Rumination Disorder | Is It More Than Just Repetitive Thoughts?

Rumination Disorder is a specific type of feeding and eating disorder characterized by the repeated and effortless regurgitation of recently ingested food. This process is distinct from vomiting as it is not forceful or associated with nausea or disgust. After the food is brought back up into the mouth, it may be re-chewed and re-swallowed, or sometimes spit out. This behavior must occur for at least one month to meet diagnostic criteria. It is crucial to distinguish this condition from cognitive rumination, which involves a pattern of repetitive, negative thinking. The term 'rumination' is used in both contexts, but this disorder refers specifically to the physical act involving digestion. The underlying mechanism often involves a learned, voluntary relaxation of the diaphragm, which increases intra-abdominal pressure and allows stomach contents to flow back up the esophagus. This action can become a subconscious habit that happens automatically after eating. Diagnosis requires ruling out other gastrointestinal conditions like gastroesophageal reflux disease (GERD) and other eating disorders such as anorexia nervosa or bulimia nervosa, as the regurgitation is not primarily driven by concerns about body weight or shape.

The core symptom of Rumination Disorder is the persistent regurgitation of food. This typically occurs within minutes of finishing a meal. Individuals with the disorder often describe the process as habitual and outside of their complete control. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the specific criteria for diagnosis include: A) Repeated regurgitation of food for a period of at least one month. B) The regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., GERD, pyloric stenosis). C) The behavior does not occur exclusively during the course of Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder, or Avoidant/Restrictive Food Intake Disorder. D) If the symptoms occur in the context of another mental disorder or neurodevelopmental disorder (e.g., intellectual disability), they are sufficiently severe to warrant additional clinical attention. Associated features may include bad breath (halitosis), dental erosion from stomach acid, and unintentional weight loss or malnutrition.

The exact cause of Rumination Disorder is not fully understood, but it is considered a learned behavior that often develops following a viral illness, a period of stress, or a gastrointestinal issue. The mechanism involves a voluntary but unconsciously maintained muscle action. The process, known as the regurgitation response, is initiated by a contraction of the abdominal muscles and a relaxation of the lower esophageal sphincter—the muscle that normally prevents food from leaving the stomach. This creates a pressure gradient that pushes food back up. This action might have initially provided a sense of relief from abdominal discomfort, and through reinforcement, it becomes an ingrained, automatic habit. The connection between the brain and the digestive system, often called the brain-gut axis, plays a significant role. Psychological factors such as stress, anxiety, and trauma can trigger or exacerbate the symptoms, highlighting the interplay between mental state and physiological function.

Rumination Disorder is frequently confused with other conditions, but key differences exist. Unlike Bulimia Nervosa, the regurgitation in Rumination Disorder is not intentional for the purpose of weight control and is not typically preceded by a binge-eating episode. The individual does not usually express distress about weight gain or body image as the primary driver of the behavior. Furthermore, the regurgitation is often described as effortless, unlike the forceful and often painful act of self-induced vomiting. It is also distinct from Gastroesophageal Reflux Disease (GERD). In GERD, the backflow of stomach acid is caused by a dysfunctional or weak lower esophageal sphincter, which is an involuntary physiological issue. In contrast, the regurgitation in Rumination Disorder is mediated by a learned response involving the contraction of abdominal muscles, even if the action has become subconscious.

Treatment for Rumination Disorder is primarily behavioral and focuses on unlearning the regurgitation response. The most effective and evidence-based technique is diaphragmatic breathing, also known as belly breathing. This method trains the individual to consciously use their diaphragm—the large muscle at the base of the lungs—during breathing. By engaging the diaphragm correctly after eating, it becomes impossible to simultaneously contract the abdominal muscles in a way that causes regurgitation. The goal is to replace the learned regurgitation habit with the new, incompatible behavior of proper diaphragmatic breathing. This requires consistent practice, especially for 10-15 minutes after each meal. In addition to this behavioral therapy, addressing any co-occurring psychological factors like stress or anxiety through psychotherapy or relaxation techniques can be beneficial. A comprehensive approach often involves collaboration between a gastroenterologist to rule out physical causes and a psychologist or behavioral therapist to implement the treatment protocol.