The main goal of this study is to investigate how OS patients perceive a social-exclusion situation and their emotional reaction to this condition, as well as the influence that specific cognitive and emotional styles, called EMS, have on the perception of specific social situations (e.g., ostracism).
Looking at the baseline differences between our subsamples, as expected, due to the inclusion and exclusion criteria to participate in this study, weight history showed a higher BMI in the OS patients, and the depression evaluation showed higher scores in OS patients than HCs.(Kroenke & Spitzer, 2002). Finally, as suggested by the literature, the results regarding EMS domains show a greater impact of EMS in the OS population. This finding confirms the possible presence of early dysfunctional cognitive schemas developed from early interpersonal experiences that could be influencing the behavior of bariatric patients (Da Luz et al., 2017).
The results demonstrate that OS patients are less aware of the excluded condition because they correctly reported fewer ball passes, higher ostracism scores, and a higher feeling of belonging and control than HC participants. These results might confirm OS patients' inability to identify negative situations or emotions. Furthermore, the results suggest the presence of a cognitive profile secondary to a specific bias for processing negative interpersonal contact, which has been proposed by previous literature (Dalrymple et al., 2018; Zijlstra et al., 2012). Moreover, the literature has already demonstrated that people with obesity use emotional suppression as a coping strategy in everyday life (Zijlstra et al., 2012), and our data confirm this finding by showing that emotional changes are reduced or opposite if compared to matched controls. The OS sample also showed no difference in impact on self-esteem, whether in the exclusion group or inclusion group. This finding could be viewed as a form of detachment from specific social-based negative experiences. But this detachment is not neutral concerning eating behaviors. Indeed, OS patients reported higher levels of drive to binge or restrain from foods, demonstrating that being excluded could affect bariatric patients by inciting a response to focus on food. The effect of food on the improvement of mood levels in obese and overweight patients is a well-known phenomenon (Leehr et al., 2015), but the evaluation of the interpersonal dynamics should be included in this model.
The IL domain is linked specifically to eating behaviors after social exclusion. This domain represents the lack of internal limits, an inability to form long-term goals, and a lack of responsibility to others, and it has already been linked to addictions and food behaviors (Aloi et al., 2020; Basile et al., 2019). Shame and overeating have already been shown to be emotional and behavioral responses to being excluded in obese subjects (Salvy et al., 2011; Westermann et al., 2015). The results of this study extend these previous findings to include patients who have had bariatric surgery. This study also shows which cognitive schemas could be implicated. The sense of self and the understanding of interpersonal boundaries could be the specific targets of interventions to improve social skills in OS patients. Moreover, the presence of cognitive schemas that could be provoked by external events is corroborated by the results of the UTB and UTR scales. Our results show that OS patients present a reaction to stressful social events (like being ostracized) significantly different from that of the HC peers (even though it was not cognitively perceived), and this reaction translated into eating behaviors. Previous studies have already shown that OS patients try to control stressful events with eating concerns or control. For this reason, these schemas could be considered an essential target of psychotherapy treatments (Moore et al., 2016; Weineland et al., 2012). Indeed, stressful events impact eating behaviors (Salvy et al., 2011), and cognitive and behavioral responses could be targeted as weight maintaining factors. Our data support this idea because it shows that, even after stable weight loss, an exclusion from social interaction could require more effort for OS patients, even if stricter eating controls are reinforced (e.g., OS patients were able to reduce their weight drastically and to keep it stable to receive contouring intervention).
Finally, the participants' expectations should be taken into consideration. Niedeggen et al. (2014) have shown that belonging, meaningful existence, and control in the NTS scale are related to the cognitive expectancy of social involvement. These thoughts and ideas can be described on a continuum ranging from ostracism to inclusion in Cyberball tasks. From this perspective, data from this study could also be interpreted as an expectation by OS patients to be excluded by peers, which could cause the mixed results on the NTS scale after the ostracism paradigm. Our controls have a similar BMI but a different maximum BMI, so they might be exposed to less social exclusion than OS patients. Obesity surgery patients could have developed a defense mechanism from negative social interactions, which is evidenced by their emotional and cognitive responses. This aspect of the research could help confirm the need for a global call to action, which has recently been advocated, because weight bias could elicit pervasive negative attitudes or beliefs, expressed as stereotypes, prejudice, and even open discrimination toward obese or overweight individuals (Cohen & Shikora, 2020).
For future research, a longitudinal approach and a research-mediated evaluation of schemas could help to establish the effects of obesity, bariatric surgery, and weight loss. Furthermore, clinical effects from improving specific cognitive schemas could augment already promising treatments focused on the management of food cues (Schag et al., 2021).
Strength and limits
In examining the methodology, the suitable match between samples (OC and HC) and the choice to use over-inclusion conditions should be considered a strength of our study because provides a strong comparison for the ostracism results. These different scenarios have been demonstrated as more acceptable conditions for clinical populations with impaired social and emotional skills (e.g., borderline personality disorder; (De Panfilis et al., 2016)). A possible limitation involves the scales used due to their self-reported nature, even though they are well-validated measures, or the cross-sectional nature of the study. Moreover, the use of the Cyberball task could be implemented into virtual reality, with a more immersive environment, that could reinforce our results. Finally, the use of a cognitive evaluation to determine the participants' food-related behaviors instead of an authentic evaluation of food behaviors after social exclusion or inclusion could also be considered a limitation of this study that may be overcome in future evaluations.