| Issues | Examples |
| Eating disorder experience, behaviours and coping | - Worsening of eating disorder symptoms, reactivation of symptoms despite treatment
- Additional anxiety and stress, contributing to emotional eating
- Secrecy about symptoms, hiding eating disorder from others, loss of control over meals due to living with others, receiving criticism for eating behaviours
- Eating disorder voice becoming stronger
- Fear and shame – not wanting shop staff to notice food purchases, therefore using different shops to manage this
- Less access to the social side of eating i.e. going out. Having to eat more alone, at home, increased restricted eating and worrying about this impacting recovery
- Anxiety and depression contributing to low self-directedness, higher eating disorder symptoms leading to less-adaptive coping strategies
- Increased compensatory exercise, exacerbated binge eating
- Difficult to manage relationship with exercise, exercise routine
- Disruption to routine and perceived control – more rumination about weight, exercise and meals, change to usual coping mechanisms
- Lack of routine and structure both perpetuating and mitigating disordered eating
- Increased drive for physical activity, eating, shape and weight concerns
- Shortages and/or excess supplies of food, more likely to binge, guilt for eating, a more negative, purely functional unenjoyable relationship with food
- Fear of deterioration in recovery, worry about potential reliance on behaviours that may interfere with recovery
- Video calls heightening awareness of the bodily self, leading to self‐criticism that is potentially harmful to recovery
- Pandemic restrictions as disruptive to recovery mindset and recovery-oriented practices
- Feeling unsettled, struggling to regulate food intake
- More compulsion around food, food thoughts becoming more prominent as social activities became curtailed
- Increased responsibility for oneself due to modified professional and personal support
- More sedentary circumstances leading to consciously planned activities to intensify exercise routines
- Exercise as stressful rather than for coping
- Working from home – more freedom and flexibility to engage in eating disorder behaviours
- Pandemic online discourse – diet, fitness, exercise – promoting eating disorders behaviours, more comparisons on social media
- Loss of motivation to work on recovery, loss of goals
- Risks with self-monitoring of weight and experiencing this as stressful
- Feeling of being watched
- Less meal structure, increased binge eating, vomiting
- Stockpiling of food items, such as those deemed “binge-worthy,” leading to intense negative reactions and compulsive urges to act on disordered thoughts and feelings.
- Misusing medications to suppress weight gain, or laxatives to suppress appetite or lose weight.
- Feeling ashamed of the associated health outcomes with eating disorders and reluctance to tell others of their physical distress or seek medical care
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| Additional distress | - Loneliness, sadness, and inner restlessness and dysfunctional coping mechanisms
- Increased interpersonal stress
- Risk of suicide and/or self-harm
- More severe pandemic related post-traumatic symptomatology, with symptoms predicted by childhood trauma and insecure attachment
- Higher levels of stress, anxiety, depression and PTSD-related symptoms, fear of losing control
- Increased time online, increased food and exercise messaging in public discourse, increased social comparisons
- Missing the casual nature of social interactions, harder to speak up, reduced access to organised social activities
- Trying to balance conflicting priorities
- Lack of value, purpose and routine – lack of motivation
- Substance use as short-term coping
- Fear of Covid-19 infection
- Feeling defeated by negative emotions linked to current events
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| Personal circumstances | - Household arguments and fear for the safety of loved ones as contributor to increased symptoms
- Helping others vs. helping oneself, with both potential positive and negative consequences
- Helping others gives a sense of purpose and counteracts loneliness, however, it also means the person’s own needs and health can come second
- People living alone – feeling confined and isolated, lack of social connection contributing to eating disorder behaviours
- Lack of privacy, feeling monitored by others – leading to distress, low mood, conflict or withdrawal
- Stress and exhaustion of caring for others – children, working from home less time for caring for oneself
- Worrying about others being infected
- Interacting more often with friends or family, including at mealtimes. This leading to feelings of sadness and anger when family members criticised, dismissed or ignored eating behaviours
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| Support networks and treatment | - Disruption to treatment outcomes, negative effects on work and treatment
- Disparity in access to eating disorder services, reliance on remote support, premature discharge, disrupted transitions into community living, treatment suspended, limited post-diagnostic support, remaining on waiting list for treatment
- Reduced contact from clinical teams, reduced time for professionals to address changes in treatment, more self-management of the illness by PWED
- Treatment delayed or stopped, loss of specialised support, GP support
- Unable to see supportive friends, increased social isolation
- Lack of non-verbal communication due to use of phones and screens
- Not being ‘bad enough’ or ‘sick enough’ to warrant support from a psychologist or psychiatrist
- Feeling of wanting to wait until the end of lockdown before seeking support
- Feel disillusioned and without support
- Access to care as frustrating and confusing
- Sense of detachment with online support, home space not feeling confidential, internet issues, connection with therapist feeling less personal
- Changes in staff and treatment in inpatient settings, difficult to build relationships with clinicians
- Inpatient patients not being able to see parents, siblings, grandparents and close friends
- Impaired psychotherapy, low uptake of videoconference therapy
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