Purging Disorder: Understanding the Complexities

August 25, 2024

Purging disorder is a mental health condition, specifically an eating disorder characterized by recurrent behaviors aimed at getting rid of consumed food (purging) to control weight or body shape. While similar to bulimia nervosa, purging disorder differs in that it does not involve episodes of binge eating. Binge eating refers to consuming an excessive amount of food beyond normal intake. Although the abuse of laxatives and diuretics is common, vomiting is the primary method of purging in individuals with this disorder.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies this disorder as “other specified feeding or eating disorder” (OSFED). This group comprises individuals with clinically significant eating disorders that do not fit the criteria for primary disorders such as anorexia nervosa, bulimia nervosa, or binge eating disorder. Despite not having its distinct category in the DSM-5, the purging disorder is equally serious as these recognized disorders.

Signs & Symptoms of Purging Disorder

Purging disorders have certain signs and symptoms that certainly are indicators of this compulsive behavior.

Self-Inflicted Vomiting

The person suffering from purging disorder has a habit of self-inflicting vomiting 3-4 times a day.¹ Due to excessive vomiting, the patient usually has oral trauma and a bad smell.

Russell’s Sign

Calluses develop on the back of hands or knuckles due to repetitive induction of vomiting with hands. This sign is diagnostic for eating disorders, specifically purging disorder and bulimia nervosa

Misuse of Laxatives

Abuse of laxatives and other drugs is a common practice among patients with purging disorders.

Anxiety

Fear is associated with eating or gaining weight; therefore, patients rush to the washrooms after meals.

Obsession with Reducing Body Weight

Fasting is one of the important symptoms of purging disorder. These patients often have a daily fasting habit.

Intense Exercise Regimen

Individuals with purging disorder often exhibit a preoccupation with rigorous exercise routines. This behavior is driven by a desire to control body shape and minimize fat accumulation.

Decreased Self-Esteem

Individuals may experience low self-worth or lack of confidence in their physical appearance.

Dental Issues

Common dental issues associated with purging disorder include tooth decay and pronounced tooth staining, which result from frequent episodes of vomiting.

When does it start?

There is no specific age when the purging disorder develops. However, teenage females experience it most frequently. Though some cases have been documented in individuals over 70 years old, eating disorders, such as purging disorders, are usually identified at an early age.² Purging disorder can affect anyone, although those in the usual age range are more likely to have it diagnosed and treated.

Risk Factors of Purging Disorder

Potential risk factors for purging disorders include:

Environmental Triggers

Being taunted at school or experiencing abuse as a youngster are two examples of events that might cause persistent stress and promote purging disorder.

Sociocultural Influences

Societal pressure to attain a certain body shape or size and exposure to media images idealizing thinness can contribute to the development of purging disorder.

Behavioral Issues

Negative and unrealistic attitudes about food and body image are common in those suffering from purging disorders.³

The person can only think about achieving the “ideal” figure or dropping weight; these thoughts eventually become obsessions and spiral out of control.

Causes of Purging Disorder

Eating disorders, including purging disorders, can affect anyone, and their precise cause is unknown. Purging disorder may have the following possible causes:

Genetics

Research indicates that there may be a genetic component to the strong family transmission of eating disorders, which are known to run in families. Having a family history of eating disorders or other mental health conditions may increase the risk of developing a purging disorder.

Neurotransmitter Imbalances

Studies reveal that individuals with eating disorders have abnormalities in their neurotransmitter systems; alterations in brain serotonin (5-hydroxytryptamine) function are thought to contribute to diverse aspects of eating disorders.⁴

History of Harmful Dieting

Engaging in restrictive dieting or having excessive concerns about weight and body image can increase the risk of developing a purging disorder.

Sexual Abuse History

Sexual abuse can cause extreme physical anguish and bodily shame. Some purging behaviors are self-punishment or an attempt to numb the emotional hurt brought on by a traumatic past.

Childhood Trauma

There is a strong correlation between eating disorders and childhood trauma, and it can have a significant impact on all aspects of development.

Recovering from Other Eating Disorders

“Symptom switching” is a regular occurrence for individuals. With anorexia, for instance, restricting may be abandoned in favor of frequent purging and binges. Alternatively, even if they stop bingeing, someone might continue to purge.

Higher Body Mass Index BMI

Higher BMI can also contribute to purging disorder, as individuals may engage in purging behaviors to control weight or manage body dissatisfaction. This can stem from societal pressures and stigma related to weight, leading to maladaptive coping mechanisms.⁵

Complications of Purging Disorder

Purging disorder can lead to various complications akin to those observed in bulimia nervosa:

Dehydration

Excessive purging can result in dehydration, leading to thirst, fatigue, and other symptoms.

Electrolyte Imbalances

Purging disrupts the balance of electrolytes in the body, affecting nerve and muscle function.

Heart Arrhythmias

Irregular heart rhythms may occur due to electrolyte imbalances, potentially leading to cardiovascular complications.

Constipation

Purging behaviors can disrupt normal bowel function, resulting in constipation and gastrointestinal discomfort.

Esophageal Damage

Frequent vomiting can lead to tooth enamel erosion and damage to the esophagus.
Without proper treatment, chronic purging can have severe, life-threatening consequences, including damage to the heart and other vital organs.

Evaluation & Diagnosis of Purging Disorder

Establishing and sustaining an efficient treatment plan may largely depend on getting a correct diagnosis. Getting a diagnosis may increase your access to treatment alternatives and accessibility.⁶
The diagnostic process for purging disorder typically involves:

Evaluation of Mental Health

Assessing for co-occurring mental health conditions to understand the broader context of the individual’s psychological well-being.

Self-Reporting

Encouraging patients to provide self-reports of their symptoms can assist healthcare professionals in devising personalized treatment strategies.

Detailed Physical Examination

Conducting a thorough physical examination to identify any physiological symptoms or complications associated with purging behaviors.

Lab tests

Blood tests may be performed to evaluate electrolyte imbalances or other physiological abnormalities that may occur as a result of purging.

Diagnostic Criteria from DSM-5

Ensuring that the individual meets the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The specific diagnostic criteria for purging disorder are not explicitly listed in the DSM-5 but fall under the OSFED category.⁷ This includes:

Recurrent purging behaviors aimed at influencing weight or body shape.
Absence of binge eating episodes.
Additional specifications include the frequency and duration of purging. On average, purging behaviors occur at least once a week. The duration of purging behaviors usually persists for a minimum of three months.

Treatment of Purging Disorder

Managing purging disorder typically involves a comprehensive approach tailored to the individual’s needs and circumstances. Here are the key components of treatment:

Psychotherapy Options:

Cognitive-Behavioral Therapy for Eating Disorders (CBT-E)

Addresses dysfunctional thoughts and behaviors related to food and body image.⁸

Family-Based Treatment

It involves the family in supporting the individual’s recovery, which is particularly effective for adolescents.

Dialectical Behavior Therapy (DBT) for Eating Disorders

Focuses on building skills to manage emotions and cope with distress.

Trauma-Based Therapies

EMDR, IFS, or psychodynamic therapy may be beneficial for individuals with trauma histories.

Medication:

While there are no FDA-approved medications specifically for the purging disorder, psychiatric medications like SSRIs may be prescribed to manage co-occurring depression or anxiety. Anticonvulsant medications, such as Topiramate, may also be used.

Hospitalization/Inpatient Treatment:

In cases of moderate to severe purging disorder, hospitalization or inpatient treatment may be necessary to stabilize acute symptoms, address malnutrition and electrolyte imbalances, or manage severe mental health concerns.

Nutrition Counseling:

Registered dietitians can provide guidance on nutritional needs and eating behaviors and dispel misconceptions about food. Nutrition counseling is often integrated into multidisciplinary treatment approaches.
It’s important to note that treatment plans should be individualized and may involve a combination of these approaches. Regular monitoring, collaboration between healthcare providers, and ongoing support are essential for a successful recovery from the purging disorder.

Tips for Effective Purging Disorder Treatment

It’s critical to remember that you must have determination and high willpower for treatment to be effective.

Practice Self-Love

Be kind to yourself and ensure you feed your body rather than punish it.

Put Self-Care First

You may care for your health by doing things you enjoy or dedicating time to hobbies.

Be patient with the Recovery Process

Staying focused on your objective, even on difficult days, is crucial since rehabilitation is never simple. Treatment and recovery will involve ups and downs.⁹

How does Purging Disorder differ from Anorexia?

Anorexia nervosa is the primary differential diagnosis for purging disorder. Unlike anorexia, where individuals restrict their food intake and often present as clinically underweight, purging disorder does not necessarily involve such weight loss.
The diagnostic criteria for purging disorder do not focus on weight or food restriction. However, individuals with both disorders commonly experience preoccupation with food, body image, weight, and issues related to control.

Purging Disorder vs. Bulimia Nervosa

The hallmarks of bulimia nervosa (BN) are recurrent cycles of bingeing and purging. They use unhealthy means to make up for the food they just ate, like vomiting, overexercising, or severe dieting.
On the other hand, when someone has a purging disorder (PD), they purge without bingeing afterward.
While there are some parallels between purging disorder and bulimia nervosa, people with bulimia purge in reaction to periods of binge eating, but the act of purging itself is what distinguishes purging disorder.

Bottom Line

Purging can permanently harm one’s health. It ultimately results in malnutrition and the permanent destruction of metabolic and nutritional balance.
However, one can still get through it with good determination and willpower to overcome this eating leading to mental disorder.

Refrences

1
Kessler RC, Berglund PA, Chiu WT, et al. The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biol Psychiatry 2013; 73(9):904–914. doi:10.1016/j.biopsych.2012.11.020]
2
Allison Nitsch, MD, Heather Dlugosz, MD, Dennis Gibson, MD and Philip S. Mehler, MD, FACP, FAED Cleveland Clinic Journal of Medicine June 2021, 88 (6) 333-343; DOI: https://doi.org/10.3949/ccjm.88a.20168
3
Stephen, E.M., Rose, J., Kenney, L., et al. Adolescent risk factors for purging in young women: findings from the national longitudinal study of adolescent health. J Eat Disord 2, 1 (2014). https://doi.org/10.1186/2050-2974-2-1
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Udo T, Grilo CM. Prevalence and correlates of DSM-5-defined eating disorders in a nationally representative sample of US adults. Biol Psychiatry 2018; 84(5):345–354. doi:10.1016/j.biopsych.2018.03.014
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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
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Murphy R, Straebler S, Cooper Z, Fairburn CG. Cognitive behavioral therapy for eating disorders. Psychiatr Clin North Am. 2010 Sep;33(3):611-27. doi: 10.1016/j.psc.2010.04.004. PMID: 20599136; PMCID: PMC2928448.
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