In love with your disease

In the old-fashioned freudian model, the pathological behavior of a mental illness is in many cases a symptom of, or compensation for, an underlying, causative problem. Once you find the cause, you’ve done the hard part. Examples: a man who is afraid of responsibility and drinks to absolve himself of it. A woman who cannot control her surroundings or her relationships, and starves herself to control her body.

The illness isn’t purely bad: it gives you something. You need it. Like the inflammatory response, or fever, it’s an immune system compensating or repairing. Like vomiting is how your body gets rid of bad food: it’s a helpful thing at first, and you do it again, and again, and then it’s not so helpful. And by then it’s too late to just stop, the nausea perpetuates itself.

You say things like “I feel that I’m fine the way I am. Which is the problem.”

I’ve been sad for longer than I’ve been anything else, I think. It’s always there, even when I’m well, which is most of the time these days. Months and months on end I feel fine. I feel great. I am happy and I know it and sometimes I even clap my hands and sing, seriously off-key, about life and its wonders. But I know it’s there waiting for me to slip. Waiting for an illness or a death in the family or a national disaster, and then it will pounce.

You ever read A Wizard of Earthsea, by Ursula K. LeGuin? That’s what it’s like. It’s always lurking. I may spend years free from it, but it will come back again, and I will have to fight it again. Eventually, I will die. Maybe it will kill me, maybe something else will. But I can never kill it. I can never truly win.

If there’s someone who would know about the relationship between the body and the mind, it’s Eliot “Follow Me Here” Gelwan. I wrote him asking about gastric bypass and mental illness, and his response was this:

In my experience, a responsible gastric bypass surgeon requires his patient to have a psychological evaluation before deciding whether to perform the procedure on a given patient. This is a little simplistic, but essentially the surgery works by reducing the volume of the stomach, producing a feeling of fullness and satiety sooner, and thereby helping the person control their eating. If someone, psychologically, eats compulsively despite feeling full, then not only will the surgery not work but it would be dangerous.

He also sent some abstracts and links to journal articles, which are included below.

Saunders, R. Compulsive eating and gastric bypass surgery: what does hunger have to do with it?
Obesity Surgery : the Official Journal of the American Society For Bariatric Surgery and of the Obesity Surgery Society of Australia and New Zealand, Vol. 11, No. 6, pp 757-61 2001

BACKGROUND: Binge eating and other patterns of disordered eating in obese patients need further investigation. In a previous study by this author, one-third of patients presenting for bariatric surgery met strict criteria for Binge Eating Disorder. It is important to clarify the role of such eating behaviors on outcome of surgery to determine whether treatments targeted specifically at these behaviors and associated psychological issues can improve surgical outcome. The aim of this paper is to raise awareness of the range of disordered eating patterns in bariatric patients, describe an approach used, and discuss issues reported by patients after surgery. METHODS: Patients completed questionnaires before surgery (QWEP, BES, BDI) and were seen for a pre-surgery mental health evaluation. High risk patients were identified and invited to attend a post-surgery group (CBT approach) as a preventive measure to help them deal with eating patterns as well as emotional adjustment. RESULTS: Disordered eating patterns can persist after surgery. While surgery may decrease actual physical hunger and reduce physical capacity for food, it is still possible to eat compulsively, although the patterns may change somewhat due to the surgical procedure. CONCLUSION: Since long-term weight maintenance depends on post-operative changes in eating behaviors, it is important to identify patients at risk for a range of disordered eating patterns so that a comprehensive treatment plan that targets the eating disturbances and associated psychological components can be implemented.

Kalarchian, M.A., Marcus, M.D., Wilson, G.T., Labouvie, E.W., Brolin, R.E., LaMarca, L.B. Binge eating among gastric bypass patients at long-term follow-up. Obesity Surgery Vol. 12, No. 2, pp. 270-5, 2002

BACKGROUND: A better understanding of the relationship of eating behavior and attitudes to weight loss following gastric bypass (GBP) will enable the development of interventions to improve outcome. Thus, the present study sought to characterize the postoperative weight, eating behavior, and attitudes toward body shape and weight in a cross-section of GBP patients. A second objective was to examine the relationship of postoperative binge eating to surgery outcome. METHODS: 99 patients who underwent GBP > 2 and

Delin, C.R., Watts, J.M., Saebel, J.L., Anderson, P.G. Eating behavior and the experience of hunger following gastric bypass surgery for morbid obesity. Obesity Surgery, Vol. 7, No. 5, pp. 405-13, 1997

BACKGROUND: Numerous different factors may contribute to the varying degrees of success observed following gastric bypass surgery. It is likely that alterations in the subjective experiences of hunger and satiety, as well as behavioral factors, are important. Our aim was to investigate the association of several factors, including qualitative aspects of hunger and satiety, eating patterns, and the emotional valence of different foods, to the weight loss that occurred following obesity surgery. METHODS: A questionnaire covering aspects of hunger, eating and satiety was administered to three groups: (1) a group of people who had undergone gastric bypass surgery with an acceptable weight loss; (2) a morbidly obese group of patients prior to their surgical intervention; (3) a group of people of normal weight. RESULTS: There were significant differences amongst the three groups in scoring on standardized eating disorder scales, in the amount they could eat, and in the experience of hunger. The presurgery, waiting-list group was more receptive to food-related than interoceptive cues when deciding to stop eating. ‘Eating styles’ also differed across the groups. CONCLUSIONS: It is concluded that changes in specific food-related behaviors and other psychological variables interact with the physical restriction to eating. The relative weighting of other variables needs further exploration.

Kalarchian, M.A., Wilson, G.T., Brolin, R.E., Bradley, L. Binge eating in bariatric surgery patients. The International Journal of Eating Disorders, Vol. 23, No. 1, pp. 89-92, 1998.

OBJECTIVE: Eating behavior, attitudes toward eating and body weight and shape, and depression were assessed in a sample of 64 morbidly obese gastric bypass surgery candidates. METHOD: The Beck Depression Inventory (BDI), the Three-Factor Eating Questionnaire (TFEQ), and the Eating Disorder Examination (EDE) were administered at the first preoperative visit. RESULTS: Twenty-five subjects (39%) reported at least one binge episode per week on average over the 3 months prior to seeking treatment. Binge eaters had significantly higher TFEQ Disinhibition and Hunger scores than nonbinge eaters. Binge eaters also differed from nonbinge eaters in terms of attitudes toward eating, shape, and weight. DISCUSSION: A significant number of gastric bypass surgery candidates report binge eating. The findings are consistent with other studies showing binge eaters to be a distinctive subgroup of the obese.

Hsu, L.K., Sullivan, S.P., Benotti, P.N. Eating disturbances and outcome of gastric bypass surgery: a pilot
The International Journal of Eating Disorders, Vol. 21, No. 4, pp. 385-90, 1997

OBJECTIVE: We examined how the outcome of gastric bypass surgery (GBP) was effected by the interaction between presurgery eating disturbance status and length of time since surgery. METHOD: Subjects were recruited from a list of patients who received GBP in the last 3 years. Twenty-seven patients 20.8 +/- 11.0 months postsurgery were interviewed. RESULTS: Both current eating disturbance status and weight regain were predicted by the interaction between presurgical eating disturbance status and length of time since surgery. The significant time period in this interaction was 2 years or more postsurgery. DISCUSSION: Patients with a presurgical eating disorder may experience a short-term improvement in their eating disorder following GBP that erodes on or after 2 years and is related to weight regain. Methods for improving surgical outcome in this population are discussed.

Hsu, L.K., Mulliken, B., McDonagh, B. et. al. Binge eating disorder in extreme obesity. International Journal of Obesity and Related Metabolic Disorders: Journal of the International Association For the Study of Obesity, Vol. 26 No. 10, pp. 1398-403, 2002

OBJECTIVE: To determine whether extremely obese binge eating disorder (BED) subjects (BED defined by the Eating Disorder Examination) differ from their extremely obese non-BED counterparts in terms of their eating disturbances, psychiatric morbidity and health status. DESIGN: Prospective clinical comparison of BED and non-BED subjects undergoing gastric bypass surgery (GBP). SUBJECTS: Thirty seven extremely obese (defined as BMI >/=40 kg/m(2)) subjects (31 women, six men), aged 22-58 y. MEASUREMENTS: Eating Disorder Examination 12th Edition (EDE), Three Factor Eating Questionnaire (TFEQ), Structured Clinical Interview for the Diagnostic and Statistical Manual-IV (SCID-IV), Short-Form Health Status Survey (SF-36), and 24 h Feeding Paradigm. RESULTS: Twenty-five percent of subjects were classified as BED (11% met full and 14% partial BED criteria) and 75% of subjects were classified as non-BED. BED (full and partial) subjects had higher eating disturbance in terms of eating concern and shape concern (as found by the EDE), higher disinhibition
(as found by the TFEQ), and they consumed more liquid meal during the 24h feeding paradigm. No difference was found in psychiatric morbidity between BED and non-BED in terms of DSM-IV Axis I diagnosis. The health status scores of both BED and non-BED subjects were significantly lower than US norms on all subscales of the SF-36, particularly the BED group. CONCLUSION: Our findings support the validity of the category of BED within a population of extremely obese individuals before undergoing GBP. BED subjects differed from their non-BED counterparts in that they had a greater disturbance in eating attitudes and behavior, a poorer physical and mental health status, and a suggestion of impaired hunger/satiety control. However, in this population of extremely obese subjects, the stability of BED warrants further study.

Kalarchian, M.A., Wilson, G.T., Brolin, R.E., Bradley, L. Effects of bariatric surgery on binge eating and related
. Eating and Weight Disorders: Ewd. Vol. 4, No. 1, pp. 1-5, 1999

The Beck Depression Inventory (BDI), the Three-Factor Eating Questionnaire (TFEQ), and the Eating Disorder Examination (EDE) were administered to 50 morbidly obese patients before and after gastric bypass surgery. Subjects were classified as non-binge or binge eaters prior to surgery. Though the two groups differed markedly before operation, they were largely indistinguishable 4 months afterward. All binge eating had ceased and mood had improved markedly. TFEQ Restraint scores increased, and Disinhibition and Hunger scores decreased. EDE
Eating Concern, Shape Concern, and Weight Concern scores dropped. EDE Restraint scores decreased in non-binge eaters and increased in binge eaters. The overall findings indicate that gastric bypass surgery had a positive short-term impact on non-binge and binge eaters alike.

Kalarchian, M.A., Wilson, G.T., Brolin, R.E., Bradley, L. Assessment of eating disorders in bariatric surgery candidates: self-report questionnaire versus interview. The International Journal of Eating Disorders Vol. 28 No. 4 pp. 465-9, 2000

OBJECTIVE: To compare the Eating Disorder Examination (EDE), an investigator-based interview for the assessment of the specific psychopathology of eating disorders, with the EDE-Q, a self-report questionnaire based directly on it. METHOD: Ninety-eight morbidly obese gastric bypass surgery candidates were administered both instruments. RESULTS: The four subscale scores (Restraint, Eating Concern, Weight Concern, and Shape Concern) generated by the EDE and EDE-Q were significantly correlated, although the questionnaire scores were significantly higher. Eating Concern and Shape Concern exhibited the lowest levels of agreement. Frequency of binges (objective bulimic episodes) as rated by the EDE and EDE-Q was significantly correlated and was not significantly different. However, variability in ratings contributed to only modest agreement with respect to classification of patients as binge eaters. DISCUSSION: Overall, there were lower levels of agreement between the EDE and EDE-Q than have been previously found in other samples.

Dymek, M.P., Le Grange, D., Neven, K., Alverdy, J. Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obesity Surgery Vol. 11, No. 1, pp. 32-9, 2001

BACKGROUND: While Roux-en-Y gastric bypass (RYGBP) appears to be the most effective procedure for weight loss in morbidly obese patients, objective outcome data regarding quality of life (QoL) and psychosocial status following surgery are lacking. METHODS: The present study examined the effects of RYGBP in 32 morbidly obese subjects on a variety of outcome measures including QoL and psychosocial functioning. Assessments were conducted before surgery, 1 to 3 weeks post-surgery, and at 6-month follow-up. RESULTS: In addition to weight loss, results show significant improvements in health-related QoL, depression, and self-esteem, as well as a significant reduction in eating pathology following surgery. Results also show that neither the presence of binge-eating disorder nor clinical depression predicted poorer outcome post-surgery. CONCLUSION: RYGBP results in a dramatic reduction in weight, and marked improvements in health-related QoL, depression, self-esteem, and eating pathology, including binge-eating in the short term. These findings need to be replicated in a larger cohort of patients and followed for a longer time before we can reach more definitive conclusions regarding the psychosocial outcome in RYGBP.

Counts, D. An adult with Prader-Willi syndrome and anorexia nervosa: a case report. The International Journal of Eating Disorders, Vol. 30, No. 2, pp. 231-3, 2001.

A 39-year-old man with Prader-Willi syndrome presents for evaluation of uncontrolled weight loss. Past history was significant for gastric bypass and prior episodes of intentional dieting. Family history was significant for an alcoholic father and two siblings with anorexia nervosa. The patient was unconcerned about his weight loss despite cachexia and did not want to stop dieting. This presentation of a restrictive eating pattern in a man with a syndrome usually associated with compulsive hyperphagia is the first known report.

Sansone, R.A., Sansone, L.A., Wiederman, M.W. The comorbidity, relationship and treatment implications of borderline personality and obesity. Journal of Psychosomatic Research Vol. 43, No. 5, pp 541-3, 1997.

Studies indicate that a significant minority of obese individuals in clinical studies meet criteria for borderline personality. Although the relationship between obesity and borderline personality remains unexplained, the following article discusses the implications of treating obesity among individuals with this personality disorder. Longitudinal intervention, normalizing or regulating eating patterns, and reframing weight plateaus are emphasized.