PORTLAND, ORE. – Despite common perceptions among medical professionals and the general public, anorexia nervosa is not a psychosocial disease, Julie K. O'Toole, M.D., said at a conference sponsored by the North Pacific Pediatric Society.
Rather, it is a brain disorder and should be seen as such, said Dr. O'Toole, medical director of the Kartini Clinic for Disordered Eating, Portland, Ore. She discussed several of the fallacies surrounding anorexia nervosa:
▸ Anorexia nervosa is caused by over-enmeshed mothers. Dr. O'Toole said she has seen no evidence of any single pattern of mothering in her patients. While it may be true that mothers draw closer to their children with anorexia, this is probably a consequence rather than a cause of the disease. Throughout the animal kingdom, mothers draw closer to offspring who are ill or otherwise in danger.
▸ Children choose anorexia to look like models, because of the extreme examples of thinness in the press. The Kartini Clinic treats children who were home-schooled on farms with no television and no access to fashion magazines. Their anorexia is identical to that of other children.
“This is not a volitional disease, andwe find [this explanation] extremely trivializing of a severe brain disorder,” Dr. O'Toole said.
Nevertheless, the dominant images of thinness in the media do make it much harder to get children into remission. Dr. O'Toole likened it to swimming upstream against the prevailing images of what women should look like. But these images are not causal.
▸ Anorexia nervosa is a condition of spoiled, upper-class kids. Several formal epidemiologic studies have failed to find any link between anorexia and social class. At the Kartini Clinic, workers engage in an informal “map epidemiology,” placing a flag corresponding to the homes of their patients in a map of the three counties of Portland. What's striking is the evenness of the distribution, with no concentration of flags in wealthier neighborhoods.
▸ Anorexia nervosa is a condition of white and Western societies. The disease has certainly been seen in non-Westernized Arabic girls, as well as Asians.
“We rarely see African American children in our Oregon practice.
“Yet even if this were the universal experience, and anorexia nervosa were a disease of Westernized whites only, that wouldn't make it a psychosocial disease,” said Dr. O'Toole.
You won't see many whites in a clinic for sickle-cell disease, but that doesn't make that disorder psychosocial in nature, she said.
Likewise, acute lymphocytic leukemia is more common among white children who have middle-class or upper-middle-class backgrounds, but that doesn't make it a psychosocial illness.
▸ Anorexia is all about control. This is the dominant paradigm these days, and even patients will attribute their disease to a need to control one thing in their lives. Dr. O'Toole regards this as too facile an explanation that implies a level of volition that patients only wish that they had.
Moreover, it's dangerous to trust a patient's own explanations of the etiology of her disease, she said. In the 16th century, people with leprosy were likely to attribute their disease to some offense they committed against God, but that didn't make it true.
“I've always been puzzled about why parents cling to the notion that they did something wrong,” Dr. O'Toole commented.
“We tell them, 'You didn't cause this. You couldn't cause this.' We would rather blame ourselves than believe that horrible things could happen to our children, and we are powerless to affect it.”
The Kartini Clinic's opening message is, “We treat children and adolescents in the belief that parents do not cause and children do not choose to have eating disorders.”
Rethinking the purely psychoanalytic model has a number of implications. For one thing, parents can quit blaming themselves, family dysfunction, or careless comments for causing their children's anorexia.
In addition, everyone can stop treating the patient as if it were a volitional disease, and useless “arguing with the disease” can cease. As a brain disorder, anorexia nervosa is not amenable to rational thought.
Furthermore, family and physicians can focus on creating a safe medical environment in which the child can achieve remission and minimize the sequelae of the disease.
Finally, rejecting the purely psychoanalytic paradigm allows the patient to receive the same compassion and understanding as do victims of other medical diseases.
A child with anorexia nervosa should be hospitalized when presenting with certain signs and symptoms. (See box.)
Of course, weight restoration is key, she added.
Selective serotonin reuptake inhibitors are not useful for anorexia nervosa as such but do treat concomitant anxiety, panic, depression, and obsessive-compulsive disorder.