¹ LIRPA – Italian Research Laboratory in Analytical Psychology, Rome

Keywords: Obesity, Eating Disorders, BED, Impulsivity, Anger, STAXI-2, BIS-11

Abstract: Obesity is frequently associated with psychiatric disorders, particularly Eating and Feeding Disorders (EFDs) such as Binge Eating Disorder (BED). Impulsivity and difficulties in anger regulation are clinically relevant aspects.

Objectives: To assess the presence of EFDs and psychiatric comorbidities in obese patients and investigate anger and impulsivity domains using the STAXI-2 and BIS-11 tests.

Methods: A total of 219 patients were recruited at two clinical centers. A structured psychiatric evaluation and psychometric battery were administered.

Results: Patients with EFDs exhibited higher levels of impulsivity and anger compared to those without EFDs.

Conclusions: A multidimensional and psychometric assessment may help identify critical clinical vulnerabilities in obesity management.

1. Introduction

Obesity is a multifactorial condition, generally defined by a body mass index (BMI) equal to or greater than 30 kg/m² (Cornier, 2022), and represents a growing public health problem in Western countries. In recent decades, the prevalence of obesity has increased significantly: in 2014, 14.9% of women and 10.8% of men were classified as obese, with an increase in mean BMI from 22 kg/m² in 1975 to 24 kg/m² (NCD Risk Factor Collaboration, 2016; Semlitsch et al., 2019).

The literature suggests a bidirectional relationship between obesity and psychiatric disorders, particularly Eating and Feeding Disorders (EFDs). Compared to the general population, obese patients often display specific psychopathological traits and cognitive characteristics, including low self-esteem, body dissatisfaction, and impulsivity (Bibiloni et al., 2017; Giel et al., 2017; Slabá et al., 2020). Conversely, individuals with severe psychiatric disorders show an increased risk of metabolic syndrome, associated with overweight and abdominal obesity, thus leading to cardiovascular diseases (Avila et al., 2015). Obesity also significantly impacts quality of life and global functioning (Taylor et al., 2013). Within the DSM-5-TR Eating and Feeding Disorders, Binge Eating Disorder (BED) is closely linked to obesity. In this context, impulsivity—often associated with food addiction—emerges as a relevant vulnerability factor. Patients with BED frequently display heightened reward sensitivity and reduced behavioral inhibition (Boswell & Grilo, 2021; Hauck et al., 2020). Neuroimaging studies have shown that obese individuals exhibit decreased activation of the caudate nucleus in response to high-calorie foods, suggesting altered reward circuitry (Babbs et al., 2013; Green et al., 2011; Stice et al., 2008). In this scenario, the psychopathological dimensions of impulsivity and anger play a significant role. Impulsivity is defined as the difficulty to inhibit automatic behaviors and a tendency to prioritize immediate rewards over long-term benefits (Sarwer et al., 2019). Impulsive individuals are more likely to adhere to high-calorie, low-nutrient diets (Bénard et al., 2019). Anger, another key construct in this context, is a negative affective state characterized by physiological arousal, self-referential thoughts, and aggressive tendencies (Berkowitz & Harmon-Jones, 2004). Anger is a critical factor in both the onset and prognosis of EFDs (Dingemans et al., 2016; Walenda et al., 2021). Elevated anger levels have been observed in patients with BED comorbid with atypical depression (Güngör et al., 2020). The treatment of obesity is multidisciplinary and includes behavioral modifications, dietary interventions, physical activity, pharmacological therapies, and bariatric surgery (Semlitsch et al., 2019). Bariatric surgery, developed in the mid-20th century, is currently reserved for severe cases of obesity and for individuals with significant comorbidities, and has demonstrated long-term effectiveness in weight reduction (Phillips & Shikora, 2018; O’Brien et al., 2019). Bariatric surgery can also lead to significant psychological improvements, including reduced levels of anger (Roberts, 2021). Given the strong relationship between obesity and psychopathology, a comprehensive psychiatric preoperative evaluation is a crucial step in the bariatric pathway. Such evaluation helps exclude disorders like Binge Eating Disorder, which may contraindicate surgery, and identify psychiatric vulnerabilities that could compromise post-surgical outcomes (Athanasiadis et al., 2021). Moreover, it allows for the transdiagnostic analysis of dysfunctional eating behaviors.

2. Materials and Methods

This study examined a sample of 219 obese patients evaluated at the Psychiatry, Clinical Psychology, and Psychiatric Rehabilitation Unit of the University Hospital of Perugia and at the DAI and Obesity Center of CittàdellaPieve.

Two populations of obese patients were included.

The first group consisted of candidates for bariatric surgery, assessed at the Psychiatry, Clinical Psychology, and Psychiatric Rehabilitation Unit of the University Hospital of Perugia. Psychiatric evaluations were conducted between January 2022 and April 2024. Referral for psychiatric assessment was part of the standard preoperative protocol, in collaboration with the Department of General and Emergency Surgery.

Inclusion criteria were: age ≥18 years, good comprehension of spoken and written Italian, and indication for bariatric surgery.

The evaluation, conducted by a multidisciplinary team, included:

• Clinical interviews aimed at diagnosing psychiatric disorders and dysfunctional eating behaviors;

Psychometric battery comprising:

• SCID-5-CV and SCID-5-PD for the assessment of major psychiatric and personality disorders;
• BES, BULIT-R, and BSQ for the detection of eating disorders;
• STAXI-2 and BIS-11 for the assessment of anger and impulsivity.

A standardized anamnesis form was completed, collecting data on age, sex, educational level, marital status, employment status, family history of obesity and psychiatric disorders, presence of organic comorbidities, and pharmacological treatments.

The second population included obese patients attending the DAI and Obesity Center of CittàdellaPieve (Umbria), treated in outpatient, semi-residential, or residential settings.

For these patients as well, structured clinical histories and the same psychometric battery were administered.

Clinical and anamnesis characteristics, as well as BIS-11 and STAXI-2 scores, were compared between patients with and without Eating and Feeding Disorders (EFDs).

Statistical analyses were conducted using SPSS version 26.0.

Descriptive analyses (mean, standard deviation, frequencies) and bivariate tests (χ² test for categorical variables; t-test or Mann-Whitney U test for continuous variables) were performed for group comparisons.

3. Results

A total of 219 individuals were recruited, including 160 women (73.1%) and 59 men (26.9%). Of these, 42 (19.2%) were recruited at the DAI and Obesity Center of CittàdellaPieve, and 177 (80.8%) at the Psychiatry Unit of the University Hospital of Perugia.

Regarding demographic and clinical variables (age, sex, education, employment status, marital status, psychiatric history, use of psychiatric medication, presence of organic comorbidities), no statistically significant differences were found between the two groups.

The overall sample had a mean age of 47.89 ± 11.383 years, ranging from 18 to 71 years.

Notably, 67 patients (30.6%) reported being unemployed or never having been employed.

Table 1.1 – Employment Status

Employment Status	Frequency	Percentage
Unemployed	30	13.7
Freelance Professional	15	6.8
Entrepreneur	6	2.7
Employee	94	42.9
Homemaker	36	16.4
Retired	20	9.1
Student	10	4.6
Missing Data	8	3.7

Only 24 patients (11.0%) had education beyond high school level.

30.1% (n=66) were single and had never been married.

A positive family history of obesity was reported by 114 patients (52.1%).

Furthermore, 142 patients (64.8%) presented obesity-related organic comorbidities, and 63 patients (28.8%) were taking psychiatric medication at the time of evaluation.

No statistically significant difference was found between the mean BMI of the two groups (42.87 ± 6.508 in Perugia vs. 44.26 ± 8.702 in CittàdellaPieve). However, Perugia patients more frequently presented with a BMI >40, indicating class III obesity (p=0.011; 82.8% vs 63.4%).

Although no significant differences were found regarding the overall frequency of previous psychiatric diagnoses, patients from CittàdellaPieve more frequently reported a history of depression (p=0.002; 47.6% vs 22.0%) and Eating and Feeding Disorders (p<0.001; 61.9% vs 16.1%).

Regarding psychometric assessment, patients from CittàdellaPieve had significantly higher BSQ scores compared to Perugia patients, suggesting greater body image dissatisfaction (p=0.011; 4.8% vs 23.8% absence of dysmorphophobia). No significant differences were observed in BES and BULIT-R scores.

Diagnostic data also differed: CittàdellaPieve patients more often received a diagnosis of EFD (p<0.001; 69.0% vs 30.7%), while no significant differences were noted for other psychiatric diagnoses.

No statistically significant difference was found between the mean BMI of the two groups (42.87 ± 6.508 in Perugia vs. 44.26 ± 8.702 in CittàdellaPieve). However, Perugia patients more frequently presented with a BMI >40, indicating class III obesity (p=0.011; 82.8% vs 63.4%).

Although no significant differences were found regarding the overall frequency of previous psychiatric diagnoses, patients from CittàdellaPieve more frequently reported a history of depression (p=0.002; 47.6% vs 22.0%) and Eating and Feeding Disorders (p<0.001; 61.9% vs 16.1%).

Regarding psychometric assessment, patients from CittàdellaPieve had significantly higher BSQ scores compared to Perugia patients, suggesting greater body image dissatisfaction (p=0.011; 4.8% vs 23.8% absence of dysmorphophobia). No significant differences were observed in BES and BULIT-R scores.

Diagnostic data also differed: CittàdellaPieve patients more often received a diagnosis of EFD (p<0.001; 69.0% vs 30.7%), while no significant differences were noted for other psychiatric diagnoses.

Table 1.2 – Final Psychiatric Diagnoses – CittàdellaPieve

Psychiatric Diagnosis	Frequency	Percentage
None	29	69.0
Major Depressive Disorder	4	9.5
Major Depressive Disorder + Anxiety Disorder NOS	2	4.8
Major Depressive Disorder + Panic Disorder	2	4.8
Mood Disorder NOS	1	2.4
Recurrent Major Depressive Disorder in Partial Remission	1	2.4
Single Episode Major Depressive Disorder in Full Remission	1	2.4
Obsessive-Compulsive Disorder + Personality Disorder NOS	1	2.4
Post-Traumatic Stress Disorder (PTSD)	1	2.4

Table 1.3 – Final Psychiatric Diagnoses – Perugia

Psychiatric Diagnosis	Frequency	Valid Percentage
None	125	72.5
Borderline Personality Disorder	6	4.7
Narcissistic Personality Disorder	4	2.9
Persistent Depressive Disorder	4	2.3
Obsessive-Compulsive Personality Disorder	3	2.3
Panic Disorder	3	1.8
Adjustment Disorder NOS	2	1.2
Paranoid Personality Disorder	2	1.2
Bipolar II Disorder	2	1.2
Obsessive-Compulsive Personality Disorder	2	1.2
Bipolar II Disorder + Borderline Personality Disorder	2	1.2
Dependent Personality Disorder	1	1.2
Alcohol Use Disorder	1	1.2
Generalized Anxiety Disorder	1	0.6
Moderate Intellectual Disability	1	0.6
Recurrent Major Depressive Disorder, Partial Remission	1	0.6
Single Episode Major Depressive Disorder, Full Remission	1	0.6
Bipolar I Disorder	1	0.6
Chronic Schizoaffective Disorder	1	0.6
Mixed Schizoaffective Disorder	1	0.6
Depressive Personality Disorder	1	0.6
Histrionic Personality Disorder	1	0.6
Schizophrenia/Psychosis	1	0.6
Specific Phobia and Other Anxiety Disorder	1	0.6
Borderline Personality Disorder + Panic Disorder	1	0.6
Borderline Personality Disorder + Generalized Anxiety Disorder	1	0.6
Dependent Personality Disorder Persistent Depressive Disorder	1	0.6
Obsessive-Compulsive Personality Disorder Persistent Depressive Disorder	1	0.6
Borderline Personality Disorder + Passive-Aggressive Personality Disorder	1	0.6
Narcissistic Personality Disorder + Obsessive-Compulsive Personality Disorder	1	0.6

Psychometric Test Results

STAXI-2 and BIS-11 results were available for a Perugia subsample (46 patients evaluated starting from 2023).

Tables 1.4 and 1.5 summarize all the BIS-11 and STAXI-2 subscale scores for CittàdellaPieve and Perugia groups.

Table 1.4 – Psychometric Results for CittàdellaPieve

Subscale	Minimum	Maximum	Mean	SD
Attentional Impulsivity	5	18	9.8	2.76
Cognitive Impulsivity	4	10	6.4	1.52
Motor Impulsivity	7	21	14.15	3.26
Perseverance	4	12	7.1	2.01
Self-Control	9	20	13.8	3.31
Cognitive Complexity	7	18	12.38	2.13
Motor Impulsivity (Factor)	10	24	16.1	3.54
Attentional Impulsivity (Factor)	15	31	21.28	3.91
Nonplanning Impulsivity (Factor)	19	34	26.08	4.47
Total BIS-11 Score	48	86	63.3	9.33
State Anger	34	53	37.5	5.26
Feeling Angry	24	33	25.6	2.32
Verbal Anger Expression	24	33	25.45	2.53
Physical Anger Expression	24	31	24.42	1.24
Trait Anger	28	49	35.6	4.18
Temperamental Anger	23	35	25.7	2.36
Reactive Anger	23	32	26.53	2.28
External Anger Expression	23	40	32.28	3.37
Internal Anger Expression	26	48	36.31	5.21
External Anger Control	29	47	39.05	4.29
Internal Anger Control	31	50	39.49	4.47
ER Index	32	80	57.31	10.64

Table 1.5 – Psychometric Results for Perugia

Subscale	Minimum	Maximum	Mean	SD
Attentional Impulsivity	4	18	8.48	3.09
Cognitive Impulsivity	3	12	5.24	1.69
Motor Impulsivity	6	21	12.98	3.09
Perseverance	4	11	6.35	1.62
Self-Control	7	18	11.96	3.02
Cognitive Complexity	7	20	12.26	2.83
Motor Impulsivity (Factor)	8	24	13.59	3.88
Attentional Impulsivity (Factor)	11	26	19.33	3.71
Nonplanning Impulsivity (Factor)	15	37	24.09	4.73
Total BIS-11 Score	37	83	57.35	9.97
State Anger	29	54	36.33	4.03
Feeling Angry	24	33	25.22	1.85
Verbal Anger Expression	23	33	24.93	1.83
Physical Anger Expression	24	27	24.22	0.63
Trait Anger	29	47	35.98	4.63
Temperamental Anger	23	30	25.22	1.94
Reactive Anger	23	33	26.85	2.49
External Anger Expression	23	49	32.52	4.11
Internal Anger Expression	27	47	35.63	5.11
External Anger Control	29	47	39.57	4.33
Internal Anger Control	22	53	40.48	6.12
ER Index	35	85	54.28	12.63

Analyzing the overall sample, 37.6% of patients had an Eating Disorder diagnosis, and 58 patients (27.4%) had a psychiatric diagnosis excluding EFDs.

Patients with EFDs presented psychiatric comorbidities significantly more frequently than those without EFDs (43.8% vs 17.4%, p<0.001).

Statistically significant differences between the two groups were observed in the mean scores of the BIS-11 subscales: Attentional Impulsivity (A) (p=0.041), Cognitive Impulsivity (Ic) (p=0.001), and Nonplanning Impulsivity (Ac) (p=0.008), as well as in the second-order factors: Motor Impulsiveness (IM) (p=0.002), Attentional Impulsiveness (IA) (p=0.020), and Nonplanning Impulsiveness (NonP) (p=0.049), including the total BIS-11 score (p=0.006). No statistically significant differences were found in the total STAXI-2 score or its subscales between the two groups.
When comparing patients diagnosed with Eating and Feeding Disorders (EFD) to those without such a diagnosis, patients with EFD exhibited significantly higher scores across several BIS-11 subscales: Attentional Impulsivity (A) (p=0.002), Cognitive Impulsivity (Ic) (p=0.007), Perseverance (P) (p=0.024), Nonplanning Impulsivity (Ac) (p=0.031), and Cognitive Complexity (Cc) (p=0.028), as well as higher scores in the second-order factors IM (p<0.001), IA (p=0.027), and NonP (p=0.002), and in the total BIS-11 score (p<0.001).
Additionally, patients with EFD showed higher STAXI-2 scores in the State Anger (S-Ang) (p=0.028), State Anger/Feeling Angry (S-Ang/S) (p=0.029), and State Anger/Verbal Expression (S-Ang/V) (p=0.025) subscales.

4. Discussion

The sample in our study was predominantly composed of women. This finding is influenced by the fact that obesity is more prevalent among women than men in most countries, and that women are also more likely to seek help for weight management, thus accessing diagnostic and treatment pathways more frequently (Cooper et al., 2021; Raspa et al., 2024).
In the analyzed sample, only a small percentage of patients had attained an education level higher than a high school diploma. This result aligns with previous studies showing that higher obesity rates occur among populations with lower socioeconomic status and lower levels of education (Drewnowski et al., 2004). It is well known that high-energy-density foods such as refined cereals, added sugars, and fats represent the most affordable options for consumers.
The finding regarding high levels of unemployment and a considerable proportion of unmarried patients in our sample is less straightforward to interpret. These data may reflect the impact of obesity on interpersonal and social functioning, considering that weight-related stigma may negatively affect healthcare access and act as a barrier to effective treatment (Puhl et al., 2023).
The prevalence of Eating and Feeding Disorders (EFD) among obese individuals was found to be high. Clinical studies confirm this association: a survey of 1383 individuals with eating disorders found that 87% of those with Binge Eating Disorder (BED) had experienced obesity at some point in their lives (Villarejo et al., 2012); similarly, a nationally representative sample of 9282 individuals found that 42% of those who had a lifetime diagnosis of BED were obese at the time of assessment (Hudson et al., 2007). Our findings are consistent with these results.
A previous Italian study of 871 patients undergoing bariatric surgery reported a 55.1% prevalence of psychiatric disorders, higher than that observed in our sample (Barbuti et al., 2022). However, the psychodiagnostic assessment used in that study differed from the one adopted in our research. It is important to highlight the difficulty in obtaining accurate data from patients seeking bariatric surgery, given the documented tendency to minimize psychopathological symptoms to facilitate surgical approval (Malik et al., 2014). Despite these limitations, available data confirm that obesity has a significant impact on mental health, as shown by the higher prevalence of psychiatric disorders in this population compared to the general population (Malik et al., 2014).
Regarding differences between the CittàdellaPieve and Perugia groups, the higher prevalence of a positive history of depression and EFD, as well as significantly higher Body Shape Questionnaire (BSQ) scores in the CittàdellaPieve group, can be explained by the different nature of the two samples. Patients from CittàdellaPieve were predominantly ‘help-seekers’ motivated toward psychological and psychiatric treatment, whereas patients from Perugia primarily sought surgical interventions, where psychiatric evaluation is a mandatory but not actively pursued step. It is therefore plausible that the first group exhibited greater awareness of the need for psychological support.
The differences observed in the STAXI-2 and BIS-11 results are also significant. The CittàdellaPieve group showed higher scores on the Attentional Impulsiveness (A), Motor Impulsiveness (Ic), and Nonplanning Impulsiveness (Ac) subscales, as well as in all three second-order factors of the BIS-11, and in the total score. These findings are likely attributable to the higher concentration of patients with EFD in this group compared to the Perugia sample.
Analyzing the entire sample of 219 subjects, patients with EFD displayed significantly higher scores on the BIS-11 subscales A, Ic, P, Ac, and Cc, and on the second-order factors, as well as the total score. Furthermore, patients with EFD showed higher STAXI-2 scores in the State Anger (S-Ang), Anger Expression-In (S-Ang/S), and Anger Expression-Out (S-Ang/V) subscales, highlighting deficits in impulsivity control and a greater tendency to experience and express anger. These findings support the evidence that the management of anger and negative emotions plays a role in the onset and maintenance of Binge Eating Disorder (Dingemans et al., 2017). Currently, there are no available studies on the use of STAXI-2 in obese patients for direct comparison. However, regarding impulsivity, a study involving 11,929 men and 39,114 women showed that BIS-11 scores greater than 71 were associated with a higher risk of obesity, emphasizing the relevance of psychological and psychiatric factors in prevention (Bernard et al., 2017). The high levels of impulsivity observed in our evaluation can thus be considered a risk factor for the onset and maintenance of EFD in obese patients, and a thorough psychometric assessment can provide a valuable tool for clinicians in planning targeted therapeutic interventions. Our data confirm that patients with EFD exhibit significantly higher scores in both impulsivity dimensions and anger experience and expression compared to patients without EFD. These findings highlight the importance of an in-depth, multidimensional psychiatric assessment in the clinical management of obese patients, both during pre-surgical screening and therapeutic interventions, to detect potential psychopathological vulnerabilities early. The results of the present study demonstrate a high prevalence of such disorders in obese subjects, as well as a strong correlation with elevated levels of impulsivity and difficulties in emotion regulation.
The integration of specific psychometric tools, such as the BIS-11 and STAXI-2, thus represents a valuable resource for identifying impulsive traits and emotional dysregulation, allowing for the design of more targeted and personalized therapeutic interventions.

Conclusions

Obesity is a complex and multifactorial condition, often associated with psychiatric comorbidities, particularly Eating and Feeding Disorders (EFD). From the perspective of Jungian analytical psychology, obesity can be interpreted not only as a medical or behavioral dysfunction but also as a somatic expression of deep, unsymbolized psychological suffering. In this view, the body becomes the theater of the unconscious, where internal conflicts andrepressed or non-integrated emotional contents emerge.Compulsive eating and weight gain can be understood as maladaptive attempts to fill a psychic void or contain unmetallized emotions such as anger or shame. Unrecognized anger may manifest as ‘anger-in,’ a self-destructive expression of repressed emotional energy, fostering dynamics of self-sabotage and body devaluation. Similarly, impulsivity can be seen as a manifestation of the Jungian Shadow — those unconscious contents of the personality that,when not integrated, erupt into everyday behavior.
It is therefore essential to develop integrated therapeutic pathways that combine nutritional, surgical, and psychotherapeutic approaches, with particular attention to the emotional and symbolic aspects underlying obesity and dysfunctional eating behaviors. Preventing relapse and improving treatment adherence will largely depend on the clinical work on dimensions such as impulsivity and anger, which may indicate deep, often unexpressed psychological distress.
In this light, a therapeutic approach such as brief analytical therapy allows for moving beyond mere behavioral management toward an exploration of the symbolic meanings of the symptom. Through tools such as dream analysis, work with inner imagery, and the narration of bodily experience, patients can initiate a process of individuation, transforming somatic distress into an opportunity for psychic growth and reconnection with the Self.

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