psychopathological similarities and differences between obese patients seeking surgical and...
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ORIGINAL ARTICLE
Psychopathological similarities and differences between obesepatients seeking surgical and non-surgical overweight treatments
Giovanni Castellini • Lucia Godini • Silvia Gorini Amedei • Valentina Galli •
Giovanna Alpigiano • Elena Mugnaini • Marco Veltri • Alessandra H. Rellini •
Carlo Maria Rotella • Carlo Faravelli • Marcello Lucchese • Valdo Ricca
Received: 27 June 2013 / Accepted: 21 August 2013 / Published online: 8 September 2013
� Springer International Publishing Switzerland 2013
Abstract
Purpose To compare the psychopathological character-
istics of obese patients seeking bariatric surgery with those
seeking a medical approach.
Methods A total of 394 consecutive outpatients seeking
bariatric surgery were compared with 683 outpatients
seeking a medical treatment. All patients were referred to
the same institution.
Results Obesity surgery patients reported higher body
mass index (BMI), objective/subjective binging and more
severe general psychopathology, while obesity medical
patients showed more eating and body shape concerns.
Depression was associated with higher BMI among obesity
surgery clinic patients, whereas eating-specific psychopa-
thology was associated with higher BMI and objective
binge-eating frequency among obesity medical clinic
patients.
Conclusions Patients seeking bariatric surgery showed
different psychopathological features compared with those
seeking a non-surgical approach. This suggests the
importance for clinicians to consider that patients could
seek bariatric surgery on the basis of the severity of the
psychological distress associated with their morbid obesity,
rather than criteria only based on clinical indication.
Keywords Bariatric surgery �Binge eating disorder �Medical treatment � Obesity � Psychopathology
Introduction
Morbid obesity, a complex syndrome that is spreading
worldwide [1, 2], is defined as a body mass index (BMI)
[40 kg/m2 or [35 with associated severe medical condi-
tions [3]. It has been considered a heterogeneous syndrome
resulting from the interactions among genetic, social,
economic, endocrine, metabolic and psychopathological
factors [4]. Morbid obesity is often refractory to dietary or
drug treatment as well as to psychotherapy or other con-
ventional interventions [5, 6], but it seems to respond to
bariatric surgery [7–10].
A high prevalence of psychiatric disorders has been
observed among obese individuals seeking both medical or
surgical treatment, in particular depression, anxiety, and
eating disorders [11–14], and considering the high rate of
comorbid mood and binge eating symptoms in obese sub-
jects [15–17], a possible relationship between obesity,
depression, and binge eating symptoms has been proposed
[18–20]. To date, several studies compared the psycho-
pathological and clinical features of bariatric with
G. Castellini � L. Godini � S. G. Amedei � V. Ricca (&)
Psychiatric Unit, Department of Neuropsychiatric Sciences,
Florence University School of Medicine, Largo Brambilla 3,
50134 Florence, Italy
e-mail: [email protected]
L. Godini � S. G. Amedei � G. Alpigiano � E. Mugnaini �M. Veltri � M. Lucchese
Bariatric Surgery Unit, Careggi Hospital, Viale Morgagni 85,
50134 Florence, Italy
V. Galli � C. Faravelli
Department of Psychology, Florence University, Via San
Niccolo, 93, 50125 Florence, Italy
A. H. Rellini
Department of Psychology, University of Vermont,
Burlington, VT, USA
C. M. Rotella
Obesity Agency, Department of Clinical Pathophysiology,
Florence University, Viale Morgagni 85, 50134 Florence, Italy
123
Eat Weight Disord (2014) 19:95–102
DOI 10.1007/s40519-013-0058-3
non-bariatric clinical samples, and it has been hypothesized
that differences exist between the two groups above and
beyond BMI, and specifically in reference to psychological
profiles [21–23]. In particular, some studies reported that
morbidly obese subjects seeking bariatric surgery showed
higher psychiatric comorbidity and lower quality of life, as
compared with other obese people [24–26]. Rutledge et al.
[23] found that low rates of depression and high rates of
obsessive compulsive disorder predicted patients consid-
ered candidates for bariatric surgery. Also, a study showed
that rates of binge eating disorder are higher in surgical
than non-surgical samples [27].
Moreover, a constellation of psychological features have
been proposed to be associated with obesity severity among
patients attending surgical treatments compared with
patients receiving behavioral or clinical interventions. For
example, depression and anxiety were not associated with
BMI and weight loss in medical weight loss treatment,
while they predicted smaller BMI loss in bariatric subjects
[14, 22, 28–30]. Finally, binge eating was positively asso-
ciated with BMI among bariatric surgery patients [26, 31],
but the same association was not observed among over-
weight/obese patients seeking medical interventions [16].
Psychopathological features represent significant out-
come modifiers for medical and surgical interventions for
obesity. When utilized in the screening process, they allow
to select appropriate treatment candidates, and they support
the development of individualized psychosocial treatment
plan [32–35]. However, the lack of consensus about stan-
dardized methods able to assess these characteristics may
have generated conflicting results when comparing differ-
ent obese samples seeking treatments [36–38].
Our hypothesis was that patients decided to ask for
obesity surgery or to a medical therapy for different rea-
sons based on their psychological profile, regardless of the
criteria for being included into one of these treatments.
These psychological profiles should be determined before
the evaluation of a possible intervention, to better target the
treatment and to consider possible psychological outcome
modifiers. Based on this hypothesis and on the extant
review of the literature, we studied obese patients assessed
in the same facility, seeking either a bariatric surgery or a
medical intervention by their initiative, before the evalua-
tion of the inclusion/exclusion criteria for each treatment.
All patients were assessed using the same procedure, in
order to:
1. compare the clinical and psychopathological charac-
teristics of obese patients seeking bariatric surgery
with those of obese patients seeking a medical weight-
loss intervention;
2. evaluate whether general psychopathology (anxiety/
depression) and eating disorder-specific psychopathology
showed a different pattern of association with overweight
severity and binge eating in the two groups of patients.
Methods
Subjects
The present cross-sectional survey was performed at the
bariatric surgery unit and the obesity medical clinic of
Careggi Teaching Hospital, University of Florence (Italy).
Both clinics are located in the same building, and patients
choose by their own initiative to address one of the two
clinics to undergo bariatric or medical treatment, which are
free of charge. Patients were assessed at their first contact
with the Careggi Hospital, before the evaluation of the
inclusion/exclusion criteria for initiating a surgical or
medical intervention. This approach allowed to evaluate
the characteristics of the subjects who asked for a specific
treatment, based on a decision taken by their initiative.
Indeed, at the moment of the reservation of the visit at the
Careggi hospital, information about the inclusion/exclusion
criteria for each intervention are not provided. In each of
the clinics, after the psychological assessment participants
receive detailed information about the treatment they have
selected.
The routine clinical assessment at our clinics included
all the diagnostic procedures and the performed clinical
assessments of the study. At the first visit, patients who
accepted to participate in the study were asked to sign a
written informed consent before the collection of data. The
study protocol was approved by the Medical School
Internal Review Board of the University of Florence. The
study enrolled overweight and obese subjects as a con-
secutive series, referring for the first time to the obesity
surgery clinic (N = 447) and the obesity medical clinic
(N = 750) of the University of Florence. In the medical
clinic, the patients are usually offered a weight-loss pro-
gram aimed at a progressive and realistic change in their
lifestyle, primarily focused on reducing energy intake and
increasing physical activity and energy expenditure.
Patients were enrolled from November 2006 to June 2011.
Considering that the aim of the study was to characterize
patients seeking different treatments in the same hospital,
the inclusion/exclusion criteria to participate to the study
were not those required for surgical or medical treatment.
Given that most of the assessment instruments were self-
reported questionnaires, cognitive impairment and illiter-
acy were assumed as exclusion criteria. Among the obesity
surgery clinic group, 45 subjects refused to participate in
the study and 8 were excluded (6 for illiteracy, 2 for
cognitive impairment); among the obesity medical clinic
96 Eat Weight Disord (2014) 19:95–102
123
group, 58 subjects refused to participate and 9 were
excluded (5 for illiteracy, 4 for cognitive impairment).
Therefore, the final sample was composed by 394 patients
from the obesity surgery clinic and 683 patients from the
obesity medical clinic.
Assessment
At the beginning of the first visit, sociodemographic, psy-
chopathological, clinical and anthropometric data were
collected by endocrinologists, psychiatrists and dieticians.
Anthropometric measures were collected by means of
standard calibrated instruments. Height (meters) was
measured using a wall-mounted stadiometer, weight
(kilograms) using electronic scales. Three expert clinicians
(V.R., S.G.A and G.C.) interviewed patients by means of
the Structured Clinical Interview for DSM-IV [39], in order
to assess lifetime prevalence of binge eating disorder, and
Axis I mental disorders.
Diagnosis of BED was performed retrospectively
according to the new criteria for DSM 5 proposed by the
Eating Disorders Work Group of the American Psychiatric
Association [40], so that the minimum frequency of binge-
eating episodes required to make a diagnosis was once per
week for 3 months. The Eating Disorder Examination
Questionnaire (EDE-Q) was adopted to investigate eating
attitudes and behavior. The self-reported EDE-Q is a 38
items questionnaire based on four subscales assessing
dietary restraint, eating concern, weight concern, and shape
concern [41–44].
The number of weekly objective and subjective binge
episodes was evaluated by means of a face-to-face clinical
interview [45], according to specific questions extracted
from the Eating Disorder Examination Interview (EDE
12.0D) [41, 44] and from DSM-V [40].
Finally, the Emotional Eating Scale (EES) [46], the
Beck Depression Inventory (BDI) [47], the Spielberg’s
State-Trait Anxiety Inventory (STAI) [48] and Symptom
Checklist (SCL-90-R) [49] were also administered.
Statistical analyses
The clinical features of the patients were tested for dif-
ferences. For between-groups comparison (obesity surgery
vs obesity medical), independent-sample t test and Chi-
square (v2) were used for continuous and categorical
variables, respectively. Multiple linear regression analyses
were also performed to evaluate the effect of being into one
group (entered as dummy variable: obesity medical
clinic = 0 vs obesity surgery clinic = 1) on the psycho-
pathological variables (dependent variables) taken into
account, adjusting for age, gender, and BMI.
Correlation analyses were performed for each group
separately. The Kolmogorov–Smirnov test was used to test
for the normal distribution of the variables. For continuous
variables, Pearson’s correlation (or Spearman correlations
for non-normally distributed variables) was adopted to
evaluate associations of BMI, objective and subjective
binge eating with different psychopathological variables
(SCL-90 GSI, BDI, STAI, EES, EDE-Q total and subscale
score). Psychopathological variables included into the
analyses were derived from the literature concerning pre-
dictors of binge eating severity, including socio-demo-
graphic variables, eating-specific (EDE-Q scores) and
general psychopathology (SCL-90, STAI, and BDI scores).
Multiple linear regression analyses were used for each
group in order to assess the effects of psychopathological
variables, on BMI, and objective and subjective binge
eating. Therefore, the dependent variables of these analyses
were, respectively, BMI, objective and subjective binge
eating, while the independent variables were those psy-
chopathological measures which were found to be associ-
ated with the dependent variables according to Pearson’s
correlations; age and gender (as dummy variable:
women = 0, men = 1) were also entered into the models.
Moreover, given that the treatment groups were supposed
to show different weight, linear regression analyses for
binge eating episodes were adjusted for BMI levels.
All analyses were performed using SPSS for windows
15.0 (Chicago Inc., USA).
Results
Comparisons between groups
The summary of participant clinical characteristics and main
psychiatric comorbidities is reported in Table 1: the three
main Axis I diagnoses observed in the sample were reported.
A higher male rate was observed in the obesity surgery clinic
group compared with the obesity medical clinic group (26.6
vs 19.9 %). Patients referred to the obesity surgery clinic
reported higher rate of unipolar depression, binge eating
disorder, and lower obsessive compulsive disorder as com-
pared with the obesity medical clinic group. Furthermore,
patients referred to the obesity surgery clinic reported higher
BMI, objective and subjective binge-eating frequency, EES,
SCL-90 global severity index, and BDI scores, compared
with the obesity medical clinic group. Furthermore, patients
referred to the obesity medical clinic showed higher age, and
EDE-Q eating concern scores compared with the obesity
surgery clinic patients.
Linear regression analyses were performed entering the
mentioned measures as dependent variables and group as
dummy variable (obesity medical clinic = 0 vs obesity
Eat Weight Disord (2014) 19:95–102 97
123
surgery clinic = 1). All the comparisons retained their
significance when adjusting for age, gender and BMI. Both
groups of patients showed a high rate (higher in obesity
surgery clinic group: 36.4 vs 30.4 %; v2 = 4.11, p = 0.04)
of previous weight loss attempts.
Psychological correlates of overweight severity
Pearson’s correlations showed that BMI was directly
associated with BDI scores in obesity surgery clinic
patients (r = 0.12; p = 0.03), and inversely associated
with EDE-Q restraint in obesity medical clinic patients
(r = -0.10; p = 0.02). Other correlations were not
significant. These variables were entered into the multiple
linear regressions, and the analyses confirmed this pattern
of associations (Table 2).
Psychological correlates of binge eating
No significant correlations were observed between clinical
variables and objective binge-eating frequency in the
obesity surgery clinic group, whereas EES (r = 0.29;
p \ 0.001), weight concern (r = 0.36; p \ 0.001), eating
concern (r = 0.28; p \ 0.001), and shape concern
(r = 0.20; p \ 0.01) scores were directly associated with
the frequency of objective binge eating in the other group.
Table 1 General characteristics
of the sample
Statistics: continuous variables
are reported as mean ± SD
BMI body mass index, SCL-90
GSI Symptom Checklist (SCL
90-R) Global Severity Index,
BDI Beck Depression
Inventory, STAI State-Trait
Anxiety Inventory; EES
Emotional Eating Scale, EDE-Q
Eating Disorder Examination
Questionnaire. Unipolar
depression includes major
depression and dysthymia
** p \ 0.01; * p \ 0.05
Obesity surgery
clinic (n: 394)
Obesity medical
clinic (n: 683)
t Student; v2
Gender (female) 289 (73.4 %) 547 (80.1 %) 6.53*
Age (years) 44.93 ± 11.37 46.70 ± 13.77 1.98*
BMI 44.63 ± 8.33 37.81 ± 6.85 13.43**
SCL-90 GSI 0.97 ± 0.60 0.86 ± 0.59 2.45*
BDI 14.77 ± 9.70 12.15 ± 9.07 4.23**
STAI state 42.78 ± 10.75 42.68 ± 12.47 0.12
STAI trait 43.78 ± 10.91 43.89 ± 12.30 0.13
Objective binge eating
(month frequency)
6.05 ± 9.69 3.67 ± 6.12 4.46**
Subjective binge eating
(month frequency)
5.43 ± 19.92 2.42 ± 5.37 3.44**
Emotional Eating Scale 1.38 ± 0.95 1.25 ± 0.95 2.09*
EDE-Q total score 2.54 ± 1.13 2.49 ± 1.18 0.58
EDE-Q restraint 1.72 ± 1.55 1.77 ± 1.48 0.57
EDE-Q eating concern 1.51 ± 1.59 1.77 ± 1.47 2.61**
EDE-Q weight concern 2.98 ± 1.41 2.83 ± 1.29 1.69
EDE-Q shape concern 3.98 ± 1.47 3.60 ± 1.90 2.96**
Previous weight loss attempts 144 (36.4 %) 208 (30.4 %) 4.11*
Unipolar depression 112 (28.3 %) 146 (21.3 %) 6.70*
Obsessive compulsive disorder 8 (2.0 %) 36 (5.3 %) 6.72*
Generalized anxiety disorder 45 (11.4 %) 95 (13.9 %) 1.39
Binge eating disorder 126 (31.8 %) 175 (25.5 %) 4.91*
Table 2 Determinant of body mass index, according to different groups
Obesity surgery clinic (n: 394) Obesity medical clinic (n: 683)
Dependent variable: BMI R2 = 0.02; F = 2.17 Dependent variable: BMI R2 = 0.01; F = 3.91
Beta p Beta p
Age 0.06 0.30 Age -0.04 0.32
Gender 0.05 0.34 Gender 0.06 0.11
BDI 0.14 0.02 EDE-Q restraint -0.08 0.03
Statistics: linear regression analyses
BMI body mass index, BDI Beck Depression Inventory, EDE-Q Eating Disorder Examination Questionnaire
98 Eat Weight Disord (2014) 19:95–102
123
These variables were entered into the multiple linear
regressions, and the analyses confirmed the association of
EES, EDE-Q weight and eating concern scores (Table 3).
The results were confirmed even when adjusting for BMI.
As far as subjective binge eating is concerned, in obesity
surgery clinic group it was directly associated with EES
scores (r = 0.17; p \ 0.01), while in obesity medical clinic
group it was directly associated with EES (r = 0.38;
p \ 0.001), EDE-Q eating concern (r = 0.42; p \ 0.001),
and EDE-Q weight concern (r = 0.30; p \ 0.001) scores.
Other correlations were not significant. These variables
were entered into the multiple linear regressions, and the
analyses confirmed the association with EES in both
groups, and EDE-Q eating concern score in obesity medi-
cal clinic group (Table 3). The results were confirmed even
when adjusting for BMI (Table 3).
Discussion
To the best of our knowledge, this is the first study which
compared a consecutive series of obese patients seeking
bariatric surgery and obese patients seeking a medical
weight-loss treatment referring to the same facility, by
means of a unique psychopathological and clinical
assessment procedure. According to the main results of the
present study, obese subjects seeking bariatric surgery and
those seeking a medical treatment seem to show relevant
differences in terms of BMI and psychopathological char-
acteristics. The differences between the two groups
retained their significance, even when adjusting for BMI
and socio-demographic features.
In particular:
1. obese patients seeking bariatric surgery showed higher
BMI, binge-eating frequency, and general psychopa-
thology severity compared with patients seeking
medical treatment;
2. different psychological features were associated with
BMI and binge eating behaviors in the two groups.
Obese subjects seeking bariatric surgery showed higher
levels of depression, confirming previous findings reporting
higher general psychopathology in patients with morbid
obesity, compared with other obese subjects [50]. As far as
binge eating behaviors are concerned, the observed higher
rates of both subjective and objective binge eating in those
subjects looking for surgery confirms previous findings [51,
52], but it is in contrast with other studies which found that
Table 3 Determinants of binge eating
Obesity surgery clinic (n: 394) Obesity medical clinic (n: 683)
Dependent variable: objective binge eating
R2 = 0.01; F = 1.75
Dependent variable: objective binge eating
R2 = 0.20; F = 25.9
Beta p Beta p
Age 0.01 0.88 Age 0.21 0.67
Gender 0.05 0.50 Gender -0.01 0.80
BMI 0.06 0.36 BMI 0.06 0.21
EES 0.20 \0.001
EDE-Q eating concern 4.77 \0.001
EDE-Q weight concern 0.12 0.04
EDE-Q shape concern 0.039 0.45
Dependent variable: subjective binge eating R2 = 0.07; F = 3.50 Dependent variable: subjective
binge eating R2 = 0.45; F = 22.95
Age 0.08 0.26 Age -0.01 0.67
Gender -0.008 0.91 Gender 0.01 0.76
BMI 0.01 0.88 BMI -0.01 0.93
EES 0.20 \0.01 EES 4.21 \0.001
EDE-Q eating concern 6.73 \0.001
EDE-Q weight concern 1.66 0.09
Statistics: Linear regression analyses assess the effects of psychopathological variables on objective and subjective binge eating. The analyses
were performed for each group entering age, gender (as dummy variable: women = 0, men = 1), and those variables which have been found to
be associated dependent variables at Pearson correlation
BMI body mass index; SCL-90 GSI Symptom Checklist (SCL 90-R) Global Severity Index, EES Emotional Eating Scale, EDE-Q Eating Disorder
Examination Questionnaire
Eat Weight Disord (2014) 19:95–102 99
123
obese bariatric candidates often show different patterns of
overeating, including snacking or high-calorie food eating
[53, 54]. The use of self-report measures could explain the
low binge eating rate of some studies; alternatively this
could be due to the possibility that some obese patients
seeking ‘approval’ for bariatric surgery may under-report
binge eating behaviors. Another explanation for higher
binge eating in bariatric surgery group could be that more
severe obese patients with higher eating and general psy-
chopathology are more likely to request a radical inter-
vention, such as obesity surgery. Nevertheless, the higher
binge-eating frequency found in the bariatric surgery group
could be explained in the light of the high general psy-
chopathology level of morbid obese patients. On one side,
binge eating was demonstrated to affect psychopathology
and quality of life not directly related to the burden of
obesity per se [55]. Conversely, depressive symptomatol-
ogy was found to be associated with a higher risk of
developing binge eating [56]. It is of note that the men-
tioned differences were maintained, even when adjusting
for BMI. This finding confirms that the psychopathological
differences detected should not be solely explained by the
severity of obesity.
Furthermore, we found that BMI and binge eating
showed different psychopathological correlates between
bariatric and non-bariatric obese patients. Obese subjects
in the obesity medical clinic showed a significant asso-
ciation of emotional eating levels with both objective and
subjective binge eating, supporting the hypothesis that this
psychological dimension has a significant role in the
maintenance of binge eating [57, 58]. Moreover, this
group of patients reported a significant association of
binge eating with eating-specific psychopathology. Nev-
ertheless, no significant association between eating psy-
chopathology and binge eating was observed in patients
seeking bariatric surgery, with the exception of a mod-
erate association of emotional eating with subjective binge
eating. It is possible that for some subgroups of morbid
obese patients, different variables maintain binge eating
across time. For example, patients referring to bariatric
surgery showed a more frequent history of restrictive
dieting periods, and previous weight loss attempts, com-
pared with the other group. Regarding this observation, it
has been demonstrated that binging and restrictive eating
co-occur, and that dieting could predispose to binge eating
[59–61].
However, other authors suggested that in morbidly
obese patients, binge eating cannot be always considered
the result of dietary restraint [45, 57, 58, 62]. It could be
hypothesized that in severe obese patients, emotional eat-
ing maintained different kinds of abnormal eating behav-
iors which were improperly assessed as subjective binge
eating, such as craving or nibbling. We could suppose a
kind of obese severity threshold: at a morbid level of
obesity, binge eating would be no longer associated with
psychopathological variables; rather it could occur within
the context of a chaotic eating pattern, not directly trig-
gered by emotional state [63].
Some limitations to the present study should be
addressed. First of all, the cross-sectional design did not
allow to clarify the causal mechanisms of the observed
associations. Moreover, the study lacks of a comparison
group of non-treatment seeking obese subjects, which
some studies reported to have different psychological
features compared with obese patients seeking a bariatric/
non-bariatric treatment. Temperament and personality
disorders were not assessed. This issue represents a
potential limitation, considering the important mediating
role of personality for different clinical variables con-
sidered in our study. Finally, our study includes different
self-reported measures, thus possibly affected by sub-
jective bias.
In conclusion, the present study has two main clinical
implications. We evaluated psychological characteristics
of obese patients who were free to choose their treatment.
Our conclusion was that morbidly obese subjects seeking
bariatric surgery are a severer population, in terms of
general and eating-specific psychopathology, and patho-
logical eating behaviors, as compared to those patients
seeking a medical treatment. Moreover, these two pop-
ulations of obese patients showed different psychological
determinants of their pathological eating behaviors,
which could interfere with the long-term outcome of both
treatments.
Therefore, we believe that an accurate psychopatho-
logical assessment in a bariatric setting should not be
merely diagnostic, but should also improve the efficacy
of surgical treatment by improving the identification of
potential areas of vulnerability [37, 64]. Moreover, it is
well known that bariatric surgery is considered the most
effective therapeutic option for morbidly obese patients
[65], and the higher BMI we found in patients referred
to the bariatric surgery seems to confirm that clinicians
referred their patients with this recommendation in their
mind. However, the results of the present study showed
that patients seeking bariatric surgery appeared to be
more severe in terms of psychological distress, binge
eating behaviors, previous diet failures, even when
adjusting for obesity level. Therefore, clinicians should
consider that a consistent rate of patients could seek for
bariatric surgery on the basis of the severity of the
psychological distress associated with their morbid
obesity, rather than on the basis of a complete clinical
indication.
Conflict of interest None.
100 Eat Weight Disord (2014) 19:95–102
123
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