Eating disorders in times of the COVID‐19 pandemic—Results from an online survey of patients with anorexia nervosa

Abstract Objective The COVID‐19 pandemic and the resulting public restrictions pose a psychological burden for humans worldwide and may be particularly detrimental for individuals with mental disorders. Therefore, the current study explored effects of the COVID‐19 pandemic on eating disorder (ED) symptoms and other psychological aspects in former inpatients with anorexia nervosa (AN). Method One‐hundred and fifty‐nine patients with AN—discharged from inpatient treatment in 2019—completed an online survey on contact history with COVID‐19, changes in ED symptoms and other psychological aspects, health care utilization, and strategies patients employed to cope during the pandemic. Results Approximately 70% of patients reported that eating, shape and weight concerns, drive for physical activity, loneliness, sadness, and inner restlessness increased during the pandemic. Access to in‐person psychotherapies and visits at the general practitioner (including weight checks) decreased by 37% and 46%, respectively. Videoconference therapy was used by 26% and telephone contacts by 35% of patients. Patients experienced daily routines, day planning and enjoyable activities as the most helpful among the most used coping strategies. Discussion The COVID‐19 pandemic poses great challenges to patients with AN. ED‐related thoughts and behaviors may be used as dysfunctional coping mechanisms to regain control over the current circumstances. E‐mental health interventions appear to be promising for supporting AN patients during these hard times. Furthermore, interventions addressing symptoms of depression and anxiety, as well as intolerance of uncertainty might help them manage their ED symptoms.

Governments imposed restrictions to slow down the spread of the disease to relieve the health system. Rules like social distancing and the shutdown of the societal life including schools and universities forced us to restructure our everyday life and social habits. An increase in the prevalence of anxiety and depression from 4% in 2019 to 20% in 2020 has been observed in the Chinese general population (Li et al., 2020). This raises concerns about the effects that the pandemic might have on existing mental illnesses.
Anorexia nervosa (AN) is a serious psychiatric illness that is associated with a low level of openness to unexpected events and avoidance of uncertainty (Hempel, Vanderbleek, & Lynch, 2018).
Thus, weight, shape, and eating concerns may increase during times when the sense of self-control decreases by external factors such as occurring in the present crisis (Fairburn, Shafran, & Cooper, 1999). An increase in eating disorder (ED) concerns may be further promoted by increased time spent on social media (Holland & Tiggemann, 2016). In addition, restrictions on doing grocery shopping may have multiple effects on eating behavior.
On the one hand, they may foster skipping meals and restricting calories but, on the other hand, they may also increase binge eating due to the increased availability of food at home brought about by food insecurity and hoarding of food (Touyz, Lacey, & Hay, 2020;Weissman, Bauer, & Thomas, 2020). Thus, in times of uncertainty and instability, ED symptoms may increase as their functions can be providing control and/or safety.
However, due to the recency of the COVID-19 pandemic, hardly any scientific studies are available. In a telephone survey of 32 patients with different EDs, 38% of patients reported increased ED symptoms and 56% reported an increase in anxiety (Fernandez-Aranda et al., 2020). Most of the patients also expressed worries about adverse effects on their treatment (Fernandez-Aranda et al., 2020). To ensure access to evidencebased treatments, a reconsideration of standard treatment approaches (Touyz et al., 2020), an increased use of self-help resources and e-health interventions have been suggested (Weissman et al., 2020). Additionally, strategies and recommendations for dealing with the COVID-19 pandemic have been proposed for patients with EDs as well as for their carers and therapists (Fernandez-Aranda et al., 2020).
Due to the lack of empirical data on the impact of the current pandemic on patients with AN, the aim of this study was to explore psychological consequences of the COVID-19 pandemic, changes in health care utilization, and possible strategies to cope with these times. Furthermore, differences in responses between adolescents and adults as well as between underweight and normal weight patients were analyzed exploratorily.

| Study participants
Former inpatients with AN who had received treatment at Schoen Clinic Roseneck (Prien am Chiemsee, Germany) and who were discharged in 2019 were contacted by e-mail and invited to complete an anonymous online survey (duration approximately 15 minutes) via www.unipark.com.

| Survey procedures and questions
Germany was in lockdown approximately from end of March to end of April 2020 (depending on the region), and the survey was conducted in the first week of May 2020. One reminder was sent 1 week later. The patients were told the following purpose of the study: "The COVID-19 pandemic has profoundly changed our everyday lives. The associated challenges can influence the symptoms of mental illnesses. To systematically investigate its impact on patients with EDs, we would kindly ask you to take part in our survey." Institutional review board approval and electronic informed patient consent were obtained.
We used a self-developed (by a team of clinicians, psychotherapists and researchers) questionnaire (see Data S1) to assess psychological consequences of the COVID-19 pandemic, which was divided into: (a) Sociodemographic and other information such as age, current selfreported height and weight, occupational situation during the COVID-19 pandemic, and contact history with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2); (b) Overall impact of the COVID-19 pandemic on ED symptoms, incidence of new symptoms, quality of life, and therapy (5-point scale with 1 = strongly agree to 5 = strongly disagree); (c) Changes during the pandemic regarding specific ED symptoms, exercise, and other eating-related behaviors (5-point scale from 1 = significantly worsened/much more often to 5 = significantly improved/ much less often); (d) Changes during the pandemic regarding general psychopathology (depressive symptoms, anxiety, other general psychopathology symptoms) (5-point scale with 1 = significantly worsened to 5 = significantly improved); (e) Worries, for example regarding infections, relapses, food insecurity, finances, and job (5-point scale with 1 = extremely worried to 5 = not at all worried); (f) Changes during the pandemic regarding interpersonal conflicts (5-point scale with 1 = significantly worsened to 5 = significantly improved); (g) Health care utilization before and during the COVID-19 pandemic; (h) Use and helpfulness of   (Cohen, 1988) and number needed to take (NNT, 9 = small effect, 4 = medium effect, and 2 = large effect) (Kraemer, 2015;Kraemer, Neri, & Spiegel, 2020) were calculated to estimate effect sizes for continuous and categorical variables, respectively. NNT was initially developed to compare treatment outcomes (number of patients needed to be treated to prevent one "failure" or negative outcome that would have occurred had the patient received the control treatment). We applied NNT to address in our study the question of "how many adults do you have to ask to find one more "failure" (e.g., one more adult patient who endorses that the pandemic worsened their ED symptoms) than if you had sampled adolescents"?
T A B L E 2 Impact of the COVID-19 pandemic on patients with anorexia nervosa

| Use and helpfulness of coping strategies during the COVID-19 pandemic
The strategies rated most useful among those most used by patients with AN were daily routines, day planning, enjoyable activities and mild physical activities. Figure 1 shows the mean responses to questions on the use and helpfulness of different strategies.

| Positive consequences of the COVID-19 pandemic
Forty-one (25.8%) of patients responded to the open-ended question. We only extracted answers related to positive consequences since most answers were related to this aspect. We identified "reduction in overall ED symptoms/taking on responsibility to recover", "reduction in specific ED symptoms", "more flexibility regarding meals and foods", "wake-up call/will to live", "trying out therapy content" and "accepting uncertainty in life" as broad themes. Exemplary quotes of the broad themes are given in Table 3.

| Responses as a function of age and body weight
In Data S2, responses of patients with AN are presented for adults vs. adolescents and underweight vs. normal weight patients, respectively.
When comparing adults and adolescents with AN (see Tables S1 and S2), we found medium effects with adults reporting more worries that others might be infected and with adolescents of being more frequently weighed by a therapist or a general practitioner before and during the pandemic. Adolescents also rated mindfulness and the opportunity to learn what one never had time to do as more helpful.
Additionally, there were several small effects with adults being in general slightly more affected and reporting a somewhat greater impairment of therapy than adolescents, with the exception that the latter ones reported somewhat more positive eating-related behaviors.
Drive for physical activity and exercise behaviors were relatively comparable between the two groups.
When comparing underweight and normal weight patients with AN (see Tables S3 and S4), we found medium effects for underweight patients who rated relaxation exercises and meditation as more helpful than normal weight patients. We found no differences regarding F I G U R E 1 Mean responses to questions on helpfulness of coping strategies. Higher scores represent higher helpfulness ratings. The values in parentheses reflect the percentages of patients that used the strategies depressive symptoms and worries, but several small effects regarding other symptoms and health care utilization.

| DISCUSSION
This is the first survey that comprehensively investigated the impact of the COVID-19 pandemic in a large sample of former inpatients with AN.

| Summary of results
While overall more patients with AN reported a worsening of symptoms, a considerable subset disagreed that their symptoms had wors- ened. An emergence of new symptoms was the exception and most patients succeeded in maintaining their weight. Quality of life deteriorated in half of patients, and many patients reported increases in depression and anxiety symptoms. Despite a decreased access to in-person psychotherapy and visits at the general practitioner including weight checks, only one in five patients reported that their treatment was deeply impaired by the pandemic. Finally, most of the patients used several coping strategies and experienced these as fairly helpful to helpful.

| Impact on ED symptoms
A substantial subset of patients reported an increase in ED cognitions and drive for physical activity. Although our data are cross-sectional and preclude discussion of temporal or causal relationships, we hypothesize that increased symptoms of depression and anxiety experienced during the pandemic may have contributed to an increased drive for physical activity as one of the functions exercising serves in patients with AN is affect regulation (Meyer, Taranis, Goodwin, & Haycraft, 2011). Similarly, focusing attention on weight and shape might have been a maladaptive strategy to cope with intolerance of uncertainty, and symptoms of depression and anxiety. In line with this, a study by Frank et al. (2012) found that intolerance of uncertainty was positively correlated with depression, drive for thinness and body dissatisfaction. Furthermore, a study by Naumann, Tuschen-Caffier, Voderholzer, and Svaldi (2014) reported that rumination in response to sadness (which was the most prevalent depressive symptom in our sample) had detrimental effects on ED symptoms.
Although a substantial subset of patients reported an overall worsening of their ED symptoms, many reported that the pandemic did not or only slightly affect their ED symptoms and some even reported improvement of symptoms. Furthermore, most patients succeeded in maintaining their weight. There are several potential reasons to explain this finding. First, all patients were former inpatients and, thus, they might have used some of the adaptive coping strategies they acquired during treatment. Second, most patients indicated that they were still receiving therapy during the pandemic, which likely helped to prevent relapse. Third, patients had a relatively high BMI and might have already experienced self-efficacy regarding managing their ED. Finally, there might have been at least a subset of patients (especially the younger ones) who returned to their parents' place and might have had a more regular meal structure, and experienced more social connectedness (despite the potential of increased family conflicts).

| Impact on symptoms of depression and anxiety
Many patients also indicated that symptoms of depression and anxiety increased during the COVID-19 pandemic. These results are in line with previous studies that have shown increases in symptoms of depression and anxiety, and loneliness in the general population (Fitzpatrick, Harris, & Drawve, 2020;Li et al., 2020). Furthermore, we investigated a sample of women, probably mostly unmarried, two factors that contributed to a higher likelihood of experiencing depressive symptoms during the COVID-19 pandemic in the general population (Fitzpatrick et al., 2020). Moreover, intolerance of uncertainty has been found to be a risk factor for symptoms of depression and anxiety in general (Mahoney & McEvoy, 2012). As intolerance of uncertainty is highly prevalent in individuals with EDs (Brown et al., 2017;Kesby, Maguire, Brownlow, & Grisham, 2017), feelings of uncertainty due to the COVID-19 pandemic may have contributed to increases in symptoms of depression and anxiety in the current sample. Also, the majority of patients reported increases in loneliness during the pandemic, which has been identified as a predictor of depressive symptoms in general (Cacioppo, Hughes, Waite, Hawkley, & Thisted, 2006).
Accordingly, more than half of the lonely participants met criteria for depression during the COVID-19 pandemic in the general population (Killgore, Cloonan, Taylor, & Dailey, 2020).

| Impact on health care utilization
Regarding health services use during the pandemic, we found a decreased access to in-person psychotherapy, but only a third of patients with AN used videoconference therapy and/or online interventions. This is not in line with suggestions that the COVID-19 pandemic might be a turning point for e-health (Torous & Wykes, 2020;Wind, Rijkeboer, Andersson, & Riper, 2020). Also, the editorials on the COVID-19 pandemic and EDs suggested to use digital interventions to ensure access to evidence-based treatments (Fernandez-Aranda et al., 2020;Touyz et al., 2020;Weissman et al., 2020), and guidance for delivering distance cognitive-behavioral therapy and family-based treatment for EDs is available (Matheson,

| Responses as a function of age and body weight
Regarding exploratory subgroup analyses, our findings suggest a somewhat different impact of the pandemic as a function of age and body weight with adults and underweight patients being slightly more affected than adolescents and normal weight patients. To the best of our knowledge, no studies exist so far that compare mental health consequences of the pandemic between adults and adolescents, neither in the general population nor in patients with mental health conditions. As differences between age and body weight groups were mostly of small magnitude, future evidence is warranted that corroborates these findings.

| Clinical implications
Our findings may have some implications for treating patients with AN during the pandemic. For example, strategies for learning to control the ED mindset such as described by Fairburn (2008) might be useful. Given the increases in symptoms of depression and anxiety, interventions aimed at helping patients cope with these symptoms might help manage their ED symptoms. As Cooper et al. (2020) have suggested, behavioral activation (such as activity monitoring and scheduling or assessment of goals and values) might be indicated to treat increased depressive symptoms and also holds promise in treating anxiety (Stein, Carl, Cuijpers, Karyotaki, & Smits, 2020). In addition, elements from acceptance and commitment therapy (ACT) (Hayes, Strosahl, & Wilson, 1999) might be applied to help patients better cope with intolerance of uncertainty. ACT might also be used to help patients explore life goals and values and to motivate or support them to view the pandemic as an opportunity to rethink life.

| Limitations
Several limitations should be considered when interpreting the current results. First, we only assessed women with AN who were discharged from inpatient treatment the year before and had a relatively high mean BMI. Therefore, results may not be transferable to women with AN who have not yet received therapy or are still at the very beginning and to other persons with other EDs. Second, all data were self-reported and, thus, may potentially be biased. For example, it cannot be excluded that at least some symptom worsening was not directly attributable to the COVID-19 pandemic. Furthermore, body weight was based on self-report, yet, women with AN are very accurate when self-reporting their own weight (McCabe, McFarlane, Polivy, & Olmsted, 2001;Meyer, Arcelus, & Wright, 2009). Third, we only assessed how often e-mental-health interventions were used, but not how often they were offered. Thus, it might be that the small percentage of patients using such interventions might not be attributable to a lack of interest or an unwillingness on patients' side, but to the fact that therapists did not offer such interventions.

| Future research
Future studies should explore whether there are more hindering factors on therapists' or on patients' side for using e-health interventions.
Furthermore, exploring the view and burden of caregivers and/or therapists during the pandemic might be interesting. Finally, longitudinal analyses might help shed light on how long lasting the negative effects reported by the patients are and if they will remit spontaneously or if additional treatment is needed.

| CONCLUSION
Taken together, this study suggests that during the COVID-19 pandemic, patients with AN were at risk for deterioration of ED and general symptoms and help-seeking may increase after the crisis. More flexible treatment modalities should be considered in treatment and relapse prevention.

ACKNOWLEDGMENT
Open access funding enabled and organized by Projekt DEAL.