Received: 16 June 2020 Accepted: 18 June 2020

DOI: 10.1002/erv.2771

SPECIAL ISSUE

COVID-19 and eating disorders during confinement:

Analysis of factors associated with resilience and
aggravation of symptoms

Isabel Baenas1,2 | Elena Caravaca-Sanz1 | Roser Granero2,3 |

1,2 1,2 1,2
Isabel Sánchez | Nadine Riesco | Giulia Testa |
1,2 4
Cristina Vintró-Alcaraz | Janet Treasure | Susana Jiménez-Murcia1,2,5 |
1,2,5
Fernando Fernández-Aranda
1
Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain
2
Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain
3
Department of Psychobiology and Methodology, Autonomous University of Barcelona, Barcelona, Spain
4
King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
5
Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain

Correspondence
Fernando Fernández-Aranda, Eating
Abstract
Disorders Unit, Department of Psychiatry, Objectives: To assess the level of deterioration in functioning of ED patients dur-
University Hospital of Bellvitge-IDIBELL ing confinement, due to COVID-19, and examine potential contributing factors
and CIBEROBN, Feixa Llarga s/n 08907
Hospitalet del Llobregat, Barcelona, (coping strategies, anxiety-depressive symptomatology and personality traits).
Spain. Methods: A total of 74 ED patients in treatment before the COVID-19 out-
Email: ffernandez@bellvitgehospital.cat
break, contributed to this study. Baseline pre-treatment evaluation included
Funding information the SCL-90R, TCI-R, EDI-2 and Y-FAS 2.0 questionnaires for general psycho-
Centro de Investigación Biomédica en pathology, personality and ED severity indexes. ED symptoms, coping strate-
Red-Fisiopatología de la Obesidad y
Nutrición; Generalitat de Catalunya -
gies, socio-demographic data and COVID-19 concerns were collected by
PERIS, Grant/Award Number: clinicians through a semi-structured telephone survey during lockdown.
SLT006/17/00246; Instituto de Salud Results: A deterioration in ED symptoms and general psychopathology (anxiety
Carlos III, Grant/Award Number:
PI17/01167; Ministerio de Educación, and depression), during lockdown, was associated with low self-directedness. Higher
Cultura y Deporte (Spain)- FPU, Grant/ ED symptomatology during confinement was associated with less-adaptive coping
Award Number: FPU16/01453; Post-
strategies to deal with lockdown situation leading to an increase in weight.
Residency Grant from Research
Committee of the University Hospital of Conclusions: These specific vulnerability factors to further confinement or stressful
Bellvitge (HUB; Barcelona, Spain) situations may help design personalized preventive and therapeutic approaches.
2019-2020
KEYWORDS
confinement, COVID-19, eating disorders, mental health, personality

1 | INTRODUCTION Health Organization (WHO) on 31rst January 2020

(WHO, 2020). The pandemic has led to a break with ordi-
The COVID-19 disease has caused major disruptions across nary routines and social contact for most of the world's pop-
the world, after being declared as a pandemic by the World ulation. People with prior mental health disorders have

Eur Eat Disorders Rev. 2020;28:855–863. wileyonlinelibrary.com/journal/erv © 2020 Eating Disorders Association and John Wiley & Sons Ltd 855
856 BAENAS ET AL.

been found to relapse during the pandemic (González-

Sanguino et al., 2020; Moccia et al., 2020; Ozamiz-
Highlights
Etxebarria, Dosil-Santamaria, Picaza-Gorrochategui, &
Idoiaga-Mondragon, 2020; Rajkumar, 2020; Temorshuizen • For the first time, associated factors were
et al., 2020; Weissman et al., 2020). Hao et al. (2020) found assessed as predictors of ED-state during
higher levels of concerns about their physical health, anger, COVID-19 lockdown.
anxiety, depression, impulsivity and intense suicidal idea- • Self-directedness was associated with an aggra-
tion stress in psychiatric patients in comparison with vation of ED and general psychopathology
healthy controls during COVID-19 confinement. Moreover, during confinement.
evidence these effects may be long-lasting (Shah • ED worsening was linked to less-adaptive cop-
et al., 2020). ing strategies in confinement situation with a
Patients with eating disorders (ED) and/or obesity rep- resulting weight increase.
resent a vulnerable group (Cornejo-Pareja, 2020;
doi:10.1002/erv.2770 van Rensburg, 2020). Symptomatic
deterioration such as purging, binging and exercise has
been reported (Phillipou et al., 2020). Moreover the physi-
cal sequel of the disorders such as weight loss in anorexia
nervosa (AN), electrolyte imbalance in bulimia nervosa 1.1 | Aims
(BN), or cardiovascular risk in binge eating disorder (BED)
amplify the risk (Chew, Wei, Vasoo, Chua, & Sim, 2020; The main aim of this study is to assess the factors that
Fernández-Aranda et al., 2020; Cornejo-Pareja et al., 2020; impact on the adjustment of people with ED to the
Touyz, Lacey, & Hay, 2020). Also constraints in food sup- COVID-19 confinement. We hypothesized that that
ply chains may increase “food insecurity” (Temorshuizen poorer social support and non-adaptive coping strategies
et al., 2020; and increase food hoarding (Touyz et al., 2020) would be associated with a greater adverse reaction.
triggering bingeing (Fernández-Aranda et al., 2020;
Temorshuizen et al., 2020. Furthermore, emotional dis-
tress in the face of environmental changes is another trig- 2 | METHOD
gering factor (Mediouni, Madiouni, & Kaczor-
Urbanowicz, 2020; Rodgers et al., 2020; Touyz et al., 2020; 2.1 | Participants
Clark-Bryan et al., 2020;https://doi.org/10.1002/erv.2762
2020). Restrictions placed on movement may have limited The sample was constituted of 74 adults, with female pre-
adaptive strategies in the face of these difficulties (Rodgers dominance (71 patients, 95.9%) and a mean age of 32.12
et al., 2020) with reduced access to support (Weissmann, (±12.84) years old. They all were diagnosed with an ED
Bauer, & Thomas 2020; Fernandez-Aranda et al., 2020). and presented for treatment to the ED Unit within the
Graell et al., 2020; https://doi.org/10.1002/erv.2763). Department of Psychiatry at a University Hospital in
In the general population, factors related to the psy- Spain: 19 AN, 12 BN, 10 BED and 33 Other Specified
chological impact include as female sex (González- Feeding or Eating Disorder (OSFED). Patients were diag-
Sanguino et al., 2020; Özdin & Bayrak Özdin, 2020; Wang, nosed according to DSM-5 criteria (APA, 2013).
Di, Ye, & Wei, 2020), low educational level and lower per-
ceived health status (Özdin & Bayrak Özdin, 2020; Wang
et al., 2020), and high perceived vulnerability to infection 2.2 | Procedure
and exposure to news (Olagoke, Olagoke, & Hughes, 2020;
Yao, 2020). Personality factors associated with better adap- The present study was carried out in accordance with the
tation include higher scores in the fight-flight system latest version of the Declaration of Helsinki. The Univer-
(related to personal safety concerns) and lower scores in sity Hospital Clinical Research Ethics Committee
the behavioural inhibition system (related to anxiety) approved the study, and signed informed consent was
(Bacon & Corr, 2020); confidence (linked to secure attach- obtained from all participants.
ment) and discomfort with closeness (associated with We used a semi-structured telephone survey designed
avoidant attachment) (Moccia et al., 2020) and conscien- by a clinician team from our Unit, regarding five main
tiousness (Carvalho, Pianowski, & Gonçalves, 2020). thematic blocks to explore: (a) socio-demographic infor-
To the best of our knowledge, ours is the first study mation; (b) ED-status; (c) COVID-19 concerns;
that examines the factors that might contribute to a (d) pandemic stress (anxiety, depressive symptoms, other
poorer adaptation to the COVID-19 pandemic. situations, and family conflicts) and, (e) coping strategies.
BAENAS ET AL. 857

This survey was administered as part of a prospective 2.3.3 | Symptom checklist-90-revised

follow-up coinciding with official COVID-19 lockdown in (SCL-90-R) (Derogatis, 1990)
the region of Catalonia (Spain) from 14th March to 11th
May 2020 and was administered during April 2020. It consists of a 90-item questionnaire that evaluates a
broad range of psychological problems and symptoms of
psychopathology by measuring nine primary symptom
2.3 | Assessments dimensions: Somatization, Obsession-Compulsion, Inter-
personal Sensitivity, Depression, Anxiety, Hostility, Pho-
2.3.1 | Eating disorders inventory-2 bic Anxiety, Paranoid Ideation, and Psychoticism. It also
(EDI-2) (Garner, 1991) includes three global indices: global severity index (over-
all psychological distress), positive symptom distress
It consists of 91 items self-report questionnaire, answered index (the intensity of symptoms), and a positive symp-
on a 6-point Likert scale, which assesses different cognitive tom total (self-reported symptoms). The global severity
and behavioural characteristics concerning ED: Drive for index can be used as a summary of the test. The
Thinness, Bulimia, Body Dissatisfaction, Ineffectiveness, validation of the scale in a Spanish population
Perfectionism, Interpersonal Distrust, Interoceptive Aware- (Derogatis, 2002), obtained a mean internal consistency
ness, Maturity Fears, Asceticism, Impulse Regulation, and of .75 (coefficient alpha). The internal consistency for this
Social Insecurity. The EDI-2 provides standardized subscale study was between adequate (α = .763 for paranoid idea-
scores and a global measure of ED severity, which can be tion) to excellent (α = .980 for global indexes).
obtained based on the sum of all the items. The validated
version for the Spanish population (Garner, 1998) had a
mean internal consistency of 0.63 (coefficient alpha). Inter- 2.3.4 | Temperament and character
nal consistency for the total score in this study was between inventory-revised (TCI-R) (Cloninger,
adequate (Cronbach-alpha α = .70 for maturity fears) to Svrakic, Przybeck, & Whitehead, 1999)
excellent (α = .953 for total score).
This questionnaire is composed of 240-items scored on a
5-point Likert scale and measures personality derived
2.3.2 | Yale food addiction scale 2.0 from three character dimensions (Self-Directedness,
(YFAS-2) (Gearhardt, Corbin, & Cooperativeness, and Self-Transcendence) and four tem-
Brownell, 2016) perament scales (Harm Avoidance, Novelty Seeking,
Reward Dependence and Persistence). Evaluation of the
It is a 35-item self-report questionnaire for measuring Spanish revised version (Gutiérrez-Zotes et al., 2004) gen-
Food Addiction (FA) during the previous 12 months. It erated an internal consistency of 0.87 (coefficient alpha).
was based on the Diagnostic and Statistical Manual of The questionnaire obtained internal consistency in this
Mental Disorders (DSM-IV-TR) (APA, 2000) criteria for study between moderate (α = .739 for cooperativeness) to
substance dependence and was adapted to the context of excellent (α = .900 for harm avoidance).
food consumption. YFAS-2, a newer version of the instru-
ment, is based on DSM-5 Criteria (APA, 2013) and evalu-
ates 11 symptoms. Two measurements are shown: (a) a 2.3.5 | Semi-structured brief telephone
continuous symptom count score that reflects the number survey during COVID-19 confinement
of fulfilled diagnostic criteria (ranging from 0 to 11), and (Eating Disorders Unit, Psychiatry
(b) a FA food addiction threshold based on the number of Department, University Hospital,
symptoms (at least two) and self-reported clinically signif- Spain, 2020)
icant impairment or distress. This final measurement
allows for the binary classification of FA food addiction First, sociodemographic information was up-dated
(present versus absent). Moreover, based on the revised regarding lockdown period in terms of employment sta-
DSM-5 taxonomy, it is possible to establish severity cut- tus, confinement compliance, affected environment by
offs: mild (between two and three symptoms), moderate COVID-19 and presence of company during this situa-
(between four and five symptoms), and severe (between tion using dichotomous response (yes/no). The second
six and eleven symptoms). The Spanish validation of the part of the survey was related to ED-state (measured as
YFAS-2 (Granero et al., 2018) had an internal consistency remaining equal, worsening, or remaining in the back-
of 0.94 (coefficient alpha). In this study, internal consis- ground). COVID-19 concerns were classified as related
tency for the total score was excellent (α = .949). to (a) own or family infection's risk and, (b) uncertain
858 BAENAS ET AL.

T A B L E 1 Association between the

Worse n = 19 Non-worse n = 55
ED-state during the confinement with
n % n % p |d| the measures registered during the
COVID-related concerns 16 84.2 36 65.5 .123 0.44 COVID-19

Concerns: Infection risk 7 36.8 14 25.5 .343 0.25

Concerns: Uncertain future 10 52.6 16 29.1 .046* 0.51a
Concerns: Employment 4 21.1 11 20.0 .922 0.03
Concerns: Medical treatments 4 21.1 1 1.8 .004* 0.68a
Concerns: Other 4 21.1 6 10.9 .265 0.28
Adaptive reactions 17 89.5 53 96.4 .252 0.28
Adaptive reactions: Social 1 5.3 13 23.6 .078 0.55a
Adaptive reactions: Leisure 8 42.1 34 61.8 .135 0.40
Adaptive reactions: Sport 2 10.5 15 27.3 .135 0.44
Adaptive reactions: Routine 8 42.1 34 61.8 .135 0.40
Adaptive reactions: Work/studies 8 42.1 14 25.5 .171 0.35
Non-adaptive reactions 10 52.6 9 16.4 .002* 0.79a
Non-adaptive reactions: COVID 1 5.3 0 0.0 .575 0.46
Non-adaptive reactions: ED 5 26.3 6 10.9 .104 0.40
Non-adaptive reactions: Other 4 21.2 2 3.6 .016* 0.57a
Anxiety 14 73.7 17 30.9 .001* 0.89a
Anxiety: Physic 6 31.6 10 18.2 .221 0.31
Anxiety: Emotional 13 68.4 14 25.5 .001* 0.89a
Anxiety: Motor 6 31.6 4 7.3 .008* 0.65a
Anxiety: Cognitive 13 68.4 11 20.0 .001* 1.02a
Depression 12 63.2 10 18.2 .001* 0.96a
Other situations 13 68.4 21 38.2 .023* 0.62a
Familiar conflicts 8 42.1 7 12.7 .006* 0.68a

*Bold: significant comparison.

a
Bold: effect size into the range mild–moderate (|d| > 0.50) to high-large (|d| > 0.80).

future, (c) employment status, (d) supply and access to 2.4 | Statistical analyses
treatments and, (e) other concerns. A yes /no evaluation
of anxiety (psychical, emotional, motor, and cognitive Statistical analysis was carried out with Stata16 for win-
dimensions), depressive symptoms (such as low mood, dows (Stata Press, 2019). The comparison between the
pessimism, or insomnia), other consequences (boredom groups of the study was done through chi-square tests
or social conflicts) and familial conflicts were made. (χ 2) for categorical variables and t test for quantitative
Finally, coping strategies during confinement were measures. Effect size for the proportion and the mean dif-
evaluated in two ways: (a) as presence or absence of ferences was estimated with Cohen's-d coefficient, con-
both adaptive and non-adaptive mechanisms and, (b) as sidering null effect for |d| < 0.20, low-poor for |d| > 0.20,
well as the kind of strategies carried out by categorizing mild-medium for |d| > 0.50 and large-high for |d| > 0.80)
the coping mechanisms in dimensions (five for adaptive (Cohen, 1988; Kelley & Preacher, 2012).
strategies: social contact; leisure; sports activities; daily Path analysis procedure assessed the underlying
routines; and academic/work activity and three dimen- relationships between the variables of the study (direct
sions for non-adaptive ones: COVID-19 over-informa- and indirect links, including mediational associations).
tion; ED behaviours and other non-adaptive This analysis was carried out as a case of structural
behaviours. An extended version of this scale has been equation modelling (SEM), with the maximum-
published in the current issue (Fernández-Aranda likelihood estimation method of parameter estimation.
et al., 2020). Due the large number of contextual and personal
BAENAS ET AL. 859

TABLE 2 Association between the ED-state during the confinement with the clinical measures prior to the COVID-19

Worse n = 19 Non-worse n = 55

Mean SD Mean SD p |d|

Age (yrs-old) 32.53 13.60 31.98 12.69 .875 0.04
Onset of the ED (yrs-old) 16.42 4.22 16.62 5.80 .892 0.04
Duration of the ED (yrs) 14.49 11.56 14.60 11.32 .971 0.01
EDI-2: Drive for thinness 13.16 4.65 12.42 6.68 .657 0.13
EDI-2: Body dissatisfaction 17.63 7.03 14.80 8.24 .185 0.37
EDI-2: Interoceptive awareness 12.47 7.80 10.44 6.72 .278 0.28
EDI-2: Bulimia 6.26 4.63 5.55 5.46 .610 0.14
EDI-2: Interpersonal distrust 6.16 4.82 5.58 5.09 .668 0.12
EDI-2: Ineffectiveness 11.63 5.89 9.98 7.36 .380 0.25
EDI-2: Maturity fears 7.42 5.49 8.07 5.06 .637 0.12
EDI-2: Perfectionism 4.84 3.47 6.04 4.84 .326 0.28
EDI-2: Impulse regulation 6.89 4.48 5.20 5.98 .263 0.32
EDI-2: Ascetic 7.95 4.39 6.89 4.93 .411 0.23
EDI-2: Social insecurity 7.68 4.99 6.89 5.11 .559 0.16
EDI-2: Total score 102.11 38.99 91.87 45.33 .383 0.24
SCL-90R: Somatization 1.49 0.98 1.83 0.94 .189 0.35
SCL-90R: Obsess./compulsive 1.93 0.80 1.87 0.82 .779 0.08
SCL-90R: Interpersonal sensitivity 2.03 0.95 1.95 1.03 .757 0.08
SCL-90R: Depressive 2.32 0.85 2.15 1.01 .512 0.18
SCL-90R: Anxiety 1.55 0.91 1.59 0.97 .899 0.03
SCL-90R: Hostility 1.65 1.21 1.25 1.03 .167 0.36
SCL-90R: Phobic anxiety 0.86 0.86 1.14 1.00 .281 0.30
SCL-90R: Paranoid ideation 1.34 0.65 1.39 0.91 .837 0.06
SCL-90R: Psychotic 1.29 0.87 1.27 0.76 .909 0.03
SCL-90R: PST score 1.70 0.77 1.70 0.81 .997 0.00
SCL-90R: GSI score 60.00 19.17 63.15 17.67 .515 0.17
SCL-90R: PSDI score 2.42 0.57 2.28 0.61 .373 0.24
YFAS: Total score 5.74 3.65 5.58 3.69 .875 0.04
TCI-R: Novelty seeking 97.11 13.35 97.24 17.07 .976 0.01
TCI-R: Harm avoidance 117.53 18.34 115.51 21.90 .720 0.10
TCI-R: Reward dependence 103.53 14.30 101.33 17.95 .631 0.14
TCI-R: Persistence 114.05 22.51 115.27 19.02 .819 0.06
TCI-R: Self-directedness 117.37 20.96 127.56 18.70 .048* 0.51a
TCI-R: Cooperativeness 133.89 9.69 137.85 13.19 .234 0.34
TCI-R: Self-transcendence 64.37 14.86 65.82 16.71 .739 0.09

*Bold: significant comparison.

a
Bold: effect size into the range mild–moderate (|d| > 0.50) to high-large (|d| > 0.80).

variables characterizing the COVID-19 confinement, a reactions, non-adaptive reactions, anxiety, depression,
latent variable was defined (labelled as “COVID” in the other problems and familiar conflicts). The goodness-of-
model, defined by the presence of concerns, adaptive fit was tested with standard statistical measures: χ 2 test,
860 BAENAS ET AL.

FIGURE 1 Path-diagram with the standardized coefficients. Note. Continuous line: significant coefficient. Dash line: non-significant
coefficient

the root mean square error of approximation (RMSEA), study, the participants were re-classified in two groups
Bentler's Comparative Fit Index (CFI), the Tucker-Lewis based on the ED state during the confinement: symp-
Index (TLI), and the standardized root mean square tom deterioration (n = 19) or not (n = 55).
residual (SRMR). Adequate fit was considered for
(Barrett, 2007) non-significant result in the χ 2 test,
RMSEA<0.08, TLI > 0.90, CFI > 0.90 and SRMR<0.10. 3.2 | Comparison of groups based on the
ED progression during COVID-19 lockdown

3 | R E SUL T S No differences between these two groups were found for

the marital status (p = .845), education levels (p = .796),
3.1 | Characteristics of the participants social index (p = .555), and diagnostic subtype (p = .294)
previous and during the confinement (see Table S1, supplementary material).
Table 1 displays the comparisons between the groups of
Coinciding with the lockdown, most patients were under- the study for the variables registered during the COVID-19
going outpatient treatment (73 patients, 98.6%). Almost lockdown. Patients who noticed an ED worsening reported
27% (20 patients) of the sample were actively working, higher prevalence of future concerns, such as access to
almost 95% (70 patients, 94.6%) had social support and medical treatment, non-adaptive reactions, symptoms of
only 17.6% (13 patients) had close people affected by anxiety and depression, adverse situations and familiar
COVID-19. conflict.
The presence of concerns related with the confine- Table 2 compares the baseline assessment between
ment for COVID-19 was reported by 52 patients (70.3%), the groups. Self-directedness was lower in the group with
a high prevalence of patients used adaptive reactions deterioration in their ED symptoms: 117.4 versus 127.6;
(n = 70, 94.6%), 19 patients (25.7%) also reported non- p = .048, |d| = 0.51).
adaptive reactions. The presence of anxiety symptoms Table S2 (supplementary material) contains the point-
was reported by 31 participants (41.9%) and depression serial correlation matrix with the associations between
by 22 (29.7%). Familial conflicts were noted by 15 individ- the variables measuring during the confinement with the
uals (20.3%) and other difficulties 34 patients (45.9%). clinical state registered previous to the COVID-19 lock-
Symptom evolution during the confinement due to down. The presence of concerns during the confinement
the COVID-19, worsened in n = 19 patients (25.7%), was related to older age and lower EDI-2 drive for thin-
and became less dominant in n = 38 (51.4). For this ness score. Non-adaptive reactions were reported by
BAENAS ET AL. 861

patients with higher score in the YFAS-2 scale, and 5 | CONCLUSIONS

depression symptoms were related to worse psychopatho-
logical state. In conclusion, the present findings suggest that an about
a quarter of patient with an ED showed a deterioration in
symptomatology, post COVID and this was mainly asso-
3.3 | Path analysis ciated with lower self-directedness. These results suggest
the relevance of identifying specific vulnerability factors
Figure 1 contains the path-diagram with the standardized among ED patients in a confinement situation in order to
coefficients obtained in the SEM. Adequate fitting was develop preventive strategies and personalized treatment
obtained: χ 2 = 67.84 (p = .201), RMSEA = 0.045, approaches.
CFI = 0.958, TLI = 0.945 and SRMR = 0.087.
The latent variable measuring the contextual and ACKNOWLEDGEMENTS
personal features during the COVID-19 lockdown was We thank CERCA Programme/Generalitat de Catalunya
associated with concerns related to the confinement, for institutional support. This work was partially
non-adaptive reactions, anxiety, depression and familial supported by Instituto de Salud Carlos III (PI17/01167)
conflicts. Results from the SEM suggest that a poorer and Generalitat de Catalunya (PERIS/SLT006/17/00246).
state during the COVID-19 lockdown and lower TCI-R CIBERObn is an initiative of ISCIII Spain. IB was par-
self-directedness score increase the likelihood of deterio- tially supported by a Post-Residency Grant from Research
rating ED symptoms during the confinement (direct Committee of the University Hospital of Bellvitge (HUB;
effects). The COVID-19 latent variable was also a media- Barcelona, Spain) 2019-2020. CVA is supported by a FPU
tional variable in the model: indicating that age, grant (FPU16/01453) from Ministerio de Educación, Cul-
self-directedness and BMI, contributed indirectly to the tura y Deporte (Spain). The funders had no role in the
deterioration in ED symptoms. study design, data collection and analysis, decision to
publish or preparation of the manuscript.

4 | DISCUSSION CONFLICT OF INTEREST

The authors declare no conflict of interest.
The present study explored the factors associated with
symptomatic deterioration in people with ED. A quarter ORCID
of patients became more symptomatic during lockdown a Isabel Baenas https://orcid.org/0000-0001-7415-0616
similar proportion to that found during the first weeks of Roser Granero https://orcid.org/0000-0001-6308-3198
confinement (Fernández-Aranda et al., 2020). The deteri- Isabel Sánchez https://orcid.org/0000-0001-5874-8204
oration was higher in people with AN followed by those Nadine Riesco https://orcid.org/0000-0002-6336-4907
with OSFED. This differential pattern aligns with other Cristina Vintró-Alcaraz https://orcid.org/0000-0001-
studies (Temorshuizen et al., 2020). 9453-8810
A novel feature of the present work was the associa- Janet Treasure https://orcid.org/0000-0003-0871-4596
tion of symptom deterioration with low levels of self- Susana Jiménez-Murcia https://orcid.org/0000-0002-
directedness. This aligns with other work in confinement 3596-8033
Moccia et al. (2020) and to the extensive literature associ- Fernando Fernández-Aranda https://orcid.org/0000-
ating in ED lower self-directedness to poorer prognosis 0002-2968-9898
(Duffy et al., 2019; Krug et al., 2011). Age and ED sever-
ity, named drive for thinness (EDI-2), were also related RE FER EN CES
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