COVID-19 and the Toll on Mental Illness, in the Context of Eating Disorders

Introduction

Mental illnesses are diseases of disconnection.  These illnesses consequently, create barriers, walls, and obstacles between the individual experiencing the illness and their loved ones. The illness itself thrives on solitude, loneliness, privacy, and closed doors. Pandemics are catalysts in creating scenarios that exacerbate illnesses. For example, social support and interactions are limited, a person’s daily routine is uprooted, in-person appointments are now virtual, creating a barrier to care. Additionally, gyms and workout facilities are closed, creating a toxic environment of feared weight gain throughout users of social media’s home workouts, and ‘flattening the curve’ of the coronavirus is the top priority, regardless of skyrocketing mental illness relapses.

Fictional Case Summaries

Bulimia Nervosa: Mrs. H is a 26-year-old female with a 13-year history of severe bulimia nervosa, recently in remission. Her exercise is finally healthy, for the appropriate reasons. She limits it to a 1-hour yoga class, rather than the excessive compensation where she would spend hours at the gym ‘working off’ a ‘fear food’ she had for lunch. Her ‘fear food’ is a food group/macronutrient that she tries to avoid because it is particularly provoking to her eating disorder, i.e., carbohydrates, regular pop, cookies, etc. She could not do her ‘normal,’ safe workouts anymore in an environment of yogis. During the shut-down, she was forced to do extreme home workouts in the seclusion of her home, with no one to check her behavior.

Binge Eating Disorder, Agoraphobia: Mr. K is a 32-year-old male with a history of binge eating disorder and agoraphobia. He has a history of extreme self-isolation and binge eating whenever his anxiety is elevated. Part of his recovery is to reconnect with past friends and family through Facebook. Since the pandemic, Facebook has become toxic to him. Facebook is full of posts featuring the feared “Quarantine 15lbs,” home workout videos, and tons of dessert and sourdough bread recipes. He has had to unfollow people due to the Quarantine workout challenges, obsession that others had about their body changing, bake-offs, and overall extreme negativity of others. Now he does not go on Facebook, but has continued behaviors that are destructive to his personal recovery.

Orthorexia, Generalized Anxiety Disorder: Mr. F is a 44-year-old man with a history of orthorexia and generalized anxiety disorder, well controlled with regular appointments and check-ins with his therapist. His in-person appointments are now virtual due to the pandemic. He lives with his wife and children, parents, and elderly grandmother in a 2-bedroom home. They have struggled financially for several years. Due to the close quarters of his home, he has not felt safe to openly discuss his condition with his care team, out of fear of being overheard. He has limited cellphone data and no access to the internet, so virtual appointments are very costly for him. Additionally, his orthorexia has been exacerbated due to the temporary closure of restaurants with ‘splurge foods’ and absurd lines for fast-food.

Anorexia Nervosa: Miss Z is a 45-year-old female with a history of anorexia nervosa. Her recovery has required laboratory tests and frequent EKGs from her Primary Care Physician to ensure her electrolytes are stable and her anemia has improved. During the pandemic, she has been unable to schedule an appointment at the hospital. Her condition is not ‘essential or life-threatening’. She has also needed to have weigh-ins with her therapist at her treatment center. Now, her lab work has been delayed due to its lack of ‘necessity,’ and she self-reports weigh-in values.

Binge Eating Disorder, Obsessive Compulsive Disorder: Ms. M is a 23-year-old female with a history of obsessive compulsive disorder and binge eating disorder. She is a 2nd year medical student studying for her Step 1 board exam. She is now forced to stay at home during the pandemic, rather than going to the school or coffee shops for long days of studying. Leaving home everyday helped remove herself from a toxic home environment, where many of her symptom use had previously occurred- obsessively checking the refrigerator, body checking, and binge episodes. Now she is trapped. Held hostage with her pantries full of food, and permanent bathroom and bedroom mirrors. This home environment may not suffice for a productive study space, which will wreak havoc on her medical education and Step 1 score.

Body Dysmorphia while in Social Isolation: Miss H is a 12yo female who has come to discover that her body looks different than her high-school aged sisters. Since the pandemic she has been surrounded by her sisters and their rhetoric about “the perfect body” which the 12 year old feels she does not have. She has heard their discussions, she has seen the looks on their faces as they stare in the mirror and speak harshly about themselves. Surrounded by negative rhetoric of her elder role-models, Miss H. has taken to escaping to the basement bathroom where she wonders if scissors would be an easier solution to shaping herself in her sisters’ image. Can scissors cut off fat?

Discussion

Bulimia Nervosa: Bulimia Nervosa is a form of disordered behavior that includes secretly and uncontrollably binging on excessive amounts of food and then using compensatory behavior, such as purging or excessively exercising to rid of the calories (7). On contrary to the ‘quarantine 15lbs’ weight gain, individuals in recovery or recovering from bulimia nervosa are in danger of over exercising on their own when organized and scheduled workout classes are canceled. According to a study in 2020 involving 203 participants, over one third of participants with bulimia nervosa, during the time of the COVID pandemic, reported an increase in their bulimic symptomatology (1). Overall, in patients experiencing bulimia nervosa, “depressive symptoms, general psychopathology, quality of life and therapy…were negatively affected” (1).

Binge Eating Disorder, Agoraphobia: Cyberbullying has taken a new lens via social media. Traditionally, cyberbullying consisted of one person bullying another. However, during the COVID pandemic, cyberbullying has taken the role of self-shaming, diet challenges, group workout videos, and new recipes. These collectively act as triggering foci for those with eating disorders or may even contribute to the primary development of disordered eating for others. Additionally, someone with agoraphobia is ultimately forced into isolation because of the stay-at-home orders, which is the exact opposite of what they should be doing to overcome their phobia. The pandemic has trended to more time spent on social media, away from people, and toward the toxic focus and “objectification of the thin ideal” while online (2). One study quotes an individual who is battling an eating disorder: “Social media mention that mentions weight gain during quarantine are triggering” (3). It is paradoxical how zoom/facetiming/google hangout technology has benefited social connectedness, while scrolling social media sites exacerbate the solitude and loneliness for those experiencing an eating disorder.

Orthorexia, Generalized Anxiety Disorder: The COVID pandemic is a time of stress, uncertainty, and disconnection. In a report from 2020, survey participants noted an increase in their anxiety from 2019, and overall, there was a greater concern for mental health than physical health during the pandemic (3). Everyone is having to live life in unprecedented ways: work, school, social functions. Those battling destructive mental health behaviors are newly relying on activities that had previously been harmful to recovery, such as cooking from home if their treatment included restaurant menus, limiting trips to the grocery stores if their treatment required fresh produce, or exploring new ways of body movement and physical activity if they had found refuge in the gym (2). People’s treatment teams and group therapies are also forcibly through telehealth technologies. In so many ways, telehealth is extraordinary- except when a video call ironically brings “heightened awareness of bodily self…prompt[ing] self-criticism” and harm to recovery (4). Ridding of on-site weigh-ins also forces someone recovering from an eating disorder to be grossly honest (2), subjecting a threat to their recovery and progress if they’re dishonest to both themself and therapist, as well as a traumatic affliction due to weight exposure.

Anorexia Nervosa: The world has witnessed unforeseeable acts of generosity and sacrifice: food deliveries for healthcare workers, thank-you letters to postal services, teachers devoting unpaid hours to virtual lesson plans, limiting the purchase of toilet-paper.  The generosity and sacrifice stretch too far in certain scenarios for those experiencing anorexia nervosa   thinking “[they] need to leave food for other people who actually need and deserve to eat and feeling like [they] don’t deserve to eat, as [they are] selfish” (4). A study conducted in Munich, Germany reported that 62% of study participants with anorexia nervosa had increased restrictive behaviors, fears regarding food scarcity, and the inability to comply with their meal plans (3). Healthcare guidelines advise those at high-risk for COVID to take extra precautions. Most people think ‘high-risk populations’ are the elderly, immunocompromised, cancer patients; generally, the “frailty in anorexia nervosa, electrolyte disturbances in bulimia nervosa, and cardiovascular risk in binge eating disorder (2)” are not included. The overall unawareness of eating disorder severity, regardless of a global pandemic, poses further concern for the existence and availability of resources for this ‘high-risk population.’

Binge Eating Disorder, Obsessive Compulsive Disorder: The beginning of the COVID pandemic was a time of food scarcity, toilet-paper hoarding, and empty shelves. It has been also a time of furloughs and unemployment. Binge eating can be problematic for families on a budget, accrue unnecessary costs, and further family conflict and tense emotionality (5), especially if high-risk binge foods have recently been stocked within a home (3). For those with eating disorders who found respite outside of their homes, away from their refrigerators and mirrors, a stay-at-home order did not provide them with safety. Having Obsessive Compulsive Disorder (OCD) and an eating disorder poses a severely devastating combination. A person can obsessively count and recount their budget while finding ways to eliminate their expenses for food (in the case of someone with restrictive eating) because “it saves money” or is “unnecessary.” Interestingly, both eating disorders and OCD are prominent in female healthcare workers (7). During a global pandemic, female healthcare workers have had the “tendency to put others’ needs before their own, negatively affecting their ability to manage their own health (2).”

Body Dysmorphia while in Social Isolation: During the pandemic, families have more close contact and interaction with one another than in the last 70 years. Unfortunately for many individuals with eating disorders, there is evidence that “parents… [are the] underlying causation of the illness (8).” This may be for several reasons: parents’ control of available food in the home, parents’ personal exercise and diet habits, or parents’ comparison and comments regarding other siblings in the home. For these reasons, “health professionals tended to perceive the family as trouble… [within treatment of an individual’s eating disorder and, therefore,] parents felt shut out and discouraged from being involved in their child’s care (8).” Alternatively, mental illness therapy and treatment has moved towards including families and friends within the care of a patient, such that the support system is encouraged to be involved with therapeutic sessions, exposure therapies, and appropriately having a role within a person’s recovery journey. “The only way we can actually do well with these girls is via the families (8),” though until family therapy is available again or alternative virtual therapies are implemented, the girls are left with inflicting trauma within their own homes throughout COVID.

Conclusion

I speak of the Coronavirus’ impact from the lens of eating disorders. However, the virus does not discriminate against any mental illness. The unique scenario of a global pandemic is that all people are affected by the new policies in place, ever-changing broadcasted news, and unfortunate devastation of this illness; not much else in the world has reached this level of impact. People have unique experiences, hardships, and levels of disruption the COVID pandemic has surmounted in their lives. Discussing the toll that COVID has on people suffering from eating disorders is just one conversation among many. Eating disorders are uniquely complex, destructive, and exacerbated in a time of food insecurity, closure of fitness centers, social isolation, and panic buying during a global pandemic. There is a lot of learning yet to do, and it is impossible to accommodate all realms of mental health when deciding the safest public health measures. Public health must pick its battles, but it is very challenging when the battle that is chosen throws a person experiencing an eating disorder on the frontline.

References

1. Schlegl, S, Meule, A, Favreau, M, Voderholzer, U. Bulimia nervosa in times of the COVID‐19 pandemic—Results from an online survey of former inpatients. Eur Eat Disorders Rev. 2020; 28: 847– 854. https://doi-org.ezp1.lib.umn.edu/10.1002/erv.2773
2. Fernández‐Aranda, F., Casas, M., Claes, L., Bryan, D.C., Favaro, A., Granero, R., Gudiol, C., Jiménez‐Murcia, S., Karwautz, A., Le Grange, D., Menchón, J.M., Tchanturia, K. and Treasure, J. (2020), COVID‐19 and implications for eating disorders. Eur Eat Disorders Rev, 28: 239-245. https://doi-org.ezp2.lib.umn.edu/10.1002/erv.2738
3. Termorshuizen, JD, Watson, HJ, Thornton, LM, et al. Early impact of COVID‐19 on individuals with self‐reported eating disorders: A survey of ~1,000 individuals in the United States and the Netherlands. Int J Eat Disord. 2020; 53: 1780– 1790. https://doi-org.ezp3.lib.umn.edu/10.1002/eat.23353
4. Shah, M., Sachdeva, M., & Johnston, H. (2020). Eating disorders in the age of COVID-19. Psychiatry Research, 290, 113122. doi:10.1016/j.psychres.2020.113122
5. Touyz, S., Lacey, H. & Hay, P. Eating disorders in the time of COVID-19. J Eat Disord 8, 19 (2020). https://doi.org/10.1186/s40337-020-00295-3