After reading a news article about a young woman who died last year due to an eating disorder and laxative abuse, I thought that it was time I blogged on the subject. It’s not an easy subject to bring up, because it touches on several major subjects that are generally considered not polite for everyday conversation. There’s the Toilet Taboo, in which we don’t like discussing defecation or urination (watch a commercial for toilet paper and count the euphemisms. Okay, I find it amusing…). There’s the addiction piece, which we also generally don’t like discussing, unless it involves a celebrity. And then there’s the fact that many sufferers–myself included–find it shameful. It’s kind of gross. It’s not something I’m proud of or like to advertise. But laxative abuse is very real, and it’s very deadly. No one really likes to talk about it, but I think we’re doing sufferers a disservice by ignoring it or glossing over it. The answer to that is: more common than you think.

Perhaps the most comprehensive study of the prevalence of laxative abuse was done as part of the Price Foundation Genetic Studies on Eating Disorders (Tozzi et al., 2006). {Until this study, the other, most recent, research estimated the prevalence of laxative abuse in EDs as “somewhere between 3-70%.” Red Curtains IkeaThat covers a LOT of territory, folks.} Discount Energy Efficient CurtainsThe researchers gathered blood and psychological data from 1021 people from a variety of locations around the world who met the DSM-IV criteria for AN, BN, and EDNOS.T Shirt Beats Audio Part of the information they gathered was on purging methods, including laxative abuse. Their findings are summarized in the table below. (If you’re having trouble reading the table, just click on it and it should take you to a larger version)

Those with the purging subtype of anorexia were most likely to use laxatives as a purging method, which correlates with other studies finding the same thing. These other studies also show that people with purging-type anorexia are most likely to use laxatives as their sole means of purging, although vomiting is generally more common on the whole. Further analysis showed that those who abused laxatives had a longer duration of illness (10.4 years vs. 8.6 years), higher levels of anxiety and perfectionism, higher harm avoidance, and greater obsessive-compulsive and ED symptoms. The researchers also found a strong association with Borderline Personality Disorder, in particular the self-harm and feelings of emptiness that frequently accompany BPD. It’s a good question, since laxatives are actually not very good as a purging method. Of course, the illusion of having successfully rid the body of food and calories can be as good as the real thing, but researchers and sufferers believe that it goes somewhat deeper than that.

After all, I learned about the inefficacy of laxatives in preventing calorie absorption soon after I started using them, and that didn’t stop a long, less-than-illustrious career of laxative abuse for me. Nor, I suspect, does it in a lot of sufferers. Researchers have developed three main theories about why people abuse laxatives. Theory One: Laxative abuse is punishing. Self-harm is common in EDs, and Tozzi et al. hypothesize that laxative abuse is an extension of self-harming behaviors. In the context of EDs, laxative abuse is usually conceptualized as purging or as a weight-control method; however, the self-harm and potentially anxiolytic features should not be overlooked. Indeed, although all forms of purging are physically destructive, laxative abuse is one of the more physically self-abusive methods of purging, and laxative abuse is often described as self-punishing or self-aggressive by patients themselves. And, much like other methods of self-harm (e.g., cutting), the abuse of laxatives likely has an anxiolytic effect that allows patients to decrease fears of weight gain and anxiety and instead focus on the pain and consequences of the laxative abuse.

If one of the driving forces behind laxative abuse is self-harm and decreased anxiety rather than weight loss, then a therapeutic intervention emphasizing the ineffectiveness of laxative abuse as a weight-control method misses the mark and would logically fail. Interventions would instead need to focus on the self-harmful aspects and teaching other, more adaptive strategies for achieving the ends that the laxative abuse is addressing. Theory Two: Laxative abuse creates feelings of emptiness. In a separate paper on laxative abuse in people with AN, researchers hypothesize that the physical and emotional feelings of emptiness are a strong driver in the use of laxatives (Kovacs & Palmer, 2004). The laxatives empty your bowels, of course, but they also provide a sense of psychological emptiness and calm when they take effect. Many patients report that the feeling of having emptied themselves is associated not only with gratifying, apparent weight loss but also with a sense of purification.

This isn’t found in the research literature, it’s just my own conjecture. That being said, there’s no reason why the above two are mutually exclusive. They can both be true at the same time. The motivations that drive our behavior are very complex and not always rational. Part of the reason I think I got hooked on laxatives (at least mentally) was that they fulfilled both of these needs: the need to punish myself for eating, and the desire to not feel anything at all. I felt lighter and freer mentally afterwards, which blotted out all of the other physical and psychological damage they brought. Although there’s a strong physical addiction to laxatives that shouldn’t be underestimated, that wasn’t really the hardest part of quitting laxatives for me. The hardest part was the psychological factors- the desire to punish myself and to empty myself of my feelings and anxieties. Ultimately, of course, it didn’t work. If you want to stop abusing laxatives, here’s a good place to start.