Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial comment
Comment On: Validity of Minnesota multiphasic personality inventory-2restructured form (MMPI-2-RF) scores as a function of gender, ethnicity, and age of bariatric surgery candidates Preoperative bariatric surgery assessments can serve several valuable functions for patients and their associated surgical programs. One primary goal is the identification of clinical issues that may benefit from additional attention or structured intervention perioperatively in an effort to maximize the chances of patients’ long-term success after surgery. To advance this aim, bariatric surgery specialists are working to determine: 1) the most relevant preoperative characteristics associated with positive and/or negative outcome, 2) efficient methods of identifying patients with these characteristics, and 3) effective ways of creating change that is associated with improved patient outcome. Behavioral health specialists have actively participated in this investigative process for many years. They have conducted descriptive, cross-sectional, longitudinal, and retrospective studies on the psychological features of bariatric surgery patients and have explored the use of psychological variables in predicting postsurgical outcomes. Although the descriptive efforts have been quite beneficial in clarifying the cognitive, behavioral, social, and emotional characteristics of bariatric surgery patients, the predictive efforts have proved much more challenging. One of the most common psychological assessment instruments that has been used within the bariatric surgery population for both descriptive and predictive purposes is the Minnesota Multiphasic Personality Inventory (MMPI, MMPI-2, MMPI-2-RF) [1–6]. In fact, Bauchowitz et al. [7] found that nearly 30% of bariatric surgery programs that included standardized psychological testing preoperatively included a personality inventory, the most common of which was the MMPI. Fabricatore et al. [8] surveyed 194 behavioral health providers involved in screening candidates for bariatric surgery and found that nearly 43% of these professionals included the MMPI as part of their assessment protocol. Descriptive studies using the MMPI have provided valuable information on this patient population. For example, clinical scale elevations are not uncommon in this patient group. Glinski et al. [9] reported that 71% of the 115
patients being screened for bariatric surgery had at least 1 clinical scale elevation and 50% had 2 or more (as defined by T score Z 65 on the revised version). The most common clinical scales elevated on the MMPI (T score Z 70) among bariatric surgery patients are the hysteria (26.5%), hypochondriasis (21.3%), and depression (19%) clinical scales [10] suggesting greater levels of depression, anxiety, and somatization compared to normative samples [11]. Maddi et al. [12] investigated the change in MMPI-2 clinical scale scores from the preoperative evaluation phase to the postoperative phase (between 6 and 12 mo). They showed both that there was a consistent pattern of improvement in the level of psychopathology postoperatively and that while the scores were elevated before bariatric surgery (suggesting possible diagnostic levels of depression and anxiety), the scores at follow-up averaged at or below the normative sample. Predictive studies have also been conducted with the MMPI in relation to postsurgical outcome. An early study reported that the combination of the patient’s age and T score for the hypochondriasis clinical scale significantly predicted poor outcome up to 4 years after bariatric surgery though this was defined solely by the surgeon’s subjective opinion [13]. Tsushima et al. [14] performed a retrospective analysis of 52 patients who underwent Roux-en-Y gastric bypass (RYGB) and found that those patients who lost o 50% of their excess weight had scored higher on the F, hysteria, paranoia, and health concerns scales at baseline than did those patients who lost 4 50% of their excess weight 1 year postoperatively. Marek et al. [15] found that presurgical scores on the MMPI-2-RF predicted some clinically relevant 1- and 3-month postoperative issues among 859 bariatric surgery patients. Specifically, they determined that MMPI-2-RF scale elevations reflecting internalizing dysfunction were correlated with a higher level of early postoperative psychological distress; scores reflecting somatization were correlated with more postoperative somatic complaints; and scores reflecting emotional/internalizing, behavioral/externalizing, cognitive complaints,
http://dx.doi.org/10.1016/j.soard.2014.11.008 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
K. L. Applegate / Surgery for Obesity and Related Diseases ] (2014) 00–00
and thought dysfunction were associated with more disordered eating behavior after surgery. Other studies have failed to show strong predictive validity for the MMPI on postbariatric surgery outcomes. Barrash et al. [16] examined 138 women applying for vertical banded gastroplasty (VBG) using cluster analyses with the MMPI. Their results suggested very limited ability to predict 12-month weight loss outcomes. Valley and Grace [17] found that preoperative MMPI scale elevations predicted medical complications and patient satisfaction with surgery, but not weight loss outcomes, among 57 VBG patients 1 year after surgery. Grana et al. [10] found that the MMPI did not differentiate among good (Z45% excess weight loss; EWL), fair (25–44% EWL), and poor (o25% EWL) weight loss outcomes 6 months after VBG among 150 surgical patients. Belanger et al. [18] found that among 143 RYGB patients, a K scale elevation on the MMPI-2 was the only predictor of poorer weight loss outcomes in the first 6 months postoperatively. Classification and diagnostic groups calculated based on assessment data did not differentiate patient outcomes postoperatively. Thus, the predictive utility of standardized psychological tests such as the MMPI has been limited in this context which affects the ways in which behavioral health specialists can use this data for postoperative planning purposes. There is now growing empirical support for the incremental validity of the MMPI-2-RF as a component of the presurgical psychological screening (compared to a clinical interview alone) on characterizing psychological symptoms or issues relative to normative samples, clarifying diagnostic impressions, and rating the validity of the information provided by the patient during the assessment (e.g., approach to testing, guardedness, defensiveness). Furthermore, the accompanying article also supports the use of the MMPI-2-RF in diverse gender, age, and ethnic groups for these exact purposes. Instruments such as the MMPI-2-RF have specific advantages for presurgical psychological screenings including a standardized process, validity data, coverage of more topics than is possible during a traditional clinical interview, and an avenue for self-disclosure beyond the face-to-face setting. Some possible disadvantages include the time and expense to patients, the necessary training for clinicians to administer and score the instrument accurately, and the limited predictive abilities noted above. Additional work is needed to better clarify the potential predictive utility of standardized testing such as the MMPI2-RF in relation to clinically useful postsurgical outcomes [18,19]. Many of the predictive studies previously published have only included outcome data for the first few months to 1–2 years after surgery. Psychological instruments may have more predictive validity for longer-term outcomes; unfortunately this data is more expensive and time consuming to obtain. In addition, the previously considered range of dependent variables may have been too narrow. There are certainly a host of topics that could be
explored when broadly conceptualizing long-term outcomes after bariatric surgery. These could include risk of weight regain in the years after surgery, reemergence of disordered eating behavior, risk of substance misuse, treatment nonadherence (e.g., to exercise recommendations, vitamin regimens, meal planning guidelines), attendance at followup medical appointments, participation in support group meetings or behavioral health programs, quality of life issues, body image, romantic relationship stability, change in psychological symptom levels after weight loss, and/or utilization of mental health resources (i.e., inpatient, outpatient, psychotropic medication). More postoperative data needs to be collected and studied on both the general psychological well-being and the capacity for sustained behavioral change among bariatric surgery patients over time. Only with this level of comprehensive study and examination may we be able to determine the true predictive utility of standardized preoperative psychological tests. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Katherine L. Applegate, Ph.D. Department of Psychiatry and Behavioral Sciences, Duke University Medical Center References [1] Hathaway SR, McKinley JC. Manual for the Minnesota Multiphasic Personality Inventory. Minneapolis, Minnesota: University of Minnesota Press, 1942:1942. [2] Butcher JN, Graham JR, Ben-Porath YS, Tellegen A, Dahlstrom WG. Minnesota Multiphasic Personality Inventory-2 (MMPI-2): Manual for administration and scoring revised edition. Minneapolis, Minnesota: University of Minnesota Press, 2001:2001. [3] Ben-Porath YS, Tellegen A. Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF): manual for administration, scoring, and interpretation. Minneapolis, Minnesota: University of Minnesota Press; 2008/2011. [4] Tellegen A, Ben-Porath, YS. Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF): technical manual. Minneapolis, Minnesota: University of Minnesota Press; 2208/2011. [5] Marek RJ, Ben-Porath YS, Windover A, et al. Assessing psychosocial functioning of bariatric surgery candidates with the Minnesota multiphasic personality inventory-2 restructured form (MMPI-2-RF). Obes Surg 2013;23:1864–73. [6] Tarescavage AM, Wygant DB, Boutacoff LI, Ben-Porath YS. Reliability, validity, and utility of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in assessments of bariatric surgery candidates. Psychol Assess 2013;25:1179–94. [7] Bauchowitz AU, Gonder-Frederick LA, Olbrisch ME, et al. Psychosocial evaluation of bariatric surgery candidates: a survey of present practices. Psychosom Med 2005;67:825–32. [8] Fabricatore AN, Crerand CE, Wadden TA, Sarwer DB, Krasucki JL. How do mental health professionals evaluate candidates for bariatric surgery? Survey results. Obes Surg 2006;16:567–73.
Short Title / Surgery for Obesity and Related Diseases ] (2014) 00–00 [9] Glinski J, Wetzler S, Goodman E. The psychology of gastric bypass surgery. Obes Surg 2001;11:581–8. [10] Grana AS, Coolidge FL, Merwin MM. Personality profiles of the morbidly obese. J Clin Psychol 1989;45:762–5. [11] Maddi SR, Khoshaba DM, Persico M, Bleecker F, VanArsdall G. Psychosocial correlates of psychopathology in a national sample of the morbidly obese. Obes Surg 1997;7:397–404. [12] Maddi SR, Fox SR, Khoshaba DM, Harvey RH, Lu JL, Persico M. Reduction in psychopathology following bariatric surgery for morbid obesity. Obes Surg 2001;11:680–5. [13] Webb WW, Morey LC, Castelnuovo-Tedesco P, Scott HW Jr. Heterogeneity of personality traits in massive obesity and outcome prediction of bariatric surgery. Int J Obes 1990;14:13–20. [14] Tsushima WT, Bridenstine MP, Balfour JF. MMPI-2 scores in the outcome prediction of gastric bypass surgery. Obes Surg 2004;14: 528–32. [15] Marek RJ, Ben-Porath YS, Merrell J, Ashton K, Heinberg LJ. Predicting one and three month postoperative somatic concerns, psychological distress, and maladaptive eating behaviors in bariatric
[16]
[17]
[18]
[19]
3
surgery candidates with the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF). Obes Surg 2014;24: 631–9. Barrash J, Rodriguez EM, Scott DH, Mason EE, Sines JO. The utility of MMPI subtypes for the prediction of weight loss after bariatric surgery. Minnesota Multiphasic Personality Inventory. Int J Obes 1987;11:115–28. Valley V, Grace DM. Psychosocial risk factors in gastric surgery for obesity: identifying guidelines for screening. Int J Obes 1987;11: 105–13. Belanger SB, Wechsler FS, Nademin ME, Virden TB 3rd. Predicting outcome of gastric bypass surgery utilizing personality scale elevations, psychosocial factors, and diagnostic group membership. Obes Surg 2010;20:1361–71. Wygant DB, Boutacoff LI, Arbisi PA, Ben-Porath YS, Kelly PH, Rupp WM. Examination of the MMPI-2 restructured clinical (RC) scales in a sample of bariatric surgery candidates. J Clin Psychol Med Settings 2007;14:197–205.
Editorial comment
Comment On: Validity of Minnesota multiphasic personality inventory-2restructured form (MMPI-2-RF) scores as a function of gender, ethnicity, and age of bariatric surgery candidates Preoperative bariatric surgery assessments can serve several valuable functions for patients and their associated surgical programs. One primary goal is the identification of clinical issues that may benefit from additional attention or structured intervention perioperatively in an effort to maximize the chances of patients’ long-term success after surgery. To advance this aim, bariatric surgery specialists are working to determine: 1) the most relevant preoperative characteristics associated with positive and/or negative outcome, 2) efficient methods of identifying patients with these characteristics, and 3) effective ways of creating change that is associated with improved patient outcome. Behavioral health specialists have actively participated in this investigative process for many years. They have conducted descriptive, cross-sectional, longitudinal, and retrospective studies on the psychological features of bariatric surgery patients and have explored the use of psychological variables in predicting postsurgical outcomes. Although the descriptive efforts have been quite beneficial in clarifying the cognitive, behavioral, social, and emotional characteristics of bariatric surgery patients, the predictive efforts have proved much more challenging. One of the most common psychological assessment instruments that has been used within the bariatric surgery population for both descriptive and predictive purposes is the Minnesota Multiphasic Personality Inventory (MMPI, MMPI-2, MMPI-2-RF) [1–6]. In fact, Bauchowitz et al. [7] found that nearly 30% of bariatric surgery programs that included standardized psychological testing preoperatively included a personality inventory, the most common of which was the MMPI. Fabricatore et al. [8] surveyed 194 behavioral health providers involved in screening candidates for bariatric surgery and found that nearly 43% of these professionals included the MMPI as part of their assessment protocol. Descriptive studies using the MMPI have provided valuable information on this patient population. For example, clinical scale elevations are not uncommon in this patient group. Glinski et al. [9] reported that 71% of the 115
patients being screened for bariatric surgery had at least 1 clinical scale elevation and 50% had 2 or more (as defined by T score Z 65 on the revised version). The most common clinical scales elevated on the MMPI (T score Z 70) among bariatric surgery patients are the hysteria (26.5%), hypochondriasis (21.3%), and depression (19%) clinical scales [10] suggesting greater levels of depression, anxiety, and somatization compared to normative samples [11]. Maddi et al. [12] investigated the change in MMPI-2 clinical scale scores from the preoperative evaluation phase to the postoperative phase (between 6 and 12 mo). They showed both that there was a consistent pattern of improvement in the level of psychopathology postoperatively and that while the scores were elevated before bariatric surgery (suggesting possible diagnostic levels of depression and anxiety), the scores at follow-up averaged at or below the normative sample. Predictive studies have also been conducted with the MMPI in relation to postsurgical outcome. An early study reported that the combination of the patient’s age and T score for the hypochondriasis clinical scale significantly predicted poor outcome up to 4 years after bariatric surgery though this was defined solely by the surgeon’s subjective opinion [13]. Tsushima et al. [14] performed a retrospective analysis of 52 patients who underwent Roux-en-Y gastric bypass (RYGB) and found that those patients who lost o 50% of their excess weight had scored higher on the F, hysteria, paranoia, and health concerns scales at baseline than did those patients who lost 4 50% of their excess weight 1 year postoperatively. Marek et al. [15] found that presurgical scores on the MMPI-2-RF predicted some clinically relevant 1- and 3-month postoperative issues among 859 bariatric surgery patients. Specifically, they determined that MMPI-2-RF scale elevations reflecting internalizing dysfunction were correlated with a higher level of early postoperative psychological distress; scores reflecting somatization were correlated with more postoperative somatic complaints; and scores reflecting emotional/internalizing, behavioral/externalizing, cognitive complaints,
http://dx.doi.org/10.1016/j.soard.2014.11.008 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
K. L. Applegate / Surgery for Obesity and Related Diseases ] (2014) 00–00
and thought dysfunction were associated with more disordered eating behavior after surgery. Other studies have failed to show strong predictive validity for the MMPI on postbariatric surgery outcomes. Barrash et al. [16] examined 138 women applying for vertical banded gastroplasty (VBG) using cluster analyses with the MMPI. Their results suggested very limited ability to predict 12-month weight loss outcomes. Valley and Grace [17] found that preoperative MMPI scale elevations predicted medical complications and patient satisfaction with surgery, but not weight loss outcomes, among 57 VBG patients 1 year after surgery. Grana et al. [10] found that the MMPI did not differentiate among good (Z45% excess weight loss; EWL), fair (25–44% EWL), and poor (o25% EWL) weight loss outcomes 6 months after VBG among 150 surgical patients. Belanger et al. [18] found that among 143 RYGB patients, a K scale elevation on the MMPI-2 was the only predictor of poorer weight loss outcomes in the first 6 months postoperatively. Classification and diagnostic groups calculated based on assessment data did not differentiate patient outcomes postoperatively. Thus, the predictive utility of standardized psychological tests such as the MMPI has been limited in this context which affects the ways in which behavioral health specialists can use this data for postoperative planning purposes. There is now growing empirical support for the incremental validity of the MMPI-2-RF as a component of the presurgical psychological screening (compared to a clinical interview alone) on characterizing psychological symptoms or issues relative to normative samples, clarifying diagnostic impressions, and rating the validity of the information provided by the patient during the assessment (e.g., approach to testing, guardedness, defensiveness). Furthermore, the accompanying article also supports the use of the MMPI-2-RF in diverse gender, age, and ethnic groups for these exact purposes. Instruments such as the MMPI-2-RF have specific advantages for presurgical psychological screenings including a standardized process, validity data, coverage of more topics than is possible during a traditional clinical interview, and an avenue for self-disclosure beyond the face-to-face setting. Some possible disadvantages include the time and expense to patients, the necessary training for clinicians to administer and score the instrument accurately, and the limited predictive abilities noted above. Additional work is needed to better clarify the potential predictive utility of standardized testing such as the MMPI2-RF in relation to clinically useful postsurgical outcomes [18,19]. Many of the predictive studies previously published have only included outcome data for the first few months to 1–2 years after surgery. Psychological instruments may have more predictive validity for longer-term outcomes; unfortunately this data is more expensive and time consuming to obtain. In addition, the previously considered range of dependent variables may have been too narrow. There are certainly a host of topics that could be
explored when broadly conceptualizing long-term outcomes after bariatric surgery. These could include risk of weight regain in the years after surgery, reemergence of disordered eating behavior, risk of substance misuse, treatment nonadherence (e.g., to exercise recommendations, vitamin regimens, meal planning guidelines), attendance at followup medical appointments, participation in support group meetings or behavioral health programs, quality of life issues, body image, romantic relationship stability, change in psychological symptom levels after weight loss, and/or utilization of mental health resources (i.e., inpatient, outpatient, psychotropic medication). More postoperative data needs to be collected and studied on both the general psychological well-being and the capacity for sustained behavioral change among bariatric surgery patients over time. Only with this level of comprehensive study and examination may we be able to determine the true predictive utility of standardized preoperative psychological tests. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Katherine L. Applegate, Ph.D. Department of Psychiatry and Behavioral Sciences, Duke University Medical Center References [1] Hathaway SR, McKinley JC. Manual for the Minnesota Multiphasic Personality Inventory. Minneapolis, Minnesota: University of Minnesota Press, 1942:1942. [2] Butcher JN, Graham JR, Ben-Porath YS, Tellegen A, Dahlstrom WG. Minnesota Multiphasic Personality Inventory-2 (MMPI-2): Manual for administration and scoring revised edition. Minneapolis, Minnesota: University of Minnesota Press, 2001:2001. [3] Ben-Porath YS, Tellegen A. Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF): manual for administration, scoring, and interpretation. Minneapolis, Minnesota: University of Minnesota Press; 2008/2011. [4] Tellegen A, Ben-Porath, YS. Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF): technical manual. Minneapolis, Minnesota: University of Minnesota Press; 2208/2011. [5] Marek RJ, Ben-Porath YS, Windover A, et al. Assessing psychosocial functioning of bariatric surgery candidates with the Minnesota multiphasic personality inventory-2 restructured form (MMPI-2-RF). Obes Surg 2013;23:1864–73. [6] Tarescavage AM, Wygant DB, Boutacoff LI, Ben-Porath YS. Reliability, validity, and utility of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in assessments of bariatric surgery candidates. Psychol Assess 2013;25:1179–94. [7] Bauchowitz AU, Gonder-Frederick LA, Olbrisch ME, et al. Psychosocial evaluation of bariatric surgery candidates: a survey of present practices. Psychosom Med 2005;67:825–32. [8] Fabricatore AN, Crerand CE, Wadden TA, Sarwer DB, Krasucki JL. How do mental health professionals evaluate candidates for bariatric surgery? Survey results. Obes Surg 2006;16:567–73.
Short Title / Surgery for Obesity and Related Diseases ] (2014) 00–00 [9] Glinski J, Wetzler S, Goodman E. The psychology of gastric bypass surgery. Obes Surg 2001;11:581–8. [10] Grana AS, Coolidge FL, Merwin MM. Personality profiles of the morbidly obese. J Clin Psychol 1989;45:762–5. [11] Maddi SR, Khoshaba DM, Persico M, Bleecker F, VanArsdall G. Psychosocial correlates of psychopathology in a national sample of the morbidly obese. Obes Surg 1997;7:397–404. [12] Maddi SR, Fox SR, Khoshaba DM, Harvey RH, Lu JL, Persico M. Reduction in psychopathology following bariatric surgery for morbid obesity. Obes Surg 2001;11:680–5. [13] Webb WW, Morey LC, Castelnuovo-Tedesco P, Scott HW Jr. Heterogeneity of personality traits in massive obesity and outcome prediction of bariatric surgery. Int J Obes 1990;14:13–20. [14] Tsushima WT, Bridenstine MP, Balfour JF. MMPI-2 scores in the outcome prediction of gastric bypass surgery. Obes Surg 2004;14: 528–32. [15] Marek RJ, Ben-Porath YS, Merrell J, Ashton K, Heinberg LJ. Predicting one and three month postoperative somatic concerns, psychological distress, and maladaptive eating behaviors in bariatric
[16]
[17]
[18]
[19]
3
surgery candidates with the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF). Obes Surg 2014;24: 631–9. Barrash J, Rodriguez EM, Scott DH, Mason EE, Sines JO. The utility of MMPI subtypes for the prediction of weight loss after bariatric surgery. Minnesota Multiphasic Personality Inventory. Int J Obes 1987;11:115–28. Valley V, Grace DM. Psychosocial risk factors in gastric surgery for obesity: identifying guidelines for screening. Int J Obes 1987;11: 105–13. Belanger SB, Wechsler FS, Nademin ME, Virden TB 3rd. Predicting outcome of gastric bypass surgery utilizing personality scale elevations, psychosocial factors, and diagnostic group membership. Obes Surg 2010;20:1361–71. Wygant DB, Boutacoff LI, Arbisi PA, Ben-Porath YS, Kelly PH, Rupp WM. Examination of the MMPI-2 restructured clinical (RC) scales in a sample of bariatric surgery candidates. J Clin Psychol Med Settings 2007;14:197–205.
