Anxiety Prior to Gastric Bypass Surgery - Case Study Example

Anxiety prior to Gastric Bypass Surgery Surgery is an invasive procedure on the body and elicits feelings ranging from anxiety to frank fear in most of the people undergoing elective surgical procedures. In emergency surgery, such as after accidents, the issue of anxiety even if present is negligible as the patient is already in pain and distress. However when a surgical procedure has to be undergone by choice and after a particular interval of time after its recommendation, it invokes anxiety in the patient. Bariatric surgery has emerged as a highly successful procedure in addressing the problem of obesity. Obesity has become a major killer disease confounded with secondary co morbidities like Type II Diabetes, hypertension, sleep apnea and cardiovascular disorders, in the last few decades. The dismal performance of conventional pharmacological, diet control and psychotherapeutic approaches have led to the development of this surgical technique which reduces the capacity of the stomach or bypasses it altogether thereby influencing the satiety center in the hypothalamus which makes people eat less. A standard Roux-en- Y gastric bypass procedure is successful in making obese people lose 61 per cent of their excess weight post operatively (Lokken et al, 2010). Although these results paint a rosy picture for a chronically obese patient, such patients are usually at a stage with co existing diseases which can alter the prognosis. The success or failure of the procedure is therefore incidental upon the patient’s peculiar situation. It is therefore normal for a patient to feel anxious before the operation as is common for all elective surgical procedures. Obese people are already down the social ladder as they are subject to ridicule in their social setting itself and the problems are confounded if they belong to certain ethnic communities which are already subject to some levels of discrimination in public life. There is a general trend among the general public and even healthcare providers to nurture negative biases towards morbidly obese people (Lokken et al, 2010). The actual procedure has a number of variations (Ainsworth, 2009). The simplest form was the reduction of the stomach size by placing a silicone band thereby reducing the actually used size of the stomach during food passage through it. A more radical procedure involve gastrectomy and the connection of the esophagus directly with the ileum but the inherent risk of complications which include malnutrition has made this method redundant and at present the Roux-en- Y gastric bypass procedure which involves a combination of surgical stomach reduction and bypass of the initial part of the small intestines is the most popular and routine procedure nowadays (Ainsworth, 2009). It is an irony that the post surgical procedure is the most distressing period of the whole procedure as the patient’s eating activity is highly compromised as only liquid diet is permitted as well as possible during the first few weeks after the surgery. Prior knowledge of this fact by people who are still in the pipeline for this kind of procedure can surely contribute to more distress and anxiety in the pre operative period. Such anticipatory anxiety is a common phenomenon in all patients expecting some medical intervention which may be non surgical or surgical in nature. Some persons are prone to anxiety even for benign medical interventions in the primary care settings which ordinarily might be just exploratory or diagnostic in nature (Gerdes & Guidi, 1987). Such situational anxiety can have many predictors which can be evaluated by the health professionals or psychoanalysts before the actual procedure is carried out and which can assist the healthcare professionals to initiate preventive steps as well as provide adequate psychological support for the patient. It has been demonstrated in previous clinical studies that obese people possess an inherent cognitive deficit which results in reduced executive functions which inhibits their ability to respond in an adaptive manner to novel situations and the proposal of surgery is definitely a highly alarming novel situation (Lokken et al, 2010). Pre-surgical psychological evaluation is therefore one of the most important aspects of bariatric surgery. It has been observed that mentally alert and stable people with an inherent will to lose weight are more successful in doing so after the actual surgical procedure than their counterparts who are compromised in mental faculties, either due to preexisting mental illnesses or other complicating factors such as alcohol and drug abuse. A psychologist can therefore recommend a delay or denial for bariatric procedure depending upon his analysis of the patient (Walfish et al, 2007). It has been observed that denial and delay decisions have so far been taken in only 15% of the cases by psychologists based upon the diagnosis of significant psychopathological conditions such as bipolar disorder or psychosis (Walfish et al, 2007). The appropriateness of a surgical procedure in general has to be predetermined by the healthcare professionals, as though a particular procedure may have its merits, it may not be suitable for certain individuals with peculiar characteristics (Kahn et al, 1998). Each individual case therefore needs independent perusal and judgment for suitability for the elective surgery intended to be performed after careful examination of pros and cons. Moreover obese persons are already prone to anxiety as their condition itself might be due to over indulgence in food due to anxious predisposition which prompts them to eat more in order to stave off difficult situations in personal relationships in their family and social setting. Bulimia nervosa and binge eating are common psychological disorders in the present generation which precipitate obesity (Doll et al, 2004). Such persons are therefore always in need of psychotherapeutic interventions which complicates the situation whenever they are to undergo a surgical procedure, both pre and post operatively. Themes relevant to health related quality of life have been identified for patients undergoing major surgery and have been categorized into six main domains which include physical well being, emotional well being, social well being, concern about quality of care at the healthcare facility or hospital, cognitive preparation and spiritual well being (Morris et al, 2006). Various elements of these major categories should ideally be considered in developing an evaluative instrument for carrying out any major surgical procedure according to the recommendation of the authors. This is especially more relevant in the present scenario where health related quality of life outcomes have attained significance in the healthcare sector. Another interesting feature of bariatric surgery is the prolonged waiting time for patients in countries like Canada where universal healthcare is a state responsibility. As it is not an emergency surgery, patients are usually put in a queue in Canada and there have been reports of some of them even dying before their turn for surgery (Christou & Efthimiou, 2009). This can well contribute to anxiety itself as an obese person can become desperate when the cure is not available immediately despite his or her intentions and will to undergo the procedure. The Qualitative Question The popularity of bariatric surgery and the high success rate in curing chronic obesity and related health disorders has made it the procedure of choice. However, it needs to be determined whether there are any variable results due to ethnicity. What may seem as an absolutely appropriate and scientifically proven procedure may not be correct for people belonging to certain ethnic groups which have different genetic makeup and social patterns which determine their mental status and perceptions about the very basis of what is appropriate for their health. This might make them apprehensive of such procedures as bariatric surgery and contribute to more anxiety and less compliance before, during and after the procedure, if it is recommended and carried out on them. Language barriers and to some degree, discrimination might predispose such patients to a lower degree of concern and care by the healthcare providers which might lead to unnoticeable anxiety and subsequent low quality of life. To determine the degree of variability in anxiety patterns based on ethnicity is therefore an interesting area for investigation. This can be achieved by differentiating patients into ethnic groups and conducting questionnaire based research in order to analyze the level of anxiety and evaluate whether there is more predisposition for anxiety among specific ethnic groups or not. The Method The study can be conducted by identifying and grouping a significant number of patients (a minimum of 50 each from white, black, Hispanic and Asian populations in the US), in the pipeline for bariatric surgery on the basis of their ethnicity and conducting a comprehensive psychological assessment and cognitive testing in an evaluation for their suitability for the procedure on the pattern previously used by Lokken et al, 2010. The authors have used validated psychoanalytical techniques which include the following focus areas: 1. Cognitive capacity evaluation. 2. Evaluation of psychiatric status based on questionnaire and interview. 3. Clinical diagnostic interview and questionnaire for evaluation of eating habit anomalies. 4. Evaluation for health behavior compliance, family and social support. The psychoanalytical techniques used by Lokken et al, 2010 include ‘Wide Range Achievement Test-4’ for evaluating reading ability and intellectual functioning, ‘Wechsler Adult Intelligence Test-III’, ‘Wisconsin Card Sorting Test’, ‘Rey Complex Figure Test’ and questionnaires based on the established technique of the ‘Beck Depression Inventory-II. The same protocol can be employed for gathering data for comparison among ethnic groups previously identified. Data Collection The data generated using the above techniques are analyzed using standard techniques and yield pertinent information which can be evaluated by employing standard statistical tools for comparison between the identified ethnic groups. The ‘Wide Range Achievement Test-4’ measures the reading ability of the patient which can yield information about the ability to understand the intricacies of the operation (Lokken et al, 2010). The ‘Wechsler Adult Intelligence Test-III’ provides an estimate of the intelligence quotient and verbal performance. ‘Wisconsin Card Sorting Test’ indicates the level of problem solving ability of the individual which is a vital indicator of one’ ability to handle a critical situation for which numerous occasions will arise both prior to and after the surgical procedure. The ‘Rey Complex Figure Test’ reveals the planning and organizational skills of the individual which serves as an indicator to the ability to manage one’s condition during a crisis. The ‘Beck Depression Inventory-II provides vital information about any preexisting depression which can be a contributing factor to anxiety and a score of below 10 in this test indicates absence of depression. The above psychoanalytical tools can generate sufficient data for a sound comparison which can assist in identifying any variations in ethnic groups which can answer the qualitative question proposed in this study. References Ainsworth, C. 2009. Full without food, New Scientist, Vol. 203 Issue 2724, p30-33 Christou, N V & Efthimiou, E. 2009. Bariatric surgery waiting times in Canada, Can J Surg, Vol. 52, No. 3, pp.229-234 Doll, H A, Peterson, S E & Stewart-Brown, S L. 2004. Eating disorders and emotional and physical well-being: Associations between student self-reports of eating disorders and quality of life as measured by the SF-36, Quality of Life Research, Vol.14, pp.705-717 Gerdes, E P, & Guidi, E J. 1987. Anxiety in Patients Awaiting Primary Medical Care, Medical Care, Vol. 25. No. 9, pp.913-922 Kahn, K L, Kosecoff, J, Chassin, M R et al. 1998. Measuring the Clinical Appropriateness of the Use of a Procedure Can We Do It?, Medical Care, Vol.26, No. 4, pp.415-422 Lokken, K L, Boeka, A B, Yellumahanthi, K et al. 2010. Cognitive Performance of Morbidly Obese Patients Seeking Bariatric Surgery, The American Surgeon, Vol. 76, pp.55-59 Morris, D B, wison, K G, clicnch J J et al. 2006. Identification of domains relevant to health-related quality of life in patients undergoing major surgery, Quality of Life Research, Vol. 15, pp. 841-854 Walfish, S, vance, D and fabricatore, A N. 2007. Psychological Evaluation of Bariatric Surgery Applicants: Procedures and Reasons for Delay or Denial of Surgery, Obesity Surgery, Vol. 17, No. 12, pp. 1578-1583 Read More