BPIPsychiatry

BulletinofIntegrative

Buletin dePsihiatrieIntegrativa

The consequences of the Covid 19 pandemic on

eating disorders
Loreta Diana Epure, Dan Cătălin Oprea, Delia Ungureanu,
Vasile Chiriţă, Roxana Chiriţă

Loreta Diana Epure - MD, residency training in psychiatry, Socola Institute of Psychiatry Iasi
Dan Cătălin Oprea - MD, residency training in psychiatry, Socola Institute of Psychiatry Iasi
Delia Ungureanu - MD, residency training in psychiatry, Socola Institute of Psychiatry Iasi
Vasile Chiriţă - MD, PhD, professor, Grigore T. Popa University and Medicine and Pharmacy Iasi
Roxana Chiriţă - MD, PhD, professor, Grigore T. Popa University and Medicine and
Pharmacy Iasi

ABSTRACT
The novel coronavirus has a great impact over mental health, individuals with eating
disorders may be particularly affected by the distancing measures, quarantine thus to a
difficult access to professional mental health services, this exacerbating phenomenology.

Eating behaviour disorders include anorexia nervosa, bulimia nervosa and binge-eating
disorder in which individuals express abnormal eating behaviours, often resulting in either
insufficient or excessive food intake.

Multiple implication factors such as genetic, biological, behavioural, and psycho-social have
been incriminated. Multiple psychiatric comorbidities can be associated like anxiety,
depression, obsessive-compulsive disorder, substance abuse, personality disorders, attention-
deficit and an increased risk of suicide. Anaemia, hydro-electrolytic disturbances,
cardiovascular diseases, gastrointestinal and endocrine dysfunctions may occur as medical
complications.

The challenge regarding eating disorders is to understand their mechanism of occurrence, in

an attempt to prevent them, as well as to treat them so that they do not put the individual's
life in danger.

KEYWORDS:
Eating disorders, covid 19 pandemic, impact.
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INTRODUCTION reassurance seeking, silencing the self, and

Eating disorders are severe disturbances of co-ruminations, working as an emotions
eating behaviours, which are more frequent in regulation strategy to handle difficult social
adolescents and young adults, but it can situations, creating a feedback loop prone to
appear also in other age groups. aggravation.
Predominantly, it manifests as a constant,
even obsessive concern about body weight, Reassurance seeking, distress may occur
body shape, with severe control over food when individuals do not receive the necessary
intake. The most common eating disorders assurance that they need from others to induce
are: anorexia nervosa, bulimia nervosa and positive feelings about them.
binge-eating disorder and their diagnoses are
based on the DSM-V criteria and ICD-11 Negative feedback-seeking, individual seek
criteria (1, 2). for negative feedback, which in turn, can lead
to distress.
Numerous variables like genetic, biological,
behavioural, social and psychological ones Self-silencing in order to avoid conflict with
are involved in the risk of developing this others individuals suppresses their thoughts
disorder (3). Serotonin is involved in appetite and affects and internalizes them.
regulation and many studies suggest that the
alteration of 5HT-1A and 5HT-2A serotonin Co-rumination involves repeatedly discussing
receptors, as well as the change in the levels problems along with other people with little
of the serotonin transporter 5HTT and 5HIAA focus on problem-solving.
have an important role in the development of
eating disorder (4). Psychological factors, These maladaptive behaviors cause
certain personality traits and body image interpersonal conflict with others, particularly
disturbance had a greater impact. Body image in one's close relationships.(8)
is associated with the exacerbation of the
symptoms of eating disorders, and not ANOREXIA NERVOSA
necessarily with its development (5). Anorexia nervosa lifetime prevalence in
Personality traits such as impulsivity, women ranges from 0.5-2.2%, compared to
perfectionism, stress reactivity, harm men, where it is ten times lower. The onset of
avoidance and novelty seeking are common in anorexia nervosa occurs frequently in
people with eating disorders (6). Western adolescence, the average age being between
cultural factors promote a slim body for 13-18 years. Studies have shown that anorexia
women, having a major role in eating nervosa with onset during adolescence tends
disorders development. In Singapore, Iran and to be associated with higher rates of
Japan, the incidence of eating disorders is remission, although the duration of treatment
continuously increasing in women exposed to extends over a long period of time, and the
western cultural factors (7). risk of relapse is particularly high after the
first 16 months after treatment and grows over
Multiple interpersonal maladaptive behaviors time. Anorexia nervosa has a mortality rate of
are implicated in eating disorders with an 5–6%, estimated to be amongst the highest of
interpersonal deficit, being prone to rejection all psychiatric illnesses (9).
and avoidance of social reward. Key
maladaptive interpersonal behavior include
 Bulletin of Integrative PsychiatryNew Series  December 2022 Year XXVIIINo. 4 (95)/35

The symptoms of anorexia nervosa include Specialized treatment is recommended for

restriction of food intake, extremely anorexia nervosa, and through the prism of
emaciation, the obsessive pursuit of methods three decades of research and the most
to obtain a low and unhealthy weight, great effective approach to eating disorders, it has
fair of gaining weight, erroneous perception been concluded that specific family-focused
of size, weight and body shape, low self- therapy for adolescents or family therapy for
image, not recognizing the severe weight loss. anorexia nervosa has the most satisfactory
The main cause of death in anorexic patients results (12). Other evidence‐based
are medical complications secondary to psychological therapies for anorexia nervosa
starvation, and suicide is the second cause. are the Maudsley Anorexia Nervosa Therapy
for Adults (MANTRA), Specialist Supportive
Anorexia nervosa is associated with somatic Clinical Management (SSCM) and Focal
complications in the reproductive, Psychodynamic Therapy (FPT). Remission
cardiovascular, gastroenterological, skeletal rates at the end of treatment which usually
system, such as hypoestrogenism, decreased lasts 40 weekly sessions vary from 23% to
bone mass density, and consequent increased 33%, with only one third of patients with
prevalence of osteopenia and osteoporosis, anorexia nervosa still in remission after 4
fertility problems, cardiac complications such years of follow-up (13). Thus, there is a need
as sinus bradycardia, prolonged QT interval for therapies aimed not only at somatic
on electrocardiography, arrhythmias, symptoms, but especially in the cognitive and
myocardial mass modification, and behavioural sphere. Enhanced cognitive
hypotension, refeeding syndrome. However, behavioural therapy is an individual-tailored
in addition to organic complications, anorexia treatment that targets the specific
nervosa is accompanied by multiple psychopathological mechanisms sustaining
psychiatric comorbidities such as mood the eating disorder. Indeed, weight-based
disorders, personality disorders, anxiety recovery does not necessarily reflect broader
disorders, obsessive-compulsive disorders, cognitive recovery, as the complex twist of
and developmental disorders (e.g., autistic cognitive and affective symptoms
spectrum, attention-deficit hyperactivity characteristic of anorexia nervosa, including
disorder). Regarding the symptoms of this the fear of weight gain, body dissatisfaction,
type of eating disorder, we can discuss the emotional dysregulation, and fear of calorie-
following: low body weight (generally below dense foods, frequently persist after weight
85% of the ideal body weight), fixation on the restoration (9).
prevention of excess weight, severe damage
to body image, amenorrhea, cold intolerance, Anorexic patients have a prognostic that
dry skin, lanugo (10). depends on the age of onset and treatment
initiation, treatment duration and associated
Patients with anorexia nervosa require complications. About 30% of patients do not
hospitalization in order to obtain a normal recover, and the rest of them recover in 5 to 6
body weight with medical and psychological years after the diagnosis (14).
stabilization. Psychotherapy plays a major
role in the treatment of these patients, because BULIMIA NERVOSA AND BINGE-
there are no studies that demonstrate the EATING DISORDER
effectiveness of drug therapy (11). Binge eating disorder can be defined as a
disorder of eating behaviour in the sense of a
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greater quantitative consumption of food therapy outcome studies suggest an

accompanied by a feeling of losing control association between depressive symptoms,
over eating (15). Binge eating was first acute sad mood, and binge-eating behavior,
described by Albert Stunkard in the 1950s, and indicate that higher levels of depression
but was not integrated into clinical diagnoses are related to more severe binge eating.
until the publication of DSM-III in 1980 with Besides the feeling of sadness, other emotions
the addition of “bulimia” which was later play a role in overeating. It should be noted
renamed bulimia nervosa. In subsequent DSM that anxiety is less important than other
editions, the understanding of binge eating emotions in the context of excessive eating,
increased, leading to the inclusion of BED as anger/frustration accounted for 95% of the
a formal diagnosis in DSM-5 in 2013 (C., moods preceding a binge-eating episode.
2019). It is characterized by recurrent (≥1 per Investigating a broad spectrum of emotions in
week for 3 months), brief (≤2 hours), binge eating disorder, Zeeck et al. found that
psychologically distressing binge-eating the number of binges was best explained by
episodes during which patients sense a lack of anger, disappointment and feelings of being
control and consume larger amounts of food hurt or lonely. These authors also concluded
than most people would under similar that emotions that are related to interpersonal
circumstances (14). This eating disorder, like experiences seem to be particularly relevant in
anorexia nervosa, is more common in women this disorder (15).
(3.5%) than men (2.0%) and in obese
individuals (5% to 30%) (6,7), especially Regarding the treatment of this eating
those who are severely obese and those behavior disorder, specific psychological
seeking obesity treatment (Brownley, 2016). therapies like the trans‐diagnostic Cognitive
It usually sets in in early adulthood, but it can Behaviour Therapy – Enhanced (CBT‐E) are
also appear in adolescence and persist long the first‐line treatment with the greatest
after midlife. impact on symptom reduction and other
outcomes, which usually lasts 20 weekly
A few decades ago, Bruch suggested that sessions (17). In addition to psychotherapy,
there is a connection between overeating and which has proven its usefulness in current
emotional state. Starting from this premise, practice, pharmacological treatment is also
more recent studies have shown that most approved for binge eating disorder. Only one
people who suffer from binge eating disorder drug is currently approved by the US Food
have at least one psychiatric comorbidity and Drug Administration for the treatment of
throughout their lives (67% to 79%), with binge eating disorder, which is the stimulant
mood and anxiety disorders amongst the most prodrug lisdexamfetamine . Numerous agents
prevalent. In addition to mood being overall from several drug classes have been
worse among individuals with binge eating investigated in clinical trials or used as off-
disorder, it is especially poor directly prior to label treatments for this type of disorder, and
binge eating. Greeno et al. investigated binge many have shown positive results. However,
antecedents in women with BED and each agent has distinct strengths and
concluded that poor mood directly preceded limitations, and patients should be matched
binge episodes. Depressive mood (i.e., with the treatment most likely to address their
sadness) has been the most frequently unique needs (18) .
examined negative emotion in this disorder.
Several cross-sectional, experimental and
 Bulletin of Integrative PsychiatryNew Series  December 2022 Year XXVIIINo. 4 (95)/37

COVID-19 PANDEMIC AND EATING tendency to symptom worsening, an

DISORDERS increasing by 48% in hospital admissions
The novel coronavirus has a great impact over compare to pre-pandemic time, increase in
mental health, individuals with eating anxiety and depression symptoms. (20)
disorders may be particularly affected by the Branley-Bellet. al(2020) evaluate the mental
distancing measures difficult access to mental well-being during pandemic in a study
health services, this exacerbating the effectuated in United Kingdom reporting from
problematic relationship with the food. a group of 129 females that 87% have a
worsened symptomatology concluding that
The lockdown has disrupted multiple routines social isolation, changes in living situation,
increasing psychological distress, impeding lack on physical activity, and time spent
the access to professional support and online impacted symptoms.(21) Phillipou et
treatment disruption, changes in meals plans al.(2020) conduct a Cross-sectional study on
and routine. Food insecurity and harmful 5469 individuals from Australia, witch 96%
messages from social media have been are women reporting an increase in binge
associated with exacerbation of the disorder. eating by 35.5%, a decrease by 43,4% in
Negative influence of mass media during physical exercises, and high anxiety
COVID-19 have a negative impact on eating levels.(22)In United States Kim S. et
disorder by stigmatizing messages regarding al.(2021) reported from 7317 participants
quarantine weight gain and panicking high levels of psychological destress
sensational news about pandemics. (14) compared to those without eating disorder,
high perceiving of stress and loneliness.(23)
A systematic review by Devoe. et al. have
examine data from 53 studies reporting a

CONCLUSIONS
Eating disorders have an increased incidence, numerous bio-psycho-social factors being involved.
The COVID-19 have a profound impact over the mental health, various factors like weight
stigmatizing messaging on media, disruptions of treatment, impeded access to personal/professional
support, changes in routines, lack of physical activities, worsen the symptomatology during
pandemic.

Public health must be involved in media messaging by encouraging nonstigmatizing weight-

inclusive alternatives, specific and realistic achievable behaviour, concise, clear and understandable
by everyone messages.

Multiple medical complication can appear in severe cases can be even life threatening.
Psychotherapy represents the first line of treatment together with hospital care, favourable results
can be obtained in most cases on the long term.

ACKNOWLEDGEMENTS AND DISCLOSURES

The authors declare that they have no potential conflicts of interest to disclose.

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Correspondence:

Dan Cătălin Oprea,

MD, residency training in psychiatry, Socola Institute of Psychiatry Iasi, [email protected]

Submission: 14.11.2022
Acceptance: 10.12.2022