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Anorexia Nervosa in a 38-Year-Old Woman 2 Years After Gastric Bypass Surgery

Received June 22, 1998; revised July 7, 1998; accepted August 20, 1998. From the Department of Orthopedic Surgery, University of Pittsburgh Medical Center; the Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University; the Department of Psychiatry, Virginia Commonwealth University, Medical College of VirginiaHospitals; and the Department of Internal Medicine, Section of Nutrition,Virginia Commonwealth University, Medical College of Virginia Hospitals. Address correspondence and reprint requests to Dr. Bulik, Virginia Institute of Psychiatric and Behavioral Genetics, P.O. Box 980126, Department of Psychiatry, Virginia Commonwealth University, Richmond, VA 23298–0126. E-mail: cbulik{at}hsc.vcu.edu

Key Words: Case Report • Anorexia Nervosa • Gastric Bypass Surgery • Eating Disorder

The emergence of frank anorexia nervosa (AN) following gastric bypass surgery for obesity highlights the importance of developing appropriate prescreening procedures and postoperative monitoring to reduce the probability of adverse outcomes. Although postbypass AN is not a common outcome, it may be a preventable one. Bonne et al.¹ reported two cases of AN in males after undergoing vertical banded gastroplasty (VBG) for treatment of morbid obesity. Further, Atchison et al.² report on two female cases of AN following gastric-reduction surgery and suggest that presurgical qualities of dependency and using food for emotional comfort may be predictors of the liability to develop AN. In this report, we describe the development of AN (binging and purging subtype) in a 38-year-old woman 2 years following gastric bypass surgery. We followed the patient from 1995 to 1998.

Medical and Psychiatric History

A frail, 38-year-old, Caucasian, married woman (Ms. X.) was admitted to the Medical College of Virginia (MCV) Hospitals of Virginia Commonwealth University, Richmond, with chest pain and numbness in her left arm. The patient' s electrocardiogram (ECG) showed U waves in leads V2–V4, and her serum potassium level was 1.7 mEq/L. Myocardial infarction was ruled out in the coronary intensive care unit, and potassium was repleted. She reported a past high weight of 305 pounds at 5` 2" (body mass index [BMI]=56 kg/m²) before gastric bypass surgery in October 1995. Shortly after the procedure, Ms. X. became preoccupied with losing weight and began using about 100 stimulant laxatives per day. She weighed 88 pounds at the time of presentation (BMI=16.2 kg/m²). The patient alternated between complete fasting and eating only toast and lettuce. She reported vomiting up to five times daily to reduce tension and to "energize herself." Her last menstrual period was 2 years ago. She claimed her ideal weight was 67 pounds.

Outpatient surgery clinic records show this eating pattern began in early follow-up after gastric bypass. Daily intake fluctuated between 200–400 kilocalories (kcal), and protein was consistently below 20 grams/day over the 2-year follow-up period. Two months after surgery, she avoided eating because of the "fear of stretching (her) pouch," and she refused vitamin supplements for fear of weight gain. Four months after surgery, it was noted that she had "anorexic tendencies." Psychiatric consultation was recommended at this time but refused. Six months after surgery, she reported hair loss and daily vomiting. Several months later, she began to see a private psychiatrist weekly. Her symptoms escalated, and she discontinued treatment after 3 months.

Ms. X. reported no other relevant medical history. Psychiatric history was significant for recurrent major depression, including a suicide attempt at age 19 by overdose. Drug use history was positive for marijuana, tobacco, alcohol abuse, and LSD (lysergic acid diethylamide) use.

This history is in marked contrast to that recorded at the time of presurgical screening. On the routine screening, conducted by a dietician, Ms. X. denied any history of serious anxiety or depression, mental health treatment, psychiatric medication, substance abuse, or self-induced vomiting. On a modified form of the Hopkins Symptoms Checklist, she marked "0" (not at all) for 95% of the items. Based on her responses in the clinical interview and to this questionnaire, she was not referred for psychiatric consultation.

Physical Examination

Following presentation to the emergency room, she was admitted to the internal medicine service. On physical examination, Ms. X. was cachectic, with loose skin hanging from her thighs and abdomen. Her skin was dry and pale, with no sign of jaundice. Her hair was brittle and thin. Her blood pressure was 100/65, pulse 80, and respiratory rate 15. Cardiovascular examination showed regular rate and rhythm without murmurs and no jugular venous distention. Abdominal examination revealed multiple skin folds and hyperactive bowel sounds. There was mild ankle edema. Neurological examination was within normal limits.

Mental Status

Ms. X.'s mental status examination revealed a pleasant, well-groomed, but emaciated white woman whose attitude was superficially cooperative. Mood was flat, and affect was appropriate. Thoughts were goal-directed and focused on current weight and urges to purge. She considered herself fat. Ms. X. was alert and oriented to person, place, and time. Her concentration, attention, calculations, memory, and abstractions were normal upon testing; however, she reported difficulties with concentration and memory. Insight and judgment were poor with reference to her persistent attempts to restrict and purge despite the potentially life-threatening effects.

Course of Inpatient Treatment

Initial laboratory studies showed severe hypokalemia and hypoalbuminemia (2.3 mg/dL); normal magnesium, phosphate, and liver enzymes; and a hemoglobin of 11.4 mg/dL. Ms. X. was given intravenous fluids with potassium chloride, multivitamins, thiamine, folate, and ranitidine. On Day 2, her ECG normalized, and her potassium rose to 2.7 mEq/L. On Day 3, it was decided to begin her on total parenteral nutrition (TPN) to replete protein and nutrient stores. She initially refused TPN but relented after being given explanations about her high mortality risk and the possibility of court-ordered treatment. On Day 4, the patient was eating 50% of her meals. After initial refusals, she complied with all medical requests, apparently placating her physicians in hopes of early discharge. On Day 6, she expressed a strong desire to go home and exercise. On Day 7, she refused transfer to Psychiatry because of concerns about stigmatization. Ultimately, it was decided to continue TPN and begin intensive cognitive–behavioral psychotherapy (CBT) while remaining on the medicine service. The patient was monitored for the development of refeeding syndrome.³ She was discharged on Day 12 of her hospital stay when her medical condition stabilized and her weight reached 122 pounds (peripheral edema accounting for about 15 pounds of this newly gained weight).

During her stay, she began CBT with the second author (C.B). She contracted to continue outpatient CBT, to have a psychiatric consult, and to maintain her weight between 105 and 110 pounds. Her basal metabolic rate was calculated by the Harris-Benedict equation and the use of Metabolic Cart Interpretation to be 1,325 kcal/day. It was explained to Ms. X. that she would need to consume greater than 1,325 kcal/day to avoid readmission.

Course of Outpatient Treatment

Ms. X. maintained her weight at 124 pounds (BMI=22.8); however, she was unable to maintain healthy eating behaviors. Soon after discharge, she began nightly objective binging and purging via vomiting. She remained laxative-free for 2 weeks but could not resist the urge to start using laxatives again. Her anorectic thoughts were severely entrenched, and she resisted CBT. She was started on 20 mg of fluoxetine and noticed a slight improvement in her mood after 2 weeks of treatment. After a 1-week holiday break, Ms. X. canceled two consecutive sessions and failed to contact her psychiatrist or internist for follow-up. She did not return phone calls and was subsequently lost to follow-up.

Discussion

Gastric bypass has been used as a last resort treatment for morbid or severe obesity. Indications for gastric bypass surgery include BMI over 40 kg/m² after failure at supervised weight-loss programs of at least 6 months.⁴ Gastric bypass surgery is considered for persons with a BMI 35 kg/m² in the presence of comorbid conditions, such as obesity hypoventilation syndrome, obstructive sleep apnea, diabetes, hypertension, and other cardiovascular diseases, pseudotumor cerebri, venous stasis disease, stress urinary incontinence, or osteoarthritis.^4,5 These BMI cutoffs are thought to be points at which the risks of continued morbid obesity outweigh the risks of surgery. Following surgery, patients typically lose on average 60% of their excess weight over 2 years.⁶ Our patient, Ms. X., presented in 1995 with a BMI of 56 kg/m². She had stress-overflow urinary incontinence, hypertension, and venous stasis disease and had not succeeded with multiple, commercial, supervised diet plans. Thus, from a medical perspective, she was an appropriate candidate for gastric bypass.

In contrast, from a psychiatric perspective, the routine screening was insufficient to detect problematic behaviors that made her a questionable candidate. The frequency of null responses on the Hopkins Symptom Checklist should have alerted the clinician. Presurgical screening of gastric bypass candidates should carefully and routinely assess the presence of binging, purging, and lifetime AN. Patients with eating disorders can be secretive about their behaviors, especially if they suspect that honesty may compromise their suitability for bypass surgery. In instances in which disordered eating is suspected, collateral information from significant others should be obtained, and the disordered eating should be treated before surgery.

Although preexisting psychiatric diagnoses appear to have little influence on weight loss,⁷ the presence of frank eating disorders, especially those that contain a binge-eating component, are likely to complicate gastric bypass surgery. Hsu et al.⁷ showed that VBG had no effect on premorbid binge eating and night eating, that is, disordered eating that existed preoperatively persisted after surgery. Ms. X. clearly had difficulties with binge eating long before undergoing bypass surgery that were not discovered during the presurgical screening.

There are several sound clinical reasons for presurgical screening for binge eating. First, it is common. Kalarchian et al.⁸ found that about 40% of persons presenting for bypass surgery can be characterized as binge eaters. Second, bariatric surgery appears to have no corrective effect on disordered eating.⁷ Third, postsurgical weight regain tends to be more common in persons with these disordered eating patterns.⁷ Hsu et al.⁷ recommended augmenting bariatric surgery with cognitive–behavioral therapy directed at correcting the disordered eating behaviors for such persons, so that patients cannot only achieve successful weight loss from the surgery, but also remission from binging and purging.

In addition, the postsurgical environment must also be evaluated. At MCV, the patient must eat blended foods for 1 month while the stomach pouch heals. The patient must then eat about 6 mini-meals because the pouch holds about 2 ounces. Follow-up is scheduled at 2 weeks, 3 months, 6 months, 12 months, 18 months, 2 years, and then yearly. During this time, the patient is encouraged to lose weight. Postoperative visit records document exercise habits, dietary intake, nutritional concerns, and social adjustments. Care should be taken not to praise the patient for excessive exercise, or losing far more weight than projected. Ms. X. was exercising 18 hours a week, for which she was praised.

A broader concern is the effects of bariatric surgery on mental health in general and whether presurgical psychiatric evaluation should be standard practice. Waters et al.⁹ found that mental health benefits that resulted from gastric bypass were observed at 6- and 12-month postsurgical follow-up; however, these effects eroded by the end of 2 years. In light of their findings, the researchers encourage continued long-term follow-up and emotional support for bypass patients. It seems equally essential for patients to have a realistic appreciation of the limitations of the effects of bariatric surgery. In addition to weight loss, bypass candidates may envision permanent improvement in their life and mental health. Surgical candidates should be made aware of the finding that—although mental health may improve in the short term after surgery—the changes are not permanent in most cases. As such, persons who evidence psychopathology on presurgical screening should be channeled into appropriate mental health services and followed appropriately after surgery.

Although gastric bypass surgery can be a potentially effective measure in combating morbid obesity, adequate presurgical screening and postsurgical monitoring are essential to prevent the development of an eating disorder. Adequate preoperative screening should include measures of both general psychopathology and eating-related pathology (e.g., Eating Disorders Inventory,¹⁰ Eating Disorders Examination¹¹) and a valid assessment of the nature and appropriateness of prior weight loss strategies. It is also critical for follow-up clinics to be supportive in the patient's quest to lose weight and exercise but remain alert for the development of excessive and unhealthy behaviors.

REFERENCES

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4. National Institutes of Health: Gastrointestinal surgery for severe obesity. Nutrition Today 1991; September/October:32–35
5. Sugerman H, Starkey J, Birkenhauer R: A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus nonsweets eaters. Ann Surg 1987; 205:613–624 [Medline]
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