ABSTRACT
Objective
Few studies have examined differences in eating disorder (ED) and general psychopathology among those who self‐induce vomiting only compared to those who misuse laxatives only and those who engage in both types of behaviors. The current study aimed to fill this gap in the literature.
Method
Participants were 1652 adults receiving treatment for an ED at a large multisite treatment facility in the United States between January 2021 and December 2024. Participants completed measures of ED psychopathology (Eating Disorders Examination‐Questionnaire; EDE‐Q), depression (Patient Health Questionnaire‐9; PHQ‐9), anxiety (Generalized Anxiety Disorder‐7; GAD‐7), and obsessive‐compulsive symptoms (Obsessive‐Compulsive Inventory‐Revised; OCI‐R) at admission.
Results
Significant differences among groups were found on all EDE‐Q subscales and the Global score, with the laxative only group and the group engaging in both behaviors scoring significantly higher than the vomiting only group. A similar pattern of results was found for the PHQ‐9, while significant differences on the GAD‐7 and OCI‐R failed to remain significant after multiple comparison corrections.
Discussion
It is possible that those who misuse laxatives, or engage in both laxative misuse and vomiting, may benefit from more intensive treatment than those who engage in self‐induced vomiting only. These individuals may also need a different form of treatment if laxative misuse is conceptualized as an addiction.
Keywords: eating disorders, laxative misuse, multiple forms of purging, purging, self‐induced vomiting
Summary
Although differences in eating disorder (ED) pathology and personality have been found between individuals who primarily restrict their food intake and those who engage in purging behaviors, few studies have examined differences between individuals who engage in various forms of purging.
In terms of ED pathology, depression, anxiety, and obsessive‐compulsive symptoms, those who engaged in laxative misuse only and those who engaged in both laxative misuse and self‐induced vomiting scored worse on nearly all measures than the self‐induced vomiting only reference group.
Those who engage in laxative misuse or multiple forms of purging may need more intensive treatment, and possibly different forms of treatment than those who engage in self‐induced vomiting only.
1. Introduction
Self‐induced vomiting and laxative misuse are two common and dangerous forms of purging associated with eating disorders (EDs). A study among inpatients with EDs found that 57% reported engaging in some form of purging (Dalle Grave et al. 2009). Few studies have directly compared individuals who engage in self‐induced vomiting but not laxative misuse to those who misuse laxatives but do not vomit. Among a community sample of adult women, Mond et al. (2006) found few differences between those who engaged in vomiting and those who engaged in laxative misuse. A small group (N = 8 of 5255) who engaged in both purging behaviors had descriptively worse scores on many measures of ED psychopathology. Haedt et al. (2006) found no differences on ED symptoms between 116 undergraduate women who vomited, used laxatives, or engaged in both behaviors. A recent clinical study of 302 inpatients with EDs compared a group with no purging behaviors, those who vomited, those who misused laxatives, and those who engaged in both purging behaviors, on several ED and general psychopathology measures. Although significant differences were found between purging and non‐purging groups, no differences were found between the three purging groups (Panero et al. 2024).
Given limited research in this area, examining differences among those who self‐induce vomiting compared to those who misuse laxatives and those who engage in both behaviors is important. The purpose of the current study is to fill this gap in the literature. It was hypothesized that those who misused laxatives only and those who engaged in both purging behaviors (vomiting and laxatives) would score higher on measures of ED and general psychopathology than those who self‐induced vomiting only.
2. Method
2.1. Participants and Procedure
Participants were 1652 adults receiving treatment for an ED at a multisite treatment facility in the United States from 1/2021 to 12/2024. Participants were eligible for the study if they had a diagnosis of anorexia nervosa‐binge/purge subtype, bulimia nervosa, or other specified feeding or eating disorder, and had completed the Eating Disorder Examination‐Questionnaire (EDE‐Q) (Fairburn and Beglin 1994, 2008) at admission. Patients were included if they endorsed one or both EDE‐Q items #s16 and 17, which assess the frequency of self‐induced vomiting and laxative use, respectively. Patients were categorized according to purging method based on their answers to these two items. Diagnoses were made by masters' level clinicians using semi‐structured interviews based on DSM‐5 criteria (APA 2013). Clinicians complete > 20 onboarding trainings covering various aspects of EDs and comorbid diagnoses and participate in weekly group supervision and frequent additional trainings throughout the year. Patients were assigned treatment at one of four levels of care (LOC): inpatient, residential, partial hospitalization, or intensive outpatient programming. Self‐report measures were completed at admission and discharge, and informed consent was provided at admission. This study was approved by Salus Institutional Review Board.
2.2. Measures
The EDE‐Q (Fairburn and Beglin 1994, 2008) is a measure of ED psychopathology. Twenty‐two items are rated on a 7‐point scale, and six items assess the frequency of the behavioral features of EDs, including purging. The measure has four subscales, each of which has excellent internal consistency in the current sample: Restraint (α = 0.81), Eating Concern (α = 0.82), Shape Concern (α = 0.91), and Weight Concern (α = 0.87), and a Global Score (α = 0.93).
The Patient Health Questionnaire‐9 (PHQ‐9) (Kroenke et al. 2001) measures depressive symptoms. Nine items are measured on a 4‐point scale. Item 9 assesses suicidal ideation. Internal consistency in the current sample was good (α = 0.79).
The Generalized Anxiety Disorder‐7 (GAD‐7) (Spitzer et al. 2006) has seven items that are measured on a 4‐point scale. Internal consistency in the current sample was good (α = 0.77).
The Obsessive‐Compulsive Inventory‐Revised (OCI‐R) (Foa et al. 2002) is a measure of obsessive‐compulsive symptoms. Items are scored on a 5‐point scale. Internal consistency in the current sample was excellent (α = 0.85).
2.3. Statistical Analyses
Comparisons between types of purging groups (laxative only, vomit only, or both) and categorical variables were conducted with chi‐square tests of independence. For continuous variables, linear regression models were used with categorical purging group as the primary independent variable, with pairwise contrasts conducted between each purging group. Multivariate linear regressions included any demographic or clinical variables that were significantly different among purging groups. Standardized Beta weights are reported for effect sizes for all statistically significant results. Two sets of multiple comparison corrections were conducted (a more conservative Bonferroni correction with functional α = 0.0333; a less conservative Holm correction with functional α = 0.0167 to α = 0.0333; Aickin and Gensler 1996). Any comparisons where the uncorrected p value is statistically significant but the corrected p value fails to reach significance with either correction are noted. All analyses were conducted in R (version 4.3.3; R Core Team 2024).
3. Results
Table 1 presents demographic and clinical variables for each purging group (abbreviated here as the vomiting only group [V], the laxative only group [L], and the group using both purging behaviors [B]), and the groups combined. Age differed significantly among groups; the L group was older than the other two groups (β = 0.26, t = 3.29, p < 0.01). Birth sex, gender identity, and race/ethnicity were not significantly different among purging groups. ED diagnosis (χ 2 = 45.06, p < 0.001) and LOC (χ 2 = 45.12, p < 0.001) were significantly different among purging groups. For BMI, multiple regressions controlled for significant demographic and clinical covariates (age, ED diagnosis, and LOC). BMI was significantly lower in the L group compared to the V group (β = −0.28, t = −4.02, p < 0.001) and the B group (β = −0.24, t = −3.10, p < 0.01).
TABLE 1.
Demographic and clinical characteristics.
| Both (N = 413) | Lax only (N = 189) | Vomit only (N = 1050) | Overall (N = 1652) | |
|---|---|---|---|---|
| Age (M, SD) | 26.7 (9.28)a | 28.9 (11.20)b | 26.5 (8.92)a | 26.8 (9.33) |
| Female sex (N, %) | 386 (93.5%) | 176 (93.1%) | 966 (92.0%) | 1528 (92.5%) |
| Gender (N, %) | ||||
| Additional gender category or other | 4 (1.0%) | 3 (1.6%) | 9 (0.9%) | 16 (1.0%) |
| Choose not to disclose | 2 (0.5%) | 0 (0%) | 4 (0.4%) | 6 (0.4%) |
| Female | 355 (86.0%) | 162 (85.7%) | 874 (83.2%) | 1391 (84.2%) |
| Female‐to‐Male (FTM)/transgender male/trans Man | 9 (2.2%) | 4 (2.1%) | 21 (2.0%) | 34 (2.1%) |
| Genderqueer, neither exclusively male nor female | 6 (1.5%) | 3 (1.6%) | 19 (1.8%) | 28 (1.7%) |
| Male | 21 (5.1%) | 10 (5.3%) | 63 (6.0%) | 94 (5.7%) |
| Male‐to‐female (MTF)/transgender female/trans woman | 3 (0.7%) | 0 (0%) | 8 (0.8%) | 11 (0.7%) |
| Non‐binary | 13 (3.1%) | 7 (3.7%) | 52 (5.0%) | 72 (4.4%) |
| Race (N, %) | ||||
| Asian | 16 (3.9%) | 1 (0.5%) | 40 (3.8%) | 57 (3.5%) |
| Black or African American | 19 (4.6%) | 10 (5.3%) | 45 (4.3%) | 74 (4.5%) |
| Caucasian | 5 (1.2%) | 0 (0%) | 4 (0.4%) | 9 (0.5%) |
| Hispanic or Latino | 21 (5.1%) | 6 (3.2%) | 67 (6.4%) | 94 (5.7%) |
| Native Hawaiian or other Pacific Islander | 1 (0.2%) | 0 (0%) | 2 (0.2%) | 3 (0.2%) |
| Other | 16 (3.9%) | 2 (1.1%) | 33 (3.1%) | 51 (3.1%) |
| Unknown | 1 (0.2%) | 1 (0.5%) | 3 (0.3%) | 5 (0.3%) |
| White | 334 (80.9%) | 169 (89.4%) | 850 (81.0%) | 1353 (81.9%) |
| American Indian or Alaska Native | 0 (0%) | 0 (0%) | 6 (0.6%) | 6 (0.4%) |
| ED diagnosis (N, %) | ||||
| AN‐BP | 163 (39.5%) | 59 (31.2%) | 396 (37.7%) | 618 (37.4%) |
| BN | 76 (18.4%) | 9 (4.8%) | 222 (21.1%) | 307 (18.6%) |
| OSFED | 174 (42.1%) | 121 (64.0%) | 432 (41.1%) | 727 (44.0%) |
| Admission level of care (N, %) | ||||
| IOP | 31 (7.5%) | 27 (14.3%) | 143 (13.6%) | 201 (12.2%) |
| PHP | 61 (14.8%) | 52 (27.5%) | 271 (25.8%) | 384 (23.2%) |
| RES | 209 (50.6%) | 70 (37.0%) | 444 (42.3%) | 723 (43.8%) |
| IP | 112 (27.1%) | 40 (21.2%) | 192 (18.3%) | 344 (20.8%) |
| BMI (M, SD) | 24.52 (8.05)a | 23.71 (7.24)b | 25.0 (8.71)a | 24.7 (8.41) |
| EDE‐Q Global (M, SD) | 4.84 (0.91)a | 4.72 (0.94)a | 4.31 (1.17)b | 4.49 (1.11) |
| EDE‐Q restraint (M, SD) | 4.68 (1.43)a | 4.49 (1.42)a | 3.99 (1.71)b | 4.22 (1.64) |
| EDE‐Q eating concern (M, SD) | 4.16 (1.17)a | 3.98 (1.17)a | 3.67 (1.30)b | 3.83 (1.27) |
| EDE‐Q shape concern (M, SD) | 5.38 (0.88)a | 5.37 (0.88)a | 4.97 (1.22)b | 5.12 (1.13) |
| EDE‐Q weight concern (M, SD) | 5.13 (1.00)a | 5.05 (1.03)a | 4.60 (1.34)b | 4.79 (1.25) |
| PHQ‐9 (M, SD) | 19.09 (5.50)a | 18.18 (5.64) | 17.59 (6.08)b | 18.0 (5.92) |
| PHQ‐9 Item 9 (M, SD) | 1.09 (1.08) | 1.12 (1.08) | 1.05 (1.07) | 1.07 (1.08) |
| GAD‐7 (M, SD) | 15.30 (4.69)a, * | 15.41 (4.38)a, * | 14.13 (5.18)b, * | 14.63 (5.00) |
| OCI‐R (M, SD) | 26.22 (16.04)a, * | 25.83 (15.31)a, * | 22.94 (15.54)b, * | 24.1 (15.74) |
Note: Outcomes with any significant differences among purging groups are in bold. Groups with different superscript letters (i.e., a/b) represent significant different values, groups with the same superscript letter (i.e., a) are not significantly different from each other, and groups with no superscript value are not significantly different from any other group for each outcome, when controlling for age, ED diagnosis, and level of care.
Abbreviations: AN‐BP, anorexia nervosa‐binge/purge subtype; BN, bulimia nervosa; BMI, body mass index; EDE‐Q, eating disorder examination‐questionnaire; GAD‐7, Generalized Anxiety Disorder‐7; IP, inpatient; IOP, intensive outpatient program; OSFED, other specified feeding or eating disorder; OCI‐R, Obsessive‐Compulsive Inventory‐Revised; PHP, partial hospitalization program; PHQ‐9, Patient Health Questionnaire‐9; RES, residential.
Indicates significant group differences become nonsignificant when performing sample‐wide multiple comparison corrections across. Categorical variables were tested with Chi‐Square tests‐of‐independence.
Multiple regressions also controlled for age, ED diagnosis, and LOC for the remaining analyses. EDE‐Q Global score was significantly different between the V and L groups (β = 0.32, t = 4.17, p < 0.001), and the B group (β = 0.39, t = 7.07, p < 0.001), with the B group scoring the highest, followed by the L group and then the V group. EDE‐Q Restraint differed significantly between the V and L groups (β = 0.22, t = 2.93, p < 0.01), and the B group (β = 0.32, t = 5.85, p < 0.001), with the same pattern of results as the Global Score. EDE‐Q Eating Concern differed significantly between the V and L groups (β = 0.28, t = 3.55, p < 0.001), and the B group (β = 0.33, t = 5.74, p < 0.001) with the same pattern of results as the Global Score. EDE‐Q Shape Concern differed significantly between the V and L groups (β = 0.30, t = 3.84, p < 0.001), and the B group (β = 0.31, t = 5.55, p < 0.001) with the V group scoring lowest, and the L and B groups scoring similarly. EDE‐Q Weight Concern differed significantly between the V and L groups (β = 0.29, t = 3.75, p < 0.001), and the B group (β = 0.36, t = 6.41, p < 0.001), with a similar pattern as the Global Score.
PHQ‐9 scores were significantly different between the V and B groups (β = 0.17, t = 3.07, p < 0.01), with the V group scoring lower. There were no significant differences between patient groups in Item 9 suicidality. GAD‐7 scores were significantly different between the V and L groups (β = 0.20, t = 2.34, p = 0.02), and the B group (β = 0.16, t = 2.55, p = 0.01), with the V group scoring lower than the other two groups. Importantly, these GAD‐7 differences failed to reach statistical significance after both multiple comparison corrections. OCI‐R scores were significantly different between the V and L groups (β = 0.19, t = 2.35, p = 0.02), and the B group (β = 0.15, t = 2.59, p < 0.01), with the V group scoring lower than the other two groups. These group differences also failed to reach statistical significance after corrections.
4. Discussion
The current study examined differences in ED and general psychopathology among those who self‐induce vomiting only, those who misuse laxatives only, and those who engage in both behaviors. As hypothesized, significant differences among groups were found on all EDE‐Q subscales and the Global score, with the vomiting only group scoring lower than the other two groups, with primarily moderate effect sizes. Although somewhat consistent with findings that patients who engage in one method of purging have lower ED psychopathology scores than patients who engage in multiple purging methods (Dieffenbacher et al. 2025; Edler et al. 2007), our findings are in stark contrast to those of Panero et al. (2024), who did not find any differences on the EDE‐Q among inpatients who vomited, those who misused laxatives, and those who engaged in both behaviors. A possible explanation for the discrepant findings involves BMI. The BMIs for the purging groups in the Panero and colleagues' study ranged from 15.8 to 17.3, well below the BMIs for patients in the current study and consistent with BMI cutoffs for anorexia nervosa. It is possible that differences between groups were masked by the cognitive impact of low BMIs (Walton et al. 2022). Findings from this study are also in contrast to those of Haedt et al. (2006), although they had a smaller nonclinical sample and used a different measure to assess ED symptoms.
Those who vomited only endorsed less depression than the group who used both purging methods. Differences between purging groups on both anxiety and obsessive‐compulsive symptoms were not statistically significant after multiple comparison correction. However, since they were significant before correction, future research on these outcomes is warranted. Descriptively, mean scores largely followed the same pattern on measures of general psychopathology as they did on measures of ED symptoms, although with smaller effect sizes.
Self‐induced vomiting and laxative misuse are both associated with potentially life‐threatening medical sequelae, and both can be uncomfortable and even painful. The question arises as to whether pre‐existing conditions determine the method of purging chosen by a given individual, or whether the method of purging leads to more severe symptoms.
Individuals who misuse laxatives have been found to be more likely to have borderline personality disorder, self‐directed hostility, and higher impulsivity compared to those with EDs who do not misuse laxatives (Bruce et al. 2003; Bryant‐Waugh et al. 2006). Impulsivity is a personality trait (Huang et al. 2024) that would likely be well‐established before the onset of the ED, suggesting that there may be certain premorbid characteristics that could lead individuals to engage in this particular behavior. However, studies have also suggested that engaging in laxative misuse itself may result in more serious symptoms. Lengvenyte et al. (2022) found that current and lifetime laxative misuse were associated with a history of suicide attempts and current suicidal ideation, perhaps due to alterations in the gut‐brain axis that could increase suicidality. Although the current study did not find differences among purging groups on suicidal ideation, it is possible that laxative misuse itself could cause more severe symptoms. Longitudinal and possibly qualitative studies are needed to determine the choice of purging method made by an individual at the onset of this behavior, which factors lead to the decision to engage in multiple forms of purging, and how purging behaviors may develop over time.
Regarding clinical implications, it is possible that individuals who misuse laxatives may benefit from more intensive treatment, or a different form of treatment than those who engage in self‐induced vomiting only. Those who use stimulant laxatives have been found to score higher on novelty‐seeking than those who engage in other forms of purging (Gibson et al. 2021). The authors suggest that this type of purging may be considered an addiction, which would entail a form of treatment that is likely different from most ED programs. Mindfulness training has been suggested as an option for addressing the impulsive nature of substance use disorders (Staiger et al. 2007). Those who misuse laxatives may benefit from learning mindfulness techniques to stop the impulsive nature of purging behaviors. This, too, represents an important area for future research.
Limitations of the study include its cross‐sectional nature and, as with many ED studies, the sample is primarily female and white. Additionally, the study was not able to focus on other forms of purging, such as diuretic misuse, due to the decision to use the EDE‐Q to assess purging. Strengths include a large and regionally diverse sample size, increasing generalizability.
The current study extends the limited research on patients who engage in different purging behaviors. Those who self‐induce vomiting generally scored lowest on ED and general psychopathology, followed by those who misuse laxatives, and then those who engage in both behaviors. Further research is needed to determine whether different forms of treatment are needed for different forms of purging.
Author Contributions
Renee D. Rienecke: conceptualization, writing – original draft. Dan V. Blalock: formal analysis, visualization, writing – original draft. Alan Duffy: data curation, writing – review and editing. Timothy D. Brewerton: writing – review and editing. Thomas Joiner: writing – review and editing. Jamie Manwaring: writing – review and editing. Philip S. Mehler: writing – review and editing.
Lived Experience Involvement Statement
No specific efforts were undertaken to involve persons with lived experience in the study design or execution, or in the preparation of this manuscript.
Funding
This research received no specific grant from any funding agency, commercial or not‐for‐profit sectors. Dr. Dan V. Blalock is supported by Career Development Award 19–035 (IK2HX003085‐01A2) from the United States Department of Veterans Affairs Health Services Research and Development (HSR&D) Service.
Ethics Statement
This study was approved by Salus Institutional Review Board.
Consent
Adult patients provided informed consent.
Conflicts of Interest
Dr. Renee D. Rienecke receives consulting fees from the Training Institute for Child and Adolescent Eating Disorders LLC, and receives royalties from Routledge and Hachette Book Group Inc. The other authors declare no conflicts of interest.
Acknowledgments
AI was not used in the study design, study execution, or manuscript preparation.
Rienecke, R. D. , Blalock D. V., Duffy A., et al. 2026. “Differences Among Purging Presentations at Admission to Treatment: Eating Disorder and General Psychopathology Symptoms.” International Journal of Eating Disorders 59, no. 8: 1794–1799. 10.1002/eat.70114.
Action Editor: Timothy Walsh
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.