Received: 16 June 2020 Accepted: 18 June 2020 DOI: 10.1002/erv.2771 SPECIAL ISSUE COVID-19 and eating disorders during confinement: Analysis of factors associated with resilience and aggravation of symptoms Isabel Baenas1,2 | Elena Caravaca-Sanz1 | Roser Granero2,3 | 1,2 1,2 1,2 Isabel Sánchez | Nadine Riesco | Giulia Testa | 1,2 4 Cristina Vintró-Alcaraz | Janet Treasure | Susana Jiménez-Murcia1,2,5 | 1,2,5 Fernando Fernández-Aranda 1 Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain 2 Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain 3 Department of Psychobiology and Methodology, Autonomous University of Barcelona, Barcelona, Spain 4 King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK 5 Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain Correspondence Fernando Fernández-Aranda, Eating Abstract Disorders Unit, Department of Psychiatry, Objectives: To assess the level of deterioration in functioning of ED patients dur- University Hospital of Bellvitge-IDIBELL ing confinement, due to COVID-19, and examine potential contributing factors and CIBEROBN, Feixa Llarga s/n 08907 Hospitalet del Llobregat, Barcelona, (coping strategies, anxiety-depressive symptomatology and personality traits). Spain. Methods: A total of 74 ED patients in treatment before the COVID-19 out- Email: ffernandez@bellvitgehospital.cat break, contributed to this study. Baseline pre-treatment evaluation included Funding information the SCL-90R, TCI-R, EDI-2 and Y-FAS 2.0 questionnaires for general psycho- Centro de Investigación Biomédica en pathology, personality and ED severity indexes. ED symptoms, coping strate- Red-Fisiopatología de la Obesidad y Nutrición; Generalitat de Catalunya - gies, socio-demographic data and COVID-19 concerns were collected by PERIS, Grant/Award Number: clinicians through a semi-structured telephone survey during lockdown. SLT006/17/00246; Instituto de Salud Results: A deterioration in ED symptoms and general psychopathology (anxiety Carlos III, Grant/Award Number: PI17/01167; Ministerio de Educación, and depression), during lockdown, was associated with low self-directedness. Higher Cultura y Deporte (Spain)- FPU, Grant/ ED symptomatology during confinement was associated with less-adaptive coping Award Number: FPU16/01453; Post- strategies to deal with lockdown situation leading to an increase in weight. Residency Grant from Research Committee of the University Hospital of Conclusions: These specific vulnerability factors to further confinement or stressful Bellvitge (HUB; Barcelona, Spain) situations may help design personalized preventive and therapeutic approaches. 2019-2020 KEYWORDS confinement, COVID-19, eating disorders, mental health, personality 1 | INTRODUCTION Health Organization (WHO) on 31rst January 2020 (WHO, 2020). The pandemic has led to a break with ordi- The COVID-19 disease has caused major disruptions across nary routines and social contact for most of the world's pop- the world, after being declared as a pandemic by the World ulation. People with prior mental health disorders have Eur Eat Disorders Rev. 2020;1–9. wileyonlinelibrary.com/journal/erv © 2020 Eating Disorders Association and John Wiley & Sons Ltd 1 2 BAENAS ET AL. been found to relapse during the pandemic (González- Sanguino et al., 2020; Moccia et al., 2020; Ozamiz- Highlights Etxebarria, Dosil-Santamaria, Picaza-Gorrochategui, & Idoiaga-Mondragon, 2020; Rajkumar, 2020; Temorshuizen • For the first time, associated factors were et al., 2020; Weissman et al., 2020). Hao et al. (2020) found assessed as predictors of ED-state during higher levels of concerns about their physical health, anger, COVID-19 lockdown. anxiety, depression, impulsivity and intense suicidal idea- • Self-directedness was associated with an aggra- tion stress in psychiatric patients in comparison with vation of ED and general psychopathology healthy controls during COVID-19 confinement. Moreover, during confinement. evidence these effects may be long-lasting (Shah • ED worsening was linked to less-adaptive cop- et al., 2020). ing strategies in confinement situation with a Patients with eating disorders (ED) and/or obesity rep- resulting weight increase. resent a vulnerable group (Cornejo-Pareja, 2020; doi:10.1002/erv.2770 van Rensburg, 2020). Symptomatic deterioration such as purging, binging and exercise has been reported (Phillipou et al., 2020). Moreover the physi- cal sequel of the disorders such as weight loss in anorexia nervosa (AN), electrolyte imbalance in bulimia nervosa 1.1 | Aims (BN), or cardiovascular risk in binge eating disorder (BED) amplify the risk (Chew, Wei, Vasoo, Chua, & Sim, 2020; The main aim of this study is to assess the factors that Fernández-Aranda et al., 2020; Cornejo-Pareja et al., 2020; impact on the adjustment of people with ED to the Touyz, Lacey, & Hay, 2020). Also constraints in food sup- COVID-19 confinement. We hypothesized that that ply chains may increase “food insecurity” (Temorshuizen poorer social support and non-adaptive coping strategies et al., 2020; and increase food hoarding (Touyz et al., 2020) would be associated with a greater adverse reaction. triggering bingeing (Fernández-Aranda et al., 2020; Temorshuizen et al., 2020. Furthermore, emotional dis- tress in the face of environmental changes is another trig- 2 | METHOD gering factor (Mediouni, Madiouni, & Kaczor- Urbanowicz, 2020; Rodgers et al., 2020; Touyz et al., 2020; 2.1 | Participants Clark-Bryan et al., 2020;https://doi.org/10.1002/erv.2762 2020). Restrictions placed on movement may have limited The sample was constituted of 74 adults, with female pre- adaptive strategies in the face of these difficulties (Rodgers dominance (71 patients, 95.9%) and a mean age of 32.12 et al., 2020) with reduced access to support (Weissmann, (±12.84) years old. They all were diagnosed with an ED Bauer, & Thomas 2020; Fernandez-Aranda et al., 2020). and presented for treatment to the ED Unit within the Graell et al., 2020; https://doi.org/10.1002/erv.2763). Department of Psychiatry at a University Hospital in In the general population, factors related to the psy- Spain: 19 AN, 12 BN, 10 BED and 33 Other Specified chological impact include as female sex (González- Feeding or Eating Disorder (OSFED). Patients were diag- Sanguino et al., 2020; Özdin & Bayrak Özdin, 2020; Wang, nosed according to DSM-5 criteria (APA, 2013). Di, Ye, & Wei, 2020), low educational level and lower per- ceived health status (Özdin & Bayrak Özdin, 2020; Wang et al., 2020), and high perceived vulnerability to infection 2.2 | Procedure and exposure to news (Olagoke, Olagoke, & Hughes, 2020; Yao, 2020). Personality factors associated with better adap- The present study was carried out in accordance with the tation include higher scores in the fight-flight system latest version of the Declaration of Helsinki. The Univer- (related to personal safety concerns) and lower scores in sity Hospital Clinical Research Ethics Committee the behavioural inhibition system (related to anxiety) approved the study, and signed informed consent was (Bacon & Corr, 2020); confidence (linked to secure attach- obtained from all participants. ment) and discomfort with closeness (associated with We used a semi-structured telephone survey designed avoidant attachment) (Moccia et al., 2020) and conscien- by a clinician team from our Unit, regarding five main tiousness (Carvalho, Pianowski, & Gonçalves, 2020). thematic blocks to explore: (a) socio-demographic infor- To the best of our knowledge, ours is the first study mation; (b) ED-status; (c) COVID-19 concerns; that examines the factors that might contribute to a (d) pandemic stress (anxiety, depressive symptoms, other poorer adaptation to the COVID-19 pandemic. situations, and family conflicts) and, (e) coping strategies. BAENAS ET AL. 3 This survey was administered as part of a prospective 2.3.3 | Symptom checklist-90-revised follow-up coinciding with official COVID-19 lockdown in (SCL-90-R) (Derogatis, 1990) the region of Catalonia (Spain) from 14th March to 11th May 2020 and was administered during April 2020. It consists of a 90-item questionnaire that evaluates a broad range of psychological problems and symptoms of psychopathology by measuring nine primary symptom 2.3 | Assessments dimensions: Somatization, Obsession-Compulsion, Inter- personal Sensitivity, Depression, Anxiety, Hostility, Pho- 2.3.1 | Eating disorders inventory-2 bic Anxiety, Paranoid Ideation, and Psychoticism. It also (EDI-2) (Garner, 1991) includes three global indices: global severity index (over- all psychological distress), positive symptom distress It consists of 91 items self-report questionnaire, answered index (the intensity of symptoms), and a positive symp- on a 6-point Likert scale, which assesses different cognitive tom total (self-reported symptoms). The global severity and behavioural characteristics concerning ED: Drive for index can be used as a summary of the test. The Thinness, Bulimia, Body Dissatisfaction, Ineffectiveness, validation of the scale in a Spanish population Perfectionism, Interpersonal Distrust, Interoceptive Aware- (Derogatis, 2002), obtained a mean internal consistency ness, Maturity Fears, Asceticism, Impulse Regulation, and of .75 (coefficient alpha). The internal consistency for this Social Insecurity. The EDI-2 provides standardized subscale study was between adequate (α = .763 for paranoid idea- scores and a global measure of ED severity, which can be tion) to excellent (α = .980 for global indexes). obtained based on the sum of all the items. The validated version for the Spanish population (Garner, 1998) had a mean internal consistency of 0.63 (coefficient alpha). Inter- 2.3.4 | Temperament and character nal consistency for the total score in this study was between inventory-revised (TCI-R) (Cloninger, adequate (Cronbach-alpha α = .70 for maturity fears) to Svrakic, Przybeck, & Whitehead, 1999) excellent (α = .953 for total score). This questionnaire is composed of 240-items scored on a 5-point Likert scale and measures personality derived 2.3.2 | Yale food addiction scale 2.0 from three character dimensions (Self-Directedness, (YFAS-2) (Gearhardt, Corbin, & Cooperativeness, and Self-Transcendence) and four tem- Brownell, 2016) perament scales (Harm Avoidance, Novelty Seeking, Reward Dependence and Persistence). Evaluation of the It is a 35-item self-report questionnaire for measuring Spanish revised version (Gutiérrez-Zotes et al., 2004) gen- Food Addiction (FA) during the previous 12 months. It erated an internal consistency of 0.87 (coefficient alpha). was based on the Diagnostic and Statistical Manual of The questionnaire obtained internal consistency in this Mental Disorders (DSM-IV-TR) (APA, 2000) criteria for study between moderate (α = .739 for cooperativeness) to substance dependence and was adapted to the context of excellent (α = .900 for harm avoidance). food consumption. YFAS-2, a newer version of the instru- ment, is based on DSM-5 Criteria (APA, 2013) and evalu- ates 11 symptoms. Two measurements are shown: (a) a 2.3.5 | Semi-structured brief telephone continuous symptom count score that reflects the number survey during COVID-19 confinement of fulfilled diagnostic criteria (ranging from 0 to 11), and (Eating Disorders Unit, Psychiatry (b) a FA food addiction threshold based on the number of Department, University Hospital, symptoms (at least two) and self-reported clinically signif- Spain, 2020) icant impairment or distress. This final measurement allows for the binary classification of FA food addiction First, sociodemographic information was up-dated (present versus absent). Moreover, based on the revised regarding lockdown period in terms of employment sta- DSM-5 taxonomy, it is possible to establish severity cut- tus, confinement compliance, affected environment by offs: mild (between two and three symptoms), moderate COVID-19 and presence of company during this situa- (between four and five symptoms), and severe (between tion using dichotomous response (yes/no). The second six and eleven symptoms). The Spanish validation of the part of the survey was related to ED-state (measured as YFAS-2 (Granero et al., 2018) had an internal consistency remaining equal, worsening, or remaining in the back- of 0.94 (coefficient alpha). In this study, internal consis- ground). COVID-19 concerns were classified as related tency for the total score was excellent (α = .949). to (a) own or family infection's risk and, (b) uncertain 4 BAENAS ET AL. T A B L E 1 Association between the Worse n = 19 Non-worse n = 55 ED-state during the confinement with n % n % p |d| the measures registered during the COVID-related concerns 16 84.2 36 65.5 .123 0.44 COVID-19 Concerns: Infection risk 7 36.8 14 25.5 .343 0.25 Concerns: Uncertain future 10 52.6 16 29.1 .046* 0.51a Concerns: Employment 4 21.1 11 20.0 .922 0.03 Concerns: Medical treatments 4 21.1 1 1.8 .004* 0.68a Concerns: Other 4 21.1 6 10.9 .265 0.28 Adaptive reactions 17 89.5 53 96.4 .252 0.28 Adaptive reactions: Social 1 5.3 13 23.6 .078 0.55a Adaptive reactions: Leisure 8 42.1 34 61.8 .135 0.40 Adaptive reactions: Sport 2 10.5 15 27.3 .135 0.44 Adaptive reactions: Routine 8 42.1 34 61.8 .135 0.40 Adaptive reactions: Work/studies 8 42.1 14 25.5 .171 0.35 Non-adaptive reactions 10 52.6 9 16.4 .002* 0.79a Non-adaptive reactions: COVID 1 5.3 0 0.0 .575 0.46 Non-adaptive reactions: ED 5 26.3 6 10.9 .104 0.40 Non-adaptive reactions: Other 4 21.2 2 3.6 .016* 0.57a Anxiety 14 73.7 17 30.9 .001* 0.89a Anxiety: Physic 6 31.6 10 18.2 .221 0.31 Anxiety: Emotional 13 68.4 14 25.5 .001* 0.89a Anxiety: Motor 6 31.6 4 7.3 .008* 0.65a Anxiety: Cognitive 13 68.4 11 20.0 .001* 1.02a Depression 12 63.2 10 18.2 .001* 0.96a Other situations 13 68.4 21 38.2 .023* 0.62a Familiar conflicts 8 42.1 7 12.7 .006* 0.68a *Bold: significant comparison. a Bold: effect size into the range mild–moderate (|d| > 0.50) to high-large (|d| > 0.80). future, (c) employment status, (d) supply and access to 2.4 | Statistical analyses treatments and, (e) other concerns. A yes /no evaluation of anxiety (psychical, emotional, motor, and cognitive Statistical analysis was carried out with Stata16 for win- dimensions), depressive symptoms (such as low mood, dows (Stata Press, 2019). The comparison between the pessimism, or insomnia), other consequences (boredom groups of the study was done through chi-square tests or social conflicts) and familial conflicts were made. (χ 2) for categorical variables and t test for quantitative Finally, coping strategies during confinement were measures. Effect size for the proportion and the mean dif- evaluated in two ways: (a) as presence or absence of ferences was estimated with Cohen's-d coefficient, con- both adaptive and non-adaptive mechanisms and, (b) as sidering null effect for |d| < 0.20, low-poor for |d| > 0.20, well as the kind of strategies carried out by categorizing mild-medium for |d| > 0.50 and large-high for |d| > 0.80) the coping mechanisms in dimensions (five for adaptive (Cohen, 1988; Kelley & Preacher, 2012). strategies: social contact; leisure; sports activities; daily Path analysis procedure assessed the underlying routines; and academic/work activity and three dimen- relationships between the variables of the study (direct sions for non-adaptive ones: COVID-19 over-informa- and indirect links, including mediational associations). tion; ED behaviours and other non-adaptive This analysis was carried out as a case of structural behaviours. An extended version of this scale has been equation modelling (SEM), with the maximum- published in the current issue (Fernández-Aranda likelihood estimation method of parameter estimation. et al., 2020). Due the large number of contextual and personal BAENAS ET AL. 5 TABLE 2 Association between the ED-state during the confinement with the clinical measures prior to the COVID-19 Worse n = 19 Non-worse n = 55 Mean SD Mean SD p |d| Age (yrs-old) 32.53 13.60 31.98 12.69 .875 0.04 Onset of the ED (yrs-old) 16.42 4.22 16.62 5.80 .892 0.04 Duration of the ED (yrs) 14.49 11.56 14.60 11.32 .971 0.01 EDI-2: Drive for thinness 13.16 4.65 12.42 6.68 .657 0.13 EDI-2: Body dissatisfaction 17.63 7.03 14.80 8.24 .185 0.37 EDI-2: Interoceptive awareness 12.47 7.80 10.44 6.72 .278 0.28 EDI-2: Bulimia 6.26 4.63 5.55 5.46 .610 0.14 EDI-2: Interpersonal distrust 6.16 4.82 5.58 5.09 .668 0.12 EDI-2: Ineffectiveness 11.63 5.89 9.98 7.36 .380 0.25 EDI-2: Maturity fears 7.42 5.49 8.07 5.06 .637 0.12 EDI-2: Perfectionism 4.84 3.47 6.04 4.84 .326 0.28 EDI-2: Impulse regulation 6.89 4.48 5.20 5.98 .263 0.32 EDI-2: Ascetic 7.95 4.39 6.89 4.93 .411 0.23 EDI-2: Social insecurity 7.68 4.99 6.89 5.11 .559 0.16 EDI-2: Total score 102.11 38.99 91.87 45.33 .383 0.24 SCL-90R: Somatization 1.49 0.98 1.83 0.94 .189 0.35 SCL-90R: Obsess./compulsive 1.93 0.80 1.87 0.82 .779 0.08 SCL-90R: Interpersonal sensitivity 2.03 0.95 1.95 1.03 .757 0.08 SCL-90R: Depressive 2.32 0.85 2.15 1.01 .512 0.18 SCL-90R: Anxiety 1.55 0.91 1.59 0.97 .899 0.03 SCL-90R: Hostility 1.65 1.21 1.25 1.03 .167 0.36 SCL-90R: Phobic anxiety 0.86 0.86 1.14 1.00 .281 0.30 SCL-90R: Paranoid ideation 1.34 0.65 1.39 0.91 .837 0.06 SCL-90R: Psychotic 1.29 0.87 1.27 0.76 .909 0.03 SCL-90R: PST score 1.70 0.77 1.70 0.81 .997 0.00 SCL-90R: GSI score 60.00 19.17 63.15 17.67 .515 0.17 SCL-90R: PSDI score 2.42 0.57 2.28 0.61 .373 0.24 YFAS: Total score 5.74 3.65 5.58 3.69 .875 0.04 TCI-R: Novelty seeking 97.11 13.35 97.24 17.07 .976 0.01 TCI-R: Harm avoidance 117.53 18.34 115.51 21.90 .720 0.10 TCI-R: Reward dependence 103.53 14.30 101.33 17.95 .631 0.14 TCI-R: Persistence 114.05 22.51 115.27 19.02 .819 0.06 TCI-R: Self-directedness 117.37 20.96 127.56 18.70 .048* 0.51a TCI-R: Cooperativeness 133.89 9.69 137.85 13.19 .234 0.34 TCI-R: Self-transcendence 64.37 14.86 65.82 16.71 .739 0.09 *Bold: significant comparison. a Bold: effect size into the range mild–moderate (|d| > 0.50) to high-large (|d| > 0.80). variables characterizing the COVID-19 confinement, a reactions, non-adaptive reactions, anxiety, depression, latent variable was defined (labelled as “COVID” in the other problems and familiar conflicts). The goodness-of- model, defined by the presence of concerns, adaptive fit was tested with standard statistical measures: χ 2 test, 6 BAENAS ET AL. FIGURE 1 Path-diagram with the standardized coefficients. Note. Continuous line: significant coefficient. Dash line: non-significant coefficient the root mean square error of approximation (RMSEA), study, the participants were re-classified in two groups Bentler's Comparative Fit Index (CFI), the Tucker-Lewis based on the ED state during the confinement: symp- Index (TLI), and the standardized root mean square tom deterioration (n = 19) or not (n = 55). residual (SRMR). Adequate fit was considered for (Barrett, 2007) non-significant result in the χ 2 test, RMSEA<0.08, TLI > 0.90, CFI > 0.90 and SRMR<0.10. 3.2 | Comparison of groups based on the ED progression during COVID-19 lockdown 3 | R E SUL T S No differences between these two groups were found for the marital status (p = .845), education levels (p = .796), 3.1 | Characteristics of the participants social index (p = .555), and diagnostic subtype (p = .294) previous and during the confinement (see Table S1, supplementary material). Table 1 displays the comparisons between the groups of Coinciding with the lockdown, most patients were under- the study for the variables registered during the COVID-19 going outpatient treatment (73 patients, 98.6%). Almost lockdown. Patients who noticed an ED worsening reported 27% (20 patients) of the sample were actively working, higher prevalence of future concerns, such as access to almost 95% (70 patients, 94.6%) had social support and medical treatment, non-adaptive reactions, symptoms of only 17.6% (13 patients) had close people affected by anxiety and depression, adverse situations and familiar COVID-19. conflict. The presence of concerns related with the confine- Table 2 compares the baseline assessment between ment for COVID-19 was reported by 52 patients (70.3%), the groups. Self-directedness was lower in the group with a high prevalence of patients used adaptive reactions deterioration in their ED symptoms: 117.4 versus 127.6; (n = 70, 94.6%), 19 patients (25.7%) also reported non- p = .048, |d| = 0.51). adaptive reactions. The presence of anxiety symptoms Table S2 (supplementary material) contains the point- was reported by 31 participants (41.9%) and depression serial correlation matrix with the associations between by 22 (29.7%). Familial conflicts were noted by 15 individ- the variables measuring during the confinement with the uals (20.3%) and other difficulties 34 patients (45.9%). clinical state registered previous to the COVID-19 lock- Symptom evolution during the confinement due to down. The presence of concerns during the confinement the COVID-19, worsened in n = 19 patients (25.7%), was related to older age and lower EDI-2 drive for thin- and became less dominant in n = 38 (51.4). For this ness score. Non-adaptive reactions were reported by BAENAS ET AL. 7 patients with higher score in the YFAS-2 scale, and 5 | CONCLUSIONS depression symptoms were related to worse psychopatho- logical state. In conclusion, the present findings suggest that an about a quarter of patient with an ED showed a deterioration in symptomatology, post COVID and this was mainly asso- 3.3 | Path analysis ciated with lower self-directedness. These results suggest the relevance of identifying specific vulnerability factors Figure 1 contains the path-diagram with the standardized among ED patients in a confinement situation in order to coefficients obtained in the SEM. Adequate fitting was develop preventive strategies and personalized treatment obtained: χ 2 = 67.84 (p = .201), RMSEA = 0.045, approaches. CFI = 0.958, TLI = 0.945 and SRMR = 0.087. The latent variable measuring the contextual and ACKNOWLEDGEMENTS personal features during the COVID-19 lockdown was We thank CERCA Programme/Generalitat de Catalunya associated with concerns related to the confinement, for institutional support. This work was partially non-adaptive reactions, anxiety, depression and familial supported by Instituto de Salud Carlos III (PI17/01167) conflicts. Results from the SEM suggest that a poorer and Generalitat de Catalunya (PERIS/SLT006/17/00246). state during the COVID-19 lockdown and lower TCI-R CIBERObn is an initiative of ISCIII Spain. IB was par- self-directedness score increase the likelihood of deterio- tially supported by a Post-Residency Grant from Research rating ED symptoms during the confinement (direct Committee of the University Hospital of Bellvitge (HUB; effects). The COVID-19 latent variable was also a media- Barcelona, Spain) 2019-2020. CVA is supported by a FPU tional variable in the model: indicating that age, grant (FPU16/01453) from Ministerio de Educación, Cul- self-directedness and BMI, contributed indirectly to the tura y Deporte (Spain). The funders had no role in the deterioration in ED symptoms. study design, data collection and analysis, decision to publish or preparation of the manuscript. 4 | DISCUSSION CONFLICT OF INTEREST The authors declare no conflict of interest. The present study explored the factors associated with symptomatic deterioration in people with ED. A quarter ORCID of patients became more symptomatic during lockdown a Isabel Baenas https://orcid.org/0000-0001-7415-0616 similar proportion to that found during the first weeks of Roser Granero https://orcid.org/0000-0001-6308-3198 confinement (Fernández-Aranda et al., 2020). The deteri- Isabel Sánchez https://orcid.org/0000-0001-5874-8204 oration was higher in people with AN followed by those Nadine Riesco https://orcid.org/0000-0002-6336-4907 with OSFED. This differential pattern aligns with other Cristina Vintró-Alcaraz https://orcid.org/0000-0001- studies (Temorshuizen et al., 2020). 9453-8810 A novel feature of the present work was the associa- Janet Treasure https://orcid.org/0000-0003-0871-4596 tion of symptom deterioration with low levels of self- Susana Jiménez-Murcia https://orcid.org/0000-0002- directedness. This aligns with other work in confinement 3596-8033 Moccia et al. (2020) and to the extensive literature associ- Fernando Fernández-Aranda https://orcid.org/0000- ating in ED lower self-directedness to poorer prognosis 0002-2968-9898 (Duffy et al., 2019; Krug et al., 2011). Age and ED sever- ity, named drive for thinness (EDI-2), were also related RE FER EN CES with COVID-19 concerns. Patients with FA food addic- APA. (2000). Diagnostic and statistical manual of mental disorders tion at baseline (Y-FAS 2.0) had more non-adaptive (4th text revision ed.). Washington, DC: American Psychiatric responses during COVID-19 lockdown. Association. Finally, some strengths of this study should be APA. (2013). Diagnostic and statistical manual of mental disorders. Washington, DC: American Psychiatric Association. highlighted. For instance, as the sample was comprised Bacon, A. M., & Corr, P. J. (2020). Coronavirus (COVID-19) in the of patients who were linked to our unit before COVID-19 United Kingdom: A personality-based perspective on concerns outbreak, the baseline assessment was thorough. The use and intention to self-isolate. British Journal of Health Psychol- of a telephone interview rather than self-report post ogy, 1–10. https://doi.org/10.1111/bjhp.12423 COVID may have increased reliability. However, the Barrett, P. (2007). Structural equation modelling: Adjudging model sample size was modest and was without a control fit. Personality and Individual Differences, 42(5), 815–824. comparison. https://doi.org/10.1016/j.paid.2006.09.018 8 BAENAS ET AL. Carvalho, L. D. F., Pianowski, G., & Gonçalves, A. P. (2020). Per- Hao, F., Tan, W., Jiang, L., Zhang, L., Zhao, X., Zou, Y., … Tam, W. sonality differences and COVID-19: Are extroversion and con- (2020). Do psychiatric patients experience more psychiatric scientiousness personality traits associated with engagement symptoms during COVID-19 pandemic and lockdown? A case- with containment measures? Trends in Psychiatry and Psycho- control study with service and research implications for therapy, 0, 1–6. https://doi.org/10.1590/2237-6089-2020 immunopsychiatry. Brain, Behavior, and Immunity, 87, Chew, Q. H., Wei, K. C., Vasoo, S., Chua, H. C., & Sim, K. (2020). 100–106. https://doi.org/10.1016/j.bbi.2020.04.069 Narrative synthesis of psychological and coping responses Kelley, K., & Preacher, K. J. (2012). On effect size. Psychological towards emerging infectious disease outbreaks in the general Methods, 17(2), 137–152. https://doi.org/10.1037/a0028086 population: Practical considerations for the COVID-19 pan- Krug, I., Root, T., Bulik, C., Granero, R., Penelo, E., Jiménez- demic. Singapore Medical Journal, 1–31. https://doi.org/10. Murcia, S., & Fernández-Aranda, F. (2011). Redefining pheno- 11622/smedj.2020046 types in eating disorders based on personality: A latent profile Cloninger, C. R., & (1999). In The Temperament and Character analysis. Psychiatry Research, 188, 439–445. https://doi.org/10. Inventory–Revised. St Louis: MO: Center for Psychobiology of 1016/j.psychres.2011.05.026 Personality, Washington University. Mediouni, M., Madiouni, R., & Kaczor-Urbanowicz, K. E. (2020). Cohen, J. (1988). Statistical power for the behavioral sciences (2nd COVID-19: How the quarantine could lead to the depreobesity. ed.). Hillsdale, NJ: Laurence Erlbaum and Associates. Obesity Medicine, 19, 100255. https://doi.org/10.1016/j.obmed. Derogatis, L. (1990). SCL-90-R. Administration, scoring and proce- 2020.100255 dures manual—II for the revised version. Baltimore, MD: Clini- Moccia, L., Janiri, D., Pepe, M., Dattoli, L., Molinaro, M., De cal Psychometric Research. Martin, V., … Di Nicola, M. (2020). Affective temperament, Derogatis, L. (2002). SCL-90-R. Cuestionario de 90 Síntomas-Man- attachment style, and the psychological impact of the COVID- ual. Madrid, Spain: TEA, Ed. 19 outbreak: An early report on the Italian general population. Duffy, M. E., Rogers, M. L., Joiner, T. E., Bergen, A. W., Brain, Behavior, and Immunity, 87, 75–79. https://doi.org/10. Berrettini, W., Bulik, C. M., … Keel, P. K. (2019). An investiga- 1016/j.bbi.2020.04.048 tion of indirect effects of personality features on anorexia Olagoke, A. A., Olagoke, O. O., & Hughes, A. M. (2020). Exposure nervosa severity through interoceptive dysfunction in individ- to coronavirus news on mainstream media: The role of risk per- uals with lifetime anorexia nervosa diagnoses. International ceptions and depression. British Journal of Health Psychology, Journal of Eating Disorders, 52, 200–205. https://doi.org/10. e12427. https://doi.org/10.1111/bjhp.12427 1002/eat.23008 Ozamiz-Etxebarria, N., Dosil-Santamaria, M., Picaza- Fernández-Aranda, F., Casas, M., Claes, L., Bryan, D. C., Gorrochategui, M., & Idoiaga-Mondragon, N. (2020). Niveles de Favaro, A., Granero, R., … Treasure, J. (2020). COVID-19 and estrés, ansiedad y depresión en la primera fase del brote del implications for eating disorders. European Eating Disorders COVID-19 en una muestra recogida en el norte de España. Review: The Journal of the Eating Disorders Association, 28(3), Cadernos De Saude Publica, 36(4), e00054020. https://doi.org/ 239–245. https://doi.org/10.1002/erv.2738 10.1590/0102-311X00054020 Garner, D. (1991). Eating disorder inventory-2, Odena: Psychological Özdin, S., & Bayrak Özdin, Ş. (2020). Levels and predictors of anxi- Assessment Resources. ety, depression and health anxiety during COVID-19 pandemic Garner, D. M. (1998). Inventario de Trastornos de la Conducta in Turkish society: The importance of gender. International Alimentaria (EDI-2)-Manual. Madrid, Spain: TEA ediciones. Journal of Social Psychiatry, 002076402092705. https://doi.org/ Gearhardt, A. N., Corbin, W. R., & Brownell, K. D. (2016). Develop- 10.1177/0020764020927051 ment of the Yale food addiction scale version 2.0. Psychology of Phillipou, A., Meyer, D., Neill, E., Tan, E. J., Toh, W. L., Van Addictive Behaviors, 30(1), 113–121. https://doi.org/10.1037/ Rheenen, T. E., & Rossell, S. L. (2020). Eating and exercise adb0000136 behaviors in eating disorders and the general population during González-Sanguino, C., Ausín, B., Castellanos, M. A.,  Saiz, J., the COVID-19 pandemic in Australia: Initial results from the López-Gómez, A., Ugidos, C., & Muñoz, M. (2020). Mental COLLATE project. The International Journal of Eating Disor- health consequences during the initial stage of the 2020 corona- ders, 53(7), 1158–1165. https://doi.org/10.1002/eat.23317 virus pandemic (COVID-19) in Spain. Brain, Behavior, and Rajkumar, R. P. (2020). COVID-19 and mental health: A review of Immunity, 87, 172–176. https://doi.org/10.1016/j.bbi.2020. the existing literature. Asian Journal of Psychiatry, 52, 102066. 05.040 https://doi.org/10.1016/j.ajp.2020.102066 Granero, R., Jiménez-Murcia, S., Gerhardt, A. N., Agüera, Z., Rodgers, R. F., Lombardo, C., Cerolini, S., Franko, D. L., Aymamí, N., Gómez-Peña, M., … Fernández-Aranda, F. (2018). Omori, M., Fuller-Tyszkiewicz, M., … Guillaume, S. (2020). The Validation of the Spanish version of the Yale Food Addiction impact of the COVID-19 pandemic on eating disorder risk and Scale 2.0 (YFAS 2.0) and clinical correlates in a sample of eat- symptoms. The International Journal of Eating Disorders, 53(7), ing disorder, gambling disorder, and healthy control partici- 1166–1170. https://doi.org/10.1002/eat.23318 pants. Frontiers in Psychiatry, 9, 208. https://doi.org/10.3389/ Shah, K., Kamrai, D., Mekala, H., Mann, B., Desai, K., & Patel, R. S. fpsyt.2018.00208 (2020). Focus on mental health during the coronavirus Gutiérrez-Zotes, J. A., Bayón, C., Montserrat, C., Valero, J., (COVID-19) pandemic: Applying learnings from the past out- Labad, A., Cloninger, C. R., & Fernández-Aranda, F. (2004). breaks. Cureus, 12, (3), e7405. https://doi.org/10.7759/cureus. Inventario del Temperamento y el Carácter-Revisado (TCI-R). 7405 Baremación y datos normativos en una muestra de población Stata Press. (2019). Stata statistical software: Release 16. Statistical general. Actas Espanolas de Psiquiatria, 32(1), 8–15. Software. College Station, Texas: StataCorp LLC. BAENAS ET AL. 9 Temorshuizen, J. D., Watson, H. J., Thornton, L. M., Borg, S., crisis. International Journal of Eating Disorders, 53(5), 369–376. Flatt, R. E., MacDermod, C. M., … Bulik, C. M. (2020). Early https://doi.org/10.1002/eat.23279 impact of COVID-19 on individuals with eating disorders: A WHO. (2020). WHO Director-Generals opening remarks at the mis- survey of ~1000 individuals in the United States and The Neth- sion briefing on COVID-19. https://doi.org/11 March 2020. erlands. medRxiv. https://doi.org/10.1101/2020.05.28.20116301 Yao, H. (2020). The more exposure to media information about Todisco, P., & Donini, L. M. (2020). Coronavirus disease 2019 (COVID- COVID-19, the more distressed you will feel. Brain, Behavior, 19) and obesity. Impact of obesity and its main comorbidities in and Immunity, 87, 167–169. https://doi.org/10.1016/j.bbi.2020. the evolution of the disease. European Eating Disorders Review, 05.031 (0123456789), 10–13. https://doi.org/10.1007/s40519-020-00938-z Touyz, S., Lacey, H., & Hay, P. (2020). Eating disorders in the time of COVID-19. Journal of Eating Disorders, 8(1), 8–10. https:// SU PP O R TI N G I N F O RMA TI O N doi.org/10.1186/s40337-020-00295-3 Additional supporting information may be found online van Rensburg, M. J. (2020). COVID19, the pandemic which may in the Supporting Information section at the end of this exemplify a need for harm-reduction approaches to eating dis- article. orders: A reflection from a person living with an eating disor- der. Journal of Eating Disorders, 31(8), 26. https://doi.org/10. 1186/s40337-020-00306-3 How to cite this article: Baenas I, Caravaca- Wang, Y., Di, Y., Ye, J., & Wei, W. (2020). Study on the public psy- Sanz E, Granero R, et al. COVID-19 and eating chological states and its related factors during the outbreak of disorders during confinement: Analysis of factors coronavirus disease 2019 (COVID-19) in some regions of associated with resilience and aggravation of China. Psychology, Health and Medicine, 1–10. https://doi.org/ 10.1080/13548506.2020.1746817 symptoms. Eur Eat Disorders Rev. 2020;1–9. Weissman, R. S., Bauer, S., & Thomas, J. J. (2020). Access to https://doi.org/10.1002/erv.2771 evidence-based care for eating disorders during the COVID-19