SINGAPORE - Eating disorder cases here have gone up during the Covid-19 pandemic amid increased stress and anxiety from the disruptions of routines.

The Singapore General Hospital (SGH), which has a well-established multi-disciplinary team that treats eating disorder cases, saw a 15 per cent increase in such cases last year from previous years.

Half of these involved anorexia nervosa, which is characterised by an abnormally low body weight and an intense fear of gaining weight.

Cases of bulimia nervosa - binge eating, followed by purging - make up the bulk of the rest. The others include avoidant restrictive food intake eating disorder, atypical anorexia nervosa and sub-threshold bulimia nervosa.

While SGH did not give exact figures, it was reported last year in IN, a student publication under The Straits Times, that the hospital had an average of 150 new patients a year under its eating disorders programme.

The rise could be due to higher levels of stress in the general population caused by the pandemic, said Dr Ng Kah Wee, director of the eating disorders programme and senior consultant at SGH's department of psychiatry.

"Stress is a contributory factor to causing psychiatric disorders and worsening symptoms," she added.

Ms Pearlene Lim, a senior clinical psychologist at Promises Healthcare, a clinic with a focus on specialist care in mental health and addictions, now gets three to six referrals for eating disorders a month, up from one to three referrals several years ago.

She said there were people whose eating disorders started during the circuit breaker.

Some might have gained a significant amount of weight during this period as a result of stress-induced overeating. This, she added, might have caused them to feel unhappy with their bodies and worry about further weight gain - in turn triggering food restriction and excessive exercising, which eventually became an eating disorder.

The pandemic has also worsened the conditions of existing patients.

Dr Ng said higher levels of close supervision by family members at home during the pandemic had caused more anxiety and tension during meals for some patients who were already struggling.

Agreeing, Ms Lim said some patients with anorexia nervosa reported that it was challenging to eat full and regular meals with their families during the circuit breaker.

"This led to frequent conflicts with their families over food. They also experienced increased guilt about having eaten more than what their eating disorder allowed them to," she said.

Patients became more anxious and depressed as their usual routines - such as going to school or work - were upended, while some even lost their jobs.

"When their anxiety and depression became worse, their eating became more erratic and purging behaviours increased," said Dr Ng.

Jane (not her real name), who recovered from anorexia nervosa three years after being diagnosed, said the sudden and unprecedented changes unleashed by the pandemic could incite fear and a perceived loss of control in patients.

"Some might turn to food as a source of comfort, or a means to soothe themselves or relinquish control," said the 25-year-old, who works in the social service sector.

Ms Lim said some patients found it easier to binge and purge while working or studying from home, further worsening their conditions during the circuit breaker.

Others who were already in the habit of working out obsessively also increased the intensity of their exercise regimens.

SGH senior physiotherapist Kirsten Eve Abdul said some had gone from exercising two to three times a week to exercising daily - and some even multiple times a day.

She said patients with eating disorders who exercise compulsively tend to prefer solitary exercises such as running, working out at the gym or following online workout videos.

With gyms closed and exercise options limited during the circuit breaker, people were encouraged to do home workouts to boost one's mood and immune system.

But the apparent competition on social media may have led some patients to engage in excessive exercise behaviours and form a dysfunctional relationship with exercise, said Mrs Kirsten.

There had been cases of patients who ran long distances daily, which led to a drop in their weight and pain in their joints, she said.

"When exercise is done excessively and there is insufficient recovery or food intake, it can lead to a drop in weight, absence of menstrual periods, repetitive strain injuries, muscle strains and tears, among other physical side effects," she added.

On the other hand, the circuit breaker helped a small number of patients. Closer supervision by family members during meals could have improved some patients' conditions, said Dr Ng.

And family members who noticed mood changes and abnormal eating behaviours in their loved ones helped to bring these to the attention of doctors in a timely manner, she added.

Ms Lim said some patients also benefited from reduced social interaction, as there were fewer opportunities to compare body sizes and shapes or be influenced by comments about their diets and appearances.

Jane stressed that the process of recovery differs for each patient and is not linear.

Recalling her own journey, she said she had often compared herself with others who could gain or lose weight without anxiety, hoping she could go back to the times before she was diagnosed with the disorder.

"While there may be times where you catch yourself slipping back into disordered patterns of thought or behaviour, it is more helpful instead to adopt a forward-looking mentality like I did, to accept my diagnosis was a challenging event that had occurred in my life (but) did not define me as a person, nor was it part of my identity," she said.

Jane was warded at a hospital to help her return to a healthy weight and was taught to recognise symptoms related to her disorder and correct her behaviour.

She said journalling and discussing what she was going through with a few trusted confidants had helped her to better process her thoughts and feelings.

"It can sometimes be a lonely, uphill climb with no end in sight. However, as with most things, the beginning may be the most challenging, but it gets easier as you grow stronger and wiser with experience," she said. "Recovery is a choice you have the autonomy to make."