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Anorexia Nervosa Subtypes: Understanding Restricting Type and Binge-Eating/Purging Type

Table of Contents

What is the restricting subtype of anorexia?

What is the binge-eating/purging type of anorexia, causes of anorexia, treatment for anorexia.

There are two subtypes of anorexia nervosa : restricting type (AN-R) and binge-eating/purging type (AN-BP). In this piece, Elizabeth Easton, PsyD, CEDS , national director of psychotherapy at Eating Recovery Center (ERC), discusses both types. This content is intended to provide clarity regarding the diagnostic criteria of anorexia nervosa. ERC acknowledges that this diagnostic criteria is limiting and not weight-inclusive. Persons in larger bodies can also have restrictive anorexia, which we discuss in this piece. 

A person with restrictive anorexia typically has an intense fear of gaining weight and a distorted sense of body image. That said, one of the biggest misconceptions   about anorexia is that it’s just about food, weight and body shape. People with anorexia often cope by focusing on these factors -- but there is much more under the surface.

“While the distress connected to food, weight and body size is very real and incredibly overwhelming, the larger concern is the avoidance of distress itself,” says Dr. Easton. “People with anorexia nervosa move away from psychological pain instead of moving through it and building resilience.”

Strictly speaking of behaviors, this subtype is characterized by a focus on weight loss through one or more of the following:

  • Excessive physical activity

anorexia restricting type

Symptoms of restricting type of anorexia

Behavioral and physical symptoms of AN-R include:

  • A shift in eating habits: A person with restrictive anorexia may demonstrate sudden shifts and concerning habits related to eating and food. This might look like calorie restriction, food obsession, refusal of food, piqued interest in fad diets, denial of hunger and other specific food-related rituals. 
  • Low weight* or sudden weight loss: This symptom may not always be obvious and will depend on a person’s age, sex, developmental stage and physical health. Low weight can be defined as weight less than minimally expected considering these factors. Someone who is experiencing restrictive anorexia may have a significant or dramatic decrease in their weight, especially over a short period of time.
  • Hypotension and orthostasis: A person with restrictive anorexia often is not getting the right amount of nutrition, so they may experience low blood pressure (below 90/60 mm Hg) and orthostasis, which occurs when blood pressure drops due to a positional change (i.e., standing or sitting up).
  • Hair thinning or hair loss: Another physical symptom one may experience is hair thinning or hair loss due to nutritional deficiencies.
  • Irregular periods: Someone may experience an absence of or delayed onset of their menstrual cycle, or experience a lighter than normal menstrual cycle. Other hormonal changes can occur, affecting males as well.

*People in larger bodies can also experience restrictive anorexia. Learn more about atypical anorexia here .

The binge-eating/purging type of anorexia is characterized by recurrent episodes of bingeing, which  includes eating large amounts of food in a relatively short time while experiencing a sense of loss of control.

This binge is usually followed by a variety of “compensatory” behaviors, or purging, aimed at regaining control of weight. Purging may include self-induced vomiting, abuse of laxatives and diuretics, or excessive physical activity.

anorexia binge purge type

Symptoms of binge-eating/purging type of anorexia

Behavioral and physical symptoms of AN-BP include:

  • Consumption of large amounts of food in a short period of time (bingeing)
  • Use of behaviors to compensate for calories consumed, including self-induced vomiting, restricting/fasting, overexercising and/or using laxatives or diuretics
  • Feeling “out of control” or ashamed over how much you eat
  • Fear of gaining weight
  • Self-esteem and self-worth tied heavily to body shape and weight
  • Withdrawal from friends, family and “normal” activities/routines
  • Failing performance in work, school and athletic engagements
  • Low or abnormal labs (can include electrolyte abnormalities)
  • Swelling of the cheeks or jaw
  • Calluses on the back of the hands and knuckles

How is anorexia binge-eating/purging type different from bulimia nervosa?

While the binge and purge behaviors in bulimia nervosa and binge-purge anorexia can look very similar, the primary difference in the diagnostic criteria for binge-purge anorexia is that the person has a low body weight for their age and height and/or a period of significant weight loss.

This diagnostic criteria is problematic and exclusionary because weight is not an indicator of health. At ERC, we provide individualized treatment plans for anyone diagnosed with bulimia nervosa or binge-purge anorexia, as identified by their care team.

Read more on bulimia nervosa here .

There is no single cause of either subtype of anorexia but rather an amalgamation of many factors, including:

  • Temperament
  • Co-occurring depression or anxiety
  • Traumatic experiences and trauma-related symptoms
  • Support system conflict
  • Emotion regulation challenges (such as high impulsivity)

Role of genetics in anorexia

There are genetic causes of both subtypes of anorexia, though there is not a specific anorexia gene. Researchers have identified correlations, and possible genetic overlap, between anorexia nervosa and other psychiatric disorders such as depression , anxiety and obsessive-compulsive disorder , as well as certain personality traits. The heritable nature of these traits, including harm avoidance, perfectionism and inflexibility, suggests the relationships may be genetic. There are also studies that show that anorexia nervosa, as well as other eating disorders , runs in families.

The heritability of anorexia has been reported between 40% and 60%, and relatives of individuals with anorexia nervosa are 11 times more likely to develop the illness than relatives of individuals without anorexia. In simpler terms, although we do not inherit anorexia per se, we can inherit a vulnerability to anorexia. There are also cultural causes of anorexia nervosa, including weight stigma and anti-fat bias.

Lasting recovery from both subtypes of anorexia nervosa is possible.

“At the heart of it, anorexia is a conditioned response to try to feel safe or less overwhelmed,” explains Dr. Easton. “In order to return to wellness, we must address that conditioned response, starting with a person’s focus on food, weight and body size, then move into other areas of distress.”

In most cases, sustainable recovery begins with nutritional rehabilitation and weight restoration. Why is this so important, if eating disorders aren’t really “about food”? When someone is severely malnourished, their brain isn't able to process the thoughts, feelings and behavior changes needed to break the cycle of their eating disorder. Making sure their body and brain are getting the nutrients they need to be able to properly function and think clearly is the first step.

Treatment for both subtypes of anorexia nervosa is very similar across the board. However, “at ERC we do treat patients with binge-purge anorexia with additional support before, during and following mealtimes when their impulses to use behaviors are at their highest,” says Dr. Easton. “This may include prior planning for use of individual coping skills and direct support from trained staff to help them move through their urges without using unhelpful behaviors.”

Addressing co-occurring conditions of anorexia

To target underlying causes, including anxiety and other co-occurring conditions, our team leverages a variety of evidence-based therapies, including cognitive behavioral therapy (CBT) , dialectical behavior therapy (DBT) , exposure therapy , acceptance and commitment therapy (ACT)  and more. The skills patients build using these therapies benefit them not only while they’re in our care, but for the rest of their lives.

Our inpatient and residential treatment programs include round-the-clock nursing supervision, psychiatric care and medication management. We also provide nourishing meals and psychosocial support to help patients make progress in recovery so they can step down to lower levels of care.

To help patients build a foundation for recovery at all levels of care, ERC also offers:

  • Nutrition education and support from registered dietitians (more on this below)
  • Comprehensive family and caregiver support
  • Alumni support
  • Support groups and community events

Our nutrition approach

We work with each patient to heal their relationship with food, so meals and snacks are an important part of anorexia treatment.

If a patient has been restricting foods, bingeing or purging, they’ll be prescribed a personalized nutrition plan based on their symptoms, underlying medical conditions and how long their eating disorder has been present. After meeting with registered dietitians and therapists regularly, receiving education on food portions, meal plating and nutrition, the goal is for each patient to develop a peaceful relationship with food.

Learn more about our nutrition approach here .

We believe -- and have seen -- that healing is possible. Looking for support? Schedule a free assessment by calling 877-825-8584 today.

This blog was clinically reviewed by Elizabeth Easton, PsyD, CEDS, in September 2023.

Read These Next:

  • 5 Self-Advocacy Tips for Fat Folks in Eating Disorder Recovery by Sharon Maxwell
  • Feeling Anxious about Weight Restoration in Anorexia Recovery
  • Anorexia in Teens
  • Anorexia in Males
  • Anorexia vs. Bulimia: What's the Difference?
  • Lanugo: Anorexia Hair Growth Explained

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anorexia nervosa purging type

What is Anorexia with Purging?

Anorexia nervosa is a serious type of eating disorder in which individuals tend to restrict the types of food they eat as well as their caloric intake. Psychologists and historians have uncovered evidence that people have been showing signs of anorexia for hundreds–or perhaps even thousands–of years.

Subtypes of Anorexia

The National Eating Disorders Collaboration lists two major subtypes of anorexia nervosa:

  • Hallmarks of the restricting subtype are the restriction of how much food eaten and what types consumed. These behaviors could also be coupled with excessive exercise.
  • Hallmarks of the binge eating and purging subtype include food restriction, binge eating, and purging. Binge eating involves eating a large amount of food while feeling a loss of control, and purging involves engaging in compensatory behavior after eating that could involve misusing enemas, laxatives, and/or diuretics and/or self-induced vomiting.

Physical signs of Anorexia’s Binge Eating and Purging Subtype

Physical signs that could suggest someone is suffering from the binge eating and purging subtype of anorexia may include:

  • Calluses and cuts across the tops of one’s finger joints
  • Swelling around the salivary glands
  • Dental issues including tooth sensitivity, cavities, tooth discoloration, and enamel erosion

There are also a host of other potential physical signs, such as: 

  • Dramatic weight loss
  • Muscle weakness
  • Poor wound healing
  • Sleep issues
  • Impaired immune system functioning
  • Yellow skin from eating lots of carrots
  • Difficulty concentrating
  • Swollen feet
  • Thinning hair on one’s head
  • Stomach cramps
  • Nonspecific gastrointestinal symptoms such as acid reflux or constipation
  • Constantly feeling cold
  • Lanugo, or fine hair on the body
  • dry/brittle nails
  • Menstrual irregularities
  • Cold, mottled hands and feet
  • Abnormal bloodwork results such as low counts or anemia
  • Abnormal laboratory findings such as low hormone levels, slow heart rate, low potassium

Anorexia Nervosa’s Health Risks

Individuals suffering from anorexia nervosa subject their bodies to a dangerous cycle of self-starvation that denies them of nutrients they need in order to function properly. The body will, in turn, slow down all of its processes in order to save energy; this could lead to sudden death due to cardiac arrest or electrolyte imbalances, emphasizing the importance of obtaining treatment. 

Who Develops Anorexia?

Anorexia is a disease that can strike anyone regardless of their race, gender, sexual orientation, age, or ethnicity. No specialist can diagnose the disease simply by looking at an individual, as people suffering from anorexia nervosa don’t always look emaciated or underweight. While anorexia is a disease that tends to appear during one’s adolescence, specialists are now diagnosing more and more children and older adults with it. 

Getting Help

Help is available for anorexia nervosa and other types of eating disorders. One such way to receive help is by reaching out to an eating disorder hotline; many places offer options to text, call, or even instant message with trained professionals. However, if you or someone you love is in a crisis, you can text “NEDA” to 741-741 and you will be put in touch with a trained volunteer at any time. Furthermore, Eating Disorder Hope has an interactive map that can be used to locate eating disorder treatment on a state-by-state basis. Additionally, we are here to help you at Eating Disorder Recovery Specialists. You can reach us via phone (866-525-2766), email , or by filling out our contact form .

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Eating Disorders

What are eating disorders.

There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are actually serious and often fatal illnesses that are associated with severe disturbances in people’s eating behaviors and related thoughts and emotions. Preoccupation with food, body weight, and shape may also signal an eating disorder. Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder.

What are the signs and symptoms of eating disorders?

Anorexia nervosa.

Anorexia nervosa is a condition where people avoid food, severely restrict food, or eat very small quantities of only certain foods. They also may weigh themselves repeatedly. Even when dangerously underweight, they may see themselves as overweight.

There are two subtypes of anorexia nervosa: a "restrictive "  subtype and a "binge-purge " subtype.

  • In the restrictive subtype of anorexia nervosa, people severely limit the amount and type of food they consume.
  • In the binge-purge  subtype of anorexia nervosa, people also greatly restrict the amount and type of food they consume. In addition, they may have binge-eating and purging episodes—eating large amounts of food in a short time followed by vomiting or using laxatives or diuretics to get rid of what was consumed.

Anorexia nervosa can be fatal. It has an extremely high death (mortality) rate compared with other mental disorders. People with anorexia are at risk of dying from medical complications associated with starvation. Suicide is the second leading cause of death for people diagnosed with anorexia nervosa.

If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline   at 988 or chat at 988lifeline.org   . In life-threatening situations, call 911.

Symptoms include:

  • Extremely restricted eating
  • Extreme thinness (emaciation)
  • A relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight
  • Intense fear of gaining weight
  • Distorted body image, a self-esteem that is heavily influenced by perceptions of body weight and shape, or a denial of the seriousness of low body weight

Other symptoms may develop over time, including:

  • Thinning of the bones (osteopenia or osteoporosis)
  • Mild anemia and muscle wasting and weakness
  • Brittle hair and nails
  • Dry and yellowish skin
  • Growth of fine hair all over the body (lanugo)
  • Severe constipation
  • Low blood pressure
  • Slowed breathing and pulse
  • Damage to the structure and function of the heart
  • Brain damage
  • Multiorgan failure
  • Drop in internal body temperature, causing a person to feel cold all the time
  • Lethargy, sluggishness, or feeling tired all the time
  • Infertility

Bulimia nervosa

Bulimia nervosa is a condition where people have recurrent and frequent episodes of eating unusually large amounts of food and feeling a lack of control over these episodes. This binge-eating is followed by behavior that compensates for the overeating such as forced vomiting, excessive use of laxatives or diuretics, fasting, excessive exercise, or a combination of these behaviors. People with bulimia nervosa may be slightly underweight, normal weight, or over overweight.

  • Chronically inflamed and sore throat
  • Swollen salivary glands in the neck and jaw area
  • Worn tooth enamel and increasingly sensitive and decaying teeth as a result of exposure to stomach acid
  • Acid reflux disorder and other gastrointestinal problems
  • Intestinal distress and irritation from laxative abuse
  • Severe dehydration from purging of fluids
  • Electrolyte imbalance (too low or too high levels of sodium, calcium, potassium, and other minerals) which can lead to stroke or heart attack

Binge-eating disorder

Binge-eating disorder is a condition where people lose control over their eating and have reoccurring episodes of eating unusually large amounts of food. Unlike bulimia nervosa, periods of binge-eating are not followed by purging, excessive exercise, or fasting. As a result, people with binge-eating disorder often are overweight or obese. Binge-eating disorder is the most common eating disorder in the U.S.

  • Eating unusually large amounts of food in a specific amount of time, such as a 2-hour period
  • Eating even when you're full or not hungry
  • Eating fast during binge episodes
  • Eating until you're uncomfortably full
  • Eating alone or in secret to avoid embarrassment
  • Feeling distressed, ashamed, or guilty about your eating
  • Frequently dieting, possibly without weight loss

Avoidant restrictive food intake disorder

Avoidant restrictive food intake disorder (ARFID), previously known as selective eating disorder, is a condition where people limit the amount or type of food eaten. Unlike anorexia nervosa, people with ARFID do not have a distorted body image or extreme fear of gaining weight. ARFID is most common in middle childhood and usually has an earlier onset than other eating disorders. Many children go through phases of picky eating, but a child with ARFID does not eat enough calories to grow and develop properly, and an adult with ARFID does not eat enough calories to maintain basic body function.

  • Dramatic restriction of types or amount of food eaten
  • Lack of appetite or interest in food
  • Dramatic weight loss
  • Upset stomach, abdominal pain, or other gastrointestinal issues with no other known cause
  • Limited range of preferred foods that becomes even more limited (“picky eating” that gets progressively worse)

What are the risk factors for eating disorders?

Eating disorders can affect people of all ages, racial/ethnic backgrounds, body weights, and genders. Eating disorders frequently appear during the teen years or young adulthood but may also develop during childhood or later in life.

Researchers are finding that eating disorders are caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors. Researchers are using the latest technology and science to better understand eating disorders.

One approach involves the study of human genes. Eating disorders run in families. Researchers are working to identify DNA variations that are linked to the increased risk of developing eating disorders.

Brain imaging studies are also providing a better understanding of eating disorders. For example, researchers have found differences in patterns of brain activity in women with eating disorders in comparison with healthy women. This kind of research can help guide the development of new means of diagnosis and treatment of eating disorders.

How are eating disorders treated?

It is important to seek treatment early for eating disorders. People with eating disorders are at higher risk for suicide and medical complications. People with eating disorders can often have other mental disorders (such as depression or anxiety) or problems with substance use. Complete recovery is possible.

Treatment plans are tailored to individual needs and may include one or more of the following:

  • Individual, group, and/or family psychotherapy
  • Medical care and monitoring
  • Nutritional counseling
  • Medications

Psychotherapies

Family-based therapy, a type of psychotherapy where parents of adolescents with anorexia nervosa assume responsibility for feeding their child, appears to be very effective in helping people gain weight and improve eating habits and moods.

To reduce or eliminate binge-eating and purging behaviors, people may undergo cognitive behavioral therapy (CBT), which is another type of psychotherapy that helps a person learn how to identify distorted or unhelpful thinking patterns and recognize and change inaccurate beliefs.

Evidence also suggests that medications such as antidepressants, antipsychotics, or mood stabilizers may also be helpful for treating eating disorders and other co-occurring illnesses such as anxiety or depression. The Food and Drug Administration’s (FDA) website  has the latest information on medication approvals, warnings, and patient information guides.

How can I find a clinical trial for an eating disorder?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. We have new and better treatment options today because of what clinical trials uncovered years ago. Be part of tomorrow’s medical breakthroughs. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you.

To learn more or find a study, visit:

  • NIMH’s Clinical Trials webpage : Information about participating in clinical trials
  • Clinicaltrials.gov: Current Studies on Eating Disorders  : List of clinical trials funded by the National Institutes of Health (NIH) being conducted across the country

Where can I learn more about eating disorders?

Free brochures and shareable resources.

  • Eating Disorders: About More Than Food : A brochure about the common eating disorders anorexia nervosa, bulimia nervosa, and binge-eating disorder, and various approaches to treatment. Also available en español .
  • Let’s Talk About Eating Disorders : An infographic with facts that can help shape conversations around eating disorders. Also available in en español .
  • Shareable Resources on Eating Disorders : Help support eating disorders awareness and education in your community. Use these digital resources, including graphics and messages, to spread the word about eating disorders.
  • Mental Health Minute: Eating Disorders : Take a mental health minute to watch this video on eating disorders.
  • Let’s Talk About Eating Disorders with NIMH Grantee Dr. Cynthia Bulik : Learn about the signs, symptoms, treatments, and the latest research on eating disorders.

Research and statistics

  • NIMH Eating Disorders Research Program : This program supports research on the etiology, core features, longitudinal course, and assessment of eating disorders.
  • Journal Articles   : References and abstracts from MEDLINE/PubMed (National Library of Medicine).
  • Statistics: Eating Disorders

Last Reviewed: January 2024

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Anorexia nervosa

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  • Anorexia nervosa is an eating disorder and a serious mental illness.

The causes of anorexia nervosa are not fully understood.

  • If you have signs of anorexia nervosa, it’s important to get help as soon as possible.

What is anorexia nervosa?

Anorexia nervosa is an eating disorder and a serious mental illness. Eating disorders are not a choice. This can be very confusing to others looking on.

Out of a fear of gaining weight, someone with anorexia nervosa may follow a restrictive diet and do too much exercise.

A person with anorexia nervosa:

  • has a very distorted body image
  • has an intense and often irrational fear of gaining weight
  • restricts their energy intake
  • does excessive exercise

The restriction in energy intake can cause a large amount of weight loss in a short period of time. It may result in you having a very low weight.

People with anorexia nervosa often see themselves as being heavy or large when they are very underweight. Their body image can have a large influence on how they feel about themselves. Extreme weight loss can drastically change the way you think and how your brain functions.

Types of anorexia nervosa

Anorexia nervosa falls into 2 general types:

  • restricting type
  • binge eating

Restricting type

People with this type of anorexia nervosa restrict the amount and type of food they eat.

This can include:

  • counting calories
  • skipping meals
  • limiting or avoiding certain food groups (such as carbohydrates)
  • following obsessive rules, such as only eating foods of a certain colour

These behaviours may be accompanied by too much exercise.

Binge eating/purging type

People with this type of anorexia place severe restrictions on the food they eat and they also purge. Purging behaviours include vomiting (being sick) or misusing laxatives, diuretics or enemas.

Some people may also binge eat — eat a large amount of food and feel out of control.

Atypical anorexia nervosa

Atypical anorexia nervosa is a type of eating disorder called Other Specified Feeding or Eating Disorders (OSFED).

This is when you have all the behaviours of anorexia nervosa, but your body mass index (BMI) is normal or above.

What are the symptoms of anorexia nervosa?

The most obvious signs of anorexia nervosa are:

  • being underweight
  • losing weight very quickly
  • having dramatic weight fluctuations
  • controlling and restricting food intake
  • being preoccupied with food and body weight

Being very thin is not the only sign of anorexia nervosa. There are other signs that you may have with anorexia nervosa.

Physical signs

Physical signs can include:

  • fainting or dizziness
  • feeling cold even when the weather is warm
  • bloating , constipation or developing food intolerances
  • feeling tired and not sleeping well
  • looking pale or having sunken eyes
  • fine hair on your face and body
  • loss of menstruation (your period) in females
  • decreased libido (sex drive) in males

Psychological signs

Psychological signs can include:

  • being preoccupied with eating, food, body shape and weight
  • being extremely dissatisfied with body image and irrational ideas about body and weight
  • being anxious, irritable or secretive at mealtimes
  • fear of gaining weight
  • depression and anxiety
  • difficulty thinking and concentrating
  • having rigid thoughts about food
  • low self-esteem and perfectionism

Behavioural signs

Behavioural signs can include:

  • intense dieting (counting calories, avoiding foods)
  • deliberately misusing laxatives, appetite suppressants, enemas and diuretics
  • obsessive behaviours around body weight or shape (repeated weighing, pinching waist or wrists)
  • avoiding eating with other people and secrecy around food
  • wanting to be alone
  • excessive exercising
  • obsessive rituals around food
  • preoccupation with cooking, recipes and nutrition
  • self-harm, substance abuse or suicide attempts

CHECK YOUR SYMPTOMS — Use the Symptom Checker and find out if you need to seek medical help.

What causes anorexia nervosa?

There are some things that can increase your risk:

  • Genetic risk factors — anorexia nervosa can run in families, suggesting there may be a genetic cause.
  • Cultural factors — related ideals of thinness promoted by the media and social media.
  • Environmental factors — including the onset of puberty , stressful life events and relationship problems .

For some people, anorexia is a way of controlling areas of life that feel out of control. Their body image can define their entire sense of self-worth.

Psychological factors such as anxiety may also play a role in the development of anorexia.

Who gets anorexia nervosa?

Anyone can get anorexia nervosa, but it’s most often diagnosed in females. This may be because many males do not show signs that are as obvious. However, the number of males diagnosed with anorexia nervosa is growing.

Anorexia usually starts in adolescence, with 4 in 10 cases being diagnosed between 15 years and 19 years.

When should I see my doctor?

If you are worried about your eating, it’s important to speak someone. You could talk to someone you trust like a friend, family member or teacher.

Your doctor is also a good place to start. They will help you take the first steps towards treatment and recovery.

If you have anorexia nervosa, the earlier you get help, the better your chances of recovery. Seriously restricting calorie intake is dangerous and can have a serious impact on your health.

If you have signs of anorexia nervosa, it is important to get help as soon as possible.

FIND A HEALTH SERVICE — The Service Finder can help you find doctors, pharmacies, hospitals and other health services.

ASK YOUR DOCTOR — Preparing for an appointment? Use the Question Builder for general tips on what to ask your GP or specialist.

How is anorexia nervosa diagnosed?

Your doctor will examine you and ask you questions about your health. They will also check for any other mental or physical complications.

Your doctor may diagnose anorexia nervosa based on your thoughts, feelings and eating behaviours.

How is anorexia nervosa treated?

It is possible to recover from anorexia nervosa, even if you have been living with the illness for many years. The road to recovery is often long and challenging. But with the right team supporting you and a high level of commitment, you can recover.

Psychological support

Seeing a psychologist or psychiatrist has been shown to reduce the length and impact of anorexia nervosa.

Cognitive behavioural therapy enhanced for eating disorders (CBT‐E) is usually the first treatment recommended for adults. This is typically delivered over 40 weekly sessions.

Family‐based therapy is usually the first treatment recommended for children and adolescents.

A psychologist can help you learn behaviours that will help you get to and maintain a healthy weight.

Other treatments

You may also see a:

  • family therapist

If you have life-threatening medical complications or have very low body weight, you may need to spend time in hospital.

Antidepressants and other medicines are sometimes used to treat anorexia nervosa, along with psychological therapy.

Complications of anorexia nervosa

If you, or someone else, is at immediate risk of suicide, call triple zero (000) now for an ambulance.

Anorexia nervosa can also cause physical complications including:

  • intestinal problems
  • problems with your immune system
  • an irregular heartbeat or other heart problems
  • osteoporosis and bone problems that can increase the risk of broken bones
  • kidney failure

Anorexia nervosa can be life threatening. This can be due to the physical or psychological impacts of the disease.

Mental health complications can include self-harm, substance abuse and suicide.

Resources and support

The National Eating Disorders Collaboration has information on evidence-informed prevention and treatment of eating disorders.

You can speak confidentially to the Butterfly National Helpline . Call 1800 33 4673, 8am to midnight AEST, 7 days a week.

Eating Disorders Families Australia (EDFA) supports the families and carers of people with an eating disorder. You can call them on 1300 195 626.

If you are thinking about suicide, you can call Lifeline on 13 11 14 or chat online.

Learn more here about the development and quality assurance of healthdirect content .

Last reviewed: November 2023

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A person with anorexia nervosa will experience significant weight loss due to food restriction and starvation together with an intense fear of gaining weight.

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Anorexia is a serious, potentially life threatening mental illness. Click here for a fact sheet on Anorexia Nervosa.

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What is anorexia nervosa? Anorexia nervosa is a mental illness in which there is a disturbance in the way a person experiences their body shape or weight as well as unhappiness with their body

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Anorexia nervosa is a psychological illness characterised by a consistent reduction in food intake, fear of gaining weight and body image distortion.

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Anorexia nervosa is a mental and eating disorder that makes people lose too much weight. Read about signs of anorexia and how to get help for your child.

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What is anorexia nervosa? | Eating disorders | ReachOut Australia

Anorexia nervosa is a type of eating disorder with some unique characteristics, such as an obsessive fear of gaining weight, distorted body image and low body weight.

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Anorexia is a serious mental illness, not a lifestyle choice or diet People with anorexia restrict both how much and what is eaten Anorexia has the highest mortality rate of any mental illness Anyone can be affected by anorexia, regardless of gender, age or ethnicity Anorexia has serious physical and mental health complications Recovery is possible; early treatment leads to the best results

Other specified feeding and eating disorders (OSFED)

A person with OSFED may present with many of the symptoms of other eating disorders such as anorexia nervosa, bulimia nervosa or binge eating disorder but will not meet the full criteria for diagnosis of these disorders.

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Successful treatment and recovery are complex processes requiring multiple steps, different treatment options and collaborative care from a multidisciplinary team.

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Anorexia Nervosa

Table of contents, signs and symptoms, bmi calculation, screening and rating scales, pathophysiology, differential diagnosis, bone density, physical exam, hospitalization, psychological.

Anorexia nervosa (AN) is an eating disorder characterized by a fear of gaining weight, strong desire to be thin, and food restriction, which results in low weight. It is the highest mortality psychiatric illness with a mortality rate of 10%.

Epidemiology

  • The incidence in low- and middle-income countries is significantly lower (see Cultural section).
  • Anorexia nervosa predominantly affects females (10:1 female-to-male ratio). [2]
  • Very rarely, it can begin before puberty or after age 40. [3]
  • Although most physiological disturbances from malnutrition are reversible with nutritional rehabilitation, some are not completely reversible (e.g. - loss of bone mineral density).
  • Some individuals will recover fully after a single episode, while others experience a chronic course over many years.
  • Hospitalization may be needed to restore weight and to treat medical complications.
  • On average, most individuals with anorexia nervosa experience remission within 5 years of presentation, but overall remission rates are lower in those who have a history of hospitalization.
  • Death most commonly results from medical complications or from suicide .
  • Suicide risk is significantly elevated in anorexia nervosa. [4]

Comorbidity

  • Bipolar, depressive, and anxiety disorders are most comorbid. [5]
  • Many individuals may have an anxiety disorder or symptoms prior to onset of their eating disorder.
  • OCD is more common in those with restricting type, while alcohol use disorder and other substance use disorders is more common in those with binge-eating/purging type. [6]

Risk Factors

  • Anxiety disorders and obsessional traits in childhood are risk factors. [7]
  • Triggers for anorexia include stressful life events, such as leaving home for college.
  • Concordance rates for anorexia nervosa in monozygotic twins are significantly higher than those for dizygotic twins
  • Anorexia nervosa is most prevalent in post-industrialized, high-income countries including Canada, the United States, many European countries, Australia, New Zealand, and Japan. [8]
  • Historical and cross-cultural variability in the prevalence of anorexia nervosa supports its association with cultures and settings in which thinness is valued.
  • Occupations and jobs that encourage thinness, such as modeling, elite athletics, and dancers, [9] are associated with increased risk.

DSM-5 Diagnostic Criteria

Criterion a.

Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

  • R - Restriction of intake leading to significantly low body weight
  • I - Intense fear of weight gain
  • D - Disturbance in perception of one's weight or body image

Criterion B

Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.

Criterion C

Disturbance in the way in which one's bodyweight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Type Specifier

  • Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behaviour (i.e. - self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
  • Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behaviour (i.e. - self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Remission Specifier

Specify if:

  • In partial remission: After full criteria for anorexia nervosa were previously met. Criterion A (low body weight) has not been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met.
  • In full remission: After full criteria for anorexia nervosa were previously met, none of the criteria have been met for a sustained period of time.

Severity Specifier

The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or, for children and adolescents, on BMI percentile. The ranges below are derived from World Health Organization (WHO) categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision.

  • Mild: BMI ≥ 17 kg/m 2
  • Moderate: BMI = 16 to 16.99 kg/m 2
  • Severe: BMI = 15 to 15.99 kg/m 2
  • Extreme: BMI < 15 kg/m 2
  • It is rare for individuals with anorexia nervosa to complain of weight loss and seek clinical attention, and they frequently lack insight or deny the problem.
  • If individuals do seek help on their own, it is usually due to distress over the somatic and/or psychological sequelae of starvation. [11]
  • However, some individuals will not binge eat but will regularly purge after eating small amounts of food.
  • The crossover between the two subtypes over the course of the disorder can be common.
  • Thus, the subtype specifiers should be used to describe current symptoms rather than longitudinal course.
  • Obsessive-compulsive symptoms, both related and unrelated to food, are often prominent. Most individuals are preoccupied with thoughts of food, and some may collect recipes or hoard food.
  • For children and adolescents, determining a BMI-for-age percentile is useful. Similar to adults, it is not possible to give definitive standards for judging whether a child or adolescent's weight is significantly low. This is because variations in developmental trajectories among youth limit the utility of simple numerical guidelines.
  • However, children and adolescents with a BMI above this cut off may still be judged to be significantly underweight if there is failure to maintain their expected growth trajectory
  • Thus, to determine whether Criterion A or anorexia nervosa is met, the clinician needs to consider not just the numerical guidelines, but also the individual's body build, weight history, and any physiological changes (e.g. - amenorrhea). [12]

Eating Disorder Scales

The scoff questionnaire.

  • S: Do you ever make yourself sick because you feel uncomfortably full?
  • C: Do you worry you have lost control over how much you eat?
  • O: Have you recently lost more than one stone [14 pounds/6.4kg] in a 3 month period?
  • F: Do you believe yourself to be fat when others say you are too thin?
  • F: Would you say that food dominates your life?
  • Functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) have shown a range of neuroanatomical abnormalities. [14] The degree to which these findings reflect changes associated with malnutrition versus primary abnormalities associated with the disorder is unclear.

Other possible causes of either significantly low body weight or significant weight loss should be considered in the differential diagnosis of anorexia nervosa, especially when the presenting features are atypical (e.g., onset after age 40 years).

  • Medical conditions such as gastrointestinal disease, hyperthyroidism, occult malignancies, and acquired immunodeficiency syndrome (AIDS) can present with serious weight loss
  • However, individuals with these disorders usually do not have a disturbance in the way their body weight or shape is experienced or the intense fear of weight gain seen in anorexia nervosa. Acute weight loss associated with a medical condition can occasionally be followed by the onset or recurrence of anorexia nervosa, which can initially be masked by the comorbid medical condition. Rarely, anorexia nervosa can develop after bariatric surgery for obesity.
  • In MDD, severe weight loss can occur, but most individuals do not have either a desire for excessive weight loss or an intense fear of gaining weight. [15]
  • Individuals with schizophrenia may have odd eating behaviours and occasionally have significant weight loss. However, they rarely show the fear of gaining weight and the body image disturbance seen in anorexia nervosa.
  • Individuals with substance use disorders may have low weight due to poor intake but generally do not have a fear gaining weight or body image disturbance . Individuals who abuse substances that reduce appetite (e.g. - cocaine, stimulants) and who also have a fear of weight gain should be evaluated for the possibility of comorbid anorexia nervosa, since substance use can be a persistent behaviour that interferes with weight gain (Criterion B).
  • Some of the features of anorexia nervosa overlap with the criteria for social phobia, OCD, and BDD. Specifically, individuals may feel humiliated or embarrassed to be seen eating in public, as in social phobia. They may have obsessions and compulsions related to food as seen in OCD. Or, they may be preoccupied with an imagined defect in their bodily appearance, as seen in BDD. If the individual with anorexia nervosa has social fears that are limited to eating behavior alone, the diagnosis of social anxiety disorder should not be made. However, if the social fears unrelated to eating behavior (e.g. - excessive fear of speaking in public) they may warrant an additional diagnosis of social phobia. Similarly, OCD should be considered only if the individual exhibits obsessions and compulsions unrelated to food (e.g. - an excessive fear of contamination), and an additional diagnosis of BDD should be considered only if the distortion is unrelated to body shape and size (e.g. - preoccupation that one's nose is too big). [16]
  • Individuals with bulimia nervosa have recurrent episodes of binge eating, engage in inappropriate behavior to avoid weight gain (e.g. - self-induced vomiting), and are also overly concerned with body shape and weight. However, unlike in anorexia nervosa, binge-eating/purging type, individuals with bulimia nervosa maintain a body weight at or above a minimally normal level. [17]
  • Individuals with ARFID may have significant weight loss or nutritional deficiency, but do not have a fear of gaining weight or of becoming fat, nor do they have a disturbance in the way they experience their body shape and weight.

Investigations

  • Various metabolic and bloodwork disturbances can occur in anorexia nervosa. Self-induced vomiting and/or misuse of laxatives, diuretics, and enemas can cause a number of disturbances that lead to abnormal laboratory findings. However, some individuals with anorexia nervosa exhibit no laboratory abnormalities.
  • Leukopenia (decreased white blood cells, WBC) is common
  • Elevated lymphocytes can occur
  • Mild anemia can occur, thrombocytopenia and, rarely, bleeding problems
  • Hyponatremia
  • Hypophosphatemia
  • Hypomagnesmia
  • Hypokalemia
  • Hypocalcemia
  • Hypozincemia
  • Self-induced vomiting may lead to metabolic alkalosis (elevated serum bicarbonate), hypochloremia, and hypokalemia; laxative abuse may also cause a mild metabolic acidosis.
  • Serum thyroxine (T4) levels are usually in the low-normal range; triiodothyronine (T3) levels are decreased, while reverse T3 (rT3) levels are elevated.
  • Hypercholesterolemia is common
  • Hepatic enzyme levels may be elevated
  • Elevated serum amylase [18]
  • Females have low serum estrogen levels, whereas males have low levels of serum testosterone.
  • Increased [19]
  • Increased [20]
  • Decreased [21]
  • Low bone mineral density, with specific areas of osteopenia or osteoporosis, is often seen. The risk of fracture is significantly elevated. [22]
  • Sinus bradycardia is common, and, rarely, arrhythmias are noted. Significant prolongation of the QTc interval is observed in some individuals. [23]
  • Most of the physical signs and symptoms of anorexia nervosa are due to starvation.
  • In prepubertal females, menarche maybe delayed.
  • There may be complaints of cold intolerance, hypothermia, and lethargy.
  • Some develop peripheral edema, especially during weight restoration or upon cessation of laxative and diuretic abuse.
  • Genitourinary changes include: polyuria
  • Gastrointestinal changes may include: constipation, non-focal abdominal pain,
  • Dermatological changes include: lanugo (a fine downy body hair), brittle hair and nails, dry or yellow skin (associated with hypercarotenemia),
  • Rarely, petechiae or ecchymoses, usually on the extremities, may indicate a bleeding disorder (e.g. - thrombocytopenia).
  • As may be seen in individuals with bulimia nervosa, individuals with anorexia nervosa who self-induce vomiting may have hypertrophy of the salivary glands, particularly the parotid glands, as well as dental enamel erosion.
  • Some individuals may have scars or calluses on the dorsal surface of the hand from repeated contact with the teeth while inducing vomiting.
  • To avert potentially irreversible effects on physical growth and development, many children and adolescents require inpatient medical treatment, even when weight loss, although rapid, has not been as severe as that suggesting a need for hospitalization in adult patients
  • Orthostatic hypotension with an increase in pulse of 20 bpm
  • Drop in standing blood pressure of 20 mmHg
  • Bradycardia <40 bpm
  • Tachycardia >110 bpm
  • Inability to sustain core body temperature
  • Refeeding syndrome can occur in significantly malnourished patients when they have a sudden increase in calorie intake.
  • The mechanism is that increased caloric intake leads to increased insulin release, which leads to hypophosphatemia, decreased potassium, and decreased magnesium.
  • This series of metabolic chances can lead to cardiac complications, rhabdomyolysis, and seizures.
  • Thus, there is a risk for Wernicke's encephalopathy , and individuals should receive IV thiamine during refeeding as well.

Once weight-gain has restarted, various forms of psychotherapy have been found to be effective for treatment of anorexia, including: [24] [25]

  • Individual therapy (CBT, IPT, and psychodynamic approaches)
  • Group therapy (CBT, IPT, and psychodynamic approaches)
  • Family-Based Therapy (Maudsley) for children and adolescents

Eating Disorder Guidelines

For patients.

  • Sheena's Place - Free Group Support for Eating Disorders (Toronto)

For Providers

  • Treasure, J. et al. Anorexia nervosa. Nature Reviews Disease Primers 1, 15074 (2015)
  • Anorexia nervosa in adolescent males. Kadoura, B. et al. CMAJ Feb 2024, 196 (6) E191

anorexia nervosa purging type

  • Patient Care & Health Information
  • Diseases & Conditions
  • Anorexia nervosa

Anorexia (an-o-REK-see-uh) nervosa — often simply called anorexia — is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with their lives.

To prevent weight gain or to continue losing weight, people with anorexia usually severely restrict the amount of food they eat. They may control calorie intake by vomiting after eating or by misusing laxatives, diet aids, diuretics or enemas. They may also try to lose weight by exercising excessively. No matter how much weight is lost, the person continues to fear weight gain.

Anorexia isn't really about food. It's an extremely unhealthy and sometimes life-threatening way to try to cope with emotional problems. When you have anorexia, you often equate thinness with self-worth.

Anorexia, like other eating disorders, can take over your life and can be very difficult to overcome. But with treatment, you can gain a better sense of who you are, return to healthier eating habits and reverse some of anorexia's serious complications.

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The physical signs and symptoms of anorexia nervosa are related to starvation. Anorexia also includes emotional and behavioral issues involving an unrealistic perception of body weight and an extremely strong fear of gaining weight or becoming fat.

It may be difficult to notice signs and symptoms because what is considered a low body weight is different for each person, and some individuals may not appear extremely thin. Also, people with anorexia often disguise their thinness, eating habits or physical problems.

Physical symptoms

Physical signs and symptoms of anorexia may include:

  • Extreme weight loss or not making expected developmental weight gains
  • Thin appearance
  • Abnormal blood counts
  • Dizziness or fainting
  • Bluish discoloration of the fingers
  • Hair that thins, breaks or falls out
  • Soft, downy hair covering the body
  • Absence of menstruation
  • Constipation and abdominal pain
  • Dry or yellowish skin
  • Intolerance of cold
  • Irregular heart rhythms
  • Low blood pressure
  • Dehydration
  • Swelling of arms or legs
  • Eroded teeth and calluses on the knuckles from induced vomiting

Some people who have anorexia binge and purge, similar to individuals who have bulimia. But people with anorexia generally struggle with an abnormally low body weight, while individuals with bulimia typically are normal to above normal weight.

Emotional and behavioral symptoms

Behavioral symptoms of anorexia may include attempts to lose weight by:

  • Severely restricting food intake through dieting or fasting
  • Exercising excessively
  • Bingeing and self-induced vomiting to get rid of food, which may include the use of laxatives, enemas, diet aids or herbal products

Emotional and behavioral signs and symptoms may include:

  • Preoccupation with food, which sometimes includes cooking elaborate meals for others but not eating them
  • Frequently skipping meals or refusing to eat
  • Denial of hunger or making excuses for not eating
  • Eating only a few certain "safe" foods, usually those low in fat and calories
  • Adopting rigid meal or eating rituals, such as spitting food out after chewing
  • Not wanting to eat in public
  • Lying about how much food has been eaten
  • Fear of gaining weight that may include repeated weighing or measuring the body
  • Frequent checking in the mirror for perceived flaws
  • Complaining about being fat or having parts of the body that are fat
  • Covering up in layers of clothing
  • Flat mood (lack of emotion)
  • Social withdrawal
  • Irritability
  • Reduced interest in sex

When to see a doctor

Unfortunately, many people with anorexia don't want treatment, at least initially. Their desire to remain thin overrides concerns about their health. If you have a loved one you're worried about, urge her or him to talk to a doctor.

If you're experiencing any of the problems listed above, or if you think you may have an eating disorder, get help. If you're hiding your anorexia from loved ones, try to find a person you trust to talk to about what's going on.

The exact cause of anorexia is unknown. As with many diseases, it's probably a combination of biological, psychological and environmental factors.

  • Biological. Although it's not yet clear which genes are involved, there may be genetic changes that make some people at higher risk of developing anorexia. Some people may have a genetic tendency toward perfectionism, sensitivity and perseverance — all traits associated with anorexia.
  • Psychological. Some people with anorexia may have obsessive-compulsive personality traits that make it easier to stick to strict diets and forgo food despite being hungry. They may have an extreme drive for perfectionism, which causes them to think they're never thin enough. And they may have high levels of anxiety and engage in restrictive eating to reduce it.
  • Environmental. Modern Western culture emphasizes thinness. Success and worth are often equated with being thin. Peer pressure may help fuel the desire to be thin, particularly among young girls.

Risk factors

Anorexia is more common in girls and women. However, boys and men have increasingly developed eating disorders, possibly related to growing social pressures.

Anorexia is also more common among teenagers. Still, people of any age can develop this eating disorder, though it's rare in those over 40. Teens may be more at risk because of all the changes their bodies go through during puberty. They may also face increased peer pressure and be more sensitive to criticism or even casual comments about weight or body shape.

Certain factors increase the risk of anorexia, including:

  • Genetics. Changes in specific genes may put certain people at higher risk of anorexia. Those with a first-degree relative — a parent, sibling or child — who had the disorder have a much higher risk of anorexia.
  • Dieting and starvation. Dieting is a risk factor for developing an eating disorder. There is strong evidence that many of the symptoms of anorexia are actually symptoms of starvation. Starvation affects the brain and influences mood changes, rigidity in thinking, anxiety and reduction in appetite. Starvation and weight loss may change the way the brain works in vulnerable individuals, which may perpetuate restrictive eating behaviors and make it difficult to return to normal eating habits.
  • Transitions. Whether it's a new school, home or job; a relationship breakup; or the death or illness of a loved one, change can bring emotional stress and increase the risk of anorexia.

Complications

Anorexia can have numerous complications. At its most severe, it can be fatal. Death may occur suddenly — even when someone is not severely underweight. This may result from abnormal heart rhythms (arrhythmias) or an imbalance of electrolytes — minerals such as sodium, potassium and calcium that maintain the balance of fluids in your body.

Other complications of anorexia include:

  • Heart problems, such as mitral valve prolapse, abnormal heart rhythms or heart failure
  • Bone loss (osteoporosis), increasing the risk of fractures
  • Loss of muscle
  • In females, absence of a period
  • In males, decreased testosterone
  • Gastrointestinal problems, such as constipation, bloating or nausea
  • Electrolyte abnormalities, such as low blood potassium, sodium and chloride
  • Kidney problems

If a person with anorexia becomes severely malnourished, every organ in the body can be damaged, including the brain, heart and kidneys. This damage may not be fully reversible, even when the anorexia is under control.

In addition to the host of physical complications, people with anorexia also commonly have other mental health disorders as well. They may include:

  • Depression, anxiety and other mood disorders
  • Personality disorders
  • Obsessive-compulsive disorders
  • Alcohol and substance misuse
  • Self-injury, suicidal thoughts or suicide attempts

There's no guaranteed way to prevent anorexia nervosa. Primary care physicians (pediatricians, family physicians and internists) may be in a good position to identify early indicators of anorexia and prevent the development of full-blown illness. For instance, they can ask questions about eating habits and satisfaction with appearance during routine medical appointments.

If you notice that a family member or friend has low self-esteem, severe dieting habits and dissatisfaction with appearance, consider talking to him or her about these issues. Although you may not be able to prevent an eating disorder from developing, you can talk about healthier behavior or treatment options.

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  • Mehler P. Anorexia nervosa in adults: Evaluation for medical complications and criteria for hospitalization to manage these complications. https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
  • Pike K. Anorexia nervosa in adults: Cognitive behavioral therapy (CBT). https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
  • Walsh BT. Anorexia nervosa in adults: Pharmacotherapy. https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
  • Anorexia nervosa. Merck Manual Professional Version. http://www.merckmanuals.com/professional/psychiatric-disorders/eating-disorders/anorexia-nervosa. Accessed Nov. 13, 2017.
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  • Brockmeyer T, et al. Advances in the treatment of anorexia nervosa: A review of established and emerging interventions. Psychological Medicine. In press. Accessed Nov. 13, 2017.
  • Davis H, et al. Pharmacotherapy of eating disorders. Current Opinion in Psychiatry. 2017;30:452.
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  • Fogarty S, et al. The role of complementary and alternative medicine in the treatment of eating disorders: A systematic review. Eating Behaviors. 2016;21:179.
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  • Lebow J, et al. The effect of atypical antipsychotic medications in individuals with anorexia nervosa: A systematic review and meta-analysis. International Journal of Eating Disorders. 2013;46:332.
  • Five things to know about safety of dietary supplements for children and teens. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/tips/child-supplements. Accessed Feb. 9, 2018.

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The transition from restrictive anorexia nervosa to binging and purging: a systematic review and meta-analysis

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  • Volume 27 , pages 857–865, ( 2022 )

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  • Riccardo Serra   ORCID: orcid.org/0000-0003-4105-5078 1 , 2 , 5 ,
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A Correction to this article was published on 02 July 2021

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Numerous studies addressed the topic of behavioral and symptomatic changes in eating disorders. Rates of transition vary widely across studies, ranging from 0 to 70.8%, depending on the diagnoses taken into account and the study design. Evidence shows that the specific transition from restrictive-type anorexia nervosa (AN-R) to disorders involving binging and purging behaviors (BPB) is related to a worsening of the clinical picture and worse long-term outcomes. The aim of this systematic review and meta-analysis is to focus on this specific transition, review existing literature, and summarize related risk factors. Medline and PsycINFO databases were searched, including prospective and retrospective studies on individuals with AN-R. The primary outcome considered was the rate of onset of BPB. Twelve studies ( N  = 725 patients) were included in the qualitative and quantitative analysis. A total of 41.84% (95% CI 33.58–50.11) of patients with AN-R manifested BPB at some point during follow-up. Risk factors for the onset of BPB included potentially treatable and untreatable factors such as the family environment, unipolar depression and higher premorbid BMI. These findings highlight that patients with AN-R frequently transition to BPB over time, with a worsening of the clinical picture. Existing studies in this field are still insufficient and heterogeneous, and further research is needed. Mental health professionals should be aware of the frequent onset of BPB in AN-R and its risk factors and take this information into account in the treatment of AN-R.

Level of evidence

Evidence obtained from a systematic review and meta-analysis, Level I.

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Outcomes of Severe and Enduring Anorexia Nervosa

anorexia nervosa purging type

Eating disorder outcomes: findings from a rapid review of over a decade of research

Jane Miskovic-Wheatley, Emma Bryant, … Sarah Maguire

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Introduction

Drifting of behavioral and psychopathological patterns can lead to permanent or temporary switches in eating disorder (ED) diagnoses over time [ 1 , 2 , 3 ]. While ED diagnoses are useful for describing and managing a patient’s current condition, frequent diagnostic transitions could limit their validity and utility in clinical and research settings. Reported rates of transition between ED diagnoses vary widely across studies, ranging from 0 to 70.8% [ 4 , 5 ]. The reasons for this high variability are still unclear. Inclusion of patients with different clinical and socio-demographic characteristics and from different settings (e.g., in-patients or out-patients services) could contribute to the variance. Another factor could be the inclusion of patients with anorexia nervosa (AN) without a sub-sample analysis of patients with restrictive-type anorexia nervosa (AN-R) and binge–purge subtype anorexia nervosa (AN-BP), potentially leading to inaccurate estimates. The changing of diagnostic criteria over time (e.g., amenorrhea criterion for AN was removed in DSM-5) might also be a confounding factor. All things considered, existing literature is heterogeneous and does not allow for clear-cut conclusions to be drawn on the subject of diagnostic transition in EDs. Although some research has been conducted, this subject still needs further investigation.

The transition from AN-R to cases involving binging and purging behaviors (BPB) offers an interesting perspective on the subject of diagnostic transition in ED. This specific transition has been shown to entail a worse clinical picture with a longer duration of illness and worse outcomes [ 6 , 7 , 8 ]. In line with this, when compared to AN-R, cases involving BPB are associated with a higher prevalence of past traumatic experience [ 9 ], comorbid mental disorders [ 10 , 11 ], maladaptive personality traits [ 12 ], suicidality [ 10 ], as well as higher levels of somatic and dissociative symptoms (i.e., an interruption in consciousness, identity, environmental awareness, or memory—which is normally well integrated in a healthy person) [ 1 , 13 ]. From a purely behavioral point of view, AN-R is characterized by a focus on weight loss (accomplished primarily through dieting, fasting and/or excessive exercise) while AN-BP, bulimia nervosa (BN) and binge–eating disorder (BED) are characterized by recurrent episodes of binging (eating large amounts of food in relatively short time while experiencing a sense of loss of control). Furthermore, in AN-BP and BN, binging behaviors are usually followed by a variety of harmful behaviors aimed at regaining control of weight such as vomiting, the use of laxatives and diuretics or excessive physical activity (purging behaviors) [ 1 ]. Interestingly, although the behavioral difference is pronounced, no significant differences were found when objectively measuring behavioral impulsivity in patients with different ED diagnoses [ 14 ]. Furthermore, some studies focused specifically on patients with AN-R transitioning to BPB (e.g., [ 8 ]) and it has been reported that 36% of patients with AN-R develop BN over time [ 15 ].

Relevantly, risk factors for transitioning between EDs have been highlighted. Physiological and environmental factors, such as higher premorbid body mass index (BMI) [ 4 ] and conflictual family environment [ 15 ], as well as depression, substance abuse, panic disorder and obsessive–compulsive disorder [ 2 , 3 ], have been associated with transitions between ED diagnoses. However, scarcity and heterogeneity of available evidence might prevent this clinically notable information from reaching mental health professionals. Accessibility to an organic source of knowledge on these data could be of clinical relevance, especially in the management of first onsets and younger patients.

This systematic review and meta-analyses aims to compare contents and provide clearer figures of available data on the transition from AN-R to BPB. It also aims to provide a unified, structured source of information on risk factors for this specific transition. This could hopefully foster further studies on the topic of diagnostic transition in EDs and ultimately push toward effective prevention strategies and specific early interventions for avoiding chronicization in the treatment of AN-R. In pursuit of its aims, this review tried to answer the following research questions: “what is the number of patients with AN-R who undergo an onset of BPB?” and “is it possible to predict which patients are at high risk for a transition from AN-R to BPB?”.

Materials and methods

Data sources.

We developed our review and meta-analysis according to the PRISMA statement [ 16 ]. The primary search strategy involved exploring databases (Medline, PsycINFO) through December 2020, to identify relevant, peer-reviewed, articles in English on long-term outcomes of patients with AN-R. The final search syntax was the following: (anorexia nervosa) AND ((follow-up study) or (course) or (predictors) or (evolution) or (crossover) or (transition) or (prediction)) AND ((bulimia) or (vomiting) or (binging) or (purging)). A filter for English language was applied. Gray literature was searched using multiple resources such as Scopus and reference tracing.

Eligibility criteria

Selection of the evidence was structured in three progressively more selective phases:

Phase 1—Title screening including only studies on the long-term outcome of patients who received the diagnosis of AN at admission.

Phase 2—Abstract screening applied all criteria of phase 1 and, in addition, only included studies on patients with a specific diagnose of AN-R.

Phase 3—Full-text screening applied all criteria of phase 2 and included only studies reporting data on the transition from AN-R to BPB that used validated diagnostic instruments.

Two authors (Serra & Di Nicolantonio) independently reviewed titles and abstracts of retrieved references. Then, the same two researchers independently reviewed the full-text versions of the articles to confirm their eligibility for inclusion. The age of participants, study setting, design and sample size were not criteria for exclusion. All disagreements were resolved in a consensus meeting with the team. Each included study was assessed using the Newcastle Ottawa Scale, an instrument developed to assess the quality of non-randomized studies on three broad perspectives: the selection of the study groups; the comparability of the groups; and the ascertainment of either the exposure or outcome of interest for case–control or cohort studies, respectively [ 17 ].

Data extraction

Two authors (Serra & Di Nicolantonio) independently extracted data from each of the included references: authors’ names , year of publication , sample size , drop-out rate , diagnostic criteria , mean BMI , rates of BPB onset , outcome criteria , therapeutic regimen (in-/out-patients/other), assessment tools , risk factors , mean age , mean age at onset and duration of illness , duration of follow-up , year and country of the study. Primary outcome was the rate of onset of BPB during follow-up for a AN-R diagnosis (i.e., the proportion of participants that engaged in BPB at some point during follow-up).

Statistical analysis

Analyses were performed using the “metaprop” command of STATA 16. We calculated pooled incidence of BPB onset with its 95% confidence interval (CI) using a random effects meta-analytic model. We also quantified heterogeneity using the I-squared measure.

A total of 1975 records were identified through database search, with 1722 remaining after duplicate removal. The screening of titles and abstracts led to 23 studies. The full-text evaluation led to the exclusion of 11 studies (Fig.  1 ). Reasons for non-inclusion in the review were diagnostic instruments not fitting inclusion criteria ( n  = 1), report from the same sample of another included study ( n  = 3), sample not fitting inclusion criteria ( n  = 6) and sample and outcome not fitting inclusion criteria ( n  = 1). The twelve studies included accounted for a total of 725 patients with a baseline diagnosis of AN-R. Table 1 summarizes results and characteristics of the included studies. All but three of the retrospective studies had a prospective design, [ 15 , 18 , 19 ]. The mean study sample size consisted of 60.41 patients (SD = 24.25) with only three studies having a sample size lower than 50 [ 4 , 20 , 21 ] and only one with less than 30 [ 22 ]. All patients were women and the mean age at baseline was 22.02 years (SD = 5.08). Reports were gathered from many different areas of the globe, improving generalizability of the findings: a total of five studies recruited patients from the USA [ 8 , 10 , 15 , 20 , 22 ], three from Italy [ 2 , 11 , 18 ], while the remaining four studies were respectively from Germany [ 21 ], Japan [ 19 ], Sweden [ 4 ] and the UK [ 23 ]. Only two studies enrolled adolescents [ 4 , 8 ]. As shown in Table 1 , six studies used DSM-IV diagnostic criteria [ 10 , 11 , 15 , 18 , 19 , 21 ], three studies used DSM-III [ 8 , 20 , 22 ], one study used both DSM-III and DSM-IV [ 4 ], and one used ICD-10 [ 23 ]. Three studies enrolled in-patients [ 8 , 20 , 21 ], three enrolled out-patients [ 2 , 11 , 19 ] and two studies enrolled patients from mixed settings [ 4 , 23 ]. Four studies did not report the specific setting of recruitment [ 10 , 15 , 18 , 22 ]. Outcome criteria used were the onset of BN [ 15 , 18 , 22 ], the onset of BPB with a specified frequency [ 10 , 11 , 23 ], the onset of BPB with no frequency cut-off [ 2 , 4 , 20 ], the onset of any BPB disorder [ 19 , 21 ], and the onset of objective binge-eating only (defined as having eaten more than other people would consider normal, as opposed to the subjective sensation of having eaten excessively) [ 8 ]. The mean age at onset of the AN-R was assessed in eight studies and was 17.44 years (SD = 2.52); mean duration of illness was 5.12 years (SD = 3.59). Average baseline BMI was 16.63 kg/m 2 (SD = 2.59). The follow-up duration of studies was long with an average of 9.05 years (SD = 6.59), ranging from a minimum of one up to 20 years. In two studies, patients died during follow-up [ 10 , 20 ], with a mean mortality rate of 2.5%. The NOS evaluation revealed good quality level and the absence of substantial source of bias in the selected studies (data available upon request).

figure 1

Flowchart of the screening and selection of literature included in qualitative and quantitative analysis

The pooled rate of AN-R patients who underwent an onset of BPB was 41.84% (95%CI 33.58–50.11). The pooled remission rate was 41.91% (95%CI 15.96–67.85; I 2  = 97.23%).

A total of seven of the studies identified risk factors for the onset of BPB in AN-R (Table 1 ) [ 2 , 4 , 8 , 11 , 15 , 18 , 19 ]. Two studies presented results from bi-variate models [ 18 , 19 ]. All other studies reported results from multivariate models and are presented in Table 2 , according to their potential treatability (modifiable/unmodifiable).

This is the first systematic review and meta-analysis of available evidence on the onset of BPB in AN-R patients. The review also includes a synopsis and categorization of reported risk factors for the onset of BPB. The onset of BPB in AN-R is consistently reported across studies, with a pooled 41.84% of the patients undergoing this transition at some point during follow-up. The pooled remission rate of 41.91% suggests that the vast majority of non-remitting patients will eventually undergo a transition to BPB. It is hard to define a specific, single psychopathological phenomenon underlying cross-over in eating disorders. Many factors are surely involved and, as for the onset of BPB in AN-R patients some of these factors were highlighted in seven of the included studies (Table 1 ).

Compared to patients with stable AN-R, undergoing an onset of BPB was consistently related to a higher premorbid BMI in well-designed bivariate and multivariate models [ 2 , 4 , 15 , 18 ]. Although further research is needed to explain this finding, researchers have hypothesized that a higher premorbid BMI could be the sign of a greater pre-existing appetitive drive or a weaker appetitive inhibition potentially facilitating the onset of binging and/or purging (the latter with the aim of weight control) while on a restrictive diet [ 4 ]. This hypothesis is also in line with genetic studies showing how obesity-related genes such as the chromosomal region 10p and the preproghrelin gene single nucleotide polymorphisms are recognized susceptibility factors for the development of bulimia [ 24 , 25 ]. Higher premorbid BMI could also be related to higher levels of body dissatisfaction, which was also correlated to higher risk of BPB onset in AN-R [ 11 ].

Another strong finding across multivariate models is the association between onset of BPB and various aspect of familial relations such as patients’ hostile attitude towards their family, high parental criticism and lack of parental expressed empathy/affection towards the patient [ 8 , 15 , 19 ]. It is important to notice how many studies in the field have shown an association between BPB and the presence of a history of trauma [ 9 , 15 , 26 ] and that, while psychological trauma is associated to diagnostic instability and BPB [ 27 , 28 ], it is not associated to AN-R [ 29 ]. In line with clinical theories such as the theory of “escape from self-awareness” [ 30 ] or the theory of “complex relational trauma” [ 31 ], given the available evidence, it is possible to state that a tense and conflictual family environment implies a higher risk of BPB onset in AN-R. Interesting in this regard, is the emerging evidence of the role of emotional dysregulation and depression in the relation between past traumatic experiences and EDs [ 32 , 33 ]. More specifically, emotional dysregulation and depression seem to have a mediating effect-linking trauma and emotional overeating, which is commonly reported by patients with eating disorders involving BPB [ 33 , 34 ]. This is in line with the presented evidence on unipolar depression, which showed a strong prospective association with the onset of BPB [ 2 ]. Further research is needed to understand whether there is a causal relation between unipolar mood disorders and the onset of BPB in AN-R. The presence of unipolar depression could, in fact, be a sign of severity or have a unique role in the onset of BPB in patients with AN-R.

One last factor to keep in mind when studying this phenomenon is starvation itself. In fact, re-nourishing after prolonged food deprivation is associated with binging, food hoarding, depressive mood and other impulsive behaviors, leading to the hypothesis of a causal link between starvation and the development of BPB [ 35 , 36 ]. As highlighted in the milestone Minnesota semi-starvation experiment and later confirmed in non-experimental conditions, binging and purging behaviors can also emerge during nutritional rehabilitation of individuals constrained to protracted dietary restriction [ 37 , 38 , 39 ].

Overall, highlighted predictors for the onset of BPB in AN-R seem to point at a biopsychosocial model involving psychological, familial and metabolic factors. In line with this, we hypothesize that no single cause can lead to such a complex transformation, rather a concausal chain pushing against the single patient’s will and psychological resources.

Limitations and future research directions

Present results should be interpreted in consideration of several limitations. First, some characteristics limit the generalizability of available data: three studies had a sample size lower than n  = 50 [ 20 , 21 , 22 ]; reports only considered women; and ten of the studies included patients regardless of current age and age of onset in spite of the early onset of AN. Second, the specificity of our research question led to the inclusion of a low number of studies, potentially limiting the generalizability of our findings. However, we believe that the focus on AN-R rather than a general group of patients with AN increases the strength of our findings. The proportion of AN-R patients undergoing an onset of BPB in any given study is related to the specific definition of “transition” and its measurement in a given study, limiting the availability of data fit for a meta-analysis. However, results showed a narrow 95% CI proving adequate homogeneity of included studies. Nevertheless, although the selection was strict it is possible that the samples include non-homogeneous clinical presentations, diagnosable as AN-R, of which slight differences are understandably not reported. Future studies in this field should apply more reliable criteria for the definition of BPB onset. In our opinion, despite seemingly different criteria used to assess the transition to BPB, the onset of any impulsive behavior (i.e., isolated binging, diagnosis of AN-BP, any BPB with a low frequency or others) is the lowest common denominator of a dramatic change in the clinical course of AN-R. Risk factors identified in included studies should be considered in future research examining predictors, mediators and moderators of the onset of BPB in AN-R patients. Given the ego-dystonic nature of binging behaviors, it is possible that sharing with patients the information that fasting may lead to BPB could increase motivation and adherence to nutritional rehabilitation and therapeutic plans. Future research could test this hypothesis to help clinicians in the management of this critical aspect of AN-R therapy.

Conclusions

Almost half of the patients with a diagnosis of AN-R will eventually undergo an onset of BPB, marking an evolution of their clinical condition with longer duration of illness and reduction of their possibility for a sustained recovery [ 7 , 8 , 40 ]. As highlighted in a recent study [ 41 ], general practitioners, nutritionists and mental health professionals have a key role in rapidly directing patients to specialist care settings to provide appropriate care. This is critical in the prevention of the permanent risks associated with starvation, the onset of BPB and the general worse outcomes related to a late diagnosis [ 6 , 42 , 43 ]. Confirmed risk factor for the onset of BPB should be systematically assessed by clinicians in patients AN-R and specific treatments (such as family therapy) should be considered in patients at high risk for the onset of BPB, especially in the evaluation and treatment of first onsets. This could lead to more prompt interventions for preventing chronicization and the evolution of the clinical picture.

What is already known on this subject?

Rates of diagnostic transition in ED vary widely across studies, ranging from 0 to 70.8%. Heterogeneity of existing research makes it hard to interpretate available data. The specific transition from restrictive-type anorexia nervosa to disorders involving binging and purging behaviors has been related to a worse long-term prognosis. Over the years, some risk factors for this transition have been identified.

What this study adds?

This study focuses on the literature from a neglected area of research, suggesting that the transition from restrictive-type anorexia nervosa to disorders involving binging and purging behaviors is common. Results are consistent across country of origin, decade when the study was performed, design of the study and clinical/nonclinical settings. Some established risk factors for the transition could be targeted in therapy.

Data availability

A database containing data from the different phases of the selection of articles was shared during the submission process (as additional material was not for review). The database will be shared upon request.

Code availability

Code will be shared upon request.

Change history

02 july 2021.

A Correction to this paper has been published: https://doi.org/10.1007/s40519-021-01244-y

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Serra, R., Di Nicolantonio, C., Di Febo, R. et al. The transition from restrictive anorexia nervosa to binging and purging: a systematic review and meta-analysis. Eat Weight Disord 27 , 857–865 (2022). https://doi.org/10.1007/s40519-021-01226-0

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Alli Spotts-De Lazzer, MA, LMFT, LPCC, CEDS-S

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Anorexia, Bulimia, Bingeing, and OSFED: More Alike Than Different

Subtle changes can shift one eating disorder diagnosis to another..

Posted November 17, 2021 | Reviewed by Gary Drevitch

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  • An individual's eating disorder diagnosis can change due to a shift in their weight or compensatory behaviors.
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The media has portrayed the looks of the three most well-recognized eating disorders—anorexia, bulimia, and binge-eating disorder (BED)—as distinct, and judgments are often made about the severity and social stigma of each. OSFED, which stands for "other specified feeding and eating disorder," is the catchall term for behaviors and attitudes almost fit one of the other three. It, too, tends to elicit judgments as “not enough to be an actual eating disorder." As an eating disorders specialist, I’m repeatedly struck by how similar these four disorders tend to be despite the perceived differences.

General Similarities

  • Involve maladaptive, unnatural, non-intuitive eating.
  • Can result in malnutrition.
  • Come with negative physical consequences.
  • Reduce the quality of a person’s life.
  • Can fly under the radar of being noticed as a problem or illness.

Many of our educational books based on the most current Diagnostic and Statistical Manual of Mental Disorders ( DSM-5 ) focus on weight as a determining factor for which eating disorder diagnosis applies. For example:

  • The primary difference between the diagnosis of anorexia nervosa with the subtype of binge-purge and bulimia nervosa can be a few pounds. Anorexia nervosa with bingeing and purging is bulimia nervosa, basically—just at a low weight.
  • The difference between anorexia nervosa (typically slim) and OSFED’s atypical anorexia nervosa (typically average to large) is weight. Data is evolving, but atypical anorexia nervosa has been shown to be as serious as anorexia nervosa . This includes medical risks and consequences.

Reminder: For many years, anorexia nervosa was recognized as having the highest mortality rate of any psychiatric disorder. It now shares that distinction with substance use disorders (e.g., opioid), which underscores the dangerousness of anorexia nervosa, typical and atypical. Do you think weight is enough to determine one diagnostic title over another (e.g., anorexia over bulimia or OSFED over anorexia)?

Compensatory Behaviors

The act of compensating or not compensating for having eaten can change one eating diagnosis into another, too. The following phrases can represent compensation: “get rid of,” “burn off,” and “balance out” after eating. Compensatory behaviors fall into two categories:

  • Non-purging matches primarily to activities such as exercising and dieting (aka restricting food). Both come with an underlying intention of controlling or manipulating calories, weight, body size, or food intake.
  • Purging involves methods that empty the body, such as vomiting, which is probably the most stereotypically portrayed purging behavior in pop culture and media.

There are other examples of both, but it’s often best not to name them since people vulnerable to eating disorders can get ideas.

Compensatory behaviors can occur in all four eating disorders mentioned:

  • Someone with binge-eating disorder binges but, according to the DSM-5, doesn’t regularly compensate for what they ate.
  • Someone with bulimia nervosa binges and regularly compensates by either non-purging or purging methods.
  • Someone with anorexia nervosa may or may not binge and regularly compensates by either non-purging or purging methods.
  • Someone with OSFED may compensate by either non-purging or purging methods, for eating or bingeing, and depending on their specific beliefs and behaviors.

Question: If you struggle with binge eating or know someone who does, is there some type of compensation occurring after a binging episode or episodes? If so, are the compensatory behaviors happening regularly (e.g., at least once a week)? I suspect that many people who’ve been given binge-eating disorder as their diagnosis may have, or have had, bulimia nervosa.

I often wish that “eating disorder” was the only diagnosis available within eating disorders. Titles can matter to the people struggling and their loved ones. For example:

  • People can view anorexia nervosa as sort of the ultimate eating disorder diagnosis.
  • People can think they aren’t sick enough to need (or deserve) help if they have OSFED.
  • Some people with bulimia nervosa believe they failed; they didn’t do it well enough to earn the title of anorexia.

If you might have an eating disorder or disordered eating , please seek help from a professional who is thoroughly trained in eating and body image issues. A professional usually pursues an eating-disorders specialty track, which involves thousands of hours of training and education . I encourage you to ask potential providers about their paths to, and background in, this specialty. Your healing is worth it.

anorexia nervosa purging type

This post expresses my opinions, does not present the full criteria of eating disorders, is for informational purposes only, and does not substitute for therapy or professional advice.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Chesney, E., Goodwin, G. M. & Fazel, S. (2014). Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry, 13 , 153-160. https://doi.org/10.1002/wps.20128

Garber, A. K., Cheng, J., Accurso, E. C., Adams, S. H., Buckelew, S. M., Kapphahn, C. J., Kreiter, A., Le Grange, D., Machen, V. I., Moscicki, A. B., Saffran, K., Sy, A. F., Wilson, L., & Golden, N. H. (2019). Weight loss and illness severity in adolescents with atypical anorexia nervosa. Pediatrics, 144 (6). e20192339. 10.1542/peds.2019-2339

Alli Spotts-De Lazzer, MA, LMFT, LPCC, CEDS-S

Alli Spotts-De Lazzer, MA, LMFT, LPCC, CEDS-S, is the author of MeaningFULL: 23 Life-Changing Stories of Conquering Dieting, Weight, and Body Image Issues.

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Psychiatry Online

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The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders

  • Catherine Crone , M.D. (Chair) ,
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At its April 2021 meeting, the American Psychiatric Association (APA) Board of Trustees approved “The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders.” The full guideline is available at APA’s Practice Guidelines website.

The goal of this guideline is to improve the quality of care and treatment outcomes for patients with eating disorders, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR; American Psychiatric Association 2022 ). Since publication of the last American Psychiatric Association (APA) practice guideline on eating disorders ( American Psychiatric Association 2006 ), there have been many studies on psychotherapies for individuals with these diagnoses as well as some studies on pharmacotherapies. Despite this, there are still substantial gaps in the availability and use of evidence-based treatments for individuals with an eating disorder ( Kazdin et al. 2017 ). This practice guideline aims to help clinicians enhance care for their patients by reviewing current evidence and providing evidence-based statements ( Box 1 ) that are intended to increase knowledge, improve assessment, and optimize treatment of eating disorders.

Box 1. Guideline Statements a

Assessment and determination of treatment plan.

APA recommends (1C) screening for the presence of an eating disorder as part of an initial psychiatric evaluation.

APA recommends (1C) that the initial evaluation of a patient with a possible eating disorder include assessment of

the patient’s height and weight history (e.g., maximum and minimum weight, recent weight changes);

presence of, patterns in, and changes in restrictive eating, food avoidance, binge eating, and other eating-related behaviors (e.g., rumination, regurgitation, chewing and spitting);

patterns and changes in food repertoire (e.g., breadth of food variety, narrowing or elimination of food groups);

presence of, patterns in, and changes in compensatory and other weight control behaviors, including dietary restriction, compulsive or driven exercise, purging behaviors (e.g., laxative use, self-induced vomiting), and use of medication to manipulate weight;

percentage of time preoccupied with food, weight, and body shape;

prior treatment and response to treatment for an eating disorder;

psychosocial impairment secondary to eating or body image concerns or behaviors; and

family history of eating disorders, other psychiatric illnesses, and other medical conditions (e.g., obesity, inflammatory bowel disease, diabetes mellitus).

APA recommends (1C) that the initial psychiatric evaluation of a patient with a possible eating disorder include weighing the patient and quantifying eating and weight control behaviors (e.g., frequency, intensity, or time spent on dietary restriction, binge eating, purging, exercise, and other compensatory behaviors).

APA recommends (1C) that the initial psychiatric evaluation of a patient with a possible eating disorder identify co-occurring health conditions, including co-occurring psychiatric disorders.

APA recommends (1C) that the initial psychiatric evaluation of a patient with a possible eating disorder include a comprehensive review of systems.

APA recommends (1C) that the initial physical examination of a patient with a possible eating disorder include assessment of vital signs, including temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure; height, weight, and BMI (or percent median BMI, BMI percentile, or BMI Z-score for children and adolescents); and physical appearance, including signs of malnutrition or purging behaviors.

APA recommends (1C) that the laboratory assessment of a patient with a possible eating disorder include a complete blood count and a comprehensive metabolic panel, including electrolytes, liver enzymes, and renal function tests.

APA recommends (1C) that an electrocardiogram be done in patients with a restrictive eating disorder, patients with severe purging behavior, and patients who are taking medications that are known to prolong QTc intervals.

APA recommends (1C) that patients with an eating disorder have a documented, comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team.

Anorexia Nervosa

10. APA recommends (1C) that patients with anorexia nervosa who require nutritional rehabilitation and weight restoration have individualized goals set for weekly weight gain and target weight.

11. APA recommends (1B) that adults with anorexia nervosa be treated with an eating disorder-focused psychotherapy, which should include normalizing eating and weight control behaviors, restoring weight, and addressing psychological aspects of the disorder (e.g., fear of weight gain, body image disturbance).

12. APA recommends (1B) that adolescents and emerging adults with anorexia nervosa who have an involved caregiver be treated with eating disorder-focused family based treatment, which should include caregiver education aimed at normalizing eating and weight control behaviors and restoring weight.

Bulimia Nervosa

13. APA recommends (1C) that adults with bulimia nervosa be treated with eating disorder-focused cognitive-behavioral therapy and that a serotonin reuptake inhibitor (e.g., 60 mg fluoxetine daily) also be prescribed, either initially or if there is minimal or no response to psychotherapy alone by 6 weeks of treatment.

14. APA suggests (2C) that adolescents and emerging adults with bulimia nervosa who have an involved caregiver be treated with eating disorder-focused family based treatment.

Binge-Eating Disorder

15. APA recommends (1C) that patients with binge-eating disorder be treated with eating disorder-focused cognitive-behavioral therapy or interpersonal therapy, in either individual or group formats.

16. APA suggests (2C) that adults with binge-eating disorder who prefer medication or have not responded to psychotherapy alone be treated with either an antidepressant medication or lisdexamfetamine.

a The authors of the guideline determined each final rating, as described in the section “Guideline Development Process” (see Table 1 in the full guideline ). A recommendation (denoted by the numeral 1 after the guideline statement) indicates confidence that the benefits of the intervention clearly outweigh harms. A suggestion (denoted by the numeral 2 after the guideline statement) indicates greater uncertainty. Although the benefits of the statement are still viewed as outweighing the harms, the balance of benefits and harms is more difficult to judge, or either the benefits or the harms may be less clear. With a suggestion, patient values and preferences may be more variable, and this can influence the clinical decision that is ultimately made. Each guideline statement also has an associated rating for the strength of supporting research evidence. Three ratings are used: high, moderate, and low (denoted by the letters A, B, and C, respectively) and reflect the level of confidence that the evidence for a guideline statement reflects a true effect based on consistency of findings across studies, directness of the effect on a specific health outcome, precision of the estimate of effect, and risk of bias in available studies ( Agency for Healthcare Research and Quality 2014 ; Balshem et al. 2011 ; Guyatt et al. 2006 ).

The lifetime prevalence of eating disorders in the United States is approximately 0.80% for anorexia nervosa (AN), 0.28% for bulimia nervosa (BN), and 0.85% for binge-eating disorder (BED) ( Udo and Grilo 2018 ), although estimates can vary depending on the study location, sample demographic characteristics, case finding, and diagnostic approaches ( Galmiche et al. 2019 ; Santomauro et al. 2021 ; Wu et al. 2020 ). Furthermore, data suggest an increasing incidence of eating disorders and inpatient care for eating disorders, particularly AN, during the COVID-19 pandemic ( Agostino et al. 2021 ; Asch et al. 2021 ; Otto et al. 2021 ; Taquet et al. 2021 ). Importantly, the lifetime burdens and psychosocial impairments associated with an eating disorder can be substantial because these illnesses can persist for decades, and they typically have an onset in adolescence or early adulthood ( Udo and Grilo 2018 ).

In the United States, for the 2018–2019 fiscal year, the total economic costs of eating disorders were estimated to be $64.7 billion, with an additional $326.5 billion attributable to reductions in well-being associated with eating disorders ( Streatfeild et al. 2021 ).

Eating disorders are also associated with increases in all-cause mortality and deaths due to suicide ( Auger et al. 2021 ; Nielsen and Vilmar 2021 ; Tith et al. 2020 ; van Hoeken and Hoek 2020 ). In addition, rates of suicide attempts are increased in individuals who have an eating disorder ( Keski-Rahkonen 2021 ; Smith et al. 2018 ; Udo et al. 2019 ). Morbidity and mortality among individuals with an eating disorder are heightened by the common co-occurrence of health conditions such as diabetes and other psychiatric disorders, particularly depression, anxiety, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), ADHD, and substance use disorders ( Ahn et al. 2019 ; Cliffe et al. 2020 ; Gibbings et al. 2021 ; Keski-Rahkonen 2021 ; Udo and Grilo 2019 ).

Accordingly, the overall goal of this guideline is to enhance the assessment and treatment of eating disorders, thereby reducing the mortality, morbidity, and significant psychosocial and health consequences of these important psychiatric conditions.

Overview of the Development Process

Since the publication of Clinical Practice Guidelines We Can Trust ( Institute of Medicine 2011 ), a report of the Institute of Medicine (now known as National Academy of Medicine), there has been an increasing focus on using clearly defined, transparent processes for rating the quality of evidence and the strength of the overall body of evidence in systematic reviews of the scientific literature. This guideline was developed using a process intended to be consistent with the recommendations of the Institute of Medicine ( Institute of Medicine 2011 ) and the Principles for the Development of Specialty Society Clinical Guidelines of the Council of Medical Specialty Societies (2012). Parameters used for the guideline’s systematic review are included with the full text of the guideline. The APA website features a full description of the guideline development process.

Rating the Strength of Research Evidence and Recommendations

Development of guideline statements entails weighing the potential benefits and harms of the statement and then identifying the level of confidence in that determination. (See Appendix G in the supplemental information accompanying the full guideline online for detailed descriptions of the potential benefits and harms for each statement.) This concept of balancing benefits and harms to determine guideline recommendations and strength of recommendations is a hallmark of GRADE (Grading of Recommendations Assessment, Development and Evaluation), which is used by multiple professional organizations around the world to develop practice guideline recommendations ( Guyatt et al. 2013 ). With the GRADE approach, recommendations are rated by assessing the confidence that the benefits of the statement outweigh the harms and burdens of the statement, determining the confidence in estimates of effect as reflected by the quality of evidence, estimating patient values and preferences (including whether they are similar across the patient population), and identifying whether resource expenditures are worth the expected net benefit of following the recommendation ( Andrews et al. 2013 ).

In weighing the balance of benefits and harms for each statement in this guideline, our level of confidence is informed by available evidence (see Appendix C in the supplemental information accompanying the full guideline online), which includes evidence from clinical trials as well as expert opinion and patient values and preferences. Evidence for the benefit of a particular intervention within a specific clinical context is identified through systematic review and is then balanced against the evidence for harms. In this regard, harms are broadly defined and may include serious adverse events, less serious adverse events that affect tolerability, minor adverse events, negative effects of the intervention on quality of life, barriers and inconveniences associated with treatment, direct and indirect costs of the intervention (including opportunity costs), and other negative aspects of the treatment that may influence decision making by the patient, the clinician, or both.

Many topics covered in this guideline have relied on forms of evidence such as consensus opinions of experienced clinicians or indirect findings from observational studies rather than research from randomized trials. It is well recognized that there are guideline topics and clinical circumstances for which high-quality evidence from clinical trials is not possible or is unethical to obtain ( Council of Medical Specialty Societies 2012 ). For example, many questions need to be asked as part of an assessment and inquiring about a particular symptom or element of the history cannot be separated out for study as a discrete intervention. It would also be impossible to separate changes in outcomes due to assessment from changes in outcomes due to ensuing treatment. Research on psychiatric assessments and some psychiatric interventions can also be complicated by multiple confounding factors such as the interaction between the clinician and the patient or the patient’s unique circumstances and experiences. The GRADE working group and guidelines developed by other professional organizations have noted that a strong recommendation or “good practice statement” may be appropriate even in the absence of research evidence when sensible alternatives do not exist ( Andrews et al. 2013 ; Brito et al. 2013 ; Djulbegovic et al. 2009 ; Hazlehurst et al. 2013 ). For each guideline statement, we have described the type and strength of the available evidence as well as the factors, including patient preferences, that were used in determining the balance of benefits and harms.

Guideline Scope

The scope of this document is shaped by the diagnostic criteria for eating disorders and by the available evidence as obtained by a systematic review of the literature through September 2021, particularly focusing on AN, BN, and BED as defined by DSM-III, DSM-III-R, DSM-IV, DSM-IV-TR, DSM-5, or ICD-10. This practice guideline addresses evidence-based pharmacological, psychotherapeutic, and other nonpharmacological treatments for eating disorders in adolescents, emerging adults, and adults. In addition, it includes statements related to assessment and treatment planning, which are an integral part of patient-centered care.

Our systematic review attempted to include literature on avoidant/restrictive food intake disorder (ARFID); however, rigorous clinical trial data were not available due to the relative recency of the introduction of this diagnosis. We have included some discussion of ARFID in the implementation sections of this document, particularly as it relates to assessment and treatment planning. We specifically excluded rumination disorder and pica from our search of the literature due to their typical age of onset in infancy or childhood and the limited evidence on their treatment. We also excluded treatment of obesity from the scope of this guideline because obesity is not categorized as an eating disorder.

Data are also limited on individuals with eating disorders and significant physical health conditions or co-occurring psychiatric conditions, including substance use disorders. Many of the available studies of eating disorders did not analyze data separately for these patient subgroups or excluded individuals with these comorbidities. Nevertheless, in the absence of more robust evidence, the statements in this guideline should generally be applicable to individuals with co-occurring conditions. Additionally, although treatment-related costs are often barriers to receiving treatment and cost-effectiveness considerations are relevant to health care policy, cost-effectiveness considerations are outside the scope of this guideline.

The full text of the practice guideline describes aspects of guideline implementation that are relevant to individual patients' circumstances and preferences. A detailed description of research evidence related to the effects of pharmacological and nonpharmacological treatments in individuals with eating disorders can be found in the appendices accompanying the full guideline at psychiatryonline.org/guidelines .

From the APA Practice Guideline Writing Group (Catherine Crone, M.D., Chair).

Practice Guidelines are assessments of scientific and clinical information that are current as of the date of authorship but are not continually updated and may not reflect the most recent evidence. They are provided as an educational service and should not be considered as a statement of the standard of care or inclusive of all proper treatments or methods of care. They are not intended to substitute for the independent professional judgment of the treating clinician. The ultimate recommendation regarding a particular assessment, clinical procedure, or treatment plan must be made by the clinician in light of the psychiatric evaluation, other clinical data, and the diagnostic and treatment options available. The guidelines are available on an “as is” basis, and APA makes no warranty, expressed or implied, regarding them. APA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the guidelines.

APA and the Guideline Writing Group especially thank Laura J. Fochtmann, M.D., M.B.I., Blair Uniacke, M.D., Seung-Hee Hong, and Jennifer Medicus for their outstanding work and effort in developing this guideline. APA also wishes to acknowledge the contributions of other APA staff including Michelle Dirst, Andrew Lyzenga, and Kristin Kroeger Ptakowski. APA wishes to give special recognition to Joel Yager, M.D. for his decades of contributions to APA and its practice guidelines, including his work on the Systematic Review Group and serving as Chair of the Eating Disorders Writing Group for three prior versions of this guideline. APA also thanks the APA Committee on Practice Guidelines (Daniel J. Anzia, M.D., Chair), liaisons from the APA Assembly for their input and assistance, and APA Councils and others for providing feedback during the comment period.

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anorexia nervosa purging type

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When you think of the term “anorexia,” what comes to mind? Most people associate it with being extremely thin and food restriction. But in reality, the differences between anorexia and other eating disorders like bulimia and BED aren’t all that black and white ( nearly all eating disorders are rooted in restriction ). This point is illustrated clearly by the anorexia binge-purge subtype (AN-BP). Though it’s not commonly known, it’s the second type of anorexia in addition to anorexia restrictive subtype (AN-R). Here’s everything you need to know about the lesser known (but equally serious) form of anorexia.

What is anorexia binge-purge subtype?

Anorexia nervosa restrictive type, the commonly known version of anorexia, is characterized by a severe limitation of food, both in terms of intake and variety. Food restriction is also a characteristic of anorexia binge-purge subtype, but people with AN-BP can also experience episodes of binge eating and purging, or eating large quantities of food in a short amount of time and then “getting rid of” the food they consumed through purging behaviors like vomiting, excessive exercise, or laxative use.

Equip’s VP of Behavioral Health Care, Angela Celio Doyle, PhD, explains that AN-BP does share some hallmark symptoms with restrictive anorexia, including food restriction and the inability to maintain a healthy weight for their body’s needs. “But in addition to restricting food, the person can also feel a loss of control when eating or react to a meal by engaging in some kind of purging behavior afterward,” Doyle says. She adds that patients must exhibit these binge eating and purging behaviors consistently for at least three months to be clinically diagnosed with AN-BP.

“There’s a lot of diagnostic crossover between different eating disorders,” Doyle goes on. “Restrictive anorexia may develop into AN-BP without treatment. Likewise, AN-BP can evolve into bulimia . Although eating disorders can appear very different, at their core they’re very similar in terms of what drives them, and so diagnoses can often overlap or change over time.”

How common is anorexia binge-purge subtype?

It’s difficult to pinpoint the exact number of people struggling with AN-BP, but there are a few data points that give a sense of how common it is.

Research shows that among hospitalized anorexia patients, as many as 47% exhibit binge eating and purging behaviors, and that about 42% of patients with restrictive anorexia eventually transition to disorders involving binge eating and purging.

More generally, up to 4% of females and 0.3% of males experience anorexia nervosa over the course of their lifetime, and so an even smaller percent would be expected to experience binge-purge type. Statistics, however, don’t always tell the full story of the severity and detrimental impact. “Even though these rates seem low at a glance, they still represent millions of people who are struggling with a very serious eating disorder,” Doyle says.

What are the symptoms of anorexia binge-purge subtype?

AN-BP is unique in that patients with this condition experience symptoms from several different eating disorder diagnoses at once. “The most common eating disorder symptoms co-occur with each other in anorexia binge-purge subtype,” says Doyle. “A person with AN-BP has at least two, but sometimes all three cardinal eating disorder behaviors: dietary restriction, binge eating, and purging.”

This combination of restrictive eating accompanied by binge and purge-related behaviors is the most characteristic sign of AN-BP. Here are some of the other most common symptoms of AN-BP

  • An intense fear of weight gain
  • A distorted perception of weight or body shape
  • An overemphasis of the importance of weight or body shape
  • Binge eating (consuming a lot of food quickly with a feeling of being out of control)
  • Self-induced vomiting
  • Misuse of laxatives or diuretics
  • Excessive exercise in order to “make up” for meals

You may be wondering what makes AN-BP different from other eating disorders with similar symptoms, like binge eating disorder and bulimia. Typically, a patient receives an AN-BP diagnosis when their symptoms and mindset more closely meet the anorexia nervosa diagnosis, even if they also exhibit the binge eating and purging behaviors characteristics of binge eating disorder or bulimia.

The role of the binge-restrict cycle

Most people with AN-BP experience something known as the binge-restrict cycle , where a period of restriction is followed by episodes of binge eating, which then triggers feelings of shame, in turn resulting in the desire to restrict (or purge) again. Doyle explains that this cycle is the body’s natural response to restricting food intake: “Restriction—even when it’s just eliminating one food group—takes us out of our body’s biological comfort zone. Our bodies know that we need consistent, well-rounded nutrition and it fights back with urges to binge.”

Because of that hard-wired survival mechanism, Doyle says that restricting food generally or certain foods specifically (unless medically necessary) is generally an unsafe and unhealthy tactic. “There are a lot of restrictive patterns that have been co-opted into the diet culture space that can do more harm than good,” she says. “This includes intermittent fasting , cleanses, elimination diets, carb cycling and so on.”

What does treatment for AN-BP look like?

As with all eating disorders, implementing swift, evidence-based treatment is the key to long-term recovery. “Effective treatment for AN-BP exists,” Doyle says. “ Enhanced cognitive behavioral therapy (also known as CBT-E) is a specific version of cognitive behavioral therapy specifically for eating disorders, and it’s the first treatment recommended to patients with AN-BP because of its strong evidence for helping the most people.”

Considered one of the most effective treatments for eating disorders, CBT-E can be used to treat a variety of eating disorders through a highly individualized plan that helps patients with:

  • Stopping binge and purge behaviors
  • Re-establishing regular eating habits
  • Confronting their distorted perceptions
  • Addressing their disordered thoughts and behaviors

“Stopping binge and purge behaviors can be a huge relief for someone struggling with AN-BP,” Doyle says. “CBT-E also focuses on the thoughts and feelings that drive the eating disorder behaviors so that the person can experience a life that is more and more symptom-free over time.

Like eating disorders themselves, each person struggling with disordered thoughts and behaviors is unique. While treatment approaches vary from person to person, experts agree that a multidisciplinary team as well as social supports, gives patients the best chances of achieving long-term recovery.

“At Equip, we offer CBT-E and our patients work with a team that includes a therapist, a dietitian, medical support, and mentorship by people who have lived experience with an eating disorder,” Doyle says. “Mentorship from someone who has been through something similar, especially for patients with lesser-known conditions like anorexia binge-purge, can provide a lot of much-needed hope.”

anorexia nervosa purging type

  • Eeden, Annelies E. van, Daphne van Hoeken, et al. 2021. “Incidence, Prevalence and Mortality of Anorexia Nervosa and Bulimia Nervosa.” Current Opinion in Psychiatry 34 (6): 515–24. https://doi.org/10.1097/yco.0000000000000739 .
  • “NIMH, Eating Disorders.” n.d. Www.nimh.nih.gov. https://www.nimh.nih.gov/health/topics/eating-disorders#:~:text=In%20the%20binge%2Dpurge%20subtype .
  • Peat, Christine, James E. Mitchell, et al. 2009. “Validity and Utility of Subtyping Anorexia Nervosa.” Edited by B. Timothy Walsh. International Journal of Eating Disorders 42 (7): 590–94. https://doi.org/10.1002/eat.20717 .
  • Serra, Riccardo, Chiara Di Nicolantonio, et al. 2021. “The Transition from Restrictive Anorexia Nervosa to Binging and Purging: A Systematic Review and Meta-Analysis.” Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, June. https://doi.org/10.1007/s40519-021-01226-0 .

anorexia nervosa purging type

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Purging Disorder vs. Bulimia Nervosa

What is purging disorder, characteristics.

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 vomiting, 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).

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, 5 th Edition (DSM-5). Rather, it is classified as an "Other Specified Feeding or Eating Disorder (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 shares many dimesnsions of pathology with some full-threshold ED diagnoses (i.e., AN, bulimia, and binge eating disorder), but is less severe than bulimia nervosa in most domains.

That said, people with purging disorder have significant morbidity and mortality.

Characteristics of purging behaviors can include:

  • Self-induced or forced vomiting
  • Misusing laxatives, diuretics, emetics, 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.

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

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.

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
  • Cardiovascular issues
  • Kidney problems

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 have a mortality rate of 5%.

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.

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.

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: 

  • The National Eating Disorders Association (NEDA) is a leading eating disorder nonprofit.
  • Alliance for Eating Disorders Awareness ("The Alliance") is a nonprofit organization providing programs and activities aimed at outreach, education, and early intervention for all eating disorders.
  • The National Association of Anorexia Nervosa and Associated Disorders, Inc. (ANAD ) is a nonprofit organization serving in areas of support, awareness, advocacy, referral, education, and prevention.

Smith KE, Crowther JH, Lavender JM. A review of purging disorder through meta-analysis. J Abnorm Psychol . 2017;126(5):565-592. doi:10.1037/abn0000243.x

National Eating Disorder Association. Other Specified Feeding and Eating Disorders.

Rohde P, Stice E, Marti CN. Development and predictive effects of eating disorder risk factors during adolescence: Implications for prevention efforts . Int J Eat Disord . 2015;(48)2:187-98. doi:10.1002/eat.22270.x

Mitchison D, Hay P. The epidemiology of eating disorders: genetic, environmental, and societal factors. Clin Epidemiol . 2014;6:89-97. doi:10.2147/CLEP.S40841.x

Koch, S., Quadflieg, N. & Fichter, M. Purging disorder: a pathway to death? A review of 11 cases. Eat Weight Disord . 2014;19, 21–29. doi:10.1007/s40519-013-0082-3.x

The National Eating Disorder Association. What to Expect From Treatment.

Avargues-Navarro ML, Borda-Mas M, Asuero-Fernández R, et al. Purging behaviors and therapeutic prognosis of women with eating disorders treated in a healthcare context . Int J Clin Health Psychol . 2017;17(2):120-127. doi:10.1016/j.ijchp.2017.03.002.x

Marvanova M, Gramith K. Role of antidepressants in the treatment of adults with anorexia nervosa. Ment Health Clin . 2018;8(3):127-137. doi:10.9740/mhc.2018.05.127.x

By Michelle Pugle Michelle Pugle, MA, MHFA is a freelance health writer as seen in Healthline, Health, Everyday Health, Psych Central, and Verywell.

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What is the restricting type of anorexia?

anorexia nervosa purging type

Anorexia nervosa (AN) is a serious eating disorder, which involves an intense fear of gaining weight, a distorted body image or perception of one's body weight, shape, or size, and, often, significantly low body weight.

To deal with their fear of gaining weight, people with AN use all types of maladaptive coping mechanisms. And while many people assume the weight loss involved with AN comes from severely limited diet or food intake, this is only one way the condition can manifest .

Restricting type AN often involves this limited diet, but the condition has a number of other distinctions.

anorexia nervosa purging type

Different types of anorexia nervosa

In fact, there are two main subtypes of anorexia nervosa:

  • Restricting type AN
  • Binge/purge type AN

Binge/purge anorexia nervosa is actually similar to bulimia nervosa (BN) or some types of binge eating disorder (BED). This subtype involves periods of binge eating, followed by the use of various purging methods, such as self-induced vomiting, as compensatory behavior. 1

Anorexia nervosa restricting type describes someone who restricts their food intake without binging and purging—or, more specifically, someone who engages in these restrictive behaviors without resorting to binging and purging in 3 months or more. 1

Instead, people who struggle with this restrictive food intake disorder will severely limit their diet or food intake, though sometimes people with restrictive type AN use other methods to limit the impact of food on their bodies, including laxative and enema misuse and excessive exercise. 1

  • Understand your anorexia treatment options
  • Side effects and health issues from anorexia
  • Can having anxiety cause someone to get anorexia?
  • What is ARFID?

Characteristics of anorexia nervosa, restricting type  

Individuals who meet the diagnostic criteria for anorexia nervosa of any type exhibit a fear of weight gain and disturbed eating and behavioral patterns connected to this fear.

What is different about anorexia nervosa restricting type is that people with this form of AN primarily prevent weight gain from restricting their food intake. They may engage in several other maladaptive behaviors, but they will not engage in binging and purging.

There may also be some other subtle differences in how this subtype presents. 

A 2016 study found that individuals with restrictive type anorexia nervosa tend to have a lower body mass index (BMI) and are less likely to use diet pills when compared with the binge/purge subtype. 2 Another study found that those who have the restricting subtype of AN are more likely to have medical complications related to being underweight, such as lower bone mineral density, liver problems, and low blood sugar levels. 3

Learn why body weight or body mass index isn't a good indication of how healthy you are. Learn more

The chronic under-eating, and accompanying significant weight loss, that occurs with restrictive type AN can also lead to malnutrition and a host of related health problems. 

Binging/purging vs. restrictive subtypes

Those with one type of AN don't necessarily always exhibit the symptoms of that type. It's also possible for individuals with anorexia nervosa to transition from one subtype to the other.

A study in the International Journal of Eating Disorders found that it is common for people to move from restrictive anorexia nervosa to the binge/purge type. And while the results showed that it is not as common for people to transition from the binge/purge to the restricting subtype, that change is certainly still possible. 4

One possible reason behind this is the hunger that can build from periods of chronic food restriction, driving people to binge in order to compensate.

A study in The Journal of Clinical Endocrinology & Metabolism found that individuals with AN restricting type tended to have higher levels of ghrelin, a hormone responsible for signaling hunger. 5 These increased ghrelin levels could lead to binging episodes, which could, in turn, be followed by a compensatory purging, eventually developing into a regular cycle and thus starting the transition to the binge/purge subtype.

Treatment for anorexia nervosa

Regardless of which subtype it presents as, anorexia nervosa requires treatment from a mental health professional to overcome.

In treatment for anorexia nervosa, someone can work through any underlying psychological issues that may be driving or maintaining an unhelpful eating pattern, learn ways to challenge unhealthy thinking patterns, and develop a healthier relationship with food and themselves.

If you’re living with AN restricting subtype, or another eating disorder, support is available. A team of treatment professionals can help you to move beyond the grips of the eating disorder and develop healthy patterns of eating that nourish your body and allow you to live a healthier, happier life. 

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Disclaimer about weight loss drugs: Within does not endorse the use of any weight loss drug or behavior and seeks to provide education on the insidious nature of diet culture. We understand the complex nature of disordered eating and eating disorders and strongly encourage anyone engaging in these behaviors to reach out for help as soon as possible. No statement should be taken as healthcare advice. All healthcare decisions should be made with your individual healthcare provider.

  • DSM-IV to DSM-5 Anorexia Nervosa Comparison . (2016, June). Substance Abuse and Mental Health Services Administration. Accessed June 2023.
  • Peterson, C. B., Pisetsky, E. M., Swanson, S. A., Crosby, R. D., Mitchell, J. E., Wonderlich, S. A., Le Grange, D., Hill, L., Powers, P., & Crow, S. J. (2016). Examining the utility of narrowing anorexia nervosa subtypes for adults . Comprehensive Psychiatry, 67 , 54–58.
  • Rylander, M., Brinton, J. T., Sabel, A. L., Mehler, P. S., & Gaudiana, J. L. (2017). A comparison of the metabolic complications and hospital course of severe anorexia nervosa by binge-purge and restricting subtypes . Eating Disorders: The Journal of Treatment & Prevention, 25 (4), 345-357.
  • Peat, C., Mitchell, J. E., Hoek, H. W., & Wonderlich, S. A. (2009). Validity and utility of subtyping anorexia nervosa . International Journal of Eating Disorders, 42 (7), 590-594.
  • Germain, N., Galusca, B., Grouselle, D., Frere, D., Billard, R., Epelbaum, J., & Estour, B. (2010). Ghrelin and obestatin circadian levels differentiate binging-purging from restrictive anorexia nervosa . The Journal of Clinical Endocrinology & Metabolism, 95 (6), 3057-3062.

Further reading

anorexia nervosa purging type

Do I have anorexia nervosa?

anorexia nervosa purging type

Fasting vs. anorexia

anorexia nervosa purging type

Self-help for anorexia nervosa

anorexia nervosa purging type

What interventions are effective for individuals with anorexia nervosa?

anorexia nervosa purging type

The similarities between anorexia nervosa and orthorexia

anorexia nervosa purging type

Examining ARFID vs. anorexia

Differences between anorexia and anorexia nervosa.

anorexia nervosa purging type

How anorexia nervosa affects your mental health

anorexia nervosa purging type

What is acute anorexia?

anorexia nervosa purging type

What causes anorexia nervosa?

anorexia nervosa purging type

What are the long term effects of anorexia nervosa?

anorexia nervosa purging type

The limitations of using BMI for anorexia diagnosis

anorexia nervosa purging type

The dangers of anorexiant diet pills

anorexia nervosa purging type

Signs you need treatment for anorexia nervosa

anorexia nervosa purging type

Signs and symptoms of anorexia nervosa

anorexia nervosa purging type

Is anorexia genetic?

anorexia nervosa purging type

Identifying anorexia risk factors

anorexia nervosa purging type

Is anorexia a disease?

anorexia nervosa purging type

How to help someone with anorexia nervosa

anorexia nervosa purging type

How does anorexia nervosa develop?

anorexia nervosa purging type

The hidden characteristics of anorexia nervosa

anorexia nervosa purging type

Harmful outcomes of the pro-ana movement

anorexia nervosa purging type

Examining the anorexia death rate

anorexia nervosa purging type

Early warning signs of anorexia nervosa

anorexia nervosa purging type

Can you have mild anorexia?

anorexia nervosa purging type

Can anorexia nervosa be cured?

anorexia nervosa purging type

Anorexia nervosa statistics: gender, race and socioeconomics

anorexia nervosa purging type

What is anorexia nervosa (AN)?

anorexia nervosa purging type

Anorexia in the transgender community

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A series of patients with purging type anorexia nervosa who do “tube vomiting”

Takeshi horie.

Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

Saki Harashima

Maiko hiraide, shuji inada, makoto otani, kazuhiro yoshiuchi.

It is important for clinicians to assess their patients’ purging behavior. Various methods of purging, such as self-induced vomiting are well-known. Because patients do not always report their purging behavior, knowing the clinical signs that indicate the behavior is useful. However, we have experienced patients who did not have the reported physical signs of self-induced vomiting because they used hoses instead of their fingers to purge their stomach contents, which they call “tube vomiting”. No other previous studies have reported the use of hoses as a purging tool.

Case presentation

We present as our main case a 20-year-old Japanese woman with anorexia nervosa who engaged in “tube vomiting.” Although she recovered well under medical treatment in our hospital, she began to lose weight and blood potassium soon after discharge. We found that she used a garden hose instead of her fingers to perform self-induced vomiting,. She inserted the hose into her stomach and evacuated the stomach contents through it, without pain. She learned this technique through a blog about eating disorders. We also present two other similar cases. In fact, many patients discuss “tube vomiting” on the internet.

Our experience suggests that a sudden decrease in the weight and blood potassium level could indicate “tube vomiting”. In addition, because many information resources are available on the internet, medical practitioners should be aware of these sites.

Purging is a significant problem for many patients with anorexia nervosa binge-eating/purging type (ANBP) and bulimia nervosa (BN). Patients who suffer from purging are not only difficult to treat but also experience a number of associated physical complications [ 1 ].

It is important for clinicians to assess patient purging behavior because the severity and prognosis of AN has been associated with the presence of purging [ 2 ]. It leads to complications such as a decrease of the serum potassium level. If purging is confirmed, the clinician should assess the method(s) used for purging to determine the course of treatment [ 3 – 5 ]. Previous studies have reported various methods of purging, such as self-induced vomiting, diet pills, laxatives, and diuretics; however, there is little information on the methods of self-induced vomiting, although there are some case reports about accidental ingestion of silverware and toothbrushes [ 5 ].

Because patients do not always report their purging behavior, clinical signs indicating the behavior are useful. A low potassium level, elevated amylase level, Russell’s sign, dental erosion, parotid gland hypertrophy, and hoarseness can be used as signs of self-induced vomiting [ 1 , 6 – 11 ]. However, we have treated patients who did not have the usual physical signs of self-induced vomiting because they used hoses instead of their fingers to purge the stomach contents, which they call “tube vomiting”. The English term “Tube vomiting” was coined by the authors because the method has not previously been mentioned in English. It is a translation of a term generally used on Japanese websites. It is based on the principle of gastric lavage, a technique used when a nasogastric tube is passed into the stomach for the removal of ingested toxic substances [ 12 ]. Because no previous studies have reported the use of hoses as a purging tool, we herein present three cases of patients who used hoses for purging. Case 1 is explained in detail because she was the first patient reporting to our department who did “tube vomiting”. Case 2 discovered the idea of “tube vomiting” on a TV drama. Case 3 began “tube vomiting” while under treatment. Although each case has different features, the critical parts are common.

A 20-year-old Japanese female with ANBP. She did not have any physical signs of self-induced vomiting, such as Russell’s sign or dental erosion. She introduced a garden hose into her stomach as a purging method.

She had her first menstruation at the age of 12 years. Her height and weight at that time were 146 cm and 43 kg (body mass index (BMI) 20.2 kg/m 2 ), respectively. At the age of 13 years, she started dietary restriction because she envied a well-shaped classmate. Soon, her weight decreased to 32 kg (BMI 15.0 kg/m 2 ) and menstruation stopped. The following year she was diagnosed with anorexia nervosa. With treatment at a local clinic, her weight returned to normal.

At the age of 15 years, while eating at a buffet with her friends she became concerned about a bulge in her abdomen and became overwhelmed with self-hatred. She remembered her sister telling her that a TV personality, who was famous as a big eater, did not gain weight because she practiced self-vomiting. That night she performed self-induced vomiting with her fingers for the first time. After that, she developed a habit of binge eating and self-induced vomiting. Although she began to see a psychiatrist at a university hospital, she could not stop this habit. At the age of 19 years, she came across a blog on “tube vomiting” written by a patient with an eating disorder. After reading it, she bought a garden hose that she inserted from her mouth into her stomach through which she easily evacuated almost all of the contents of her stomach. This led to sudden weight loss and a fall in her blood potassium level. At that time, she weighed only 30 kg (BMI 14.1 kg/m 2 ) and her blood potassium level was 2.0 mEq/L (reference values: 3.6-4.8 mEq/L), which led to her hospitalization at the university hospital. During that hospital stay, her weight gradually increased to 36 kg and symptoms improved through behavioral therapy with operant conditioning. She was discharged from the hospital eight weeks later. However, she did not inform her doctor of her use of a hose as a purging tool and resumed “tube vomiting” after being discharged.

At the age of 20 years, she moved to another area and visited our department at the University of Tokyo Hospital. She was admitted because her weight was 27.3 kg (BMI 12.8 kg/m 2 ) and her potassium and amylase levels were 2.0 mEq/L and 250 U/L (reference values: 44–132 U/L), respectively. No physical signs of self-induced vomiting, such as Russel’s sign, dental erosion, or swelling of the salivary glands, were observed.

During hospitalization, she was treated with behavioral therapy. She gradually increased her amount of the energy intake to 2,600 kcal per day, without self-induced vomiting. Five weeks later, her weight had increased to 32.0 kg, and she was discharged. However, she resumed binge eating and purging soon after the discharge. Twelve days later, her weight had decreased to 30.3 kg (BMI 12.6 kg/m 2 ) and her potassium level was 2.5 mEq/L; therefore, she was readmitted to the hospital.

Her doctor wondered why her weight and potassium had decreased so rapidly. At the first admission, we were not aware that she performed “tube vomiting” because she said that she had started vomiting using her fingers and then learned to vomit by only contracting her abdominal muscles. However, during her second admission to the hospital, she confessed that she used a garden hose (Fig.  1 ). The hose was made of vinyl chloride and was bought at an ordinary garden store. She inserted it from the mouth to the stomach by herself to evacuate the contents of her stomach.

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The hose actually used by Case 1 for “tube vomiting”

She was repeatedly hospitalized, and we persevered with her treatment. We determined a way to prevent her from buying and using hoses and taught her how to improve her eating habits so that she could lead a normal social life. Finally, she was able to consistently hold a job and stopped “tube vomiting”.

Case 2 was a 34-year-old Japanese female patient with ANBP. Her weight at admission was 37.4 kg (BMI 15.8 kg/m 2 ) and her potassium and amylase levels were 4.8 mEq/L and 125 U/L, respectively. Regarding the physical signs of self-induced vomiting, Russel’s sign was absent; however, dental erosion and swelling of the salivary glands were observed. The patient was married at the age of 23 years, and months later she started a diet due to psychological stress. She started binge eating and purging at the age of 28 years. At first, she did not explain her method of purging, but she told us the truth after we persisted in asking about the details. Whenever she felt she had eaten too much, she induced vomiting with her finger for the first eight months. One day, she was inspired to try a new way when watching a TV drama. The main character was a doctor who had his patient vomit a toxic substance through a hose, a process known as gastric lavage. She bought a silicone garden hose and began “tube vomiting” in her kitchen for about three hours once or twice a day.

Case 3 was a 21-year-old Japanese female patient with ANBP. Her age was 18 years at the onset of the disorder. Two and a half years later, she was determined to see a specialist for her eating disorder and visited our hospital. Her weight at admission was 31.8 kg (BMI 13.7 kg/m 2 ) and her potassium and amylase levels were 3.5 mEq/L and 80 U/L, respectively. Although she claimed never to have performed self-induced vomiting, Russel’s sign and swelling of the parotid glands were observed. After five weeks of inpatient treatment, she was discharged at a weight of 35.4 kg with a blood potassium level of 3.8 mEq/L, and a blood amylase level of 95 U/L. Although she gradually increased her body weight, she decided to binge-eat and searched for vomiting methods on the internet. She accessed the same website that Case 1 had found and bought a garden hose. During that period, she irregularly visited the hospital, and when she did visit she refused to allow us to measure her body weight. About three months later, she confessed that she had been “tube vomiting” five times per day and that she had been doing it for three months (six months after she was discharged). She was aware of the risks of vomiting using the tube, but could not stop.

We experienced patients with ANBP who used a hose as a purging tool, “tube vomiting”. No previous study has reported this method of purging. The patients began self-induced vomiting using their fingers, but they felt it very difficult to do. They found an easier way that used a garden hose and adopted it to induce vomiting, without experiencing any physical distress. Once they learned “tube vomiting”, they stopped using their fingers. A concern is that they did not seriously consider the possible physical risks, such as false insertion into the trachea or perforation of the esophagus.

The hoses used for self-induced vomiting were made of silicone or vinyl chloride. The outer diameter of the hose as recommended by the blog was approximately 12 mm, with an inner diameter of approximately 9 mm. Such hoses are readily available at ordinary garden centers throughout the world. Moreover, the price is low, approximately one dollar per meter. “Tube vomiting” is well known on the internet in Japan; however, no studies published in academic journals have reported it.

Our research on the internet found that the oldest record concerning the method of self-induced vomiting by a hose was on September 12, 2002 [ 13 ] and that the term “tube vomiting” first appeared on August 6, 2003 [ 14 ]. They were both written in Japanese; thus, “tube vomiting” has not become well known among researchers or clinicians.

The patients reported in the present study bought garden hoses at a neighborhood garden store. The method of vomiting using a nasogastric tube has also been introduced on the internet. In Japan, medical nasogastric tubes can be easily purchased online.

Unless we pay sufficient attention to detailed enquiry of patients regarding the method used for purging, such behavioral trends in purging method will not be identified because they are not always reported due to the associated shame. Because Russel’s sign, dental erosion, or physical signs are not obvious in some cases, we should suspect “tube vomiting” when there is a sudden decrease in the weight and blood potassium level of patients with eating disorders. We think that more of the stomach contents are discharged when using a tube than when using fingers, which could be the cause of the sudden decrease in weight and blood potassium level, although this is only a clinical impression. We would like to further investigate this in future studies.

After we experienced these cases, we began to carefully inquire of our patients the methods they used to induce vomiting. Only ANBP patients confessed to “tube vomiting”, but we cannot calculate an accurate rate because we were not able to get the required information from all patients. However, this is very important information, so further consideration will be needed. We would like to summarize and present more cases in the future.

There are several blogs and social networking services actively accessed by patients with eating disorders in Japan that contain information on “tube vomiting”. Unfortunately, patients have easy access to such information, but little or no understanding of the hazards. Few medical practitioners are aware of the content of these websites. Education about “tube vomiting” and its hazards will be important to combat this emerging problem.

On the internet, there are code words written in English, such as “Pro-Ana” (pro-anorexia) and “Pro-Mia” (pro-bulimia), and communities of people with eating disorders who support each other in staying anorexic or bulimic and refusing treatment [ 15 , 16 ]. “Tube vomiting” has not yet been mentioned in English on these websites, so it would be difficult for non Japanese to study the phenomenon. Because the problem could spread more widely in Japan and throughout the world, it is important to study this problem, provide educational programs to combat it, and to do preventive activities such as searching sites on portals such as Yahoo and Google to monitor this harmful information.

Acknowledgements

Not applicable.

There was no funding for the present case report.

Availability of data and supporting materials

There were no data available or supporting materials because the present manuscript was a case report.

Authors’ contributions

All authors were involved in the management of these patients and the preparation of the case reports. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

All study participants provided written informed consent for publication.

Ethics approval and consent to participate

Need for approval by the ethics committee was waived because the present manuscript was a case report.

Abbreviations

Contributor information.

Takeshi Horie, Email: [email protected] .

Saki Harashima, Email: [email protected] .

Ryo Yoneda, Email: pj.ca.nimu@ykt-adenoyr .

Maiko Hiraide, Email: moc.liamg@21ediarihokiam .

Shuji Inada, Email: pj.ca.nimu@ykt-adaniihs .

Makoto Otani, Email: pj.en.ebolgib.aum@inato-m .

Kazuhiro Yoshiuchi, Email: pj.ca.nimu@ykt-cuihsoyk .

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Am Fam Physician. 2024;109(2):185-187

Author disclosure: No relevant financial relationships.

Key Points for Practice

• Anorexia nervosa is best treated by monitored renourishment with psychotherapy. Most patients without worsening symptoms can receive outpatient treatment, especially with family support.

• Bulimia nervosa is best treated with CBT and fluoxetine, 60 mg daily.

• Binge-eating disorder is best treated with CBT or interpersonal psychotherapy with antidepressant medications or lisdexamfetamine when pharmacotherapy is indicated. Lisdexamfetamine has been studied mostly in patients who have obesity.

From the AFP Editors

Eating disorders affect nearly 2% of Americans during their lifetime and are more common in women and individuals in the LGBTQ+ community. Eating disorders commonly occur in patients with diabetes mellitus, depression, anxiety, post-traumatic stress disorder, substance use disorders, obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder, all of which increase mortality risk. These disorders can be difficult to recognize, and the American Psychiatric Association (APA) has released guidelines aimed to reduce the harm from eating disorders.

The U.S. Preventive Services Task Force reports insufficient evidence for routine screening for eating disorders in adolescents and adults. The American Academy of Pediatrics recommends asking all adolescents about eating patterns and body image. The APA recommends screening as part of an initial psychiatric evaluation.

People with eating disorders often lack insight into the presence or severity of disease, and physicians may overlook an eating disorder in patients with a normal body mass index. Single-question screening or the SCOFF questionnaire (two positive responses suggests an eating disorder) is recommended when there is not time for a formal screening questionnaire ( Table 1 ) .

Physicians should ask about maladaptive eating, including food changes and behaviors, eating rituals, binge eating, and purging. Patients with eating disorders often report abdominal discomfort with eating, constipation, early satiety, bloating, nausea, and heartburn, which are often signs of starvation and disordered eating rather than gastrointestinal disease. Menstrual irregularities are common with disordered eating.

Because patients often underreport symptoms, family members may notice concerning behaviors first. The degree of weight loss should be noted, based on growth-chart curves for children, because of risks of refeeding. Patients may have bradycardia, hypotension, or hypothermia. Physical examination may show proximal or temporal muscle wasting, ankle and pedal edema, lanugo hair, hair loss, dry skin, vitamin deficiencies, parotid gland enlargement, dental erosions, callouses on the dorsum of the hand, or evidence of self-injurious behaviors.

Laboratory analysis should include a complete blood count, electrolytes, liver enzymes, and renal function tests, but normal results do not necessarily exclude an eating disorder. Electrocardiography is recommended for all patients with restrictive eating disorder or severe purging behavior and in those taking medications known to prolong QTc intervals.

Most patients can be monitored with outpatient care, where they can remain with their families and continue with school or work. Careful monitoring should include an office weight check at least weekly after voiding and with shoes and outerwear removed. To ensure patients are not artificially increasing weight with water, checking urine-specific gravity should be considered. Patients with indications suggesting a worsening course should be moved to a higher level of care ( Table 2 ) .

Anorexia Nervosa

After medical stabilization in patients with anorexia nervosa, nutritional rehabilitation and weight restoration are critical components of treatment. If consistent weight increases can be maintained, outpatient weight restoration is appropriate with the support of family. A nurturing emotional environment is important for renourishment.

Individualized target weights should be established with the patient, despite likely patient hesitancy to accept this goal. An initial body mass index target of 20 kg per m 2 is often used for adults, whereas adolescent targets depend on growth-chart curves. Weight restoration normally takes several months, and a goal of gaining 1 to 2 lb per week is realistic in outpatient programs. Consultation with and direction from a registered dietitian are important during renourishment.

Refeeding syndrome is the most serious complication of renourishment and may present with rhabdomyolysis, hemolytic anemia, seizures, cardiac arrhythmias, and sudden death. Hypophosphatemia is a characteristic marker of refeeding syndrome. Initial calorie prescriptions of 1,500 to 2,000 kcal per day and eventual intake of 3,000 to 4,000 kcal per day are effective and do not appear to lead to refeeding syndrome.

Although changes in body shape and function during renourishment can be distressing for the patient, these can be offset by improvement in psychological complications of semi-starvation. Physical activity is important but may have to be limited early in renourishment and when compulsive exercise is an element of weight-control behaviors.

Medications do not aid weight gain. Selective serotonin reuptake inhibitors (SSRIs) are effective for psychological comorbidities but do not improve weight gain. Olanzapine (Zyprexa) may be helpful, but its effectiveness is limited by adverse effects. Bupropion and medications that prolong QTc intervals should be avoided if there are purging behaviors. Hormonal treatments do not appear to improve weight gain.

Psychotherapy can be moderately effective in normalizing eating and weight-control behaviors. Cognitive behavior therapy (CBT) focuses on cognitive distortions surrounding food and weight and implementing an experimental model of change. Enhanced CBT uses a more formalized, manual-based program. Focal psychodynamic therapy places a greater focus on relationships and insight rather than cognitions and behaviors. Supportive management by other health care professionals using workbooks and telephone coaching can be beneficial. For adolescents, family-based therapy involving caregiver education is recommended.

Bulimia Nervosa

For bulimia nervosa, eating disorder–focused CBT should be combined with an SSRI. Use of fluoxetine, 60 mg daily, has the most evidence, including in patients who have symptoms that do not improve with psychotherapy. Other SSRIs can be used if fluoxetine is not tolerated, but bupropion and citalopram should be avoided.

CBT can be delivered individually or in a group. Some evidence suggests that guided self-help using a manual or the internet can be helpful. Family-based therapy can be beneficial for adolescents or adults who live with a caregiver or family member who can participate in treatment.

Binge-Eating Disorder

Patients with binge-eating disorder can also benefit from therapy and medication. Antidepressant medications reduce binge eating even in the absence of depressive or anxiety symptoms. Lisdexamfetamine (Vyvanse) has been associated with modest short-term benefit in patients with binge-eating disorder who are obese. Topiramate can reduce binge eating but leads to more adverse effects than other medications.

Eating disorder–focused CBT and interpersonal psychotherapy are effective for binge-eating disorder. Interpersonal psychotherapy involves evaluating past and current symptoms and relating them to the patient's interpersonal and social context.

Guideline source: American Psychiatric Association

Published source: Crone C, Fochtmann LJ, Attia E, et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders. Fourth edition . American Psychiatric Association; 2023.

Available at:  https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424865

The views expressed are those of the author and do not necessarily reflect the official policy or position of the Naval Undersea Medical Institute, Uniformed Services University of the Health Sciences, U.S. Navy, U.S. Department of Defense, or U.S. government.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, associate medical editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide .

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