Psychology, Health & Medicine

ISSN: 1354-8506 (Print) 1465-3966 (Online) Journal homepage: https://www.tandfonline.com/loi/cphm20

Psychological distress in women with polycystic

ovary syndrome: the role of attachment and
coping

Signe Simon, Merle Keitel, Cara Bigony & Jennie Park-Taylor

To cite this article: Signe Simon, Merle Keitel, Cara Bigony & Jennie Park-Taylor (2020):
Psychological distress in women with polycystic ovary syndrome: the role of attachment and
coping, Psychology, Health & Medicine, DOI: 10.1080/13548506.2020.1754436

To link to this article: https://doi.org/10.1080/13548506.2020.1754436

Published online: 20 Apr 2020.

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PSYCHOLOGY, HEALTH & MEDICINE
https://doi.org/10.1080/13548506.2020.1754436

Psychological distress in women with polycystic ovary

syndrome: the role of attachment and coping
Signe Simon, Merle Keitel, Cara Bigony and Jennie Park-Taylor
Fordham University, Graduate School of Education, New York, NY, USA

ABSTRACT ARTICLE HISTORY

Polycystic ovary syndrome (PCOS), a chronic female endocrine dis- Received 17 June 2019
order, is a leading cause of infertility and its symptoms tend to Accepted 31 March 2020
negatively affect appearance, physical health, and psychological KEYWORDS
well-being. Utilizing attachment theory as a theoretical framework, polycystic ovary syndrome;
this study examined the relationships among anxious and avoidant attachment; hyperactivating
attachment, hyperactivating and deactivating coping, and psycho- coping; deactivating coping;
logical distress in a sample of 183 women diagnosed with PCOS. distress
Hierarchical multiple regression analyses revealed significant rela-
tionships among attachment, coping, and distress as well as media-
tion effects. Implications, limitations, and recommendations for
future research are discussed.

PCOS affects between 4.8 and 8% of women (Azziz et al., 2004), with estimates up to 20%
depending on diagnostic criteria used (Sirmans & Pate, 2013). PCOS is associated with
significant negative health and psychological outcomes. Compared to women without
PCOS, women with PCOS were twice as likely to be hospitalized for diabetes, obesity,
hypertension, and heart disease, and were eight times more likely to require infertility
treatment (Hart & Doherty, 2015). Women with PCOS were found to be more anxious
(Jedel et al., 2010), angry, and have lower quality of life (Borghi et al., 2018). Borghi and
colleagues also showed a potentially reciprocal relationship between physical PCOS
symptoms (e.g., hirsutism) and women’s ability to manage illness anxiety. Similarly,
a meta-analysis revealed that women with PCOS have higher depression scores than
matched controls of reproductive age without PCOS (Dokras et al., 2011). Further,
women with PCOS were twice as likely to be hospitalized for stress, anxiety, depression,
illicit drug use, and self-harm behaviors (Hart & Doherty, 2015).
This recent research highlights the importance of helping women with PCOS develop
adaptive coping strategies. The current study examined how attachment relates to coping
and distress in women with PCOS. Kessler et al.’s (2002) integrative model of attachment
provided a theoretical framework whereby internalized representations of attachment
figures are posited to influence our beliefs about our ability to regulate when under stress.
Attachment anxiety and avoidance likely affect how women with PCOS cope with the
condition, interact with health care providers, and seek social support. Women with high
attachment anxiety and/or avoidance may engage in coping behaviors that compromise

CONTACT Signe Simon ssimon8@fordham.edu

© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 S. SIMON ET AL.

their long-term care. If that is the case, tailoring treatment to women with different
attachment styles may be important.

Attachment and coping

Research on coping with PCOS is limited, and the influence of attachment on coping
with PCOS has not been explored despite the broader literature supporting a relationship
between attachment and coping (e.g., Bayley et al., 2009). Interventions to help women
with PCOS are thus likely uninformed by attachment. In order to determine the most
effective interventions to help women cope with the physical and psychological toll of
PCOS, it is important that the role of attachment in coping be established.
The attachment relationship experienced in childhood is the context in which we
internalize the self–other representations that set our expectations about others’ avail-
ability to help in moments of distress (Bowlby, 1969; Sobel, 1982). Attachment patterns
have been categorized as secure, anxious, and avoidant. Securely attached individuals
utilize adaptive strategies to regulate emotions. Under stress, these individuals maintain
a positive view of self and confidence in their ability to self-regulate (Mikulincer &
Shaver, 2010). Anxiously attached individuals experience attachment figures as unpre-
dictable and have low levels of distress tolerance. They use hyperactivating coping
strategies, such as catastrophizing and wishful thinking, intensifying negative emotions
to gain the attention of attachment figures (Mikulincer & Shaver, 2010). Anxiously
attached individuals may seek social support in ways that could overwhelm potential
supports. Avoidantly attached individuals experience attachment figures as unavailable,
leading to self-reliance and intimacy avoidance (Mikulincer & Shaver, 2010). When
stressed, these individuals use deactivating strategies, increasing self-reliance, suppress
emotion, and create distance from attachment figures (Mikulincer et al., 2003). However,
under intense or prolonged distress, these beliefs that they can tolerate stress alone lead to
strategies that actually increase symptoms (Kobak & Sceery, 1988).
No studies have examined attachment, coping, and distress in women with PCOS.
Research on women experiencing infertility (a condition associated with PCOS), how-
ever, shows links between insecure attachment and negative psychological symptoms
(Amir et al., 1999). Furthermore, Bayley et al. (2009) found that both anxious and
avoidant attachment are associated with women’s infertility stress, and that avoidance
and self-blame coping mediated the relationship between anxious attachment and stress.
Negative emotional coping has been observed in chronically ill women with high levels of
attachment anxiety, and diverting coping was observed in women with high attachment
avoidance (Schmidt et al., 2002). Given that adaptive coping strategies are necessary for
long-term psychological and physical functioning (e.g., Ussher & Perz, 2017), and are
strongly linked to attachment styles, investigating these variables can increase our under-
standing of women coping with PCOS.

Present study
This study examined the effects of anxious and avoidant attachment on distress and
coping strategies in a national sample of women with PCOS in their reproductive years. It
was hypothesized that: (a) both anxious and avoidant attachment scores respectively
 PSYCHOLOGY, HEALTH & MEDICINE 3

would be significantly associated with scores for distress and hyperactivating and deac-
tivating coping strategies to manage PCOS, (b) that the relationship between anxious
attachment and distress would be mediated by use of hyperactivating and deactivating
coping strategies, and (c) that the relationship between avoidant attachment and distress
would be mediated by the degree of use of hyperactivating and deactivating coping
strategies.

Method
Participants
Participants were 183 women aged 25 to 45 (mean age 33.67); who received a PCOS
diagnosis; were fluent in English and reported being troubled by PCOS symptoms. Mean
age at diagnosis was 26.12 (SD = 6.74). The sample consisted of White (79.8%), Black
(7.1%), Hispanic (4.9%), and Asian (4.9%) participants. On a 7-point, Likert-scale
measure of PCOS symptoms, participants scored an average of 4.40 (SD = 1.05), indicat-
ing significant symptoms. Participants reported distress due to irregular menstruation,
fatigue and sleep issues, obesity and unwanted hair. Notably, 35.5% of women reported
current infertility problems. Most women (67%) were being treated for PCOS [e.g., birth
control pills (29%), nutritional counseling (23%)]. One quarter of participants (24.6%)
reported a psychiatric diagnosis and 30% reported receiving mental health treatment.
A power analysis was conducted using G*Power (Faul et al., 2009) for regression
analyses using nine predictors to account for study variables and potential covariates. The
significance value was set at p<.05, the power was set at .80, and the effect size was set to
medium (ƭ2 = .15). The required sample for this study was determined to be 114. The final
sample of 183 exceeded the recommended sample size.

Measures
Demographic questionnaire
This questionnaire assessed gender, age, race/ethnicity, socioeconomic status, occupa-
tion, and medical history (including age of diagnosis, mental health diagnoses, treatment,
and medications).

PCOS symptom questionnaire

The severity of physical PCOS-specific symptoms (i.e., unwanted hair, weight gain,
irregular menstruation, sleep problems, pelvic pain, hair loss, fatigue, small ovarian
cysts, acne or patches of dark skin, infertility) was measured on a 7-point Likert scale
(1 = not at all, 7 = very much). These criteria aligned with the American Congress of
Obstetricians and Gynecologists (2011) designation of PCOS symptoms.

Experience of close relationships-revised

(ECR-R; Fraley et al., 2000). This 36-item instrument assessed anxiety and avoidance
attachment (each represented by 18 items) on a 7-point Likert scale ranging from 1
(strongly disagree) to 7 (strongly agree). Cronbach alpha coefficients for avoidant and
anxious attachment were .94 and 96, respectively.
4 S. SIMON ET AL.

Coping strategies inventory

(CSI; Tobin et al., 1983). This 72-item measure assessed, on a 5-point Likert scale, how
individuals cope with PCOS. Four of eight subscales were analyzed (e.g., Wishful
Thinking, Express Emotion, Problem Avoidance, and Social Withdrawal.). The
Hyperactivating Coping scale was composed of the Wishful Thinking and Express
Emotion subscales; the Deactivating Coping scale was composed of the Problem
Avoidance and Social Withdrawal subscales. Both scales showed strong internal consis-
tency (Cronbach’s α = .89 for hyperactivating and .92 for deactivating coping).

Kessler distress scale

(KD10; Kessler et al., 2002). This 10-item questionnaire measures global psychological
distress (primarily depression and anxiety) on a 5-point Likert scale ranging from 1 (none
of the time) to 5 (all of the time). Possible scores range from 10 to 50 with 50 signifying the
most distress (Andrews & Slade, 2001). The KD10 demonstrated strong internal con-
sistency (α = . 94).

Procedures
APA ethical guidelines were followed and IRB approval obtained. The investigators used
Qualtrics, a web-based research panel recruitment service (http://www.qualtrics.com/).
Email invitations to qualifying participants are randomized to reduce bias and contain no
specifics about the survey topic other than that the participant qualifies. Our participants
met criteria if they were aged 25 to 45, had a PCOS diagnosis, were troubled by PCOS
symptoms, and did not have diabetes or cancer. Given elevated anxiety and depression
rates in women with PCOS, women with psychiatric diagnoses were included.
Participants completed self-report surveys and were each paid 20. USD Administration
order was as follows: (a) demographics, (b) PCOS symptoms, (c) ECR-R, (d) CSI, and (e)
K10. Symptom questions were presented early to prime participants to think about their
PCOS as they answered attachment and distress questions.

Results
Descriptive statistics were computed for attachment and coping subscales (see Table 1)
and all subscales were normally distributed. Paired samples t-tests showed a significant
difference between anxious and avoidant scores (t = 3.15, p < .001). On average, anxiety
scores were .31 points higher than avoidant scores (SD = 1.35). Participants employed

Table 1. Descriptive Statistics: Research Variables.

Variable M SD Min Max zskewness α
Avoidant Attachment 3.20 1.20 1.00 6.56 −0.04 .94
Anxious Attachment 3.52 1.60 1.00 6.61 −0.67 .96
Hyperactivating 3.03 0.70 1.33 4.67 –0.58 .89
Deactivating 2.63 0.80 1.11 4.67 1.82 .92
Distress 2.83 0.98 1.00 5.00 0.16 .94
N = 183. zskewness = skewness divided by skewness standard error. The possible range of averaged scores for Avoidant and
Anxious Attachment was 1.00 to 7.00, Hyperactivating and Deactivating was 1.00 to 5.00, and Distress was 1.00 to 5.00.
 PSYCHOLOGY, HEALTH & MEDICINE 5

hyperactivating coping (mean = 3.03) strategies to a greater extent than deactivating

coping (mean = 2.63) strategies (t = 8.35, p < .001).
Prior to hypothesis testing, Spearman rho coefficients were calculated to assess for
potential covariates. Higher education and annual household income were associated
with significantly less distress, while psychiatric diagnosis, receiving mental health treat-
ment, and high PCOS symptom levels were associated with significantly higher distress.
The five covariates were collectively entered in the first step of the hierarchical multiple
linear regression (HMLR) analysis to test the following hypotheses.

Hypothesis 1
Our first hypothesis was that anxious and avoidant attachment scores would be signifi-
cantly associated with both distress and hyperactivating coping (HC) and deactivating
coping (DC) strategies to manage PCOS. HMLR analyses were conducted to determine if
(a) the independent variables (anxious and avoidant attachment) significantly predicted
the dependent variable (distress), (b) the independent variables (anxious and avoidant
attachment) significantly predicted the mediators (HC and DC), and (c) the mediators
(HC and DC) significantly predicted distress.
Relationships between independent variables, anxious and avoidant attachment, and
the dependent variable, distress, were examined. KD10 scores were regressed onto
anxious attachment scores, revealing that anxious attachment significantly predicted
distress, R2 = .51; F(6, 175) = 29.77, p < .001; β = .43, p < .001. KD10 scores were
regressed onto avoidant attachment scores, revealing that avoidant attachment signifi-
cantly predicted distress, R2 = .45; F(6, 175) = 23.91, p < .001; β = .31, p < .001.
Next, the relationship between the independent variables, anxious and avoidant
attachment, and mediators (HC and DC) were examined. HC scores were regressed
onto anxious attachment scores, revealing that anxious attachment significantly predicts
HC, R2 = .18; F(6, 175) = 6.59, p < .001; β = .28, p < .001. DC scores were regressed onto
anxious attachment scores and revealed that anxious attachment significantly predicted
DC, R2 = .37; F(6, 175) = 16.98, p < .001; β = .46, p < .001.
When HC scores were regressed onto avoidant attachment scores, findings showed
that avoidant attachment did not significantly predict HC, R2 = .13; F(6, 175) = 4.16,
p < .01; β = −.06, p = .62. When DC scores were regressed onto avoidant attachment
scores, findings revealed that avoidant attachment significantly predicted DC, R2 = .28; F
(6, 175) = 11.08, p < .001; β = .29, p < .001. The relationships between the mediators and
dependent variable were examined. Both DC, R2 = .63; F(6, 175) = 49.05, p < .001; β = .58,
p < .001, and HC, R2 = .47; F(6, 175) = 25.37, p < .001; β = .35, p < .001, predicted distress.

Hypotheses 2 and 3: mediation analyses

Three models were examined for mediation effects using HMLR. Mediation analyses
were conducted to examine whether HC and DC would mediate the relationship between
attachment anxiety and distress, and to examine whether DC would mediate the relation-
ship between attachment avoidance and distress. For each analysis, CSI scores and ECR-
R scores were regressed onto KD10 scores, and the Sobel test, a conservative test of
significance for mediation effects (Sobel, 1982), was used.
6 S. SIMON ET AL.

Table 2. Model 1 mediation regression analyses: attachment anxiety

and hyperactivating coping.
Distress
Step R2 β p
Step 1 .34***
PCOS symptom level .42*** < .001
Household income −.13 .062
Education .00 .960
Psychiatric diagnosis −.18* .034
Mental health treatment −.22** .007
Step 2 .51***
Attachment anxiety .43*** < .001
Step 3 .56***
Hyperactivating coping .26*** < .001
Attachment anxiety .35*** < .001
N = 183.
*p < .05. **p < .01. ***p < .001.

For hypothesis 2, to examine whether HC was a mediator of the relationship between

attachment anxiety and distress, covariates were entered in Step 1, followed by attach-
ment anxiety in Step 2, and HC in Step 3. Findings show that attachment anxiety
continued to account for a significant portion of the variance, R2 = .56; F(7,
174) = 31.55, p < .001; β = .35, p < .001. A significant indirect effect (z = 3.12, p < .01),
indicated that HC partially mediates the relationship between anxious attachment and
distress (see Table 2).
To examine whether DC mediates between attachment anxiety and distress, covariates
were entered in Step 1, followed by attachment anxiety in Step 2, and DC in Step 3.
Findings show that attachment anxiety continued to account for a significant portion of
the variance in distress, R2 = .66; F(7, 174) = 46.98, p < .001; β = .21, p < .001. The finding
of a significant indirect effect (z = 5.96, p < .001) indicated that DC only partially
mediated the relationship between attachment anxiety and distress (see Table 3).
For hypothesis 3, when examining DC as a mediator of the relationship between
attachment avoidance and distress, attachment avoidance continued to account for
a significant portion of the variance in distress, R2 = .65; F(7, 174) = 46.00, p < .001;

Table 3. Model 2 mediation regression analyses: attachment anxiety

and deactivating coping.
Distress
Step R2 β p
Step 1 .34***
PCOS symptom level .42*** < .001
Household income −.13 .062
Education .00 .960
Psychiatric diagnosis −.18* .034
Mental health treatment −.22** .007
Step 2 .51***
Attachment anxiety .43*** < .001
Step 3 .56***
Deactivating coping .48*** < .001
Attachment anxiety .21*** < .001
N = 183.
*p < .05. **p < .01. ***p < .001.
 PSYCHOLOGY, HEALTH & MEDICINE 7

Table 4. Model 3 mediation regression analyses: attachment avoid-

ance and deactivating coping.
Distress
Step R2 β p
Step 1 .34***
PCOS symptom level .42*** < .001
Household income −.13 .062
Education .00 .960
Psychiatric diagnosis −.18* .034
Mental health treatment −.22** .007
Step 2 .45**
Attachment avoidance .31*** < .001
Step 3 .65***
Deactivating coping .53*** < .001
Attachment avoidance .16** .001
N = 183.
*p < .05. **p < .01. ***p < .001.

β = .16, p < .0. A significant indirect effect (z = 4.11, p < .001), indicated that DC partially
mediated the relationship between avoidant attachment and distress (see Table 4).

Discussion
Anxious attachment was a significant predictor of HC, DC, and distress and both coping
strategies partially mediated the relationship between anxious attachment and distress.
Research supports the association between anxious attachment and HC (e.g., Cassidy,
1994), whereas the association between anxious attachment and DC has not been
supported in prior studies. One interpretation of the finding that attachment anxiety is
significantly associated with DC is that the appearance-related symptoms (e.g., hirsutism
and acne) may result in social withdrawal, a deactivating strategy, to avoid perceived
judgment. The goal of social withdrawal may reflect a worry about social acceptance
given visible symptoms, considering that participants rated obesity and unwanted hair
were rated as high concerns, and that women with high attachment anxiety have been
found to experience heightened body image concerns (Cash et al., 2004). Anxious
attachment has also been associated with a lack of perceived social support under distress
(Gick & Sirois, 2010). High levels of anxious attachment in women with PCOS may
alternately lead to HC strategies to elicit care from others, while deactivating patterns of
social withdrawal may exist when social supports are perceived as being unavailable. This
may be significant for anxiously attached women with PCOS who have concerns about
appearance and may withdraw to avoid social rejection, rather than reaching out for
support.
HC, and to a greater extent DC, partially mediated the relationship between anxious
attachment and distress in women with PCOS. These strategies accounted for
a significant portion of the variance in distress and point to the importance of helping
women employ alternative coping strategies given their anxious attachment. Notably, DC
strategies accounted for more distress than did HC strategies. One possible explanation is
that deactivating strategies run counter to the anxious attachment goal of obtaining care
8 S. SIMON ET AL.

from others (Cassidy, 1994) and may be experienced as ego-dystonic and therefore result
in elevated distress.
Avoidant attachment was significantly associated with DC and stress, but not HC. DC
partially mediated between avoidant attachment and psychological distress. The deacti-
vating pattern of social withdrawal and problem avoidance used by women with high
attachment avoidance is concerning in the context of coping with PCOS because attach-
ment avoidance is associated with poor treatment adherence (Turan et al., 2003),
particularly when patients experience poor communication with treatment providers
(Ciechanowski et al., 2001). If patients do not address symptoms and avoid help,
symptoms may worsen, leading to greater distress and potentially long-term health
consequences.
DC was the only significant mediator between avoidant attachment and distress.
Studies (e.g., Benson et al., 2010; Sigmon et al., 2004) show that depression and anxiety
are negative consequences of withdrawal. In contrast, active coping to reduce PCOS
symptoms is beneficial, providing further support for the detrimental effects of DC.

Implications
Attachment can help us understand how women with PCOS cope and inform the
development of interventions. Professionals can be educated about attachment so they
can identify insecurely attached patients and help women with attachment anxiety and
avoidance employ adaptive coping. Given PCOS’s chronic nature and possible long-term
mental and physical health consequences, engaging patients according to attachment
orientation could help minimize long-term risks. Women with attachment anxiety may
benefit from interventions that enhance reliable support experiences (e.g., regular
appointments with providers), and increase affect regulation (e.g., breathing exercises),
and self-confidence in coping (e.g., psychoeducation). PCOS support groups may foster
stability and provide needed assistance. As women with attachment avoidance likely
suppress distress and underreport symptoms, Maunder and Hunter (2001) suggested
that for these patients, doctors frame treatment as a way to maintain control and self-
reliance, and emphasize the importance of reporting symptoms and adhering to treat-
ment recommendations.

Study limitations and future research directions

Limitations include the predominantly White sample and the inclusion of only partici-
pants troubled by PCOS symptoms, limiting generalizability. Results were based on self-
report data, potentially limiting validity. The coping scales may not have reflected the full
range of strategies.
Longitudinal studies exploring the long-term impact of HC and DC on physical and
psychological symptoms of PCOS are warranted. Attachment has been increasingly
examined in relation to health outcomes, with literature showing significant associations
between insecure attachment and poor health outcomes (e.g., McWilliams & Bailey,
2010). Assessing the extent to which these coping strategies impact long-term health
outcomes is crucial to determining the importance of considering attachment in women
undergoing PCOS treatment.
 PSYCHOLOGY, HEALTH & MEDICINE 9

As participants indicated that medical professionals provided inadequate information

about PCOS, future research could explore the associations among attachment, interac-
tions with healthcare providers, and PCOS symptoms to help us to understand how these
interactions impact women with various attachment patterns.

Disclosure statement
No potential conflict of interest was reported by the authors.

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