DOI: 10.1002/erv.2738 EDITORIAL COVID-19 and implications for eating disorders 1 | B ACKGROUND cardiovascular risk in binge eating disorder (BED)], and psychological stress due to confinement and the distress Coronavirus disease 2019 (COVID-19), emerged only a caused by uncertainty and a decrease in usual treatment few months ago in China, is now a global pandemic (see (Dalle Grave, 2020). We might anticipate that the severity Figures 1 and 2). The significant medical complications, of the ED symptomatology and carer burden will morbidity and the rapid international spread have led to increase, as it may not be possible to readily implement the swift adoption of important public health and political treatment according to evidence-based guidelines measures across the world. Most countries have chosen to (Peckmezian & Paxton, 2020; van den Berg et al., 2019). isolate positive cases and those they are in close contact Concerns about health and fitness during confine- with, and to limit social interactions to reduce transmis- ment might serve as a precipitating factor for the devel- sion. The overall consequences of COVID-19 on health, opment of an ED in vulnerable individuals. Further risk humanitarian and economic domains remain unknown. factors may also contribute to the likelihood of develop- As of April 15, 2020, the World Health Organization ing and ED, such as increased time spent using social- (WHO) reported 1,914,916 confirmed cases of infection media and the toxic influence of the objectification of the (with 123,010 deaths) extending to almost all countries thin ideal. Isolation and loneliness are common conse- across the globe (https://www.who.int/docs/default-source/ quences of AN and may be exaggerated by imposed quar- coronaviruse/situation-reports/20200415-sitrep-86-covid-19. antine. Problems with emotional regulation may trigger pdf?sfvrsn=c615ea20_2). ED symptoms (binge eating episodes and consequent Besides the consequences that this pandemic is hav- purging behaviors) (Manasse et al., 2018), while a conse- ing on public health (Onder, Rezza & Brusaferro, 2020), quence of increased external control may be reduced food it stands to have an important impact on mental health intake (Masheb, Dorflinger, Rolls, Mitchell, & (Fiorillo & Gorwood, 2020; Li, Wang, Xue, Zhao, & Grilo, 2016). Maladaptive emotional reactions from fam- Zhu, 2020; Torales et al., 2020), including the mental ily members under the stress of confinement may lead to state of patients who are suffering from the infection, aggression and/or fragmentation and splitting. family members who have lost loved ones due to this dis- In a pilot study at the ED Unit of the Department of ease, health professionals, the general population and Psychiatry, at the University Hospital of Bellvitge patients who had a mental health problem before the (Barcelona, Spain), we used a survey to monitor the pandemic, who have seen their symptoms increase impact of the first two weeks of confinement. A total of and/or have had their treatment disrupted (Duan & 32 patients [13 AN, 10 BN), 5 other specified feeding or Zhu, 2020; Kang et al., 2020; Xiang et al., 2020; Wang ED (OSFED) and 4 BED], with a mean age of 29.2 years et al., 2020). Several studies in Asia are reporting a higher old (range 16–49), most of them females (N = 29; 90.6%), prevalence of post-traumatic stress disorders (PTSD) after took part in this telephone survey. Most of the patients COVID-19 within the general population (Liu presented worries about increased uncertainties in their et al., 2020; Wang, Pan et al., 2020) and problems with lives, such as the risk of COVID-19 infection of them- anxiety and depression (Nguyen et al., 2020; Qiu et al., selves or their loved ones, the negative impact on their 2020; Cao et al., 2020; Wang, Di, Ye & Wei, 2020). work, and their treatment. Almost 38% (12 out of 32) reported impairments in their ED symptomatology and 56.2% (18 out of 32) reported additional anxiety symp- 2 | G E NER A L I M P L IC AT I O NS FOR toms, of whom, four patients noted that stress made it EATING DISORDERS difficult for them to control their grazing behavior and emotional eating. The effect of COVID-19 on eating disorder (ED) patients In the context of COVID-19, and in many health settings, remains unknown. These patients are at high physical only urgent visits and inpatient treatments settings for severe risk [for example, frailty in anorexia nervosa (AN), elec- ED cases are provided and—where possible—online treat- trolyte disturbances on bulimia nervosa (BN), and ments (instead of face-to-face) have been recommended. Eur Eat Disorders Rev. 2020;28:239–245. wileyonlinelibrary.com/journal/erv © 2020 John Wiley & Sons, Ltd and Eating Disorders Association 239 240 EDITORIAL F I G U R E 1 Distribution in Europe of number of cumulative infected cases due to COVID-19. Source: https://www.ecdc.europa.eu/en/ publications-data/download-todays-data-geographic-distribution-covid-19-cases-worldwide [Colour figure can be viewed at wileyonlinelibrary.com] F I G U R E 2 Distribution in Europe of number of cumulative deaths due to COVID-19. Source: https://www.ecdc.europa.eu/en/ publications-data/download-todays-data-geographic-distribution-covid-19-cases-worldwide [Colour figure can be viewed at wileyonlinelibrary.com] Restrictions include the closure of day hospitals and outpa- care providers and their support system (families and fri- tient facilities (e.g., Spain, Austria, USA and UK). However, ends) can be managed by individual or group methods of in many countries, there has been a rapid implementation telecommunication. The latter overcomes problems in con- of technological interventions in order to provide telemedi- fidentiality, as general, rather than individual, matters are cine counseling and online treatments (including family discussed. It allows for families to get support and reduces psychoeducation), as it is known that delays in starting the stigma they may feel. Online- and e-health measures for appropriate treatments for newly referred patients can lead ED patients have been developed and tested for over to worsening of symptomatology. This can allow ED 20 years worldwide and are available for implementation, patients to be treated in outpatient settings during the but more research is necessary (Anastasiadou et al., 2018; COVID-19 period. Also, communication between health Anderson et al., 2017; Barakat et al., 2019; Vollert EDITORIAL 241 et al., 2019; Zerwas et al., 2017). However, some aspects of of the neighborhood) were used to counteract loneliness. the assessment can be challenging to monitor without face- However, there was recognition among some patients to-face contact or some form of surrogate measure (Keshen that a tendency to put others' needs before their own neg- et al., 2020; McLean et al., 2019), especially in more extreme atively affected their ability to manage their own health. cases (e.g., severely underweight, non-suicidal self-injury, Strategies for self-care (e.g., relaxing distractions, includ- self-destructive patients). In these cases, hospitalisation can ing reading/television/photography) were discussed be necessary, for safeguarding the patient, their families among the patients as important when dealing with over- and professionals (Dalle Grave, 2020). whelming feelings associated with the sudden change in daily life. Carers did not report strategies for self-care other than the need to stay in communication with fam- 3 | EDS AN D FAMI LY CON CER NS ily/friends/neighbours/support groups. In the following section, we describe some of the chal- lenges and solutions to managing AN in the community 3.3 | Challenges of reduced professional in the context of COVID-19. This information comes support from an online multifamily chat group consisting of patients with a diagnosis of AN (n = 8) and their carers Fears around sudden reduction in contact with the in the UK. The group was anonymous, although patient/ patients' clinical teams were strongly expressed by the carer usernames were labelled with P and C, respectively. group. A lack of time for professionals to prepare patients The topic of the group focused on how they were coping and their families for a change in treatment was con- with the rapidly changing environment. Isolation was nected to increased feelings of panic and a sense of loss recognised by patients and carers as being negatively of control already felt with the escalation of COVID-19. associated with their mental health. The following Although some patients had access to online therapy, it themes emerged (see Table 1): was agreed that a lack of face-to-face accountability (i.e., lack of weigh-ins) would require increased self- management for patients. Patients and carers alike feared 3.1 | Connecting in isolation for a deterioration in AN recovery. There was an aware- ness among all that this period of uncertainty and insta- Handling the dramatic shift in communication during iso- bility would lead to increased reliance on ED thoughts lation prompted discussion on strategies to stay connected. and behaviours. In particular, how to manage reliance on AN patients were ambivalent about using social media activities that had the potential to be harmful to recovery and video calls. A negative consequence of video calls was (e.g., obsessive exercise and cooking) were discussed as the heightened awareness of bodily self, which prompted being critical for managing ED recovery at home. self-criticism that they perceived as harmful to their recov- ery. Some patients coped with this through modifying what was visible in their social media accounts and sought 3.4 | Balancing the needs of the ED comfort in viewing positive and recovery-focused peer- individual within the family support accounts. However, others believed it was safer not to use potentially triggering forms of communication. A need for routine and structure was highlighted as being Carers demonstrated a strong awareness around the issues crucial for patients as a way of coping with change and of isolation and increased communication challenges for preventing boredom, which often led to increased ED their loved ones with AN, as well as for themselves. How- preoccupations. Carers described their increased role in ever, they were resourceful in learning and sharing ideas the support and management of their loved one's recov- for remote communication methods. ery. They shared creative ideas such as creating meal plans at home and undertaking therapeutic activities (e.g., constructing restaurant challenges at home). “Stay 3.2 | Helping others versus helping at home” and self-isolation strategies were discussed as oneself resulting in increased burden for carers and changing family dynamics. Balancing the needs of the individuals Helping vulnerable others was highlighted as providing a with an ED (for stability) with flexibility to adjust for the sense of purpose for both patients and carers. Reaching needs of the whole family, particularly children, was seen out to friends and family as well as people in need of sup- as crucial but challenging. It was evidently difficult to port within the wider community (e.g., elderly members balance multiple care giving needs and work adjustment, 242 EDITORIAL TABLE 1 Results obtained from qualitative analysis around the different domains Themes Example quotes from AN patients (P) and carers (C) Connecting in isolation P1: “I don't like using the phone or video calling… I don't want to see myself, but I do want to see the person I'm talking to. The problem is that you don't get the same level of non-verbal communication, which I really need. It's going to be tough!” P2 “Social media can be unhelpful with different adverts popping up or comments from others. Which makes the isolation feel worse […] For that reason, I won't use social media to try and protect my mental health.” P4: “…you can filter it so only people who have positive or helpful content can be seen. I have found it great to stay connected.” C5: “i think social media can trigger many negative thoughts, but i try to concentrate and only look at the positive and helpful things there are. As a carer, its also easy to feel isolated and generally whilst others are empathetic, it's hard to truly understand. When I'm finding things hard, I connect with pages or those who I know can really help.” Helping others versus helping oneself P4 “I have also been offering support and listening ear to those who are feeling particularly anxious presently. This makes me feel a little more connected when able to talk through issues.” P5 “I feel like I've being very socially isolated for a long time […] and find it really fuels my depression. However, I've now joined a community project to help elderly people and those who are vulnerable” P6: “I know when I feel threatened (by C-19 for example!), I go into 'drive' mode and try to take on the world and do everything for everyone. Eating is usually the first casualty of this behaviour.” P2: “…I agree about the challenge of C-19 and feel that I may struggle a lot with the change and on these days won't push myself but try to be kind to myself by maybe watching a film.” Challenges of reduced professional P5: “I think I'm most worried if I can't have any appointments and miss weigh ins in which I support know for me can be helpful to not constantly be knowing my weight all the time but I think going from one extreme to another will be hard. Also carrying on challenges such as going to restaurants etc well will come to a stop… I'm worried how this will affect my recovery.” P6: “…My ED treatment has gone virtual. I completely understand and agree with it as a course of action, but it will certainly lack something both in terms of therapeutic content and physically with a lack of weigh ins etc. The level of accountability seems far lower, but in some ways the incentive to ensure health at such an unsettling time (and with kids to care for) weighs in the opposite direction. It's certainly a very unsettling time.” C2: “My daughter finds cooking a stress reliever but […] she will now have much more time on her hands at home and it will be a question of not allowing cooking to be the only thing she does as this in itself can become a compulsion and unhelpful.” Balancing the needs of the ED P3: “…[I]… like structure and routine whereas my husband and kids are the opposite which i individual within the family find challenging” P7: “I will try and plan some non-ED activities to do with my carer. Hopefully this isolation period will be a good bonding experience and a time during which I can challenge some ED behaviours within a safe environment and with support” C2: “…definitely a good idea to plan in non-ED activities in the weeks ahead - there is a lot of unknown and I think most patients with an ED find this extremely challenging at the best of times.” C8: “Thanks [patient] for the reminder that our daughter may appreciate more help than usual in planning activities to keep her busy in these chaotic times.” whether working from home, sudden lack of employ- et al., 2018; Raven, Wurie, & Witter, 2018). A recent ment, or increased workload. study in China in health care workers (nurses, physi- cians) who were exposed to COVID-19 showed that 4 | T H E R A P I S T AN D S T A F F many of them were suffering from distress, depression, WORKING I N ED anxiety and insomnia (Lai et al., 2020). Symptom sever- ity was more pronounced in nurses, women and front- Pandemics pose a double care burden on health care line health care workers (Lai et al., 2020). Quarantine professionals (Aoun, Joundi, & El Gerges, 2019; Li can lead to post-traumatic stress symptoms, anger, EDITORIAL 243 confusion, and suicide. The severity of these symptoms ACKNOWLEDGEMENTS increases with the duration of the quarantine and can We thank CERCA Programme/ Generalitat de Catalunya persist over many years (Brooks et al., 2020). Health care for institutional support. This work was partially professionals have concerns about becoming infected supported by Instituto de Salud Carlos III (PI17/01167 themselves, causing their units to be understaffed and SLT006/17/00246). CIBEROobn and CIBERSAM are and/or infecting their loved ones (Brooks et al., 2020). both initiatives of ISCIII Spain. We thank Dr. Monica Self-care, teamwork, networking and cooperation Leslie, Isabel Sánchez, Isabel Baenas, Nadine Riesco, between health care professionals is crucial. The follow- Paolo PP Machado, Jon Arcelus, Walter Bouman, Jue ing factors reduced stress: (i) communication with col- Chen, Nathalie T. Godart, Anna Keski-Rahkonen, Youl- leagues from own/other centers, (ii) team supervision, Ri Kim, Anders Hakansson, Tetyana Ilnytska, Jan (iii) appreciation from clients/superiors/society and Rosenvinge, Daniel Stein, Mikhail F. Borisenkov, Sergey (iv) awareness of doing something meaningful (Binder Popov, Ferenc Túry, Brigita Bax and Robert van Voren, et al., 2020). Finally, in this critical situation, where fears for their translations and suggestions in the rec- and uncertainty are involved, it is also important for ommended material. health care professionals to disconnect from work and to take care of themselves. Self-care includes structuring the Fernando Fernández-Aranda1,2,3 day, developing a connected healthy lifestyle and Miquel Casas4,5,6 accessing professional help when necessary Laurence Claes7,8 (Counselling & Development Centre, 2020; Greenberg, Danielle Clark Bryan9 Docherty, Gnanapragasam, & Wessely, 2020). Angela Favaro10 Roser Granero2,11 Carlota Gudiol3,12,13 5 | FUTURE CH ALLEN G ES AND Susana Jiménez-Murcia1,2,3 POT ENTIAL T H ERAPY CH AN G E S Andreas Karwautz14 Daniel Le Grange15 The COVID-19 pandemic will have important clinical Jose M. Menchón1,3,5 repercussions for mental health and may produce sub- Kate Tchanturia9 stantial changes in the usual diagnostic and therapeu- Janet Treasure9 tic strategies. It highlights the core need for connection 1 and the pain of loneliness which are often central but Department of Psychiatry, University Hospital of Bellvitge- sometimes forgotten symptoms of people with pre- IDIBELL, Barcelona, Spain 2 existing mental health problems. Patients, such as CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), those with EDs, who often have poor insight into their Instituto Salud Carlos III, Madrid, Spain 3 illness and find social–emotional communication diffi- Department of Clinical Sciences, School of Medicine and cult, may delay help-seeking. Likewise, this fact will Health Sciences, University of Barcelona, Barcelona, Spain 4 become even more relevant in cases in which there is, Departamento de Psiquiatría y Medicina Legal, in addition to the ED, dual disorders and/or comorbid- Universitat Autònoma de Barcelona, Barcelona, Spain 5 ity with other pathologies, which complicates the pro- CIBER Salud Mental (CIBERSAM), Instituto Salud gression and severity of the main ED (see some Carlos III, Madrid, Spain 6 recommendations in Table S1, as supplementary infor- Vall d'hebron Institut de Recerca (VHIR), Barcelona, mation online, and its translation into different Spain 7 languages). Faculty of Psychology and Educational Sciences, Necessity, the mother of invention, may again be University of Leuven, Leuven, Belgium 8 proved to lead to a step change in our care models. Faculty of Medicine and Health Sciences, University of Thus, the current enforced immersion in new online Antwerp, Antwerp, Belgium 9 therapeutic and management strategies may lead to King's College London, Department of Psychological more widespread adoption of more efficient and Medicine, Institute of Psychiatry, Psychology and effective, mixed methods of connection. Because we Neuroscience (IoPPN), London, UK 10 are forced to overcome our own fear of novelty and Department of Neuroscience, University of Padua and uncertainty, we may find we have more choice and Neuroscience Center (PNC), University of Padua, Padua, flexibility with a more personalized treatment Italy 11 palette as to what and how might work best Department of Psychobiology and Methodology, for whom. 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