Self-compassion, perfectionism, impostor phenomenon, stress and anxiety in patients with localized provoked vulvodynia

Abstract Studies have shown that psychological distress has a role in the symptomology of localized provoked vulvodynia. Therefore, psychosocial support has been presented as a valuable part of the treatment. However, little is known about which psychological variables that coincide with localized provoked vulvodynia. The purpose of this study was to identify qualities of psychological distress in patients with localized provoked vulvodynia. Patients with localized provoked vulvodynia were consecutively recruited to participate in this cross-sectional questionnaire-based study. Participants completed a self-report questionnaire measuring perfectionism, impostor phenomenon, self-compassion, anxiety and perceived stress. A sample of 30 patients were included. Questionnaire results suggestive of perfectionism was seen in 63%, impostor phenomenon in 80%, low self-compassion in 27%, anxiety in 43% and perceived stress in 23% of the participants. The level of self-compassion was higher in patients in a committed relationship. The investigated qualities appear to be more common in patients with localized provoked vulvodynia than in comparable groups. Impostor phenomenon and perfectionism were particularly common, with more than half of the study population scoring above the cutoff for clinical significance. This motivates research to investigate if interventions targeting impostor phenomenon and perfectionism, may aid in the treatment of localized provoked vulvodynia.


Introduction
Localized provoked vulvodynia (LPV) is a disorder characterized by chronic idiopathic vulvar pain [1].Women affected by the syndrome typically describe a burning or stinging sensation in the vestibular region of the vulva provoked by external stimulus, such as the fabric from clothing or penetration [2].
The etiology behind LPV is unclear, and the condition is currently diagnosed through symptomatology and gynecological examination where differential diagnoses are ruled out [1].According to previous studies, the cause is probably multifactorial with both physiological and psychosocial factors contributing to the symptoms [3].Furthermore, LPV has been connected to a lower quality of life [4], a vulnerable personality [5] and a higher rate of psychological distress [6,7].A mapping of Swedish patient registry data has also shown that 17% of LPV patients experienced depression and that 23% experienced anxiety disorders while prevalences in the control group were 7% and 11%, respectively [8].
Pelvic floor rehabilitation, pain management and psychosocial support are common treatment components in light of the biopsychosocial explanatory model [9].Although psychosocial support has been presented as a valuable part of the treatment, little is known about the specifics of which psychological qualities that coincide with LPV.In this study, an assortment of traits with an established connection to psychological distress, have been selected for further mapping to bridge the current knowledge gap.
Perfectionism can be described as the pursuit of flawlessness and the act of holding oneself to high standards.As such, it has been argued that the trait can be divided into two categories -normal perfectionism, in which a person feels satisfied when the standards have been met, and dysfunctional perfectionism where a person will not feel satisfaction regardless of whether the standards have or have not been met [10].The latter has been described as clinically relevant perfectionism and has been shown to correlate with psychological comorbidity [11].
Impostor phenomenon describes a persistent feeling of being fraudulent in situation where there is no objective evidence of fraud [12].People who suffer from impostor phenomenon attribute their successes to luck or error, and their failure to internalize achievements leads to a persistent fear of being revealed as fraudulent as well as not being able to replicate success [13].They are also more prone to overgeneralizing the implications of single failures, for example by being more likely to attribute failures to internal faults [14].Furthermore, impostor phenomenon has been associated to negative mental health effects [15].
The concept of stress has a been defined in numerous ways.Lazarus and Folkman defines psychological stress as "a relationship between the person and the environment that is appraised by the individual as taxing or exceeding his or her resources and endangering his or her well-being" [16].In short, the occurrence of stress reactions is determined by the way a person perceives the situation.This type of stress, perceived stress, has been shown to correlate with psychological distress [17].
Although feeling anxious at times is a normal part of life, it is important to differ that from pathological forms of anxiety.Anxiety disorders are the most common type of mental disorders and are often comorbid with other psychiatric illnesses, most commonly depression [18].
Unlike the aforementioned traits, self-compassion has been identified as a promotor of psychological wellbeing [19].The trait has been described to entail three components -self kindness, the ability to be supportive of oneself; common humanity, being able to recognize feelings of inadequacy as a part of the human experience; and mindfulness, seeing ones experiences in a balanced manner [20].The presence of these characteristics has been suggested to provide emotional resilience, resulting in better mental health with a lower rate of depression and anxiety [21].
Previous studies imply that there is a psychological element to LPV and that patients with this condition experience psychological distress at a higher rate than the general population [4][5][6][7].This motivates further inspection of qualities that correlate with psychological wellbeing as they could potentially have an impact on symptoms and treatment response.Their identification provides the opportunity to introduce targeted intervention which might improve the treatment for a largely underserved patient group.The aim of this study is therefore to identify the prevalence of perfectionism, self-compassion, impostor phenomenon, anxiety, and stress in patients with LPV.

Materials and methods
This cross-sectional study was conducted at the Dermatology and Venereology Clinic at the University Hospital of Umeå and was approved by the Swedish Ethical Review Authority Dnr 2022-01511-01.Patients with diagnosed LPV, treated at the clinic between the 9 th of September 2021 and the 31 st of October 2022 were consecutively invited to participate in the study.Willing participants were asked to complete anonymous questionnaires either at the clinic in paper format or at home in a digital form.Exclusion criteria were age under 18, lack of autonomy and an insufficient understanding of both Swedish and English as the questionnaires would only be available in those languages.All study participants were current patients treated by our multidisciplinary team with treatments including patient education, topical ointment, psychosocial counseling, home exercises and physical therapy.

Questionnaires
All questionnaires were available in both Swedish and English.
The Clinical Perfectionism Questionnaire 6-item (CPQ-6) was used to measure the degree of perfectionism [22].The CPQ-6 is a shortened version of the twelve-item CPQ and consists of six items pertaining to clinically relevant aspects of perfectionism during the last month.Using a four-point response scale, ranging from 1 (not at all) to 4 (all the time), the respondent is prompted to score the items.Scores range from 6 to 24 and a score between 6-10 indicates no/limited level of perfectionism, 11-15 moderate level, 16-20 high level and 21-24 extremely high level.
Self-compassion was measured using the short form of the Self-Compassion Scale (SCS-SF) [21].The self-report measure includes twelve items that measure six dimensions of self-compassion -self-kindness, self judgment, common humanity, isolation, mindfulness, and over-identification.Scores are given on a five-point scale from 1 (almost never) to 5 (almost always), where the minimum score is 12 (adjusted score 1.00) and maximum score is 60 (adjusted score 5.00).A score between 1.00-2.49implies a low degree of self-compassion, 2.50-3.50 a moderate degree and 3.51-5.00a high degree.
To assess the presence of impostor phenomenon among the participants, the twenty-item Clance Impostor Phenomenon Scale (CIPS) was used [23].The CIPS assesses an assortment of traits associated with impostor phenomenon such as the fear of failure, attribution of success to luck and the fear of being able to repeat success.In this measure, participants rate how true each item is to them on a five-point Likert scale, from 1 (almost never) to 5 (very true).The scales total score ranges from 20 to 100 with 20-40 points implying a low rate of impostor phenomenon feelings, 41-60 a moderate rate, 61-80 a frequent rate and 81-100 an intense rate.
The four-item Perceived Stress Scale (PSS-4) was used to assess perceived stress [24].This instrument evaluates positive and negative elements in the perception and coping of stress on a five-point response scale from 1 (never) to 5 (very often).Scores range from 0 to 16, where a score between 0-8 indicates normal levels and 9-16 indicates elevated levels.
Participants were also asked to complete the twoitem Generalized Anxiety disorder-2 (GAD-2) self-report questionnaire [25].The GAD-2 is a screening tool for anxiety disorders, primarily generalized anxiety disorder, mainly used in primary care facilities for assessing how often a person is bothered by core symptoms of anxiety.Scores are given on a four-point scale from 0 (not at all) to 3 (nearly every day) with the score range 0 to 6. 0-2 points imply no/mild anxiety levels and 3-6 is a strong signal for anxiety disorders.

Statistical analysis
The survey was constructed in Microsoft Forms.Data was transferred to Microsoft Excel where variables were sorted, recoded, and labeled before being imported to SPSS (Version 28.0,IBM Corp).Prevalences of questionnaire results suggestive of perfectionism, impostor phenomenon, low self-compassion, stress and anxiety were primary outcome measures.Secondary outcome measures were comparison of prevalences between groups based on age, relationship status and pain duration.The v2-test was used for comparing prevalences between groups.A p-value of <0.05 was considered statistically significant.

Demographic characteristics
A total of 35 patients were identified and invited to participate in the study, all with Swedish as their mother tongue.Of those, 30 provided written consent and completed the questionnaires (85.7% response rate).Of the respondents, 20 (66.7%) were under the age of 30 and 23 (76.7%) were in a committed relationship.The symptom duration varied greatly in the group with respondents reporting durations between 4-6 months to 20þ years (Table 1).

Overall outcomes
In terms of prevalence, presented in counts and percentages in Table 2, 63.3% of respondents presented high or extremely high level of perfectionism; 80.0% displayed frequent or intense symptoms of the impostor phenomenon; 43.3% exhibited heightened anxiety levels; 23.3% experienced elevated levels of perceived stress, and 26.7% showed a low degree of selfcompassion.

Correlation between psychological factors and demographic characteristics
To evaluate the relationship between prevalences and background variables v2-tests were performed (Table 3).The variables assessed were age, relationship status and symptom duration.When comparing prevalences between patients older or younger than 30 years, no significant difference was observed.There was also no significant difference in prevalences when comparing patients with a symptom duration longer or shorter than five years.A significant interaction could however be seen between self-compassion and relationship status.Patients in a committed relationship were more likely to have a score indicating a higher degree of self-compassion compared to those who were single, X 2 (1, N ¼ 30) ¼ 4.3, p ¼ .037.

Discussion
In this study we could see high prevalences of impostor phenomenon and perfectionism in women with LPV.This is, to our knowledge, the first study that has investigated the prevalence of impostor phenomenon, low self-compassion, and perfectionism in the patient group.We were furthermore able to conclude that self-compassion scores were higher among patients in a committed relationship.More than half of the study population scored above the cutoffs indicating impostor phenomenon and perfectionism, 80% and 63% respectively, suggesting that these characteristics were common in the patient group.To compare these prevalences with other populations, the prevalence of impostor phenomenon in a group of women in higher education found in another study was 65,6% when applying the same cutoffs for clinical significance [26].Medical students, a group where perfectionistic tendencies have been described as a typical characteristic [27], had perfectionism prevalences of 25% and 19% in two studies 25% and 19% [28,29], which is considerably lower than what we found in this study population.As for anxiety and perceived stress, 43% and 23% of the study participants scored above the cutoffs indicating elevated levels of anxiety and stress.In comparable groups of women, the prevalence was found to be 28% and 10% respectively [30,31].Finally, 27% of the participants in the current study exhibited a low degree of self-compassion as compared to 19% found in another study observing an adolescent female sample [32].
Multiple of the findings in this study correspond with what has been previously shown regarding the relationship between LPV and the investigated qualities.Anxiety has earlier been presented as a common feature in patients with LPV, as reported by Wylie et al. and Trib� o et al. [33,34].The disorder has also been linked to stress by Ehrstr€ om et al. [35].Previous research has suggested a possible connection between perfectionism and LPV [36].For instance, high self-imposed standards in multiple domains were observed in one study [37].
As previously stated, all the investigated qualities have an established connection to psychological distress.Knowing this, it is reasonable to speculate that the factors examined in this study may have an influence on the symptomology of LPV as psychological factors contribute to the symptoms.Depression and anxiety, both of which have been extensively linked to the inspected qualities, have for instance been shown to influence the risk of developing LPV by increasing the risk up to four times [38].However, it is important to emphasize that no temporal relationship can be established from this study, thus making it impossible to determine whether these characteristics preceded or succeeded the onset of the disorder.It is not unlikely that some of the investigated qualities are partly caused by the disorder, seeing as pain disorders in general have been presented as a risk factor for psychological distress [39].
Future longitudinal studies may inform on the temporal relation and mechanism between psychological  qualities and LPV, but in any case, interventions may be appropriate.Such interventions are a potential aid in the treatment of LPV but even if this is not so, they may be warranted as measures to increase the patient's general quality of life, as both impostor phenomenon and perfectionism stand out as very common.
Although the results of this study shine light on the prevalence of these characteristics, it is important to note its limitations when interpreting the findings.An important limitation is the lack of a control group, which does not allow comparison to a normative population and makes it difficult to define what constitutes a high or low prevalence.Secondly, the small sample size consisting of thirty patients treated at a single facility is not optimal, limiting the possibility to confidently infer the results on both all patients in the area and patients at other facilities, i.e. the study's generalizability.However, validated questionnaires used extensively in previous research enhance the reliability and a high response rate limits selection bias.It should also be stressed that we have not included analysis of partners of the patients in this study.Since partners are negatively affected by this condition, this could have an influence on the patients [40].
To summarize, the investigated variables appear to be more common in patients with LPV than in comparable groups.Impostor phenomenon and perfectionism appear to be especially common.These findings motivate research into whether targeted intervention, suggestibly intervention targeting impostor phenomenon and perfectionism, may aid in the treatment of LPV.

Table 2 .
Distribution of survey scores among study participants (n ¼ 30).

Table 3 .
Prevalence of survey results indicating stress, anxiety, low self-compassion, perfectionism and impostor phenomenon with regard to age, relationship status and pain duration.