"I noticed that the family was saying goodbye to me, until I realized that I would be admitted the next day."
Eating disorders are the mental illnesses with the highest mortality rate, but 70% can be cured with perseverance, time and treatment in a specialized unit.
BarcelonaEating disorders (ED) have doubled among Catalan teenagers since the lockdown due to the Covid pandemic. Diagnoses have increased especially among girls between 10 and 19 years old, regardless of their socioeconomic level and family situation. However, anorexia, bulimia and binge eating disorders are not only the domain of children and adolescents. The Catalan health survey indicates that there are currently more than 85,000 people who suffer from some type of ED. All these data were revealed last October, within the framework of a Sant Pau Talks in which, through several professionals from the hospital's ED unit and the witnesses of some of its former patients, the causes and personal and family effects of this group of mental illnesses were addressed, as well as the phases of their journey and the importance of this cure.
One of the witnesses was Maria Crivillé, 19, who is currently studying social work. Maria remembers perfectly the starting point of bulimia. "When I was 12, my brothers and I changed schools and I immediately felt like I didn't fit in," she explains. Maria began to suffer bullying. "I didn't pay any attention to the first 'Maria, you're fat', I thought it would all go away, but soon there were misdeeds like having my things taken from my pencil case," she adds. Everything began to get worse, to the point that she began not wanting to go to school. At that time, no one knew what she was going through. She began to associate the fact of not fitting in with comments about her body, and problems with food soon began to appear. "I thought that if I managed to lose weight, the problem would disappear," she says. She began not eating (restrictive anorexia), but her body did not tolerate it. "I was hungry, my body needed food, and I started throwing everything up and developing bulimia," she said.
Multifactorial origin
Eating disorders are a group of mental health disorders with a multifactorial origin, in which genetic, psychological and sociocultural factors are involved. Eduard Serrano, a doctor in psychology and coordinator of the Eating Disorders Unit at the San Juan de Dios Hospital, points out that genetics would explain around 70% of cases, especially in anorexia nervosa. However, "this does not mean that if the mother has suffered from anorexia, the son or daughter will develop the same disorder at all costs." There are also psychological factors "of the individual's personality, with traits related to self-demand, obsessiveness, low self-esteem or perfectionism."
Finally, Serrano continues, there is a set of sociocultural factors, "such as aesthetic models or beauty ideals based on extreme thinness and the influence of fashion, the media and, lately and especially in adolescents, also social networks, especially Instagram and Tik, aesthetic and encourage comparisons between bodies, with the aggravation that in many cases the images are not real, but retouched, which makes it more difficult to accept one's own body". Making a metaphor, Serrano points out, genetic factors "provide the gun", environmental factors "load it" and stressful life events (the separation of parents, the loss of a friend, a breakup or, as in Maria's case, bullying at school).
For the coordinator of the TCA unit at San Juan de Dios, the most important thing is to understand that an TCA "is not a choice that the person makes, but an illness." There are symptoms, he continues, that are shared with the population at risk, such as the fact that, in Barcelona, 63% of girls and 55% of boys do not like each other, but then the sum of factors makes this TCA crystallize. "The person does not want to be sick, perhaps they have modified their diet to look better or try to fit in and it has gotten out of control," says Serrano, who warns that, despite being illnesses of mental origin, they have many physical consequences, such as malnutrition and damage to vital organs. In this sense, he emphasizes, there is a better prognosis "when an early diagnosis is made, when specialized treatment is started immediately and when the family is also involved in it from the beginning."
Denial of the problem
At home, Maria had never said anything about what was happening to her, but her character changed radically. The physical changes also began to become evident. "I started an exam period and I didn't have the ability to perform. I was physically exhausted," she explains. One day at school everything came out and she explained it to a teacher, but in a superficial way. "I told her that I wasn't eating and that, from time to time, I vomited," she remembers. She also asked her not to tell her parents, that she would tell them herself. "That same afternoon I told my parents; I explained to them that I didn't have a good relationship with food, but not why," she clarifies.
A few days later, Maria and her mother, Anna, went shopping. When Anna saw her daughter without clothes in the fitting room - something that hadn't happened for a long time - she realized everything. Shortly after, Anna took her daughter to her first medical visit, where she was diagnosed with bulimia. "I remember telling the doctor no, that he was wrong. That day I didn't want to listen to him. I didn't want to know what bulimia was. I was very angry with my mother for taking me to the doctor and with that doctor, because he said he was making things up," she says then. "María was not aware of being sick, she had never heard of eating disorders and she didn't know what anorexia and bulimia were. "I didn't give it the importance I should have given it," she admits now.
Serrano confirms that the patient is not aware of the problem "and, therefore, has no motivation for treatment or change." The adolescent is brought by the family. "He or she does not see problems in the core symptoms, he or she thinks he or she is in control and has changed his or her diet for health, he or she is not aware of the seriousness of malnutrition," he adds. The professionals who are dedicated to it already know that it is a characteristic of the disorder and they work on it with the family. With the patient, he or she explains, "some other symptom must be addressed, such as the sadness, irritability, sleeping difficulties or problems with the family, to establish a bond, achieve a therapeutic alliance and start a process of change."
Cheating on the family
Maria remembers how one day her mother told her that they would visit the hospital on Sunday of that week. The day before, a family meal was organised at home. "I could tell that the family was saying goodbye to me in a certain way, but they couldn't say goodbye, of course. My puppets hugged me and I didn't understand anything. Until I deduced that the next day they would admit me somewhere... And so it was. I spent three months without getting out of bed. "People think that an eating disorder only means that the person stops eating, but it implies much more: I had many problems at an organic level," she says. The tests showed this, to the surprise of her father, Àlex Crivillé, who today recognizes that, up to that moment, María had managed to fool them all.
Her father remembers that she ate, but in a very gluttonous way. Afterwards she didn't eat or she didn't finish the food and, in the afternoons, she ate in a very compulsive way and then disappeared. "She put on music in the bathroom and when we knocked on the door and called her, she didn't answer," It was very difficult for Alex and Anna to detect Maria's bulimia. "She looked fine," he says. "She did look a bit pale, but I remember that before she was admitted we were playing ping-pong, and I was very surprised when, with the results of the analysis in hand, they told us that she had to be admitted urgently."
Maria explained to them that she had a monster in her head that told her what to do, like how to vomit, and that it was superior to her. She says that she associated her illness with the image of Barbie – pink, tall and thin – which represented her ideal of beauty. The young woman also points out that, when the illness took hold of her so much, lying always came first. "Now I think and believe that there came a point where I believed my own lies," she says. During her stay at the day centre, when she returned on Mondays after spending the weekend at home, she defended that she had taken it very well. "The reality was that I had been doing what my head had told me all the time," she adds.
The coordinator of the TCA unit at San Juan de Dios Hospital, Eduard Serrano, explains that the family is very important as a prevention agent. "What they should do, above all, is to boost their children's self-esteem. They should separate it from physical appearance and focus on personality, values, skills and academic and sporting milestones..." he explains, as well as promoting this positive body self-image and being role models, which means "not commenting on bodies, not commenting on bodies, not commenting on bodies. Healthy lifestyle habits and healthy eating habits should also be promoted, and if parents, for example, have to go on a diet, "focus on health and not on aesthetics." However, derogatory comments about their own bodies should be avoided, which influences girls in particular. Finally, the psychologist recommends, "they should be helped to develop a critical sense of social networks and the wonderful and unreal life that they help spread, and encourage communication at home so that children and adolescents have the confidence and security to explain what worries them and thus, if necessary, be able to intervene."
Outpatient treatment, the majority option
Just after entering the hospital's TCA unit, the doctor asked Maria if she didn't feel like crying, and she replied that she wouldn't cry "over this nonsense." At that time, Maria "was a 13-year-old girl angry because she had been locked in a room without understanding why." During that first stay, which lasted three months, "she was lucky," she says, that her parents came to see her a couple of times a day. Afterwards she continued the treatment at the day centre, where she spent the day and had the main meals and individual and group therapies. In the afternoon she returned home to spend the night. "I wasn't quite well, I didn't finish the treatment, so they had to admit me again," she remembers.
That stay was totally different, with colleagues who were going through the same thing as her. "I saw very serious cases, but for me mine wasn't. You become aware of it when the years go by and you remember the whole process," she points out. The first few days she didn't see her parents, and then, when she started to see them very gradually, Covid arrived and she was confined there. She couldn't see her family until almost two months later. "I never thought I could die from the eating disorder," she admits now, almost five years later and already recovered.
Maria's case, who initially had to be admitted to the hospital, is not the usual one. What determines the treatment plan is the severity of the disorder. The ideal, says Eduard Serrano, is to start on an outpatient basis, which is the majority option. However, he stresses, there are some objectives: "In the case of anorexia, restore a healthy weight and nutritional status. In the case of bulimia and binge eating, restore the eating behavior pattern and nutritional status." The coordinator of the TCA unit at San Juan de Dios explains that the focus must also be on the consequences of these disorders, "that is why the team that works in the unit is multidisciplinary: psychology, psychiatry, nursing, social work, social educator, teaching..."
of greater intensity, such as the day hospital (where the patient stays between one and two months) or, for the most serious cases, hospital admission (with a stay of between two and three weeks). Finally, the unit also has a relapse prevention program, "since it is a disease in which, once the diet and certain medical parameters have been restored and normalized, steps can be taken back in the face of stress factors." In this sense, concludes its coordinator, "the patient must continue to be visited for at least a year to ensure that he or she has all the tools to avoid a relapse."
Once they reach the age of majority, adolescents affected by an eating disorder arrive at the TCA unit at the Hospital de Sant Pau. A little earlier, says Dr. Mar Carceller, head of the TCA unit at the hospital's psychiatry service, "from the children's eating disorder units they are referred so that they can be seen and, later, if necessary, the transfer is made." The transition, she explains, is a process that causes anxiety for the patient's family, since in this new scenario it is worked on from the autonomy and voluntary decision of the patient, while in the pediatric units it is the parents who decide whether the patient undergoes the treatment or not. "We cannot do this, because they are already adults and, therefore, they decide, and we have to work with the patient's motivation to want to undergo the treatment," says Carceller. Despite the initial insecurity that this arouses in parents, the psychiatrist highlights that, "when it is the patient themselves who takes the reins of their treatment, the results are much better and more sustained over time." In Carceller's opinion, the fact of sharing therapy with adults is a gain, "since they see how an eating disorder can progress and how it can affect life at various stages, something that does not happen when you are younger because you do not have long-term plans or feel out how it will affect you as a family, in your studies or in your life as a couple." Being part of a heterogeneous group, in this sense, can also "become a motivating factor when it comes to undergoing treatment."