In a letter to the editor of the New York Times Magazine, dated December 2, 2007, regarding bariatric surgery, psychiatrist Amanda Itzkoff stated,
I have no doubt that a markedly obese patient without other medical cause for obesity (i.e., thyroid disease) already has a severe problem. Without treating the compulsion that underlies such behavior, it is no wonder that patients who have surgery, but no psychiatric treatment may develop “new” psychiatric symptoms like gambling, compulsive shopping and alcoholism.

This so reflects the views prevalent in the 1970’s that obesity is a psychological problem. In my opinion, simplistic thinking like that further victimizes people who have enough trouble medically, socially, and physically. Current thinking is enhanced by awareness of the impact of evolution in which sensory and physiological mechanisms controlling food intake were meant to protect us against energy depletion. It seems that existing mechanisms of taste, appetite or satiety are not as equipped for the prevention of dietary excess as they are for the promotion of it. According to one author among many, “Far from being an abnormality or a disease, obesity may represent an adaptive response to the current environmental conditions.” Drewnowski, p 53 (Fairburn and Brownell).

Those who attempt to restrict dietary intake are fighting their own bodies. An article in the November 9, 2007 issue of Science magazine noted that the body attempts to maintain body fat stores within as narrow a range as it does temperature. Those who restrict their diets severely are headed, in the long run, for defeat and many are headed for eating disorders. Mice put on carefully monitored body-fat reducing diets lose weight quickly the first time. They lose weight much more slowly the second time and even more slowly the third. Everywhere there is evidence that the body actively defends an elevated level of body fat. That’s how my ancestors got from the frozen wastes of the tundra to the relative warmth of the United States.

For many who are morbidly obese and who have done every diet and exercise touted by the weight control industry and have failed, bariatric surgery may be a rational solution, particularly with the newer procedures. This is not to say there are not psychological aspects of the problem. Anorexia and bulimia are some of the life-threatening results of dieting and seem to be correlated with certain personality types. It is yet to be revealed, however, which came first: the eating disorder and then the personality disorder or the personality disorder as a result of the eating disorder or both. Symptom substitution for those who have this surgery is not automatic.

If those of us doing psychological evaluations for bariatric surgery don’t have a command of the literature on obesity, we will be joining the ranks of those who contribute to the current societal attitude toward the obese. We will take a lot of their money to keep them from a treatment that, although radical, does cure diabetes and hypertension and seems to improve self-esteem. It is noteworthy that while candidates for gastric bypass surgery on average display a high degree of presurgical psychopathology on the MMPI-2, post-surgically, the levels of psychopathology on this test decline significantly, indicating an improvement in emotional status (Arbisi and Seims). The authors note that attempts to predict positive surgical outcome with the MMPI-2 have not met with success.

That said, I do evaluate people prior to bariatric surgery. I tell them that I don’t consider it my job to keep them from having the surgery they want. I am straightforward about the fact that we can no more predict a particular psychological outcome than a physician can predict every surgical complication. However, I do consider it might job to look for whatever challenges there may be to their recovery. “Because bariatric surgery not only reduces body weight, it alters body image and the way people treat you, we want to know about your methods of coping with problems, resiliency, and willingness to take support from others…your treatment team just wants to ‘have your back’.”

By the way, I consider it a conflict of interest to do a pre-surgical evaluation and then refer to myself for post-surgical psychological follow-up. If I think the person will benefit from a psychologist, provide three recommendations partially based on what I know about the needs of the patient and the skills of the particular therapist to whom I refer.

I usually give a fairly lengthy intake interview regarding the usual demographic and historical information we all take. I especially document any medications they may be taking because the actual size of the pill may be too large to ingest and there may be a need for a new mode of administration or a change. Included are evaluations of eating and dietary styles (binge-eating, overeating, grazing and night-eating), substance use (carbonated beverages may compromise pouch integrity, nicotine may slow healing and create ulcers, certain medications may damage the pouch). I look for evidence of a history impulsive behavior, compulsive behavior or habits. I want to know what they know about their proposed surgical interventions, their coping skills, emotional modulation and ability to set boundaries. Psychopathology need not prevent a candidate from a bariatric surgery. However, we do want to know something about the person’s social environment, history of suicidal behavior or psychiatric hospitalizations, participation with a psychiatrist and psychologist.
I usually administer the Millon Behavioral Medicine Diagnostic (MBMD) with bariatric norms and prefer it to the MMPI-2. This is because the majority of bariatric candidates are more similar to medical patients and to non-psychiatric samples than to psychiatric patients. Further, the report includes the patient’s coping strategies. I also use the Eating Disorder Examination by Fairburn and Cooper or the Eating Disorder Inventory-3 by David Garner, Ph.D.

These are not a lot of tests. In my opinion there should not be. Eating is a behavior. We are screening for the aspects of the eating behavior which are changeworthy and evaluating the extent to which the patient will cooperate in his own care and receive and use support if needed. We can only guess. These are, after all, self-reports. But they are directly related to the relevant issues. That’s consistent with our training in assessment. Using every test in our quiver runs the risk of matrix error and only jacks up the costs.

I then schedule a follow-up appointment with the patient and present her with the report which I’m going to provide the physician. I ask the patient if she thinks there’s anything I’ve missed. I ask him if he thinks I said something wrong. I consider this report an aspect of informed consent…..e.g, “This is what you usually do either habitually or under stress. It can hurt you. But here’s what you do to cope. Use it.” Usually they say something like, “Well, that’s me!” Then I give them another copy of the report and they take it to their physician.

Now I’ve done my job, and it is up to the patient, the physician, the treatment team and any post-surgical psychotherapy that’s warranted.