A deep dive into purging behavior, associated diagnoses, and strategies for cessation.
Eating disorders are becoming increasingly prevalent. They affect individuals of all ages, gender, and cultural backgrounds. It’s a significant public health problem, and the numbers are quite alarming.
Unfortunately, cultural norms —of toxic dieting and fixation on weight— are making the problems worse. Despite the disheartening realities of eating disorders, getting help early is important because it leads to better outcomes.
Purging Behaviors
While there are too many harmful symptoms and behaviors associated with eating disorders to name here, purging is more common than you might guess.
Lifetime estimates suggest 1 in 6 women and 1 in 33 men will endorse purging at some point in their lifetime. Of course, this prevalence doesn’t make it safe. It’s commonly assumed that purging behaviors are synonymous with self-induced vomiting. However, purging can involve the misuse of laxatives and diuretics too.
Sometimes purging is impulsive, but it can be planned also. This unhealthy behavior may be used to manage fear of weight gain, a fear that is central to eating disorders of all types.
The Dangers Can Be Quite Serious
Purging behaviors can be highly dangerous in the short term due to fluid shifts in the body and in the long term too. These compensatory strategies can lead to death through cardiac arrest and other serious consequences. Below is a brief survey of what can go wrong.
Potential Physical and Psychological Risks
Purging behaviors may make recovery from eating disorders even more difficult because of the impact on the mind and spirit —eroding feelings of motivation, self-worth, interfering in supportive relationships, harming self-efficacy, and adding self-imposed negative pressure.
Teeth: Tooth enamel can be eroded when gastric acid enters the mouth. Teeth may become weakened and have thermal sensitivity.
Swelling in cheeks: Parotid (salivary) glands can swell, causing the cheeks to look puffy.
Damage to hands: Calluses and burns from gastric acid can appear on the knuckles and hands.
Esophagus: Food and acids passing up through the esophagus can cause bleeding or, in the worst cases, rupture.
Stomach: Persistent purging can lead to small amounts of food feeling uncomfortable, due to a dysregulated digestive system.
Appetite: Hunger and fullness may be impaired.
Electrolytes: Fainting, fever, digestive problems, confusion, blood pressure changes, heart palpitations, seizures, cardiac arrest and even death can be caused by imbalance in potassium and sodium. Such electrolyte imbalances can be extremely dangerous.
Relationships: The secrecy of purging behaviors and the shame that often accompanies it can harm close relationships.
Functioning at work and other responsibilities: Eating and purging in secret places and hiding to engage in purge can interfere with tasks of daily living, as well as carrying out work and other responsibilities.
Guilt, shame, worthlessness: People may feel guilt, shame, anxiety or depression -which can add to feeling worthless and out of control- and these feelings can trigger a binge. The negative emotions that follow self-induced vomiting, can lead back to binge eating or purging. Unfortunately, the vicious cycle may start over again.
Potential Triggers and Vulnerabilities
Is it Bulimia Nervosa? Anorexia Nervosa? Two eating disorders that involve purging behaviors in their diagnosis are bulimia nervosa and anorexia nervosa with binge–purge subtype. These disorders share a connection: weight is associated with self-worth and may be accompanied by a distorted body image.
In some individuals, purging may occur after any instance of eating. Mood, thoughts, and behaviors can all act as triggers.
Positive emotions: An absence of positive or happy emotions is associated with purging.
Weight worries: Having negative body and weight perceptions may trigger purging episodes.
Negative emotions: Avoiding, escaping, or soothing negative affect—uncomfortable and low emotions—has also been identified as triggering and maintaining purging behavior.
Eating past a comfortable state of fullness: The most obvious physical trigger for purging is, by definition, purging because it is a compensatory action to eating. After an objective episode of binge eating, an individual may feel especially compelled to get rid of what they’ve eaten.
Eating something “forbidden”: Purging may follow a subjective binge eating episode, when the behavior compensates for a type of food considered off limits or an amount of food that is not more than others might eat at a similar time.
Genetics: Research confirms that genetics play a role in purging; studies conducted with families and twins reveal that an individual is 9.6 times more likely to develop BN (binge eating plus purging) if they have a relative with the disorder.
BMI, poverty and more: One study that looked at data on adolescents from the National Longitudinal Study of Adolescent Health, showed the following:
“Several childhood variables were identified to increase risk for purging.
Higher BMI, suicide attempts, overweight self-perception, parental poverty, depression symptoms, hyperactivity-impulsivity, delinquent behaviors, low self-esteem, and never having lived with one (or both) parent (s) were associated with purging.
Higher BMI and depressive symptoms were associated with purging.”
—Stephen et al
How Will You Start Recovery? Step 1
Stand in the Light
Denial and high levels of shame and secrecy are common for those with eating disorders, especially for those with purging behaviors.
Accept that you are sick enough: Even if you’re able to seem okay to others and even if you’re not as sick as someone else, purging is enough of a reason to seek recovery. Purging is taxing. It can heighten depression, anxiety, low self-esteem, and social isolation; don’t deny the physical and psychological dangers of an eating disorder.
Reach out For Support
Don’t keep it a secret: Even if you have been “successfully” hiding purging. Support is important during recovery.
Take a deep breath and tell someone: Even if you don’t think anyone will understand.
Look for Inspiration
Feeling hopeless can get in the way of recovery.
Notice hopeful messages: Sometimes when we feel down, we look for negative cues and messages that confirm our negative beliefs. Try acting opposite by paying attention to messages grounded in realistic optimism. Many people have shared their own recovery stories.
Inspirational stories about overcoming eating disorders are plentiful. If you’re willing to think about what might be possible for you, consider these quotes:
“It made my voice bad, the acid on your vocal cords—it’s very bad. But for those of you who don’t sing, you may not have that excuse until it’s too late. It’s very dangerous.”
—Lady Gaga
“I think the hardest part to get to is that point of asking for help or reaching out to other people and being honest with yourself.”
—Mary-Kate Olsen
“Stop trying to find something in food that will make you feel better. I used to have eating disorders; I’d binge and purge all the time… I tried to medicate myself with food when people made fun of me…. I’d always turn to food.”
—Richard Simmons
“Eating disorders don’t discriminate.”…”To have a breakthrough you have to have a breakdown, and I definitely went through both of those—in hindsight, it saved my life.” … “The decision to take control of it is the scariest thing I’ve ever done, and this is coming from someone who dives with sharks and jumps out of airplanes for fun.”
—Kesha
Seek Evidence-Based Strategies for Cessation: Step 2
Much work has been done on the ways to heal eating disorders, including the management of and reduction in purging behaviors. It may seem as if you are physically and psychologically dependent on the behavior to feel at ease, but you’re not. However, you may be stuck in a negative cycle, temporarily. Confronting the myths that can maintain purging can motivate change.
Challenge Myths
Fact: Vomiting cannot get rid of all the calories consumed, even when done immediately after eating. Purging is not an effective way to manage your eating habits.
Fact: Vomiting tends to lead to weight gain and continued cycles of overeating.
Fact: Genetic vulnerability does not determine your future. While genetics may make you vulnerable, your environment and behavior can cause epigenetic changes that affect gene expression, turning some genes on or off. In other words, your genes are not your destiny.
Fact: Even if you feel hopeless, there are treatments that work. You can recover.
Appetite-Focused Cognitive Behavioral Therapy
A common cognitive trap experienced in people with purging behaviors is an excessive focus on food. Unfortunately, many therapeutic methods may increase one’s focus on food-related thoughts to work at controlling those thoughts.
AF-CBT approach: Combines a mindfulness approach—mindfulness of bodily sensations at minute levels of detail—with CBT.
Monitor bodily sensations: Closely reinstates the idea that “moderate hunger” is a cue to eat and “moderate fullness” is a sign to stop. This reduces the urge to eat beyond fullness then compensate, and it’s a way to honor and trust the body.
Family Meals
Research is robust; eating family meals together is positive for children and adolescents.
The benefits: Eating together as a family is associated with a decreased risk of purging behaviors and a reduction in extreme dieting in adolescents.
“Kids in particular, but teens also, are like sponges—they are soaking in everything around them. And that includes their parents’ relationship with food.
Bringing the family around the dinner table to eat a balanced meal with protein, carbohydrate, vegetables and sweets teaches kids that a balanced approach to eating with lots of variety is normal—because parents do it, it becomes their normal.
Family dinners also allow an opportunity to engage each member of the family in discussion around their day; it shows interest in the child and that their views are important and cherished in the family.”
—Dr. Jennifer Goetz, Child and Adolescent Psychiatrist at McLean Hospital
Plan To Cope
Predictably, life presents us with challenging situations. Your body will not be perfect, and negative emotions will come and sometimes they will feel intense. Therefore, planning for coping is a helpful life skill that can be practiced for stopping purging.
The cope ahead skill: A DBT skill intended to have you consider how you can best prepare to reduce stress ahead of time. When you know the most vulnerable times for purging, you can make a plan for how to handle those situations. While purging may provide temporary relief, it won’t last and it can seriously harm you. You deserve better.
For example: All of us, at one time or another have eaten more than we wanted to, feeling uncomfortably full. Plan now for how you will handle it when that situation arises in the future. Feeling uncomfortably full, eating a forbidden food, or having a negative body image does not have to lead to purging.
Be curious: Build your recovery coping skills, instead of continuing purging. What will I do when I feel too full in the future? Who will I reach out to when I experience intense negative emotions? How will I soothe myself? How can I speak to myself with compassion when my eating is imperfect? How will I change my tone of voice to be gentle and what kind self-talk statements will I say the next time I have negative thoughts about my body?
Honor your uniqueness: Spending time with people we care about and exercising increases resilience. Being in nature can be calming too. But, you aren’t exactly like anyone else. Who brings you comfort? Where do you feel best? What self-talk, tone of voice, and activities improve your coping when you’re stressed?
Find your path to recovery!
References:
Ackard, D., Cronemeyer, C. L., Franzen, L. M., Richter, S. A., & Norstrom, J. (2011). Number of different purging behaviors used among women with eating disorders: Psychological, behavioral, self-efficacy and quality of life outcomes. Eating Disorders, 19(2), 156–174. https://doi.org/10.1080/10640266.2010.511909
Barakat, S., McLean, S.A., Bryant, E. et al. (2023). Risk factors for eating disorders: Findings from a rapid review. J Eat Disord 11, 8. https://doi.org/10.1186/s40337-022-00717-4
Dicker S. L. & Craighead, L. W. (2004). Appetite-focused cognitive-behavioral therapy in the treatment of binge eating with purging. Cognitive and Behavioural Practice, 11(2), 213–221. https://doi.org/10.1016/S1077-7229(04)80032-4
Forney, K. J., Buchman-Schmitt, J. M., Keel, P. K., & Frank, G. K. W. (2016). The medical complications associated with purging. International Journal of Eating Disorders, 49(3), 249–259. https://doi.org/10.1002/eat.22504
Goldschmidt, A. B., Accurso, E. C., Schreiber-Gregory, D. N., Crosby, R. D., Cao, L., Engel, S. G., Mitchell, J. E., Crow, S. J., Peterson, C. B., LeGrange, D., Wonderlich, S. A. (2015). Behavioral, emotional, and situational context of purging episodes in anorexia nervosa. International Journal of Eating Disorders, 48(3), 341–344. https://doi.org/10.1002/eat.22381
Matt, A. A. H. (2012). Ecological momentary assessment of purging disorder (Doctoral dissertation, The University of Iowa).
http://www.cci.health.wa.gov.au
Stephen, E.M., Rose, J., Kenney, L. et al. (2014). Adolescent risk factors for purging in young women: Findings from the national longitudinal study of adolescent health. J Eat Disord 2, 1. https://doi.org/10.1186/2050-2974-2-1
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