Personality of MMPI success
characteristics profile in weight
Sally F. Johnson,2
M.S.,
and age of onset reduction1
Wendell
ABSTRACT
Of these, ventory
Department PA,
SC,
F and MA
though
these
occur
more
frequently
initial profiles. weight
to
weight
statistically
scales.
patterns were subjects than
significant
and
subjects
of
at the Obese
show
Mayo female
in obese
persons,
the
male
having those for
either
and onset whose the
female
Obese
The
score
of
on the
Q
MMPI
a 2-year
period.
profiles
of the
obese
50,000
patients
seen
in the
on the
F, PD,
had
significantly
higher
scale
traits
over
MMPI
subjects
significantly
than
scores
the
reference
as measured
profile
codes
by point
population.
the
out
higher
MMPI
may
the presence
of
rather than a single personality pattern characteristic in the success in achieving a loss of 10% or more obese
subjects
having
of obesity before age obesity began later male
clinic
M.D.
Multiphasic Personality Inin order to determine success
male
had
personality
individual
among obese persons no apparent differences the
regimen.
Clinic.
certain
in an obesity
population
subjects lower
that
seen
medical
to
Clifford F. Gastineau,4
by the Minnesota of 4 to 28 months
dietary
a general
relation of obesity
and
was
factors periods
a significantly
findings
among
Obese reduction
Ph.D.,
of a conventional those
Medicine MA
scales,
Even
diverse behavior of obesity. There
142 obese
by means
of Internal and
of
compared
on the
Swenson,3
assessment of personality and 71 were followed for
reduction were
scores
M.
A group 116 had (MM P1),
at weight subjects
in obesity:
or female
normal
or
abnormal
12 years were slightly more than this, but the differences
subjects.
Am.
J. C/in.
successful were
Nutr.
of
MMPI
29: 626
in not 632,
1976.
Obesity is recognized as a nationwide problem which has become nearly an obsession throughout the American population. Yet results of therapy for controlling weight have met with only limited success (1-3). Encouraging results from behavior modification (4) and group therapy (5) suggest that psychological factors may strongly influence results of treatment. What are the psychological factors that determine success in achieving weight loss? Can we identify any personality characteristics of the obese person which will enable us to predict the likelihood of his achieving significant weight loss? The objectives of the study were: I) to identify the personality traits of obese persons by objective psychological assessment. 2) to determine whether by using psychological tests one can predict probability of success in weight reduction. 3) to determine whether age of onset of obesity influences success in weight reduction. If one could identify either a characteristic personality profile in obesity or a set of personality characteristics that influenced
626
The
American
Journal
of Clinical
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either success or failure, then inferences as to psychological factors that may influence the development of obesity might be drawn and perhaps more effective treatment programs could be devised. Previous attempts have not succeeded in identifying a specific personality profile for the obese person (6-8). Emotional stability (3, 9) and an older age (3, 10) of onset have been said to favor success in weight reduction. Methods Subjects A group of ranging in age
142 patients from 10 to
(Ill females 73 years was
and 31 referred
males) to an
“Abridgment of thesis submitted by Sally F. Johnson to the Faculty of the Graduate School of the University of Minnesota in partial fulfillment of the requirements for the MS. degree in nutrition. Degree granted in 1973. 2 Department of Dietetics and Nutrition. The University of Kansas Medical Center, Kansas City, Kansas 66103. 3Section of Psychology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55901. Director of Nutrition Clinic, Department of Internal Medicine, Mayo Clinic and Mayo Foundation.
Nutrition
29: JUNE
1976,
pp. 626-632.
Printed
in U.S.A.
PERSONALITY obesity
clinic
during
a 2-year
period.
CHARACTERISTICS
Criteria
for
inclu-
sion in this group were a substantial degree of overweight, and a willingness to cooperate in dietary instruction and evaluation of the problem. A few subjects were only moderately obese, but were prepared to undertake the same dietary regimen and studies due to their concern about their weight. Weight and height were measured with indoor clothing, but without shoes. The midpoint value of the range for medium frame found in the Metropolitan Life Insurance tables ( I I ) was chosen as the ideal weight for measuring the excess pounds and percent overweight.
Comparison
ofpersonality
profi/es
The Minnesota Multiphasic Personality Inventory (MMPI) (12) is a widely-used instrument for personality assessment which consists of 550 behavioral descriptive statements to which the subject responds true or false as each statement applies to him. For scoring purposes, the items are grouped together into fourteen basic scales in order to obtain a personality profile. This profile is made up of four validity scales and ten clinical scales. The validity scales measure test-taking attitudes in addition to inferring certain personality traits, and are named the following: cannot say (Q), lie (L), frequency (F), and correction (K). The basic clinical scales relate to various psychiatric syndromes, namely, hypochondriasis (HS), depression (D), hysteria (HY), psychopathic deviate (PD), masculinity-feminity (MF), paranoia (PA), psychasthenia (PT), schizophrenia (SC), hypomania (MA), and social introversion (SI). These scales are used primarily to provide characteristics rather ric disorder. The MMPI was patients. Mean MMPI were compared with
a general assessment of personality than to note a particular psychiatadministered to 120 of these 142 profiles of these obese patients mean MMPI profiles obtained at
the Mayo Clinic from a general medical population comprised of approximately 25,000 males and 25,000 females seen in the Department of Internal Medicine over a 2-year period for various medical problems (13). Therapeutic
regimen
The caloric reduction was five, or 73.9%,
range of the diets prescribed from 800 to 1,200 calories. of the 142 patients were
for weight One hundred instructed in
an 800-calorie diet consisting of approximately 60 g of protein, 30 g of fat, and 80 g of carbohydrate (14). In addition to the dietary therapy, the subjects were encouraged to establish a regular program of exercise. Procedure
for
evaluation
of
success
in
/osing
weight
Results of weight-losing efforts were obtained at the time of follow-up visits in about one-third of instances, and from responses to letters of inquiry in the others. (Three of the 142 patients were excluded because the interval of time since they had received dietary instructions was less than 4 months when the study was concluded.) Patients reporting their progress in losing weight were considered as being “more successful” or “less successful” in weight reduction. A weight loss of I) at least 10% of initial weight or 2) reduction of weight to within 20% of the ideal weight was arbitrarily chosen as a criterion for
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IN
inclusion
in the
OBESITY “more
627 successful”
group.
The
second
cri-
terion was used in order to consider the success of the small number of patients having a lesser degree of overweight, in whom a weight loss of less than 10% of the initial weight brought them to what they felt was a satisfactory weight. A weight loss of less than 10% of initial weight or a change in weight level equal to or greater than the starting weight was chosen as a criterion for inclusion in the “less successful” group. To determine whether there was a relationship between the results of the MMPI and success in losing weight, patients with normal MMPI profiles were compared with those having abnormal MMPI profiles. A normal profile is designated as one which has no T score of 70 or above among the basic clusical scales. To determine whether success in losing weight is influenced by the age of onset of obesity, a group consisting of subjects having onset of obesity before the age of 12 (designated as “childhood onset”) was compared with those who became obese at 12 years of age or older (designated as “adolescent-adult onset”).
Results Weights
of patients
The mean initial weight of the 31 men was 303.2 ± 8l.9 pounds, while the mean initial weight of the 111 women was 236.9 ± 56.9 pounds. The mean ideal weight of the 31 men was 156.8 ± l7.5 pounds, while the mean ideal weight of the 111 women was 130.0 ± l0.5 pounds. Degree
of obesity
The 31 men had a mean excess of 146.4 ± 70.5” pounds or 91.6 ± 39.1” percent overweight. The 11 1 women had a mean excess of 106.9 ± 52.3” pounds or 81.6 ± 38.2” percent overweight. Of the 142 patients, 116 (26 males and 90 females), or 81.7% of the group, were at least 50% above the ideal weight. Comparison of mean MMPI profiles of the subjects with those of general medical population MMPI profiles were considered as valid if fewer than 120 items were left unanswered in the test. By this definition, valid profiles were obtained from 116 of the 120 patients taking the test. This group of patients consisted of 24 males and 92 females. Graphic comparison of the MMPI profiles of the male obese subjects with the mean profiles of the general medical population is “Standard
deviation.
JOHNSON
628
illustrated in Figure 1. In the comparison of the mean MMPI T scores of the two male groups, it is noted that the obese male group scored significantly higher than the male medical group on the F and MA scales (statistical significance determined by the Student’s t test method). Mean MMPI profiles of the female obese subjects and the medical population are illustrated in Figure 2. The obese female subjects have a significantly higher score than the medical female group in the F, PD, PA, SC, and MA scales, and a significantly lower score on the Q scale.
Follow-up
of weight change
Of 139 patients contacted for follow-up results of the weight reduction program, 71 (17 males and 54 females), or 51% of the group, provided information on their weightlosing efforts at one or more intervals of time ranging from 4 to 28 months after receiving dietary instructions. The 17 male patients had 80
ET
a mean change from initial weight of 35.2 ± 32.8” pounds or -11.5 ± 9.1” percent at the last interval of time when they reported. The 54 female patients had a mean change from initial weight of -22.3 ± 26.3” pounds or -9.3 ± 10.2” percent when they last reported on their weight change. The change from initial weight, expressed in mean pounds and percent, is presented in Table 1 for the 17 male patients and Table 2 for the 54 female patients reporting at various intervals of time. The data show a greater weight loss for the male patients than the female patients. However, there is an increase in the change from the initial weight until the interval of time from 7 to 10 months for both groups of patients. After this interval of time, there is a return toward the original weight. Response of individual patients to the weight reduction program is not reflected by the changes from initial weight given in Tables 1 and 2. Five (four female patients and one male patient), or 3.6%, of the 139 patients were successful in reducing their weight to -
-
80
70
qJ
AL.
70
60
-
:
#{188} 0
50Normal medical Obese medical P OOi
-
40
-
*
LIll F”
O
K
Hs
DIIIHy
Pd
MfIll Pa
Pt
(24277) (24) 4C
FIG.
TABLE Weight
scales
I.
Basic
Mean
1 change
after
MMPI
diet
profiles
started
Time after start of diet (months)’
4-6 7-10 11-15 16-21 22-28 ‘Time interval
interval determined at the time the study
clinical
scales
of male
(male
medical
1257231
Obese
medical
192)
* ScIllMo”Si 0”
Validity
Normal
L
F*
Validity
patients.
FIG.
Hs
K
D
Hy
scales
2.
P
I
I
I
I
Pd’
Mt
Pa’
Pt
Sc
Basic
Mean
MMPI
profiles
001
I
clinical
I Mo’
Si
scales
of female
patients.
patients)
No. of patients”
30 28 23 14 3 according to the was terminated.
Pts reporting at each time interval No.
%
17 6 13 6 1
56.7 21.4 56.5 42.9 33.3
nearest
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month.
Chang e from mean
initial weight ± SD
Pounds -39.9± -67.7 -36.2± -33.2 -43.0
b Number
±
± ±
35.6 64.3 30.6 19.8 0.0
% -11.7±9.1 17.2
±
12.2
-11.9±8.9 11.9 -22.4
±
7.4 0.0
-
±
of patients in the study for each reporting
PERSONALITY TABLE Weight
2 change
after
diet
started
(female
Time after start of diet (months)’
No. of Pt?
4-6 7-10 lI-IS 16-21 22-28
109 88 69 53 25
‘Time interval
interval determined at the time the study
TABLE 3 Relationship
of MMPI
results
CHARACTERISTICS
Pts reporting at each time interval
according to the was terminated.
to success
Time after start of diet (months) 4-6 7-10 lI-IS 16-28
17 6 13 7
629
OBESITY
patients)
%
Pounds
37 17 20 9 7
33.9 19.3 29.0 17.0 28.0
-24.1± 18.3 -32.6±28.8 -21.6± 23.8 -7.9 ± 24.0 -9.6 ± 24.7
nearest
in weight
month.
reduction’
More successful No. %
No. 6 3 5 3
4 2 3 2
66.7 66.7 60.0 66.7
e from mean
Chang
No.
Pts with normal No. pts reporting at each time interval
IN
Number
(male
% -10.4±7.2 -12.9± 10.8 -9.3 ±8.9 -3.8 ± 10.0 -5.3 ± 13.0
of patients
#{176}
initial weight ± SD
in the study
for each
reporting
patients) Pta with abnorma
profile”
Less succcsf No. 2 1 2 1
1 profiler
More No
% 33.3 33.3 40.0 33.3
Less
No.
7 1 5 2
4 1 3 2
%
No.
%
57.1 100.0 60.0 100.0
3 0 2 0
42.9 0.0 40.0 0.0
‘Criteria of success: I) more successful = reduction of weight to within 20% of ideal weight or a weight loss greater than or equal to 10% of initial weight. 2) less successful = weight loss less than 10% of initial weight or a change in weight to a level greater than or equal to the initial weight. ‘ Normal profile = profile having all T scores less than 70. Abnormal profile = profile having I or more T scores 70 or more.
TABLE
4
Relationship
of MMPI
results
to success
in weight
reduction’
(female
patients) Pts with abno rmal profiler
Pts with nor mal profile” No. pts reporting at each time interval
Time after start of diet (months)
No.
No. 37 17 20 14
4-6 7 10 Il-IS 16-28
15 9 6 3
Less successful
More successful %
8 5 3 2
‘Criteria of success: I) more successful = reduction than or equal to 10% of initial weight. 2) less successful weight to a level greater than or equal to the initial 70. C Abnormal profile = profile having I or more
53.3 55.6 50.0 66.7
No.
%
7 4 3 1
17 7 9 8
46.7 44.4 50.0 33.3
showed loss.
a gain
Relationship weight
in weight
of MMPI
Less successful
More successful %
9 4 6 5
-
52.9 57.1 66.7 62.5
of weight to within 20% of ideal weight = weight loss less than 10% of initial weight. b Normal profile = having T scores 70 or more.
within 20% of the ideal weight. These patients were all less than 50% above ideal weight initially. Certain trends were evident for the majority of patients reporting. Information from patients who were followed for less than 1 year usually indicated a weight loss with each interval of time after the start of diet. Information from the patients who were followed for more than 1 year frequently
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No.
No.
No.
%
8 3 3 3
47.1 42.9 33.3 37.5
or a weight loss greater weight or a change in all I scores less than
after
profiles
an initial
weight
to success
in
reduction
The success in weight reduction as it relates to the male and female patients having normal and abnormal MMPI profiles is shown in Tables 3 and 4. Although differences in the
630
JOHNSON
ET
latter (mean at the time
degree of success are noted at various intervals of time, there is no apparent trend in the rate of success according to the type of MMPI profile. of age
Relationship
success
in weight
at onset reduction
of obesity
of age
at onset
of obesi
MMPI
to
ty to su ccess
age 44, mean of this study.
characteristics
Time after start of diet (months)
in weight
reduction’
17 6 13 7
4-6 7-10 11-15 16-28
More successful
No.
13 6 10 4
(male
of age
at onset
of obesity
Less successful %
No.
%
8 4 6 3
61.5 66.7 60.0 75.0
5 2 4 1
38.5 33.3 40.0 25.0
in weight
Pts with onset childhood(l-l No. pts reporting at each time interval
37 17 20 14
Time after start of diet (months)
4-6 7-10 11-15 16-28
No.
19 9 7 7
reduction’ of obesity I yrs)
More successful
(female
No.
%
No.
1 0 2 2
25.0 0.0 66.7 66.7
3 0 1 1
20% of ideal loss less than
No.
%
11 6 5 4
57.9 66.7 71.4 57.1
8 3 2 3
42.1 33.3 28.6 42.9
% 75.0 0.0 33.3 33.3
weight or a weight loss of 10% of initial weight or a
patients)
No.
%
‘Criteria of success: 1) more successful = reduction in weight than or equal to 10% of initial weight. 2) less successful = weight weight to a level greater than or equal to the initial weight.
Less successful
Pts with onset adolescence-adulthood
Less successful
of obesity in ( 12 yrs)
More successful
4 0 3 3
in
No.
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subjects
patients)
No.
No.
to success
of obese
Pts with onset adolescence-adulthood
‘Criteria of success: I) more successful = reduction in weight to within greater than or equal to 10% of initial weight. 2) less successful = weight change in weight to a level greater than or equal to the initial weight.
TABLE 6 Relationship
73.8%)
Of the various studies of which we are aware, using the MMPI to evaluate the personality characteristics of obese persons (15-19), only a portion of the work reported by Crumpton et al. (15) closely resembles this study. Crumpton et al. did not find any significant differences in the comparison of mean MMPI profiles of the group of obese men and a group of general male medical and surgical patients, each group containing 29 subjects. Our study, however, does show some significant differences in the MMPI profile of obese subjects and those of the general medical population. Significantly higher mean T scores on the F scale for the male and female obese subjects
Pts with onset of obesity in childhood (1-Il yrs) No. pts reporting at each time interval
overweight
Discussion
The relationship of age at onset of obesity to success in weight reduction for the male and female obese patients is illustrated in Tables 5 and 6. For most of the reporting intervals of time, there is a greater percentage of more successful patients among those who became obese during childhood than those who became obese during adolescence-adulthood for both the male and female patients, although the differences are not statistically significant. The childhood-onset and the adolescentadult-onset groups differed also in that the former were younger (mean age 30 years) and heavier (mean overweight 93%) than the TABLE 5 Relationship
AL.
18 8 13 7
to within 20% of ideal loss of less than 10%
More successful
of
obesity
in
(
12
yrs.)
Less successful
No.
%
No.
%
9 4 7 4
50.0 50.0 53.8 57.1
9 4 6 3
50.0 50.0 46.2 42.9
weight or a weight loss greater of initial weight or a change in
PERSONALITY
CHARACTERISTICS
than the medical population suggest the possible presence of more dissatisfaction in family and social relationships among obese persons than nonobese persons. Significant elevations in the MA scale for the male and female obese patients may be related to the subjective unrest that often occurs in obese persons, particularly if the need for food was established early in childhood (20). The significantly greater difference on the PD scale for the obese female subjects than the female medical subjects may indicate that obese women are more nonconforming and impulsive than women of normal weight. The significant difference on the PA scale showing more interpersonal sensitivity for the female obese persons than the female medical subjects is perhaps associated with the feelings incurred by social disapproval of the obese state. Explanation of the significant difference in the SC scale for the reference and obese subjects is guarded because of the diversification of the items comprising this scale. However, the larger mean T score for the female obese subjects may be related to the social alienation that results from being obese. Although the scores on the Q scale indicate that the medical female subjects omitted more items on the test than the obese female subjects, the number of items excluded by either group probably had little effect on the validity of the test for both of the mean T scores on this scale are below fifty. Results of this study do not indicate whether the prominent personality characteristics as revealed by the MMPI profiles are a cause or result of the obesity. This would be difficult to determine because the MMPI was administered to the obese subjects after they had become overweight. Even though the findings show that particular personality traits may be apparent in obese persons, the individual MMPI profile codes point out the presence of diverse behavior patterns among obese persons, rather than a single personality pattern characteristic of obesity.
Relationship of MMPI findings and age of onset of obesity to success in weight reduction
no
McLaren relationship
(21)
and Penick between the
et al. (4) noted responses to the
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IN OBESITY
631
MMPI and success in losing weight for persons participating in programs for the treatment of obesity. Mullins (10) reported a greater success in weight reduction for patients with adult obesity than those with juvenile obesity, defined as being known as “fatty at school.” In an experimental nutrition clinic, Young et al. (3) found that obesity occurring in childhood or before the age of 18 years is more difficult to treat than that occurring in adulthood. The studies of McLaren (21) and Penick et al. (4) are in agreement with our finding that there is no apparent relationship between the type of MMPI profile and success in losing weight. However, the results of the present study are somewhat different from those of Mullins (10) and Young et al. (3), in that we noted a greater percentage of more successful patients among those who developed obesity during childhood than those who became obese during adolescence-adulthood . These differences are not large enough to be statistically significant for either the male or female patients. Furthermore, the younger age and greater degree of obesity at the time of the study may have, in some way, facilitated weight reduction by the childhood-onset group. Although reduction to an ideal or desirable weight is often used as the criterion for successful treatment of obesity, losses of 10% or more of initial weight may provide an appreciable amelioration of the symptoms and physiological stresses imposed by obesity and should not be looked upon as complete failure. The large percentage of patients not answering letters of inquiry or returning for follow-up suggest that the results of the dietary efforts of the entire group may have been less successful than the data in Tables 1 and 2 indicated, since the nonreporters were presumably the less successful. We
find
no
clue
in
the
MMPI
characteris-
of these obese subjects as a group or of the more or less successful subgroups to suggest that there is any particular personality trait or traits which could be exploited in prevention of obesity or in the development of effective treatment programs. This does not exclude the possibility that other modes of psychological testing might yield different results. tics
a
632
JOHNSON
References 1. FRANKLIN, R. E., AND E. H. RYNEARSON. An evaluation of the effectiveness of diet instruction for the obese. Mayo Clin. Proc. 35: 123, 1960. 2. STUNKARD, A. J., AND M. MCLAREN-HUME. The results of treatment for obesity. Arch. Intern. Med. 103: 79, 1959. 3. YOUNG, C. M., N. S. MOORE, K. K. BERRESFORD AND B. M. EINSET. What can be done for the obese patient? Am. Practitioner Dig. Treat. 6: 685, 1955. 4. PENICK, S. B., R. FluoN, S. Fox AND A. J. STUNKARD, Behavior modification in the treatment of obesity. Psychosomat. Med. 33: 49, 1971. 5. STUNKARD, A., H. LEVINE AND S. Fox, A study of a self-help group for obesity. Excerpta Med. International Congress Series No. 213, p. 223, 1969. 6. BRUCH, H. Prognosis and treatment of obesity from a psychiatrist’s point of view. J. Am Med. Women’s Assoc. 19: 745, 1964. 7. KAPLAN, H. I., AND H. S. KAPLAN. The psychosomatic concept of obesity. J. Nervous Mental Disease 125: 181, 1957. 8. WEINBERG, N., M. MENDELSON AND A. J. STUNKARD, A failure to find distinctive personality features in a group of obese men. Am. J. Psychiat. 117: 1035, 1961. 9. DARLING, C. D., AND J. SUMMERSKILL. Emotional factors in obesity and weight reduction. J. Am. Dietet. Assoc. 29: 1204, 1953. 10. MULLINS, A. G. The prognosis in juvenile obesity. Arch. Disease Childhood 33: 307, 1958.
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ET 11.
12.
AL. New
weight
cal 40:
Bulletin 1, 1959.
14.
15.
16. 17.
18.
19.
20.
21.
for
men
Metropolitan
and Life
women. Insurance
StatistiCo.
S. R., AND J. C. MCKINLEY, Minnesota Personality Inventory Manual, 2nd ed., The Psychological Corporation, 1951. SWENSON, W. M., J. S. PEARSON AND D. OSBORNE, An MMPI Source Book: Basic Item, Scale, and Pattern Data on 50,000 Medical Patients. Minneapolis: University of Minnesota Press, 1973. Committee on Dietetics of the Mayo Clinic: Mayo Clinic Diet Manual, 4th ed. Philadelphia: W. B. Saunders Company, 1971, p. 71. CRUMPTON, E., D. B. WINE AND H. GROOT, MMPI profiles of obese men and six other diagnostic categories. Psychol. Rept. 19: 1110, 1966. FELLNER, C. H., AND H. LEVITT, A new approach to overweight. Am. J. Clin. Nutr. 15: 50, 1964. KOLLAR, E. J., R. M. ATKINSON AND D. L. ALBIN, The effectiveness of fasting in the treatment of superobesity. Psychosomatics 10: 125, 1968. REIVICH, R. S., R. A. RUIZ AND R. M. LAPI, Extreme obesity-psychiatric, psychometric and psychotherapeutic aspects. J. Kansas Med. Soc. 67: 134, 1966. WERKMAN, S. L., AND E. S. GREENBERG, Personality and interest patterns in obese adolescent girls. Psychosomat. Med. 29: 72, 1967. SWANSON, D. W., AND F. A. DINELLO, Severe obesity as a habituation syndrome: evidence during a starvation study. Arch. Gen. Psychiat. 22: 120, 1970. MCLAREN, B. A. Nutritional control of overweight. Can. J. Public Health 58: 483, 1967. HATHAWAY,
Multiphasic New York:
13.
standards of the
characteristics profile in weight
Sally F. Johnson,2
M.S.,
and age of onset reduction1
Wendell
ABSTRACT
Of these, ventory
Department PA,
SC,
F and MA
though
these
occur
more
frequently
initial profiles. weight
to
weight
statistically
scales.
patterns were subjects than
significant
and
subjects
of
at the Obese
show
Mayo female
in obese
persons,
the
male
having those for
either
and onset whose the
female
Obese
The
score
of
on the
Q
MMPI
a 2-year
period.
profiles
of the
obese
50,000
patients
seen
in the
on the
F, PD,
had
significantly
higher
scale
traits
over
MMPI
subjects
significantly
than
scores
the
reference
as measured
profile
codes
by point
population.
the
out
higher
MMPI
may
the presence
of
rather than a single personality pattern characteristic in the success in achieving a loss of 10% or more obese
subjects
having
of obesity before age obesity began later male
clinic
M.D.
Multiphasic Personality Inin order to determine success
male
had
personality
individual
among obese persons no apparent differences the
regimen.
Clinic.
certain
in an obesity
population
subjects lower
that
seen
medical
to
Clifford F. Gastineau,4
by the Minnesota of 4 to 28 months
dietary
a general
relation of obesity
and
was
factors periods
a significantly
findings
among
Obese reduction
Ph.D.,
of a conventional those
Medicine MA
scales,
Even
diverse behavior of obesity. There
142 obese
by means
of Internal and
of
compared
on the
Swenson,3
assessment of personality and 71 were followed for
reduction were
scores
M.
A group 116 had (MM P1),
at weight subjects
in obesity:
or female
normal
or
abnormal
12 years were slightly more than this, but the differences
subjects.
Am.
J. C/in.
successful were
Nutr.
of
MMPI
29: 626
in not 632,
1976.
Obesity is recognized as a nationwide problem which has become nearly an obsession throughout the American population. Yet results of therapy for controlling weight have met with only limited success (1-3). Encouraging results from behavior modification (4) and group therapy (5) suggest that psychological factors may strongly influence results of treatment. What are the psychological factors that determine success in achieving weight loss? Can we identify any personality characteristics of the obese person which will enable us to predict the likelihood of his achieving significant weight loss? The objectives of the study were: I) to identify the personality traits of obese persons by objective psychological assessment. 2) to determine whether by using psychological tests one can predict probability of success in weight reduction. 3) to determine whether age of onset of obesity influences success in weight reduction. If one could identify either a characteristic personality profile in obesity or a set of personality characteristics that influenced
626
The
American
Journal
of Clinical
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either success or failure, then inferences as to psychological factors that may influence the development of obesity might be drawn and perhaps more effective treatment programs could be devised. Previous attempts have not succeeded in identifying a specific personality profile for the obese person (6-8). Emotional stability (3, 9) and an older age (3, 10) of onset have been said to favor success in weight reduction. Methods Subjects A group of ranging in age
142 patients from 10 to
(Ill females 73 years was
and 31 referred
males) to an
“Abridgment of thesis submitted by Sally F. Johnson to the Faculty of the Graduate School of the University of Minnesota in partial fulfillment of the requirements for the MS. degree in nutrition. Degree granted in 1973. 2 Department of Dietetics and Nutrition. The University of Kansas Medical Center, Kansas City, Kansas 66103. 3Section of Psychology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55901. Director of Nutrition Clinic, Department of Internal Medicine, Mayo Clinic and Mayo Foundation.
Nutrition
29: JUNE
1976,
pp. 626-632.
Printed
in U.S.A.
PERSONALITY obesity
clinic
during
a 2-year
period.
CHARACTERISTICS
Criteria
for
inclu-
sion in this group were a substantial degree of overweight, and a willingness to cooperate in dietary instruction and evaluation of the problem. A few subjects were only moderately obese, but were prepared to undertake the same dietary regimen and studies due to their concern about their weight. Weight and height were measured with indoor clothing, but without shoes. The midpoint value of the range for medium frame found in the Metropolitan Life Insurance tables ( I I ) was chosen as the ideal weight for measuring the excess pounds and percent overweight.
Comparison
ofpersonality
profi/es
The Minnesota Multiphasic Personality Inventory (MMPI) (12) is a widely-used instrument for personality assessment which consists of 550 behavioral descriptive statements to which the subject responds true or false as each statement applies to him. For scoring purposes, the items are grouped together into fourteen basic scales in order to obtain a personality profile. This profile is made up of four validity scales and ten clinical scales. The validity scales measure test-taking attitudes in addition to inferring certain personality traits, and are named the following: cannot say (Q), lie (L), frequency (F), and correction (K). The basic clinical scales relate to various psychiatric syndromes, namely, hypochondriasis (HS), depression (D), hysteria (HY), psychopathic deviate (PD), masculinity-feminity (MF), paranoia (PA), psychasthenia (PT), schizophrenia (SC), hypomania (MA), and social introversion (SI). These scales are used primarily to provide characteristics rather ric disorder. The MMPI was patients. Mean MMPI were compared with
a general assessment of personality than to note a particular psychiatadministered to 120 of these 142 profiles of these obese patients mean MMPI profiles obtained at
the Mayo Clinic from a general medical population comprised of approximately 25,000 males and 25,000 females seen in the Department of Internal Medicine over a 2-year period for various medical problems (13). Therapeutic
regimen
The caloric reduction was five, or 73.9%,
range of the diets prescribed from 800 to 1,200 calories. of the 142 patients were
for weight One hundred instructed in
an 800-calorie diet consisting of approximately 60 g of protein, 30 g of fat, and 80 g of carbohydrate (14). In addition to the dietary therapy, the subjects were encouraged to establish a regular program of exercise. Procedure
for
evaluation
of
success
in
/osing
weight
Results of weight-losing efforts were obtained at the time of follow-up visits in about one-third of instances, and from responses to letters of inquiry in the others. (Three of the 142 patients were excluded because the interval of time since they had received dietary instructions was less than 4 months when the study was concluded.) Patients reporting their progress in losing weight were considered as being “more successful” or “less successful” in weight reduction. A weight loss of I) at least 10% of initial weight or 2) reduction of weight to within 20% of the ideal weight was arbitrarily chosen as a criterion for
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IN
inclusion
in the
OBESITY “more
627 successful”
group.
The
second
cri-
terion was used in order to consider the success of the small number of patients having a lesser degree of overweight, in whom a weight loss of less than 10% of the initial weight brought them to what they felt was a satisfactory weight. A weight loss of less than 10% of initial weight or a change in weight level equal to or greater than the starting weight was chosen as a criterion for inclusion in the “less successful” group. To determine whether there was a relationship between the results of the MMPI and success in losing weight, patients with normal MMPI profiles were compared with those having abnormal MMPI profiles. A normal profile is designated as one which has no T score of 70 or above among the basic clusical scales. To determine whether success in losing weight is influenced by the age of onset of obesity, a group consisting of subjects having onset of obesity before the age of 12 (designated as “childhood onset”) was compared with those who became obese at 12 years of age or older (designated as “adolescent-adult onset”).
Results Weights
of patients
The mean initial weight of the 31 men was 303.2 ± 8l.9 pounds, while the mean initial weight of the 111 women was 236.9 ± 56.9 pounds. The mean ideal weight of the 31 men was 156.8 ± l7.5 pounds, while the mean ideal weight of the 111 women was 130.0 ± l0.5 pounds. Degree
of obesity
The 31 men had a mean excess of 146.4 ± 70.5” pounds or 91.6 ± 39.1” percent overweight. The 11 1 women had a mean excess of 106.9 ± 52.3” pounds or 81.6 ± 38.2” percent overweight. Of the 142 patients, 116 (26 males and 90 females), or 81.7% of the group, were at least 50% above the ideal weight. Comparison of mean MMPI profiles of the subjects with those of general medical population MMPI profiles were considered as valid if fewer than 120 items were left unanswered in the test. By this definition, valid profiles were obtained from 116 of the 120 patients taking the test. This group of patients consisted of 24 males and 92 females. Graphic comparison of the MMPI profiles of the male obese subjects with the mean profiles of the general medical population is “Standard
deviation.
JOHNSON
628
illustrated in Figure 1. In the comparison of the mean MMPI T scores of the two male groups, it is noted that the obese male group scored significantly higher than the male medical group on the F and MA scales (statistical significance determined by the Student’s t test method). Mean MMPI profiles of the female obese subjects and the medical population are illustrated in Figure 2. The obese female subjects have a significantly higher score than the medical female group in the F, PD, PA, SC, and MA scales, and a significantly lower score on the Q scale.
Follow-up
of weight change
Of 139 patients contacted for follow-up results of the weight reduction program, 71 (17 males and 54 females), or 51% of the group, provided information on their weightlosing efforts at one or more intervals of time ranging from 4 to 28 months after receiving dietary instructions. The 17 male patients had 80
ET
a mean change from initial weight of 35.2 ± 32.8” pounds or -11.5 ± 9.1” percent at the last interval of time when they reported. The 54 female patients had a mean change from initial weight of -22.3 ± 26.3” pounds or -9.3 ± 10.2” percent when they last reported on their weight change. The change from initial weight, expressed in mean pounds and percent, is presented in Table 1 for the 17 male patients and Table 2 for the 54 female patients reporting at various intervals of time. The data show a greater weight loss for the male patients than the female patients. However, there is an increase in the change from the initial weight until the interval of time from 7 to 10 months for both groups of patients. After this interval of time, there is a return toward the original weight. Response of individual patients to the weight reduction program is not reflected by the changes from initial weight given in Tables 1 and 2. Five (four female patients and one male patient), or 3.6%, of the 139 patients were successful in reducing their weight to -
-
80
70
qJ
AL.
70
60
-
:
#{188} 0
50Normal medical Obese medical P OOi
-
40
-
*
LIll F”
O
K
Hs
DIIIHy
Pd
MfIll Pa
Pt
(24277) (24) 4C
FIG.
TABLE Weight
scales
I.
Basic
Mean
1 change
after
MMPI
diet
profiles
started
Time after start of diet (months)’
4-6 7-10 11-15 16-21 22-28 ‘Time interval
interval determined at the time the study
clinical
scales
of male
(male
medical
1257231
Obese
medical
192)
* ScIllMo”Si 0”
Validity
Normal
L
F*
Validity
patients.
FIG.
Hs
K
D
Hy
scales
2.
P
I
I
I
I
Pd’
Mt
Pa’
Pt
Sc
Basic
Mean
MMPI
profiles
001
I
clinical
I Mo’
Si
scales
of female
patients.
patients)
No. of patients”
30 28 23 14 3 according to the was terminated.
Pts reporting at each time interval No.
%
17 6 13 6 1
56.7 21.4 56.5 42.9 33.3
nearest
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month.
Chang e from mean
initial weight ± SD
Pounds -39.9± -67.7 -36.2± -33.2 -43.0
b Number
±
± ±
35.6 64.3 30.6 19.8 0.0
% -11.7±9.1 17.2
±
12.2
-11.9±8.9 11.9 -22.4
±
7.4 0.0
-
±
of patients in the study for each reporting
PERSONALITY TABLE Weight
2 change
after
diet
started
(female
Time after start of diet (months)’
No. of Pt?
4-6 7-10 lI-IS 16-21 22-28
109 88 69 53 25
‘Time interval
interval determined at the time the study
TABLE 3 Relationship
of MMPI
results
CHARACTERISTICS
Pts reporting at each time interval
according to the was terminated.
to success
Time after start of diet (months) 4-6 7-10 lI-IS 16-28
17 6 13 7
629
OBESITY
patients)
%
Pounds
37 17 20 9 7
33.9 19.3 29.0 17.0 28.0
-24.1± 18.3 -32.6±28.8 -21.6± 23.8 -7.9 ± 24.0 -9.6 ± 24.7
nearest
in weight
month.
reduction’
More successful No. %
No. 6 3 5 3
4 2 3 2
66.7 66.7 60.0 66.7
e from mean
Chang
No.
Pts with normal No. pts reporting at each time interval
IN
Number
(male
% -10.4±7.2 -12.9± 10.8 -9.3 ±8.9 -3.8 ± 10.0 -5.3 ± 13.0
of patients
#{176}
initial weight ± SD
in the study
for each
reporting
patients) Pta with abnorma
profile”
Less succcsf No. 2 1 2 1
1 profiler
More No
% 33.3 33.3 40.0 33.3
Less
No.
7 1 5 2
4 1 3 2
%
No.
%
57.1 100.0 60.0 100.0
3 0 2 0
42.9 0.0 40.0 0.0
‘Criteria of success: I) more successful = reduction of weight to within 20% of ideal weight or a weight loss greater than or equal to 10% of initial weight. 2) less successful = weight loss less than 10% of initial weight or a change in weight to a level greater than or equal to the initial weight. ‘ Normal profile = profile having all T scores less than 70. Abnormal profile = profile having I or more T scores 70 or more.
TABLE
4
Relationship
of MMPI
results
to success
in weight
reduction’
(female
patients) Pts with abno rmal profiler
Pts with nor mal profile” No. pts reporting at each time interval
Time after start of diet (months)
No.
No. 37 17 20 14
4-6 7 10 Il-IS 16-28
15 9 6 3
Less successful
More successful %
8 5 3 2
‘Criteria of success: I) more successful = reduction than or equal to 10% of initial weight. 2) less successful weight to a level greater than or equal to the initial 70. C Abnormal profile = profile having I or more
53.3 55.6 50.0 66.7
No.
%
7 4 3 1
17 7 9 8
46.7 44.4 50.0 33.3
showed loss.
a gain
Relationship weight
in weight
of MMPI
Less successful
More successful %
9 4 6 5
-
52.9 57.1 66.7 62.5
of weight to within 20% of ideal weight = weight loss less than 10% of initial weight. b Normal profile = having T scores 70 or more.
within 20% of the ideal weight. These patients were all less than 50% above ideal weight initially. Certain trends were evident for the majority of patients reporting. Information from patients who were followed for less than 1 year usually indicated a weight loss with each interval of time after the start of diet. Information from the patients who were followed for more than 1 year frequently
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No.
No.
No.
%
8 3 3 3
47.1 42.9 33.3 37.5
or a weight loss greater weight or a change in all I scores less than
after
profiles
an initial
weight
to success
in
reduction
The success in weight reduction as it relates to the male and female patients having normal and abnormal MMPI profiles is shown in Tables 3 and 4. Although differences in the
630
JOHNSON
ET
latter (mean at the time
degree of success are noted at various intervals of time, there is no apparent trend in the rate of success according to the type of MMPI profile. of age
Relationship
success
in weight
at onset reduction
of obesity
of age
at onset
of obesi
MMPI
to
ty to su ccess
age 44, mean of this study.
characteristics
Time after start of diet (months)
in weight
reduction’
17 6 13 7
4-6 7-10 11-15 16-28
More successful
No.
13 6 10 4
(male
of age
at onset
of obesity
Less successful %
No.
%
8 4 6 3
61.5 66.7 60.0 75.0
5 2 4 1
38.5 33.3 40.0 25.0
in weight
Pts with onset childhood(l-l No. pts reporting at each time interval
37 17 20 14
Time after start of diet (months)
4-6 7-10 11-15 16-28
No.
19 9 7 7
reduction’ of obesity I yrs)
More successful
(female
No.
%
No.
1 0 2 2
25.0 0.0 66.7 66.7
3 0 1 1
20% of ideal loss less than
No.
%
11 6 5 4
57.9 66.7 71.4 57.1
8 3 2 3
42.1 33.3 28.6 42.9
% 75.0 0.0 33.3 33.3
weight or a weight loss of 10% of initial weight or a
patients)
No.
%
‘Criteria of success: 1) more successful = reduction in weight than or equal to 10% of initial weight. 2) less successful = weight weight to a level greater than or equal to the initial weight.
Less successful
Pts with onset adolescence-adulthood
Less successful
of obesity in ( 12 yrs)
More successful
4 0 3 3
in
No.
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subjects
patients)
No.
No.
to success
of obese
Pts with onset adolescence-adulthood
‘Criteria of success: I) more successful = reduction in weight to within greater than or equal to 10% of initial weight. 2) less successful = weight change in weight to a level greater than or equal to the initial weight.
TABLE 6 Relationship
73.8%)
Of the various studies of which we are aware, using the MMPI to evaluate the personality characteristics of obese persons (15-19), only a portion of the work reported by Crumpton et al. (15) closely resembles this study. Crumpton et al. did not find any significant differences in the comparison of mean MMPI profiles of the group of obese men and a group of general male medical and surgical patients, each group containing 29 subjects. Our study, however, does show some significant differences in the MMPI profile of obese subjects and those of the general medical population. Significantly higher mean T scores on the F scale for the male and female obese subjects
Pts with onset of obesity in childhood (1-Il yrs) No. pts reporting at each time interval
overweight
Discussion
The relationship of age at onset of obesity to success in weight reduction for the male and female obese patients is illustrated in Tables 5 and 6. For most of the reporting intervals of time, there is a greater percentage of more successful patients among those who became obese during childhood than those who became obese during adolescence-adulthood for both the male and female patients, although the differences are not statistically significant. The childhood-onset and the adolescentadult-onset groups differed also in that the former were younger (mean age 30 years) and heavier (mean overweight 93%) than the TABLE 5 Relationship
AL.
18 8 13 7
to within 20% of ideal loss of less than 10%
More successful
of
obesity
in
(
12
yrs.)
Less successful
No.
%
No.
%
9 4 7 4
50.0 50.0 53.8 57.1
9 4 6 3
50.0 50.0 46.2 42.9
weight or a weight loss greater of initial weight or a change in
PERSONALITY
CHARACTERISTICS
than the medical population suggest the possible presence of more dissatisfaction in family and social relationships among obese persons than nonobese persons. Significant elevations in the MA scale for the male and female obese patients may be related to the subjective unrest that often occurs in obese persons, particularly if the need for food was established early in childhood (20). The significantly greater difference on the PD scale for the obese female subjects than the female medical subjects may indicate that obese women are more nonconforming and impulsive than women of normal weight. The significant difference on the PA scale showing more interpersonal sensitivity for the female obese persons than the female medical subjects is perhaps associated with the feelings incurred by social disapproval of the obese state. Explanation of the significant difference in the SC scale for the reference and obese subjects is guarded because of the diversification of the items comprising this scale. However, the larger mean T score for the female obese subjects may be related to the social alienation that results from being obese. Although the scores on the Q scale indicate that the medical female subjects omitted more items on the test than the obese female subjects, the number of items excluded by either group probably had little effect on the validity of the test for both of the mean T scores on this scale are below fifty. Results of this study do not indicate whether the prominent personality characteristics as revealed by the MMPI profiles are a cause or result of the obesity. This would be difficult to determine because the MMPI was administered to the obese subjects after they had become overweight. Even though the findings show that particular personality traits may be apparent in obese persons, the individual MMPI profile codes point out the presence of diverse behavior patterns among obese persons, rather than a single personality pattern characteristic of obesity.
Relationship of MMPI findings and age of onset of obesity to success in weight reduction
no
McLaren relationship
(21)
and Penick between the
et al. (4) noted responses to the
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IN OBESITY
631
MMPI and success in losing weight for persons participating in programs for the treatment of obesity. Mullins (10) reported a greater success in weight reduction for patients with adult obesity than those with juvenile obesity, defined as being known as “fatty at school.” In an experimental nutrition clinic, Young et al. (3) found that obesity occurring in childhood or before the age of 18 years is more difficult to treat than that occurring in adulthood. The studies of McLaren (21) and Penick et al. (4) are in agreement with our finding that there is no apparent relationship between the type of MMPI profile and success in losing weight. However, the results of the present study are somewhat different from those of Mullins (10) and Young et al. (3), in that we noted a greater percentage of more successful patients among those who developed obesity during childhood than those who became obese during adolescence-adulthood . These differences are not large enough to be statistically significant for either the male or female patients. Furthermore, the younger age and greater degree of obesity at the time of the study may have, in some way, facilitated weight reduction by the childhood-onset group. Although reduction to an ideal or desirable weight is often used as the criterion for successful treatment of obesity, losses of 10% or more of initial weight may provide an appreciable amelioration of the symptoms and physiological stresses imposed by obesity and should not be looked upon as complete failure. The large percentage of patients not answering letters of inquiry or returning for follow-up suggest that the results of the dietary efforts of the entire group may have been less successful than the data in Tables 1 and 2 indicated, since the nonreporters were presumably the less successful. We
find
no
clue
in
the
MMPI
characteris-
of these obese subjects as a group or of the more or less successful subgroups to suggest that there is any particular personality trait or traits which could be exploited in prevention of obesity or in the development of effective treatment programs. This does not exclude the possibility that other modes of psychological testing might yield different results. tics
a
632
JOHNSON
References 1. FRANKLIN, R. E., AND E. H. RYNEARSON. An evaluation of the effectiveness of diet instruction for the obese. Mayo Clin. Proc. 35: 123, 1960. 2. STUNKARD, A. J., AND M. MCLAREN-HUME. The results of treatment for obesity. Arch. Intern. Med. 103: 79, 1959. 3. YOUNG, C. M., N. S. MOORE, K. K. BERRESFORD AND B. M. EINSET. What can be done for the obese patient? Am. Practitioner Dig. Treat. 6: 685, 1955. 4. PENICK, S. B., R. FluoN, S. Fox AND A. J. STUNKARD, Behavior modification in the treatment of obesity. Psychosomat. Med. 33: 49, 1971. 5. STUNKARD, A., H. LEVINE AND S. Fox, A study of a self-help group for obesity. Excerpta Med. International Congress Series No. 213, p. 223, 1969. 6. BRUCH, H. Prognosis and treatment of obesity from a psychiatrist’s point of view. J. Am Med. Women’s Assoc. 19: 745, 1964. 7. KAPLAN, H. I., AND H. S. KAPLAN. The psychosomatic concept of obesity. J. Nervous Mental Disease 125: 181, 1957. 8. WEINBERG, N., M. MENDELSON AND A. J. STUNKARD, A failure to find distinctive personality features in a group of obese men. Am. J. Psychiat. 117: 1035, 1961. 9. DARLING, C. D., AND J. SUMMERSKILL. Emotional factors in obesity and weight reduction. J. Am. Dietet. Assoc. 29: 1204, 1953. 10. MULLINS, A. G. The prognosis in juvenile obesity. Arch. Disease Childhood 33: 307, 1958.
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ET 11.
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S. R., AND J. C. MCKINLEY, Minnesota Personality Inventory Manual, 2nd ed., The Psychological Corporation, 1951. SWENSON, W. M., J. S. PEARSON AND D. OSBORNE, An MMPI Source Book: Basic Item, Scale, and Pattern Data on 50,000 Medical Patients. Minneapolis: University of Minnesota Press, 1973. Committee on Dietetics of the Mayo Clinic: Mayo Clinic Diet Manual, 4th ed. Philadelphia: W. B. Saunders Company, 1971, p. 71. CRUMPTON, E., D. B. WINE AND H. GROOT, MMPI profiles of obese men and six other diagnostic categories. Psychol. Rept. 19: 1110, 1966. FELLNER, C. H., AND H. LEVITT, A new approach to overweight. Am. J. Clin. Nutr. 15: 50, 1964. KOLLAR, E. J., R. M. ATKINSON AND D. L. ALBIN, The effectiveness of fasting in the treatment of superobesity. Psychosomatics 10: 125, 1968. REIVICH, R. S., R. A. RUIZ AND R. M. LAPI, Extreme obesity-psychiatric, psychometric and psychotherapeutic aspects. J. Kansas Med. Soc. 67: 134, 1966. WERKMAN, S. L., AND E. S. GREENBERG, Personality and interest patterns in obese adolescent girls. Psychosomat. Med. 29: 72, 1967. SWANSON, D. W., AND F. A. DINELLO, Severe obesity as a habituation syndrome: evidence during a starvation study. Arch. Gen. Psychiat. 22: 120, 1970. MCLAREN, B. A. Nutritional control of overweight. Can. J. Public Health 58: 483, 1967. HATHAWAY,
Multiphasic New York:
13.
standards of the
![[Age at onset of obesity in children].](/assets/img/hold.png)
