Q. One of my young adult patients, who has had a history of obesity, anorexia nervosa (AN), and binge eating disorder (BED) successfully underwent sleeve gastrectomy, which stopped her binge eating. She lost significant weight after surgery but has since developed self-injurious behavior. Do you have any suggestions?
A. A Danish study describes a case very similar to your patient’s (J Eat Disord.2018; 6:24). Dr. Louise Taekker and her co-workers at the University of Copenhagen, Denmark, treated a 24-year-old woman who began cutting herself after undergoing successful bariatric surgery. Their patient was a participant in a multidisciplinary research project, the GO Bypass Study. The study’s goals were to identify factors contributing to variations in weight loss after bariatric surgery. The study followed patients for about 2 years and examined them during 5 study visits over that time: at baseline, 1 week before gastric bypass, and 1.5, 6, and 8 months after surgery.
This patient had a severe history of both restrictive-type AN and BED beginning at age 16. By age 18, the eating disorder moved to BED, and her lowest weight was 99 lb (45 kg) and her lowest BMI was 16.5. She had a high degree of body dissatisfaction, which had been present since she was a child. She avoided scales and mirrors and avoided public displays. When she had emotional challenges, such as after an argument with a partner, she would binge-eat. She also had depression, and was being treated with antidepressives, which were described as helpful. She described her binges as something that provided a sense of security and comfort in a world of pain and chaos. Her partner was emotionally supportive, and had helped the patient gain healthier eating habits. While the psychosocial assessment found that the patient needed emotional support, and close monitoring, gastric surgery was not ruled out.
In-depth interviews revealed a rocky course after surgery. About a year after her gastric surgery, she left her partner of 7 years and revealed that she had begun intentionally cutting herself several times a week. In the months after the breakup, she had also become anxious, confused and desolate, and made two successive suicide attempts. The patient said this behavior had become a substitute for binge eating.
The authors found that while the patient’s overall psychiatric symptoms remain high, and above the clinical case cut-off, symptoms of an eating disorder and depression have improved notably after bariatric surgery. Despite this, the patient continues to have difficulty regulating her emotions, and her attachment style is more anxious and her avoidant behavior has increased.
The authors note that the cutting behavior reflects that the binge eating and self-harm served the same function, to regulate emotions. They also commented that research and clinical literature argue that symptoms can substitute of each other, and this will be a problem until the underlying basic causes have been treated and cured. When such a compulsive behavior seems to be replaced by another, such as binge eating to cutting, in this case, this is called ‘addiction transfer,’ ‘cross-addiction,’ and ‘symptom substitution.’ Gastric surgery makes binge eating impossible since the person’s anatomy is changed.
The literature does suggest risk for impulsive behaviors such as drinking may rise after bariatric surgery; this picture could be viewed as fitting with that. One book that has been around for a number of years is Cutting: Understanding and Overcoming Self-Mutilation, by Dr. Steven Levenkron. New York, NY: W. W. Norton, 1998, previously reviewed in Eating Disorders Review.Moreover, this person might well represent the mixture of issues for which DBT was designed.