Physical and psychological correlates of self and body compassion in women with polycystic ovary syndrome

Abstract

This international cross-sectional study examined the level and potential correlates of self and body compassion in women (n = 227) with polycystic ovary syndrome (PCOS). Participants completed an online survey examining quality of life, psychological health, body image and self and body compassion. Low levels of self and body compassion were found, with depression and body image concern identified as negative correlates of self and body compassion. Physical health was identified as a positive correlate of body compassion. The findings identify the important relationship between body image, psychological health and self and body compassion in women with PCOS.

Keywords

body compassion body image polycystic ovary syndrome psychological health quality of life self-compassion

Introduction

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders affecting women of reproductive age and is characterised by the heterogeneous presentation of hyperandrogenism (the presence of excessive testosterone in females) and ovulatory dysfunction (March et al., 2010). Several studies have documented the relationship between the physiological effects of hyperandrogenism and low self-esteem, increased fear of negative appearance evaluation and body dissatisfaction and uneasiness (Scaruffi et al., 2019).

One of the major factors influencing body dissatisfaction for women with PCOS appears to be weight. Obese women with PCOS report low self-esteem, trust in others and higher sensitivity to criticism when compared to women without PCOS (Açmaz et al., 2013). Obese women with PCOS report lower quality of life than obese women without chronic illnesses generally (Hahn et al., 2005; Shishehgar et al., 2016). Kogure et al. (2019) found higher levels of depressive symptoms, as measured by the Hospital Anxiety Depression Measurement Scale (HADS-S), were linked to higher weight and BMI, and dissatisfaction with body shape in a sample of 94 women with PCOS.

In addition to the symptom of weight gain, a range of PCOS symptoms have been found to be negatively associated with quality of life (QoL) and psychological and physical health and wellbeing (Blay et al., 2016; Cronin et al., 1998; McCook et al., 2015). Coping with PCOS symptoms, fear regarding infertility, loss of femininity and sexuality, body image concerns and lower self-worth may all contribute to poorer mental health outcomes (Deeks et al., 2011). The process of managing PCOS symptoms and lifestyle adaptations has been linked to higher rates of psychological distress including depression, anxiety, panic attacks, difficulty concentrating, fatigue, disordered eating and chronic stress (Barnard et al., 2007; Podfigurna-Stopa et al., 2015).

Psychological distress is, in turn, frequently associated with low health related quality of life (HRQoL) (Açmaz et al., 2013; Barnard et al., 2007; Ching et al., 2007). In A study of 1359 women, those with PCOS reported lower HRQoL than healthy controls on seven domains assessed with the Polycystic Ovary Syndrome Health-related Quality of Life Questionnaire (PCOSQ) including: emotional disturbance, weight, infertility, acne, menstrual symptoms, menstrual predictability and hirsutism (Barnard et al., 2007). Women with PCOS consistently report significantly lower rates of HRQoL than healthy controls in studies using PCOS specific (Cronin et al., 1998) and general HRQoL measures (Barnard et al., 2007; Ching et al., 2007; Jones et al., 2011), indicating that the experience of specific PCOS symptoms contributes to lower quality of life outcomes.

Although much of the research to date has focussed on the presence and experience of the physical and psychological symptoms associated with PCOS (Blay et al., 2016; Cronin et al., 1998; McCook et al., 2015), less is known about the association between PCOS and a woman’s self-concept or her relationship with her body. Changes in the appearance of the body and it’s biological functioning can be associated with a sense of shame and negative sense of self (Podfigurna-Stopa et al., 2015). Self-confidence and body-image have been demonstrated to be important determinants of psychological health and health promoting behaviours (Baker and Gringart, 2009). Understanding how women with PCOS feel about, and view, their bodies is important as poor body image has been linked to avoidance of positive health behaviours (Vartanian and Novak, 2011) and higher psychological distress (Cash et al., 2004).

With the introduction of Mindfulness and Acceptance based (MAB) psychological interventions, aimed at promoting kindness and compassion towards the self (self-compassion), a greater emphasis is being placed on an individual’s relational experience with their body rather than to individual constructs such as body image. Neff (2003a) defined self-compassion as being open to one’s suffering as opposed to avoiding it and approaching oneself with kindness in the promotion of healing. Neff (2003a) posited that there are three key aspects of self-compassion, namely self-kindness (taking an approach of understanding rather than self-criticalness or judgement), mindfulness (defusing from painful thoughts and feelings instead of engaging in overidentification or suppression) and common humanity (an ability to recognise one’s own experience as part of the larger human experience rather than viewing them as isolating).

Self-compassion has been identified as a protective factor against poor psychological health and impaired body image, with research suggesting that higher levels of self-compassion are associated with weaker connections between self-objectification and negative body attitudes (Liss and Erchull, 2015). A recent meta-analysis investigating the relationship between self-compassion, physical health and health behaviours (94 peer-reviewed articles, N = 29, 5558 pooled sample) indicated that although self-compassion has been conceptualised in several ways since Neff’s (2003a) model, much of the research in this domain has focussed on the original formulation (Phillips and Hine, 2021). The findings indicated positive associations between self-compassion, physical health and health behaviour, with a strong effect observed for overall physical health and support for the proposition that self-compassion can promote better physical health (Phillips and Hine, 2021).

Higher levels of self-compassion have also been linked with engagement in positive health behaviours (Dunne et al., 2018), enhanced psychological wellbeing (MacBeth and Gumley, 2012), adaptive responses to physical illness (Brion et al., 2014), fewer illness-related symptoms (Hall et al., 2013) and lower levels of pain intensity (Allen et al., 2012), all of which are associated with PCOS. Given that self-compassion may lower defensiveness, negative emotion and self-criticalness (Terry and Leary, 2011), and the level of emotional distress associated with physical health symptoms (Hall et al., 2013), further exploration in a PCOS sample is warranted. Further research regarding the association between self-compassion and reactions to physical health conditions, such as PCOS, may provide a greater understanding of how individual’s cope with chronic conditions and facilitate the availability of evidence-based interventions designed to enhance self-compassion (Brion et al., 2014).

However, due to its broad scope, simply measuring and targeting self-compassion may not fully capture the relationship an individual has with their body when living with a persistent health condition such as PCOS. Directly targeting and enhancing body compassion over more general self-compassion may be particularly beneficial for women with PCOS due to the reported low HRQoL, higher psychological distress and impaired body image. Altman et al. (2020) proposed the construct of Body Compassion, a new body-focussed MAB construct, designed to bridge the constructs of body image and self-compassion. By linking aspects of body image and self-compassion, the new concept of body compassion may better inform how individuals relate to their bodies, particularly those living with persistent health conditions such as PCOS. Body compassion was found to be positively related to body image flexibility and self-compassion and negatively related to BMI (Altman et al., 2020) and has also been found to be negatively associated with experiences of shame and disordered eating in women (Oliveira et al., 2018). Although the initial research of Altman et al. (2020) is promising, further research is required to validate the measure of body compassion and to understand the role of body compassion in clinical samples, such as PCOS.

As the physical symptoms of PCOS are strongly associated with impaired body image and lower psychological health, an approach that bridges the relationship between the mind and the body holds promise for women with PCOS. Understanding the role of body compassion in the experience of PCOS is important given the recent modifications to clinical guidelines on the diagnosis and management of PCOS which recommend increasing the focus on emotional wellbeing and HRQoL (Teede et al., 2018).

Aims and hypotheses

Although it is already understood that psychological distress is heightened whilst HRQoL is lowered among women with PCOS (Blay et al., 2016; McCook et al., 2015), the current study aims to add to this current body of literature, whilst examining the association of these factors with body image and self and body compassion. It is hypothesised that, due to the psychological and physical consequence of PCOS-related symptoms, women with PCOS will report impaired body image and low levels of self and body compassion. Regression analyses will look at the degree to which physical, psychological and body image factors correlate with self and body compassion in women with PCOS.

Method

Participants

Data was gathered from 227 women, aged between 18 and 48 years, with PCOS (M_age = 30.57, SD = 6.70). PCOS inclusion criteria were based on self-report of at least two of the three Rotterdam diagnostic criteria: (1) presence of polycystic ovaries; (2) hyperandrogenism; (3) irregular menstrual cycle. Of the 227 women 96.9% endorsed two or more of the Rotterdam criteria and reported a medically confirmed diagnosis, with 99.1% of the sample endorsing the presence of polycystic ovaries. Women with a current diagnosis of an eating disorder or body dysmorphic disorder were excluded. A priori GPower analysis suggested that a minimum of 123 participants were required for hierarchical multiple regression analyses, with three blocks (physical, psychological, body-image) and 15 correlates, to detect medium-sized effects.

Procedure

Participants were recruited through social media platforms and women’s health/gynaecological facilities and completed an anonymous 25-minute online survey using REDCap (Research Electronic Data Capture) survey platform hosted by the University of Tasmania (Harris et al., 2019). Participants were reminded of their right to withdraw after answering the final survey question prior to response submission. The research and data collection processes were approved by the University of Tasmania’s Human Research Ethics Committee (Social Sciences: H0018163).

Measures

In addition to basic demographic and health-based information (e.g. weight, height, reproductive history), participants also completed the following measures:

Short-Form Health Survey (SF-36) (Ware and Sherbourne, 1992) a 36-item multi-purpose health survey that produces an 8-scale functional health profile. Subscale scores include Physical Functioning (PF), Role Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role Emotional (RE) and Mental Health (MH). Scores range from 0 to 100 with lower the scores indicating greater disability. The SF-36 has been found to have excellent criterion validity and internal consistency (with α > 0.08 for each dimension) and is considered a sound measure for assessing health in homogenous populations (Jenkinson et al., 1994). Cronbach’s α was 0.919.

Patient-Reported Outcomes Measurement Information System – Emotional Distress Short Forms (PROMIS; Pilkonis et al., 2011) ask the respondent to rate symptom severity during the past 7 days on a 5-point scale (1 = never; 2 = rarely; 3 = sometimes; 4 = often; and 5 = always). The PROMIS measures were developed by the National Institutes of Health to measure and compare patient-reported outcomes across a range of chronic conditions (Cella et al., 2007). The PROMIS Emotional Distress (8-item) is measure of affective and cognitive manifestations of depression in adults. Scores range from 8 to 40 with higher scores indicating greater severity of depression. Cronbach’s α was 0.940. The PROMIS Anxiety Short Form (7-item) assesses anxiety in adults. Scores range from 7 to 35 with higher scores indicate greater severity of anxiety. Cronbach’s α was 0.919.

Physical Health Symptoms (PHQ-15) (Kroenke et al., 2002) assesses somatic concern in adults across 15 physical symptoms that account for greater than 90% of the physical complaints that may be reported in outpatient settings. Each item rated on a 3-point scale (0 = not bothered at all; 1 = bothered a little; 2 = bothered a lot) and scores range from 0 to 30, with higher scores indicating increased somatic concern. The PHQ-15 has been found to have excellent internal reliability (Cronbach’s α of 0.80) in primary care (Van Ravesteijn et al., 2009) and obstetrics-gynaecology samples (Kroenke et al., 2002). Cronbach’s α was 0.797.

Self-Compassion Scale (Neff, 2003b) measures self-compassion, via 26 items, as a system-level balance between compassionate attributes (kindness, common humanity, mindfulness) and actions (reduced self-judgement, isolation and over-identification). The scale items assess how an individual views their self-directed actions in times of difficulty (e.g. ‘When I’m going through a very hard time, I give myself the caring and tenderness I need’) and items are presented on a Likert scale of 1 (almost never) to 5 (almost always). The negative domains of self-judgement, isolation and over-identification are reverse scored to produce the total level of self-compassion (Neff, 2003b), with higher scores representing higher levels of self-compassion. The 26-item Self-Compassion Scale has been shown to have good internal reliability (0.92). Cronbach’s α was 0.758.

Body Compassion Scale (Altman et al., 2020) is a 23-item tool designed to assess the level of compassion an individual holds towards their body (e.g. ‘I try to see my body’s failings as something everyone experiences in one way or another’). The measure provides three subscale scores (Defusion, Common Humanity, Acceptance) and a total body compassion score. Items are rated on a 5-point Likert scale, where 1 = ‘almost never’ and 5 = ‘almost always’. Internal consistency across the subscales and total score is excellent (Altman et al., 2020). Cronbach’s α was 0.933.

Body Attitude Test (Probst et al., 1995) provides a measure of a person’s subjective experience of, and attitude towards, their own body. A total score and three factor scores (negative appreciation of body size, lack of familiarity with one’s own body, general body dissatisfaction) are computed. The clinical cut-off score for differentiating between patients and normal population is ⩾36, with higher scores indicating higher impairment. The measure has been well validated for use with clinical and nonclinical populations and test-retest results indicate that the BAT is a valid and reliable measure (Probst et al., 1995). Cronbach’s α was 0.929.

Body Image Concern Inventory (Littleton et al., 2005) assesses dysmorphic concern in adults. The questionnaire includes items related to body dissatisfaction, checking and camouflaging and avoidance of social interactions due to concerns about appearance and participants rate the frequency of a feeling or behaviour on a Likert scale of 1 = ‘Never’ to 5 = ‘Always’. The BICI has excellent sensitivity (96%) and a score of 72 (score range 19–95) is used as a cut-off for clinical concern. The BICI has excellent internal consistency, concurrent, content and convergent validity and is viewed as a highly useful brief measure for measuring body image concerns (Littleton et al., 2005). Cronbach’s α was 0.869.

Health-Related Quality of Life Questionnaire for Polycystic Ovary Syndrome (PCOSQ) (Cronin et al., 1998) tool, a 26-item measuring five areas of PCOS-specific HRQoL (emotions, body hair, weight, infertility problems and menstrual problems). Scores range from 0 to 7 within each domain. High scores (7) indicate good quality of life whereas low scores indicate low quality of life (0). The PCOSQ has demonstrated good internal reliability, concurrent validity and discriminant validity (Coffey et al., 2006). Cronbach’s α was 0.916.

Design and data analysis

A cross-sectional design was utilised and statistical analyses were carried out using SPSS 24. Bivariate correlation analysis was conducted to assess the association between outcome measures. Hierarchical multiple regression analysis (MRA) was used to explore the unique contribution that physical (block 1), psychological (block 2) and body image (block 3) factors have in influencing self and body compassion for women with PCOS.

Results

Sample characteristics

Table 1 presents the demographic data for the study sample. Most of the respondents resided in Australia, were engaged in full-time employment, and were married. A large percentage of the total sample were heterosexual, not menopausal and had never been pregnant. Women in the sample had experienced PCOS symptoms for an average of 13.19 years (SD = 7.97). BMI ranged from 18.94 to 48.87 (M = 32.83, SD = 7.30) and over one third of the sample reported a diagnostic delay of 5 years or more (40.1%). Hypertension (11.5%), diabetes (10.1%) and dyslipidaemia (9.3%) rates were reported within the sample.

Table 1.

Demographic information for the study sample of women with PCOS.

Variable	N	%
Country of residence
Australia	124	54.6
Oceania (e.g. N.Z., Papua New Guinea)	5	2.2
United Kingdom	23	10.1
Europe (excluding the United Kingdom)	12	5.3
North America	52	22.9
Asia	3	1.3
Africa	8	3.5
Highest academic level attained
High school or below	15	6.6
Year 12 or equivalent	40	17.6
Vocational certificate/qualification	41	18.1
Bachelor’s degree	83	36.6
Postgraduate degree	48	21.1
Employment type
Student	38	16.7
Employed – part-time	54	23.8
Employed – full-time	105	46.3
Self-employed	14	6.2
Unemployed	16	7.0
Relationship status
Single	65	28.6
Committed – living separately	19	8.4
Committed – living together	39	17.2
Married – living together	104	45.8
Sexual orientation
Asexual	15	6.6
Bisexual	27	11.9
Heterosexual	168	74.0
Lesbian	17	7.5
Peri/menopause
I do not experience symptoms of perimenopause.	199	87.7
I experience symptoms of perimenopause.	21	9.3
I experienced a medical menopause.	7	3.1
Reproductive history
Currently trying to conceive.	23	10.1
Never been pregnant	108	47.6
Have been pregnant and have not experienced a miscarriage.	49	21.6
Have been pregnant and have had one or more births and one or more miscarriages.	35	15.4
Have been pregnant but each pregnancy has ended with a miscarriage.	12	5.3

The mean standardised scores for depression (M = 60.67, SD = 8.91) and anxiety (M = 61.92, SD = 9.20) fell within the moderate clinical range and a medium level of somatic concern was noted (M = 11.80, SD = 5.51). The poorest areas of SF-36 HRQoL was noted for fatigue (M = 28.30, SD = 17.14), emotional health (M = 50.41, SD = 19.18) and role limitations associated with emotional health (M = 44.79, SD = 19.80). Women rated their overall health-related quality of life as poor (M = 44.58, SD = 21.01) indicating the negative link between PCOS and a range of life domains. The PCOSQ was used to assess PCOS-specific HRQoL. Women reported the highest impairment for PCOSQ weight (M = 2.32, SD = 1.63), PCOSQ menstrual symptoms (M = 3.31, SD = 1.26), PCOSQ fertility (M = 3.62, SD = 1.82) and PCOSQ emotions (M = 3.59, SD = 1.19). Excessive hair growth was assessed as having the lowest impairment of HRQoL (M = 3.73, SD = 1.79).

Body image

Most of the women in the current PCOS sample scored at or above the BAT clinical cut-off point of 36 (BAT ⩾ 36 = 85.2%), indicating clinical levels of concern regarding their subjective body experience and attitude. Over one third of the sample (36.5%) reported body dysmorphic concerns at or above the BICI clinical cut-off score of 72. Bivariate correlations (Table 2) revealed statistically significant moderate positive correlations between depression and anxiety for the two body image measures, with higher levels of depressive or anxious symptomatology associated with higher body image concern and poorer subjective body experience and attitude. Significant small to moderate negative correlations were noted between PCOSQ Emotion and the SF-36 Emotional domain score for both body image measures, with lower HRQoL in these areas associated with higher levels of body image concern and poorer subjective body experience and attitude.

Table 2.

Spearman’s Rho correlations between self and body compassion and the physical, psychological and body image outcomes for PCOS sample.

Outcome	1.	2.	3.	4.	5.	6.	7.	8.	9.	10.	11.	12.	13.	14.	15.	16.	17.	18.	19.
1. BMI	–	0.001	0.012	0.110	0.001	0.001	0.001	0.001	0.001	0.001	0.176	0.006	0.001	0.001	0.018	0.001	0.001	0.001	0.001
2. PEDS	0.29	–	0.001	0.001	0.014	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001
3. PAS	0.16	0.72	–	0.001	0.085	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001
4. PHQ-15	0.12	0.32	0.46	–	0.041	0.001	0.003	0.001	0.154	0.001	0.025	0.001	0.001	0.001	0.014	0.001	0.009	0.001	0.013
5. SD	0.31	0.14	0.16	0.14	–	0.156	0.056	0.552	0.009	0.043	0.209	0.019	0.011	0.030	0.809	0.139	0.071	0.127	0.141
6. SC	−0.27	−0.62	−0.50	−0.25	−0.10	–	0.001	0.001	0.001	0.001	0.001	0.014	0.001	0.001	0.001	0.001	0.001	0.001	0.001
7. BC	−0.34	−0.50	−0.38	−0.19	−0.13	0.63	–	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001
8. PQE	−0.31	−0.54	−0.51	−0.42	−0.04	0.48	0.47	–	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001
9. PQH	−0.32	−0.29	−0.28	−0.10	−0.17	0.32	0.31	0.50	–	0.001	0.001	0.001	0.011	0.162	0.001	0.001	0.001	0.001	0.001
10. PQW	−0.44	−0.37	−0.35	−0.25	−0.13	0.42	0.57	0.57	0.30	–	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001	0.001
11. PQF	−0.10	−0.30	−0.25	−0.12	−0.17	0.25	0.29	0.60	0.21	0.29	–	0.001	0.005	0.001	0.013	0.014	0.051	0.058	0.013
12. PQM	−0.18	−0.25	−0.27	−0.47	−0.19	0.16	0.23	0.63	0.23	0.32	0.39	–	0.001	0.001	0.003	0.001	0.002	0.001	0.035
13. SFPD	−0.35	−0.48	−0.41	−0.61	−0.17	0.34	0.40	0.48	0.17	0.36	0.19	0.47	–	0.001	0.001	0.001	0.001	0.001	0.001
14. SFED	−0.27	−0.70	−0.59	−0.42	−0.14	0.47	0.37	0.46	0.09	0.34	0.22	0.33	0.67	–	0.001	0.001	0.007	0.001	0.001
15. BICI	0.16	0.38	0.35	0.16	−0.02	−0.43	−0.66	−0.42	−0.26	−0.53	−0.16	−0.20	−0.26	−0.30	–	0.001	0.001	0.001	0.001
16. BATT	0.28	0.34	0.31	0.22	0.10	−0.39	−0.62	−0.38	−0.24	−0.63	−0.16	−0.22	−0.33	−0.26	0.77	–	0.001	0.001	0.001
17. BATF1	0.27	0.23	0.22	0.17	0.12	−0.30	−0.53	−0.30	−0.22	−0.62	−0.13	−0.21	−0.31	−0.19	0.64	0.91	–	0.001	0.001
18. BATF2	0.24	0.32	0.31	0.26	0.10	−0.30	−0.38	−0.34	−0.21	−0.37	−0.13	−0.25	−0.31	−0.28	0.49	0.77	0.56	–	0.001
19. BATF3	0.34	0.39	0.31	0.17	0.10	−0.48	−0.71	−0.37	−0.25	−0.62	−0.17	−0.14	−0.30	−0.28	0.77	0.84	0.75	0.48	–

PCOS:N = 189. Italic font = significance level (two-tailed). Spearman rho correlation presented in bottom half of matrix. Bold font = p = 0.05 to 0.001.

BMI: body mass index; PEDS: PROMIS emotional distress short form; PAS: PROMIS anxiety short form; PHQ-15: physical health symptoms; SD: duration of PCOS symptoms; SC: self-compassion score; BC: body compassion score; PQE: PCOSQ emotion; PQH: PCOSQ hair; PQW: PCOSQ weight; PQF: PCOSQ fertility; PQM: PCOSQ menstrual symptoms; SFPD: SF-36 physical domain score; SFED: SF-36 emotional domain score; BICI: body image concern inventory; BATT: body attitude test total; BATF1: body attitude test factor 1; BATF2: body attitude test factor 2; BATF3: body attitude test factor 3.

Self-compassion

Women with PCOS reported low to moderately low levels of self-compassion in general across the subscales of the SCS-26. The lowest scoring positive self-compassion domain was kindness (M = 2.50, SD = 0.84, low range) compared to humanity (M = 2.78, SD = 0.85) and mindfulness (M = 2.86, SD = 0.85) which fell just within lower end of the moderate range. The women reported scores within the high range for the negative self-compassion domains of isolation (M = 3.54, SD = 0.94), overidentification (M = 3.56, SD = 0.93) and negative self-judgement (M = 3.70, SD = 0.91).

Bivariate correlations (Table 2) revealed statistically significant correlations for self-compassion and physical, psychological and body image outcomes. Higher BMI and somatic symptom concern were associated with significantly lower levels of self-compassion. Women with lower PCOSQ weight, PCOSQ fertility and PCOSQ Menstrual scores and higher SF-36 physical domain scores had statistically significantly higher levels of self-compassion. Self-compassion was also found to correlate significantly negatively with depression and anxiety, with higher scores correlated with lower levels of self-compassion. A statistically significant positive correlation was indicated for the SF-36 mental health score, with higher levels of mental health linked to higher levels of self-compassion. Statistically significant negative correlations were indicated for self-compassion and all body image outcome scores, with higher BAT and BICI scores associated with lower levels of self-compassion.

Correlates of self-compassion for women with PCOS

Hierarchical Multiple Regression Analysis (MRA) was conducted to examine the unique contribution of individual physical, psychological and body image outcomes on self-compassion. In combination, the correlate variables accounted for 49.6% of the variance adjusted R² = 0.46, F (15, 266) = 13.86, p = 0.001. By Cohen’s (1988) conventions, a combined effect of this magnitude is considered large, ƒ² = 0.98. As can be seen in Table 3, on step one of the MRA average pain level, somatic concern, PCOSQ body hair, PCOSQ weight and SF-36 physical domain scores were the only significant correlates of self-compassion. When psychological factors were added on step two, depression and PCOSQ emotion were found to be the only significant correlates of self-compassion. When body image outcomes were added on step three, depression and body image concern were significant negative correlates of self-compassion. Higher levels of depressive symptomatology and body image concern were associated with a significantly lower levels of self-compassion.

Table 3.

MRA analysis for correlates of self-compassion for women with PCOS.

Variable	R ²	F	b	95% CI		β	t ^#	p
Variable	R ²	F	b	Lower	Upper	β	t ^#	p
Step 1	0.25	9.26*
BMI			−0.05	−0.13	0.03	−0.09	−1.25	0.213
Symptom duration			0.04	−0.02	0.10	0.08	0.19	0.186
Average pain			0.03	0.008	0.05	0.21	2.71	0.007*
PHQ-15			−0.15	−0.27	−0.03	−0.20	−2.42	0.016*
PCOSQ hair			0.45	0.17	0.73	0.21	3.19	0.002*
PCOSQ weight			0.37	0.03	0.03	0.15	2.13	0.034*
PCOSQ menstrual			−0.21	−0.66	0.25	−0.07	−0.91	0.365
SF-36 physical domain			0.06	0.02	0.09	0.28	3.34	0.001*
Step 2	0.46	16.71*
BMI			−0.03	−0.10	0.03	−0.06	−1.01	0.312
Symptom duration			0.02	−0.03	0.08	0.05	0.89	0.376
Average pain			0.02	−0.01	0.04	0.11	1.65	0.100
PHQ-15			−0.07	−0.18	0.04	−0.09	−1.20	0.233
PCOSQ hair			0.14	−0.14	0.42	0.06	0.99	0.322
PCOSQ weight			0.08	−0.24	0.40	0.03	0.49	0.624
PCOSQ menstrual			−0.34	−0.79	0.12	−0.11	−1.46	0.146
SF-36 physical domain			0.01	−0.03	0.04	0.02	0.17	0.863
Depression (PEDs)			−0.20	−0.28	−0.12	−0.45	−4.95	0.001*
Anxiety (PAS)			−0.01	−0.07	0.07	−0.01	−0.07	0.946
PCOSQ emotion			0.74	0.07	1.42	0.23	2.17	0.031*
PCOSQ fertility			−0.13	−0.41	0.15	−0.06	−0.91	0.364
SF-36 emotion domain			0.01	−0.02	0.04	0.08	0.93	0.352
Step 3	0.50	6.76*
BMI			−0.05	−0.11	0.02	−0.09	−1.48	0.142
Symptom duration			0.01	−0.05	0.06	0.02	0.31	0.759
Average pain			0.01	−0.01	0.03	0.09	1.28	0.203
PHQ-15			−0.08	−0.19	0.03	−0.11	−1.46	0.147
PCOSQ hair			0.13	−0.14	0.40	0.06	0.95	0.344
PCOSQ weight			−0.22	−0.58	0.15	−0.09	−1.19	0.237
PCOSQ menstrual			−0.30	−0.74	0.14	−0.10	−1.34	0.181
SF-36 physical domain			−0.01	−0.04	0.03	−0.03	−0.36	0.723
Depression (PEDs)			−0.19	−0.27	−0.11	−0.43	−4.92	0.001*
Anxiety (PAS)			0.01	−0.06	0.08	0.03	0.37	0.714
PCOSQ emotion			0.59	−0.08	1.26	0.18	1.74	0.084
PCOSQ fertility			−0.05	−0.33	0.23	−0.02	−0.35	0.729
SF-36 emotion domain			0.01	−0.01	0.04	0.09	1.05	0.291
BICI			−0.04	−0.09	−0.01	−0.17	−2.01	0.039*
BAT			−0.02	−0.06	0.02	−0.08	−0.85	0.394

p = 0.05 to 0.001.

Body compassion

The average level of body compassion noted in the PCOS sample (M = 55.87, SD = 16.42) was lower than the average score (M = 72.16, SD = 15.83) reported in a healthy sample (Altman et al., 2020). Moderate levels of defusion (M = 22.40, SD = 8.36) were noted, where a score of 8 indicates a high level of defusion and 45 a low level of defusion. The common humanity (M = 22.07, SD = 7.38, 8 = low, 45 = high) and acceptance (M = 11.40, SD = 4.64, 5 = low, 25 = high) factors scores were noted to be moderate.

As can be seen in Table 2, body compassion was statistically positively correlated with PCOSQ weight, PCOSQ hair and the SF-36 physical domain, with lower levels of weight and hirsutism concern and higher physical health associated with higher levels of body compassion. Body compassion was also positively statistically significantly correlated with SF-36 mental health and PCOSQ emotion scores, with higher mental health and emotional health scores associated with higher levels of body compassion. Depression and anxiety were statistically negatively correlated with body compassion, with higher levels of distress and anxiety associated with lower body compassion. Statistically significant negative correlations were indicated for body compassion and all body image outcome scores, with higher BAT and BICI scores associated with lower levels of body compassion in women.

Correlates of body compassion for women with PCOS

Hierarchical Multiple Regression Analysis (MRA) was conducted to examine the unique contribution of individual physical, psychological and body image outcomes on body compassion. In combination, the correlate variables accounted for 61% of the variance, adjusted R² = 0.58, F (15, 226) = 21.99, p = 0.001. By Cohen’s (1988) conventions, a combined effect of this magnitude is considered medium, ƒ² = 0.22. As can be seen in Table 4, on step one of the MRA PCOSQ weight and SF-36 Physical domain were the only significant correlates of body compassion. When psychological factors were added on step two, PCOSQ weight, SF-36 Physical domain and depression were found to be the only significant correlates of body compassion. When body image outcomes were added on step three, depression and body image concern were statistically significant negative correlates of body compassion. Higher levels of depressed mood and body image concern were associated with significantly lower body compassion. SF-36 physical domain and PCOSQ fertility were found to be the only positive statistically significant correlates of body compassion on step three, with higher perceived physical health and lower distress associated with fertility concerns associated with higher levels of body compassion.

Table 4.

MRA analysis for correlates of body compassion for women with PCOS.

Variable	R ²	F	B	95% CI		β	t ^#	p
Variable	R ²	F	B	Lower	Upper	β	t ^#	p
Step 1	0.39	17.38*
BMI			−0.02	−0.12	0.08	−0.03	−0.42	0.673
Symptom duration			0.02	−0.06	0.09	0.02	0.43	0.670
Average pain			0.02	−0.01	0.05	0.11	1.61	0.109
PHQ-15			0.01	−0.14	0.16	0.01	0.08	0.938
PCOSQ hair			0.32	−0.03	0.68	0.11	1.82	0.071
PCOSQ weight			1.45	1.02	1.88	0.43	6.68	0.001*
PCOSQ menstrual			−0.16	−0.73	0.41	−0.04	−0.55	0.585
SF-36 physical domain			0.10	0.06	0.14	0.35	4.56	0.001*
Step 2	0.45	4.77*
BMI			−0.01	−0.11	0.08	0.02	−0.29	0.770
Symptom duration			−0.01	−0.09	0.07	−0.01	−0.24	0.815
Average pain			0.01	−0.01	0.04	0.07	0.99	0.322
PHQ-15			0.07	−0.09	0.22	0.07	0.85	0.395
PCOSQ hair			0.01	−0.38	0.40	0.01	0.06	0.950
PCOSQ weight			1.23	0.78	1.68	0.37	5.41	0.001*
PCOSQ menstrual			−0.35	−0.99	0.28	−0.08	−1.10	0.274
SF-36 physical domain			0.08	0.03	0.13	0.30	3.32	0.001*
Depression (PEDs)			−0.16	−0.27	−0.05	−0.26	−2.88	0.004*
Anxiety (PAS)			−0.02	−0.12	0.08	−0.03	−0.35	0.725
PCOSQ emotion			0.51	−0.44	1.46	0.11	1.06	0.292
PCOSQ fertility			0.15	−0.24	0.55	0.05	0.76	0.448
SF-36 emotion domain			−0.03	−0.07	0.01	−0.12	−1.34	0.183
Step 3	0.61	42.96*
BMI			−0.06	−0.14	0.02	−0.08	−1.51	0.132
Symptom duration			−0.06	−0.13	0.01	−0.09	−1.86	0.065
Average pain			0.01	−0.02	0.03	0.01	0.08	0.940
PHQ-15			0.03	−0.11	0.15	0.03	0.37	0.710
PCOSQ hair			−0.02	−0.35	0.31	−0.01	−0.11	0.909
PCOSQ weight			0.40	−0.05	0.84	0.12	1.77	0.079
PCOSQ menstrual			−0.23	−0.78	0.31	−0.05	−0.85	0.394
SF-36 physical domain			0.06	0.02	0.10	0.20	2.65	0.009*
Depression (PEDs)			−0.14	−0.24	−0.05	−0.23	−3.00	0.003*
Anxiety (PAS)			0.03	−0.06	0.11	0.05	0.67	0.504
PCOSQ emotion			−0.03	−0.85	0.79	−0.01	−0.08	0.939
PCOSQ fertility			0.42	0.08	0.76	0.14	2.42	0.016*
SF-36 emotion domain			−0.03	−0.06	0.01	−0.11	−1.46	0.145
BICI			−0.16	−0.21	−0.11	−0.46	−6.22	0.001*
BAT			−0.02	−0.07	0.03	−0.07	−0.91	0.363

p = 0.05 to 0.001.

Discussion

The present study examined the association between PCOS, body image, HRQoL, psychological health and determined the nature of these factors in self and body compassion. Results supported the hypotheses that women with PCOS experience low HRQoL, psychological health, impaired body image and low self and body compassion. It was found that depressed mood and body image concern were significant negative correlates of self and body compassion. Higher SF-36 physical domain and lower PCOSQ fertility scores were also found to be significant positive correlates of body compassion in women with PCOS.

The level of depression and anxiety noted in the sample is consistent with previous literature linking poorer psychological outcomes with PCOS (Altinok et al., 2014; Rowlands et al., 2016). Higher rates of depressive and anxious symptoms appear to be related to the experience of and general dissatisfaction with one’s own body in women with PCOS (Himelein and Thatcher, 2006). In the current study, psychological distress was associated with body image related HRQoL domains including weight, hair growth, fertility and menstrual irregularities. Weight, hirsutism and infertility have been associated with low HRQoL and higher psychological distress in numerous studies (Altinok et al., 2018; Deeks et al., 2010).

HRQoL in the current study was most impaired in relation to weight, menstrual, fertility and emotions and least impaired by hair growth despite its impact on psychological distress. Greenwood et al. (2018) reported that PCOS women with depressive symptoms rated their HRQoL as lower than PCOS women without depressive symptoms, indicating that level of psychological distress is an important consideration for HRQoL. The findings of the current study indicate that the way women perceive and feel about their bodies and PCOS related symptoms is negatively associated with perceived HRQoL and psychological health.

Consistent with the research indicating that women with PCOS experience body dissatisfaction at significantly higher rates than their healthy counterparts, the average level of body image concern noted in the current sample was high. Of note, a large percentage of the current PCOS sample reported clinically elevated levels of body image concern, an indicator for potential body dysmorphia. Body dysmorphia is associated with preoccupation with a perceived flaw in an individual’s physical appearance (Vashi, 2016). Some of the common areas of preoccupation for individuals with body dysmorphia include bodily hair and skin. However, for women with PCOS, their concern is about the visual PCOS symptom rather than a perceived flaw. It is important that their concern associated with the visual appearance of a PCOS symptom is not dismissed as dysmorphic and that the presence of the symptom is addressed medically. Psychological therapies may then be used to address any further psychological distress associated with the PCOS symptom, particularly in relation to acceptance of the symptom and overall self-concept.

Higher levels of depression and anxiety were also associated higher body image concern and poorer subjective body experience and attitude in the current PCOS sample. Significant reductions in emotional HRQoL were associated with higher levels of body image concern and greater negative subjective body experience and attitude. This is consistent with the association between body image factors and psychological distress and HRQoL reported in the literature (Deeks et al., 2011; Scaruffi et al., 2019). In combination, this indicates the relationship women with PCOS have with their bodies is linked to their psychological health and self-concept. The finding that women with PCOS report low self-compassion, and that impaired body image and depression influence self-compassion, is important given that self-compassion has been identified as a protective factor for psychological health and body image (Foroughi et al., 2019; Liss and Erchull, 2015).

From a clinical perspective, the current findings add meaning beyond previous research linking physical symptoms of PCOS to body image by identifying the important relationship between body image, psychological health and body compassion in women with PCOS. Body compassion is an emerging concept in clinical research that bridges the constructs of body image and self-compassion (Altman et al., 2020) and is most importantly fluid and changeable making it a suitable target for psychological intervention. The Altman et al. (2020) body compassion measure provides important insights into underlying mindfulness and acceptance-based constructs. Using this measure, the current study has demonstrated that body compassion is low in women with PCOS and that the concept is related to the experience of physiological symptoms, psychological distress, HRQoL and body image. It follows, that developing body compassion in women with PCOS could have important implications for both psychological health and HRQoL.

Psychological support for women with PCOS may be enhanced by including body compassion in the assessment and treatment of psychological distress associated with PCOS. It is recommended that psychological assessment of women with PCOS include body image measures and not be limited to measures of depressed mood and anxiety. Whilst the PHQ-15 (Kroenke et al., 2002) may effectively differentiate the experiences of women with PCOS from healthy controls, more specific measures of unique PCOS symptomology such as the PCOSQ (Cronin et al., 1998) should form part of routine screening in general health and psychological practices. Therapeutic programmes should go beyond self-compassion therapy to develop body-specific compassion due to its relationship to depression and body image in women with PCOS. This approach also needs to incorporate an understanding of the relationship women with PCOS have with their bodies and how this is associated with their self-concept which in turn is linked to their psychological health and quality of life. We argue that such interventions need to foster body compassion in women with PCOS to lower depressive symptoms and body image dissatisfaction.

Limitations

Analysis of the reproductive groups indicated that there was no significant difference between those reporting ‘never been pregnant’ and the other reproductive history categories on the PCOSQ Fertility score, however it would be useful to include a ‘have been unable to fall pregnant’ category in future research to differentiate the experience of women who have been unable to conceive from those who have not tried or do not plan to. The PCOS-specific information was self-report in nature and not clinically confirmed. The cross-sectional nature of the findings limits examination of potential variability in self and body compassion and further research is required to determine any longitudinal variations that may exist. Furthermore, the global distribution of the sample was skewed and data relating to participant race and gender identity was not recorded. Future research is needed that is inclusive of transgender and gender diverse individuals to determine generalisability of the findings. Given the strong correlation between the measures of self and body compassion, further research is required to determine the reliability of the Body Compassion Scale as a measure that specifically differentiates between self and body compassion.

Conclusion

Our findings add weight to the emerging concept of body compassion as a bridge between the constructs of self-compassion and body image. Higher levels of depression and body image concern were linked to lower levels of both self and body compassion for women living with PCOS. The findings of the current study indicate that the way women perceive and feel about their bodies and PCOS related symptoms is negatively associated with self and body compassion, HRQoL and psychological health.

Research Data

sj-sav-2-hpq-10.1177_13591053211059390 – for Physical and psychological correlates of self and body compassion in women with polycystic ovary syndrome

sj-sav-2-hpq-10.1177_13591053211059390 for Physical and psychological correlates of self and body compassion in women with polycystic ovary syndrome by Leesa M Van Niekerk, Holly Bromfield and Mandy Matthewson in Journal of Health Psychology

This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us-sagepub-com-s.web.bisu.edu.cn/en-us/nam/open-access-at-sage).

Research Data

sj-spv-1-hpq-10.1177_13591053211059390 – for Physical and psychological correlates of self and body compassion in women with polycystic ovary syndrome

sj-spv-1-hpq-10.1177_13591053211059390 for Physical and psychological correlates of self and body compassion in women with polycystic ovary syndrome by Leesa M Van Niekerk, Holly Bromfield and Mandy Matthewson in Journal of Health Psychology

Footnotes

Data Sharing Statement

The current article includes the complete raw dataset collected in the study including the participants’ data set, syntax file and log files for analysis. These files are all available in the Figshare repository and as Supplemental Material via the SAGE Journals platform.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Leesa M Van Niekerk

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