of distress tolerance were more likely to undergo bariatric surgery (p
OBES SURG DOI 10.1007/s11695-015-1926-x
ORIGINAL CONTRIBUTIONS
Distress Tolerance and Psychological Comorbidity in Patients Seeking Bariatric Surgery Afton M. Koball 1 & Susan M. Himes 2 & Leslie Sim 3 & Matthew M. Clark 3 & Maria L. Collazo-Clavell 4 & Manpreet Mundi 4 & Todd Kellogg 5 & Karen Graszer 3 & Karen B. Grothe 3
# Springer Science+Business Media New York 2015
Abstract Introduction/Purpose Distress intolerance is characterized by a low threshold for negative emotional experiences and lack of emotion regulation and has been shown to predict various health outcomes. As such, the primary aim of this study was to determine the association between distress tolerance and psychological variables (eating behaviors, mood, substance use, trauma history), completion of bariatric surgery, and post-bariatric surgery weight loss outcomes and follow up with a provider. Materials and Methods Two hundred forty-eight patients (75 % female, 89 % Caucasian) underwent a multidisciplinary evaluation for bariatric surgery and were assessed for psychiatric disorders via semi-structured clinical interview and psychometric questionnaires. Results Low distress tolerance was associated with symptoms of depression (p≤0.001), anxiety (p≤0.001), disordered eating behaviors (p≤0.001), substance abuse (p≤0.001), a history of being the victim of childhood sexual abuse (p≤0.001),
and with high BMI (p9), disordered eating behaviors, and a history of childhood sexual abuse reported greater difficulty tolerating negative emotional states compared with patients denying current psychopathology, substance abuse, or history of childhood abuse (see Table 2). In terms of eating self-efficacy, patients with higher overall scores on the DTS endorsed higher (better) ability to resist eating when confronted with negative emotions (p≤0.01), social pressures (p≤0.001), physical discomfort (p≤0.01), and positive activities (p≤0.001). Baseline (pre-bariatric surgery) body mass index was negatively correlated with distress tolerance (p≤0.05). Bariatric Surgery Completion and Postsurgery Outcomes Ninety patients underwent bariatric surgery. Patients endorsing higher levels of distress tolerance were more likely to undergo bariatric surgery (4.04±0.8 vs. 3.73±0.9, χ2 (6, N= 248)=7.29, p9 (N=25) BDI-II>20 (N=41)
3.6±0.9 3.6±0.9 3.6+0.9 3.6±1.0 3.3±0.9 3.2±0.9 3.1±1.0
3.5±1.2 3.6±1.1 3.8+0.8 3.6±1.2 3.2±1.0 3.1±1.1 3.0±1.2
3.5±1.1 3.6±1.1 3.2+1.1 3.7±1.0 3.4±1.0 3.4±1.0 3.2±.1.1
3.7±1.2 3.7±1.1 3.6+1.3 3.6±1.2 3.2±1.3 3.1±1.1 3.0±1.2
3.6±0.9 3.6±1.0 3.7+1.4 3.8±0.9 3.3±0.9 3.2±1.0 3.2±1.0
0.001 ≤0.001 0.001 ≤0.001 0.01 ≤0.001 ≤0.001
All data are mean±standard deviation. P values given are comparing overall DTS score for patients with and without psychopathology/history of sexual abuse and variables of interest. DTS distress tolerance scale, BDI-II beck depression inventory-11, GAD-7 generalized anxiety disorder scale-7, CTQ childhood trauma questionnaire
OBES SURG
prior to moving forward with surgery; some patients may not agree with these recommendations and chose not to seek counseling or bariatric surgery at our facility. Additionally, perhaps patients were advised not to have bariatric surgery by the multidisciplinary team due to psychological or medical contraindications. It also may have been that patients who felt greater ability to withstand stressors in their lives felt most prepared to undergo surgery, and did so, while those who were not able to tolerate stressors put off or decided against surgery. Exploration of why these patients do not undergo surgery is warranted in future research. It is perhaps not surprising that distress tolerance was not associated with postoperative weight loss outcomes, especially when considering that patients with higher ability to tolerate distress were the patients most likely to undergo bariatric surgery (ceiling effect). An additional explanation for the lack of association between distress tolerance and weight loss outcomes is the duration of the follow-up weights only being 2 years post-bariatric surgery. Some research has suggested that challenges post-bariatric surgery are more likely to occur farther out from surgery. For example, in a study of 152 postbariatric surgery patients, 11 patients were psychiatrically hospitalized after having bariatric surgery, on average, between 21 and 38 months after having surgery [36]. In a clinical chart review of 28 post-bariatric surgery patients who sought treatment for alcohol use disorders, the patients began problem drinking 17 months after having bariatric surgery but did not meet criteria for an alcohol use disorder until 37 months postbariatric surgery [39]. Finally, patients who sought treatment for weight regain after having bariatric surgery participated in the intervention, on average, 4 years post-bariatric surgery [41]. Therefore longer-term follow-up may be needed to find an association between distress tolerance and outcomes from bariatric surgery. Furthermore, while this study suggested that distress tolerance was not related to follow up with a provider at 6, 12, or 24 months post-bariatric surgery, adherence is an important determinant of weight loss success [42], and further examination of this construct is worthwhile. There are limitations to the current study that warrant discussion. Results are based on correlational data that is retrospective and cannot infer directional causality. In fact, one important consideration is whether distress tolerance or psychopathology came first for patients; this may represent a Bchicken or egg^ phenomenon. Diagnostic information was not collected with a structured clinical interview, which would better control for assessment standardization; there may have been some variability or error in diagnostic assessment. Finally, the relative short-term post-surgery follow-up is a limitation; follow-up >2 years post-surgery may shed greater light into the impact of distress tolerance on weight loss or weight regain post-bariatric surgery.
Conclusion Results from this study highlight cross-sectional relationships between distress tolerance, psychological concerns, and the ability to successfully undergo bariatric surgery. Perhaps interventions aimed at increasing distress tolerance (e.g., dialectical behavioral therapy and/or acceptance and commitment therapy) or building resilience may prove beneficial to patients who seek to undergo bariatric surgery, or distress tolerance can be a variable to help predict surgical yield among patients inquiring about bariatric surgery, although future research is needed. Compliance with Ethical Standards BAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.^ Conflict of Interest The authors declare that they have no competing interests. Informed Consent Informed consent was obtained from all individual participants included in the study.
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