Three recent papers I’ve been part of all circle the same idea from different angles: the people who struggle most with eating are often the ones who don’t fit the diagnostic boxes we’ve built for them. Here’s a recap of that work, and why I think the future of this field is dimensional rather than categorical.
The Box Problem
Most of how we classify eating behavior assumes clean categories. You either have an eating disorder or you have “food addiction.” You either restrict or you binge. You’re either driven by body image or by something more reward-based. The diagnostic manuals reinforce these splits, and treatment systems organize themselves around them.
But anyone who has spent time with real patients knows the boundaries are porous. Someone restricts for years, then develops loss-of-control eating later in life. Someone resolves a substance problem only to find compulsive eating takes its place. Someone presents with classic binge eating, but the thing they’re chasing isn’t the food at all. These aren’t exceptions to be explained away. They’re the norm, and they tell us something important: eating behavior lives on a spectrum, shaped by individual biology, history, and neurodevelopment, not in tidy compartments.
I’ve come to think of this as a neurodiversity question. People’s brains are wired differently, and those differences show up in how they relate to food. When we force everyone through the same categorical lens, we miss the people whose wiring doesn’t match the template.
A Unified Theory of Restrictive and Addictive Eating
The most ambitious of the three papers is a theoretical review I wrote with Alan Logan, published in the Journal of Eating Disorders. We proposed a unified life course model that brings together two traditions that have historically talked past each other: the eating disorder field, which tends to emphasize dietary restraint and societal pressures, and the addiction field, which emphasizes the modern food environment and addiction-like responses to ultra-processed foods.
Rather than pick a side, we traced how both can grow from shared roots. Generational trauma and early adversity sit upstream of both. From there, things tend to diverge depending on predisposing factors — one pathway leaning more toward rigid, control-oriented patterns, another toward impulsive, reward-seeking ones. The key move is that these aren’t fixed destinations. People can carry features of both, and they can shift between them over a lifetime, especially during stress, transition, or even treatment itself.
I’m keeping this light here on purpose, because I want to go deeper on the model elsewhere. But the headline for this audience is simple: a dimensional framework gives clinicians more clues and patients more grace. Where you sit on the continuum has direct implications for what kind of help actually fits, and that position can move.
When the Reinforcer Isn’t the Food
The second paper, a Perspective in Frontiers in Psychiatry led by Vera Tarman, which I contributed to, illustrates the box problem beautifully. It describes a pattern Vera calls compulsive high-volume eating, with a focus on people whose compulsive eating centers on the pursuit of extreme fullness rather than on any particular tasty or “forbidden” food.
This matters because so much of how we think about binge eating and food addiction assumes the pull is toward palatability — the specific trigger food, the sugar, the hyper-palatable combination. But for some people, the food is almost beside the point. What they’re chasing is an internal state: the heavy, stretched, maximally full sensation that brings a kind of calm or relief. Some describe needing progressively more volume over time to reach that same endpoint, and real distress when they try to stop short of it.
It’s an atypical presentation that blurs the line between binge eating disorder and food addiction, and it points to the gut-brain axis, satiety signaling, and stress physiology rather than to taste alone. It’s exactly the kind of presentation a categorical system tends to render invisible. Once you’re thinking dimensionally, it comes into focus.
You can read that paper here.
Out-of-the-Box Interventions Can Help
The third paper, published in Frontiers in Public Health, is a study I co-authored evaluating Liberate, an online, community-based intervention for people with self-reported ultra-processed food addiction. It pairs addiction-informed psychoeducation and peer support with a real-food, lower-carbohydrate dietary approach.
I want to be careful and honest about what this was: a secondary analysis of a feasibility study, single-arm, without a control group. It can’t establish efficacy, and controlled trials are the necessary next step. But the signal was encouraging. Participants’ binge eating symptoms improved meaningfully, and the gains were largely maintained at six-month follow-up, with no sign that the approach made things worse.
That last part is the piece I find most worth sitting with. There’s a longstanding and well-founded caution in eating disorder care against excluding food groups, because in the context of low-calorie or punitive dieting, restriction genuinely can fuel the restrict-binge cycle. But this intervention wasn’t that. It was structured, satiating, abstinence-oriented in a specific sense, and wrapped in psychological and community support. For a subset of people whose eating looks more addiction-like, an approach that the conventional playbook would flag as risky appeared to help. That’s not an argument that it’s right for everyone. It’s an argument against assuming one philosophy fits all.
You can read that paper here.
The Thread That Ties Them Together
Put these three together, and the same message keeps surfacing: a unified model that refuses the false binary between restriction and addiction. An atypical presentation that only makes sense once you stop sorting people into types. An unconventional intervention that worked for people the standard approach often leaves behind. Each one is a small argument for the same large idea: we serve people better when we assess where they actually are than when we decide in advance which box they belong in.
This is what I mean by dimensional over categorical. It isn’t a rejection of the diagnosis. It’s a recognition that diagnosis is a starting point, not the whole picture, and that the whole picture includes a person’s neurobiology, their developmental history, and the specific internal logic of their relationship with food.
Understanding Your Own Biology
One reason categorical thinking persists is that it’s easier. Looking at the whole person takes more — more time, more curiosity, and often more data than a standard intake provides. Part of what I’ve been building toward is making that deeper look more accessible.
If you’ve ever felt like you don’t fit the boxes, that the standard explanations never quite described your experience, comprehensive functional and metabolic testing can be one way to start understanding your individual biology rather than guessing at it. That’s a core part of the work we do at FxMed Mental Health. The goal isn’t another label. It’s a clearer, more individualized starting point for figuring out what might actually help you.
Key Takeaways
- Eating behavior exists on a dimensional continuum, not in discrete diagnostic boxes, and many people carry features of more than one pattern.
- The Unified Theory of Restrictive and Addictive Eating integrates the eating disorder and addiction traditions rather than forcing a choice between them, and recognizes that people can shift along the continuum over a lifetime.
- Some compulsive eating is organized around the internal state of extreme fullness rather than around specific palatable foods — an atypical presentation that categorical systems tend to miss.
- Unconventional, addiction-informed interventions show early promise for people whose eating looks more addiction-like, challenging the assumption that one nutritional philosophy fits everyone.
- Understanding your individual biology, rather than starting from a label, opens the door to more personalized care.
