Rosey has lived with bulimia for more than a decade. The 31-year-old resident of Melbourne, Australia, started therapy for her eating disorder six years ago. Although she says she had never considered herself “cured,” she had reached a point in her recovery that felt hopeful and manageable. Then along came the novel coronavirus.
When mandatory COVID-19 lockdowns began in Australia in March, Rosey’s anxiety went into overdrive. “I’m single, I live alone, my family lives in another state, and I’m not able to see friends,” she says, adding that her need for control—something she has now lost in almost every area of her life—has played a major role in the resurgence of symptoms: “To have everything I knew and had control over, including how I managed my illness, ripped away has been one of the hardest things.”
Rosey is living an experience that may be familiar to anyone dealing with an eating disorder while weathering the unexpected storms of 2020. Recent research indicates that pandemic-related stay-at-home orders have ramped up anorexia, bulimia and binge-eating disorder symptoms.
Isolation Hits Home
A study published last month in the International Journal of Eating Disorders revealed that during the first few months of the pandemic, many individuals with anorexia reported restricting their eating more. Meanwhile others with bulimia and binge-eating disorder reported more bingeing urges and episodes. Respondents also noted increased anxiety and concern about COVID-19’s impact on their mental health. More than one third of the 1,021 participants (511 in the U.S. and 510 in the Netherlands) said their eating disorder had worsened—and they attributed this change to issues such as a lack of structure, a triggering environment, the absence of social support and an inability to obtain foods that fit their meal plans.
“While no one knows for sure what causes eating disorders, a growing consensus suggests that [they result from] a range of biological, psychological and sociocultural factors,” says Claire Mysko, CEO of the National Eating Disorders Association, who was not involved in the study. She notes that many of those who struggle with these disorders have a co-occurring condition, such as anxiety or depression.
The paper’s senior author Cynthia M. Bulik of the University of North Carolina at Chapel Hill (UNC) notes that anxiety and depression are on the rise for many because of the pandemic—and this increase can present specific triggers to those with eating disorders. Such triggers “are almost custom-made to exacerbate their illness,” says Bulik, who is the founding director of the UNC Center of Excellence for Eating Disorders.
One major provocation is social isolation. “Eating disorders are something individuals usually keep private, and there can be a lot of shame around behaviors,” says Ellen E. Fitzsimmons-Craft, an assistant professor of psychiatry at Washington University School of Medicine, who specializes in eating disorder prevention and treatment research. These disorders “also thrive in isolation, so it’s not surprising we’re seeing an increase in disordered behaviors and even some relapse among those who were doing well prior to lockdown,” says Fitzsimmons-Craft, who was not involved in the new study.
To fill the void left by physical distancing, many people are logging hours online—a phenomenon that may actually be complicating matters for some with eating disorders. “Social media messages about being productive, effectively using time in quarantine and avoiding the ‘COVID-19 weight gain’ have led to increased negative self-talk,” says Shiri Sadeh-Sharvit, associate director of training at the Center for m2Health at Palo Alto University.
Sadeh-Sharvit and her colleagues published a paper in July that examined risks and recommendations for people suffering from eating disorders in this unprecedented situation. Lead study author Marita Cooper, a postdoctoral fellow at the Johns Hopkins University School of Medicine, says food-specific issues related to the pandemic also play a role. “Reduced food access, or food insecurity, [has] been rampant,” she says. “The need to stock a ‘quarantine pantry’ can be a significant challenge, potentially triggering bingeing and compensatory episodes,” such as self-induced vomiting, laxative misuse, fasting or excessive exercise.
Sarah Adler, a psychologist at Stanford University’s Eating Disorder and Weight Control Clinic, says food scarcity can create anxiety in anyone. But, she adds, “the specific stress and anxiety associated with decisions about food and availability of food can dramatically increase anxiety in folks with eating disorders.”
Food is one part of the eating disorder equation; exercise is often another. “For those whose disorder includes compulsive exercise, either they’re very anxious because they can’t go to the gym or find themselves exercising excessively at home because there are no barriers to doing so,” Bulik says, adding that some people might even experience both of these effects.
Rosey knows about this problem firsthand. She says she has ramped up her home exercise routine since the pandemic began. “I knew I wouldn’t be able to stick to my very strict and regimented workout schedule with gyms closed, which sent my body dysmorphia into a downward spiral,” she says. “I walk or jog every day to know how many calories I’ve burned.”
The pandemic has also highlighted the limitations of electronic means of accessing treatment. In Bulik’s research, 47 percent of U.S. respondents say telehealth (seeking care over the phone or online) is not cutting it, compared with in-person treatment. And 45 percent of those surveyed in the U.S. say they are not receiving treatment at all.
“Face-to-face therapy has largely been discontinued, so a primary source of support and accountability has been moved online,” Bulik says. “Some things are just hard to do online, like weighing to make sure someone is not losing too much weight or [to see] whether they’re gaining according to plan. The logistics are much more complex with virtual care.”
Rosey says continuing therapy by phone has been helpful—to an extent. “Talking to someone who knows my history has lifted a bit of the weight off my shoulders,” she says. “But I think taking away that face-to-face interaction removes a lot of the accountability.”
One possible upside is that providers can now glean more insights about what works online and what does not. “Clinicians cannot assume that virtual therapy is the same as in-the-room therapy,” Bulik says. “You have to do a lot of experimenting to make sure patients have safe and private spaces and work together to figure out ways to make it function as close to a face-to-face session as possible.” She also recommends augmenting sessions with digital resources such as Recovery Record, an eating-disorder-recovery app that uses cognitive behavioral therapy techniques to allow users to track progress and share data with their treatment team. Fitzsimmons-Craft is conducting a study investigating the benefits of another mobile mental health app. “Digital mental health can bring treatment to people exactly when and where they need it,” she says.
“I believe the delivery of treatment will change in the wake of COVID-19,” says Ruth Striegel Weissman, a professor of psychology at Wesleyan University. “We’ll see far more telehealth, and I think therapists will get better at it. What’s unusual about the current situation is that the change was rapid, and therapists themselves are in a state of transition and stress.” She says the sudden shift has left many experts scrambling. And some of her colleagues have been forced to take client calls from their closet because of a lack of privacy at home.
Another potential bright side: although the majority of respondents to Bulik’s survey reported lockdown-related adversity, others said they noticed positive effects, including greater family connection, more self-care time and increased motivation for recovery. “I was fascinated that some [people] actually reported improvements,” Weissman says. “A crisis such as COVID-19 may help ‘reset’ behavioral patterns and, for some people, represent an opportunity for positive change or personal growth.”
According to Cooper, the treatment industry needs to adapt and catch up. “Eating disorders are manageable and treatable—most people who receive evidence-based treatment will recover,” she says. “We just need to improve accessibility and reduce stigma about accessing treatment.”
For Rosey, the struggle continues. “Every day I tell myself it will be better,” she says. “I try to put some of the management methods I’ve used over the years into practice. Some days, it works. But others, I feel powerless.”
If you or someone you know is struggling with an eating disorder, you can contact the National Eating Disorders Association’s Helpline by calling (800) 931-2237 or clicking here to chat. For crisis situations, you can text “NEDA” to 741741 to connect to a trained volunteer at the Crisis Text Line.