Concerns about Psychological Evaluations for Bariatric Surgery Patients

| September 23, 2013

This column is dedicated to covering a variety of topics relevant to the multidisciplinary care of the bariatric surgical patient.

Column Editor and Interviewer: Karen Schulz, RN, APN
President of the Integrated Health Section of the ASMBS; Clinical Nurse Specialist, University Hospitals of Cleveland, Cleveland, Ohio

This month: An Interview with Dene Berman, PhD, ABPP

Bariatric Times. 2013;10(9):24–25.

KS: One concern that comes up frequently when discussing psychological evaluation of patients before bariatric surgery is that patients may not answer the questions truthfully. What are some reasons that may cause patients to not answer truthfully?

DB: For most patients, seeing a psychologist is a hard challenge to face, regardless of the reason for the visit. Most patients come to the office to deal with issues that they wish would go away without ever having to talk about them. We get the call for an appointment when something usually happens that overshadows the reluctance to talk. Bariatric patients are a good example of this. There is often shame and vulnerability associated with morbid obesity that would ordinarily keep people from making that call to the psychologist’s office. However, the desire to have bariatric surgery and the requirement to have a psychological evaluation prior to surgery makes that call a necessity.

As part of the interview, psychologists ask very personal questions to a patient they have never met before. One can hardly blame a person for their reluctance to discuss deeply personal matters to a perfect stranger, regardless of whether that stranger is a psychologist. Some of those issues that one might want to deny or minimize are very personal topics that the patient may rarely or perhaps even never talked to anyone before. Such personal topics can include physical and/or sexual abuse or violence, suicidality, a history of legal problems, past mental health treatment, and the like.

One cannot fault a patient from the desire to create a good impression if that patient believes that doing so will facilitate a positive evaluation. Will disclosing one’s substance use lead to a negative evaluation? Perhaps so, depending on the nature of the use. So, too, is the case for binge eating. One source cites the incidence of binge eating to be as high as 52 percent among the patients seeking bariatric surgery.1 My own recent experience differs from this very high number. Over the past six months, I have administered a questionnaire to the past 50 patients, asking them the extent to which certain symptoms consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR) criteria for binge eating. Only six patients (12%) met the diagnostic criteria, including some patients with body mass indices (BMIs) above 60kg/m2 who denied eating larger than normal-sized portions.

KS: What precautions do you take when performing a psychological evaluation for bariatric patients to screen for truthfulness in their answers?

DB: There are a number of ways to determine how forthright patients are when undergoing psychological evaluation. Many psychologists, such as myself, use the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) as part of the test battery included in bariatric evaluations. The MMPI-2-RF contains 10 different validity scales making it possible to determine such things as random responding, fixed responding by answering one way (e.g., True) regardless of item content, over-reporting of symptoms, under-reporting of symptoms, claims of uncommon virtues, or even subtle attempts to portray oneself in a positive light.

Another way of determining how truthful patients are is to look at consistency of responses over different tests. For example, patients are asked about suicidality in our own questionnaire, on the Beck Depression Inventory-II (BDI–II), and on the MMPI-2-RF). In this way, it is easy to see if a patient is responding to questions consistently.

Another test, the Shipley-2, measures cognitive abilities. It is not possible to fake responses that ask factual questions, like synonyms, or logical problems, unless one would have a prior copy of the test. There are safeguards built into psychological tests that prohibit them from being available to the public.

One more safeguard is when verbal reports of a patient are made to a psychologist, some of what the patient says can be compared to objective data provided by other sources. One example might be the patient’s report of weight, which will inevitably be compared to the weight measured on the bariatric clinic scale.

Nevertheless, there are aspects of the evaluation that are susceptible to manipulation. The BDI-II directly asks patients about their symptoms of depression. Patients can deny or minimize symptoms on this test but, psychologists also look at depression scores on other tests, like the MMPI-2-RF and can follow up with the patient if there is not consistency across tests.

Perhaps most susceptible to manipulation are the straightforward questions about a patient’s history, such as substance abuse or history of abuse. It should be noted, however, that the psychological evaluation is not the only source of input to the bariatric team. Input from physicians, nutritionists, and others provide a check on the verbal report of the patient. While possible, it is not likely that a patient would provide exactly the same false information to all the professionals who have input.

So, while there are safeguards to protect against fabricated responses, in the final analysis, it is no more possible to guard against all fabrications than it would be in other settings.

KS: Is it true that patients can find instructions on “how to pass a pre-bariatric surgery psychological evaluation?”

DB: Not having heard of a source for instructions on “how to pass a pre-bariatric surgery psychological evaluation,” I turned to the source that many patients go to for advice of all sorts—the internet. I did find one site that gave advice on “How to Pass the Weight Loss Surgery Pre-op Psych Eval” (http://voices.yahoo.com/how-pass-weight-loss-surgery-pre-op-psych-eval-4911520.html). Surprisingly, that site advised patients to be honest and be themselves.

This recommendation points to the fact that psychological evaluations for bariatric surgery are not meant to trick patients. They are intended to determine risk factors that might compromise a patient’s ability to have successful surgery and post-operative adjustment. When risk factors, like binge eating or vegetative depression, are identified, it is incumbent on the psychologist to help patients get the support they need to increase their chances for success.

KS: Do you encourage patients before their screening to tell the truth?

DB: Yes, we urge patients to cooperate by being as honest and open as possible, and assure them of confidentiality of their responses, except to those sources that they explicitly authorize. We also tell them that our goal, should we find concerns, is to help them utilize a support system that will help them get ready for successful surgery.

KS: In your experience, are most patients truthful in their pre-screening evaluations?

DB: In my experience, bariatric surgery patients have a story to tell that is often painful, with many experiences of ridicule, defeat, and often, demoralization. Most patients welcome the opportunity to tell their story, especially in the confidential setting of a psychologist’s office.

KS: Lastly, what are the negative or troubling consequences of patients being untruthful in their psych interview and being approved for surgery?

DB: There can be many consequences. Perhaps the most troubling is that patients have risk factors that will jeopardize their bariatric surgical success. For example, a patient who has a binge eating disorder but does not reveal this condition and binge eats immediately after discharge from the hospital can literally put their life at risk.

Sometimes it is apparent that the patient has not been truthful and their surgery is postponed until their responses can be verified. An example of this wouild be a patient who indicated that he or she had been psychiatrically hospitalized but reported that he or she had not been referred for follow-up mental health treatment. In that case, he or she was asked to sign a release of information and his or her statements were compared to the hospital record.

Finally, any concerns that the surgery center or I as the psychologist have about a patient are communicated. Many times the director of a bariatric center or one of the team members (e.g., the nutritionist) and I have compared notes by phone or e-mail. We have also recently adopted a coordination of care form for use between my office and the hospital bariatric team.
I am pleased to say that, by and large, patients see psychologists as a part of the team, concerned about their care, and offering help to assure a success surgical and lifestyle outcome.

KS: Dr. Berman, thank you for taking the time to speak with us.

References
1. Powers PS, Perez A, Boyd F, Rosemurgy A. Eating pathology before and after bariatric surgery: A prospective study. Int J Eat Disorder. 1999; 25 (3):293–300. .

Funding: No funding was provided.

Financial disclosures: The author reports no conflicts of interest relevant to the content of this article.

Author affiliation
Dr. Berman is a Board Certified Clinical Psychologist. He is the Clinical Director of Lifespan Counseling Associates in Beavercreek, Ohio and Clinical Professor in the School of Professional Psychology, Wright State University, Dayton, Ohio.

Category: Hot Topics in Integrated Health, Past Articles

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