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Social phobia and quality of life in morbidly obese patients before and after bariatric surgery
Journal of Affective Disorders 179 (2015) 95–100
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Research report
Social phobia and quality of life in morbidly obese patients before and after bariatric surgery Antonio Mirijello a, Cristina D’Angelo a, Amerigo Iaconelli b, Esmeralda Capristo b, Anna Ferrulli a, Laura Leccesi b, Anthony Cossari c, Raffaele Landolfi a, Giovanni Addolorato a,n a
Internal Medicine Unit, Department of Medical Sciences, Catholic University, Rome, Italy Metabolic Unit, Department of Medical Sciences, Catholic University, Rome, Italy c Department of Economics, Statistics and Finance, University of Calabria, Rende, Italy b
art ic l e i nf o
a b s t r a c t
Article history: Received 29 January 2015 Received in revised form 17 March 2015 Accepted 18 March 2015 Available online 27 March 2015
Background: Morbidly obesity is characterized by physical and psychological comorbidities which are associated with reduced quality of life. Bariatric surgery has been linked to a reduction of psychopathology other than to a reduction of weight and improvement in physical functioning. Aim of the present study was to compare psychological features of two groups of morbidly obese patients, before and after bariatric surgery, assessing social phobia and quality of life. Methods: A total of 46 morbidly obese patients were enrolled in the study. Of them, 20 were waiting for bilio-pancreatic diversion (group A), while 26 had already undergone surgical procedure (group B). Psychometric evaluation assessed social phobia, fear for the body-shape and quality of life, using appropriate psychometric tests. Results: The percentage of patients showing social phobia was significantly higher compared to a sample of healthy controls (p¼ 0.004), both in group A (p¼ 0.003) and in group B (p ¼0.029). No differences in percentage of patients affected by social phobia were found between groups. A significantly higher percentage of patients affected by distress about the body (p o0.0001) was found in group A with respect to group B. A reduction of quality of life was found in both groups. Conclusions: The present study shows a high prevalence of social phobia in a population of morbidly obese patients, both before and after surgery. A general reduction of quality of life was also observed, with a partial improvement after surgery. Future studies are needed to clarify the relationship between social phobia and quality of life in surgically-treated morbidly obese patients. & 2015 Elsevier B.V. All rights reserved.
Keywords: Obesity BMI Social anxiety disorder Quality of life
1. Introduction During the last decade the prevalence of obesity increased in the general population, both in male and female (Cello and Rogers, 2013; Berghöfer et al., 2008; James, 2008). At present obesity is considered one of the major public health problems (Haslam and James, 2005) both in developed and in developing countries since the risk of morbidity and mortality (James, 2008). The highest risk of morbidity and mortality is related to morbidly obesity (Bray, 2004), characterized by a body mass index (BMI) higher than 40 kg/m2. Reduced quality of life (QoL) and several psychological disorders have been reported in patients affected by morbidly obesity (van Hout et al., 2006). n Correspondence to: Institute of Internal Medicine, Catholic University of Rome, Gemelli Hospital Largo Gemelli 8, 00168 Rome, Italy. Tel.: þ39 06 30154334; fax: þ39 06 35502775. E-mail address: [email protected] (G. Addolorato).
http://dx.doi.org/10.1016/j.jad.2015.03.030 0165-0327/& 2015 Elsevier B.V. All rights reserved.
Anxiety, depression, neuroticism, negative body image have been described in these patients (Scott et al., 2008; Malhotra et al., 2002). Moreover, because of their body shape, obese patients are frequently targeted with discriminative behaviors by friends and colleagues, with the possible risk to develop social anxiety disorders. Social Anxiety Disorder, also called Social Phobia, is included among the anxiety disorders and it is characterized by a marked fear of performance, an excessive fear of scrutiny, and fear of acting in an embarrassing way (American Psychiatric Association, 2013). Social phobia differs from shyness and performance anxiety in its greater severity, pervasiveness, resultant distress and impairment (Schneier, 2006). Subjects affected by social phobia usually avoid situations in which a social interaction is required, as speaking in public, or situations in which they are observed, like eating and/or drinking in public places (Schneier, 2006). Consequently these subjects avoid important activities as attending classes and meetings; if they attend these activities, they usually avoid an active participation with possible negative consequences on their work and/or social life (Addolorato et al.,
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undergone surgical procedure (Group B). Written informed consent was obtained from all the participants. A group of 50 healthy control subjects (40F, mean age 35.5 710.5) selected so as to match probands on the basis of gender, age, residence, employment and socio-economic status were studied as a control group. They were recruited from among members of our hospital staff and their relatives and included both white- and blue-collar workers (Addolorato et al., 2008). Surgery employed bilio-pancreatic diversion according to Scopinaro technique. This malabsorptive surgical procedure (Scopinaro et al., 1979) consists of an approximately 60% distal gastric resection with stapled closure of the duodenal stump. The residual volume of the stomach is about 300 ml. The small bowel is transected at 2.5 m from the ileo-caecal valve, and its distal end is anastomosed to the remaining stomach. The proximal end of the ileum, comprising the remaining small bowel (involved in carrying bilio-pancreatic juice but excluded from food transit), is anastomosed in an end-to-side fashion to the bowel, 50 cm proximal to the ileo-caecal valve. Consequently, the total length of absorbing bowel is reduced to 250 cm, the final 50 cm of which, the so-called common channel, represents the site where ingested food and bilio-pancreatic juices mix.
2008). The etiology of social phobia seems to be related to both hereditary and environmental factors (Kendler et al., 1992). These factors include daily living limitations that affect personal performances with the related avoidant behavior. Other than anxiety and depression, morbid obese subjects usually show an avoidant behavior and the presence of social retirement have been described in these patients (Simon et al., 2006). At present few data are available on social phobia in morbid obese patients. Bariatric surgery has been described as an intervention resulting in long-term weight reduction for morbid obesity (Mamplekou et al., 2005). Data concerning the effect of surgical intervention on QoL and psychological co-morbidities of obese patients strongly support this procedure (Ballantyne, 2003; van Hout et al., 2006; Vincent et al., 2012). However at present there are no data about the impact of bariatric surgery on social phobia in morbid obese patients, although it has been hypothesized that bariatric surgery could improve psychiatric comorbidities in these patients (Lier et al., 2013). Aim of the present study was to evaluate social phobia in a sample of morbidly obese patients waiting surgery compared with a sample of patients treated by bilio-pancreatic diversion (BPD); both groups were compared with a group of healthy controls. QoL was assessed in order to verify if its improvement after surgery was associated with an improvement of social anxiety. State and trait anxiety, current depression and body shape were also evaluated.
2.1. Psychometric evaluation A questionnaire exacting information on their level of education, work status, socio-economic and marital status (Table 1) together with different self-rating psychometric tests was given to all patients. Social phobia was assessed by the Liebowitz Social Anxiety Scale (LSAS) (Liebowitz, 1987). The LSAS is one of the most frequently used clinician-administered scale to assess social phobia (Zimmermann et al., 2004). Its validity, reliability and treatment sensitivity have been widely proven (Mennin et al., 2002; Heimberg et al., 1999). The scale is a 24-item questionnaire depicting different social situations. For each situation, the clinician is asked to rate the patient's level of fear and avoidance on a 4-point Likert-type scale. The fear scale ratings range from 0 (no fear) to 3 (severe fear). The avoidance ratings also range from 0 to 3 and are based on the percentage of times a particular situation is avoided [0 ¼never; 1¼ occasionally (10%); 2 ¼often (33–67%); 3¼ usually (67–100%)]. The overall score represents the index used to assess social phobia (LSAS-T) (Heimberg et al., 1999). LSAS-T holds two cut-off scores of 30 and 60, respectively, for the non-generalized and generalized social phobia, as recently reported by Mennin et al. (2002). Patients scoring 430 were considered positive to the test. State and trait anxiety were assessed by the State and Trait Anxiety Inventory (STAI), made up of two axes (y1 for state anxiety
2. Methods A total of 60 morbidly obese patients consecutively referred the Metabolic Unit of our Department of Internal Medicine were initially evaluated for the study. Of them, 30 patients were waiting for surgical treatment while 30 were in follow-up (44.4761.1 months, range 2–218 months) after BPD according to Scopinaro. The diagnosis of morbidly obesity was made on the basis of BMI (Burguera et al., 2007). Inclusion criteria were: BMI440 before surgical intervention. Exclusion criteria were: the presence of psychiatric disorders other than anxiety and/or depression, alcohol abuse and/ or other substance addiction, consumption of psychotropic drugs. Among 60 patients initially evaluated, 6 (10%) refused to participate to the study, 8 (13.4%) were taking psychoactive drugs; all these patients were excluded from the statistical evaluation. A sample of 46 patients, 14 males (30.4%) and 32 females (69.6%) (mean age 42.5 710.9, range 21–69 years old), was finally considered for the statistical analysis. Of them, 20 patients were awaiting for surgical treatment (Group A) while 26 had already Table 1 a. Clinical characteristics of the sample. Variables
All patients n¼ 46
Males n ¼14
Females n¼32
Mean age7 7 SD Weight (kg) BMI
42.5 7 10.9 111.8 7 32.3 40.0 7 9.6
41.5 714.1 140.8 735.8 45.2 712.1
42.9 7 9.3 99.17 20.8 37.8 7 7.5
p (Male vs Female) ns 0.001 0.05
Group A n¼ 20
Group B n ¼26
p (A vs B)
44.0 7 12.5 134.5 7 27.6 47.17 8
41.3 79.6 94.3 723.8 34.6 76.9
Ns o 0.0001 o 0.0001
Table 1b. Variables
Group A N ¼20
Males n ¼10
Females n¼ 10
Weight (kg) BMI
134.5 727.6 47.1 78
150.17 31.2 48.67 10.6
119.0 7 10.0 45.5 7 4.1
p (Male vs Female) 0.013 ns
Group B n¼ 26
Male N¼ 4
Female N ¼22
94.3 7 23.8 34.6 7 6.9
117.5 7 40.3 36.4 7 12.5
90.17 17.9 34.2 7 5.7
p (A vs B) ns ns
Table 1c.
Group B
Weight before surgery (kg)
Weight (kg)
Δ Weight
p
BMI before surgery
BMI
Δ BMI
p
135.97 24.4
94.3 723.8
41.6 7 20.2
o 0.0001
50.3 7 8.4
34.6 7 6.9
15.7 7 8.4
o 0.0001
A. Mirijello et al. / Journal of Affective Disorders 179 (2015) 95–100
2.2. Statistical analysis Several analyses were carried out on the available data using the free software R (R Core Team, 2013). First, a preliminary descriptive analysis was performed in order to summarize the dataset. Results from such analysis are reported throughout the paper. Then, a number of significance tests were run to tentatively explore the relationships among variables. In particular, correlation was tested for pairs of quantitative variables, and two-sample t-tests were used for comparing various numerical variables, such as psychometric scores, in pre-surgical vs post-surgical patients and/or in males vs females; moreover, for each coded psychometric variable, the proportions of patients positive to the psychometric test were compared in pre-surgical and post-surgical patients. Also, the proportions of patients affected by social phobia were compared in
80 70 60 50
p= 0.003
p= ns
Patients Group A Group B Controls
p= 0.004 p= 0.029
%
and y2 for trait anxiety), both consisting of 20 multiple choice items (Spielberg et al., 1983); each item has a score from 1 to 4 so that the total point score of y-1 and y-2 axes can range from 20 to 80 (Spielberg et al., 1983). This test was selected on the basis of its simplicity, validity and reliability (Grillon et al., 1993). In particular, the STAI test permits a distinction between existing anxiety and the predisposition to the anxious reaction as a personality characteristic, as previously described (Addolorato et al., 1998). This theory is based on the conceptual distinction between anxiety as a transitory state and anxiety as a relatively stable personality trait. State anxiety is conceptualized as an emotive state characterized by subjective feelings perceived on a conscious level, such as apprehension and tension, which vary with time; anxiety as a trait refers to individuals with continuous disposition towards anxiety (Addolorato et al., 2001). The subjects evaluated were grouped as high-anxious and lowanxious and a value of 40 was used to distinguish between the two groups, according to Spielberg et al. (1983) and Weinstein (1995). Current depression was assessed by the Zung Self-rating Depression Scale (Zung-SDS) (Zung, 1965). The Zung-SDS contains 20 multiple items with a score from 1 to 4 each, so that the total point score of more than 49 is considered high. The point score is based on the frequency of depressive symptoms: minor symptoms which occur frequently therefore have a high score. This test constitutes an effective instrument in screening for depression in a clinical setting (Kaplan and Sadock, 1995) and its positive predictive value of a diagnosis of depression is between 88.7% and 92.3% (Magruder et al., 1995). Fear and distress about body shape were assessed by Body Shape Questionnaire (BSQ) (Warren et al., 2008). The BSQ consists with 34 items. Patients rate items on a scale from 1 to 6. BSQ is used to evaluate fear of putting on weight, feelings of low selfesteem because of one's appearance, the desire to lose weight and body dissatisfaction. Its validity, reliability and treatment sensitivity have been widely proven (Matz et al., 2002; Grilo and Masheb, 2005; Rosen et al., 1996). Following Cooper and Taylor (1988), we classified the scores in 4 categories: not worried about body shape o81, slightly worried¼81–110, moderately worried ¼111–140, extremely worried 4140. QoL was assessed by Short Form-36 (SF-36) (Brazier et al., 1992). The SF-36 consists of 36 multiple choice questions. These questions are ordered in eight dimension, from mainly physical to mainly psychological: Physical Functioning (PF), Role-Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role-Emotional (RE) and Mental Health (MH). The SF-36 can also be divided into two aggregate summary measures: the Physical Component Summary (PCS) and the Mental Component Summary (MCS). The sum of the SF-36 item scores within each dimension is transformed into a scale ranging from 0 (poor health) to 100 (good health).
97
40 30 20 10 0
LSAS
LSAS
LSAS
LSAS
Fig. 1. Percentage of patients and controls affected by social phobia and their statistical comparison. (Patients: total sample of patients; Group A: patients awaiting surgical treatment; Group B: patients treated by bilio-pancreatic diversion; Controls: healthy controls; LSAS: Liebowitz Social Anxiety Scale).
a number of groups of patients, such as all available patients vs healthy controls. Some modeling procedures were then used to find out influential factors on a number of response variables. Logistic regression was applied for each coded score to identify factors among the candidate predictors which determine that a patient is positive to the corresponding psychometric test. Specifically, binary logistic regression was employed for two-level coded scores (STAI y1, STAI y2, ZUNG), while ordinal logistic regression was performed on coded scores with an ordinal scale (BSQ, LSAS). Moreover, analysis of covariance was run to assess the influence of candidate explanatory variables, both factors and covariates, on each of the QoL variables. For both logistic regression and analysis of covariance, the candidate predictors were surgery, gender, age and BMIafter surgery, and models with only main-effect terms were considered; model checking techniques did not reveal any inadequacies in such models. For all inferential analyses, statistical significance was declared for p-Valueso0.05, except for a case in which the Bonferroni correction was applied, as described later; results from such analyses are presented extensively in Section 3.
3. Results Characteristics of the sample: age, weight BMI and their statistical comparisons are showed in Table 1. Fig. 1 shows the percentage of patients affected by social phobia (both generalized and non-generalized forms). Five patients belonging to Group A and three patients belonging to Group B showed the generalized form of social anxiety. In interpreting p-Values, the Bonferroni correction is used for such tests on percentages (proportions), to account for the fact that four tests are being performed simultaneously; therefore significance is declared for p-Values o0.05/ 4 ¼0.0125. The percentage of patients showing social phobia was significantly higher compared to a sample of healthy controls (43% vs 16%; p ¼ 0.004); moreover, the percentage of patients affected by social phobia was significantly higher in group A with respect to healthy controls (50% vs 16%, 0.003), and in group B (38.5% vs 16%, 0.029) with respect to healthy controls (Fig. 1). No differences in percentage of patients affected by social phobia were found between group A and group B (Fig. 1). Fig. 2 shows the percentage of patients affected by state anxiety, trait anxiety, current depression and distress about body shape. A significantly higher percentage of patients affected by distress about the body (po0.0001) was found in group A with respect to group B.
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No significant differences were found in percentages of patients affected by state anxiety, trait anxiety and current depression between two groups of patients. Results from the computation of correlations among variables showed a direct correlation between age and state anxiety (p¼0.041) in patients belonging to group A. An inverse correlation between age and social phobia (p¼0.025) was found in patients belonging to group B. A direct correlation between patients' weight and BSQ scores (p¼0.036) and between BMI and BSQ scores (p¼ 0.012) was found for the whole set of patients. Moreover an inverse correlation between Δ-BMI and BSQ scores (p¼0.008) was found. Logistic regression analysis showed that BSQ scores were negatively affected by surgery (p¼0.01), meaning that patients undergoing surgery have lower distress for body shape. Moreover, gender turned out to be influential for LSAS (p¼0.035), suggesting that males have lower propensity than females to show social phobia. In addition, logistic regression was applied only to patients belonging to group A and to group B, respectively. Obviously, in both cases surgery was excluded from the set of predictors. In the case of group A, no significant effect was found. For group B, Δ-BMI (which was added as predictor) was found to have a negative effect on BSQ (p¼0.024), hence the propensity to be positive to BSQ test, for patients who underwent surgery, decreases as their BMI decreases. Table 2 shows mean scores (SD) of SF-36, together with standard deviations, for the whole group of patients and for group A and group B, respectively; in the two latter cases, medians are also reported. Moreover, t-tests for the difference of means were performed in order to compare mean scores in the two groups of patients. The associated p-Values are included in the table, showing that PF, GH, and PCS mean scores are significantly different in the two groups, in particular they turn to be higher for patients who underwent surgery. As far as analysis of covariance is concerned, a negative effect of age on physical functioning (PF) scores (p¼ 0.033) was found. Body
100 80
p<0.0001 p=ns
p=ns
Group A Group B
60 40 p=ns
20 0
STAIy1
STAIy2
Zung-SDS
BSQ
Fig. 2. Percentage of patients, divided into two groups, affected by state anxiety, trait anxiety, current depression, distress about body shape and their statistical comparison. (Group A: patients awaiting surgical treatment; Group B: patients treated by bilio-pancreatic diversion).
pain (BP) was negatively affected by BMI (p¼ 0.042) and by surgical procedure (p ¼0.029), suggesting that highest BP scores were associated with lowest BMIs and with group B patients. Age negatively influenced General Health (GH) (p ¼0.012) and Role Emotional (RE) (p ¼0.047), with similar interpretation as before. In addition, GH was strongly affected by surgery (p ¼0.000), giving indication that GH scores were higher in patients who underwent surgical procedure. Regarding Mental Health (MH), we found results analogous to BP. In fact, both BMI (p ¼0.023) and surgery (p ¼0.051) turned out to be the influential.
4. Discussion The present study shows a significantly higher prevalence of social phobia in a sample of morbidly obese patients consecutively referred to our Metabolic Unit in comparison with healthy controls. No significant differences were found in the prevalence of social phobia between patients awaiting for surgery and BPD-treated patients. Social phobia is a condition characterized by fear and/or avoidance of situations that involve possible scrutiny by others (Stein et al., 2000). A high prevalence of social phobia in bariatric surgery patients have been described by other authors (Rosik, 2005; Lier et al., 2013). The higher prevalence of this disorder found in our study could be partly due to the use of different psychometric tests (i. e. Psychiatric Diagnostic Screening Questionnaire vs Liebowitz Social Anxiety Scale), and partly due to population's cultural differences (US vs Italy). On this connection it has been reported that obesityassociated cultural stigma could induce social phobia (Rosik, 2005). Several reasons could determine the onset of social phobia in morbidly obese patients. Before surgery, obese patients are frequently targeted with discriminative behaviors by friends and colleagues because of their body shape. Moreover, common feelings in morbidly obese patients include the fear of being judged as unattractive by colleagues and friends. This observation is supported by the higher prevalence of social anxiety symptoms among our female patients. These feelings could produce a social retirement and reduce physical activities (i.e. walking or jogging) with the consequent worsening of obesity itself. After surgery, these patients have an extremely high expectation of weight loss (Kubik et al., 2013); if weight loss is not enough as expected, it could drive morbid obese patients into a substantial social retirement. Moreover, surgeryrelated changes in lifestyle, including dietary and bowel habits, could cause the worry of the urgency to find sanitary facilities that possibly might not be available. All these aspects produce in these patients limitations in quality of life and a reduction in social activities (such as going to parties or eating in public places). According to our psychometric findings, it could be hypothesized that the high expectance in term of improving body shape after surgery is higher in younger patients, supporting the evidence of a higher propensity to show social phobia for younger patients after surgery.
Table 2 Mean scores and standard deviation of SF-36 results.
Physical Functioning (PF) Role Physical (RP) Bodily pain (BP) General Health (GH) Vitality (VT) Social Functioning (SF) Role Emotional (RE) Mental Health (MH) Physical Component Summary (PCS) Mental Component Summary (MCS)
All patients Mean (SD)
Group A Mean (SD)
Median
Group B Mean (SD)
Median
p-Value
69.5 51.6 59.2 55.8 53.9 63.3 54.2 63.5 42.7 43.7
57.7 42.5 53.9 43.7 51.7 65.0 48.3 62.2 37.9 44.1
70 50 51.3 40 57.5 62.5 33.3 64 39.35 46.5
78.6 58.6 63.3 65.1 55.5 62.0 58.8 64.6 46.4 43.4
85 75 73.0 69.5 60 62.5 66.7 68 48.10 44.84
0.002 0.184 0.275 0.001 0.608 0.687 0.359 0.704 0.003 0.826
(24.3) (40.6) (28.8) (23.0) (24.7) (24.5) (38.1) (21.0) (10.1) (11.5)
(26.7) (35.4) (29.4) (24.2) (26.4) (21.6) (35.0) (22.1) (9.4) (11.1)
(17.9) (43.5) (28.1) (17.2) (23.6) (26.8) (40.4) (20.5) (9.2) (12.0)
A. Mirijello et al. / Journal of Affective Disorders 179 (2015) 95–100
A high prevalence of state anxiety, trait anxiety and distress about the body shape was found. Among our patients, 59% showed state anxiety, 67% showed trait anxiety and 13% showed current depression. These percentages are higher than those found in general population (Somers et al., 2006; Waraich et al., 2004), but in line with literature data of morbidly obese patients (Brunault et al., 2012). Anxiety and depression in these cluster of patients could represent the symptom of the non-acceptance of the body shape (reactive state) and they could represent a co-factor in weight gain. The direct correlation between age and state anxiety could reflect the growing worry of patients for their medical and psychological condition. Moreover, in line with literature data (de Zwaan et al., 2002), a general reduction of QoL was also found. Bariatric surgery has been reported to reduce physical comorbidities of morbidly obese patients and to positively influence their quality of life (Vincent et al., 2012). Analyzing subgroups, patients treated by surgery showed a significantly lower prevalence of distress about the body (BSQ) with respect to the subgroup of patients waiting for surgical intervention. The inverse correlation between age and social anxiety scores in this subgroup of patients, could be related to a reached psychological acceptation of their body shape. No differences were found in the prevalence of state and trait anxiety and current depression between the two subgroups. Unsurprisingly, patients' weight and BMI showed a linear correlation with levels of distress about the body; similarly, Δ-BMI was inversely correlated to levels of distress about the body. These observations reflect the effect of surgery on psychometric profile, in particular reducing levels of distress about body shape and improving body perception. The persistence of a high prevalence of trait anxiety in surgically-treated patients could reflect a personality trait, and could be directly related to presurgical weight (Wedin et al., 2012), as previously reported. A general reduction in quality of life as measured by SF-36 was observed in our patients. Patients awaiting for surgery generally showed lower scores with respect to patients already treated by surgery. Unsurprisingly, age had a negative influence on physical functioning, general health and limitations due to emotional role. Moreover, surgical procedure showed a positive impact on BP and significantly increased GH and MH scores. These effects could be directly related to the body weight reduction (such as in the case of the body pain reduction), or due to the tendency to the improvement in psychometric characteristics (such as in the case of general perception of health and mental health). In conclusion the present study shows a high prevalence of social phobia in a population of morbidly obese patients, both before and after BPD, with respect to a non-morbdly obese group of patients. In the past few years this psychological disorder has gained considerable importance (Rosik, 2005; Schneier, 2006) since patients with social phobia usually experience high levels of anxiety in anticipation of social encounters and in active participation in encounters, meetings or activities (Addolorato et al., 2008). Common consequences include the high reduction in social life and the risk of school and/or work failure with the related academic and/or occupational impairment. All these factors can lead to the development of depression (Liebowitz, 1999) or can worse preexisting psychological disturbances (Rosik, 2005). It is conceivable that a treatment targeted to the reduction of body weight and consequently to the normalization of body shape could improve psychological profile and the feeling of inadequacy in these patients (Rosik, 2005; van Hout et al., 2006). This study has some limitations. The small sample-size and the short follow-up time could have limited the exact estimation of social phobia. In our sample of surgical-treated patients social phobia was lower, but non significantly, with respect to presurgical patients. This could be in line with data showing a reduction of social anxiety in morbidly obese patients after 1 year
99
from surgery (Lier et al., 2013). On this connection, the use of LSAS in patients with health problems (i.e. morbidly obesity) might need further confirmations (Mennin et al., 2002). Consequently, future longitudinal studies on a larger sample of patients are needed to clarify these possible social phobia-induced risks. At present, however, all these findings indicate the possible utility of psychological support counseling in these patients in addition to the medical management.
Role of funding source This study was supported by the Italian Ministry for University, Scientific and Technological Research (MURST).
Conflict of interest Authors declare no conflict of interest.
Acknowledgments We thank Dr. Ms. Caterina Mirijello for her expert revision of English language.
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James, W.P., 2008. The epidemiology of obesity: the size of the problem. J. Inter. Med. 263, 336–352. Kaplan, H.I., Sadock, B.J., 1995. Comprensive Textbook of Psychiatry. Williams & Wilkins, New York. Kendler, K.S., Neale, M.C., Kessler, R.C., Heath, A.C., Eaves, L.J., 1992. The genetic epidemiology of phobias in women: the interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia. Arch. Gen. Psychiatry 49, 273–281. Kubik, J.F., Gill, R.S., Laffin, M., Karmali, S., 2013. The impact of bariatric surgery on psychological health. J. Obes. 2013, 837989. Liebowitz, M.R., 1987. Social phobia. Mod. Probl. Pharmacopsychiatry 22, 141–173. Liebowitz, M.R., 1999. Update on the diagnosis and treatment of social anxiety disorder. J. Clin. Psychiatry 60 (Suppl.18), S22–S26. Lier, H.Ø., Biringer, E., Stubhaug, B., Tangen, T., 2013. Prevalence of psychiatric disorders before and 1 year after bariatric surgery: the role of shame in maintenance of psychiatric disorders in patients undergoing bariatric surgery. Nord. J. Psychiatry 67, 89–96. Magruder, K.M., Norquist, G.S., Feil, M.B., Kopans, B., Jacobs, D., 1995. Who comes to a voluntary depression screening program? Am. J. Psychiatry 152, 1615–1622. Malhotra, S., King, K.H., Welge, J.A., Brusman-Lovins, L., McElroy, S.L., 2002. Venlafaxine treatment of binge-eating disorder associated with obesity: a series of 35 patients. J. Clin. Psychiatry 63, 802–806. Mamplekou, E., Komesidou, V., Bissias, C.H., Papakonstantinou, A., Melissas, J., 2005. Psychological condition and quality of life in patients with morbid obesity before and after surgical weight loss. Obes. Surg. 15, 1177–1184. Matz, P.E., Foster, G.D., Faith, M.S., Wadden, T.A., 2002. Correlates of body image dissatisfaction among overweight women seeking weight loss. J. Consult. Clin. Psychol. 70, 1040–1044. Mennin, D.S., Fresco, D.M., Heimberg, R.G., Schneier, F.R., Davies, S.O., Liebowitz, M. R., 2002. Screening for social anxiety disorder in the clinical setting: using the Liebowitz Social Anxiety Scale. J. Anxiety Disord. 16, 661–673. R Core Team, 2013. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL 〈http://www.R-pro ject.org/〉. Rosen, J.C., Jones, A., Ramirez, E., Waxman, S., 1996. Body Shape Questionnaire: studies of validity and reliability. Int. J. Eat. Disord. 20, 315–319. Rosik, C.H., 2005. Psychiatric symptoms among prospective bariatric surgery patients: rates of prevalence and their relation to social desirability, pursuit of surgery, and follow-up attendance. Obes. Surg. 15, 677–683.
Schneier, F.R., 2006. Clinical practice. Social anxiety disorder. N. Engl. J. Med. 355, 1029–1036. Scopinaro, N., Gianetta, E., Civalleri, D., Bonalumi, U., Bachi, V., 1979. Biliopancreatic bypass for obesity: 1. An experimental study in dogs. Br. J. Surg. 66, 613–617. Scott, K.M., McGee, M.A., Wells, J.E., Oakley Browne, M.A., 2008. Obesity and mental disorders in the adult general population. J. Psychosom. Res. 64, 97–105. Simon, G.E., Von Korff, M., Saunders, K., Miglioretti, D.L., Crane, P.K., van Belle, G., Kessler, R.C., 2006. Association between obesity and psychiatric disorders in the US adult population. Arch. Gen. Psychiatry 63, 824–830. Somers, J.M., Goldner, E.M., Waraich, P., Hsu, L., 2006. Prevalence and incidence studies of anxiety disorders: a systematic review of the literature. Can. J. Psychiatry 51, 100–113. Spielberg, C.D., Gorsuch, R.L., Lushene, R.E., 1983. Manual for the State-Trait Anxiety Inventory. Consulting Psychologist Press, Palo Alto, CA. Stein, M.B., Torgrud, L.J., Walker, J.R., 2000. Social phobia symptoms, subtypes, and severity: findings from a community survey. Arch. Gen. Psychiatry 57, 1046–1052. van Hout, G.C., Boekestein, P., Fortuin, F.A., Pelle, A.J., van Heck, G.L., 2006. Psychosocial functioning following bariatric surgery. Obes. Surg. 16, 787–794. Vincent, H.K., Ben-David, K., Conrad, B.P., Lamb, K.M., Seay, A.N., Vincent, K.R., 2012. Rapid changes in gait, musculoskeletal pain, and quality of life after bariatric surgery. Surg. Obes. Relat. Dis. 8, 346–354. Waraich, P., Goldner, E.M., Somers, J.M., Hsu, L., 2004. Prevalence and incidence studies of mood disorders: a systematic review of the literature. Can. J. Psychiatry 49, 124–138. Warren, C.S., Cepeda-Benito, A., Gleaves, D.H., Moreno, S., Rodriguez, S., Fernandez, M.C., Fingeret, M.C., Pearson, C.A., 2008. English and Spanish versions of the body shape questionnaire: measurement equivalence across ethnicity and clinical status. Int. J. Eat. Disord. 41, 265–272. Wedin, S., Byrne, K., Morgan, K., Lepage, M., Goldman, R., Crowley, N., Galloway, S., Borckardt, J.J., 2012. Presurgical weight is associated with pain, functional impairment, and anxiety among gastric bypass surgery patients. Pain Res. Treat. 2012, 412174. Weinstein, A.M., 1995. Visual ERPs evidence for enhanced processing of threatening information in anxious university students. Biol. Psychiatry 13, 847–858. Zimmermann, G., Pin, M.A., Krenz, S., Bouchat, A., Favrat, B., Besson, J., Zullino, D.F., 2004. Prevalence of social phobia in a clinical sample of drug dependent patients. J. Affect. Disord. 83, 83–87. Zung, W.W., 1965. A self-rating depression scale. Arch. Gen. Psychiatry 12, 63–70.
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Social phobia and quality of life in morbidly obese patients before and after bariatric surgery Antonio Mirijello a, Cristina D’Angelo a, Amerigo Iaconelli b, Esmeralda Capristo b, Anna Ferrulli a, Laura Leccesi b, Anthony Cossari c, Raffaele Landolfi a, Giovanni Addolorato a,n a
Internal Medicine Unit, Department of Medical Sciences, Catholic University, Rome, Italy Metabolic Unit, Department of Medical Sciences, Catholic University, Rome, Italy c Department of Economics, Statistics and Finance, University of Calabria, Rende, Italy b
art ic l e i nf o
a b s t r a c t
Article history: Received 29 January 2015 Received in revised form 17 March 2015 Accepted 18 March 2015 Available online 27 March 2015
Background: Morbidly obesity is characterized by physical and psychological comorbidities which are associated with reduced quality of life. Bariatric surgery has been linked to a reduction of psychopathology other than to a reduction of weight and improvement in physical functioning. Aim of the present study was to compare psychological features of two groups of morbidly obese patients, before and after bariatric surgery, assessing social phobia and quality of life. Methods: A total of 46 morbidly obese patients were enrolled in the study. Of them, 20 were waiting for bilio-pancreatic diversion (group A), while 26 had already undergone surgical procedure (group B). Psychometric evaluation assessed social phobia, fear for the body-shape and quality of life, using appropriate psychometric tests. Results: The percentage of patients showing social phobia was significantly higher compared to a sample of healthy controls (p¼ 0.004), both in group A (p¼ 0.003) and in group B (p ¼0.029). No differences in percentage of patients affected by social phobia were found between groups. A significantly higher percentage of patients affected by distress about the body (p o0.0001) was found in group A with respect to group B. A reduction of quality of life was found in both groups. Conclusions: The present study shows a high prevalence of social phobia in a population of morbidly obese patients, both before and after surgery. A general reduction of quality of life was also observed, with a partial improvement after surgery. Future studies are needed to clarify the relationship between social phobia and quality of life in surgically-treated morbidly obese patients. & 2015 Elsevier B.V. All rights reserved.
Keywords: Obesity BMI Social anxiety disorder Quality of life
1. Introduction During the last decade the prevalence of obesity increased in the general population, both in male and female (Cello and Rogers, 2013; Berghöfer et al., 2008; James, 2008). At present obesity is considered one of the major public health problems (Haslam and James, 2005) both in developed and in developing countries since the risk of morbidity and mortality (James, 2008). The highest risk of morbidity and mortality is related to morbidly obesity (Bray, 2004), characterized by a body mass index (BMI) higher than 40 kg/m2. Reduced quality of life (QoL) and several psychological disorders have been reported in patients affected by morbidly obesity (van Hout et al., 2006). n Correspondence to: Institute of Internal Medicine, Catholic University of Rome, Gemelli Hospital Largo Gemelli 8, 00168 Rome, Italy. Tel.: þ39 06 30154334; fax: þ39 06 35502775. E-mail address: [email protected] (G. Addolorato).
http://dx.doi.org/10.1016/j.jad.2015.03.030 0165-0327/& 2015 Elsevier B.V. All rights reserved.
Anxiety, depression, neuroticism, negative body image have been described in these patients (Scott et al., 2008; Malhotra et al., 2002). Moreover, because of their body shape, obese patients are frequently targeted with discriminative behaviors by friends and colleagues, with the possible risk to develop social anxiety disorders. Social Anxiety Disorder, also called Social Phobia, is included among the anxiety disorders and it is characterized by a marked fear of performance, an excessive fear of scrutiny, and fear of acting in an embarrassing way (American Psychiatric Association, 2013). Social phobia differs from shyness and performance anxiety in its greater severity, pervasiveness, resultant distress and impairment (Schneier, 2006). Subjects affected by social phobia usually avoid situations in which a social interaction is required, as speaking in public, or situations in which they are observed, like eating and/or drinking in public places (Schneier, 2006). Consequently these subjects avoid important activities as attending classes and meetings; if they attend these activities, they usually avoid an active participation with possible negative consequences on their work and/or social life (Addolorato et al.,
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undergone surgical procedure (Group B). Written informed consent was obtained from all the participants. A group of 50 healthy control subjects (40F, mean age 35.5 710.5) selected so as to match probands on the basis of gender, age, residence, employment and socio-economic status were studied as a control group. They were recruited from among members of our hospital staff and their relatives and included both white- and blue-collar workers (Addolorato et al., 2008). Surgery employed bilio-pancreatic diversion according to Scopinaro technique. This malabsorptive surgical procedure (Scopinaro et al., 1979) consists of an approximately 60% distal gastric resection with stapled closure of the duodenal stump. The residual volume of the stomach is about 300 ml. The small bowel is transected at 2.5 m from the ileo-caecal valve, and its distal end is anastomosed to the remaining stomach. The proximal end of the ileum, comprising the remaining small bowel (involved in carrying bilio-pancreatic juice but excluded from food transit), is anastomosed in an end-to-side fashion to the bowel, 50 cm proximal to the ileo-caecal valve. Consequently, the total length of absorbing bowel is reduced to 250 cm, the final 50 cm of which, the so-called common channel, represents the site where ingested food and bilio-pancreatic juices mix.
2008). The etiology of social phobia seems to be related to both hereditary and environmental factors (Kendler et al., 1992). These factors include daily living limitations that affect personal performances with the related avoidant behavior. Other than anxiety and depression, morbid obese subjects usually show an avoidant behavior and the presence of social retirement have been described in these patients (Simon et al., 2006). At present few data are available on social phobia in morbid obese patients. Bariatric surgery has been described as an intervention resulting in long-term weight reduction for morbid obesity (Mamplekou et al., 2005). Data concerning the effect of surgical intervention on QoL and psychological co-morbidities of obese patients strongly support this procedure (Ballantyne, 2003; van Hout et al., 2006; Vincent et al., 2012). However at present there are no data about the impact of bariatric surgery on social phobia in morbid obese patients, although it has been hypothesized that bariatric surgery could improve psychiatric comorbidities in these patients (Lier et al., 2013). Aim of the present study was to evaluate social phobia in a sample of morbidly obese patients waiting surgery compared with a sample of patients treated by bilio-pancreatic diversion (BPD); both groups were compared with a group of healthy controls. QoL was assessed in order to verify if its improvement after surgery was associated with an improvement of social anxiety. State and trait anxiety, current depression and body shape were also evaluated.
2.1. Psychometric evaluation A questionnaire exacting information on their level of education, work status, socio-economic and marital status (Table 1) together with different self-rating psychometric tests was given to all patients. Social phobia was assessed by the Liebowitz Social Anxiety Scale (LSAS) (Liebowitz, 1987). The LSAS is one of the most frequently used clinician-administered scale to assess social phobia (Zimmermann et al., 2004). Its validity, reliability and treatment sensitivity have been widely proven (Mennin et al., 2002; Heimberg et al., 1999). The scale is a 24-item questionnaire depicting different social situations. For each situation, the clinician is asked to rate the patient's level of fear and avoidance on a 4-point Likert-type scale. The fear scale ratings range from 0 (no fear) to 3 (severe fear). The avoidance ratings also range from 0 to 3 and are based on the percentage of times a particular situation is avoided [0 ¼never; 1¼ occasionally (10%); 2 ¼often (33–67%); 3¼ usually (67–100%)]. The overall score represents the index used to assess social phobia (LSAS-T) (Heimberg et al., 1999). LSAS-T holds two cut-off scores of 30 and 60, respectively, for the non-generalized and generalized social phobia, as recently reported by Mennin et al. (2002). Patients scoring 430 were considered positive to the test. State and trait anxiety were assessed by the State and Trait Anxiety Inventory (STAI), made up of two axes (y1 for state anxiety
2. Methods A total of 60 morbidly obese patients consecutively referred the Metabolic Unit of our Department of Internal Medicine were initially evaluated for the study. Of them, 30 patients were waiting for surgical treatment while 30 were in follow-up (44.4761.1 months, range 2–218 months) after BPD according to Scopinaro. The diagnosis of morbidly obesity was made on the basis of BMI (Burguera et al., 2007). Inclusion criteria were: BMI440 before surgical intervention. Exclusion criteria were: the presence of psychiatric disorders other than anxiety and/or depression, alcohol abuse and/ or other substance addiction, consumption of psychotropic drugs. Among 60 patients initially evaluated, 6 (10%) refused to participate to the study, 8 (13.4%) were taking psychoactive drugs; all these patients were excluded from the statistical evaluation. A sample of 46 patients, 14 males (30.4%) and 32 females (69.6%) (mean age 42.5 710.9, range 21–69 years old), was finally considered for the statistical analysis. Of them, 20 patients were awaiting for surgical treatment (Group A) while 26 had already Table 1 a. Clinical characteristics of the sample. Variables
All patients n¼ 46
Males n ¼14
Females n¼32
Mean age7 7 SD Weight (kg) BMI
42.5 7 10.9 111.8 7 32.3 40.0 7 9.6
41.5 714.1 140.8 735.8 45.2 712.1
42.9 7 9.3 99.17 20.8 37.8 7 7.5
p (Male vs Female) ns 0.001 0.05
Group A n¼ 20
Group B n ¼26
p (A vs B)
44.0 7 12.5 134.5 7 27.6 47.17 8
41.3 79.6 94.3 723.8 34.6 76.9
Ns o 0.0001 o 0.0001
Table 1b. Variables
Group A N ¼20
Males n ¼10
Females n¼ 10
Weight (kg) BMI
134.5 727.6 47.1 78
150.17 31.2 48.67 10.6
119.0 7 10.0 45.5 7 4.1
p (Male vs Female) 0.013 ns
Group B n¼ 26
Male N¼ 4
Female N ¼22
94.3 7 23.8 34.6 7 6.9
117.5 7 40.3 36.4 7 12.5
90.17 17.9 34.2 7 5.7
p (A vs B) ns ns
Table 1c.
Group B
Weight before surgery (kg)
Weight (kg)
Δ Weight
p
BMI before surgery
BMI
Δ BMI
p
135.97 24.4
94.3 723.8
41.6 7 20.2
o 0.0001
50.3 7 8.4
34.6 7 6.9
15.7 7 8.4
o 0.0001
A. Mirijello et al. / Journal of Affective Disorders 179 (2015) 95–100
2.2. Statistical analysis Several analyses were carried out on the available data using the free software R (R Core Team, 2013). First, a preliminary descriptive analysis was performed in order to summarize the dataset. Results from such analysis are reported throughout the paper. Then, a number of significance tests were run to tentatively explore the relationships among variables. In particular, correlation was tested for pairs of quantitative variables, and two-sample t-tests were used for comparing various numerical variables, such as psychometric scores, in pre-surgical vs post-surgical patients and/or in males vs females; moreover, for each coded psychometric variable, the proportions of patients positive to the psychometric test were compared in pre-surgical and post-surgical patients. Also, the proportions of patients affected by social phobia were compared in
80 70 60 50
p= 0.003
p= ns
Patients Group A Group B Controls
p= 0.004 p= 0.029
%
and y2 for trait anxiety), both consisting of 20 multiple choice items (Spielberg et al., 1983); each item has a score from 1 to 4 so that the total point score of y-1 and y-2 axes can range from 20 to 80 (Spielberg et al., 1983). This test was selected on the basis of its simplicity, validity and reliability (Grillon et al., 1993). In particular, the STAI test permits a distinction between existing anxiety and the predisposition to the anxious reaction as a personality characteristic, as previously described (Addolorato et al., 1998). This theory is based on the conceptual distinction between anxiety as a transitory state and anxiety as a relatively stable personality trait. State anxiety is conceptualized as an emotive state characterized by subjective feelings perceived on a conscious level, such as apprehension and tension, which vary with time; anxiety as a trait refers to individuals with continuous disposition towards anxiety (Addolorato et al., 2001). The subjects evaluated were grouped as high-anxious and lowanxious and a value of 40 was used to distinguish between the two groups, according to Spielberg et al. (1983) and Weinstein (1995). Current depression was assessed by the Zung Self-rating Depression Scale (Zung-SDS) (Zung, 1965). The Zung-SDS contains 20 multiple items with a score from 1 to 4 each, so that the total point score of more than 49 is considered high. The point score is based on the frequency of depressive symptoms: minor symptoms which occur frequently therefore have a high score. This test constitutes an effective instrument in screening for depression in a clinical setting (Kaplan and Sadock, 1995) and its positive predictive value of a diagnosis of depression is between 88.7% and 92.3% (Magruder et al., 1995). Fear and distress about body shape were assessed by Body Shape Questionnaire (BSQ) (Warren et al., 2008). The BSQ consists with 34 items. Patients rate items on a scale from 1 to 6. BSQ is used to evaluate fear of putting on weight, feelings of low selfesteem because of one's appearance, the desire to lose weight and body dissatisfaction. Its validity, reliability and treatment sensitivity have been widely proven (Matz et al., 2002; Grilo and Masheb, 2005; Rosen et al., 1996). Following Cooper and Taylor (1988), we classified the scores in 4 categories: not worried about body shape o81, slightly worried¼81–110, moderately worried ¼111–140, extremely worried 4140. QoL was assessed by Short Form-36 (SF-36) (Brazier et al., 1992). The SF-36 consists of 36 multiple choice questions. These questions are ordered in eight dimension, from mainly physical to mainly psychological: Physical Functioning (PF), Role-Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role-Emotional (RE) and Mental Health (MH). The SF-36 can also be divided into two aggregate summary measures: the Physical Component Summary (PCS) and the Mental Component Summary (MCS). The sum of the SF-36 item scores within each dimension is transformed into a scale ranging from 0 (poor health) to 100 (good health).
97
40 30 20 10 0
LSAS
LSAS
LSAS
LSAS
Fig. 1. Percentage of patients and controls affected by social phobia and their statistical comparison. (Patients: total sample of patients; Group A: patients awaiting surgical treatment; Group B: patients treated by bilio-pancreatic diversion; Controls: healthy controls; LSAS: Liebowitz Social Anxiety Scale).
a number of groups of patients, such as all available patients vs healthy controls. Some modeling procedures were then used to find out influential factors on a number of response variables. Logistic regression was applied for each coded score to identify factors among the candidate predictors which determine that a patient is positive to the corresponding psychometric test. Specifically, binary logistic regression was employed for two-level coded scores (STAI y1, STAI y2, ZUNG), while ordinal logistic regression was performed on coded scores with an ordinal scale (BSQ, LSAS). Moreover, analysis of covariance was run to assess the influence of candidate explanatory variables, both factors and covariates, on each of the QoL variables. For both logistic regression and analysis of covariance, the candidate predictors were surgery, gender, age and BMIafter surgery, and models with only main-effect terms were considered; model checking techniques did not reveal any inadequacies in such models. For all inferential analyses, statistical significance was declared for p-Valueso0.05, except for a case in which the Bonferroni correction was applied, as described later; results from such analyses are presented extensively in Section 3.
3. Results Characteristics of the sample: age, weight BMI and their statistical comparisons are showed in Table 1. Fig. 1 shows the percentage of patients affected by social phobia (both generalized and non-generalized forms). Five patients belonging to Group A and three patients belonging to Group B showed the generalized form of social anxiety. In interpreting p-Values, the Bonferroni correction is used for such tests on percentages (proportions), to account for the fact that four tests are being performed simultaneously; therefore significance is declared for p-Values o0.05/ 4 ¼0.0125. The percentage of patients showing social phobia was significantly higher compared to a sample of healthy controls (43% vs 16%; p ¼ 0.004); moreover, the percentage of patients affected by social phobia was significantly higher in group A with respect to healthy controls (50% vs 16%, 0.003), and in group B (38.5% vs 16%, 0.029) with respect to healthy controls (Fig. 1). No differences in percentage of patients affected by social phobia were found between group A and group B (Fig. 1). Fig. 2 shows the percentage of patients affected by state anxiety, trait anxiety, current depression and distress about body shape. A significantly higher percentage of patients affected by distress about the body (po0.0001) was found in group A with respect to group B.
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No significant differences were found in percentages of patients affected by state anxiety, trait anxiety and current depression between two groups of patients. Results from the computation of correlations among variables showed a direct correlation between age and state anxiety (p¼0.041) in patients belonging to group A. An inverse correlation between age and social phobia (p¼0.025) was found in patients belonging to group B. A direct correlation between patients' weight and BSQ scores (p¼0.036) and between BMI and BSQ scores (p¼ 0.012) was found for the whole set of patients. Moreover an inverse correlation between Δ-BMI and BSQ scores (p¼0.008) was found. Logistic regression analysis showed that BSQ scores were negatively affected by surgery (p¼0.01), meaning that patients undergoing surgery have lower distress for body shape. Moreover, gender turned out to be influential for LSAS (p¼0.035), suggesting that males have lower propensity than females to show social phobia. In addition, logistic regression was applied only to patients belonging to group A and to group B, respectively. Obviously, in both cases surgery was excluded from the set of predictors. In the case of group A, no significant effect was found. For group B, Δ-BMI (which was added as predictor) was found to have a negative effect on BSQ (p¼0.024), hence the propensity to be positive to BSQ test, for patients who underwent surgery, decreases as their BMI decreases. Table 2 shows mean scores (SD) of SF-36, together with standard deviations, for the whole group of patients and for group A and group B, respectively; in the two latter cases, medians are also reported. Moreover, t-tests for the difference of means were performed in order to compare mean scores in the two groups of patients. The associated p-Values are included in the table, showing that PF, GH, and PCS mean scores are significantly different in the two groups, in particular they turn to be higher for patients who underwent surgery. As far as analysis of covariance is concerned, a negative effect of age on physical functioning (PF) scores (p¼ 0.033) was found. Body
100 80
p<0.0001 p=ns
p=ns
Group A Group B
60 40 p=ns
20 0
STAIy1
STAIy2
Zung-SDS
BSQ
Fig. 2. Percentage of patients, divided into two groups, affected by state anxiety, trait anxiety, current depression, distress about body shape and their statistical comparison. (Group A: patients awaiting surgical treatment; Group B: patients treated by bilio-pancreatic diversion).
pain (BP) was negatively affected by BMI (p¼ 0.042) and by surgical procedure (p ¼0.029), suggesting that highest BP scores were associated with lowest BMIs and with group B patients. Age negatively influenced General Health (GH) (p ¼0.012) and Role Emotional (RE) (p ¼0.047), with similar interpretation as before. In addition, GH was strongly affected by surgery (p ¼0.000), giving indication that GH scores were higher in patients who underwent surgical procedure. Regarding Mental Health (MH), we found results analogous to BP. In fact, both BMI (p ¼0.023) and surgery (p ¼0.051) turned out to be the influential.
4. Discussion The present study shows a significantly higher prevalence of social phobia in a sample of morbidly obese patients consecutively referred to our Metabolic Unit in comparison with healthy controls. No significant differences were found in the prevalence of social phobia between patients awaiting for surgery and BPD-treated patients. Social phobia is a condition characterized by fear and/or avoidance of situations that involve possible scrutiny by others (Stein et al., 2000). A high prevalence of social phobia in bariatric surgery patients have been described by other authors (Rosik, 2005; Lier et al., 2013). The higher prevalence of this disorder found in our study could be partly due to the use of different psychometric tests (i. e. Psychiatric Diagnostic Screening Questionnaire vs Liebowitz Social Anxiety Scale), and partly due to population's cultural differences (US vs Italy). On this connection it has been reported that obesityassociated cultural stigma could induce social phobia (Rosik, 2005). Several reasons could determine the onset of social phobia in morbidly obese patients. Before surgery, obese patients are frequently targeted with discriminative behaviors by friends and colleagues because of their body shape. Moreover, common feelings in morbidly obese patients include the fear of being judged as unattractive by colleagues and friends. This observation is supported by the higher prevalence of social anxiety symptoms among our female patients. These feelings could produce a social retirement and reduce physical activities (i.e. walking or jogging) with the consequent worsening of obesity itself. After surgery, these patients have an extremely high expectation of weight loss (Kubik et al., 2013); if weight loss is not enough as expected, it could drive morbid obese patients into a substantial social retirement. Moreover, surgeryrelated changes in lifestyle, including dietary and bowel habits, could cause the worry of the urgency to find sanitary facilities that possibly might not be available. All these aspects produce in these patients limitations in quality of life and a reduction in social activities (such as going to parties or eating in public places). According to our psychometric findings, it could be hypothesized that the high expectance in term of improving body shape after surgery is higher in younger patients, supporting the evidence of a higher propensity to show social phobia for younger patients after surgery.
Table 2 Mean scores and standard deviation of SF-36 results.
Physical Functioning (PF) Role Physical (RP) Bodily pain (BP) General Health (GH) Vitality (VT) Social Functioning (SF) Role Emotional (RE) Mental Health (MH) Physical Component Summary (PCS) Mental Component Summary (MCS)
All patients Mean (SD)
Group A Mean (SD)
Median
Group B Mean (SD)
Median
p-Value
69.5 51.6 59.2 55.8 53.9 63.3 54.2 63.5 42.7 43.7
57.7 42.5 53.9 43.7 51.7 65.0 48.3 62.2 37.9 44.1
70 50 51.3 40 57.5 62.5 33.3 64 39.35 46.5
78.6 58.6 63.3 65.1 55.5 62.0 58.8 64.6 46.4 43.4
85 75 73.0 69.5 60 62.5 66.7 68 48.10 44.84
0.002 0.184 0.275 0.001 0.608 0.687 0.359 0.704 0.003 0.826
(24.3) (40.6) (28.8) (23.0) (24.7) (24.5) (38.1) (21.0) (10.1) (11.5)
(26.7) (35.4) (29.4) (24.2) (26.4) (21.6) (35.0) (22.1) (9.4) (11.1)
(17.9) (43.5) (28.1) (17.2) (23.6) (26.8) (40.4) (20.5) (9.2) (12.0)
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A high prevalence of state anxiety, trait anxiety and distress about the body shape was found. Among our patients, 59% showed state anxiety, 67% showed trait anxiety and 13% showed current depression. These percentages are higher than those found in general population (Somers et al., 2006; Waraich et al., 2004), but in line with literature data of morbidly obese patients (Brunault et al., 2012). Anxiety and depression in these cluster of patients could represent the symptom of the non-acceptance of the body shape (reactive state) and they could represent a co-factor in weight gain. The direct correlation between age and state anxiety could reflect the growing worry of patients for their medical and psychological condition. Moreover, in line with literature data (de Zwaan et al., 2002), a general reduction of QoL was also found. Bariatric surgery has been reported to reduce physical comorbidities of morbidly obese patients and to positively influence their quality of life (Vincent et al., 2012). Analyzing subgroups, patients treated by surgery showed a significantly lower prevalence of distress about the body (BSQ) with respect to the subgroup of patients waiting for surgical intervention. The inverse correlation between age and social anxiety scores in this subgroup of patients, could be related to a reached psychological acceptation of their body shape. No differences were found in the prevalence of state and trait anxiety and current depression between the two subgroups. Unsurprisingly, patients' weight and BMI showed a linear correlation with levels of distress about the body; similarly, Δ-BMI was inversely correlated to levels of distress about the body. These observations reflect the effect of surgery on psychometric profile, in particular reducing levels of distress about body shape and improving body perception. The persistence of a high prevalence of trait anxiety in surgically-treated patients could reflect a personality trait, and could be directly related to presurgical weight (Wedin et al., 2012), as previously reported. A general reduction in quality of life as measured by SF-36 was observed in our patients. Patients awaiting for surgery generally showed lower scores with respect to patients already treated by surgery. Unsurprisingly, age had a negative influence on physical functioning, general health and limitations due to emotional role. Moreover, surgical procedure showed a positive impact on BP and significantly increased GH and MH scores. These effects could be directly related to the body weight reduction (such as in the case of the body pain reduction), or due to the tendency to the improvement in psychometric characteristics (such as in the case of general perception of health and mental health). In conclusion the present study shows a high prevalence of social phobia in a population of morbidly obese patients, both before and after BPD, with respect to a non-morbdly obese group of patients. In the past few years this psychological disorder has gained considerable importance (Rosik, 2005; Schneier, 2006) since patients with social phobia usually experience high levels of anxiety in anticipation of social encounters and in active participation in encounters, meetings or activities (Addolorato et al., 2008). Common consequences include the high reduction in social life and the risk of school and/or work failure with the related academic and/or occupational impairment. All these factors can lead to the development of depression (Liebowitz, 1999) or can worse preexisting psychological disturbances (Rosik, 2005). It is conceivable that a treatment targeted to the reduction of body weight and consequently to the normalization of body shape could improve psychological profile and the feeling of inadequacy in these patients (Rosik, 2005; van Hout et al., 2006). This study has some limitations. The small sample-size and the short follow-up time could have limited the exact estimation of social phobia. In our sample of surgical-treated patients social phobia was lower, but non significantly, with respect to presurgical patients. This could be in line with data showing a reduction of social anxiety in morbidly obese patients after 1 year
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from surgery (Lier et al., 2013). On this connection, the use of LSAS in patients with health problems (i.e. morbidly obesity) might need further confirmations (Mennin et al., 2002). Consequently, future longitudinal studies on a larger sample of patients are needed to clarify these possible social phobia-induced risks. At present, however, all these findings indicate the possible utility of psychological support counseling in these patients in addition to the medical management.
Role of funding source This study was supported by the Italian Ministry for University, Scientific and Technological Research (MURST).
Conflict of interest Authors declare no conflict of interest.
Acknowledgments We thank Dr. Ms. Caterina Mirijello for her expert revision of English language.
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