Pervasive refusal syndrome (PRS) 21 years on: a re-conceptualisation and a renaming

Children's Peritraumatic Responses During Sexual Abuse Incidents: Exploring the Narratives of Children From Different Ethnoreligious Groups in Israel

The peritraumatic response of children during incidents of child sexual abuse (CSA) is a neglected construct in the literature. Despite the widespread use of the fight-flight-freeze model, recent studies have shown that in the unique context of child abuse, additional peritraumatic responses could be relevant. The current mixed-methods study examined children's peritraumatic responses to CSA. The sample consisted of 249 forensic interviews with children aged from 4 to 13 years. An initial qualitative analysis resulted in identifying various ways in which the children responded to the abuse, the children's decision-making around these responses, as well their perceptions of their response. This analysis was followed by quantitative analyses, which explored the frequency of these peritraumatic responses and their correlation with the characteristics of the children and abuse. Six peritraumatic response categories were identified, the most common being fight, flight, and fear. Only ethnoreligious identity was significantly correlated with the fight-or-flight response, with a significantly lower frequency among Muslim and ultra-Orthodox Jewish children. Frequency of abuse and perpetrator familiarity were correlated with the frequency of the fight-or-flight response, indicating that the latter was less relevant in reoccurring incidents of abuse and with perpetrators who were family members. The findings promote the conceptualization of children's peritraumatic responses during incidents of abuse and the realization of the crucial role of children's ecological systems in their peritraumatic responses to incidents of abuse.

Pervasive Refusal Syndrome: Three Case Reports—Autism as a Predisposing Factor and Gentle Coercion to Shorten Duration of Disorder?

Background

Pervasive refusal syndrome (PRS) is a severe child psychiatric syndrome not yet included in the international classification and mostly affecting girls aged 7-15 years. Hospital admission and severe loss of function extend for many months and years but most recover. Autism has been suggested as a predisposing factor but largely lacks support for typical cases of PRS. Treatment is not evidence-based and described as requiring a lengthy inpatient stay with a very gradual and sensitive rehabilitation program. Case Presentations. Three cases of pervasive refusal syndrome (PRS) in girls aged 9–16 years are presented to report autism as a predisposing factor and to discuss gentle coercion as part of the management strategy to speed up the lengthy recovery. The cases, which met the proposed criteria and typical background characteristics, were noted with the addition of undiagnosed autism in two cases. The duration of inpatient admission was 8–14 months. Disease duration was 15-36 months. An adequate but negative lorazepam trial to rule out catatonia was carried out. Treatment was in one case successfully expedited with gentle coercion within a transparent management plan. Rehabilitation was slower in PRS with comorbid autism; additionally, accommodations to school and living support needed to be put in place.

Conclusions

PRS is a useful clinical entity and best perceived as a primitive reaction to overwhelming stress rather than as catatonia. Autism might be another predisposing factor and needs to be assessed. A psychoeducational approach and a clear management plan support rehabilitation. A gentle coercion might hasten recovery.

Pervasive refusal syndrome: systematic review of case reports

Pervasive refusal syndrome (PRS) is a complex condition that affects young people leading to social withdrawal, inability or refusal to eat, drink, mobilise or speak. The affected individual regresses and is unable to self-care and quite characteristically will resist rehabilitation, worsen with praise or remain entirely passive. This systematic review was aimed at describing clinical features of PRS, current interventions and to summarise some of the nosological aspects of the condition. Without language restriction, an electronic search was conducted in Embase, PsychInfo, Medline, Cochrane library, and PubMed databases yielding 29 articles with a total of 79 cases. We performed a risk of assessment bias using an adapted Newcastle-Ottawa Scale and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 124 articles were identified, of which 29 were included and these yielded 79 cases. Seventy-six percent of the studies had a low rate of risk of assessment bias (good quality). Our results show that PRS overlaps with several conditions, mainly affects young females aged 7-15 years and has a recovery rate of 78% if diagnosed and treated early but the duration of inpatient treatment may last up to 9.44 months (8.82 SD). The patients had multiple inter-dependent risks. The major predisposing factors included vulnerable premorbid personality and pre-existing mental disorder. Precipitating factors were stressors such as infection and traumatic experiences. Enmeshed parent-child relationship served as a maintaining factor. The themes of treatment approach are essentially rehabilitative: (1) working collaboratively with patient and family, (2) having access to multidisciplinary team, and (3) peer/group supervision. This study has systematically evaluated a large sample of patients with PRS to ascertain its clinical features and the core elements of its treatment. Its key treatment approach is a multi-modal rehabilitative strategy that is compassionate, transparent and inclusive.

Pervasive refusal syndrome in child asylum seekers on Nauru

OBJECTIVES

Between 2013 and 2019, an estimated 200 children seeking asylum in Australia were detained on the island of Nauru. In 2018, 15 of these children developed the rare and life-threatening pervasive refusal syndrome (PRS). This paper describes the PRS case cluster, the complexities faced by clinicians managing these cases, and the lessons that can be learned from this outbreak.

CONCLUSIONS

The emergence of PRS on Nauru highlighted the risks of long-term detention of children in settings that are unable to meet their physical and psycho-social needs. The case cluster also underscored (a) the difficulties faced by doctors working in conditions where their medical and legal obligations may be in direct conflict, and (b) the role of clinicians in patient advocacy.

A Child is Being Caged: Resignation Syndrome and the Psychopolitics of Petrification

Uppgivenhetssyndrom, or resignation syndrome (RS), is a disorder that until recently was thought to affect the children of refugees in Sweden alone. The heuristic of psychopolitics is used to theorize RS as a form of abjection (Bataille, Kristeva) and petrification (Fanon, Marriott), and the movement from petrification to petrification in hallucinosis (Fanon, Bion) is delineated: first these children are petrified by persecutory and culturally specific stereotypes that precede and exceed them symbolically, and then, through a succession of shocks, they enter a post-traumatic stupor in which the faltering symbolization of the stereotype gives way to the (dis)embodiment of abject thinghood. Marriott's distinction between mirror as mask and mask as mirror allows the attribution of RS not only to sociocultural mimesis and the psychosocial impact of stereotypes (mirror as mask) but also to a socially imposed absence that the stereotype simultaneously conceals and reveals (mask as mirror). RS (petrification in hallucinosis) is considered the (dis)embodiment of this socially imposed absence.

Asylum seeking children and adolescents in Australian immigration detention on Nauru: a longitudinal cohort study

INTRODUCTION

Immigration detention has a profound and negative impact on the physical health, mental health, development and social-emotional well-being of children, adolescents and their families. Australian clinicians will report results from detailed health and well-being assessments of asylum seeking children and adolescents who have experienced prolonged immigration detention.

METHODS AND ANALYSIS

This is a national, multicentre study with a longitudinal cohort design that will document health and well-being outcomes of the children and adolescents who have been detained in offshore detention on the remote island of Nauru. Outcome measures will be reported from the time arrival in Australia and repeated over a 5-year follow-up period. Measures include demographics, residency history and refugee status, physical health and well-being outcomes (including mental health, development and social-emotional well-being), clinical service utilisation and psychosocial risk and protective factors for health and well-being (eg, adverse childhood experiences). Longitudinal follow-up will capture outcomes over a 5-year period after arrival in Australia. Analysis will be undertaken to explore baseline risk and protective factors, with regression analyses to assess their impact on health and well-being outcomes. To understand how children's outcomes change over time, multilevel regression analysis will be utilised. Structural equation modelling will be conducted to explore the correlation between baseline factors, mediational factors and outcomes to assess trajectories over time.

ETHICS AND DISSEMINATION

This research project was approved by the Sydney Children's Hospitals Network Human Research Ethics Committee. Subsequent site-specific approvals have been approved in 5 of the 11 governing bodies where the clinical consultations took place. In order to ensure this research is relevant and sensitive to the needs of the cohort, our research team includes an asylum seeker who has spent time in Australian immigration detention. Results will be presented at conferences and published in peer-reviewed Medline-indexed journals.

Pervasive refusal syndrome in asylum-seeking children: Review of the current evidence

This study reviews the current evidence in pervasive refusal syndrome (PRS) in asylum-seeking children. Refugees can experience a variety of traumas throughout the process of migration. Children can be exposed to multiple traumas such as experienced or witnessed physical or sexual violence, loss and bereavement, parental separation and the threat of persecution and/or kidnapping. The third stage of the migration journey can add further stress; children and families may experience multiple rejections of asylum application effectively living in limbo with the constant threat of deportation. High rates of mental health disorder are well documented in young asylum seekers, particularly depression, anxiety and post-traumatic stress disorder (PTSD). PRS is less frequently described but nonetheless a severe and life-threatening condition affecting young asylum seekers. Traumatisation, cultural factors and hostile asylum processes are specific moderating factors seen in asylum-seeking children. Asylum-seeking children normally make a full recovery from PRS. This study suggests a link between prolonged asylum processes and hostile foreign policy in developing and maintaining illness; similar cases are now being reported in other countries with hostile foreign policies. These findings are therefore relevant to clinicians and politicians working with this vulnerable group.

[Pervasive refusal syndrome in children]

Pervasive refusal syndrome is a rare clinical disorder affecting children and teenagers. It is characterised by social withdrawal and opposition which significantly affects how patients function and their treatment. The twenty or so cases reported in literature help to specify the main diagnostic and therapeutic elements. Early recognition of pervasive refusal syndrome is essential in order to treat these young patients as effectively as possible.

Agency, embodiment and enactment in psychosomatic theory and practice

In this paper, we examine some of the conceptual, pragmatic and moral dilemmas intrinsic to psychosomatic explanation in medicine, psychiatry and psychology. Psychosomatic explanation invokes a social grey zone in which ambiguities and conflicts about agency, causality and moral responsibility abound. This conflict reflects the deep-seated dualism in Western ontology and concepts of personhood that plays out in psychosomatic research, theory and practice. Illnesses that are seen as psychologically mediated tend also to be viewed as less real or legitimate. New forms of this dualism are evident in philosophical attacks on Engel's biopsychosocial approach, which was a mainstay of earlier psychosomatic theory, and in the recent Research Domain Criteria research programme of the US National institute of Mental Health which opts for exclusively biological modes of explanation of illness. We use the example of resignation syndrome among refugee children in Sweden to show how efforts to account for such medically unexplained symptoms raise problems of the ascription of agency. We argue for an integrative multilevel approach that builds on recent work in embodied and enactive cognitive science. On this view, agency can have many fine gradations that emerge through looping effects that link neurophenomenology, narrative practices and cultural affordances in particular social contexts. This multilevel ecosocial view points the way towards a renewed biopsychosocial approach in training and clinical practice that can advance person-centred medicine and psychiatry.

A systematic scoping review of diagnostic validity in avoidant/restrictive food intake disorder

OBJECTIVE

Avoidant/restrictive food intake disorder (ARFID) was introduced as a new diagnosis in the DSM-5. This systematic scoping review explores how ARFID as a diagnostic entity is conceptualized in the research literature and evaluates the diagnostic validity according to the Feighner criteria.

METHOD

A systematic scoping review of papers on ARFID in PubMed/MEDLINE and Web of Science was undertaken, following PRISMA and Joanna Briggs Institute guidelines.

RESULTS

Fifty-one original research publications, 23 reviews and commentaries, and 20 case reports were identified. The use of ARFID as a conceptual category varies significantly within this literature. At this time, the ARFID diagnosis does not fulfil the Feighner criteria for evaluating the validity of diagnostic constructs, the most urgent problem being the demarcation toward other disorders. A three-dimensional model-lack of interest in food, selectivity based on sensory sensitivity, and fear of aversive consequences-is gaining support in the research literature.

DISCUSSION

The introduction of the ARFID diagnosis has undoubtedly increased the recognition of a previously largely neglected group of patients. However, this article points to an inability of the current DSM-5 diagnostic criteria to ensure optimal diagnostic validity, which risks making them less useful in clinical practice and in epidemiological research. To increase the conceptual validity of the ARFID construct, several possible alterations to the current diagnostic criteria are suggested, including a stronger emphasis of the three identified subdomains and further clarifying the boundaries of ARFID.

Catatonia in children and adolescents: New perspectives

INTRODUCTION

Catatonia is a rare and severe psychomotor condition in children and adolescents. In the current report, we aimed to review the recent literature.

METHOD

Using a PRISMA approach, we searched MEDLINE between 1982 and 2017 using the keywords 'CATATONIA' and 'CHILD' or 'ADOLESCENT'. In total, we reviewed 130 reports (controlled study, N=4; clinical chart, N=23; case report, N=54; and editorial/review, N=42).

RESULTS

Several aspects seem to be age specific: (1) although the clinical presentation resembles that in adults, some symptoms are important in children and adolescents (e.g., psychomotor regression). (2) Associated disorders are similar to that found in adults; however, schizophrenia is more frequently observed than mood disorder. Additionally, a history of neurodevelopmental disorders maybe encountered. (3) Morbidity and mortality are among the worst in child psychiatry. (4) Underlying organic conditions are highly prevalent (>20% of the cases), and their search is warranted because some diagnoses may result in specific treatments (e.g., immune-suppressor therapy for autoimmune conditions). (5) Symptomatic approaches - high dose of benzodiazepines and electroconvulsive therapy (ECT) - are as efficient in children or adolescents as they are in adults, but this finding needs to be acknowledged because a resistance against the use of ECT or high-dose medication exists among child psychiatrists.

DISCUSSION

Recent advances in child and adolescent catatonia research have offered major improvements in understanding catatonia and in new therapeutic opportunities. The syndrome is rare, but these advances need to be acknowledged in order to direct patients to centers that have developed a specific expertise.

Retreating From Life: The Boy Whose Body Experienced His Pain

The expression of psychological distress through somatic symptoms is most prevalent among children. Somatic symptom disorders represent a difficult category of disorders to treat and they are often misdiagnosed due to their physical symptomology and dismissed due to their malingering stigma. The current case report follows the treatment of David, a 10-year-old Caucasian male, admitted into the pediatric psychiatric ward of a general hospital, uncommunicative, showing little signs of responsiveness, and dependent on nursing staff for basic needs. Following a complex treatment protocol which integrated key elements of psychodynamic and cognitive-behavior (CBT) treatment recommendations for somatic disorders, David was discharged after 6 months as an inpatient. This in-depth case study provides a synthesis of the varied research on somatic symptom disorders and an acute understanding of how to combine the understanding of complex family dynamics and individual personality structure with empirically reinforced treatment strategies.

A General Pediatrics and Integrative Medicine Approach to Pervasive Refusal Syndrome: A Case Report

INTRODUCTION

Pervasive refusal syndrome (PRS) describes children with social withdrawal who become unable to walk, eat, or care for themselves. This case report examines whether an integrative medicine approach is useful for treating PRS.

CASE PRESENTATION

A seven-year-old girl with symptoms most consistent with PRS and depression was admitted to a pediatric ward in Germany that integrates conventional pediatric and psychosomatic care with anthroposophic medicine. She was integrated into the structured activities of the ward and received massages, movement therapy, and color light therapy. Her parents were fully integrated into her care. After four weeks, she talked again, showed increased appetite, and supported herself when moved passively. She made a full recovery within four weeks after hospital discharge.

DISCUSSION

Integration of parents and an integrative medicine approach providing a variety of comforting sensory experiences was helpful for this patient with PRS.

Resignation Syndrome: Catatonia? Culture-Bound?

Resignation syndrome (RS) designates a long-standing disorder predominately affecting psychologically traumatized children and adolescents in the midst of a strenuous and lengthy migration process. Typically a depressive onset is followed by gradual withdrawal progressing via stupor into a state that prompts tube feeding and is characterized by failure to respond even to painful stimuli. The patient is seemingly unconscious. Recovery ensues within months to years and is claimed to be dependent on the restoration of hope to the family. Descriptions of disorders resembling RS can be found in the literature and the condition is unlikely novel. Nevertheless, the magnitude and geographical distribution stand out. Several hundred cases have been reported exclusively in Sweden in the past decade prompting the Swedish National Board of Health and Welfare to recognize RS as a separate diagnostic entity. The currently prevailing stress hypothesis fails to account for the regional distribution and contributes little to treatment. Consequently, a re-evaluation of diagnostics and treatment is required. Psychogenic catatonia is proposed to supply the best fit with the clinical presentation. Treatment response, altered brain metabolism or preserved awareness would support this hypothesis. Epidemiological data suggests culture-bound beliefs and expectations to generate and direct symptom expression and we argue that culture-bound psychogenesis can accommodate the endemic distribution. Last, we review recent models of predictive coding indicating how expectation processes are crucially involved in the placebo and nocebo effect, delusions and conversion disorders. Building on this theoretical framework we propose a neurobiological model of RS in which the impact of overwhelming negative expectations are directly causative of the down-regulation of higher order and lower order behavioral systems in particularly vulnerable individuals.

Functional coma

Functional coma - here defined as a prolonged motionless dissociative attack with absent or reduced response to external stimuli - is a relatively rare presentation. In this chapter we examine a wide range of terms used to describe states of unresponsiveness in which psychologic factors are relevant to etiology, such as depressive stupor, catatonia, nonepileptic "pseudostatus," and factitious disorders, and discuss the place of functional or psychogenic coma among these. Historically, diagnosis of functional coma has sometimes been reached after prolonged investigation and exclusion of other diagnoses. However, as is the case with other functional disorders, diagnosis should preferably be made on the basis of positive findings that provide evidence of inconsistency between an apparent comatose state and normal waking nervous system functioning. In our review of physical signs, we find some evidence for the presence of firm resistance to eye opening as reasonably sensitive and specific for functional coma, as well as the eye gaze sign, in which patients tend to look to the ground when turned on to one side. Noxious stimuli such as Harvey's sign (application of high-frequency vibrating tuning fork to the nasal mucosa) can also be helpful, although patients with this disorder are often remarkably unresponsive to usually painful stimuli, particularly as more commonly applied using sternal or nail bed pressure. The use of repeated painful stimuli is therefore not recommended. We also discuss the role of general anesthesia and other physiologic triggers to functional coma.

Pervasive refusal syndrome - A clinical challenge

Pervasive refusal syndrome is described as a condition comprising varying degrees of refusal across several domains; social withdrawal; resistance to treatment and is potentially life threatening with no detectable organic cause. Female predominance, refusal to eat with low weight, body image distortion, depressive features, premorbid personality issues similar to eating disorders have been noted, with 67% cases having complete recovery. In this paper, we describe what is probably the first case reported from India, of a child, who presented with neuropsychiatric symptoms, and treated with electroconvulsive therapy along with medications, but, sadly had a fatal outcome.