LONG: my personal notes for psych eval

[Guest guest]

Folks,

On March 25, waterlilys@... posted considerations from

the North American Association for the Study of

Obesity re the psychological evaluation. I parsed them

and added my own observations and had them ready for the

psychologist. He never asked me most of those questions,

concentrating instead on how satisfied I was with my work, my

marriage, etc. In other words, did I have a positive outlook on

life; was I stable, centered, and did I have the support of other

people? At first, the psychologist had proposed several hours of

testing and a few interviews. I told him that that was

" excessive, " and that what I needed was his evaluation that

I understood what the surgery was all about and that I was competent

to make my own decisions about having the surgery. He accepted

my counter-proposal and agreed to render his opinion after one $200

session.

So, it becomes clear that each tester will have a different

agenda and a different approach, and I have no idea how useful the

observations below might be, but I offer them for those of you who are

so concerned about the testing. (I have removed some of the more

personal stuff.)

YMMV (your mileage may vary)

--Steve

===============================================

According to North American Association for

the Study of Obesity :

" Bariatric surgery should not be attempted in patients who have

a

history of noncompliance or have psychotic illnesses, including

schizophrenia and personality disorders, suicidal behavior,

substance

abuse, and uncontrolled

depression.

No, I have none of the above. (Of course,

how am I to prove that in 50 minutes?)

Psychological Evaluation

To properly assess the patient's psychological well-being, a

preoperative psychological evaluation ought to beneficially

include,

as deemed appropriate, screening for

depression,

I have been depressed from time to time.

It is mostly seasonal, coming in the dark months. Could be

seasonal affective disorder. But, I get through it OK without

medication. Mainly by knowing that " This, too, shall

pass. " (We discussed special light bulbs...)

suicide,

No suicidal intent or serious thoughts of

suicide.

eating disorders,

Apart from eating more calories than my

body burns, I have no significant eating disorders.

and psychosis.

I am not psychotic. (Sure, ...

)

In addition, history should include

any

possible psychological trauma, such as

sexual abuse,

None.

marital

dysfunction,

Have had two previous marriages that ended

in divorce. My present marriage is mutually supportive, mature

and fulfilling.

or posttraumatic stress

disorders,

None.

plus other life stressors, such as a

history of substance abuse,

None.

the patient's level of

self-esteem,

My self-esteem is appropriately robust.

I am a good person, and I have been fortunate to have been given many

opportunities throughout my life, and I have been even more fortunate

to have been able to capitalize on many of those opportunities to

accomplish satisfying achievements. The principal threat to my

self-esteem is my appearance, which is directly the result of my

obesity.

and quality-of-life

measures.

The quality of my life is satisfying and

high, save for matters relating to my obesity: flights of stairs,

having to bend over to tie my shoes, having to walk long distances,

for example, all are things that most people can do without thinking,

but I regard as challenges to be gotten through. On the other

hand, I am also painfully aware that the quality of my life will

continue to degrade significantly if I do not take off close to 200

pounds.

Preoperative Patient Education

As an adjunct to the evaluations detailed above, it is important

for

the patient to know the nature of the proposed surgical

procedure,

Bilio-Pancreatic Diversion with Duodenal

Switch (BPD/DS) entails stapling and resection of over two-thirds of

the stomach, leaving what amounts to a sleeve of stomach along the

greater curvature; separation and closing of the of the duodenum

several centimeters beyond the pylorus, sectioning of the small

intestine near the ileal-jejunal junction reattaching the ileum to the

duodenal stub distal to the pylorus, and attaching the distal end of

the jejunum to the ileum near the large bowel through an anastomosis

in the ileal wall. The bile and pancreatic juices flow through

the duodenal-jejunal loop and meet the partially digested food in this

final common loop distal to the anastomosis. The reduced stomach

volume restricts the amount of food intake and is responsible for much

of the rapid weight loss in the first year, and the reduction in

intestinal absorption from the shortened intestinal loop keeps the

weight off through malabsorption.

its risks,

Operative risks include risks of

anesthesia, stroke, internal bleeding if the surgeon slips and nicks

an internal organ, and heart attack.

Chief risk post-op is an internal leak

leading to sepsis and possible death. The surgeon does leak testing

during the surgery and also has a distasteful (to the patient) leak

test administered on the day after surgery.

Another major risk is from blood clots that

can form in the legs and travel to the lungs causing death. Best

preventative for this is to get out of bed and walk as early after

surgery and as often as possible. Similar considerations for

fluid in lungs. Best preventative is to cough and cough and

cough.

Long-term, the chief risk is malnutrition:

vitamin (A, D, E and K), protein, iron, and calcium deficiencies that

do not respond to supplements and could lead to osteoporosis and/or

death. The incidence is very low, but it could

happen.

the expected weight loss over

time,

75-80% of " excess weight " in 18

months, with little or no regain.

as well as the required postoperative

dietary intake,

> 70 g of protein, > 1200 mg

calcium, ADEK vitamins, multivitamins, reduced sugar, plenty of

water.

and level of physical

activity.

Regular exercise (I already do 30 minutes

on a recumbent bike and 15-20 minutes of weight training every other

day--duration ~18 months).

In addition, the anticipated lifestyle

changes,

Moderated eating. No alcohol for at

least 6 months, thereafter a glass of wine as a rarity (that describes

my present relationship with alcohol); no smoking (I am not a smoker);

moderated eating, as aided by the reduced stomach volume.

In addition, looser and malodorous stools

and flatus are not uncommon for about the first six months

post-operatively, but can persist in some individuals.

Persistent lactose intolerance is also not uncommon. Nausea is

also not uncommon for about four weeks following surgery.

the need for compliance and follow-up

visits,

Understood and agreed [periodic visits,

blood work to test for micronutrients, etc.].

and the anticipated health benefits of

the surgery

Reduction in severity and/or disappearance

of many of the co-morbidities.

should all be communicated to the

patient in

the preoperative

period. "

--