As physically mature individuals, teenagers face changes in social norms and expectations. To adapt to these changes, they often need to change their identity and self-awareness as well as responses. Therefore, puberty is a period of significant developments related to biological, psychological, and social problems. Abnormal maturational timing may lead to an increase in the risk for emotional and behavioral problems during adolescence. In particular, earlier pubertal maturation in girls may cause a number of problems compared with on-time or later maturation¹⁾. Early maturation in girls provokes social changes and social chaos for which they may not be prepared²⁾.

Early maturing girls are more likely to experience body dissatisfaction and low self-esteem during adolescence^3,4). Furthermore, early puberty in girls has been reported as a risk factor for depression^4,5). The degree of physical maturity is related to low self-esteem during adolescence, which affects perception about body image and eating behavior⁶⁾. Eating behavior, perception about body image, and depression are inter-related and are known to be affected by a number of factors such as biological, social, and psychological environments.

Although many studies have examined early maturity or puberty, little is known about body image and depression in girls with precocious puberty receiving treatment with gonadotropin-releasing hormone (GnRH) analogues. This study aimed to evaluate the perception of body image and the degree of depression in girls with precocious puberty receiving GnRH analogue therapy.

We investigated the association between perception of body image and degree of depression by comparing the depression score and satisfaction with weight, height, or overall body build and figure. Patients and controls who were dissatisfied with their overall body build and figure showed a significantly higher mean depression score than those who were neutral or satisfied with their overall body build and figure. In addition, patients and controls who thought that their breast were more mature than the actual appearance showed a significantly higher depression score. In multiple linear regression analysis, T3 (Tanner stages 3–5 by self-awareness) and dissatisfaction about overall body build and figure significantly affected the depression score.

Puberty accompanies physical changes in the body such as breast development, appearance of pubic hair and/or menarche. When faced with rapid body changes, teenagers may become apprehensive of being unable to control their physical maturity ontheir own⁹⁾. This might provoke negative affect, fear, and confusion especially in younger girls.

Previous studies have reported that early maturing girls tend to be dissatisfied with their height and/or weight. Many maturing girls hoped to be thinner, while early maturing boys tended to be satisfied with their height and/or weight. The more the girls matured, the higher the dissatisfaction with body weight reported by them. In addition, boys and girls showed a difference in the degree of recognition of puberty¹⁰⁾. In this study, satisfaction with body weight was not associated with early maturation, but with a combination of other factors and overall pubertal maturity. The perception of their body image may be affected by physical, emotional, and social factors and/or their actual body weight, BMI. The perception of their body weight is also associated with many complicated factors, rather than just the presence or absence of early maturity.

This study found no statistical difference in weight, height, and BMI between precocious pubertal patients and controls. Patients had a more obese body image and an exaggerated perception about their breast development regardless of the objective physical findings, though their height, weight, and BMI were not statistically different from the controls; these 2 distorted body images were not independent of each other.

Social comparison is one of the most important factors influencing body awareness¹¹⁾. The ideal images of celebrities such as thin women and muscular men affect the perception about body image in the general public. Such media exposure causes people to accept these images as the standard of attractiveness. Social comparison to these images brings a discrepancy in attractiveness between oneself and the other, negatively affecting the perception of the body image. Body satisfaction has typically been higher among males than among females, with adolescent girls tending to have more negative body image by the comparison among peers. When the perception and/or degree of their physical maturity are not consistent with peers, it may lead to teasing or induce social problems. In addition, seclusion or hyperactivity develops when a child notices that she differs from her peers. Early pubertal development is associated both with an initiation of smoking and drinking at a younger age and an increased likelihood of a lifetime diagnosis of substance abuse³⁾. The body image is affected by the way of recognizing their own overall body build and figure, rather than their actual overall body build and figure. Adolescent girls' body image is also influenced by the social relationship with their mothers (i.e., the same-sex parent), not fathers¹²⁾.

There was no significant difference in mean depression scores between the patients and controls and between the normal weight and overweight subgroups. We commonly speculate the mental health status of overweight and obese girls to be poorer¹³⁾. There was, however, no difference in depression scores between the normal weight and overweight groups in this study. There also was no significant difference in depression scores according to age.

Early puberty has been reported to be associated withdepression^5,14). Various hormones secreted during puberty are known to cause depressive symptoms¹⁵⁾. However, the pubertal environment in which hormones are suddenly released, social factors, and the action of the hormones themselves are interrelated. These factors contribute to depression in combination, rather than alone¹⁶⁾. In particular, pubertal timing, rather than pubertal status, is the most important contributor to the emergence of depressive symptoms in adolescent girls^2,17). The most reasonable explanation for the effect of puberty timing on depressive symptoms is the psychological and social problems caused by the physical changes during early pubertal time¹⁸⁾. For example, physically maturing girls have difficulty maintaining relationships with the same sex peers who have not matured at a similar rate. Early maturing girls may face environmentally difficulties even before they are emotionally and cognitively ready¹⁷⁾. Menarche is a much more dramatic and rapid transition than other pubertal developments; therefore, experiencing menarche earlier than one's peers may raise a sense of emotional distance and isolation, leading to onset of depressive symptoms in early maturing girls than in those who physically mature later¹⁸⁾.

There are several limitations in our study. The number of patients and controls was not enough to allow a more detailed comparison of normal weight, overweight, and obesity. Many questions in the questionnaire were left unanswered despite explanation provided by the investigator and the help with filling out the questionnaire by guardians. In the future, we need to take account of the child's relationship with their parents, self-esteem, and other socioeconomic factors in girls in the prepubertal or pubertal state in which they worry and feel stress about their identity.

In this study, we found that patients have a more obese body image and exaggerated perception about their breast development regardless of the actual physical findings. The wrong perception of body image seems to contribute to depression score. The distorted body image can be corrected by instilling better understanding of physical development in girls with precocious puberty. Moreover, psychological encouragement and education is useful to correct patients' body image of precocious puberty.