Conociendo el interior de un obeso
Durante el tratamiento de Obesos Mórbidos, los profesionales nos encontramos con el paciente “físico” que es lo fácilmente visible y oculto dentro de su propia historia, en su interior, están las causas de su actual enfermedad. Nos resulta muy difícil acceder a esta instancia, y necesitamos varias consultas para empezar a conocer algún dato que nos acercará al paciente y de ésta manera a la mejor solución posible.
Muchos de ustedes, sino TODOS, se presentan ansiosos esperando la magia que los llevará a solucionar un problema tan grave que los hace sumamente infelices. Para nosotros los “cirujanos”, lo más fácil y más simple aunque parezca raro es operar, para ello nos hemos entrenado toda nuestra carrera y lo seguimos haciendo día tras día. Lo difícil y complicado es a mi entender, intentar conocer y profundizar en el interior, acercarse a la realidad que lo define y poder desde ese lugar ayudarlo.
Para lograr de ese fin es que intentamos desde el consultorio, las reuniones, caminatas hasta el foro de Familia Bariátrica estar cerca.
Creen ustedes que la Obesidad es solamente una enfermedad?
En mi opinión creo que probablemente la Obesidad sea una manifestación externa de intrincadas cuestiones que comienzan en lo genético y se entrelazan con la historia de cada uno, con su infancia y su desarrollo, las relaciones humanas, la seguridad ó inseguridad de la vida, la independencia ó la falta de ella, la confianza en uno mismo ó la falta…y también el AMOR (…y la falta?).
Las opinines vertidas aquí son propias y me disculpo ya que salen de un Cirujano con mínimos conocimientos de psicología, pero con experiencia de campo.
Les envío un saludo afectuoso a cada uno de ustedes.
Aspectos de la psicología de la obesidad
En la década de los años 50, se describió la obesidad como un trastorno mental. Sin embargo, en la actualidad sabemos que las causas psicológicas no explican completamente el desarrollo de esta enfermedad. Sólo se han podido identificar algunas conductas psicopatológicas como:
1. La sobreingesta de alimentos mediante atracones, el llamado Binge Eating Disorder (BED) o trastorno por atracón, para disminuir al ansiedad.
2. Una casi exclusiva demostración de afecto de los padres a los hijos durante la infancia, a través de alimentos8.
Actualmente las causas psicológicas de la obesidad siguen poco claras y estas no han podido ser clasificadas dentro de la Clasificación Internacional de Enfermedades (CIE-10) de la Organización Mundial de la Salud, ni en la Asociación Psiquiátrica Americana (DSM-IV-TR)9.
Se sabe que el aspecto psicosocial de la obesidad está determinado por la interacción de la persona con su ambiente sociocultural. El ambiente y sus integrantes tempranamente discriminan y emiten juicios contra los obesos, con adjetivos como flojo, feo y sucio, según datos aportados por Wadden el año 200110. El mismo autor confirma además, que las mujeres son más susceptibles de desarrollar alteraciones del ánimo y que mientras más grave sea el cuadro depresivo asociado a BED, mayor será la obesidad. La mayoría de los estudios epidemiológicos señalan que los obesos tienen una peor calidad de vida, alteración de su imagen corporal, antecedente de abuso sexual en la infancia y una mayor frecuencia de trastornos de alimentación.
El BED es el más prevalente de estos trastornos y se observa aproximadamente entre un 19% y un 33%11-13 de los obesos que acuden a cirugía, seguido por la bulimia nerviosa en un 1,6%14. La investigación de Glinski11 confirma y complementa lo anterior. En su estudio evaluaron a 115 pacientes obesos mórbidos que serían sometidos a cirugía de by-pass gástrico. El 59% sufría de algún trastorno psiquiátrico, siendo los más frecuentes los trastornos de personalidad en un 36%, las alteraciones del ánimo en un 19%, y trastornos de ansiedad en un 17%. Además estos pacientes tendían a ser negadores, impulsivos, somatizadores, presentaban dificultad para modular sus afectos y pensamiento dicotómico (todo o nada), junto a conductas autodestructivas y baja autoestima.
Black15, buscando comorbilidad psiquiátrica en pacientes sometidos a cirugía bariátrica, constataron trastornos de personalidad en el 56% de los pacientes, siendo los trastornos tipo cluster A (trastornos esquizotípico, esquizoide y paranoide) los más frecuentes con un 49%, luego los cluster B (limítrofe, histriónico, disocial y narcisista) con un 29% y finalmente un 5% para el cluster C (dependiente, obsesivo-compulsivo y agresivo-pasivo). Weil señaló que los obesos tendrían mayor prevalencia de psicopatologías 78%, especialmente trastornos psiquiátricos y de personalidad comparados con los no-obesos.
Si bien ambos trabajos son estudios en poblaciones pequeñas es posible plantear que los pacientes con obesidad mórbida presentan una elevada comorbilidad psiquiátrica.
Aspectos psiquiátricos
Clark y su equipo demostraron que la disminución de peso después del tratamiento quirúrgico dependía de varios factores, entre ellos, del estado psiquiátrico del paciente. Observaron que los pacientes con enfermedad psiquiátrica atendidos en forma adecuada previamente a la cirugía, lograron disminuir significativamente el peso, en comparación al grupo que no recibió esta atención. Asimismo observaron que el tratamiento psiquiátrico preoperatorio disminuyó la tasa de hospitalizaciones postoperatorias19.
Algunos autores afirman que la patología psiquiátrica previa no influiría sobre el pronóstico, siempre y cuando el paciente reciba un adecuado tratamiento psiquiátrico antes de la cirugía y una estricta vigilancia psiquiátrica postoperatoria10,20,21. Se ha visto que sería útil la psicoterapia en el pre y postoperatorio, ya que promueve una mayor estabilidad psicológica del paciente y le ayuda a mantener el peso perdido22,23.
La relación entre BED y la cirugía bariátrica es todavía incierta. Existen casos en que este desaparece en el seguimiento a los cuatro meses24, o a los dos años12,25. Muchos de los pacientes si bien no cumplen con los criterios de BED post cirugía, presentan abuso de laxantes e inducción de vómitos repetidas 33%20.
Hsu y cols. refieren que este síndrome disminuye por el Síndrome de Dumping12. Éste impide la ingesta de comida en grandes cantidades, como ocurre en el BED, al producir desagradables manifestaciones autonómicas y gastrointestinales. Con el tiempo el tubo digestivo comenzará a adaptarse, permitiendo la ingesta de mayor volumen de comida por lo que volverá a aparecer el BED, disminuyendo a su vez el dumping. Esto ocurre aproximadamente entre los 18 y 24 meses, lo que conlleva una menor disminución de peso post cirugía, en comparación a los pacientes no-BED26. Por este motivo es importante el diagnóstico precoz del BED, y su tratamiento con antidepresivos y psicoterapia8,27, además de un seguimiento psiquiátrico postoperatorio.
La pérdida de peso gracias a la cirugía bariátrica en pacientes obesos mórbidos tiene consecuencias psicosociales favorables. Estos pacientes mejoran los índices de calidad de vida casi inmediatamente, con un aumento del índice de salud global y una mejor adaptación social. La duración y frecuencia de la ansiedad, depresión o enojo también disminuye10,26. La distorsión de la imagen corporal presente en el 70% de los pacientes previo cirugía bariátrica se reduce al 4% en el postoperatorio26.
A pesar de estos alentadores resultados, no se debe olvidar que los pacientes obesos mórbidos son más vulnerables a desarrollar trastornos psiquiátricos, especialmente depresión. Ryden en su estudio sobre secuelas psicológicas de los trastornos metabólicos y clínicos observa que el 40% de los pacientes sin historia de trastornos del ánimo previo cirugía bariátrica, los presenta en el postoperatorio28. Otros estudios14,25, señalan cifras menores al 16%.
Cabe destacar finalmente que una de las complicaciones de la cirugía bariátrica a largo plazo es el suicidio con un porcentaje entre 8,8% y 37,5%12.
Recomendaciones
Los tratamientos quirúrgicos para obesidad mórbida parecen tener buenos resultados. Sin embargo la cirugía es sólo una parte de un largo proceso multidisciplinario, que no trata la causa de la obesidad; sólo disminuye la ingesta de comida a través del síndrome de dumping, restricción gástrica y malabsorción. Por esto debemos tener presente que “la cirugía no es el final del tratamiento sino sólo una etapa del tratamiento contra la obesidad morbida”29.
El tratamiento adecuado debe considerar estrategias para controlar los factores que gobiernan la ingesta de comida. Estos son: conducta alimentaria, funcionamiento psicosocial y metabolismo. El tratamiento quirúrgico incluye por estas razones además de la cirugía, apoyo nutricional, médico, psicológico y psiquiátrico, entre otros.
Pensamos que los cambios psicosociales a corto plazo que experimentan los pacientes bariátricos son un terreno propicio para educar de nuevo la conducta alimentaria, potenciando de esta forma los resultados a largo plazo de la cirugía. Esta educación deberá ser dirigida por especialistas del ámbito psiquiátrico30.
Rev. Chilena de Cirugía. Vol 58 – Nº 6, Diciembre 2006; págs. 481-485 Drs. FRANCISCO BUSTAMANTE.1, CATALINA WILLIAMS D.1, Srs. EDUARDO VEGA P.2, y BENJAMÍN PRIETO D.2
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