2003, Number 5
Development of bulimia nervosa after bariatric surgery in morbid obesity patients.
Vargas A, Rojas-Ruiz MT, Sánchez RS, Salín-Pascual RJ
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Language: Spanish
References: 18
Page: 28-32
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ABSTRACT
Obesity is a chronic disorder that calls for a multidisciplinary approach. Bariatric surgery is one option, usually at the end of different alternatives.Bariatric surgery offers good results, but that depends on the selection of the patients after a careful evaluation. Part of this evaluation consists of psychiatric and psychological examinations. The main goal of these is to determine if there are any disorders that may interfere with the adherence to the post-surgical treatment. Some of the disorders which may result in a disqualification of a patient are the following: psychosis, mental retardation, dementia, drug dependence, severe personality disorders and severe eating disorders. This article includes three case studies of obese patients who underwent bariatric surgery and developed bulimia nervosa a short time after the surgery.
First case Claudia is a Catholic, single, 33-year old woman from Mexico City. She was admitted to INCMNSZ in 1997 with a diagnosis of morbid obesity and obesity-associated pneumopathy. A psychiatric evaluation performed then showed impulsive and aggressive behavior, lack of tolerance to frustration, and a possible borderline personality disorder. In June 1998, bariatric surgery was performed. The first year after the surgery, she had a dramatic weight loss of 50 kg. Concomitantly, she developed epigastalgia, frequent vomit, anxiety, insomnia, feeling of hopelessness, and sadness.
She also began to self-induce vomiting and taking laxative substances, without adherence to a diet or nutritional indications. She went on binges which consisted mostly of forbidden carbohydrate-rich meals. Two years after bariatric surgery, in a subsequent psychiatric evaluation, she had gained 9 kg. She was prescribed paroxetine 20 mg/day and underwent psychotherapy for 18 months, with some improvement. She dropped her treatment and persisted on the bulimic pattern, without any family support.
Second case Beatriz is a 30-year old married, Catholic, female medical veterinarian with no family history for psychiatric disorders or obesity. At 22 she manifested low self-esteem, easy crying, insomnia, death ideation, and binges without compensatory behavior. She gained 23 kg in one year. In 1994, she was admitted to the obesity clinic of INCMNSZ and was put on a diet without good adherence. She was examined for the first time at the psychiatry department in November 1998, and delusions about damage and reference were then detected. She showed autoagressive behavior, adynamia, asthenia, and auditory hallucinations. She was referred to the Instituto Nacional de Psiquiatría Ramón de la Fuente (INPRF), as an inpatient. She underwent bariatric surgery at the INCMNSZ in May 1999, with a total weight loss of about 38 kg by the end of the first year after the operation. About the same time, she resumed chocolate binges (1 kg/ per binge) and posterior vomiting. She felt guilty and angry. In February 2001, she carried out a new suicidal attempt with a knife, and was admitted once again in a psychiatric hospital. Seven sessions of electro-convulsive therapy were administered because of the severity of the suicidal ideation. She improved and was discharged and prescribed paroxetine 30 mg/day, lorazepam 1 mg at bedtime and risperidone 2 mg/day.
Third case Rocío is 29-year old married, Catholic female with high school level. There was no personal history of drug abuse and she had no family history of psychiatric disorders or obesity. She was an overweight child and during her adolescence she put on more weight, which she associated to her bad family relationship. She became intolerant, with high levels of anxiety, depression, anhedonia, lack of energy, impulsivity and death thoughts. At 17, she had a suicidal attempt with medications. She did not require hospitalization and recovered at home. From the ages of 18 to 25, she had a weight gain of 30 to 40 kg. After two pregnancies, she had gained a total of 108 kg. In 1998, she had her first band gastroplasty. After that, Rocío had a weight reduction of 30 kg in a six-month period. Nonetheless, six months later she developed feelings of apathy and depression, with sadness, irritability, low energy, anxiety and two or three episodes per week of binge eating followed by vomiting. She is currently on antidepressants and showing bad treatment adherence.
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