Chapter 9: Feeding and Eating Problems

Raskin examines feeding and eating problems, exploring how diagnostic systems, historical understandings, biological mechanisms, psychological theories, and sociocultural forces shape these conditions. Case studies highlight anorexia nervosa (Marta’s severe restriction and distorted body image), bulimia nervosa (Zayna’s cycles of bingeing and purging), binge-eating disorder (Daemyn’s compulsive overeating and shame), avoidant/restrictive food intake disorder (Wendy’s extreme picky eating), pica (Alastair’s ingestion of chalk, soap, and pebbles), and rumination disorder (Simone’s re-chewing and regurgitation). DSM-5-TR and ICD-11 recognize these six disorders, distinguishing eating problems—dominated by body image concerns—from feeding problems, which are more common in childhood and involve inadequate or unusual eating behaviors. The chapter discusses anorexia’s restricting and binge-purge subtypes, bulimia’s compensatory behaviors, and debates over atypical anorexia and bulimia diagnoses. BED’s recognition in DSM-5 is explored, along with concerns about pathologizing normal eating variation. Orthorexia nervosa, an obsession with “healthy eating,” is introduced as a proposed but controversial diagnosis. Alternative perspectives include the PDM-2’s focus on unmet relational needs, HiTOP’s dimensional model, and PTMF’s interpretation of eating problems as threat responses to mistreatment. Historical perspectives trace anorexia from ancient Greece, through religious fasting, Richard Morton’s 1694 descriptions, Gull and Lasègue’s 19th-century medicalization, and Hilde Bruch’s psychoanalytic formulations in the 20th century, to bulimia’s recognition in the late 1970s. Biological perspectives detail serotonin and dopamine dysregulation, tryptophan deficiency, hypothalamus and HPA axis hyperactivity, mesolimbic reward pathway disturbances, genetic heritability (50%+ for anorexia and bulimia), candidate gene and GWAS findings, evolutionary hypotheses (sexual competition, reproductive suppression, adapted-to-flee famine, and binge eating as survival adaptation), and immune system links via inflammatory cytokines and gut microbiota. Psychological perspectives review psychodynamic accounts of oral impregnation, attachment insecurity, and perfectionism; interpersonal therapy (IPT) focusing on role conflicts; CBT approaches such as in vivo food exposure, response prevention, and enhanced CBT-E’s “core psychopathology” of weight/shape-driven self-worth; CBT-AR for ARFID; ACT’s cognitive defusion and thought parade exercises; EFT’s emphasis on accessing suppressed emotions; and narrative therapy’s externalization of the “eating disorder voice.” Sociocultural perspectives emphasize the Western ideal of thinness, globalization of eating problems, socioeconomic status differences, race and ethnicity research, objectification theory, media and social media influences, and muscle dysmorphia in men. Cultural practices of pica, stigma, and social justice critiques are addressed. Service user narratives highlight underrepresentation of people of color in eating disorder awareness, stigma as weakness, and challenges of recovery. Systems perspectives explore Minuchin’s psychosomatic families, structural family therapy, and the Maudsley model of family-based treatment (FBT) for anorexia and bulimia, with evidence of effectiveness but also limits. The chapter concludes with debates on whether eating disorders are culture-bound syndromes or universal conditions shaped by biopsychosocial processes.