What is going to happen if the dream of being slim and loved is fullfilled?

Who is loved?

Top- Obesity - Top

From the

"Pleasant Fat Person"

to Stigma and to the

"Post-Operation Slim Person"

Literature Review

Factors causing obesity

Aspects of Developmental Psychology

Aspects of Social Psychology

Psychological Results of loosing weight by gastric surgery

Questions and Research

Psychological Measures

References

Elisabeth Ardelt, Psychologisches Institut der Universität Salzburg, Hellbrunnerstraße 34, 5020 Salzburg, Austria

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1. Literature Review

If one wants to report on psychological aspects of obesity, one must make two things clear.

Firstly in clinical Psychology, up to the 1980s, too many psychological models (not only in the field of obesity research) began from a too generalized starting point.

Nowadays, the trend is moving away from the belief in homogeneity of certain groups and from oversimplified psychosomatic causal models (oral replacement satisfaction for frustrations of whatever type or - in a different field: Mother is sitting on your chest = asthma).

Secondly a socialpsychological approach: between the 1970s and the 1980s, a dramatic change in the image of fat people took place through socalled "pointing-finger campaigns".

Current literature can be summarized as follows:

1 Factors causing obesity

1.1. 1 Personality factors

Research on the personality structure of obese people has up to now been neither clear (Pudel, 1991) nor has it allowed the making of any clear statements about cause and effect of obesity.

As regards personality, the following postulations were agreed upon: dependency, fear and increased scores on depression (e.g. Frost et al. 1981, Ross 1994). However, completely contradictory findings have also been made (e.g. Pietro et al. 1992), e.g. lower scores in depression in obese men (Hafner 1987). I will return to the point that there is certainly a difference in coping between the sexes (see Connor-Greene 1988).

1.1. 2 Aspects of Developmental Psychology

Psychoanalysis blames extreme deprivation in childhood as well as extreme "spoiling" for "oral disturbances". That is to say, obese people find it very difficult to find a happy medium (Battagay, 1992).

With regard to family constellation (position in the family, etc.) we only found one striking detail, which is that obesity occures significantly more often in children of single mothers. A second study substantiates this result, regarding a noticeably frequent loss of the father ( Wolf, 1993).

Herman & Polivy (1987) showed that obese siblings tend to be made the scapegoats within the family. Compared to a control group the relationships between these children and other members of the family can much rarer be considered to be open, warm and satisfactory (see also: Pachinger 1997).

In contrast to these results are those of Erzigkeit (1978) which found "being the baby of the family" and "spoiling" in 30% of a population of 300 obese people. But, altogether being obese seems to entail extremes, namely those of "too much" or "too little". If one considers a normal childhood, contacts with obese people seem to be normal rather than exceptional. Prevalence for this disorder is high, inheritance, too. The latter explains 20 to 40% of the mean deviation. For that reason we will have to (by using multidimensional models) search for further favorable factors or - following new trends - factors, which will help us not to develop an eating disorder.

A study (Hammar, 1977 see Pachinger 1997) was able to show, that in childhood obese people are treated or comforted significantly more often by the giving of candy. Pudel & Maus (1990) included other external regulations on top of these other childhood conditioning-processes, such as: mealtime habits ("whatever is put on the table must be eaten up"), latent pressure ("if you eat up, your mummy will be happy; the sun will shine tomorrow" - the unreliability of meteorological predictions makes it almost impossible to disprove this theory) or imitation ("your brother has eaten up, too...", etc.). All in all, this behavioral theory is based on the assumption that external regulation of food intake must lead to the deconditioning of the ability to react to internal states.

External factors are of great importance, too (Pudel, 1988): Life-events, such as marriage, pregnancy (see Bradley 1992) or leaving one’s job for good tend to reduce even further the amount of remaining self-control.

1.1. 3 Aspects of Social Psychology

Looking at the obvious behavioral side, we have all got to know obese people who seem to feel insecure, and some who seem to feel secure. In particular, research in the last few years has been depressing, due to the already mentioned "pointing-finger effect" of the nuitrition-campaigns. Insecurity, oversensitivity and isolation are predominant. Sometimes one is confronted with a pseudosecure appearance, supported by phantasies of being the greatest (best, most intelligent, etc.), including "overcontrol of emotions" and "indirect expression of hostility", which will inevitably be destroyed over and over again and which will start a new vicious circle (Klotter, 1990).

Monello and Mayer (1968 in Diedrichsen 1991, see also Crandall 1994) found similarities between obese people and other disadvantaged (discriminated against) minorities. The change of the picture from the "happy fat person", which was still dominant in a German opinion poll in 1970 (Ernährungsbericht, 1971) has changed to a mainly negative heterostereotype of fat people having a "weak character" and being "stupid" and "ugly" (Bodenstedt et al. 1980, Wadden & Stunkard 1985, Machacek 1987, de Jong 1993). Women suffer most from these prejudices. But men, even after successful surgery, are more passive than women. The relatively low interest in sex is comparable in both sexes before and after surgery (Pudel & Maus 1990).

It is important to mention the necessitiy of a distinction between juvenile and adult obesity and that the onset of obesity has to be pinpointed. With children and adolescents psychosocial factors are of greater impotance. To oversimplify a little, children suffer more extremely and are also more often discriminated against (Gortmaker 1993, Hill & Silver 1995).

A study by Klotter (1990) found, that children, who were shown pictures of other - handicapped or obese children, rated the obese children as less likeable than the handicapped ones.

This public image and view of oneself affects the social network of the person concerned. Social networks of obese people are small in comparison to those of people of normal weight. They name less people who they feel "liked" by, get less praise and can name less people who support them practically and who would lend them money. Obese women claim to have significantly less social contacts with men than with women Relationships between partners are very close, often symbiotic. (see Sommerhuber, 1994; Radleberger 1997).

1. 2 Psychological Results of loosing weight by gastric surgery

The results of losing weight, which are summarized in literature, are not unitary, either. Dramatic positive personality changes (see Stunkard et al. 1986, Larsen & Torgerson 1989) towards stability and extraversion (to aggression) are reported on, also changes in mood, reduction of feelings of helplessness, etc. (Castelnuovo & Schiebel 1976, Loewig 1993). Some people of Loewig´s study and a study by Weiss (1994, see also Baumeister et al. 1989) points out the danger of significantly negative psychopathological postoperative changes in those patients who only underwent surgery for psychosocial reasons, as opposed to those patients, who had the operation done on medical grounds.

Bull & Legorreta (1991) also report on negative long-term effects of weight reduction: In their study unimproved psychological problems could still be found 30 months after the operation in half of the patients. Other studies talk about an "in between-high" after the operation, followed by a return to the preoperative psychological state. These results correspond with other studies, which lead to "indication lists" (Misovich, 1983 in: Radlberger 1997) which can be summarized by the fact that unproblematic obese people are more suitable for having the operation.

These discrepancies are not surprising. Half your life self-confidence is whittled-away or it never came to exist in the first place. The dream of having an adored, highly rated or at least an acceptable body is dreamt...and suddenly the patient realizes that there are ways to make the dream come true. But this begs the question, WHO and What is actually highly rated, adored, accepted? At best, the external change can assist the person to change his or her behavior and let them feel that looks are important but that his or her "inner values" are also appreciated. At worst, the development of a healthy self-confidence cannot be caught up, new vicious circles begin. Now the patient is center of attention in a positive sense, but he or she is very alone.

1. 3 Information about surgery

Statistics say that only roughly 10% of the obese patients get information about the operation from their physician, the rest from friends or newspapers. Our data confirms these results. Results of decision theory suggest a primacy-effect, meaning that first information is retained the longest and that it is used in the actual decision making process. For this reason we included the latter in our research.

On grounds of the literature review (the mentioned studies are only examples of the current knowledge in this field) we considered screening useful in order to enable differentiation.

2. Questions and Research

Description of a group of obese people, who are going to be operated on, in order to find types which will enable us to predict postoperative psychological condition.

We would like to differentiate these factors with regard to quantity and quality of the patient’s social network (SONET), the personality structure (Gießen), the coping strategy, the mental condition (Condition Scale) and the decision structure (Questionnaire).

Theories that guide research: The group of obese people can be divided into at least four types, which possibly consist of further distinguishable subgroups

1. "On the whole, everything is o.k., my body is not o.k.":

Psychologically healthy obese people who wish for a weight which does not threaten their health and who want an attractive body suitable for having a partner, a job and friends. The latter wish is understandable, because certain looks and weight standards are dictated by society.

2. "Nothing is o.k., my body isn’t either" (as a reaction, sometimes also as a protection to/against nothing being o.k.)

Psychologically severly disturbed people, who are obese due to a traumatic event, e.g. abuse, fear of closeness and sexuality - obesity as a defence mechanism or e.g.

reaction to a loss, whereby fear and tension are worked off by eating).

3. " A lot is not o.k. and therefore / neither is my body"

(sometimes vice versa: chicken or the egg problem):

Psychologically disturbed people, who are (genetically) obese due to these disturbances or in addition to them. Obesity can worsen these disturbances .

In this regard there are two options which don’t contradict each other and which can also both apply:

Inability to stick to borders, addictive character (or restricted cognitive and behavioral repertoires, meaning the difficulty of giving up bad habits, including eating as a treat etc. ): E.g. "Eat up so that you’ll be as big and strong as your dad" (learning by reinforcement). And/or

Errors in perception, meaning internal emotional states can only be differenciated with great difficulty, almost all needs are interpreted as hunger (Learning by discriminating).

4. " My body is not o.k., therefore some things are difficult"

People with minor psychological problems: e.g. low social skills, no appropriate professional education and training or professional status, unsatisfactory choice of partner, etc. clearly as a result of being obese.

3. Psychological Measures

Following action research we want to add our scientific activity possibilities of advice and therapy and of individually adapted preparation and aftercare for our subjects.

Type 1 - None

Type 2 and 3 - Psychotherapy

Typ 4 - Attending counselling, short term therapy (e.g. therapy manuals in groups, self-assertion training, information about professional possibilities, etc.)

 

Literature:

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Bodenstedt, A. et al. (1980). Der Druck auf die Dicken. Aus dem Ernährungsbericht der Bundesregierung. Bild der wissenschaft 8, 88- 95.

Bradley, P. (1992). Pregnancy as a cause of obesity and its treatment. International Journal of Obesity, 16, 935-936.

Bull, R. & Legorreta, G. (1991). Outcome of gastric Surgery for morbid obesity. Weigth change and personality traits. Psychotherapy of Psychosomatics, 56, 146-156.

Castelnuovo, P. & Schiebel, D. (1976). Studies of Superobesity. American Journal of Psychiatry 133, 26-33.

Connor-Greene, P. Gender differences in body weight perception and weight loss strategies of college students. Woman health, 14, 27-42.

Crandall, C. (1994). Prejudice against fat people. Journal of Personality and Social Psychology 66, 882-895.

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