|Year : 2014 | Volume
| Issue : 1 | Page : 14-21
Dynamic aspects of obesity in a sample of Egyptian women
Magdy M Arafa1, Hoda A Hussein1, Wafaa A Fahmy2, Shereen M Abd El Mawella1, Shimaa M Nassar1
1 Department of Psychiatry, Faculty of Medicine, Cairo University, Cairo, Egypt
2 Department of Community Medicine, National Nutrition Institute, Cairo, Egypt
|Date of Submission||29-Oct-2013|
|Date of Acceptance||10-Dec-2013|
|Date of Web Publication||18-Feb-2014|
Hoda A Hussein
Department of Psychiatry, Faculty of Medicine, Cairo University, Cairo
Source of Support: None, Conflict of Interest: None
Obesity is actually conceptualized as a complex, multifactorial disorder, in which genetic, psychological, physiological, environmental, and socioeconomic factors play a major role. The nature of the relationship between obesity and psychological distress continues to be debated by researchers and clinicians. Some studies have suggested a relationship between being overweight and having increased psychiatric symptoms, and an association between obesity and several lifetime psychiatric disorders, whereas other studies have found no association at all.
It is hypothesized that there are differences between obese and normal-weight women in different dynamic aspects; therefore, here, we compare them in terms of defense mechanisms, self-esteem, and body image. Also, we attempt to explore the association between the degree of obesity and the severity of psychopathology.
Patients and methods
This was a case-control cross-sectional study, in which a group of 40 obese women seeking treatment for obesity were recruited from the National Nutrition Institute (BMI ≥ 30), and a group of 40 healthy normal-weight women were recruited from among the general population (control sample). They were subjected to the following psychometric procedures: Symptom Check List-90-R (SCL-90-R), Body Image Questionnaire (BIQ), Rosenberg Self-Esteem Scale (RSES), and Defense Style Questionnaire (DSQ-40).
In terms of SCL-90-R, there was a significant difference between the two groups in the somatization, hostility, and paranoid ideation subscales; the scores for these on SCL-90-R were higher in the obese group. For BIQ, there was a statistically highly significant difference between the two groups; obese individuals had a disturbed body image compared with those in the control group. For DSQ-40, the obese women showed excessive use of immature defenses (displacement) and the control group showed frequent usage of neurotic defenses (reaction formation); there was a significant difference between the two groups in the two defenses. There was no significant difference in self-esteem. There was a positive correlation between BMI and the somatization subscale, BMI and the phobia subscale, and BMI and the Global Severity Index subscale of SCL-90-R in the obese group. There was a positive correlation between BMI and the depression subscale and BMI and the interpersonal sensitivity subscale of SCL-90-R in the control group. There was a negative correlation between BMI and mature defense styles in the obese group, whereas in the control group, there was a positive correlation between BMI and immature defense styles. There were no significant correlations between BMI and both BIQ and RSES.
Obese women have more disturbed body image, immature defense mechanisms, and psychopathology than the control group.
Keywords: Body image, defense mechanisms, dynamic aspects, obesity, self-esteem
|How to cite this article:|
Arafa MM, Hussein HA, Fahmy WA, Abd El Mawella SM, Nassar SM. Dynamic aspects of obesity in a sample of Egyptian women. Egypt J Psychiatr 2014;35:14-21
|How to cite this URL:|
Arafa MM, Hussein HA, Fahmy WA, Abd El Mawella SM, Nassar SM. Dynamic aspects of obesity in a sample of Egyptian women. Egypt J Psychiatr [serial online] 2014 [cited 2018 Nov 18];35:14-21. Available from: http://new.ejpsy.eg.net/text.asp?2014/35/1/14/127265
| Introduction|| |
Obesity is actually conceptualized as a complex, multifactorial disorder, in which genetic, psychological, physiological, environmental, and socioeconomic factors play a major role (Devlin et al., 2000). Obesity is clinically defined in terms of BMI, which was calculated using the standard formula (weight in kilograms/height in meters squared), and was included by National Institutes of Health (2010) as a recoded six-category variable: underweight (BMI ≤ 18.4), normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), class I obesity (BMI 30.0-34.9), class II obesity (BMI 35.0-39.9), and class III obesity (BMI ≥ 40.0).
The nature of the relationship between obesity and psychological distress continues to be debated by researchers and clinicians. Some studies have suggested a relationship between being overweight and having increased psychiatric symptoms, and an association between obesity and several lifetime psychiatric disorders (Kim et al., 2007; Mather et al., 2008), whereas other studies have found no association at all (Carpenter et al., 2000; Roberts et al., 2003).
Recent evidence has shown that there is an increasing prevalence of mood and anxiety disorders among obese individuals compared with normal-weight individuals (Simon et al., 2006). From psychodynamic perspectives, social rejection, which can affect self-esteem, is faced by many obese individuals. Attitudes against obesity are apparent in health professionals, even among obesity specialists, although having more personal experience and empathy, some of this negativity may be offset (Schwartz et al., 2003).
At the same time, body image problems are highly prevalent in overweight and obese individuals, especially among those seeking treatment, and can undermine successful weight management, predicting poorer weight outcomes and increasing chances of relapse (Teixeira et al., 2004).
Another aspect of obesity that only a few studies have focused on is the defense mechanisms of obese individuals; defense mechanisms are 'automatic psychological processes that protect the individual against anxiety and awareness of internal or external dangers or stressors' (American Psychiatric Association, 1994). Ego defense mechanisms differ from coping skills as coping skills require the awareness and decision to manage and resolve a conflict, whereas ego defense mechanisms act without conscious awareness and can only interfere with the inner psychological state, producing a distortion of reality (Cramer, 1998b).
| Aim of the study|| |
It is hypothesized that there are differences between obese and normal-weight women in different dynamic aspects; therefore, we compared them in terms of defense mechanisms, self-esteem, and body image. Also, we attempted to explore the association between the degree of obesity and the severity of psychopathology.
| Participants and methods|| |
This was a case-control study; the sample included two groups: a group of 40 obese women seeking treatment for obesity, recruited from the National Nutrition Institute (BMI ≥ 30), and a group of 40 healthy normal-weight women recruited from among the general population (control sample). Both obese and control participants provided written informed consent, after a full explanation of the study design was provided, which had been approved by the local ethics committee.
Women of Egyptian nationality, literate, and in the age range of 18-55 years were included.
Pregnant or lactating women, those with any major psychiatric disorder on axis I of DSM-IV, concurrent medical illnesses, uncontrolled health conditions (uncontrolled hypertension or diabetes), women using appetite suppressants, and women with a history of obesity surgery were excluded.
The patients' interviews were conducted three times per week (Saturday, Monday, Wednesday), at a rate of 2-3 patients on each study day, for a period of at least 1 h for each participant. The study was carried out over 5 months, from December to April 2012, for both groups.
Both groups were subjected to the following assessment:
- Semi structural interview, carried out in Kasr El Aini Hospital.
- All participants underwent evaluation of body weight (kg) and height (m).
- Psychometric procedures:
- Symptom Check List-90-R (SCL-90-R) (Derogatis and Savitz, 2000).
- Body Image Questionnaire (BIQ) (Shokeer, 2002).
- Rosenberg Self-Esteem Scale (RSES) (Rosenberg, 1965).
- Défense Style Questionnaire (DSQ-40) (Andrews et al., 1993).
Symptom check list-90-R (Derogatis and Savitz, 2000)
This is a self-report psychometric questionnaire. It is designed to evaluate a broad range of psychological problems and symptoms of psychopathology. It is also used to measure the progress and the outcome of psychiatric and psychological treatments and for research purposes. The SCL-90-R is normed on individuals 13 years of age and older. It consists of 90 items, and takes 12-15 min to administer, yielding nine scores along primary symptom dimensions and three scores for global distress indices.
The primary symptom dimensions are somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.
Global indices are the Global Severity Index (GSI) to measure overall psychological distress, Positive Symptom Distress Index (PSDI) to measure the intensity of symptoms, and Positive Symptom Total (PST) for number of self-reported symptoms. A high number of studies have been carried out showing the reliability, validity, and utility of the instrument (Derogatis and Savitz, 2000). It is one of the most widely used measures of psychological distress in clinical practice and research.
The Arabic version was formulated by Dr Abd El Rakib Ahmed El Behery (El Behery, 1984).
Body image questionnaire (Shokeer, 2002)
This is a scale that is based on the premise that body image as a mental picture of body at the time of rest and movement or either. It is derived from internal perception of external appearance and internal body accompanied by emotional experiences and its reflection on interactions with self and others. It is a self-rated scale comprising 26 items. Every participant answers in three grades, from totally accepting to totally not accepting, with a score from 0 to 2 for each item, normal range 8-20 for men and 10-22 for women, above which the body image is considered disturbed.
Rosenberg Self-esteem scale (Rosenberg, 1965)
The RSES is used to assess the participant's self-esteem. It reflects a global sense of self-worth. The scale comprises a 10-item inventory, five positively worded and five negatively worded questions. It contains positive as well as negative items to ensure that the participants pay attention to the statements. Participants respond as 'strongly agree' to 'strongly disagree' on this scale. The scoring for some items needs to be reversed so that in each case, the scores go from lower to higher self-esteem. The mean score of all items was used to represent the participants' score on self-esteem.
The Arabic version was formulated by Bayoumy HA (2007).
Defense style questionnaire (Andrews et al., 1993)
The DSQ is an 88-item self-reported questionnaire to assess conscious derivatives of defense mechanisms, with the aim of identifying characteristic styles, conscious or unconscious, of how individuals deal with conflict, on the basis of the idea that individuals can accurately comment on their behavior. Bond et al. (1983) then Andrews et al. (1993) revised this version to DSQ-40 to measure 20 defense mechanisms; each defense is equally represented by two items. It can yield both 20 individual defences' scores and three defense-style scores namely mature, neurotic, and immature.
There are two items for each of the 20 defences; it is a self-report measure, which can be applied easily and has been used widely to determine the levels of maturity of defences. The rating of the scale is made on a nine-point scale for all variables; the participant responds by matching his/her degree of agreement or disagreement on this nine-point scale. Score 1 indicates strongly disagree, whereas score 9 indicates strongly agree. Scoring is uncomplicated, and individual defense scores are simply the average of the two items for that defense. Defense styles' scores are simply the average of the defense scores contributing toward that style. The Arabic version was formulated by Bayoumy HA (2007).
- Statistical analysis was carried out using the statistical package for social sciences (version 14.0; SPSS Inc., Chicago, Illinois, USA) for Windows.
- Continuous variables were analyzed as mean values±SD, rates and proportions were calculated for categorical data.
- The categorical variables and differences were analyzed using χ2 (Surwillo, 1980) tests and Fisher's exact test, when appropriate.
- Differences among continuous variables with a normal distribution were analyzed using Student's t-test (Surwillo, 1980); for continuous variables without a normal distribution, we used nonparametric tests and differences were analyzed using the Mann-Whitney U-test.
- Correlations among BMI and other parameters were determined using Pearson's test.
- All tests were two tailed, P-values less than 0.05 were considered significant and those less than 0.001 were considered highly significant.
| Results|| |
There were no statistically significant differences between the group of obese women and the control group in age, educational level, and history of medical or psychiatric illness, but there were significant differences in marital status and occupation as most obese women were married and housewives whereas most of the women in the control group were working and single. There were also significant differences between the two groups in a family history of obesity, being higher in the obese group [Table 1].
Symptom check list-90-R
[Table 2] shows that there are significant differences between the two groups as in the obese group, somatization, hostility, paranoid ideation, and PSDI are much higher in the obese group than the control group.
|Table 2: Comparison of the mean and SD of the total scores of the symptom check List-90-R between the two groups|
Click here to view
Body image questionnaire
[Table 3] shows that disturbed body image was significantly high in the obese group.
|Table 3: Differences between two groups in number of disturbed body image|
Click here to view
[Table 4] shows that there is no statistically significant difference between the two groups in RSES.
There was no statistically significant difference between the two groups in defense styles. However, there were statistically significant differences between the two groups in individual defense mechanisms as displacement was used more by the obese group whereas reaction formation was used more by the control group [Table 5].
|Table 4: Comparison of the mean total scores of the Rosenberg Self-Esteem Scale between the two groups|
Click here to view
|Table 5: Comparison of the mean defense styles between the two groups using the defense style questionnaire|
Click here to view
[Table 6] shows that there is was statistically significant negative correlation between BMI and somatization, BMI and phobia, and BMI and GSI in the obese group whereas in the control group, there was a statistically borderline significant positive correlation between BMI and depression and BMI and interpersonal sensitivity.
|Table 6: Correlation between results of Symptom Check List-90-R and body mass index in the two groups|
Click here to view
[Table 7] shows that there is a statistically significant negative correlation between BMI and mature defense styles in the obese group whereas in the control group, there is a statistically significant positive correlation between BMI and immature defense styles.
|Table 7: Correlation between the results of defense style Questionnaire-40 and body mass index in the two groups|
Click here to view
| Discussion|| |
There were significant differences in marital status and occupation as most of the obese women were married and housewives, whereas most of the women in the control group were working and single. This is in agreement with Simon (2002), who found that obese individuals were more frequently married, or living in a partnership, and less frequently divorced. This is also in agreement with the study by Sarlio-Lδhteenkorva and Lahelma (1999), who found that the relation between BMI and unemployment has also been shown to exist in obese women. It is possible that unemployed individuals are more vulnerable to obesity than working ones as staying at home may lead to lack of physical activity and they may be more susceptible to various stressors.
In terms of a family history of obesity 67.5% of the women in the obese group had obese relatives and 40% of the women in the control group had obese relatives (P = 0.014). This is in agreement with Farooqi and O'Rahilly (2007), who found that heritable factors appear to be responsible for 45-75% of the individual variations in BMI and the potential impact of genetic determinants of metabolic rate on the predisposition to obesity must be considered. Studies of families and twins showed that a significant component of obesity is related to genetic heritability 30-70%. For example, twins share the same fat (adiposity) level as their biological parents (Hill et al., 2000).
We found significant differences between the obese group and the control group in somatization, hostility, paranoid ideation, and PSDI subscales of the SCL-90-R. For somatization, there was a significant difference between the two groups. It was manifested more in the obese group (P = 0.027). These findings are in agreement with Petroni et al. (2007), who found that somatization and weight cycling were the only factors capable of affecting the mental health of obese individuals. These results are also in agreement with Rosik (2005), who found that behavioral changes are present in nearly half of all obese individuals, and somatization was also the main psychiatric disorder found in those individuals.
In terms of hostility, there was a significant difference between the two groups. It was manifested more in the obese group (P = 0.007). These findings are in agreement with Everson et al. (1997), who found that individuals with higher weight had higher hostility scores. The few prospective studies available on hostility have reported that hostility was found to be higher among obese men, but not among women. Rδikkönen et al. (1999) found that among middle-aged women, trait anger was associated with weight gain, but not hostility. Ravaja et al. (1996) concluded that anger-hostility in particular is related to metabolic syndrome, which is especially related to central obesity. However, hostility could be a consequence of discrimination against obese individuals.
For paranoid ideation, there was a significant difference between the two groups. It was manifested more in the obese group (P = 0.031). These findings are in agreement with Puhl and Brownell (2006), who found that stigmatization that often accompanies excess adiposity may cause a shift in women's personality toward being more paranoid, antisocial, or avoidant, and this will lead to a subsequent increase in the rate of obesity because of a decrease in activities outside the home.
The PSDI, which reflects the intensity of the symptoms, was more pronounced in the obese group (P = 0.038). These findings are in agreement with Fitzgibbon et al. (1993), who found that obese participants seeking treatment reported higher levels of psychological distress compared with those not seeking treatment.
A total of 52.5% of the women in the obese group had a disturbed body image whereas 2.5% of the women in the control group had a disturbed body image. There was a highly significant difference between the two groups (P = 0.001). Wott and Carels (2010) showed that acceptance from friends and family was crucial to the development and maintenance of a positive body image. Craig et al. (2007) cited that women are under more pressure to be thin and experience greater body dissatisfaction because of sociocultural pressures, which encourage body dissatisfaction and a drive for thinness among women. These factors may trigger or maintain obesity through mechanisms such as emotional eating, which has fueled an increase in the prevalence of obesity worldwide (Chen and Brown, 2005).
The scores on the RSES were equal in the two groups. There was no significant difference between the two groups (P = 1.0). These findings are in agreement with Simon (2002), who found that self-esteem is normal in obese individuals of low socioeconomic status. In contrast, Wardle et al. (2002) reported that the link between body weight and self-esteem was significantly different between the obese and the healthy-weight group.
Global assessment of the defense style showed that there was no statistically significant difference between the two groups, P was 0.68 for mature style, P was 0.78 for neurotic style, and P was 0.43 for immature style. These findings are in agreement with Cramer (2002), who found in his research that there was no significant difference between obese and normal-weight individuals in defense styles.
In terms of neurotic defense mechanisms (reaction formation) was present significantly in the control group (P = 0.003). The concept of reaction formation involves converting a socially unacceptable impulse into its opposite. To apply this notion for protection of self-esteem, one may propose that individuals may have some unacceptable traits; thus, they behave in a way that would show them to have the opposite trait as acknowledging these impulses or feelings could damage self-esteem (Cramer, 1998a).
Among the immature defense mechanisms, displacement was present significantly in the obese group (P = 0.028). This is in agreement with Horowitz et al. (1993), who found that obese individuals excessively use immature defenses, such as rationalization, devaluation, displacement, and affective isolation. It might be that when faced with stressful events, the negative emotions of obese individuals might reduce their ability to manage emotional states and affects effectively. In this framework, overeating may play the role of a homeostatic mechanism used to regulate mood to avoid negative affect or to cope with adverse life events.
On studying significant correlations between the degree of obesity and changes in the psychopathological profile of the obese participants, we found a positive correlation between BMI and the somatization subscale of the SCL-90-R. This is in agreement with Petroni et al. (2007) and Rosik et al. (2005), who found that somatization is present in nearly half of all morbidly obese patients. However, Hach et al. (2007) have shown that the incidence of psychopathological disturbances among obese individuals is the same as that observed among nonobese individuals.
For the phobia subscale, there was a statistically significant positive correlation in the obese group between BMI and phobia subscale; this is agreement with Herpertz et al. (2006), who found that specific phobia seems to be correlated with obesity. Mather et al. (2008) found that obese women are more likely to report specific phobia and social phobia. Scott et al. (2008) found an association between obesity, agoraphobia, post-traumatic stress disorder, and specific phobia.
Carr and Friedman (2005) and Puhl and Brownell (2006) found that obesity may be associated with anxiety disorders, through social discrimination against obese individuals. Puhl and Heuer (2010) found that low self-esteem is another factor that makes obese individuals anxious as they consider themselves inadequate, and the environment is hostile, which in turn, leads to the development of psychological distress, social avoidance and anxiety.
It is possible that the way others view obese individuals may become the way obese individuals view themselves. They blame themselves for being fat and try hard to become thinner (which is usually done without planning and leads to failure); thus, preoccupation with weight control leads to excessive worry and anxiety and more eating.
For the GSI subscale, there was a statistically borderline significant positive correlation in the obese group between BMI and the GSI subscale, which indicated that obese women are more prone to psychological distresses than normal-weight women.
This result is in agreement with a previous work by Grover et al. (2003), who found that a high propensity for psychological distress in obese women, compared with normal-weight women, and this may be because women have increased tendency to internalize the stigma related to obesity.
In the control group, there was a statistically borderline significant positive correlation between BMI and depression. This is in agreement with Johnston et al. (2004), who found that the increasing prevalence of affective disorders is because of increasing BMI. They found that the lifetime prevalence of depression is 23.7% among women and 6.3% among men.
Barry et al. (2002) found that there is an association between obesity and major depression, particularly among women.
For the interpersonal sensitivity subscale, there was a statistically borderline significant positive correlation between BMI and interpersonal sensitivity, which reflects the propensity of normal-weight individuals to experience interpersonal sensitivity if they are gaining weight.
Interpersonal sensitivity has a broad construct that can include judging other's emotions from nonverbal cues (Mayer et al., 2003).
Horchner et al. (2002) reported that obese women showed avoidance, wait and see, and passive response patterns as coping behavior. Their relationships were perceived as being relatively unreliable and not very intimate. It has been hypothesized that high scores on the paranoid subscale coincided with the difficulties in expressing aggressive feelings and interpersonal sensitivity (Tuthill et al., 2006).
Despite the highly significant relationship between body image dissatisfaction and obesity, there was no statistically significant correlation between BMI and BIQ in the obese group (P > 0.05) [Table 8]. These results were in agreement with results found in another research by Bearman et al. (2006), who reported that BMI was not found to predict body image dissatisfaction.
|Table 8: Correlation between results of body mass index and both of Body Image Questionnaire and Rosenberg Self-Esteem Scale in the two groups|
Click here to view
Heinberg et al. (2002) argued that some moderate level of concern in terms of body image may adaptively motivate weight loss and maintenance in the face of improved body satisfaction. Perhaps continued weight vigilance and some anxiety in terms of becoming fat again may promote healthy eating and exercise behaviors to prevent regaining of weight.
There was no significant correlation between BMI and self-esteem (P > 0.05), and this is in agreement with Palmer (2003), who found that BMI was not a significant predicting factor in self-esteem.
Lowery et al. (2005) suggested that obese individuals might have low self-esteem, but the data have been inconsistent and reviewers disagree on the overall trend.
There was a statistically significant negative correlation between BMI and mature defense style in the obese group (P < 0.05). This is in agreement with Cramer (2002), who found that increase in BMI is because of the lack of use of mature defense styles.
Mature defenses are commonly found among emotionally healthy adults and are considered mature. The use of these defenses enhances pleasure and feelings of control; it helps integrate conflicting emotions and thoughts.
In the control group, there was a statistically significant positive correlation, between BMI and immature defense style, it increased with elevated BMI in the control group; these findings were in agreement with the result of our study, which showed that obese individuals tend to use an immature (displacement) defense mechanism. This was also in agreement with Cramer (2002), who found that obese individuals excessively use immature defenses overall.
Ellsworth et al. (1986) reported that there is an improvement in defensive functioning toward a more mature style in obese individuals when they lose weight.
- In terms of marital status, we could not match both groups as most of the obese women were married, whereas most of the women in the control group were single.
- In terms of occupational history, we could not match both groups as most of the women in the obese group were not working, whereas the women in the control group were employed.
The study population was predominantly composed of low and middle social class women, which may limit the generalizability of these findings to high socioeconomic status.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
|1.||American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders: DSM IV. 4th ed. Washington: American Psychiatric Association. |
|2.||Andrews G, Page AC, Neilson M (1993). Sending your teenagers away: controlled stress decreases neurotic vulnerability. Arch Gen Psychiatry 50:585-589. |
|3.||Barry D, Grilo CM, Masheb RM (2002). Gender differences in patients with binge eating disorder. Int J Eat Disord 31:63-70. |
|4.||Bayoumy HA (2007). A comparative study of dynamic dimensions in Egyptian patients with anxiety and depressive disorders. |
|5.||Bearman SK, Presnell K, Martinez E, Stice E (2006). The skinny on body dissatisfaction: a longitudinal study on adolescent girls and boys. J Youth Adolesc 35:229-241. |
|6.||Bond MP, Gardner ST, Christian J and Sigal JJ (1983). Empirical study of self-rated defense styles. Archives of General Psychiatry, 40:333-338. |
|7.||Carpenter K, Hasin D, Allison D, Faith M (2000). Relationship between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study. Am J Public Health 90:251-257. |
|8.||Carr D, Friedman MA (2005). Is obesity stigmatizing? Body weight perceived discrimination and psychological well-being in the United States. J Health Soc Behav 46:244-259. |
|9.||Chen EY, Brown M (2005). Obesity stigma in sexual relationships. Obes Res 13:1393-1397. |
|10.||Craig AB, Martz DM, Bazzini DG (2007). Peer pressure to 'Fat talk': does audience type influence how women portray their body image? Eat Behav 8:244-250. |
|11.||Cramer P (1998a). Coping and defense mechanisms: what's the difference? J Pers 66:895-918. |
|12.||Cramer P (1998b). Defensiveness and defense mechanisms. J Pers 66:879-893. |
|13.||Cramer P (2002). Defense mechanisms, behavior and affect in young adulthood. J Pers 70:103−126. |
|14.||Derogatis LR, Savitz KLME Maruish (editor) (2000). The SCL-90-R and the Brief Symptom Inventory (BSI) in primary care. In: . Handbook of psychological assessment in primary care settings. Mahwah, NJ: Lawrence Erlbaum Associates. 236:297-334. |
|15.||Devlin MJ, Yanowski SZ, Wilson GT (2000). Obesity: what mental health professionals need to know? Am J Psychiatry 157:854-886. |
|16.||El Behery A (1984). Symptom Check List 90 Revised (Arabic version), Series of Egyptians Psychological tests. El Nahda Egyptian Publications. |
|17.||Ellsworth GA, Strain GW, Strain JJ, Vaillant GE, Knittle J, Zumoff B (1986). Defense maturity ratings and sustained weight loss in obesity. Psychosomatics 27:772-781. |
|18.||Everson SA, Kauhanen J, Kaplan GA, Goldberg DE (1997). Hostility and increased risk of mortality and acute myocardial infarction: the mediating role of behavioral risk factors. Am J Epidemiol 146:142-152. |
|19.||Farooqi IS, O'Rahilly SO (2007). Genetic factors in human obesity. Obes Rev 8:37-40. |
|20.||Fitzgibbon ML, Stolley MR, Kirschenbaum DS (1993). Obese people who seek treatment have different characteristics than those who do not seek treatment. Health Psychol 12:342-345. |
|21.||Grover VP, Keel PK, Mitchell JP (2003). Gender differences in implicit weight identity. Int J Eat Disord 34:125-135. |
|22.||Hach I, Ruhl UE, Klose M, Klotsche J, Kirsh W, Jacob F (2007). Obesity and the risk for mental disorders in a representative German adult sample. Eur J Public Health 17:297-305. |
|23.||Heinberg LJ, Thompson JK, Matzon JL. RH Striegel-Moore, L Smolak, (editors) (2002). Body image dissatisfaction as a motivation for health lifestyle change: is some distress beneficial? In: Eating disorders: innovative directions in research and practice. Washington, DC: American Psychological Association. 215-232. |
|24.||Herpertz S, Burgmer R, Stang A, de ZM, Wolf AM (2006). Prevalence of mental disorders in normal-weight and obese individuals with and without weight loss treatment in a German urban population. J Psychosom Res 61:95-103. |
|25.||Hill JO, Wyatt HR, Melanson EL (2000). Genetic and environmental contributions to obesity. Med Clin North Am 84:333-346. |
|26.||Horchner R, Tuinebreijer WE, Kelder H, van UE (2002). Coping behavior and loneliness among obese patients. Obes Surg 12:864-868. |
|27.||Horowitz LM, Rosenberg SE, Bartholomew K (1993). Interpersonal problems, attachment styles and outcome in brief dynamic psychotherapy. J Consult Clin Psychol 61:549-560. |
|28.||Johnston E, Johnson S, McLeod P, Johnston M (2004). The relation of body mass index to depressive symptoms. Can J Public Health 95:175-183. |
|29.||Kim JY, Oh DJ, Yoon TY, Choi JM, Choe BK (2007). The impacts of obesity on psychological well-being: a cross-sectional study about depressive mood and quality of life. J Prev Med Pub Health 40:191-195. |
|30.||Lowery SE, Kurpius SER, Befort C, Blanks EH, Sollenberger S, Nicpon MF, Huser L (2005). Body image, self-esteem and health related behaviours among male and female first year college students. J Coll Student Dev 46:612-623. |
|31.||Mather AA, Cox BJ, Enns MW, Sareen J (2008). Association between body weight and personality disorders in a nationally representative sample. Psychosom Med 70:1012-1019. |
|32.||Mayer JD, Salovey P, Caruso DR, Sitarenios G (2003). Measuring emotional intelligence with the MSCEIT V2.0. Emotion 3:7-105. |
|33.||National Institutes of Health (2010). How are overweight and obesity diagnosed? National Institutes of Health. http://www.nhlbi.nih.gov/health/health-topics/topics/obe/diagnosis.html |
|34.||Palmer CJ (2003). Body mass index, self-esteem, and suicide risk in clinically depressed African American and White American females. J Black Psychol 29:408-428. |
|35.||Petroni ML, Villanova N, Avagnina S, Fusco MA, Fatati G, Compare A, Marchesini G (2007). Psychological distress in morbid obesity in relation to weight history. Obes Surg 17:391-399. |
|36.||Puhl RM, Brownell KD (2006). Psychosocial origins of obesity stigma: toward changing a powerful and pervasive bias. Obes Rev 4:213-227. |
|37.||Puhl RM, Heuer CA (2010). Obesity stigma: important considerations for public health. Am J Public Health 100:1019-1028. |
|38.||Räikkönen K, Matthews KA, Kuller LH, Reiber C, Bunker CH (1999). Anger, hostility, and visceral adipose tissue in healthy postmenopausal women. Metab Clin Exp 48:1146-1151. |
|39.||Ravaja N, Keltikangas-Järvinen L, Keskivaara P (1996). Type A factors as predictors of changes in the metabolic syndrome precursors in adolescents and young adults - a 3-year follow-up study. Health Psychol 15:18-29. |
|40.||Roberts RE, Deleger S, Strawbridge WJ, Kaplan GA (2003). Prospective association between obesity and depression: evidence from the Alameda County study. Int J Obes Relat Metab Disord 27:514-521. |
|41.||Rosenberg M (1965). Society and the adolescent self-image. Princeton: Princeton University Press. |
|42.||Rosik CH (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. |
|43.||Sarlio-Lähteenkorva S, Lahelma E (1999). The association of body mass index with social and economic disadvantage in women and men. Int J Epidemiol 28:445-449. |
|44.||Schwartz MB, Chambliss HO, Brownell KD, Blair SN (2003). Weight bias among health professionals specializing in obesity. Obes Res 11:1033-1039. |
|45.||Scott KM, Bruffaerts R, Simon GE, Alonso J (2008). Obesity and mental disorders in the general population: results from the world mental health surveys. Int J Obes (London) 32:192−200. |
|46.||Shokeer Z (2002). Body Image Questionnaire, Series of Egyptians Psychological tests. El Nahda Egyptian Publications. |
|47.||Simon GE, Von Korff M, Saunders K, Miglioretti DL (2006). Association between obesity and psychiatric disorders in the US adult population. Arch Gen Psychiatry 63:824−830. |
|48.||Simon RW (2002). Revisiting the relationships among gender, marital status and mental health. AJS 107:1065-1096. |
|49.||Surwillo WW (1980). Experimental design in psychiatry. New York: Grune & Stratton. |
|50.||Teixeira PJ, Going SB, Houtkooper LB, Cussler EC (2004). Pretreatment predictors of attrition and successful weight management in women. Int J Obes Relat Metab Disord 28:1124-1133. |
|51.||Tuthill A, Slawik H, O'Rahilly S, Finer N (2006). Psychiatric co-morbidities in patients attending specialist obesity services in the UK. QJM 99:317-325. |
|52.||Wardle J, Waller J, Jarvis M (2002). Sex differences in the association of socioeconomic status with obesity. Am J Public Health 92:1299-1304. |
|53.||Wott CB, Carels RA (2010). Overt weight stigma, psychological distress, and weight loss treatment outcomes. J Health Psychol 15:608-614. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]