Title: Can self-compassion and mindfulness predict psychological wellbeing in individuals with
endometriosis? Findings from an online survey
Version: 5 Date: 23 May 2025
Reviewer's report:
PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
Yes - the approach is appropriate
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
Yes - experiments and analyses were performed appropriately
STATISTICS - Is the use of statistics in the manuscript appropriate?
Yes - appropriate statistical analyses have been used in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
Yes - the author's interpretation is reasonable
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Yes - current version is technically sound
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: Yes
ADDITIONAL REQUESTS/SUGGESTIONS:
Can self-compassion and mindfulness predict psychological wellbeing in individuals with
endometriosis Findings from an online survey
Ive read the final paper again. PFA my comments.
Thanks for the opportunity to review the work.
Reviewer Comment (RC) 1: Thank you for the revisions made to the manuscript. I appreciate the
clarification regarding the criteria for selecting variables in the hierarchical regression models.
My original concern was about the initial selection criteria, not the comparisons between models
based on R2. However, your revised manuscript has adequately addressed this concern by
providing a more comprehensive theoretical background that clarifies the role and relevance
of the variables included in the model. This enhancement reduces the reliance on statistical
significance alone and strengthens the overall argument. Author Response (AR): Thank you
for your careful review, which greatly contributed to improving the quality of our manuscript,
particularly in terms of the theoretical background, reporting of methods, statistical analyses,
and presentation of findings. RC 2: Regarding the decision to categorize the self-compassion
variable, I appreciate the explanation that this was based on previous research practices.
However, simply following past studies does not fully justify the loss of information that results
from categorizing a continuous variable. It would be beneficial to provide a clearer rationale,
such as how this approach improves the interpretation or understanding of the relationships
between variables. This would help prevent any concerns about p value manipulation and
ensure transparency in your analytical decisions. AR: The reviewer is absolutely right. We
have now clarified that Neff, the author of the Self Compassion Scale, provides guidance
regarding the three self-compassion categories (low, moderate, high), which can be found
here: https://self-compassion.org/wp-content/uploads/2021/03/SCS information.pdf. Since this
categorization approach has also been used in previous endometriosis research—cited in our
manuscript—we decided to replicate the analysis to allow for comparison with existing findings.
These clarifications have been incorporated into the manuscript, specifically in the section
describing the scale. RC: I congratulate you on the efforts made to consider the points I raised
and for the significant improvements reflected in the manuscript. Given the advancements in
addressing these concerns and the study's potential to contribute meaningfully to the state of
the art in this area, I believe the manuscript should be accepted for publication. AR: Thank you
so much.
My comments- Have gone through the manuscript and changes made. The current version is
acceptable for publication.
PEER REVIEWER ASSESSMENTS: OBJECTIVE - Full research articles: is there a clear
objective that addresses a testable research question(s) (brief or other article types: is there
a clear objective)? RC: Yes - there is a clear objective AR: Thank you. DESIGN - Is the
current approach (including controls and analysis protocols) appropriate for the objective?
RC: Yes - the approach is appropriate AR: Thank you. EXECUTION - Are the experiments
and analyses performed with technical rigor to allow confidence in the results? RC: Yes
- experiments and analyses were performed appropriately AR: Thank you. S - Is the of s
in the manuscript appropriate? RC: Yes - appropriate al analyses have been d in the study
AR: Thank you. INTERPRETATION - Is the current interpretation/discussion of the results
reasonable and not overstated? RC: No - there are minor issues OVERALL MANUSCRIPT
POTENTIAL - Is the current version of this work technically sound? If not, can revisions be
made to make the work technically sound? RC: Probably - with minor revisions AR: Although
Reviewer 1 recommended our manuscript for publication, some minor concerns were still raised.
We have addressed these points and incorporated additional information into the manuscript
accordingly. Reviewer 3 did not provide specific suggestions; however, we have made every
effort to ensure clarity and precision in our reporting. PEER REVIEWER COMMENTS:
RC: GENERAL COMMENTS: meets best practise. good work AR: Thank you. Authors’
Note: We understand that the following section contains our point-by-point responses to the
reviewers from the previous round of revision, including the evaluation provided by Reviewer
3. REQUESTED REVISIONS: Reviewer’s comments Author’s response My comments The
authors investigate how psychological well-being may be influenced by protective factors
such as mindfulness and self-compassion in the context of living with endometriosis. They
employed a cross sectional study design and collected from a large sample. While the topic under
investigation is highly relevant, my primary concern, as detailed below, is the lack of an overall
theoretical rationale for the selection of variables, which is crucial for accurately understanding
the associations between the processes of interest. Additionally, there are concerns regarding
the quality of the al analyses employed. We thank Reviewer 1 for their insightful comments.
Every effort has been made to address their concerns and improve clarity. Satisfactory AR:
Thank you. In the background section (line 50), the authors stated that the characteristics of
the painful symptoms depend on the location of the endometriotic lesion. This statement is
not entirely accurate. Women with lesions in one organ or tissue can develop pain at a distant
site due to alteration in nociceptive processing (e.g., viscero-visceral hyperalgesia) and are
not limited to primary hyperalgesia, as the authors suggest. Please revise this phrase to avoid
misunderstandings. Yes, the statement was unclear and has been corrected according to this
suggestion. Moreover, additional material has been added to clarify the complex nature of the
pain experience in endometriosis (lines 50-57). Satisfactory AR: Thank you. When explaining
mindfulness (line 111), the authors correctly described the difference between Kabat-Zinn and
Langer's conceptualizations. However, the term "mindfulness meditation" is d, referring to
Kabat-Zinn's perspective. To improve clarity, I suggest the authors elucidate the distinction
between the state of mindfulness practiced in mindfulness meditation and the trait of one’s
natural predisposition to be mindful in daily life. The latter is what is actually under investigation
in the present study. : Additional information has been provided in the Background (see the
section entitled “Mindfulness”). Satisfactory AR: Thank you. The reason for the uncommon
choice of the Langerian mindfulness conceptualization, which has much less evidence and
a known theoretical scope in the biomedical literature, was not explained (line 118). Please
provide a rationale for choosing this specific approach over the more commonly known Kabat-
Zinn's perspective. This is particularly important given that, when the authors refer to the
relevance of mindfulness to women with endometriosis, they cite only studies employing
Kabat-Zinn's approach (line 123-129). The rationale for choosing the Langerian approach was
clarified in the paragraph entitled “Mindfulness”, particularly from line 169 to 173. Satisfactory
AR: Thank you. The study aims to investigate the association between mindfulness, self-
compassion, and psychological well-being. Additionally, the associations of two other variables
—time since diagnosis and pain symptoms—with the main predictors are to be explored (line
133). Why did the authors choose to investigate the association time since diagnosis among
many other theoretically valid options? Its relevance in another cross-sectional study is not
sufficient justification, given that many other variables were also relevant. For example, the
duration of pelvic pain seems more valuable than the time since diagnosis itself, as it is unlikely
that simply carrying an endometriosis diagnosis without symptoms would be associated with
mindfulness, self-compassion, and psychological well-being—it would likely be confounded
by the time spent suffering pain. Similarly, the emphasis on age in the introduction is unclear
(line 135). Is this variable relevant enough to be highlighted? Clarifications on these points
were provided in the Background and in the Methods section. Fair AR: Thank you. Pain
symptoms were also reported as a predictor in the al section. Why test their association with
mindfulness and self-compassion? If the authors aim to explore whether pain symptoms mediate
the relationship between mindfulness, self-compassion, and psychological well-being (which
would be plausible), it would be more informative to compare different s with and without
pain as a predictor. This approach would represent a better of hierarchical s, grounded in the
theoretical connections between the main variables, especially when a true mediation analysis
is not feasible due to the cross sectional study design. Additional material was provided in the
Background and in the Methods section . Fair, although confusion is still present. Pls discuss with
stats expert. AR: Unfortunately, we were not given clear indications to understand the nature of
this confusion. Since Reviewer 1—who had initially raised the concerns—expressed satisfaction
with our revision, we did not make significant changes based on this point alone. Nevertheless,
we carefully re-examined all the statistical analyses, as well as the “Statistical Analyses” section
of the manuscript. Additional clarification has now been provided regarding the final set of
analyses (i.e., the multivariate analyses of variance using the levels of self-compassion as the
independent variable). It is crucial to provide a clear theoretical rationale to avoid unnecessary
multiple-association tests. This is even more critical in a non-preregistered study to maintain
transparency and avoid suspicions of p-hacking by readers. The Reviewer is correct. In the
original version of our article, the Background section did not provide an adequate theoretical
rationale. We hope that the additional and updated material we have incorporated has improved
the theoretical foundation. Satisfactory AR: Thank you. Please specify the time interval for
which the pain symptoms were assessed—was it over one month, one week, or another period?
This information is important to convey the reliability of the measurement. Additionally,
consider whether "noncyclic pelvic pain" might be a more precise term than "chronic pelvic
pain," as the latter can encompass any form of chronic pain in the region. Pain symptoms
were assessed focusing on the past six months (see lines 208-209). Following the reviewer’s
suggestion, we decided to the term "non-menstrual pelvic pain" rather than "noncyclic pelvic
pain." We hope the reviewer agrees with this terminology. Fair AR: Thank you. Again, a clear
theoretical framework based on previous understanding of the processes involved should be
the foundation for variable selection. The authors decided to include some relevant variables,
but many other critical confounders and covariates were omitted, such as lifestyle factors (e.g.,
physical activity, alcohol consumption, smoking) and mental health conditions (e.g., anxiety,
depression, personality traits like neuroticism or openness). Were these or other important
variables collected? Or were they collected and deemed less theoretically valuable than, for
example, time since diagnosis and endometriosis stage and type? These choices do not seem
theoretically justifiable. The variables indicated by the reviewer were not collected, as these
aspects were beyond the aims of our study. We hope we have clarified our methodological
choices by expanding on the theoretical background. However, we acknowledged the omission
of other important variables as a limitation in the Discussion section (lines 423-428). We
also clarified that our study did not aim at understanding processes. Fair AR: Thank you. All
independent variables are referred to as predictors, but some are more appropriately classified as
covariates or confounders, given that their predictive value is not the primary interest. The lack
of specification makes it difficult to understand the hypothesized role of each variable. Please
provide these specifications to improve comprehensibility. Yes, the reviewer is correct. There
were only two potential predictors in our study: self-compassion and mindfulness. The other
variables were included in our regression to enhance the rigor of our analyses, as we wanted to
control for the effects of potential confounders associated with psychological wellbeing. These
specifications were provided in the Methods section (see the paragraph entitled “al analyses”).
Fair AR: Thank you. The main analysis was based on al significance (p-value less than 0.05) in
univariate and bivariate analyses. This approach is flawed, particularly given the large sample
size, which can amplify the issue (false positives). Reliance on p-values without a solid rationale
can lead to misleading conclusions and overlook the importance of effect size and practical
significance. For example, the p-values for the correlations between age and psychological well-
being (r = .132, p = 0.001) and between dysmenorrhea and psychological well-being (r = -.161,
p = 0.001) were both highly significant, despite their low correlation strengths. Is it appropriate
to attribute the same importance to these variables in the decision to include them in a multiple
regression ? ally, their significance levels are almost equal, but their theoretical importance is
very different. Actually, that was not our approach. We did not merely rely on al significance. For
our main analyses (hierarchical multiple regressions), we provided the values of #R2 to specify
the change in R2 values from one to another. For multivariate analysis of variance, we included
values of #2p. Although this was not specified in the Methods, in the Results and the Discussion
section we provided comments on the magnitude of Pearson correlations (see for example lines
366-369; see also the comments on the values of r provided in the Results). In the section focd
on al analyses, we simply clarified the pre planned level of al significance. However, additional
information has been included to avoid misunderstanding (lines 248-251). Fair AR: Thank you.
Additionally, the authors categorized the variable self-compassion, an approach that results in
a loss of information, while keeping mindfulness in its original scale. Why did the authors
decide to categorize self-compassion? Clarifications were provided in the Methods section (lines
221-223). The categorical variable created according to Neff’s indications was d only in the final
set of analyses, which explored associations between self-compassion and the other variables
of interest, as done in previous endometriosis research. Fair AR: In response to the comments
provided by Reviewer 1, we have added clarifications to the manuscript (please refer to our
detailed responses to the reviewer). The explanation given by the authors—"determining the
distinct effects of the predictors of interest while controlling for the effect of other variables
associated with PGWB-S"—to justify the of significance in the univariate and bivariate analysis
does not make sense. A better approach would be to select variables based on a theoretical
rationale and develop two multiple regression s, one for each predictor of interest (SCS-Total
and LMS-Total). Then, test if the difference between the s is significant. This approach reduces
the risk of Type I errors, increases the validity of the , and enhances interpretability by ensuring
that the selection of variables is grounded in existing research. We don’t fully understand the
reviewer’s statement: “[…] to justify the of significance.” Our intention was to adopt a more
rigorous approach to examine the associations between the two predictors and psychological
wellbeing using multiple regression. We hope we have clarified these aspects, considering
the specific aims of our study. Fair AR: Thank you. To address supposed multicollinearity
between pain symptom variables, the authors summarized them into a single variable using
principal component analysis (PCA). This choice is unnecessary. Pearson correlations ranged
from 0.275 to 0.538, indicating moderate correlations, which typically do not ca significant
collinearity issues. Collinearity becomes more concerning with correlations exceeding 0.7 or
0.8. The principal components may lack direct or meaningful interpretation in the context of
the original variables, potentially obscuring the results. Response: This choice was motivated
by the fact that pain was not conceptualized as a predictor. Therefore, we were not interested
in examining associations between specific types of pain and psychological wellbeing. Our
aim was just to control for the effects of an important variable that is strongly associated with
psychological health in individuals with endometriosis. For this reason, we chose to retain this
approach. Fair, discuss with stats expert to improve representation of results in diff tables and f
igures /formats to avoid confusion. AR: Thank you. We do not fully understand the suggestion
provided. Since Reviewer 1 was satisfied and recommended publication, we decided not to make
significant changes to our tables. In Table 3, we replaced p values reported as .000 with <0.001.
My comments- Have gone through the manuscript and changes made. The final sections such
as results and conclusion have come out really well. The current version is acceptable for
publication.
Pages 7-12 duplication of previous files and explained above.-no comments.