Skip to main content
    • Aa
    • Aa

Co-morbidity and disorder-related distress and impairment in purging disorder

  • P. K. Keel (a1), B. E. Wolfe (a2), J. A. Gravener (a1) and D. C. Jimerson (a3)

Recent studies suggest that purging disorder (PD) may be a common eating disorder that is associated with clinically significant levels of distress and high levels of psychiatric co-morbidity. However, no study has established evidence of disorder-related impairment or whether distress is specifically related to PD rather than to co-morbid disorders.


Three groups of normal-weight women [non-eating disorder controls (n=38), with PD (n=24), and with bulimia nervosa (BN)-purging subtype (n=57)] completed structured clinical interviews and self-report assessments.


Both PD and BN were associated with significant co-morbidity and elevations on indicators of distress and impairment compared to controls. Compared to BN, PD was associated with lower rates of current and lifetime mood disorders but higher rates of current anxiety disorders. Elevated distress and impairment were maintained in PD and BN after controlling for Axis I and Axis II disorders.


PD is associated with elevated distress and impairment and should be considered for inclusion as a provisional disorder in nosological schemes such as the Diagnostic and Statistical Manual to facilitate much-needed research on this clinically significant syndrome.

Corresponding author
*Address for correspondence: P. K. Keel, Ph.D., E11 Seashore Hall, Iowa City, IA 52246, USA. (Email:
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

AT Beck , CH Ward , M Mendelson , J Mock , J Erbaugh (1961). An inventory for measuring depression. Archives of General Psychiatry 4, 561571.

J Berkson (1946). Limitations of application of fourfold table analysis to hospital data. Biometrics 2, 4753.

RB Binford , D le Grange (2005). Adolescents with bulimia nervosa and eating disorder not otherwise specified-purging only. International Journal of Eating Disorders 38, 157161.

J Cohen (1977). Statistical Power Analysis for the Behavioral Sciences – Revised. Academic Press: New York.

CG Fairburn , K Bohn (2005). Eating disorder NOS (EDNOS): an example of the troublesome ‘not otherwise specified’ (NOS) category in DSM-IV. Behaviour Research and Therapy 43, 691701.

A Favaro , S Ferrara , P Santonastaso (2003). The spectrum of eating disorders in young women: a prevalence study in a general population sample. Psychosomatic Medicine 65, 701708.

A Fossati , C Maffei , M Bagnato , D Donati , M Donini , M Fiorilli , L Novella , M Ansoldi (1998). Brief communication: criterion validity of the personality diagnostic questionnaire – 4+(PDQ-4+) in a mixed psychiatric sample. Journal of Personality Disorders 12, 172178.

KA Halmi , WS Agras , S Crow , J Mitchell , GT Wilson , SW Bryson , HC Kraemer (2005). Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs. Archives of General Psychiatry 62, 776781.

JI Hudson , E Hiripi , HG Pope Jr., RC Kessler (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry 61, 348358.

PK Keel , A Haedt , C Edler (2005). Purging disorder: an ominous variant of bulimia nervosa? International Journal of Eating Disorders 38, 191199.

PK Keel , SA Mayer , JH Harnden-Fischer (2001). Importance of size in defining binge eating episodes in bulimia nervosa. International Journal of Eating Disorders 29, 294301.

H Leitenberg , J Gross , J Peterson , JL Rosen (1984). Analysis of an anxiety model and the process of change during exposure plus response prevention treatment of bulimia nervosa. Behaviour Therapy 15, 320.

LA McWilliams , BJ Cox , MW Enns (2003). Psychometric properties of an index of emotional distress in the U.S. National Comorbidity Survey. Social Psychiatry & Psychiatric Epidemiology 38, 256261.

J Mond , P Hay , B Rodgers , C Owen , R Crosby , J Mitchell (2006). Use of extreme weight control behaviors with and without binge eating in a community sample: implications for the classification of bulimic-type eating disorders. International Journal of Eating Disorders 39, 294302.

J Ormel , AJ Oldehinkel , WA Nolen , W Vollebergh (2004). Psychosocial disability before, during, and after a major depressive episode: A 3-wave population-based study of state, scar, and trait effects. Archives of General Psychiatry 61, 387392.

JH Patton , MS Stanford , ES Barratt (1995). Factor structure of the Barratt impulsiveness scale. Journal of Clinical Psychology 51, 768774.

J Polivy , CP Herman (2002). Causes of eating disorders. Annual Review of Psychology 53, 187213.

M Rorty , J Yager , JG Buckwalter , E Rossotto (1999). Social support, social adjustment, and recovery status in bulimia nervosa. International Journal of Eating Disorders 26, 112.

J Rosen , L Vara , S Wendt , H Leitenberg (1990). Validity studies of the Eating Disorders Examination. International Journal of Eating Disorders 9, 519528.

CD Spielberger , PR Vagg (1984). Psychometric properties of the STAI: a reply to Ramanaiah, Franzen, and Schill. Journal of Personality Assessment 48, 9597.

AJ Stunkard , S Messick (1985). The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. Journal of Psychosomatic Research 29, 7183.

TD Wade (2007). A retrospective comparison of purging type disorders: Eating disorder not otherwise specified and bulimia nervosa. International Journal of Eating Disorders 40, 16.

TD Wade , JL Bergin , M Tiggemann , CM Bulik , CG Fairburn (2006). Prevalence and long-term course of lifetime eating disorders in an adult Australian twin cohort. Australian & New Zealand Journal of Psychiatry 40, 121128.

MM Weissman , S Bothwell (1976). Assessment of social adjustment by patient self-report. Archives of General Psychiatry 33, 11111115.

G Wilson , D Smith (1989). Assessment of bulimia nervosa: an evaluation of the Eating Disorders Examination. International Journal of Eating Disorders 8, 173179.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Full text views

Total number of HTML views: 2
Total number of PDF views: 11 *
Loading metrics...

Abstract views

Total abstract views: 73 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 26th May 2017. This data will be updated every 24 hours.