Received: 30 May 2020 Revised: 6 August 2020 Accepted: 6 August 2020

DOI: 10.1002/eat.23368

BRIEF REPORT

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

Giovanni Castellini PhD1 | Emanuele Cassioli MD1 | Eleonora Rossi MD1 |

Matteo Innocenti MD1 | Veronica Gironi MD1 | Giulia Sanfilippo MD1 |
Federica Felciai MD1 | Alessio M. Monteleone PhD2 | Valdo Ricca MD1

1
Psychiatry Unit, Department of Health
Sciences, University of Florence, Florence, Abstract
Italy Objective: the aim of this longitudinal study was to evaluate the impact of COVID-19 epi-
2
Department of Psychiatry, University of
demic on Eating Disorders (EDs) patients, considering the role of pre-existing vulnerabilities.
Campania “Luigi Vanvitelli”, Naples, Italy
Method: 74 patients with Anorexia Nervosa (AN) or Bulimia Nervosa (BN) and
Correspondence
97 healthy controls (HCs) were evaluated before lockdown (T1) and during lockdown
Giovanni Castellini, Psychiatry Unit,
Department of Health Sciences, University of (T2). Patients were also evaluated at the beginning of treatment (T0). Questionnaires
Florence, Florence, Italy.
were collected to assess psychopathology, childhood trauma, attachment style, and
Email: giovanni.castellini@unifi.it
COVID-19-related post-traumatic symptoms.
Action Editor: Ruth Weissman
Results: A different trend between patients and HCs was observed only for pathological
eating behaviors. Patients experienced increased compensatory exercise during lock-
down; 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 symp-
toms 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. Individ-
uals with early trauma or insecure attachment were particularly vulnerable.

KEYWORDS
attachment style, childhood trauma, Covid-19, eating disorders, epidemic, lockdown, post-
traumatic stress disorder, quarantine

1 | I N T RO DU CT I O N Coronavirus (Sars-CoV-2). In few weeks, the national and regional

governments imposed a progressively increasing level of isolation,
By the end of February 2020, some cases of pneumonia in the north with the final general lockdown on March ninth. Several scientific
of Italy were attributed for the first time to a novel form of reports seem to indicate the importance of a particular focus on

Int J Eat Disord. 2020;53:1855–1862. wileyonlinelibrary.com/journal/eat © 2020 Wiley Periodicals LLC 1855
1856 CASTELLINI ET AL.

mental health in this peculiar dramatic period (Brooks et al., 2020; group of healthy controls in terms of their psychological status before
Fiorillo & Gorwood, 2020; Shigemura, Ursano, Morganstein, Kuro- and after the lockdown, in order to evaluate whether participants with
sawa, & Benedek, 2020; Yao, Chen, & Xu, 2020). Preliminary reports EDs represented a more vulnerable population to the effects of
indicated that during epidemic or disasters many persons experience COVID-19 pandemic (hypothesis 1). Secondly, it was investigated
negative emotional effects, due to the fear of contagion and of the whether the lockdown period significantly interfered with the recov-
death of family members (Cao et al., 2020; Wang, Di, Ye, & ery process (hypothesis 2): thus, the study evaluated the longitudinal
Wei, 2020). Anxiety, sadness, anger and loneliness might also rise outcome of patients already under treatment before the pandemic,
from social distancing and quarantine (Cao et al., 2020; Fernández- considering the psychopathological changes intervening before and
Aranda et al., 2020; Kavoor, 2020; Nguyen et al., 2020; Qiu during the lockdown period, and comparing the results between diag-
et al., 2020; Wang, Di, et al., 2020). More specifically, COVID-19 epi- nostic categories, namely Anorexia Nervosa (AN) and Bulimia Nervosa
demic may have been experienced as a traumatic event, thus, (BN). Finally, it was hypothesized that factors preceding the pandemic
resulting in an increase of post-traumatic stress disorder (PTSD) symp- might be associated with worsening of psychopathology during the
toms (Liu, Gayle, Wilder-Smith, & Rocklöv, 2020; Wang et al., 2020). lockdown (hypothesis 3). In particular, it was evaluated whether hav-
However, it has been suggested that people may have heteroge- ing obtained a remission from EDs before the lockdown had a protec-
neous responses to the pandemic consequences, also on the basis of tive role on the psychopathological outcome during the pandemic.
pre-existing psychopathological features (Fiorillo & Gorwood, 2020), Furthermore, it was evaluated whether a history of childhood trauma
which might increase the vulnerability to the emotional consequences or particular attachment style was associated with the psychopatho-
of any disaster-related trauma (Brooks et al., 2020). Indeed, Yao logical outcome during the lockdown, in terms of development of
et al. (2020) underlined the necessity of evaluating the effects of pan- COVID-19-related PTSD symptoms, and evolution of EDs
demic and isolation on patients with psychiatric disorders, and Brooks symptomatology.
et al. (2020) and Fiorillo & Gorwood (2020) suggested that this per-
sons might need extra-support in this particular situation.
Persons with psychiatric disorders often report interpersonal dif- 2 | METHODS
ficulties which might exacerbate the effect of isolation, and prelimi-
nary findings seem to demonstrate that history of childhood 2.1 | Study design
maltreatment and attachment features predict the extent of mental
health burden during the lockdown (Moccia et al., 2020). From this This is an observational, longitudinal study of a group of patients with
perspective, patients with eating disorders (EDs) seem to represent a EDs and of Healthy Controls (HCs), both evaluated a few months
particularly vulnerable population to the effect of the unexpected before the onset of COVID-19 epidemic (T1) and during lockdown
environmental conditions during the COVID-19 pandemic, consider- (T2). Patients with EDs were also evaluated at the beginning of treat-
ing their specific psychopathology and the need for a continuous ment (T0).
assistance in the active phase of their disorders (Touyz, Lacey, & The study was approved by the local Ethics Committee. All partic-
Hay, 2020; Weissman, Bauer, & Thomas, 2020). Indeed, the reduction ipants provided informed consent prior to study enrollment.
of treatment implementation and the confinement have been hypoth-
esized to possibly worsen psychological stress and the severity of ED
specific symptomatology (Dalle Grave, 2020; Murphy, Calugi, Coo- 2.2 | Participants
per, & Dalle Grave, 2020; Peckmezian & Paxton, 2020; Van den Berg
et al., 2019). Patients attending the Outpatient Clinic for EDs of the University of
Clinicians need to have clear information regarding the possible Florence were enrolled, providing they met the following inclusion
interference with the recovery process of patients with EDs already criteria: female sex, aged 18–60 years, current DSM 5 diagnosis of
under treatment, and protocols should be optimized to manage this AN or BN. Exclusion criteria were as follows: comorbid psychotic dis-
situation in the future. In particular, it is important to compare the lon- order, illiteracy, intellectual disability, severe medical conditions pre-
gitudinal outcomes under normal treatment conditions with the ones cluding outpatient treatment, current use of psychoactive medications
during the lockdown, in order to understand whether adopting alter- except for antidepressant and benzodiazepines, which were kept sta-
native forms of assistance (e.g., online visits) and isolation would ble during the study.
impact health care of patients with EDs. The control group (which was deemed adequate since it was com-
However, up to now, the available literature on psychopathologi- parable in terms of gender and age) was initially recruited from the
cal consequences of lockdown following COVID-19 epidemic did not community of Tuscany by means of local advertisements, for a study
provide reliable information regarding the pre-epidemic period, in about the psychopathology of EDs. Participants provided their con-
patients with EDs already under treatment at the beginning of the sent to be re-contacted for further investigations on similar topics.
pandemic. Thus, the present study attempted to overcome this limita- Inclusion criteria for control group were: absence of any lifetime ED,
tion, adopting a longitudinal design, and testing three main hypothe- evaluated by means of a structured interview (SCID-5-RV, First, Wil-
ses. First, the study compared a group of patients with EDs with a liams, Karg, & Spitzer, 2015), and body mass index (BMI) between
CASTELLINI ET AL. 1857

18.5–25.0 kg/m2, and absence of intellectual disability, illiteracy, cur- areas of daily living. All these data were coded as dummy variables
rent/lifetime Axis I psychiatric disorders. (absence/presence of a condition or a moderate to severe worsening/
change). During lockdown, data previously obtained through a face-to-
face clinical interview were collected in the same way via a telephone
2.3 | Procedures or an online video call, while the self-report questionnaires were
converted into digital format and administered via a dedicated online
The online survey was performed from April 22nd, 2020, until May platform. The only significant difference between pre-lockdown and in-
third, 2020 (T2). The present time frame covered the advanced phase lockdown assessments was the online digital nature of the self-report
of the COVID-19 epidemic in Italy, starting 6 weeks after the Italian questionnaires, as opposed to the previous paper format.
Government declaration of lockdown (Governo Italiano, Presidenza Patients were considered in full remission, when they did not
del Consiglio dei Ministri, 2020) until the last days of the so-called meet the DSM 5 criteria for any ED at T1 and T2 (including EDs not
phase 1 of lockdown itself. otherwise specified). In particular, the criteria adopted by Turner et al.
The cohort of patients was initially enrolled for the longitudinal (BMI > 18.5; no reported objective binges, vomiting, or laxative use in
observation performed at the clinic between January and September the past 28 days, EDE-Q total score under one SD above the commu-
2019 (T0). Patients included in the study were all under treatment, nity mean) were considered (Turner, Marshall, Stopa, & Waller, 2015).
and they were regularly re-evaluated with follow-up assessments Crossover was defined as a diagnostic change toward a different ED
every 3 months. The last follow-up performed by each patient before diagnosis (this outcome variable also included those AN restricting
the detection of the first cases of COVID-19 in Italy was included in type patients who developed binge/purge behaviors). The aforemen-
the present study and considered as a pre-lockdown evaluation (T1). tioned variables were defined according to the DSM 5 criteria and
All T1 assessments were carried out between November 2019 and were collected by means of a structured interview performed by two
January 2020. expert psychiatrists (G.C., V.R.) (First et al., 2015).
The control group was recruited from December 1, 2019 until
January 15, 2020 (T1).
Of the 86 Caucasian ED patients referred, 2 were excluded, 2.5 | Treatment
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 During the pre-lockdown period, eligible patients were provided with
3 lost to follow-up. Only these patients were included into the survey an individual Enhanced Cognitive Behavioral Therapy
(37 with AN, 37 with BN). Of the 116 Caucasian participants referred (Fairburn, 2008), with a frequency of one session per week (which
for the control group, 7 were excluded and 97 were available for the varied according to the treatment phase). During the lockdown,
second follow-up (in-lockdown). patients received online medical examinations to assess their general
psychopathological and clinical conditions, and psychotherapy ses-
sions delivered via internet using a webcam, with the same therapists
2.4 | Assessment 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
Sociodemographic and clinical data were evaluated regularly as part performed on average 30 psychotherapy sessions, while in the T1-T2
of the routine assessments for patients with EDs performed at the period they performed on average 16, of which the last 6 or 7 were
Outpatient Clinic for EDs, through a clinical interview by two expert online via webcam due to the lockdown measures.
psychiatrists (G.C., V.R.). All evaluations (T0, T1, T2) included the
clinical interview and self-administered questionnaires to assess gen-
eral (Brief Symptom Inventory, BSI) (Derogatis & Melisaratos, 1983) 2.6 | Statistical analyses
and ED-specific (Eating Disorder Examination Questionnaire, EDE-
Q) (Calugi et al., 2018; Fairburn, 2008) psychopathology. T0 assess- In order to evaluate whether patients with EDs represented a more
ment also included questionnaires on early trauma (Childhood vulnerable population to the effects of COVID-19 pandemic (hypoth-
Trauma Questionnaire–Short Form, CTQ-SF) (Bernstein et al., 2003) esis 1), comparisons between patients and controls were performed,
and attachment style (Experiences in Close Relationships–Revised, in terms of COVID-19-related post-traumatic stress symptoms and
ECR-R) (Fraley, Waller, & Brennan, 2000). Moreover, during lock- longitudinal variations of psychopathology and pathological eating
down (T2) COVID-19-related post-traumatic symptoms were evalu- behaviors (T1-T2). Between groups comparisons were performed
ated by means of a version of the Impact of Event Scale-Revised using Analysis of Covariance (ANCOVA) with post-hoc testing,
(IES-R) (Weiss & Marmar, 1997) which was specifically adapted for whereas for dichotomous variables Binomial Logistic Regression was
the investigation of COVID-19-related post-traumatic stress psycho- used. A repeated measures approach was adopted for longitudinal
pathology. Finally, a dedicated, self-report questionnaire was admin- analyses, using Linear Mixed Model with random intercepts and Time,
istered at T2 to collect different information regarding variables of Group and Time*Group as fixed effects. All the analyses were
interest, such as lockdown conditions and variations in different adjusted for age and education.
1858 CASTELLINI ET AL.

A similar repeated measures approach with Linear Mixed Models Longitudinal data are illustrated in Figure 1.
was used in order to test for changes in the longitudinal course of all Table 2 reports the comparisons between patients and HC of the
clinical variables before and after the lockdown (T0-T1-T2), among changes in psychopathology, pathological eating behaviors and BMI
patients with AN and BN (hypotheses 2); Time*Group interaction occurring after the lockdown (T1-T2 period). According to Linear
effect was inserted in all models to test for differences between the Mixed Models (Time*Group interaction) patients and HC reported a
two diagnoses. Post hoc analyses were carried out to identify the vari- different pre-post lockdown variation of objective binge eating and
ations at each timepoint, to study whether the COVID-19 pandemic compensatory physical exercise: in particular, an increase in the two
and the lockdown occurred in the T1-T2 period could cause symp- pathological behaviors was observed for ED patients, while no differ-
tomatic relapses. ence between T1 and T2 emerged for the control group (Table 2). No
Finally, it was evaluated whether the clinical status before the significant effect was observed for BSI scores.
lockdown, COVID-19-related environmental conditions and the CTQ Considering COVID-19-related post-traumatic stress symptoms
and ECR-R scores were associated with psychopathological changes scores developed the during lockdown period, patients reported
and onset of PTSD symptoms during lockdown (hypothesis 3). There- higher total IES-R scores and hyperarousal symptoms as compared
fore, these variables were entered as covariates in Linear Mixed with the other participants (Table 2).
Models (along with their interaction with Time), with BSI, EDE-Q,
objective binge eating and physical exercise as dependent variables,
and linear and binomial logistic regression analyses were used to 3.2 | Psychopathological variations before and
study their effect on COVID-19-related post-traumatic psychopathol- during the lockdown
ogy. Statistical analyses were performed using IBM SPSS Statistics
v.25 (IBM Corp., 2017). Mixed Model indicated a significant improvement in general psycho-
pathology during the pre-lockdown period for both EDs diagnoses
(Cohen's d for AN: 0.66; Cohen's d for BN: 0.78), while no significant
3 | RESULTS changes were observed after the lockdown measures (Figure 1a).
Considering ED-specific psychopathology, BN patients showed a sig-
3.1 | Comparisons between patients and controls nificant reduction at the first follow-up (Cohen's d: 0.52), but no
in terms of psychopathological outcomes change at the next one; conversely, AN patients showed an improve-
ment in both T0-T1 (Cohen's d: 0.39) and T1-T2 comparisons
Table 1 shows data regarding the socio-demographic characteristics (Cohen's d: 0.26) (Figure 1b).
of the sample at T2. Only two patients reported having received a Considering monthly objective binge eating, BN patients reported
screening test for COVID-19 (both resulted negative), while none of a significant reduction from baseline to T1 (Cohen's d: 1.06) and a sig-
the HCs performed a screening test or received a confirmed COVID- nificant increase after the lockdown measures (Cohen's d: 0.32), while
19 diagnosis. Within environmental factors, ED patients reported participants with AN only showed a significant T0-T1 variation
more frequently that they lived alone and did not have a partner and (Cohen's d: 0.41), with no change at T2 (Figure 1c). All patients
greater fear for the safety of loved ones as compared with HCs. showed a significant increase in exercise after the lockdown with

T A B L E 1 Sociodemographic characteristics and COVID-19-related environmental conditions of the sample during lockdown (T2) for patients
and HCs. 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

Patients (n = 74) HCs (n = 97) Effect size

Age (years) 31.74 ± 12.76 30.45 ± 10.89
Graduatesa 22 (29.7) 61 (62.9) OR = 0.25 [0.13–0.48]
Having a partner 40 (54.0) 71 (73.2) OR = 0.39 [0.20–0.78]
Living alone 12 (16.2) 5 (5.2) OR = 4.37 [1.39–13.79]
Not working 51 (68.9) 49 (50.5)
Having a loved one with COVID-19 6 (8.1) 8 (8.2)
Reporting a moderate to severe economic damage 15 (20.3) 10 (10.3)
Intensification of household arguments 9 (12.2) 3 (6.7)
Fear for the safety of loved ones 25 (33.8) 23 (23.7) OR = 2.14 [1.02–4.48]

Abbreviations: ANOVA, analysis of variance; BMI, body mass index; HCs, healthy controls; OR, odds ratio.
a
Adjusted only for age.
CASTELLINI ET AL. 1859

F I G U R E 1 Longitudinal course of general psychopathology (panel a), eating disorder psychopathology (panel b), objective binge-eating
monthly episodes (panel c), and compensatory physical exercise monthly episodes (panel d), divided by diagnoses. Error bars represent standard
errors. For ED patients, post hoc comparisons between timepoints for each group are reported as following: *Significantly different from T0
(p < .05). #Significantly different from T1 (p < .05). BMI, body mass index; BSI-GSI: Brief Symptom Inventory—Global Severity Index; EDE-Q:
Eating Disorder Examination Questionnaire [Color figure can be viewed at wileyonlinelibrary.com]

T A B L E 2 Longitudinal data on psychopathology, pathological behaviors and weight status, for patients and HCs, together with in-lockdown
COVID-19-related post-traumatic stress symptoms scores. For longitudinal data, variables that changed over time differently between patients
and controls (as indicated by a statistically significant Time*Group interaction in the Linear Mixed Model) are marked in bold

Patients (n = 74) HCs (n = 97)

Pre-lockdown (T1) In-lockdown (T2) Pre-lockdown (T1) In-lockdown (T2) Effect size
BSI-GSI 1.11 ± 0.72 0.99 ± 2.33 0.54 ± 0.41 0.49 ± 0.48
EDE-Q Total score 2.72 ± 1.72 2.33 ± 1.63 1.06 ± 1.09 1.04 ± 1.01
Objective binge eating 2.33 ± 2.51 4.32 ± 7.17a 0.57 ± 1.52 1.12 ± 3.61 Cohen's d = 0.53
Compensatory physical exercise 0.69 ± 1.84 3.53 ± 7.72a 0.58 ± 3.33 0.84 ± 3.47 Cohen's d = 0.39
2
BMI (kg/m ) 22.31 ± 7.06 21.99 ± 6.19 21.56 ± 3.04 21.79 ± 2.96
IES-AV — 0.94 ± 0.67 — 0.82 ± 0.61
IES-IN — 0.90 ± 0.81 — 0.71 ± 0.56
IES-HY — 1.23 ± 0.91 — 0.96 ± 0.72 Cohen's d = 0.33
IES-total score — 22.07 ± 15.90 — 17.96 ± 11.41 Cohen's d = 0.30

Notes: IES scores were compared by means of ANCOVA. All statistical analyses were adjusted by age and education. For statistically significant variations
and comparisons the effect size is reported (Cohens' d).
Abbreviations: ANCOVA, Analysis of Covariance; AV, Avoidance; HCs, Healthy Controls; HY, Hyperarousal; IES, Impact of Event Scale; IN, Intrusion.
a
Post hoc are reported as significant variation from T1 (p < .05).

respect to T1 (Cohen's d for AN: 0.32; Cohen's d for BN: 0.30) and 19 a partial remission (3 from AN and 16 from BN). However, at
(Figure 1d). Finally, BMI increased significantly with each follow-up in T2 10 of these remitted individuals reported a relapse into BN
AN (T0-T1 Cohen's d: 0.54; T1-T2 Cohen's d: 0.71), while it remained (of which 2 had an initial diagnosis of AN and 8 of BN). Relapse rate
substantially stable in BN (Figure 1e). Data on psychopathological and was not associated with baseline diagnosis (Fisher's exact test p = .67).
behavioral measures and BMI for patients at each follow-up are A total of 8 patients who met criteria for AN at T1 experienced a diag-
reported in Table S1. nostic crossover to BN during the lockdown period. At the final follow-
Considering diagnostic changes before and after the lockdown, at up, 11 participants reported full remission and 17 partial remission,
T1, 10 patients had obtained a full remission (5 from AN, 5 from BN) whereas 21 still reported a diagnosis of AN and 25 of BN.
1860 CASTELLINI ET AL.

3.3 | Pre-lockdown predictors of expect in a normal condition of treatment. The present results were
psychopathological outcome during the pandemic in largely expected, considering that the government limitations made
patients with EDs the face-to-face programs really challenging, shifting most of the clini-
cal activity toward video conferencing (telehealth) (Fernández-Aranda
Having obtained remission at T1 did not affect the trend of psychopa- et al., 2020). Different explanations have been already suggested for
thology or physical exercise in the subsequent T1-T2 period. Indeed, binge eating onset or worsening during the pandemic. From one side,
Time*Remission interaction was not found to be significant when the “food insecurity” mechanism has been proposed (Weissman
inserted in the model. However, a significant interaction was found in et al., 2020), with pervasive media coverage about threats of food
the binge-eating model, indicating that most of the patients who had shortages (Rasmusson, Lydecker, Coffino, White, & Grilo, 2019). Fur-
achieved remission at the previous follow-up showed a relapse of thermore, it is also possible that the intense use of social media might
binge eating symptomatology at T2 (T1: 0.75 ± 0.94, T2: 4.24 ± 5.79; heightened awareness of bodily self, having a toxic influence on the
Cohen's d: 0.64) (Figure S1). objectification of the thin ideal (Fernández-Aranda et al., 2020), thus
Considering environmental factors, household arguments were exacerbating the binge eating vicious cycle, as well as the concerns
associated with a higher increase in pathological physical exercise dur- about health and fitness during confinement. It is also possible that
ing the lockdown (T1: 0.53 ± 1.34, T2: 2.33 ± 5.76 vs. T1: high binge eating represented an epiphenomenon of pervasive emo-
0.94 ± 1.61, T2: 7.56 ± 11.34, p = .014, Cohen's d for patients tion dysregulation, exacerbated by the preoccupations about one's
reporting this factor: 0.62), while fear for the safety of loved ones own and other's safety, or about the worsening economic conditions
predicted a higher increase in binge-eating episodes (T1: 1.39 ± 2.13, (Weissman et al., 2020), and by the obstacles in treatment protocols.
T2: 2.24 ± 5.17 vs T1: 0.83 ± 1.47, T2: 5.05 ± 6.99, p = .012, Cohen's A further confirmation to this interpretation is represented by the
d for patients reporting this factor: 0.67). association between environmental conditions during the lockdown
Childhood trauma significantly predicted COVID-19-related post- such as household arguments and the fear for the safety of loved ones
traumatic symptomatology in patients with an initial diagnosis of AN with the increase of symptoms severity during the pandemic. Indeed,
(β = 0.34, p = .031), in particular considering emotional (β = 0.40, fear and adverse conditions during the forced cohabitation might
p = .012) and sexual abuse (β = 0.50, p = .001). Taking into account increase stress, consequently promoting binge eating.
the adult attachment style, a distinct pattern was found according to The interpretation of results in the group of patients with AN
the two EDs diagnoses: in patients with AN, avoidance was signifi- appeared to be more controversial. From one side these patients
cantly associated with in-lockdown post-traumatic psychopathology showed a further improvement of ED psychopathology and a progres-
(β = 0.38, p = .044), while a positive association was found for anxious sive weight gain during lockdown. Furthermore, for some important
attachment in BN (β = 0.57, p = .005). 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 fur-
ther improvements. This result could be explained as a kind of conse-
4 | DISCUSSION quence of the efficacy of the treatment patients continued to receive.
Therefore, this is a further confirmation of the importance of e-
This is one of the first studies which provided preliminary evidences therapy for patients with eating disorders in a period of lockdown and
for the psychopathological impact of COVID-19 epidemic, by means difficulties to access to public services (Weissman et al., 2020). On the
of a longitudinal observation of patients with EDs, before and during other hand, patients with AN experienced an exacerbation of com-
the lockdown period. Overall, the main hypotheses of the study were pensatory physical activity, and a non-negligible number of them
partially supported. Not all the patients with EDs seemed to report a experienced diagnostic crossover. Thus, even though the quarantine
specific increase of distress as compared with what happened to con- appeared to have less impact on patients with AN as compared with
trols, under similar conditions. Some patients appeared to be more BN, both groups of patients reported a worsening of pathological
vulnerable to the impact of lockdown, in terms of relapses into patho- behaviors, which could represent a possible hint of an imminent exac-
logical eating behaviors, namely patients with BN, and those erbation of the disease.
experiencing household arguments and fear for the loved ones, while According to previous observations on general population (Qiu
participants with a history of childhood trauma and insecure attach- et al., 2020; Wang, Di, et al., 2020), a non-negligible number of HCs
ment styles were more likely to report COVID-19-related post- reported a self-perceived worsening of their mental health status from
traumatic stress symptoms. different points of view, including anxiety, sadness, and sleep. How-
More in details, the lockdown follow-up showed that for patients ever, in the present sample, patients with EDs did not report a more
with BN the difficulties associated with the COVID-19 period signifi- severe increase of these symptoms as compared to HC. This result
cantly interfered with the recovery process, in terms of lack of further could be interpreted considering that participants with EDs who often
reduction of psychopathology, exacerbation of binge eating and com- report a severe social isolation might have been less sensitive to the
pensatory physical exercise. The positive trajectory of improvement lockdown effects, and thus to its psychopathological consequences.
observed before the lookdown was clearly interrupted during the pan- Regarding the lack of significant worsening of ED-specific psychopa-
demic period, thus showing an inverse tendency of what we would thology in patients, putative positive meaning of confinement might
CASTELLINI ET AL. 1861

be the reduced exposition to the gaze of the others, and to the judg- OR CID
ment or criticisms from friends, doctors, or other family members. Giovanni Castellini https://orcid.org/0000-0003-1265-491X
Accordingly, this point might explain the lack of significant increase of Emanuele Cassioli https://orcid.org/0000-0003-3623-7096
weight and shape concern in a period of less-intense treatment. Eleonora Rossi https://orcid.org/0000-0003-4755-3879
As far as COVID-19-related post-traumatic stress symptoms are Alessio M. Monteleone https://orcid.org/0000-0002-6786-4458
concerned, an increase of interpersonal and family conflicts, probably
exacerbated by the forced cohabitation during lockdown, was found RE FE RE NCE S
to be associated with greater symptomatology, as measured by IES. In Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D.,
particular, it is interesting to note that among patients with AN IES Ahluvalia, T., … Zule, W. (2003). Development and validation of a brief
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scores were predicted by greater emotional and sexual abuse as well
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as avoidant attachment style, while anxious attachment style 00541-0
predicted IES scores in BN patients. According to previous observa- Brady, S. (2008). The impact of sexual abuse on sexual identity formation
tions (Brady, 2008; Striegel-Moore, Dohm, Pike, Wilfley, & in gay men. Journal of Child Sexual Abuse, 17(3–4), 359–376. https://
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Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S.,
history of childhood abuse may be particularly vulnerable to emotion Greenberg, N., & Gideon, J. R. (2020). The psychological impact of
dysregulation associated with increased family conflicts during forced quarantine and how to reduce it: Rapid review of the evidence. Lancet,
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30460-8
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