Chewing and Spitting
Chewing and spitting (CHSP) is among the lesser-known and less-studied eating disorder behaviours. It consists of chewing food, and spitting it out before swallowing. The focus is most often foods that individuals do not allow themselves to ingest for emotional or physiological reasons, usually foods higher in fats or sugar, or with a higher caloric content. It often relates to fears regarding what may occur if the person allowed themselves to eat that food, such as feeling pleasure and then overeating. It can have the effect of mimicking the physiological or emotional response of having just eaten.
Chewing and spitting has some similarities to bingeing in that it involves consuming larger amounts of high calorie foods than intended, but is also similar to restrictive eating in that the food is not actually ingested.
The CHSP behaviour is not specifically included in the DSM-V (the Diagnostic and Statistical Manual -fifth edition). Chewing and spitting is reported across a range of eating disorders found in the DSM-V including anorexia (AN), bulimia (BN), binge eating disorder (BED), and other specified feeding or eating disorders (OSFED). It is also found in individuals without eating disorders, such as athletes following strict diets, people with diabetes, and the increasing population of people who have undergone bariatric surgery.
One of the first published CHSP case reports (De Zwaan, International Journal of Psychiatry in Clinical Practice, vol 1, 1997 ) described a 19-year-old woman with anorexia accompanied by chewing and spitting: she either spent hours in the bathroom or spit the food into carrier bags, both at home and while walking on the streets. The chewing and spitting out took up to 6 hours every day, preventing her from studying and from developing and maintaining a social life; at family dinners, she managed to hide the food from her plate in her pockets and under the table without her parents noticing. She felt deep shame about her behaviour, but was unable to stop .
Research on CHSP is sparse. Studies show that it is more commonly associated with other restrictive eating disorder behaviours (such as laxative or diet pill abuse, dietary restriction, and excessive exercise) than with binge/purge behaviours.
Studies do show that CHSP is associated with more severe eating disorder symptoms and with suicidal ideation; those who struggle with CHSP, relative to those who don't, score higher levels of body image concerns, preoccupation with shape and weight, depression, anxiety and obsessive compulsive behaviour.
A study by Guarda, Coughlin et al. (Eating Behaviours Volume 5, Issue 3, July 2004, Pages 231-239) showed among eating disorder patients admitted to a behavioural, inpatient, and partial hospitalisation programme for eating disorders , 34 percent admitted to at least one episode of chewing and spitting in the month prior to admission, and 19 percent reported being regular chewers/spitters who engaged in the behaviour several times a week. The prevalence of chewing and spitting out food has been estimated to be about 31 percent of patients post-bariatric surgery.
In this paper, Guarda notes that the behaviour is diverse in presentation but is described as "driven and compelling and is sometimes associated with feelings of loss of control. As with most eating disorder behaviours, its escalation can lead to social exclusion, severe food obsession, self-loathing, guilt, and remorse.For individuals who chew and spit large amounts of food daily, financial difficulties can be a further consequence.”
Medical Consequences of Chewing and Spitting
The physical consequences of chewing and spitting can be serious. Symptoms are similar to those found with vomiting in BN and can include:
visibly swollen salivary glands
dental problems such as cavities and tooth decay
Addressing these medical symptoms requires stopping the behaviour. Warm compresses and tart sweets can help provide relief for swollen salivary glands. If you need help with dental, hormonal and gastrointestinal issues because of chewing and spitting, you should see a dentist and a GP.
Assessing and Addressing Chewing and Spitting
Chewing and spitting is not commonly assessed by professionals, and clients may be reluctant to report it due to shame about the behaviour.
Little in treatment literature or guidance specifically addresses chewing and spitting so far. Psychotherapy and nutrition therapy for patients with eating disorders who chew and spit need to address the normalisation of eating behaviours through the adoption of regular meals; Cognitive-behavioural strategies can be helpful in addressing chewing and spitting and must include acknowledgement of feelings of shame, challenging of dietary rules, management of emotional distress, and practice of increased flexibility.
Worried About Someone?
If someone you know is displaying signs of an eating disorder, you may want to watch for signs of chewing and spitting. Specific signs of chewing and spitting may include:
traces of chewed but undigested food in their room, in the bathroom, or in the trash
eating in private or away from home
secretive behaviour at meals
signs of shame around eating
If you are chewing and spitting, you're not alone. It's important to seek help from a recovery coach,a therapist or other professional who is well-versed in eating disorders.