Anorexia. The sticky animal that insists on not leaving

He was losing weight from week to week, he had a lot of tension drops and muscle cramps, he wanted to go back to eating and he couldn’t. “I wanted to say ‘no’ to the disease, say ‘no’ to the voice in my head that was telling me not to eat, but my behavior remained the same or got worse. I ate less and less, but I couldn’t sit still. Each day was worse than the one before. I was dying.” Joana ended up talking to the psychiatrist who accompanied her and asked her to be hospitalized.

In September last year, she was welcomed at the Elysio de Moura Residence, in the Valongo Pole of the University Hospital Center of São João (Hospital de São João). Inaugurated in 2015, the residence is intended for patients with eating disorders, over 18 years old. Anorexia is the most frequent – more than 90% of residents have the disease.

TOO MANY SICK PEOPLE TO FEW BEDS

Hospitalizations for anorexia are, nowadays, one of the main concerns of physicians, psychologists and other health professionals working in the field. Data sent by the Ministry of Health to Expresso show that hospitalization episodes have tripled in the last five years, from 66 in 2018 to 191 in 2022. This increase has consequences on the ground, with specialists often being forced to making decisions as difficult as asking a patient to stay at home waiting for a vacancy, because hospital beds are few and full.

At Hospital de Santa Maria, part of the Centro Hospitalar Universitário Lisboa Norte, it has become customary to have more than ten girls waiting to be admitted, says Jennifer Santos, a psychiatrist linked to eating disorders at the hospital. “There is an increase in serious cases requiring hospitalization and the time we have to wait for an available bed is increasing.” In extreme situations, patients can be temporarily hospitalized in hospitals in their areas of residence, but many wait at home. When they are finally hospitalized, they are even more thin, fragile and malnourished, remaining in institutions for long periods, which makes it difficult to release beds. “It’s a vicious cycle.” Waiting also affects the course of the disease, making recovery difficult.

In the child psychiatry internment at the Hospital Dona Estefânia, in the Centro Hospitalar Lisboa Central, there are still free beds, but they are increasingly being used by people with eating disorders, especially anorexia. Currently, they occupy almost half of the 16 beds in the service, when before there were a maximum of four. “We noticed a very large increase in admissions. To suddenly have half the beds occupied by patients with eating disorders is a new experience for us. It has been complicated”, says Margarida Marques, child psychiatrist and unit coordinator.

ADMISSIONS HAVE TRIPLED IN THE LAST FIVE YEARS
Number of hospitalizations with a history of anorexia as the main or additional diagnosis

SOURCE: Central Administration of the Health System (ACSS), of the Ministry of Health

For some of these recent patients, hospitalization was the first contact they had with specialized health care: they arrived spontaneously, in a serious condition, without having been referred by other health professionals, without a diagnosis of anorexia and without any kind of help doctor. The hospitalization was the “inaugural episode, which somehow reflects a failure in the diagnosis, in the outpatient clinic and in access to health care in general”.

“Accessibility to the SNS is one of the main flaws in the treatment of these patients at the moment”, agrees Manuel Gonçalves Pinho, psychiatrist and co-author of a recent study on hospitalizations for anorexia in Portugal. He explains that the lack of human resources and the workload faced by health professionals prevent consultations on a regular basis. There are patients who have to wait “a year and a half” to be treated.

Others have to travel distances of hundreds of kilometers by bus to attend appointments. “People who live outside major urban centers, such as Lisbon, Porto or Coimbra, where accessibility is easy, end up being more vulnerable.” For the psychiatrist, “it’s no use having fantastic treatment structures if we’re just dealing with the remnants of what was badly done in the past.”

At the Centro Hospitalar e Universitário de Coimbra, admissions have almost tripled in the last three years, going from an average of three to four per year to the current 12, points out Tânia Silva, a psychiatrist at the hospital.

Patrícia Nunes, a psychiatrist at the Hospital de São João and coordinator of the Elysio de Moura Residence, also reports an increase, in 2021, in unscheduled hospitalizations, that is, through the emergency room, which was “very rare”. More people were also admitted after just one or two visits to the hospital. “The level of severity was such that they had to be hospitalized right away”, even though hospitalization is, as a rule, a measure of last resort – most people are followed up in outpatient consultations. The pandemic is presented as one of the possible justifications for the increase in these situations, due to less access to health care, breaking routines at school or at work, and isolation. In the hospital’s psychiatry service, appointments were made by telephone and even the residence in Valongo was closed for some time. “We were very limited”, acknowledges the psychiatrist. For Margarida Marques, the problem is older than that.

“DISNESS IMPRESSES US IN A CAGE THAT LOOKS GOLDEN”

Joana has a rosary around her neck. On the bedside table beside the bed is an edition of the Bible. The first historical references to anorexia concern saints such as Catherine of Siena, in Italy, and Alexandrina de Balasar, in Portugal. They fasted radically and for a long time, believing that this was the only way they could truly approach God.

Even before being hospitalized for the first time, Joana had followed some diets and physical exercises to lose weight, although she had a “normal weight”. “The physical image was already important to me at that time. I thought I could lose some weight and look prettier. I also wanted to be a better person, a better student, a better daughter and better control what happened to me and what the people around me did.”

At the age of 16, he started an even more restrictive diet and stopped having almost all meals of the day, with the exception of dinner, which he could not avoid due to the presence of his parents. For lunch, she ate only grated carrots, lettuce and a piece of fruit. “Setting up an eating plan in my head and sticking to it was a win.”

As he got sick, that need for control and perfection grew until it became unbearable. “At first, it seemed like everything was working out and that I had found paradise.” But the situation got worse, to the point where it was difficult for him to get up from a chair or bed without having a drop in tension.