Melanie D'Andrea, Manager of Clinical Partnerships at Equip, experienced an eating disorder for the first time after going through a break-up at 18. D’Andrea began purging, a hallmark symptom of bulimia that involves “getting rid” of food after consuming a large quantity of it (aka ‘bingeing’). But while bulimia is often stereotyped as an illness that involves one very specific type of purging — vomiting — D’Andrea’s symptoms included a different, but equally dangerous behavior.

“My purging came in the form of compulsive exercise,” she says. What began as an interest in yoga and treadmill running eventually spiraled into an obsession that consumed D’Andrea day and night. “I started tracking calories in and calories out, using exercise as a form of punishment for eating ‘poorly,’ and making sure to ‘burn off’ every cookie or Frappuccino I consumed.”

Over time, D’Andrea discovered another way to achieve the “empty” feeling she craved: laxatives. “It began in small doses but quickly escalated to taking large volumes daily, ” she says. “Laxatives, along with compulsive exercise, became my daily habits. Eventually, the laxative abuse meant I could no longer exercise due to lack of energy, inability to run without needing to use the restroom, and increasing depression.”

D’Andrea’s experience illustrates an important, but widely unknown fact about bulimia: it doesn’t always involve vomiting. So what is purging? While it can commonly take the form of vomiting after meals, it can also appear as laxative or diuretic abuse, excessive exercise, compensatory restriction, and more—and all these forms of purging can be just as serious and dangerous. Here’s what everyone should know about the realities of bulimia, the different forms of purging, and why anyone struggling with any of these behaviors deserves care.

What is purging?

Bulimia is characterized by the uncontrollable consumption of large amounts of food (bingeing), followed by purging methods to get rid of the food, which can manifest in a variety of different ways.

“Purging is the intentional act of compensating for calories,” says Equip Psychotherapist Hannah Bishop, LPC. “The stereotype for what is purging is recognized as vomiting, but that doesn’t mean other behaviors can’t fall into this definition."

What are the different types of purging?

Oftentimes, bulimia patients will experience a combination of multiple purging behaviors. Here’s what you should know about the types of purging and their dangers.

Self-induced vomiting

Vomiting in an effort to expel “excess” food is a very common behavior in bulimia patients. One study found that 56% of bulimia patients experienced self-induced vomiting at least once per day. A common sign of this behavior is frequent trips to the bathroom after meals and medical complications including:

• Stomach rupture
• Heart and kidney problem
• Dental problems including stained teeth, tooth erosion, and cavities
• Irregular menstrual periods
• Inflamed esophagus

Self-induced vomiting is a very serious purging behavior in itself, and can become even more serious when combined with other forms of purging.

Excessive exercise

As D’Andrea experienced, purging can often appear in the form of compulsive exercise (some people refer to this as “exercise bulimia” or “exercise addiction”). According to research, “problematic exercise” — which can be characterized by intense preoccupation and compulsivity around exercise and using exercise for weight regulation — occurs in about 55% of bulimia patients.

Just because compulsive exercise is often lauded as an admirable achievement doesn’t mean it’s in any way safe. “I struggled with compulsive exercise and would often receive many compliments on my ‘determination,’ which would fuel the eating disorder,” Bishop says.

Overexercising can result in everything from fatigue and depression to overuse injuries and the loss of menstrual periods. “Exercising seems so normalized in today’s society, but the ‘why’ behind it is what matters,” Equip Peer Mentor Gabrielle Terzano says. “If you’re using exercise to compensate for what you ate, then it may be a sign that you’re using exercise to purge.”

Misuse of laxatives, diuretics (water pills), or diet pills

Many people with bulimia misuse various medications and pills in an effort to purge. Not only is this practice ineffective for weight loss, it’s also highly dangerous. Laxatives artificially stimulate the large intestine to empty, but most calories are actually absorbed before food reaches this part of the digestive system. The "weight" that's lost from laxatives, diuretics, or diet pills is most often a combination of water, electrolytes, minerals, indigestible fiber, and colon waste.

Studies suggest that anywhere from 10-60% of people in the U.S. with eating disorders have ever misused laxatives. The medical problems associated with laxative abuse is a long list, including electrolyte imbalances and changes to the body’s pH levels that could result in potentially lethal kidney and cardiovascular complications.

Eating very little or not at all (fasting or compensatory restriction)

While food restriction is often exclusively associated with anorexia, it’s a symptom that’s common to all eating disorders — including bulimia. In most cases, the binges that are characteristic of bulimia are preceded by periods of restriction. The resulting biological hunger from that restriction can trigger a binge and make the person feel they’ve lost control. This combination often leads people to restrict after binges in an attempt to “make up” for the episode, but the restriction only perpetuates the harmful cycle.

Insulin misuse/mismanagement

Insulin misuse/mismanagement, also sometimes called “diabulimia,” is a form of purging specific to people with diabetes. Research has indicated that some people with Type 1 diabetes (T1D1) may restrict or use extra insulin as a form of purging. Insulin by itself doesn’t affect weight: when someone with T1D1 correctly manages their condition with insulin their weight isn't affected, but research has shown that up to 40% of young people assigned female at birth and 10% of young people assigned male at birth with T1D take less insulin than they need in an effort to lose weight. The negative effects of insulin mismanagement include severe dehydration, serious infections, eye damage, cardiovascular, kidney, and liver disease, and much more.

How to help yourself or someone you know who struggles with purging

Everyone who struggles with any type of purging deserves immediate, effective support — period. It’s important that you or your loved one seek out specialized treatment where providers are educated on the complexities of bulimia and the variety of ways it can show up in patients.

It’s also important to note that if someone is exhibiting purging behaviors but not episodes of bingeing, they may fit the criteria for purging disorder, a sub-type of Other Specified Feeding and Eating Disorder (OSFED.) It’s important to seek out a provider who will listen carefully to your symptoms and give you a proper diagnosis.

Urge surfing technique

In bulimia treatment, patients learn various coping skills that can help replace or resist the urge to engage in purging behaviors. One example Terzano encourages patients to explore is called “urge surfing,” and describes a technique used to avoid acting on harmful behaviors. “If you feel the urge to purge, set a timer for ten minutes before you act on it,” she says. “Even if you do end up going through with the behavior, it’s still progress if you’re able to delay it! And then do this over and over again because repetition is key.”

Therapy

Therapy can also be a key to recovering from purging behaviors. Using modalities like CBT-E and DBT, a therapist can help a patient unpack the underlying issues that may have caused them to begin the binge and purge cycle in the first place, and create a plan on how to break it. In fact, CBT-E is proven to be most effective when treating bulimia.

Like other eating disorders, relapse can be a common part of the recovery journey. Terzano wants all patients and their loved ones to know that relapse isn't equivalent to failure. “It can take time to completely stop the behavior and even more time for the urges to stop completely,” she says. “Oftentimes when we feel stressed, we want to turn to a behavior that will make us feel better in the moment. Purging may give you instant satisfaction and gratification, but it won’t help in the long-term.”

Equip is a virtual eating disorder program where patients work with a 5-person care team specialized in using CBT-E and other evidence-based modalities to treat bulimia. These providers work together to help the patient understand and combat their unique purging behaviors. Schedule a free consultation to learn more.