Transfer of Addiction and Considerations for Preventive Measures in Bariatric Surgery: Part II

By Melodie K Moorehead, PhD, and Cynthia L. Alexander, PsyD

Melodie K Moorehead, PhD, receiver of the ASBS Golden Circle of Excellence Award for her contributions to the field, has specialized in bariatric surgery psychology for more than two decades. Licensed as a psychologist and has a Certificate of Proficiency in the Treatment of Alcohol and Other Psychoactive Substance Use Disorders, granted by the College of Professional Psychology: American Psychological Association Practice Organization. The office of Drs. Moorehead, Parish, and Associates, PA, is credited with the multi-purpose, dramatic audio 2-CD set, The Gift and The Tool.

Cynthia L. Alexander, PsyD, is a licensed clinical psychologist working full-time at Cleveland Clinic Florida Bariatric Institute. She is also an adjunct professor at Nova Southeastern University and works for the 17th Circuit Court of Florida. She is the author of the book The Emotional First Aid Kit, A Practical Guide to Life after Bariatric Surgery.

INTRODUCTION

As professionals in the field of weight loss surgery, it is crucial that we continue to explore the impact of the addiction factor after bariatric surgical procedures. Further, we must educate patients and families on the possibility of transferring from one type of unhealthy behavior (excessive consumption of food) to other forms of behavior that can lead a patient down an unhealthy path. The addiction factor is by no means limited to excessive food or alcohol consumption; it can show up as uncontrolled spending, drug-related difficulties, smoking, sexual promiscuity, or compulsive gambling. In fact, virtually any behavior exhibited in excess can interfere with the goals of a comprehensive bariatric surgery program.

Psychological informed consent can help promote a patient’s awareness that surgery is a tool that helps people to sustain healthy weight loss. However, the procedures are not magic, nor are they a cure for the disease of morbid obesity or the addiction factor. Psychological informed consent can also provide documentation in medical charts. According to Walter Lindstrom, JD, a well known attorney with specialization in bariatric surgery, more allied health-care providers are being named in lawsuits as more surgeons decide to go bare on malpractice coverage. Perhaps medical documentation on the part of mental health professionals regarding potential transfer of addiction issues following weight loss surgery will provide protection for more than the patient.

COMMON DENOMINATORS PLAYING A PART IN THE DEVELOPMENT OF REGRESSIVE COPING STRATEGIES

Factors common to a regressive style of stress coping—food addiction, depression, and other psychological comorbidities—that result in vicious cycles can have several perpetuating elements with physical, biochemical, or emotional origins. Individuals who are morbidly/superobese often experience diminished self esteem and suffer from a poor self-image, feelings of discrimination, anxiety, and depression (particularly if obesity occurred in childhood). As discussed previously, nearly all morbidly obese patients handle difficult feelings and emotional stressors regressively. Will science help us to understand how a tendency to avoid stress by overeating and seeking food for emotional comfort becomes self-medication (possibly triggering neurochemical changes in the brain), or will research point us in another direction?

People suffering with other addictive issues also tend to display similar characteristics, such as regressive stress coping behavior, and turn to the drug of their choice for comfort or escape from difficult feelings. Edward Livingston, MD, concluded in his poster presentation at the 2006 ASBS conference that, “Psychological disorders increase with obesity, whereas substance abuse decreases. These data suggest overeating and substance abuse are very different disorders.”1

IDENTIFYING COMMON PATHWAYS OF FOOD ADDICTION AND OTHER FORMS OF SUBSTANCE ADDICTION

Individuals with depressive disorders, drug addicts, alcoholics, smokers, and many morbidly/superobese people share overactivity in one of the body’s major stress response mechanisms, the limbic-hypothalamic-pituitary-adrenal axis (LHPA). Drs. Cynthia Buffington and Moorehead began hypothesizing about these pathways as early as 2003 at the IFSO conference in Salamanca, Spain.2

Briefly during the IFSO conference, Drs. Moorehead and Buffington described such overactivity along this (LHPA) axis, which included lowering serotonin and thus impacting brain chemistry. Changes in the brain not only affect mood, but also can cause the body to crave carbohydrates and in particular sugar, which temporarily increases serotonin activities and improves mood. In this way, the individual may be using carbohydrates to self-medicate and to feel better, or “normal.” Low serotonin can also interfere with other regulators of eating behavior resulting in fat cravings, increased appetite, and reduced satiety. Sugar and fat, in particular, coupled with the smell or taste of food, can stimulate dopaminergic activities or the reward system of the brain, producing enjoyment and good feelings. This is the same pathway that causes the euphoria or good feelings derived from the use of heroine, amphetamines, cocaine, alcohol, and nicotine. Low serotonin and enhanced LHPA activities can increase the susceptibility of this system to abuse, chronic use of substances, down-regulating, or blunting of the dopaminergic response to stimuli. When this happens, more of the substance—food—is needed to feel good, which is to say, “normal.”

The possibility exists that more research will point out many morbidly obese/superobese patients have a blunted dopaminergic response to food in the limbic areas of the brain. This might help explain why the morbidly obese/superobese person would have to eat increasing amounts of food to derive a degree of satisfaction. In the obese patient, neuroimaging studies have found neuropeptide responses to food that are similar in appearance to other forms of addictive behavior. [3,4] These above descriptions may begin to offer some insight into one of the reasons why the morbidly obese/superobese patient following surgery may be vulnerable to transfer of addiction issues and why some morbidly obese/superobese are as addicted to food as alcoholics are to alcohol and smokers are to cigarettes.

THE NEW SCIENCE OF ADDICTION

We could learn from the worldwide fellowship of Alcoholics Anonymous, and their lifelong program strategy, by ensuring the provision of lifetime recovery support for bariatric surgery patients. Rather than lose so many patients to postoperative follow up, how can we attract worldwide lifelong involvement? Healthcare providers and our institional administrators might first need to debate and resolve resistance to recognizing and accepting addiction as a formidable factor to be reckoned with. Perhaps when we provide postoperative services that are as effective as patients perceive the surgery itself will be, we will be in a better position to accomplish many goals, including the much needed Centers of Excellence demand for rigorous long-term follow-up and data collection.

It is certainly clear from the Wall Street Journal article, “The New Science of Addiction: Emergence of Alcoholism after Weight-Loss Surgery Offers Clues to Roots of Dependency,”5 that no one really knows how many people who seek bariatric surgery may transfer addiction to something else equally devastating after obtaining surgery. Patient safety, both preoperatively and postoperatively, is first and foremost among bariatric professionals. For example, we would not think of dropping routine hospital use of compression boots or blood thinners. Similarly, with the issue of addiction, we can provide a foundation of routine psychological treatment to all patients, beginning with preoperative preparation. After surgery, we can build upon the motivation for recovery during program participation.

Before, during, and after surgery, emotional and psychological needs must be addressed. While attending bariatric surgery conferences, some of us have seen cartoons that show a human brain with a band around it and a caption reading, “Bariatric surgery is not brain surgery!” However blunt, this truism acknowledges the need to address the intake of food for reasons beyond ( sometimes in spite of) physical hunger, or even after experiencing physical satiety. In a keynote address to the 2005 IFSO Congress, Dr. Moorehead underscored: “…the best postoperative support is preoperative support.” A cost-efficient and effective preoperative program that can initiate this process of psychoeducation may help our patients recognize and embrace a simple truth, one that Alcoholics Anonymous also embraces: No one ever graduated from such a program of recovery.

CONSIDERATIONS FOR PREVENTING TRANSFER OF ADDICTION

Much more research needs to be done to better understand the interactions of bariatric surgery and the addiction factor. Still, a framework that addresses the underlying biological cause of transfer of addiction is emerging.

Knowing the biological factors that may lead to addiction is helpful, but it isn’t the whole solution. At the 2006 ASBS meeting, Dr. Buffington presented The Changes in Alcohol Sensitivity and Effects with Gastric Bypass, referring to a sample of 139 anonymous responders. The poster abstract concluded: “A total of five patients in the study population received a DUI, all within the early postoperative period and after only one drink.”6 This study, of course, is not examining addiction factor because even small amounts of alcohol can cause significant intoxication in some individuals following surgery.

It does underscore the need, though, to turn our focus toward the prevention of transfer of addiction particularly when alcohol enters the picture.

After surgery, danger may lie in the most ordinary social setting if alcohol is served. Unquestionably, some bariatric patients are far more susceptible to alcohol after surgery, making addiction transfer more likely. It is important to look at the biological, social, and emotional aspects of transfer of addiction. As one patient put it: “…the enjoyment of wine is not only socially acceptable, it is respected.” Our society values the knowledge of the wine connoisseur, and the appreciation of wine is a hobby for many people. Therefore, unsuspecting bariatric patients may fall into the trap of dependence while pursuing a hobby or socially acceptable ritual.

WHAT CAN BE DONE TO HELP PREVENT TRANSFER OF ADDICTION?

Education is the most important aspect of preparation for the bariatric patient. Armed with the knowledge of possible postoperative addictions, an educated patient may notice early warning signs and seek the appropriate assistance. Without education, the patient may not initially see the connection between bariatric surgery and and alcohol use until it is too late.

It is strongly recommended that a two-part education be provided to every bariatric surgery candidate. Before surgery, a cognitive approach would consist of a lecture by trained bariatric personnel. After surgery, experiential education would consist of a professional, trained in-group process that can get people talking about real life issues and potential challenges that are often faced following surgery.

This kind of group experience can build needed coping skills and help in development of personal support systems. Support groups can also be a potent recovery source, where sophisticated process can again be facilitated effectively. Well-managed bariatric support groups can add to the participants’ repertoire of skills and help people interact in meaningful ways. Support groups that are run this way deepen members’ shared experience. An ongoing group will deepen members’ shared experiences and will grow as your practice grows. Because the group is authentic and meaningful, people will learn more about themselves through sharing common life experiences. This is a major part of the recovery process for many patients.

In addition to educating new patients, it may be equally important to educate the millions of postoperative bariatric patients—often the forgotten patient. They may be years out from surgery, yet they may be at a higher risk of developing a transfer of addiction. At the very least, this is a subject that must be addressed in postoperative groups.

We now know that those patients whose onset of obesity was between birth and five years of age score highest on the Addiction Scale. Screening for timeframe of onset of obesity may assist in identifying those who may be at higher risk for transfer of addiction. The Ardelt-Moorehead Eating Habits Questionnaire (referred to as the “Addiction Scale”) was described in Part 1 of this article. Briefly, the Addiction Scale is an 11-item Likert scale based on criteria drawn from the American Psychiatric Association’s Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) and the International Statistical Classification of Diseases, Tenth Edition (ICD-10) criteria for dependency and cravings. The scale is undergoing a normalization study in the US in collaboration with the Cleveland Clinic Florida. The principle investigators are Cynthia Alexander, PsyD, Melodie Moorehead, PhD, and Elisabeth Ardelt-Gattinger, PhD. Dr. Ardelt-Gattinger, in a broad-range European obesity project, is soon to publish data that declares the following:

* craving/addiction to abnormal food intake is the strongest predictor of weight loss;

* the Addiction Scale can differentiate across the body mass index (BMI) classes significantly; and

* 99 percent of adults with BMI>40 fulfill minimum criteria for craving and dependency.

The implications of this fact-finding are that the addiction scale may provide a tool to help surgeons with surgery selection choice based on psychological patient characteristics. Dr. Ardelt-Gattinger also validated the Addiction Scale against the Moorehead-Ardelt Quality of Life Questionnaire (M-AII)7 and determined that the higher the addiction score, the lower the quality of life even when one controls for BMI.

The research shows a clear link between regressive preoperative coping strategies and postoperative transfer of addiction. With that in mind, it is highly recommended that stress management education be an integral component of every patient’s preparation for surgery and postoperative aftercare. Patty Worrells said it best in her 2006 Bariatric Times article:8

“We need to find healthy and more appropriate coping mechanisms for dealing with issues that don’t go away simply because we lose weight. These issues stay under the surface and reappear sometimes when we least expect them. I believe preoperative and postoperative counseling by someone who understands bariatric surgery is one of the most important things we can do for our community of bariatric surgery patients.”

We must be careful when we attempt to attribute behavior strictly to biological causes. A purely biological explanation can lead to feelings of helplessness, powerlessness, and an external locus of control in our patients. Understanding the biological causes for this vulnerability of transfer of addiction may certainly aid the patient in making realistic attributions for the problem, but the best treatment at this time is still psychological. Biologically-based urges and predispositions may provide an added layer of challenge for the person trying to change, but it need not mean the patient will not gain control. Even when the behavior of eating is largely emotional, it is the cognitive and behavioral interventions that allow the decision-making and control— recovery—to take place.

The initial psychological/mental health evaluation may prove to be the most efficient way to identify patients who need individual therapy. Standardized mental health evaluations, performed by program bariatric surgery mental health specialists, can help healthcare providers to understand the unique strengths and challenges of each patient seeking bariatric surgery. The initial evaluation may also prove most useful for coupling needed interventional therapy with conjunctive and more formal, targeted group settings. This three-tier approach is a sound beginning for creation of an effective treatment plan. A medication evaluation sometimes can also be an adjunct and valuable tool as well. Biological treatments will undoubtedly become more available as we continue to gain information through continued research.

Patients who eat “out of control” when they are really seeking psychological satiety in the form of inner satisfaction, contentment, a sense of wholeness, or personal fulfillment may find an unpleasant surprise following surgery. Though initially patients can feel physically full and experience a wonderful improvement in quality of life, unresolved issues may allow comorbidities to take over. Sometimes the best surgery and the best medication management are just not enough. It is understood that people seeking surgery are whole beings who cannot be divided into separate compartments (i.e., physical, biochemical, hormonal, emotional, and spiritual). We need to take into account all driving forces when treating a disease as insidious as morbid obesity. As bariatric psychologists, we confront the realities all too often regarding the hidden prejudice and contempt the morbidly obese hold for themselves and others. One study9 found that, “Children no more than six years of age describe silhouettes of an obese child as lazy, dirty, stupid, ugly, cheats and liars.” The study also describes a scenario where “black-and-white line drawings of a normal-weight child, an obese child, and children with various handicaps (including missing hands and facial disfigurement) were shown to a variety of audiences. Both children and adults rated the obese child as the least likable. This prejudice extended across races, rural and urban dwellers, and saddest of all, even among obese persons themselves.” We must use our experience and expertise as an integral component of a multidisciplinary team to help our patients address the chronic and often vicious cycles that drive the void.

The bariatric surgeon is the head of the team. The surgeon has the ability to see the whole picture. The surgeon can choose to assemble the needed team and intervene in an all too often neglected aspect of care. We have front-page documentation that more is needed besides excellent weight loss and resolution of comorbid conditions to fill the perpetuated “void.” The authors of this article are fortunate to work with surgeons who have chosen to include bariatric psychology in the overall treatment of patients.

It is very common to hear, “If I could have just made behavioral modifications to correct my problem, I would not have needed the surgery!”

To these people we would say, “You may be right,” yet the behavioral modifications, driven by new beliefs and decision-making regarding how to handle life, are the most important aspects of long-term weight loss maintenance.

Nonetheless, surgery is a tool. People need to learn not only how to use the tool, but also how to utilize a variety of tools to help get the job done safely. Helping people learn the skills of “living life on life’s terms” is also an important tool for reducing stress. Strategies for successful living include staying purposeful, learning ways of showing gratitude and appreciation for oneself and others, and responding—taking time to think an action all the way through to its likely consequence—rather than reacting in a knee-jerk fashion. Other life strategies/tools might be developing new stress management styles, such as learning to relax through a strong craving that may feel terrifying or developing kinder inner self-talk about oneself. All of these methods can be appropriately addressed in a comprehensive program in meaningful ways that will help patients better manage their chronic stress and inner void. Improving patients’ stress management (coping) skills within bariatric programs is likely the single most important thing that we can do to help patients fill their inner void.

FURTHER SUGGESTIONS

Bariatric surgery continues to rise worldwide. We as a professional society, and many of our patients, have continued to work to broaden the understanding of the surgical procedures available, as well as to concretize the growing recognition of bariatric surgery as a legitimate and effective treatment for morbid/superobesity. The membership of both the ASBS and IFSO can congratulate itself as being largely responsible for the organized education of both the general public and the medical communities regarding the efficacy of bariatric surgery.

This process of education about bariatric surgery will only be enhanced as we continue to incorporate what the emerging evidence suggests. That is, when treating the disease of morbid obesity, one cannot sever the emotional and psychological factors from the physical and biological aspects of the disease of morbid obesity. For many reasons, bariatric surgery patients are best served within a multidisciplinary team approach.

Obesity is a family affair. A multidisciplinary approach that includes an onsite mental health specialist who is trained in the growing field of bariatric surgery can be the missing link for our patient population and their loved ones. This type of approach may also engender more sympathetic coverage by the mass media. To this end, we are aware that change takes time and that sometimes for meaningful change to occur, a gradual evolution can help make the change more satisfying and enduring.

ACKNOWLEDGMENTS

We would like to thank Colleen Hutchinson for the idea to team the authors on the subject of this writing; Dr. Ardelt-Gattinger is recognized for her pioneering and continued research in the field of obesity; appreciation is offered to Cynthia Buffington, PhD, and Kendra McDonald, RN, for their dedication and considerations on this topic; and we also thank Gladys Strain, PhD, for preliminary reading and providing current references for this article, and Lisa Stewart, PhD, for lending her expertise. Lastly, we recognize the value of a good professional editor and thank William C. Banks for his assistance and fresh third eye outside of the specialty area of bariatric surgery.

REFERENCES

1. Livingston EH. Obesity, psychological testing, and substance abuse. SOARD 2006;2(3);312.
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SUGGESTED READINGS

1. Kleiner KD, Good MS, Frost-Pineda K, et al. Body mass index and alcohol use. J Addict Dis 2004; 23:105–18.
2. Wang GJ, Volkow ND, Thanos PK, Fowler JS. Similarity between obesity and drug addiction as assessed by neurofunctional imaging: A concept review. J Addict Dis 2004;23:39–53.
3. Ardelt-Gattinger E, Lechner H. Psychological aspects of bariatric surgery. Zentralbl Chir 2002; 127:1057–63.
4. Moorehead MK, Buffington CK, Marema RT. Helplessness over food, addictive behavior, and surgical weight loss success. Obes Surg 13:194, 2003.
5. Moorehead MK, Marema RT, Buffington CK. The ‘Hope’ Factor. Obes Surg 2003;13:2003.
6. Buffington CK, Moorehead MK, Marema RT. Food Addiction and Mood: A Common Etiology? Obes Surg 2003;13:197.
7. Alcoholics Anonymous: The Story How Many Thousands of Men and Women Have Recovered from Alcoholism, Third Edition. Alcoholism Anonymous World Services, Inc. New York City, 1976.
8. Andrews G, Lemont D, Myers S, Nelson E, Smiertka J. Caring for the Surgical Weight Loss Patient. Sierra Madre, CA: Wheat Field Publications, 2003.
9. Bocchieri L, Meana M, Fisher B. Perceived psychosocial outcomes of gastric bypass surgery: A qualitative study. Obes Surg 2002;12:781–8.
10. Hoffman L. Constructing Realities: An Art of Lenses. Family Process, 1990.
11. Kvale, Steinar (Ed.) Psychology and Post Modernism. London: Sage Publications, 1992.
12. McNamee S, Gergen KJ. Therapy as social construction. London: Sage Publications, 1992.
13. Parry, Alan. A Universe of Stories.Family

Category: Commentary, Past Articles