Standardizing Presurgical Psychological Evaluations with the PsyBari Psychological Test

Abstract

This article is a review of the PsyBari, a psychological test designed specifically for bariatric surgery candidates.

Full text

INTRODUCTION
In 1991, the National Institutes
of Health (NIH) recommended that
bariatric surgery patients receive
presurgical psychological clearance.
Since then, surgical associations
and health insurance companies
have begun to require presurgical
psychological evaluations.1,2 These
evaluations aim to identify patients
who are at increased risk for a wide
variety of postsurgical
psychological, interpersonal,
behavioral, and/or medical
problems, such as binge eating,
substance/alcohol abuse,
depression, suicidal ideation,
anxiety,medical adherence, and
weight regain.3In spite of this
requirement, empirical evidence on
psychosocial outcomes to bariatric
surgery remains sparse.
Researchers are only beginning to
understand the multifaceted and
long-term responses to bariatric
surgery and even less is known
about using presurgical
psychological profiles to predict
surgical outcomes.4Due to the lack
of solid empirical evidence,
psychologists have not been able to
develop standardized criteria for
these evaluations. They use a wide
range of assessment procedures and
ultimately have to rely on their own
judgment when deciding which
patients should receive surgical
clearance.5
Clinical Developments and Metabolic Insights in Total Bariatric Patient Care
Volume 7, Number 9 September 2010
APeer-Reviewed Publication
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INTRODUCTION
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INTRODUCTION
The American College of Surgeons
Bariatric Surgery Center Network
(ACS BSCN) Accreditation Program
was established in 2005 in response to
the national obesity epidemic and the
increasing need to advance safe, high-
quality care for bariatric surgical
patients. The ACS BSCN
Accreditation Program offers seven
levels of accreditation that encompass
abroad range of facilities that are
engaged in the practice of high-quality
bariatric surgery in the United States
and Canada. These facilities undergo
an independent, voluntary,and
rigorous peer-reviewed evaluation in
accordance with nationally recognized
bariatric surgical standards.
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UPDATE ON AMERICAN COLLEGE OF SURGEONS BARIATRIC
SURGERYCENTER NETWORK
An Interview with Ninh T. Nguyen, MD, FACS
XXXXX: XXXxx
Standardizing
Presurgical
Psychological
Evaluations
with the
PsyBari
Psychological
Test
by DAVID MAHONY, PhD, ABPP
DON’T
MISS!
by XXXXX

9Review
Bariatric Times • September 2010
Continued from page 1
THE CREATION OF THE PSYBARI
Due to the lack of empirical
evidence in this area, and the lack of
standardized criteria for presurgical
psychological evaluations, the
PsyBari was created.6The PsyBari is
a115-item psychological test
designed specifically to evaluate
bariatric surgery patients. It is a
comprehensive test that assesses
psychosocial constructs
demonstrated to be, or considered
to be, relevant to postsurgical
functioning (Figure 1). This includes
well-researched constructs, such as
depression and binge eating, and
those constructs that have not
received much research attention,
such as surgical anxiety and
motivation to complete the surgery.
AN EVOLVING INSTRUMENT
The PsyBari includes 11 scales
as well as validity and response style
indicators. It can be revised
frequently as researchers identify
new empirically validated constructs
of interest, clarify the underlying
structure of these constructs, and/or
determine the utility of these
constructs. For example, when
multiple publications demonstrated
that carbohydrate cravings can
influence postsurgical weight regain,
items assessing this craving pattern
were included in the test.7
Conversely, when factor analyses did
not reveal anger as a factor for
women and publications did not
report anger as a postsurgical
problem for women, these items
were removed from the female
version of the test.8In this way, as
our understanding of the
postsurgical psychosocial effects of
bariatric surgery progresses, the
PsyBari can incorporate the
changes. At present, the test is
updated every two years. As
research efforts in this area ramp up
and more users provide data,
revisions could occur as frequently
as once per year.
The test items, scales, and
scoring can also be modified for
specific subgroups since not all
bariatric surgery patients are the
same and a meaningful psychological
assessment has to recognize these
differences. For example, many
studies have found differences in the
patterns of depression between men
and women with obesity. This
includes the finding that women are
more likely to report feeling
depressed because their weight
impairs their social functioning while
men are more likely to report feeling
depressed because their weight
impairs their physical abilities.8With
these results, the depression scale
was individually configured for each
gender so that it accurately
measures the underlying structures
of depression of each gender. Future
studies can clarify if response styles,
such as social desirability, are
involved in these underlying
structural differences. In these ways,
the PsyBari evolves to incorporate
new findings, remove outdated items
and/or constructs, and over time,
improve its overall utility.
Since the PsyBari was designed
specifically for bariatric surgery
patients, many of the test’sitems
will give the clinician information
that is normally obtained during the
clinical interview (Figures 1 and 2).
Clinicians can review patient scores,
as well as individual responses, and
determine which areas need an in-
depth assessment. For example,
there are items that assess the
patient’s understanding of
postsurgical responsibilities, such as
being limited to eating four or five
ounces of food. Patients that are not
knowledgeable about these
responsibilities can be further
evaluated during the interview and
educated, if necessary.It is
important to note that although the
test does not replace the need for a
clinical interview,it can provide
guidance to the interviewer as to
which areas need to be addressed in
depth.
In order to determine how the
response styles may influence a
patient’s results, the PsyBari
includes validity indicators including
overall level of denial, endorsement
of items infrequently endorsed by
others, “all-or-nothing” response
style (i.e., patients who
predominantly endorse 1’s or 5’s on
a5-point scale), and the
“sometimes” response styles (i.e.,
patients who predominantly endorse
3’s, or “sometimes,” on a 5-point
scale). Similar to other psychological
tests, clinicians can interpret the
PsyBari results with an
understanding of how a patient’s
response style may have influenced
the results. For example, if the
validity indicators indicate that a
patient was not entirely forthcoming
(e.g., high levels of denial), the
clinician can interpret the test
results with this in mind and further
probe for denial during an interview.
For researchers, the test can be
customized to fit the needs of their
specific topics. Research subjects
are often inundated with
questionnaires and researchers often
do not need to collect data on the
entire test. For example, binge
eating researchers can administer
the binge eating scale items while
leaving out other items that assess
constructs that do not relate to their
research topic. In this way,more
data are collected to validate the
test and the researcher can use a
reliable instrument instead of an ad-
hoc measure.
RELIABILITY AND VALIDITY
The PsyBari has undergone a
series of reliability and validity
studies and the results are
encouraging.8–10 The overall
Cronbach’sαis 0.930, (0.940 for
men and 0.927 for women; Table 1).
When looking at the individual
subscales, 9 out of 11 have good
reliability (α>0.70). Exploratory
factor analyses identified six factors
for each gender.8Some factors were
common for both genders, some
were unique for each gender, and
some consisted of mixed constructs.
The six factors for women are
awareness of eating habits, early life
problems due to weight, dysphoric
Standardizing Presurgical
Psychological Evaluations
with the PsyBari
Psychological Test
by DAVID MAHONY, PhD, ABPP
Bariatric Times. 2010;7(9):X–XX
ABSTRACT
Bariatric surgery candidates are required to receive psychological clearance before they
are eligible for surgery. In spite of this requirement, little is known about psychosocial
complications, and even less is known about predicting complications. Psychologists have
little empirical evidence for guidance and have resorted to using a wide variety of
assessment practices. In an effort to standardize the presurgical evaluation and
empirically identify psychosocial contraindications, the PsyBari was created. The PsyBari
is a 115-item psychological test that measures constructs relevant to surgical outcomes.
It was designed specifically for bariatric surgerypatients and can be updated as new
information becomes available. Reliability studies indicate that it is a reliable instrument
[Cronbach’sα=0.930, (0.940 for men and 0.927 for women)]. Factor analysis results
show that both men and women have six underlying factors. Some of these factors are
similar for both genders while others are unique. The test can effectively identify
subgroups within the bariatric surgery population and it can accurately predict
psychosocial markers, such as a history of sexual abuse. As further work is done, the goal
of the PsyBari is to identify surgical contraindications, including risk for substance/alcohol
abuse, suicidal ideation, weight regain, and to determine if a patient is motivated enough
to complete surgery.
KEY WORDS
Bariatric surgery, psychological evaluation, PsyBari

feelings about weight, weight-
related impairment, surgical anxiety,
and guilty feelings related to eating.
The six factors for men were
physical impairment with
depression, awareness of eating
habits, early life problems due to
weight, interpersonal support with
anxiety about weight, anger, and
guilty feelings about eating habits.
IDENTIFYING SUBGROUPS
As can be seen from the
exploratory factor analysis, one of
the main findings from the
validation studies is that male and
female patients have different
psychological profiles. Additionally,
when looking at presurgical
differences between the genders,
women are more experienced at
dieting, more depressed, more
socially anxious, and more likely to
report a history of panic attacks.9
Differences were also found
between patients that disclosed a
history of sexual abuse as compared
to those that did not disclose a
history of sexual abuse. Specifically,
patients that disclosed a history of
sexual abuse were more likely to
also disclose a history of physical
abuse, psychological treatment,
psychiatric treatment, and
psychiatric hospitalization. In
addition, women were more likely
than men to also disclose a history
of suicidal ideation.10 Most studies
on bariatric surgery patients assume
that these patients are a
homogeneous group. These results
show that men and women have
distinct psychological profiles and
they also indicate that surgical
contraindications may differ
depending on gender. In other
words, factors that place men at risk
for postsurgical problems may not
be the same ones that place women
at risk.
Other subgroups may also exist
within the bariatric surgery
population, such as age, race, and
age of obesity onset. A recent
finding that female bariatric surgery
patients under age 24 are at risk for
postsurgical suicide offers a clue in
this area.11 The implication is that
young female patients have a
distinct postsurgical complication
that needs to be identified during
the presurgical evaluation.
PREDICTIVE ABILITIES
The PsyBari was designed to be
able to predict which patients would
develop postsurgical psychosocial
problems. An intriguing look into its
predictive abilities came with the
most recent publication.10 This study
focused on the patients who
disclosed a history of sexual abuse.
Alogistical regression found that for
women, a history of physical abuse
and suicidal ideation predicted
sexual abuse status correctly 82
percent of the time. While for men,
ahistory of psychological problems,
psychiatric medications, psychiatric
hospitalization, and suicidal ideation
predicted sexual abuse status
correctly 94 percent of the time.
These results are intriguing because
although the PsyBari was not
designed to predict a patient’s
sexual abuse status, it seems to do
this well. Future studies will focus
an clarifying the PsyBari’s ability to
predict specific postsurgical
psychosocial problems.
UNIQUE PSYCHOMETRIC
CONCERNS
The results of the validation
studies have furthered our
knowledge about bariatric surgery
patients and helped to identify
distinct subgroups. They also
identified psychometric parameters
that are unique to bariatric surgery
patients. By interviewing patients
about their experiences when taking
the test and conducting missing
data analyses and factor analyses,
several psychometric concerns have
emerged. One of the initial concerns
is the length of time it takes to
complete the PsyBari. Patients
become increasingly restless if the
test takes longer than 30 minutes. In
fact, when using longer tests, or a
combination of tests, patients often
respond to items randomly (in order
to complete the test faster) or they
simply refuse to complete all of the
items. Because of this, the PsyBari
is calibrated to take approximately
30 minutes to complete although
overall completion time ranges from
15 to 60 minutes.
Another concern is the wording
of the items. Patients have
difficulties with negatively worded
or double-negative items (e.g., I
have never been in a psychiatric
hospital). When queried on their
responses, patients report being
confused about the wording and
often leave the item blank or put an
incorrect response. Patients also
complain about items that seem to
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Bariatric Times • September 2010
TABLE 1. PsyBari Scales and Reliability—Cronbach’sα
ALPHA
FULL MALE FEMALE
All Items .930 .940 .927
Scales
Faking Good/Malingering/Denial .814 .789 .823
Surgical Motivation .754 .801 .724
Emotional Eating Habits .892 .898 .889
Anger Scale .683 .726 .668
Obesity-Related Depression Scale .775 .780 .778
Weight-Related Impairment Scale .841 .876 .813
Weight Related Social
Impairment .727 .726 .731
Knowledge of PS Dietary
Restrictions .518 .574 .496
Substance/Alcohol Abuse .617 .771 .481
Surgical Anxiety Index .809 .787 .818
Binge Eating .789 .748 .802
have no relevance to weight or
bariatric surgery. For example, when
asked if they are depressed, they
will often respond no and complain
that this is an intrusive question. But
when asked if they are depressed
about their weight, they are more
willing to respond yes. Due to these
constraints, the test items are all
written simply, directly, and when
possible, they relate to the topic of
weight, eating habits, or bariatric
surgery. This does leave the test
vulnerable to social desirability
response styles, which will be
clarified in future studies.
FUTURE DIRECTIONS
With the results of these and
future validation studies, the PsyBari
can achieve its ultimate goal of
accurately identifying distinct
contraindications for bariatric
surgery for each patient. The test
will be able to determine which
patients are at risk for specific
postsurgical psychological,
behavioral, interpersonal, and
medical adherence problems. This
includes determining which patients
are unlikely to go through with
surgery and which ones will
experience significant weight regain.
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9 Mahony D. Psychological gender
differences in bariatric surgery
candidates. Obes Surg.
2008;18(5):607–610.
10 Mahony D. Assessing sexual
abuse/attack histories with bariatric
surgery patients. JChild Sex Abus.
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FUNDING:
There was no funding for the development of
this article.
FINANCIAL DISCLOSURES:
The author reports no conflicts of interest
relevant to the content of this article.
AUTHOR AFFILIATION:
Dr.Mahony is a clinical psychologist from
Lutheran Medical Center,Brooklyn, New
York
ADDRESS FOR
CORRESPONDENCE:
David Mahony,PhD,
ABPP,Lutheran Medical
Center,155 55th St.,
Suite 5333, Brooklyn, NY
11220; Phone: (718)
630-8600; Fax: (718)
630-8615; E-mail: Dmahony@lmcmc.com