¹Resident doctor of Family and Community Medicine, Príncipe de Asturias University Hospital, Alcalá de Henares, Madrid, Spain

²General practitioner, Canillejas Primary Health Care Center, Madrid, Spain

³General practitioner, Vitigudino Primary Health Care Center, Salamanca, Spain

⁴Pharmacist, San José Pharmacy, Las Palmas de Gran Canaria, Las Palmas, Spain

*Corresponding author: Áurea Redondo-Sendino, General practitioner, Canillejas Primary Health Care Center, Madrid, Spain, E-mail: [email protected]

Received Date: November 30, 2020

Published Date: December 27, 2020

Copyright: Redondo-Sendino A, et al. © 2020.

Citation: Redondo-Sendino A, et al. (2020). Anorexia Nervosa Debut during COVID Pandemic Confinement. Mathews J Psychiatry Ment Health. (5)1:27.

ABSTRACT

The new coronavirus 2019-nCoV disease (COVID 19) has had a huge impact on global health. On the one hand, the measures adopted by health authorities, according to the needs of public health, have had a negative effect in mental health. The isolation, the quarantine, the social distancing and the confinement have drastically modified our eating habits and exercise patterns and in vulnerable people have triggered or aggravated eating disorders. Moreover, there has been a change in the organization of medical assistance, which used to be all face-to-face interviews and has now became mostly phone call consults. This has affected the quality of medical assistance. Hereafter we are going to describe a patient’s case that was diagnosed with severe anorexia nervosa during the COVID-19 confinement in Spain.

KEYWORDS: Anorexia nervosa; Coronavirus; COVID-19; Pandemic; Eating disorder

ABBREVIATIONS

COVID-19: coronavirus 2019-nCoV; AN: Anorexia Nervosa; BMI: Body Mass Index; FSH: Follicle Stimulating Hormone; LH: luteinizing Hormone; EAT: Eating Attitudes Test.

INTRODUCTION

The new disease produced by coronavirus 2019-ncoV or COVID has become a new challenge for mental health all around the world. The isolation, the quarantine, the social distancing and the confinement have modified interpersonal relationships and everyday activities including our eating habits and exercise patterns. Particularly, in vulnerable people has triggered or aggravated eating disorders, such as anorexia nervosa (AN). Furthermore, medical consults, which used to be all face-to-face, have become mostly telephone calls, which has made even more difficult to diagnose some diseases such as anorexia nervosa [1-3]. We are now going to describe a patient’s case that during the confinement debuted with severe anorexia nervosa.

CASE REPORT

20-year-old woman, diagnosed with anxious adaptive disorder in psychological treatment that consulted via telephone with her general practitioner because she had 1-month amenorrhea and cutaneous xerosis. During the confinement she had modified her exercise patterns, was eating only twice a day and her weight had decreased to 41 kilogrames, with a body mass index (BMI) of 17. Fifteen days later we conducted a follow up, where the patient told us she was still in amenorrhea, continued with the same eating habits and exercise patterns. We decided to see her in person and to do a blood test, where several alterations compatible with AN where found, such as: low FSH and LH (FSH 0,12 mUI/ml and LH 0,04 mUI/ml), hypoglycemia (glucose 56 mg/dl), minor kidney failure (Creatinine 1.16 mg/dl and glomerular filtration 58.97 ml/min), hypercholesterolemia (cholesterol 265 mg/dl) e hypophosphatemia (2,2 mg/dl). During the interview the patient showed a rigid and prepared speech, even bringing a notebook with everything she wanted to go through written down. She told us that every day she made a balance between the ingested and burnt calories, that she practiced 6 hours of exercise per day and that she drank 4 liters of liquid per day, 2 of them at least of tea, because it had a diuretic and laxative effect. Afterwards she went through the EAT 26 test (eating attitude test) where she obtained 38 points, being this punctuation very superior to the 20 score points that were the cutting point (Table 1).  In the physical exploration the blood pressure was 80/50 mmHg, the weight was 35.1 kilogrames and the BMI was 15,19. The patient was normal colored, well hydrated and perfunded and presented signs of malnutrition. In the skin we could observe an increase of facial hair, lanugo, an increase of the bone structures relief according to the lack of adipose panicle and various hyperkeratotic lesions in the knuckles of both hands that match self-provoked vomits. The cardiac auscultation highlighted a 35 beats per minute bradycardia. We prescribed a 1500 calories diet, we sent her to the Psychiatry service and made an appointment for a new blood analysis. The psychiatrist prescribed psychotherapeutical treatment and sertraline 50 milligrams per day, in order to decrease her obsessive-compulsive conduct. Nowadays she is under a strict psychiatric control and followed up by her general practitioner. The patient was having an unsatisfying evolution so the psychiatrist considered hospitalization.

1. I am terrified about being overweight 2. I avoid eating when I am hungry 3. I find myself preoccupied with food 4. I have gone on eating binges where I feel that I may not be able to stop 5. I cut my food into small pieces 6. I am aware of the calorie content of foods I eat 7. Particularly I avoid foods with high carbohydrate content (i.e bread, rice, potatos, etc.) 8. I feel that others would prefer if I ate more 9. I vomit after I have eaten 10. I feel extremely guilty after eating 11. I am preoccupied with a desire to be thinner 12. I think about burning up calories when I exercise 13. Other people think I am too thin 14. I am preoccupied with the thought of having fat on my body 15. I take longer that other to eat meals 16. I avoid foods with sugar in them 17. I eat diet foods 18. I feel that food controls my life 19. I display self-control around food 20. I feel that other pressure me to eat 21. I give too much time and thought to food 22. I feel uncomfortable after eating sweets 23. I engage in dieting behavior 24. I like my stomach to be empty 25. I enjoy trying new rich foods 26. I have the impulse to vomit after meals

Possible answers: always, usually, often, sometimes, rarely, never.

EAT-26 valoration: The total score of the EAT-26 test is the sum of the 26 items. The score 3, 2, 1, 0, 0, 0 in the positive direction counts as three points always, usually and often. Only item 25 counts on the opposite way. The score above 20 points shows the presence of eating disorders conducts and attitudes.

Table 1: Eating attitudes test (EAT-26).

DISCUSSION AND CONCLUSION

Anorexia nervosa is an eating disorder characterized by the extreme self-starvation due to a distorted body image and a pathological fear to become obese that is controlled with restrictive diets or purgative behaviors. This disease affects 0.3% of the Spanish population, especially women (prevalence 10:1 versus men) of 12 to 25 years old [1]. Although the ethipathogenic is still unknown, several associated factors have been described: biological (genetical and neurobiological), psychological, familiar and sociocultural [1]. Among these last ones we can find excessive body cult and social success based on thinness, which are enhanced by the use of technologies and the excessive exposure on social media [2]. During the emergency state that took place between March and June 2020 in Spain, a lot of measures were adopted by the government such as isolation, quarantine, social distancing and confinement. These changes have drastically modified social interactions, which have translated as people not leaving their houses, having plenty of hours of inactivity and an increase of the time spent in social media. Moreover, patient attention has radically changed from face-to-face consults to being mostly telephonic assistance, which modified the quality of the medical consults.

The stressing situation generated by the COVID pandemic and the sanitary measures adopted by the government have triggered important changes in our social life and accessibility to heath care, which have generated a huge impact in mental health, both in people previously diagnosed or in the general population [3,4]. Particularly, eating disorders, isolation and loneliness have associated an increase on the time available to practice sports, an increase in anxiety and a decrease in the feeling of self-control, resulting in the loss of impulse control [2].

Furthermore, the excessive health concern and the increase of time spent in social media could have been a precipitating factor in the development of eating disorders, such as the case described. Behavioral changes have been described in patients with eating disorders such as an increase in starvation, binge eating, purgative conducts and exercise levels [3]. In some countries, like USA or Australia, there has been an increase of the number of AN cases registered in Pediatric wards [5]. There has also been described several cases that patients that developed AN during confinement [6], such as our current case. Even though there has not been established a causal relationship between social distancing during the pandemic and the development of eating disorders, it is important to take them into account as important precipitating factors in vulnerable patients, such as young patients.

Therefore, as general practitioners we have to stay alert and diagnose as soon as possible eating disorders, especially in cases of young women that consult with amenorrhea, where we should ask for changing eating habits, changes in exercise patterns and practicing a complete physical exploration in order to do an early diagnosis and provide an adequate psychotherapeutical support.

Conflicts of Interest

There are not any sources of support. There are not any sources of funding. There are not any conflicts of interest.

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