Bariatric surgery
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The document discusses bariatric surgery for obesity treatment and the psychological evaluation and support needed for patients undergoing such surgery. It covers factors like assessing patients for active mental illness, substance abuse issues, or risk of noncompliance that could exclude them from surgery. For suitable candidates, it recommends providing psychological treatment both before and after surgery to address issues like eating triggers, coping skills, and maintaining lifestyle changes needed for successful weight loss and health outcomes.
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Bariatric surgery
- 1. Treating the Bariatric Surgery Patient Brooke Schauder, PhD Erie Psychology Consortium Pacific Graduate School of Psychology
- 5. What is Bariatric Surgery?
Editor's Notes
- First of all, obesity has been linked directly to increased mortality – not even including other health problems. -More importantly though, it is linked with a number of fatal diseases, including high blood pressure, type II diabetes, high cholesterol, joint and muscle problems (knee and hip problems) there’s been a link to cancer
- Read: so they’ve found that the effects of obesity may be reversible in many cases, if caught before it begins to interfere with other system functions, such as heart disease, etc. Also, and this is very unfortunate for our field, but alternative treatments, including diets and exercise are not very effective in the morbidly obese population. On average, in many of the clinical trials, patients only lost 1-2 lbs over the course of a few months and most gained that and more back.
- This is a video showing laparoscopic surgery – most common way to perform gastric bypass – uses slendar surgicla instruments and a camera called a laaroscope and moniters it through a lense to perform surgery There is a major incision – an invasive and traumatic surgery. The stomach is divided into 2 parts and then sealed with staples and stitches. This leaves a pouch the size of a golf ball where food is received. The small intestine is then cut lower down and brought up to go directly into the new pouch. The old stomach and intestine is connected below to another portion of the small intestine. Food then bypasses the old stomach entirely, however the stomach still secretes normal digestive juices and enzymes into the lower intestine in order to digest food and so that nutrients are absorbed normally.
- The majority of complications following surgery arise from the patient’s non-compliance with treatment. Not only is the diet extremely restricted, which I’ll go into next, but there is a lot of care required for the healing of the large wound. Not following up with routine check –ups increases these odds, so the patient must make all scheduled appointments.
- If they don’t chew their food, can cause obstruction as the stomach and intestine openings are much smaller
- The surgery is not a magic tool – patient must continue to restrict calories. For many, appetite is decreased, but it is possible to stretch the stomach and still overeat or rip stitches
- Has this patient tried a number of different weight loss attempts and failed? It is important that they have made signfiicant efforts and haven’t simply heard of surgery and decided to try. Asking if they plan to exercise often reveals whether they have a realistic plan for weight following surgery – if they do not, it strongly suggests that they see surgery as a magic tool and they do not have to provide their own effort to become healthy Substance use is strongly contraindicated, both because it may harm their judgment following surgery and also because it suggests they do not have healthy coping mechanisms in place for dealing with the stress of a surgery
- 6 months of stable psychiatric status is key – recommended as the minimum by much of the literature. Therefore, when I make my recommendations for therapy for those who are not ready, I suggest at least 6 months.
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- Most research does show that rates of mental disorders are somewhat higher in this population of morbidly obese people seeking surgery. Rates of those with psychiatric diagnosis are about 50%.
- in addition to treating any comorbid psychiatric disorder, such as substance abuse or dealing with an Axis II disorder, there are a number of steps bariatric patients must go through emotionally before they are ready. The first step with a pre-surgical patient is to identify the cause or source of their overeating. Did it start in childhood - what need were they meeting with food? Whether they were sexually or physically abused is very important in the beginning of therapy. Next, find out if the patient sees surgery as a magic tool for getting a perfect life : do they plan to exercise – help them understand the strict limitations and restrictions following surgery and that it will not be easy. This is when it is very important that they understand all of the regulations on the phases of eating after surgery – they may start to grasp the intensity of this procedure and realize it is too much. -Then, they should fully comprehend the traumatic nature of the surgery – they will be cut open. How have they before handled medical problems. Have they ever undergone medical procedure? Some desensitization at this point may be necessary. -Identify eating triggers or weaknesses (holidays, family stress) and develop plans for coping with this stress – relaxation therapy may be very beneficial for these patients -Next, the patient needs new coping mechanisms now that their major one, food, is no longer available – exercise, hobbies -Many need to develop better social networks – so encouraging to develop family supports – social networks, plan for ongoing group treatment
- Often bariatric candidates have external locus of control – attribute negative and positive events in life to outside forces, as either chance or other people. It’s important to help them realize that they control their own fate. This can be done by setting behavioral plans, goals, and rewarding themselves for accomplishments. By visually keeping track of failures as well as setbacks, they can realize they have influence over what happens to them. This is why it is very important to keep a food jounral prior to surgery – this way they have to stop attributing weight to chance.
- It has been found that losing 5-10 % of weight before surgery usually correlates with better outcomes – for a couple of reasons. It separates those who can comply with treatment from those who cannot and it also decreases the mortality rate during the surgical procedure (one study found shorter hospital LOS post surgery, easier breathing under anesthesia) Patient’s may argue that they cannot lose this or they would not be opting for surgical procedure, however remind them that this is only f or approx 6 months prior to surgery and they are not expected to “keep it off” without extra help that surgery will provide Some may also have a lot of anxiety about the surgery – relaxation training – understanding exactly what they will do during the surgery, and identifying what exactly the fear is is helpful - is it a blood phobia, phobia of being under anasthesia, etc. Some may have a problem with following Dr’s orders – being compliant with medicines – practicing taking vitamins is a good way to behaviorally habituate to a daily routine. As for hostility toward medical staff, find out if it is anger toward authority in general – possibly more of an antisocial type character Food journal is important at this point – in order to determine if the patient is really ready to comply with strict eating pattern following surgery
- Continuing to work on a non-defensive attitude is important following the surgery as well -Patient should have a reward system for achievable small goals – don’t make the goal too big -Often right after surgery the patient second guesses their decision – very difficult adjustment period with that diet as well as pain from healing and restriction of activity. Weight loss happens fast, but not immediately. After a short period of time though, weight loss often happens quickly.
- CBT therapy is probably the best approach – many of them in particular struggle with black and white thinking around eating: They feel like a failure if they stray in any way from the diet and therefore go off of it all together. Attempting to help them see partial success and partial loss, rather than giving up, which is extremely dangerous. Catastrophic thinking often happens if the weight loss is slower than expected – they start to get scared that the whole thing was a mistake and they will never meet target weight, again this can become dangerous because they may feel the desire to “give up” Teach them to assume that there WILL be setbacks and relapses
- 2 nd is on the web