Dr. Julie O’Toole, founder of Kartini Clinic, a pediatric eating disorder treatment clinic in Portland, OR, is a former primary care pediatrician who has been treating eating disorders exclusively since 1998. She's the author of a new book, “Give Food a Chance,” with a radical suggestion: Parents and the media have nothing to do with the causes of anorexia.
In fact, drawing on research and clinical experience, O’Toole argues that anorexia is an organic, brain-based disorder (one caused by a quirk in the brain's wiring) rather than a psychosocial disorder (one caused or influenced by life experience and maladjustment)—a disorder more like epilepsy than anxiety or OCD.
While anorexia is traditionally considered a psychosocial disorder, O'Toole recasts it as "a brain-based biological disorder with profound psychosocial ramifications."
Today, YouBeauty is talking with Dr. O’Toole about what this means for eating disorder treatment and why it’s so important that we change the way we think about anorexia.
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YB: A lot of people tend to blame parents or the media for eating disorders but I was struck by your book because you really take a different approach.
Dr. O'Toole: Right. One of the great insights of the late 20th century was that mind and brain are not even opposite sides of the same coin—they are the same coin. Eric Kandel, who won the Nobel Prize in medicine, says, “Mind is a range of functions carried out by the brain.” So the kind of brain/mind dichotomy that we all grew up thinking about and believing is just irrelevant and wrong.
I like to explain to people that if you look at Type 1 diabetes, where the pancreas doesn’t produce insulin adequately, the whole system is affected. There are profound psychosocial ramifications, but it’s not primarily a psychosocial illness. Anorexia nervosa is like that, but the organ that’s affected is the brain. As the pancreas produces insulin, so the brain produces behavior.
The behaviors—the refusal to maintain body weight, the refusal to eat adequately—these are merely symptoms of what’s going on in the brain. In fact, the latest thinking is that this is probably a neurobiological or developmental disorder that has its roots in earliest life, possibly even prenatal life.
YB: What would going on in the prenatal environment to cause an eating disorder?
Dr. O'Toole: I think the short answer is that we really have no idea. But we do know that there is a strong genetic component to anorexia nervosa. Without a genetic predisposition, no environmental trigger or stressor will produce anorexia nervosa. But in a person who has this genetic vulnerability, something happens to alter the brain’s wiring. Is that something a virus? Is it stress hormones? Heavens, we really have no idea.
YB: So you don’t support the idea that anorexia could be caused by cultural images of very thin women?
Dr. O'Toole: I think it’s a giant red herring. But I do think it affects people with eating disorders the way it affects all of us. People do not think clearly about body shape and weight. We just don’t. Part of the reason for that is this excessive emphasis on thinness. So while I don’t think it causes anorexia nervosa or has anything to do with the cause of anorexia nervosa, it does make getting better a lot more difficult.
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YB: So what are the implications of it being an organic, brain-based disorder? How does that differ from a psychological disorder?
Dr. O'Toole: Well for one thing, we can stop blaming parents. I can’t tell you how many times even other physicians will tell me, “Oh, it’s obvious why she has anorexia, I mean look at her mother, she’s a mess.” The implication of this being a neurodevelopmental brain disorder is that parents do not cause it and children do not choose to have it. So this has the potential to be profoundly destigmatizing.
YB: And is this the same for anorexia and bulimia or is it possible that bulimia does have a stronger psychological component and anorexia is a separate disorder?
Dr. O'Toole: Well, since I’m primarily a pediatric eating disorder doctor, we do see patients with bulimia nervosa but the overwhelming majority of our patients have anorexia nervosa.
YB: Why do you think you see more cases of anorexia in younger people?
Dr. O'Toole: Bulimia nervosa is just a rare diagnosis in early childhood. Anorexia is also a rare diagnosis but it’s more common. You really don’t start to see a predominance of binging and purging behaviors until 14 and older, but most of the kids we see are under 12.
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YB: Wow. I didn’t realize that kids under 12 years old could have anorexia.
Dr. O'Toole: Oh, absolutely. I think our youngest patient is six. It’s quite rare, however eight is not as rare and 10 is not rare. So unfortunately, these illnesses can strike kids who are very young, and boys, of course.
Actually, one of the things early on that convinced me that this was a biological disorder was the fact that a 10-year-old farm boy with no access to fashion magazines and all this kind of stuff could get it and it would look exactly like anybody else’s anorexia nervosa. We call those cases paradigm busters. The 10-year-old farm boy causes you to rethink everything that you’ve been taught before.
YB: That’s so sad that such young kids are able to develop eating disorders.
Dr. O'Toole: Well, if we hark back to them being biological disorders, it’s no weirder or sadder than the fact that eight-year-olds get cancer. Which is a pretty shocking and awful thing too. Anorexia is just another of the medical conditions to which humans can be prone.
YB: And do you think it’s empowering for kids or families to think of this as a brain disorder?
Dr. O'Toole: I hope so. If you’ve been told that an eating disorder means you’re superficial or want to look like a model, you’ll feel like a loser. You’ll think, why can’t I just get better? Why am I so concerned with my appearance? To be told, look, this is not your fault. You didn’t sign up for this. You didn’t ask to have this and furthermore, when you look around your family, it’s extremely likely that you will find other affected family members. That allows for compassion to enter the picture.
YB: Do you think that we will one day find a cure for anorexia?
Dr. O'Toole: Absolutely. I think we’re far from it right now, but we’re moving in that direction by trying to understand the biology. That’s the first step.
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