Statistic of Those to Continuously Battle Against Anorexia
For people with anorexia, COVID-19 presents new challenges
The disruption of daily life due to COVID-19 poses new stressors for those with eating disorders or pursuing recovery.
Several weeks into COVID-19 isolation, Shira Strongin could feel her anxiety escalating and her negative thoughts circling. She was sleeping late and trying to keep up with online college courses — all excuses to skip breakfast and other meals or snacks. It didn't help that she was experiencing some stomach issues.
As part of Strongin's recovery since she completed treatment for anorexia nervosa last November, she's not supposed to regularly weigh herself so as not to become overly preoccupied with the numbers. But she recognized the emerging signs of a relapse. When she stood on a scale March 25, she weighed in eight pounds less than three weeks before. Strongin has since enrolled in an intensive outpatient program, which she started attending virtually through video sessions in early April. The 21-year-old describes her move to seek help as a preventive step.
"If I go down the full-blown relapse rabbit hole, I'm not going to be able to get the kind of help I need and get the kind of [in person] treatment that I need for a very long time."
The disruption of daily routines due to COVID-19 poses particular stressors for those with eating disorders or pursuing recovery, psychologists say. Anxiety and obsessive-compulsive disorder, which already plays a role in some eating disorders, may be understandably amplified by pandemic uncertainties and worries about inadvertent contagion, they say. Meanwhile, procuring food is more fraught for everyone now, as social distancing guidelines encourage limiting of grocery shopping trips and shoppers are finding shortages when they do make it to the store.
Psychologists who treat eating disorders, whether it's anorexia nervosa, binge eating disorder or bulimia nervosa, focus a lot on helping patients build anxiety-management skills and create routines and structures around meals and snacks, says Christina Wierenga, PhD, an associate professor of psychiatry at the University of California San Diego who specializes in eating disorders. "We don't have the data, but I wouldn't be surprised if this crisis contributes to a higher relapse rate," Wierenga says. "Often times people in recovery do well because they can eat the same food over and over again."
But Wierenga and other psychologists note that the pandemic also has boosted creative energy in the field, as they search for and share notes about ways to use video and other tech tools to better support patients amid isolation. Among some strategies: scheduling video sessions over meals and joining patients virtually on a walk through the grocery store. With screen sharing, one possibility is that a psychologist can help a patient fill a grocery cart through an online delivery service, brainstorming alternative foods in real time, says Cynthia Bulik, PhD, founding director of the University of North Carolina Center of Excellence for Eating Disorders in Chapel Hill, North Carolina.
"Creativity and flexibility is the name of the game right now," Bulik says. "You can do a lot without actually being in the room."
COVID-19 challenges
Part of treatment in a non-COVID-19 time involves working with patients on ways to get out more, becoming more connected with others and join activities, Wierenga says. "Isolation is a real concern. Our patients tend to socially isolate anyway. They have social anxiety. A lot of times they're depressed."
Plus, the very real worry about contracting the virus can serve as a crutch to further isolate and restrict food, says Nancy Zucker, PhD, who directs the Duke Center for Eating Disorders in Durham, North Carolina. "Self-deception is such a dangerous thing on the best of days," she says. "It would be so easy to talk oneself into the fact that, 'No, it's safer for me to stay inside and not go out and get food.'"
For that reason, it's important to push for specifics, Zucker says. If patients say they have "enough food" at home, Zucker will ask them to detail what's in the refrigerator and on their cupboard shelves.
To protect patients from losing hard-won ground in recent weeks, Bulik and Zucker have helped them think through and build a new routine as onsite classes shut down, gyms close and job circumstances change. "When someone is recovering, one of the things that protects someone is schedules and routines, filling the space, and kind of suffocating out the eating disorder," Zucker says.
Bulik has worked with a patient during video sessions, perhaps using screen share when feasible, to block out a schedule of activities around the daily regimen of meals and snacks. While tech-related creativity is important, don't lose sight of compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), she cautions.
One persistent challenge is that it's more difficult for psychologists to check their patients' physical health virtually, Wierenga says. As UCSD moves primarily to virtual sessions, there's been discussion about buying blood pressure cuffs for patients to take readings at home, she says. Watching out for a low heart rate is especially important if someone has been recently hospitalized or hasn't returned to their recommended weight, she says.
Monitoring weight for home-bound patients also is problematic, Wierenga says. At UCSD, patients are typically being asked to come in once a week. That varies depending upon the patient's circumstances, but it's less than the three times weekly approach during partial hospitalization, she says.
Stretch opportunities
While unsettling for all involved, this period presents opportunities for growth, Zucker says. Someone with an eating disorder may be very rigid about food choices, she says, "and those safe foods may not be available." Psychologists can work with patients to settle on alternative foods to challenge themselves with, ideally before they go shopping, she says.
With coaching, patients may learn to lean more on partners and others in the home, strengthening bonds, Bulik says. "It's a time where radical honesty might actually help bring your partner on board."
Two days after Strongin stood on the scale, she temporarily moved from her Washington, D.C., studio apartment to live with her parents nearby. "Just being isolated in my room was not super helpful or healthy," she says.
Shortly before starting intensive outpatient treatment, her voice sounds strong and buoyant. It feels good, she says, to have a plan. (She subsequently moved back to her apartment once she started treatment, as the set up was better to comply with the Health Information Portability and Accountability Act).
While Strongin likes a lot of aspects of video therapy, such as talking from the comfort of home, she agrees that it's easier for patients to camouflage.
People are more likely to wear baggier clothes at home, and video tends to focus on the face and upper body, making it more difficult to detect weight changes than in person, she points out. Strongin knows of patients who continue to body check, measuring their arms and wrists during the session, outside of the therapist's view.
"I hope that therapists don't let up on their patients," she says. "Finding creative ways to keep patients accountable is really important."
Helpful resources
- Academy for Eating Disorders: The professional organization offers online discussion groups for members along with resources.
- National Center of Excellence for Eating Disorders: The center has compiled an online library broken into sections for patients, parents and health-care providers.
- National Eating Disorders Association (NEDA) hotline: (800) 931-2237. The hotline is staffed by volunteers. Hours that are open for calling are listed online. For crisis situations, text "NEDA" to 741741.
- NEDA COVID-19 Forum: In addition to its other forums, NEDA has set up a moderated forum to explore concerns and challenges during the pandemic.
- F.E.A.S.T.: This nonprofit group for loved ones of those with eating disorders has compiled resources for navigating the pandemic, including links to their parent forums.
Source: https://www.apa.org/topics/covid-19/eating-disorders
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