• Bariatric Surgery
• Body Uneasiness
• Psychopathology

BACKGROUND: among people with obesity, individuals seeking weight loss treatment, especially bariatric surgery, seem to display a high degree of uneasiness toward the body. The concept of ‘obesity dysmorphia’ (OD) has been proposed as a new psychiatric condition in order to define the distress related to perceptual and cognitive distortions of the self, that are a consequence of obesity and the major reason that motivates obese individuals toward surgical procedures. In contrast with this view, the distress related to the self-image in this population may be more properly explained by the presence of an underlying atypical depression, rather than a specific OD condition. The aim of our study was to explore the relationship between body uneasiness and psychopathology, and to investigate the clinical correlates of body uneasiness in a sample of obese patients referred for bariatric surgery.
METHODS: the sample was composed of 238 obese patients (BMI ≥ 30 kg/m2) referred for bariatric surgery to the Obesity Centre of the Endocrinology Unit in Pisa University Hospital between January 2006 and November 2016. During presurgical evaluation, all patients were routinely interviewed by licensed psychiatrists. Anthropometric data, such as weight and BMI, and lifetime diagnoses of psychiatric disorders were collected. The Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I) was employed for the psychiatric evaluations. The severity of current psychopathological symptoms was investigated through the Symptom Checklist-90-Revised (SCL-90-R). Body uneasiness was investigated through the Body Uneasiness Test (BUT) - part A, a psychometric instrument developed to explore all the negative dimensions of body image and correlated dysfunctional behaviours. BUT subscales were compared between female and male patients, and patients with and without mood, anxiety and eating disorders. The correlations between BUT subscales and anthropometric data and SCL-90-R subscales were tested. Two different multivariate linear regression analyses were performed to test whether anthropometric data, lifetime mood disorders and current psychopathology independently predicted body uneasiness. Stepwise model selection was applied to both the analyses.
RESULTS: the majority of patients were females (N=176, 73.9%), had a mean age of 44 years (mean = 44.23, SD = 10.85) and a mean BMI of 46.42, SD = 7.42. More than a third of the sample had a lifetime diagnosis of mood (36.1 %) or eating disorders (34.9%). Among mood disorders, major depressive disorder (14.3%) and bipolar disorder type II (11.3%) were the most frequent diagnoses. Among eating disorders, BED represented the most prevalent diagnosis (34.0%). BUT scores showed a significantly higher body uneasiness in females, when compared to males, in all the BUT subscales (p<0.001). Significant differences in the BUT subscales, except for BUT-CSM, were especially observed between patients with and without mood disorders (p<0.01). Correlation analysis between the BUT and SCL-90-R subscales showed a positive association between all the subscales (p= 0.000). Multivariate regression analysis showed that age and BMI were not predictors of the degree of body uneasiness, and neither was the occurrence of a lifetime diagnosis of mood disorders, while controlling for current comorbid psychopathology. Instead, body uneasiness was positively associated with the severity of the current general psychopathology (SCL-GSI) and with gender (female) (p=0.000), as confirmed by the stepwise model selection analysis; also, when considering all the SCL-90-R subscales, body uneasiness was positively associated with the severity of Interpersonal Sensitivity (p= 0.000).
CONCLUSIONS: in our sample the severity of the psychopathological distress reported by the bariatric patients before the surgery, together with being female or being diagnosed with lifetime mood disorders, represent the main correlates of the degree of body uneasiness in bariatric subjects. Moreover, a high level of interpersonal sensitivity, related with atypical features of depression and emotional over-reactivity, also seems to be an important predictor of body uneasiness severity. In conclusion, our study seems to support the role of psychopathological distress, specifically in terms of interpersonal sensitivity and atypical depression, as a predictor of body uneasiness in bariatric patients, rather than the necessity for a novel specific diagnosis. In this population, the assessment and treatment of depression with atypical features and negative affect might be a potential way to improve post-surgical outcomes and body image concerns in bariatric subjects with psychiatric distress. At the same time, pre- and post-surgical assessment of body dissatisfaction should be encouraged in clinical settings, as it appears to be an important indicator of improvement of psychological well-being after surgery. Further studies should investigate the correlation between poor body image and the persistence of interpersonal sensitivity, or symptoms of atypical depression, in the outcome of obesity treatment, in particular in weight loss maintenance.