Purging Disorder vs. Bulimia Nervosa

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Many people strictly associate the word "purging" with bulimia nervosa (BN) because it can be a feature of this eating disorder, which is characterized by a recurrent cycle of binging (consuming excessive amounts of food) and purging (using unhealthy ways to compensate for the food they just ate such as excessive exercising or extreme dieting). But purging also exists on its own in purging disorder (PD), where purging takes place in the absence of binging.

Purging disorder also has additional features that differentiate it from bulimia and other eating disorders like anorexia nervosa (AN).

Man suffering bulimia
Man suffering bulimia. doram, Getty Images

What Is Purging Disorder?

Purging disorder is an eating disorder characterized by the compulsion to purge in order to induce weight loss or alter body shape.

Unlike bulimia, purging disorder is not a formal diagnosis in the Diagnostic And Statistical Manual Of Mental Disorders, 5th Edition (DSM-5). Rather, it is classified as an "Other Specified Feeding and Eating Disorders (OSFED)," which was previously known as "Eating Disorder Not Otherwise Specified (EDNOS)." As such, PD does not have one clear definition like other specified eating disorders. 

The lack of clear definition does not mean this type of disordered eating is any less serious than bulimia or anorexia. Research suggests that PD is a clinically significant eating disorder (ED) that has substantial comorbidity (meaning its likely to accompany other diagnoses) and severity that is on par with some full-threshold ED diagnoses (i.e., AN and binge eating disorder), but is less severe than bulimia nervosa in most domains.

That said, people with purging disorder have been found just as likely to die as a result of their eating disorder as people with anorexia or bulimia.

Characteristics

Characteristics of purging behaviors can include:

  • Self-induced or forced vomiting
  • Misusing laxatives, diuretics, emetics (enemas), or other drugs
  • Excessive exercising
  • Extreme fasting or dieting

Eating disorders like purging disorder can be triggered through any life stage, but typically emerge in adolescence or early adulthood.

Purging disorder differs from bulimia in that the latter is characterized by feeling like that you are not in control of your eating. Research suggests that people with bulimia experience relatively more frequent loss of control compared to people with purging disorder, and this has been associated with more purging and larger binge episodes. With that said, people with purging disorder appear to experience greater stress around eating and body image than those with bulimia (in part because the binge and purge cycle is regarded as a regimented means of weight control).

Unlike anorexia, PD predominantly affects women in normal or larger weight categories. 

Diagnosis

Feeding and eating disorders are diagnosed based on criteria established in the DSM-5. A person must present with feeding or eating behaviors that cause clinically significant distress and impairment to be diagnosed with one. Due to the lack of clear definition, bulimia and anorexia often take precedence when rendering a diagnosis.

Some defining characteristics of purging disorder may be able to help identify affected individuals, including:

  • The absence of binging
  • Being of normal weight
  • Feelings in control of one's weight
  • Some may feel their vomiting is automatic
  • Restrictive eating behaviors
  • Being preoccupied with body image concerns

Medical complications of compulsive purging:

  • Dental complications due to the acidic nature of vomit
  • Salivary gland swelling from self-induced vomiting
  • Oral bleeding, particularly if using a tool to induce vomiting 
  • Irritation to the stomach and intestinal wall lining
  • Rectal bleeding from pressure produced by vomiting process
  • Cardiovascular issues (heart attack or seizure due to laxatives and diuretics misuse)
  • Kidney problems from laxative and diuretic misuse

Causes

Eating disorders are medical illnesses with complex biological and social factors that severely impact one’s well-being. Researchers continue their efforts trying to isolate the underlying causes of this disorder. Research suggests sexual or physical abuse and/or participating in appearance- or weight-focused sports or competitions may increase the likelihood of developing an eating disorder.

Examples of biological risk factors include:

  • A family history of eating disorder or other mental illness
  • A history of dieting
  • Type 1 diabetes

Examples of psychological factors include:

  • Negative body image or body dissatisfaction
  • Poor self-esteem or esteem attached heavily to appearance
  • Body dysmorphia
  • Perfectionism and behavioral inflexibility
  • History of mental illness like anxiety disorders

Examples of sociocultural factors include:

  • Thin-ideal internalization
  • Weight stigma and bullying
  • Limited social networks
  • Intergenerational traumas
  • Acculturation
  • Dysfunctional family dynamics
  • Body-focused careers
  • Major and stressful life changes

Purging as a Form of Self-Harm

Purging disorder can be considered a mode of self-harm much like self-inflicted non-suicidal injuries. One study estimated that PD can be fatal (result in suicide) for 5% of all cases. Researchers hypothesized the acquired capability for self-harm and the exposure to painful life events that develop it may represent another risk factor for purging behavior. Moreover, women who engage in one self-harming behavior are at risk of engaging in others.

People with purging disorder are at higher risk of suicidality, as well as depression, anxiety, impulsivity, substance use, dietary restraint, body dissatisfaction, and eating psychopathology, compared with controls in a study.

Treatment

Eating disorder treatment generally encompasses the following factors:

  • Correcting life-threatening medical and psychiatric symptoms
  • Interrupting eating disorder behaviors
  • Establishing normalized eating and nutritional rehabilitation
  • Challenging unhelpful and unhealthy ED-related thoughts and behaviors
  • Addressing ongoing medical and mental health issues
  • Establishing a plan to prevent relapse

Psychotherapy, specifically cognitive behavioral therapy (CBT), is generally advised since it has shown effectiveness in treating a range of eating disorders. Research has shown that after intervention, CBT improves anxiety and depressive symptoms, drive for thinness, body dissatisfaction, and symptoms of bulimia. Other options for treatment can include medical care and monitoring via hospitalization or in outpatient treatment programs, nutritional counseling, medications, or a combination of these approaches. 

While pharmaceuticals should never be the sole treatment approach, selective serotonin reuptake inhibitors (SSRIs) antidepressants like Prozac (fluoxetine) and Zoloft (sertraline) can be helpful in managing symptoms of depression, anxiety, and obsessive compulsive disorder. One study suggests these medications may aid in relapse prevention and improvement of psychiatric symptoms in weight-restored anorexic patients.

Prognosis in Women

Research has shown the prognosis for women with PD who receive treatment over time is greater in purging participants than those with other forms of disordered eating. The biggest improvements were in body dissatisfaction and anxiety.

Coping

Here are some helpful tips people with purging disorder can try to cope with their condition. Remember that nothing can take the place of professional treatment for an eating disorder.  

Don’t Try to Recover in Isolation

Eating disorders do not develop in isolation, and they are not treated in isolation either. Reaching out for professional help is important to recovery. Being open and honest with others like parents, friends, and school advisors is also a way to gain support and understanding. If you feel like you are alone or have no support network, talk to your treatment provider about ways to process ongoing relationships and feel less alone. 

Don’t Play the Blame Game

It really is no one’s fault. While you may have a complicated family dynamic or have experienced abuse and trauma, remember that no one thing or person (including yourself) is responsible for your eating disorder. Eating disorders occur due to a complex web of factors, and blaming yourself or others will only create additional emotional stress. 

Don’t Give Up Hope 

Recovery is possible and you are worthy of receiving and following treatment. It doesn’t matter if you think someone else has it worse or if you feel like there is no end in sight right now. Getting better from an eating disorder is an ongoing journey that requires you to trust in the process.

Resources for Help

Reach out to the following organizations for more information: 

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