CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. The role of a mental health professional working with surgical weight-loss patients is diverse.
It is a pleasure to contribute to this issue on psychological considerations of bariatric surgery. Common responsibilities of a mental health professional in a bariatric surgery program include conducting pre-surgical psychological evaluations, running support groups, and providing individual psychological services to patients before and after surgery.
Both the Surgical Review Corporation and the American College of Surgeons require the involvement of mental health experts in screening bariatric patients for their respective accreditation processes. Recent studies suggest that morbidly obese patients may have significant symptoms of depression, eating disorders, poor body image, low QOL, and other coexisting mental disorders.5,14-20 In addition to attempting to avoid post-operative psychiatric crises, there is also a strong desire for surgical weight-loss practices to avoid legal proceedings in the event of an adverse surgical outcome. Interestingly, there is still little consensus as to what the contents of a psychological evaluation should be. There is also little consensus as to what specific psychological factors predict outcome, despite the increased focus on inventories or structured tests to identify such variables (GM Boulton-Lewis, unpublished material, 2008).6,10 Numerous variables, including age, gender, socioeconomic status, comorbidities, pre-operative body mass index, prior weight-loss attempts, eating disorders, disordered eating, personality disorders, motivational factors, history of sexual abuse, and social support, among others, have all received some investigation into their effect on surgical outcome, yet none have demonstrated any consistent effects (GM Boulton-Lewis, unpublished material, 2008). Mental health services can be provided as either a prophylaxis against the occurrence of difficulties or a way to address them as they occur. My initial role as the consulting psychologist to the NYU Program for Surgical Weight Loss was to conduct pre-surgical psychological evaluations. I created a questionnaire that assesses eating habits, social support, weight-loss history, and mental health history among other areas and have revised it over the years. Patients are often anxious about the evaluation because they either have never met with a mental health professional or fear that they will disclose information that will disqualify them from surgery. The majority of patients with anxiety fear they may disclose something that will disqualify them from having surgery. Interestingly, a primary objective in having surgery cited by an overwhelming number of patients is to end the psychological exhaustion from dieting and chronic feelings of failure for their inability to lose weight. When patients recognize that the objective is not to try to disqualify them, the assessment becomes a conversation more than an evaluation.
In the experience of myself and colleagues at NYU, patients with histories of psychopathology, if appropriately managed in follow-up care, can react well.
Patients who have been sexually abused or who are socially anxious are often aware of, and have reservations about, making their body more appealing to others.
Patients also express concern that the expectations they have of themselves and that others have of them will change. It has been my experience that most morbidly obese patients either are, or can become, suitable candidates for surgery. Almost all patients who have followed up with me after surgery have been successful from the perspective of weight loss. Interestingly, some of the issues that have received significant media coverage have not been common concerns among my patients. I have seen numerous people who continued to have issues with emotional eating and binge eating following surgery, but many of these patients achieved expected weight loss and did not report dissatisfaction from surgery.
In my experience, patients who present for bariatric surgery can be viewed as being in one of two groups: those who are generally satisfied with their lives and those who are not. Those in the latter group are typically the patients who present for post-operative psychotherapy; their lives remain unsatisfying despite the weight loss.
By my observation, many patients go through a series of four stages in making the psychological adjustments to dramatic weight loss following bariatric surgery (Table 2). During the second stage, patients may begin to incorporate other tools such as dietary change and exercise and are trying to achieve weight-loss goals whether measured by pounds or by sizes.
During the third stage, patients have achieved or approximated major milestones such as losing 75 or 100 pounds or achieving a desired size. There is a significant contribution that mental health professionals can and do make to bariatric surgery patients and surgeons alike.
E-newsletter Opt-inSent no more than 2–3 times each month, our E-Newsletter brings you recent findings and commentary from the psychiatric literature. Surely the fairest, most democratic way is for parties to be required to spell out to voters in advance of a local election exactly what it's council tax proposals are, and then be legally required to stick to them if they are elected. Friends of the Shelter volunteers work hard to make the shelter a warm, inviting place to build relationships between adopters and the cats. Despite the widespread protests that erupted last year, the rate at which people are killed by the police in the US has accelerated. It’s perhaps portentous that a poll to find Britain’s national bird had last week been decided in overwhelming favour of the robin. Chief executive David Harker said: “First Class Futures really will bring huge benefits to the North East if it is able to realise its vision of raising ВЈ100,000. Yorkshire travel to Durham looking for their third successive North Division win after beating Derbyshire at Headingley and, last Friday, Nottinghamshire at Trent Bridge. Kaag says the UN is also looking into recent reports of chlorine gas attacks in the country. Although the research has been pretty clear that there are health benefits to not sitting, we are just starting to understand that standing alone may be a good alternative, said Dr. The researchers then lumped the data in with nine other studies that measured chocolate consumption and heart disease. It was his second injury of the season and he didn't appear again, but while he has been troubled only by the odd niggle this year he has been unable to regain his form. We can do this for him and dance for him, make him well, make him strong, put him on the front, and all his team, dancer Timmy Galalingu said.
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He also won the FIFA Club World Cup and European Super Cup two times each and the Spanish Super Cup six times. However, Rob Youhill suffered a dislocated elbow on Saturday which will sideline him for two to three weeks. Disciplined, well organised and extremely hard to break down, Newcastle have rarely looked like conceding throughout their six-game winning run, and aside from tipping over a Richard Dunne header, Tim Krul was barely tested against QPR.
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He and Chris Rushworth quickly removed the home openers and it became 49 for three when replaced Arshad and struck with his fifth ball.
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The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Physicians should only claim credit commensurate with the extent of their participation in the activity. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship.
Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest. Huberman is clinical instructor in the Department of Psychiatry at New York University School of Medicine and in private practice in New York City. Huberman reports no affiliation with or financial interest in any organization that may pose a conflict of interest. Primary responsibilities include the provision of patients’ evaluations prior to surgery and either individual or group counseling after surgery. I began working as the consulting psychologist to the New York University (NYU) Program for Surgical Weight Loss in 2000 and have had the good fortune of working with Christine Ren Fielding, MD, George Fielding, MD, and Marina Kurian, MD. Having worked extensively as a cognitive-behavioral psychologist focusing on health-behavior change, I was leery that bariatric surgery was another hoax or quick fix for obesity.
A mental health professional is typically a member of the team along with nurses, a nutritionist, surgeons, and other clinical staff.
Numerous experts agree that psychopathology and a number of pre-morbid psychological difficulties can have an effect on post-operative success.12-13 However, findings of studies investigating underlying psychopathology or other emotional obstacles in the bariatric population have yielded inconsistent results. For example, a surgeon would have difficulty defending him- or herself against a legal proceeding from a patient with poorly controlled bipolar disorder who experienced an adverse surgical outcome if the surgeon made little effort to identify and evaluate that such a pre-morbid psychiatric history was present.
Some professionals use structured inventories and psychological instruments such as the Minnesota Multiphasic Personality Inventory-2, Medical Outcomes Study 36-item short form health survey, and a variety of instruments that assess the presence and severity of eating disorders while other professionals rely primarily on a structured clinical interview.27 There is little evidence that any method or instrument of assessment is superior in either identifying inappropriate candidates for surgery or predicting long-term success from surgery. When patients struggle to achieve satisfactory weight loss and medical explanations are inadequate, it is reasonable to consider that psychological variables may be involved. I was familiarized with the types of surgeries, current literature, and nature of the information she wanted me to acquire through the evaluation.
The questionnaire serves as a template that would enable me to take the patient through a structured yet simple process that is more like a conversation than a clinical interview. Patients who have never met with a mental health professional will often ask where the couch is, which is a prompt to explain the objectives of this meeting.
Most patients that present for surgery have successfully lost weight before and many have lost >50 pounds on more than one occasion. For many, this meeting will be their only interaction with a mental health professional, and it is my responsibility that they leave the meeting with a favorable impression of our profession. In fact, one study found that patients who met criteria for MDD before surgery did better than non-depressed patients in terms of total weight loss.36 It does not appear that the presence of any particular personality type, trait, or characteristic assures an unsatisfactory outcome from surgery. I ask patients to consider the issues they believe cause behavioral and emotional difficulties after surgery and how they would address them should they occur. If a patient appears unsuitable, it is likely that he or she is simply not ready at that time. Most are seeking assistance in making the emotional and behavioral adjustments in their personal and social lives that their weight loss has necessitated. Those in the former group generally want to lose weight to address health concerns or to stop their weight from interfering with their ability to enjoy their lives as they are.
Such patients often have impaired esteem, poor body image, unsatisfying or non-existent intimate relationships, minimal or unsatisfying social contacts, and other issues that need to be addressed. During the first stage, the focus is on maintaining compliance with dietary rules and on losing weight. Rudimentary psychological changes occur such as learning to accept compliments and adjusting to changes in social interactions. Many will punctuate their accomplishment through a physical achievement or by taking a major step in their personal lives. It is the stage during which depression and other emotional difficulties are most likely to occur. They play a vital role in patient selection, preparation, and education before surgery and inpatient care following surgery. Psychosocial and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery.
Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers.
Behavioral and psychological factors in the assessment and treatment of obesity surgery patients. The Boston interview for gastric bypass: determining the psychological suitability of surgical candidates.
Binge eating and its relationship to outcome after laparoscopic adjustable gastric banding. Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study.
Bariatric surgery: what the plaintiff’s lawyers think, the defense lawyers, and most importantly the jurors! Do support groups play a role in weight loss after laparoscopic adjustable gastric banding?
The perceived effectiveness of continuing care and group support in the long-term self-help treatment of obesity.
Association between support group attendance and weight loss after Roux-en-Y gastric bypass.
I've been thinking about it a lot recently - because my kids are going to go to school soon so we're trying to work that out - and realise how important that is, but I never had an inspirational teacher.
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Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. Early submission of this posttest is encouraged: please submit this posttest by August 1, 2010 to be eligible for credit. The field has changed in numerous ways since 2000, and the knowledge base regarding the psychological impact of weight-loss surgery has grown considerably. After having the privilege to work with >5,000 patients, I think that bariatric surgery may represent the only empirically valid treatment for morbid obesity.
Some programs require pre-surgical psychological evaluations of all patients while others do not.5-10 Numerous programs offer support groups while others do not.
Early studies seemed to suggest there was no greater incidence of psychopathology among the morbidly obese. At these times, the surgeon can consult with the mental health professional regarding a difficult case or could refer the patient for psychotherapy. There is some debate as to whether support groups or therapy groups are more appropriate28; however, there is little debate that such groups are helpful and desirable. My objective in conducting the evaluations was to follow generally accepted practices and to address particular questions and concerns. The latter question often indicates the patient’s primary objective in having surgery and what his or her expectations are from surgery. Unfortunately, most patients believe that maintaining such weight loss with diet and exercise is commonplace and indicate that their family and friends believe this as well, although virtually all clinical research suggests this is hardly the case.
In doing so, I believe that patients may be more willing to seek out help should the need arise in the future.
Colleagues indicated their practice of disqualifying candidates if they expressed a history of major depressive disorder (MDD), suicidality, substance abuse, eating disorders, and other issues. Numerous morbidly obese patients report that others have ignored them, failed to make eye contact, or rolled their eyes and sighed when they came near. For example, many patients fear that they will feel pressure to begin dating now that they are thinner or to begin interviewing for a new job now that concern about weight discrimination has diminished. Many patients have presented for surgery in the midst of other issues (ie, divorce, recent loss of a loved one), and when I suggest that they wait until such issues are resolved, it is generally well received. I have yet to speak to a patient who has expressed regret with his or her decision to have surgery. Such patients usually adjust well after surgery, as their primary objective is to lose weight to better enjoy what is already present in their lives.
Patients are in pursuit of their weight-loss goal and the changes they anticipate will occur when that goal is reached.

I have had numerous patients run a marathon or take a physically demanding vacation while others will post their profile on an Internet dating site or begin attending social events. In many regards, the treatment of morbid obesity through bariatric surgery is as much psychological as it is physical.
Ren Fielding and I met 7 years ago, I asked her what motivated her to work with the morbidly obese. The factory-inspired modern building is honest, hard-working architecture that sits in what was the industrial heart of Milwaukee. Roy Blunt, R-Mo., said it Obama is making the right move but said the president should have sought a congressional vote on this issue earlier.
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6 when Iowa City Officer Ben Hektoen noticed "an odor of ingested alcohol" coming from the vehicle,the Iowa City Press-Citizen reported. If the issue of state restructuring will resolve the ossue, Nepal will ensure a new constitution and there will be a new president, vice president, prime minister and other major political posts, sources said.
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In February, hundreds of children were forcibly conscripted in the northeastern town of Malakal by a government-aligned militia. A spokeswoman for the commission says the plan limits participation in the Jonah crab fishery to fishermen who hold an American lobster permit or can prove previous participation in the crab fishery. While there is no consensus regarding the content of pre-surgical evaluations or the criteria used to exclude patients from surgery, it is generally accepted that the evaluation is necessary and beneficial. This author is unaware of any program that requires patients to participate in ongoing psychological counseling following surgery although some may recommend this practice and make such services available. My objectives for the pre-surgical evaluations have evolved to include the following, as shown in Table 1.
I can generally explain to the patient why I believe he or she is not presently suitable for surgery and have him or her take steps to address my concerns before moving forward. I have since worked with individuals who have had histories of numerous diagnoses and many have done well in terms of both weight loss and improvements in QOL. Fewer patients understand why I ask about potential emotional difficulties that could arise should they be successful in losing weight. They anticipate that social interactions will change considerably when they begin to lose weight and some have anxiety about these changes. For the vast majority of patients, the medical and psychological benefits of bariatric surgery significantly outweigh its potential consequences so much that there must be an extraordinary reason to deny a patient this opportunity. Most patients express satisfaction with the outcome of their surgery, including many who have experienced complications related to surgery. Much has been discussed on this topic and more research is required37 before any conclusions are drawn.
Emotionally, there can be excitement from losing weight or apprehension if complications are experienced and weight loss is slow.
This stage involves experimentation and risk taking as if to demonstrate to themselves and others that they are truly a new person. The life-long objective to defeat obesity in terms of numerical weight may have been accomplished.
The crisp, hard edges of the building, which takes on a tire tread-like texture, show deference to the supple shapes and sheen of the bikes that park along the open-air streets, meant to re-create the feel of annual bike rallies in places like Sturgis, S.D. That tragedy led to the country s first Disaster Management Act, followed eight months later by the establishment of the Disaster Management Centre. Prize or prize certificates will not be mailed to the winner without the winner s prior written consent in which the winner shall agree to assume its risk of loss.
The caller told authorities that one person had made it out, but two people were still inside the residence. Tensions between Egypt and Iran heightened when the Islamic Republic named a street after Khalid Islambouli, who assassinated Egyptian President Anwar Al-Sadat in October 1981. Last week, it widened thecorridor by5 kopeks andsaid that it will continue toadd 5 kopeks tothe corridor foreach $600 million ofintervention money it spends onkeeping theruble inthe corridor. 22, 2013, the Philippines unilaterally initiated compulsory arbitration proceedings with respect to the relevant issues between China and the Philippines in the South China Sea. While both treatments relieved the hot flashes these drugs are designed to treat, in neither case did the scientists find any changes in cognition or thinking, for better or worse.
Thehouse's chef serves fine grilled meat, boiled sprats, andFrench fries, among many other treats.
Phelps admitted to smoking marijuana before driving his car and agreed to take a breath test and evaluation for marijuana intoxication. At a press conference in Kathmandu on Tuesday afternoon, the political parties appealed for calm after violent protests erupted in the western region of the country against the proposed six-state federal set-up.
Tel Aviv defines such goods as dual use - meaning that while they are needed for the civilian population, they could also potentially be used by militant groups in attacks. Le but de cet v nement, qui est aussi celui de ce groupe financ par des capitaux trangers, tant de diaboliser et de diffamer l arm e isra lienne.Il semble donc que le gouvernement ait finalement d cid de r pondre aux provocations. The game is striking in both its anime-style art style and its attitude, which includes God checking in on your progress by calling your guardian angel over a mobile phone.
All his 12 children are to be beneficiaries, but the deciding votes will be held by his wife and one of his children. There is still no official number of dead since the fighting started, but officials estimate in the tens of thousands, while an additional 1.5 million people have been internally displaced and 500,000 have fled abroad. It has two other LNG developments on its books a 5-mtpa plant at Vladivostok that could be on line by 2018 and could expand to 10 mtpa in the 2020s; and the 10 mtpa Baltic LNG project that could be producing in 2018. Our goal is to provide members with opportunities to establish relationships with other moms who have common interests. Some patients have dieted for so long that they forgot that weight loss in and of itself is not the final objective. I continue to assess the presence of Axis I and II pathology but move on to other areas if these issues are absent or are well controlled. Most cannot see weight loss as anything other than desirable, but for patients who see beyond that particular end, they understand completely. For this reason, it is imperative that the pre-surgical evaluation is conducted by a clinician who has expertise in the field, so that patients are not inappropriately screened out of surgery, and that those who are allowed to proceed are fully educated and emotionally prepared to do so. Weight-loss surgery is a powerful tool that enables dramatic weight loss and helps patients to make significant life changes. In circumstances where my patients have reported increased alcohol consumption following surgery, it has generally been a natural consequence of becoming more socially active after losing weight and not a cause for alarm. Many continue to emotionally feel like their formerly obese selves long after the weight has been lost.
In addition, as the field is growing with the rising number of patients undergoing bariatric surgery, familiarity with the issues faced by these patients is necessary. Panicker submitted that it was mandatory for units with more than 10 workers and engaged in continuous processing, manufacturing, and distribution of any product to come within the ambit of the Act. The Promoter, its sponsor, or promotional partner are not responsible for the safe arrival of a prize or prize certificate. The next day, while inaugurating a road while Scioli stood at her side, she said: "We could have saved so much time if (the opposition) had realized just a little sooner" the value of the policies. Inother words, theCentral Bank is revving up tomanage acontrolled, slow-moving devaluation ofthe ruble that will soften theblow ofan external crisis andpreserve Russia's hard currency reserves: If Greece has acontrolled default, Russia will respond with acontrolled devaluation.
Since then, the Philippines has obstinately pushed for the above-mentioned arbitration proceedings despite repeated objections of China. Here's an idea for MBC, start collecting the rates from those that don't pay rather than hammering the ones that do pay.
Phelps then asked Hektoen if he would take a Snapchat selfie, according to the criminal complaint.
A Republican rewrite without Democratic input will not inspire broad confidence that elected representatives will put the public's interest over their own or those of special interests financing their campaigns. In addition, 16 of the 33 Senate seats are up in the November election under the new legislative districts more favorable for Republicans, meaning their party could pick up enough seats to regain the majority. In May-June last year, a Chinese naval task force held military exercises with Cameroon and Nigeria, the first time that the Chinese navy appeared in the west coast of Africa. The world of El Shaddai ' is mesmerizing and beautiful and an amazing place to escape for hours. Another product is an antibiotic foam for treatment of Impetigo, an infectious disease, which is due to begin a Phase III trial after talks with the US Food and Drug Administration (FDA).
The Business Networking Group within Sierra Moms connects and supports mothers in their entrepreneurial and business endeavors. This article suggests pre-surgical evaluations should not primarily focus on psychopathology but on patient expectations and preparedness for the behavioral and emotional changes following surgery. Therefore, weight-loss surgery should be made available to the majority of patients unless extraordinary circumstances suggest otherwise. However, there are physiologic changes in the way alcohol is absorbed and metabolized, particularly following gastric bypass and other malabsorptive surgeries, and patients need to be aware of the potential problems associated with this phenomenon. The focus of their life needs to transition from losing weight to adjusting to life in a thinner body and moving beyond weight-related objectives. He alleged that the unit processes used syringes and gloves and transports them to Coimbatore to be sold to medical equipment manufacturing units without proper licence from the DFB.
The decision to federate the country into six provinces with tentative demarcation of borders sparked protests in various parts of the country. It's a quiet performance yet so assured that it takes you mere seconds to learn to read his silences. Reid Ribble, a Wisconsin Republican, and his Democratic colleague in the House, Jim Cooper of Tennessee, unveiled a pair of bills back in March that got little notice but could go a long way to making the nation's reapportionment process less partisan. Shapcott is one of the world’s leading researchers on how to effectively market to, and teach, women the game of golf.
Common reasons patients present for post-operative psychotherapy are reviewed and a stage model of psychological change following surgery is presented. For most patients, goals include improvements in physical functioning, improved esteem, improved health, and improved interpersonal relationships. This is the stage during which changes in one’s personal, social, and professional lives are to occur and is thus ongoing. On another note perhaps Mallon might reflect on the cost of investigations into his behaviour that of his ex-colleagues that cost the town a fortune under Lancet!
It is the second largest town in North Sinai and the only major population centre remaining in the restive corner of the peninsula, which borders the Gaza Strip and Israel.
Three people were killed and over half a dozen injured in violence that broke out in Surkhet district in mid-western Nepal. Success in working through this stage will define overall success from bariatric surgery for many patients. Present at the conference were Prime Minister Sushil Koirala, CPN-UML chairman Jhala Nath Khanal, UCPN (Maoist) chairman Pushpa Kamal Dahal and MJF-L chairman Bijayakumar Gachhadar. Chaque ann e, les Pays-Bas consacrent plusieurs millions d euros au financement, direct ou indirect, d organisations dont le seul objectif est la diabolisation d Isra l.
L ambassade isra lienne La Haye et le ministre des Affaires trang res doivent exiger un arr t imm diat de cette campagne subversive et diffamatoire.

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