Type D Personality, Stress Levels, and Coping Strategies in Women with Androgenetic Alopecia and Polycystic Ovary Syndrome

Abstract

Background

The study was aimed to determine level of stress and using of coping strategies and frequency of type D personality in women with androgenetic alopecia with polycystic ovary syndrome (PCOS), to correlate personality type with level of stress and coping strategies, and to correlate severity of alopecia with personality type, level of stress, and coping strategies.

Material/Methods

The study was conducted in 2023 and included 146 Polish women aged 18 to 45 years with androgenetic alopecia and PCOS. A questionnaire containing social-demographic data, gynecological and obstetric history, health history, history of diagnosis, and treatment of PCOS in the past and present. Three standardized questionnaires were used: the Type-D Scale (DS)-14, Perceived Stress Scale (PSS)-10, and Coping Orientation to Problems Experienced (COPE) inventory.

Results

Type D personality was found in 45% of patients. Most patients perceived high levels of stress (44%) and most frequently used active and supportive strategies, with avoidance strategies being less frequent. Women with type D personality experienced significantly higher levels of stress, used active strategies less often, and used avoidant strategies more often. Stages of androgenetic alopecia did not correlate with type D personality or levels of perceived stress.

Conclusions

In women with androgenetic alopecia, type D personality is determinative of a high level of perceived stress and more frequent use of dysfunctional coping strategies. The severity of the condition did not correlate with personality type and level of stress, while it was related to certain coping strategies.

Introduction

Androgenetic alopecia is a progressive process of scalp hair loss due to the changes in the dynamics of the hair cycle [1,2]. This type of hair loss is the most common type of hair loss, affects approximately 50% of women with hair loss [3], and clinically manifests as diffuse hair thinning, while the frontal hairline is usually preserved. There can also be areas of thinning, particularly in the frontal, temporal, and mid-scalp regions [4–6].

It has been found that one-third of women with androgenetic alopecia have abnormal androgen levels, and the factor most often associated with the development of hyperandrogenism is polycystic ovary syndrome (PCOS) [6,7]. This raises the questions of whether women with androgenetic alopecia present with particularly high levels of stress and what coping strategies they use.

From the medical perspective, alopecia is viewed as a relatively benign dermatological condition of an aesthetic nature. Despite this, as documented by research, it can lead to serious psychosocial consequences [8]. Although reactions to hair loss are an individual matter, many women with androgenetic alopecia believe they have a severe condition, with negative consequences for their psychological well-being [9]. This detrimental impact is due to the cultural importance of hair and appearance for self-image and social identity [10]. The fear of losing one’s hair was shown to be as great as that of having a heart attack [11].

For women, the absence of healthy hair, particularly at a young age, is associated with reduced self-esteem and perception of one’s attractiveness and femininity, as well as low self-confidence [12]. Because of this, women can experience frustration, sadness, and lower overall well-being and quality of life [5]. Hair loss also increases stress and social anxiety, due to fear of negative perception and reactions from other people [13]. Consequently, this can lead to withdrawal from social situations and gradual isolation [14].

Studies to date show that stress levels can be particularly high in patients with hair loss and other skin diseases [15–18]. A new field, trichopsychodermatology, has even emerged to address the relationship between stress and hair loss as well as the negative psychosocial consequences of hair loss [19]. Stress can contribute to the perpetuation or exacerbation of hair loss, triggering a self-perpetuating vicious cycle [20].

The coping strategies used constitute a factor that significantly influences the level of stress experienced and its somatic and psychological consequences. Coping strategies are a set of individual cognitive and behavioral efforts aimed at changing, adapting, or reinterpreting a stressful situation and reducing suffering [21]. A distinction is made between active coping, which aims to solve the problem, and avoidant coping, which involves reducing aversive emotions caused by a stressful situation [22]. As research results show, patients with alopecia often show deficits in coping with stress, and the use of avoidance strategies is maladaptive and maintains or increases the level of stress experienced [13,23].

Similar trends are observed in the case of other diseases. Studies of women with PCOS found that they use passive strategies to cope with stress significantly more often than do healthy women, and these are predictors of high levels of anxiety and depression [24]. In turn, in patients with psoriasis, passive strategies for coping with stress intensify the symptoms of the disease and negatively affect their overall psychophysical condition [25–27].

Another factor that significantly influences the level of stress experienced, but also the choice of coping strategies, is type D personality. The type D personality consists of 2 subdimensions: negative affectivity (tendency to experience sadness, anxiety, anger, or irritation) and social inhibition (the tendency to avoid people and social interactions and to inhibit the expression of emotions) [28–30].

The simultaneous presence of negative affectivity and social inhibition can lead to chronic stress and negatively affect overall mental and physical health. Findings also suggest that type D personality can lead to dysfunctional coping strategies in disease-related situations, translating to lower quality of life, higher rates of comorbid psychiatric disorders and, in some cases, worse disease control and prognosis [31,32].

To the best of our knowledge, stress levels, coping strategies, frequency of type D personality, and the correlation between these parameters have not yet been studied in women with PCOS and androgenetic alopecia.

Objective

The objective of the study was to answer the following questions:

1. What are the level of stress and coping strategies and what is the frequency of type D personality among women presenting with androgenetic alopecia in the course of PCOS?

2. Does type D personality correlate with stress levels and coping strategies?

3. Does the severity of alopecia in women with PCOS correlate with type D personality, stress levels, and coping strategies?

Material and Methods

Study Group

The data were collected in 2023 at the outpatient clinic “The Clinic Warsaw” in Warsaw, Poland, and at the Institute of Rural Medicine in Lublin, Poland.

The study included 146 women aged 18 to 45 years with PCOS with symptoms of androgenization in the form of androgenetic alopecia. The selection of this age group at reproductive age 18 to 45 years ensured the homogeneity of the study group. Women over the age of 45 often experience symptoms of menopause, which can cause changes in their emotional state. Women under 18 are teenagers whose emotional state is different from that of women of reproductive age.

PCOS in the studied women was confirmed by the Rotterdam criteria. In 2003, the American Society for Reproductive Medicine and the European Society for Human Reproduction and Embryology, reaffirmed PCOS as a “syndrome”, but expanded its definition to 3 diagnostic features (or diagnostic criteria), known as the Rotterdam criteria. They include (1) oligo-anovulation, (2) hyperandrogenism (clinical and/or biochemical), and (3) polycystic ovaries evidenced by ultrasound techniques. Other diseases causing hyperandrogenism have to be excluded during the differential diagnostic stage. Since the presence of 2 out of the 3 criteria is required for PCOS diagnosis, each patient was examined by a medical doctor for androgenic disorders: hirsutism (Ferriman-Gallwey scale) and androgenetic alopecia (Savin scale).

The inclusion criteria were age 18 to 45 years, PCOS, and androgenic alopecia. The exclusion criteria were previously diagnosed depression or other mental disease, addictions, and diagnosed chronic diseases.

The research tools included a questionnaire containing social-demographic data, data on gynecological and obstetric history, health history, and history of diagnosis and treatment of PCOS in the past and now. Three standardized questionnaires were used: the Type-D Scale (DS)-14, Perceived Stress Scale (PSS)-10, and Coping Orientation to Problems Experienced (COPE) inventory.

The study received an approval by the Ethics Committee of the Institute of Rural Medicine in Lublin, Poland (protocol number INW4/2019, date March 13, 2019) and is agreement with the Declaration of Helsinki.

Savin Scale of Androgenic Alopecia

The Savin Scale was used to measure androgenic alopecia in the examined women. It is worth mentioning that a different scale is used to measure alopecia in men.

Figure 1 presents a range of images showing the degree of severity, from no hair loss to severe hair loss in women, according to the Savin scale. Stage I, which in an early stage of hair loss, indicates initial signs of hair thinning and consists of 4 substages: I-1, I-2, I-3, and I-4. Stage II indicates moderate hair loss and consists of 2 substages, II-1 and II-2. Stage III indicates extensive hair loss. The following eighth stage is advanced hair loss. The ninth final stage indicates frontal anterior recession [33].

Figure 1.

Savin scale. Figure was generated in Microsoft Paint, Microsoft, Redmond, USA.

DS-14 Questionnaire

To assess the presence of type D personality, the DS-14 questionnaire, which had been validated in Polish, was used [34,35]]. It consists of 2 subscales: negative affectivity and social inhibition, with 7 items each. The respondent selects 1 answer from a 5-point Likert scale to each item, with the answers scored as follows: 0=false, 1=rather false, 2=neutral, 3=rather true, and 4=true. There is no reversal of coding. Total scores in the negative affectivity and social inhibition subscales are the sum of the answers to all the 7 items in the 2 subscales, respectively, and range from 0 to 28, where high negative affectivity or social inhibition is indicated by at least 10 points. If the score in both subscales is at least 10 points, type D personality is diagnosed. A higher score means a higher intensity of type D personality.

The Cronbach alpha coefficient for the Polish version of DS-14 is 0.86 for negative affectivity and 0.84 for social inhibition.

PSS-10 Scale

To assess the level of perceived stress, the Polish adaptation of the PSS-10 scale was used. It contains 10 questions regarding how often certain feelings and situations related to personal events occurred in the last month [35,36]. The respondent selects 1 answer from a 5-point Likert scale to each question, with the answers scored as follows: 0=never, 1=almost never, 2=sometimes, 3=fairly often, and 4=very often. The points for 4 questions, 4, 5, 7, and 8, must be reversed. The overall score of the scale is the sum of all points and is from 0 to 40, with a higher score indicating a higher level of perceived stress. The test result is interpreted as follows: 0–13 points indicates a low level of perceived stress, 14–26 points indicates a moderate level of perceived stress, and 27–40 points indicates a high level of perceived stress.

The Cronbach alpha coefficient for the Polish version of the PSS-10 is 0.86.

COPE Inventory

To present different ways that the examined women coped with stress and how often they used them, the COPE inventory by Carver et al, which was validated in Polish, was applied [35,37]. It consists of 60 items divided into 15 strategies (4 items in each strategy). The respondent selects 1 answer from a 4-point scale to each item, with answers scored as follows: 1=“I usually don’t do this at all”, 2=“I usually do this a little bit”, 3=“I usually do this a medium amount”, and 4=“I usually do this a lot”. There is no reversal of coding.

Total scores for each of the 15 strategies are the arithmetic mean of the answers to the 4 items belonging to its respective strategy. The scores for the strategies range from 1 to 4 and indicate how often a given strategy is used. A higher score means a higher frequency of using the strategy. The 15 strategies were divided into 3 factors: active-coping, avoidant-coping, and socially-supported.

The Cronbach alpha coefficient for the Polish version of the COPE inventory ranges from 0.48 to 0.94 for the 15 different strategies.

Statistical Methods

The statistical analyses were conducted using STATISTICA 13 software (StatSoft Polska Sp. z o.o. Cracow, Poland).

The mean (M) and standard deviation (SD) were estimated for the continuous variables, as well as the absolute numbers (n) and percentages (%) of the occurrence of the items for categorical variables.

The t test was used to compare age, body mass index (BMI), level of stress (scores), and frequency of using stress-coping strategies between women with and without type D personality. The Pearson chi-square test was used to compare the 3 levels of stress between women with and without type D personality, 3 levels of stress between stages of androgenic alopecia, and stages of androgenic alopecia between women with and without type D personality. The F test analysis of variance was used to compare level of stress (scores) and frequency of using stress-coping strategies between the stages of androgenic alopecia. The significance level was assumed to be 0.05 in all the statistical tests used.

Results

Characteristics of Women with Androgenic Alopecia

Table 1 presents the results for age, BMI, and Savin scale for androgenic alopecia. The examined women were aged from 22 to 45 years, 32.2±6.4 years on average, and the predominant age group was 20–29 years (41.1%). The mean BMI was 22 kg/m², and most of the women had normal weight (89%). Most of the examined women had I-1 stage of hair loss (48%), followed by stage I-2 (24%), I-3 (135), I-4 (5.5%), II-1 (3%), II-2 (5%), and III (2%). For further analyses, because of the small sample sizes of the groups of women with stages II-1, II-2, and III, they were combined into 1 group of 14 women in total.

Table 1.

Study group characteristics (N=146).

Characteristic	Category, parameter	Result
Age (years)	Min–Max, M±SD	22–45, 32.2±6.4
	20–29, n (%)	60 (41.10)
	30–39	52 (35.62)
	40–45	34 (23.29)
Body mass index (kg/m2)	Min–Max, M±SD	17.71–28.73, 21.94±2.18
	Underweight, n (%)	6 (4.11)
	Normal weight	130 (89.04)
	Overweight	10 (6.85)
Savin scale for androgenic alopecia	I-1, n (%)	70 (47.95)
	I-2	35 (23.97)
	I-3	19 (13.01)
	I-4	8 (5.48)
	II-1	4 (2.74)
	II-2	7 (4.79)
	III	3 (2.05)

M – mean; SD – standard deviation.

Figure 2 presents the results for age and BMI by the Savin scale for androgenic alopecia of the examined women. The groups of women with different stages of androgenic alopecia differed significantly in terms of age (P<0.001); however, they did not differ in terms of BMI (P=0.771). The first 2 groups of women with the lowest stages of androgenic alopecia (I-1 and I-2) were significantly younger than the women with higher stages (I-3, I-4, II-1, II-2, and III), with a mean age of approximately 30 vs approximately 40 years.

Figure 2.

(A) Age by stage of androgenic alopecia. (B) Body mass index by stage of androgenic alopecia. P for F test analysis of variance. Figures were generated in STATISTICA 13.3 software, Statsoft, Cracow, Poland.

Psychological Test Results in Women with Androgenic Alopecia

Three psychological test were used: the DS-14 questionnaire to assess type of personality, PSS-10 scale to assess level of stress, and COPE inventory to assess ways of coping with stress.

Table 2 presents the results for type D personality according to the DS-14 in the examined women. High negative affectivity was found in approximately 60% of the examined women and high social inhibition in 65%. Both high negative affectivity and high social inhibition, which results in type D personality, was found in 45% of the examined women.

Table 2.

Type of personality according to DS-14 in the study group (N=146).

Factor	Category, parameter	Result
Negative affectivity	Scores, Min–Max, M±SD	4–26, 11.2±5.2
	High, n (%)	87 (59.59)
Social inhibition	Scores, Min–Max, M±SD	1–27, 10.8±5.6
	High, n (%)	95 (65.07)
Type D personality	Yes, n (%)	66 (45.21)

Scale 0–28 points. Score is high at 10 points or higher. Type D of personality if at least 10 scores both in negative affectivity and in social inhibition. M – mean; SD – standard deviation.

Table 3 presents the results for level of perceived stress according to the PSS-10 in the examined women. Most of the women showed a high level of perceived stress (44%), whereas a similar number of women showed low and moderate level of perceived stress (27.4% and 29%, respectively).

Table 3.

Level of perceived stress according to PSS-10 in the study group (N=146).

PSS	Category, parameter	Total (N=146)
Scores	Min–Max, M±SD	0–36, 18.1±7.6
Interval	Low (0–13), n (%)	40 (27.40)
	Moderate (14–26)	42 (28.77)
	High (27–40)	64 (43.84)

Scale 0–40. M – mean; SD – standard deviation.

Figure 3 presents how often the examined women used different ways of coping with stress, according to the COPE inventory. The most frequent ways of coping with stress used by the examined women were planning, positive reinterpretation, active-coping, and suppression of competing activities, which belong to the active-coping strategies, and instrumental and emotional social supports and focus on and venting of emotions, which belong to the socially-supported strategies.

Figure 3.

Ways of coping with stress according to COPE inventory in the study group (N=146) Midpoint=mean; Whisker=mean±SD. The COPE inventory is a 4-point scale, in which: 1=I usually don’t do this at all; 2=I usually do this a little bit; 3=I usually do this a medium amount; 4=I usually do this a lot. Figure was generated in Microsoft Excel 18, Microsoft, Redmond, USA.

The medium frequent ways of coping with stress used by the examined women were acceptance and restraint-coping, which belong to the active-coping strategies, and religion and mental disengagement, which belong to the avoidant-coping strategies.

The least frequent ways of coping with stress used by the examined women were denial, substance use, humor, and behavioral disengagement, which belong to the avoidant-coping strategies.

Level of Stress and Ways of Coping with Stress by Type of Personality

Table 4 presents the level of perceived stress according to the PSS-10 by type of personality of the examined women. On comparing PSS-10 scores between the 2 groups of women, with and without type D personality, a significantly higher level of stress was found in the women with type D personality (21.7 points, on average) than in the women without type D personality (15.2 points, on average, P<0.001).

Table 4.

Level of perceived stress according to PSS-10, by type of personality (N=146).

PSS	Category, parameter	Type D (n=66)	Type Non-D (N=80)	P
Scores	Min–Max, M±SD	21.7±6.2	15.2±7.3	<0.001 for t test
Interval	Low, n (%)	5 (7.58)	35 (43.75)	<0.001 for chi-square test
	Moderate	20 (30.30)	22 (27.50)
	High	41 (62.12)	23 (28.75)

Scale 0–40.

Also, the 2 groups of women, with and without type D personality, differed significantly in terms of the 3 intervals of the PSS-10 (low, moderate, and high level of stress; P<0.001). The higher percentage of women with type D personality had a higher level of perceived stress (62%) than did women without type D personality (29%). A moderate level of perceived stress occurred with the same frequency in both groups of women (approximately 30%). The lower percentage of women with type D personality had a low level of perceived stress (8%) than did the women without type D personality (44%).

Figure 4 presents frequency of different ways of coping with stress, according to the COPE, by type of personality of the examined women. In comparison with the women without type D personality, the women with type D personality used the following self-sufficient strategies less often: planning, positive reinterpretation, active-coping, suppression of competing activities, and restraint-coping. Similarly, they used the following socially-supported strategies less often: instrumental and emotional social supports. On the contrary, the women with type D personality used the following avoidant-coping strategies more often: denial, substance use, humor, and behavioral disengagement.

Figure 4.

Ways of coping with stress according to COPE inventory, by type of personality (N=146). Midpoint=mean, * significant differences. The COPE inventory is a 4-point scale, in which: 1=I usually don’t do this at all; 2=I usually do this a little bit; 3=I usually do this a medium amount; 4=I usually do this a lot The t test was used for analysis. Figure was generated in Microsoft Excel 18, Microsoft, Redmond, USA.

The frequency of the following strategies did not significantly differ between the women with and without type D personality: acceptance, religion, mental disengagement, and focus on and venting of emotions.

Stages of Androgenic Alopecia and Psychological Test Results

Stages of androgenic alopecia did not correlate with type D personality, according to the DS-14 (Table 5; P=0.205). Stages of androgenic alopecia did not correlate with the level of perceived stress, according to the PSS-10 (Table 6; P=0.898 for scores and P=0.710 for intervals: low, moderate, and high levels of stress).

Table 5.

Type of personality according to DS-14, by stage of androgenic alopecia, n (%).

Stages of androgenic alopecia	Type D (n=66)	Type non-D (n=80)
I-1	37 (56.06)	33 (41.25)
I-2	10 (15.15)	25 (31.25)
I-3	9 (13.64)	10 (12.50)
I-4	3 (4.55)	5 (6.25)
II-1, II-2, III	7 (10.61)	7 (8.75)

P=0.205 for chi-square test.

Table 6.

Level of perceived stress according to PSS-10, by stage of androgenic alopecia (N=146).

PSS	Category, parameter	Stages of androgenic alopecia					P
		I-1	I-2	I-3	I-4	II-1, II-2, III
Scores	M±SD	2.2±0.8	2.1±0.8	2.2±1.0	2.1±0.8	2.4±0.7	0.898*
Interval	Low, n (%)	19 (27.14)	10 (28.57)	7 (36.84)	2 (25.00)	2 (14.29)	0.710**
	Moderate	20 (28.57)	12 (34.29)	2 (10.53)	3 (37.50)	5 (35.71)
	High	31 (44.29)	13 (37.14)	10 (52.63)	3 (37.50)	7 (50.00)

Scale 0–40.

^*F test analysis of variance;

^**chi-square test.

On the contrary, the stages of androgenic alopecia correlated with frequency of different ways of coping with stress, according to the COPE (Figure 5). The women with I-4 stage of androgenic alopecia used the following strategies more often: positive reinterpretation, acceptance, mental disengagement, denial, and emotional social support than did the women with other stages of androgenic alopecia. Moreover, they used the following strategies less often: restraint-coping, religion, and behavioral disengagement. However, the frequency of using the following strategies did not correlate with the stages of androgenic alopecia: planning, active coping, suppression of competing activities, humor, substance use, instrumental social support, and focus on and venting of emotions (P>0.05).

Figure 5.

Ways of coping with stress according to COPE, by stages of androgenic alopecia (N=146). Midpoint=mean, * significant differences. The COPE inventory is a 4-point scale, in which: 1=I usually don’t do this at all; 2=I usually do this a little bit; 3=I usually do this a medium amount; 4=I usually do this a lot F test analysis of variance was used. Figure was generated in Microsoft Excel 18, Microsoft, Redmond, USA.

Discussion

The first study on androgenetic alopecia in only women was conducted in 1994. As many as 88% of the 58 female participants reported that hair loss had a negative impact on their daily lives, 75% claimed that it had a negative impact on their self-esteem, and 50% reported experiencing social problems due to hair loss [14,38]. Studies comparing male and female patients with androgenetic alopecia revealed that women experienced the problem differently from men [12,18,39,40]. Our study group consisted of patients with PCOS at an average age of 32.2±6.4 years, whose hair loss was most often in stage I-1 (48%). Other studies also support the observation that, in most patients with androgenetic alopecia, the disorder follows a mild course [39,41]. Women with androgenetic alopecia of stage I-1 and I-2 were significantly younger than women with higher stages of the disorder (mean age of about 30 vs about 40 years), as confirmed by other observations [1,5,39].

The objectives of the study were to determine the level of stress and coping strategies among women presenting with androgenetic alopecia in the course of PCOS, frequency of type D personality among the study patients, any potential correlation between type D personality and the level of stress and coping strategies, and any potential correlation between the severity of alopecia with type D personality, stress level, and coping strategies.

Most of our study participants with PCOS and androgenic alopecia reported high levels of perceived stress (44%), with low and moderate levels amounting to 27.4% and 29%, respectively. The average level of perceived stress as assessed using a scale of 0 through 40 was 18±7.6. In the comparison of patients with androgenetic alopecia with patients with another dermatological condition, patients with androgenetic alopecia were found to be more stressed, experience greater social anxiety, and have lower self-esteem [19,40]. Patients experiencing hair loss (androgenetic alopecia or alopecia areata) reported a greater number of stressful life events in the past 6 months, and the level of perceived stress was almost double that of healthy controls [42,43]. The odds ratio for high stress level in androgenetic alopecia was as high as 7.75 [44].

Some studies have pointed to even higher levels of stress as perceived by patients experiencing hair loss. In a study by Cash et al, as many as 70% of women with hair loss said they were upset or very upset about it [15]. Very high levels of stress exposure (7 and 8 points on a scale of 1 to 10) were reported by patients in another study [41], while 81.3% of patients reported experiencing stress every day [45]. For other dermatological diseases, such as psoriasis and atopic dermatitis, high levels of stress were experienced by 30% and 70% of patients, respectively [46]. In our study and those of other authors, the level of stress experienced in patients with alopecia is high.

To live with a disease, patients use a variety of coping strategies to manage the stress resulting from the disease. While all coping strategies can be useful, some argue that patients making use of active strategies better adapt to living with the disease [47]. This is because active coping strategies provide a sense of greater control over the situation, while avoidant coping can amplify emotions and enhance the stress perceived [48].

In our study, female patients most frequently resorted to active strategies, such as planning, positive reinterpretation, active coping, and suppression of competing actions. Socially supported strategies (instrumental and emotional social support, focusing on and venting of emotions) were also commonly used. The least frequent coping strategies in the surveyed group included denial, the use of psychoactive substances, humor, and behavioral disengagement, all categorized as avoidant coping strategies. This observation seems to be particularly interesting, especially in the context of the results of our previous research. In these studies, women with PCOS but without androgenic alopecia used passive strategies to cope with stress more often than did healthy women [24]].

A study by Tabolli et al showed that women with androgenetic alopecia were more likely to adopt active coping strategies than were male patients [12]. In studies of alopecia areata, patients were far more likely to use active strategies and far less likely to use dysfunctional strategies [23,25,32]. Some studies have found an impaired ability to cope with stress in patients with alopecia areata, while no differences were found in this regard by other authors [23,49]. Therefore, the hypothesis that women with androgenetic alopecia use maladaptive strategies to cope with stress is not confirmed.

Since type D personality moderates stress levels and the ways of coping with stress [23,25,32], we investigated whether such a relationship exists in women with PCOS and androgenic alopecia. Significantly higher stress levels were found in women with type D personality. High levels of stress were experienced by 62% of women with type D personality, compared with 29% of women without type D personality. Women with type D personality were less likely to use active strategies, such as planning, positive reinterpretation, active coping, suppression of competing actions, and refraining from actions, while being more likely to use avoidant strategies, such as denial, substance use, humor, and disengagement. We were not able to find any studies with which we could directly relate our observations. In one study, coping strategies in patients with androgenic alopecia were considered in the context of alexithymia (inability to understand, identify, name, and express emotions). Active strategies were negatively correlated with alexithymia as opposed to avoidant strategies, for which positive correlation with alexithymia was observed [12].

The prevalence of type D personality in the general population is estimated at 13% to 34% [50]. In our study group of women with PCOS and androgenetic alopecia, high negative affectivity scores were found in about 60%, whereas high social inhibition scores were obtained by 65%; type D personality was identified in 45% of patients. In patients with alopecia areata, the prevalence of type D personality was 35%, compared with 15% in the control group [32]. In contrast, in patients with chronic spontaneous urticaria, type D personality was observed in 28% of patients, whereas 37.3% of patients presented with high social inhibition scores, and 66.67% presented with high negative affectivity scores [51]. The prevalence of type D personality in patients with psoriasis was studied by Molina-Leyva et al, who found a higher prevalence of type D personality in patients with psoriasis than in controls (38.7% vs 23.7%) [52]. In patients with acne vulgaris and in a control group, type D personality was present in 40.67% and 15.67%, respectively [32]. In the group of women with androgenetic alopecia in the course of PCOS, type D personality occurs more often than in other dermatological diseases. The hypothesis that this type of personality is a predictor of the use of less adaptive strategies for coping with stress was also confirmed.

The next step in our study consisted in determining whether the stage of alopecia in women with PCOS correlates with type D personality, stress levels, and coping strategies. Stages of androgenetic alopecia were found not to correlate with type D personality and levels of perceived stress. Likewise, stress levels, patient satisfaction, and quality of life scores were not associated with the degree of hair loss in other studies [41,53].

On the other hand, disease severity was related to type D personality in patients with alopecia areata [45]. In patients with chronic spontaneous urticaria and acne, type D personality was not associated with disease severity or poorer disease control [51,54].

In our study, the severity of the disease correlated with certain ways of coping with stress. Female patients with androgenetic alopecia at stage I-4 were more likely to use active strategies (positive reinterpretation, acceptance), avoidance strategies (distraction, denial), and supportive strategies (seeking emotional social support) than were women with other stages of androgenetic alopecia. In contrast, they were less likely to use avoidance strategies (religion and disengagement) as well as the active strategy of refraining from action. This suggests that women with PCOS and androgenic alopecia of greater severity, while making use of different coping strategies, do not resort to the more dysfunctional ones. This part of our analysis warrants the conclusion that the clinical assessment of androgenetic alopecia does not necessarily correlate with the perception of hair loss and its negative psychological impact in women with PCOS and androgenic alopecia [12,14].

The clinical implications of the study are as follows: Physicians need to be aware of the psychological effects of androgenetic alopecia in women, especially given the limited effectiveness of the currently available treatment options. Understanding the impact of hair loss on the psychological condition of patients is important to be able to provide them with comprehensive help. Patients with higher risk of stress and poorer coping strategies cannot be identified by means of assessing the severity of the disease. Therefore, screening for type D personality could be useful in detecting those at particular risk. Patients with type D personality could benefit from additional psychological support as complementary treatment. Further research is also needed to determine what forms of psychological support would be most effective in this group of patients [4,18,55].

Limitations of the Study

The study had a number of limitations. One limitation was the cross-sectional type of survey, preventing comprehensive evaluation of all the studied aspects. Another limitation was the use of self-reporting questionnaires, which may have resulted in biased responses. The scope of the future research in this area should also include other elements of functioning and other mental disorders and dysfunctions in women with PCOS and androgenic alopecia.

Conclusions

Type D personality was found in 45% of the examined women with PCOS and androgenic alopecia. Type D personality was determinative of a high level of perceived stress and more frequent use of dysfunctional coping strategies. Active strategies are the most common ways of coping with stress in women with PCOS and androgenic alopecia. The severity of the condition did not correlate with type D personality and stress levels, while it was related to certain coping strategies, with no trend toward more dysfunctional strategies observed.