Eating Disorders and Mental Health in the COVID Era
Part 1: Tracking trends in the pandemic: eating disorders vs. other disorders.
Posted Jun 30, 2020
COVID-19 has changed a lot of things, including health and illness beyond the virus. I've been struck by the difference, in reports on the effects of pandemic-era life, between eating disorders and other conditions. Some people with anxiety and depression, the two most common mental illnesses, are finding life harder than usual. That isn't surprising: There are some big, obvious things that might be exacerbating anxiety and depression at the moment, especially if you’re vulnerable or disadvantaged in other ways (Frank et al., 2020 preprint). COVID is inflaming all the human inequalities that already existed.
Overall, the trends are complicated, and most of the research studies are currently only available as preprints that haven't yet gone through peer review. (Some in the higher-profile areas of vaccine/treatment development have been subject to high-profile retractions.) But in general populations across the world, mental health seems to have worsened in the early days of the pandemic (Jia et al., 2020 preprint; Jung et al., 2020 preprint; Newby et al., 2020 preprint). Then, at least in data where longer-term trends are visible, levels of deterioration seem to have stabilized. A UK study collecting weekly data on trajectories of anxiety and depression since early March found small improvements in depression and anxiety during the first two months of lockdown (Fancourt et al., 2020 preprint), with people with pre-existing anxiety or depression showing better stabilization than others. The authors comment, "It is possible that individuals with diagnosed mental health conditions experienced greater increases in anxiety in the lead-up to lockdown coming in, and then subsequently had greater recoveries."
"Lockdown relief" has been taking many forms, in people with and without existing mental health problems. For people with such problems, the relief might manifest as freedom from FOMO or liberation from the pressure to be always traveling, always proving one's productivity, never sleeping enough. It might be more like the weight that is lifted when the awful thing has happened: The anxiety is over, because the disaster is here, and I am dealing with it. The relief might also be about how this type of disaster puts others in perspective, and encourages gratitude for the things that are still OK. It might have something to do with seeing other people experiencing something a little like what you've long been suffering with (e.g. OCD around personal hygiene), and so feeling less alone and less inclined to self-judgment. The lower exacerbation than one might expect amongst those already affected may be thanks to the fact that if you know you have a problem of this kind, you probably already have at least some tools for dealing with it, and/or are more likely to know when you need help. (Laura Bradley in The Daily Beast and Farrah Jarral in The Guardian are good on these factors.)
So a trend that would have been unsurprising—people with existing anxiety or depression doing increasingly badly relative to the general population—seems not to have materialized. Given the scale of the pandemic, the general population has also been displaying a more encouraging response than we might have expected. (Benedict Cary reports on human resilience to natural disasters in The New York Times.)
So where do eating disorders fit into all this? I'm not aware of any large-scale survey on pandemic-era eating disorders, but the evidence we do have suggests a bleaker picture. Some studies focus on eating and exercise habits, some including observations on the possible mechanisms by which lockdown may be changing things, e.g. boredom and/or stress leading to comfort eating (e.g. Di Renzo et al., 2020). Early position pieces published by eating disorder researchers have tended to enumerate ways in which the pandemic and the lockdown are likely to exacerbate eating disorder-related problems. Along with legitimised hoarding (with the added complication that for many people with highly regimented eating habits, even having to switch brands feels difficult) and conducive conditions for binge-eating or emotional eating, there's the physical vulnerability that malnutrition and other facets of eating disorders intensify, the increased channeling of social contact through social media, and the particularly anorexic pathology of wearing yourself out trying to help everyone but yourself (Fernández-Aranda et al., 2020; Touyz et al., 2020). Anecdotal reports of difficulties of all these types have accumulated (see e.g. Emma Goldberg’s account in the NYT, Helen Coffey in the Independent, and June Alexander in The Diary Healer).
If we think back over the timeline of the pandemic, there's nothing surprising in reports of difficulties with eating disorders intensifying since March. In the beginning, there was a sudden uncertainty about food availability. This may have reassured some people that their food anxieties were at last universal, but for many people, it probably just intensified the swirling worries around food by adding in another, objectively present source of anxiety: Can I get the foods I know I can eat? The more restricted you in your food choices and habits, the less robust you are to any change, and this was not a small change.
Then there was the flipside and exacerbator of food shortages: hoarding. This a classic disordered habit centered on needing to know that you have the right things to eat, now socially validated. This was an interesting time: A very brief moment when people were hoarding maximally energy-dense foods because they were worried they wouldn't have enough to eat.
Sometime in late March I remember being surprised—a finely balanced mixture of annoyance, pleasure, and curiosity—to find that all the whole milk was gone from the supermarket, but there was quite a lot of semi-skimmed left. Had the country finally woken up to the folly that is straining most of the goodness out of something that was never even very energy-dense in the first place? Might everyone realise how much more economical, better tasting, and generally better for you full-fat milk is than the watery alternatives and never look back?
Of course, it didn't turn out like that. Soon production and transport restabilized, and the shelves reverted back to the same old proportions of red, green, and blue. The brief respite from the standard aspirations—to minimize the nutritional value of all the food we create and consume at great planetary and financial cost—ended. Prior priorities re-established themselves, with a vengeance: The overriding dietary preoccupation in Western lockdown after the first few weeks has been with eating too much. A little bit of pleasant homeliness has clung on in the form of sourdough cultures and other forms of retro domesticity, but overall the unfamiliar "how can I make sure I eat enough?" capitulated rapidly to the familiar, "how can I make sure I don't eat too much?" amplified by stay-at-home orders. And this amplification is hard for anyone whose mental landscape is already torn between these two opposing forces.
The same pattern has played out with physical activity. "How can I make myself and my family safe?" soon reverted to "how can I waste as much energy as possible?" again magnified by the lockdown. It’s remarkable just how ubiquitous recommendations have been to solve all pandemic-era problems with more exercise, from worries about weight gain to procrastination. This is particularly unhelpful for people whose eating disorder involves an exercise addiction, as many do.
From what we can tell so far, then, something different seems to be going on with eating disorders versus other comparable health conditions. In the second part of this post, I’ll ask where next: What do these divergent trends suggest for the structures of mental health and illness in life after lockdown?
Di Renzo, L., Gualtieri, P., Pivari, F., Soldati, L., Attinà, A., Cinelli, G., ... & Esposito, E. (2020). Eating habits and lifestyle changes during COVID-19 lockdown: An Italian survey. Journal of Translational Medicine, 18(1), 1-15. Open-access full text here.
Fancourt, D., Steptoe, A., & Bu, F. (2020). Trajectories of depression and anxiety during enforced isolation due to COVID-19: Longitudinal analyses of 59,318 adults in the UK with and without diagnosed mental illness. medRxiv open-access repository here.
Fernández‐Aranda, F., Casas, M., Claes, L., Bryan, D. C., Favaro, A., Granero, R., ... & Menchón, J. M. (2020). COVID‐19 and implications for eating disorders. European Eating Disorders Review, 28(3), 239. Open-access full text here.
Jia, R., Ayling, K., Chalder, T., Massey, A., Broadbent, E., Coupland, C., & Vedhara, K. (2020). Mental health in the UK during the COVID-19 pandemic: Early observations. medRxiv open-access preprint repository here.
Jung, S., Kneer, J., & Krueger, T. (2020). The German COVID-19 survey on mental health: Primary results. medRxiv open-access preprint repository here.
Newby, J., O'Moore, K., Tang, S., Christensen, H., & Faasse, K. (2020). Acute mental health responses during the COVID-19 pandemic in Australia. medRxiv open-access preprint repository here.
Touyz, S., Lacey, H., & Hay, P. (2020). Eating disorders in the time of COVID-19. Journal of Eating Disorders, 8(19). Open-access full text here.