Medical Consequences of Purging

For anyone purging in pursuit of a “healthy” weight, the medical complications of purging eliminate the notion that this could make anyone healthier. All purging methods cause severe loss of bodily fluid because water is the primary component of matter expelled from the body. Dehydration contributes to low blood pressure, slow and irregular heartbeat, and kidney problems. Purging also contributes to electrolyte imbalances, which negatively impact heart and kidney function and can trigger seizures, muscle weakness, and breakdown of muscle tissue. Stomach acid from vomit causes sores in the mouth and erodes teeth. Laxative misuse can trigger uncontrollable diarrhea and constipation. In insulin-dependent diabetics, reducing or omitting insulin increases blood sugar concentrations, which can lead to blindness, kidney failure, nerve damage, cardiovascular disease, amputation, coma, and death. Individuals who purge should seek medical care, and physicians should follow published guidelines for evaluating medical status.

Feeling Sick

Eating is fundamental to our survival and subject to numerous biological regulators that influence when, what, and how much we eat. This makes biological factors central to any answer for why someone develops purging disorder. Genetic factors impact body weight and temperament and may even influence a person’s susceptibility to nausea and vomiting. Yet data from family and twin studies suggest that genes may play a slightly smaller role in risk for purging disorder compared to other eating disorders. Instead, biological responses to food intake may explain the unique configuration of purging after consuming normal amounts of food in purging disorder. Compared to those with bulimia, individuals with purging disorder have greater release of hormones that trigger the brain to stop eating. Compared to those with bulimia and those without an eating disorder, individuals with purging disorder release excessive amounts of a hormone that triggers feelings of nausea and stomachache.

What Happens in Treatment

Effective treatment requires a team of health professionals working together. Team members should include, at minimum, a physician, a dietitian, and a therapist. Many treatments begin with psychoeducation to explain what maintains purging disorder, the consequences of the illness, and why a chosen therapy facilitates recovery. This chapter describes therapies that have been used to treat patients with purging disorder, including family-based treatment in adolescents, cognitive-behavioral therapy in adolescents and adults, and integrated cognitive affective therapy in adults. Most treatments require adaptation to effectively address purging as a primary symptom rather than as a response to binge eating. At this time, there are no randomized controlled trials focused on treatment for purging disorder. This means clinicians bear the responsibility of identifying a first line of treatment for their patients with purging disorder and evaluating the treatment’s effectiveness.

Getting Help

The first step in getting a treatment that works is getting treatment, yet there is a vast chasm between the number of people suffering from purging disorder and the number receiving care. This chapter covers barriers to treatment that may uniquely impact those with purging disorder, making it invisible in clinical settings. To help those seeking treatment as well as those providing treatment, this chapter presents what should happen during assessment and how findings should inform level of care. This information is intended to help clinicians recognize purging disorder when they see it. Clinicians should always ask about purging behavior even in those who are not underweight and who do not binge. In addition, assessments should evaluate medical stability, suicide risk, and related problems with mood, anxiety, and substance use to inform a treatment plan.

Who, When, and Where?

Answering “who, when, and where?” establishes the public health burden associated with purging disorder and gives us insight into why someone develops the illness. Right now, over 2 million girls and women in the United States have purging disorder, and they are joined by another half-million boys and men. Cases of hysterical vomiting from the late 1800s resemble purging disorder in some respects, but vomiting in purging disorder is intentional and directed toward influencing weight or shape, supporting the influence of modern idealization of thinness. Finally, we see the emergence of purging to control weight and purging disorder following the introduction of Western cultural ideals into non-Western contexts. Non-Western cultures further shape the clinical presentation of purging disorder with misuse of traditional herbal emetics to produce purging.

Purging Unwanted Calories and Feelings

Sociocultural influences provide an insufficient explanation for why someone develops purging disorder because most people in our culture never develop this problem. Differences in how we perceive, respond to, and shape our environments emerge from psychological factors that impact our thoughts, feelings, and behaviors and explain why only some people purge. Psychological theories describe a pathway from anxious temperaments to the emergence of perfectionism to avoid threats and control uncertainty supported by evidence. During adolescence, changes in biology and in social context increase focus on the body, making it both a threat and a target for perfectionistic strivings. Inability to achieve perfection increases distress, and purging relieves distress temporarily. However, purging never resolves the original source of distress and becomes its own source of shame. Use of multiple purging methods is linked to childhood trauma history, comorbid depression, anxiety disorders, substance use problems, and suicidality.

Fear of Fat

Fear of fat drives people with purging disorder to engage in extreme methods to rid their body of weight. Our social context creates and reinforces that fear by linking weight to health, beauty, moral character, and popularity. Multiple levels in our environment convey these messages, including mass media, peers, and family, and influence the likelihood of purging. Although these beliefs are widely held, they deviate from facts. Behaviors rather than body weight are the strongest determinant of health. The association between weight and beauty is highly subjective and malleable. There is no association between body weight and moral character. The majority of the U.S. population is not living in social isolation despite possessing body weights that deviate from the thin/muscular ideal. Interventions designed to improve healthy behaviors and reduce internalization of the thin ideal have demonstrated success in reducing purging, supporting the value of recognizing and rejecting fear of fat.

Do We Need Another Eating Disorder?

Most people know about anorexia and some know about bulimia, but very few have ever heard of purging disorder. Purging disorder is an eating disorder characterized by self-induced vomiting or misuse of laxatives, diuretics, or other medications to influence weight or shape in individuals who are not underweight and who do not have large binges. This chapter describes how and when purging disorder was first identified, placing it in the context of the identification of other eating disorders and the factors that determine whether a condition should be considered a new mental disorder. It describes how purging disorder came to be included as an “other specified feeding or eating disorder” in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.

Outcomes Near and Far

What does the future hold for someone with purging disorder? Across studies including 943 individuals with purging disorder, approximately 3 out of 5 people (60%) had an eating disorder at follow-up anywhere from 11 weeks after they started treatment to 10 years after they were recruited from the community. Most continue to have an eating disorder characterized by purging or compulsive exercise in the absence of binge eating, but some progress to bingeing and purging. An average of 10 years after diagnosis with purging disorder, only 40% had no eating disorder. One study reported that 1 in 20 purging disorder inpatients died by 9-year follow-up, with suicide and medical complications of the eating disorder explaining all but one death in this cohort. These sobering statistics underscore the need to do better, and this chapter ends with a call for action to advance understanding and improve interventions for purging disorder.