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.
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.
It might be hard to tell if a person has purging disorder. If you are worried about yourself or someone you know, here are some of the warning signs and symptoms to look out for:
- Comments or behaviors that show a lot of worry about food, dieting, or weight loss
- Frequent trips to the bathroom
- Signs or smells of vomiting
- Cutsor calluses on hands from forced vomiting
- Dental problems or sensitive teeth
- Frequent use of mouthwash, mints, or gum
- Wrappers from laxatives or diuretics
It’s not clear what causes purging disorder. Many factors may influence a person’s risk. Girls or women have purging disorder more often than boys or men. Estimates show that about 2.5% to 5% of adolescent girls may have this eating disorder.
People with the following may be more likely to develop purging disorder:
- Higher weight or body mass index (BMI)
- Fear of gaining weight
- A focus on being thin
- Unhappiness or frustration with their body
- A history of dieting to lose weight
- Feelings of losing control over their eating even if they don’t eat too much
- Less care from their mother while growing up
Some studies show that people with purging disorder may react differently to food. For instance, their stomachs may make more of certain hormones after eating. Those hormones might cause them to feel too full even when they haven’t eaten much.
So far, researchers haven’t found any genetic risks for the disorder. More research is needed to better understand the risks and causes
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.
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.
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.
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