Impact of binge eating disorder in the psychopathological profile of obese women

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Comprehensive Psychiatry 51 (2010) 110 – 114 www.elsevier.com/locate/comppsych

Impact of binge eating disorder in the psychopathological profile of obese women Julia Fandiñoa , Rodrigo O. Moreiraa,b,c,⁎, Carolina Preisslerb , Caroline W. Gayab , Marcelo Papelbauma , Walmir F. Coutinhoa,b , Jose C. Appolinarioa a

Grupo de Obesidade e Transtornos Alimentares (GOTA) do Instituto Estadual de Diabetes e Endocrinologia (IEDE) e do Instituto de Psiquiatria da Universidade do Brasil (IPUB), Rio de Janeiro, Brazil b Pontifícia Universidade Católica do Rio de Janeiro (PUC-RJ), Rio de Janeiro, Brazil c Centro de Ensino Superior de Valença – Fundação Educacional Dom Andre Arcoverde, Valença, Brazil

Abstract Objective: Our objective was to evaluate the psychopathological profile of obese women with binge eating disorder (BED) using the Symptom Checklist-90 (SCL-90). Methods: Two hundred twelve obese women who seek for weight loss treatment were sequentially selected to participate in the study. Binge eating disorder was diagnosed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Binge eating disorder severity was assessed using Binge Eating Scale. Depressive symptoms were assessed using Beck Depression Inventory. The psychopathological profile was assessed using the SCL-90. Results: Binge eating disorder was diagnosed in 54 patients (26.6%). Obese patients with BED presented significant higher scores in all domains of SCL-90 (P b .05 for all) in comparison with obese patients without BED. A significant relationship was found among Binge Eating Scale, Beck Depression Inventory, and all domains of the SCL-90 (P b .05 for all). After linear regression, obsessivity-compulsivity (P = .03), interpersonal sensitivity (P = .0064), paranoid ideas (P = .03), and psychoticism (P = .01) were independently related to the severity of BED. Conclusion: Obese women with BED presented a more severe psychopathological profile than obese controls. Among all, obsessivitycompulsivity, interpersonal sensitivity, paranoid ideas, and psychoticism seem to be strongly linked to BED severity. © 2010 Elsevier Inc. All rights reserved.

1. Introduction The prevalence of obesity has increased substantially in the last 30 years. Recent data indicate that approximately 20% of Brazilian men and 25% of Brazilian women 20 to 59 years old are obese [1]. One possible explanation for this obesity epidemic includes several social changes that induce physical inactivity and increased feeding [2]. Some factors could ease weight gain, which defines obesity as a multifactorial disease: (1) genetic factors have permissive action on the environmental factors (susceptibility genes); (2) environmental factors, such as sedentarism and bad eating ⁎ Corresponding author. Instituto Estadual de Diabetes e Endocrinologia, Rua Moncorvo Filho n° 90 – Centro, Rio de Janeiro/RJ CEP 20.211340, Brasil. E-mail address: [email protected] (R.O. Moreira). 0010-440X/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2009.03.011

habits; (3) psychogenic, psychosocial, and cultural factors that define psychogenic obesity [3]. The presence of weight excess is associated with several medical comorbidities. Although clinical comorbidities (ie, diabetes mellitus, dyslipidemia, hypertension, among others) are well known, psychiatric comorbidities are still a matter of debate. Evidence can be found demonstrating that obesity and psychopathology are related, whereas a few articles also suggest that no correlation exists between them [4]. Binge eating disorder (BED) is a psychiatric disorder characterized by episodic uncontrolled consumption of large amounts of food in the absence of inappropriate compensatory methods that characterize bulimia nervosa. The provisional criteria for BED, which have been included in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Appendix B, state that the individual must experience significant distress related to

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binge eating and must endorse several behavioral indicators of loss of control [5]. Binge Eating Disorder is the most common eating disorder found in obese patients. The prevalence of BED ranges from approximately 0.3% to 7% in community samples to between 9% and 30% in obesity clinics, and from 9% to 47% among bariatric surgery patients [6-8]. In the Brazilian population, obese patients with BED were significantly more likely to meet criteria for a lifetime diagnosis of any Axis I disorder, any mood disorder (including current or past major depressive disorder), and any anxiety disorder [9]. In addition, BED was already associated with an increased body mass index (BMI) [10]. For instance, Gruzca et al [8] confirmed the strong association between weight category and BED. Nearly 70% of binge eater subjects report BMI of 30 and above, whereas slightly fewer than 30% of non–binge eaters reported comparable BMI. The Symptom Checklist-90 (SCL-90) is a self-report, multidimensional scale idealized by Derogatis et al [11]. The use of SCL-90 allows the assessment of a broad spectrum of psychological problems and psychopathological symptoms. According to Derogatis and Lazarus [12], SCL90 could be used by psychologists and psychiatrists in mental health, medical and educational establishments, or research as a tool to evaluate symptoms intensity and its dimension. This scale is a self-report and multidimensional instrument with 90 items organized in 9 dimensions to assess primary psychopathologies and 3 global pathology indexes, which reflect psychopathological profile of the respondent [11,13]. The aim of this study is to investigate the psychopathological profile of obese patients with BED using the SCL-90.

2. Methods 2.1. Participants Two hundred twelve women with obesity (BMI ≥30 kg/m2 ) who seek treatment for weight excess were sequentially evaluated in the Grupo de Obesidade e Transtornos Alimentares of the Instituto Estadual de Diabetes e Endocrinologia do Rio de Janeiro. The protocol was approved by the Ethics in Research Committee of this institution. All the participants gave written informed consent before their inclusion in the study. The exclusion criteria in the study were the following: patients with insufficient educational level for understanding the scales, patients with type 2 diabetes, organic disease that were associated with obesity (including overt hypothyroidism and Cushing syndrome, among others), history of bariatric surgery, psychiatric diseases under pharmacological treatment or any other condition that, in the researcher opinion, might have compromised the filling or the understanding of the scales.

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2.2. Anthropometric evaluation All participants had the following anthropometrical data registered: body weight (kg), height (m), and BMI. Body Mass Index was calculated as weight in kilograms divided by the square of height in meters (kg/m2). 2.3. Social demographic factors Initially, all participants were examined using a sociodemographic questionnaire. The educational level was rated as the total number of years of formal education completed by each patient. Marital status of individuals was rated as either married (living with someone else) or unmarried (living unaccompanied). Familiar income was rated as the number of the Brazilian minimum salary, which currently corresponds to 150 US dollars. 2.4. Psychopathological evaluation The diagnosis of BED was made by experienced psychiatrists (JF, MP, and JCA) using the Portuguese version of the Structured Clinical Interview for DSM-IV [14]. The severity of depressive symptoms was assessed using the Beck Depression Inventory (BDI). The Portuguese version of the BDI used in this study has been validated in nonclinical populations [15]. The severity of binge eating was assessed using the Portuguese version of Binge Eating Scale (BES) [16]. The BES is a scale with 16 items and 62 sentences. Each sentence is classified according to gravity (0 to 3). Final score is constituted adding up results. The Portuguese version of BES has already been validated in our population [17,18]. The SCL-90 is a multidimensional inventory projected to evaluate a wide spectrum of psychological problems and psychopathological symptoms [19]. It is composed of 90 items, which might be answered according to a 5-point scale, graded from 0 to 4, from “none” to “extremely.” This scale has 9 primary domains of symptoms: somatization (S), obsessivity-compulsivity (OC), interpersonal sensitivity (SI), depression (D), anxiety (An), hostility (H), phobic anxiety (FA), paranoid ideas (PI), and psychoticism (Os). They are used for the calculation of the Global Severity Index (GSI). The SCL-90 has been already translated into Portuguese and used in a Brazilian population [13]. 2.5. Statistical analysis Data were evaluated using GraphPad InStat 3.00 program to Windows 95 (GraphPad Software, San Diego, CA). Comparison among different groups was done with Student t test for parametric variables and Mann-Whitney for the analysis of nonparametric variables. Correlation analysis was done using Pearson test for parametric variables and Spearman test for nonparametric variables. Linear regression was used to identify the impact of independent variables in all domains of SCL-90. Two-tailed

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Table 1 Comparison of demographic data and psychiatric symptoms in obese patients according to the presence of the diagnosis of BED

Anthropometric evaluation Age (y) Familiar income (minimum salary) Marital status (unmarried/married) BMI (kg/m2) Waist (cm) Psychiatric symptoms BDI BES

BED (n = 54)

Non-BED (n = 149)

37.2 ± 11.3 2.14 ± 1.09 29/25 40.5 ± 6.68 111.3 ± 13.8

39.0 ± 12.3 2.23 ± 1.03 67/83 40.2 ± 7.54 109.3 ± 13.8

25.0 ± 10.0 29.4 ± 8.0

18.4 ± 9.8 19.6 ± 9.4

SCL-90 domains

P

.44 .53 .26 .47 .36 b.0001 b.0001

tests were used for all analysis. A P level below .05 was considered significant.

3. Results Two hundred twelve patients were sequentially evaluated. Nine patients with bulimia nervosa were excluded from the analysis. Binge eating disorder was identified in 54 patients (26.6%). Table 1 presents the characteristics of the sample. Table 2 presents the scores obtained from obese patients with SCL-90 according to the presence of BED. The relationship between the severity of depressive symptoms (BDI), binge eating (BES), and the different domain of the SCL-90 was also studied. A significant relationship was found among BES, BDI, and all domains of the SCL-90 (Table 3). Linear regression was used to determine whether the severity of BED correlated independently of BDI with any domain of SCL-90 in the whole population. After regression, the relationship between the following domains and BES was still significant: obsessivity-compulsivity (P = .03), interpersonal sensitivity (P = .0064), paranoid ideas (P = .03), and psychoticism (P = .01), besides GSI (P = .012). Finally, linear regression was also used to determine whether binge eating severity correlated independently of BDI with any domain of SCL-90 according to the presence of BED. In obese individuals without BED, only obsessivity-compulTable 2 Comparison of different domains of SCL-90 according to the presence of BED SCL-90 domains

BED (n = 54) Non-BED (n = 149) P

Somatization Obsessivity-Compulsivity Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideas Psychoticism GSI

1.855 ± 0.930 1.892 ± 0.936 1.978 ± 0.867 1.879 ± 0.867 1.497 ± 0.888 1.241 ± 0.787 1.187 ± 0.938 1.512 ± 0.746 1.363 ± 0.800 1.664 ± 0.720

1.448 ± 0.766 1.450 ± 0.866 1.405 ± 0.908 1.341 ± 0.828 1.084 ± 0.701 1.013 ± 0.850 0.795 ± 0.798 1.036 ± 0.758 0.898 ± 0.648 1.205 ± 0.637

Table 3 Correlation between the different domains of SCL-90 and BES and BDI

.0019 .0019 .0001 .002 .0031 .027 .0064 b.0001 .001 b.0001

Somatization Obsessivity-Compulsivity Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideas Psychoticism GSI

BES

BDI

r

P

R

P

0.48 0.57 0.69 0.77 0.61 0.48 0.49 0.61 0.62 0.74

b.0001 b.0001 b.0001 b.0001 b.0001 b.001 b.001 b.001 b.001 b.0001

0.36 0.46 0.54 0.53 0.47 0.39 0.38 0.46 0.51 0.55

b.001 b.0001 b.0001 b.0001 b.0001 b.001 b.001 .001 b.001 b.0001

sivity correlated independently with binge eating severity, with only borderline significance (P = .0468). In obese women with BED, interpersonal sensitivity correlated independently of depressive symptoms with binge eating severity (P = .003). Paranoid ideas and psychoticism almost reached statistical significance (P = .051 and P = .082, respectively). 4. Discussion Our study evaluated consecutively 203 women seeking treatment for obesity in the Obesity and Eating Disorders Group of the State Institute of Diabetes and Endocrinology of Rio de Janeiro. Our objective was to investigate the psychopathological profile of obese patients according to the presence of BED. The most important results were (i) the prevalence of BED in our sample was 26.6%, and no differences were observed in BMI of these patients; (ii) obese women with BED showed higher scores in all SCL-90 domains and in the GSI; (iii) all SCL-90 domains presented a significant correlation with the severity of BED; (iv) after linear regression, the correlation between BES and SCL-90 was maintained in the following domains: obsessivecompulsive, interpersonal sensitivity, paranoid ideas, psychoticism, and GSI. The prevalence of BED verified in this study (26.6%) is similar to that observed in another study (24.2%) that also used a structured interview for BED diagnosis in individuals seeking for obesity treatment [20]. It is also similar to the one observed in morbidly obese patients waiting for bariatric surgery [9]. One possible explanation for this finding is the high BMI of our sample, similar to that observed in studies evaluating surgical treatment of morbid obesity [6]. The higher prevalence of BED in this population may be an indirect evidence that these patients may present a more severe psychopathological profile. However, although several studies have already demonstrated a relationship between the severity of obesity and specific traces of psychiatric syndromes, these correlations are a matter of debate [10,21-23]. The association between BED and psychopathology, especially depression, is well described in the literature. In our sample, obese individuals with BED showed higher

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scores in BES and BDI than obese patients without BED. In another study in Brazil, obese binge eaters were significantly more likely to meet criteria for a current diagnosis of any Axis I disorder (mood disorder and anxiety disorder) than obese non–binge eaters [9]. Specifically, obese women who binge eat were characterized by significantly higher rates of lifetime major depressive disorder than obese women who do not binge eat [22]. It is interesting to notice that the presence of other psychopathologies related to BED has already been studied [24]. The presence of behavior disorders associated with personality disorders and with high rates of psychopathology has been observed in obese patients with BED [22]. It is worth noticing that in our sample, obese women with BED had higher scores in all domains of SCL-90. Therefore, it is possible that the presence of BED has a direct impact in various areas of individual functioning. The association between BED and the obsessivecompulsive domain has already been described in the literature [25-27]. Some authors have proposed that BED should be included in the obsessive-compulsive disorder spectrum due to the persistent concern with food and weight. Besides, binge eating episode also looks like a repetitive ritual [26]. A comparative study among obese women with and without BED showed a significant relationship among obesity, BED, and obsessive-compulsive personality traits [27]. The results were partially yielded in our study also by demonstrating a direct correlation between BED severity and the obsessive-compulsive domain of SCL-90. On the other hand, the obsessive-compulsive disorder, per se, could be related to a greater severity of eating disorders and general psychological parameters [28]. However, some authors stand up for the independence among these disorders and psychopathology. In a case report, the improvement of BED had no repercussion on the remission of obsessive symptoms in a patient with obsessive-compulsive disorder (no connection with eating behavior). The dichotomic response observed in this case could corroborate the hypothesis that these are different pathologies despite showing similar clinical characteristics [29]. More specifically, it seems that the relationship between BED and compulsive-obsessive traits could be part of the same disease spectrum just when obsessive symptoms are related to food and weight. Otherwise, we could suggest that they are independent psychiatric disorders. The interpersonal sensitivity dimension of SCL-90 has its focus on unsatisfactory, inferiority feelings, self-depreciation, low self-esteem, and great discomfort during interpersonal interactions [13]. Assertions as “Do not feel comfortable in eating or drinking in public,” “Do not feel comfortable when people are watching or talking about you,” and “Feeling that you are being criticized by others” can be viewed as an indirect indicative of psychopathological aspects related to social anxiety due to binge eating or excessive weight. Indirect evidence of this relation can also be observed in some studies. For example, Bulik et al [27]

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demonstrated that obese women with BED have a worse self-esteem than women without BED. Petroni et al [25] also found a correlation between weight cycling, defined as weight oscillation after age of 20 years, and the presence of BED and higher scores of interpersonal sensitivity in SCL90. It is possible that severe eating psychopathology and refractory treatment (indirectly indicated by cycling) could interfere in interpersonal relationship of these patients due to concern about others thoughts related to them. It is also interesting to notice that this was the strongest correlation with binge severity in women with BED. The paranoid ideas domain is represented by paranoid behaviors as a disorganized way of thought. Hostility, distrust, greatness, being the center of attention, being afraid to lose autonomy, and disappointment are considered the main signs of this domain [13]. Questions like “Feeling that others are blamed by most of your difficulties,” “Feeling that people will take advantage of you,” and “Feeling that you are observed by others or that they talk about you” may reflect some aspects related to the incapacity of control while eating. Furthermore, feelings related to loss of autonomy and disappointment are also considered in the evaluation of BED, as well as observed in some assertions of BES, such as “I feel incapable of controlling eating impulses” or “I am afraid of not being capable of stopping eating by myself.” A few studies have already demonstrated a relationship between Axis II disorders (disorders related to personality) and BED [22,23]. However, no investigation correlated, more specifically, the presence of paranoid traits with binge eating. Women with BED seem to have an increased prevalence of Axis II disorders, but these findings were not confirmed when personality disorders were individually evaluated in relation to those women without BED [22]. Another study has also correlated the presence of BED to the presence of other personality disorders, as borderline or avoidant, but not to paranoid personality disorder [25]. To the best of our knowledge, this is the first evidence of a relationship between paranoid ideas and BED. One possible explanation for the relationship between the severity of paranoid ideas and BED is that the concern patients have of being observed during their meals are due to the possibility of losing control while eating. The psychoticism domain is represented by assertions related to reserve, withdrawal, isolation, and schizoid lifestyle. Schizoid personality disorder is represented by keeping a distance from social relationship, with a restricted interval of emotional expression [5,13]. Some assertions of SCL-90, such as “The idea that something is wrong with my body” or “Never feeling closer to another person” may be correlated with some questions of BES, like “I fell embarrassed with my body weight and I frequently fell shamed of myself” and “I try to avoid social contacts because of this embarrassment.” Furthermore, some aspects of BED diagnosis express social isolation because of loss of control while eating, such as “eating alone because of embarrassment due to the amount of food you consume” or “Feeling repulse,

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depression or guilty after excessive eating” [16,17]. In a previous study, higher index of psychoticism domain was associated with the presence of eating disorders. However, patients with bulimia nervosa had higher scores in SCL-90 than patients with BED [30]. Perhaps, concerns with corporal acceptance, generally more prominent in patients with BN, could be associated more directly with social isolation. The GSI evaluates general psychopathology levels related to all dimensions of SCL-90 [13]. In agreement with our findings, most studies have also observed higher scores of the GSI among patients with BED when compared to non– binge eaters, independently of body weight [21,25,30,31]. The higher scores observed in these patients would corroborate the hypothesis that BED could influence psychopathological aspects related to several areas of functioning and not only those areas related to depression and BED. This finding could also partially explain why the presence of BED is frequently associated with other psychiatric disorders. To the best of our knowledge, a few studies have already tried to evaluate other psychiatric trails in obese patients with BED. In this study, we verified a significant association among all domains of SCL-90 and BED. More specifically, we could observe a significant relationship among the severity of BED and obsessive-compulsive, interpersonal sensitivity, paranoid ideas, and the psychoticism domains. These data suggest that the presence of a severe eating disturbance might also present symptoms in several psychopathological spheres. Therefore, in investigation of eating disorders, especially in obese patients, the impact of this diagnosis in global functioning could be used as a severity marker. Furthermore, psychotherapy of BED should be focused on global psychic dysfunction of these patients.

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