bariatric ppt

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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

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Psychological Assessment

of the Patient Undergoing

Bariatric Surgery

Dr.Sherif Saad (M.B.B.Ch., M.Sc., M.D.)

Consultant of PsychiatryInternational member of American Psychiatric Association (APA)

International member of European Psychiatric Association (EPA

Psychological Assessment of the

patient undergoing bariatric surgery 2

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

Unhealthy Trends in Saudi Arabia

Psychological Assessment of the

patient undergoing bariatric surgery 4

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

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

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

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

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

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

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

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

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

Pre-Operative Bariatric Surgery Psychological Evaluation

Common categories of assessment include:

Behavioral.

Cognitive/Emotional.

Developmental history.

Current life situation.

Motivation and expectations.

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patient undergoing bariatric surgery 14

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 HistoryPsychological Assessment of the

patient undergoing bariatric surgery 15

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

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.

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patient undergoing bariatric surgery 17

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

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

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

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

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patient undergoing bariatric surgery 21

The Pre-Operative Bariatric Surgery

Psychological Evaluation should

result in one of the following

recommendations:

Psychological Assessment of the

patient undergoing bariatric surgery 22

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

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

Good candidate for bariatric surgery, butongoing 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

Good candidate for bariatric surgery

If there are no risks or any of past criteria.

Psychological Assessment of the

patient undergoing bariatric surgery 26

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

ConclusionMost 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

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

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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.

The Reward Deficiency Syndrome

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patient undergoing bariatric surgery 31

Psychological Assessment of the

patient undergoing bariatric surgery 32

Psychological Assessment of the

patient undergoing bariatric surgery 33