Analysis of Biological Stress Indices in Patients with Gastrointestinal Cancer Based on Perceived Stress Mediated by Rumination using Structural Equation Modeling

Document Type : Original Article


1 Department of Health Psychology, Kish International Branch, Islamic Azad University, Kish Island, Iran.

2 Assistant Professor, Department of Clinical Psychology, Kharazmi University, Tehran, Iran.

3 Assistant Professor, Brain and Cognition Clinic, Institute for Cognitive Sciences, Tehran, Iran.


Background: Considering the prevalence of this disease and the high mortality rate of gastric cancer in the country, it is necessary to investigate the causes and factors affecting this disease's incidence.
Objective: This study aimed to analyze the structural equations of biological stress indices in patients with gastrointestinal cancer based on perceived stress mediated by rumination.
Methods: This research was a descriptive-correlational study of structural equation modeling. The statistical population of this study included all patients with gastrointestinal cancer referred to Reza-Mashhad hospital and Avicenna Hospital in Tehran in 2020, of which 250 patients were selected by convenience sampling method. Data were collected using the perceived stress scale (PSS), Nolen and Hoxma rumination questionnaire, and biological stress indices. Data were analyzed using structural equation modeling and Pearson correlation statistical methods using SPSS.22 and AMOS.22 software.
Results: The results showed that perceived stress (β=0.45, P0>0.001) directly affected rumination. Also, rumination (β=0.30, P=0.001) had a direct effect on biological stress indices. Rumination played a mediating role in the relationship between perceived stress and biological stress indices (RMSEA: 0.001; AGFI: 0.93).
Conclusion: Considering that perceived stress and rumination are effective on biological stress of gastrointestinal patients, it is necessary for therapists to pay attention to modifying beliefs related to stress and rumination in the psychological health of gastrointestinal patients in order to improve the quality of life of patients.


  1. Aldao A, Gee DG, De Los Reyes A, Seager I. Emotion regulation as a transdiagnostic factor in the development of internalizing and externalizing psychopathology: Current and future directions. Development and psychopathology. 2016 Nov;28(4pt1):927-46.
  2. Connolly SL, Wagner CA, Shapero BG, Pendergast LL, Abramson LY, Alloy LB. Rumination prospectively predicts executive functioning impairments in adolescents. Journal of Behavior Therapy and Experimental Psychiatry. 2014 Mar 1;45(1):46-56.
  3. Dodds SE, Pace TW, Bell ML, Fiero M, Negi LT, Raison CL, Weihs KL. Feasibility of Cognitively-Based Compassion Training (CBCT) for breast cancer survivors: a randomized, wait list controlled pilot study. Supportive Care in Cancer. 2015 Dec 1;23(12):3599-608.
  4. Du J, Huang J, An Y, Xu W. The relationship between stress and negative emotion: The Mediating role of rumination. Clin Res. 2018;4(1):1-5.
  5. Guendelman S, Medeiros S, Rampes H. Mindfulness and emotion regulation: Insights from neurobiological, psychological, and clinical studies. Frontiers in Psychology. 2017 Mar 6;8:220.
  6. Jensen LF, Pedersen AF, Andersen B, Vedsted P. Self-assessed health, perceived stress and non-participation in breast cancer screening: A Danish cohort study. Preventive medicine. 2015 Dec 1;81:392-8.
  7. Li Y, Gu S, Wang Z, Li H, Xu X, Zhu H, Deng S, Ma X, Feng G, Wang F, Huang JH. Relationship between stressful life events and sleep quality: rumination as a mediator and resilience as a moderator. Frontiers in psychiatry. 2019 May 27;10:348.
  8. Nolen-Hoeksema S, Wisco BE, Lyubomirsky S. Rethinking rumination. Perspectives on psychological science. 2008 Sep;3(5):400-24.
  9. Lueboonthavatchai P. Prevalence and psychosocial factors of anxiety and depression in breast cancer patients. Journal-Medical Association of Thailand. 2007 Oct 1;90(10):2164.
  10. Plummer M, Franceschi S, Vignat J, Forman D, de Martel C. Global burden of gastric cancer attributable to Helicobacter pylori. International journal of cancer. 2015 Jan 15;136(2):487-90.
  11. Quan L, Zhen R, Yao B, Zhou X, Yu D. The role of perceived severity of disaster, rumination, and trait resilience in the relationship between rainstorm-related experiences and PTSD amongst chinese adolescents following rainstorm disasters. Archives of psychiatric nursing. 2017 Oct 1;31(5):507-15.
  12. Rahimi F, Heidari M. Time trend analysis of stomach cancer incidence in the west of Iran. Health and Development Journal. 2020 Aug 24;1(2):100.
  13. Greer S, Morris T. The study of psychological factors in breast cancer: problems of method. Social Science & Medicine. Part A: Medical Psychology & Medical Sociology. 1978 Jan 1;12:129-34.
  14. Shields CG, Rousseau SJ. A pilot study of an intervention for breast cancer survivors and their spouses. Family Process. 2004 Mar;43(1):95-107.
  15. Wagner CA, Alloy LB, Abramson LY. Trait rumination, depression, and executive functions in early adolescence. Journal of youth and adolescence. 2015 Jan 1;44(1):18-36.
  16. Thanoi W, Klainin-Yobas P. Assessing rumination response style among undergraduate nursing students: A construct validation study. Nurse Education Today. 2015 May 1;35(5):641-6.
  17. Cohen S, Kamarck T, Mermelstein R. Perceived stress scale. Measuring stress: A guide for health and social scientists. 1994;10:1-2.
  18. Nolen-Hoeksema S, Morrow J. Effects of rumination and distraction on naturally occurring depressed mood. Cognition & Emotion. 1993 Nov 1;7(6):561-70.