خلق و خوی، نگرش به خوردن و خشم در زنان چاق با و بدون اختلال پرخوری افراطی

Objective: The aim of this study was to evaluate the anger levels and their management in obese patients. Methods: A total of 103 obese women [51 with Binge Eating Disorder (BED) and 52 without BED] were included in the study and compared to 93 healthy controls. They were assessed with the State–Trait Anger Expression Inventory (STAXI), Beck Depression Inventory (BDI), and Eating Disorder Inventory-2 (EDI-2). Results: The BDI score is higher in obese subjects than in controls and obese binge eaters have higher levels of depression than obese patients without BED. Differences among the three groups can be found in almost all subscales of the EDI-2, even after controlling for the variable depression (BDI). For STAXI, the only difference among the three groups, which remains significant after controlling for depression, is the tendency to express anger outside (AX-OUT), which is higher in obese binge eaters. The correlation study highlights the importance of impulsivity in the group of obese binge eaters, whereas in obese patients without BED, the tendency toward anger suppression (AX-IN) is seen. Discussion: Obese patients with BED might be considered a subgroup deserving greater psychiatric interest, both for the greater severity of the eating disorder and for the comorbidity with subthreshold depressive symptoms and with borderline personality traits. In obese patients without BED, eating behavior seems more correlated to the psychological functioning typical of psychosomatic disorders. Implications for treatment are discussed.

Obesity is a chronic disorder, with a high prevalence in Western society [1] and a complex etiology, representing a serious risk for the health implications it entails (e.g., diabetes mellitus, hypertension, heart disease, etc.) and severely compromising the psychosocial functioning and quality of life of patients suffering from it [2]. Obesity is not included in the DSM-IV categorization of eating disorders (EDs) (American Psychiatric Association, APA) [3]; therefore, the current diagnosis of obesity is made according to a single clinical criterion suggested by recent clinical guidelines developed by the National Heart, Lung and Blood Institute. A body mass index (BMI; kg/m2) between 25 and 29.9 defines “overweight,” and a BMI higher than 30 defines obesity [4]. Moreover, a BMI of 30–34.9 is classified as Class I obesity, 35–39.9 as Class II obesity, and 40 or higher as Class III or extreme obesity [4]. Even though obesity is not considered an ED per se, it is characterized by some psychological features common to EDs, including impulsivity and low self-esteem [5] and [6], body dissatisfaction [7], perfectionistic attitude [8], and disinhibition [5]. Other authors have highlighted an association between a higher body weight and symptoms of borderline personality [9]. With more detailed investigations in the last decade, the opinion that two distinct and specific subgroups of obese patients exist has gathered proponents [10] and [11]: obese binge eaters (nonpurging) and nonbinge eaters. Binge-eating obese individuals exhibit significantly more eating and weight-related pathology, as well as more severe psychopathology than obese individuals who do not binge eat [12] and [13]. Particularly, binge eaters show higher levels of depression [14]. However, some authors consider it difficult to understand whether these psychopathologic correlates are a cause or a consequence of overeating [15]. Moreover, the psychopathology level does not seem related to weight [16]. In EDs, aggressiveness and anger are relevant psychopathologic core features [17] because they can influence course and treatment outcome [18], [19] and [20]. Some authors have demonstrated that in EDs, correlations exist among severity of disturbed eating patterns, low degrees of self-assertiveness, high levels of self-directed hostility [21], and difficulty in expressing anger [22] and [23]. Moreover, in these disorders, impulsive actions can be correlated with difficulties in expressing anger [17], [24] and [25]. Although some psychological and psychopathologic elements have been investigated in obesity, only a few studies have dealt with anger management in obese patients. The study of aggressiveness and anger in EDs has shown interesting results and has long been a peculiar research area of psychosomatic medicine [26]; anger proved to play an important role in severe medical conditions as hypertension [27] and [28], infarct [29], visceral fat tissue [30], and cardiovascular reactivity during interpersonal conflict [31]. The prevalence of such conditions is high in obesity [32]. In this study, anger has not been studied as a unitary construct, but in its multifaceted nature, according to the conceptualization of Spielberger [33]. This author has stressed the importance of considering anger both as an emotional state and as a trait. State–anger is a changeable emotional condition, including feelings ranging from tension to fury, which are usually accompanied by the activation of the autonomic nervous system. Trait–anger depends on the individual's predisposition toward anger experiences. Individuals with a high trait–anger experience state–anger more frequently and more intensely than those with a low trait–anger. Moreover, Spielberger stresses the fact that individuals are very different in the way they express anger; anger can be directed and addressed to other people or things (outside), or it can be turned inside, where it is suppressed and restrained [33]. The aim of this study was to evaluate the mood, eating attitudes, and anger in obese subjects and in a nonclinical control group, thus testing the hypothesis that obese binge eaters and nonbinge eaters are two distinct subgroups. Secondarily, a correlation study will be performed to determine whether an association exists among the aforesaid anger expression levels and modalities, mood state, and the eating-related psychopathology and overweight.

In conclusion, four major pieces of evidence emerge from this study: (a) obese patients with BED have greater degrees of depression and a more severe eating-related psychopathology with respect to obesity without BED; (b) obese patients with BED show greater levels of hostility, criticism, and externalized anger, independent of depression levels; (c) obese patients with greater depression levels have a greater tendency toward anger suppression, independent of the group they belong to (BED and non-BED); and (d) in obese patients with BED, anger is strongly correlated to impulsivity. Hence, the hypothesis that two different groups of obese patients exist is supported. From a therapeutic viewpoint, depression, impulsivity, and anger should become targets for the psychiatrist in the treatment and case management of obese patients with and without BED. Individuals suffering from obesity and BED should benefit from a therapeutic network, such as that used for the management of other EDs [53], including a dietary approach, individual or group psychotherapy [2], [54] and [55], and specific psychopharmacologic treatment in those with more severe depression, impulsivity, and anger [56] and [57].