The emotional impact of bariatric surgery in patients with morbid obesity

Abstracts

A cirurgia bariátrica é um método que tem sido utilizado para o emagrecimento e resgate da saúde. Em muitos casos, porém, o emagrecimento súbito incorre em quadros psiquiátricos, tais como: sintomas depressivos, ansiedade, uso de substâncias, alterações comportamentais e ideação suicida, dentre outras situações, associadas às mudanças emocionais que o paciente vivencia com o novo estado físico e psíquico. O atual estudo teve como objetivo analisar as expectativas, fantasias, resultados, dificuldades e frustrações enfrentadas após o procedimento cirúrgico. Realizou-se um relato de caso das informações colhidas com seis pacientes em acompanhamento num hospital público de Santa Catarina e que desenvolveram sintomas de sofrimento psíquico após a cirurgia bariátrica. Cada paciente participou de duas sessões de entrevistas semi-estruturadas. A pesquisa foi submetida e aprovada pela comissão de ética da Universidade de Joinville. Os resultados obtidos demonstram que as mudanças psicológicas decorrentes da cirurgia foram marcantes. Em determinados casos, as entrevistadas expressaram expectativas além do emagrecimento, como a resolução dos conflitos interpessoais e conjugais, assim como mudanças de traços definidos de suas personalidades. Constatou-se, também, o uso de substâncias (álcool e tabaco) associado a comportamentos de risco (envolvimento extraconjugal e direção perigosa). O problema da obesidade ficou evidenciado como parte de uma complexa situação que envolve o estado físico e emocional das pessoas, e sua resolução, por vezes, expõe as dificuldades e as limitações psíquicas dos pacientes.

Obesidade mórbida; cirurgia bariátrica; adaptação psicológica

CASE REPORT

The emotional impact of bariatric surgery in patients with morbid obesity

Cristiano Waihrich Leal^I; Nelma Baldin^II

^IMSc. student. Professor, Universidade da Região de Joinville (UNIVILLE), Joinville, SC, Brazil

^IIPhD. Graduate professor, UNIVILLE

^{Correspondence}

ABSTRACT

Bariatric surgery has been used for health recovery and weight loss. In many cases, however, abrupt weight loss produces psychiatric symptoms, such as depression, anxiety, use of drugs, behavioral changes and suicidal ideation, among other situations, all related to the emotional changes faced by the patient in his new physical and chemical state. This study aimed at analyzing hopes, fantasies, results, difficulties, and frustrations present after a surgical procedure. This case report resulted from the data collected from six patients being followed at a public hospital in Santa Catarina, Brazil, who developed symptoms of psychic suffering after the bariatric surgery. Each patient participated in two sessions of semi-structured interviews. This research was approved by the ethics committee of Universidade de Joinville. Results show that psychological changes resulting from the bariatric surgery were remarkable. In some cases, patients expressed expectations beyond weight loss, such as resolution of marital and interpersonal conflicts, as well as changes in stable personality traits. Use of substances (alcohol and tobacco) associated with risk behavior (extra-marital relationships and dangerous driving) was also detected. The problem of obesity was evidenced as part of a complex situation that involves both physical and mental status, and its solution sometimes exposes the patient's difficulties and psychological limitations.

Keywords: Morbid obesity, bariatric surgery, psychological adaptation.

Introduction

Modern intervention techniques for weight loss - among which is bariatric surgery - have been developed for the treatment of obesity (as a method for weight loss), especially in its morbid form. However, even being extremely efficient, with extremely satisfactory results for a considerable number of individuals, such techniques for weight loss have also faced another type of problem to those who use them: psychological changes after the surgery.¹

Since it is a new entity, psychiatric complications occurred after the surgery do not have instruments to measure them yet.² In many cases, abrupt weight loss produces psychiatric symptoms, such as depression, anxiety, alcoholism and excessive expenses, among other situations.

Younger patients and those with higher alcohol consumption had worse postsurgical course,³ and 1/3 of patients may have worsening of marital relationship.⁴

It is worth stressing that obesity is often associated with psychiatric changes, and may reach prevalence of up to 50% of morbid obese patients,³ as well as be related to increased difficulty in interpersonal relationships.⁵ Personality disorders indicated less weight loss after the surgery.^6,7 Some psychiatric changes are absolute contraindications for bariatric surgery, such as active psychosis, current use of alcohol or drugs, chaotic life situation and inability to cooperate with postsurgical treatment.⁸

On the other hand, long-term studies showed improvement in traits of oral character, such as dependence, submission and insecurity, while detecting increase in obsessive traits and behaviors.⁹

Esthetic factors are often the main motivators in the search of bariatric surgery, reinforced by prejudices that obese patients are more fragile and socially stigmatized.¹⁰

Excessive food consumption can be associated with reinforcing stimuli at eating moments and negative or late aversive stimuli, which are not always identified by the individual, besides being related to inherited and environmental factors.^11,12 On the other hand, it is also associated with behavioral factors, as a learning product.¹³ Consumption of foods is often related to source of secondary psychic gains.¹⁴

Based on those assumptions, this study aims at reporting the psychological phenomena involved in the procedure of bariatric surgery and their implications, as well as expectations, fantasies, results, difficulties and frustrations faced by patients in the postsurgical period.

To do so, six female patients being followed at a public hospital that developed symptoms of psychic suffering after the surgery were selected.

Case Description

Of the six interviewees, five of them were already under drug treatment with antidepressants before having any contact with the research procedures.

Considering the general situation of the interviewees, it was verified that, before the surgery, their mean weight was 127.5 kg. That status had a tendency for reduction, after the surgery, with mean reduction of 39.3% in weight. However, despite weight loss, the interviewees did not seem to be satisfied.

Interviewee 1, married, 26 years old, chose to undergo that surgery for esthetic reasons. After the procedure, her life had major changes: she had an extramarital affair because she felt "more desired by men," and started having a more active attitude in her marriage. She reports that "before the surgery he [her husband] had affairs, now it is payback time." Due to her obesity, she stopped performing many activities, even those that are part of everyday routine, such as going to a store to buy clothes. She reported being ashamed and, for that reason, asked her mother or sister-in-law to go and get clothes to try them at home. She is emphatic when the subject is her obesity: "I hated myself!" She reported changes in roles of the couple with the following statement: "When I was fat, it was hard enough for my marriage... I don't know whether it was because I was fat or whether it was all in my mind. It was quite complicated... My husband used to be the problem (sic)... Now I'm the one who's boring, always nagging about everything."

After the surgery, she developed the habit of drinking more frequently. Over the past months, she had worsening of symptoms, even with a suicide attempt because she believed she was gaining weight again. She claimed she believed it was impossible to gain weight again.

Interviewee 2, married, 36 years old, reported that food has always served as an "escape" for her anxiety, a fact that started in her childhood, because she had a conflicting relationship with her father. She claims that, at that time, she used to wake up in the middle of the night and eat to avoid being reprehended by her father. She reports that the surgery served to rescue her self-esteem, especially regarding the relationship with her husband. Before the surgery, she already had a diagnosis of hypothyroidism and interrupted drug treatment for that disease even before being submitted to the surgery, because she "thought she was taking too many pills." She ignored - or seemed to ignore - the importance a proper treatment of the endocrinological disease would have on weight loss. She states that nowadays her major difficulty in terms of food is due to the fact that she cannot swallow meat. She only chews it and throws it away. She observes that, although she can no longer eat as much as she used to, she developed the habit of feeling pleasure in cooking for her relatives, which compensates her limitation of food consumption. She currently presents changes in attitudes. She reports that she became aware that she could no longer be submissive to everything and everyone. She is not so passive at home, while her husband goes out with friends to have fun. She chose to "have her own life," go out and have fun with friends, and "no longer wait for the others to be happy."

Interviewee 3, single, 39 years old, reports that she started eating compulsively and gaining weight when she was 9 years old and was sexually abused. Food was a refugee for her anxiety. When she reached levels of morbid obesity, she started inducing vomits to eliminate ingested food, after she watched a television show in which "the models did that to lose weight." She had the understanding that the surgery would eliminate all her shyness. She states that, after the procedure, she started having a behavior similar "to that of a teenager" (sic), since she started going out at night, impulsively having relationships with men (considering that she had never had a sexual relationship so far), drinking exaggeratedly and drunk driving. She points out that she overvalued the surgery, hoping that, after the procedure, she could obtain "changes" in characteristics that are actually intrinsic to her personality, and not to her appearance. Her major anxiety and reason for her "depression" (sic), at this moment, is the fact that she is gaining weight again. She is being assessed by the medical staff once again in order to be submitted to a second surgery.

Interviewee 4, married, 41 years old, reports that she was raised in a family that discriminated obese people, despite her parents also being obese. She reports that her father was repressive and critical as to her weight, claiming that "nobody would like her because she was fat." She reports that she was submitted to the surgery to treat health problems caused by her obesity. Soon after the procedure, she needed to start a psychiatric treatment, since she had an intense fear of returning to her previous weight. She believes that her major frustration with the surgery is that she needs to use laxatives daily to maintain her intestinal activity preserved. For that reason, she states that she stopped taking some drugs that were needed to treat diseases resulting from her obesity, but had to start using others that she had never needed up to that moment. Thus, the myth that the surgery would provide her freedom from any type of drug and embarrassment in her life was dispelled.

Interviewee 5, married, considers her frustrated marriage as the main reason of her obesity. Her marriage, according to the interviewee, was performed due to family pressure. Choice of her husband was performed by her father, considering the candidate's genetic origins The surgery had the clear objective of being a turning point in her life. She wanted to get rid of her obesity with the aim of becoming strong enough to achieve "changes" and, perhaps, divorce from her husband. Despite improving her self-esteem, losing weight revealed the failure in her marital and sexual life. Since obesity was no longer an obstacle for her sexual performance, she started perceiving that there was a distance between the couple and a strong affective incompatibility. That started being a reason for sadness. The anxiety that she currently has causes her vomiting, which has a strong associated emotional load: "I feel a really strong pain... And anxiety too, which is not only physical pain!" Nowadays, she developed the habit of smoking (hidden from the rest of the family). She also got involved with another person, with whom she has been having an extramarital relationship.

Interviewee 6 sought the surgery basically with the aim of recovering her health, especially searching for relief for a joint pain in her knee, caused by weight overload. In her case, the surgery "opened the doors to make her a braver woman," since she had to undergo the procedure without family support and, in this sense, she started facing adverse situations serenely. She reports, for instance, that after undergoing a gastric reduction surgery, she summoned courage to undergo an eye surgery, which she had been avoiding for years because she never felt ready for it. She also pointed significant improvement in her marital relationship, including gains in her sexual life. Her major frustration and reason of her depressive symptoms, according to her own interpretation, is that she did not lose enough weight to relieve knee pain, thus she did not reach her main goal.

Discussion

Description that fat can be seen as a sign of protection and isolation and that, if it is abruptly taken away from the individual, may bring him chaos and panic is supported by the analysis of interviewee 3's statements. It was verified that the interviewee's shyness was intrinsically associated with her personality, and not exactly to her fat. The anxiety process started when she realized that deeper (emotional) changes had to be put into effect, and not only superficial changes, such as esthetics and weight loss.

For interviewee 1, the surgery was not seen as an effective and practical technique to rescue her self-esteem. Weight increase that she has been facing after the surgery is being a reason of anxiety and even suicidal thoughts. In addition, she had a fragile personality, having difficulty in dealing with frustrations.

In some cases, aggressiveness started being a feeling reported by patients after the surgery,⁵ such as for example in interviewees 5 and 1. In both cases, a certain degree of hostility with their husbands could be perceived; in patient 1, because it improved her self-esteem, and this became a confrontation for her husband, who used to be a reckless person; and in patient 5, because she felt an increase in her "vital energy" after losing weight, becoming able to face her husband's aggressiveness.

For interviewee 5, the technical surgery of weight loss is like being "reborn," "becoming another person," which is the most evident dependence on an external factor as a real motivation of intimal changes. Although she was submitted to the surgery more than 1 year ago, she could not separate from her husband.

On the other hand, studies carried out in morbid obese patients submitted to bariatric surgery report patients' abandonment of psychotherapeutic treatment follow-up, as well as the importance of such follow-up.¹³ In our study, only one patient was having psychotherapeutic follow-up when the interviews were performed.

For interviewee 2, there was a clear impossibility of dissociating her esthetic from the professional environment, obesity being as obstacle for her success.

With regard to interviewee 6, her current situation shows that she had expectations beyond those able to be achieved concerning weight loss.

In the medical literature there are reports of suicide after bariatric surgery.¹⁶ All patients already suffered from previous depression and had been submitted to psychiatric treatment.

Psychology recognizes the benefits that weight loss can bring to the patient, but the issue of fast and marked weight loss cause by surgical techniques is seen with less enthusiasm.¹⁷ Obesity often works as a false mental and body self, which protects a real fragile and poorly structured self, attributing to it an enormous difficulty of losing weight by some patients.¹⁸

Use of obesity as a defense for facing life situations or even as an escape can be complicated and generate anxiety.¹⁵

Consequently, it is possible to have a proper perception of the complexity that each patient faces when treating morbid obesity, as well as the required degree of personality maturity by any person who is submitted to such treatment.

References

Received July 3, 2007.

Accepted August 7, 2007.

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Publication Dates

• Publication in this collection
  31 Mar 2008
• Date of issue
  Dec 2007

History

• Accepted
  07 Aug 2007
• Received
  03 July 2007