Treatment of Rumination Syndrome
Rumination syndrome should be treated primarily with diaphragmatic breathing techniques, not SSRIs. SSRIs have no established role in the treatment of rumination syndrome, which is a functional gastrointestinal disorder requiring behavioral interventions as first-line therapy 1.
Primary Treatment Approach
Diaphragmatic breathing is the cornerstone of treatment for rumination syndrome and should be implemented as the primary intervention 1. This behavioral technique directly addresses the pathophysiologic mechanism of rumination by preventing the involuntary abdominal wall contraction that drives regurgitation 1.
Implementation of Diaphragmatic Breathing
- Provide hands-on instruction and coaching on proper diaphragmatic breathing technique 2
- Use relaxing auditory media to facilitate learning and practice 2
- Practice the technique during and immediately after meals when rumination typically occurs 1
- Continue regular practice to maintain symptom control 1
Role of Pharmacotherapy
Tricyclic Antidepressants (Not SSRIs)
When pharmacotherapy is indicated, tricyclic antidepressants (TCAs) combined with diaphragmatic breathing show superior outcomes compared to behavioral therapy alone 2. In a study of 44 patients treated with this combination approach, 90.9% reported symptom improvement with a mean subjective improvement of 68.9%, and 45.5% achieved ≥80% improvement 2.
The rationale for TCAs (not SSRIs) is based on:
- Addressing gastric visceral hypersensitivity that accompanies rumination 2
- Managing comorbid anxiety present in approximately 66% of patients 2
- Treating the psychological stress that typically precedes symptom onset 2
Why SSRIs Are Not Recommended
There is no evidence supporting SSRI use for rumination syndrome. The available literature does not include controlled trials of SSRIs for this condition 3. While SSRIs are mentioned in guidelines for other functional disorders like globus sensation 4, they have no established efficacy for rumination syndrome specifically 1, 3.
Augmented Interventions
Cognitive-Behavioral Techniques
For patients with concurrent disordered eating or when diaphragmatic breathing alone is insufficient:
- Implement behavioral experimentation to challenge maladaptive beliefs 5
- Use self-monitoring to increase awareness of rumination triggers 5
- Apply cognitive restructuring for associated eating disorder symptoms 5
Additional Behavioral Methods
- Gum chewing has shown success in individual cases 3
- Behavior modification techniques may be helpful as adjunctive therapy 3
Clinical Pitfalls to Avoid
Do not prescribe SSRIs as first-line or even second-line treatment for rumination syndrome. This represents a fundamental misunderstanding of the disorder's pathophysiology and treatment evidence base 1, 3.
Do not delay diagnosis due to patient shame about symptoms. Patients rarely volunteer a history of rumination, so clinicians must routinely ask about postprandial regurgitation and rechewing behaviors 3.
Do not overlook the temporal relationship between psychological stressors and symptom onset. Approximately 66% of patients report symptoms beginning after an identifiable stressor, which informs the treatment approach 2.
Expected Outcomes
With appropriate treatment combining TCAs and diaphragmatic breathing: