Représentation de soi et vécu de l’espace corporel chez des sujets obèses sévères en attente de chirurgie bariatrique

Abstract

ObjectivesThe objective of this study is to describe how appear, in severely obese patients waiting for bariatric surgery, the self representation and psychic representations of own body and of bodily space. The aim is not here to identify psychological factors of severe obesity, but to describe which somatopsychic conditions are involved in the life situation of these patients. Authors propose theoretical discussions about body image to give understanding of how body is lived in severe obesity. Arguments give explanations of emotions and mental representations that severely obese patients construct. It is so useful to understand how those mental states and body image can be transformed by way of bariatric surgery. Materials and methodsThe methodology exploring the subjective self is based on a double approach: a quantitative external evaluation (clinical scales: obesity, anxiety, depression), and a qualitative internal evaluation of subjective state (Rorschach test). Quantitative evaluation uses both the Dutch Eating Behavior Questionnaire (DEBQ) to assess behaviors and motivations giving troubles in eating and obesity, and the Hospital Anxiety and Depression Scale (HADS) to assess emotions in people arriving in hospitalization. Qualitative evaluation uses Rorschach ink blot test (RCH) to describe body image as it is lived by patients, RCH gives information about mentalization and psychic process. Seven criterions are used to describe body image and work of mentalization, 766 Rorschach's response are analyzed with those seven criterions, RCH's data are associated with the two clinical scales’ data to discuss how patients appear to psychiatrist/psychologist in time of waiting bariatric surgery. Subjects of our study are 43 severely obese patients (BMI: 45; male 19%, mean age 39; female 81%, mean age 41). Every patient has been assessed during hospitalization before bariatric surgery by psychologist in single case analysis. ResultsResults show two elements. First, scales bring only little information, whereas projective method (Rorschach) indicates somatopsychic troubles in psychological functioning. Then, the subjective self in obese patients presents an atypic mood of bodily space, which defines an atypic self representation, identity is affected. Mentalization is disturbed for each patient, no psychiatric diagnosis can be held but personality is about to be pathological. HADS and DEBQ give little information about psychic life and can’t screen affective disturbance when RCH reveals both hidden body image troubles and psychic suffers. All criterions used to describe body image and emotions related to own body are pathological. Psychological health is in weakness, identity is disturbed and it could be understood as risk factor for failed surgery treatment. Actually, if body image and body experiences are disturbed before surgery it is not surprising to verify that body image and body experiences can be although disturbed after surgery and fast weight-loss. Fast weight-loss can be a risk factor of deep disturbance of psychic functioning, psychopathological disease can be induced. Literature considers that 18% of patient after bariatric surgery are in check and severe obesity has set in again, part of them are probably individuals with psychological complications. Our results suggest that psychic modification and identity modification are too difficult for patients if somatopsychic criterions in time of waiting surgery are already disturbed. ConclusionsIn these conditions, the question of fast weight-loss after surgery can be asked, because causing deep disturbances, forcing to fast global identity reorganization, while somatopsychic functioning before surgery is already often affected. Research perspectives and clinical indication are led. Authors propose that each patient waiting for bariatric surgery should have a clinical assessment of the self representation and psychic representations of own body and of bodily space, this clinical setting could reveals psychic risk factor, and each patients should have then a clinical assessment 12 month after surgery. If somatic complications appear they could be better understood in term of psychic disturbance.