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: valdo.ricca@unifi.it

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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