Yes, many people with anorexia nervosa do purge. While anorexia is most commonly associated with severe food restriction, roughly 1 in 5 people diagnosed with the condition regularly purge at least once a week. The diagnostic manual used by mental health professionals actually defines two distinct subtypes of anorexia: the restricting type, which involves limiting food intake without purging, and the binge-eating/purging type, which includes regular purging behavior.
The Two Subtypes of Anorexia
The DSM-5, the standard reference for psychiatric diagnoses, splits anorexia nervosa into two categories based on what behaviors a person has used during the last three months. The restricting type applies when someone has not regularly engaged in binge eating or purging. The binge-eating/purging type applies when they have. Both subtypes share the same core features: significantly low body weight, an intense fear of gaining weight, and a distorted perception of body size or shape.
This distinction matters because people often assume anorexia means only starving yourself. In reality, someone with anorexia can alternate between periods of restriction and episodes of purging, or they may purge even small amounts of food that wouldn’t qualify as a binge. The key difference between this subtype and bulimia nervosa is body weight. A person with anorexia who purges is at a significantly low weight, while someone with bulimia typically maintains a weight in or above the normal range.
What Purging Looks Like in Anorexia
Purging in anorexia involves the same behaviors seen in bulimia: self-induced vomiting, misuse of laxatives, misuse of diuretics (water pills), and use of enemas. Some people rely on one method exclusively, while others cycle through several. The goal is always the same: to rid the body of calories that have been consumed, driven by an overwhelming fear of weight gain.
Excessive exercise occupies a complicated space in this picture. It has never been included as an official diagnostic criterion for anorexia in either the DSM or the international classification systems, even though it is extremely common among people with the disorder. Clinically, compulsive exercise functions much like purging, as it’s used to “cancel out” food intake. But because exercise is generally viewed as healthy, it can make early signs of anorexia easier to overlook, especially when vomiting or laxative use isn’t present. Someone exercising for hours a day to compensate for eating may not raise alarm bells the way other purging behaviors would.
How Common Is Purging in Anorexia?
A retrospective study of 339 patients with anorexia nervosa found that 22% engaged in purging behavior at least once a week during the preceding three months. That’s a significant minority. In treatment and research settings, the binge-eating/purging subtype actually outnumbers the restricting subtype in many study populations. One longitudinal study tracking long-term outcomes included 51 participants with the restricting subtype compared to 85 with the binge/purge subtype, suggesting the purging presentation is far from rare.
People can also shift between subtypes over the course of their illness. Someone who starts out purely restricting food may develop purging behaviors months or years later, and vice versa. This fluidity is one reason clinicians reassess the subtype based on the most recent three-month window rather than assigning a permanent label.
Physical Signs of Purging
Purging in the context of anorexia is especially dangerous because it compounds the risks of an already malnourished body. When someone who is severely underweight also vomits regularly or misuses laxatives, the strain on the heart and kidneys intensifies. Purging depletes electrolytes like potassium and sodium, which are critical for keeping the heart beating in a normal rhythm. In a body that is already depleted from inadequate nutrition, these shifts can become life-threatening more quickly.
Visible signs that someone may be purging include swollen glands along the jawline, damaged or discolored tooth enamel from repeated exposure to stomach acid, calluses or scars on the knuckles from inducing vomiting (sometimes called Russell’s sign), and frequent complaints of sore throat or acid reflux. Laxative misuse can cause chronic constipation, bloating, and abdominal cramping, which paradoxically may reinforce the cycle by making the person feel “full” and more desperate to purge.
Why the Distinction Matters for Treatment
The presence of purging in anorexia changes the treatment picture. Purging behaviors carry their own medical risks that need monitoring, particularly electrolyte imbalances and damage to the esophagus and digestive system. Someone with the binge/purge subtype may also be dealing with a different psychological profile, including higher levels of impulsivity and emotional dysregulation compared to those with the restricting type.
The most well-supported therapies for anorexia in adults include Enhanced Cognitive Behavioral Therapy (CBT-E), which directly targets the thought patterns and behaviors driving both restriction and purging. Other approaches with evidence behind them include Specialist Supportive Clinical Management and the Maudsley Anorexia Nervosa Treatment for Adults. For people whose purging is closely tied to difficulty managing emotions, dialectical behavioral therapy and acceptance and commitment therapy have also been used. Treatment typically addresses both the weight restoration component and the purging behaviors simultaneously, since tackling only one without the other tends to leave the door open for relapse.
The bottom line is that anorexia and purging are not mutually exclusive. Thinking of anorexia as “just not eating” misses a significant portion of people living with the disorder and can delay recognition of behaviors that carry serious, sometimes fatal, medical consequences.