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Eye on Psi Chi: Spring 2015

Purging Disorder
and Other Eating Disorders
With Pamela K. Keel, PhD

Bradley Cannon, Psi Chi Writer

This article was written shortly after Dr. Pamela K. Keel's Psi Chi Distinguished Lecture at SWPA 2015 in Wichita, KS.
When you imagine someone with an eating disorder, you probably picture an extremely over- or underweight individual. The person you envision may also have unhealthy eating habits such as binge eating or food purging via self-induced vomiting or the misuse of diet aids or laxatives. However, what about individuals of average weight who don’t binge eat but do have dangerous purging habits that negatively affect their health in the present and future?
Dr. Pamela K. Keel from Florida State University has dedicated a large part of her professional career to recognize and better understand this group of people who suffer from what is referred to as purging disorder (PD). According to Dr. Keel, PD is an eating disorder that shares characteristics with both anorexia nervosa (AN) and bulimia nervosa (BN) in that individuals who have PD experience concern with weight and shape, and often feel intense fear of gaining weight or becoming fat. They may place a great deal of importance in terms of how they feel about themselves as people based on their overall figure. This causes them to perceive food as something that might make them fat or change their shape.
Who Is Most Likely to Have an Eating Disorder?
Florida blue sky and white fluffy clouds do not stop Dr. Keel from scheduling 45 minutes to speak with us about the characteristics and dangers of PD and other eating disorders. Sitting in her relatively new office overlooking the university’s Mike Long Track, she says, “Eating disorders are severe forms of mental illness, and many people do not realize that, among all mental disorders, eating disorders are associated with one of the highest risks of death. A recent study out of Germany looked at five-year outcome in PD, AN, and BN (Koch, Quadflieg, & Fichter, 2013). One of the startling findings was that 1 out of 20 of the patients with PD had died before the 5-year follow-up! This death rate was significantly higher than observed for BN. It did not significantly differ from AN, but it was also descriptively a little higher than what was observed for AN. Those findings would need to be replicated, but it would seem that PD is associated with an increased risk of premature death like other eating disorders.”
Purging disorder may cause dehydration, electrolyte imbalances, low blood pressure, heart arrhythmia, broken blood vessels in the eyes, and numerous other negative side effects. When asked why people engage in purging despite these risks, Dr. Keel explains that no one thing leads to an eating disorder. She briefly describes the three main influencing factors below.
Culture. “Imagine someone who is born female in a culture that idealizes thinness, has large quantities of highly palatable food, and has lots of encouragement to indulge in eating that food. However, the same culture also says that the person has to be thin in order to be beautiful—and not just beautiful, but also acceptable and liked and successful in a very broad way. Beauty has been idealized, not just in terms of appearance, but in terms of how people are viewed as human beings.”
Psychological features. “The same individual may also be psychologically perfectionistic, more inclined to strive for those cultural ideals, and also characterized by higher levels of negative affect. Thus, they may be particularly prone to try to find a way to feel better about their lives. In terms of personality features, they may also be more likely to have problems with negative urgency, the tendency to react in ways that are potentially self-destructive when feeling unhappy. If they experience increases in negative affect, they may be less likely to keep food that they have eaten down.”
Biological makeup. “On top of this, the individual may have features that influence how they physically feel when they eat. In other words, eating may make them feel really uncomfortable because of how their bodies respond to food in a way that other people’s bodies don’t. Individuals with PD express feeling excessively full, bloated, and an increased desire to vomit. That may also contribute to the propensity to purge after eating a normal or small amount of food.”

As Dr. Keel reemphasizes, “If you imagine all of these factors working together, you can appreciate why it would be incredibly hard to just stop engaging in the behavior even with the costs being as high as they are. In fact, when you think about how high the costs are to continue purging, you know there’s got to be a lot there maintaining it.”
Why Official Recognition of PD Matters
Despite the severity of PD, many people have still never heard of it. One reason for this is that the term has only recently been listed as an Other Specified Feeding or Eating Disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013. To describe the importance of having a disorder officially recognized, Dr. Keel uses the example of how binge eating disorder (BED) research increased after it was added in the DSM-IV in 1994. “BED was first introduced into the literature by Albert Stunkard in 1959 to describe a subset of individuals presenting for obesity treatments and characterized by having large, out-of-control binge eating episodes. These individuals didn’t do anything to compensate for their eating, so in many ways, it looked like they were the opposite of anorexia nervosa. A search of PsycARTICLES from 1959 to 1994 reveals only 15 publications on BED. However, if you look from 1994 (when BED was listed in the DSM-IV) to around April or May of 2013 (when the DSM-V came out), you will find more than 850 published works.”
“That’s clearly a dramatic increase in research on BED, and many of those studies looked at treatments in terms of using cognitive behavioral therapy, interpersonal therapy, and antidepressant medication; it turns out each can be helpful to individuals with BED. This is very compelling evidence from recent history that (a) getting something officially recognized impacts what we focus on as researchers, and (b) what we focus on as researchers impacts our knowledge, which then impacts our ability to help people who suffer from these problems.”
Dr. Keel has encountered individuals with PD when she was a clinical fellow at Massachusetts General Hospital and via her eating disorder research. She has also been contacted by people who found out about her research online. Through these communications, an additional reason becomes clear about why it is essential that PD be officially listed in the DSM. “In one e-mail,” Dr. Keel recounts, “I remember a woman describing that she had struggled with trying to understand if she had an eating disorder because she hadn’t seen a match between herself and the descriptions for AN and BN.” Incredibly, this woman had been telling herself that maybe she didn’t have an eating disorder because she was not starving herself or having binge eating episodes. She might not have kept researching and found out that she had a problem at all if she had not been frightened because she had noticed that she often vomited blood.
Future Treatments for PD
In preparation for this interview, Dr. Keel went online to see what was currently funded in terms of eating disorder treatment studies through the National Institute of Mental Health. Although she did find some treatment trials for AN, BED, and for more broadly defined eating disorders, she located nothing currently in the works for PD.
This absence of current treatment trials probably delays the timeline for specific PD treatments, which is especially disheartening considering the individuals whose lives may depend on it. Fortunately, Dr. Keel is not one to become discouraged. When asked what future treatments might look like, she says, “My guess is that people would start with approaches that have demonstrated efficacy for AN and BN because PD does share some features in common. For adolescents, family-based treatments may be useful. For late adolescents and adults, cognitive behavioral therapy may be useful. However, the key is to actually test these questions empirically, rather than assuming that things will work, regardless of clinical presentation.”
Indeed, Dr. Keel is quick to mention that it is important to never skip steps in the research process. She says, “To be a scientist, you have to be incredibly patient. You have to be really good at paying attention to your long-term objective because not a lot is gained by investing time and resources in trying to develop a treatment before you have a good understanding of the maintaining factors of an illness.”
The Path to Eating Disorder Research
Dr. Keel’s enthusiastic attitude does not reflect unseasonedness, but rather her longstanding perseverance to understand eating disorders. In fact, she first became interested in this topic during her sophomore year in college when she was an anthropology major who happened to take a psychology elective on eating disorders. “I found myself not just doing the required reading, but also doing the recommended reading. Then, I found myself talking to people in the dining hall about the reading. When I ran out of things to read, I went out and found new things, and I had a sense that this is probably how I should feel about something that I would want to spend a career on. Being drawn to something at that level was a new experience for me.”
According to Dr. Keel, one influence that contributed to her success is the fact that she had multiple mentors throughout her education and professional life. “I went to the North Carolina School of Science and Math, which is a public residential high school. Even back then, I would go and talk to one of my instructors, Dr. Steve Warshaw, during office hours on a regular basis. Sometimes we would talk about the class and about what I wanted to do professionally. When I took Intro to Psychology in my junior year at college, I met with Dr. Todd Heatherton during office hours, took a research assistant position with him in my senior year, and helped him with a large study. When I went to the University of Minnesota, my number of mentors increased even more. They included my graduate advisor Dr. Gloria Leon, Drs. William Grove and Bill Iacona in the clinical program, as well as Jim Mitchell and Scott Crow in the department of psychiatry.”
“No one person can give you everything you need. What is really effective is to identify the people who are really good in areas that you need mentorship in, and then work with them to receive guidance in those areas. Go to different people for your different mentorship needs. That’s something I continue to do. As you get further along in your career, you will kind of shift more toward peer mentorship where you learn from people of your same age group. At some level, you also learn from people who are younger than you too.” Dr. Keel pauses to laugh. “That’s one of the things that happens as you get older: You have to be more flexible about who you learn from!”
Dr. Keel hopes that future psychologists will become involved in PD research, especially those with expertise in treatment research. In order to inspire and support future researchers, she provides the following advice to students. “The first step to get engaged in research is to read so that you will have an understanding of what’s been done, what’s already known, and what questions remain unanswered for a topic thatyou are excited about. Identify a faculty member who shares your interests and go to them with those important questions that haven’t been answered yet to see if there is an opportunity. This may involve adding to a study that they are already doing or developing your own study, whether it be an independent research project or a senior honors thesis. Think about the ways that you can actively become a part of doing research. Then, do the study, collect the data, and write up your results. That’s how I got started, and that’s how the students I have worked with got started too.”
Ask an Expert: Dr. Keel Discusses Eating Disorders
How do you know if you have an eating disorder?
“Don’t rely on matching yourself to the diagnostic criteria in the DSM. They’re too narrow, and it becomes too easy to not meet criteria for AN, BN, or BED. Instead, pay attention to whether your eating patterns are causing you distress. Are you distressed about your eating? Do your eating patterns interfere with your ability to fulfill a major role in your life? Do they inhibit your work as a student or at your job? Do they hinder your friendships or relationships with family members? Also pay attention to your physical health. Are your eating patterns in some way hurting you physically? If any of these things are true, that is evidence that you have an eating disorder.”
If you recognize someone with a disorder, when is it appropriate to say something?
“It is difficult to give one answer that is context free on this one. In many ways, it depends on the nature of your relationship with the person. If you are a close friend or relative, you don’t want to ignore the problem or pretend that everything is okay. It is appropriate to express concern toward someone you care about when you see them struggling. But you also want to approach in a nonjudgemental and information-seeking way, rather than making up your mind that you know what is going on. You want to start with a statement such as ‘I feel concerned because this is what I am seeing. What do you think is going on?’ In other words, let the person talk to you.”
“You also want to be available as a source of support. You want to reinforce how their well-being is most important to you and that you want to be supportive to them in doing what they can to be as healthy and happy as possible. You want to offer to be available to them to think about options and problem-solve around those options, but you don’t want to put yourself into a position of feeling like it is your responsibility to treat them. You already have an important relationship with this person, important enough that you would bring up this really difficult topic with them. You need to protect that relationship. You can’t try to be the person’s therapist. Instead, you want to support them in getting the help that they need.”
What tactics should you avoid when talking to someone about their eating disorder?
“Don’t be the food police. Don’t be the person monitoring whether they are eating the way that you think they should be eating. That will likely create a very bad dynamic in which the person avoids being around you and feels defensive and awkward, which will make their relationship with food harder than it already is.”
"The other thing is to be very self-aware of your behavior around your own eating and around conversations you have about weight and shape. Concerns about weight and shape are so ubiquitous that it is really normative for people to engage in fat-talk, which is where people make self-denigrating statements about their weight, shape, or eating. Those kinds of statements can be very confusing to someone struggling with an eating disorder. On the one hand, the person hears that you are concerned about their eating and that you want them to be healthy, and yet they also hear you express concerns about being too fat. That sort of mixed message is kind of like saying ‘I don’t want you to be concerned about being too fat, but now I’m going to talk about my concerns about being too fat.’ Instead, really try to think about how you interact with food and how you manage your own body image.”
What encouragements would you offer to someone with an eating disorder?
“I think the first thing I would say is that, across studies, there is reasonably good evidence that getting any form of treatment is better than getting none. It is worth the time, money, energy, and effort to go ahead and look into available resources to get help because, in general, something is better than nothing. Then, depending on the kind of eating disorder that you have, there are some very good specific treatments that can help you get better. An individual who might have been struggling with an eating disorder for years may be able to get treatment and, within months, be completely remitted. Most people who achieve remission from an eating disorder actually maintain that remission and do so over long periods of time. There really is an opportunity to do something about an eating disorder.”

Koch, S., Quadflieg, N., & Fichter, M. (2013). Purging disorder: A comparison to established eating disorders with purging behavior. European Eating Disorders Review, 21, 265–275. doi:10.1002/erv.2231

Pamela K. Keel, PhD, is a professor of psychology and director of the Eating Behaviors Research Clinic at Florida State University. In addition, Dr. Keel is codirector of the NIMHfunded Integrated Clinical Neuroscience Training program and is the director of Clinical Training for Florida State University’s Clinical Psychology doctoral program. She has authored more than 180 papers and two books on eating disorders. She is an associate editor for the Journal of Abnormal Psychology and serves as a standing member of an NIH grant review panel. Dr. Keel was elected as a fellow of the Academy for Eating Disorders (AED), the Association for Psychological Science (APS), and the American Psychological Association (APA). She served as president for the Eating Disorders Research Society and president for the Academy for Eating Disorders.

Copyright 2015 (Volume 19, Issue 3) by Psi Chi, the International Honor Society in Psychology


Eye on Psi Chi is a magazine designed to keep members and alumni up-to-date with all the latest information about Psi Chi’s programs, awards, and chapter activities. It features informative articles about careers, graduate school admission, chapter ideas, personal development, the various fields of psychology, and important issues related to our discipline.

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Terms to Know
Readers who are less familiar with eating disorders are encouraged to review the following brief definitions.

  Binge eating disorder (BED) = Usually occurs in overweight or obese individuals who eat excessive amounts of food 
  Bulimia nervosa (BN) = Usually occurs in individuals of normal weight who binge eat and then use (a) purging methods such as self-induced vomiting or the misuse of diet aids or laxatives, or (b) nonpurging methods such as fasting or excessive exercise to lose weight

Anorexia nervosa (AN) = Occurs in underweight individuals who may also binge eat and purge

Purging disorder (PD) = Usually occurs in individuals of average weight who purge but do not binge eat





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