Rumination-regurgitation disorder

Essential (Required) Features:

• The intentional and repeated bringing up of previously swallowed food back to the mouth (i.e., regurgitation), which may be re-chewed and re-swallowed (i.e., rumination), or may be deliberately spat out (but not as in vomiting).
• The regurgitation behaviour is frequent (at least several times per week) and sustained over a period of at least several weeks.
• The diagnosis should only be assigned to individuals who have reached a developmental age of at least 2 years.
• The regurgitation behaviour is not a manifestation of another medical condition that directly causes regurgitation (e.g., esophageal strictures or neuromuscular disorders affecting esophageal functioning) or causes nausea or vomiting (e.g., pyloric stenosis).

Additional Clinical Features:

• In Rumination-Regurgitation Disorder, the regurgitation behaviour is intentional; for example, individuals may contract the tongue or abdominal muscles or cough in order to induce regurgitation. Individuals with Rumination-Regurgitation Disorder are able to regurgitate food with relative ease and may derive some reduction of anxiety or pleasure from the behaviour.
• Individuals with Rumination-Regurgitation Disorder often experience shame and embarrassment about the behaviour and try to keep the behaviour a secret because they recognize it as socially unacceptable.
• Individuals with Rumination-Regurgitation Disorder are often reluctant to seek treatment. The disorder may persist for a very long duration if left untreated.

Course Features:

• Rumination-Regurgitation Disorder is slightly more prevalent among individuals with Disorders of Intellectual Development and Autism Spectrum Disorder whereby it may serve a self-soothing or self-stimulating function.
• Rumination-Regurgitation Disorder may be chronic or continuous, or it may be episodic. In episodic cases, the behaviour may be associated with stress or anxiety.
• Adolescents and adults may be less likely to re-chew the regurgitated food and older adults may choose to shallow or spit out the material depending on the social situation.

Developmental Presentations:

• Onset of Rumination-Regurgitation Disorder may occur across early and later childhood, adolescence, and adulthood.
• Rumination-Regurgitation Disorder can create a substantial risk for choking in very young children due to their inability to control their swallowing.

Culture-Related Features:

• Some cases of what has been considered to be ‘psychogenic vomiting’ or vomiting as a somatoform expression of distress, particularly in South Asia, may be better diagnosed as cultural variants of Rumination-Regurgitation Disorder.
• Induced vomiting may be part of some yogic practices and should not be considered a sign of the disorder unless the vomiting exceeds cultural norms and is associated with distress or impairment.

Sex- and/or Gender-Related Features:

• There are no known differences in clinical features across genders.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Infant Rumination Syndrome: Rumination-Regurgitation Disorder should not be diagnosed in infants. Similar phenomena in infants should be diagnosed as Infant Rumination Syndrome in the grouping of Functional digestive disorders of infants, toddlers or children in the ICD-11 chapter on Diseases of the Digestive System.
• Boundary with self-induced vomiting: Rumination-Regurgitation Disorder should be distinguished from self-induced vomiting. Self-induced vomiting may occur as a part of the presentation of Anorexia Nervosa, Binge-Purge Type or Bulimia Nervosa. Self-induced vomiting may also occur as a culturally sanctioned practice (e.g., among practitioners of yoga) that is not associated with a mental disorder.
• Boundary with psychogenic vomiting: The differentiation from ‘psychogenic vomiting’, or vomiting as a somatic expression of distress, particularly in South Asia, is based on the fact that regurgitation in Rumination-Regurgitation Disorder is typically volitional and intentional.