As the rates of obesity increase, so do the medical problems caused and exacerbated by this physical state. For many, traditional methods of weight loss have proven ineffective for achieving and maintaining significant weight reduction. Bariatric surgery (ie, laparoscopic gastric banding, gastric bypass) offers these patients the opportunity to experience significant weight loss that can be maintained. The number of obese patients seeking bariatric surgery is steadily rising. But, unlike traditional diets for which risks are low and discontinuation can occur at any time, bariatric surgery has inherent risks and requires highly restrictive, long-term behavioral changes afterwards. Therefore, these patients typically are required to complete a thorough evaluation, including psychological assessment, to determine their appropriateness for surgery.

1. Psychological Assessment
of the Patient Undergoing
Bariatric Surgery
Dr.Sherif Saad
(M.B.B.Ch., M.Sc., M.D.)
Consultant of Psychiatry
International member of American Psychiatric Association (APA)
International member of European Psychiatric Association (EPA

2. Psychological Assessment of the
patient undergoing bariatric surgery 2

3. After losing half her weight, can the
Egyptian Eman Ahmed walk again?
Egyptian Eman Ahmed, who weighed 500
kg when she was airlifted to India in
February this year, has managed to lose
242 kg after two months of treatment that
included surgery and a special diet.
The moot question now is – will she be
able to walk again? According to Dr
Muffazal Lakdawala, the doctor directing
the team of surgeons treating her at Saifee
Hospital in Mumbai, she is very short and
her legs have not developed at all below
her knees.
Psychological Assessment of the
patient undergoing bariatric surgery 3

4. Unhealthy Trends in Saudi Arabia
Psychological Assessment of the
patient undergoing bariatric surgery 4

5. Nearly half of children in Jeddah ‘at risk of obesity’!!!
By Saudi Gazette Jeddah Monday, 4 May 2015
“About 40 percent of children in Jeddah, Saudi
Arabia, are overweight and at risk of becoming
obese, according to a medical survey”.
The survey, conducted by students of the college of
pediatrics at King Abdulaziz University, said a large
number of children do not play any kind of sports and
are gaining weight.
The study was conducted at a number of shopping
malls in Jeddah as part of a health awareness
campaign organized by the college.
Dr. Abdul Moien Eid Al-Agha, professor of pediatrics
and supervisor of the campaign, said excessive
weight is a warning sign of obesity and all its
associated diseases including diabetes.
Psychological Assessment of the
patient undergoing bariatric surgery 5

6.  Obesity exposes patients to the risk of embarrassment, frustration, and
hopelessness.
 It is real and poignant, and these indignities are not easily ameliorated,
especially as many of them are bolstered by opinions and comments of
individuals close to the patients, such as family members, and thus are
even more painful.
Psychological Assessment of the
patient undergoing bariatric surgery 6

7. Obesity surgery …….. challenges
 As the rates of obesity increase, so do the medical problems
caused and exacerbated by this physical state.
 Traditional methods of weight loss have proven ineffective for
achieving and maintaining significant weight reduction for many
cases..
 Bariatric surgery (ie, laparoscopic gastric banding, gastric
bypass) offers these patients the opportunity to experience
significant weight loss that can be maintained.
 The number of obese patients seeking bariatric surgery is
steadily rising. But, unlike traditional diets for which risks are
low and discontinuation can occur at any time, bariatric surgery
has inherent risks and requires highly restrictive, long-term
behavioral changes afterwards.
 Therefore, these patients typically are required to complete a
thorough evaluation, including psychological assessment, to
determine their appropriateness for surgery.
Psychological Assessment of the
patient undergoing bariatric surgery 7

8. Obesity surgery …….. multidisciplinary team
Psychological Assessment of the
patient undergoing bariatric surgery 8
 Patients should be
“selected carefully after
evaluation by a
multidisciplinary team
with medical, surgical,
psychiatric, and
nutritional expertise.”
Bauchowitz A., et al. Evaluation of expectations and knowledge in bariatric
surgery patients. Surg Obes Relat Dis. 2007

9. Pre-Operative Bariatric Surgery Psychological Evaluation
Psychological Assessment of the
patient undergoing bariatric surgery 9
 Although psychological
evaluation has become
standard for most surgery
programs, no clear guidelines
exist about what that
assessment must involve.
Fabricatore A. N., et al. How do mental health professionals
evaluate candidates for bariatric surgery? Survey results. Obes Surg. 2006

10. Obesity surgery …….. Psychological evaluation
 Many patients often are hesitant and uncomfortable with the notion of
seeing a psychologist before surgery.
 However, the information discussed during the clinical interview is
critical not only for assessing their appropriateness for surgery but also
for enhancing their success during the post surgery adjustment.
 Many patients report, after the interview, how valuable it was for them
to examine the issues raised.
 The core parts of the clinical interview include reasons for seeking
surgery, weight and diet history, current eating behaviors,
understanding of the surgery and its associated lifestyle changes, social
supports and history, and psychiatric symptoms (current and past).
Psychological Assessment of the
patient undergoing bariatric surgery 10

11. Pre-Operative Bariatric Surgery Psychological Evaluation :
WHY?
 When a surgeon assesses patients for bariatric surgery, he/she
ascertains their general health, to assess the degree of risk.
 Behavioral health specialists can no more “predict” a particular
psychological outcome than the physician can “predict” a surgical or
medical complication.
 However, via the pre-operative behavioral health assessment,
identify psychosocial risk factors and make recommendations to
both the client and surgical group that are aimed at facilitating the
best possible outcome for the patient.
Psychological Assessment of the
patient undergoing bariatric surgery 11

12. Pre-Operative Bariatric Surgery Psychological Evaluation :
WHY?
 Patients are typically faced with initial dietary restrictions, permanent
changes in eating and dietary habits, altered body sensations and
experiences, shifting body image and self care behaviors, new cognitions
and feelings, and an emerging and different lifestyle.
 Patients may realize sometimes unexpected and significant changes in
relationships that may result in marked stress.
 Bariatric surgery is a highly effective procedure that not only reconfigures
and/or restricts a patient’s stomach, but significantly affects their
psyche as well.
 Generally patients will need a secure identity, sound psychological
resources, resiliency, effective coping strategies, and willingness to access
meaningful support from others.
Psychological Assessment of the
patient undergoing bariatric surgery 12

13. Pre-Operative Bariatric Surgery Psychological Evaluation :
WHY?
 When problematic pre-surgery psychosocial factors are identified,
the clinician is able to alert the treatment team and the patient, and
make appropriate recommendations.
 Recommendations may include:
• pharmacological interventions,
• psycho-education,
• psychotherapy to address potential post surgery stumbling blocks,
• nutritional consultation,
• close aftercare monitoring, and/or
• bariatric surgery support group attendance.
Psychological Assessment of the
patient undergoing bariatric surgery 13

14. Pre-Operative Bariatric Surgery Psychological Evaluation
Common categories of assessment include:
 Behavioral.
 Cognitive/Emotional.
 Developmental history.
 Current life situation.
 Motivation and expectations.
Psychological Assessment of the
patient undergoing bariatric surgery 14

15. Pre-Operative Bariatric Surgery Psychological Evaluation
Behavioral Aspects
 Previous Attempts at Weight Management
 Eating and Dietary Styles:
 Maladaptive eating behaviors:
• Binge eating
• Overeating
• Grazing(Compulsive overeating)
• Night eating syndrome
 Physical Activity and Inactivity
 Health-Related Risk-Taking Behavior
 Impulsive behavior
 Compulsive behavior
 Substance Use
 Legal History
Psychological Assessment of the
patient undergoing bariatric surgery 15

16. Pre-Operative Bariatric Surgery Psychological Evaluation
Cognitive and Emotional
 Cognitive Functioning
 Knowledge of Obesity and Surgical Interventions
 Coping Skills, Emotional Modulation, Boundaries
 Psychopathology
Psychological Assessment of the
patient undergoing bariatric surgery 16

17. Pre-Operative Bariatric Surgery Psychological Evaluation
Developmental History
 Patient recollection about the stability of their childhood, any
significant adverse events and long-term impact.
 Parental availability and stability as well as the quality of the bond
with the identified patient.
 Degree and quality of attachments in social relationships outside
the home.
 Any childhood history of weight-related ridicule and its related
impact.
 An understanding of the childhood role that food played, along
with any attempts to use it as a source of love, comfort,
companionship, control or dissociation.
Psychological Assessment of the
patient undergoing bariatric surgery 17

18.  Stressors
 What significant life stressors have occurred in the past year or are ongoing.
 What stressors the candidate expects in the upcoming year .
 How well the candidate is or is not likely to cope with the rapid, widespread post surgery
changes.
 Utilization of Social Support
 Social support is positively related to faster recovery and negatively related to
premature mortality.
 Social support is related to successful weight loss for people attending a general
behavioral weight loss program.
 Bariatric patients who regularly attend postoperative support groups are more
successful in their weight loss and maintenance.
Pre-Operative Bariatric Surgery Psychological Evaluation
Current Life Situation
Psychological Assessment of the
patient undergoing bariatric surgery 18

19. Motivation
 Patient motivation and reasons for pursuing surgery are critical variables to
assess.
 Most patients will state the obvious medical benefits.
 It is also important to have them discuss their more private motivations, if any, for
having weight loss surgery.
Expectations
 What expectations does the patient have concerning psychosocial, emotional and
lifestyle challenges and adjustments post surgery, both short and long-term?
 “throwing in the towel” , when it happened?
Pre-Operative Bariatric Surgery Psychological Evaluation
Motivation and Expectations
Psychological Assessment of the
patient undergoing bariatric surgery 19

20.  Psychological tests may be categorized in many different ways. The
types of instruments typically used in pre-surgical assessment
include:
 Multi scale inventories that assess different aspects of a person’s
emotional functioning or personality based upon responses to a set
of questions.
 Shorter single scale inventories. Measures that assess a specific
emotional problem such as depression or anxiety.
 Specialized inventories. Types that are commonly used in our
patient population include inventories that measure quality of life
and those that measure eating behavior.
Psychological Assessment of the
patient undergoing bariatric surgery 20
Pre-Operative Bariatric Surgery Psychological Evaluation
Psychological Testing

21. Recommended interviews/assessment tools that should be
administered as part of this evaluation
 Minnesota Multiphasic Personality Inventory®-2. (MMPI®-2)
 Alcohol Use Disorder Test-core (AUDIT-C): 3 items, < 4 minutes to
administer and score.
 Drug Abuse Screening Test (DAST©): 20 items, < 7 minutes to
administer and score.
 Millon Behavioral Medicine Diagnostic (MBMD©): 165 items, 30-45
minutes to administer
 Multidimensional Health Locus of Control (MHLC): 18 items, < 10
minutes to administer
 Questionnaire on Weight and Eating Patterns-Revised (QEWP-R©):
28 items, < 20 minutes to administer
Psychological Assessment of the
patient undergoing bariatric surgery 21

22. The Pre-Operative Bariatric Surgery
Psychological Evaluation should
result in one of the following
recommendations:
Psychological Assessment of the
patient undergoing bariatric surgery 22

23. Poor candidate for bariatric surgery,
(should state if this is considered permanent or whether the patient
should be reassessed at a future date when these issues may have
resolved)
 Presence of acute psychosis (defined as current evidence of active
psychosis and/or mental health hospitalization for psychosis within past 1
year)
 History of multiple suicide attempts within the past 5 years
 Alcohol use disorder within past 6 months
 Other substance use disorder within past 6 months
 Acute exacerbation of borderline personality disorder as indicated by
medical record and/or clinical interview
 History of poor adherence with medical regimens: appointment keeping,
follow-up instructions, and any evidence that patient is very high risk for
non-adherence
 Dementia
Psychological Assessment of the
patient undergoing bariatric surgery 23

24. Poor candidate for bariatric surgery at
this time, but reassessment is recommended
after a period :
 Poorly controlled mental illness(es) or cognitive impairment that may
interfere with ability of patient to comply with necessary instructions and
follow up (e.g. poorly controlled OCD, severe depression/anxiety, severe
bipolar disorder.
 Severe binge eating disorder as measured by tools and confirmed by
clinical interview.
 Unstable social environment (homeless, lack of access to a kitchen, lack
of social support) as assessed by clinical interview
 Very low self-efficacy/self-motivation/personal responsibility
 Other severe behavioral problems.
Psychological Assessment of the
patient undergoing bariatric surgery 24

25. Good candidate for bariatric surgery, but
ongoing focused behavioral intervention to enhance their ability to benefit from
bariatric surgery before and after surgery is recommended for the following
issues:
 Mild-Moderate Binge Eating Disorder.
 Other mild or moderate behavioral problems.
 Moderately low self-efficacy/self-motivation/personal
responsibility .
 Reasonably well-controlled chronic mental illness, including
schizophrenia, depression, bipolar disorder, anxiety disorders, OCD,
personality disorders, alcohol or substance use disorders in
remission
 History of an isolated suicide attempt in the distant past
Psychological Assessment of the
patient undergoing bariatric surgery 25

26. Good candidate for bariatric surgery
 If there are no risks or any of past criteria.
Psychological Assessment of the
patient undergoing bariatric surgery 26

27.  Recommendations:
 Mild depression after surgery is not uncommon, especially
if there are complications and hospital readmissions.
 Severe depression is much less common.
 Suicidal ideation is a serious red-flag that should be
immediately addressed.
 All patients should receive education before surgery as to
the possibility of depression, and the higher rates of suicide in
this population.
 They should also be given education on the symptoms of
depression, and concrete steps to follow to get help if they
notice they are becoming depressed.
 Most bariatric programs have many patients, and it is
unrealistic to monitor the ongoing mental health of every
patient. At Cleveland Clinic, we give patients education about
the possibility of depression after bariatric surgery, and
they are strongly encouraged to call if there is a problem or
question.
Psychological Assessment of the
patient undergoing bariatric surgery 27

28.  Conclusion
Most patients will not become depressed
after surgery, but the possibility is present.
 Therefore it is strongly recommended that each
patient receive education about postoperative
depression, including the recent study showing
the elevated rate of suicide.
 It is important that patients do not make the
illogical assumption that suicide is a side
effect of bariatric surgery. At this point, we do
know that there is a potential vulnerability that
should be addressed, but we do not yet know all
of the facts concerning this finding.
 Preoperative education should be provided for
all patients, along with steps to take if they do
become depressed.
 With adequate education and support,
hopefully postoperative depression may be
reduced.
Psychological Assessment of the
patient undergoing bariatric surgery 28

29. Dopamine Hypothesis of Reward
 Postulates that the actions of drugs of
abuse are rewarding as a consequence of
activation of dopamine in the mesolimbic
dopamine system.
 A similar mechanism occurs with
amphetamine, cocaine, nicotine and food.
Psychological Assessment of the
patient undergoing bariatric surgery 29

30. 30
Obesity and Brain Reward
Human dopamine projections:
(1) The nigrostriatal projection, which is concerned with movement .
(2) and (3) The mesolimbic dopamine projection, which is involved in reward-
related functions.

31. The Reward Deficiency Syndrome
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patient undergoing bariatric surgery 31

32. Psychological Assessment of the
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33. Psychological Assessment of the
patient undergoing bariatric surgery 33