Endocrine Abstracts

Case History: A 55 year old woman with a BMI of 57.4 was referred to our service to assess her suitability for bariatric surgery given her psychiatric surgery. Her problems with weight began aged 8 when she was sexually abused. She saw a doctor aged 14 who prescribed amphetamines for her weight, and states her problems with drugs as an adult (LSD, cannabis, amphetamines) stemmed from this. She has a diagnosis of EUPD-borderline type, and was prescribed quetiapine which had kept her relatively stable. She had a history of bingeing and purging but had not done so for 25 years. She picks her skin every day as a type of self-harm and eats the scabs. She has a history of four suicide attempts: three were overdoses and one was when she set fire to a boat with her inside it in 2011. At the time of initial assessment she had begun CBT for agoraphobia and was in the process of switching from quetiapine to aripiprazole.

Investigations: Mental state examination was in keeping with a diagnosis of EUPD, with labile mood. She reported hearing the voices of dead people since childhood, but had no other symptoms of psychosis. She reported intermittent suicidal ideation, but had a clear plan that she would definitely kill herself if she was not allowed to have bariatric surgery.

Management: Collateral psychiatric history was obtained from her GP and a plan made to review her after finishing the CBT. At review she had shown significant willing to improve her health by stopping smoking, improving her diet, switching her antipsychotic and engaging with CBT. She had been discharged by her community mental health team (CMHT) due to her stable mental health. However she continued to state that she would kill herself if she were not allowed bariatric surgery, and had drunk two glasses of wine prior to the appointment. It was felt that on balance she should be allowed surgery, but that there were significant inherent risks in either decision.

Discussion: There is evidence suggesting that patients who actively self-harm should not be allowed bariatric surgery due to an association with risk of relapse post-operatively. It was felt that in this case, her mental state had been stable for 5 years, and she had demonstrated enduring commitment to improving her maladaptive behaviours in other ways. However this case was laden with significant risks whichever decision was made.