Preoperative Psychological Evaluation For Bariatric Surgery
December 17, 2013What to Look for in Your Evaluation
by Barbara Maxwell, RN, PhD
Southwest Medical Psychology
The decision to seek bariatric surgery-whether it is to try to get rid of all the pills, the high blood pressure, the diabetes, the sore and aching bones, or to actually prevent the onset of these diseases-is a very emotional decision. Once you have made it, it seems as if nothing can happen fast enough! Yet, there are many steps you must complete before you can be considered a candidate for this life-changing surgery. One of the many steps in the process may be a preoperative psychological exam. Not all insurance companies and surgeons require this, so you should check with your insurance company and your surgeon to find out if it is a requirement. It is important to find out about your particular situation.
If you are required to have such an evaluation, you should make sure it is done by a qualified licensed professional who has the requisite academic coursework and training required to administer and interpret psychological tests. The majority of the time, this is a licensed psychologist. Although it more unusual, it may be the psychiatrist who has had the appropriate training.
Once you have found out that this is something you must do, what next? Consult your insurance company and try to find a covered provider who meets the qualifications named above. When patients come to see me, I usually have them make two appointments: one to complete the testing process and another one for the clinical interview between the patient and myself. Other professionals may have different arrangements. Make sure you understand what it is you need to do at every step-it will make the process easier for you. Be aware that a really thorough evaluation will include both psychological testing and a clinical interview.
Many of the individuals I see will admit to being a bit (maybe a lot) nervous when they come to see me. This is perfectly normal and natural; you have answered hundreds of questions, some of which seem pretty strange! You may have spent time wondering what you are supposed to say or what the doctor wants to see in you. You may have, either knowingly or unknowingly, tried to present yourself as being unusually virtuous or free of flaws that even the average person will admit to having. You may have exaggerated your symptoms with the idea that the more distressed you seem, the better the doctor will understand how badly you want this surgery. These are all common mistakes that patients make when taking these rather long personality inventories.
What we would like for you to do-and indeed what the test booklet instructions will tell you to do-is to answer honestly, to read the directions carefully and to refer back to them if you become confused during the test. I have had some patients tell me they were answering "through my husbands eyes" or "as if I were still a child". We are interested in your answers as you are now and nobody else's. So, just relax, take some refreshing deep breaths, and spend a moment thinking positive thoughts like, "I can do this. I will read the directions and do just fine." The MMPI-2 (Minnesota Multiphasic Personality Inventory-2) is available in English and Spanish both in print and on audiocassette tapes. Be sure to let the professional you see know if you have reading difficulties or need assistance. I do not permit family or friends to be in the same room when my patients are testing. This is to prevent response bias, which can invalidate a test and require that you re-test. In the case of a patient who is deaf, it is the responsibility of the psychologist to arrange and pay for a sign interpreter for the testing and clinical interview appointments. Psychological tests should be adequately monitored by a qualified person. This may be a person trained by the psychologist to proctor the testing process and score the completed test. In the absence of such a person, the psychologist monitors the patients' process and does the scoring him or herself. During a test, if my patients need to take a break, they are certainly encouraged to do so. This is a long testing process, but it is not supposed to be a torture session! Lunch breaks are also encouraged since many patients are diabetic.
You may also wonder, "What do these tests find out about me?" "Why are they called personal inventories?" These are the most commonly heard questions, and rightly so! Let me start by defining the term "personality" as mental health professionals know it. Personality is that pattern of traits that define a person over time. Personality is enduring. For example, someone could have a "dependent personality". Such an individual has historically been uncomfortable alone, and needs the company and constant support of others. They may have difficulty making decisions on their own. These traits tend to be stable over time, hence the term dependent personality.
So personality inventories gives us a picture of important aspects of personality. The pattern of scores across the different scales provides information that helps determine whether there is a serious pathology present, whether there is some problem but not a serious one, or whether the profile (the pattern of scores across the different scales) is "within normal limits". It is important to know that each of the personality inventories contains "validity scales". These scales are able to detect efforts on the part of the person taking the test to exaggerate symptoms, fake insanity, or try to appear free of any flaws or pathology. They also detect random responding, inconsistent responding, all true responding, or all false responding. Importantly, they also identify what is known as a "cry for help" pattern. Each inventory allows for some excluded items. However, each test has a number of missing answers that will invalidate the test. So you can see that it is important to just relax, answer honestly for yourself and try to complete all items. Be sure to take a break if you need to-fatigue and lapsed concentration is not helpful! If you have sleep apnea and fall to sleep easily during the day, try to have some way of waking yourself periodically, such as an alarm on your watch. Get up and walk around and take some refreshing deep breaths.
Once the testing is completed, it is time for the clinical interview. You may think, "What is she going to ask me? This person is going to decide whether or not I can have the surgery. I have heard good things/bad things about this person. I'm scared!" Let me encourage you to calm yourself and relax if you are nervous. Many bookstores sell relaxation tapes. Listen to them. They will be useful for many things, including postoperative pain management after your surgery. Above all, realize that the professional doing the evaluation is not the person who decides whether or not you have your surgery. We make diagnoses and recommendations and provide our professional opinion to the surgeon. The surgeon and the insurance company look at the preoperative psychological evaluation in concert with many factors, including your medical status, and they decide whether or not the surgery should move forward.
I try to make my office a calming place: room lighting, a fountain, and pictures of nature all help to relax patients and put them at their ease. That helps me establish a friendly but professional atmosphere. The clinical interview that I use is a semi-structured interview. That means that the interview is designed to collect information that is relevant for an evaluation of someone seeking bariatric surgery. The interview takes between 45 and 60 minutes, but may last longer, depending on the patient. I will spend as much time as it takes with each person. At the end of the clinical interview, I review the results of the patient's psychological tests with them. If the patient is considered a good candidate, I tell them so at once. If I have identified a potential problem, such as depression or binge eating, then I provide the patient with instructions as to how to address these issues so that they may proceed towards their weight-related health goals.
For example, if the depression is moderate and uncomplicated (no history of abuse, for example), I recommend that the patient consult with their family doctor for evaluation for possible antidepressant therapy. If a patient does not wish to take medication, I recommend individual psychotherapy. Whatever the patient chooses to do, they must demonstrate that their depression is resolved prior to proceeding. This can be accomplished by periodic administration of a brief measure of depression (for example, the Beck Depression Inventory-II) or by the receipt of a summary of the patient's psychotherapy that states that, in the opinion of the therapist, the patient is no longer depressed. In the case of binge eating, which is found in around 40-60 percent of obese patients, behavior modification therapy is recommended. Nothing seems to get obese patients going quite like being told they meet the criteria for a diagnosis of binge eating disorder. I have had many patients become quite angry with me upon hearing this. Interestingly, these are usually the people that come to me after a support group, or a preoperative education class, and thank me for sending them for behavior modification! Behavior modification therapy should be performed by someone with experience in it, since it is critical to the patient's progress. If I receive a report that is handwritten, only one paragraph, or a few sentences in length, describing how the therapy addressed the patient's anger, for example, the patient is informed that they will have to re-do the behavior modification with someone who is qualified to do it. So, if you are asked to undergo behavior modification therapy, make sure you check your provider list. When you call for an appointment, ask if the doctor does behavior modification for binge eating . Also, on a couple of occasions, I have had patients call me back and tell me that the therapist was opposed to bariatric surgery and tried to talk them out of it. If this happens to you, get up and leave. If a mental health professional does not feel that they can work with a patient, they are ethically obligated to tell the patient and then offer referrals. A little research up front will save you trouble.
If you are asked to do anything in preparation for your surgery, try to view it as an extra level of preparation and not just another delay. Outcome research in bariatric surgery has identified binge eating as a threat to the long-term success of your surgery. Remember, binge eating has absolutely nothing to do with hunger or your body's need for nutrients. It is a pattern of behaviors designed to reduce stress, whether it is the stress of depression, anger, or celebration. Its origin is in your head, not your stomach, and that is where you must deal with it!
So, the preoperative psychological evaluation is designed to rule out the obvious unfit candidate (active psychosis, active alcoholism or drug abuse, and so forth). But it is also designed to identify potential problem areas and provide you with a way to address these preoperatively so that you can proceed towards your life goals!
