The chain-mediating effect of societal pressure on appearance and body image on fear of negative evaluation and social anxiety in women with polycystic ovary syndrome: a cross-lagged panel analysis

Objective (Prospective Longitudinal Observational Study) This study aimed to examine the longitudinal chain mediating roles of physical appearance social pressure and body image in the relationship between fear of negative evaluation (FNE) and social anxiety among women with polycystic ovary syndrome (PCOS), and to clarify the temporal sequencing among these variables. Methods Convenience sampling was used to recruit 264 women with PCOS. Participants completed the Sociocultural Attitudes Towards Appearance Questionnaire-4 Revised (SATAQ-4R), Body Image States Scale (BISS), Brief Fear of Negative Evaluation Scale (BFNE), and Social Anxiety Scale (SAS) at baseline (T0), 3 months (T1), and 6 months (T2), yielding 242 valid cases. Data were analyzed using measurement invariance testing, cross-lagged panel analysis (CLPA), and bootstrapping. Results Full measurement invariance was established across the three timepoints (ΔCFI ≤0.01, ΔTLI ≤0.01). The final CLPA model demonstrated excellent fit (CFI = 0.988, TLI = 0.959, RMSEA = 0.023, 90% CI: 0.021–0.026). T0 FNE positively predicted T1 appearance social pressure (β = 0.25, P <0.001) and T1 SA (β = 0.23, P <0.001), and negatively predicted T1 body image (β = −0.19, P <0.001). T1 appearance social pressure positively predicted T2 SA (β = 0.22, P <0.001). T1 body image negatively predicted T2 SA (β = −0.18, P <0.01). T1 SA positively predicted T2 FNE (β = 0.13, P <0.001). Bootstrap analyses revealed significant indirect effects via T1 appearance social pressure (β = 0.055, 95% CI: 0.028–0.082) and T1 body image (β = 0.034, 95% CI: 0.015–0.053), as well as a significant chain mediation effect (β = 0.018, 95% CI: 0.007–0.029). Conclusion Longitudinal evidence supports a chain mediating pathway wherein elevated fear of negative evaluation at baseline is prospectively associated with subsequent increases in appearance social pressure and declines in body image, which in turn correspond to higher levels of social anxiety in women with PCOS. Findings support the potential utility of early psychological screening and targeted interventions addressing maladaptive cognitions and body image disturbances, although causal efficacy requires validation via randomized controlled trials.