Psychological characteristics of patients submitted to bariatric surgery

Abstracts

INTRODUÇÃO: O grande número de pacientes submetidos a cirurgia bariátrica e que, no pós-operatório, apresentam complicações psicológicas e psiquiátricas justifica uma investigação pré-operatória acurada, bem como categorização daqueles que se submeterão ao procedimento cirúrgico, visando predizer eventuais complicações e individualizar condutas psicológicas que possam favorecer a adesão do paciente. A avaliação psicodinâmica pode fornecer elementos para tal categorização e, assim, propor estratégias de abordagem pré e pós-operatória eficazes. Procuramos identificar estruturas de personalidade que possam orientar o acompanhamento pós-operatório, bem como critérios auxiliares de inclusão/exclusão do procedimento cirúrgico. MÉTODO: Relato de pesquisa empírica conduzida em atendimentos a pacientes submetidos a cirurgia bariátrica, em grupo terapêutico aberto. DISCUSSÃO: Pacientes, depois de operados, podem passar por determinadas fases de reestruturação emocional, como uma primeira fase de triunfo, seguida de fase de risco para surgimento de quadros melancólicos e de novas adições. Identificamos três categorias estruturais psicológicas: estrutura melancólica, cujos pacientes parecem ter maior possibilidade de desenvolver outras condutas aditivas no pós-operatório, sobretudo alimentares, por não suportarem a frustração pela perda; estrutura desmentalizada, na qual, por faltar uma capacidade elaborativa, o paciente não consegue reorganizar-se frente ao desafio de permanecer com peso controlado; e, finalmente, a estrutura perversa, cujos sujeitos mantêm a programada perda de peso, porém a custas de comportamentos que levam desconfortos à equipe de saúde. Estabelecer categorias psicológicas classificatórias pode ser crucial para que se proponham condutas no pós-operatório, inclusive indicação de psicoterapia com especialista, visando a individualizar o atendimento incrementando sucesso terapêutico específico.

Obesidade mórbida; cirurgia bariátrica; psicanálise; psicologia médica; psicoterapia de grupo

THEORETICAL-CLINICAL COMMUNICATION

Psychological characteristics of patients undergoing bariatric surgery*

Ronis Magdaleno Jr.^I; Elinton Adami Chaim^II; Egberto Ribeiro Turato^III

^IPsychiatrist, psychoanalyst. Member of the Brazilian Psychoanalytic Society of São Paulo. PhD student in Mental Health, Department of Medical Psychology and Psychiatry, Faculty of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil.

^IIPhD. Surgeon, head of the Bariatric Surgery Service, Department of Surgery, Hospital de Clínicas, UNICAMP.

^IIIProfessor. Psychiatrist. Coordinator of the Laboratory of Clinical-Qualitative Research, Faculty of Medical Sciences, UNICAMP.

Correspondence

ABSTRACT

INTRODUCTION: The great number of patients submitted bariatric surgery who have psychological and psychiatric complications during the postoperative period require a thorough preoperative investigation and a categorization with the purpose of predicting possible complications and personalizing psychological care that might favor patient compliance. Psychodynamic assessment may provide data for such categorization and, thus, suggest effective pre- and postoperative approach strategies. Therefore, the objective of this study was to identify personality structures that may be useful in the postoperative follow-up, as well as additional inclusion and exclusion criteria for the surgical procedure.

METHOD: Report of empirical survey conducted during psychotherapy sessions with an open group of patients who underwent bariatric surgery.

DISCUSSION: After surgery, patients may experience phases of emotional restructuring, such as an initial phase of feeling triumphant, followed by a phase when there is risk of melancholic behavior and new addictions. We identified three categories of psychological structures: melancholic structure (patients seem to be more likely to develop other postoperative addictive behaviors, mainly eating disorders, since they cannot tolerate the frustration of the loss); dementalized structure (due to the lack of elaborative capacity, patients are unable to reorganize themselves in face of the challenge of keeping their weight under control); and perverse structure (patients comply with the scheduled weight loss; however, their behavior makes the health team experience uncomfortable situations). Establishing psychological categories may be crucial in order to suggest postoperative management strategies, including referral to a psychotherapist with the purpose of providing personalized care, thus increasing specific therapeutic success.

Keywords: Morbid obesity, bariatric surgery, psychoanalysis, medical psychology, group psychotherapy.

Introduction

Obesity is a chronic disease with increasing prevalence. And due to its associated risks, it has been considered one of the main public health problems of society.¹ In addition to those problems that have a direct influence on the individual's quality of life, it causes an increased incidence of several other pathological conditions.

According to the World Health Organization 2006 report,¹ "obesity has reached epidemic proportions globally, with more than 1 billion adults overweight — at least 300 million of them clinically obese — and is a major contributor to the global burden of chronic disease and disability." Such data have served as a warning to authorities and have required great effort from physicians and other health professionals in order to find ways to control and treat obesity.

The major problem regarding treatments for morbid obesity is related to the maintenance of long-term weight loss. Thus, bariatric surgery has emerged as an effective therapeutic tool, being actually able to reduce the therapeutic failures of clinical and nutritional therapies.^2,3

During the National Institutes of Health (NIH) Consensus Development Conference of 1991,³ bariatric surgery was recommended for well-informed and motivated patients with acceptable operative risks and class III obesity, and for those with class II obesity and high-risk pre-morbid conditions. Careful selection of candidates for the surgery carried out by a multidisciplinary team has been also suggested as a crucial aspect.

Segal & Fandiño,⁴ in accordance with the NIH recommendation, considered that "the necessity of clinical, laboratory and psychiatric evaluation on a regular basis in the pre- and postoperative periods must be clear," but the authors warned that "the psychological criteria are being increasingly disregarded during selection of candidates for these procedures, probably due to the absence of instruments that allow for an adequate prognostic accuracy, showing an increasingly subjective evidence-based clinical evaluation" (free translation based on the original text in Portuguese).

A survey conducted by Appolinário⁵ shows that long-term postoperative follow-up studies involving patients who underwent bariatric surgery "reported several psychiatric conditions causing death during the postoperative period, suicidal being the main event" (free translation). Omalu et al.⁶ presented case reports of previously depressed patients who committed suicide after the bariatric surgery. These findings suggest that there is lack of balance among the psychiatric forces of such individuals during the postoperative period and that the new symptoms emerging during this phase are basically self-aggressive. Leal & Baldin⁷ presented case reports that showed increased aggressiveness in patients after the surgery.

These authors' concern is relevant, since the surgical procedure has been recommended and performed at an increasing frequency, and cautions regarding the psychological and psychiatric consequences of this procedure, which remain poorly known, have not been well-established yet.

Kalarchian et al.,⁸ after carrying out a thorough investigation on psychiatric disorders, including both axis I and II of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV),⁹ concluded that there is "compelling evidence that psychiatric disorders are a major concern for this patient population, not only because they are relatively common but also because they are associated with severity of obesity and decreased functional health status."

Magdaleno et al.¹⁰ showed that, in spite of the acute physical and psychiatric changes imposed by the bariatric surgery, social acceptance and the feeling of recovering the identity that was covered by excess of body fat, breaks the vicious cycle of low self-esteem - increased anxiety - eating urge, with a significant improvement of patients' quality of life.¹⁰ From a psychodynamic point of view, obesity is the final effect of a complex set of psychiatric difficulties and their interaction with the environment, having its origin in the early phases of human development.^11,12

Since Freud,^13,14 it has been known that, during the early phases of development, there is predominance of child's hate regarding the environment that causes frustration. The child's attacks against the environment are intense, and, depending on the environment's response, they can damage the child's relational system with others, impairing his/her basic psychic functions. During this period, the symbolic function of embodiment, which is expressed by eating, is the model available for the child to relate to the world. The structuring of the most primitive symptoms that would be expressed later as addictive behaviors, among them morbid obesity, would occur based on the failures at this crucial moment when the child's relational system is being built. The inability to create a symbolic reference that is able to make this strong pressure of primitive impulses somehow useful fails to provide an immediate body discharge path to these primitive impulses.

According to Mahler,¹¹ the cohesive identity of the child's body image is based on his/her early experiences in the sensorial and motor fields, experienced in the fusional relationship with the mother. The child learns and understands the world through this relationship. It is during this phase that the Self is built based on the mother's image. Winnicott¹⁵ named this developmental moment as the "mirror phase," during which the child should be able to recognize himself/herself through his/her mother's eyes, and the process of building his/her own identity is initiated after that. Failures at these initial moments of formation of the Self constrain the baby to defend himself, structuring impaired areas in the psychism. These areas make him unable to deal with the pressure imposed by his body.

Also according to Winnicott,¹⁶ during the baby's normal development, the "good-enough mother" shelters the baby inside her "internal environment" and protects him from internal and external disturbed tensions, therefore, providing a progressive differentiation of the child's soma towards the creation of a psychosoma, which will be responsible for being the mediator between the internal intense demands and the demands from the external world. Thus, the psychosoma would be a structure that is built based on the relationship of the body and its drives with the environment. If there is any failure during this maturation process, some parts of this body keep functioning in a primitive manner, without an organizing mediation, and these parts are susceptible to the immediate discharge of tension. Tustin,¹² based on a study involving children with psychogenic autism, suggested that adults may have isolated areas of their personality with an autistic functioning, which would serve as the structural basis of mental disorders such as addictions, eating disorders and morbid obesity, among others.

The relevant problem concerning this is that the removal or the surgical blockage of the symptom creates a new field of study regarding the individual's biopsychological dynamics, since anxiety, which somehow was dealt with through the symptom, has its discharge path blocked in an "artificial and acute" manner after the bariatric surgery. The objective of this study is to define, based on the understanding of the experience of patients undergoing the surgery, some strategies to manage the patients and the health professional team involved in the performance of the bariatric surgery.

Method

The present study is the result of clinical and psychological analyses originated from the researcher's acculturation process while doing field research and is related to a PhD project in mental health involving subjects who underwent bariatric surgery at the Bariatric Surgery Service of Hospital de Clínicas of Universidade Estadual de Campinas (UNICAMP), Campinas, state of São Paulo, Brazil. Acculturation is the usual procedure employed in qualitative investigations with a humanistic basis and it aims at constituting a representative sample in research according to the qualitative clinical method.¹⁷

This article presents a report of empirical observation performed during the delivery of psychological care to patients who underwent bariatric surgery at Hospital de Clínicas of UNICAMP based on the use of the clinical method in an open psychotherapy group. The clinical method is aimed at adapting to the problems arising during clinical observation, using instruments related to the clinical practice, based on empiricism and the theory related to clinical performance.¹⁸ Therefore, the origin of the method is the researcher's clinical attitude, based on the "acceptance of existential and emotional suffering of the individual being studied by the researcher"¹⁷ (free translation).

Arruda¹⁸ adds that the clinical attitude, in addition to the use of the interpretative model of human sciences, enables "understanding, connection of senses and development of knowledge" (free translation). Hence, these authors emphasize the possibility of a qualitative approach to the research process and to data analysis while using a clinical method,¹⁹ and, therefore, this procedure constitutes a scientific tool for investigation, validating the results generated by its use.

We used clinical observation of patients who participated in open psychotherapy groups. There were weekly sessions conducted by psychologists from the Outpatient Clinic of Bariatric Surgery of Hospital de Clínicas of UNICAMP. The groups are formed based on invitation and spontaneous participation of patients who underwent the surgery. The group has a broad therapeutic focus, which aims at solving doubts about practical problems of the postoperative period, identifying conflicts, understanding the patients' psychic dynamics and, finally, enabling the patients to better deal with the challenge they have to face after the surgery. The group's main objective is to help patients to adapt to their new life status, and, as a consequence, improve treatment compliance and provide the patients with tools to help them keep loosing weight.

Based on the material that spontaneously emerged during the sessions, what we were able to identify in the group dynamics and the discussion with our colleagues from the Laboratory of Qualitative and Clinical Research, we identified some phenomena that are part of the psychic reality of such subjects, and we believe that these phenomena are common during the postoperative period of bariatric surgery.

Discussion

Statement about the clinical experience in the postoperative group

"... but for us everything is so difficult because we think with our bodies."

The subject who starts participating in the postoperative group is somehow a winner. This individual has overcome the challenges of the postoperative period, survived the surgery, endured the first month after surgery, during which the liquid and pasty diet is always experienced as "a suffering to be tolerated for the sake of a major cause" (sentence uttered by a participant of the group). However, such feeling of victory, ends up being covered by the difficulty of the situation to which these subjects are exposed. Eating, which was previously experienced as an unconditional pleasure, except for some guilt due to the amount of food, becomes a problem to be faced: food "does not goes down well", "gets twisted", "gets stuck", often causes vomiting, dumping. The pleasure of eating is quite reduced. And then, what to do with the individuals whose only pleasure in life was eating? How to deal with subjects who "think with their bodies?"

From this moment on, these subjects have to start facing the problems. Before the surgery, even if they have been provided with guidance and information on the difficulties, they were fascinated by their certainty of solving all their problems after the surgery,^20,21 just like magic.

A clinical situation that occurred during a psychotherapy session illustrates this. During one of our meetings, we discussed that a frequent problem arising in these groups is the obese patients' difficulty in adapting to the social patterns. In the course of the discussion, one of the patients commented: "our problem is the turnstiles on buses, if you don't pay attention, you can get stuck." There was immediate agreement from the group. Other participants started joking about their lives regarding their own experiences with bus turnstiles. Then, there was a feeling of excitement mixed with relief, because almost all of them were able to pass the turnstiles now.

The therapist interfered and said "but now that all of you can pass the turnstiles, what can you do?" There was a general discomfort in the group, and anxiety was present again. The therapist's question reminds the group of the anxiety underlying the triumph that the patient is trying to maintain: the idea that the surgery could solve all their problems. Reality, however, is very different from that. Life's problems are not metaphorically solved by passing a turnstile or concretely solved by undergoing a surgery. The therapist's question aimed at inducing thinking, providing these individuals who "think with their bodies" with the possibility of "thinking with their heads," considering and improving their abilities to elaborate.

After surpassing this milestone, which in this case is the surgery, there is a phase of intense challenges, maybe even bigger than before, since the whole defensive system that was built around eating and obesity is blocked. The subject has to quickly learn how to deal with his anxieties in different manners. Sometimes, it is not possible, and it makes countless pathological channels to be open. We can say that obesity, experienced by all of them as a great problem, is also, deeply inside, an answer for all problems. Hence, the obvious conclusion that emerges very often: after solving the obesity problem, everything will be solved. The moment when such illusion fades away is critical, and we observe that the subject gets susceptible to emotional and psychiatric complications as described next.

Psychological experiences during postoperative period

As we tried to illustrate using the clinical material mentioned above, the first reaction seen in most patients is a certain belief of "triumph" over the previous status of obesity. It is as if the whole problem had been defeated by the surgery. This reaction is strongly reinforced by the visible weight loss and by the positive reinforcement provided by health professionals, relatives and other patients. This is the initial period of time defined by the team and patients as honey moon. During this period, weight loss is so evident that the positive reinforcement from health professionals and other patients is so constant that it compensates any amount of suffering. The patient feels as he/she was in a "fashion show," and that all that suffering caused by social exclusion, rejection for being fat, and the narcissistic wound that represents a body that does not fit the standards, suddenly disappears.

However, as for every honey moon, such period has an end. And the honey moon is replaced by other feelings that sometimes "seem to come out of the blue:" anxiety, sensation of indefinite boredom, emptiness, as if there is something missing, feelings of sadness, an urge to keep eating snacks all the time... but even though weight loss is still visible, the physical trauma of surgery starts healing, there is increasing balance and willingness to keep struggling.

The thread appears when reality shows that the patient may gain weight again in spite of the surgery. At this moment — 1 year or longer after the surgery — the symptom "obesity," which was blocked by surgery, may start to try new ways to express itself if there was not a successful therapeutic follow-up. It is possible to observe two main paths: the depressive path and the compulsive path.

The first one starts with vague symptoms: sensation of emptiness, loss of interest for those things that used to be very important, loss of efficacy at work, and anxiety. In the most severe cases, it can become depressive disorders, as described in the literature.^22,23

The second path that can emerge is compulsion. It has been often observed that after the first period of triumph over the symptom, the impulsive characteristic, present in the basis of the obese patient's personality, starts to be increasingly present and leads the individual towards food. Then there is terror and fascination regarding cookies that melt in their mouth, tapioca flour biscuits, condensed milk, ice-cream and chocolate. An internal battle takes place. The patient is less strict with his/her diet and starts putting on weight again. After a psychotherapy session with the group, one of the patients declared: "doctor, I don't know what to do, I don't feel hungry, but I spend all day long eating cookies, and I'm putting on weight again, but I can't stop it." This statement is strongly characterized by an anxiety that overflows through the tiresome appearance of a lady that is visibly captive of an internal endless battle, that is, the compulsive behavior is still present and it is the body path, not the thought path, that is available for this patient. How can we provide or favor thinking activities to subjects who, during almost their whole life, had their body as their preferential way to deal with internal conflicts and tensions? And that is their great challenge.

The peculiar characteristic of this population makes the health professional team to face quite unique issues and requires special therapeutic approaches. Since the essence of the psychological structure of the patient with morbid obesity is constituted by primitive elements connected to problems of the early phases of emotional development, with intense feelings of hate regarding frustration and absence, we observe this internal emotional world to overflow into the outpatient clinic environment and sometimes it affects how the team and health professionals function. Such phenomenon occurs through massive projective identification²⁴ of psychic elements inside the team. It is easy to identify rejective attitudes regarding certain patients who put on weight again or who cannot follow their diet restrictions correctly, or even regarding those patients who have complaints related to the surgery (pain, food intolerance, etc). We believe that these feelings are the result of massive projection of the patients' internal world into the team. This fact is practically important, since it suggests there is need of training the members of the health team and, more important than that, providing them with psychotherapeutic support so that they are able to identify and elaborate this heavy burden of affections imposed by the patient. If these measures are not taken, health care professionals can easily make mistakes, since this kind of feelings and reactions incited by the obese patient are often related to rejection and prejudice.^25,26

Thus, the emotional responses that emerge in the clinical environment should be the focus of the psychological care received by the multidisciplinary team. Guidelines, clarifications and psychological support procedures are quite necessary inside a group of patients that functions based on primitive psychic patterns. These patients often experience feelings of abandonment and emptiness during the postoperative period, mainly in the late postoperative period, when they are distant from the initial period of "honey moon" with regard to the surgery and the health team. It is very important that the team is prepared to deal with those aspects related to the patients' emotional dynamics that will contaminate the team's work environment with feelings of rejection (often disguised as reactive formations such as "excessive affection" or "idealization" of the team or its members), dependence and adherence. These responses, if not perceived, tend to incite responses from the team, and they may lead the patients — which are the most fragile part of this setting — to unconsciously reject the team and treatment, causing them to drop out from the postoperative follow-up.

Great portion of the difficulty of dealing with patients who function at the body level — and patients with morbid obesity are examples of that — is that they communicate mainly through non-verbal elements, which are more deeply felt than rationally understood.^11,24 Thus, any attempt to understand and respond to this communication based on rationality tends to generate a sterile repetition, which hinders the understanding of pre-verbal communication, leading to negative responses both from the patients and the health team.

A classification proposal for the psychological structures of obese patients and their postoperative management

These experiences allow us to suggest some guidelines regarding the functioning of the multidisciplinary team. Firstly, it is necessary to understand the mental structure of the subjects who seek treatment at our outpatient clinic.

Based on the clinical observation of patients and on psychodynamic references, we identified three groups of patients: those with a melancholic structure, the ones with a dementalized structure and those presenting a perverse structure. Each one of these structures has different ways to face the challenges imposed by the surgery, with different postoperative prognosis and complications.

Based on Freud's description of melancholy,²⁷ which consists of a condition that leads the individual to live with the "shadow of the lost object" imbedded inside the Self and from which the individual is not able to escape, we defined a melancholic structure. After undergoing surgery, these patients will face great difficulties to endure the absence represented by the restriction of food intake, having a higher probability of developing depressive and anxious disorders. They are more likely to develop eating strategies that compensate the restriction imposed by the surgery, that is, these are the patients that "eat snacks" all day long in a compulsive manner; they get anxious, but cannot control this behavior. The feeling of absence becomes unbearable when they reactivate the experience of losing their love object. These are the patients who respond to the treatment with antidepressive drugs, although they present a poor response.

The dementalized structure is, according to our point of view, a great postoperative challenge, since these are individuals who function using very few mental elements to elaborate, and who, therefore, have a very poor contact with themselves and the others. Currently, many psychoanalysts have been trying to substantiate the emptiness and deficit pathologies, among them is morbid obesity,^28-31 using metapsychology. There is poor mental representation in such pathologies, with great impairment of symbolization and, as a consequence, lack of elaborative thinking. These patients, because they lack elements for elaboration, use their bodies as their main path of drive discharge. For them, the technical guidelines and information mean very little or cannot be used due to their lack of listening and understanding elements. Some of them eat almost the same amount of food as they did before the surgery just some months after the procedure, as an automated and poorly elaborated behavior. The challenge imposed by the surgery is not well understood. These patients' participation in the therapeutic group is very discreet; they keep quiet and do not share their opinions; they pay attention to the other members' conversation. The risk of not being able to comply with the initial proposal of treatment, and even not being able to understand the complexity of weight loss process, very often leads them to gain the weight they lost in a few years; therefore, the surgery becomes an unnecessary risk.

Such attitude shows what we call the psychic emptiness, and it characterizes the deficit pathologies. We should, therefore, question the surgical recommendation for these subjects, or, in other words, we should revise the criteria for surgical recommendation, which might be more strict, being limited to those individuals for whom obesity brings great health complications, with high risk of death.

In conclusion, based on Freud's ideas on fetishism,³² we proposed a perverse structure. According to Freud, there are some individuals who create maneuvers to confound the perception of the limits imposed by reality. When they have to face the inevitable absences that reality continuously imposes, they act as if these absences did not exist, and finally the others simply have to function as supporting actors in this mockery of completeness. These are subjects who create deadlocks because they need to avoid the reality of absence all the time and, with that purpose, they use other people's compliance. Therefore, they will be the patients who create postoperative problems because of their demands regarding the multidisciplinary team, they will be especially demanding with physicians. Since the body path is the most sensitive one, body complaints will be the most frequent, such as undefined abdominal pain, vomiting episodes with no clinical reason, food intolerance and bulimic episodes. These are patients who cause the most intense negative emotional responses in the team and even among the other patients. They need continuous attention from the team, are constantly complaining, making the team responsible for their suffering, and always conveying the message that "now that you performed the surgery, you are responsible for my lack of satisfaction." There is massive projection into the team of their lack of satisfaction regarding the reality that make them frustrated, and usually the team's response is rejection, and sometimes there is even a masked aggression towards the patient. In the therapeutic group, these patients are disruptive, they incite the group against the therapists and team, "delate" the failures in the care system and the flaws of team members. They seek the team's help in an invasive and adhesive manner, what induces the most intense negative countertransference reactions.

Based on these theoretical-clinical suppositions, it becomes evident that ideally any candidate for a bariatric surgery should go through an investigative process regarding his/her mental structure, and they should also be managed using a deep psychotherapeutic approach before the surgery. However, this kind of process would make the surgical procedure almost impossible to be carried out due to its complexity, in addition to the refusal of most patients to comply with that, since they want a quick solution for their problem. This reality can be improved by the presence of experts in mental health who are experienced in psychodynamic practices, as well as in the use of psychotherapeutic techniques. Such professionals would be in charge of previously identifying the mental structure of the candidates for surgery, suggesting individual psychological approach strategies for the pre- and postoperative period, with the aim of preventing psychological complications from making the risk accepted by the patients and by the team unnecessary.

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• 32. Freud S. Fetichismo. In: Freud S. Obras completas. vol. 9. Rio de Janeiro: Imago; 1974. p. 175-85.

*

Este estudo foi realizado no Ambulatório de Cirurgia Bariátrica do Hospital de Clínicas da Universidade Estadual de Campinas, e sua execução contou com a colaboração do Laboratório de Pesquisa Clínico Qualitativo da Faculdade de Ciências Médicas da UNICAMP, coordenado pelo Prof. Dr. Egberto Ribeiro Turato. É parte de projeto de pesquisa de doutorado na área se Saúde Mental, devidamente aprovado pelo Comitê de Ética em Pesquisa da Faculdade de Ciências Médicas, UNICAMP (parecer nº 534/2006). Título do projeto: "Vivências emocionais de mulheres submetidas à cirurgia bariátrica no HC-UNICAMP: um estudo clínico-qualitativo".

Publication Dates

• Publication in this collection
  24 Aug 2009
• Date of issue
  2009

History

• Accepted
  05 Nov 2008
• Received
  22 Apr 2008