Identifying Purging Disorder

If you purge or exercise excessively, you might wonder whether you would be considered to have bulimia nervosa. But what if you purge but don’t binge? This may mean that you have a different problem: purging disorder.

What Is Purging Disorder?

Purging disorder is an eating disorder that is diagnosed when a person purges to influence body shape or weight but does not binge. It can be thought of as bulimia nervosa without bingeing. Many who write about the disorder seem to assume that vomiting is the default form of purging, but laxative and diuretic misuse are also common. Some people 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 people 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 in the DSM-5, purging disorder can be just as serious as any of these other disorders.

An Unclear and Evolving Definition

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 people 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 ultimately be defined.

Who Gets Purging Disorder?

Purging disorder most commonly emerges in late adolescence and early adulthood. It affects primarily women and people who are classified as normal weight or larger. Because of the current diagnostic system, which prioritizes the diagnosis of anorexia nervosa, purging disorder specifically cannot be diagnosed in people who are underweight. People 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% of adult patients and 24% to 28% of adolescent patients. It might become a more common diagnosis if excessive exercise gets classified as part of purging disorder.

How Purging Disorder Is 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 people 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 people 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 in “Clinical Handbook of Complex and Atypical Eating Disorders,” patients with purging disorder “often resemble patients with anorexia nervosa in temperament and interpersonal interactions more than they resemble patients with bulimia nervosa.”

Other Disorders That Occur Alongside Purging Disorder

Patients with purging disorder often have other psychological disorders:

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

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

Risks of Purging Disorder

Purging by vomiting is 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 the disruption of normal bowel functioning. Diuretic misuse can also 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.

People 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, 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.