COVID Lockdowns Linked to PTSD in Patients With Eating Disorders

Liam Davenport

April 28, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

COVID-19 and its resulting lockdowns are linked to posttraumatic stress disorder (PTSD) symptoms and other adverse outcomes among patients with eating disorders (EDs), two new studies show.

Results of the first study show that patients with EDs had more stress, anxiety, depression, and PTSD-related symptoms during the lockdowns than their mentally healthy peers.

In the second study, treatment-related symptom improvement among patients with bulimia nervosa (BN) slowed following lockdown. In addition, patients with BN or anorexia nervosa (AN) experienced significant worsening of disorder-specific behaviors, including binge eating and overexercising

Because of the strict lockdown measures introduced by the Italian government to contain the COVID-19 pandemic, "everyday life of all citizens was disrupted," Veronica Nisticò, MS, Università Degli Studi Di Milano, Italy, who led the first study, told delegates attending the virtual European Psychiatric Association (EPA) 2021 Congress.

In addition to difficulties in accessing healthcare, "it became difficult to go to the supermarket, to the gym, and to have the social support we were all used to," all of which had a well-documented impact on mental health, she added

Loss of Control

Previous research suggests that individuals with EDs experience high levels of anxiety and an increase in binge eating, exercise, and purging behaviors, said Nisticò.

To investigate further, the researchers conducted a longitudinal study of the changes in prevalence of adverse outcomes. In the study, two assessments were conducted.

In the first assessment, conducted in April 2020, the researchers assessed 59 outpatients with EDs and 43 unaffected hospital staff and their acquaintances. The second group served as the control group.

Participants completed an online survey that included several standardized depression and anxiety scales, as well as an ad hoc survey adapted from the Eating Disorder Examination Questionnaire. This assessed changes in restrictive dieting, control over food, body image, and psychological well-being in comparison with prepandemic levels.

The results, which were also recently published online in Eating and Weight Disorders ― Studies on Anorexia, Bulimia and Obesity, showed that patients with EDs experienced significantly more stress, anxiety, depression, and PTSD-related symptoms in comparison with control persons (P < .05 for all).

In addition, the investigators found that those with EDs were more fearful of losing control over their eating behavior, spent more time thinking about food and their body, and became more uncomfortable seeing their body than before the lockdown in comparison with those without EDs (P < .05).

Clinical Implications

A second assessment, which occurred in June 2020, after lockdown restrictions were lifted, included 40 patients with EDs who had taken part in the first assessment. This time, participants were asked to compare their current eating behavior to their eating behavior during the lockdown.

Although the lifting of lockdown restrictions was associated with significant improvement in PTSD-related symptoms, the impact on stress, anxiety, and depression persisted.

These findings, said Nisticó, support the hypothesis that specific conditions that occurred during the lockdown had a direct effect on specific eating disorder symptoms.

These findings, she added, should be considered when developing interventions for EDs in the context of individual psychotherapy and when designing large, preventive interventions.

In the second study, Eleonora Rossi, MD, Psychiatric Unit, Department of Health Sciences, University of Florence, Florence, Italy, and colleagues examined the longitudinal impact of the pandemic on individuals with EDs.

They examined 74 patients with AN or BN who had undergone baseline assessments and had completed a number of questionnaires in the first months of 2019 in conjunction with being enrolled in another study.

Participants were treated with enhanced cognitive-behavioral therapy and were reevaluated between November 2019 and January 2020. They were then compared with 97 healthy individuals.

Bulimia Patients More Vulnerable

After the outbreak of the pandemic, most treatment was administered online, so patients were able to continue therapy, Rossi said during her presentation.

All participants were assessed again in April 2020, 6 weeks after the start of Italy's lockdown.

The results, which were published in the International Journal of Eating Disorders, show that the patients with EDs "underwent a significant improvement in terms of general and eating disorder specific psychopathology" during the first treatment period, Rossi reported. In addition, among those with AN, body mass index increased significantly (P < .05 for all).

Patients with AN continued to improve during the lockdown when therapy was administered online. However, improvements that had occurred among those with BN slowed, Rossi noted.

In addition, both groups of patients with EDs experienced a worsening of their pathologic eating behaviors during the lockdown, in particular, objective binge eating and compensatory physical exercise (P < .05).

"Indeed, the positive trajectory of improvement observed before lockdown was clearly interrupted during the pandemic period," Rossi said. This could "represent a possible hint of an imminent exacerbation of the disease."

The results also suggest that the occurrence of arguments within the household and fear regarding the safety of loved ones predicted an increase in symptoms during the lockdown, she added.

In addition, patients with BN reported more severe COVID-related PTSD symptoms than did those with AN and the control group. This increase in severity of symptoms was more prevalent among patients who had a history of childhood trauma and among those with insecure attachment, suggesting that such patients may be more vulnerable.

Evidence of Recovery

Commenting on the studies for Medscape Medical News, David Spiegel, MD, associate chair of psychiatry, Stanford University, Palo Alto, California, noted that EDs commonly occur after physical or sexual trauma earlier in life.

"It's a standard thing with trauma-related disorders that any other, even relatively minor, traumatic experience can exacerbate PTSD symptoms," said Spiegel, who was not involved in the studies. In addition, the trauma of the COVID pandemic "was not minor," he added.

"The relative isolation and the lack of outside contact may focus many people with eating disorders even more on their struggles with how they are taking care of their bodies," said Spiegel.

"It struck me that the anorexia nervosa group were more impervious than the bulimia nervosa group, but I think that's the case with the disorder. In some ways it's more severe, obviously a more life-threatening disorder," he added.

The "hopeful thing is that there seemed to be some evidence of recovery and improvement, particularly with the posttraumatic stress exacerbation, as time went on," Spiegel said, "and that's a good thing."

The study authors and Spiegel report no relevant financial relationships.

European Psychiatric Association (EPA) 2021 Congress: Abstracts O059 and 0071. Presented April 10, 2021.

Eat Weight Disord. Published online February 13, 2021. Full article

J Eat Disord. Published online August 28, 2020. Full article

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