Abstract
One apparently uncommon, but unfortunate outcome of patients undergoing bariatric surgery procedures is the development of clinically significant eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN). The exact incidence of such an outcome is unknown. The case of a 43-year-old woman 5 years after gastric banding surgery is presented. The patient had never been evaluated by a mental health professional prior to the surgery. As assessed retrospectively, she had met criteria for non-purging bulimia nervosa (BN) prior to the operation; however, she had never received eating disorder treatment. After the surgery she rapidly developed purging bulimia nervosa and reduced her weight from 120 kg to 49 kg (BMI 18.4 kg/m2). She continued to be dissatisfied with her weight and expressed the intention to lose more weight. She ate less than she would have been able due to the restriction, experienced subjective binge eating episodes, and started to self-induce vomiting up to 17 times a day. Every time she reached a weight plateau she asked her surgeon to further inflate the gastric band to increase the degree of restriction which was done 4 times after the surgery. She kept her eating disorder a secret and was apparently a treatment success with regard to the amount of weight loss. She sought treatment because after 5 years she started to regain weight and developed an intense fear of further weight increase. In addition, the patient met criteria for recurrent depressive disorder.
She was treated with sertralin for acute depression and cognitive behavior therapy for her eating disorder. She was able to accept a reduced band fill and a higher weight range (75 kg, BMI 28.2 kg/m2). In this patient her untreated eating disorder persisted and even worsened after gastric banding. Patients should be seen by a mental health professional prior to bariatric surgery and adequate psychotherapeutic support should be offered after bariatric surgery.
Zusammenfassung
Die Kasuistik beschreibt eine 43-jährige Patientin, die sich 5 Jahre nach Magenbandimplantation mit einer bulimischen Essstörung und einer depressiven Episode in der Psychosomatik vorstellte. In der Exploration wurde deutlich, dass sie bereits seit dem frühen Erwachsenenalter die Kriterien für eine non-purging Bulimia nervosa (BN) erfüllte. Eine psychische Begutachtung vor der Operation fand jedoch nie statt. Nach Magenbandimplantation war die Essstörung ohne Unterbrechung weiterhin vorhanden, hat aber, auch durch die chirurgisch bedingte Restriktion, ihr Bild verändert. Es kamen anorektische Symptome hinzu, wie etwa die Unzufriedenheit mit dem Gewicht trotz eines Gewichtsverlusts in einen fast anorektischen Bereich mit einem minimalen BMI von 18.4 kg/m2. Zudem entwickelte die Patientin postoperativ ein bulimisches Kompensationsverhalten im Sinne von selbst induziertem Erbrechen mit dem Ziel, eine raschere und ausgeprägtere Gewichtsreduktion zu erreichen. Die Patientin hat diese Verhaltensweisen lange Zeit verheimlicht. Die Patientin litt außerdem an einer rezidivierenden depressiven Störung, einer häufigen Komorbidität bei bulimischen Patientinnen. Die Essstörung sowie die depressive Episode konnten erfolgreich mit Therapieansätzen behandelt werden, die sich bei BN und Depression generell bewährt haben – störungsorientierte kognitive Verhaltenstherapie und Serotonin- Wiederaufnahmehemmer. Der Fallbericht macht deutlich, dass vor chirurgischer Adipositastherapie eine psychische Evaluation durchgeführt werden sollte und dass postoperativ bei Bedarf rasch und über einen ausreichend langen Zeitraum psychische Betreuung angeboten werden sollte.
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de Zwaan, M., Mühlhans, B. Der Verlauf einer Bulimia nervosa nach Magenbandimplantation. Psychosom Konsiliarpsychiatr 1, 154–157 (2007). https://doi.org/10.1007/s11800-007-0029-5
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DOI: https://doi.org/10.1007/s11800-007-0029-5