So What Is Rumination Disorder?
According to the DSM-5 criteria, to be diagnosed as having Rumination Disorder a person must display:
Repeated regurgitation of food for a period of at least one month Regurgitated food may be re-chewed, re-swallowed, or spit out.
The repeated regurgitation is not due to a medication condition (e.g. gastrointestinal condition).
The behaviour does not occur exclusively in the course of Anorexia Nervosa, Bulimia Nervosa, BED, or Avoidant/Restrictive Food Intake disorder.
If occurring in the presence of another mental disorder (e.g. intellectual developmental disorder), it is severe enough to warrant independent clinical attention.
Rumination has been described as a symptom in association with eating disorders, but also as a separate disorder.
Studies (such as Eckern, James and Mitchell (1999)[i]) have found a high incidence of rumination in association with Eating Disorders and have underlined the importance of screening for rumination among Eating Disorders among individuals who ruminate and for screening for rumination among Eating Disorder clients.
Pathophysiology
While the pathophysiology (physiological process by which the abnormal condition develops and progresses) of rumination remains largely unclear, one way it might happen is that gastric distention with food is followed by abdominal compression and relaxation of the lower oesophageal sphincter, allowing the stomach contents to be regurgitated and rechewed and then swallowed or expelled.
Possible causes for this relaxation of the lower oesophageal sphincter:
Learned voluntary relaxation
Simultaneous relaxation with increased intra-abdominal pressure
Adaptation of the belch reflex
Symptoms of rumination can include the following:
Weight loss
Halitosis
Indigestion
Chronically raw and chapped lips
Vomit may be noted on the individual's chin, neck, and upper garments.
Regurgitation typically begins within minutes of a meal and may last for several hours. Regurgitation occurs almost every day following most meals.
Regurgitation is generally described as effortless and is rarely associated with forceful abdominal contractions or retching.
Physical findings in patients with rumination may include the following:
Regurgitation
Vomiting not visible to others
Unexplained weight loss, growth failure
Symptoms of malnutrition
Antecedent behaviours including postural changes, putting hands into mouth, and gentle gagging motion of the neck region
The patient may appear to derive satisfaction and sensory pleasure from mouthing the vomit rather than considering vomitus in the mouth disgusting
Tooth decay and erosion
Aspiration that may cause recurrent bronchitis or pneumonia, reflex laryngospasm, bronchospasm, and/or asthma
Premalignant changes of the lining of the oesophagus with chronic rumination
Rumination is a potentially a very serious disorder.
Possible effects may be
Halitosis
Malnutrition
Weight loss
Growth failure
Electrolyte imbalance
Dehydration
Gastric disorders
Upper respiratory tract distress
Dental Problems
Aspiration
Choking
Pneumonia
Death
What actually causes rumination disorder?
Although the aetiology of rumination is unknown, multiple theories have been advanced to explain the disorder. These theories range from psychosocial factors to organic origins. Cultural, socioeconomic, organic, psychodynamic and psychiatric (e.g. depression and anxiety) factors have been implicated. In terms of heredity, occurrences in families have been reported, as of yet, no genetic association has been established.
Some possible physical causes of rumination include the following:
Dilatation of the lower end of the oesophagus or of the stomach
Overaction of the sphincter muscles in the upper portions of the alimentary canal
Cardiospasm
Pylorospasm (spasm of pyloric sphincter)
Gastric hyperacidity
Achlorhydria (absence of hydrochloric acid in gastric secretions)
Movements of the tongue
Insufficient mastication
Pathologic conditioned reflex
Air Swallowing
Finger or hand sucking
When rumination is associated with Eating Disorders symptoms should be addressed simultaneously. The treatment of adult rumination syndrome consists of reassurance, behaviour therapy, psychotherapy and relaxation therapies.
[i] Eckern, James and Mitchell, Int J Eat Disord 26: 414–419, 1999