Comparing the effectiveness of emotion-focused and... : Journal of Education and Health Promotion (2024)

Introduction

Polycystic ovary syndrome (PCOS) is a heterogeneous disease that usually occurs in women of childbearing age, and is associated with complications such as infertility, obesity, insulin resistance, and increased androgen levels.^[1] This syndrome is an endocrinopathy disorder characterized by chronic hyperandrogenism and anovulation, and its symptoms appear in the early years of puberty with irregular menstrual cycles, ovulation, and acne.^[2] Polycystic ovary syndrome is associated with significant complications and reduced quality of life^[3] and causes complications such as overweight, menstrual disorders, depression, anxiety, isolation, reduction of femininity characteristics, and disruption of marital relationships.^[4]

The increase in the prevalence of eating disorders followed by overweight in women with PCOS causes body image dissatisfaction.^[5] Dissatisfaction with body image is a negative evaluation of personal physical characteristics, including dissatisfaction with body shape, gender, sexual organs, and appearance, and it plays an important role in quality of life.^[6] Research has shown that in women with PCOS, the level of stress caused by body image is high, and this factor increases the level of anxiety and depression.^[7] Women with PCOS feel less satisfied with their physical appearance and show more social anxiety and fear.^[8] Emotional problems such as anxiety and depression are common among women with PCOS, compared to healthy women.^[9] In previous studies, it has been determined that PCOS is associated with anxiety^[10] and depression^[11] and a lower quality of life.^[12]

Among the therapies that seem to be effective on body image and anxiety and depression in women with PCOS are emotion-focused therapy (EFT) and cognitive-behavioral therapy (CBT). These methods guide the therapist and clients toward strategies that enable awareness, acceptance, application, regulation of emotions and emotions, and the experience of correcting emotions and emotions with the help of the therapist. Emotion-focused therapy is based on the premise that the most efficient way to change maladaptive emotions is not through changing the way you think or learning a new skill, but through activating more adaptive emotions.^[13] For this reason, it can be a predictor of success in the treatment of a syndrome such as PCOS, and have lasting effects in its treatment. Emotion-focused therapy has been proven effective in the treatment of many disorders such as depression, anxiety, and eating disorders.^[14] Therapy helps patients to become aware of their feelings and reconstruct the abnormal cognitive–emotional schemas that are often the basis of anxiety symptoms and ultimately recover.^[15] Research has shown that EFT is an effective intervention method for improving body image for women.^[16]

Cognitive-behavioral therapy is undoubtedly one of the most important developments in the process of improving psychopathology in the last 50 years. This therapy can cause self-monitoring, setting realistic and attainable goals, developing new coping skills to control or prevent the recurrence of complications caused by this syndrome, and promoting alternative behaviors in psychological and emotional crisis situations in women with PCOS.^[17] The set of disorders that have responded well to CBT include psychotic disorders, depression, anxiety disorders, personality disorders, aggression, discomfort caused by pain and chronic fatigue, pregnancy complications, and women’s hormonal imbalance.^[18] Cognitive-behavioral therapy causes brain activation and functional changes in the amygdala, insula, and anterior corticolimbic circuits of the brain, which control cognitive, motivational, and emotional aspects of physiology and behavior and can be effective in improving the performance of people with chronic diseases.^[19] Additionally, CBT is recommended by the American Psychological Association and the American College of Physicians as a first-line treatment for depression.^[20]

According to the research background, it is possible that both treatment methods are effective in the treatment of PCOS complications due to underlying reasons. So far, limited research has been done to investigate the effects of EFT and CBT on body image, anxiety, and depression in women with PCOS. Considering the extent of the consequences of this syndrome in women, despite the use of drug treatments, the application of psychological therapies can be effective to a large extent. Based on this, this research intends to achieve a general treatment in addition to maintenance drug treatments to improve the complications of this syndrome by comparing the effectiveness of therapeutic methods of EFT and CBT from the aspect of body image, anxiety, and depression in women with PCOS. With the aim of which of EFT and CBT therapies can be more effective on body image, anxiety, and depression in women with PCOS.

Materials and Methods

Study design and setting

The current research is a semi-experimental study with a pre-test and post-test design with a control and follow-up group. Women with PCOS between the ages of 25 and 45 who referred to the infertility clinic of Afzalipur Hospital in Kerman were included in this study. The method of conducting the study was that after coordinating with the Hospital, researcher referred to the infertility department and selected women with PCOS who were ready to cooperate. After introducing and stating the objectives and the necessity of conducting the research in order to comply with ethical points, first, the consent form for participation in the study was completed by the subjects and they were given the opportunity to withdraw from the research at any moment they wished. The participants were assured that all their information would be kept confidential. Then, the demographic characteristics, body image, depression, and anxiety questionnaires were provided to them and collected after completion. A total of 45 patients were selected by convenience sampling method. Then, participants were randomly divided into 3 groups of 15 people and matching was done based on being married, age, and education. The first group includes 15 women with PCOS who received EFT during eleven sessions. The second group included 15 women with PCOS who received CBT during eighteen sessions, and the third group included 15 women with PCOS who were placed in the control group and did not receive any therapy. The summary of the interventional sessions are presented in Tables 1 and 2. Inclusion criteria were: women aged 25–45 years, having a minimum education to be able to answer the questionnaires and complete an informed consent form stating that participation in treatment sessions is voluntary, not suffering from physical and mental diseases and substance abuse. Exclusion criteria included: participating in interventional studies related to mental health at the same time, having an unexpected pregnancy and surgery, and having more than two absences for various reasons.

Study participants and sampling

The statistical population of the study includes all women with PCOS between 25 and 45 years of age who visited the infertility clinic of Afzalipur Hospital in Kerman. The research sample consisted of 45 patients and was selected by available sampling method. The participants were randomly divided into 3 groups. 15 people divided and matched based on being married, age, and education, the first group included 15 women during eleven EFT sessions, the second group included 15 women who received CBT during eighteen sessions, and the third group included 15 women with PCOS who were in the group were controlled and did not receive any treatment.

Data collection tool and technique

The following tools and techniques were used to collect data.

Body Image Questionnaire (BIQ): This questionnaire contains 46 items designed to assess body image by Cash et al.^[21] In its initial form, the BIQ has 6 subscales, which include appearance evaluation, appearance orientation, fitness evaluation, fitness orientation, overweight preoccupation or subjective weight, and body areas satisfaction. This questionnaire is in the form of a Likert scale, in which questions 1–37 are graded from 5 completely agree to 1 completely disagree, and questions 38–46 are graded from 5 very satisfied to 1 very dissatisfied. Scores from 46 to 108 indicate a person’s level of bad satisfaction with the multidimensional relationships of his body. Scores from 108 to 170 indicate a person’s average satisfaction with the multidimensional relationships of his body, and scores from 170 to 230 indicate a person’s good satisfaction with the multidimensional relationships of his body. Cash et al., showed that all subscales of the questionnaire have acceptable internal consistency and stability, and the validity of the subscales ranged from 0.83 to 0.92 Cronbach’s alpha.^[21] The Persian version of the BIQ was validated in the study of Izaadi et al.^[22] and Cronbach’s alpha of the whole questionnaire was reported as 0.87. In this study, the total Cronbach’s alpha was 0.82.

Depression Inventory-short form: The depression inventory was prepared by Beck and Steer in 1961 and its revised form was published in 1987. This questionnaire has 21 questions and its scoring is based on Likert scale from 0 to 3. The validity of the questionnaire using the test–retest method has been reported as 0.48 to 0.86.^[23] In Iran, Rajabi^[24] reported the Cronbach’s alpha coefficient for the whole questionnaire as 0.89, the correlation coefficient between the short form and the 21-question form as 0.67. In the present study, the total Cronbach’s alpha was 0.86.

Beck Anxiety Inventory (BAI): The anxiety inventory was introduced by Iron Beck, 1990. Beck Anxiety Inventory is a self-report questionnaire prepared to measure the intensity of anxiety in teenagers and adults. Its internal hom*ogeneity using alpha coefficient is 0.92, its reliability is 0.75 with a retest interval of one week, and the correlation of its items varies from 0.30 to 0.76.^[25] Kaviani and Mousavi^[26] validated its Persian version and reported its reliability coefficient as 0.92 with a two-week interval. In this study, Cronbach’s alpha was calculated at 0.81.

Treatment sessions for women with PCOS were conducted based on Leahy’s cognitive-therapy techniques^[27] and Johnson’s EFP,^[28] and the content validity of the treatment protocols was checked and confirmed by psychological specialists and psychotherapists. Then, the subjects responded to body image, anxiety, and depression questionnaires immediately after holding the training sessions and three months after the end of the therapy sessions. The data were analyzed by using analysis of covariance and IBM SPSS Statistics version 21.0.

Ethical consideration

This study was approved by the ethical committee of the Islamic Azad University Torbat-e Jam branch with the ethical code IR.IAU.TJ.REC.1401.043.

Results

The mean and standard deviation of body image, anxiety, and depression scores are shown in Table 3. The Kolmogorov–Smirnov test was used to check the normality of the variables. The results showed that the presumption of normality of research variables was observed and the distribution of all variables was normal (P > 0.05). To check the hom*ogeneity of variance–covariance matrices, the Boxes M test was applied (M = 9.33, F = 1.42, P < 0.05). Levine’s test was used to investigation the variances in the dependent variable. F values in Levine’s test for body image (F = 0.01, P < 0.05), anxiety (F = 1.174, P < 0.05), and depression (F = 0.09, P < 0.05) are not significant. Therefore, the error variances in the research variables in the experimental and control groups do not have a significant difference, in other words, the difference between the groups is significant.

Boxes M test was also used to check the equality of the covariance of the groups and the results showed that the hypothesis of the equality of the covariance of the groups was confirmed at the level of 0.05 (F = 1.15, P = 0.255).

Multivariate Analysis of Covariance (MANCOVA) was used to investigate the effectiveness of EFT and CBT on body image, anxiety, and depression in women with PCOS. According to the results, as can be seen in Table 4, the significance levels of Pillai’s effect, Wilks’s lambda, Hotelling’s effect, and Roy’s largest root are less than 0.05, which indicates that two experimental groups and the control group have a significant difference in at least one of the variables. This shows that the therapies of EFT and CBT are effective on each of the study variables such as body image, anxiety, and depression.

The results of MANCOVA in Table 5 show that the effectiveness of EFT on body image, anxiety, and depression is significant (P < 0.05); According to the results, it can be said that the amount of this effect on body image is 21%, anxiety 14% and depression 21%. Also, the effectiveness of CBT on body image, anxiety, and depression was significant (P < 0.05); the effect size on body image is 47%, anxiety 22%, and depression 38%. Considering the effect coefficient, the comparison of the two therapies shows that the effect of CBT on body image, anxiety, and depression was more than EFT.

Also, the post-test and follow-up mean were compared, which results are shown in Table 6. According to the results, there is no significant difference between the post-test and follow-up scores (P > 0.05), in other words, the therapy effect was permanent and there was no change in the mean follow-up scores compared to the post-test.

Discussion

The present study was conducted with the aim of comparing the effectiveness of EFT and CBT on body image, anxiety, and depression in women with PCOS. According to the results, EFT and CBT were effective on body image, anxiety, and depression of women with PCOS, while the effectiveness of CBT was more than EFT on research variables. The results of this study were consistent with the findings of Glisenti et al.,^[29] Najafi et al.,^[30] Paulson et al.,^[7] and Cooney et al.^[20] Hamdan-Mansour et al. showed in their research that the use of CBT is very effective in reducing depression symptoms.^[31] Also, Heidary and Akbarzadeh found that women with PCOS who have overweight and obesity and symptoms of anxiety and depression improved significantly after receiving CBT, which indicates CBT can increase the level of health-promoting behaviors.^[32] Geschwind et al. also found that CBT improves depression.^[33] In explaining the results of the present study, it can be said that negative perceptions of body image in patients with PCOS are associated with dissatisfaction with appearance, decreased female identity, decreased feeling of sexual attractiveness, and self-consciousness about appearance. Many women’s self-esteem is based solely on their body image, and thus affects their social functioning and interpersonal relationships. As a result, the attitude towards the body is different in women with PCOS.^[34] These women have symptoms of body deformity disorder, depression, and anxiety. Research has shown that psychotherapy interventions aimed at improving body image may also reduce symptoms of depression and anxiety.^[35] In cases where a person has severe dissatisfaction with his body image, this issue can lead to body dysmorphia disorder, which is characterized by an irrational focus on illusory or partial body defects.^[36] Moreover, studies have shown that depression level in obese women with PCOS is more than healthy obese women.^[37] One of the interventions that can play a major role in improving the complications caused by a chronic disease and the problems caused by it is CBT, because the main goal of this therapy is to change people’s beliefs and behaviors that affect their performance.^[38] Therefore, CBT helps to reduce body image dissatisfaction through changing beliefs. Because the main emphasis of this approach is on the effectiveness that cognition, emotion, and behaviors have on each other.^[39]

In CBT, unreasonable cognitions and negative hypotheses are challenged, which play a role in creating unpleasant emotional conditions. In order to have a successful treatment, it is necessary to solve underlying problems such as anxiety and depression.^[40] By changing the beliefs and as a result of changing the behavior, performance, and habits of these people and by challenging unreasonable cognitions and negative hypotheses, they can gain more ability to deal with the problems caused by the syndrome and have a healthier lifestyle along with the maintenance of drug treatment. In EFT, examining the basic factors of processing emotional schemas, such as cognitive-behavioral and emotional factors, is considered as the main therapeutic goal. Therefore, it can be said that people can learn with the experience they gain in the emotional awareness stage, instead of suppressing their emotions or being defeated by them, they should be aware of their emotions and come to the knowledge that negative emotions are not necessarily stable and can be controlled.^[41]

According to previous studies, the complications of PCOS are depression, anxiety, overweight, and inappropriate body image, and CBT is the standard model of psychological intervention for the treatment of this group of sufferers.^[42] Therefore, the effectiveness of this treatment can be explained. Emotion-focused therapy is also an effective approach and a standard model of psychological intervention to reduce the incompatible negative cycle and deepen emotional experiences, especially attachment, increasing awareness of emotions, expressing new emotions, coping with the difficulties of emotional regulation, and appropriate emotional expression in the conditions faced with problems^[43] and in this way, it can be effective in treating the wide complications of this syndrome.

Regarding the comparison of two therapy approaches, considering that body image, anxiety, and depression are among the disorders that are strongly influenced by unreasonable cognitions and negative hypotheses. In CBT, unreasonable cognitions and negative hypotheses that play a role in creating unpleasant emotional conditions are challenged, so the effectiveness of CBT seems natural. Also, one of the other factors that cause body image dissatisfaction, anxiety, and depression in women with PCOS is low self-esteem and feeling of self-efficacy. According to Lowndes et al.,^[44] an important issue that can be raised about the effectiveness of CBT is the increase in self-efficacy of people participating in the therapy period after receiving CBT. Accordingly, the effect of CBT is more than EFT in women with PCOS.

Limitation and recommendation

This study had limitations in that it was not possible for all women with PCOS to participate in the research, and also the samples of the present study were limited to a specific geographical region, which can limit the generalizability of the results. Since this research was unique to the Kerman city, it is suggested to be used in other communities as well. It is also recommended that therapists use CBT in order to increase body image satisfaction and reduce anxiety and depression in women with PCOS.

Conclusion

According to the research results, CBT can reduce body image dissatisfaction, anxiety, and depression in women with PCOS. Therefore, it is necessary to use this therapy in order to increase the level of satisfaction with the body image and reduce the anxiety and depression of women with PCOS. Also, therapists are advised to pay attention to the effectiveness of this treatment therapy.

Ethical considerations

In order to comply with ethical issues, written consent was obtained from the subjects before entering the research. The subjects entered the research voluntarily and there was no compulsion in this case. In addition, the information about the subjects was kept confidential.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

This article was approved by the Ethics Committee of Islamic Azad University, Torbat-e Jam branch, with the code IR.IAU.TJ.REC.1401.043. We hereby express our gratitude to the patients and medical staff that cooperated with the researchers.

References