. Akoka N, Kung PH, Carey HJ, Felmingham KL, Steward T. The specific impacts of abuse adverse childhood experiences on repetitive negative thinking in major depressive disorder. J Affect Disord. 2026;399:120961.
8. Xiong Y, Lindersten P, Gong T, Magnusson PKE, Liu S, Lu Y. Adverse Childhood Experiences and Treatment-Resistant Depression. JAMA Netw Open. 2026;9(3):e260222.
9. Dos Santos MAB, Guerra AEP, Sayão MMA, da Silva Selani AL, Betarelli BC, de Faria Siqueira I, et al. The Role of Adverse Childhood Experiences in the Development of Major Depressive Disorder and Treatment-Resistant Depression. Child Psychiatry Hum Dev. 2026.
10. Moulds ML, Mcevoy PM. Repetitive negative thinking as a transdiagnostic cognitive process. Nat Rev Psychol. 2025;4(2):127-41.
11. Hosseinzadeh Oskouei A, Sardarzehi R, Zamani Zarchi MS, Tavallaei Zavareh SA, Shams J, Kianimoghadam AS, et al. The mediating role of feelings of hopelessness and repetitive negative thinking in the relationship between perfectionism and depressive symptoms among medical students with suicidal ideation. Front Psychiatry. 2025;16:1560653.
12. Lippard ETC, Nemeroff CB. The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders. Am J Psychiatry. 2023;180(8):548-64.
13. Mattioni L, Nikčević AV, Ferri F, Spada MM, Sestieri C. An integrative model of perseverative thinking. Dialogues Clin Neurosci. 2025;27(1):34-54.
14. Brosschot JF, Gerin W, Thayer JF. The perseverative cognition hypothesis: a review of worry, prolonged stress-related physiological activation, and health. J Psychosom Res. 2006;60(2):113-24.
15. Zagaria A, Ottaviani C, Lombardo C, Ballesio A. Perseverative Cognition as a Mediator Between Perceived Stress and Sleep Disturbance: A Structural Equation Modeling Meta-analysis (meta-SEM). Ann Behav Med. 2023;57(6):463-71.
16. Lopez JM, Lohmann S, Mekawi Y, Hughes C, Sunderrajan A, Tengshe C, et al. Perseverative Negative Thinking, Self-Control, and Executive Functioning in Symptoms of Depression and Anxiety: A Comprehensive Meta-Analysis of Competing Models. Clin Psychol Sci. 2025;14(1):24-40.
17. Ottaviani C, Shahabi L, Tarvainen M, Cook I, Abrams M, Shapiro D. Cognitive, behavioral, and autonomic correlates of mind wandering and perseverative cognition in major depression. Front Neurosci. 2014;8:433.
18. Creed F. Psychiatric disorders comorbid with general medical illnesses and functional somatic disorders: The Lifelines cohort study. PLoS One. 2023;18(5):e0286410.
19. Chen L, Jia S, Li P, Shi Z, Li Y. Experiences and coping strategies of somatic symptoms in patients with depressive disorder: A qualitative study. Arch Psychiatr Nurs. 2022;38:6-13.
20. Appel JE, Vrijsen JN, Marchetti I, Becker ES, Collard RM, van Eijndhoven P, et al. The Role of Perseverative Cognition for Both Mental and Somatic Disorders in a Naturalistic Psychiatric Patient Sample. Psychosom Med. 2021;83(9):1058-66.
21. Mattioni L, Spada MM, Ferri F, Sestieri C. The relationship between perseverative thinking, proactive control, and inhibition in psychological distress: a study in a women's cohort. Sci Rep. 2023;13(1):19319.
22. Park H, Sanchez SM, Kuplicki R, Tsuchiyagaito A, Khalsa SS, Paulus MP, et al. Attenuated interoceptive processing in individuals with major depressive disorder and high repetitive negative thinking. J Psychiatr Res. 2022;156:237-44.
23. Everaert J, Joormann J. Emotion regulation difficulties related to depression and anxiety: A network approach to model relations among symptoms, positive reappraisal, and repetitive negative thinking. Clin Psychol Sci. 2019;7(6):1304-18.
24. Everaert J, Benisty H, Gadassi Polack R, Joormann J, Mishne G. Which features of repetitive negative thinking and positive reappraisal predict depression? An in-depth investigation using artificial neural networks with feature selection. J Psychopathol Clin Sci. 2022;131(7):754-68.
25. Hsu KJ, Mullarkey M, Dobias M, Beevers CG, Björgvinsson T. Symptom-level network analysis distinguishes unique associations of repetitive negative thinking and experiential avoidance with depression and anxiety in a transdiagnostic clinical sample. Cognit Ther Res. 2022;46(6):1062-74.
26. Strine TW, Edwards VJ, Dube SR, Wagenfeld M, Dhingra S, Prehn AW, et al. The mediating sex-specific effect of psychological distress on the relationship between adverse childhood experiences and current smoking among adults. Subst Abuse Treat Prev Policy. 2012;7:30.
27. Zashchirinskaia O, Isagulova E. Childhood Trauma as a Risk Factor for High Risk Behaviors in Adolescents with Borderline Personality Disorder. Iran J Psychiatry. 2023;18(1):65-71.
28. Mahoney AE, McEvoy PM, Moulds ML. Psychometric properties of the Repetitive Thinking Questionnaire in a clinical sample. J Anxiety Disord. 2012;26(2):359-67.
29. McEvoy PM, Salmon K, Hyett MP, Jose PE, Gutenbrunner C, Bryson K, et al. Repetitive Negative Thinking as a Transdiagnostic Predictor of Depression and Anxiety Symptoms in Adolescents. Assessment. 2019;26(2):324-35.
30. Hybelius J, Kosic A, Salomonsson S, Wachtler C, Wallert J, Nordin S, et al. Measurement Properties of the Patient Health Questionnaire-15 and Somatic Symptom Scale-8: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2024;7(11):e2446603.
31. von Glischinski M, von Brachel R, Hirschfeld G. How depressed is "depressed"? A systematic review and diagnostic meta-analysis of optimal cut points for the Beck Depression Inventory revised (BDI-II). Qual Life Res. 2019;28(5):1111-8.
32. Wilson-Genderson M, Heid AR, Cartwright F, Pruchno R. Adverse childhood experiences, adult trauma, and depressive symptom trajectories. Aging Ment Health. 2022;26(11):2170-8.
33. Giampetruzzi E, Tan AC, LoPilato A, Kitay B, Riva Posse P, McDonald WM, et al. The impact of adverse childhood experiences on adult depression severity and treatment outcomes. J Affect Disord. 2023;333:233-9.
34. McCarrick D, Prestwich A, O'Connor DB. Perseverative cognition and health behaviours: exploring the role of intentions and perceived behavioural control. Psychol Health. 2024;39(9):1183-99.
35. Ciobotaru D, Jones CJ, Cohen Kadosh R, Violante IR, Cropley M. "Too much of a burden": Lived experiences of depressive rumination in early adulthood. J Couns Psychol. 2024;71(4):255-67.
36. Denovan A, Dagnall N, Lofthouse G. Neuroticism and Somatic Complaints: Concomitant Effects of Rumination and Worry. Behav Cogn Psychother. 2019;47(4):431-45.
37. Jopling E, Tracy A, LeMoult J. Childhood Maltreatment, Negative Self-Referential Processing, and Depressive Symptoms During Stress. Psychol Res Behav Manag. 2020;13:79-87.
38. Tjoelker FM, Jeuring HW, Aprahamian I, Naarding P, Marijnissen RM, Hendriks GJ, et al. The impact of a history of child abuse on cognitive performance: a cross-sectional study in older patients with a depressive, anxiety, or somatic symptom disorder. BMC Geriatr. 2022;22(1):377.
39. Bell IH, Marx W, Nguyen K, Grace S, Gleeson J, Alvarez-Jimenez M. The effect of psychological treatment on repetitive negative thinking in youth depression and anxiety: a meta-analysis and meta-regression. Psychol Med. 2023;53(1):6-16.
40. Khaleghi A, Samiei H, Zarafshan H, Baloochi SA, Mohammadi MR. Effectiveness of fMRI-based Neurofeedback Therapy on Depression: A Systematic Review. Clin Psychopharmacol Neurosci. 2025;23(3):337-55.
41. Ajluni V. Integrating psychiatry and family medicine in the management of somatic symptom disorders: Diagnosis, collaboration, and communication strategies. J Gen Fam Med. 2025;26(1):12-8.
42. Tabasi M, Mostafavi SA, Oreyzi H, Mohammadi MR, Khaleghi A. The Effectiveness of Transcranial Direct Current Stimulation (tDCS) and Omega-3 on Food Craving, Executive Functions, Weight, and Depressive Symptoms in Patients with Depression and Overweight: A Randomized Controlled Trial. Iran J Psychiatry. 2024;19(2):158-73.
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| Adverse Childhood Experiences Childhood Traumas Depression Negative Thinking Somatic Symptoms | ||
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How to Cite
1.
Dilnoza N, Rajab Q, Kamol K, Mirzaeva S, Rano E, Khayitov J. Repetitive Negative Thinking and Somatic Symptoms as Mediators of the Relationship between Childhood Abuse and Depression Severity in Major Depressive Disorder. Iran J Psychiatry. 2026;:1-11.
