What is Rumination Syndrome?

Trigger warning: This article is purely for the sake of information/education, and as such, you will find some graphic descriptions of disordered behaviors (including vomiting and ruminating). Proceed with caution.

Welcome back to our 6th installment of our comprehensive overviews of the major DSM-identified eating disorders. To see the complete list of overviews and learn more about another eating disorder, click here.

Today wraps up the six independent eating disorders, as identified by the DSM 5. There will still be one more eating disorder to cover, but that is going to be part of the Otherwise Specified Feeding and Eating Disorders (OSFED) umbrella. Stay tuned for that!

We cap off these six with one you have likely never heard of, unless you or someone you know has personally suffered from it or you are a practitioner required to know about this. Rumination has been around for a long time, yet it has remained a medical anomaly for a variety of reasons (which you’ll read more about below). Let’s dive into this enigmatic disease and fully cover all angles.


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Definition and Diagnosis

Rumination syndrome, known by its shorthand rumination, is likely the least commonly cited and most widely misunderstood of the six major DSM-identified eating disorders.  It is fundamentally a disorder of regurgitation, but due to its downstream adverse effects and [often] voluntary nature, it has been identified as its own eating/feeding disorder.  

It is first and foremost important to clarify that this is not an emetic response.  The vomiting reflex involves a deep-seated trigger (probably located in the chemoreceptor trigger zone [CTZ] in the medulla oblongata) designed to forcefully expel harmful toxins in the small intestine backwards through the GI tract and out the mouth.  This is the biological response we see with voluntary purging (such as in anorexia nervosa purge type, bulimia nervosa, or purging disorder).  

Rather, this is a regurgitation response, meaning food that was only recently ingested is being brought back up.  This food has only made it to the level of the pharynx or esophagus at this point, meaning it has not made contact with any stomach acid or bile.  For these reasons, though the inability to keep food down and the cumulative degradation of the lower esophageal sphincter are all calls for concern, the worry of excess acidity in the upper GI tract or electrolyte imbalances are not as severe as they would be in the case of purging (Papadopoulos & Mimidis, 2007).

The behavior is actually completely normal in ruminant animals (otherwise known as ruminants, mammals able to store, ferment, and reprocess foods in a specialized secondary stomach called a rumen).  These include sheep, cattle, cows, giraffes, and deer.  Importantly, humans do not have rumens and did not evolve to prosper from regurgitation; as such, this is definitively dysfunctional in all cases.

To be diagnosed with rumination, four criteria must be met:

  • Food is repeatedly regurgitated over a period of at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out.

  • This frequent regurgitation is not attributable to an associated gastrointestinal or other medical condition (i.e. gastroesophageal reflux, pyloric stenosis).

  • This does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder (BED), or avoidant/restrictive food intake disorder (ARFID).

  • If the behavior occurs within the context of another mental disorder (such as generalized anxiety disorder) or neurodevelopmental disorder (such as an intellectual disability), it must be sufficiently severe to warrant independent clinical attention.

To further clarify the third criterion, the DSM states that rumination cannot occur as an intentional means of weight loss.  The “chew and spit” behavior, that bears a superficial resemblance to ruminating, is in fact a symptom of body image-related eating disorders, such as bulimia nervosa (Aouad, Hay, Soh & Touyz, 2016).  And though individuals with AN, BN, or BED cannot receive a concurrent rumination diagnosis, individuals with pica can (Hartmann, Becker, Hampton & Bryant-Waugh, 2012).

The second sentence of the first criterion here represents a change from the DSM-IV, which required that food be re-chewed after regurgitation for an official diagnosis.  Since studies are now finding that rumination symptoms can include re-swallowing or spitting out of food, this change has been reflected (Papadopoulos & Mimidis, 2007).

The onset of this disorder is almost always during the first year of life, excluding those with severe learning disabilities, for whom onset can occur anywhere in the lifespan (Green, Alioto, Mousa & Di Lorenzo, 2011).

What do ruminations look like?

With rumination, foods (often only partially digested) are regurgitated soon after consumption, often within minutes.  This behavior is usually secretive. There is no nausea, vomiting, or subjective experience of disgust associated with these ruminations (Raha, Sarma, Thilakan & Punnoose, 2017).  Rather, ruminations often appear effortless and painless; rarely are there ever even retching or gastric contractions involved.  Some even describe the experience as pleasurable (Wolke, Skuse & Reilly, 2013).

These episodes look markedly distinct from episodes of purging, which characteristically include violent contractions, retching, pain - especially during purge marathons, common in those with the OSFED condition purging disorder (Forney, Buchman-Schmitt, Keel & Frank, 2016) - and a sour, bitter aftertaste.    

These ruminations will likely occur daily for most meals, meaning it leaves the sufferer at an increased risk of malnutrition.  This is especially true in children, as they are missing out on essential nutrients during a critical window of life. Even into adolescence and beyond, individuals with rumination may restrict their eating out of embarrassment of the behavior.

History

The term rumination comes from the Latin word ruminare, literally “to chew the cud.”  The first clinical documentation of rumination came from the Italian anatomist and surgeon Fabricius ab Aquapendente in 1618.  The anatomist was describing a patient of his, a nobleman from the Italian city of Padua, who was said to have “ruminated like a cow” (Herbst, Friedland & Zboralske, 1971).

Into the 20th century, the disorder was seen more and more, yet it was seen almost solely as a disorder of infancy and early childhood.  It was not until later in the 20th century that adult cases of rumination became evident (Sidhu & Rick, 2009).

Statistics

The epidemiology of rumination syndrome is almost a complete unknown.  Due to subjectivity in diagnosis (for example, differentiating emetic and regurgitative responses) and a general absence of understanding, collecting large scale data on cases of rumination is next to impossible.  This will likely change, especially with the release of the next DSM, but for now, the literature relies almost exclusively on individual case studies and field reports.

Like pica, rumination is disproportionately more common in those with learning disabilities (again, based off the limited research available) (Khan, Hyman, Cocjin & Di Lorenzo, 2000).  It can also potentially be confused with gastroesophageal reflux disease (GERD), colloquially known as “heartburn,” since both deal with a weakened lower esophageal sphincter and some degree of retroperistalsis (whether that be acid reflux or ruminations) (Chial et al., 2003).

Etiology and Pathophysiology

Though this is still a new area of research, and subsequently the disorder is poorly understood, any possible etiology must start with an explanation of the variance in gastric motility.  In other words, the most important variable here is how those with rumination are able to bring food back up so soon.  Likely, two events are occurring once consumed food enters the stomach: abdominal pressure increases in response to gastric distention and the lower esophageal sphincter (which separates the stomach and esophagus) relaxes.  This sphincter normally functions to keep peristalsis from reversing, so if it is weakened, smooth muscle contractions in the stomach can push food back up into the esophagus.

How this happens is another question.  It could be a variation of the belch reflex: distension of the stomach usually signals to momentarily relax the lower esophageal sphincter, so that gas can be pushed through to provide gastrointestinal relief.  It’s possible that this response is dysregulated or somehow strengthened with rumination syndrome. The body’s attempt to relieve gastric distress could simply be inappropriately controlled, such that instead of gas, entire bits of food are released back up the tract.

Another explanation, which better explains the voluntary cases of rumination, is that this relaxation of the sphincter is a learned response.  For a host of possible reasons, individuals could have learned to control this belch reflex and voluntarily regurgitate.  

Another prominent theory is that rumination originates as a response to abdomino-gastric strain (Tucker, Knowles, Wright & Fox, 2013). This is explained further in the following flowchart, which demonstrates how initial gastric triggers may lead to the common behavioral response of this abdomino-gastric strain, which then eventually culminates in some variation of rumination behavior:

Tucker E ,  Knowles K ,  Wright J ,  Fox MR . Rumination variations: aetiology and classification of abnormal behavioural responses to digestive symptoms based on high-resolution manometry studies.  Alimentary Pharmacology & Therapeutics  37: 263–274, 2013.

Tucker E, Knowles K, Wright J, Fox MR. Rumination variations: aetiology and classification of abnormal behavioural responses to digestive symptoms based on high-resolution manometry studies. Alimentary Pharmacology & Therapeutics 37: 263–274, 2013.

Dangers

While purging behaviors carry their own potential health risks, due to electrolyte imbalances and inappropriate levels of acidity in the upper GI tract, ruminations too have specific risks to watch for.

Some potentially dangerous symptoms that could arise from chronic ruminating include (O’Brien, Bruce & Camilleri, 1995):

  • Halitosis (mouth odor)

  • Aspiration and choking

  • Development of gastric disorders

  • An inability to keep solid foods down

Treatment

One mode of unofficial treatment for rumination is diaphragmatic breathing (Talley, 2011).  This involves lying down, placing one hand on the chest and one on the stomach, and then concentrating on keeping the breath at the stomach (technically, at the level of the diaphragm).  This ostensibly teaches the patient to relax their diaphragm during and after meals, so as to prevent backflow of foods post-meal.  Though this may sound rudimentary and overly simplistic, at least one major trial has found it to be effective, eliminating rumination behaviors in as many as 66% of patients (Chitkara, Van Tilburg, Whitehead & Talley, 2006).

Mild aversion therapy, which involves teaching an association between rumination episodes and some negative event (and, conversely, teaching patients to associate normal and complete consumption of foods with some positive result), has shown to be at least partly effective for children and those with learning disabilities (Wagaman, Williams & Camilleri, 1998).

Since rumination behaviors are virtually never voluntary in grown adults of normal intelligence, early studies have shown that an emphasis on habit reversal and reassurance can be instrumental in achieving full remission (Johnson, Corrigan, Crusco & Jarrell, 1987).

Prognosis

With the proper combination of behavioral therapy and adoption of diaphragmatic breathing techniques, more than 50% of patients will see a dramatic reduction in symptoms, and as many as 30% can achieve full remission (Chial et al., 2003).  The disorder may be markedly more difficult to treat in patients who have a history of bulimic or purging tendencies (Larocca & Della-Fera, 1986).

Resources

  • NEDA - The largest national eating disorder advocacy forum, which regularly hosts outreach events, funds important research, and directly helps those affected via their helpline.

  • IFFGD (International Foundation for Functional Gastrointestinal Disorders) - This organization serves to spread awareness, support research, and help those struggling with functional GI disorders, such as rumination.

  • AED (Academy for Eating Disorders) - Organization that specializes in ensuring the professional standards of eating disorder research, treatment, and information.

NEDA’s Helpline number is: 1-800-931-2237

References

  1. Aouad P, Hay P, Soh N, Touyz S. Chew and Spit (CHSP): a systematic review. J Eat Disord 4, 2016.

  2. Chial HJ, Camilleri M, Williams DE, Litzinger K, Perrault J. Rumination syndrome in children and adolescents: diagnosis, treatment, and prognosis. Pediatrics 111: 158–162, 2003.

  3. Chitkara DK, Van Tilburg M, Whitehead WE, Talley NJ. Teaching diaphragmatic breathing for rumination syndrome. Am J Gastroenterol 101: 2449–2452, 2006.

  4. Forney KJ, Buchman-Schmitt JM, Keel PK, Frank GKW. The Medical Complications Associated with Purging. Int J Eat Disord 49: 249–259, 2016.

  5. Green AD, Alioto A, Mousa H, Di Lorenzo C. Severe pediatric rumination syndrome: successful interdisciplinary inpatient management. J Pediatr Gastroenterol Nutr 52: 414–418, 2011.

  6. Hartmann AS, Becker AE, Hampton C, Bryant-Waugh R. Pica and Rumination Disorder in DSM-5. Psychiatric Annals 42: 426–430, 2012.

  7. Herbst J, Friedland GW, Zboralske FF. Rumination. Br Med J 4: 3, 1971.

  8. Johnson WG, Corrigan SA, Crusco AH, Jarrell MP. Behavioral assessment and treatment of postprandial regurgitation. J Clin Gastroenterol 9: 679–684, 1987.

  9. Khan S, Hyman PE, Cocjin J, Di Lorenzo C. Rumination syndrome in adolescents. J Pediatr 136: 528–531, 2000.

  10. Larocca FE, Della-Fera MA. Rumination: its significance in adults with bulimia nervosa. Psychosomatics 27: 209–212, 1986.

  11. O’Brien MD, Bruce BK, Camilleri M. The rumination syndrome: clinical features rather than manometric diagnosis. Gastroenterology 108: 1024–1029, 1995.

  12. Papadopoulos V, Mimidis K. The rumination syndrome in adults: a review of the pathophysiology, diagnosis and treatment. J Postgrad Med 53: 203–206, 2007.

  13. Raha B, Sarma S, Thilakan P, Punnoose ZM. Rumination Disorder: An Unexplained Case of Recurrent Vomiting. Indian J Psychol Med 39: 361–363, 2017.

  14. Sidhu S, Rick J. Erosive Eosinophilic Esophagitis in Rumination Syndrome. Jefferson Journal of Psychiatry 22, 2009.

  15. Talley NJ. Rumination Syndrome. Gastroenterol Hepatol (N Y) 7: 117–118, 2011.

  16. Tucker E, Knowles K, Wright J, Fox MR. Rumination variations: aetiology and classification of abnormal behavioural responses to digestive symptoms based on high-resolution manometry studies. Alimentary Pharmacology & Therapeutics 37: 263–274, 2013.

  17. Wagaman JR, Williams DE, Camilleri M. Behavioral intervention for the treatment of rumination. J Pediatr Gastroenterol Nutr 27: 596–598, 1998.

  18. Wolke D, Skuse D, Reilly S. The nature and consequences of feeding problems in infancy. Childhood Feeding Problems and Adolescent Eating Disorders: 2013.

  19. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5). American Psychiatric Association, 2013.