Kaplan + Sadock's Synopsis of Psychiatry, 11e

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31.9b Rumination Disorder

No definitive treatment exists for pica per se; most treatment is aimed at education and behavior modification. Treatments emphasize psychosocial, environmental, behavioral, and family guidance approaches. An effort should be made to ameliorate any significant psychosocial stressors. When lead is present in the surroundings, it must be eliminated or rendered inaccessible or the child must be moved to new surroundings. When pica persists in the absence of any toxic manifesta- tions, behavioral techniques have been utilized. Positive rein- forcement, modeling, behavioral shaping, and overcorrection treatment have been used. Increasing parental attention, stimu- lation, and emotional nurturance may yield positive results. A study found that pica occurred most frequently in impoverished environments, and in some patients, correcting an iron or zinc deficiency has eliminated pica. Medical complications (e.g., lead poisoning) that develop secondarily to the pica must also be treated. 31.9b Rumination Disorder Rumination is an effortless and painless regurgitation of par- tially digested food into the mouth soon after a meal, which is either swallowed or spit out. Rumination can be observed in developmentally normal infants who put their thumb or hand in the mouth, suck their tongue rhythmically, and arch their back to initiate regurgitation. This behavior pattern may be observed in infants who receive inadequate emotional interac- tion and have learned to soothe and may stimulate themselves through rumination. However, rumination syndromes can be found to occur in children and adolescents, and rumination is considered to a functional gastrointestinal disorder. The patho- physiology of rumination is not well understood; however, it often involves a rise in intragastric pressure, generated by either voluntary or unintentional contraction of the abdomi- nal wall muscles causing movement of gastric contents back up into the esophagus. The onset of the disorder can occur in infancy, childhood, or adolescence. In infants, it typically occurs between 3 months and 12 months of age, and once the regurgitation occurs, the food may be swallowed or spit out. Infants who ruminate are characteristically observed to strain with their backs arched and head back to bring the food back into their mouths and appear to find the experience pleasur- able. Infants who are “experienced” ruminators are able to bring up the food through tongue movements and may not spit out the food at all, but hold it in their mouths and re-swallow it. The disorder is less common in older children, adolescents, and adults. It varies in severity and is sometimes associated with medical conditions, such as hiatal hernia, that result in esophageal reflux. In its most severe form, the disorder can cause malnutrition and be fatal. The diagnosis of rumination disorder can be made even if an infant has attained a normal weight for his or her age. Failure to thrive, therefore, is not a necessary criterion of this disorder, but it is sometimes a sequela. According to DSM-5, the disorder must be present for at least 1 month after a period of normal functioning, and not better accounted for by gastrointestinal ill- ness, or psychiatric or medical conditions.

paper, her mother was coached to engage her in a play activity rather than screaming at her and grabbing her mouth. Chantal and her mother continued in therapy for a year, during which their relationship gradually became more interactive and warm, while Chantal’s chewing behaviors decreased, and even her thumb sucking abated.

Pathology and Laboratory Examination

No single laboratory test confirms or rules out a diagnosis of pica, but several laboratory tests are useful because pica has sometimes been associated with abnormal levels of lead. Levels of iron and zinc in serum should be determined and corrected if low. In rare cases when this is the etiology, pica may disappear when oral iron and zinc are administered. Hemoglobin level should be determined to rule out anemia. Differential Diagnosis The differential diagnosis of pica includes avoidance of food, anorexia, or rarely iron and zinc deficiencies. Pica may occur in conjunction with failure to thrive, and be comorbid with schizophrenia, autism spectrum disorder and Kleine-Levin syndrome. In psychosocial dwarfism, a dramatic but reversible endocrinological and behavioral form of failure to thrive, chil- dren often show bizarre behaviors, including ingesting toilet water, garbage, and other nonnutritive substances. Lead intoxi- cation may be associated with pica. In children who exhibit pica that warrants clinical intervention, along with a known medical disorder, both disorders should be coded according to DSM-5. In certain regions of the world and among certain cultures, such as the Australian aborigines, rates of pica in pregnant women are reportedly high. According to DSM-5, however, if such practices are culturally accepted, the diagnostic criteria for pica are not met. Course and Prognosis The prognosis for pica is usually good, and typically in chil- dren with normal intellectual function, pica generally remits spontaneously within several months. In childhood, pica usu- ally resolves with increasing age; in pregnant women, pica is usually limited to the term of the pregnancy. In some adults with pica, particularly those who also have autism spectrum disorder and intellectual disability, pica can continue for years. Follow-up data on these populations are too limited to permit conclusions. Treatment The first step in determining appropriate treatment of pica is to investigate the specific situation whenever possible. When pica occurs in the context of child neglect or maltreatment, clearly those circumstances must be immediately corrected. Expo- sure to toxic substances, such as lead, must also be eliminated.