Psychosocial Aspects of PCOS Andrea Mechanick Braverman, PhD
PCOS: Issues and Challenges Psychological: depression, anxiety, self-esteem and reactions Irregular periods Hair growth Health Type 2 Diabetes Increased risk of cardiovascular disease eg. strokes, heart attacks Acne Infertility Disease distress
Hirsutism Excessive hair due to elevated androgen levels Is associated with distress So what is good self-care? Medical management Electrolysis Laser removal Waxing
Hirsutism 229 patients with PCOS Ages 14-52 Clinicians and patients rated degree of hirsutism using the modiefied Ferriman-Gallwey instrument Beck Depression Inventory Fast screen Only self-ratings of hirsutism were significantly associated with depression Higher degrees of hirsutism by both were moderately associated with more negative QoL impact Patients rated hirsutism as more severe than clinicians Pasch L, He SY, Huddleston H, Cedars MI, Beshay A, Zane LT, Shinkai K. Clinician vs Self-ratings of Hirsutism in Patients With Polycystic Ovarian Syndrome: Associations With Quality of Life and Depression. JAMA Dermatol. 2016 Mar 4. doi: 10.1001/jamadermatol.2016.0358. [Epub ahead of print]
And other issues.. Foggy brain/concentration problems? Sexual side effects Pain during intercourse
Managing a chronic disease
Chicken or Egg Syndrome? Are mood/emotional problems in PCOS are caused by the distress associated with the symptoms often seen in PCOS or are they part of PCOS?
Anxiety and Depression 12 comparative studies were included; all studies assessed depression (910 women with PCOS and 1347 controls) and 6 also assessed anxiety (208 women with PCOS and 169 controls) women with PCOS on average tend to experience mildly elevated anxiety and depression, significantly more than women without PCOS women with PCOS with lower BMI tended to have slightly lower anxiety and depression scores, suggesting that having a lower BMI reduces anxiety and depression Barry JA, Kuczmierczyk AR, Hardiman PJ. Anxiety and depression in polycystic ovary syndrome: a systematic review and meta-analysis. Human Reproduction, Vol.26, No.9 pp. 2442 2451, 2011.
More research Higher emotional distress was consistently found in PCOS patients (28 studies with 2384 patients and 2705 control women) and in all the three examined emotional distress domains; i.e. depression, anxiety and the emotional Quality of Life measures Many women perceive the visible features of PCOS (e.g. hirsutism) and its common correlates (e.g. infertility and obesity) as stigmatizing and a source of distress depression was present in obese and infertile women as well as in lean and fertile patients with PCOS Veltman-Verhulst SM, Boivin J, Eijkemans M, Fauser B. Emotional distress is a common risk in women with polycystic ovary syndrome: a systematic review and meta-analysis of 28 studies. Human Reproduction Update, Vol.18, No.6 pp. 638 651, 2012
Should we be screening for anxiety and depression?
Screening for Anxiety & Depression The U.S. Preventive Services Task Force (USPSTF) recommends screening in all adults regardless of risk factors. However, there are a number of factors that are associated with an increased risk of depression. Among general adult populations, prevalence rates vary by sex, age, race/ethnicity, education, marital status, geographic location, and employment. Women, young and middle-aged adults, and nonwhite individuals have higher rates of depression than their counterparts, as do persons who are undereducated, previously married, and unemployed. Other groups at increased risk of developing depression include persons with chronic illnesses (e.g., cancer or cardiovascular disease), other mental health disorders (including substance misuse), and a family history of psychiatric disorders. Risk factors for depression during pregnancy and postpartum include prenatal depression, poor self-esteem, childcare stress, prenatal anxiety, life stress, decreased social support, single/unpartnered relationship status, history of depression, difficult infant temperament, maternity blues, lower socioeconomic status, and unintended pregnancy. Among older adults, risk factors for depression include disability and poor health status related to medical illness complicated grief, chronic sleep disturbance, loneliness, and a personal history of depression. However, the presence or absence of risk factors alone cannot distinguish patients with depression from patients without depression. Screening Tests The Patient Health Questionnaire (PHQ) is the most commonly used depression screening instrument in the United States. Other commonly used depression screening instruments include the Hospital Anxiety and Depression Scales in adults, the Geriatric Depression Scale in older adults, and the Edinburgh Postnatal Depression Scale (EPDS) in postpartum and pregnant women. All positive screening tests should trigger additional assessment that considers severity of depression and comorbid psychological problems (e.g., anxiety, panic attacks, or substance abuse), alternate diagnoses, and medical conditions.
Great idea but then what. Biggest barrier to screening is access to good mental health services
Weight, body image, and distortion
Obesity and Psychological Wellbeing Distress with elevated BMI? 403 women stratified by BMI and PCOS/not PCOS Obesity, overweight, normal weight not different for general mood or fertility specific distress PCOS status had elevated shape concerns and anxiety independent of BMI Rodino IS, Byrne S, Sanders KA. Obesity and psychological wellbeing in patients undergoing fertility treatment. Reprod Biomed Online. 2016 Jan;32(1):104-12.
How do we distort our own self-image?
Infertility Associated independently with high levels of distress Impact of treatment Impact on relationship with partner
Finding and building support
Physical and Emotional Support Find a physician with whom you can partner Bring along a health partner Find your support network (and keep a deep bench) No one person can do all the support Consider skills building with a therapist
Anti-Isolation
Counseling and other tools
Counseling Normalize Building skills: guided imagery, muscle relaxation Mindfulness Acknowledging the fears and reactions Understand the role of counseling Recognizing and alleviating burden Giving coping strategies Reducing suffering CBT
Cognitive Behavioral Therapy (CBT) Considers that we all have core beliefs, thoughts and reactions that can be inaccurate, distorted or negative Training to be aware of these allows for the ability to challenge these negative thoughts and beliefs
http://www.therapistaid.com/therapy-worksheet/core-beliefs/cbt/none
How it can work Situation: I have excess hair Core Belief: I am unattractive Thought: People will judge me Behavior: I will take the best care of myself Challenge: Maybe people see me differently than I see myself
Not! I have excess hair I feel unattractive
So.How Do We Help Women (and their Supporters) View PCOS?
How To Frame Things? OR OR
OR
OR
Exercise? Why?
Exercise > 3-5 times week Increase energy Reduce muscle discomfort Reduce depression and anxiety Improve sleep Reduce hot flashes Improve body image Weight control Weight bearing exercise Helps with cognitive functioning Improve health outcomes Small steps add up! Start slow and build up!
Sleep Quantity and Quality 34
Coping With Stress in General Stress arises when individuals perceive that they cannot adequately cope with the demands being made on them or with demands being made on them or with threats to their well-being. Lazarus, R.S. (1966)
Stress Anything that stimulates and increases your level of alertness Stress is perceived as pressure and strain with a sense of urgency attached
Psychoeducation about stress: Anxious Irritable Lonely Have feelings of worthlessness Are blaming others Hostile or aggressive behavior Experiencing emotional outbursts/crying
Women: Multitasking, Rumination, Insomnia, Agitation & Depression
Teaching about Compare-atitis
Cognitive Reframing PCOS Me
We Can Move This But not this
We do this all the time..
Teaching active self care! What s BS? Breath Shoulders Being present and mindful
Set Reasonable Expectations
Increase Support Ask for Help! Reduce isolation Not the only one walking in your shoes Ask for support
Ultimately
Help PCOS Women Rock the Journey!