Body Image Concerns and Eating Disorders in Post-Organ Transplant Recipients

Introduction

Organ transplantation has been determined in the literature to cause an increase in anxiety and depression resulting from worries of graft survival and adjustment to life-time medications. In addition, organ transplant recipients may suffer from psychological distress related to identity, self-worth and changes in relationships and career. Transplantation affects all aspects of a patient’s life causing distress related to the loss of body part, changes in diet, sexual problems and issues regarding social and professional roles [1]. Transplant recipients can also exhibit psychological distress related to body image [2, 3, 4]. Body image is defined as one’s own set of images, fantasies, and meanings regarding the body, its parts and function which is an integral component of self-image and the basis of self- representation [5].

Case Example

A 43-year-old male liver transplant recipient one- year post- transplant surgery has been fully committed to maintaining his sobriety, physical health and has returned to school to become a substance counselor. He communicates often with his transplant team, attends his weekly outpatient rehab meetings and meets with a therapist weekly. He has a history of generalized anxiety disorder but appeared to be managing his symptoms without medication. He displays a pleasant demeanor and gratitude for this new life. He was focused on eating well, was exercising daily and was conscious of any fluid retention or bodily changes. From the perspective of all providers, he had been adjusting well and recovering from surgery both emotionally and physically.

Unexpectedly and quite suddenly, the patient’s behavior became peculiar. He stopped going to his outpatient substance counseling and therapy meetings. He was brought to the hospital’s emergency room by his parents after they had found him on the floor, reporting he was not eating, not taking his immunosuppressant medications and had relapsed with a few drinks of alcohol. A psychiatric evaluation was conducted and collaboration with his care team had determined the patient was suffering from a form of body dysphoric disorder and an eating disorder. He enrolled in a voluntary inpatient psych program for one week and began taking medication to manage his anxiety. He disclosed he did not express the seriousness of his body image issues to his therapist or other providers and was actively working to resolve these issues as well as taking anti-anxiety medications. The patient returned to outpatient therapy sessions and treatment goals focused on working on a deeper psychodynamic level. Sessions explored how his early social relationships, recent divorce, alcohol abuse history, and anger issues related to his current psychological distress post-transplant. In addition, his anxiety and perfectionism were explored as there were behaviors post-transplant that became obsessive regarding exercise, nutrition and weight related concerns.

Clinical Practice

The literature has discussed the negative impact on body image as a result of medical illness [6]. Body image concerns can arise post-organ transplant surgery from feelings related to surgery scars, weight gain and the integration of someone else’s organ in the body. The increase in weight gain, dietary requirements, side effects of immunosuppressant medications and overall psychological adjustment to transplantation can create disordered eating. Organ transplant recipients who develop disordered eating and who engage in weight controlling behaviors may increase the potential risk of graft loss and death [7]. Adolescent organ transplant recipients are also a vulnerable group for developing body image issues since that population considers changes in body image to be a significant stressor in their life [7].

The Body Image States Scale (BISS) (Appendix A) is a validated 6-item scale used to assess satisfaction with a person’s own body image [8]. It consists of six domains: dissatisfaction–satisfaction with one’s overall physical appearance; dissatisfaction–satisfaction with one’s body size and shape; dissatisfaction–satisfaction with one’s weight; feelings of physical attractiveness– unattractiveness; current feelings about one’s looks relative to how one usually feels; and evaluation of one’s appearance relative to how the average person looks. The BISS can be particularly useful as a clinical tool for assessing the body images states of organ transplant recipients.

Negative body image may go undetected in organ transplant recipients as was in the case study above. Patients experiencing psychological distress typically mask their inner struggles associated with an eating disorder [9]. Initial therapeutic focus should include a psychodynamic approach to develop an understanding of the patient’s psychological functioning. Paul Schilder, an Austrian psychiatrist, believed the concept of body image is an integration of one’s bodily experiences and the meaning constructed regarding these experiences during childhood [10]. In addition, the literature has established the important role in the link between body image and self-esteem [11, 12, 13, 14]. A solid therapeutic relationship is essential when working with these patients. Psychodynamic psychotherapy focuses not only on the symptoms of the eating disorder but a strong therapeutic relationship can assist the patient in the creation of a new sense of self [9]. It is also important the therapist address any resistance to treatment and manage the possible transference and countertransference that may arise [15, 16].

Cognitive behavioral therapy also has been found to be one of the most-accepted therapeutic approaches for changing negative body image through the modification of dysfunctional thoughts, feelings, and behaviors [17]. Several components, such as a psycho-education, mindfulness, self- regulation, change of irrational automatic thoughts, self-talk, and behavioral components like exposure and relaxation are effective strategies to manage preoccupation with thoughts about food, eating, and weight. Disordered eating has a strong correlation to mood and anxiety disorders, OCD, ADHD and substance disorders. Pharmacological interventions to treat these comorbid conditions might also be useful in the treatment of eating disorders [18].

Conclusion

Organ transplant recipients receive limited information on the psychological distress of transplant surgery. Patients can be embarrassed to discuss their psychological symptoms with their medical providers. In addition, providers may not be aware that such disorders exist. Increasing discussions and awareness of body image concerns between providers and transplant recipients is critical for success in long term graft survival and optimal medical outcomes. Referrals to mental health professionals for appropriate interventions can decrease the anxiety related to dichotomous thinking, cognitive distortions regarding the perceptions others regarding one’s body and address the psychological adjustment to organ transplantation.