Introversion

Today, during one of my pre-op psych evaluations, I heard a woman say “I just feel like once I start losing weight and start feeling so much better about my self- I will stop doing all the destructive things that got me here. Don’t you think?”
My response was “no I don’t agree.” I went on to explain that hers was a common assumption, a dangerous “magic-bullet” fantasy about what weight loss surgery can do.
Here’s why: The part of our brain that is responsible for the thought : “wow I look so much better, I better not mess this up,” or “I feel better than I have ever felt in my life, I am a changed person,” is not the same part of the brain that wakes us up in the middle of the night and says: “go on, finish that 1/2 pint of Chunky Monkey in the freezer, there’s only a little bit left anyway, and I have been so good here lately.”
We are dealing with two very different brains; the frontal cortex and the reptilian mid brain. The frontal cortex is the most newly developed (relative to other parts of the brain) part of the brain. It is the component that separates us from animals. It gives us the ability to think about consequences, plan, and execute. It is the “higher” part of ourselves, that often says “why do I keep on doing the same things I keep saying I won’t do anymore?” Or “I feel so out of control. This _______ (eating, smoking, drinking, gambling, pick your poison) is a temporary solution that produces long term pain. I have to find a different way.”
Our reptilian midbrain is the Commodore 64 to our MAC; it is the palm pilot to our iPhone; the horse and buggy to our Prius; the Tommy Lee to our Oprah. Our midbrain is antique equipment, long ago evolved to keep us alive and hence the reason it is still with us today- it keeps us alive. Our midbrain contains the parts of the brain that make us recoil at the site of a snake or a spider in our peripheral vision. It is hardwired to not have to go through superfluous channels of the brain that might otherwise say “hmmm what is that crawling over there? How do I feel about that? Oh its just a spider, my aunt had a collection of spiders, maybe I should collect things, etc etc.” We just jump, and process later.
That very system has helped humans survive for thousands of years. There is an adaptive quality to a brain that proverbially acts and asks forgiveness later. That very old structure once kept us out of harm’s way when a pack of tigers were first seen galloping across a horizon, or when a rivaling tribe could be heard in the far off distance, threatening to pillage our territory.
Our midbrain is associated with learning and reward. Learning what makes us feel bad, what eats us (in the past that would be in a literal sense- like tigers, but presently it might be a mercurial supervisor or unending debt), and even more relevant to this article- what makes us feel good. When our brains come across something that makes us feel good (ex: sex, drugs, food), we are then flooded with an influx of the powerful neurotransmitter- dopamine. Just like not everyone that is exposed to drugs will develop an addiction, not everyone that eats a Nutella crepe will develop a food addiction.
Much of the research on obesity currently, postulates that food addiction, no dissimilar than alcohol or drug addiction- is a reward system dysfunction or dysregulation, born out of genetic predisposition. It’s almost as if some brains think “if one slice of pizza feels good, how would four slices of pizza taste?”
To break these two very different parts up in a different, more basic way; our frontal cortex is the voluntary, while our midbrain is the involuntary.
This very dangerous fantasy, many people carry into weight loss surgery is a myth that I try to dispel quickly. This type of “magic bullet’ thinking is the very thing that gets so many gastric bypass and sleeve patients into trouble years down the road. No one wants to look at triggers. No one wants to sit with a therapist and devise a strategic coping plan. We want a pill, a surgery, a 16 minute solution to a 40 year old problem.
This is not to say that weight loss surgery is not a solution, just that its only part of the solution.

Despite our best intentions, we are still in some ways animalistic, hedonically-driven to feed our most basic impulses. This is part and parcel of why recidivism is the rule not the exception when it comes to recovery from most addiction. So what does this mean? Are all weight loss surgery patients destined for disappointment and disenchantment when the WLS honeymoon ends? No. But the answer to long term change lies more in two-pronged approach to long term weight loss success; surgery + behavioral change.
Simply thinking ourself slim is a fantasy. Think about your specific triggers for eating. For some it is that golden hour when all the kids are in bed and Narcos is queued up on your Netflix. For others it is that 2-3pm mid day slump. For some - it is when they are alone, the only time they can eat with abandon free from others’ judgement or their own embarrassment.
Whatever your triggers- the key is to identify what need is being met in that moment and to find a non-food alternative to meet each particular need ( many people have multiple triggers for over eating). If it is because its “your time,” after the kids are in bed- maybe you invest in a foot massager, or cultivate a self care space with textures, aromatherapy, candles, and books. If your trigger is that mid day slump, maybe you develop a yoga routine easily done in the office to help re-energize you. If it is the secretive quality to the trigger of being alone and eating, maybe it is finding another thing that is just your own that no one knows (going to a movie in the middle of the day, getting an overly priced facial on your lunch hour, playing hooky with your kid one day, etc).
The rule of the brain is : what fires together, wires together. So over time- if you have paired 8pm, Narcos, and nachos- you have created a neurological super highway. The moment 8pm rolls around, you are likely already getting the chips ready and didn’t even realize the thought pathway that just occurred. The idea is to repair our triggers with alternative behaviors and over time “clip those wires” or create “toll roads” to our superhighways (aka neurosynaptic pruning), so that we no longer experience such strong urges and can call upon the higher structures of our frontal cortex to guide the way again.
When we are in the midst of addiction, it is important to understand that our frontal cortex is not at the wheel. It has been duck taped and tied to a chair in the basement by our hedonic midbrain who is used to getting what it wants when it wants it. The closer we come to accepting this principle, the closer we come to being more mindful of our midbrain’s powerful rationalizations and sick contracts and see them for just that. We are better able to dis-identify from the thought, knowing it is not coming from our best self, but from our most carnal self.
Think of that distant cousin that only shows up when they need something, the Uncle Eddy that tells you he’ll move the RV when he leaves next month, indifferent to how it makes you feel. Except in addiction- that distant cousin has taken over, pretending its you until you can no longer tell the difference.
References
http://brainspotting-switzerland.ch/4_artikel/Corrigan & Grand 2013 Med Hyp paper (proofs).pdf
Blum K, Chen AL, Giordano J, Borsten J, Chen TJ, et al. The addictive brain: all roads lead to dopamine. J Psychoactive Drugs. 2012;44:134–143. [PubMed]
Avena NM, Gold JA, Kroll C, Gold MS. Further developments in the neurobiology of food and addiction: update on the state of the science. Nutrition. 2012;28:341–343. [PMC free article] [PubMed]
Gearhardt AN, Yokum S, Orr PT, Stice E, Corbin WR, et al. Neural correlates of food addiction. Arch Gen Psychiatry. 2011;68:808–816. [PMC free article] [PubMed]
Saper CB, Chou TC, Elmquist JK. The need to feed: homeostatic and hedonic control of eating. Neuron. 2002;36:199–211. [PubMed]
Stice E, Yokum S, Zald D, Dagher A. Dopamine-based reward circuitry responsivity, genetics, and overeating. Curr Top Behav Neurosci. 2011;6:81–93. [PubMed]
Blum K, Sheridan PJ, Wood RC, Braverman ER, Chen TJ, et al. The D2 dopamine receptor gene as a determinant of reward deficiency syndrome. J R Soc Med. 1996;89:396–400. [PMC free article] [PubMed]
Comings DE, Flanagan SD, Dietz G, Muhleman D, Knell E, et al. The dopamine D2 receptor (DRD2) as a major gene in obesity and height. Biochem Med Metab Biol. 1993;50:176–185. [PubMed]
Noble EP, Noble RE, Ritchie T, Syndulko K, Bohlman MC, et al. D2 dopamine receptor gene and obesity. Int J Eat Disord. 1994;15:205–217. [PubMed]
Blumenthal DM, Gold MS. Neurobiology of food addiction. Curr Opin Clin Nutr Metab Care. 2010;13:359–365. [PubMed]
Volkow ND, Wang GJ, Fowler JS, Telang F. Overlapping neuronal circuits in addiction and obesity: evidence of systems pathology. Philos Trans R Soc Lond B Biol Sci. 2008;363:3191–3200. [PMC free article] [PubMed]
Volkow ND, Wang GJ, Baler RD. Reward, dopamine and the control of food intake: implications for obesity. Trends Cogn Sci. 2011;15:37–46. [PMC free article] [PubMed]

Freedom from Medical Chains
Medical benefits are probably most closely related to weight loss, but they are still worth noting as a “side” benefit of Weight Loss Surgery. As you lose weight, you may have improvements in blood sugar control, blood pressure, and cholesterol levels. You may have less joint and back pain. You may have fewer trips to the doctor, and be able to take fewer medications.
Better Sleep
Never underestimate the power of sleep! Losing weight can help you sleep more deeply so you feel better all day, every day. Your sleep can improve as you feel more comfortable in bed, and if you had sleep apnea that goes away or diminishes with weight loss. Just think how good life could be if you did not have to did not have to use a CPAP machine!
New Food Finds
Strange but true…there is a whole food world aside from burgers, burritos, fries, and bagels. Who knew that you might end up loving to start your day with oatmeal cottage cheese protein pancakes? Your favorite snack could turn out to be kale chips with parmesan. Dinner might be roasted cauliflower with grilled salmon – something you might never have considered when your go-to was mac and cheese from a box.
Sure, you might miss a few foods, but you might notice that you are loving all kinds of new health foods, and the way they make you feel. On top of it, eating slowly can help you savor each bite and enjoy the textures and flavors more.
Saving Money
Saving money probably was not your main reason for considering weight loss surgery, especially if your insurance is not footing the bill. Still, Weight Loss Surgery could be a financial gain in the long run as you consider some potential savings.
Lower medical bills for doctors’ visits, prescription medications, and complications such as complications of diabetes. Fewer sick days taken from work. Lower food bills as you eat less and potentially eat more homemade food. Fewer “extras,” such as higher prices of plus-sized clothing or needing to reserve two seats on a plane. More Meaningful Relationships
Were your relationships built around food before Weight Loss Surgery? Did you consider your friends your best eating buddies, with each of your meetings at a restaurant or each other’s houses for a (unhealthy) meal? Weight loss surgery frees you up to explore other interests. Deepen your relationships with your friends as you walk together or meet at museums or other sights instead of depending on food to bring you together. And, if you do meet for a meal or snack, feel good knowing you can focus on the conversation as you eat slowly.
Confidence
Ultimately, weight loss surgery is for you, and you can benefit inside as you look better on the outside. You can gain confidence from your new looks, maybe as you fit into clothes you love, or you see a few muscles popping out. Confidence also comes from your achievements. If you can do something as hard as going through Weight Loss Surgery and sticking to all those healthy lifestyle changes, you can do pretty much anything you set your mind to.
Energy
Energy is a wonderful thing, but it may be in short supply when you are carrying around extra pounds. Lose a few, and you might feel your endurance explode. You can keep up with your kids, enjoy a day at the mall or beach, and go on vacations. Getting through the work day can be easier. Life is better all around when you have energy.
Bariatric surgery is a weight loss tool, and it is so much more. Use it properly, and you can make great gains in many areas of your life. Part 2 of the series – to be published soon – will discuss ways to get what you deserve – maximum gains from Weight Loss Surgery!

Reversibility
Each Weight Loss Surgery (WLS) type is designed to be permanent. However, the Adjustable Gastric Band (AGB) is fully reversible if necessary since the surgeon can remove the band from around your stomach. The Gastric Bypass (RNY) can be reversed, although the procedure is more complicated. The Gastric Sleeve (VSG) is absolutely irreversible since it involves removing most of your stomach from your body. Because of its reversibility, the AGB may be the choice for some younger patients or for those who do not want to take a dramatic step that affects their actual body parts.
Invasiveness and Recovery
The AGB is least invasive and has the shortest recovery time. It can even be an outpatient procedure, and you could get back to work in a week. This might be the only realistic option if you have very little sick leave available or you do not want to tell work colleagues about your surgery. The RNY and VSG are inpatient and require longer recovery times
Safety: Complications and Side Effects
Some risks of the AGB are band slippage or leakage, or erosion of the band. You could have vomiting or reflux if your band is displaced or filled too tight. Since the band can be removed, most of the complications can be stopped by emptying or removing the band.
The VSG has a higher rate of complications than the band. They can include leakage at the suture site. Nearly a quarter of RNY patients have complications of some sort, with more serious ones including staple line separation or leaks. You might opt for the AGB if you have a lower BMI without many health issues, or you might be more willing to take on RNY risks if your BMI is higher and you are more concerned about obesity-related issues such as diabetes.
The risk for nutritional deficiencies is higher with RNY and VSG. You can greatly lower your risk by taking the appropriate nutritional supplements, but you need to be prepared to take your bariatric vitamins for life. The effects of vitamin and mineral deficiencies can include osteoporosis, anemia, and nerve damage.
A Sweet Tooth and Dumping Syndrome
What are you looking to get out of your WLS? If all you need is help with portion control, AGB may be for you. It only helps with portion control, and it is up to you to make healthy food choices. On the other hand, the gastric bypass is best if you are looking for a tool to help you avoid sweets. That is because of the malabsorptive nature of RNY.
With RNY, your food passes through the lower part of your small intestine with less digestion than it would before surgery. Sugars that get to your small intestine can give you symptoms of dumping syndrome, including weakness, extreme fullness, diarrhea, nausea, and vomiting. Foods that cause dumping syndrome tend to be sugary and high-carb foods, such as candy, soft drinks, cakes, and pastries. Dairy and alcohol can also cause problems.
Most patients who get RNY have dumping syndrome at some point. Dumping syndrome can be beneficial because it gives you extra motivation to eat right – you know that if you grab that brownie, you may be headed for hours of misery! That can be a good reason to choose RNY. However, if the thought of dumping syndrome scares you, RNY is not for you!
There are many factors to consider as you choose your WLS type, but keep in mind that the decision is individual. You need to choose the WLS type that will work for you, even if it is not the one that worked for someone else. The decision is something to make after one or more serious conversations with your surgeon.

“ The wound is where the light enters you.”
- Rumi



When I work with pre and post-op bariatric surgery patients, I consistently go over this idea of being "full from within." Many people question, "what does that mean for me? What does that look like?"
My response is that for one to be truly full, we must first clear out the old toxicity, wounds, and hurtful schemas we've picked up throughout the years. How does one get over a hurt? There is not "getting over." You go through it. You have to feel it to heal it.
If you have underwent gastric sleeve, bypass, or balloon surgery and still feel like there is a missing piece- it is likely that there are some deeper psychological toxicities that need to be cleared. The first step to doing so is sitting still, sitting with the feelings, and it is in stillness that our heart finally starts to answer the questions our mind has failed to thus far.
Yet so many have been taught not to feel. That there must be an easier way- a shortcut. 1 in every 8 Americans is on some form of psychotropic medication. 1 In his book, Anatomy of an Epidemic, science journalist Robert Whitaker states that since 1987, the percentage of the population receiving federal disability payment for mental illness has tripled; among children under the age of 18, the percentage has grown by a factor of 35.1

While Whitaker recognized that in the short-term, these medications help people to feel better, he started to realize that over time- drugs make many patients sicker than they would have been if they had never been medicated. 1 He does not make the argument that all people should stop their meds. He believes in the utility of them, just more sparingly than they are currently utilized.

However, throughout my years in the practice of therapy- I have noticed a trend of moving people away from feeling. Crying is actually a symptom in the DSM-V. We have pathologized a human feeling! When psychiatrists and therapists witness a patient tearful too many times in session, their next conclusion is that something must be wrong and they must be medicated.

This frustrates me so much as a clinician and as a person who has done her share of work in her own personal therapy. When we are broken, we are broken open. Being broken is a starting point, not a symptom that something has gone awry.

It is at the point of our deepest pain and grief that we have the greatest opportunity for growth. I find myself telling patients over and over- “you can’t “get over” it, you must “go through” it.” Yet, so many of us have been indoctrinated to think that if we spend more than a day being sad, we must have depression, or if we feel nervous a little bit longer than we’d like to- we must have an anxiety disorder. We definitely “are Bipolar” if we have a mood swing.

We have been taught to not feel the yin, only the yang of our emotions. It’s societally acceptable to talk about how happy your weekend was, or how much fun you had on vacation- but watch the uncomfortable shifting in chairs that takes place when you open up about how you just haven’t felt like yourself lately.

In our world of quick fixes, where we can have a conference across the world, over a computer, communicate a message in two seconds via text, or post a picture that all of our family can see instantly- we also want instant relief for our suffering. Yet, suffering is part of the human condition. It is through experiencing our deepest sorrows, we are able to appreciate our greatest joys. But we must first be willing to sit in the muck.

"Out of the mud, grows the lotus." -Thich Nhat Hanh

Part and parcel of any addiction (food, drugs, alcohol, etc.) is that the addict is particularly uncomfortable with being uncomfortable. However, the cure is right there for the taking.

“So what does this look like in real life?” you ask. “How do I open the wound, bring in the light, and clear out the infection that started all of this in the first place?” You start with presence. You start with a still and open heart. You start with a spiritual vulnerability that allows you to be at peace with not knowing what will happen next. You sit broken open and wait for the light to enter over time.

The most important piece in all of this is being able to create a consistent forum where you hold the space. This could be a therapist’s office, it could be a weekly walk with a friend, a journal practice, or it could be as simple as a prayer every night.

You set the priority to hold the space and to sit in the muck. Maybe it starts with emotions that have no words? Maybe it starts with visceral, physical feelings, that you have to simply sit with for a while? Maybe you are lucky enough to immediately put in words where your wound all started and its just floating around in your thoughts, waiting to be articulated? Perhaps it starts with a behavior you tend to do all of the time that you know comes from a place of pain?

Case Study:

I had a client who continuously posted on social media sites. She had a constant need to feel recognized and admired. She knew there was something behind it and wanted to get to the bottom of where this was coming from.

Session over session, we sat with that need. We talked about what she wanted to get from each of those posts and why she was still “on E,” left with an empty psychological tank.

The short story of Narcissus goes that he disdained people who loved him. After Nemesis noticed this he lured him to a pool that cast his own reflection. Narcissus fell in love with this pool, not realizing it was merely an image. Unable to leave the beauty of his reflection, he lost his will to live. He stared at this reflection until he died. 59

Growing up, this client never quite got the love and admiration we all need from our parents. When we love something so much and don’t get that back- it is that unrequited love that leaves a narcissistic wound. It doesn’t necessarily always start with parents. It can be a formative romantic relationship, but it usually starts with parents.

When we are flying from couch to couch saying “look at me mommy I’m superman!” and our mom says “get off that couch now!” instead of “look at how strong and powerful you are,” we begin forming the wound. Unfortunately, without recognizing this- many people will go throughout their life trying to heal it through other people or other things instead of within themselves. (recall the wizard of oz’s moral of the story).

It was up to this client to stop the instinctual need to post and each time she had this inclination to look within for what she needed. Eventually, she developed a muscle for self validation, and the posting behavior stopped.

The lesson in this case study is to hopefully help guide you to your wound. If we have a food addiction and feel out of control, you can bet we have a wound. Instead of distracting through bad habits, addictions, unhealthy relationships, or external wants- it is time to finally create a place of presence to start the healing process.

Mind Meal: Sit in silence for at least 15 minutes. Visualize in your mind’s eye your heart with a bridge of white light to your head. What does it say? Where is the pain? Where is the wound? How might you start filling yourself up for good?

Want to learn more about how to be truly full from within. Check out Dr. Colleen's latest book aimed at helping one focus on why they eat vs. what they eat, and stop the "diet yo-yo" for good. You can also sign up for her free course : Full From Within, here.
1 Retrieved: June 2, 2017 https://www.madinamerica.com/author/rwhitaker/

The Right Mindset for Smart Decisions
It is no surprise that you are at your best when you are rested, relaxed, and confident. That goes for almost every aspect of your life, and it holds true for weight loss. Thinking clearly lets you “weigh” the consequences of the hard-boiled egg versus the French fries for a snack so you can see the benefits of choosing the egg for weight loss outweigh the benefits of choosing the fries for a few minutes of pleasure.
Self-confidence also lets you make the right choices. When you are confident, you know that you have the power to choose. You realize that are not a victim of circumstances, and you do not need to eat something just because it is available to you. You know that you have the power to say no to the things you should not eat, and the power to find the things you should.
Better Sleep, Better Choices
Sleep is not just a luxury to feel guilty about. Adequate sleep may be the missing key to your weight loss program. When you get enough sleep, you have lower levels of a hormone called ghrelin. Ghrelin makes you hungry, and less ghrelin helps keep hunger in check. Getting enough sleep also lowers carb and sugar cravings and gives you the strength to make rational decisions. Think protein and veggies, not potato chips and cookies.
Stress, Hormones, and Your Weight
In addition to your daily choices, there are behind-the-scenes factors that can cause weight gain when you are stressed. Hormones affect your metabolism and can cause weight gain when they are not balanced. Too much stress, for example, raises levels of a hormone called cortisol. Cortisol increases raise your hunger levels, which can lead to you overeat. It also affects your fat storage. You might gain more fat in your abdominal area, which is a health risk for diabetes, heart disease, and more.
Tips for Chilling Out
The first trick for relaxing is to get over your guilt. It is not only okay to kick back, but it is healthy. It may be surprisingly tough when you are out of practice, though. Here are some ideas for stepping back from your busy life and giving your mind a chance to recover for a healthier body.
Set aside 10 minutes for yourself every day. Meditate, take a bath, read, or do something else that is just for you. Get more sleep if you find yourself waking up tired or struggling to get through the day. Exercise most days. A quiet stroll on the beach or a hike may seem like out-of-reach dreams, but any exercise helps clear your mind. Restorative yoga, a cycling class, and home exercise DVDs all do the trick. Stretch. It loosens your muscles and gives you a chance to think through your day. Weight loss surgery success takes a lot of hard work, but there are some ways to get more bang for your buck without working harder. Take a chill pill, and you might find that the extra relaxation gives you the strength and stamina to lose more weight.