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Q. We have an unusual problem, and hope you can help. One of our patients, a woman in her late 20s, recently had successful bariatric surgery, but then shortly afterward began harming herself, and has shown suicidal thoughts. Prior to her surgery she was obese and had a history of binge eating disorder (BED). Of course, after her surgery, bingeing was no longer possible. (S.W., Charlottesville, NC)
A. Recent reports have documented an increase in self-harm behaviors after gastric bypass, which affects about 20% of those who undergo this surgery (Curr Opin Psychiatry. 2016; 29:340). The American Society for Metabolism and Bariatric Surgery estimates 228,000 persons underwent gastric bypass surgery in 2018.
Dr. Louise Taekker and colleagues at the University of Copenhagen have reported a case very similar to yours (J Eat Disord. 2018; 6:24). Their case involved a 24-year-old patient who was a participant in a research project, the GO Bypass study (Cont Clin Trials Communications. 2018; 10:121), which aimed to identify factors that contribute to variations in weight loss after gastric bypass. GO study participants were followed for about 2 years, and were seen at 5 time points after surgery. At the time of surgery, the woman weighed 101 kg (220 lb) and had a body mass index (BMI, kg/m2) of 37. Eighteen months later, she had lost 27 kg (59.5 lb), and had a BMI of 31.
Eighteen months after surgery, during one of the follow-up visits the patient admitted that she had begun cutting herself on both forearms. She disclosed that her 7-year relationship had ended and the breakup led to a relapse into depression, followed by two suicide attempts. An important earlier finding on the pre-surgical psychosocial assessment was the woman’s severe history of restrictive AN and BED. The patient had a high degree of body dissatisfaction, which had bothered her since childhood.
The patient was very forthright about how her cutting behavior functioned as a substitute for binge eating, which was now impossible after the gastric bypass. While some have advocated that addiction transfer, cross addiction, or symptom substitution may be the underlying cause for such a substitution, the authors dispute this because “there is no evidence for a theoretical rationale of unresolved psychological problems causing one compulsive behavior after the other.” Instead, in this case the authors prefer describing their patient’s behavior from a coping perspective.
In their case, the transfer of binge eating to cutting could be traced to the patient’s eating disorder, which was driven by negative affect; in recent years this was less active due to her stable relationship with a partner. When the relationship broke up, the woman’s difficulties with emotion regulation reappeared. Now the patient substituted a rapid self-destructive way of dealing with her emotions, substituting cutting for her earlier binge eating.
Thus, you might also consider the possibility that your patient has substituted self-harm for binge eating, in which difficulty in regulating emotion plays a central role.
The authors point out that their case is a clear example of the insufficiency of merely measuring weight loss and the absence of physical complications as criteria for successful gastric bypass surgery. A thorough clinical pre-surgery psychosocial assessment with a prolonged follow-up are needed for vulnerable patients.
-SC