LB was a 37-year-old married, morbidly obese, African-American female who was evaluated by psychiatry on the surgical inpatient service for a complaint of “panic attacks.” Concurrently, she was suffering from intractable nausea and vomiting 30 days after a successful gastric bypass surgery.
Initially following gastric bypass, LB had experienced an uneventful recovery and was tolerating a liquid diet well. At approximately 30 days post-op, LB advanced her diet to soft solids and, at this time, started to develop postprandial nausea and vomiting. Her vomiting worsened and became severe enough to necessitate emergency department visits on post-op days 34, 40, and 48, when her surgeon recommended that she be admitted to the hospital for further workup. LB weighed 357 lbs (162.3 kg, BMI of 53.5), down from her initial weight of 426 lbs (193.6 kg, BMI of 63.8). In an attempt to identify the etiology of her symptoms, she underwent a pelvic and abdominal CT scan, a right upper quadrant ultrasound, and an esophagogastroduodenoscopy (EGD), all of which were negative. She also reported being compliant with her surgical follow-up care and diet.
LB had a past medical history of morbid obesity, obstructive sleep apnea, degenerative joint disease, and chronic low back pain, and she had seen a psychiatrist one time only as part of her clearance for surgery. While taking a social history, she described herself as being a very active child and stated that she had excelled in school. However, she mentioned that in her teenage years she had been the victim of date rape.
Psychiatry was consulted on hospital day number two for “panic attacks.” Upon examination, LB appeared fatigued and slightly disheveled, and acknowledged feeling depressed. Initially, LB's thought content was fixated on her persistent vomiting, however, with some encouragement, she spoke extensively about the date rape and its impact on her.
LB admitted to having been raped by a friend when she was 16. When asked how she coped with the experience, LB stated that she “held it in and tried to forget about it”. Following the rape, she ate increasing amounts of food, gained weight, decreased her previously high activity level, and became more “closed off” toward family and friends. She had not discussed this event with a clinician until the preoperative psychiatric assessment for her gastric bypass.
While discussing the event, she was calm, but reserved and limited in her emotional responsiveness. She did admit to some hopelessness, helplessness, and desperation regarding her persistent vomiting. She noted that she had developed an aversion to the smell of food. These cognitions led to the physiologic response of vomiting, palpitations, anxiety, and panic. In conjunction to the cognitive symptoms of depression, she had an inability to initiate and maintain sleep.
To address the depressive symptoms and insomnia, mirtazapine 15 mg orally at night was started. Mirtazapine has the additional benefit of antagonizing 5-HT3 receptors, adding anti-emetic and anti-nausea properties. LB reported improved sleep with this medication, and she received two follow up consultations involving psychoeducation about somatization and panic, as well as insight into the dynamics behind her symptoms. She was able to appreciate the psychological impact of the rape on the development of her obesity. Food may have initially been used as comfort or distraction. It mollified or “self medicated” the significant anger that she had at her offender and the excess weight helped to bind her angry affect. On a deeper, more subconscious level, the weight may have functioned to ward off any other sexual advances. In LB's own words, it was a “shield.”
LB was discharged on hospital day four with arrangements for outpatient counseling and a prescription for the antidepressant agent. At a two-month follow up, the patient reported that the nausea and vomiting had resolved, she was participating in therapy, and reported feeling much better. It is unlikely that her symptoms resolved spontaneously because they abated only after collaborative psychiatric involvement, which was requested after diagnostic tests failed to identify a specific cause. Ultimately, her symptoms improved after she was examined in more depth than ER visits allow, and permitted to discuss the origins of her weight gain.