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Comprehensive Psychiatry 55 (2014) 1415 1421
www.elsevier.com/locate/comppsych

Mediating effects of depression and anxiety on the relationship between

bullying involvement and pain problems among adolescents in Taiwan
Cheng-Fang Yen a, b, 1 , I-Mei Lin c, 1 , Tai-Ling Liu a, b , Huei-Fan Hu d,, Chung-Ping Cheng e,
a
Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan
b
Department of Psychiatry, Faculty of Medicine, and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Taiwan
c
Department of Psychology, College of Humanities and Social Science, Kaohsiung Medical University, Taiwan
d
Department of Psychiatry, Tainan Municipal Hospital, Taiwan
e
Department of Psychology, National Cheng Kung University, Taiwan

Abstract

Background: This study aimed to examine the mediating effects of depression and anxiety on the relationships of bullying victimization and
perpetration with pain among adolescents in Taiwan.
Method: A total of 4976 students of junior and senior high schools completed the questionnaires. Bullying victimization and perpetration,
pain problems, depression, and anxiety were assessed. The mediating effects of depression and anxiety on the relationship between bullying
involvement and pain problems and the moderating effects of sex on the medicating roles of depression and anxiety were examined by
structural equation model.
Results: Both depression and anxiety were significant mediators of the relationship between bullying victimization and pain problems among
adolescents. Depression was also a significant mediator of the relationship between bullying perpetration and pain problems among
adolescents. Sex had no moderating effect on the mediating role of depression/anxiety on the association between bullying involvement and
pain problems.
Conclusions: Medical and educational professionals should survey and intervene in depression and anxiety when managing pain problems
among adolescents involved in bullying.
2014 Elsevier Inc. All rights reserved.

1. Introduction
Victimization of bullying is one of the most traumatic
experiences for youths. Meta-analyses of previous studies in
children and adolescents have found that a significant
association of bullying victimization exists not only with
internalizing [1] and externalizing problems [2] but also with
psychosomatic problems [3]. Pain is one of the psychosomatic
problems that have been frequently examined among victims
of bullying. A 6-month cohort study on children in the
Netherlands found that victims of bullying had a significantly
higher chance of developing new abdominal pain than those
not involved in bullying [4]. A significant association between
victimization and pain was not only found in Western youths
Correspondence to: H.-F. Hu, Department of Psychiatry, Tainan
Municipal Hospital, 670 Chongde Road, East District, Tainan 701, Taiwan.
Tel.: +886 6 2609926886; fax: +886 6 2606351.
E-mail addresses: cych07205@gmail.com (H.-F. Hu),
cpcheng.psy@gmail.com (C.-P. Cheng).
1
Dr. C.F. Yen and Dr. I.M. Lin contributed equally to this study.
http://dx.doi.org/10.1016/j.comppsych.2014.05.006
0010-440X/ 2014 Elsevier Inc. All rights reserved.
[4] but also in non-Western youths [5,6]. These findings stress
the importance for clinicians and health practitioners to
establish whether bullying victimization plays a contributing
role in the etiology of pain symptoms [4].
Compared with bullying victimization, the relationship of
bullying perpetration with pain has been examined less in
previous studies. Meanwhile, the results of previous studies
were mixed. Some studies found that bullying perpetrators
were more likely to report headache, neck and shoulder pain,
stomachache, or backache than those who did not perpetrate
bullying [710], whereas some studies did not find a
significant association between bullying perpetration and
pain symptoms [11,12]. Bullying perpetrators have been
found to have poor mental health [13,14]. Whether or not
pain is a significant psychosomatic problem among bullying
perpetrators as it is among victims requires further study.
How the relationship between bullying involvement and
pain develops is still unknown. One of possible mechanisms
is that physical bullying may directly result in victims'
physical pain symptoms. However, this direct mechanism
1416 C.-F. Yen et al. / Comprehensive Psychiatry 55 (2014) 14151421
cannot be applied to victims of non-physical bullying and
perpetrators of bullying. There may be factors that mediate
the relationship between bullying victimization and perpe-
tration and pain. Emotional problems are the factors that
have strong potentials to mediate the association between
bullying victimization and perpetration and pain because of
several reasons described below. First, research has found
that both youths who are bullied [15,16] and those who bully
others [14,17] have significantly greater risks of depression
and anxiety than those who are not involved in bullying.
Second, significant associations of depression and anxiety
with pain were found [18]. Third, based on the transactional
model of coping [19], experiencing bullying victimization is
an event with potential stress, and those who experience
bullying victimization may use primary appraisal to evaluate
whether this event is harmful, threatening, or challenging.
Then, in secondary appraisal, victims evaluate whether their
own coping abilities and resources are sufficient to overcome
the harm, threat, or challenge. If the victims evaluate their
coping abilities and resources as insufficient, they may
develop physiological (such as physical symptoms), cognitive
(such as a negative attitude toward themselves), emotional
(such as depression and anxiety), and behavioral (such as
avoidance) responses to bullying. Given that there are
significant associations among bullying involvement, depres-
sion, anxiety, and pain, it is reasonable to hypothesize that
depression and anxiety may mediate the relationship between
bullying involvement and pain. However, based on our best
knowledge, there has been no study examining this hypothesis.
If depression and anxiety are mediators of the relationship
between bullying involvement and pain among adolescents,
depression and anxiety should be targets of intervention when
clinical and educational professionals try to help those who are
involved in bullying to manage pain problems.
Sex differences in the relationship between bullying
involvement and pain among adolescents and the mediating
effects of depression and anxiety are other issues that need
further study. Although sex differences have been found in the
prevalence of bullying involvement [20], depression [21],
anxiety [22], and pain symptoms [23] among adolescents, sex
difference in the relationship between bullying involvement
and pain among adolescents has seldom been examined, and
the results of limited studies were mixed. A previous study
found that being bullied had a strong relationship with the
development of abdominal pain in girls, whereas there was no
such relationship in boys [4]. Another study found that the
associations of bullying victimization with headache and
backache were stronger in boys than in girls [11]. However,
one study found that the significant association between
bullying victimization and poor physical health was similar in
both sexes [24]. Meanwhile, if depression and anxiety mediate
the relationship between bullying involvement and pain,
whether sex has a moderating effect on the mediating roles of
depression and anxiety needs further study. If there are sex
differences in the relationship between bullying involvement
and pain and in the mediating roles of depression and anxiety,
clinical and educational professionals must take sex differ-
ences into consideration when helping adolescents who are
involved in bullying to manage pain problems.
The aims of this study were to examine the mediating
effects of depression and anxiety on the relationships of
bullying victimization and perpetration with pain problems
among adolescents in Taiwan. This study also aimed to
examine the moderating roles of sex in the relationships of
bullying victimization and perpetration with pain problems
and the mediating effects of depression and anxiety on the
relationships. We hypothesized that both bullying victimi-
zation and perpetration are significantly associated with pain
problems by the mediation of depression and anxiety. We
also hypothesized that sex has a moderating effect on the
relationship between bullying involvement and pain prob-
lems and on the mediating effects of depression and anxiety.
2. Methods
2.1. Participants
This study was based on data from the 2009 Project for the
Health of Children and Adolescents in Southern Taiwan,
which was a mental health research survey of adolescents in
grades 7 through 12 (age 12 to 18) [22]. This health survey
project recruited adolescent students from three metropolitan
areas and four counties in southern Taiwan. On the basis of the
definitions of rural and urban districts in the TaiwanFukien
Demographic Fact Book [25] and based on school and grade
characteristics, a stratified random sampling strategy was used
to ensure that there was proportional representation of districts,
schools, and grades. In 2009, there were 202,883 students in 143
senior high/vocational schools and 254,130 students in 205 junior
high schools in this area. Five junior high schools and four senior
high/vocational schools were randomly selected from rural
districts; similarly, five senior high/vocational schools and five
junior high schools were randomly selected from urban districts.
The classes in these schools were further stratified into three levels
based on grade in primary, junior high, and senior high/vocational
schools. Then, a total of 6703 high school students were randomly
selected based on the ratio of students in each grade.
The institutional review board of Kaohsiung Medical
University agreed to the use of passive consent from parents
and students. Before conducting the study, we prepared a leaflet
explaining the purpose and procedures of the study. Students took
the leaflet home to their parents or main caretakers, who could
telephone the researchers, write in a communication book, or ask
their children directly to refuse to join the study. The students also
had the right to refuse to participate in this study by returning
blank questionnaires along with those from other students.
2.2. Instruments
2.2.1. Chinese version of the School Bullying Experience
Questionnaire (C-SBEQ)
The self-reported C-SBEQ was used to evaluate partici-
pants' involvement in school bullying in the previous 1 year.
 C.-F. Yen et al. / Comprehensive Psychiatry 55 (2014) 14151421
Depression
Bullying victimization
or perpetration
Anxiety
Sex
Fig. 1. Hypothesized model of the associations among bullying involvement, depression, anxiety, and pain problems in adolescents.
The 16 items on the C-SBEQ were rated on a Likert 4-point
scale, with scores ranging from 0 (never) to 3 (all the time)
[26]. Items 1 to 8 on this scale evaluate the severity of bullying
victimization, including social exclusion, being called a mean
nickname, being spoken ill of, being beaten up, being forced to
do work, and having money, school supplies, and snacks taken
away. Items 9 to 16 evaluate the severity of bullying
perpetration. Higher total scores of items 1 to 8 and items 9 to
16 indicate more severe levels of bullying victimization and
perpetration, respectively. A previous study found that the test
retest and internal reliability values of all subscales of the C-
SBEQ and their congruent validity with bullying involvement
nominated by classmates and teachers were satisfactory [27].
2.2.2. Pain Subscale of the Taiwanese Quality of Life
Questionnaire for Adolescents (TQOLQA)
In this study the three items on the Pain Subscale of the
self-administered TQOLQA were applied to measure pain
problems over the preceding 2 weeks [28], including Do
you worry about pain? Do you have any difficulty in
managing or coping with pain? and Does your pain
interfere with things you need to do? Each item is rated on a
5-point Likert scale, with scores ranging from 1 (not at all) to
5 (very much). A higher total score indicates more severe
pain problems. Cronbach's coefficient was .77 for the Pain
Subscale [28].
2.2.3. Mandarin Chinese version of the Center for
Epidemiological Studies-Depression Scale (MC-CES-D)
The 20-item MC-CES-D is a self-administered 4-point
evaluation scale assessing the frequencies of depressive
symptoms in the preceding week, with scores ranging from 0
(none or very few) to 3 (always) [29,30]. Higher CES-D
scores indicate more severe depression. The psychometrics
of the MC-CES-D for assessing depressive symptoms
among nonreferred adolescents in Taiwan were examined
in a previous study [31]. The internal consistency (Cronbach's
alpha) of the MC-CES-D in the present study was 0.94.
1417
Pain problems
2.2.4. Taiwanese version of the Multidimensional Anxiety
Scale for Children (MASC-T)
The MASC-T evaluates the level of anxiety symptoms in
adolescents, with 39 items answered on a Likert 4-point scale,
with scores ranging from 0 (never true) to 3 (often true)
[32,33]. Higher scores on the total MASC-T indicate more
severe anxiety symptoms. The psychometrics of the MASC-T
were examined in a community sample of 12,536 Taiwanese
children and adolescents across gender and age and the results
have been described elsewhere [33]. The internal consistency
(Cronbach's alpha) of the MASC-T in the present study was
0.89. Because one item on the MASC-T inquired about
participants' pain feeling, we excluded this item and summed
the scores of the other 38 items for analysis.
2.3. Procedure and statistical analysis
A total of 6445 students (96.2%) agreed to join this study.
Of the 258 students who refused to join this study, 68 students
refused based on their parents' opinion, 128 returned blank
questionnaires, and 62 were absent when the research assis-
tants visited their classes. Each participant completed the
research questionnaire anonymously under the direction of
research assistants in each classroom during school hours.
All students received a gift worth NT$33 (1 US dollar) at the
end of the assessment.
The hypothesized model of the associations among bullying
involvement (victimization and perpetration), depression,
anxiety, and pain problems in adolescents is shown in Fig. 1.
The mediating effects of depression/anxiety on the associations
between bullying involvement and pain problems were tested
by the multiple-group structural equation model (SEM) in girls
and in boys separately, and age was also included as a covariate.
The moderating effects of sex on the three paths from bullying
involvement to pain problems were tested by chi-squared of
SEM between main effect models with and without a
moderating term (sex). The main effects of sex on bullying
involvement, depression, anxiety, and pain problems were also
tested by chi-squared of SEM.
1418 C.-F. Yen et al. / Comprehensive Psychiatry 55 (2014) 14151421
Table 1
Mediating effects of depression and anxiety on the paths from bullying victimization and perpetration to pain: structural equation model. a
Bullying involvement Depression
(BI)
BI Depression
Beta t Beta
Girls
Victimization 0.37 15.79
Perpetration 0.07 2.99
Boys
Victimization 0.36 14.25
Perpetration 0.12 4.63
3. Results
3.1. Characteristics of the participants
A total of 4976 participants (77.2%) completed the
research questionnaires without omission. Male participants
(n = 653, 54.1%) were more likely to have missing data in
the questionnaires than females (n = 553, 45.9%, 2 =
22.96, p b 0.001). Those who had missing data in the
questionnaires were younger than those who had no missing
data (14.36 1.80 years vs. 14.89 1.80 years, t = 9.17,
p b 0.001). Among those who completed the research
questionnaires without omission, 3894 (78.3%) and 3922
(78.8%) participants reported any experience of bullying
victimization and perpetration on the on the C-SBEQ.
respectively. Among the participants reporting experience
of bullying victimization, 2140 participants (55.0%) were
girls and 1754 (45.0%) were boys. Their mean age (standard
deviation [SD]) was 14.9 years (1.8 years). Their severities
of bullying victimization, depression, anxiety, and pain
were 3.5 (2.5), 16.7 (9.8), 40.3 (15.0), and 4.5 (2.0),
respectively. Among the participants reporting experience
of bullying perpetration, 2109 participants (53.8%) were
girls and 1813 (46.2%) were boys. Their mean age (standard
deviation [SD]) was 14.9 years (1.8 years). Their severities
of bullying perpetration, depression, anxiety, and pain were
3.3 (2.4), 16.1 (9.7), 39.3 (15.0), and 4.4 (2.0), respectively.
3.1.1. Relationship between bullying involvement and pain
problems and the mediating effects of depression and anxiety
The results of examining the mediating effects of
depression/anxiety on the relationship between bullying
involvement and pain problems by SEM are shown in
Table 1. The results indicated that in both girls and boys, severe
bullying victimization and perpetration were significantly
associated with severe depression, and severe depression
was significantly associated with severe pain problems.
Depression mediated the relationships of both bullying
victimization and perpetration with pain problems in both
girls and boys.
The results of SEM also indicated that in both girls and
boys, severe bullying victimization was significantly associ-
ated with severe anxiety, and severe anxiety was significantly
Depression Pain BI Depression Pain
t Beta t
0.14 5.44 .05 5.14
0.14 5.44 .01 2.62
0.09 3.26 .03 3.18
0.09 3.26 .01 2.67
associated with severe pain problems. Anxiety mediated the
relationship between bullying victimization and pain problems
in both girls and boys. However, severe bullying perpetration
was not significantly associated with severe anxiety, and the
mediating role of anxiety in the relationship between bullying
perpetration and pain problems was not supported (Table 1).
After controlling for the effects of depression and anxiety, the
relationships between bullying involvement and pain were not
significant, indicating that the paths from bullying victimization
to pain problems in girls and boys were completely mediated by
depression and anxiety. It also indicated that the paths from
bullying perpetration to pain problems in girls and boys were
completely mediated by depression. The final models of the
associations among bullying victimization and perpetration,
depression, anxiety, and pain problems are shown in Fig. 2.
The moderating effects of sex on the mediating effects of
depression and anxiety were further examined (Table 2).
The results of SEM did not support that sex had a
moderating effect on the mediating role of depression and
anxiety in the associations of bullying victimization and
perpetration with pain problems. However, sex differences
were significant in bullying victimization, perpetration, and
anxiety (Table 3), which indicated that sex difference should
be considered when approaching bullying involvement and
related mood problems.
4. Discussion
The first important finding of this study was that both
depression and anxiety are significant mediators of the
relationship between bullying victimization and pain prob-
lems among adolescents. The Transactional Model of
Coping [19] can contribute to the understanding of the
relationships among bullying involvement, depression and
anxiety, and pain problems [34]. Based on the Transactional
Model of Coping [19], both depression/anxiety and pain
problems might be common stress responses to bullying
when victims evaluate their coping abilities and resources as
insufficient. Meanwhile, depression/anxiety might be a new
stress event that bullying victims could not effectively
manage, and thus further pain problems develop. Another
 C.-F. Yen et al. / Comprehensive Psychiatry 55 (2014) 14151421 1419

Table 1
Mediating effects of depression and anxiety on the paths from bullying victimization and perpetration to pain: structural equation model a
Anxiety
BI Anxiety Anxiety Pain BI Anxiety Pain BI Pain
Beta t Beta t Beta t Beta t

0.27 11.16 0.41 17.22 .11 9.36 0.05 1.86

0.01 0.39 0.41 17.22 .00 0.39 0.04 1.65

0.31 11.58 0.47 19.01 .16 9.89 0.00 0.17

0.04 1.58 0.47 19.01 .02 1.58 0.01 0.40

possible explanation is that bullying victims with a higher
severity of depression/anxiety reaction may have a higher
level of sensitivity to pain [35]. It is also noteworthy that the
measurement of pain problems used in this study may
contribute to the mediating effects of depression/anxiety.
Difficulty in managing or coping with pain was one
component of pain problems measured in this study.
Depression and anxiety may increase adolescents' difficulty
in managing or coping with pain, which partially accounts
for the association between depression/anxiety and pain
problems [36]. This study also measured the worry about
pain. The similarity shared by worry and anxiety may
increase the predictive value of anxiety for pain problems.
This study also found that depression is a significant
mediator of the relationship between bullying perpetration
and pain problems among adolescents. Research has found
that children who habitually bully are significantly more
likely to experience high levels of depression [14] and
suicidal ideation [37]. It has been hypothesized that the
psychological effects of having engaged repeatedly in
unjustifiable acts of aggressiveness against less powerful
individuals result in depression among bullying perpetrators
[36]. It is also possible that both aggressive behaviors and
depression are secondary to a chaotic lifestyle, adverse
psychosocial environments and family background [38].
Depression may further increase individuals' sensitivity to
pain [35] or difficulty in coping with pain [36]. The results of
this study did not find a significant association between
bullying perpetration and anxiety. Meanwhile, bullying
perpetration had no significant direct or indirect association
with pain problems. This raises the possibility that bullying
perpetrators have a lower physical arousal to pain than non-
perpetrators. A previous study found that bullying perpetra-
tors have a lower level of harm avoidance than non-
perpetrators [39]. Further study is needed to examine
whether low physical arousal to pain and low harm
avoidance account for the tendency of bullying perpetration
in adolescents.
Given that there are sex differences in bullying involve-
ment [20], depression [21], anxiety [22], and pain symptoms
[23] among adolescents, one might hypothesize that sex may
play a moderating role on the medicating effects of
depression/anxiety on the relationship between bullying
involvement and pain among adolescents. However, the

a Depression

Bullying victimization Pain problems

Anxiety

b Depression

Bullying perpetration Pain problems

Fig. 2. Final models of the associations among bullying victimization (a) and perpetration (b), depression, anxiety, and pain problems in adolescents.
1420 C.-F. Yen et al. / Comprehensive Psychiatry 55 (2014) 14151421
Table 2
Moderating effects of sex on the paths from bullying victimization and perpetration to pain and on the mediating effects of depression and anxiety: structural
equation model. a
Bullying
involvement
BI Pain, chi-squared BI Depression Pain, chi-squared
(BI)
Victimization 2.80 3.02
Perpetration .98 .09
BI: bullying involvement.
a
Controlling for the effect of age in all analyses. All effects are nonsignificant.
present study did not support the hypothesis. Although sex
did not moderate the mediating effects of depression/anxiety,
sex differences were significant in bullying victimization,
perpetration, and anxiety in the present study, which further
support that adolescent health problems are related to
different social contexts for boys and girls [40].
The results of this study have several important
implications. Clinical and educational professionals should
provide programs to prevent the development of bullying, as
well as psychological intervention programs to improve
depression and anxiety among adolescents involved in
bullying. Clinical and educational professionals should be
aware of the possibility that youths may be involved in
bullying when pain complaints are presented. Meanwhile,
clinical and educational professionals should take depression
and anxiety into consideration and provide psychological
and pharmacological interventions to improve depression
and anxiety.
This study is one of the first to examine the mediating
effects of depression and anxiety on the relationship of
bullying victimization and perpetration with pain problems
and the moderating effects of sex among adolescents.
However, there were several limitations of our investigation
that deserve attention. First, the cross-sectional research
design of this study limited our ability to draw conclusions
regarding the causal relationships between bullying involve-
ment, depression/anxiety, and pain problems. Second, the
data were provided by the adolescents themselves, and
further study applying other sources of information or
measurement is needed to replicate the results of this study.
Meanwhile, the problem of shared-method variance resulted
from the sole information source requires careful consider-
ation. Third, this study did not inquire as to specific types of
Table 3
Main effects of sex on bullying victimization, perpetration, depression, anxiety and pain: structural equation model. a
Victimization Perpetration
Girls 17.90 43.16
Boys 15.82 37.31
Chi-squared 16.90 67.65
a
Controlling for the effect of age in all analyses.
b
Controlling for the effect of bullying involvement.
c
Controlling for the effects of bullying involvement, depression and anxiety.
p b .001.
Moderating effect of sex
BI Anxiety Pain, chi-squared
1.04
.72
pain symptoms, such as abdomen pain, headache, and
muscle pain. Whether bullying involvement has different
relationships with different types of pain symptoms needs
further study. However, this study not only examined general
pain feeling but also examined participants' difficulty in
coping with pain and interference with daily activity. The
evaluation of pain symptoms in this study could provide a
comprehensive understanding toward adolescents' pain
problems. Lastly, the time span is various among the
measuring scales. For example, the C-SBEQ measured
bullying experience during the last year, whereas pain
problems, depression, and anxiety symptoms were assessed
during recent 2 weeks, 1 week and 1 month, respectively.
The discrepancy of time span among the measurements may
lessen the inference among bullying experience, depression/
anxiety, and pain problems.
5. Conclusion
This study found that depression and anxiety mediated the
relationship between bullying involvement and pain prob-
lems. When managing pain problems among adolescents
involved in bullying, clinical and educational professionals
should take depression and anxiety into consideration and
provide psychological and pharmacological interventions to
improve depression and anxiety.
Acknowledgment
This study was partially supported by grants NSC 98-
2410-H-037-005-MY3 and 99-2314-B-037-028-MY2
awarded by the National Science Council, Taiwan (ROC)
Mean
Depression Anxiety Pain
3.41 3.07 14.89
3.77 3.78 14.91
1.72 b 22.26 b 1.64 c
 C.-F. Yen et al. / Comprehensive Psychiatry 55 (2014) 14151421
and grant KMUH 100-0R48 awarded by Kaohsiung Medical
University Hospital.
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