In the past four weeks, coronavirus disease 2019 (COVID-19) has dramatically expanded across the world with a major outbreak in Italy, my home country. As of March 21, 2020, the number of COVID-19 cases in Italy reached 53,578 with 4,825 total deaths.
To limit the COVID-19 diffusion, the Italian government decided to put the whole country on lockdown. Schools, universities, bars, hotels, and shops, except for those selling food, drugs, electronics, and warehouses, are closed, and the National Health System is trying to cope with the increasing number of patients needing ventilation support in intensive care units. In the last few days, other European countries and those in North America have adopted similar procedures.
On February 26, the Lancet published a review by Samantha Brooks and colleagues from King’s College in London of 24 studies on the psychological impact of quarantine. Most studies reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Children and adolescents seem particularly at risk of post-traumatic stress disorder, according to the review.
The authors recommended that “in situations where quarantine is considered necessary, officials should quarantine individuals for no longer than required, provide a clear rationale for quarantine and information about protocols, and ensure that sufficient supplies are provided. Appeals to altruism by reminding the public about the benefits of quarantine to wider society can be favorable.”
People with eating disorders have a high risk of relapsing or worsening the severity of their disorder, due to infection fears and the effect of the quarantine, and for the shortage of adequate psychological and psychiatric treatments due to the pandemic.
Infection fears tend to increase the feeling of not being in control that, in people with eating disorders, is often managed with an increase of dietary restrictions or other extreme weight control behaviors or with binge-eating episodes.
On the other hand, the quarantine, creating the separation and restriction of movement, can contribute to the maintenance of the eating disorder psychopathology through several mechanisms. For example:
- The limited possibility of walking and exercising can increase the fear of weight gain that is usually addressed, accentuating the dietary restriction.
- The exposure to high food supplies at home can be a potent trigger of binge-eating episodes, in those with this form of eating disorder.
- Staying at home can increase social isolation, a common feature associated with eating disorders, and create an important obstacle to improve interpersonal functioning: a key goal to reduce the overvaluation of shape and weight and their control. Moreover, this isolation prevents the person from addressing important expressions maintaining eating disorder psychopathology (i.e. avoidance of social eating and body exposure).
- If one does not live alone then spending increased time with others may bring additional strains and accentuate some expressions of the eating disorders.
In people with eating disorders and other co-occurring conditions, such as depression, anxiety, obsessive-compulsive disorder, post-traumatic disorder, and substance use disorder, the rumination, preoccupation, and anxiety triggered by the COVID-19 pandemic can accentuate the severity of the comorbid condition that often interacts negatively with the eating disorder psychopathology.
Finally, people underweight with an eating disorder are at higher risk of medical complications associated with malnutrition and, although we have no data, they might be at higher physical risk in the case of a SARS-CoV-2 infection.
There are no easy solutions to the problems above. However, it is possible to maintain the delivery of outpatient psychological treatments using online technology with some adaptations. Moreover, some clinical centers have already implemented virtual intensive outpatient services.
In the coming days, the training group of Enhanced Cognitive Behavior Therapy (CBT-E), an evidence-based treatment for all eating disorders, will release specific suggestions for delivering treatment online and helping patients with eating disorders cope with the anxiety associated with infection fears and the effect of quarantine.
However, certain patients with eating disorders do not respond to outpatient treatment or cannot be managed safely or practicably on an outpatient basis. Most of these patients have anorexia nervosa. In these cases, even in the COVID-19 period, intensive treatment is needed, but it should be adapted to include all the precautions to maintain the safety of both patients and healthcare personnel. This requires, for example, educating patients to minimize the risk (e.g., frequently washing their hands with soap and water for at least 20 seconds, avoiding touching their eyes, nose, or mouth with unwashed hands, maintaining several feet of distance between themselves and other patients), increasing cleaning efforts with disinfectants, restricting all visitors, suspending external therapeutic passes, using surgical masks, conducting all family sessions virtually, and maintaining the possibility that patients can connect online with significant others. Moreover, a specific protocol should be devised and implemented to address how to manage a patient tested positive for the coronavirus.
We all have to navigate this difficult period, but those with eating disorders have to cope with additional challenges related to the interaction of their psychopathology with the threats associated with the COVID-19 pandemic. This requires designing a new way to deliver treatments and to integrate standard strategies and procedures to address both the eating disorder and fears related to infection and social isolation.
Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet, 395(10227), 912-920. doi:10.1016/s0140-6736(20)30460-8