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Body image, personality profiles and alexithymia in patients with polycystic ovary syndrome (PCOS)
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DOI:10.1080/0167482X.2018.1530210
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BODY IMAGE, PERSONALITY PROFILES, AND ALEXITHYMIA IN 1
PATIENTS WITH POLYCYSTIC OVARY SYNDROME (PCOS) 2
3
Elisabetta Scaruffi, Isabella Giulia Franzoi, Cristina Civilotti, Fanny Guglielmucci,
4
Luana La Marca, Michela Tomelini, Fabio Veglia, Antonella Granieri
5 6 7
Elisabetta Scaruffi
8
Edo ed Elvo Tempia Valenta Foundation
9
Via Malta 3, 13900 Biella - Italy
10
+39 3497840915; elisabetta.scaruffi@libero.it
11
Psychologist, Psychotherapist, Specialized in Developmental Psychology
12 13
Isabella Giulia Franzoi
14
Department of Psychology, University of Turin
15
Via Po 14, 10123 Turin - Italy
16
+39 011 670 3062; isabellagiulia.franzoi@unito.it
17
Psychologist, Psychotherapist, Specialized in Clinical Psychology (D.Clin.Psy)
18
PhD student in Psychological, Anthropological and Educational Sciences (University
19 of Turin) 20 21 Cristina Civilotti 22
Department of Psychology, University of Turin
23
Via Po 14, 10123 Turin - Italy
24
+39 011 6703073; cristina.civilotti@unito.it
25
PhD, psychologist, psychotherapist. Contract professor at the University of Study of
26
Turin and the SSF Rebaudengo (Turin) affiliated with the Faculty of Educational
27
Sciences of the Salesian Pontifical University.
28 29
Fanny Guglielmucci
30
Department of Psychology, University of Turin
31
Via Po 14, 10123 Turin - Italy
+39 011 670 3062; fanny.guglielmucci@unito.it
33
Psychologist, Psychotherapist, Specialized in Clinical Psychology (D.Clin.Psy)
34
PhD student in Psychological, Anthropological and Educational Sciences (University
35 of Turin) 36 37 Luana La Marca 38
Faculty of Human Sciences, UKE – Kore University of Enna
39
Cittadella Universitaria, SN/R14, 94100 Enna – Italy
40
+39 325 222 4343; luana.lamarca1@gmail.com
41
Psychologist, PhD student in Social Inclusion in Multicultural Context (UKE – Kore
42 University of Enna) 43 44 Michela Tomelini 45
Department of Medical Sciences, Division of Endocrinology and Metabolism,
46
University of Turin
47
Corso Trapani 4, 10139 Turin – Italy
48
+39 339 178 64 599; michela.tomelini@unito.it
49
Specialized in Endocrinology and Metabolic Diseases
50 PhD in Medical Physiopathology 51 52 Fabio Veglia 53
Department of Psychology, University of Turin
54
Via Po 14, 10123 Turin - Italy
55
+39 011 6703073; fabio.veglia@unito.it
56
PhD, psychologist, psychotherapist. Full Professor at the University of Turin.
57
Director of the Cognitive Psychotherapy School of Turin and the Mastery
58
Interaction Development Institute of Novara.
59 60
Antonella Granieri
61
Department of Psychology, University of Turin
62
Via Po 14, 10123 Turin - Italy
63
+39 011 670 3062
antonella.granieri@unito.it
65
Psychologist, Psychotherapist, Specialized in Clinical Psychology (D.Clin.Psy)
66
Full Member of the Italian Psychoanalytic Association and of the International
67
Psychoanalytical Association
68
Associate Professor in Clinical Psychology, Past Director of the Post Graduate
69
School in Clinical Psychology (Department of Psychology, University of Turin)
70 71
Corresponding Author 72
Isabella Giulia Franzoi
73 Department of Psychology 74 University of Turin 75 via Po 14 76 10123, Turin – Italy 77 isabellagiulia.franzoi@unito.it 78 ORCID ID: 0000-0002-2455-330X 79 80 Abstract 81
Aim: Polycystic ovary syndrome (PCOS) is a common endocrine-metabolic disorder.
82
It affects women’s physical well-being and leads to great psychological distress.
83
Indeed, women with PCOS show a compromised quality of life as well as impaired
84
emotional well-being. The aim of the present study is to assess personality
85
characteristics, body image, and alexithymia in women with PCOS. Materials and
86
Methods: 59 women with PCOS and 38 healthy controls were administered the
87
Toronto Alexithymia Scale, the Body Uneasiness Test, and the Minnesota
88
Multiphasic Personality Inventory-2. Results: The PCOS group showed higher values
89
of alexithymia and a higher body uneasiness. They also showed higher values on
90
many Clinical, Content, and Supplementary scales of the Minnesota Multiphasic
91
Personality Inventory-2. Discussion: It seems that physical appearance and bodily
92
function have a central place in the minds of women with PCOS, as well as in their
93
relationships. However, it is a body they find it hard to feel and with which they
94
mostly feel uncomfortable. Their approach to the outside world seems to be
95
characterized by a certain degree of immaturity, anger, hostility, and distrust. Low
self-esteem also seems to be connected to a certain tendency toward introversion and
97
withdrawal. This leads to problems in social, professional, and intimate relationships.
98 99
Keywords: Polycystic ovary syndrome, Personality, Alexithymia, Body Image, 100
MMPI-2
101 102 103
1. Introduction 104
Polycystic ovary syndrome (PCOS) is a common endocrine-metabolic disorder
105
affecting reproductive-age women. Its estimated prevalence ranges from 5% to 10%
106
of adult female population [1-3], but can be up to 20% depending on the diagnostic
107
criteria used [4]. The National Institute of Health criteria include only
108
hyperandrogenism and anovulation [5], whereas the Rotterdam consensus workshop
109
of the European Society for Human Reproduction and Embryology/American
110
Society for Reproductive Medicine added as a third criterion the ultrasonographic
111
evidence of polycystic ovaries, stating that any 2 of the 3 criteria are sufficient for
112
diagnosis [6]. This leads to an increased prevalence of the syndrome [7].
113
Symptoms include anovulation, irregular menstrual cycles, micropolycystic
114
ovaries and clinical and/or biochemical hyperandrogenism (e.g., hirsutism, acne,
115
alopecia) [8-10]. PCOS is also associated with obesity, and it is the leading cause of
116
female infertility [11]. Long-term health risks associated with PCOS include type 2
117
diabetes [12,13], uterine and endometrial cancer [14,15], irritable bowel syndrome
118
[16], thyroid disorders [17,18], and metabolic disturbances (i.e., cardiovascular disease
119
[19], dyslipidemia, and hypertension [15,20]).
120
The causes of PCOS are still unknown, although some studies suggest that a
121
combination of insulin resistance and an increase in androgens contribute to its
122
development [21], as well as genetics [22,23].
123
PCOS affects women’s physical well-being and leads to great psychological
124
distress, compromising their quality of life [24-26]. It was found to be co-morbid
125
with several mental disorders (Table 1). Depending on the disorder and the criteria
126
used for the assessment, its comorbidity with mood disorders ranges from 18.2% to
127
81%, while its comorbidity with anxiety disorders ranges from 2.8% to 35.7%
[27-128
34]. Women with PCOS not only seem to be more depressed than controls, but their
129
level of depression tends to be more severe [31-33]. Studies have shown that PCOS
130
seems to be comorbid with other mental disorders such as bipolar and posttraumatic
131
stress disorders, somatization, and obsessive–compulsive functioning [35,36].
132
Moreover, women with PCOS are approximately twice as likely to be hospitalized for
133
stress, anxiety, depression, illicit drug use, and self-harm behaviors [37].
The low level of quality of life in women with PCOS has been related to
135
anxiety and depression. However, it is difficult to determine whether depression
136
and/or anxiety influence lower perceived quality of life or whether poor perception
137
of quality of life increases depression and/or anxiety [27].
138
It has also been suggested that PCOS symptoms contribute to decreasing
139
women’s quality of life [38,39]. Hirsutism, acne, and obesity deeply undermine
140
women’s self-esteem, self-image, and self-worth due to a lower perception of the
141
feminine identity, with a great impact on their social life as well as intimate and sexual
142
relationships [40-42]. Body image is also compromised by infertility and sterility, and
143
the pressure that women with PCOS feel to have children early in life has been
144
identified as an additional source of stress [33,43].
145
The relationship between PCOS and psychological distress, psychiatric
146
disorders, and quality of life has been extensively studied, as well as the body image
147
of women with PCOS. However, psychological aspects such as personality,
148
attachment style, and emotion regulation are deeply understudied in relation to this
149
disorder, even though they have a great importance for the clinical management of
150
the disease.
151
Indeed, as far as we know, only two studies have explored the relationship
152
between PCOS and personality profiles: one through the Rorschach test [44] and one
153
through the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) [45],
154
underlining that patients with PCOS show higher rates of clinical elevations on
155
depression, hysteria, psychasthenia, and hypomania, as well as higher absolute scores
156
on the same scales.
157
Only one study has investigated emotion regulation strategies in women with
158
PCOS [46], and no study has investigated attachment related to this syndrome.
159
The overall rationale of our study was to assess (1a) personality
160
characteristics, (1b) emotional awareness, (1c) emotion regulation strategies, (1d)
161
attachment, and (1e) body image in a group of women with PCOS by comparing
162
them to a control group of healthy women. At the same time, we wanted to explore
163
(2a) whether psychological variables such as attachment, emotion dysregulation and
164
body uneasiness were associated with an impaired quality of life, and (2b) whether
165
such associations differ in women with PCOS and in the controls.
We hypothesized that compared to controls, women with PCOS are
167
characterized by (1a) more dysfunctional personality characteristics, (1b) lower
168
emotional awareness, (1c) more dysfunctional emotion regulation strategies, (1d)
169
more insecure attachment, and (1e) worse body image. We also hypothesized that
170
(2a) emotion dysregulation, insecure attachment, and body uneasiness are connected
171
to a lower quality of life, and that (2b) the association between quality of life and
172
psychological variables differs between women with PCOS and in the controls, with
173
a stronger association between physical quality of life, emotion dysregulation, and
174
insecure attachment in women with PCOS than in the controls.
175
Since the study has taken into account a number of different variables
176
concerning psychological functioning in women with PCOS, in the present paper we
177
would like to focus on hypotheses 1a, 1b, and 1e. Results concerning our other
178
hypotheses are presented elsewhere [47].
179 180
2. Materials and Methods 181
2.1 Participants 182
We progressively enrolled a convenience sample of 59 outpatients at the two
183
gynecological endocrinology services of the University Hospital Città della Scienza e
184
della Salute in Turin. Inclusion criteria for PCOS patients were defined according to
185
the revised criteria of the Rotterdam Consensus Workshop [6]. As stated before,
186
these criteria require 2 out of 3 between oligo- and/or anovulation, clinical and/or
187
biochemical signs of hyperandrogenism and polycystic ovaries, with the exclusion of
188
other etiologies. Oligomenorrhoea was defined as an interval between two
189
menstruations of at least 35 days, whereas amenorrhoea was defined as the absence
190
of vaginal bleeding for at least 3 months. Data on menstrual patterns were
self-191
reported. Clinical hyperandrogenism was defined as the presence of hirsutism
192
(Ferriman-Gallwey total score > 5), acne, and/or androgenic alopecia. Biochemical
193
hyperandrogenism was determined by total testosterone, dehydroepiandrosterone
194
(DHEAS), and sex hormone-binding globulin (SHBG) on fasting blood samples.
195
Women with other causes of androgen excess or related disorders, such as congenital
196
adrenal hyperplasia, Cushing syndrome, or an androgen-secreting tumor were
197
excluded. All the patients underwent a transvaginal ultrasonography to assess ovarian
morphology. Polycystic ovarian morphology was diagnosed according to the
199
presence of 12 or more follicles in each ovary measuring 2–9 mm in diameter and/or
200
the presence of increased ovarian volume (>10 ml) in 1 or both ovaries [48].
201
The control group of 38 healthy age-matched women was enrolled through local
202
general practitioners. Inclusion criteria for the control group were (1) absence of
203
severe gynecological diseases and (2) history of a regular menstrual cycle.
204
Exclusion criteria for both the PCOS and the control groups were (1) having a poor
205
knowledge of the Italian language, (2) having a certified psychiatric diagnosis, (3)
206
having a certified diagnosis of a neurogenerative disease (i.e., Alzheimer disease,
207
Parkinson disease, etc.), (4) having a certified medical disease,(5) being pregnant, (6)
208
having been in psychiatric or psychological therapy in the last 6 months. Criterion 1
209
was set in order to ensure a correct understanding of the questionnaires; Criteria 2-6
210
were set in order to exclude the influence of other psychological, neurological, or
211
physical variables on our data.
212 213
2.2 Ethical approval 214
The study protocol was approved by the Hospital Ethical Committee. All
215
participants were given a complete description of the study and gave informed
216
written consent before entering the study. All research procedures were conducted in
217
accordance with the ethical standards of the committees responsible for human
218
experimentation (institutional and national) and with the Helsinki Declaration of
219 1975, as revised in 2000. 220 221 2.3 Measures 222
This research is part of a wider study aimed at assessing psychological variables in
223
women with PCOS compared to a control group [47]. The complete study included
224
the administration of the Short-Form Health Survey (SF-36), the Attachment Style
225
Questionnaire (ASQ), the Difficulties in Emotion Regulation Scale (DERS), the
226
Toronto Alexithymia Scale (TAS-20), the Body Uneasiness Test (BUT), and the
227
MMPI-2.
228
The administration was conducted at the clinic in the presence of a
229
psychologist. Because of the number of measures and the number of items in the
MMPI-2, the questionnaires were completed in two sessions: one in which the
231
MMPI-2 were administered, and one for the other measures. Half of the sample
232
completed the MMPI-2 in the first session, and the other half in the second one. The
233
average time to completion was 84 minutes for the MMPI-2 (range 53-101 minutes)
234
and 46 minutes for the other questionnaires (range 23-65 minutes).
235
For the purposes of the present research, we consider only the scores
236
obtained from the TAS-20, the BUT and the MMPI-2.
237
The TAS-20 [49,50] is a frequently used 20-item self-reported measure of
238
alexithymia. The psychometric properties of the scale have been validated across
239
cultures. A score of ≥61 is considered to be indicative of alexithymia, whereas scores
240
between 51 and 60 indicate borderline alexithymia. It has a 3-factor structure:
241
Difficulty in Identifying Feelings DIF); Difficulty in Describing Feelings
(TAS-242
DDF), and Externally Oriented Thinking (TAS-EOT). Cronbach’s alpha coefficients
243
were .89 for TAS-DIF, .83 for TAS-DDF, and .81 for TAS-EOT.
244
The BUT [51] is a 71-item self-administered questionnaire for the clinical
245
assessment of body image disorders and related psychopathologies. It consists of 2
246
different scales: the BUT-A is a 34-item scale assessing body shape, weight
247
dissatisfaction, avoidance, compulsive control behaviors, detachment, and
248
estrangement feelings towards one’s own body; the BUT-B is a 37-item scale
249
assessing specific worries about particular body parts, shapes, or functions such as
250
buttocks, odor, blushing. For the purpose of this study, analyses were performed on
251
the Global Severity Index (BUT-GSI), which is computed as the average of the
252
scores observed on the 34 items comprising the BUT-A section, and the Positive
253
Symptom Total Index (BUT-PST), which represents the total number of BUT-B
254
items rated higher than zero. In this study, the internal consistency reliability
255
coefficients were .91 for the BUT-A and .88 for the BUT-B.
256
The MMPI-2 [52,53] is a standardized psycho-diagnostic instrument that
257
consists in 567 dichotomous questions (true or false) designed to provide
258
psychopathological information in different scales: 3 Validity Scales, 10 Clinical
259
Scales, 16 Supplementary Scales, and 15 Content Scales. The results on the MMPI-2
260
test are expressed in standardized t scores. Thus, a scale score is considered indicative
261
of psychological dysfunction when the t value is ≥65. We dichotomously classified
each individual in terms of whether or not each scale was in the clinically elevated
263
range. The internal consistency reliability coefficients in our sample ranged between
264
.23 and .91 for the Clinical Scales (Masculinity/Femininity vs Social Introversion);
265
between .72 and .88 for the Content Scales (Type A vs Depression), and between .65
266
and .91 for the Supplementary Scales (Addiction Potential Scale vs Posttraumatic
267 Stress Disorder). 268 269 2.4 Statistical Analyses 270
All statistical analyses were conducted using the Statistical Package for the Social
271
Sciences (IBM Corp., Armonk, NY, USA) version 24. All tests were 2-tailed, and we
272
set the statistical significance at p ≤ 0.05. We performed descriptive statistics to
273
describe demographic and clinical features in the two samples. The existence of
274
mean differences across the PCOS and control groups on the demographic and
275
clinical data was investigated using t tests and Pearson Chi-squares.
276 277
3. Results 278
Descriptive statistics for the demographic and clinical data for the PCOS and the
279
Control groups are reported in Table 2. As expected, women with PCOS show a
280
higher mean value on Body Mass Index (BMI; p ≤ 0.000).
281
Tables 3 to 5 present the clinical data for the PCOS and the control groups.
282
Concerning the TAS-20 (Table 3), the PCOS group shows higher values than the
283
control group on the Difficulty in Identifying Feelings scale ( p = 0.025) and in the
284
Total scale (p = 0.036). On the BUT (Table 4), PCOS patients show higher values
285
compared to the controls in both the Positive Symptom Total Index (p = 0.015) and
286
the Global Severity Index (p = 0.002) scales. On the MMPI-2 (Table 5), patients with
287
PCOS show significantly higher values in the Frequency Validity Scale (p ≤ 0.001)
288
and lower values in the Defensiveness Scale (p ≤ 0.011). Patients show higher values
289
in 8 out of 10 Clinical Scales: Hypochondriasis (p ≤ 0.002), Depression (p = 0.001),
290
Hysteria (p = 0.038), Psychopathic Deviation (p = 0.004), Paranoia (p = 0.011),
291
Psychasthenia (p = 0.003), Schizophrenia (p = 0.003), and Social Introversion (p =
292
0.005). On the Content Scales, women with PCOS show higher values on the
293
following scales: Anxiety (p ≤ 0.001), Fears (p = 0.017), Obsessiveness (p = 0.001),
Depression (p ≤ 0.001), Health Concerns (p ≤ 0.001), Low Self-Esteem (p = 0.001),
295
Social Discomfort (p = 0.024), Family Problems (p = 0.002), Work Interference
296
(55.92 ± 11.23 vs. 48.63 ± 8.05, p ≤ 0.001), and Negative Treatment Indicators (p =
297
0.001). On Supplementary Scales, PCOS patients show higher values on the
298
following scales: Back F (p ≤ 0.001), Posttraumatic Stress Disorder (p ≤ 0.001), and
299
Marital Distress (p ≤ 0.026).
300
As shown in Table 6, PCOS patients have significantly higher percentages of
301
clinical elevation on the following scales: Frequency (p = 0.039), Hypochondriasis (p
302
= 0.032), Depression (p = 0.008), Psychopathic Deviation (p = 0.008), Paranoia (p =
303
0.030), Schizophrenia (p = 0.005), Anxiety (p = 0.014), Depression (p = 0.003),
304
Family Problems (p = 0.046), Work Interference (p = 0.012), Posttraumatic Stress
305
Disorder (p = 0.005), and Marital Distress (p = 0.017).
306 307
4. Discussion 308
This study is part of more complex research aimed at assessing the psychological
309
characteristics of women with PCOS compared to a control group of healthy women
310
and exploring potential correlations between some of these characteristics [47].
311
However, with the number of different variables taken into account, in this paper we
312
chose to focus on the assessment of personality characteristics, emotional awareness,
313
and body image in the group of women with PCOS compared to controls. It was
314
hypothesized that women with PCOS exhibit worse body image, lower emotional
315
awareness, and more dysfunctional personality characteristics.
316
Results confirm all of our hypotheses.
317
Consistent with previous literature [1], the present study shows a higher BMI
318
in women with PCOS. Moreover, results confirm our first hypothesis, indicating that
319
PCOS patients are characterized by a higher body uneasiness than healthy controls.
320
Disease-related body appearance (e.g., obesity, hirsutism, and acne) may contribute
321
to reducing the feminine identity of patients, compromising their body image.
322
Women with PCOS tend not to see themselves as fitting social and media standards
323
for body appearance, and this can give rise to depression and impairment in their
324
emotional well-being.
Concerning our second hypothesis, a higher overall alexithymia score
326
emerged as well as a greater difficulty in identifying feelings. From a psychoanalytic
327
perspective, we can hypothesize that not only do PCOS patients feel unease with
328
their own bodies—perceived as inadequate, wrong, or somehow bad—but they also
329
struggle with the subsymbolic messages that arise from their hatred body. In other
330
words, their difficulties at a somatopsychic level seem to be connected to both the
331
looking–seeing domain and the feeling–sensing one [47]When it comes to our last
332
hypothesis, differences emerged in many scales, much more than the ones that were
333
found statistically significant in the only other study that has investigated the
334
relationship between PCOS and personality domains through the MMPI-2 [45]. We
335
found significant differences in the mean scores on Frequency (F) and Defensiveness
336
(K) Validity Scales. Among Clinical Scales, we found significant differences in the
337
mean scores of Hypochondriasis (Hs), Depression (D), Hysteria (Hy), Psychopathic
338
Deviation (Pd), Paranoia (Pa), Psychasthenia (Pt), Schizophrenia (Sc), and Social
339
Introversion (Si). On the Content Scales, women with PCOS show higher values of
340
Anxiety (ANX), Fears (FRS), Obsessiveness (OBS), Depression (DEP), Health
341
Concerns (HEA), Low Self-Esteem (LSE), Social Discomfort (SOD), Family
342
Problems (FAM), Work Interference (WRK), and Negative Treatment Indicators
343
(TRT). On Supplementary Scales, PCOS patients show higher values on Back F (Fb),
344
Posttraumatic Stress Disorder (PK), and Marital Distress Scale (MDS). Moreover,
345
PCOS patients showed significantly higher percentages of clinical elevation on
346
Frequency (F), Hypochondriasis (Hs), Depression (D), Psychopathic Deviation (Pd),
347
Paranoia (Pa), Schizophrenia (Sc), Anxiety (ANX), Depression (DEP), Family
348
Problems (FAM), Work Interference (WRK), Posttraumatic Stress Disorder (PK),
349
and Marital Distress (MD).
350
Women with PCOS seem to experience greater psychological distress (F; Fb)
351
than healthy controls, as well as fewer defenses against their mental suffering (K),
352
affecting their internal lives with intense feelings of anguish and despair.
353
Consistent with previous research [27,30,44], PCOS patients seem to
354
experience higher levels of anxiety and depression (D, ANX, FRS, DEP).
355
The relationship between PCOS, anxiety, and depression has been widely
356
debated. Indeed, many studies support the idea that PCOS clinical facets (e.g.
obesity, testosterone levels, hirsutism, and menstrual irregularities) may be risk
358
factors for psychological distress and depression in patients with and without PCOS
359
[54-57]. However, other studies have pointed out that depression and anxiety are
360
independent from PCOS symptoms, such as obesity, hirsutism, or acne [30,58].
361
From our psychoanalytical perspective, since the perception of self-worth has been
362
found to influence mood [59,60], it would be interesting to further research the
363
connection between depression levels and impaired body image.
364
Scores on the somatic scales (Hs, Hy) were higher in women with PCOS than
365
in the controls. It seems that body appearance and body functioning have a central
366
place in the minds of women with PCOS as well as in their relationships. However, it
367
is a body they find it hard to feel and with which they mostly feel uncomfortable, as
368
suggested by the results obtained with the BUT. This, together with alexithymia, can
369
have a great impact on illness perception [61] and can exacerbate their worries about
370
their health (HEA).
371
Women with PCOS show higher levels of posttraumatic symptomatology
372
(PK). We can assume that living with a gynecological disease can be in itself a
373
traumatic condition that gives rise to dysregulated emotions. Moreover, traumatic
374
conditions during development can increase women’s somatopsychic vulnerability
375
and their risk for physical health problems [62], leading to more dysfunctional
376
emotion regulation strategies [63,64].
377
The constant preoccupation with a body they found it difficult to feel,
378
together with a distorted body image, can be traced to the root of some obsessions
379
(Pt, OBS), which could be explained by fixation on the idea that there is something
380
strange in them they need to fix. This is consistent with previous literature showing
381
that PCOS patients exhibit an exaggerated introspective behavior that could lead to
382
pathological self-criticism and ruminative thinking [44].
383
Moreover, women with PCOS seem to be sometimes immature in dealing
384
with the external world, so that they cannot pursue their desires and fantasies with
385
reality-anchored intentionality and fulfilling behaviors (Sc).
386
Hatred of the body and its limits is often projected on the outside world (Pa),
387
giving rise to intense anger, hostility, and distrust (Pd; TRT). These results are
388
consistent with previous research in underlining that women with PCOS seem to use
more psychic energy than needed, to express their anger outwardly, and to have
390
difficulty tolerating frustration [65,66].
391
The result is higher introversion and withdrawal from others (Si), connected
392
to low self-esteem (LSE) and leading to problems in social, professional, and intimate
393
relationships (MDS; SOD; FAM; WRK).
394
These results are consistent with previous research [9,67-69] in underlining
395
that PCOS strongly impacts the social lives of women, adversely affecting their
396
leisure time as well as their relationships with their families and friends, mostly
397
because of their perceived unattractiveness. It also compromises marital
398
relationships; women with PCOS often indicate lower satisfaction with their sex lives
399
and a lower perception of their own sexual attractiveness.
400 401
Limitations and clinical implications 402
This study has some critical limitations. First of all, the generalizability of the results
403
is limited by our small, Italian-only convenience sample, collected in only one center.
404
Second, the cross-sectional design does not allow for causal inferences or following
405
the development of the variables over time. Further longitudinal studies are needed.
406
Psychological variables were assessed through self-report measures; further studies
407
should also take into account clinical and observational data. In addition, variables
408
likely to influence psychological factors, such as hormonal levels, different symptoms
409
(such as hirsutism, infertility, etc.), or gravity of symptoms were not examined in our
410
study. Future research should take these aspects into account.
411
Despite these limitations, the present study gives a more comprehensive
412
evaluation of the psychological functions of women with PCOS. In particular, it
413
sheds light on body image, emotional awareness, and specific dysfunctional
414
personality characteristics in women with PCOS.
415
These results are of great importance for both psychologists and
416
gynecologists that take care of PCOS women and may have relevant clinical
417
implications for planning psychological interventions for this population.
418
In fact, psychological variables are often inconspicuously and marginally
419
taken into account in the clinical management of physical disorders such as PCOS.
420
However, underlining specific dysfunctional psychological profiles in women with
PCOS highlights the need for integrated health care protocols that also take women’s
422
mental functioning in to account, in both the assessment and the treatment phase.
423
Moreover, our preliminary results may help clinicians pay attention to quality
424
of life, depression, and anxiety in women with PCOS, as well as the personality
425
characteristics of these women, an aspect that has been widely understudied and
426
underestimated in previous research and in clinical practice.
427
This may improve patients’ psychological and physical well-being as well as
428
their compliance and the quality of the clinical management of the disease [70-72],
429
benefitting the societal costs of the health care system [73].
430 431
Conflict of Interest Statement 432
The authors have no conflicts of interest to declare.
433 434
Acknowledgments 435
The authors would like to thank Chiara Manieri and Rosa Francesca Novi, who
436
contributed to the clinical study, and Davide Marengo, who contributed to a
437
previous version of the manuscript.
438 439
Authors and Contributors 440
ES contributed to the study design, drafting and critical revision of the manuscript.
441
IGF contributed to the study design, the analysis and interpretation of data, drafting
442
and critical revision of the manuscript. CC and FG contributed to the analysis and
443
interpretation of data, drafting and critical revision of the manuscript. LLM, MT and
444
FV contributed to the interpretation of data and drafting the manuscript. AG
445
contributed to interpretation of data, giving an important clinical and intellectual
446
contribution.
447
All authors approve the final version of the paper to be published and agree to be
448
accountable for all aspects of the work in ensuring that questions related to the
449
accuracy or integrity of any part of the work are appropriately investigated and
450
resolved.
451 452
Current knowledge on the subject. 453
• Women with PCOS show impaired emotional well-being (in particular,
454
anxiety and depression).
455
• Women with PCOS show body dissatisfaction and compromised quality of
456
life.
457
• On the MMPI-2 clinical scales, patients with PCOS show higher rates of
458
clinical elevations on depression, hysteria, psychasthenia, and hypomania, as
459
well as higher absolute scores on the same scales.
460 461
What this study adds. 462
• In our research, women with PCOS seem to be characterized by a
463
dysfunctional body image and a compromised emotional awareness.
464
• They show significant differences compared to our sample of healthy women
465
in the mean scores of many Validity, Clinical, Content, and Supplementary
466
scales of the MMPI-2. In particular, they seem to have fewer defenses against
467
mental suffering. Moreover, it seems that body appearance and bodily
468
function have a central place in their mind as well as in their relationships.
469
However, it is a body they find it hard to feel and with which they mostly feel
470
uncomfortable.
471
• Their approach to the outside world seems to be conflictual, and they seem
472
to be characterized by introversion and withdrawal. This may lead to
473
problems in social, professional, and intimate relationships.
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Tables 706
707 708
Table 1. Most common co-morbidities
709 Co-morbidities Prevalences Mood disorders 18.2% - 81% Self-reported moodiness 81% Depression 5% - 40% Bipolar Disorder 7.7% -11.1% Dysthymia 4.2% Chronic anxiety 35.7% Anxiety 18% - 34% Self-reported anxiety 27% Generalized Anxiety Disorder 13% - 9.7%
Anxiety + depression 15% Social phobia 4.2% - 27% Agoraphobia 2.8% Personality Disorders 2.9% Schizoaffective disorder 1.7 % PTSD 1.4% BED 1.4% Schizophrenia 1.4% Somatoform disorder 0.9% 710 711 712
Table 2. Descriptive statistics
713
PCOS Controls t-test (p values)
N M SD N M SD Age 59 25.64 5.09 38 25.08 4.81 -0.545 (0.587) BMI 59 25.85 6.17 38 21.81 4.32 -3.782 (≤0.001) School years 59 15.93 3.62 38 16.24 2.68 -0.446 (0.657) 714 715 716 717
Table 3. TAS-20
718
PCOS Controls t-test (p values)
M SD M SD
TAS-DIF 50.56 18.49 42.10 16.93 -2.270 (0.025)
TAS-DDF 54.37 20.33 51.89 21.11 -0.577 (0.565)
TAS-EOT 42.08 10.44 38.29 11.44 -1.679 (0.096)
TAS TOT 48.12 12.07 43.03 10.52 -2.131 (0.036)
Legend: DIF=Difficulty in Identifying Feelings; DDF=Difficulty in Describing Feelings; TAS-719
EOT=Externally Oriented Thinking; TAS TOT= Total Score of Alexithymia 720
721 722
Table 4. BUT
723
PCOS Controls t-test (p values)
M SD M SD
PST 19.59 9.99 14.66 8.82 -2.483 (0.015)
GSI 1.68 1.03 1.05 0.81 -3.201 (0.002) Legend: PST=Positive Symptom Total Index; GSI=Global Severity Index 724 725 726 727 Table 5. MMPI-2 728
PCOS Controls t-test (p values)
M DS M DS L 51.00 8.73 53.16 7.06 1.277 (0.205) F 57.49 12.13 48.97 7.39 -3.884 (≤0.001) K 46.83 10.39 52.42 10.47 2.579 (0.011) Hs 60.91 11.91 53.42 11.05 -3.111 (0.002) D 58.39 13.22 50.45 10.18 -3.330 (0.001) Hy 54.85 10.62 50.50 8.81 -2.099 (0.038) Pd 59.78 8.38 55.92 4.40 -2.969 (0.004) Mf 46.24 9.36 47.87 7.65 0.898 (0.371) Pa 55.98 10.93 50.37 9.49 -2.596 (0.011) Pt 57.19 11.24 51 8.75 -3.034 (0.003) Sc 59.12 9.26 54.55 5.44 -3.055 (0.003) Ma 50.76 10.18 51.47 9.59 0.343 (0.732) Si 54.30 10.36 48.16 10.23 -2.867 (0.005)
ANX 57.88 12.34 49.53 9.79 -3.698 (≤0.001) FRS 52.17 10.21 47.76 7.61 -2.429 (0.017) OBS 55.53 11.82 48.47 8.11 -3.382 (0.001) DEP 55.75 10.11 47.68 7.95 -4.153 (≤0.001) HEA 60.36 12.28 51.55 10.53 -3.639 (≤0.001) BIZ 53.92 10.31 51.40 7.49 -1.301 (0.196) ANG 50.76 10.85 49.42 9.63 -0.621 (0.536) CYN 53.58 11.36 49.87 10.19 -1.633 (0.106) ASP 49.03 7.58 46.84 7.07 -1.427 (0.157) TPA 52.56 12.19 51.32 10.77 -0.513 (0.609) LSE 54.31 11.35 47.63 8.46 -3.309 (0.001) SOD 53.39 11.82 48.13 9.73 -2.287 (0.024) FAM 53.68 11.01 47.63 7.78 -3.167 (0.002) WRK 55.92 11.23 48.63 8.05 -3.716 (≤0.001) TRT 54.73 10.90 48.45 9.22 -2.938 (0.004) Fb 55.54 13.12 46.84 6.64 -4.309 (≤0.001) TRIN 65.44 10.19 64.32 8.23 -0.571 (0.569) VRIN 52.29 10.37 48.47 8.70 -1.881 (0.063) MAC 48.76 10.29 49.11 9.70 0.184 (0.870) APS 48.17 8.56 47.61 8.08 -0.324 (0.747) AAS 55.29 10.32 54.58 11.30 -0.318 (0.751) PK 58.07 13.00 48.74 8.98 -4.179 (≤0.001) OH 48.88 9.38 51.58 8.57 1.429 (0.156) MDS 53.97 12.61 49.21 8.15 -2.256 (0.026)
Legend: L=Lie; F=Frequency; K=Defensiveness; Hs=Hypochondriasis; D=Depression; Hy=Hysteria; 729
Pd=Psychopathic Deviation; Mf=Masculinity/Femininity; Pa=Paranoia; Pt=Psychasthenia; Sc=Schizophrenia; 730
Ma=Hypomania; Si=Social Introversion; ANX=Anxiety; FRS=Fears; OBS=Obsessiveness; DEP=Depression; 731
HEA=Health Concerns; BIZ=Bizarre Mentation; ANG=Anger; CYN=Cynicism; ASP=Antisocial Practices; 732
TPA=Type A; LSE=Low Self-Esteem; SOD=Social Discomfort; FAM=Family Problems; Fb=Back F; 733
TRIN=True Response Inconsistency; VRIN=Variable Response Inconsistency; MAC=MacAndrew Scale; 734
APS=Addiction Potential Scale; AAS=Addiction Admission Scale; PK=Post-traumatic Stress Disorder; 735
OH=Over-controlled Hostility; MDS=Marital Distress Scale. 736 737 738 739 740 741
Table 6. Percentage of elevations in MMPI-2 scales.
742
PCOS Controls Chi squares (p values) L 1.7% 2.6% 0.100 (0.751) F 20.3% 5.3% 4.254 (0.039) K 5.1% 13.2% 1.991 (0.158) Hs 39.0% 18.4% 4.574 (0.032) D 30.5% 7.9% 6.968 (0.008) Hy 16.9% 7.9% 1.633 (0.201) Pd 22.0% 2.6% 7.045 (0.008) Mf 0% 0% Constant Pa 16.9% 2.6% 4.713 (0.030) Pt 22.0% 7.9% 3.355 (0.067) Sc 23.7% 2.6% 7.870 (0.005) Ma 10.2% 10.5% 0.003 (0.955) Si 16.9% 7.9% 1.633 (0.201) ANX 32.2% 10.5% 6.004 (0.014) FRS 11.9% 2.6% 2.604 (0.107) OBS 16.9% 5.3% 2.912 (0.088) DEP 20.3% 0.0% 8.820 (0.003) HEA 28.8% 15.8% 2.167 (0.141) BIZ 11.9% 2.6% 2.604 (0.107) ANG 10.2% 7.9% 0.142 (0.706) CYN 15.3% 10.5% 0.445 (0.505) ASP 3.4% 2.6% 0.044 (0.833) TPA 13.6% 13.2% 0.003 (0.955) LSE 18.6% 5.3% 3.566 (0.059) SOD 11.9% 5.3% 1.197 (0.274) FAM 15.3% 2.6% 3.983 (0.046) WRK 20.3% 2.6% 6.244 (0.012) TRT 13.6% 5.3% 1.720 (0.190) Fb 18.6% 0% 7.991 (0.005) TRIN 35.6% 36.8% 0.016 (0.901) VRIN 6.8% 2.6% 0.813 (0.367) MAC 3.4% 7.9% 0.959 (0.327) APS 0% 2.6% 1.569 (0.210) AAS 15.3% 18.4% 0.168 (0.682) PK 32.2% 7.9% 7.788 (0.005) OH 1.7% 5.3% 0.982 (0.322)
MDS 23.7% 5.3% 5.722 (0.017) 743
