The mediator role of difficulties in emotion regulation in the relationship between guilt and shame-proneness and somatic symptoms

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Nweke This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5930990/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Psychology → Version 1 posted 8 You are reading this latest preprint version Abstract Background Shame is a distressing self-conscious emotion which arises from evaluating oneself as immodest or indecorous and leads to avoidant behaviour as well as defensive anger. Guilt is the negative appraisal of a behaviour or thought and provides readiness to take action to compensate for the wrongdoing. Experiencing these emotions more intensely and frequently with interruptions during the daily life is named as shame or guilt-proneness. Emotion regulation includes processing and regulation of emotions to keep one pursuing goals in life. Individuals who lack effective skills to regulate their emotions or adopt ineffective ones experience difficulties in emotion regulation. Somatic symptoms include medically unexplained symptoms that one suffers from. Mostly, these symptoms, such as headache, dizziness or nausea, are due to unprocessed emotions carried from childhood as a result of maltreatment or abuse. The literature shows that these variables are related to each other. Methods This study focuses on how emotion regulation difficulties mediate between shame and guilt-proneness and somatic symptoms. The data were collected from 374 participants on online platforms using questionnaires with relevant scales. In order to summarize the data collected descriptive statistics was conducted and the relationship between variables was understood with correlation analysis. Furthermore, predictor role of shame-proneness was analysed with regression analysis and mediation analysis was employed to reveal the mediator role difficulties in emotion regulation in relationship between shame-proneness and somatic symptoms. Conclusion The results illustrated that all variables except guilt-proneness were associated with each other and difficulties in emotion regulation have a mediator role between two variables. The results can benefit mental health workers and patients who lack emotion regulation strategies and deal with somatic symptoms. somatization emotion regulation shame guilt trauma Figures Figure 1 Figure 2 Introduction Guilt and shame are considered as self-conscious emotions which arise from perceived violation of moral rules or deviation from the ideal self-image, however differ in terms of adjustment, pathology and interpersonal aspects [ 1 ]. Shame and guilt are experienced in different ways emotionally. Shame is directed at the self and involves negative evaluation with a sense of helplessness and passivity in correcting oneself. The focus of the feeling is the entire self, and one attaches negative evaluations, such as ‘I am a bad person’ or ‘I am worthless’ as a result of a violation of moral rules [ 2 ]. These attributions make one feel diminished and one lacks self-esteem and has a desire to withdraw socially. Lewis mentions that during an episode of shame, one has a tendency to hide and distance oneself from other individuals and avoid eye contact by lowering the head [ 3 ]. In contrast, the feeling of guilt is directed towards a specific behaviour rather than the entire self, and one can distinguish between the guilt-provoking behaviour and the self. Guilt does not have an impact on the sense of self and identity as in experiencing shame. Furthermore, feeling regret and remorse as a result of a behaving wrongly gives a chance to engage in constructive actions, such as confession, apologizing and changing previous behaviour patterns, which give room for regulating the emotion and repairing interpersonal relationships [ 4 ]. Evidence suggests that guilt promotes pro-social behaviour towards those who have been wronged and reinforces improved social bonds; thus, benefits both parties as a tool to repair wrongdoing [ 5 ] In some cases, shame and guilt are not temporary emotions but may be a part of personality trait as a result of experiencing frequently and intensely causing interruption social and daily life. Individuals who are likely to make internal and stable attributions of shame or guilt regardless of the circumstances are named shame-prone or guilt-prone individuals [ 6 ]. A shame-prone person is more likely to blame oneself for the way of acting, engage in higher rates of self-attributions for interpersonal conflicts and experience lower self-esteem. Additionally, shame proneness is significantly related to depression, social anxiety, avoidance of other people and fear of being negatively evaluated due to being overly self-conscious. Shame-proneness leads to blaming others to externalize the sense of shame and provide relief from distressing emotions. On the other hand, a guilt-prone individual internalizes self-blaming emotions in times of transgression due to awareness of moral rules, ideal self-concept, and a tendency to conduct negative self-evaluation and self-criticism, which are crucial aspects of guilt-proneness [ 7 ]. Guilt-prone individuals seek forgiveness from ones whom they believe treated with disrespect or violated and hold a strong belief that they deserve punishment for their misbehaving. These individuals have tendency to experience remorse for personal wrongdoing even when the wrongdoing is private and has no impact on others [ 8 ]. Sense of guilt leads to either solely experiencing negative emotions associated with the disappointing action or engaging in constructive behaviours to compensate for the transgression with desire to repair or amend the guilt-provoking situation [ 9 ]. Thompson defines emotion regulation as the process of observation, evaluation and modification of emotional reactions, especially the intensive aspects of keeping functioning toward one’s goals [ 10 ]. Emotion regulation consists of several processes that occur at various points in regulating emotions. The process model of emotion regulation provides a framework for emotion regulation strategies with four stages of generation and expression of an emotion [ 11 ]. According to the model, initially, a response is generated by internal or external stimuli; secondly, the situation draws attention; thirdly, the situation is evaluated; and finally, an emotional response occurs in case the situation is appraised as relevant to one’s goals. Emotion regulation strategies can be applied at any point of the process and generally fall into one of two categories which are antecedent focused or response focused. Antecedent-focused strategies are adopted during the first three stages of the emotion process and are considered effective in adjusting the severity and duration of responses. On the other hand, response-focused strategies occur during the model’s final stage, leading to intensified levels of emotional experience [ 12 ]. Maladaptive response-focused strategies include expressive suppression and rumination. Both strategies lead to intensification of emotional responses rather than modulation in terms of physiology and subjective experience [ 13 ]. Hughes et al found out that shame-proneness is associated with maladaptive emotion regulation strategies such as suppression which refers to inhibiting emotional expressions. The same study concludes that shame-proneness is negatively correlated with effective emotion regulation strategies such as impulse and anger control, down-regulation of negative affect and up-regulation of positive affect as well as adjusting emotional responses to the situation [ 14 ]. On the other hand, guilt-proneness is related to adaptive strategies such as reappraisal which involves reframing a situation cognitively to adjust the significance of emotional response [ 15 ]. Emotion dysregulation is a pattern of emotion regulation that draws one back from one’s goals and daily functioning. Dysregulation of emotions occurs due to either adopting maladaptive emotion regulation strategies or lacking adaptive regulation strategies to deal with emotional responses [ 14 ]. Maltreatment during childhood may lead to a lack of emotion regulation strategies due to modelling maladaptive strategies and punishment of emotional expressions [ 15 ]. According to Ford, emotion regulation is an ability which develops during early childhood. The responsiveness and involvement of the caregivers as well as interactions between caregiver and child are considered as key for emotion regulation [ 16 ]. Shipman et al shows that children who were neglected had lesser ability to comprehend negative emotions such as anger and sadness with fewer skills to regulate emotions. These children had a negative expectation about their mothers’ response to expression of anger and sadness which is assumed as the cause of suppression of emotions which is an ineffective emotion regulation strategy [ 17 ]. Somatic symptoms might be physical or bodily symptoms associated with a certain medical condition or labelled as medically unexplained symptoms without any detected biological cause [ 18 ]. Lack of medical explanation or any biological reason for the symptoms does not mean that the symptoms are not real or do not exist. For example, one might suffer from headaches or nausea without any attribution to a medical condition or illness. Previously, somatic symptoms were considered the narrowing of one’s attention to certain sensory stimuli, ignoring others due to exposure to trauma [ 19 ]. Furthermore, it was conceptualized as the suppression of certain memories from the body and the manifestation of these memories as somatic symptoms being triggered by certain stimuli. Such individuals were named as hysterical. Lately, somatization has been accepted as an expression of mental and emotional distress as bodily symptoms, which varies from the concept of hysteria [ 20 ]. According to the psychodynamic model, one’s inner conflicts are reflected as physical distress, and impulses related to anxiety manifest as physical symptoms and complaints through the autonomic nervous system. Somatization prevents anxiety of inner conflict from being conscious [ 21 ]. Somatic symptoms and difficulties in emotion regulation are related according to the literature. Growing up in an adverse environment might prevent children from acquiring the knowledge and skills needed to regulate their emotions. Being neglected or abused deprives children of relevant emotion regulation strategies when dealing with distressing emotional responses. Furthermore, maltreated children may prefer to avoid awareness of emotions to feel protected against overwhelming emotions and thoughts [ 22 ]. Avoidance of emotional experiences and lack of emotion regulation abilities as a result of maltreatment and past trauma lead to affective experiences becoming somatised instead of verbally expressed. According to Ogrodniczuk et al., alexithymia is the mediator in the relationship between childhood trauma and somatic symptoms [ 23 ]. Shame and guilt-proneness are closely related to somatization among individuals with childhood trauma and maltreatment. The literature illustrates the association between abuse during childhood and self-conscious emotions, such as shame and guilt [ 24 – 26 ]. Shame and guilt evoked from early maltreatment are difficult affects to be regulated and processed emotionally and cognitively. As a result, these emotions are expected to contribute to somatic symptoms as a representation of inner conflict. During the times of childhood, when one lacks skills to express and process negative emotions, such as badness, inadequacy and remorse as a consequence of traumatic abuse or neglect, these emotional experiences might manifest themselves as somatic symptoms in the body [ 27 ]. Another study by Kealy et al. puts forward that shame has a mediator role in the relationship between childhood maltreatment, including abuse and neglect and somatization [ 28 ]. The study discusses that neglected individuals might identify with rejecting parents in an attempt to gratify need of warmth and acceptance along with a defective and unworthy representation of themselves. Negative emotions associated with this self-image may be represented as somatic symptoms, which lead to shame-related aches and pains. Another perspective on the relationship between somatization and shame and guilt-proneness is that shame might be so overwhelming to process and regulate for one with a past of childhood abuse that cognitively unprocessed emotions are experienced as somatic symptoms [ 28 ]. Shame-proneness is positively associated with difficulties in emotion regulation, while guilt-proneness leads to the application of effective emotion regulation strategies. Tangney & Dearing illustrate that guilt emotion is positively correlated with adaptive processing strategies, such as improved empathy to avoid the emotion in the future and enhanced interpersonal skills [ 29 ]. On the other hand, shame is associated with psychopathological struggles, difficulties in regulating anger and interpersonal conflicts. Overall, the literature illustrates that feelings of shame are common among individuals with past childhood maltreatment and abuse. This emotion is considered difficult and overwhelming to process with effective emotion regulation strategies. Additionally, these individuals may lack the knowledge and skills to regulate distressing emotions due to a lack of modelling and neglect. That’s why an association between shame-proneness and difficulties in emotion regulation strategies is expected. On the other hand, guilt-proneness is considered to lead to more effective emotion regulation strategies, such as empathy and improved interpersonal relationships to avoid previous feelings of guilt. Therefore, an association between guilt-proneness and difficulties in emotion regulation is not expected. Furthermore, somatization is also common among individuals who are not able to regulate the emotion of shame due to past trauma. This occurs as unprocessed emotions manifest themselves as bodily symptoms. As a result, associations between somatic symptoms, shame proneness and difficulties are expected. Among three variables, it is hypothesised that difficulties in emotion regulation have a mediator role in the relationship between shame-proneness and somatic symptoms, as overwhelming shame emotion is difficult to regulate and leads to experiencing somatic symptoms. On the other hand, no mediator role of difficulties in emotion regulation is expected in the relationship between guilt-proneness and somatic symptoms, as guilt-proneness leads to more effective emotion regulation strategies. The hypotheses of the study are as follows: H1: There is an association between shame-proneness and somatic symptoms H2: There is an association between guilt-proneness and somatic symptoms H3: There is an association between shame-proneness and difficulties in emotion regulation strategies. H4: There is no association between guilt-proneness and difficulties in emotion regulation strategies. H5: Difficulties in emotion regulation strategies have a mediator role in the relationship between shame-proneness and somatic symptoms. Method Research Model This research was a descriptive study with a correlational research design aiming to understand the relationship between shame and guilt-proneness, difficulties in emotion regulation and somatic symptoms. Correlational research determines relationship and direction of association between two or more variables but does not provide cause and effect relationship. Population and Sample of this Stud -Study Group The study population consisted of adults above the age of 18 who filled out the questionnaires prepared on the online platforms. The total sample size was 374. One hundred seventy-four of the participants were women, while 200 of them were men. The mean age of participants was 45 (SD = 12.7). In terms of education levels, most participants hold a bachelor’s degree, with a percentage of 49%. This was followed by high school grads, master’s degree holders and doctorate degree holders with percentages of 28%, 18% and 4%. Three hundred seven participants were currently working while 67 of them did not have a job. One hundred eighty of participants mentioned their marital status as married while 146 of them were single, 38 of them were divorced and 10 were widowed. The sampling technique used in this research was random sampling which helps increase representativeness of the sample group to general population. Data Collecting Tools Guilt and Shame Proneness Scale Guilt and shame proneness scale (GASP) has four four-item scales of Guilt-Negative-Behaviour Evaluation, Guilt-Repair, Shame-Negative-Self-Evaluation and Shame-Withdraw that measure individual differences in experiencing shame and guilt across various personal situations. The items are answers on a 7-point Likert-type scale. All reliability coefficients of the scale exceed .60 proves the reliability of the scale [ 30 ]. In the current study, the Cronbach’s alpha for the scale is calculated as 0.806. Difficulties in Emotion Regulation Scale : The Difficulties in Emotion Regulation Scale (DERS) is a 36-item self-report scale with six subscales: non-acceptance of emotional responses, difficulty engaging in goal-directed behaviour, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies and lack of emotional clarity. The items are scored on a 5-point Likert scale. The Cronbach’s alpha coefficient for scale is calculated as 0.90 [ 31 ]. In the current study, it is found to be 0.957. Somatic Symptom Scale Somatic Symptom Scale (SSS-8) is an 8-item inventory that aims to measure somatic symptom burden. The Cronbach’s alpha coefficient for the scale is 0.81. The items are scored on a 5-point Likert-type scale. Higher scores indicate higher levels of somatic burden [ 32 ]. In the current study, the Cronbach’s alpha coefficient is calculated as 0.839. Data Analysis The data obtained from this study were analysed using the SPSS 26.0 program. Frequency analysis was used to reveal demographic data about the participants and descriptive statistics for obtaining information about the scales, such as standard deviation, skewness and kurtois. The hypotheses of this study were tested using Pearson correlation analysis to understand the relationship between variables. Additionally, the mediation analysis was conducted using the SPSS Process Macro extension according to the bootstrapping method of Hayes [ 33 ]. Findings This section includes results of analysis for descriptive statistics, correlation analysis to understand the relationship between variables, regression analysis and mediation analysis aiming to determine whether there was a mediating role of difficulties in emotion regulation in relationship between shame and guilt-proneness and somatic symptoms. The hypotheses of this study, except relationship between guilt-proneness and somatic symptoms, were accepted according to the results obtained with statistical analysis (Table 1). The correlation analysis results among the variables are presented in Table 2. Pearson correlation coefficients were conducted to examine the relationships among difficulties in emotion regulation, shame and guilt proneness, and somatic symptoms. As shown in the table difficulties in emotion regulation was found to be significantly positively correlated with shame and guilt proneness (r = .221, p < .05) and somatic symptoms (r = .550, p < .05). Shame and guilt-proneness was found to be significantly correlated with limited access to emotion regulation strategies (r = .254, p < .05) and non-acceptance of emotional responses (r = .220, p < .05) subscales of difficulties in emotion regulation variable. Somatic symptoms showed significant positive correlations with all subscales of emotion regulation, including impulse control difficulties (r = .561, p < .01), limited access to emotion regulation strategies (r = .489, p < .01), non-acceptance of emotional responses (r = .391, p < .01), difficulty engaging in goal-directed behaviour and (r = .446, p < .01), and lack of emotional clarity (r = .375, p < .01). According to the results, somatic symptoms were positively correlated with shame and guilt-proneness (r=.191, p<0.05). Significant relationship was found between somatic symptoms and shame-negative-self-evaluation (r = .550, p < .05) and shame-withdrawal (r = .347, p < .05) subscales. According to the results the hypothesis that there is a positive relationship between shame proneness and somatic symptoms has been confirmed. According to the results, there was statistically significant (p<.05) and positive (.132) relationship between the shame-negative self-evaluation subscale of shame-proneness and somatic symptoms and statistically significant (p<.05) and positive (.347) relationship between shame-withdraw subscale and somatic symptoms. Thus, as the scores the participants receive from the shame-negative self-evaluation and shame-withdraw sub-scales increase, their scores from the somatic symptoms scale are also expected to increase. The hypothesis that “There is a positive relationship between shame proneness and difficulties in emotion regulation’’ has also been confirmed. According to the results, there was statistically significant (p<.05) and positive (.176) relationships between shame-negative self-evaluation subscale and difficulties in emotion regulation scores, and statistically significant (p<.05) and positive (.481) relationships between shame-withdraw subscale and difficulties in emotion regulation scores. As the scores obtained from the negative self-evaluation and withdraw subscales increase, the scores obtained from the emotion regulation difficulties scale will also increase according to the results. The hypothesis of “There is a relationship between proneness to guilt and somatic symptoms’’ could not be confirmed. According to the results, there was no statistically significant relationship between the guilt-negative behaviour evaluation and guilt-repair sub-dimensions and somatic symptoms (p>.05). The hypothesis of “There is no relationship between proneness to guilt and difficulties in emotion regulation’’ was confirmed. According to the results, there was a negative relationship between the subscales of proneness to guilt, negative behaviour (-.011) and repair (-.086), and difficulties in emotion regulation, but this relationship was not statistically significant (p>.05). Table 3 indicates the results of the regression analysis examining the predictive effect of shame-proneness on difficulties in emotion regulation and somatic symptoms. According to the results, shame proneness had a statistically significant effect on difficulties in emotion regulation (p<.05; B=0.437). Shame proneness explained 19.1% of difficulties in emotion regulation, which is R2. A 1-unit increase in the scores obtained from the shame proneness subscale will increase the scores obtained from the difficulties in emotion regulation scale by .437. Shame proneness also had a statistically significant effect on somatic symptoms (p<.05; B=0.318). Shame proneness explained 10.1% of somatic symptoms, which is R2. A 1-unit increase in the scores obtained from the shame-proneness subscale will increase the scores obtained from the somatic symptoms scale by .318 (Figure 1) Figure 1 shows the results regarding the mediating role of difficulties in emotion regulation in the relationship between shame proneness and somatic symptoms. According to the results, shame proneness, the independent variable of the study, had a statistically significant effect on difficulties in emotion regulation (path a) (p<.05). Shame proneness also had a statistically significant effect on the dependent variable, somatic symptoms (path c) (p<.05). There was also a statistically significant effect of the combined effect of shame proneness and difficulties in emotion regulation on somatic symptoms (path b) (p<.05). In path c’, where the mediating variable effect was examined, the effect of the existing significant effect of shame proneness and somatic symptoms continued without deterioration when difficulties in emotion regulation, which was included in the model as a mediating variable, is included (p<.05; B=0.096). According to these results, difficulties in emotion regulation had a partial mediating role in the relationship between shame proneness and somatic symptoms, confirming the final hypothesis of this study (Figure 2). A mediation analysis was conducted to evaluate mediator roles of subscales of difficulties in emotion regulation scale (Non-acceptance of Emotional Responses [DERS1], Difficulties Engaging in Goal-Directed Behavior [DERS 2], Impulse Control Difficulties [DERS 3], Limited Access to Emotion Regulation Strategies [DERS 4], and Lack of Emotional Clarity [DERS 5]) in the relationship between shame and somatic symptoms. The total effect of shame on somatic symptoms was significant, b=0.2678, SE=0.0408,t(372)=6.57,p<.001,95%CI[0.1877,0.3480] with a standardized coefficient of β=0.3224. The direct effect of shame on somatic symptoms was not significant, b=0.0708, SE=0.0400, t (367) =1.77, p=.078, suggesting potential full mediation. The total indirect effect of shame on somatic symptoms through the mediators was significant, b=0.1971, BootSE=0.0263,95% CI [0.1478,0.2514]. Among the mediators, DERS4 (Lack of Emotional Clarity) demonstrated the strongest indirect effect, b=0.1625, BootSE=0.0413,95%CI [0.0851,0.2466]. None of the other mediators yielded significant indirect effects (DERS 1: b=0.0382, BootSE=0.0240,95% CI [−0.0092,0.0867]; DERS 2: b=−0.0104, BootSE=0.0247,95% CI [−0.0600,0.0376] DERS 3: b=−0.0028, BootSE=0.0193,95%CI [−0.0415,0.0353] b = -0.0028, BootSE = 0.0193, 95% CI [-0.0415, 0.0353]; DERS 5: b=0.0095, BootSE=0.0142,95%CI [−0.0156,0.0408]). Discussion, Conclusion and Recommmendations According to the findings of this study, shame-proneness and somatic symptoms were significantly associated. This finding is consistent with the relevant data from the literature. The study of Kealy et al. found that shame is a predictor for somatic symptoms [28]. The present study considers that when shame is not processed or cognitively regulated, it manifests as unexplained bodily symptoms, which refer to somatization. Especially among children who might not be able to communicate their emotions efficiently, somatization of shame is common. Furthermore, Pineles et al. reached the conclusion that shame-proneness is closely related to both somatic and post-traumatic stress disorder symptoms in their study conducted with 156 female participants [34]. Overall, shame proneness and somatic symptoms are two closely related variables. As shame-prone individuals are more likely to adopt self-destructive emotion regulation strategies, they find it difficult to deal with their emotions. Suppression of negative emotions such as sadness and anger is one of the common ways for shame-prone individuals to deploy while dealing with negative experiences and this approach to emotions might further amplify the intensity of them. The intensified and unexpressed emotions are expected to manifest as bodily symptoms such as headache, fatigue, limb pain and stomach ache. Additionally, withdrawing oneself from society as a coping strategy deprives shame-prone individual from communicating the internal experiences with others which might give way to relief. The isolation from social resources might also bring additional emotional burden of feeling rejected and unaccepted. Another study finding is the correlation between shame-proneness and difficulties in emotion regulation. Elison et al. mention shame as a difficult emotion to process cognitively and emotionally [35]. Puhalla et al. declare that men combat veterans who are prone to shame and post-traumatic stress disorder symptoms find it difficult to regulate their emotions [36]. The study of Lanteigne et al. revealed that shame-proneness is linked with dysfunctional emotion regulation strategies, such as emotional suppression [37]. Tatar and Miu concluded that higher use of maladaptive and lower use of adaptive emotion regulation strategies are common among shame-prone individuals [38]. The link between two variables can be attributed to the fact that shame-prone individuals are more likely to withdraw from society, engage in self-destructive emotion regulation activities such as abuse of alcohol and drugs and suffer from aggression due to low self-esteem and negative self-image they hold about themselves. As shame-prone individuals hold the belief that expression of negative emotions will lead to judgement and intolerance from others, they prefer to supress them and avoid social interactions in times of distress. Additionally, shame can be considered a difficult emotion to regulate due to being seen as a sign of weakness by society causing to consider oneself as flawed and become unmotivated to feel better. On the other hand, no correlation is found between guilt-proneness and emotion regulation difficulties. The study by Tatar and Miu shows that guilt-prone individuals are likely to adopt dysfunctional emotion regulation strategies, such as catastrophizing and blaming others, and benefit from adaptive strategies, including positive reappraisal while dealing with distressing emotions [38]. Guilt is an emotion that is directed toward a situation instead of a whole identity, unlike shame. Thus, guilt-prone individuals are more likely to consider reframing guilt-provoking experiences and engage in constructive behaviours with others whom they believe are harmed by their actions. The fact that guilt is not associated with lowered self-esteem like shame, guilt-prone individuals might feel more motivated to express their internal experiences and engage in effective emotion regulation strategies. Additionally, experiencing guilt might lead to feelings of empathy which is expected to guide guilt-prone individual to repair their relationships with others regulating their emotions. Another study finding is that shame-proneness is a predictor for both difficulties in emotion regulation and somatic symptoms. An individual who is prone to shame is also expected to struggle with dealing with negative emotions. This might be because of the nature of shame, which forces one to withdraw from society and benefit less from expressing emotions due to a sense of inferiority among others and expectation of criticism for opening themselves. This lack of expression causes unexplained medical conditions of somatic symptoms as unresolved affects manifest themselves as somatization. Additionally, this puts forward that shame is a difficult emotion to regulate and process unlike other emotions which are more accepted by the society. This finding is parallel to the final hypothesis of this study which is accepted by mediation analysis. Difficulties in emotion regulation have a mediator role in the relationship between shame and somatic symptoms. This can be attributed to the fact that unprocessed and difficult-to-express shame is manifested as somatic symptoms due to a lack of effective emotion regulation strategies or adopting maladaptive ones. Shame prone-individuals deprive themselves from effective emotion-regulation strategies as they hold negative believes about themselves and expect rejection from others for who they are. These cognitions make them prefer withdrawal from others and suppression of internal experiences. As a result of emotional and behavioural avoidance, intensified and unresolved emotions manifest themselves as somatic symptoms. Among the subscales of difficulties of the emotion regulation scale, limited access to emotion regulation strategies had a significant mediator role between shame-proneness and somatic symptoms. This finding illustrates that shame-prone individuals lack relevant emotion regulation strategies to deal with negative emotions and experience somatization as a result. This can be attributed to neglect during childhood which is considered as a cause of both shame-proneness, identifying oneself as rejected and unworthy by care-givers and lacking guidance or modelling for learning emotion regulation skills to resolve negative emotions as an adult. This study puts forward that shame-prone individuals struggle with expressing and processing their emotions with effective emotion regulation strategies and mainly adopt dysfunctional ways to deal with their negative internal experiences which prevent them to engage in goal-oriented behaviours in life. The literature illustrates that somatization is common among individuals who find it hard to express their emotions and regulate them and shame-prone individuals experience somatic symptoms due to their inability to resolve negative emotions. The present study can be considered as a guide for therapists and clients who suffer from shame-proneness and somatic symptoms. The link that both conditions are combined is a result of lacking effective emotion regulation strategies that might provide therapists and medical practitioners with to guide clients towards beneficial emotion regulation skills. Initially, clients can be informed about their situation with psychoeducation, then be approached with recent therapeutic techniques, such as Acceptance and Commitment Therapy [39], Mindfulness or Compassion-focused Therapies, which are acceptance-based ways towards emotions to regulate them effectively [40]. Furthermore, informing patients about the actual cause of somatic symptoms will provide relief about any other medical condition and reduce costs for screening and doctor visits. This study has some limitations. Initially, it is correlation research and not experimental. That’s why a causational interpretation cannot be made based on the results, while the predictive role of the variable is confirmed with regression and mediation analysis. Secondly, the data for the study are collected from a limited number of participants at one time. To increase the generalizability of the results, the study can be conducted with different samples more than one. Thirdly, results can show differences across different cultures, so conducting research with samples with different cultural orientations might lead to various results showing cultural differences related to emotion regulation and shame-proneness. Finally, this study ignores other mediator variables that might have a role in the relationship between shame-proneness and somatic symptoms. This study can be replicated using other relevant mediator variables to test their roles. Declarations Ethics approval and consent to participate Ethical committee approval was obtained from Bahçeşehir Cyprus University on 15.05.2024 with the BAU/EK-2024/02 approval number to conduct this study. The research is conducted in accordance with the Declaration of Helsinki. The participants were provided informed consent before participating in the study. No personal information was collected from the participants and no minors were involved in the study. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding Not applicable Authors' contributions EE prepared the introduction section regarding background information and hypotheses. Both EE and GN contributed to the methodology section. Data analysis and result section were conducted by GN. Discussion of research findings is written by EE interpreting results. Reference list is prepared by EE. All authors read and approved the final manuscript. Acknowledgements Not applicable References Woien SL, Ernst HA, Patock-Peckham JA, Nagoshi CT. 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Psychol Bull. 2004;130(5):793. http://dx.doi.org/10.1037/0033-2909.130.5.793 . Lipowski ZJ. Review of consultation psychiatry and psychosomatic medicine: III. Theoretical issues. Psychosom Med. 1968;30(4):395–422. Kirmayer LJ, Young A. Culture and somatization: clinical, epidemiological, and ethnographic perspectives. Psychosom Med. 1998;60(4):420–30. Fonagy P, Allison E. What is mentalization? The concept and its foundations in developmental research. Minding the child. Routledge; 2013. pp. 11–34. Ogrodniczuk JS, Joyce AS, Abbass AA. Childhood maltreatment and somatic complaints among adult psychiatric outpatients: Exploring the mediating role of alexithymia. Psychother Psychosom. 2014;83(5):322–4. http://dx.doi.org/10.1159/000363769 . Aakvaag HF, Thoresen S, Wentzel-Larsen T, Dyb G, Røysamb E, Olff M. Broken and guilty since it happened: A population study of trauma-related shame and guilt after violence and sexual abuse. J Affect Disord. 2016;204:16–23. Claesson K, Sohlberg S. Internalized shame and early interactions characterized by indifference, abandonment and rejection: Replicated findings. Clin Psychol Psychother. 2002;9(4):277–84. Feiring C, Taska LS. The persistence of shame following sexual abuse: A longitudinal look at risk and recovery. Child Maltreat. 2005;10(4):337–49. http://dx.doi.org/10.1177/1077559505276686 . Kealy D, Rice SM, Ogrodniczuk JS, Spidel A. Childhood trauma and somatic symptoms among psychiatric outpatients: Investigating the role of shame and guilt. Psychiatry Res. 2018;268:169–74. http://dx.doi.org/10.1016/j.psychres.2018.06.072 . Tangney JP, Dearing RL. Gender differences in morality. 2002. Cohen TR, Wolf ST, Panter AT, Insko CA. Introducing the GASP scale: a new measure of guilt and shame proneness. J Pers Soc Psychol. 2011;100(5):947. http://dx.doi.org/10.1037/a0022641 . Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav Assess. 2004;26:41–54. Gierk B, Kohlmann S, Kroenke K, Spangenberg L, Zenger M, Brähler E, et al. The somatic symptom scale–8 (SSS-8): a brief measure of somatic symptom burden. JAMA Intern Med. 2014;174(3):399–407. http://dx.doi.org/10.1001/jamainternmed.2013.12179 . Hayes AF. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. 2018. Pineles SL, Street AE, Koenen KC. The differential relationships of shame–proneness and guilt–proneness to psychological and somatization symptoms. J Soc Clin Psychol. 2006;25(6):688–704. http://dx.doi.org/10.1521/jscp.2006.25.6.688 . Elison J, Garofalo C, Velotti P. Shame and aggression: Theoretical considerations. Aggress Violent Behav. 2014;19(4):447–53. Puhalla A, Flynn A, Vaught A. Shame as a moderator between emotion dysregulation and posttraumatic stress disorder severity among combat veterans seeking residential treatment. J Affect Disord. 2021;283:236–42. http://dx.doi.org/10.1016/j.jad.2021.01.079 . Lanteigne DM, Flynn JJ, Eastabrook JM, Hollenstein T. Discordant patterns among emotional experience, arousal, and expression in adolescence: Relations with emotion regulation and internalizing problems. Can J Behav Sci. 2014;46(1):29. Tătar A, Miu AC. Individual differences in emotion regulation, childhood trauma and proneness to shame and guilt in adolescence. PLoS ONE. 2016;11(11):e0167299. http://dx.doi.org/10.1371/journal.pone.0171151 . Hayes SC, Pierson H. Acceptance and commitment therapy. Acceptance and Commitment Therapy. Springer US; 2005. pp. 1–4. Gilbert P. Introducing compassion-focused therapy. Adv Psychiatr Treat. 2009;15(3):199–208. Tables Table 1 Descriptive statistics Min Max Mean SD Skewness Kurtosis Difficulties in emotion regulation 16,00 79,00 39,39 15,181 , 363 -,745 Clarity 2,00 10,00 3,97 1,920 ,844 ,044 Goals 3,00 15,00 9,39 3,352 -,232 -,819 Impulse 3,00 15,00 5,61 3,063 1,245 ,797 Strategies 5,00 25,00 12,87 5,564 ,249 -,997 Non-acceptance 3,00 15,00 7,53 3,723 ,371 -1,050 Shame and guilt-proneness 33,00 111,00 80,26 12,769 -,725 , 951 Negative Behavior Evaluation 4,00 28,00 22,17 5,127 -,916 ,221 Repair 8,00 28,00 22,97 3,785 -,716 ,544 Negative Self Evaluation 6,00 28,00 23,21 4,501 -1,220 1,679 Withdraw 4,00 28,00 11,90 5,000 ,721 ,195 Somatic symptoms , 00 27,00 8,38 6,386 , 842 , 113 Table 2 Correlation analysis between difficulties in emotion regulation, shame and guilt-proneness and somatic symptoms 1 2 3 4 5 6 7 8 9 10 11 12 1.Difficulties in emotion regulation 1 2Lack of emotional clarity ,710 ** 1 3.Difficulty engaging in goal-directed behaviour ,853 ** ,478 ** 1 4. Impulse control difficulties ,806 ** ,581 ** ,608 ** 1 5.Limited access to emotion regulation strategies ,948 ** ,599 ** ,807 ** ,674 ** 1 6. Non-acceptance of emotional responses ,864 ** ,576 ** ,624 ** ,608 ** ,780 ** 1 7.Shame and guilt-proneness ,221 ** ,057 ,219 ** ,089 ,254 ** ,220 ** 1 8.guilt-negative behaviour evaluation -,011 -,082 ,004 -,110* ,021 ,052 ,804 ** 1 9.guilt-repair -,086 -,175 ** -,011 -,174 ** -,026 -,068 ,714 ** ,626 ** 1 10.shame-negative self-evaluation ,176 ** -,012 ,210 ** ,010 ,222 ** ,196 ** ,823 ** ,586 ** ,550 ** 1 11.guilt-withdraw ,481 ** ,374 ** ,375 ** ,462 ** ,447 ** ,384 ** ,447 ** ,028 -,070 ,186 ** 1 12. Somatic symptoms ,550 ** ,375 ** ,446 ** ,390 ** ,561 ** ,489 ** ,191 ** ,033 -,016 ,132 ** ,347 ** 1 Table 3 Regression analysis to evaluate to what extent Shame-proneness predicts Difficulties in emotion regulation and Somatic symptoms Model Unstandardized Coefficients Standard Coefficients t p R 2 B Std. Error Beta 1 Constant 7,576 3,491 2,170 ,031 ,191 Shame-proneness ,906 ,097 ,437 9,310 ,000 Dependent variable: Difficulties in emotion regulation Model Unstandardized Coefficients Standard Coefficients t p R 2 B Std. Error Beta 1 Constant -1,357 1,548 -,877 ,381 ,101 Shame-proneness ,277 ,043 ,318 6,425 ,000 Dependent variable: Somatic Symptoms Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5930990","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":444196747,"identity":"3ddfb662-030d-4ccf-922e-2dd7b065f494","order_by":0,"name":"Erinç Erbildim","email":"data:image/png;base64,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","orcid":"","institution":"Bahçeşehir Cyprus University","correspondingAuthor":true,"prefix":"","firstName":"Erinç","middleName":"","lastName":"Erbildim","suffix":""},{"id":444196748,"identity":"e061fd15-41b1-41c8-ba74-0e186132660c","order_by":1,"name":"Gabriel E. Nweke","email":"","orcid":"","institution":"Girne American University","correspondingAuthor":false,"prefix":"","firstName":"Gabriel","middleName":"E.","lastName":"Nweke","suffix":""}],"badges":[],"createdAt":"2025-01-30 14:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5930990/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5930990/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40359-025-02909-4","type":"published","date":"2025-07-01T15:57:47+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81002313,"identity":"c8dd9ee5-8dde-4e57-bbe9-fff3cbe9d0d8","added_by":"auto","created_at":"2025-04-21 06:33:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":13059,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMediator role of difficulties in emotion regulation in the relationship between shame-proneness and somatic symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e***p \u0026lt; .001, *p \u0026lt; .05. Standardized coefficients are reported\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5930990/v1/5121edad236ac3e4ded7216b.png"},{"id":81002314,"identity":"85ad4133-95a2-42d2-b0e8-1fc8d601c7fd","added_by":"auto","created_at":"2025-04-21 06:33:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":50879,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMultiple mediation model of the effect of shame-proneness on somatic symptoms through subscales of difficulties in emotion regulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e***p \u0026lt; .001. Standardized coefficients are reported.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5930990/v1/a8337802ec0b908a748ec19b.png"},{"id":86179048,"identity":"ff710c87-49b2-47c6-9768-16d74a0770b4","added_by":"auto","created_at":"2025-07-07 16:14:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":939671,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5930990/v1/4187299f-5e97-489f-a60a-cff485c7d401.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The mediator role of difficulties in emotion regulation in the relationship between guilt and shame-proneness and somatic symptoms","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGuilt and shame are considered as self-conscious emotions which arise from perceived violation of moral rules or deviation from the ideal self-image, however differ in terms of adjustment, pathology and interpersonal aspects [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eShame and guilt are experienced in different ways emotionally. Shame is directed at the self and involves negative evaluation with a sense of helplessness and passivity in correcting oneself. The focus of the feeling is the entire self, and one attaches negative evaluations, such as \u0026lsquo;I am a bad person\u0026rsquo; or \u0026lsquo;I am worthless\u0026rsquo; as a result of a violation of moral rules [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These attributions make one feel diminished and one lacks self-esteem and has a desire to withdraw socially. Lewis mentions that during an episode of shame, one has a tendency to hide and distance oneself from other individuals and avoid eye contact by lowering the head [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In contrast, the feeling of guilt is directed towards a specific behaviour rather than the entire self, and one can distinguish between the guilt-provoking behaviour and the self. Guilt does not have an impact on the sense of self and identity as in experiencing shame. Furthermore, feeling regret and remorse as a result of a behaving wrongly gives a chance to engage in constructive actions, such as confession, apologizing and changing previous behaviour patterns, which give room for regulating the emotion and repairing interpersonal relationships [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Evidence suggests that guilt promotes pro-social behaviour towards those who have been wronged and reinforces improved social bonds; thus, benefits both parties as a tool to repair wrongdoing [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn some cases, shame and guilt are not temporary emotions but may be a part of personality trait as a result of experiencing frequently and intensely causing interruption social and daily life. Individuals who are likely to make internal and stable attributions of shame or guilt regardless of the circumstances are named shame-prone or guilt-prone individuals [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A shame-prone person is more likely to blame oneself for the way of acting, engage in higher rates of self-attributions for interpersonal conflicts and experience lower self-esteem. Additionally, shame proneness is significantly related to depression, social anxiety, avoidance of other people and fear of being negatively evaluated due to being overly self-conscious. Shame-proneness leads to blaming others to externalize the sense of shame and provide relief from distressing emotions. On the other hand, a guilt-prone individual internalizes self-blaming emotions in times of transgression due to awareness of moral rules, ideal self-concept, and a tendency to conduct negative self-evaluation and self-criticism, which are crucial aspects of guilt-proneness [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Guilt-prone individuals seek forgiveness from ones whom they believe treated with disrespect or violated and hold a strong belief that they deserve punishment for their misbehaving. These individuals have tendency to experience remorse for personal wrongdoing even when the wrongdoing is private and has no impact on others [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Sense of guilt leads to either solely experiencing negative emotions associated with the disappointing action or engaging in constructive behaviours to compensate for the transgression with desire to repair or amend the guilt-provoking situation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThompson defines emotion regulation as the process of observation, evaluation and modification of emotional reactions, especially the intensive aspects of keeping functioning toward one\u0026rsquo;s goals [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Emotion regulation consists of several processes that occur at various points in regulating emotions. The process model of emotion regulation provides a framework for emotion regulation strategies with four stages of generation and expression of an emotion [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. According to the model, initially, a response is generated by internal or external stimuli; secondly, the situation draws attention; thirdly, the situation is evaluated; and finally, an emotional response occurs in case the situation is appraised as relevant to one\u0026rsquo;s goals.\u003c/p\u003e \u003cp\u003eEmotion regulation strategies can be applied at any point of the process and generally fall into one of two categories which are antecedent focused or response focused. Antecedent-focused strategies are adopted during the first three stages of the emotion process and are considered effective in adjusting the severity and duration of responses. On the other hand, response-focused strategies occur during the model\u0026rsquo;s final stage, leading to intensified levels of emotional experience [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Maladaptive response-focused strategies include expressive suppression and rumination. Both strategies lead to intensification of emotional responses rather than modulation in terms of physiology and subjective experience [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Hughes et al found out that shame-proneness is associated with maladaptive emotion regulation strategies such as suppression which refers to inhibiting emotional expressions. The same study concludes that shame-proneness is negatively correlated with effective emotion regulation strategies such as impulse and anger control, down-regulation of negative affect and up-regulation of positive affect as well as adjusting emotional responses to the situation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. On the other hand, guilt-proneness is related to adaptive strategies such as reappraisal which involves reframing a situation cognitively to adjust the significance of emotional response [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmotion dysregulation is a pattern of emotion regulation that draws one back from one\u0026rsquo;s goals and daily functioning. Dysregulation of emotions occurs due to either adopting maladaptive emotion regulation strategies or lacking adaptive regulation strategies to deal with emotional responses [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Maltreatment during childhood may lead to a lack of emotion regulation strategies due to modelling maladaptive strategies and punishment of emotional expressions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. According to Ford, emotion regulation is an ability which develops during early childhood. The responsiveness and involvement of the caregivers as well as interactions between caregiver and child are considered as key for emotion regulation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Shipman et al shows that children who were neglected had lesser ability to comprehend negative emotions such as anger and sadness with fewer skills to regulate emotions. These children had a negative expectation about their mothers\u0026rsquo; response to expression of anger and sadness which is assumed as the cause of suppression of emotions which is an ineffective emotion regulation strategy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSomatic symptoms might be physical or bodily symptoms associated with a certain medical condition or labelled as medically unexplained symptoms without any detected biological cause [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Lack of medical explanation or any biological reason for the symptoms does not mean that the symptoms are not real or do not exist. For example, one might suffer from headaches or nausea without any attribution to a medical condition or illness.\u003c/p\u003e \u003cp\u003ePreviously, somatic symptoms were considered the narrowing of one\u0026rsquo;s attention to certain sensory stimuli, ignoring others due to exposure to trauma [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Furthermore, it was conceptualized as the suppression of certain memories from the body and the manifestation of these memories as somatic symptoms being triggered by certain stimuli. Such individuals were named as hysterical. Lately, somatization has been accepted as an expression of mental and emotional distress as bodily symptoms, which varies from the concept of hysteria [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. According to the psychodynamic model, one\u0026rsquo;s inner conflicts are reflected as physical distress, and impulses related to anxiety manifest as physical symptoms and complaints through the autonomic nervous system. Somatization prevents anxiety of inner conflict from being conscious [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSomatic symptoms and difficulties in emotion regulation are related according to the literature. Growing up in an adverse environment might prevent children from acquiring the knowledge and skills needed to regulate their emotions. Being neglected or abused deprives children of relevant emotion regulation strategies when dealing with distressing emotional responses. Furthermore, maltreated children may prefer to avoid awareness of emotions to feel protected against overwhelming emotions and thoughts [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Avoidance of emotional experiences and lack of emotion regulation abilities as a result of maltreatment and past trauma lead to affective experiences becoming somatised instead of verbally expressed. According to Ogrodniczuk et al., alexithymia is the mediator in the relationship between childhood trauma and somatic symptoms [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eShame and guilt-proneness are closely related to somatization among individuals with childhood trauma and maltreatment. The literature illustrates the association between abuse during childhood and self-conscious emotions, such as shame and guilt [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Shame and guilt evoked from early maltreatment are difficult affects to be regulated and processed emotionally and cognitively. As a result, these emotions are expected to contribute to somatic symptoms as a representation of inner conflict. During the times of childhood, when one lacks skills to express and process negative emotions, such as badness, inadequacy and remorse as a consequence of traumatic abuse or neglect, these emotional experiences might manifest themselves as somatic symptoms in the body [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Another study by Kealy et al. puts forward that shame has a mediator role in the relationship between childhood maltreatment, including abuse and neglect and somatization [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The study discusses that neglected individuals might identify with rejecting parents in an attempt to gratify need of warmth and acceptance along with a defective and unworthy representation of themselves. Negative emotions associated with this self-image may be represented as somatic symptoms, which lead to shame-related aches and pains. Another perspective on the relationship between somatization and shame and guilt-proneness is that shame might be so overwhelming to process and regulate for one with a past of childhood abuse that cognitively unprocessed emotions are experienced as somatic symptoms [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eShame-proneness is positively associated with difficulties in emotion regulation, while guilt-proneness leads to the application of effective emotion regulation strategies. Tangney \u0026amp; Dearing illustrate that guilt emotion is positively correlated with adaptive processing strategies, such as improved empathy to avoid the emotion in the future and enhanced interpersonal skills [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. On the other hand, shame is associated with psychopathological struggles, difficulties in regulating anger and interpersonal conflicts.\u003c/p\u003e \u003cp\u003eOverall, the literature illustrates that feelings of shame are common among individuals with past childhood maltreatment and abuse. This emotion is considered difficult and overwhelming to process with effective emotion regulation strategies. Additionally, these individuals may lack the knowledge and skills to regulate distressing emotions due to a lack of modelling and neglect. That\u0026rsquo;s why an association between shame-proneness and difficulties in emotion regulation strategies is expected. On the other hand, guilt-proneness is considered to lead to more effective emotion regulation strategies, such as empathy and improved interpersonal relationships to avoid previous feelings of guilt. Therefore, an association between guilt-proneness and difficulties in emotion regulation is not expected. Furthermore, somatization is also common among individuals who are not able to regulate the emotion of shame due to past trauma. This occurs as unprocessed emotions manifest themselves as bodily symptoms. As a result, associations between somatic symptoms, shame proneness and difficulties are expected. Among three variables, it is hypothesised that difficulties in emotion regulation have a mediator role in the relationship between shame-proneness and somatic symptoms, as overwhelming shame emotion is difficult to regulate and leads to experiencing somatic symptoms. On the other hand, no mediator role of difficulties in emotion regulation is expected in the relationship between guilt-proneness and somatic symptoms, as guilt-proneness leads to more effective emotion regulation strategies.\u003c/p\u003e \u003cp\u003eThe hypotheses of the study are as follows:\u003c/p\u003e \u003cp\u003eH1: There is an association between shame-proneness and somatic symptoms\u003c/p\u003e \u003cp\u003eH2: There is an association between guilt-proneness and somatic symptoms\u003c/p\u003e \u003cp\u003eH3: There is an association between shame-proneness and difficulties in emotion regulation strategies.\u003c/p\u003e \u003cp\u003eH4: There is no association between guilt-proneness and difficulties in emotion regulation strategies.\u003c/p\u003e \u003cp\u003eH5: Difficulties in emotion regulation strategies have a mediator role in the relationship between shame-proneness and somatic symptoms.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch Model\u003c/h2\u003e \u003cp\u003eThis research was a descriptive study with a correlational research design aiming to understand the relationship between shame and guilt-proneness, difficulties in emotion regulation and somatic symptoms. Correlational research determines relationship and direction of association between two or more variables but does not provide cause and effect relationship.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePopulation and Sample of this Stud -Study Group\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of adults above the age of 18 who filled out the questionnaires prepared on the online platforms. The total sample size was 374. One hundred seventy-four of the participants were women, while 200 of them were men. The mean age of participants was 45 (SD\u0026thinsp;=\u0026thinsp;12.7). In terms of education levels, most participants hold a bachelor\u0026rsquo;s degree, with a percentage of 49%. This was followed by high school grads, master\u0026rsquo;s degree holders and doctorate degree holders with percentages of 28%, 18% and 4%. Three hundred seven participants were currently working while 67 of them did not have a job. One hundred eighty of participants mentioned their marital status as married while 146 of them were single, 38 of them were divorced and 10 were widowed. The sampling technique used in this research was random sampling which helps increase representativeness of the sample group to general population.\u003c/p\u003e\n\u003ch3\u003eData Collecting Tools\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eGuilt and Shame Proneness Scale\u003c/strong\u003e \u003cp\u003eGuilt and shame proneness scale (GASP) has four four-item scales of Guilt-Negative-Behaviour Evaluation, Guilt-Repair, Shame-Negative-Self-Evaluation and Shame-Withdraw that measure individual differences in experiencing shame and guilt across various personal situations. The items are answers on a 7-point Likert-type scale. All reliability coefficients of the scale exceed .60 proves the reliability of the scale [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In the current study, the Cronbach\u0026rsquo;s alpha for the scale is calculated as 0.806.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eDifficulties in Emotion Regulation Scale\u003c/b\u003e: The Difficulties in Emotion Regulation Scale (DERS) is a 36-item self-report scale with six subscales: non-acceptance of emotional responses, difficulty engaging in goal-directed behaviour, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies and lack of emotional clarity. The items are scored on a 5-point Likert scale. The Cronbach\u0026rsquo;s alpha coefficient for scale is calculated as 0.90 [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In the current study, it is found to be 0.957.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSomatic Symptom Scale\u003c/strong\u003e \u003cp\u003eSomatic Symptom Scale (SSS-8) is an 8-item inventory that aims to measure somatic symptom burden. The Cronbach\u0026rsquo;s alpha coefficient for the scale is 0.81. The items are scored on a 5-point Likert-type scale. Higher scores indicate higher levels of somatic burden [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In the current study, the Cronbach\u0026rsquo;s alpha coefficient is calculated as 0.839.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe data obtained from this study were analysed using the SPSS 26.0 program. Frequency analysis was used to reveal demographic data about the participants and descriptive statistics for obtaining information about the scales, such as standard deviation, skewness and kurtois. The hypotheses of this study were tested using Pearson correlation analysis to understand the relationship between variables. Additionally, the mediation analysis was conducted using the SPSS Process Macro extension according to the bootstrapping method of Hayes [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Findings","content":"\u003cp\u003eThis section includes results of analysis for descriptive statistics, correlation analysis to understand the relationship between variables, regression analysis and mediation analysis aiming to determine whether there was a mediating role of difficulties in emotion regulation in relationship between shame and guilt-proneness and somatic symptoms. The hypotheses of this study, except relationship between guilt-proneness and somatic symptoms, were accepted according to the results obtained with statistical analysis (Table 1).\u003c/p\u003e\n\u003cp\u003eThe correlation analysis results among the variables are presented in Table 2. Pearson correlation coefficients were conducted to examine the relationships among difficulties in emotion regulation, shame and guilt proneness, and somatic symptoms. As shown in the table difficulties in emotion regulation was found to be significantly positively correlated with shame and guilt proneness (r = .221, p \u0026lt; .05) and somatic symptoms (r = .550, p \u0026lt; .05). Shame and guilt-proneness was found to be significantly correlated with limited access to emotion regulation strategies (r = .254, p \u0026lt; .05) and non-acceptance of emotional responses (r = .220, p \u0026lt; .05) subscales of difficulties in emotion regulation variable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSomatic symptoms showed significant positive correlations with all subscales of emotion regulation, including impulse control difficulties (r = .561, p \u0026lt; .01), limited access to emotion regulation strategies (r = .489, p \u0026lt; .01), non-acceptance of emotional responses (r = .391, p \u0026lt; .01), difficulty engaging in goal-directed behaviour and (r = .446, p \u0026lt; .01), and lack of emotional clarity (r = .375, p \u0026lt; .01).\u003c/p\u003e\n\u003cp\u003eAccording to the results, somatic symptoms were positively correlated with shame and guilt-proneness (r=.191, p\u0026lt;0.05). Significant relationship was found between somatic symptoms and shame-negative-self-evaluation (r = .550, p \u0026lt; .05) and shame-withdrawal (r = .347, p \u0026lt; .05) subscales.\u003c/p\u003e\n\u003cp\u003eAccording to the results the hypothesis that there is a positive relationship between shame proneness and somatic symptoms has been confirmed. According to the results, there was statistically significant (p\u0026lt;.05) and positive (.132) relationship between the shame-negative self-evaluation subscale of shame-proneness and somatic symptoms and statistically significant (p\u0026lt;.05) and positive (.347) relationship between shame-withdraw subscale and somatic symptoms. Thus, as the scores the participants receive from the shame-negative self-evaluation and shame-withdraw sub-scales increase, their scores from the somatic symptoms scale are also expected to increase.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe hypothesis that \u0026ldquo;There is a positive relationship between shame proneness and difficulties in emotion regulation\u0026rsquo;\u0026rsquo; has also been confirmed. According to the results, there was statistically significant (p\u0026lt;.05) and positive (.176) relationships between shame-negative self-evaluation subscale and difficulties in emotion regulation scores, and statistically significant (p\u0026lt;.05) and positive (.481) relationships between shame-withdraw subscale and difficulties in emotion regulation scores. As the scores obtained from the negative self-evaluation and withdraw subscales increase, the scores obtained from the emotion regulation difficulties scale will also increase according to the results.\u003c/p\u003e\n\u003cp\u003eThe hypothesis of \u0026ldquo;There is a relationship between proneness to guilt and somatic symptoms\u0026rsquo;\u0026rsquo; could not be confirmed. According to the results, there was no statistically significant relationship between the guilt-negative behaviour evaluation and guilt-repair sub-dimensions and somatic symptoms (p\u0026gt;.05).\u003c/p\u003e\n\u003cp\u003eThe hypothesis of \u0026ldquo;There is no relationship between proneness to guilt and difficulties in emotion regulation\u0026rsquo;\u0026rsquo; was confirmed. According to the results, there was a negative relationship between the subscales of proneness to guilt, negative behaviour (-.011) and repair (-.086), and difficulties in emotion regulation, but this relationship was not statistically significant (p\u0026gt;.05).\u003c/p\u003e\n\u003cp\u003eTable 3 indicates the results of the regression analysis examining the predictive effect of shame-proneness on difficulties in emotion regulation and somatic symptoms. According to the results, shame proneness had a statistically significant effect on difficulties in emotion regulation (p\u0026lt;.05; B=0.437). Shame proneness explained 19.1% of difficulties in emotion regulation, which is R2. A 1-unit increase in the scores obtained from the shame proneness subscale will increase the scores obtained from the difficulties in emotion regulation scale by .437.\u003c/p\u003e\n\u003cp\u003eShame proneness also had a statistically significant effect on somatic symptoms (p\u0026lt;.05; B=0.318). Shame proneness explained 10.1% of somatic symptoms, which is R2. A 1-unit increase in the scores obtained from the shame-proneness subscale will increase the scores obtained from the somatic symptoms scale by .318 (Figure 1)\u003c/p\u003e\n\u003cp\u003eFigure 1 shows the results regarding the mediating role of difficulties in emotion regulation in the relationship between shame proneness and somatic symptoms. According to the results, shame proneness, the independent variable of the study, had a statistically significant effect on difficulties in emotion regulation (path a) (p\u0026lt;.05). Shame proneness also had a statistically significant effect on the dependent variable, somatic symptoms (path c) (p\u0026lt;.05). There was also a statistically significant effect of the combined effect of shame proneness and difficulties in emotion regulation on somatic symptoms (path b) (p\u0026lt;.05). In path c\u0026rsquo;, where the mediating variable effect was examined, the effect of the existing significant effect of shame proneness and somatic symptoms continued without deterioration when difficulties in emotion regulation, which was included in the model as a mediating variable, is included (p\u0026lt;.05; B=0.096). According to these results, difficulties in emotion regulation had a partial mediating role in the relationship between shame proneness and somatic symptoms, confirming the final hypothesis of this study (Figure 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA mediation analysis was conducted to evaluate mediator roles of subscales of difficulties in emotion regulation scale (Non-acceptance of Emotional Responses [DERS1], Difficulties Engaging in Goal-Directed Behavior [DERS 2], Impulse Control Difficulties [DERS 3], Limited Access to Emotion Regulation Strategies [DERS 4], and Lack of Emotional Clarity [DERS 5]) in the relationship between shame and somatic symptoms.\u003c/p\u003e\n\u003cp\u003eThe total effect of shame on somatic symptoms was significant, b=0.2678, SE=0.0408,t(372)=6.57,p\u0026lt;.001,95%CI[0.1877,0.3480] with a standardized coefficient of \u0026beta;=0.3224. The direct effect of shame on somatic symptoms was not significant, b=0.0708, SE=0.0400, t (367) =1.77, p=.078, suggesting potential full mediation.\u003c/p\u003e\n\u003cp\u003eThe total indirect effect of shame on somatic symptoms through the mediators was significant, b=0.1971, BootSE=0.0263,95% CI [0.1478,0.2514]. Among the mediators, DERS4 (Lack of Emotional Clarity) demonstrated the strongest indirect effect, b=0.1625, BootSE=0.0413,95%CI [0.0851,0.2466].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNone of the other mediators yielded significant indirect effects (DERS 1: b=0.0382, BootSE=0.0240,95% CI [\u0026minus;0.0092,0.0867]; DERS 2: b=\u0026minus;0.0104, BootSE=0.0247,95% CI [\u0026minus;0.0600,0.0376] DERS 3: b=\u0026minus;0.0028, BootSE=0.0193,95%CI [\u0026minus;0.0415,0.0353] b = -0.0028, BootSE = 0.0193, 95% CI [-0.0415, 0.0353]; DERS 5: b=0.0095, BootSE=0.0142,95%CI [\u0026minus;0.0156,0.0408]).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion, Conclusion and Recommmendations ","content":"\u003cp\u003eAccording to the findings of this study, shame-proneness and somatic symptoms were significantly associated. This finding is consistent with the relevant data from the literature. The study of Kealy et al. found that shame is a predictor for somatic symptoms [28]. The present study considers that when shame is not processed or cognitively regulated, it manifests as unexplained bodily symptoms, which refer to somatization. Especially among children who might not be able to communicate their emotions efficiently, somatization of shame is common. Furthermore, Pineles et al. reached the conclusion that shame-proneness is closely related to both somatic and post-traumatic stress disorder symptoms in their study conducted with 156 female participants [34]. Overall, shame proneness and somatic symptoms are two closely related variables. As shame-prone individuals are more likely to adopt self-destructive emotion regulation strategies, they find it difficult to deal with their emotions. Suppression of negative emotions such as sadness and anger is one of the common ways for shame-prone individuals to deploy while dealing with negative experiences and this approach to emotions might further amplify the intensity of them. The intensified and unexpressed emotions are expected to manifest as bodily symptoms such as headache, fatigue, limb pain and stomach ache. Additionally, withdrawing oneself from society as a coping strategy deprives shame-prone individual from communicating the internal experiences with others which might give way to relief. The isolation from social resources might also bring additional emotional burden of feeling rejected and unaccepted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother study finding is the correlation between shame-proneness and difficulties in emotion regulation. Elison et al. mention shame as a difficult emotion to process cognitively and emotionally [35]. Puhalla et al. declare that men combat veterans who are prone to shame and post-traumatic stress disorder symptoms find it difficult to regulate their emotions [36]. The study of Lanteigne et al. revealed that shame-proneness is linked with dysfunctional emotion regulation strategies, such as emotional suppression [37]. Tatar and Miu concluded that higher use of maladaptive and lower use of adaptive emotion regulation strategies are common among shame-prone individuals [38]. The link between two variables can be attributed to the fact that shame-prone individuals are more likely to withdraw from society, engage in self-destructive emotion regulation activities such as abuse of alcohol and drugs and suffer from aggression due to low self-esteem and negative self-image they hold about themselves. As shame-prone individuals hold the belief that expression of negative emotions will lead to judgement and intolerance from others, they prefer to supress them and avoid social interactions in times of distress. Additionally, shame can be considered a difficult emotion to regulate due to being seen as a sign of weakness by society causing to consider oneself as flawed and become unmotivated to feel better. On the other hand, no correlation is found between guilt-proneness and emotion regulation difficulties. The study by Tatar and Miu shows that guilt-prone individuals are likely to adopt dysfunctional emotion regulation strategies, such as catastrophizing and blaming others, and benefit from adaptive strategies, including positive reappraisal while dealing with distressing emotions [38]. Guilt is an emotion that is directed toward a situation instead of a whole identity, unlike shame. Thus, guilt-prone individuals are more likely to consider reframing guilt-provoking experiences and engage in constructive behaviours with others whom they believe are harmed by their actions. The fact that guilt is not associated with lowered self-esteem like shame, guilt-prone individuals might feel more motivated to express their internal experiences and engage in effective emotion regulation strategies. Additionally, experiencing guilt might lead to feelings of empathy which is expected to guide guilt-prone individual to repair their relationships with others regulating their emotions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother study finding is that\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eshame-proneness is a predictor for both difficulties in emotion regulation and somatic symptoms. An individual who is prone to shame is also expected to struggle with dealing with negative emotions. This might be because of the nature of shame, which forces one to withdraw from society and benefit less from expressing emotions due to a sense of inferiority among others and expectation of criticism for opening themselves. This lack of expression causes unexplained medical conditions of somatic symptoms as unresolved affects manifest themselves as somatization. Additionally, this puts forward that shame is a difficult emotion to regulate and process unlike other emotions which are more accepted by the society. This finding is parallel to the final hypothesis of this study which is accepted by mediation analysis. Difficulties in emotion regulation have a mediator role in the relationship between shame and somatic symptoms. This can be attributed to the fact that unprocessed and difficult-to-express shame is manifested as somatic symptoms due to a lack of effective emotion regulation strategies or adopting maladaptive ones. Shame prone-individuals deprive themselves from effective emotion-regulation strategies as they hold negative believes about themselves and expect rejection from others for who they are. These cognitions make them prefer withdrawal from others and suppression of internal experiences. As a result of emotional and behavioural avoidance, intensified and unresolved emotions manifest themselves as somatic symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the subscales of difficulties of the emotion regulation scale, limited access to emotion regulation strategies had a significant mediator role between shame-proneness and somatic symptoms. This finding illustrates that shame-prone individuals lack relevant emotion regulation strategies to deal with negative emotions and experience somatization as a result. This can be attributed to neglect during childhood which is considered as a cause of both shame-proneness, identifying oneself as rejected and unworthy by care-givers and lacking guidance or modelling for learning emotion regulation skills to resolve negative emotions as an adult.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study puts forward that shame-prone individuals struggle with expressing and processing their emotions with effective emotion regulation strategies and mainly adopt dysfunctional ways to deal with their negative internal experiences which prevent them to engage in goal-oriented behaviours in life. The literature illustrates that somatization is common among individuals who find it hard to express their emotions and regulate them and shame-prone individuals experience somatic symptoms due to their inability to resolve negative emotions. The present study can be considered as a guide for therapists and clients who suffer from shame-proneness and somatic symptoms. The link that both conditions are combined is a result of lacking effective emotion regulation strategies that might provide therapists and medical practitioners with to guide clients towards beneficial emotion regulation skills. Initially, clients can be informed about their situation with psychoeducation, then be approached with recent therapeutic techniques, such as Acceptance and Commitment Therapy [39], Mindfulness or Compassion-focused Therapies, which are acceptance-based ways towards emotions to regulate them effectively [40]. Furthermore, informing patients about the actual cause of somatic symptoms will provide relief about any other medical condition and reduce costs for screening and doctor visits.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has some limitations. Initially, it is correlation research and not experimental. That\u0026rsquo;s why a causational interpretation cannot be made based on the results, while the predictive role of the variable is confirmed with regression and mediation analysis. Secondly, the data for the study are collected from a limited number of participants at one time. To increase the generalizability of the results, the study can be conducted with different samples more than one. Thirdly, results can show differences across different cultures, so conducting research with samples with different cultural orientations might lead to various results showing cultural differences related to emotion regulation and shame-proneness. Finally, this study ignores other mediator variables that might have a role in the relationship between shame-proneness and somatic symptoms. This study can be replicated using other relevant mediator variables to test their roles.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical committee approval was obtained from Bah\u0026ccedil;eşehir Cyprus University on 15.05.2024 with the BAU/EK-2024/02 approval number to conduct this study. The research is conducted in accordance with the Declaration of Helsinki. The participants were provided informed consent before participating in the study. No personal information was collected from the participants and no minors were involved in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEE prepared the introduction section regarding background information and hypotheses. Both EE and GN contributed to the methodology section. Data analysis and result section were conducted by GN. Discussion of research findings is written by EE interpreting results. Reference list is prepared by EE. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWoien SL, Ernst HA, Patock-Peckham JA, Nagoshi CT. Validation of the TOSCA to measure shame and guilt. Pers Individ Dif. 2003;35(2):313\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis HB. Shame and guilt in neurosis. Psychoanal Rev. 1971;58(3):419.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis M. The role of the self in shame. 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Adv Psychiatr Treat. 2009;15(3):199\u0026ndash;208.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDescriptive statistics\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMin\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMax\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMean\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSD\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSkewness\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eKurtosis\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eDifficulties in emotion regulation\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e16,00\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e79,00\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan 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align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNon-acceptance\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3,00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e15,00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7,53\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3,723\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,371\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-1,050\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eShame and guilt-proneness\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e33,00\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e111,00\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e80,26\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e12,769\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e-,725\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e951\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNegative Behavior Evaluation\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4,00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e28,00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e22,17\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5,127\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,916\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,221\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRepair\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8,00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e28,00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e22,97\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3,785\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,716\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,544\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNegative Self Evaluation\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6,00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e28,00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e23,21\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4,501\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-1,220\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1,679\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eWithdraw\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4,00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e28,00\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11,90\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5,000\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,721\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,195\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eSomatic symptoms\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e00\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e27,00\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e8,38\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e6,386\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e842\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e113\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCorrelation analysis between difficulties in emotion regulation, shame and guilt-proneness and somatic symptoms\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e9\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e1.Difficulties in emotion regulation\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2Lack of emotional clarity\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,710\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.Difficulty engaging in goal-directed behaviour\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,853\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,478\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4. Impulse control difficulties\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,806\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,581\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,608\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5.Limited access to emotion regulation strategies\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,948\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,599\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,807\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,674\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6. Non-acceptance of emotional responses\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,864\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,576\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,624\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,608\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,780\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e7.Shame and guilt-proneness\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,221\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,057\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,219\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,089\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,254\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,220\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8.guilt-negative behaviour evaluation\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,011\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,082\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,004\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,110*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,021\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,052\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,804\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e9.guilt-repair\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,086\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,175\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,011\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,174\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,026\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,068\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,714\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,626\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10.shame-negative self-evaluation\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,176\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,012\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,210\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,010\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,222\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,196\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,823\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,586\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,550\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11.guilt-withdraw\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,481\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,374\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,375\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,462\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,447\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,384\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,447\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,028\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,070\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,186\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12.\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eSomatic symptoms\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,550\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,375\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,446\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,390\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,561\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,489\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,191\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,033\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,016\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,132\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,347\u003csup\u003e**\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRegression analysis to evaluate to what extent Shame-proneness predicts Difficulties in emotion regulation and Somatic symptoms\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eModel\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUnstandardized Coefficients\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStandard Coefficients\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003et\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ep\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eB\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStd. Error\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBeta\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConstant\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7,576\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3,491\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2,170\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,031\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,191\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eShame-proneness\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,906\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,097\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,437\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e9,310\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,000\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDependent variable: Difficulties in emotion regulation\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eModel\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUnstandardized Coefficients\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStandard Coefficients\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003et\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ep\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eB\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStd. Error\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBeta\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConstant\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-1,357\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1,548\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-,877\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,381\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,101\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eShame-proneness\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,277\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,043\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,318\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6,425\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e,000\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDependent variable: Somatic Symptoms\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"somatization, emotion regulation, shame, guilt, trauma","lastPublishedDoi":"10.21203/rs.3.rs-5930990/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5930990/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eShame is a distressing self-conscious emotion which arises from evaluating oneself as immodest or indecorous and leads to avoidant behaviour as well as defensive anger. Guilt is the negative appraisal of a behaviour or thought and provides readiness to take action to compensate for the wrongdoing. Experiencing these emotions more intensely and frequently with interruptions during the daily life is named as shame or guilt-proneness. Emotion regulation includes processing and regulation of emotions to keep one pursuing goals in life. Individuals who lack effective skills to regulate their emotions or adopt ineffective ones experience difficulties in emotion regulation. Somatic symptoms include medically unexplained symptoms that one suffers from. Mostly, these symptoms, such as headache, dizziness or nausea, are due to unprocessed emotions carried from childhood as a result of maltreatment or abuse. The literature shows that these variables are related to each other.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study focuses on how emotion regulation difficulties mediate between shame and guilt-proneness and somatic symptoms. The data were collected from 374 participants on online platforms using questionnaires with relevant scales. In order to summarize the data collected descriptive statistics was conducted and the relationship between variables was understood with correlation analysis. Furthermore, predictor role of shame-proneness was analysed with regression analysis and mediation analysis was employed to reveal the mediator role difficulties in emotion regulation in relationship between shame-proneness and somatic symptoms.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe results illustrated that all variables except guilt-proneness were associated with each other and difficulties in emotion regulation have a mediator role between two variables. The results can benefit mental health workers and patients who lack emotion regulation strategies and deal with somatic symptoms.\u003c/p\u003e","manuscriptTitle":"The mediator role of difficulties in emotion regulation in the relationship between guilt and shame-proneness and somatic symptoms","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 06:33:20","doi":"10.21203/rs.3.rs-5930990/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-16T04:25:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-15T13:27:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285338023228534032818636628272457832934","date":"2025-04-18T05:33:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-17T06:24:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231253091350733872704713447349669378095","date":"2025-04-17T05:21:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-17T02:33:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-17T02:28:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-04-14T10:45:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"72a35a03-6855-41db-bbb6-66fb17aef0f8","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:03:48+00:00","versionOfRecord":{"articleIdentity":"rs-5930990","link":"https://doi.org/10.1186/s40359-025-02909-4","journal":{"identity":"bmc-psychology","isVorOnly":false,"title":"BMC Psychology"},"publishedOn":"2025-07-01 15:57:47","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2025-04-21 06:33:20","video":"","vorDoi":"10.1186/s40359-025-02909-4","vorDoiUrl":"https://doi.org/10.1186/s40359-025-02909-4","workflowStages":[]},"version":"v1","identity":"rs-5930990","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5930990","identity":"rs-5930990","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}