The first clinical description of rumination is that made in 1618 by an Italian anatomist, Fabricious ab Aquapendente. It seems that before this date the medical literature had not dealt with rumination simply because it was considered a disorder, but it was culturally tolerated as a pleasant habit.
The description of rumination as an abnormal phenomenon, culturally deplorable, later began to join the theories that postulated the existence of a blood link between people addicted to rumination and the bovine species. The first attempts to cure rumination date back to the 1950s, when the pathogenesis of the disorder was attributed to the interpersonal relationship of the infant with the mother (Fredericks, 2000)
This disorder is characterized by repeated regurgitation, chewing, and swallowing of food for at least a month. In order to speak of Rumination Disorder , regurgitation cannot be justified by a gastrointestinal pathology nor is it exclusively associated with another eating disorder. In particular, Rumination Disorder is characterized by:
- regurgitation in the mouth without nausea;
- involuntary retching;
- disgust;
- re-chewing.
The disorder can be diagnosed at all ages but is found mainly associated with intellectual disability. Diagnosis in neonatal age (3-12 months) is facilitated by the position that infants assume in the presence of Rumination Disorder : stretching and arching of the back with the head thrown back associated with sucking movements with the tongue. They show themselves hungry between one regurgitation and the next and lose weight by not exceeding the planned weight stages; in the most serious cases it can lead to malnutrition (mortality rates up to 25% are reported). Psychosocial problems such as poor environmental stimulation, abandonment, stressful life events, and problems in the parent-child relationship can be predisposing factors. In some cases, the Disorder. Nutrition Disorder of Infancy or Early Childhood . In children, however, the disorder frequently undergoes spontaneous remission.
In the presence of intellectual disability, Rumination Disorder seems to have a self-soothing or self-stimulating function similar to that of other repetitive behaviors such as, for example, head banging.
Instead, adults and adolescents can mask the regurgitation behavior through specific gestures that significantly harm people’s social and relational life:
- put your hand in front of your mouth;
- to cough;
- avoid eating in public;
- avoid eating food before a social activity;
- avoid breakfast (fear of being able to throw up at work).
Treatment
In order to identify the correct interventions, it is first of all necessary to distinguish rumination from vomiting and related behaviors. The inability to recognize physiological elements among the etiological factors, such as iatrogenic impairment of laryngeal and esophageal function or gastroesophageal reflux due to structural deficits, can result in a dangerous degeneration of the patient’s state of health and in the application of therapies inappropriate.
MEDICAL APPROACH :
- blood test for anemia;
- endocrine functions – hormones;
- serum electrolytes;
- endoscopy;
- radiological examinations.
Surgical interventions that involve the treatment of hiatal hernias or the artificial closure of the cardia, the opening of the esophagus into the stomach, result in the reduction of rumination and vomiting behaviors. However, surgical interventions should be limited to cases for which a physiological etiology has been clearly diagnosed and, in any case, to people who have been found to be refractory to less invasive therapies.
PSYCHIATRIC APPROACH : For the treatment of some cases of Rumination Disorder it may be useful to consider the dual diagnosis of mental retardation and psychopathology. Rumination in adults with mental retardation has been associated with particular psychological conditions, such as depression and chronic anxiety. It is not unwarranted to think that depression or anxiety may contribute to the onset of Rumination Disorder in people with mental retardation. Therefore, the determination of a dual diagnosis in people with mental retardation can provide useful guidance for appropriate treatment.
COGNITIVE BEHAVIORAL APPROACH : Behavioral interventions for the treatment of Rumination Disorder took hold in the 1960s as aversive procedures designed to reduce this behavior in people with mental retardation began to yield some results. In the functional analysis it is good to immediately distinguish vomiting with partial or absent re-ingestion (reinforced by the external environment) from rumination with re-swallowing (reinforced by self-stimulation). Therapies can be divided into two categories: aversive and non-aversive.
- Aversive therapy: in vogue until the end of the 1980s, this therapy involved the use of techniques such as hypercorrection, subtraction of positive things, the use of substances with an unpleasant taste. Since there are no fading procedures (gradual and progressive attenuation) of aversive interventions of proven efficacy, for ethical reasons these procedures should only be used as short-term interventions in severe situations.
- Non-aversive therapy: the techniques used are satiation, differential positive reinforcement of incompatible or alternative behaviors, extinction, specific feeding techniques, contingent physical exercise and the use of combined interventions.
