Investigation of the Relationship Between Family Accommodation, Alexithymia, and Emotional Regulation Difficulty in Obsessive-Compulsive Disorder
Article information
Abstract
Objective
The aim of the study is to explore the relationship between family accommodation, emotion regulation difficulties, and alexithymia in obsessive-compulsive disorder (OCD).
Methods
The study group consisted of 107 individuals diagnosed with OCD, while the control group included 151 healthy individuals. Sociodemographic data form, Yale-Brown Obsessive Compulsive Scale (YBOCS), Family Accommodation Scale-Patient Version (FASPV), Toronto Alexithymia Scale (TAS), and Difficulties in Emotion Regulation Scale (DERS) were used to collect data.
Results
In our study, it was found that the median DERS and TAS scores of the participants were significantly higher in the OCD group than in the control group. A moderate positive correlation was found between FAS-PV and the total score of YBOCS (p=0.002, r=0.302). Statistically significant, low to moderate, positive correlations were observed between FAS-PV and the total score of DERS (p=0.001, r=0.319). Furthermore, a statistically significant, moderate to low correlation was found between YBOCS and the total score of DERS. A positive and substantial influence on FAS-PV is provided by the YBOCS variable (B=0.571, p=0.01).
Conclusion
In conclusion, this study found that difficulty in emotion regulation and alexithymia levels were higher in individuals with OCD compared to healthy controls, and that family accommodation was related to both difficulties in emotion regulation and alexithymia. Finally, it was determined that difficulty in emotion regulation has a mediating effect in the relationship between family accommodation and alexithymia. It is suggested that longitudinal studies be conducted to further support the data presented by this study.
INTRODUCTION
Obsessive-compulsive disorder (OCD) is defined by intrusive, unwanted thoughts, images, or urges that cause significant distress, accompanied by repetitive behavioral or mental actions aimed at alleviating this discomfort [1]. As a heterogeneous condition, OCD encompasses various themes, including contamination, order and symmetry, doubt and checking, and unacceptable or distressing thoughts [2]. The symptoms of OCD not only affect individuals directly but also impact their family relationships. In turn, the family environment can significantly influence the progression and manifestation of OCD symptoms [3]. Family accommodation describes the modifications family members make to their daily routines or their participation in the patient’s rituals to minimize or prevent anxiety in individuals with OCD [4]. Research indicates that up to 99% of family members of individuals with OCD engage in at least one form of family accommodation, often on a daily basis [5]. Family accommodation plays a critical role in symptom persistence and recovery, with higher levels of family accommodation linked to greater OCD symptom severity and poorer treatment outcomes [5]. Moreover, family members’ understanding of and reactions to psychiatric illnesses strongly affect treatment-seeking behaviors and therapeutic outcomes [6].
One factor influencing treatment response in psychiatric disorders is alexithymia [2], a personality trait characterized by difficulty in recognizing and expressing emotions. Alexithymia has been closely associated with OCD [7], with research consistently demonstrating that individuals with OCD tend to exhibit higher levels of alexithymia [8-10]. Similarly, Üstündağ and Şen Gökçeimam [11] (2020) observed that OCD patients often face challenges in identifying and articulating their emotions. Alexithymia has significant implications for emotional regulation [11]; as difficulties in recognizing and expressing emotions can hinder the ability to manage emotions effectively, particularly in stressful situations [10]. Emotional regulation difficulty refers to challenges in managing impulsive behaviors triggered by negative emotions, sustaining goal-directed actions, and employing adaptive emotional regulation strategies [12-14]. A key element in managing negative emotions is the ability to identify and express them effectively [15]. When individuals fail to understand their emotional experiences, these emotions may appear more threatening and overwhelming [15]. For individuals with OCD, distinguishing imagined mental events from reality is often problematic, exacerbating the distress caused by intrusive thoughts and reinforcing the perception that these thoughts are closely tied to reality [10]. Aldao and Nolen-Hoeksema [16] (2011) observed that poorly regulated emotions can lead to compulsive behaviors aimed at escaping or alleviating such distress. Emotional hypersensitivity, coupled with a tendency to reject or avoid emotions, often results in avoidance of emotionally charged situations and reliance on compulsive behaviors or reassurance-seeking strategies to manage negative emotions. These patterns can significantly influence the severity of compulsions, treatment-seeking behaviors, and treatment outcomes in individuals with OCD. Recognizing emotional regulation difficulties and their contributing factors is therefore essential for effective intervention and support.
A review of the literature indicates an absence of studies exploring the relationship between family accommodation, emotional regulation difficulties, and alexithymia in OCD. To address this gap, the present study aims to explore the interplay among these variables in individuals diagnosed with OCD. Specifically, it hypothesizes that OCD patients with higher levels of alexithymia are likely to experience greater difficulties in emotional regulation. Additionally, the study seeks to examine the relationships between family accommodation, emotional regulation difficulties, alexithymia, and OCD severity. Our research aims to answer the following questions in line with our hypotheses: 1) Is family accommodation related to emotion regulation difficulties and alexithymia levels in individuals with OCD? 2) Is there a predictive effect of OCS, emotion regulation difficulties, and alexithymia levels on family accommodation in OCD? 3) Is there a mediating effect of emotion regulation difficulties in the relationship between family accommodation and alexithymia?
METHODS
Sample
The sample for this study was drawn from individuals who visited the psychiatry outpatient clinic of a training and research hospital in Türkiye’s Central Anatolia region between December 2023 and December 2024. Patients who applied to the psychiatry outpatient clinic and were diagnosed with OCD according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [1] based on the evaluation of a psychiatrist and who did not meet the diagnosis of another psychiatric disorder according to DSM-5 were included in the study. The control group consisted of healthy individuals matched to the OCD group in terms of age and gender. A theoretical power analysis, using an independent samples t-test, indicated that a minimum sample size of 200 participants (100 per group) would be required to achieve a test power of 0.8 (1-β), an effect size (ES) of 0.62, and a Type 1 error rate (alpha) of 0.0515. Scales were administered to 120 patients diagnosed with OCD by a psychiatrist, all of whom agreed to participate in the study. However, 13 patients were excluded due to incomplete responses on the data collection forms. The final sample consisted of 107 individuals with OCD and 151 healthy controls, with the control group comprising hospital staff and their relatives.
Both groups comprised literate individuals aged 18–65 years, with no additional psychiatric conditions. For the OCD group, inclusion required a diagnosis of OCD based on DSM-5 criteria, while the control group consisted of individuals without any psychiatric diagnoses. Before the implementation phase of the study, participants underwent psychiatric evaluations, and those not meeting the inclusion criteria were excluded. The exclusion criteria included: any neurological or psychiatric conditions that could interfere with answering the questions, comorbid conditions (e.g., psychotic disorders, bipolar disorder, mood disorders, substance dependency), organic or mental issues that could hinder understanding or completing the scales, age outside the 18–65 years range, and refusal to participate. Additionally, since family accommodation was a key aspect of this study, individuals living alone were excluded.
Procedure
Participants were informed that their identities and personal data collected during the study would remain confidential and that they could withdraw at any time. The research was conducted between December 2023 and December 2024 at a psychiatry outpatient clinic in a training and research hospital in Türkiye’s Central Anatolia region. Data were collected by a psychiatrist working at this institution through face-to-face interviews, which lasted approximately 20–25 minutes. Prior to the study, participants were informed of its purpose, and both written and verbal consent were obtained.
Data collection tools
The researchers used a sociodemographic data form along with the Yale-Brown Obsessive Compulsive Scale (YBOCS), Family Accommodation Scale-Patient Version (FAS-PV), Difficulties in Emotion Regulation Scale (DERS), and Toronto Alexithymia Scale (TAS).
Sociodemographic data form
This form, created by the researchers, contained information about the sociodemographic attributes of the participants.
YBOCS
This is a scale developed to rate the quality and severity of obsessive-compulsive symptoms (OCS) [17,18]. YBOCS is an interviewer-administered scale. It consists of a total of 19 items, but only the first 10 items are used to determine the total score. The first five items evaluate obsessions, and items 6–10 evaluate compulsions. The score of each item varies between 0 and 4, with the total score ranging from 0 to 40. Karamustafalıoğlu et al. [19] adapted the scale to Turkish and performed the validity and reliability. The original study reported the Cronbach’s alpha value of the scale to be 0.98, and we determined it to be 0.91 in the current study.
FAS-PV
Wu et al. [20] developed the FAS, and Çöldür [21] performed the validity and reliability analyses of the Turkish version of this scale. In this scale, the respondent is the individual with OCD. The scale provides information about patient symptoms and family members’ accommodation of and involvement in symptoms. The first part of the FAS consists of an OCD symptom checklist, and the second part consists of 19 items evaluating the frequency of the accommodation behaviors of family members. In the second part, the frequency of such behaviors is also measured with a five-point Likert type evaluation. The total score is calculated by adding up the scores of 19 items in the second part. FAS has four subscales: direct participation in and facilitation of OCD symptoms; avoidance of OCD triggers; assuming patient’s responsibilities; and modifying personal responsibilities. The Cronbach alpha value for the entire scale was 0.89 in the original study and 0.89 in the current study.
TAS
This 20-item scale developed by Bagby et al. [22,23] in 1994 was adapted to Turkish by Güleç et al. [24]. It is a 5-point Likert type scale (1=Never to 5=Always). The participant marks the extent each item describes him/herself. The scale includes three alexithymia sub-dimensions: “difficulty to recognize emotions (TAS-A),” “difficulty to express emotions (TAS-B),” and “extraverted thinking (TAS-C).” Certain scale items are scored in reverse. The total Cronbach’s alpha coefficient of the scale was determined as 0.78. The Cronbach’s alpha value of this study is 0.91.
DERS
The DERS is a self-report scale developed by Gratz and Roemer [13] in 2004 to examine difficulties in emotion regulation across four dimensions. The scale consists of 36 items scored from 1 to 5 and includes six sub-scales: nonacceptance of emotional responses, difficulty engaging in goal-directed behavior, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity. Higher scores indicate greater difficulties in these areas. The Turkish validity and reliability study of the scale was conducted by Ruganci and Gençöz [25], who reported a Cronbach’s alpha coefficient of 0.94. In this study, the Cronbach’s alpha coefficient was found to be 0.95.
Biostatistical data analysis
Qualitative variables were summarized by calculating frequency (percentage). Pearson’s chi-square test, Yates continuity correction test, and Fisher’s exact test were used where appropriate to examine the associations of qualitative variables with patient and healthy groups. The Shapiro-Wilk (W) test was used to examine whether the quantitative variables were normally distributed. Variables that were not normally distributed were summarized with median (interquartile range [IQR]) values using the Mann-Whitney U test statistic and the ES was given. In multiple regression analysis, the relationship between independent variables was examined with the backward elimination model; direct or indirect effects of the relationship between variables were examined by mediator analysis. In all results, p≤0.05 was considered statistically significant. Statistical analyses were performed using the SPSS version 26.0 package program (IBM Corp.).
Ethics approval
Ethical approval for the study was obtained from the Nigde Omer Halisdemir University Non-Interventional Clinical Research Ethics Committee (protocol number: 2023/109, dated 18/11/2023), and necessary permissions were secured from all relevant institutions. The study was conducted in accordance with the principles outlined in the Helsinki Declaration.
RESULTS
In Table 1, the differences between the groups were examined by comparing the clinical and demographic characteristics of the group of OCD group and control group. The significant differences were found level in categories such as number of cohabitants, marital status, educational level, and prevalence of mental disorder in the family (p-values for all variables are <0.01). These data show how similar the sex and age characteristics are for both groups. There is no significant difference in the age variable according to sex in the OCD group and healthy control group.
Descriptive statistics on demographic and clinical characteristics of OCD and control group
The median scores for the scales used are shown in Table 2. The OCD group has a median score of 26 for both FAS-PV and YBOCS. When comparing the median scores of the OCD and Control groups on the DERS and TAS, it was found that all subscale and total scores on both scales were significantly higher in the OCD group than in the control group.
Mean FAS-PV and YBOCS scores of individuals diagnosed with OCD and comparison of the mean DERS and TAS scores of the groups
The correlation matrix for the scales used in the OCD group is shown in Table 3. A moderate positive correlation was found between FAS-PV and the total score of YBOCS (p=0.002, r=0.302). Statistically significant, low to moderate, positive correlations were observed between FAS-PV and the total score of DERS, as well as the Non-Acceptance, Strategy, Impulse, and Goal subscale scores (r and p-values, respectively: r=0.319, p=0.001; r=0.334, p<0.001; r=0.362, p<0.001; r=0.240, p=0.013; r=0.218, p=0.024). A statistically significant, moderate to low positive relationship was found between FAS-PV and TAS-total, as well as the TAS-A and TAS-B subscale scores (r and p-values, respectively: r=0.267, p=0.005; r=0.276, p=0.004; r=0.302, p=0.002). Furthermore, a statistically significant, moderate to low correlation was found between YBOCS and the total score of DERS, as well as the Non-Acceptance, Strategy, Impulse, and Goal subscale scores (r and p-values, respectively: r=0.324, p=0.001; r=0.373, p<0.001; r=0.442, p=0.001; r=0.300, p=0.002; r=0.216, p=0.026). A statistically significant positive correlation was also found between YBOCS and the total score of TAS, as well as the TAS-A and TAS-B subscale scores (r and p-values, respectively: r=0.248, p=0.01; r=0.338, p<0.01; r=0.224, p=0.02).
Examining the relationship between variables for the patient group using correlation analysis
The findings of the regression study with the backward elimination model, one of the regression stepwise models, to determine the factors affecting FAS-PV are shown in Table 4. FAS-PV was examined in the first model as a function of the variables YBOCS, DERS-total, and TAS-total. A positive and substantial influence on FAS-PV is provided by the YBOCS variable (B=0.571, p=0.01). As a result, FAS-PV increases by 0.571 units for every unit that the YBOCS score increases. It was determined that the DERS-total (B=0.13, p=0.085). FASPV was not significantly impacted by the TAS-total variable (B=0.067, p=0.701). The model’s overall significance was statistically significant according to F=6.866 and p<0.001. The second model showed a higher impact on FAS-PV from the YBOCS and DERS-total variables. Consistent with the first model, YBOCS continued to have a positive and significant impact (B=0.576, p=0.009). In this model, the DERS-total variable also showed significance and had a favourable effect on FAS-PV (B=0.148, p=0.012). The second model had a high overall significance and was statistically significant at the F=10.309, p<0.001. Additionally, Table 4 shows that the Tolerance values for all variables vary between 0.54 and 0.881, and the variance inflation factor (VIF) values range between 1.135 and 1.854. The findings demonstrate the absence of multicollinearity in the regression model. Per the interpretation guidelines, Tolerance values under 0.1 signify a significant presence of multicollinearity, values under 0.2 imply a possible concern, whereas VIF values below 5 typically denote no issue, values ranging from 5 to 10 necessitate caution, and values exceeding 10 indicate a severe multicollinearity problem [26]. As a result, the Tolerance and VIF values for the variables in this research are within acceptable bounds, and the regression model fulfills the criterion of no multicollinearity. YBOCS and DERStotal factors are significant predictors of FAS-PV, according to these findings.
Determination of the factors affecting the effects of family harmony with regression model
The statistical significance of the effects of TAS-total on FAS-PV was evaluated using the p-values in Table 5. First, the p-value for the overall effect of TAS-total on FAS-PV was 0.008. According to the 95% confidence interval, the p-value indicates that the effect of TAS-total on FAS-PV is statistically significant and positive. It is noteworthy that the p-value of 0.595 for the direct effect is significantly higher than the significance level (usually p<0.05). As a result, family cohesion is not statistically influenced in a way that would allow TAS-total to work directly. When the ES data are evaluated, the ES value of the direct effect is 0.9570, but the ES value of the overall effect is 0.3718. This indicates that the overall effect may be affected more by indirect effects. In the study of indirect effects, the indirect effect with the ES value of 0.2761 and the confidence interval of 0.0251–0.5439 is determined by using the DERS-total mediator variable. To evaluate the stability and dependability of the indirect impact, the BootSE of the indirect effect is 0.1314. Additionally, the BootSE of 0.0885 and ES of 0.1882 are recorded for the completely standardized indirect effect. Based on the mediator variable DERS-total, these findings imply that the indirect impact is a considerable part of the effect of TAS-total on FAS-PV and is also statistically significant. So, it can be concluded that this mediating variable plays a secondary role in the majority of the overall impact of TAS-total on FAS-PV.
The effect of total, direct, and indirect effects of TAS-total variable on FAS-PV with mediator analysis
DISCUSSION
When examining the sociodemographic and clinical characteristics of this study, we found that the healthy control group and individuals diagnosed with OCD were matched in terms of age and sex, with a higher proportion of female participants in both groups compared to males. The literature suggests that individuals diagnosed with OCD are typically in the young-to-middle adulthood stage, and that OCD is more prevalent in females than in males [27]. Therefore, study sample aligns with the literature in terms of age and sex distribution related to OCD prevalence [28,29]. Additionally, in our sample, the OCD group was found to have a lower level of education, a higher proportion of married participants, and a greater number of individuals living in nuclear families compared to the control group. Since the aim of this study was to evaluate family accommodation in OCD, individuals living alone were specifically excluded from the research. The difference in the proportion of cohabiting individuals between the groups is likely due to the higher number of married individuals in the OCD group, which resulted in a greater number of individuals living in nuclear families compared to the control group. A review of the literature shows that in Türkiye, the marriage rate among individuals diagnosed with OCD is typically higher than the rate of single individuals, with about two-thirds of those diagnosed being married [26]. Although the OCD group in this study had a higher proportion of married participants compared to the control group, the rate was lower than what is reported in the literature, which can likely be attributed to the younger average age of our sample.
In this study, the median value for FAS-PV in the OCD group was found to be 26. A moderate positive correlation was found between family accommodation and the level of OCS. Previous studies have shown that family accommodation scores tend to be lower [21,30,31]. One possible explanation for this difference is that we excluded individuals with OCD who live alone from our sample. A study conducted in China reported that a family-centered structure resulted in higher family accommodation [32]. Previous research has frequently reported a relationship between OCS levels and family accommodation, and our findings are consistent with the literature [4,33-35]. Mowrer’s two-stage theory [36] of fear and avoidance helps explain the observed results in OCD. According to this theory, obsessive fears become distressing when a neutral stimulus is associated with an unpleasant or traumatic experience (classical conditioning). In the second stage, any behavior that alleviates this obsessive fear can become habitual due to negative reinforcement, effectively reducing anxiety (operant conditioning) [3]. From Mowrer’s perspective, it can be concluded that family harmony strengthens operant conditioning, which may explain the observed increase in OCD symptoms. It is believed that as the severity of OCD symptoms increases, family members’ feelings of wanting to help intensify, which may result in the symptoms being more prominently exhibited [35]. Therefore, family accommodation is an important factor that can prevent the patient from being overwhelmed by the illness and witnessing its consequences, thereby contributing to the continuation or exacerbation of the disorder.
In this study, we found that difficulty in emotion regulation and alexithymia levels in the OCD group were positively correlated with the level of OCS and were statistically significantly higher compared to the control group. Similar findings have been reported in studies examining alexithymia levels and difficulty in emotion regulation in individuals diagnosed with OCD [7,9,37-39]. In contrast, this study investigated the relationship between family accommodation, alexithymia, and difficulty in emotion regulation in OCD and found a statistically significant positive relationship between family accommodation and both emotion regulation difficulty and alexithymia. Specifically, as family accommodation increased in OCD, patients exhibited more alexithymic traits and greater difficulty in regulating their emotions. It is known that family accommodation can help avoid anxiety-inducing stimuli or situations [5]. However, family accommodation may also indirectly reinforce irrational obsessive thoughts or the belief that a relative cannot cope with the distress caused by these thoughts. Furthermore, it has been reported that individuals with OCD who experience high family accommodation have fewer opportunities to apply self-regulation or coping skills [5]. A study conducted on adolescents with OCD found that family accommodation, as a parenting substyle, was higher in parents of adolescents with poor emotion control [40]. It was observed that parents of adolescents with OCD exhibited pathological levels of approval behaviors to reduce OCD-related stress in their children and more frequently adjusted their routines to accommodate this distress, often relying on family accommodation [41]. Similarly, as seen in alexithymia, difficulty in identifying and labeling emotions can lead individuals to develop more concrete and understandable ways of coping [7]. Therefore, the regulatory actions taken by families can increase patients’ difficulty in identifying and expressing their emotions, prevent the development of emotion regulation skills, and hinder their ability to tolerate stress.
In the first regression model established within the study to identify the factors affecting family accommodation, family accommodation was examined as a function of OCS, difficulty in emotion regulation, and alexithymia. It was found that as the OCS level increased, family accommodation increased by 0.571 units. Although difficulty in emotion regulation did not have a statistically significant effect on family accommodation, it showed a borderline significant effect. In the second model, both OCS level and difficulty in emotion regulation were found to have a stronger impact on family accommodation. Consistent with the first model, the second model also showed that OCS level continued to have a positive and significant effect. Additionally, in this model, difficulty in emotion regulation was found to be statistically significant. According to the results of the regression analysis, OCS level and difficulty in emotion regulation are significant predictors of family accommodation. The finding that OCS level predicts family accommodation is frequently reported in the literature [35,42], making it an expected result. Emotion regulation is not only an individual process but can also be supported or hindered through interactions with close others, including family members [43,44]. More specifically, some individuals learn to rely on themselves first to reduce distress, while others turn to others for help in regulating their emotions [45]. Therefore, identifying the significant predictive effect of difficulty in emotion regulation, along with OCS level, on family accommodation in OCD is important. In this context, the predictive effect of difficulty in emotion regulation on family accommodation, alongside OCS level, provides valuable insight into how interpersonal processes contribute to the maintenance of psychopathology. Additionally, one of the significant findings of the study is related to the effects of alexithymia on family accommodation. It was found that the overall effect of alexithymia on family accommodation is significant, with indirect effects playing a more prominent role. In the relationship between family accommodation and alexithymia, difficulty in emotion regulation was found to have a mediating effect. Therefore, it can be concluded that difficulty in emotion regulation plays a secondary role in the overall effect of alexithymia on family accommodation.
Limitations
This study has several limitations. One limitation is that we did not examine the effect of the traditional societal structure in our region on family accommodation. Additionally, the fact that this study was conducted in a single center and had a cross-sectional design is other limitations. Previous studies have reported that family accommodation is variably related to the subdimensions of OCD symptoms [3] and not evaluating these subdimensions in our study is an important limitation. Another limitation is the use of the self-report scale FAS-PV to assess family accommodation. In addition, our findings regarding sociodemographic data were discussed in the first paragraph of the discussion, but the fact that characteristics such as education level and marital status differ between groups is also among our limitations. In this study, we specifically excluded individuals living alone in order to evaluate family accommodation, but this can be considered a limitation considering that it can be perceived as selection bias. Additionally, our sample did not demonstrate homogeneity in terms of medical treatment status. The decrease in both OCS and emotion regulation difficulties with medical treatment may have also led to a change in family accommodation. Therefore, the lack of homogeneity in the patient group in terms of medical treatment status can be considered a limitation. The cross-sectional design of our study can be considered a limitation in terms of causal determination.
In conclusion, these research results are significant because it is one of the first to examine the relationship between family accommodation, emotion regulation difficulties, and alexithymia, which has recently been emphasized as important in OCD and suggested for inclusion in the diagnostic criteria [5]. This study found that levels of family accommodation, emotion regulation difficulties, and alexithymia were higher in individuals with OCD compared to healthy controls, and that family accommodation was associated with both emotion regulation difficulties and alexithymia. One of our key findings is the determination that, beyond OCD level, emotion regulation difficulties have a predictive effect on family accommodation. Finally, emotion regulation difficulties were found to mediate effect in the relationship between family accommodation and alexithymia. We believe that our findings regarding family accommodation in OCD may contribute to therapeutic interventions that can impact recovery during the treatment process. Indeed, while integrating the family into OCD treatment is a standard practice in children, treatment processes are generally conducted independently of the family in the adult population [46]. However, we emphasize that treatment goals should include teaching family members the basic principles of behavior management (including how to ignore undesirable behaviors and attend to more desirable ones)—that is, how to cope with symptoms—rather than simply adapting to symptoms. We emphasize that a decrease in family accommodation may strengthen positive cognitive, behavioral, and physiological strategies associated with emotion regulation and reduce negative cognitive, behavioral, and physiological strategies underlying emotion dysregulation. It is suggested that longitudinal studies be conducted to further support the data presented by this study.
Notes
Availability of Data and Material
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.
Author Contributions
Conceptualization: all authors. Data curation: Fatma Kartal, Aydın Kurt. Formal analysis: Fatma Kartal, Hatice Polat. Funding: all authors. Investigation: Fatma Kartal, Hatice Polat. Methodology: Fatma Kartal, Hatice Polat. Project administration: Fatma Kartal, Hatice Polat. Resources: all authors. Software: Fatma Kartal, Hatice Polat. Supervision: all authors. Validation: Fatma Kartal, Hatice Polat. Visualization: Fatma Kartal, Hatice Polat. Writing— original draft: Fatma Kartal, Hatice Polat. Writing—review & editing: Fatma Kartal, Hatice Polat.
Funding Statement
None
Acknowledgments
None