Discussion
Our data describe a population of obese patient substantially similar, in terms of socio-demographic indexes and burden of comorbid medical pathology, to other samples described in bariatric surgery literature.
DSM-IV Axis I disorders prevalence is on average if confronted with that of other similar surveys.
Our sample shows a high prevalence of Binge Eating Disorder that could be explained in light of the two-steps detection offered by both clinical and psychometric interviews. Research data show also a high prevalence of mood disorders in obese subjects vs non-obese subjects(Malik et al., 2014), along with a more severe load, in terms of both mood comorbidity and dimensional psychopatology, for subjects with a greater degree of obesity or obesity-related medical conditions (Wadden et al., 2006). Our data fall only partially in line with these findings, with more than half of our subjects reporting lifetime mood disorders but little or no association between obesity severity indicators and axis I comorbidity or dimensional psychopathology indices.
Looking at BED comorbidity, the available research literature shows a generally higher prevalence of both DSM-IV comorbid conditions and higher values of dimensional psychopathology indices (Dahl et al., 2012; Petribu et al., 2006). Our data are not showing a significant association between lifetime BED and mood disorder or panic comorbidity history. Looking at dimensional psychopathological indices, we see higher scores in single domains in both Panic-agoraphobic (Drug sensitivity and Phobia) and Eating (eating discontrol) spectra for the Binge-eating subgroup.
While the latter could be seen as redundant, if clinically sound, the specific nature of the panic spectrum index could, at least, warrant some further investigation on the matter of treatment
compliance and the issue of post-bariatric adverse reactions (e.g. dumping syndrome, among others) in BED comorbid obese patients when they are to be declared eligible for obesity surgery.
Impulsivity measures, commonly assessed in the literature ((Meule, 2013), among others), once again in our sample show a significant worse profile for BED subjects, while limited to self-control secondary order factor of the BIS-11.
As for cross sectional psychopathology, the data from SCL-90 show us a significant, if small, higher score in the Psychoticism domain, once again for BED patients.
Regarding sub-threshold mood symptoms, our data don’t show significant differences between groups,either defined by BED comorbidity or obesity measures. In a sample of patients suffering from Major Depressive Episode . a recent work ha shown a higher prevalence and levels of both Hypomanic traits and clear symptoms in the obese subgroup vs the non-obese(Vannucchi, Toni, Maremmani, & Perugi, 2014). Our data don’t allow us, at this point, to discriminate obese patients by moods-SR bipolar spectrum domains.
Statistical Analysis showed a low, but statistically significative difference between obesity groups for Motor and the dependent Motor Impulsivity sub-domain (p=0,028; Mean difference 0,528). This result seems to point out a lesser motor impulsivity for patients with higher (41-49Kg/m2) BMI.
Impulsivity measures, intuitively linked to construct of eating discontrol and behavioural correlates of interpersonal sensitivity, have been studied extensively in the literature, and linked to obesity models such as the food addiction model (Meule, 2013; Meule, Heckel, Jurowich, Vögele, &
Kübler, 2014) (Volkow & Wise, 2005). The data available are still few and so this result can’t be easily confronted with pre-existing research. Analogous, results were found by our research group in a preliminary analysis (Cecconi, 2012), revealing a lesser temperamental load for morbidly obese patients (BMI>50) when confronted to less severely obese subjects.
Some limitations of this work must considered:
sample size prevented from carrying out more powerful statistical analysis. Further data collection is underway and our research group aims to ...
Another issue that has become strongly evident in the course of clinical evaluations has been a double bias bound to the modality of access to this specific Bariatric Protocol. Many of our patients were sent to pre-surgical evaluation after having chosen, by themselves, this kind of approach; thus every clinical evaluation, including Psychiatric interviews and Psychometric self-reports, were seen as “tests” to be passed in order to obtain a “solution” more than a therapeutic evaluation. This of course led many subjects to minimise symptoms, and also to soften description of personality traits such as reactivity to life events. In some cases, an adjunct psychological evaluation of coping styles, resources and resiliency could have mitigated this effect but such an intervention would have spanned well beyond the scope of the psychiatrist involvement as a liaison consultant. This same reticency led to a score of missing data among self-report questionnaires.
A further, methodological limit must be acknowledged: our data lack two features commonly present in scientific literature: the presence of a control group and a post-surgical data collection.
While initial study design included such procedures, study subjects adherence and suitable outpatient availability have posed an obstacle to protocol fulfilment.
In the end, our data have allowed us to replicate literature findings regarding comorbidity, while pointing out a worse psychopathological burden for patients with a BED diagnosis. While we collected and analysed our results, the availability of DSM 5 diagnostic criteria for BED, bearing an expected higher diagnosis rate in light of the broader approved criteria, definitely changed the scenario. Today a diagnosis of Binge eating Disorder, fully distinct from other
EDNOS, would allow for better diagnostic sensibility in terms of both clinical research and patient management.
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