RESEARCH ARTICLE

Subtypes of Personality and ‘Locus of Control’ in Bariatric Patients

and their Effect on Weight Loss, Eating Disorder and Depressive
Symptoms, and Quality of Life
Carolin Peterhänsel1,2* , Katja Linde1, Birgit Wagner3, Arne Dietrich2,4 & Anette Kersting1,2
1
Department of Psychosomatic Medicine and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
2
Integrated Research and Treatment Center (IFB) Adiposity Diseases, Leipzig University Medical Center, Leipzig, Germany
3
MSB Medical School Berlin, Germany
4
Department of Surgery, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany

Abstract
The present study subdivided personality types in a bariatric sample and investigated their impact on weight loss and psychopathology 6
and 12 months after surgery. One hundred thirty participants answered questionnaires on personality (NEO-FFI), ‘locus of control’
(IPC), depression severity (BDI-II), eating disorder psychopathology (EDE-Q), and health-related quality of life (HRQoL; SF-12).
K-means cluster analyses were used to identify subtypes. Two subtypes emerged: an ‘emotionally dysregulated/undercontrolled’ cluster
defined by high neuroticism and external orientation and a ‘resilient/high functioning’ cluster with the reverse pattern. Prior to surgery,
the first subtype reported more eating disorder and depressive symptoms and less HRQoL. Differences persisted regarding depression
and mental HRQoL until 12 months after surgery, except in the areas weight loss and eating disorders. Personality seems to influence
the improvement or maintenance of psychiatric symptoms after bariatric surgery. Future research could elucidate whether adapted treat-
ment programmes could have an influence on the improvement of procedure outcomes. Copyright © 2017 John Wiley & Sons, Ltd and
Eating Disorders Association.
Received 28 March 2017; Revised 31 May 2017; Accepted 12 June 2017

Keywords
Personality; locus of control; bariatric surgery; eating disorders; depression

*Correspondence Carolin Peterhänsel, University of Leipzig, Integrated Research and Treatment Center (IFB) Adiposity Diseases, Department of Psychosomatic
Medicine, Semmelweisstraße 10, 04103 Leipzig, Germany. Phone: 0049-(0)341-9718951; Fax: 0049-(0)341-9718849
Email: carolin.peterhaensel@medizin.uni-leipzig.de

Published online 18 July 2017 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2534

INTRODUCTION of unusually large amounts of food, a sense of loss of control over

Overweight (body mass index, BMI ≥ 25 kg/m2) and obesity
(BMI ≥ 30 kg/m2) are counted among the ‘leading global risks
for mortality in the world’ (World Health Organization, 2009),
especially because of their relation to high somatic comorbidity
(Kopelman, 2000). Hence, studies need to be done to examine
aetiological factors causing obesity and develop effective ap-
proaches for reversing this increase (Jebb, 1997; Wyatt, Winters,
& Dubbert, 2006). Recent research concludes that obesity results
from an interaction of a multitude of variables and that some con-
tributing factors have yet to be identified (Jebb, 1997; Wright &
Aronne, 2012).
Several studies have already been conducted to ascertain
whether there is an association between personality traits and obe-
sity. Recent surveys found tendencies towards neuroticism, im-
pulsivity and sensitivity to reward to be risk factors for the
development of obesity, and conscientiousness and self-control
to be protective factors (Gerlach, Herpertz, & Loeber, 2015).
Many patients with obesity suffer from an eating disorder
(De Zwaan, 2001; Duncan, Ziobrowski, & Nicol, 2017; Villarejo
et al., 2012) such as bulimia nervosa (defined by the consumption
eating, and recurrent purging behaviours) and binge eating disor-
der (BED, characterized by binge eating episodes with no purging
behaviours) (American Psychiatric Association, 2013), with binge
eating disorder being the eating disorder with the highest preva-
lence rates in bariatric samples (Kalarchian et al., 2007). Some
studies have reported that patients with obesity who suffer from
eating disorders have higher neuroticism scores (Dahl et al.,
2012) and less effortful control (Müller et al., 2012), and other
studies have observed this group to exhibit above average levels
of harm avoidance and low self-directedness, persistence and co-
operativeness (Villarejo et al., 2014). Some authors already define
sufferers of BED as a personality subtype of people with obesity
(Dalton, Blundell, & Finlayson, 2013).
A substantial proportion of patients with obesity decide to un-
dergo bariatric surgery, a procedure proved to lead to substantial
weight loss and the improvement of co-morbid conditions
(Buchwald et al., 2004). An account of research on personality
factors in bariatric surgery patients and, if mentioned, their influ-
ence on the outcome of the procedure is given in the narrative re-
view by Claes and Müller (2015). Because the included studies
used different underlying models of personality, the authors

Eur. Eat. Disorders Rev. 25 (2017) 397–405 Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association. 397
Personality Subtypes in Bariatric Patients
focused on two studies that combine several temperament traits
to build personality subtypes, one based on the NEO-FFI (Claes,
Vandereycken, Vandeputte, & Braet, 2013), and another based
on behavioural activation and inhibition as well as effortful con-
trol (Müller, Claes, Wilderjans, & de Zwaan, 2014). The authors
indicate a differentiation between two prototypes. One is labelled
the ‘resilient/high functioning’ subtype and is characterized by a
counterbalanced profile scoring low on neuroticism, and the sec-
ond is named ‘emotionally dysregulated/undercontrolled’ and is
characterized by high neuroticism scores and low values on the
other scales of the NEO-FFI (Claes et al., 2013). Differences be-
tween both subtypes become evident in several psychological do-
mains, with the ‘emotionally dysregulated/undercontrolled’
subgroup showing more eating disorder symptoms (especially
binge eating), psychological impairments like depression and anx-
iety, and coping strategies that are avoidant and depressive (Claes
et al., 2013; Müller et al., 2014). These studies on personality sub-
types set their focus on one measuring point; thus, no conclusions
can be drawn about the impact personality traits have on surgery
outcomes in the long term.
Another dimension of personality is based on the theory of
‘control of reinforcement’ or ‘locus of control’. Rotter (1966) de-
scribed it as the degree to which individuals attribute a reward to
be determined by their own behaviour and/or characteristics. In-
dividuals with more internal control take more responsibility over
their lives whereas those oriented more towards external control
believe in more external factors like chance, luck and fate, or the
influence of powerful others (Rotter, 1966). Levenson (1972,
1973) elaborated further on this theory by distinguishing within
the dimension of external control between external chance orienta-
tion and external orientation of powerful others.
‘Locus of control’ has been researched with regard to its predic-
tive function in weight loss programmes and in the maintenance
of lost weight but not in bariatric populations. The results of stud-
ies that have evaluated weight loss programmes are somewhat in-
consistent. Many studies point out a relation between internal
control orientation and weight loss, while others do not differen-
tiate between internally and externally oriented individuals
(Elfhag & Rössner, 2005; Teixeira, Going, Sardinha, & Lohman,
2005). The same tendency was found in studies on weight loss
maintenance (Anastasiou, Fappa, Karfopoulou, Gkza, &
Yannakoulia, 2015; Elfhag & Rössner, 2005).
To our knowledge, studies on ‘locus of control’ in bariatric pa-
tients are missing as well as research on the predictive function of
personality subtypes on outcomes after bariatric surgery. Hence,
the aim of the present study was to use cluster analyses to identify
personality subtypes in patients undergoing bariatric surgery
based on the scales of the NEO-FFI (Costa & McCrae, 1992)
and the dimensions of ‘locus of control’ characterized by
Levenson (1972). This approach is in accordance with the Claes
and Müller (2015) findings but expands on recent studies by in-
cluding another temperament dimension. A further addition to
preceding research work is the examination of how personality
subtypes impact postoperative variables up to 12 months after
bariatric surgery. Concretely, we wanted to figure out both
whether patients of distinct classifications differed in preoperative
characteristics, and whether the subtyping could predict postop-
erative outcomes 6 and 12 months after surgery. Next to weight
398 Eur. Eat. Disorders Rev. 25 (2017) 397–405 Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
C. Peterhänsel et al.
loss, we examined psychological dimensions like eating disorder
psychopathology and depression severity along with health-
related quality of life (HRQoL) as dependent variables.
On the basis of recent findings (Claes & Müller, 2015), we hy-
pothesized the emergence of two subtypes within our bariatric
sample, one more ‘resilient/high functioning’ and the other ‘emo-
tionally dysregulated/undercontrolled’. Further, we expected the
‘resilient/high functioning’ type to be more internally oriented
whereas the ‘emotionally dysregulated/undercontrolled’ type was
anticipated to be more externally oriented. Additionally, a signif-
icant difference between the personality types was hypothesized
regarding HRQoL, depression severity and eating disorder psy-
chopathology at all assessment points with the ‘emotionally
dysregulated/undercontrolled´ subtype being more prone to psy-
chological disturbances. A significant amelioration of these scores
was anticipated due to the bariatric procedure for all patients of
the sample, independently of the related cluster.
MATERIALS AND METHODS
Participants
The sample for the present study consists of patients who
underwent bariatric surgery between November 2011 and April
2014. They were asked to participate in the study during their
pre-operative surgical consultation at the obesity outpatient clinic
of the Integrated Research and Treatment Center (IFB) Adiposity
Diseases Leipzig. Those interested in participating provided their
written informed consent. Patients were only recruited if they ful-
filled the following inclusion criteria: (i) BMI exceeding 40 kg/m2
or BMI exceeding 35 kg/m2 in combination with a comorbid dis-
order (e.g. hypertension); (ii) aged between 18 and 65; and (iii)
sufficient German language skills. Of the initial 207 patients
who fulfilled the inclusion criteria and were potentially available
for the 12-month follow-up period, 198 participants completed
baseline questionnaires (95.65%). Patients with a secondary bar-
iatric procedure were excluded (n = 8) as well as those not avail-
able for follow-up measurements (n = 35). To avoid a possible
bias in the data, another 21 participants were excluded because
they returned their questionnaires later than three months after
a follow-up point. Four more participants were excluded from
the analyses due to missing data on their personality question-
naires. In total, data from 130 participants could be included in
the analyses (65.65% of the baseline population). These 130 par-
ticipants were compared to those who had filled out baseline as-
sessment (n = 68) regarding sociodemographic variables. We
found that they differed significantly from each other regarding
gender distribution with 72.3% females in the analysed group
and 54.4% in the excluded group but no other differences were
found.
The study was conducted according to the Declaration of Hel-
sinki and was approved by the local ethical committee of the Uni-
versity of Leipzig.
Measures
Patients were asked to fill out questionnaires prior to surgery as
well as at 6- and 12-month follow-up points. In addition to de-
mographic data like date of birth, gender, education, employment
and marital status, information regarding comorbid somatic
C. Peterhänsel et al.
conditions, prior search for professional help, and actual height
and weight were also collected. Objective data on weight and
BMI was also taken from patient charts and used to calculate per-
cent of excess weight loss (%EWL). Self-reported values were used
if objective data were missing.
We used the German version (Borkenau & Ostendorf, 1993) of
the NEO-FFI (Costa & McCrae, 1992), a 60-item self-report ques-
tionnaire designed to measure personality facets based on the five-
factor theory of personality. Differences between persons can be
described by means of their values on the stable dimensions neu-
roticism, extraversion, openness to experience, agreeableness and con-
scientiousness (McCrae & Costa, 1999). In our sample, Cronbach’s
α was .76 which stands for an acceptable internal consistency. The
German version (Krampen, 1981) of the ‘locus of control’ ques-
tionnaire (IPC) (Levenson, 1972) consists of 24 items and assesses
the construct ‘control of reinforcement’ that is further differenti-
ated into the dimensions internal control, powerful others external
control orientation and chance control orientation. In the context
of this subdivision, individuals who feel strongly controlled by
powerful others in an ordered world have a potential influence
through purposeful action and are therefore more similar to indi-
viduals with an internal ‘locus of control’ (Levenson, 1973, 1981).
The internal consistency of the scale within our population was
acceptable (Cronbach’s α = .78). The Eating Disorder Examina-
tion—Questionnaire (EDE-Q) (Hilbert & Tuschen-Caffier,
2006) is designed to measure aspects of disordered eating on the
dimensions restraint, eating concern, shape concern and weight con-
cern. There are also questions concerning loss of control over eat-
ing within the past 28 days (item 14) as well as objective binge
episodes (item 15) defined as consumption of a large amount of
food with the sense of lost control over eating (Fairburn & Beglin,
1994). Cronbach’s α for the items of the Global score was
.77 (αRestraint = .66; αEating Concern = .69; αWeight Concern = .47; αShape
Concern = .75). Depressive symptoms were assessed using the 21-
item Beck Depression Inventory-II (BDI-II) (Hautzinger, Keller,
& Kühner, 2006), and internal consistency was excellent
(Cronbach’s α = .92). A value of 14 is proven to mark the cut-
off between inconspicuous symptoms and the indication of a ma-
jor depressive disorder (Beck, Steer, & Brown, 1996). HRQoL,
and the component scales for physical (PCS; Cronbach’s α = .84)
and mental HRQoL (MCS; Cronbach’s α = .81) in particular, were
measured with the Short-Form (SF-12) Health-Survey (Bullinger
& Kirchberger, 1998).
Statistical methods
Analyses were done using SPSS, Version 24. We chose a
partitioning cluster analysis approach (k-means) to identify sub-
types of personality on the basis of the five NEO-FFI and the three
IPC dimensions. With this technique, homogeneity within the
cluster is defined by the squared sum of the statistical dispersion,
which is intended to be kept at a minimum (Bacher, 2001). In or-
der to equalize the eight scales, they were first standardized into z-
scores. Thereafter, nine different cluster solutions (ranging from
one to nine clusters) were performed and tested to formally ascer-
tain the appropriate cluster solution. The test statistics calculated
were: Eta2, PRE-coefficients and F-max statistics.
Eta2 specifies the variance explained by a particular cluster so-
lution by comparing it with a further cluster solution. A cluster
Eur. Eat. Disorders Rev. 25 (2017) 397–405 Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
Personality Subtypes in Bariatric Patients
solution is chosen if the Eta2 of following cluster solutions does
not substantially contribute to explaining a variance. The PRE-
coefficient (proportional reduction of errors) describes the rela-
tive improvement of the error of dispersion, and accordingly,
the reduction of the error of one cluster solution in comparison
to the preceding one. As well as with Eta2, if a particular cluster
solution is not substantially better than the one that preceded it,
the preceding one is chosen. Because both Eta2 and the PRE-
coefficient are affected by the number of clusters, the F-max sta-
tistic was calculated, thus providing a representation of the rela-
tion between the explained dispersion in comparison with the
unexplained dispersion. This statistic is independent of the num-
ber of clusters, and the cluster solution with the highest F-max
value is chosen.
The test statistics pointed to a two-cluster solution for describ-
ing personality subtypes, and a verification of the stability of the
cluster solution is recommended. Bacher (2001) and Schendera
(2011) describe an approach for testing whether cases are stably
attributable to one cluster regardless of what the given start values
are. Using this method, the original cluster solution was com-
pared to a further cluster solution with determined instead of ran-
dom start values that were derived from hierarchical cluster
analysis done with the WARD method on a random sample
(50% of the original sample). Kappa was calculated to test the
match between both cluster solutions. Values ≥ .75 are considered
excellent, and a poor agreement is indicated by a Kappa value ≤
.40 (Fleiss, Levin, & Paik, 2003).
The different subtypes are described via means of the z-
standardized scales of the NEO-FFI and the IPC. Comparisons
between the two clusters concerning baseline demographic and
psychopathological data as well as help-seeking behaviour and so-
matic comorbidities were calculated using χ 2-tests, Mann–
Whitney U-tests, and t-tests. χ2-tests were also used to compare
the clusters regarding somatic comorbidities at follow-up mea-
surements. Repeated measures ANOVA were conducted to iden-
tify changes between the three measuring points regarding BMI,
excess weight loss, the subscales and global score of the EDE-Q,
binge eating severity and loss of control eating, depression severity
and the two component scales of the SF-12 due to the cluster
solution.
RESULTS
The results of the k-means cluster analyses in combination with
the test statistics indicated that a two-cluster solution depicts the
data best. As can be seen in Table 1, the PRE-coefficient is highest
for the two-cluster solution, but also values of the models with
four or eight clusters suggest a good error reduction. Considering
Eta2, the solutions with two, three, four and eight clusters explain
substantial variance of the data, but with regard to the F-max
values, the two-cluster model is outstanding and was therefore
chosen. A Kappa of K = .985, p < .001 was calculated by compar-
ing the chosen model to another two-cluster solution with deter-
mined start values signifying a very good accordance between the
two models and confirming the stability of the found cluster
solution.
Expressions of the two clusters on the scales of the NEO-FFI
and IPC are shown in Figure 1. Means, standard deviations and
399
Personality Subtypes in Bariatric Patients C. Peterhänsel et al.

Table 1 Test statistics to ascertain the appropriate cluster solution

1 Cluster 2 Clusters 3 Clusters 4 Clusters 5 Clusters 6 Clusters 7 Clusters 8 Clusters 9 Clusters

PRE-coefficient .00 .26 .08 .10 .08 .03 .04 .10 .02
2
Eta .00 .26 .32 .39 .44 .46 .48 .54 .54
F-max .00 45.54 30.32 26.96 24.41 20.96 19.05 20.06 18.01

PRE-coefficient: proportional reduction of errors-coefficient.

Table 3 Characteristics of the study population for cluster 1 and cluster 2

Cluster 1
‘emotionally Cluster 2
dysregulated/ ‘resilient/high
undercontrolled’ functioning’ Test
N = 65 N = 65 statistic p-Value

Age at baseline, M (SD) 47.31 (10.55) 47.48 (10.39) .016* .927

Gender distribution, %
Female 66.2 78.5 2.459† .117
Marital status, %
Married or cohabiting 75.4 78.5 .173† .677
Education, %
3.109†
a
Low 23.4 12.3 .211
Middle 64.1 69.2
Figure 1. Characterization of the cluster solution by standardized scores of the High 12.5 18.5
scales of the NEO-Five-Factor Inventory (neuroticism, extraversion, openness, Employment, %
4.629†
b
agreeableness, conscientiousness) and the locus of control questionnaire Employed 34.9 54.0 .031
(internality, powerful others, chance). [Colour figure can be viewed at Type of surgery, %
Roux-en-Y gastric bypass 86.2 87.7 .068† .795
wileyonlinelibrary.com]
Sleeve gastrectomy 13.8 12.3
2
BMI (kg/m ), M (SD)
the results of the ANOVA between the clusters are presented in Baseline 50.39 (8.22) 49.47 (7.69) .567††
c
.568
Table 2. With the exception of the IPC internality scale, the clus- T1 38.83 (7.27) 38.6 (6.77)
ters differ significantly from each other. In particular, cluster 1 is T2 35.86 (6.91) 35.07 (6.41)
defined by higher scores on neuroticism and the externally oriented %Excess weight loss, M (SD)
.282††
d
(powerful others, chance) scales of the IPC and lower scores on Baseline-T1 47.74 (18.74) 49.22 (17.69) .597
the dimensions extraversion, openness to experience, agreeableness, Baseline-T2 59.79 (21.3) 62.26 (18.55)
conscientiousness and internality. For cluster 2, the opposite was
aN = 129, bN = 126, cN = 130, df = 2, dN = 130, df = 1.
found. In accordance with previous publications (Claes et al., a
* T-test was used.
2013; Müller et al., 2014), the subtypes are labelled ‘emotionally †b
Chi-squared test was used.
dysregulated/undercontrolled’ (cluster 1) and ‘resilient/high func- ††c
Repeated measures ANOVA, between subjects factor: cluster, within subjects
tioning’ (cluster 2). factor: time.
A comparison of the clusters in terms of sociodemographic
characteristics, BMI and excess weight loss up to 12 months after 78.5%). A significant difference was found in the area of employ-
surgery can be found in Table 3. Most patients of both subtypes ment status with participants assigned to cluster 1 reporting a
were female (66.2 and 78.5%) and in a relationship (75.4 and higher incidence of unemployment. The bariatric procedure most
Table 2 Description of cluster 1 and cluster 2 by means and standard deviations of the NEO-FFI and the IPC scales

Cluster 1 ‘emotionally dysregulated/undercontrolled’ Cluster 2 ‘resilient/high functioning’ Test statistic (F) p-Value

NEO-FFI Neuroticism 0.64 (0.79) 0.68 (0.69) 101.717 <.001

NEO-FFI Extraversion 0.50 (0.91) 0.52 (0.81) 45.168 <.001
NEO-FFI Openness 0.38 (0.84) 0.38 (1.02) 21.475 <.001
NEO-FFI Agreeableness 0.52 (0.82) 0.52 (0.90) 47.412 <.001
NEO-FFI Conscientiousness 0.43 (0.95) 0.46 (0.84) 32.155 <.001
IPC Internality 0.11 (0.86) 0.10 (1.13) 1.428 .234
IPC Powerful others 0.66 (0.73) 0.65 (0.80) 94.239 <.001
IPC Chance 0.59 (0.75) 0.59 (0.87) 68.125 <.001

ANOVA was used to test differences between both subtypes.

400 Eur. Eat. Disorders Rev. 25 (2017) 397–405 Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
C. Peterhänsel et al. Personality Subtypes in Bariatric Patients

often applied was Roux-en-Y gastric bypass surgery (86.2 and Table 5 Comparison of help-seeking behaviour and somatic comorbidities
87.7%). Baseline BMI was similar for both subtypes (50.39 and between cluster 1 and cluster 2
49.47 kg/m2) and weight loss after bariatric surgery did not differ
significantly between the clusters. Cluster 1
Significant differences between the two subtypes were found ‘emotionally Cluster 2
in terms of baseline psychopathology (Table 4). Patients dysregulated/ ‘resilient/high
undercontrolled’ functioning’ Test
assigned to the ‘emotionally dysregulated/undercontrolled’
N = 65 N = 65 statistic p-Value
cluster had substantially higher scores on the EDE-Q scales
eating concern, weight concern, shape concern and the Global Professional help-seeking, baseline, %
score. Neither the restraint scale nor the items measuring binge General practitioner 46.2 56.9 1.509 .219
eating episodes and loss of control eating indicated significant Nutritionist 83.1 73.8 1.639 .201
differences between the two subtypes. A further distinction was Dietary program 49.2 43.1 .495 .482
Psychotherapy 12.3 23.1 2.588 .108
found on the BDI-II with significantly higher scores for the
Somatic comorbidities, Baseline, %
‘emotionally dysregulated/undercontrolled’ subtype that also
Hypertension 72.3 69.2 .149 .700
exceeded the cut-off score. This cluster also reported less physical Diabetes mellitus 44.6 43.1 .031 .860
and mental HRQoL in comparison to the ‘resilient/high Sleep apnea 16.9 27.7 2.175 .140
functioning’ subgroup. Bone-joint diseases 64.6 67.7 .137 .711
The clusters were compared regarding help-seeking behaviour Somatic comorbidities, T1, %
and somatic comorbidities at all measuring points (Table 5). No Hypertension 53.8 49.2 .277 .599
differences occurred in the help-seeking behaviour at all measur- Diabetes mellitus 26.2 32.3 .595 .441
ing points, and therefore we just demonstrated baseline values. Sleep apnea 10.8 24.6 4.279 .039
In terms of somatic comorbidities, the only significant difference Bone-joint diseases 53.8 68.8 3.018 .082
Somatic comorbidities, T2, %
between both groups was found for sleep apnea at 6-month
Hypertension 63.1 50.8 2.008 .157
follow-up.
Diabetes mellitus 21.5 26.2 .381 .537
Results of repeated measures ANOVA to compare the two clus- Sleep apnea 10.8 20.0 2.127 .145
ters with respect to changing psychopathology and HRQoL scores Bone-joint diseases 48.4 56.9 .932 .334
are presented in Table 6. The F-values and significance levels show
both the effect of time and the interaction between time and clus- Chi-squared test was used to measure differences between the clusters.
ter assignment. The effect of time was significant for all scales. In
particular, the depression severity and disordered eating scores DISCUSSION
decreased whereas HRQoL physical and mental values increased
and therefore indicate significant improvements. As far as the in- The aim of the present study was to identify subtypes of patients
teraction effect is concerned, it can be pointed out that there were undergoing bariatric surgery by means of the NEO-FFI and IPC
significant differences between the two subtypes regarding depres- scales and the impact of personality traits on loss of excess
sion severity and mental HRQoL with the ‘emotional weight, psychopathology and HRQoL at baseline, 6-month and
dysregulated/undercontrolled’ subtype reporting more depressive 12-month follow-up measurement points. A two-cluster solu-
symptoms and less mental HRQoL than the ‘resilient/high func- tion was proven that confirms and adds to previous findings
tioning’ group. No differences were found in terms of eating dis- about the dimensions of ‘locus of control’. People from the
order psychopathology and physical HRQoL. ‘emotionally dysregulated/undercontrolled’ cluster were found

Table 4 Baseline psychopathology of the two clusters; Mann–Whitney U-test and a t-test were used to compare values between the clusters

Cluster 1 ‘emotionally Cluster 2 ‘resilient/

dysregulated/undercontrolled’ high functioning’ Test value p-Value

.002†††
a
EDE-Q Global score, M (SD) 3.05 (0.84) 2.51 (0.99) 1274.500
.240†††
b
EDE-Q Restraint, M (SD) 2.85 (1.37) 2.56 (1.46) 1831.000
.009†††
c
EDE-Q Eating concern, M (SD) 1.54 (1.35) 0.98 (1.06) 1472.500
†††d
EDE-Q Weight concern, M (SD) 3.64 (0.94) 2.89 (1.05) 1181.000 <.001
.010†††
e
EDE-Q Shape concern, M (SD) 4.23 (1.05) 3.60 (1.38) 1536.500
†††f
Binge-eating severity (EDE-Q), M (SD) 3.44 (6.76) 2.37 (5.62) 1874.500 .557
.124†††
g
Loss of control eating (EDE-Q), M (SD) 2.84 (6.17) 2.23 (5.32) 1744.500
†††h
BDI sum score, M (SD) 17.07 (11.46) 7.25 (6.44) 939.500β <.001
.045†††
k
SF-12 PCS, M (SD) 31.71 (10.02) 35.42 (10.62) 2.021
†††l
SF-12 MCS, M (SD) 44.20 (11.48) 52.66 (8.72) 1144.000 <.001

***T-test was used.

††† a b c d e f g h k l
Mann–Whitney U-test was used; N = 123; N = 129; N = 127; N = 128; N = 129; N = 127; N = 126; N = 130; N = 127; N = 127.

Eur. Eat. Disorders Rev. 25 (2017) 397–405 Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association. 401
Personality Subtypes in Bariatric Patients C. Peterhänsel et al.

Table 6 Results of the repeated measures ANOVA: the first F-value shows the time effect; the second F-value represents the effect of the interaction between time
and cluster *

Cluster 1 ‘emotionally Cluster 2 ‘resilient/

dysregulated/undercontrolled’ high functioning’ F-value time p-Value F-value interaction p-Value

Depression severity (BDI-II), M (SD)

Baseline 17.07 (11.46) 7.18 (6.46) 22.407a <0.001 6.336 0.005
T1 10.27 (9.45) 4.01 (5.51)
T2 9.16 (9.59) 4.33 (5.9)
SF-12 PCS, M (SD)
Baseline 31.52 (10.28) 35.42 (10.62) 111.912b <0.001 1.838 0.164
T1 42.13 (10.70) 46.46 (9.47)
T2 42.53 (11.83) 48.88 (9.33)
SF-12 MCS, M (SD)
Baseline 43.69 (11.53) 52.66 (8.72) 16.893c <0.001 6.162 0.004
T1 48.82 (11.18) 57.09 (6.14)
T2 51.45 (9.23) 54.98 (7.86)
EDE-Q Global Score, M (SD)
Baseline 3.03 (0.83) 2.53 (0.94) 99.852d <0.001 1.572 0.212
T1 1.81 (0.99) 1.5 (0.93)
T2 1.68 (1.09) 1.13 (0.91)
EDE-Q Restraint, M (SD)
Baseline 2.82 (1.35) 2.56 (1.45) 31.685e <0.001 .010 .528
T1 1.92 (1.54) 1.94 (1.62)
T2 1.65 (1.48) 1.41 (1.52)
EDE-Q Eating concern, M (SD)
Baseline 1.57 (1.35) 0.99 (1.06) 26.220f <0.001 1.521 0.225
T1 0.55 (0.78) 0.32 (0.59)
T2 0.61 (0.95) 0.29 (0.56)
EDE-Q Weight concern, M (SD)
Baseline 3.65 (0.91) 2.94 (0.98) 105.896g <0.001 1.296 0.278
T1 2. 28 (1.15) 1.85 (1.07)
T2 2.08 (1.31) 1.42 (1.10)
EDE-Q Shape concern, M (SD)
Baseline 4.23 (1.05) 3.61 (1.38) 96.456h <0.001 0.233 0.793
T1 2.81 (1.54) 2.08 (1.51)
T2 2.57 (1.63) 1.77 (1.46)
Binge-eating severity (EDE-Q), M (SD)
Baseline 3.58 (6.90) 2.37 (5.62) 12.568i <0.001 1.355 .260
T1 0.31 (1.39) 0.43 (1.79)
T2 0.19 (0.80) 0.22 (0.83)
Loss of control eating (EDE-Q), M (SD)
Baseline 2.9 (6.27) 2.23 (5.32) 11.923k <0.001 .310 .625
T1 0.20 (0.63) 0.25 (1.35)
T2 0.78 (2.31) 0.48 (2.31)

a
N = 129, df = 1.569,
b
N = 123, df = 2,
c
N = 123, df = 1.742,
d
N = 113, df = 2,
e
= 125, df = 2,
f
N = 122, df = 1.486,
g
N = 123, df = 2,
h
N = 128, df = 2,
i
N = 124, df = 1.100,
k
N = 124, df = 1.228.
*Differences of the mean values in comparison to Table 4 arise because for the ANOVA only those patients who filled out all measuring points were included.

to be significantly more externally oriented than patients from finding consistent with those of previous studies (Claes et al.,
the ‘resilient/high functioning’ subgroup. Significant differences 2013; Müller et al., 2014). An innovation to prior research work
between both clusters appeared at baseline regarding eating dis- is the examination of the influence of personality subtypes on
order psychopathology, symptoms of depression and HRQoL, a changes in psychopathology, HRQoL and loss of excess weight

402 Eur. Eat. Disorders Rev. 25 (2017) 397–405 Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
C. Peterhänsel et al.
after bariatric procedures. It can be emphasized that the ‘emo-
tionally dysregulated/undercontrolled’ subtype still reported
more depressive symptoms and less mental HRQoL 12 months
after the procedure, but no significant differences remained in
terms of eating disorder severity, physical HRQoL, and loss of
excess weight.
The finding that patients in the ‘emotionally dysregulated/
undercontrolled’ subgroup show significantly more symptoms of
psychiatric disorders extends previous findings. In recent studies,
strong relations between high neuroticism, low conscientiousness
and psychiatric disorders like depression, anxiety and substance
abuse (Kotov, Gamez, Schmidt, & Watson, 2010) were found.
Conscientiousness and neuroticism were also found to correlate
strongly with eating disorders in people with obesity (Elfhag &
Morey, 2008; Gade, Rosenvinge, Hjelmesæth, & Friborg, 2014).
Improvements in the psychopathological constructs were found
for the whole sample, a result which corresponds to recent litera-
ture findings on bariatric patients (Castellini et al., 2014). Our
findings regarding the distribution of ‘locus of control’ within
the personality subtypes confirm the cluster solution in respect
to content. Meta-analyses found that external control orientation
is strongly associated with depressiveness and anxiety (Benassi,
Sweeney, & Dufour, 1988; Kennedy, Lynch, & Schwab, 1998)
and that it is as a risk factor for binge eating (Williams, Spencer,
& Edelmann, 1987). No significant differences emerged on the in-
ternality scale. This result was unexpected because internal con-
trol orientation has been found to be a protective factor for
several health issues (Gale, Batty, & Deary, 2008). On the other
hand, when Adolfsson et al. (Adolfsson, Andersson, Elofsson,
Rössner, & Undén, 2005) reviewed the findings of the few studies
existing on ‘locus of control’ and body weight, they were ambigu-
ous in their summarizing statements about whether people with
obesity are more internally oriented or not. Future research on
‘locus of control’ in people with obesity and/or bariatric patients
could focus on whether or not subgroups distinguished by vari-
ances in internality scores emerge.
No significant differences between the two personality subtypes
were found in terms of weight loss. In recent publications, several
domains of personality predicting weight outcomes after bariatric
surgery were researched, but no clear conclusions could be drawn.
Some studies showed no influence (van Hout, Hagendoren,
Verschure, & van Heck, 2009), and others found higher persis-
tence, body dissatisfaction and self-directedness to have an influ-
ence on amounts of weight lost (Gordon, Sallet, & Sallet, 2014;
Leombruni et al., 2007). Cooperativeness and associated with this
seeking for social support was also found to have a positive influ-
ence on successful weight loss after surgery (Agüera et al., 2015).
One study proposed a neurotic predisposition as predictor with
a negative effect on weight loss that was fully mediated by
emotional eating (Canetti, Berry, & Elizur, 2009). Because the
mentioned studies only investigated follow-up time periods of
up to two years after bariatric surgery, it would be interesting
for future studies to explore whether personality has an impact
on longer-term weight-loss.
Reference studies on weight loss and weight maintenance as-
sociated with ‘locus of control’ were investigated in a more gen-
eral population of people with obesity. Prior studies have
proposed that people with an internal ‘locus of control’ have
Eur. Eat. Disorders Rev. 25 (2017) 397–405 Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
Personality Subtypes in Bariatric Patients
an advantage in achieving and maintaining weight loss
(Anastasiou et al., 2015; Teixeira et al., 2005) although no abso-
lute conclusions were drawn. For future research, it would be
interesting to find out if control orientation differs between bar-
iatric patients and whether longer follow-up periods might find
larger differences in weight loss appearing over time. Another
subject of further research could be the follow-up care of pa-
tients. As far as weight loss programmes are concerned, current
findings suggest that interventions should be tailored to partici-
pants’ predominant control orientation. For externally oriented
persons, a group setting would lead to the best results, whereas
individual programmes with more self-determination would bet-
ter serve internally oriented people (Adolfsson et al., 2005). This
could play an important role in the aftercare of bariatric patients
by helping them to achieve and maintain a healthy weight.
Future research could also focus on the stability of personality
traits after a bariatric procedure and whether changes have an in-
fluence on surgery outcomes. It has been found that drastic life
changes like crises, stressors and transition periods (Stewart, Sokol,
Healy, & Chester, 1986) as well as changing social environments
provide an opportunity for personality change (Ardelt, 2000).
Bariatric surgery could be seen as a life event (Luhmann, Hofmann,
Eid, & Lucas, 2012), and therefore it is possible that patients who
undergo this procedure might experience a restructuring of their
temperament. Rydén et al. (2004) conducted a repeated measure
of personality facets in bariatric patients and found some scales
to have changed two years after surgery.
Recent literature found that the improvement of somatic co-
morbidities can have an influence on HRQoL, especially the
PCS scale (Julia et al., 2013; Peterhänsel, Nagl, Wagner, Dietrich,
& Kersting, 2017) and could therefore also have an influence on
the other psychological variables. Because within our analysed
clusters no significant differences occurred (except of sleep apnea
at 6-month follow-up) we can assume that they did not have a
major effect on the differences on the psychological scales. Fur-
ther analyses on larger samples or with more follow-up points
could explore whether clusters differ significantly in the improve-
ment of somatic comorbidities and whether this has an influence
on psychological variables.
The present study also has some limitations. Because differ-
ences on the EDE-Q have been observed to disappear after sur-
gery, it could be tested whether this questionnaire is able to
measure eating disturbances in patients after bariatric surgery.
As far as binge eating episodes are concerned, we recommend
adapting the criteria because patients still report feelings of los-
ing control over eating after having undergone bariatric surgery,
even when they have not been consuming objectively large
amounts of food (Niego, Kofman, Weiss, & Geliebter, 2007).
In line with this, Colles and colleagues (Colles, Dixon, &
O’Brien, 2008) proposed that uncontrolled eating after surgery
persists, while also stating that many patients with prior binge
eating habits develop grazing behaviour as a form of high-risk
eating patterns. Picking and nibbling behaviours also seem to
occur more often after bariatric surgery (Conceição et al.,
2014). Parker and colleagues suggest the use of a revised version
of the EDE-Q with a distinct factor structure that has been
found to have an improved internal consistency in a bariatric
population (Parker, Mitchell, O’Brien, & Brennan, 2016). It is
403
Personality Subtypes in Bariatric Patients C. Peterhänsel et al.

also noteworthy that the weight concern scale in our sample had
a poor reliability, and therefore the results should be interpreted
with caution. Another limitation is the relatively small sample
size and the fact that it was recruited at only one surgical centre.
Also, the difference between the analysed patients and those who
were excluded from the analyses may be a sign of a selection
bias. More comprehensive research on the impact of personality
clusters on psychological outcomes after bariatric surgery could
confirm our results. Moreover, our analyses only took into ac-
count a follow-up period of up to 12 months after surgery. Re-
cent publications that also investigated effects on psychological
scales for people undergoing bariatric surgery showed major im-
provements shortly after the operation (Castellini et al., 2014),
but long-term studies are ambiguous in their findings. On one
hand, although mental health domains seem to improve less
than physical HRQoL, they still show significantly better results
than the ones found in a control group (Driscoll, Gregory,
Fardy, & Twells, 2016). Another study reported that patients
scored equally or even more poorly on depressive, anxiety and
mental HRQoL scales in comparison to baseline values
(Herpertz et al., 2015). More long-term studies are needed to
explore whether psychological improvements are permanent,
and whether personality subtypes influence the maintenance of
well-being.
Some implications for the clinical practice can be derived from
our findings. We found significant ameliorations on the scales
measuring psychopathology for all participants, but still there is
a subgroup of patients presenting more pronounced difficulties
than others. The influence of psychological well-being on the out-
come of bariatric surgery is important (Wimmelmann, Dela, &
Mortensen, 2014), and hence, regular psychological screening
before the procedure but also afterwards is recommended. If nec-
essary, psychological support should be offered to increase the re-
sults of the surgery but also to maintain successful outcomes.
Following the suggestions regarding the predominant control ori-
entation of patients (Adolfsson et al., 2005), patients could partic-
ipate in a group programme or receive more individual support.
ACKNOWLEDGEMENTS
This work was supported by the Federal Ministry of Education
and Research (BMBF), Germany, FKZ: 01EO1001.

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