The Potential Pathway Among Self-Focused Attention, Rumination, Perceived Stress and Female Psychosomatic Symptoms

The Potential Pathway Among Self-Focused Attention, Rumination, Perceived Stress and Female Psychosomatic Symptoms | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Potential Pathway Among Self-Focused Attention, Rumination, Perceived Stress and Female Psychosomatic Symptoms Moya Xu, Shulin Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8259525/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Background Psychosomatic symptoms are common among females, which reflect complex interactions among biological, psychological, and cognitive processes. Although biological mechanisms have been well established, they offer limited guidance for psychological interventions. This study focuses on self-focused attention (SFA), rumination, and perceived stress to reveal the cognitive pathways contributing to female psychosomatic symptoms. Methods This cross-sectional study was conducted in China in 2024, recruiting 839 women with a mean age of 26.50 ± 6.08 years. Standardized questionnaires were used to collect data on somatic symptoms, anxiety symptoms, self-focused attention, rumination, and perceived stress. Data analysis employed IBM SPSS 29.0 and AMOS 30.0 software, with a significance level set at p < 0.05. Analytical methods used included descriptive statistics, correlation, hierarchical regression analyses, and structural equation modeling (SEM). Results Perceived stress (r = .696, p < .01), rumination (r = .759, p < .01), and SFA (r = .132, p < .01) were significantly positively correlated with female psychosomatic symptoms. SFA (r = .265, p < .01) and perceived stress (r = .706, p < .01) were also significantly positively correlated with rumination. Only SFA and perceived stress showed no significant association. SEM analysis indicated that rumination and perceived stress fully mediated the relationship between self-focus attention and psychosomatic symptoms. The model fit indicators showed that the final model fit was acceptable (χ²[71] = 461.159, χ²/df = 6.495, CFI = .963, IFI = .963, TLI = .953, RMR = .039). Conclusions This study indicated that when developing interventions to reduce psychosomatic symptoms in females, all these variables should be comprehensively considered. female psychosomatic symptoms self-focused attention perceived stress Figures Figure 1 Introduction Psychosomatic disorders include symptom complexes that show the interaction between mental and physical dysfunction, or syndrome comorbidity [1]. Psychosomatic disorders are defined as physical illnesses caused by mental disruptive outcomes in which psychological stress affects somatic functioning to the point of distress [2]. The term refers to somatization driven or worsened by psychological variables, such as chronic pain or functional gastrointestinal issues, demonstrate a markedly higher prevalence in females [3]. Studies also demonstrate that females have significantly higher levels of anxiety and depression compared to males [4,5]. Hormonal variations specific to females, such as those occurring during menstrual cycles, pregnancy, postpartum periods, and menopause, have been shown to have a more pronounced impact on female mental health. Furthermore, a sociological perspective indicates that females are more susceptible to diverse stressors, such as the inequitable allocation of conventional familial roles and caregiving duties, alongside societal pressures concerning appearance and accomplishment [6,7]. Nonetheless, the clinical diagnosis of these symptoms is inadequate and offers little comfort, and their underlying processes are highly contentious. The mind-body connection is fundamental for comprehending the intricate interplay between mental and physical states, especially in health and disease contexts. This bidirectional association indicates that psychological states can affect physical health, while physical conditions can also have significant impacts. The cause of psychosomatic symptoms can be attributed to biological factors. Research indicates that stress perception is a crucial biopsychosocial determinant influencing the psychosomatic health of females [8]. Health changes generally come from the interaction of the central nervous system, endocrine system, and immune system [9]. Initially, at the neuroendocrine level, persistent stress perpetually stimulates the hypothalamic-pituitary-adrenal (HPA) axis [10]. The pituitary gland releases adrenocorticotropic hormone (ACTH), which promotes the synthesis of glucocorticoids. This results in persistently increased cortisol levels, which subsequently impact multiple physiological systems, and explains why women experiencing high stress are more prone to metabolic syndrome and allergy disorders [11]. Stress promotes the release of pro-inflammatory cytokines within the immune system [12]. It amplifies cerebral sensitization through vagal afferent impulses, markedly reducing the threshold for the perception of physiological signals such as pain [13]. Moreover, stress has been demonstrated to modify immune responses, aggravating autoimmune disorders and impeding healing processes [14,15]. In addition to its influence on the immune system, stress correlates with pain sensitivity, notably affecting chronic illnesses including chronic fatigue syndrome and fibromyalgia [16,17]. Moreover, perceived stress exhibits a positive correlation with other psychosomatic symptoms, such as peptic ulcers, migraines, and musculoskeletal pain [18–20]. The association between perceived stress and psychosomatic symptoms is not only diverse but also widespread, it across various communities. In higher education groups, perceived stress and psychosomatic symptoms have a notable positive connection, which is particularly pronounced in females [21,22]. Consistent findings have been observed among nursing populations [23]. Similar findings have been observed across different stages of women's lives, including depression and anxiety among nulliparous, peripartum, and pregnant women [24–26]. Perceived stress directly predicts somatic symptoms [27] and interacts with rumination to exacerbate physiological dysregulation [28]. Rumination indicates a tendency to constantly concentrate on distress symptoms and their potential causes and consequences without pursuing active problem-solving [29]. Individuals exhibiting elevated rumination demonstrate increased cortisol reactivity in response to stress, a mechanism that may contribute to psychosomatic symptoms [30], Nonetheless, it remains ambiguous whether perceived stress influences the relationship between rumination and psychosomatic symptoms, especially as a cognitive extension of self-focused attention. The traditional biomedical model emphasizes physiological factors such as hormonal fluctuations, yet struggles to explain why females with similar physiological characteristics exhibit significant variations in the severity of psychosomatic symptoms. Moreover, it fails to inform subsequent interventions. Therefore, exploring the mechanisms underlying psychosomatic symptoms from a psychological perspective holds significant value. Existing evidence suggests that psychological and cognitive factors may amplify the physiological susceptibility through neuroendocrine pathways [31]. Therefore, identifying specific cognitive factors and clarifying the underlying mechanisms is crucial for operationalization. This approach transforms broad psychological concepts into explicit, testable pathways. which helps replace speculative descriptions such as somatization. Rumination and Self-focused attention Self-focused attention (SFA) is the tendency to consciously direct attention away from the surrounding environment. The term is defined as the tendency to allocate cognitive resources to internal states and self-referential information [32]. Rumination and SFA have been demonstrated to be correlated, primarily within the context of social anxiety disorder [33]. Post-event rumination frequently occurs following unsuccessful or ambiguously effective social interactions, particularly when individuals perceive high social costs and develop negative self-perceptions due to anticipated catastrophic outcomes [33]. Research on non-clinical university samples indicates that trait self-focus predicts subsequent increases in rumination. Numerous studies indicate that self-focused attention promotes negative rumination in adolescents [34,35]. In a female-dominated sample, SFA showed a stronger correlation with negative affect, with rumination serving as one of the mediating variables. The effects generated by rumination were stronger than those from non-ruminative self-focus [36]. However, few studies have specifically examined the association between clinical symptoms and these two variables, and even fewer have put the focus on females. This phenomenon can be attributed to the inherent nature of SFA, which does not manifest as a pathological condition, rather, it is considered an integral component of human characteristics. Rumination and Stress Numerous studies have confirmed that rumination and perceived stress are predictive factors for certain disorders, and these two predictors interact with each other, although findings are inconsistent. For instance, rumination influences multiple vital psychological processes in individuals with fibromyalgia and is a significant contributor to their stress levels [37]. In premenstrual dysphoric disorder (PMDD), premenstrual symptoms, perceived stress, and daily rumination may mutually reinforce each other, forming a vicious cycle that maintains and exacerbates premenstrual symptoms over the long term[38]. Though rumination has been identified as a significant predictor of PMDD [39], perceived stress is not always predictive [40–43]. In depression, stress significantly moderates the relationship between rumination and depressive symptoms, yet gender influences this moderation pattern. A study has revealed the moderating effects of stress and rumination on depressive symptoms. The association between rumination and depressive symptoms in females appears to be influenced by stress levels, whereas in males, the link between rumination and depression disappears when stress levels are low. In another model, rumination moderates the relationship between stress and depressive symptoms, further highlighting the existence of gender differences. For females, rumination levels influence the extent to which stress affects depressive symptoms; for males, rumination simultaneously affects both stress and depressive symptoms regardless of its level [44]. On the other hand, rumination has the mediating effect on perceived stress and depressive symptoms, which has been validated among college students [45,46]. Additionally, individuals prone to rumination exhibit higher levels of post-traumatic stress symptoms [47,48]. Therefore, the specific mechanisms through which rumination and perceived stress interact and influence psychosomatic symptoms, particularly within female populations remain unclear. Self-focused Attention and Psychosomatic Somatic symptoms, including sensations, arousal, physical symptoms, and emotions, constitute a self-perceived experience [49]. Coping strategies such as avoidance, behavioral disengagement, and substance use primarily focus on alleviating negative experiences. So that for psychosomatic disorders, these strategies are preferred over actively addressing underlying issues [50,51]. Thus, attention, as a passive psychological element, exhibits adaptability to be considered. Heightened SFA frequently accompanies various psychopathologies, such as depression, anxiety, and schizophrenia[52], as excessive SFA is often associated with a series of negative cognitive processes. Since SFA may increase the likelihood of internal information entering consciousness, which is a prerequisite for experiencing somatic symptoms. Accordingly, focusing on the self can prompt individuals to encounter a heightened prevalence of somatic symptoms and perceive more intense bodily activity. Research indicates that SFA serves as an indicator of negative cognitive patterns, which themselves are risk factors for depression and anxiety. These disorders will be activated under stress [53]. SFA is comprised of two aspects: private self-focus, which involves the attention to one's own experiences, and public self-focus, which involves the attention to others' evaluations [54]. Research indicates that private self-focus correlates more strongly with depression and generalized anxiety, while public self-focus shows greater association with social anxiety disorder [36]. However, it should be noted that SFA is not always maladaptive. A study has demonstrated a correlation between SFA and increased self-control, as well as cognitive flexibility, concurrently, such attention has been shown to reduce symptoms of depression and anxiety [55]. According to Mor & Winquist's [36] cognitive resource allocation model, SFA can be considered a neutral attentional control mechanism whose adaptive value is dependent on the interaction between the type of attentional focus and the regulatory strategy employed. Experimental research has demonstrated that, compared to abstract forms of self-focus, induced concrete forms of self-focus are associated with reduced negative emotional reactivity following failure experiences[56]. It is investigated that attention can be modified to enhance emotional regulation , and SFA has been shown to strengthen psychological adjustment in specific forms or situations [57,58]. The impact of SFA on somatic symptoms does not occur in isolation, but rather requires interaction with emotions to influence somatic symptoms [59]. Self-reflection and insight, two components of self-focus, have been identified as being genuine adaptive factors in SFA for the self-regulation process [57,60], and they facilitate psychological adjustment. However, it remains unclear whether negative or positive symptoms dominate in the perception of somatic symptoms. Consequently, the role of SFA in determining psychosomatic symptoms requires further investigation. Rumination and Psychosomatic Symptoms Researches on stress, coping, and disease have largely failed to take into account persistent cognitive phenomena such as worry, rumination, and other similar symptoms. The majority of stress studies have focused on stimulus characteristics or individuals' perceptions of them, with much less on enduring cognitive processes that may serve as mediators [61]. The perseverative cognition hypothesis explains how stress chronically impacts physical and mental health. This, in turn, has been demonstrated to impact mental health including depression and anxiety, as well as physiological systems such as the cardiovascular, autonomic nervous, and endocrine systems [61]. Rumination, as a prototypical form of perseverative cognition, manifests as repetitive, intrusive, negative cognitions [29,62]. It represents an extendable cognitive process that may function as a cognitive extension of SFA [63,64]. An experimental study indicates that induced rumination has a detrimental effect on mood and increases physiological arousal [29], while attentional diversion or conscious self-monitoring buffers these effects. As demonstrated in the study by Johnson and Whisman [65], females have been found to demonstrate a higher propensity towards rumination traits and a heightened vulnerability to stress-related disorder. Studies across countries indicate that rumination about stressful events is positively correlated with individual stress levels and psychosomatic symptoms [66–70]. Despite this, few studies have examined rumination as a mediator between SFA and psychosomatic symptoms. The Present Study In the current research context, there remains a gap in studies examining the relationship between female SFA, rumination, perceived stress, and psychosomatic symptoms. To address these gaps, this study innovatively constructs and proposes a structural equation model aimed at deeply analyzing and clarifying the intrinsic connections and operational mechanisms among these four key variables. Through this model, we expect to reveal the complex interactive processes between females’ psychological and physical health, thus providing a novel theoretical perspective and empirical basis for females’ health research. The present study focuses specifically on rumination and perceived stress as key mediating factors. From the concept of rumination, which refers to the tendency to repeatedly focus on distressing symptoms and their potential causes and consequences [71], it can be inferred that rumination may serve as a key link between SFA and an individual's experience of distress, thereby influencing the emergence of psychosomatic symptoms. Furthermore, perceived stress, defined as an individual's subjective experience of external stressors, has been demonstrated to have a strong correlation with psychosomatic symptoms [72]. This finding indicates that perceived stress has the capacity to modify an individual's physiological response patterns when exposed to stress, thereby either exacerbating or alleviating the severity of psychosomatic symptoms. Based on the theoretical foundations and research findings outlined above, this study further proposes three core hypotheses. Firstly, we hypothesize that rumination would mediate SFA and psychosomatic symptoms. This hypothesis is grounded in the following logic: SFA heightens individuals' awareness of their internal states and emotional experiences. When this focus shifts toward repetitive rumination on negative emotions, rumination becomes the key mediating mechanism through which SFA influences psychosomatic symptoms. Secondly, we hypothesize that rumination and perceived stress exert a chain-mediated effect between SFA and psychosomatic symptoms. This hypothesis is derived from a comprehensive understanding of the association between stress and health. When individuals face stress, their perceived stress levels trigger a series of physiological and psychological responses. In the presence of rumination, perceived stress may further intensify negative emotions and psychological distress, thereby exacerbating psychosomatic symptoms. This mediating role reflects the bridging function of perceived stress between rumination and psychosomatic symptoms, highlighting its significant role in females’ health issues. In summary, this study is not only theoretically innovative but also holds significant practical implications. By examining the relationship between SFA, rumination, perceived stress and psychosomatic symptoms in females, the study highlights the necessity of adopting comprehensive strategies to improve the health and well-being of females. We advocate for a holistic, integrated healthcare approach within the medical field that not only addresses the physical health concerns of the female population but also prioritizes their mental well-being. This approach must fully recognize the critical role attributed to effective management of SFA, rumination, and perceived stress in shaping female health outcomes. Method Participants Participants were recruited online via online social media platforms. Eligibility criteria included being female and aged between 18 and 59 years. A total of 928 individuals participated in the study. After screening for missing or invalid data, 839 valid responses were retained for analysis. All participants provided informed consent and the study adhered to ethical guidelines approved by the institutional ethics committee. Materials Self-Focused Attention Self-focused attention was assessed using the Chinese version of the Self-Focused Attention Scale (SFAS) , originally developed by Kiropoulos & Klimidis [73] and revised by Xiao [74]. The scale contains 17 items across four subscales: Public Body Consciousness, Public Self-Consciousness, Private Self-Consciousness, Private Body Consciousness . Items are rated on a 5-point Likert scale (1 = "not at all true" to 5 = "completely true"). Higher scores indicate greater self-focused attention. In the present study, the SFAS showed good internal consistency ( Cronbach’s α = 0.822 ). Rumination Rumination was measured using the Chinese version of the Ruminative Response Scale (RRS-CV) , revised by Han & Yang [75]. The RRS-CV includes 22 items covering three dimensions: compulsive thinking , reflective pondering , and symptomatic rumination . Items are rated on a 4-point Likert scale. Higher scores reflect greater ruminative tendencies. The scale demonstrated excellent reliability in this study ( Cronbach’s α = 0.956 ). Perceived Stress Perceived stress was assessed using the 10-item Chinese version of the Perceived Stress Scale (PSS-10) , originally developed by Cohen et al. [76] and revised by Chen et al. [77]. The PSS-10 measures two subdimensions: helplessness and self-efficacy beliefs . Items are scored on a 5-point Likert scale, with items 4, 5, 7, and 8 reverse-scored. Higher scores indicate greater perceived stress. The Cronbach’s alpha in this study was 0.838 . Psychosomatic Symptoms Psychosomatic symptoms were modeled as a latent variable inferred from two observed indicators: The Generalized Anxiety Disorder-7 (GAD-7) , which measures the frequency of anxiety symptoms [78]. Each of the 7 items is rated on a 4-point Likert scale ranging from 0 (“not at all”) to 3 (“nearly every day”). Internal consistency in this sample was excellent ( Cronbach’s α = 0.925 ). The Patient Health Questionnaire-15 (PHQ-15) , which evaluates the severity of somatic symptoms [79]. Each item is rated similarly on a 0 to 3 scale. The PHQ-15 demonstrated good reliability in this study ( Cronbach’s α = 0.865 ). These two instruments were used as observed variables loading onto a single latent construct of Psychosomatic Symptoms in the structural equation model. This approach follows established practices in structural equation modeling (SEM) where a higher-order construct is inferred from multiple related but distinct measures [80]. The latent structure allows for the simultaneous estimation of shared variance across anxiety and somatic symptomatology, providing a more robust and theoretically coherent representation of psychosomatic symptom burden [81]. Procedure Data collection was conducted in December 2024 . The online questionnaire link was distributed through various online social media platforms, mainly through WeChat. Participants accessed the survey voluntarily, and only those who provided informed consent could proceed. The survey was self-administered and required approximately 10 minutes to complete. Participants who completed the survey would receive a 5RMB reward. To ensure data quality, attention-check items were applied. Data analyses All statistical analyses were conducted using IBM SPSS 29.0 and AMOS 30.0. Statistical significance was set at p < .05 for all inferential tests. Prior to main analyses, Kolmogorov–Smirnov tests were conducted to assess the normality of each continuous variable. Values<2 is the criterion for normal distribution verification [82]. Descriptive statistics were used to summarize participants’ demographic characteristics. Pearson correlation coefficients were computed to examine correlations among key psychological variables. Although SEM was the primary analytical technique used to test the hypothesized model and mediation pathways, preliminary linear regression analyses were also conducted to explore direct relationships between key independent and dependent variables, serving as a pre-validation process prior to model construction. SEM was employed to examine the hypothesized mediation model. In the model, SFA was treated as an independent variable, rumination and perceived stress as sequential mediators, and psychosomatic symptoms as the latent dependent variable indicated by GAD-7 and PHQ-15 total scores. Based on previous studies, scale items were randomly packed into 2-4 parcels, which were used as manifest variables in the SEM procedures [83]. Path coefficients were estimated using the maximum likelihood method. Model fit was evaluated using multiple indices with acceptable criteria: χ2/df < 5; RMR 0.90; TLI> 0.90; NFI > 0.90; IFI > 0.90 [84]. Indirect effects were tested using bootstrapping with 3000 resamples and bias-corrected 95% confidence intervals. Results Participant Characteristics The sample consisted of 839 individuals. The participants ranged in age from 18 to 59 years (M= 26.50, SD= 6.08). Among them, 67.2% were single, 32.2% married or cohabiting, and 0.6% divorced or widowed. Regarding occupational status, the largest group consisted of students (n= 218, 26.0%). This was followed by freelance workers (n= 57, 6.8%) and administrative staff (n= 57, 6.8%). Other commonly reported occupations included product/operations staff (n= 50, 6.0%), teachers (n= 44, 5.2%), and self-employed individuals (n= 43, 5.1%). Remaining occupations such as marketing personnel, technical professionals, service workers, and others each accounted for less than 5% of the total sample and were grouped under "Other" in subsequent analyses. Descriptive Statistics and Correlation Analysis Table 1 shows the correlation between the variables being studied to determine which variables to include in the path model. All variables showed satisfactory internal consistency (α> .95). Psychosomatic symptoms were strongly and positively correlated with both perceived stress (r= .696, p< .01) and rumination (r= .759, p< .01), and weakly correlated with SFA (r = .132, p < .01). Rumination was positively correlated with both SFA (r= .265, p< .01) and perceived stress (r= .706, p .05), suggesting that their relationship is not direct but may be mediated by other variables, such as rumination. These patterns illustrated that higher SFA relates to greater rumination, which in turn is associated with elevated perceived stress and psychosomatic symptoms. No common method bias was detected after grouping all items for EFA according to Harmon’s test. The first factor explained 30.8% of the total variance, which was lower than the 40% threshold [85]. Table 1 Pearson correlation coefficients between variables (n=839) Variables Min-Max Mean (SD) SK KU r 2 3 4 1.Psychosomatic Symptoms 0.00-2.50 0.86 (0.54) 0.49 -0.65 0.696** 0.132** 0.759** 2. Perceived Stress 0.00-4.00 1.73 (0.70) -0.06 -0.12 0.004 0.706** 3. Self-focused Attention 1.24-5.00 3.73 (0.52) -0.57 1.10 0.265** 4. Rumination 1.00-4.00 2.33 (0.67) 0.04 -0.71 SD Standard Deviation, SK Skewness, KU Kurtosis, r=Pearson’s correlation coefficient, ** P <0.01; Hierarchical Regression Analysis To preliminarily examine the predictive effects of self-focused attention (SFA) and the potential mediators, hierarchical regression analyses were conducted, as shown in Table 2. In Step 1, entering SFA alone yielded a small but significant model, R²= 0.017, F(1, 837)= 14.862, p< .001. SFA positively predicted symptoms (β= 0.138, p< .001). In Step 2, adding rumination substantially improved the model, ΔR²= 0.564 (final R²= 0.582), F(1, 836) = 581.157, p < .001. Rumination was a strong positive predictor (β= 0.632, p< .001), and the coefficient for SFA became negative and smaller in magnitude (β= −0.078, p= .001), suggesting possible mediation via rumination. In Step 3, entering perceived stress produced an additional increment in explained variance, ΔR²= 0.046(final R²= 0.628), F(1, 835)= 469.415, p< .001. In the final model, perceived stress (β= 0.244, p< .001) and rumination (β= 0.438, p< .001) were significant positive predictors, whereas SFA was no longer significant (β= −0.013, p= .591). This pattern is compatible with a pathway in which SFA relates to psychosomatic symptoms indirectly through rumination and perceived stress. Table 2 Hierarchical Regression Predicting Psychosomatic Symptoms (n=839) Step Predictor β R² ΔR² F(df) p 1 SFA .138 .017 .017 14.862 (1, 837) < .001 2 SFA -.078 .001 Rumination .632 .582 .564 581.157 (1, 836) < .001 3 SFA -.013 .591 Rumination .438 < .001 Perceived Stress .244 .628 .046 469.415 (1, 835) < .001 Structural Equation Modeling The hypothesized mediation model was tested using Structural Equation Modeling (SEM). The model demonstrated acceptable fit (CFI= .963, IFI= .963, TLI= .953, RMR= .039) (shown in Figure 1). To account for shared wording variance between two indicators of the same construct, we allowed their measurement errors to covary (i.e., residual covariance between PSS1 and PSS2), a theoretically defensible adjustment suggested by the modification indices; this yielded a small improvement in absolute fit χ²[71]= 461.159 χ²/df= 6.495 while leaving the pattern of structural paths unchanged. Though the chi-square statistic is greater than the acceptable value, it is sensitive to sample size, so large samples may yield significant results even with strong model fit [86]. Some of the paths were significant. SFA positively predicted rumination (β= 0.250, p< 0.001). Rumination, in turn, significantly predicted both perceived stress (β= 0.853, p< 0.001) and psychosomatic symptoms (β= 0.739, p.05), indicated that if there is a mediating effect, it is fully mediating. Besides, the path between ruminatin and psychosomatic symptoms was marginally significant (β= 0.176, p=0.05). The mediating effect and the associated 95% confidence intervals are presented in Table 3. According to the results, SFA indirectly influenced psychosomatic symptoms through two mediators. However, the specific indirect effect via rumination alone was not significant. The results indicated that the effect of SFA on psychosomatic symptoms operates primarily through the fully chain mediation of rumination and perceived stress. Table 3 Bootstrapping Indirect effects and 95% confidence intervals (CI) for the meditational model Pathways Estimate 95% CI p SFA- Rumination- Psychosomatic symptoms .044 [-.006, .095] .075 SFA- Rumination- Perceived stress- Psychosomatic symptoms .158 [.096, .238] .001 Total indirect effect .202 [.130, .268] .001 Direct effect -.044 [-.086, .001] .001 Total effect .158 [.073, .236] .001 Discussion The present study identifies SFA, rumination, and perceived stress as key psychological mechanisms underlying psychosomatic symptoms. Although current interventions, such as compassion-focused therapy (CFT) and gratitude interventions, are effective in alleviating symptoms such as anxiety and depression, they often operate broadly and lack clarity regarding which specific psychological constructs they modulate [87,88]. Moreover, research findings suggest that positive psychology interventions (PPI) are effective in enhancing well-being among clinical samples with mental and physical illnesses, as well as in treating common psychological symptoms, including depression and anxiety [89]. This lack of specificity limits their ability to guide mechanism-driven intervention design. In contrast, the chain of mechanisms offers meaningful insights into the psychological processes underlying female psychosomatic health issues. SFA does not directly predict psychosomatic symptoms, indicating that SFA itself is not sufficient to cause measurable physical and mental symptoms. This finding implies that SFA is a relatively upstream cognitive model, and its detrimental consequences usually depend on subsequent evaluative or emotional processing instead of operating independently [90]. Notably, the specific indirect effect of rumination alone was not significant, suggesting that only when rumination heightens perceived stress will there be an increase in the level of psychosomatic symptoms. This aligns with prior research indicating that repetitive negative thinking serves as a cognitive vulnerability factor for various psychological and physiological health outcomes [29,91]. Rumination appears to function as an intermediate cognitive process, it is not merely a reflection of distress but also a mechanism that amplifies the perception of stress and its physiological consequences [29,92]. Our findings confirm this mechanism, identifying rumination as a cognitive pathway that contributes to negative emotions and physiological arousal. This chain pathway supports the perseverative cognition hypothesis (PCH), which states that prolonged cognitive engagement with stressors, such as rumination and worry, leads to sustained physiological activation and ultimately adverse health outcomes [61]. It emphasizes how enduring cognitive processes extend the stress experience, affecting both psychological and physical aspects [28]. Perceived stress, which is the emotional and subjective evaluation of stressors, further mediates the link between rumination and psychosomatic symptoms. This supports the idea that subjective stress, rather than objective events, may be more relevant in predicting health outcomes, particularly when filtered through ruminative thought patterns [92]. The mediating pathway illustrates how sustained cognition about stressors leads to internalized tension and ultimately physical discomfort, consistent with PCH predictions. The significance of this indirect pathway suggests that perceived stress may be a more proximal predictor of psychosomatic outcomes than rumination itself. Limitation Although this study offers valuable insights, several limitations should be acknowledged. First, the cross-sectional design makes it difficult to establish temporal sequence or causality among variables. Psychosomatic symptoms may reciprocally influence cognition, by intensifying SFA or rumination, which suggesting potential bidirectional effects. Although the results indicate the mediating relationships consistent with our theoretical model, causal direction cannot be established. To clarify the complex framework requires future longitudinal or experimental designs. Furthermore, cross-sectional study captures only participants' psychological states at a specific point of time. The statistics may reflect transient emotions or temporary stressors which fail to represent stable and enduring cognitive traits. Furthermore, the convenience sampling method employed and the limit age range used in this study resulted in an unbalanced age distribution. Thus, the findings may lack generalizability to the broader female population and encounter constraints when applied to broader female groups. Future research should employ diverse or stratified sampling methods to balance the diversity of participants and ensure the demographic representativeness, which may help to explore the potential developmental differences across age groups. Finally, all participants shared the same cultural background, so replicative studies across diverse sociocultural contexts are necessary to test whether the identified cognitive pathways exhibit cross-cultural universality. Clinical and Practical Implications The findings of this study offer valuable insights into practical implications for the prevention and intervention of female psychosomatic symptoms. Specifically, the mediating roles of rumination and perceived stress offer opportunities to optimize interventions at different stages of psychological risk. Although SFA cannot directly predict psychosomatic symptoms, the indirect pathway of the chain mediators suggesting the importance of early recognition of high level SFA. Besides, rumination is not detrimental enough to trigger psychosomatic symptoms unless if perceived stress is heightened by it. This pattern reflects the significance of considering to address the stress appraisal and reactivity during the intervention. Mindfulness-Based Stress Reduction (MBSR), for example, it may disrupt the mediating pathway from rumination to perceived stress. Addressing the emotional evaluation component of stress with these techniques can reduce perceived stress and its psychosomatic symptoms, particularly among cognitively inflexible populations. If individuals continuously interpret daily events as highly stressful, the interventions only reduce repetitive thinking may not fully relief psychosomatic symptoms. Possible interventions targeting females with higher SFA could direct on attention training to lower the possibility for maladaptive rumination. For example, shifting self-monitoring from abstract trait judgements to concrete behavioral cues or on self-reflection and insight levels can prevent the transition from neutral self-awareness to pathological, persistent rumination [93]. For individuals already exhibiting rumination tendencies, findings suggests that interventions should not only target rumination but also focus on reducing perceived stress to prevent or reduce psychosomatic symptoms. From an assessment perspective, our findings suggest that traditional evaluations should incorporate dynamic analysis. For females with high SFA but low rumination, maintaining self-awareness may be beneficial. In contrast, individuals with high SFA and high rumination may benefit from targeted interventions that address cognitive rigidity, such as cognitive diffusion or metacognitive techniques. These applications support a more personalized and preventative approach to females’ psychosomatic health. Conclusion In summary, this study provides empirical support for the enduring cognitive hypothesis, demonstrating that self-focus attention primarily influences psychosomatic symptoms through its impact on rumination and perceived stress. These two mediating factors constitute the cognitive-emotional link between attention and symptoms, and should be the main focus of future research and interventions in female health. Abbreviations SEM: Structural Equation Modeling; HPA axis: Hypothalamic-pituitary-adrenal axis; ACTH: Adrenocorticotropic hormone; SFA: Self-focused Attention; PMDD: Premenstrual Dysphoric Disorder; SFAS: Self-Focused Attention Scale; RRS-CV: Chinese version of the Ruminative Response Scale; PSS-10: Perceived Stress Scale; GAD-7: Generalized Anxiety Disorder-7; PHQ-15: Patient Health Questionnaire-15; CFT: Compassion-focused Therapy; PPI: Positive Psychology Interventions; PCH: Perseverative Cognition Hypothesis; MBSR: Mindfulness-Based Stress Reduction. Declarations Ethics approval and consent to participate The study was approved by the Institutional Review Board (IRB) of the Department of Psychology and Behavioral Science, Zhejiang University (IRB approval code: [2025]038). Informed consent was obtained from all individual participants included in the study. Consent for publication Not Applicable. Availability of data and materials The datasets used and/or analyzed in this study may be made available upon reasonable request to the corresponding author. Competing interests The authors declared that they have no competing interests. Funding None Authors' contributions MYX completed the study design, material preparation, data collection and analysis, and manuscript writing; SLC supervised the study and revised the manuscript. Acknowledgements We sincerely appreciate the contributions of all participants in this study. References Ulyukin IM, Kiseleva NV, Rassokhin VV, Orlova ES, Sechin AA. Psychosomatic disorders (distress, depression, anxiety, somatization) in young patients who have had COVID-19. Medical academic journal. 2021;21:63–72. https://doi.org/10.17816/MAJ79127 Nisar H, Srivastava R. Fundamental Concept of Psychosomatic Disorders: A Review. International Journal of Contemporary Medicine Surgery and Radiology. 2017;3:12–8. Kajantie E, Phillips DIW. 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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-8259525","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588310427,"identity":"97fbd3c3-e192-46b5-854c-5e823235ada1","order_by":0,"name":"Moya Xu","email":"","orcid":"","institution":"Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Moya","middleName":"","lastName":"Xu","suffix":""},{"id":588310428,"identity":"774f06d8-88a5-4f52-9db3-c84d206549a3","order_by":1,"name":"Shulin Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDACCSBmbGCQYWNgPgDmMBwgUgsPGwNbAolaGBh4DCAihLTwz24+9vDnjsM8fNI9nz9YtjHI8d1IYPxcgM+SO8fSjXnPHOZhkzm7wUCyjcFY8kYCs/QMPFoMJHLMpBnbgFokcjckALUkbriRwMbMg1dL/jfJn2AtOQ8OALXUE6Elh02CF6KFsQGoJcGAkBaJG2lm0rxt6UAtacYMEuckDGeeedgsjU8L/4zkZ0CHWcvJz0h+/FmizEae73jywc/4tKAAZglYNBENGD8Qr3YUjIJRMApGEAAAL8dD2e83nHkAAAAASUVORK5CYII=","orcid":"","institution":"Zhejiang University","correspondingAuthor":true,"prefix":"","firstName":"Shulin","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2025-12-02 10:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8259525/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8259525/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102332380,"identity":"1a420e1a-f6f2-4430-9875-1c1d639684d2","added_by":"auto","created_at":"2026-02-10 15:30:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1965920,"visible":true,"origin":"","legend":"\u003cp\u003eThe Structural Equation Model Regarding the Mediating Effects of Rumination and Perceived Stress in the Relationship of SFA to Psychosomatic symptoms.\u003c/p\u003e\n\u003cp\u003e**\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8259525/v1/76dc8c1e1a9a6e53428336e9.png"},{"id":102397743,"identity":"2a3df5ae-1b51-4b17-be68-2b38e496d7e8","added_by":"auto","created_at":"2026-02-11 10:19:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2962815,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8259525/v1/c81a5d96-c384-4af8-ad35-d474e6ceb9e7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Potential Pathway Among Self-Focused Attention, Rumination, Perceived Stress and Female Psychosomatic Symptoms","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePsychosomatic disorders include symptom complexes that show the interaction between mental and physical dysfunction, or syndrome comorbidity [1]. Psychosomatic disorders are defined as physical illnesses caused by mental disruptive outcomes in which psychological stress affects somatic functioning to the point of distress [2]. The term refers to somatization driven or worsened by psychological variables, such as chronic pain or functional gastrointestinal issues, demonstrate a markedly higher prevalence in females [3]. Studies also demonstrate that females have significantly higher levels of anxiety and depression compared to males [4,5]. Hormonal variations specific to females, such as those occurring during menstrual cycles, pregnancy, postpartum periods, and menopause, have been shown to have a more pronounced impact on female mental health. Furthermore, a sociological perspective indicates that females are more susceptible to diverse stressors, such as the inequitable allocation of conventional familial roles and caregiving duties, alongside societal pressures concerning appearance and accomplishment [6,7]. Nonetheless, the clinical diagnosis of these symptoms is inadequate and offers little comfort, and their underlying processes are highly contentious. The mind-body connection is fundamental for comprehending the intricate interplay between mental and physical states, especially in health and disease contexts. This bidirectional association indicates that psychological states can affect physical health, while physical conditions can also have significant impacts.\u003c/p\u003e\n\u003cp\u003eThe cause of psychosomatic symptoms can be attributed to biological factors. Research indicates that stress perception is a crucial biopsychosocial determinant influencing the psychosomatic health of females [8]. Health changes generally come from the interaction of the central nervous system, endocrine system, and immune system [9]. Initially, at the neuroendocrine level, persistent stress perpetually stimulates the hypothalamic-pituitary-adrenal (HPA) axis [10]. The pituitary gland releases adrenocorticotropic hormone (ACTH), which promotes the synthesis of glucocorticoids. This results in persistently increased cortisol levels, which subsequently impact multiple physiological systems, and explains why women experiencing high stress are more prone to metabolic syndrome and allergy disorders [11]. Stress promotes the release of pro-inflammatory cytokines within the immune system [12]. It amplifies cerebral sensitization through vagal afferent impulses, markedly reducing the threshold for the perception of physiological signals such as pain [13]. Moreover, stress has been demonstrated to modify immune responses, aggravating autoimmune disorders and impeding healing processes [14,15]. In addition to its influence on the immune system, stress correlates with pain sensitivity, notably affecting chronic illnesses including chronic fatigue syndrome and fibromyalgia [16,17]. Moreover, perceived stress exhibits a positive correlation with other psychosomatic symptoms, such as peptic ulcers, migraines, and musculoskeletal pain [18\u0026ndash;20]. The association between perceived stress and psychosomatic symptoms is not only diverse but also widespread, it across various communities. In higher education groups, perceived stress and psychosomatic symptoms have a notable positive connection, which is particularly pronounced in females [21,22]. Consistent findings have been observed among nursing populations [23]. Similar findings have been observed across different stages of women\u0026apos;s lives, including depression and anxiety among nulliparous, peripartum, and pregnant women [24\u0026ndash;26]. Perceived stress directly predicts somatic symptoms [27] and interacts with rumination to exacerbate physiological dysregulation [28]. Rumination indicates a tendency to constantly concentrate on distress symptoms and their potential causes and consequences without pursuing active problem-solving [29]. Individuals exhibiting elevated rumination demonstrate increased cortisol reactivity in response to stress, a mechanism that may contribute to psychosomatic symptoms [30],\u0026nbsp;Nonetheless, it remains ambiguous whether perceived stress influences the relationship between rumination and psychosomatic symptoms, especially as a cognitive extension of self-focused attention.\u003c/p\u003e\n\u003cp\u003eThe traditional biomedical model emphasizes physiological factors such as hormonal fluctuations, yet struggles to explain why females with similar physiological characteristics exhibit significant variations in the severity of psychosomatic symptoms. Moreover, it fails to inform subsequent interventions. Therefore, exploring the mechanisms underlying psychosomatic symptoms from a psychological perspective holds significant value. Existing evidence suggests that psychological and cognitive factors may amplify the physiological susceptibility through neuroendocrine pathways [31]. Therefore, identifying specific cognitive factors and clarifying the underlying mechanisms is crucial for operationalization. This approach transforms broad psychological concepts into explicit, testable pathways. which helps replace speculative descriptions such as somatization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRumination and Self-focused attention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelf-focused attention (SFA) is the tendency to consciously direct attention away from the surrounding environment. The term is defined as the tendency to allocate cognitive resources to internal states and self-referential information [32]. Rumination and SFA have been demonstrated to be correlated, primarily within the context of social anxiety disorder [33]. Post-event rumination frequently occurs following unsuccessful or ambiguously effective social interactions, particularly when individuals perceive high social costs and develop negative self-perceptions due to anticipated catastrophic outcomes [33]. Research on non-clinical university samples indicates that trait self-focus predicts subsequent increases in rumination. Numerous studies indicate that self-focused attention promotes negative rumination in adolescents [34,35]. In a female-dominated sample, SFA showed a stronger correlation with negative affect, with rumination serving as one of the mediating variables. The effects generated by rumination were stronger than those from non-ruminative self-focus [36]. However, few studies have specifically examined the association between clinical symptoms and these two variables, and even fewer have put the focus on females. This phenomenon can be attributed to the inherent nature of SFA, which does not manifest as a pathological condition, rather, it is considered an integral component of human characteristics. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRumination and Stress\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNumerous studies have confirmed that rumination and perceived stress are predictive factors for certain disorders, and these two predictors interact with each other, although findings are inconsistent. For instance, rumination influences multiple vital psychological processes in individuals with fibromyalgia and is a significant contributor to their stress levels [37]. In premenstrual dysphoric disorder (PMDD), premenstrual symptoms, perceived stress, and daily rumination may mutually reinforce each other, forming a vicious cycle that maintains and exacerbates premenstrual symptoms over the long term[38]. Though rumination has been identified as a significant predictor of PMDD [39], perceived stress is not always predictive [40\u0026ndash;43]. In depression, stress significantly moderates the relationship between rumination and depressive symptoms, yet gender influences this moderation pattern. A study has revealed the moderating effects of stress and rumination on depressive symptoms. The association between rumination and depressive symptoms in females appears to be influenced by stress levels, whereas in males, the link between rumination and depression disappears when stress levels are low. In another model, rumination moderates the relationship between stress and depressive symptoms, further highlighting the existence of gender differences. For females, rumination levels influence the extent to which stress affects depressive symptoms; for males, rumination simultaneously affects both stress and depressive symptoms regardless of its level [44]. On the other hand, rumination has the mediating effect on perceived stress and depressive symptoms, which has been validated among college students [45,46]. Additionally, individuals prone to rumination exhibit higher levels of post-traumatic stress symptoms [47,48]. Therefore, the specific mechanisms through which rumination and perceived stress interact and influence psychosomatic symptoms, particularly within female populations remain unclear.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-focused Attention and Psychosomatic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSomatic symptoms, including sensations, arousal, physical symptoms, and emotions, constitute a self-perceived experience [49]. Coping strategies such as avoidance, behavioral disengagement, and substance use primarily focus on alleviating negative experiences. So that for psychosomatic disorders, these strategies are preferred over actively addressing underlying issues [50,51]. Thus, attention, as a passive psychological element, exhibits adaptability to be considered. Heightened SFA frequently accompanies various psychopathologies, such as depression, anxiety, and schizophrenia[52], as excessive SFA is often associated with a series of negative cognitive processes. Since SFA may increase the likelihood of internal information entering consciousness, which is a prerequisite for experiencing somatic symptoms. Accordingly, focusing on the self can prompt individuals to encounter a heightened prevalence of somatic symptoms and perceive more intense bodily activity. Research indicates that SFA serves as an indicator of negative cognitive patterns, which themselves are risk factors for depression and anxiety. These disorders will be activated under stress [53]. SFA is comprised of two aspects: private self-focus, which involves the attention to one\u0026apos;s own experiences, and public self-focus, which involves the attention to others\u0026apos; evaluations [54]. Research indicates that private self-focus correlates more strongly with depression and generalized anxiety, while public self-focus shows greater association with social anxiety disorder [36]. However, it should be noted that SFA is not always maladaptive. A study has demonstrated a correlation between SFA and increased self-control, as well as cognitive flexibility, concurrently, such attention has been shown to reduce symptoms of depression and anxiety [55]. According to Mor \u0026amp; Winquist\u0026apos;s [36] cognitive resource allocation model, SFA can be considered a neutral attentional control mechanism whose adaptive value is dependent on the interaction between the type of attentional focus and the regulatory strategy employed. Experimental research has demonstrated that, compared to abstract forms of self-focus, induced concrete forms of self-focus are associated with reduced negative emotional reactivity following failure experiences[56]. It is investigated that attention can be modified to enhance emotional regulation , and SFA has been shown to strengthen psychological adjustment in specific forms or situations [57,58]. The impact of SFA on somatic symptoms does not occur in isolation, but rather requires interaction with emotions to influence somatic symptoms [59]. Self-reflection and insight, two components of self-focus, have been identified as being genuine adaptive factors in SFA for the self-regulation process [57,60], and they facilitate psychological adjustment. However, it remains unclear whether negative or positive symptoms dominate in the perception of somatic symptoms. Consequently, the role of SFA in determining psychosomatic symptoms requires further investigation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRumination and Psychosomatic Symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearches on stress, coping, and disease have largely failed to take into account persistent cognitive phenomena such as worry, rumination, and other similar symptoms. The majority of stress studies have focused on stimulus characteristics or individuals\u0026apos; perceptions of them, with much less on enduring cognitive processes that may serve as mediators [61]. The perseverative cognition hypothesis explains how stress chronically impacts physical and mental health. This, in turn, has been demonstrated to impact mental health including depression and anxiety, as well as physiological systems such as the cardiovascular, autonomic nervous, and endocrine systems [61]. Rumination, as a prototypical form of perseverative cognition, manifests as repetitive, intrusive, negative cognitions [29,62]. It represents an extendable cognitive process that may function as a cognitive extension of SFA [63,64]. An experimental study indicates that induced rumination has a detrimental effect on mood and increases physiological arousal [29], while attentional diversion or conscious self-monitoring buffers these effects. As demonstrated in the study by Johnson and Whisman [65], females have been found to demonstrate a higher propensity towards rumination traits and a heightened vulnerability to stress-related disorder. Studies across countries indicate that rumination about stressful events is positively correlated with individual stress levels and psychosomatic symptoms [66\u0026ndash;70]. Despite this, few studies have examined rumination as a mediator between SFA and psychosomatic symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Present Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the current research context, there remains a gap in studies examining the relationship between female SFA, rumination, perceived stress, and psychosomatic symptoms. To address these gaps, this study innovatively constructs and proposes a structural equation model aimed at deeply analyzing and clarifying the intrinsic connections and operational mechanisms among these four key variables. Through this model, we expect to reveal the complex interactive processes between females\u0026rsquo; psychological and physical health, thus providing a novel theoretical perspective and empirical basis for females\u0026rsquo; health research. The present study focuses specifically on rumination and perceived stress as key mediating factors. From the concept of rumination, which refers to the tendency to repeatedly focus on distressing symptoms and their potential causes and consequences\u0026nbsp;[71], it can be inferred that rumination may serve as a key link between SFA and an individual\u0026apos;s experience of distress, thereby influencing the emergence of psychosomatic symptoms. Furthermore, perceived stress, defined as an individual\u0026apos;s subjective experience of external stressors, has been demonstrated to have a strong correlation with psychosomatic symptoms [72]. This finding indicates that perceived stress has the capacity to modify an individual\u0026apos;s physiological response patterns when exposed to stress, thereby either exacerbating or alleviating the severity of psychosomatic symptoms.\u003c/p\u003e\n\u003cp\u003eBased on the theoretical foundations and research findings outlined above, this study further proposes three core hypotheses. Firstly, we hypothesize that rumination would mediate SFA and psychosomatic symptoms. This hypothesis is grounded in the following logic: SFA heightens individuals\u0026apos; awareness of their internal states and emotional experiences. When this focus shifts toward repetitive rumination on negative emotions, rumination becomes the key mediating mechanism through which SFA influences psychosomatic symptoms. Secondly, we hypothesize that rumination and perceived stress exert a chain-mediated effect between SFA and psychosomatic symptoms. This hypothesis is derived from a comprehensive understanding of the association between stress and health. When individuals face stress, their perceived stress levels trigger a series of physiological and psychological responses. In the presence of rumination, perceived stress may further intensify negative emotions and psychological distress, thereby exacerbating psychosomatic symptoms. This mediating role reflects the bridging function of perceived stress between rumination and psychosomatic symptoms, highlighting its significant role in females\u0026rsquo; health issues.\u003c/p\u003e\n\u003cp\u003eIn summary, this study is not only theoretically innovative but also holds significant practical implications. By examining the relationship between SFA, rumination, perceived stress and psychosomatic symptoms in females, the study highlights the necessity of adopting comprehensive strategies to improve the health and well-being of females. We advocate for a holistic, integrated healthcare approach within the medical field that not only addresses the physical health concerns of the female population but also prioritizes their mental well-being. This approach must fully recognize the critical role attributed to effective management of SFA, rumination, and perceived stress in shaping female health outcomes.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were recruited online via online social media platforms. Eligibility criteria included being female and aged between 18 and 59 years. A total of 928 individuals participated in the study. After screening for missing or invalid data, 839 valid responses were retained for analysis. All participants provided informed consent and the study adhered to ethical guidelines approved by the institutional ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSelf-Focused Attention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelf-focused attention was assessed using the \u003cstrong\u003eChinese version of the Self-Focused Attention Scale (SFAS)\u003c/strong\u003e, originally developed by Kiropoulos \u0026amp; Klimidis [73] and revised by\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eXiao [74]. The scale contains \u003cstrong\u003e17 items\u003c/strong\u003e across four subscales: \u003cem\u003ePublic Body Consciousness, Public Self-Consciousness, Private Self-Consciousness, Private Body Consciousness\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e Items are rated on a 5-point Likert scale (1 = \u0026quot;not at all true\u0026quot; to 5 = \u0026quot;completely true\u0026quot;). Higher scores indicate greater self-focused attention. In the present study, the SFAS showed good internal consistency (\u003cstrong\u003eCronbach\u0026rsquo;s \u0026alpha; = 0.822\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRumination\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRumination was measured using the \u003cstrong\u003eChinese version of the Ruminative Response Scale (RRS-CV)\u003c/strong\u003e, revised by Han \u0026amp; Yang [75]. The RRS-CV includes \u003cstrong\u003e22 items\u003c/strong\u003e covering three dimensions: \u003cem\u003ecompulsive thinking\u003c/em\u003e\u003cem\u003e, \u003cem\u003ereflective pondering\u003c/em\u003e,\u0026nbsp;\u003c/em\u003eand\u003cem\u003e\u0026nbsp;\u003cem\u003esymptomatic rumination\u003c/em\u003e\u003c/em\u003e. Items are rated on a 4-point Likert scale. Higher scores reflect greater ruminative tendencies. The scale demonstrated excellent reliability in this study (\u003cstrong\u003eCronbach\u0026rsquo;s \u0026alpha; = 0.956\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerceived Stress\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePerceived stress was assessed using the \u003cstrong\u003e10-item Chinese version of the Perceived Stress Scale (PSS-10)\u003c/strong\u003e, originally developed by Cohen et al. [76] and revised by Chen\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eet al. [77]. The PSS-10 measures two subdimensions: \u003cem\u003ehelplessness\u003c/em\u003e\u003cem\u003e\u0026nbsp;and \u003cem\u003eself-efficacy beliefs\u003c/em\u003e.\u003c/em\u003e Items are scored on a 5-point Likert scale, with items 4, 5, 7, and 8 reverse-scored. Higher scores indicate greater perceived stress. The Cronbach\u0026rsquo;s alpha in this study was \u003cstrong\u003e0.838\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePsychosomatic Symptoms\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePsychosomatic symptoms were modeled as a \u003cstrong\u003elatent variable\u003c/strong\u003e inferred from two observed indicators: The \u003cstrong\u003eGeneralized Anxiety Disorder-7 (GAD-7)\u003c/strong\u003e, which measures the frequency of anxiety symptoms [78]. Each of the 7 items is rated on a 4-point Likert scale ranging from 0 (\u0026ldquo;not at all\u0026rdquo;) to 3 (\u0026ldquo;nearly every day\u0026rdquo;). Internal consistency in this sample was excellent (\u003cstrong\u003eCronbach\u0026rsquo;s \u0026alpha; = 0.925\u003c/strong\u003e). The \u003cstrong\u003ePatient Health Questionnaire-15 (PHQ-15)\u003c/strong\u003e, which evaluates the severity of somatic symptoms [79]. Each item is rated similarly on a 0 to 3 scale. The PHQ-15 demonstrated good reliability in this study (\u003cstrong\u003eCronbach\u0026rsquo;s \u0026alpha; = 0.865\u003c/strong\u003e). These two instruments were used as observed variables loading onto a single latent construct of \u003cem\u003ePsychosomatic Symptoms\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003ein the structural equation model.\u003c/p\u003e\n\u003cp\u003eThis approach follows established practices in structural equation modeling (SEM) where a higher-order construct is inferred from multiple related but distinct measures [80]. The latent structure allows for the simultaneous estimation of shared variance across anxiety and somatic symptomatology, providing a more robust and theoretically coherent representation of psychosomatic symptom burden [81].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection was conducted in December\u003cstrong\u003e\u0026nbsp;2024\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e The online questionnaire link was distributed through various online social media platforms, mainly through WeChat. Participants accessed the survey voluntarily, and only those who provided informed consent could proceed. The survey was self-administered and required approximately \u003cstrong\u003e10 minutes\u003c/strong\u003e to complete. Participants who completed the survey would receive a 5RMB reward. To ensure data quality, attention-check items were applied.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were conducted using IBM SPSS 29.0 and AMOS 30.0. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026lt; .05 for all inferential tests. Prior to main analyses, Kolmogorov\u0026ndash;Smirnov tests were conducted to assess the normality of each continuous variable. Values\u0026lt;2 is the criterion for normal distribution verification [82]. Descriptive statistics were used to summarize participants\u0026rsquo; demographic characteristics. Pearson correlation coefficients were computed to examine correlations among key psychological variables. Although SEM was the primary analytical technique used to test the hypothesized model and mediation pathways, preliminary linear regression analyses were also conducted to explore direct relationships between key independent and dependent variables, serving as a pre-validation process prior to model construction.\u003c/p\u003e\n\u003cp\u003eSEM was employed to examine the hypothesized mediation model. In the model, SFA was treated as an independent variable, \u003cstrong\u003erumination\u003c/strong\u003e and \u003cstrong\u003eperceived stress\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eas sequential mediators, and \u003cstrong\u003epsychosomatic symptoms\u003c/strong\u003e as the latent dependent variable indicated by \u003cstrong\u003eGAD-7\u003c/strong\u003e and \u003cstrong\u003ePHQ-15\u003c/strong\u003e total scores. Based on previous studies, scale items were randomly packed into 2-4 parcels, which were used as manifest variables in the SEM procedures [83]. Path coefficients were estimated using the maximum likelihood method. Model fit was evaluated using multiple indices with acceptable criteria: \u0026chi;2/df \u0026lt; 5; RMR\u0026lt; 0.08; CFI \u0026gt; 0.90; TLI\u0026gt; 0.90; NFI \u0026gt; 0.90; IFI \u0026gt; 0.90 [84]. Indirect effects were tested using \u003cstrong\u003ebootstrapping with 3000 resamples\u003c/strong\u003e and bias-corrected 95% confidence intervals.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample consisted of 839 individuals. The participants ranged in age from 18 to 59 years (M= 26.50, SD= 6.08). Among them, 67.2% were single, 32.2% married or cohabiting, and 0.6% divorced or widowed. Regarding occupational status, the largest group consisted of students (n= 218, 26.0%). This was followed by freelance workers (n= 57, 6.8%) and administrative staff (n= 57, 6.8%). Other commonly reported occupations included product/operations staff (n= 50, 6.0%), teachers (n= 44, 5.2%), and self-employed individuals (n= 43, 5.1%). Remaining occupations such as marketing personnel, technical professionals, service workers, and others each accounted for less than 5% of the total sample and were grouped under \u0026quot;Other\u0026quot; in subsequent analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescriptive Statistics and Correlation Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 shows the correlation between the variables being studied to determine which variables to include in the path model. All variables showed satisfactory internal consistency (\u0026alpha;\u0026gt; .95). Psychosomatic symptoms were strongly and positively correlated with both perceived stress (r= .696, p\u0026lt; .01) and rumination (r= .759, p\u0026lt; .01), and weakly correlated with SFA (r = .132, p \u0026lt; .01). Rumination was positively correlated with both SFA (r= .265, p\u0026lt; .01) and perceived stress (r= .706, p\u0026lt; .01). Critically, there was no significant correlation between SFA and perceived stress (r= .004, p\u0026gt; .05), suggesting that their relationship is not direct but may be mediated by other variables, such as rumination. These patterns illustrated that higher SFA relates to greater rumination, which in turn is associated with elevated perceived stress and psychosomatic symptoms. No common method bias was detected after grouping all items for EFA according to Harmon\u0026rsquo;s test. The first factor explained 30.8% of the total variance, which was lower than the 40% threshold [85].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Pearson correlation coefficients between variables (n=839)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"645\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin-Max\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKU\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003er\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e1.Psychosomatic Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.00-2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.86 (0.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e-0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0.696**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.132**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.759**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e2. Perceived Stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.00-4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e1.73 (0.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e-0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e-0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.706**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e3. Self-focused Attention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.24-5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e3.73 (0.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e-0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.265**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e4. Rumination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.00-4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e2.33 (0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e-0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 645px;\"\u003e\n \u003cp\u003eSD Standard Deviation, SK Skewness, KU Kurtosis, r=Pearson\u0026rsquo;s correlation coefficient, **\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eHierarchical Regression Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo preliminarily examine the predictive effects of self-focused attention (SFA) and the potential mediators, hierarchical regression analyses were conducted, as shown in Table 2. In Step 1, entering SFA alone yielded a small but significant model, R\u0026sup2;= 0.017, F(1, 837)= 14.862, p\u0026lt; .001. SFA positively predicted symptoms (\u0026beta;= 0.138, p\u0026lt; .001).\u003c/p\u003e\n\u003cp\u003eIn Step 2, adding rumination substantially improved the model, \u0026Delta;R\u0026sup2;= 0.564 (final R\u0026sup2;= 0.582), F(1, 836) = 581.157, p \u0026lt; .001. Rumination was a strong positive predictor (\u0026beta;= 0.632, p\u0026lt; .001), and the coefficient for SFA became negative and smaller in magnitude (\u0026beta;= \u0026minus;0.078, p= .001), suggesting possible mediation via rumination.\u003c/p\u003e\n\u003cp\u003eIn Step 3, entering perceived stress produced an additional increment in explained variance, \u0026Delta;R\u0026sup2;= 0.046(final R\u0026sup2;= 0.628), F(1, 835)= 469.415, p\u0026lt; .001. In the final model, perceived stress (\u0026beta;= 0.244, p\u0026lt; .001) and rumination (\u0026beta;= 0.438, p\u0026lt; .001) were significant positive predictors, whereas SFA was no longer significant (\u0026beta;= \u0026minus;0.013, p= .591). This pattern is compatible with a pathway in which SFA relates to psychosomatic symptoms indirectly through rumination and perceived stress.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eHierarchical Regression Predicting Psychosomatic Symptoms (n=839)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"669\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eR\u0026sup2;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026Delta;R\u0026sup2;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF(df)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSFA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e.138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e14.862 (1, 837)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSFA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e-.078\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eRumination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e.632\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e.582\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e.564\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e581.157 (1, 836)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSFA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e-.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e.591\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eRumination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e.438\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ePerceived Stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e.244\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e.628\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e.046\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e469.415 (1, 835)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eStructural Equation Modeling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe hypothesized mediation model was tested using Structural Equation Modeling (SEM). The model demonstrated acceptable fit (CFI= .963, IFI= .963, TLI= .953, RMR= .039) (shown in Figure 1). To account for shared wording variance between two indicators of the same construct, we allowed their measurement errors to covary (i.e., residual covariance between PSS1 and PSS2), a theoretically defensible adjustment suggested by the modification indices; this yielded a small improvement in absolute fit \u0026chi;\u0026sup2;[71]= 461.159 \u0026chi;\u0026sup2;/df= 6.495 while leaving the pattern of structural paths unchanged. Though the chi-square statistic is greater than the acceptable value, it is sensitive to sample size, so large samples may yield significant results even with strong model fit [86].\u003c/p\u003e\n\u003cp\u003eSome of the paths were significant. SFA positively predicted rumination (\u0026beta;= 0.250, p\u0026lt; 0.001). Rumination, in turn, significantly predicted both perceived stress (\u0026beta;= 0.853, p\u0026lt; 0.001) and psychosomatic symptoms (\u0026beta;= 0.739, p\u0026lt; 0.001). The path between SFA and psychosomatic symptoms was not significant (\u0026beta;= -0.044, p=0.057\u0026gt;.05), indicated that if there is a mediating effect, it is fully mediating. Besides, the path between ruminatin and psychosomatic symptoms was marginally significant (\u0026beta;= 0.176, p=0.05).\u003c/p\u003e\n\u003cp\u003eThe mediating effect and the associated 95% confidence intervals are presented in Table 3. According to the results, SFA indirectly influenced psychosomatic symptoms through two mediators. However, the specific indirect effect via rumination alone was not significant. The results indicated that the effect of SFA on psychosomatic symptoms operates primarily through the fully chain mediation of rumination and perceived stress.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"529\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 529px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Bootstrapping Indirect effects and 95% confidence intervals (CI) for the meditational model\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePathways\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eSFA- Rumination- Psychosomatic symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e[-.006, .095]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e.075\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eSFA- Rumination- Perceived stress- Psychosomatic symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e.158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e[.096, .238]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eTotal indirect effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e.202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e[.130, .268]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eDirect effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e-.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e[-.086, .001]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eTotal effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e.158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e[.073, .236]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study identifies SFA, rumination, and perceived stress as key psychological mechanisms underlying psychosomatic symptoms. Although current interventions, such as compassion-focused therapy (CFT) and gratitude interventions, are effective in alleviating symptoms such as anxiety and depression, they often operate broadly and lack clarity regarding which specific psychological constructs they modulate [87,88]. Moreover, research findings suggest that positive psychology interventions (PPI) are effective in enhancing well-being among clinical samples with mental and physical illnesses, as well as in treating common psychological symptoms, including depression and anxiety [89]. This lack of specificity limits their ability to guide mechanism-driven intervention design.\u003c/p\u003e \u003cp\u003eIn contrast, the chain of mechanisms offers meaningful insights into the psychological processes underlying female psychosomatic health issues. SFA does not directly predict psychosomatic symptoms, indicating that SFA itself is not sufficient to cause measurable physical and mental symptoms. This finding implies that SFA is a relatively upstream cognitive model, and its detrimental consequences usually depend on subsequent evaluative or emotional processing instead of operating independently [90]. Notably, the specific indirect effect of rumination alone was not significant, suggesting that only when rumination heightens perceived stress will there be an increase in the level of psychosomatic symptoms. This aligns with prior research indicating that repetitive negative thinking serves as a cognitive vulnerability factor for various psychological and physiological health outcomes [29,91]. Rumination appears to function as an intermediate cognitive process, it is not merely a reflection of distress but also a mechanism that amplifies the perception of stress and its physiological consequences [29,92]. Our findings confirm this mechanism, identifying rumination as a cognitive pathway that contributes to negative emotions and physiological arousal. This chain pathway supports the perseverative cognition hypothesis (PCH), which states that prolonged cognitive engagement with stressors, such as rumination and worry, leads to sustained physiological activation and ultimately adverse health outcomes [61]. It emphasizes how enduring cognitive processes extend the stress experience, affecting both psychological and physical aspects [28]. Perceived stress, which is the emotional and subjective evaluation of stressors, further mediates the link between rumination and psychosomatic symptoms. This supports the idea that subjective stress, rather than objective events, may be more relevant in predicting health outcomes, particularly when filtered through ruminative thought patterns [92]. The mediating pathway illustrates how sustained cognition about stressors leads to internalized tension and ultimately physical discomfort, consistent with PCH predictions. The significance of this indirect pathway suggests that perceived stress may be a more proximal predictor of psychosomatic outcomes than rumination itself.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eAlthough this study offers valuable insights, several limitations should be acknowledged. First, the cross-sectional design makes it difficult to establish temporal sequence or causality among variables. Psychosomatic symptoms may reciprocally influence cognition, by intensifying SFA or rumination, which suggesting potential bidirectional effects. Although the results indicate the mediating relationships consistent with our theoretical model, causal direction cannot be established. To clarify the complex framework requires future longitudinal or experimental designs. Furthermore, cross-sectional study captures only participants' psychological states at a specific point of time. The statistics may reflect transient emotions or temporary stressors which fail to represent stable and enduring cognitive traits. Furthermore, the convenience sampling method employed and the limit age range used in this study resulted in an unbalanced age distribution. Thus, the findings may lack generalizability to the broader female population and encounter constraints when applied to broader female groups. Future research should employ diverse or stratified sampling methods to balance the diversity of participants and ensure the demographic representativeness, which may help to explore the potential developmental differences across age groups. Finally, all participants shared the same cultural background, so replicative studies across diverse sociocultural contexts are necessary to test whether the identified cognitive pathways exhibit cross-cultural universality.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eClinical and Practical Implications\u003c/h2\u003e \u003cp\u003eThe findings of this study offer valuable insights into practical implications for the prevention and intervention of female psychosomatic symptoms. Specifically, the mediating roles of rumination and perceived stress offer opportunities to optimize interventions at different stages of psychological risk. Although SFA cannot directly predict psychosomatic symptoms, the indirect pathway of the chain mediators suggesting the importance of early recognition of high level SFA. Besides, rumination is not detrimental enough to trigger psychosomatic symptoms unless if perceived stress is heightened by it. This pattern reflects the significance of considering to address the stress appraisal and reactivity during the intervention. Mindfulness-Based Stress Reduction (MBSR), for example, it may disrupt the mediating pathway from rumination to perceived stress. Addressing the emotional evaluation component of stress with these techniques can reduce perceived stress and its psychosomatic symptoms, particularly among cognitively inflexible populations. If individuals continuously interpret daily events as highly stressful, the interventions only reduce repetitive thinking may not fully relief psychosomatic symptoms. Possible interventions targeting females with higher SFA could direct on attention training to lower the possibility for maladaptive rumination. For example, shifting self-monitoring from abstract trait judgements to concrete behavioral cues or on self-reflection and insight levels can prevent the transition from neutral self-awareness to pathological, persistent rumination [93]. For individuals already exhibiting rumination tendencies, findings suggests that interventions should not only target rumination but also focus on reducing perceived stress to prevent or reduce psychosomatic symptoms.\u003c/p\u003e \u003cp\u003eFrom an assessment perspective, our findings suggest that traditional evaluations should incorporate dynamic analysis. For females with high SFA but low rumination, maintaining self-awareness may be beneficial. In contrast, individuals with high SFA and high rumination may benefit from targeted interventions that address cognitive rigidity, such as cognitive diffusion or metacognitive techniques. These applications support a more personalized and preventative approach to females\u0026rsquo; psychosomatic health.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, this study provides empirical support for the enduring cognitive hypothesis, demonstrating that self-focus attention primarily influences psychosomatic symptoms through its impact on rumination and perceived stress. These two mediating factors constitute the cognitive-emotional link between attention and symptoms, and should be the main focus of future research and interventions in female health.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSEM: Structural Equation Modeling; HPA axis: Hypothalamic-pituitary-adrenal axis; ACTH: Adrenocorticotropic hormone; SFA: Self-focused Attention; PMDD: Premenstrual Dysphoric Disorder; SFAS: Self-Focused Attention Scale; RRS-CV: Chinese version of the Ruminative Response Scale; PSS-10: Perceived Stress Scale; GAD-7: Generalized Anxiety Disorder-7; PHQ-15: Patient Health Questionnaire-15; CFT: Compassion-focused Therapy; PPI: Positive Psychology Interventions; PCH: Perseverative Cognition Hypothesis; MBSR: Mindfulness-Based Stress Reduction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board (IRB) of the Department of Psychology and Behavioral Science, Zhejiang University (IRB approval code: [2025]038). Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed in this study may be made available upon reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMYX completed the study design, material preparation, data collection and analysis, and manuscript writing; SLC supervised the study and revised the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely appreciate the contributions of all participants in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUlyukin IM, Kiseleva NV, Rassokhin VV, Orlova ES, Sechin AA. 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PLoS ONE. 2016;11:e0163952. https://doi.org/10.1371/journal.pone.0163952\u003c/li\u003e\n\u003cli\u003eJohnson DP, Whisman MA. Gender differences in rumination: A meta-analysis. Personality and Individual Differences. 2013;55:367\u0026ndash;74. \u003c/li\u003e\n\u003cli\u003eDenovan A, Dagnall N, Lofthouse G. Neuroticism and Somatic Complaints: Concomitant Effects of Rumination and Worry. Behav Cogn Psychother. 2019;47:431\u0026ndash;45. https://doi.org/10.1017/S1352465818000619\u003c/li\u003e\n\u003cli\u003eLarionow P, Ageenkova EK, Dedenok MI. Towards Psychosomatic Medicine: The Role of Age and Emotional Characteristics in People with Psychosomatic Disorders. j. 2022;35:143\u0026ndash;56. https://doi.org/10.17951/j.2022.35.3.143-156\u003c/li\u003e\n\u003cli\u003eMarcus DK, Hughes KT, Arnau RC. Health anxiety, rumination, and negative affect: A mediational analysis. 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Fit Indices in Structural Equation Modeling and Confirmatory Factor Analysis: Reporting Guidelines. Asian J Econ Busin Acc. 2024;24:561\u0026ndash;77. https://doi.org/10.9734/ajeba/2024/v24i71430\u003c/li\u003e\n\u003cli\u003eBoggiss AL, Consedine NS, Brenton-Peters JM, Hofman PL, Serlachius AS. A systematic review of gratitude interventions: Effects on physical health and health behaviors. Journal of Psychosomatic Research. 2020;135:110165. https://doi.org/10.1016/j.jpsychores.2020.110165\u003c/li\u003e\n\u003cli\u003eGilbert P. Introducing compassion-focused therapy. Advances in psychiatric treatment. 2009;15:199\u0026ndash;208. https://doi.org/10.1192/apt.bp.107.005264\u003c/li\u003e\n\u003cli\u003eChakhssi F, Kraiss JT, Sommers-Spijkerman M, Bohlmeijer ET. The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: a systematic review and meta-analysis. BMC Psychiatry. 2018;18:211. https://doi.org/10.1186/s12888-018-1739-2\u003c/li\u003e\n\u003cli\u003eGaydukevych D, Kocovski NL. Effect of self-focused attention on post-event processing in social anxiety. Behaviour Research and Therapy. 2012;50:47\u0026ndash;55. https://doi.org/10.1016/j.brat.2011.10.010\u003c/li\u003e\n\u003cli\u003eMcLaughlin KA, Borkovec TD, Sibrava NJ. The Effects of Worry and Rumination on Affect States and Cognitive Activity. Behavior Therapy. 2007;38:23\u0026ndash;38. https://doi.org/10.1016/j.beth.2006.03.003\u003c/li\u003e\n\u003cli\u003eHilt LM, Aldao A, Fischer K. Rumination and multi-modal emotional reactivity. Cognition and Emotion. 2015;29:1486\u0026ndash;95. https://doi.org/10.1080/02699931.2014.989816\u003c/li\u003e\n\u003cli\u003eNakajima M, Takano K, Tanno Y. Adaptive functions of self-focused attention: Insight and depressive and anxiety symptoms. Psychiatry Research. 2017;249:275\u0026ndash;80. https://doi.org/10.1016/j.psychres.2017.01.026 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"female, psychosomatic symptoms, self-focused attention, perceived stress","lastPublishedDoi":"10.21203/rs.3.rs-8259525/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8259525/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePsychosomatic symptoms are common among females, which reflect complex interactions among biological, psychological, and cognitive processes. Although biological mechanisms have been well established, they offer limited guidance for psychological interventions. This study focuses on self-focused attention (SFA), rumination, and perceived stress to reveal the cognitive pathways contributing to female psychosomatic symptoms.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted in China in 2024, recruiting 839 women with a mean age of 26.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.08 years. Standardized questionnaires were used to collect data on somatic symptoms, anxiety symptoms, self-focused attention, rumination, and perceived stress. Data analysis employed IBM SPSS 29.0 and AMOS 30.0 software, with a significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Analytical methods used included descriptive statistics, correlation, hierarchical regression analyses, and structural equation modeling (SEM).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePerceived stress (r\u0026thinsp;=\u0026thinsp;.696, p\u0026thinsp;\u0026lt;\u0026thinsp;.01), rumination (r\u0026thinsp;=\u0026thinsp;.759, p\u0026thinsp;\u0026lt;\u0026thinsp;.01), and SFA (r\u0026thinsp;=\u0026thinsp;.132, p\u0026thinsp;\u0026lt;\u0026thinsp;.01) were significantly positively correlated with female psychosomatic symptoms. SFA (r\u0026thinsp;=\u0026thinsp;.265, p\u0026thinsp;\u0026lt;\u0026thinsp;.01) and perceived stress (r\u0026thinsp;=\u0026thinsp;.706, p\u0026thinsp;\u0026lt;\u0026thinsp;.01) were also significantly positively correlated with rumination. Only SFA and perceived stress showed no significant association. SEM analysis indicated that rumination and perceived stress fully mediated the relationship between self-focus attention and psychosomatic symptoms. The model fit indicators showed that the final model fit was acceptable (χ\u0026sup2;[71]\u0026thinsp;=\u0026thinsp;461.159, χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;6.495, CFI\u0026thinsp;=\u0026thinsp;.963, IFI\u0026thinsp;=\u0026thinsp;.963, TLI\u0026thinsp;=\u0026thinsp;.953, RMR\u0026thinsp;=\u0026thinsp;.039).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study indicated that when developing interventions to reduce psychosomatic symptoms in females, all these variables should be comprehensively considered.\u003c/p\u003e","manuscriptTitle":"The Potential Pathway Among Self-Focused Attention, Rumination, Perceived Stress and Female Psychosomatic Symptoms","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 15:30:25","doi":"10.21203/rs.3.rs-8259525/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-03T05:27:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T01:07:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"85780508030217919204803978882122095343","date":"2026-03-26T09:28:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49412424909059581535023576108840233659","date":"2026-03-25T23:55:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"157665604407001443822908871833249281092","date":"2026-03-23T18:24:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187706863538529226288397267347642691983","date":"2026-03-23T12:24:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330394598419185372904932479093065398322","date":"2026-03-21T12:54:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T18:20:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143727062151012351582688975876080181828","date":"2026-03-11T15:36:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"726677359132674265307661152382185990","date":"2026-02-15T11:47:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"18452189415784214467271114315749275196","date":"2026-02-07T16:55:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T14:38:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-20T12:49:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-02T23:18:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-02T23:17:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-12-02T10:47:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"046fb5bd-bd8f-4ce8-8a04-4170d7a4ce92","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T11:39:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 15:30:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8259525","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8259525","identity":"rs-8259525","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}