Title: Depression, anxiety, and stress in polycystic ovary syndrome: understanding the impact
of adult separation anxiety and uncertainty intolerance
Version: 3 Date: 31 May 2025
Reviewer's report:
I would like to start off my peer review 2 by thanking the authors for revising their manuscript
after peer review 1, the addition of relevant materials, procedures, and literature clarified the
argument/hypothesis of this manuscript and also demonstrates a clear commitment to improving
the manuscript.
A central issue that remains unresolved in this manuscript is its lack of a clearly defined
research focus. As it stands, the paper moves between at least three distinct thematic areas:
(1) the prevalence of adult separation anxiety (ASA) in women with PCOS, (2) the role of
intolerance of uncertainty (IU) as a transdiagnostic vulnerability factor, and (3) the potential
influence of specific PCOS symptom clusters (e.g., hyperandrogenism or metabolic features)
on psychological comorbidities: without clearly articulating how these strands are conceptually
or methodologically integrated. This lack of cohesion raises the question: is the primary
contribution of the study to document the frequency of ASA in a previously unexamined clinical
population (PCOS)? Or is the central claim about IU as a mediating or moderating factor shaping
ASA, anxiety, and depression in this population? Or, alternatively, is the paper advancing a
claim about PCOS heterogeneity—that distinct symptom constellations may differentially relate
to ASA and IU? Each of these directions is potentially valuable.
1. Clarify Focus of Manuscript
My concern for peer review 2 is that the central argument still lacks clarity. A focused
revision, guided by a clearer articulation of the main aim (ASA prevalence? IU as mechanism?
symptom heterogeneity?), could significantly strengthen the contribution. I’m not sure what the
relationship between the variables is.
There’s a shifting focus throughout this manuscript. Is the manuscript about ASA prevalence in
PCOS, or the role of IU as a transdiagnostic vulnerability, or symptom cluster heterogeneity?
These threads could come together but, right now, they are fragmented and unclear. So, authors
would be better off clarifying the relationship between the variables.
PCOS symptom clusters (e.g., acne, endocrine markers) # Stress, depression, anxiety #
Intolerance of Uncertainty (IU) # Adult Separation Anxiety (ASA)
(The arrows are not for directionality, but to show the
A clear statement about this is important in this manuscript. Until then, the logical transitions
are still weak.
The manuscript then brings in a lot of other variables in the discussion: The argument sometimes
jumps between points without clearly articulating the link. For example, it goes from the
difficulty of comparing prevalence data to suggesting that education level may explain the high
rate, but doesn’t clearly explain how education would affect ASA.
2. Stigmatizing Language
I previously highlighted the need to revise the exclusion criteria language to avoid stigmatizing
terminology, such as “mental retardation.” Unfortunately, this language remains unchanged. I
strongly encourage the authors to update their terminology in line with accepted clinical and
psychological standards (such as American Medical Association’s inclusive language guidance
in 2021, APA, and UN) to enhance both the scientific quality and social responsibility of their
work.
The authors write: “Exclusion criteria were illiteracy, presence of chronic psychiatric diseases
such as mental retardation, psychotic disorder, bipolar disorder, neurologic and metabolic
comorbidities that may affect cognitive functions.”
It could instead say,  “Exclusion criteria included illiteracy, current or past diagnoses of severe
psychiatric disorders (e.g., psychosis, bipolar disorder), or neurological or metabolic conditions
likely to impact cognitive functioning.”
I would like to emphasize the importance of revising the language around psychiatric and
cognitive conditions in the manuscript. Terms such as “mental retardation” are considered
outdated, inaccurate, and stigmatizing in contemporary clinical and academic discourse. Using
such terminology can perpetuate harmful stereotypes and contribute to social exclusion of
vulnerable populations. Given that this study addresses mental health and psychological
symptoms, it is especially critical that the language reflects respect, dignity, and current
standards. Inclusive, person-first language (e.g., “intellectual disability” rather than “mental
retardation”) aligns with international guidelines and promotes ethical research practices. This
not only improves the manuscript’s professionalism but also its ethical integrity, ensuring it does
not unintentionally reinforce stigma the study seeks to challenge.
3. Please correct “Materyal Method”
4. In the Sociodemographic Data Form section, please use consistent terms
Sociodemographic Data Form or Questionnaire?
This questionnaire, developed by the researchers, included questions about the participants'
gender, age, educational status, marital status, smoking, duration of illness, age at first
menstruation, height and weight.
5. Questionnaires section
“Adult Separation Anxiety Questionnaire was developed by Manicavasagar et al.”
In what year?
“In 2007, Carleton et al. developed the Intolerance of Uncertainty Scale. Based on the 27-item
scale that Freeston et al. had already made, a 12-item short form was made[22]."
Carleton built theirs by basing it on Freeston et al? Please clarify.
6. Split last section into discussion, limitations, and conclusion.
It runs too long and is a bit jumbled. You could also write the discussion with different parts
focusing on the relationship between variables not just variables themselves, for example:
Paragraph 1, PCOS symptom clusters (e.g., acne, endocrine markers) # Stress, depression,
anxiety in PCOS
Paragraph 2, Stress, depression, anxiety in PCOS # Intolerance of Uncertainty (IU) in PCOS
Paragraph 3, Intolerance of Uncertainty (IU) in PCOS # Adult Separation Anxiety (ASA) in
PCOS
Therefore, PCOS symptom clusters (e.g., acne, endocrine markers) # Adult Separation Anxiety
(ASA), at least, I think?
With the final paragraph leading to your limitations and conclusion.
7. Fragmented writing in discussion and conclusion section
- “our findings are consistent with the literature" is too generic and used a handful of times in
this paper without stating what is specifically consistent in that statement.  A stronger version
would briefly indicate how or which studies (even in general terms, e.g., "as previous research
has suggested…”).
This is a good example in the manuscript, “These findings align with existing research
suggesting that the psychological impact of PCOS may vary depending on the specific symptom
profile.”
- Since there's a stated absence of research on ASA in PCOS, you might be able to both say it’s
the first study and then repeatedly say it confirms earlier work without building the relationship
between the variables. You could say that it aligns with or advances or contrasts.
- The idea of hormonal dysregulation or social stigma moderating these mechanisms is
interesting but not elaborated, sourced, or argued through.
- The shift from prevalence data to discussing CBT outcomes for panic disorder patients
introduces a new clinical variable that distracts from the main argument about PCOS and ASA.
To fix this, the authors could make a section for conclusions/implications.
Final Comments:
The authors' idea of trying the three thematic areas is interesting! However, it requires a more
clarification before publication. To improve the paper, I recommend choosing one clear focus.
Then, explain how the other ideas help support that focus. This will help readers understand the
value of your study and make the message stronger.