Obesity is increasing explosively in both developed and developing countries. It is a chronic metabolic disorder with numerous medical complications and comorbidities. The health hazards and medical costs associated with obesity are enormous, making measures against it an urgent worldwide issue. Although various efforts to control it have been made, it cannot be said that they have been sufficiently successful. Obesity is a complex multifactorial disease, with genetic, biological, psychological, behavioral, familial, social, cultural, and environmental factors that can impact the onset and progress in a wide variety of ways. Thus, obesity treatment needs to be comprehensive, taking into account the chronic and multifactorial aspects of this insidious disease. This paper outlines the biological and psychosocial factors involved in and treatments for obesity, along with recent findings and problems.

Obesity is one of the representative psychosomatic diseases with complex psychosocial factors affecting its onset and clinical course. Various treatments including behavioral therapy have been attempted, however the issues of treatment attrition and weight loss maintenance remain on the table. With regards to these issues, cognitive features that are characteristic to patients with obesity have increasingly been revealed, bringing light to the “Personalized cognitive-behavioral therapy for obesity : CBT-OB”. Recently, weight stigma is becoming a public concern, not only remaining as a medical problem. There is now a clearer association between the weight stigma and the patients’ medical outcomes. From these backgrounds, it is estimated that the role of psychosomatic medicine will progressively expand with regards to the treatment of obesity.

Mental disorders cause problems in daily and social life due to various symptoms and dysfunctions. Mental disorders reduce QOL, but obesity is also a factor that lowers QOL, and the coexistence of both is a major problem. Most mental disorders are strongly associated with obesity, and obesity may already coexist early in the onset.

There are various causes of obesity in mentally disorder patients, including individual factors such as decreased activity and unhealthy lifestyles, and environmental influences. There are many problems in solving this problem, but we will consider each of the typical mental disorders such as schizophrenia and depression based on their characteristics.

Obesity is a multifactorial disease in which genetic, physiological, behavioral, psychosocial, and environmental factors contribute to its onset and clinical course. Since using non-surgical treatments such as diet, exercise, and medication often achieve limited results for weight loss, bariatric surgery has been added to treatment for obesity worldwide these past few decades, and its efficacy and safety has been attested. However, it has been pointed out that preoperative assessments of the patient's psychiatric and psychosocial status is important for bariatric surgery, because of the forced suppression of eating behavior after the operation. In Japan, laparoscopic sleeve gastrectomy, which is one type of bariatric surgery, has been covered by national health insurance since April 2014, and is considered to become more frequent in treatment for obesity. Therefore, we think it necessary for mental health specialists (psychosomatic physicians, psychiatrists, psychologists, etc.) to understand procedures and assessment for this operation in advance. This section describes preoperative psychiatric and psychosocial assessments and exclusion criteria for bariatric surgery, and emphasizes the importance of information sharing among multidisciplinary teams.

Background : We retrospectively examined the effect of preoperative lifestyle modification induced by cognitive behavior therapy (CBT) on weight loss after bariatric surgery.

Methods : From August 2012 to April 2019, 59 patients with obesity attempted lifestyle modifications using CBT to achieve preoperative weight loss before laparoscopic sleeve gastrectomy. Psychologists retrospectively evaluated and divided the patients into four groups as follows ; Good : patients who modified their lifestyle and maintained their changes. Unstable : patients who were unable to maintain a modified lifestyle. Resistant : patients who did not try to modify their lifestyle. Short : patients with an insufficient intervention period.

Results : The total weight loss (percentage) from the first visit at each time point (at surgery, 1, 2, 3, 4, and 5 years after surgery) was as follows. Good : 10.9%, 37.3%, 36.2%, 27.2%, 23.9%, 23.2%. Unstable : 7.9%, 26.0%, 24.8%, 24.2%, 22.6%, 14.5%. Resistant : 9.8%, 31.7%, 29.2%, 29.8%, 27.8%, 28.4%. Short : 8.6%, 29.7%, 29.8%, 27.1%, 27.3%, 25.3%. There were 59, 55, 42, 31, 24, and 18 patients assessed at each time point. The “Good” group showed significantly better weight loss compared with the other groups until the second year after surgery (p=0.029 at the 1st year and P=0.04 at the 2nd year), after which this group regained weight.

Conclusions : Preoperative lifestyle modification using CBT is effective for postoperative weight loss. To maintain this favorable effect, long-term interventions must be continued after surgery.

Objectives : Previous studies have revealed the relationships between alexithymia, cognitive emotion regulation, and mental health. However, precise association of these three variables regarding directionality and causality remains uncertain. The aim of the present study is to investigate the potential mediating role of alexithymic traits on the relationship between cognitive emotion regulation strategies and mental health states by psychological measures in a general sample.

Methods : A three part questionnaire is devised in this study to evaluate 150 university students : A 20-item Toronto Alexithymia Scale (TAS-20) to assess alexithymia tendency ; a General Health Questionnaire-28 (GHQ-28) for assessing mental health states. Finally, in order to assess cognitive emotion regulation strategies, the Cognitive Emotion Regulation Questionnaire (CERQ).

Results : There is a significant correlation between each factor of the TAS-20 and the CERQ. An analysis of covariance structure is performed to examine the relationship among the CERQ, the TAS-20 and the GHQ28. The results indicated the “difficulty in identifying feelings (DIF)” factor of the TAS-20 is significant when related to a more frequent use of specific cognitive emotion regulation strategies, such as : rumination, self-blame, and catastrophizing. These three negative strategies have been reported as typical maladaptive cognitive strategies relating to various psychopathologies. Furthermore, the “difficulty in describing feeling (DDF)” factor of the TAS-20 is significant when related to self-blame and catastrophizing. The alexithymic traits mediated the association between cognitive emotion regulation strategies and mental health problems.

Conclusions : These results suggest that specific cognitive emotion regulation strategies play important roles in alexithymia relating to their poor mental health. Therefore, it can be beneficial to introduce specific cognitive interventions to persons with alexithymia.

We report a case of masked depression in which visual approach in addition to auditory approach was effective in understanding the concept of good me and bad me. A 33-year-old female had been suffering from headache, chest pain, back pain, loss of appetite, loss of body weight, general fatigue etc. for several years. She was admitted to our hospital and was treated with the method following behavior restriction therapy. She wrote papers describing her feelings and thoughts every day. The concept of good me and bad me was explained to her showing a conceptual diagram accompanied by oral language. She commented that the diagram helped her to understand that the therapist had the exchange of conversation with good me and that she didn't have to deny everything about her because she was ill due to bad me that is a part of her. She underwent an IQ test with the WAIS-Ⅳ. Her general cognitive ability was assessed as the average range intellectual functioning by measuring Full Scale Intelligence Quotient (FSIQ). The composite score of Perceptual Reasoning Index (PRI) was higher than that of Working memory Index (WMI) and Verbal Comprehension Index (VCI). These differences between the composite scores were significant and the difference between PRI and WMI was considered to be clinically meaningful as the base rate of this difference was 11.3% (less than 15%). PRI reflects an individual's ability to understand visual information and to solve novel abstract visual problems. WMI reflects the ability to hold auditory information in short-term memory and to manipulate that information. VCI reflects an individual's ability to understand, learn and retain verbal information and to use language to solve novel problems. Therefore, the differences between her composite scores of PRI, WMI and VCI may have been associated with the efficacy of the visual approach. Her composite score of WMI was relatively low. This result implies that she was better at thinking while writing than thinking in her mind and may have been associated with the efficacy of writing papers describing her feelings and thoughts. In conclusion, assessing patients' cognitive trait might be invaluable in considering effective methods of treatment for the patients with masked depression accompanied by alexithymia.