Eating disorders in the era of the COVID-19 pandemic.

COVID-19 pandemic and its socio-economic consequences have been influencing considerably the Greek population and especially those people that are vulnerable or are actually suffering from a mental disorder. Considering eating disorders (ED) there are reports of a number of factors that increase the stress experienced by patients. The most important of them are:1 A. Quarantine and house confinement. Many ED patients report poor relationships with other family members or in some cases falling victims of some type of abusive behavior by other family members. Prolonged compulsory house confinement could have a negative impact in the course of ED. It should be noted that a similar negative impact of the pandemic has been observed in family members that have unsuccessfully tried to balance the need of the patients with the need of the rest of the family. B. Changes in exercising. Quarantine has severely influenced patients that have been doing vigorous and compulsive exercise. C. Food fear. During the first quarantine in March 2020, there were rumors of forthcoming extreme shortages of necessary products and food. D. Restrictions in the access to mental health facilities and therapists. In many countries, a substantial number of mental health programs were temporarily shut down during the first wave of the pandemic. E. Isolation of people residing alone in cities far away from the family home. F. Financial adversities due to slow down of economic activities causes by quarantine. g. Increase in obsessive fear concerning body health and food purity due to orthorexia nervosa onset or relapse.2 Research conducted during the pandemic showed that women suffering from ED reported more often than men increase in ED symptomatology, in the number of hours spent exercising and in the intensity of preoccupation with their body image and social appearance.2 A meta-analysis of ED studies during the pandemic showed that 65% of the patients reported a deterioration of ED symptomatology.3 Contrary to the above, the longitudinal studies that were included in the meta-analysis did not report any substantial difference in BMI and ed symptomatology before and after the first quarantine.3 Anorexia nervosa patients seemed to be more influenced than patients suffering from bulimia nervosa and ED non otherwise specified.3 Other longitudinal studies reported that bulimia nervosa patients were greatly influenced during the quarantine showing signs of slower remission or even relapse of the bulimic symptoms.4 Family conflict and intense fear for the life of loved ones could predict a relapse of the ED symptomatology.4 Young people were often caught in the following dilemma. On the one hand, consumption of palatable food could be used as a coping mechanism for regulating emotions such as anxiety, sorrow, and loneliness caused by prolonged house isolation. On the other hand, the increasing presence in the virtual reality environment of social networks has intensified the need for a perfect slim and fit body that could attract more followers and ensure social approval and success.5,6 A special interest group that was affected by the pandemic, was university students. ED symptomatology increased, especially among female students. Stress and depression related to social isolation and disruption of educational activities have been correlated with ED manifestation, especially bulimia nervosa.7 Fortunately, young patients seem to adjust adequately to internet-based treatments. There are indications that therapy through teleconference could prove quite effective for the treatment of ED.8 There are reports that this type of treatment is not attractive for anorexia nervosa patients, while all other ED patients are well adjusted to it.1 The consequences of the pandemic considerably affected mental health experts that have been treating ED patients as the number of new and relapsed clients raised dramatically. The situation was worsened by the fact that a large number of those patients had to be treated distantly. It has been reported that often conduct with other colleagues, the feeling of higher purpose or duty, recognition of their effort and supervision are some of the factors that can protect therapists from professional burn-out.1.