Psychiatrists warned of a “tsunami” of eating disorders post-lockdown. The world responded by more than just warranting the ominous premonitions.

As COVID-19 itself transpired fully-fledged, major cities retreated into nationwide lockdowns, social distancing was implemented nearly everywhere, and the world itself shut down. Shutting these global doors in an effort to save us from one pandemic unwittingly opened the doors to another, often kept hushed up, suppressed, censored and otherwise severely misunderstood. What “pandemic” could possibly render such an effect, we might ask ourselves?

That would be the pandemic of mental illness, and specifically, in this case — the pandemic of eating disorders (EDs). With a 128% increase in the number of patients waiting for routine treatment compared to the year before the pandemic, the “tsunami” of eating disorders that psychiatrists warned of during the COVID-19 pandemic has hit health services in full force [1]. When the world retreated into realms of masks, lockdowns, and daily-case-number news updates, serious mental disorders like anorexia nervosa and bulimia nervosa rubbed their hands together gleefully, eyes shining in anticipation — what better place for an eating disorder to thrive than the isolation accompanying a global pandemic?

With unhelpful worldwide conversations rapidly circulating around “COVID-19 kgs”, “lockdown diets”, and rigorous COVID-19 exercise regimes, those already vulnerable to these messages became inadvertently triggered by conversations intended to target another population altogether. By inherently linking “health” to “weight”, our global lens has focused on something as insignificant as a number on a scale, even in the midst of a life-threatening pandemic.

With social isolation already stifling the state of affairs, well-intended messages concerning weight gain during the lockdowns put more pressure on a society already focusing heavily on weight control en masse. This created a space for eating disorders to be fed, watered, and nurtured. 86.7% of participants in one NCBI study reported that their eating disorder symptoms worsened during the pandemic lockdown, whilst 41.9% of participants reported a reactivation or relapse of ED symptoms [2].

Figure 1: Due to monumental pressure on the mental health sector, many UK GP practices are no longer making referrals to mental health services but instead advising patients to directly contact relevant services [3].

Dr Lorna Richards, a psychiatrist specialising in adult eating disorders at The Priory Group, described to The Guardian how the rise in eating disorder behaviour could be attributed to many factors affiliated with the pandemic, some of which included “fear and uncertainty, fuelling anxiety symptoms” and changes to people’s routine and home lives [1]. She also noted that the “focus on eating and weight control can become a way of coping”, with many using weight-control measures such as food restriction, purging, or over-exercising to provide “a sense of control or mastery” during particularly challenging times [1].

With reported cases of eating disorders skyrocketing, we now turn the lens to this “tabooed” illness and its long-denied inadequate care and support — a “chronic” underfunding of services and attention, as Dr Agnes Ayton, the chair of the Eating Disorder Faculty at the Royal College of Psychiatrists put it [1]. Over half (60%) of General Practioners (GP) affiliated with the NHS indicated in early 2023 that it is now extremely difficult for even dangerously ill young patients to access the specialist treatment and care they need to get well, with one GP despairing that we are “fighting a losing battle” and in a silent “crisis” [4]. 60% of GPs also fear that their young patients will come to serious harm due to lack of treatment access from adolescent eating disorder services. One GP said that “the provision is awful and I worry my young patients may die”. Another GP described specialist NHS services available in their area as “virtually nonexistent and not fit for purpose” [4].

Figure 2: The overall eating disorder admission rates in Waikato, New Zealand, from 2019 to 2020. There is a drop in the count of total admissions in April 2020, in parallel with an increase in the count of eating disorder admissions [5].

Glossary

Anorexia nervosa (AN): A mental illness and a type of eating disorder caused by a wide range of environmental, emotional, psychological, biological, occupational, and social factors. This disorder is often characterised by an intense fear of eating and gaining weight. It can lead to many disturbances in all aspects of health, including (but not limited to) obsessive thinking and actions (e.g. intense exercise, fasting), depression, heightened anxiety, social difficulties, and malnutrition.

Please note: everybody’s experience with AN is unique. Please reach out for help if you think you or someone you know might be struggling.

Eating Disorders Association of New Zealand Helpline - 0800 2 EDANZ / 0800 2 33269

Bulimia nervosa (BN): A mental illness and a type of eating disorder caused by a wide range of environmental, emotional, psychological, biological, occupational, and social factors. This disorder is often characterised by taking steps (e.g. purging or fasting) to avoid weight gain following eating what the person may consider a “large” amount of food. This disorder can also lead to difficulties in all areas of health, including (but not limited to) social difficulties, depression, heightened anxiety, and malnutrition.

Please note: everybody’s experience with BN is unique. Please reach out for help if you think you or someone you know might be struggling.

Eating Disorders Association of New Zealand Helpline - 0800 2 EDANZ / 0800 2 33269

Eating disorders, far from the stereotypical “teenage girls wanting to look like a model on the cover of a Vogue magazine”, are in fact, complex illnesses resulting from a wide range of biological, environmental, psychological, occupational, social, and emotional factors that can affect anyone, regardless of age, background, sexual or gender orientation, ethnicity, or demographic [6].

Biological factors deeply affect the brain circuitry of affected individuals. Links have been found to the levels of particular hormones (such as dopamine) in our brains, and other factors may include variants in the serotonin transporter gene in those with bulimia nervosa. Walter Kaye, a prominent eating disorder researcher, investigated the level of the hormone serotonin in patients. He found that patients with the eating disorder anorexia nervosa tend to have a higher level of serotonin in their brains and that they “feel better” by performing actions that effectively decrease their serotonin level. However, as sufferers continue to carry out disordered actions like dangerously restricting their food intake, the brain’s response is to increase the number of serotonin receptors, resulting in the more efficient utilisation of the remaining serotonin. This ultimately means that in order to maintain the feeling of “feeling better”, the person needs to starve themselves even more — which leads, in essence, to the illness’s vicious and potentially deadly cycle. When a person suffering from anorexia begins to eat again, serotonin levels soar, which causes extreme anxiety and total emotional upheaval — a“fight or flight” response.

Please reach out for help if you think you or someone you know may be struggling. There is always hope. Support Organisations are available to help support you:

0800 2 EDANZ / 0800 2 33269 or (09) 5222 679 (Eating Disorders Association of New Zealand)

Lifeline – 0800 543 354 (0800 LIFELINE) or free text 4357 (HELP)

Youthline — Free call 0800 376 633 or Free text 234

Recovery from all types of eating disorders can be extremely difficult without adequate support, because often the individual believes they are not suffering and do not need help. At the same time, they may be severely malnourished, or suffering from severe maladaptive cognitions with the potential to seriously diminish quality of life. Like serotonin, dopamine also controls a complex neural network and overlap of processes within the brain. Scientific evidence suggests that individuals performing disordered actions feel a boost of dopamine after performing a disordered task, further reinforcing the very actions that make the individual unwell [7].

Because our brain is highly neuroplastic, the more actions an individual performs to relieve their anxiety about food or eating, the more neurally wired our brains become to execute that action, and the more neurally entrenched the illness itself becomes. As one GP said, “The threshold for seeing patients is too high, so illness is entrenched by the time any meaningful support is given. The treatment received is too little and too late.” [3]. Due to the “flood” effect post-pandemic, individuals who reach ED-recovery providers are already in dire need of help, whilst others, also in dire need, are “backlogged” and forced to wait while their illness only worsens. Consequently, those with early ED symptoms are forced to wait even longer, meaning that by the time these patients receive help, the illness has likely had enough time to become “established”. As a result, both in New Zealand and globally, healthcare systems have experienced somewhat of an “onslaught” with emergency departments being relied upon more and more for patients with eating disorders [5]. To prevent such neural-entrenchment from developing, preventative treatment should ideally be commonplace. This would help to assist patients to effectively “disrupt” networks of neural connections that lead to the thought patterns and subsequent harmful behaviours seen in those living with EDs [3]. To address this treatment gap, knowledge, research, enhanced awareness and education, as well as substantially-improved medical and psychological ED treatment and care/ support funding needs to be implemented into Aotearoa New Zealand’s healthcare system [5].

Overall, it is essential for us, as budding scientists, to become aware of the science behind these mental health disorders so that we may work towards combining our unique neurobiological, chemical, pharmacological, physical, statistical, and psychological knowledge to champion treatments and research in this long-denied space. We must advocate for fair, equitable treatment for all illnesses and disorders, no matter their prior unfounded stigma, while recognising the implications and challenges of what accompanies the science we work for. As Anastasia Amour, a celebrated member of the Eating Disorder Recovery Community, once said, “Eating disorders are deadly...and the silence around them even more so.” [6].

Figure 3: The rate of eating disorder admissions per 10,000 admissions to Waikato DHB hospitals. Compared to 2019, 2020 was consistently increased, with a significant spike coinciding with the commencement of lockdown around March to April [5].