What Is Purging Disorder?

Purging Disorder
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If you purge or exercise excessively, you might wonder whether you would be considered to have bulimia nervosa. However, maybe you do not binge. This may mean that you have a different problem: you may have purging disorder.

What Is Purging Disorder?

Purging disorder is an eating disorder that is diagnosed when a person purges to influence shape or weight but does not binge. It can be thought of as bulimia nervosa without the bingeing. Most writing about the disorder seems to assume that vomiting is the default form of purging, but laxative and diuretic misuse are also common. Many patients also engage in other behaviors to compensate for eating, including excessive exercise and extreme fasting.

Although purging disorder has likely existed for some time, it was first formally recognized by Keel and colleagues in 2005. Purging disorder has been studied far less than bulimia nervosa. Indeed, many patients with purging disorder may have been incorrectly diagnosed as having bulimia nervosa or may not have been diagnosed at all.

Purging disorder is not listed as an official disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Instead, it is included as a described condition within the category of Other Specified Feeding and Eating disorder (OSFED). This category includes individuals with clinically significant eating disorders who do not meet criteria for one of the primary eating disorders including anorexia nervosa, bulimia nervosa, or binge eating disorder. Even though it lacks its own official category, purging disorder can be just as serious as any of these other disorders.

Not Clearly Defined

Because purging disorder is not well-defined, researchers have not totally agreed on what it comprises. One of the challenges with our current diagnostic system is deciding into which basket a person with a certain group of symptoms should be placed.

For example, driven exercise has more recently been included as a potential purging behavior. Even though exercise is commonly considered a healthy and socially acceptable behavior—in a way that vomiting or laxative use is not—excessive exercise can be a serious problem.

However, it is not yet clear that excessive exercise behavior is by itself sufficient for a diagnosis of purging disorder. One set of researchers believe that it should be. In their recent study, they found that individuals who engage in regular driven exercise (but do not use other methods of purging) have similar psychopathology as those who purge regularly by vomiting or laxative misuse.

Thus the research is ongoing and as a result, it is unclear exactly how purging disorder will be defined.

Who Gets Purging Disorder?

Purging disorder most commonly emerges in late adolescence and early adulthood. It affects primarily females and people who are classified as normal weight or greater. Because of the current diagnostic system, which prioritizes the diagnosis of anorexia nervosa, purging disorder specifically cannot be diagnosed in individuals who are underweight. Individuals who are underweight and engage in purging would instead be diagnosed with anorexia nervosa, binge/purge subtype.

As a proportion of those seeking treatment for an eating disorder, research indicates that purging disorder is the presenting problem in 5 to 10 percent of adult patients and 24 to 28 percent of adolescent patients. It might become a more common diagnosis if individuals with excessive exercise get classified as having purging disorder.

How Is Purging Disorder Different From Bulimia Nervosa and Anorexia Nervosa?

By definition, people with purging disorder do not have the episodes of eating unusually large amounts of food that characterize bulimia nervosa (otherwise they would meet criteria for bulimia nervosa). However, they may often feel that they have eaten “too much” when they have actually only eaten a normal amount of food. They may purge after meals. They may experience similar levels of guilt and shame to those who purge after eating large amounts of food.

Research shows that patients who purge but do not binge have severe symptoms that include restrictive eating, a preoccupation with eating disorder thoughts, and body image concerns. A primary difference between purging disorder and bulimia may be that patients with bulimia nervosa report a greater loss of control over food. Some research suggests that purging disorder may be less severe than bulimia nervosa.

Patients with purging disorder often report feelings of gastrointestinal distress after eating and more distress than healthy people and patients with bulimia nervosa. Some patients with purging disorder may feel that their vomiting is automatic.

According to Keel and colleagues (2017), patients with purging disorder “often resemble patients with anorexia nervosa in temperament and interpersonal interactions more than they resemble patients with bulimia nervosa” (p. 191).

Other Disorders That Occur Alongside Purging Disorder

Patients with purging disorder often have other psychological disorders:

  • Up to 70 percent have a mood disorder
  • Up to 43 percent have an anxiety disorder
  • Up to 17 percent have a substance use disorder

Purging disorder is also associated with elevated risk of suicide and intentional self-harm.

Risks of Purging Disorder

Purging by vomiting is an extremely concerning behavior because it carries numerous medical risks ranging from metabolic disturbances, electrolyte imbalances that could lead to heart attack, dental problems, esophageal tears, and swollen salivary glands. Purging disorder can also cause problems with the bones and gastrointestinal systems and is associated with an elevated mortality risk. Misuse of laxatives can cause dependence on them and disruption of normal bowel functioning. Abuse of diuretics can lead to significant medical consequences.

Treatment for Purging Disorder

Unfortunately, as of the time of writing, no randomized controlled treatment trials have been conducted for individuals with purging disorder. There are no evidence-based treatments specifically for the disorder. There is some indication from the inclusion of patients with purging disorder in transdiagnostic treatment trials that they may benefit from Cognitive Behavioral Therapy (CBT-E), the most successful treatment for adults with bulimia nervosa. Modules that address mood intolerance and problem-solving may be particularly helpful. These strategies help patients to tolerate feelings of fullness and anxiety and help them to develop other coping skills.

Patients with purging disorder may also benefit from exposure with response prevention, which could involve eating normal amounts of food, learning to reinterpret physical sensations as a normal part of the digestive process, and preventing purging. Adolescents with purging disorder may be best served by Family-Based Treatment (FBT), the leading treatment for adolescents with anorexia nervosa, although research is limited.

According to Keel and colleagues (2017), patients with purging disorder who purge after what they believe is out of control eating—a behavior similar to patients with bulimia nervosa—may respond better to treatment. This could be because the feeling of loss of control eating is so unpleasant. By contrast, patients who purge but do not experience any feelings of loss of control over eating may have less motivation for treatment because their behavior does not feel problematic to them. They may appear more like patients with anorexia nervosa who do not experience their restriction as a problem. This latter group may also be less willing to engage in treatment due to fear of weight gain if they stop purging.

A Word From Verywell

People who engage in purging and similar behaviors may be ashamed and reluctant to seek help. However, it is important to get professional attention and the sooner the better. If you or a loved one is engaging in eating disorder behaviors such as vomiting, misuse of laxatives or diuretics, or excessive exercise, please seek help.

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