Augmenting Diaphragmatic Breathing With Behavioral Exposure: Single-Case Experimental Design for Rumination Disorder

Abstract

ObjectiveRumination disorder (RD) is a feeding/eating disorder and disorder of gut-brain interaction characterized by repeated, effortless regurgitations. Diaphragmatic breathing is the most widely used treatment technique for RD, theoretically as a competing response to the habitual contraction of the abdominal wall. However, in light of diaphragmatic breathing’s lack of effectiveness for some patients, we created a comprehensive treatment to test the incremental effect of behavioral exposure on symptom change. MethodIn a single-case experimental design, we present the treatment of a 27-year-old patient with a 9-year history of untreated RD. The patient completed a comprehensive six-session cognitive-behavioral treatment for RD, comprising a 1-week phase of self-monitoring regurgitations + psychoeducation (Phase A), a 6-week phase of diaphragmatic breathing (+ identification of secondary maintenance mechanisms) (Phase B), and a 3-week phase of diaphragmatic breathing + behavioral exposure (Phase C). We compared change in daily symptom data between Phases B and C, and also report 20-month follow-up data. ResultsThe patient’s daily regurgitation frequency did not change during Phase B (diaphragmatic breathing alone), even with the elimination of foods that had become associated with regurgitations. However, she achieved a significant reduction in regurgitations during Phase C, with symptom remission extending to 20-month follow-up. Phase C included purposefully breaking learned associations with food stimuli using behavioral exposure. ConclusionsOur data suggest that when diaphragmatic breathing alone is not effective in reducing symptoms, further cognitive and behavioral techniques like behavioral exposure can augment the effect of diaphragmatic breathing on symptom reduction.