In March, I unexpectedly moved in with my boyfriend after California led the country with a COVID-19 shelter-in-place order. Also unexpected was the arrival of a third party into our one-bedroom apartment: my eating disorder (ED).
My relationship with my ED predates that of my romantic partnership by about 20 years. I started toying with diets in middle school, received an official anorexia diagnosis by my 18th birthday, and completed two stints in intensive outpatient treatment over the following decade and a half. I brought my eating disorder to college, studied abroad with it in London, toted it around my first magazine job, and almost dropped out of grad school because of it. Over all that time, countless medical, therapy, and nutrition appointments, well-meaning remarks that pulled every trigger (“but you look so healthy!”), and full-on family blowouts that threatened the most meaningful connections in my life, I got to know my eating disorder on a level of intimacy I wasn’t sure I’d ever have with an actual person.
By the time I met my boyfriend a year ago, I’d made massive strides in my recovery. The eating disorder had steadily loosened its hold on me, and for the first time in my life, I’d created a healthy structure around my eating and exercise habits that felt realistic and sustainable. Then the pandemic hit.
The good news is I haven’t experienced a full relapse or fallen too far back into the old destructive patterns that to this day still beckon me with the comforting familiarity of a warm blanket and Real Housewives marathon. Compulsive calorie counting, grueling workouts, and the mental gymnastics required to engage in both have robbed me of countless experiences and opportunities while offering a false but soothing panacea for just about every stressful life scenario.
But the truth is, mandated social isolation and an unprecedented amount of time with my own thoughts have reawakened old patterns and behaviors I’d hoped were long gone: more intense scrutiny of my reflection on every trip past the hallway mirror, and workouts that have slowly crept up in length and intensity for the sheer reason that I have all the time and none of the excuses to cut them short.
I’ve had the extremely fortunate privilege to invest years of time and money into recovery, and I’ve been able to pull myself back from the brink of a full-on relapse. But the resurfaced feelings have left me wondering how people in more vulnerable positions are faring as they quarantine with their mental illness.
The answer, according to new research out of the U.S. and Netherlands from top ED experts, is: not great. I first met Cynthia Bulik, PhD, when I wrote about her groundbreaking research on midlife eating disorders in 2016. When I reached out to Bulik, Distinguished Professor of Eating Disorders in the Department of Psychiatry of the School of Medicine at University of North Carolina at Chapel Hill, to ask her if there were any current studies on the impact of quarantine on eating disorders, she had just finished a paper on the very topic. The study, published earlier this week in the International Journal of Eating Disorders, looked at the experience of about 1,000 people in the U.S. and the Netherlands, and it finds that people with anorexia are reporting increased restriction and fears about being able to find foods consistent with their meal plan. Those with bulimia and binge eating disorder are reporting increases in their binge eating episodes and urges to binge. Across the board, people with eating disorders are reporting marked increases in anxiety since 2019 and are expressing greater concerns about the impact COVID-19 is having on their mental health over their physical health.
“Some of the biggest issues people with eating disorders are facing are a lack of structure to their days and a lack of social support,” Buliks tells me. “And 68% of respondents screened positive for generalized anxiety disorder on top of their eating disorder. Even those individuals who were recovered are concerned that pandemic will lead to relapse.”
All of that lines up with my experience these last few months. Eating disorders thrive on isolation, and in the absence of regular, real-life social support from friends and family and consistent therapy sessions and doctor and nutritionist appointments, people with EDs are at risk for real, significant, potentially lethal repercussions.
“These research findings reinforce what we’ve seen since the pandemic began,” says Claire Mysko, CEO of the National Eating Disorders Association (NEDA). “The stressors associated with social distancing and isolation have exacerbated eating disorders behaviors in those with histories of eating disorders.”
Eating disorders have one of the highest mortality rates of any mental illness. (Until very recently, anorexia had the highest mortality rate.) They’re slippery diagnoses that can be tricky to spot and tougher to treat. You can’t tell if someone has an eating disorder by assessing their weight, race, religion, gender, or sexual orientation. The disorders have chameleonlike capabilities that make them conveniently concealable, and in a time of necessary seclusion, the 30-million-plus people (in the United States alone) who deal with them are in unprecedented trouble.
The unfortunate addendum is that according to Bulik’s new research, online therapy isn’t working for many people. “There are limits to telehealth for people with eating disorders,” she says. “Accountability is something—being in a room with someone somehow keeps you more accountable than talking to them on Zoom. You can hide things on Zoom. But when you are face-to-face in the room with your therapist, it’s a different story.”
Looking back on my recovery journey, the biggest turning point came during my second intensive outpatient program. The small, homey, independently run treatment center operated on an entirely different set of rules and principles than I’d experienced in my first (failed) attempt at outpatient recovery. Rather than drawing hard lines and boundaries around after-hours communication between therapists and clients, the heads of the organization encouraged regular text check-ins and more personal, human connections cultivated through chats and meal times outside of regular treatment hours.
That’s where I met Alyssa Mass, MFT, a Los Angeles–based psychotherapist who specializes in eating disorders. When we worked together at the treatment center, we had traditional 50-minute therapy sessions, but we also ate dinners together, discussed our favorite pop songs, and texted over the weekends when I was in the midst of panic attacks. The approach to treatment was anything but traditional, but it worked—both for her and for me. “We were encouraged to communicate with clients outside of sessions, and at other places that’s just a big no,” she says. “But realistically, I would so much rather talk to a client in a moment of crisis when they’re sitting down to eat a meal and panicking than have them get worked up about it, experience shame and engage in negative behaviors because of it, and then tell me about it during our session five days later. For clients to know that you’re available, whether or not they need you, can be a big deal.” For me, it was a game changer.
Bulik agrees that the treatment industry will have to catch up quickly to meet the needs of clients in the COVID era, and that might look a lot more like the treatment I received when I worked with Mass, pre-quarantine. “Therapists can’t assume that telehealth is automatically equivalent to face-to-face treatment,” Bulik says. “They need to work collaboratively with patients to ensure that there is a private space where they can feel safe and come up with ways to boost accountability, like sharing the screen while clients shop on Instacart, or have a session during a meal to help manage anxiety. It will take a lot of nimbleness and creativity to approximate the special safe environment of a face-to-face therapy session online.”
All of that sounds ideal, but conventional health care and ingrained approaches to afflictions like eating disorders don’t shift overnight. So what should someone do if they, like me, have noticed an uptick in problematic thoughts and behaviors? Use the digital age to your advantage.
“If you don't have the luxury of therapy, literally google ‘free eating disorder groups,’” Mass says. “Seek out accounts that are helpful in recovery and be careful to avoid those that do the opposite—in isolation, harmful voices and messages can be especially insidious.”
“In March and April, we saw a 78% increase in messages sent to the NEDA Helpline”—the online portal for the National Eating Disorders Association—“compared with the same period last year,” Mysko says. “We know that our community is looking for virtual resources now more than ever.”
For me, that means curtailing my time on the Instagram explore page, which I find inexplicably filled with fitness influencers and diet tips. It means making more time and space in my life for loved ones in the only way that’s safe and responsible right now—more texts, more FaceTimes, more honesty about what’s going on in my life and theirs during a truly novel time of uncertainty, fear, and chaos. And it means actively investing in those relationships by whatever means necessary to find nourishment and fuel for legitimate happiness that the abusive reign of my eating disorder continuously promised and never delivered. And it means repeatedly pushing my eating disorder out the front door of our one-bedroom quarantine home, because honestly, there just isn’t room for three of us here.
If you or someone you know is struggling with an eating disorder, you can call the National Eating Disorders Association Helpline at 800-931-2237, text “NEDA” to 741-741, or click here to chat.