Rumination Disorder DSM-5 307.53 (F98.21)
DSM-5 Category: Feeding and Eating Disorders
Introduction
Rumination, often called regurgitation, is a digestive function of animals with compartmentalized stomachs, such as cows and sheep. This allows the animal to re-chew the food, enhancing absorption of the food and overall nutrition (Tack, Blondeau, Boecxstaens & Rommel, 2011). In humans, however, rumination disorder is an eating disorder characterized by the regurgitation of undigested food. Rumination is different from other eating disorders, such as anorexia nervosa or bulimia nervosa, because it is involuntary (Talley, 2011). Regurgitation is not used as a means of losing or otherwise controlling weight (Hartmann, Becker, Hampton, & Bryant-Waugh 2012). Rumination disorder also does not involve indigestion, nausea, vomiting or related feelings of disgust or discomfort (Talley, et al., 2001, American Psychiatric Association, 2013). Instead, individuals use coughing, tongue movements or abdominal tongue contractions to bring food back to the mouth (Hartmann, et al., 2012). Young infants often arch their backs and make sucking movements with their tongue to stimulate regurgitation. Unlike eating disorders that involve weight management, rumination disorders can affect young infants as well as children and adults with mental disabilities (Hartmann, et al., 2012).
Symptoms of Rumination Disorder
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the primary symptom of rumination disorder is the repeated regurgitation of food that persists for at least one month (American Psychiatric Association, 2013). Adults typically spit out the regurgitated food, but infants, young children and adults with developmental disabilities may re-chew and swallow the food ((Bryant-Waugh, Markham, Kriepe & Walsh, 2010). Rumination typically occurs for one to two hours after completing a meal and typically happens every meal (Talley, 2011), although some patients experience symptoms episodically (American Psychiatric Association, 2013). The DSM-5 explains that diagnosis of rumination disorder requires that the regurgitation not be related to any gastrointestinal disorder and not be exclusively related to an eating disorder intended to control weight. Onset of symptoms can occur at any time during the lifespan, although in infants, symptoms usually present between three and twelve months (American Psychiatric Association, 2013).
Prevalence
Many patients find pleasure in the habitual regurgitating behavior related to rumination disorder. Some describe it as soothing, or a coping strategy for dealing with anxiety. Still, many patients are aware that the behavior is socially unacceptable and try to hide it. Because of this, the prevalence of Rumination Disorder is difficult to determine (Hartmann, et al., 2012). Although it is estimated to occur in 6-10% of institutionalized patients, prevalence among the general population is unknown. It is estimated that a quarter of infants present with some type of feeding problem during the first year. However, many conditions can explain regurgitation in infants, including reflux, poor muscle tone, sensitivity to texture, inexperience with food, and other underlying medical conditions (Bryant-Waugh, et al., 2010). Experts also believe that rumination disorder in adults is commonly misdiagnosed (Tack, 2011) or goes unreported (Talley, 2011).
Co-morbidity
Rumination disorder may occur with other mental disorders, such as generalized anxiety disorder or intellectual development disorder. Rumination behaviors can lead to medical concerns such as dehydration, malnutrition, esophageal damage, dental complications, and bad breath. In infants and young children diagnosed with rumination disorder, weight loss or failure to gain weight is common (Hartmann, et al., 2012). Because rumination disorder affects nutrition, symptom associated with malnutrition, such as growth and learning delays may also occur. Although rare, rumination disorder can result in death, particularly in infants (American Psychiatric Association, 2013). For teens and adults, social functioning may also be impaired when the patient is embarrassed of the behavior (Hartman, et al., 2012).
Social Impairment
For teens and adults with rumination disorder, the regurgitating behavior can be very embarrassing. Common coping strategies include eating alone and avoiding social situations that involve food. Some individuals with rumination disorder avoid eating before social events, such as school, work, dates or parties in fear of regurgitating during the event. Additionally, the DSM-5 states that change in weight, bad breath, and bad dental hygiene can create additional embarrassing conditions that may result in socially avoidant behavior (American Psychiatric Association 2013).
Behavioral Treatment for Rumination Disorder
To date, there is no medication that can effectively treat rumination disorder. Similarly, no medical intervention, such as surgery has been proven effective. Because rumination is a learned behavior, most experts believe that behavioral therapy is the best approach. One method is called diaphragmatic breathing training (Tallley, 2011). Diaphragmatic breathing is extremely simple and easy for most patients to learn. It is learned by placing one hand on the chest and the other hand on the abdomen. The patient is then instructed that the hand placed on the abdomen may only move as the result of breathing (Talley, et al., 2011). This method aids patients in learning to relax their diaphragm both during and after eating, the time when most rumination behaviors occur (Talley, 2011).
Interestingly, diaphragmatic breathing and regurgitation are physically incompatible. Because the body can do only one or the other at any given time, diaphragmatic breathing eliminates rumination behaviors. One study found that such treatment eliminated rumination behaviors in as many of 66% of patients, while reducing behaviors in 55% of patients (Talley, et al., 2011). Chewing gum after meals, during the time when rumination is most like to occur; is another simple yet effective treatment for rumination disorder. Similar to the rationale behind diaphragmatic breathing, chewing gum and regurgitating are incompatible activities. Chewing gum is particularly effective in reducing symptoms in children, as well as in adults with developmental delays (Rhine & Tarbox, 2009, Talley, et al., 2011).
Conclusion
Rumination disorder is an eating disorder characterized by involuntary and sometimes pleasurable regurgitation of food. Rumination disorder is not the result of a gastrointestinal disorder, or desire to control weight. Because rumination is embarrassing for many adults, and difficult to diagnose in infants, it often goes undiagnosed. Therefore, prevalence is unclear. Although rumination rarely results in death, dehydration and malnutrition are dangerous side effects that can occur when the disorder goes untreated. Less serious effects, such as bad breath, dental hygiene problems and weight loss can cause embarrassment for adults dealing with rumination disorder. Because no physiological treatment exists for rumination disorder, behavioral treatments are preferred by doctors. The most common and effective treatment involves teaching the patient to breath in a manner incompatible with rumination.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Bryant-Waugh, R., Markham, L, Kriepe, R.E., Walsh, B.T. (2010). Feeding and eating disorders in childhood. International Journal of Eating Disorders. 43(2): 98-111
Rhine, D. and Tarbox, J. (2009). Chewing gum as a treatment for rumination in a child with autism. Journal of Applied Behavioral Analysis. 42(2): 381-5.
Tack, J., Blondeau, K., Boecxstaens, V. and Rommel, N. (2011). The pathophysiology, differential diagnosis and management of rumination syndrome. 33(7): 782-788
Talley, N.J. (2011). Rumination Syndrome. Gastroenterol Hepatol (NY). 2011 February; 7(2): 117–118.
Hartmann, A., Becker, A.E., Hampton, C., Bryant-Waugh, R. (2012). Pica and rumination disorder in DSM-5. Psychiatric Annals. 42(11): 426-430
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