key: cord-0872581-58b9rhx3 authors: Castellini, Giovanni; Cassioli, Emanuele; Rossi, Eleonora; Innocenti, Matteo; Gironi, Veronica; Sanfilippo, Giulia; Felciai, Federica; Monteleone, Alessio M.; Ricca, Valdo title: The impact of COVID‐19 epidemic on eating disorders: A longitudinal observation of pre versus post psychopathological features in a sample of patients with eating disorders and a group of healthy controls date: 2020-08-28 journal: Int J Eat Disord DOI: 10.1002/eat.23368 sha: b85ff82911bb13d89eb5cc93f5b24514c9d55554 doc_id: 872581 cord_uid: 58b9rhx3 OBJECTIVE: the aim of this longitudinal study was to evaluate the impact of COVID‐19 epidemic on Eating Disorders (EDs) patients, considering the role of pre‐existing vulnerabilities. METHOD: 74 patients with Anorexia Nervosa (AN) or Bulimia Nervosa (BN) and 97 healthy controls (HCs) were evaluated before lockdown (T1) and during lockdown (T2). Patients were also evaluated at the beginning of treatment (T0). Questionnaires were collected to assess psychopathology, childhood trauma, attachment style, and COVID‐19‐related post‐traumatic symptoms. RESULTS: A different trend between patients and HCs was observed only for pathological eating behaviors. Patients experienced increased compensatory exercise during lockdown; BN patients also exacerbated binge eating. Lockdown interfered with treatment outcomes: the descending trend of ED‐specific psychopathology was interrupted during the epidemic in BN patients. Previously remitted patients showed re‐exacerbation of binge eating after lockdown. Household arguments and fear for the safety of loved ones predicted increased symptoms during the lockdown. BN patients reported more severe COVID‐19‐related post‐traumatic symptomatology than AN and HCs, and these symptoms were predicted by childhood trauma and insecure attachment. DISCUSSION: COVID‐19 epidemic significantly impacted on EDs, both in terms of post‐traumatic symptomatology and interference with the recovery process. Individuals with early trauma or insecure attachment were particularly vulnerable. mental health in this peculiar dramatic period (Brooks et al., 2020; Fiorillo & Gorwood, 2020; Shigemura, Ursano, Morganstein, Kurosawa, & Benedek, 2020; Yao, Chen, & Xu, 2020) . Preliminary reports indicated that during epidemic or disasters many persons experience negative emotional effects, due to the fear of contagion and of the death of family members (Cao et al., 2020; Wang, Di, Ye, & Wei, 2020) . Anxiety, sadness, anger and loneliness might also rise from social distancing and quarantine (Cao et al., 2020; Fernández-Aranda et al., 2020; Kavoor, 2020; Nguyen et al., 2020; Qiu et al., 2020; Wang, Di, et al., 2020) . More specifically, COVID-19 epidemic may have been experienced as a traumatic event, thus, resulting in an increase of post-traumatic stress disorder (PTSD) symptoms (Liu, Gayle, Wilder-Smith, & Rocklöv, 2020; . However, it has been suggested that people may have heterogeneous responses to the pandemic consequences, also on the basis of pre-existing psychopathological features (Fiorillo & Gorwood, 2020) , which might increase the vulnerability to the emotional consequences of any disaster-related trauma (Brooks et al., 2020) . Indeed, Yao et al. (2020) underlined the necessity of evaluating the effects of pandemic and isolation on patients with psychiatric disorders, and Brooks et al. (2020) and Fiorillo & Gorwood (2020) suggested that this persons might need extra-support in this particular situation. Persons with psychiatric disorders often report interpersonal difficulties which might exacerbate the effect of isolation, and preliminary findings seem to demonstrate that history of childhood maltreatment and attachment features predict the extent of mental health burden during the lockdown (Moccia et al., 2020) . From this perspective, patients with eating disorders (EDs) seem to represent a particularly vulnerable population to the effect of the unexpected environmental conditions during the COVID-19 pandemic, considering their specific psychopathology and the need for a continuous assistance in the active phase of their disorders (Touyz, Lacey, & Hay, 2020; Weissman, Bauer, & Thomas, 2020) . Indeed, the reduction of treatment implementation and the confinement have been hypothesized to possibly worsen psychological stress and the severity of ED specific symptomatology (Dalle Grave, 2020; Murphy, Calugi, Cooper, & Dalle Grave, 2020; Peckmezian & Paxton, 2020; Van den Berg et al., 2019) . Clinicians need to have clear information regarding the possible interference with the recovery process of patients with EDs already under treatment, and protocols should be optimized to manage this situation in the future. In particular, it is important to compare the longitudinal outcomes under normal treatment conditions with the ones during the lockdown, in order to understand whether adopting alternative forms of assistance (e.g., online visits) and isolation would impact health care of patients with EDs. However, up to now, the available literature on psychopathological consequences of lockdown following COVID-19 epidemic did not provide reliable information regarding the pre-epidemic period, in patients with EDs already under treatment at the beginning of the pandemic. Thus, the present study attempted to overcome this limitation, adopting a longitudinal design, and testing three main hypotheses. First, the study compared a group of patients with EDs with a group of healthy controls in terms of their psychological status before and after the lockdown, in order to evaluate whether participants with EDs represented a more vulnerable population to the effects of COVID-19 pandemic (hypothesis 1). Secondly, it was investigated whether the lockdown period significantly interfered with the recovery process (hypothesis 2): thus, the study evaluated the longitudinal outcome of patients already under treatment before the pandemic, considering the psychopathological changes intervening before and during the lockdown period, and comparing the results between diagnostic categories, namely Anorexia Nervosa (AN) and Bulimia Nervosa (BN). Finally, it was hypothesized that factors preceding the pandemic might be associated with worsening of psychopathology during the lockdown (hypothesis 3). In particular, it was evaluated whether having obtained a remission from EDs before the lockdown had a protective role on the psychopathological outcome during the pandemic. Furthermore, it was evaluated whether a history of childhood trauma or particular attachment style was associated with the psychopathological outcome during the lockdown, in terms of development of COVID-19-related PTSD symptoms, and evolution of EDs symptomatology. This is an observational, longitudinal study of a group of patients with EDs and of Healthy Controls (HCs), both evaluated a few months before the onset of COVID-19 epidemic (T1) and during lockdown (T2). Patients with EDs were also evaluated at the beginning of treatment (T0). The study was approved by the local Ethics Committee. All participants provided informed consent prior to study enrollment. Patients attending the Outpatient Clinic for EDs of the University of Florence were enrolled, providing they met the following inclusion criteria: female sex, aged 18-60 years, current DSM 5 diagnosis of AN or BN. Exclusion criteria were as follows: comorbid psychotic disorder, illiteracy, intellectual disability, severe medical conditions precluding outpatient treatment, current use of psychoactive medications except for antidepressant and benzodiazepines, which were kept stable during the study. The control group (which was deemed adequate since it was comparable in terms of gender and age) was initially recruited from the community of Tuscany by means of local advertisements, for a study about the psychopathology of EDs. Participants provided their consent to be re-contacted for further investigations on similar topics. Inclusion criteria for control group were: absence of any lifetime ED, evaluated by means of a structured interview (SCID-5-RV, First, Williams, Karg, & Spitzer, 2015) , and body mass index (BMI) between 18.5-25.0 kg/m 2 , and absence of intellectual disability, illiteracy, current/lifetime Axis I psychiatric disorders. The online survey was performed from April 22nd, 2020, until May third, 2020 (T2). The present time frame covered the advanced phase of the COVID-19 epidemic in Italy, starting 6 weeks after the Italian Government declaration of lockdown (Governo Italiano, Presidenza del Consiglio dei Ministri, 2020) until the last days of the so-called phase 1 of lockdown itself. The cohort of patients was initially enrolled for the longitudinal observation performed at the clinic between January and September 2019 (T0). Patients included in the study were all under treatment, and they were regularly re-evaluated with follow-up assessments every 3 months. The last follow-up performed by each patient before the detection of the first cases of COVID-19 in Italy was included in the present study and considered as a pre-lockdown evaluation (T1). All T1 assessments were carried out between November 2019 and January 2020. The control group was recruited from December 1, 2019 until January 15, 2020 (T1). Of the 86 Caucasian ED patients referred, 2 were excluded, 76 were available for the pre-lockdown follow-up (T1), and 74 were available for the in-lockdown follow-up (T2), with 7 dropouts and 3 lost to follow-up. Only these patients were included into the survey (37 with AN, 37 with BN). Of the 116 Caucasian participants referred for the control group, 7 were excluded and 97 were available for the second follow-up (in-lockdown). Sociodemographic and clinical data were evaluated regularly as part of the routine assessments for patients with EDs performed at the Outpatient Clinic for EDs, through a clinical interview by two expert psychiatrists (G.C., V.R.). All evaluations (T0, T1, T2) included the clinical interview and self-administered questionnaires to assess general (Brief Symptom Inventory, BSI) (Derogatis & Melisaratos, 1983) and ED-specific (Eating Disorder Examination Questionnaire, EDE-Q) (Calugi et al., 2018; Fairburn, 2008) psychopathology. T0 assessment also included questionnaires on early trauma (Childhood Trauma Questionnaire-Short Form, CTQ-SF) (Bernstein et al., 2003) and attachment style (Experiences in Close Relationships-Revised, ECR-R) (Fraley, Waller, & Brennan, 2000) . Moreover, during lockdown (T2) COVID-19-related post-traumatic symptoms were evaluated by means of a version of the Impact of Event Scale-Revised (IES-R) (Weiss & Marmar, 1997) which was specifically adapted for the investigation of COVID-19-related post-traumatic stress psychopathology. Finally, a dedicated, self-report questionnaire was administered at T2 to collect different information regarding variables of interest, such as lockdown conditions and variations in different areas of daily living. All these data were coded as dummy variables (absence/presence of a condition or a moderate to severe worsening/ change). During lockdown, data previously obtained through a face-toface clinical interview were collected in the same way via a telephone or an online video call, while the self-report questionnaires were converted into digital format and administered via a dedicated online platform. The only significant difference between pre-lockdown and inlockdown assessments was the online digital nature of the self-report questionnaires, as opposed to the previous paper format. Patients were considered in full remission, when they did not meet the DSM 5 criteria for any ED at T1 and T2 (including EDs not otherwise specified). In particular, the criteria adopted by Turner et al. (BMI > 18.5 ; no reported objective binges, vomiting, or laxative use in the past 28 days, EDE-Q total score under one SD above the community mean) were considered (Turner, Marshall, Stopa, & Waller, 2015) . Crossover was defined as a diagnostic change toward a different ED diagnosis (this outcome variable also included those AN restricting type patients who developed binge/purge behaviors). The aforementioned variables were defined according to the DSM 5 criteria and were collected by means of a structured interview performed by two expert psychiatrists (G.C., V.R.) (First et al., 2015) . During the pre-lockdown period, eligible patients were provided with an individual Enhanced Cognitive Behavioral Therapy (Fairburn, 2008) , with a frequency of one session per week (which varied according to the treatment phase). During the lockdown, patients received online medical examinations to assess their general psychopathological and clinical conditions, and psychotherapy sessions delivered via internet using a webcam, with the same therapists and the same frequency with which they were carried out before the lockdown. In the T0-T1 period, the patients included in the study had performed on average 30 psychotherapy sessions, while in the T1-T2 period they performed on average 16, of which the last 6 or 7 were online via webcam due to the lockdown measures. Longitudinal data are illustrated in Figure 1 . 3.2 | Psychopathological variations before and during the lockdown For dichotomous variables, data are reported with frequencies and percentages, and differences between patients and HCs were studied using Binomial Logistic Regression (adjusted for age and education). Age is reported as mean ± SD and was compared using ANOVA. All statistical analyses were adjusted for age and education; statistically significant comparisons are indicated in bold Table S1 . Considering diagnostic changes before and after the lockdown, at 3.3 | Pre-lockdown predictors of psychopathological outcome during the pandemic in patients with EDs Having obtained remission at T1 did not affect the trend of psychopathology or physical exercise in the subsequent T1-T2 period. Indeed, Time*Remission interaction was not found to be significant when inserted in the model. However, a significant interaction was found in the binge-eating model, indicating that most of the patients who had achieved remission at the previous follow-up showed a relapse of binge eating symptomatology at T2 (T1: 0.75 ± 0.94, T2: 4.24 ± 5.79; Cohen's d: 0.64) ( Figure S1 ). (Weissman et al., 2020) , and by the obstacles in treatment protocols. A further confirmation to this interpretation is represented by the association between environmental conditions during the lockdown such as household arguments and the fear for the safety of loved ones with the increase of symptoms severity during the pandemic. Indeed, fear and adverse conditions during the forced cohabitation might increase stress, consequently promoting binge eating. The interpretation of results in the group of patients with AN appeared to be more controversial. From one side these patients showed a further improvement of ED psychopathology and a progressive weight gain during lockdown. Furthermore, for some important variables such as EDE-Q scores, all groups did not report any decline at T2 as compared with T1, and in the case AN they even show further improvements. This result could be explained as a kind of consequence of the efficacy of the treatment patients continued to receive. Therefore, this is a further confirmation of the importance of etherapy for patients with eating disorders in a period of lockdown and difficulties to access to public services (Weissman et al., 2020) . On the other hand, patients with AN experienced an exacerbation of compensatory physical activity, and a non-negligible number of them experienced diagnostic crossover. Thus, even though the quarantine appeared to have less impact on patients with AN as compared with BN, both groups of patients reported a worsening of pathological behaviors, which could represent a possible hint of an imminent exacerbation of the disease. According to previous observations on general population (Qiu et al., 2020; Wang, Di, et al., 2020) , a non-negligible number of HCs reported a self-perceived worsening of their mental health status from different points of view, including anxiety, sadness, and sleep. However, in the present sample, patients with EDs did not report a more severe increase of these symptoms as compared to HC. This result could be interpreted considering that participants with EDs who often report a severe social isolation might have been less sensitive to the lockdown effects, and thus to its psychopathological consequences. Regarding the lack of significant worsening of ED-specific psychopathology in patients, putative positive meaning of confinement might be the reduced exposition to the gaze of the others, and to the judgment or criticisms from friends, doctors, or other family members. Accordingly, this point might explain the lack of significant increase of weight and shape concern in a period of less-intense treatment. As far as COVID-19-related post-traumatic stress symptoms are concerned, an increase of interpersonal and family conflicts, probably exacerbated by the forced cohabitation during lockdown, was found to be associated with greater symptomatology, as measured by IES. In particular, it is interesting to note that among patients with AN IES scores were predicted by greater emotional and sexual abuse as well as avoidant attachment style, while anxious attachment style predicted IES scores in BN patients. According to previous observations (Brady, 2008; Striegel-Moore, Dohm, Pike, Wilfley, & Fairburn, 2002) , it is reasonable to conclude that individuals with a history of childhood abuse may be particularly vulnerable to emotion dysregulation associated with increased family conflicts during forced cohabitation, thus reporting greater PTSD symptoms. The present study had some limitations: the sample size is quite small, and patients included were all under treatment. The T1-T2 interval included some weeks preceding the beginning of the lockdown, thus it is not possible to completely separate the change occurring before and after the lockdown. However, it is important to note that given the extraordinary and unpredictable nature of the COVID pandemic, it was impossible to plan a study with closer follow up time points. Furthermore, considering that only patients received a treatment and that HCs did not receive any form of support during the lockdown, it might not be possible to separate treatment effects from the virus/lockdown effects. The lockdown phase was mostly evaluated with online questionnaires. Finally, no baseline levels of the Impact of Event Scale-Revised (IES-R) were available, considering that this instrument was administered in order to assess the specific COVID-19-related post-traumatic stress psychopathology. Overall, the study highlighted that quarantine during COVID-19 epidemic interfered with the recovery process of patients with ED, in terms of relapses of pathological eating behaviors. Bulimic patients and those without remission seem to be more vulnerable, while participants with a history of childhood abuse were more likely to report PTSD symptoms related to the pandemic. The implementation of technological interventions to provide telemedicine and online treatments (including family psychoeducation) might allow clinicians not just to maintain the good results of the previous interventions but also to monitor potentially damaging adverse environmental factors. None. 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The data that support the findings of this study are available from the corresponding author upon reasonable request.