Rumination disorder (rumination syndrome) is an eating and feeding disorder in which food is involuntarily regurgitated into the mouth. In general, eating disorders encompass a spectrum of mental illnesses that affect an individual’s feeding, eating, and exercise habits. Though it may seem unlikely, rumination disorder is closely linked to the brain. Unlike traditional gastrointestinal (GI) conditions, rumination disorder is categorized as a functional GI disorder, denoting a disruption in the communication between the brain and the digestive system. 

Here, we provide background on rumination disorder, overview common symptoms and complications with the syndrome, and highlight some promising treatments. 

Background on Rumination Disorder

Rumination itself refers to the effortless and repeated regurgitation of food in the mouth. This phenomenon is different than vomiting or retching, as the bolus (the mass of food) hasn’t been exposed to the stomach acid. As a result, it likely tastes and looks the same as when it was first eaten. People with rumination syndrome describe feeling a need to burp or relieve abdominal pressure before regurgitating the food. Along the same lines, regurgitation is followed by a sense of physical relief. This effortless regurgitation typically occurs during or shortly after a meal. After the food is regurgitated, this action is followed by either re-chewing and swallowing it or expelling it.

Who Rumination Disorder Affects

Rumination disorder affects people of all ages and genders. A 2022 study revealed a 3.1% prevalence of ruminations syndrome worldwide, though it is difficult to know the actual number of people affected. It is typically more common in infants, young children, and children with cognitive impairments. However, because of the stigmas around eating disorders, this generalization may be skewed by the fact that adolescents and adults may try to hide the behavior out of embarrassment. For adults who reported, it is also found more commonly in females versus males. Other factors associated with rumination disorder include depression and anxiety, a recent GI illness or disorder, or a previous diagnosis of bulimia nervosa. 

Why and How Rumination Disorder Develops

In the normal process of digestion, food travels from the mouth, down the esophagus, and into the stomach. However, in the case of rumination disorder, if the stomach perceives the food as uncomfortable, abdominal muscles contract, initiating the regurgitation process.

While there may not be a specific trigger or cause, rumination disorder may emerge after an illness or during periods of heightened stress. However, there isn’t a single cause as the roots of this disorder lie in the complex signals exchanged between the brain and the gut. Over time, these actions become ingrained as a habit, with the pattern automatically unfolding in response to eating or drinking. Fortunately, psychological and behavioral treatments exist to guide the body in unlearning this habitual response, offering hope and support for those grappling with rumination disorder.

Physiology of Rumination

Rumination disorder is a complex and habitual reaction to the miscommunications between the brain and the digestive tract. Conditions like this are known as functional gastrointestinal disorders. While no disease or physical ailment is present, the symptoms are an involuntary and potentially harmful result of how the brain and the stomach interact.  

The physiological mechanisms underlying rumination syndrome involve the involuntary contraction of abdominal muscles paired with the relaxation of the lower esophageal sphincter (LES). Another potential contributing factor is the belch reflex, wherein the act of swallowing air induces the relaxation of the LES, triggering the regurgitation process. Understanding these intricate physiological responses can help both individuals living with rumination disorder and the healthcare professionals providing care.

Causes of Rumination Disorder

But why does it happen? As we mentioned above, rumination disorder develops due to miscommunications between the GI tract and the brain. In normal digestion, a seamless communication channel, known as the gut/brain axis (GBA), orchestrates the complex process. The GBA and the body’s microbiome have direct impacts on one’s mental health, including the potential development of anxiety, depression, and eating disorders. Rumination disorder develops because of a hiccup in the connection between these two systems, training the body to automatically regurgitate food after eating. Over time, these actions evolve into a habitual pattern, becoming automatic responses to the act of eating or drinking.

Rumination syndrome often starts due to a triggering event, like a viral disease, GI disorder, or change in stress levels. However, once the trigger passes, the person continues to experience regurgitation. Diagnosis of rumination disorder can be tricky, as it is sometimes confused with bulimia nervosa, gastroesophageal reflux disease (GERD), or gastroparesis. 

Symptoms of Rumination Syndrome

Recognizing the symptoms of rumination disorder is crucial for early diagnosis and intervention, as this disorder often persists untreated for extended periods. Typical symptoms include:

• Involuntary and easy regurgitation: Occurs within minutes of eating.
• Bad breath: A potential consequence of the disorder’s impact on oral health.
• Unchanged taste of regurgitated food: As digestive acids haven’t initiated the nutrient breakdown process, the taste remains the same.
• Altered eating habits: Some patients may change their eating patterns in an attempt to avoid or control regurgitation.
• Abdominal pain: Some individuals may experience abdominal discomfort as a form of pressure relief after regurgitation.
• Nausea: Some people may experience nausea before or after regurgitation episodes. 

Potential Complications

Left untreated, rumination disorder can give rise to a range of serious complications. The consequences include:

• Unhealthy weight loss: Despite the lack of proper digestion, signals to the brain indicate fullness, leading to unhealthy weight loss.
• Malnutrition: Regurgitated food lacks essential nutrient breakdown, contributing to nutritional deficiencies.
• Dehydration: People with rumination disorder may struggle to maintain proper electrolyte balance and can suffer from dehydration.
• Worn teeth: Exposure of dental enamel to regurgitated stomach contents can result in tooth decay.
• Social isolation: Individuals may experience social withdrawal due to the distressing and stigmatized nature of the disorder.
• Esophageal damage: Over time, untreated rumination disorder can lead to damage to the esophagus.
• Pneumonia: Regurgitation involves a heightened risk of developing aspiration pneumonia because the lungs have a more likely exposure to gastric contents.

Diagnosis of Rumination Syndrome

Because of its similarities with other medical conditions, diagnosing rumination disorder can present an obstacle to getting treatment. This process is further complicated by the varying symptoms. The DSM-5 states the following diagnostic criteria:

• Repeated, involuntary regurgitation of undigested food several times per day, continuing for at least one month.
• The regurgitation is not due to other GI conditions.
• Regurgitation happens soon after feeding or eating, and the regurgitated food is either rechewed and swallowed or spit out.

To identify rumination disorder, clinicians may ask questions like:

• What does the regurgitated food look or taste like? In rumination disorder, the food has not been digested yet. 
• How often does regurgitation happen and how soon after eating?
• Do medications for reflux help reduce regurgitation?

In some cases, medical professionals may conduct imaging or testing to rule out other GI conditions and evaluate the extent of malnutrition. This may include a gastric emptying test to measure how long food takes to enter the small intestine from the stomach or an upper endoscopy and x-ray to examine the inside of the esophagus and stomach. 

Treatment Options for Rumination Disorder

Addressing rumination disorder involves a multidimensional approach as there are currently no medications specifically tailored for its treatment. Instead, the primary focus lies in behavioral therapies aimed at retraining the brain-gut connection to facilitate proper digestion. Working closely with clinical psychologists is a pivotal component of this therapeutic process.

• Behavioral Therapy: Treatment for the disorder itself often uses a combination of different supportive therapies. These therapeutic approaches involve restructuring ingrained behavioral patterns. Two common modalities include Habit Reversal Training (HRT) and exposure and response prevention (ERP). HRT focuses on breaking the automatic response of regurgitation, while ERP aims to diminish anxiety triggers associated with the disorder.
• Nutritional Rehabilitation: In cases where rumination syndrome has led to severe weight loss and malnutrition, treatment may emphasize nutritional rehabilitation. This involves developing dietary plans and nutritional support to address deficiencies.
• Diaphragmatic Breathing: One of the most common and effective practices is a breathing technique that physically prevents the abdominal contractions leading to regurgitation or vomiting. Diaphragmatic breathing counters the body’s urge to engage in the habitual act of rumination.

By diligently addressing the underlying miscommunication between the brain and the gut, these treatments empower individuals to navigate the challenging journey of overcoming rumination disorder. The collaboration between individuals, clinicians, and supportive networks fosters resilience and provides a foundation for sustained recovery.

You’re Not Alone: The Alliance Can Help

Like many eating and feeding disorders, rumination disorder is a complex condition that is intertwined with both one’s mental and physical health. If you have a loved one struggling with rumination disorder or you are dealing with it yourself, know that you are not alone. At the Alliance, we hope to provide education and support to help anyone dealing with eating and feeding disorders take steps to recovery. Our team of mental health clinicians can help you get connected with the right treatment, including therapists and support groups. Call our helpline or refer to our resources page to learn more about potential treatments.