Personality subtypes in female prebariatric obese patients: do they differ in eating disorder symptoms, psychological complaints and coping behaviour?

BRIEF REPORTPersonality Subtypes in Female Pre-Bariatric Obese Patients:Do They Differ in Eating Disorder Symptoms, PsychologicalComplaints and Coping Behaviour?Laurence Claes1*, Walter Vandereycken1,2, An Vandeputte2 & Caroline Braet2,31Department of Psychology, Catholic University of Leuven, Leuven, Belgium2Eetexpert.be, Bergestraat 60, 3220 Holsbeek, Belgium3Department of Psychology, University of Ghent, Ghent, Belgium In the pre-bariatric psychological assessment of 102 morbidly obese women, two personality subtypes emerged: a resilient/high functioningsubtype with a ‘normal’ personality profile and an emotional dysregulated/undercontrolled subtype, characterized by high neuroticism andlow extraversion/conscientiousness. Emotional dysregulated/undercontrolled patients showed more concerns about eating/weight/shape,more binge eating driven by emotions and external triggers, more psychological complaints (such as depression and anxiety) and more avoid-ance and depressive coping reactions than resilient/high functioning patients. Further research should clarify whether these clearly differentpsychological profiles are related to different outcomes (weight loss or well-being) of bariatric surgery. Copyright 2012 John Wiley & Sons,Ltd and Eating Disorders Association.
Supporting information may be found in the online version of this article.
obesity; psychological assessment; personality types; eating disorders; bariatric surgery Laurence Claes, KUL Department of Psychology, Tiensestraat 102, B-3000 Leuven, Belgium. Tel.: +32-16-326133; Fax: +32-16-325916.
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2188 able to tailor treatments to the individual patients’ needs (Braet &Beyers, 2009).
In most western industrialized countries, obesity has become a Eating pathology markers — eating disorder symptoms in major health problem. In 2008, 13% of the male and 14% of the general and dietary restraint in particular — may indicate a poor female adult population in Belgium showed a body mass index prognosis in obese patients with binge eating problems and have [BMI = weight in kg/(length in meters)2] ≥ 30, with the highest been associated with excessive weight gain. Therefore, Grilo, prevalence of obesity in the age range 55–64 years (Drieskens, Masheb, and Wilson (2001) tried to identify subtypes on the basis 2008). Bariatric surgery as treatment for severe (BMI 35–49) and of the presence or the absence of particular eating disorder symp- morbid (BMI ≥ 40) obesity can offer a satisfying solution for the toms and psychopathology. Cluster analysis revealed a dietary- patient confronted with the physical and psychological risks and negative affect subtype and a pure dietary subtype. Remarkably, consequences (van den Oever & Volckaert, 2006). Many studies the subtype characterized with high scores on negative affect (for overview, see Müller et al., 2012) have made a differentiation appears to be related to poorer treatment response. Hence, asses- between obese patients with and without binge eating disorder sing a broader range of pretreatment characteristics besides eating (BED) and eating disorder patients with and without a lifetime disorder symptoms can be useful in developing an optimal treat- history of obesity (Villarejo et al., 2012): Differences were found ment plan matched to the patients’ strengths and weaknesses.
in terms of eating attitudes and behaviour (Hsu et al., 2002; Wilfley, Therefore, the present study is aimed at differentiating subtypes Schwartz, Spurrell, & Fairburn, 2000), comorbid psychopathology in morbidly obese pre-bariatric patients in correlation with eating (Jones-Corneille et al., 2012; Mühlhans, Horbach, & de Zwaan, disorder pathology, psychological symptoms and coping styles.
2009; Rosenberger, Henderson, & Grilo, 2006) and personality Up till now, there exist surprisingly few studies that focus on disorders/traits (e.g. Auerbach-Barber, 1998; Bulik, Sullivan, & subgroups in adult obese patients. Only Jansen, Havermans, Kendler, 2002; Fassino et al., 2002; Specker, de Zwaan, Raymond, Nederkoorn, and Roefs (2008) performed a cluster analysis in a & Mitchell, 1994; van Hanswijck de Jonge, van Furth, Lacey, & community sample of overweight and obese people, and found Waller, 2003). So, it seems that there exist different subgroups in a cluster high in negative affect and another one low in negative obese patients, with different needs among these patients. By affect. There were no differences in BMI between both clusters, assessing the pretreatment characteristics of patients, we may be but patients in the high negative affect cluster showed more Eur. Eat. Disorders Rev. (2012) 2012 John Wiley & Sons, Ltd and Eating Disorders Association.
Personality Sybtypes in Pre-Bariatric Obese Patients frequent binge eating and more body-related worrying. So, it respect to medical comorbidity (as noted in the patients’ charts), seems important to test also in obese pre-bariatric samples if there 19.6% (n = 20) had high blood pressure, 22.5% (n = 23) rheuma- exists a subtype of patients characterized by emotional dysregula- toid arthritis, 16.7% (n = 17) high levels of cholesterol, 13.7% tion that is assumed to induce emotional eating (Grilo et al., (n = 14) diabetes type 2, 6.9% (n = 7) pulmonary disease, 1% 2001) and binge eating, known as maladaptive coping strategies (n = 1) a cerebrovascular accident and 5.9% (n = 6) sleep apnea.
that complicate weight loss. Furthermore, if we find thesesubtypes in obese pre-bariatric samples, we can plead for more psychological support and fine-tuned interventions specifically To determine the personality prototypes, we made use of the in the emotionally dysregulated subgroup.
NEO-FFI (Costa & McCrae, 1992; Dutch version: Hoekstra, Previous research in eating disorder patients, based on the Ormel, & de Fruyt, 1996). The NEO-FFI is a well-known instru- Neuroticism, Extraversion, Openness to Experience—Five Factor ment to assess both normal and abnormal variants of personality Inventory (NEO-FFI), showed three personality clusters: a dysre- functioning. Furthermore, previous research on personality sub- gulated/undercontrolled cluster, characterized by elevated scores types in eating disorder patients also used the NEO-FFI (e.g. Claes on Neuroticism and low scores on Conscientiousness and Agree- et al., 2006), which makes it possible to compare these findings ableness; a constricted/overcontrolled cluster, characterized by with those in obese patients. The NEO-FFI is a 60-item self-report high scores on Neuroticism and Conscientiousness and low scores measure of five major personality traits: Neuroticism, Extraver- on Openness to Experience; and a high functioning/resilient clus- sion, Openness to Experience, Agreeableness and Conscientious- ter without pronounced personality pathology (Claes et al., 2006; ness. Items are answered on a five-point scale ranging from Thompson-Brenner & Westen, 2005). Remarkably, differentia- ‘strongly agree’ to ‘strongly disagree’. There is considerable tion on other dimensions such as personality characteristics has evidence for the reliability and construct validity of the Dutch not yet been explored in obese samples but certainly worthwhile to consider. Expanding the findings of Jansen et al. (2008) in a To assess the eating disorder-related problems in our present community sample, the first aim of the present study is to find sample, we used the Eating Disorder Examination—Self-Report out whether we can identify different personality subtypes in a Questionnaire Version (EDE-Q; Fairburn & Beglin, 1994). The sample of pre-bariatric obese patients, on the basis of the Big Five EDE-Q is a 41-item measure adapted from the Eating Disorder personality dimensions. This approach is recognized as the most Examination (EDE; Cooper & Fairburn, 1987), a structured clin- comprehensive way of characterizing people (Markon, Krueger, ical interview assessing the key behavioural features and associated & Watson, 2005). Moreover, on the basis of the Big Five psychopathology of eating disorders. The EDE-Q consists of four personality traits, it is also possible to identify highly resilient subscales: Restraint, Weight Concern, Shape Concern and Eating people (e.g. Claes et al., 2006). If subtyping is possible based on Concern. Luce and Crowther (1999) reported excellent internal one test covering the most important personality characteristics, consistency and test–retest reliability for the four subscales.
it is a cost-effective way of assessing pretreatment characteristics.
To get a better idea of the factors that trigger binge-eating epi- Interestingly, the personality profiles in eating disorders are sodes, we also applied the Dutch Eating Behaviour Questionnaire characterized by differences on a broad range of patient character- (DEBQ; Van Strien, Frijters, Bergers, & Defares, 1986). This 33-item istics (coping skills, depression, interpersonal functioning self-report questionnaire, to be rated on a five-point scale, assesses and impulsivity) on which treatment techniques can be focused three separate factors of eating behaviour: restrained eating (items (e.g. Claes et al., 2006; Thompson-Brenner & Westen, 2005).
related to weight control), emotional eating (eating related to emo- However, little is known about the fact whether obese subtypes tional states) and external eating (eating related to external cues).
also differ on these patient characteristics. Therefore, as a second Several studies have confirmed the convergent, discriminative and aim, we want to study whether also in obese samples there exists concurrent validity of the DEBQ (Van Strien et al., 1986). Weight a personality subtype showing more eating disorder-related fluctuations were calculated by subtracting the DEBQ Lowest symptoms (e.g. binge eating), more psychological symptoms Weight item (in kilograms) from the DEBQ Highest Weight item (e.g. depression) and more maladaptive coping behaviours (in kilograms) as assessed during adulthood.
To assess affective and interpersonal psychopathology, we made use of the Symptom Checklist (SCL-90; Dutch version: Arrindell & Ettema, 1986). The SCL-90 is a well-known measurefor the assessment of a wide range of psychiatric symptoms. It consists of 90 items (symptoms) to be rated on a five-point scale The original sample consisted of 135 female obese patients who ranging from ‘not at all applicable’ to ‘strongly applicable’. Along were psychologically screened as part of their pre-bariatric surgery with a global measure for psychoneuroticism, it measures symp- assessment. We have excluded 10 patients who did not complete toms of general anxiety, phobic anxiety, depression, somatization, the assessment and 23 patients who already underwent a surgical obsessions/compulsions, paranoid ideation and interpersonal intervention for their obesity (most often, gastric banding). The sensitivity, hostility, and sleeplessness. The validity studies of the mean BMI of the remaining sample (n = 102) was 40.7 (SD = 4.16; SCL-90 demonstrate ‘good’ to ‘very good’ levels of concurrent, range 31–52): 2.9% (n = 3) suffered from obesity grade 1 (BMI convergent, discriminant and construct validity (Arrindell & 30–34.9), 26.5% (n = 27) from obesity grade 2 (BMI 35–39.9) and 70.6% (n = 72) from obesity grade 3 (BMI ≥ 40). The mean Finally, to assess the adaptive and maladaptive coping strategies age of the sample was 36.4 years (SD = 10.86; range 18–64). With of our patients, we used the Utrecht Coping List (UCL; Schreurs, Eur. Eat. Disorders Rev. (2012) 2012 John Wiley & Sons, Ltd and Eating Disorders Association.
Personality Sybtypes in Pre-Bariatric Obese Patients van de Willige, Brosschot, Tellegen, & Graus, 1993). The UCL Table 1 Means and standard deviations of the NEO-FFI scales for the RHF and consists of 47 items rated on a four-point scale and divided across seven scales that measure a variety of different coping strategiesand techniques: Active Problem Solving, Palliative Reactions, Passive/Depressive Reactions, Avoidance, Social Support Seeking, Expression of Emotions and Self-Soothing Thoughts. There isconsiderable evidence for the reliability and construct validity of To determine the personality subtypes in our sample, cluster analysis was performed on the five NEO-FFI personality scales by means of the K-means cluster analysis procedure provided by RHF, resilient/high functioning subtype; EDU, emotional dysregulated/undercon- SPSS 19 (SPSS Inc., Chicago, IL, USA). To cross-validate the trolled subtype; NEO-FFI, Neuroticism, Extraversion, Openness to Experience— obtained cluster solution, we also performed a model-based cluster analysis by using the S-PLUS 8 software program and the MCLUST library (Fraley & Raftery, 2003). To externally validate the clusters, we performed MANOVAs with the personality clusters as independent variables and the demographic variables,eating disorder symptoms, psychological symptoms and copingstrategies as dependent variables.
above the mean on Neuroticism and below the mean on Extraver-sion, Agreeableness and Conscientiousness, whereas the opposite The cluster analyses revealed that a two-cluster solution fitted the data best. In Figure, 1, mean z-standardized NEO-FFI scale scores With respect to age, we did not find significant differences for the two subtypes in the total sample are presented. The first between RHF patients (Mage = 38.61, SD = 9.93) and EDU patients subtype (on the left) is characterized by a negative score on (Mage = 34.73, SD = 11.34) [F(1, 97) = 3.19, ns]. Similarly, RHF Neuroticism and positive scores on Extraversion, Openness, patients did not significantly differ from EDU patients with Agreeableness and Conscientiousness, whereas the second respect to the level of education [w(3) = 3.33, ns]. The distribution subtype (on the right) is characterized by the opposite pattern.
of education for the RHF/EDU patients was as follows: elementary On the basis of the literature (e.g. Asendorpf, Borkenau, Osten- school (4.7% vs 11.1%), secondary school (60.5% vs 66.7%), dorf, & van Aken, 2001), patients of subtype 1 (n = 44, 43.1%) higher education outside university (30.2% vs 16.7%) and univer- are therefore called resilient/high functioning (RHF), whereas patients of subtype 2 (n = 58; 56.9%) are called emotionally dysre-gulated/undercontrolled (EDU). The results of the MANOVA Personality subtypes and eating disorder-related with the personality clusters as independent variables and the NEO-FFI scales as dependent variables (Table 1) showed signifi- The current BMI of the RHF patients was similar to the BMI of cant differences between the two clusters on all NEO-FFI scales the EDU patients, and the same results were found for weight [Wilks’ Lambda = 0.36, F(5, 96) = 33.16, p < 0.001]. Compared fluctuations (Table 2). However, we found significant differences with data of normal controls (manual), the EDU group scored between EDU and RHF patients with respect to the EDE-Q scales[Wilks’ Lambda = 0.75, F(4, 82) = 6.71, p < 0.001]. The EDU patients scored significantly higher on the EDE-Q Eating, Weight and Shape Concern scales than RHF patients, whereas no signifi- cant differences emerged with respect to the EDE-Q scale Restraint. With respect to eating disorder-related behaviours, EDU patients reported significantly more EDE-Q objective (1) = 4.21, p < 0.05] than RHF patients.
Finally, we found significant differences between EDU and RHF patients with respect to the DEBQ scales [Wilks’ Lambda = 0.86, F(3, 92) = 4.63, p < 0.01]. The EDU patients scored significantly higher on the DEBQ Emotional Eating and External Eating scales than RHF patients, whereas the RHF patients scored significantlyhigher than EDU patients on the DEBQ scale Restraint Eating.
Figure 1 Two personality subtypes characterized by their standardized Big Five When comparing the scores on emotional and external eating patterns in the female obese sample (N = 102) with data of normal controls, the EDU morbidly obese patients Eur. Eat. Disorders Rev. (2012) 2012 John Wiley & Sons, Ltd and Eating Disorders Association.
Personality Sybtypes in Pre-Bariatric Obese Patients Table 2 Means and standard deviations of the BMI, weight fluctuation, EDE-Q Table 3 Means and standard deviations of the SCL-90 scales for the RHF and DEBQ scales for the RHF and EDU subtypes RHF, resilient/high functioning subtype; EDU, emotional dysregulated/undercon- RHF, resilient/high functioning subtype; EDU, emotional dysregulated/undercon- trolled subtype; BMI, body mass index; EDE-Q, Eating Disorder Examination— trolled subtype; SCL-90, Symptom Checklist.
Self-Report Questionnaire Version; DEBQ, Dutch Eating Behaviour Questionnaire.
1Five patients did not complete the SCL-90.
scored high on both scales, whereas the RHF group scored on the Table 4 Means and standard deviations of the UCL scales for the RHF Personality subtypes and psychological symptoms Overall, EDU patients showed significantly more psychological symptoms than RHF patients [Wilks’ Lambda = 0.65, F(9,85) = 4.95, p < 0.001] on the SCL-90: Agoraphobia, Anxiety, Depression, Somatization, Insufficiency of Thinking, Interpersonal Sensitivity, Hostility, Psychoticism and Psychoneuroticism (total score) except for Sleeping Problems. Compared with data of normal controls, the EDU patients scored high to very high on all the SCL- 90 scales, whereas the RHF group scored in the medium to above Personality subtypes and coping behaviour RHF, resilient/high functioning subtype; EDU, emotional dysregulated/undercon- Finally, we found significant differences between EDU and RHF trolled subtype; UCL, Utrecht Coping List.
patients with respect to coping behaviour [Wilks’ Lambda = 0.67, 1Two patients did not complete the UCL.
F(7, 92) = 6.39, p < 0.001]. RHF patients scored significantly higher on UCL scale Active Problem Solving, whereas EDU patients scored significantly higher on the UCL scales Palliative Reactions, Avoidant Coping and Depressive Coping. Comparedwith data of normal controls, the EDU group scored high onPalliative Reactions, Avoidant Coping and Depressive Coping, a ‘normal’ personality profile, and an EDU subtype (56.9%), char- whereas RHF scored high on Active Problem Solving (Table 4).
acterized by high Neuroticism, low Extraversion/Agreeablenessand lower Conscientiousness. Obese people belonging to the latter subtype can be described as high on negative affect, with poorsocial contacts and less cognitive control. These findings confirm Our major aims were to identify personality subtypes of morbidly the results of Rydén et al. (2003, 2004) who reported that severely obese female patients who applied for bariatric surgery and to inves- obese patients seeking treatment were characterized by more tigate whether these subtypes showed differences in weight and anxiety, impulsivity and irritability than a non-obese reference eating behaviours, psychological complaints and coping strategies.
group and Kalarchian et al. (2007), who reported that patients On the basis of the Big Five personality traits, we were able to seeking bariatric surgery were more likely to have a personality identify two personality subtypes: an RHF subtype (43.1%), with disorder, characterized by anxious and fearful behaviour. Our Eur. Eat. Disorders Rev. (2012) 2012 John Wiley & Sons, Ltd and Eating Disorders Association.
Personality Sybtypes in Pre-Bariatric Obese Patients findings also replicate Jansen et al. (2008) who were the first to reported by Grilo et al. (2001) who showed that the negative affect identify in obese people two subtypes with one scoring high on subtype was characterized by more binge eating and less adequate negative affect. Furthermore, personality subtypes were already emotion regulation strategies, which increase the probability of a identified in a group of female eating disorder patients, in which poor outcome, given that eating behaviours were used as a coping on the basis of four of the five NEO subscales, also an EDU strategy with the increase of weight as a negative consequence. In subtype was found, besides an RHF subtype and an overcontrolled contrast, obese patients of the RHF subtype were characterized by subtype (Claes et al., 2006). An overcontrolled subtype was not lower degrees of weight concerns and psychological symptoms, prevalent in our morbidly obese sample, but this is not surprising probably thanks to their more active coping styles (to deal with given that the overcontrolled subtype was found primarily among restrictive anorexia nervosa patients, characterized by emotional Given that we were able to distinguish personality subtypes instability but also rigidity/obsessiveness (Claes et al., 2006), a with different psychological profiles in our group of morbidly feature that is usually absent in morbidly obese patients.
obese patients, further research is necessary to investigate whether With respect to eating disorder-related behaviours, EDU these profiles also have predictive power with respect to the out- patients engaged significantly more in binge eating compared with come of treatment in general, and bariatric surgery in particular, RHF patients, and their binge episodes seemed primarily triggered in terms of weight loss and general well-being. Such research is by external cues and emotions. Given their personality subtype needed to guide the treatment of choice for patients with more characterized by high negative affect and more impulsive/less con- at risk personality features and related psychopathology.
trolled nature, it is not surprising that the EDU patients give in However, the results of this study are not without limitations.
easier to ‘attractive’ food cues compared with RHF patients. Also, First of all, the sample consists of morbidly obese female patients the higher score on emotional eating in the EDU patients is in line who were all applying for bariatric surgery. The results of the with Elfhag and Morey (2008), who also found significant associa- study can therefore not be generalized to male patients and tions between emotional eating and high neuroticism, low extra- morbidly obese patients who are not seeking bariatric surgery.
version and low conscientiousness. The correlations between Furthermore, because patients came from different centres each Emotional Eating and Neuroticism (r = .40, n = 99), Extraversion using their own procedure of physical assessment, information (r = À.26, n = 99) and Conscientiousness (r = À.32, n = 99) in on somatic comorbidity needs to be interpreted with caution.
our sample confirm this hypothesis.
Finally, a more systematic psychiatric assessment, including Axis Compared with RHF patients, EDU patients also reported I and Axis II diagnoses, would be advisable but was not available more concerns about their eating, weight and body shape, although their actual BMI was similar (see also Jansen et al.,2008). Further, they have higher scores on anxiety-related anddepression-related symptoms, and higher scores on avoidance and depressive coping styles. This seems to indicate that the eatingbehaviour of the EDU patients could have an emotion-regulating The authors would like to thank the following members of the function (avoiding or escaping from negative affect). The correla- Obesity Task Force of Eetexpert.be for their help with data collec- tions between the scores of the EDE-Q subscales and the SCL-90 tion: Bex Annelies, Boekaerts Els, Brants Lies, Brunelli Barbara, and UCL subscales confirm this hypothesis. Similar findings were Dhaene Sophie, D’Haese Katrien, Gijbels Sylvia and Strauven An.
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