PATIENTS WITH EATING DISORDERS IN THE TIME OF COVID-19

The article presents the issues of mental functioning of people with eating disorders during the COVID-19 pandemic, referring to the selected foreign studies in which researchers are looking for data on risk factors for eating disorders during a pandemic. COVID-19 spreads rapidly around the world, forcing people to take immediate action and change their lifestyle. There have been radical changes in social life for which society was not ready. Isolation and the need to maintain social distance limited access to health care, which had a significant impact on the mental functioning of people with mental disorders, including people with eating disorders. Numerous studies are undertaken around the world to determine this impact, and the results obtained so far indicate a deterioration in the functioning of people with eating disorders. Therapists and clinicians are looking for the possibility of implementing modifications in the treatment programs in order to adapt them to the restrictions in the best possible way, but also to the needs and goals of the patient. During the lock-down period, it was recommended to use a remote form of meetings, but not every patient and therapist / physician was able to find their way around it, as a result some patients remained without specialist care. As a result, the risk of complete withdrawal from treatment or its irregularity was increased, and the mental functioning of patients deteriorated.


Introduction
The COVID-19 pandemic has left its mark on the physical and mental health of mankind [1][2][3][4]. The so-called lockdown had a significant impact on access to health care for people with mental disorders, including eating disorders (ED). Most of the research to date show that eating disorder behaviors can aggravate during a pandemic (Table 1), so scientists are now looking for information on how the COVID-19 pandemic and its associated social disruptions increase the risk and symptoms of eating disorders [ 5]. Individual results of the research indicate that in some aspects of functioning, patients with ED experience improvement, and in others, deterioration (Table 1). It is noticed that in the case of patients diagnosed with anorexia nervosa, the level of restrictive behaviors increases, and in the case of bulimic table continued on the next page patients there are more episodes of binge eating [6]. Patients struggle with feelings of failure, anxiety, dissatisfaction with themselves due to loss of control over eating behavior. As for the average person, food supplies are one of the conditions for feeling safe during a pandemic, for people with ED they can trigger/intensify inadequate eating behavior. Standard strategies used by patients before COVID-19 are not always applicable in the new reality [7]. • growing concerns about food, body shape and body weight, • greater need for physical effort, • feeling of loneliness, • sadness, • generalized anxiety, • restrictions on access to treatment (medical and psychotherapeutic), • use of helpful strategies such as: planning their day, maintaining their daily routine, using enjoyable activities Schlegl et al., The first qualitative studies show that the COVID-19 pandemic and its associated social isolation not only increases and deepens symptoms in ED patients, but also adversely affects their parents/caregivers. This is due to, inter alia, limited access to medical care and difficulties in the implementation of therapeutic treatment in the case of outpatients. This increases the sense of burden and anxiety in patients' parents, which worsens the functioning of the family and, as a consequence, deepens the symptoms of eating disorders in children and adolescents [8].

Risk factors for eating disorders during COVID-19
Branley-Bell and Talbot [9] claim that the symptoms of eating disorders may be exacerbated by media exposure, difficulties in everyday life, social isolation, increased anxiety related to the fear of infection, or a marked effect on sleep and physical activity. Research by Monteleone et al. [4] suggest that fear of infection, social isolation and the perceived low quality of therapeutic relationships are intensified in patients with ED, and factors such as the type of interventions and treatment strategies, patient's age, economic condition and duration of the disease are not responsible for the deterioration of their functioning. Some scientists suggest that the pandemic increases the risk of using inadequate emotion regulation strategies, while blocking access to the right ones that previously helped patients [10]. On the other hand, it is noted that people with mental disorders are more susceptible to the negative impact of stressors (such as pandemic) because of the tendency to use dysfunctional coping strategies [11]. An increased risk of depression, anxiety, post-traumatic stress syndrome (PTSD), self-harm and suicide in the population of people with ED as a result of the negative impact of a pandemic caused by insulation COVID-19 [12,13] were talked over. Moreover, patients with insecure attachment style and childhood trauma are more vulnerable to develop PTSD [14]. Wang et al. suggest that the combination of various stress-generating factors (e.g. health problems, social isolation and economic crisis) may increase the risk of mental disorders or exacerbate pre-existing mental disorders in the entire population (including children and adolescents) [15].
Cooper et al. [16] present a detailed study of the risk factors of eating disorders during the COVID-19 pandemic, describing their influence on the severity of ED symptoms and the deterioration of patients' functioning. According to them, one of the important factors is limited access to food (limited assortment and availability of stores, lack of funds, the need to choose products with a long shelf life and make purchases in advance), which is associated with restrictions and the progressing economic crisis. This factor favours dysregulation in nutrition, increasing the risk of entry into alternating cycle of compulsive eating and restrictive. In the case of people with an Avoidant/Restrictive Food Intake Disorder (ARFID), limited access to food exacerbates the limitations in access to the so-called secure database of products (e.g. specific brands). Due to the fact that patients with ARFID are unable to consume products from outside their safe list, it is associated with an increase in their malnutrition and poses a threat to their lives [16]. Another factor -excessive media use, resulting from reduced direct contact, also has a significant impact on the functioning of ED patients. Previous research has already shown that using social media increases their symptoms by interacting with weight loss and healthy eating content and by modelling on thinness icons. In the era of pandemic, due to limited physical activity and a tendency to frequent snacking and increased risk of overweight and obesity, media were full of content for keeping your body weight and body shape, which only aggravated the already restrictive eating habits of people with ED [16,17 ].
Closing the gym and fitness centers because of the restrictions limited the possibility of fulfilling exercise needs. In people with ED, physical activity plays a compensatory role, and limiting or depriving them of this possibility may provoke other compensatory table continued on the next page behaviors (both adaptive and non-adaptive -e.g. limiting caloric intake, purging) [16]. Limited access to medical care precludes people with ED from following the treatment pathway in accordance with established priorities. The priority is regular check-ups with specialists, which allow to monitor the medical and mental condition of the patient and maintain his/her motivation for treatment at an adequate level. Patients at the initial stage of treatment are particularly at risk, as it may be associated with a decrease in motivation and withdrawal from therapy [16].
The functioning of patients with ED is also influenced by other factors. Concerns about the economic crisis (threat of unemployment, loss of work, the need to combine work with childcare) generate chronic stress. Constantly focusing on symptoms from the body looking for signs of a potential COVID-19 infection increases anxiety levels and, consequently, ED symptoms. Social isolation and the associated loneliness contribute to the generation and maintenance of ED, because, as has been known for a long time, social support plays an important role in the treatment of eating disorders. Implementation of working life in the home space blurs the boundaries between the sphere of professional life and the sphere of private life, which increases the perfectionist aspirations of people with ED, which are additionally supported by the environment (social pressure for selfrealization and productivity) [10,16].

Coping strategies for people with eating disorders during COVID-19
Bearing in mind that patients with eating disorders tend to use inadequate ways of coping with difficult situations (e.g. avoiding, focusing on emotions) [18], it is worth supporting them in undertaking adaptive forms of coping, thus reducing the risk of increasing their difficulties. During a pandemic, it is recommended to use a variety of strategies (including problem-solving and tension-reduction strategies), but with a clear predominance of the latter ( Table 2). The limitations of COVID-19 significantly affected the range of choices Often, the only thing left for the patient was to use self-regulating emotional strategies that bring relief. However, it should be remembered that these strategies are often an introduction and prepare the ground for strategies that enable coping with a difficult situation [19].

Table 2. Summary of interventions and coping strategies proposed for treating people with ED during the COVID-19 pandemic
Using the available forms of help Due to the fact that eating disorders, as one of the most difficult to treat, require regular clinical observation [11], patients with ED, regardless of their nature, should remain in constant contact with specialists. This contact may take the form of individual or group sessions online via instant messaging, and correspondence through text messages or e-mails. Additionally, patients can use digital applications that allow them to increase self-control and fulfil planned goals [16].
Psychotherapy is just one aspect of treating a patient with an eating disorder. It is also necessary to constantly monitor the dietary parameters and the somatic state of the patient due to frequent health complications, including cardiological, endocrine or haematological complications [20,21], which often require medical intervention. Research reports that remote treatment may bring relatively satisfactory results by reducing ED symptoms [8], but not all treatment procedures are available in such conditions. Monitoring the vital parameters and body weight of the patient, as well as direct observation of his/her appearance or behaviour, which are the source of initial information on the patient's general health condition, are often impossible to implement remotely [7].
The proposed strategies also include the development of adequate control techniques in the area of eating, which is associated with planning meals, snacks and maintaining regularity in eating. It is also useful to equip the patient with a set of strategies that can be used in difficult situations to limit the use of maladaptive forms of coping (including restrictive eating behaviour, overeating, purging). Patients are advised to exercise mindfulness in the area of eating and learn the signals of satiety and hunger that the body sends [16].
Introducing changes to media use is essential. Limiting contact information on COVID-19 and its negative effects, which generate fear and anxiety increase, will reduce the risks of non-adaptive strategy to reduce tension. Educating the patient on the methods of influence used in the media reduces his sensitivity to distorted content concerning appearance, body weight and figure [16]. Social support is a protective factor in ED, so it is important to make changes in terms of social activity. Searching for opportunities to connect with family and friends develops bonds and increases a sense of security. Involvement in activities that give the patient satisfaction, positively influence his/her self-esteem and allow him/her to spend his free time should also be supported [16].

E-therapy in the treatment of eating disorders
In the time of the coronavirus, both patients and specialists have been forced to quickly adapt to the new situation. It was necessary to move from in-patient meetings to online meetings using the available instant messaging services [5]. Therefore, standard procedures for working with patients with eating disorders need to be modified in the light of the difficulties caused by COVID-19 [22]. In the process of psychotherapy of people with ED, working on distortions of the body image should be included, while stimulating the development of pro-health attitudes towards the body. This process should be multifaceted, and the therapeutic procedures used should be adjusted to the severity of symptoms and the structure of the patient's personality [21]. The key to the process of psychotherapy, regardless of the paradigm, in which the therapist works, is the healing effect of therapeutic alliance, based on empathy, openness and authenticity [20,21]. Selected studies show that it is possible to form an alliance in the therapeutic process conducted online [24], but it requires an appropriate level of patient motivation [25]. In psychotherapy of people with disturbed body image, the following techniques can be used: relaxation techniques, mirror technique, body awareness exercises (including breathing, touch and massage exercises), body contour technique, pantomime and projection techniques [26]. The possibility of their use in remote space is limited, which calls into question the effectiveness of such therapy.

Summary
The period of pandemic requires greater flexibility from therapists, and from patients to seek adequate methods of coping with a crisis situation. Undoubtedly, the COVID-19 pandemic is a strong stressor that damages the sense of security of both patients and professionals working in the medical industry. Currently, numerous studies are carried out around the world on the impact of pandemic on the functioning of patients with eating disorders. New therapeutic methods or modifications to the already used methods are sought, that can be adapted to the new conditions and will bring tangible benefits to patients. The advantage of e-therapy is its easy access, a variety of proposed interactions or the possibility of contact at different times of the day, but it also has its limitations [25]. During a pandemic, online therapy has become an alternative to classic psychotherapy, which is often impossible for various reasons. Patients with ED can reach for support and learn coping strategies adapted to the contemporary social conditions through the use of a variety of communicators. However, due to the variability of ED patients with regard to the type and severity of symptoms, personality structure, and comorbidities, online therapy may not be sufficient.