85 Rumination Disorder (307.53)

DSM-IV-TR criteria

• A. Repeated regurgitation and rechewing of food for a period of at least one month following a period of normal functioning.
• B. The behavior is not due to an associated gastrointestinal or other medical condition (e.g.,esophageal reflux).
• C. The behavior does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa. If the symptoms occur exclusively during the course of Mental Retardation or a Pervasive Developmental Disorder, they are sufficiently severe to warrant clinical attention.

Associated features

• A child or infant with rumination disorder will often experience repeated regurgitation and/or re-chewing of food as well as weight loss, bad breath and tooth decay, repeated stomachaches and indigestion, and raw and chapped lips. Vomitus may be seen on the individual’s chin, neck, and clothing, but the regurgitation is often not visible to others. When associated weight loss and growth failure occurs, it can often seem unexplained.
• In children and adults, regurgitation typically occurs within minutes of a meal and may last several hours. It generally occurs regularly after most meals. The individual with rumination disorder may appear to gain satisfaction from mouthing the regurgitated food rather than being disgusted by the vomitus, as well.
• The adult also experiences tooth decay and erosion as well as aspiration, but generally does not experience weight loss as with children and infants. The aspiration associated with this disorder can cause recurrent bronchitis or pneumonia, bronchospasms, reflex laryngospasms, and asthma.

Child vs. adult presentation

• Little is known about the prevalence of rumination disorder. We do know that rumination has been reported in not only infants and adults with mental retardation but also in infants, children, and adults of normal intelligence.
• Lack of information on the prevalence of the disorder may be due to secrecy of those actually diagnosed.

Gender and cultural differences in presentation

Rumination occurs in both males and females, but seems to be more common among male infants. Rumination disorder has often been reported in other countries, but the frequency is unclear. Most of the studies conducted relating to the disorder have been shown to be unreliable.

Epidemiology

• Although there are no recent systematic prevalence reports of rumination disorder, the cases that have been studied and reported suggest that rumination is a very rare disorder. The typical age of onset is between the age of 3 and 12 months.
• In individuals with mental retardation, the onset of this disorder can occur at any age, but typically occurs around the age of 6.

Etiology

• The exact cause of rumination is unclear. However, several theories, ranging from psychosocial to organic origins have been proposed. One of the most common psychosocial theories of the etiology of rumination disorder is the development due to an abnormal mother-infant/child relationship. In terms of this relationship, lack of stimulation, neglect, and stressful life situations are some of the factors associated with this disorder.
• One of the most common learning based-theories proposes that the development of this disorder is for the purpose of self-stimulation. The self-stimulation tends to increase after the pleasurable sensations produced by the process of rumination or the increased attention from others after the ruminating. Negative Reinforcement relating to stress may play a part in the cause of rumination.

Empirically supported treatments

• Treatment of this disorder often depends on the etiology and associated behavior. Treatment is usually a behavioral modification plan designed to promote normal eating behavior. In this type of treatment, efforts are typically directed toward the parent-child relationship and are often focused on improving the caregiver’s ability to recognize and respond to the child’s needs in the appropriate fashion. Parents may be taught parenting techniques that aim to increase attention, interaction, and stimulation.
• Generally, rumination in infants of average intelligence stops on its own, but the disorder should still be treated because infants without treatment could experience malnutrition and dehydration, which could eventually lead to death.