Resignation Syndrome: Catatonia? Culture-Bound?

Asserting a Functional Neurological Symptom Disorder with a Complementary Diagnostic Approach: A Brief Report

INTRODUCTION

Functional neurological symptom disorder (FNSD) is a common diagnosis among adolescents. However, we feel it is a difficult diagnosis to assess because of the diversity of its clinical manifestations, the rapid changes in its nosography over the years, and its common imbrication with established somatic diagnoses. We would like to illustrate this hypothesis through a case presentation and the original diagnostic process that emerged from it.

METHODS

We chose to present our diagnosis approach through the case of an 11-year-old boy who showed a progressive loss of motor and sensory function to the point of total dependency, and then suddenly switched between this state and a "normal" physical presentation, while deliriously claiming to be an angel.

RESULTS

All possible infectious, autoimmune, metabolic, and toxic disorders were ruled out. After the successive therapeutic failures of antidepressants and neuroleptics, FNSD was diagnosed.

CONCLUSION

The DSM-5-TR classification was insufficient to explain the full clinical picture and a complementary approach (biblical, psychoanalytical, and historical) was used to analyze the cause of this atypical presentation.

Client States: Australia's Offshore Detainees and the Limits of Therapy

Mental health has become an exceptionally important social and public health issue in Australia. The government has invested billions of dollars in new services, while ubiquitous ad campaigns call on ordinary people to tend to their psychological well-being. This national valorization of mental health is striking, given the well-documented psychiatric harm suffered by refugees under Australia's offshore detention regime. This article draws on ethnographic work with a group of volunteer therapists who provide crisis counseling to these detained refugees over WhatsApp, allowing them to intervene in scenarios where therapy is inaccessible but badly needed. Highlighting the predictable challenges and surprising affordances of delivering care in this restrictive and high-stakes context, I show how my informants forge a genuine therapeutic connection with their clients. While this intervention is meaningful, I argue that the volunteers are aware that it is no substitute for winning political freedom.

The neurobiology of functional neurological disorders characterised by impaired awareness

We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.

Separation and not residency permit restores function in resignation syndrome: a retrospective cohort study

Despite poor treatment results, a family-oriented approach and the securing of residency have been deemed essential to recovery from resignation syndrome (RS). In a retrospective cohort study, we evaluated an alternative method involving environmental therapy, with patients separated from their parents, while actively abstaining from involving the asylum process in treatment. We examined medical records, social services acts, and residential care home acts from 13 individuals treated at Solsidan residential care home between 2005 and 2020. Severity and outcome were assessed with Clinical Global Impression, Severity and Improvement subscales. Thirteen participants were included and out of these nine (69%) recovered, i.e. they very much or much improved. Out of the eight that were separated, all recovered, also, one non-separated recovered. The difference in outcome between subjects separated and not was significant (p = 0.007). Moreover, out of the five which received a residency permit during treatment, one recovered whereas four did not. The difference in outcome between subjects granted residency and not was significant (p = 0.007). The data revealed three (23%) cases of simulation where parents were suspected to have instigated symptoms. Our evaluation suggests that separation from parents and abstaining from invoking residency permit could be essential components when treating RS. Relying on a family-oriented approach, and residency could even be detrimental to recovery. The examined intervention was successful also in cases of probable malingering by proxy.

Dediagnosing - a novel framework for making people less ill

Diagnosing constitutes a substantial part of healthcare work and triggers a wide range of actions including the prescription of medicines. Dediagnosing is proposed as a novel framework for removing diagnoses that do not contribute to the reduction of persons' suffering and should be introduced to make people less ill. Dediagnosing comes together with other efforts to reduce overuse, such as deimplementation, deprescribing, decommissioning, and disinvestment. Because diagnoses may influence identity construction and social rights, dediagnosing must be conducted in close collaboration with the patient.

Social Bottom-Up Approaches in Post-COVID-19 Scenario: The AGOGHÈ Project

The AGOGHÈ Project aims to produce innovative and entrepreneurial models following the global socioeconomic changes caused by COVID-19. Its objectives include (i) generating awareness, education and social skills through dedicated ethical workstations and workgroups; (ii) developing a novel figure called “Social Trainer” who represents a professional opportunity for young graduates, able to discuss, explain and guide others through the maze of active citizenship rules. The project was developed in the Quartieri Spagnoli of Naples (Italy). The current manuscript reports preliminary data from the local community collected between November and December 2020. Results provide an insight into the neighbourhood, where the lockdown produced an increment in school dropouts and irreparable economic damage. In conclusion, the approach proposed with the AGOGHÈ Project, fully described here, is predicted to be beneficial in increasing social, cultural and economic aspects in the local area and in facilitating a dialogue between people, stakeholders and governments engaging in novel resolutions for post-COVID-19 crises.

Psychomotor Predictive Processing

Psychomotor experience can be based on what people predict they will experience, rather than on sensory inputs. It has been argued that disconnects between human experience and sensory inputs can be addressed better through further development of predictive processing theory. In this paper, the scope of predictive processing theory is extended through three developments. First, by going beyond previous studies that have encompassed embodied cognition but have not addressed some fundamental aspects of psychomotor functioning. Second, by proposing a scientific basis for explaining predictive processing that spans objective neuroscience and subjective experience. Third, by providing an explanation of predictive processing that can be incorporated into the planning and operation of systems involving robots and other new technologies. This is necessary because such systems are becoming increasingly common and move us farther away from the hunter-gatherer lifestyles within which our psychomotor functioning evolved. For example, beliefs that workplace robots are threatening can generate anxiety, while wearing hardware, such as augmented reality headsets and exoskeletons, can impede the natural functioning of psychomotor systems. The primary contribution of the paper is the introduction of a new formulation of hierarchical predictive processing that is focused on psychomotor functioning.

Diagnostic and Therapeutic Challenges of Catatonia in an Adolescent With High Functioning Autism Spectrum Disorder: A Case Report

Catatonia is a psychomotor syndrome with specific clusters of speech, behavioral and motor features. Although potentially life-threatening, especially in its malignant form accompanied with autonomic dysregulation and medical complications, it is a treatable condition, when promptly identified. For a long time catatonia was considered a marker of schizophrenia, thus limiting the possibility of diagnosis and treatment. Due to growing awareness and studies on the subject, it is now known that catatonia can occur in the context of a number of diseases, including psychotic, affective and neurodevelopmental disorders. In recent years, there's been a renewed interest in the recognition and definition of catatonia in neurodevelopmental disorders, such as Autism Spectrum Disorder (ASD), where the differential diagnosis poses great challenges, given the considerable overlapping of signs and symptoms between the conditions. We present the case of a 15 year old boy with High Functioning ASD with a sudden onset of severe catatonic symptoms and the co-existence of psychotic symptoms, whose complex clinical course raises many questions on the differentiation and relation of said disorders.

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.

Asylum-seeking children with resignation syndrome: catatonia or traumatic withdrawal syndrome?

In the beginning of the 2000s, an increasing number of asylum-seeking children in Sweden fell into a stuporous condition. In the present study, we report 46 consecutive children with the most severe form of this illness where the children were unable to give any response at all, did not react to pain, cold or touching, could not be supported to sit or stand on their feet, could not do anything when requested, and in most cases had enuresis/encopresis. A minority of the children came from war zones (n = 8, 17.4%). A majority belonged to an ethnic or religious minority (n = 32, 69.6%) in their homeland and almost all were persecuted (n = 43, 93.5%). All had either experienced violence themselves or had witnessed or heard about violence against close family members. The age of onset of the first symptom of illness for boys was 11.2 years [CI 9.6-12.8], for girls 11.8 yrs.[CI 10.4-13.2], and the age for falling into stupor for boys was 12.9 years [CI 11.6-14.1] years and was the same for girls, 12.9 years [CI 11.6-14.2] years. Girls tended to have depression before entering the stuporous condition, while the boys tended to have PTSD first (Chi-square = 3.73, p = 0.054). A majority of the children had one (n = 13, 28.3%) or both parents (n = 14, 30.4%) suffering from mental or severe physical disorder. It is discussed whether the presented condition is a separate entity or if the syndrome should be regarded as a variant of catatonia, and whether benzodiazepines should be tried.

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.

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.

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.

Assessing Post-Traumatic Tonic Immobility Responses: The Scale for Tonic Immobility Occurring Post-Trauma

BACKGROUND

Peri-traumatic tonic immobility has been associated with the development and course of post-traumatic stress disorder. Despite serving as an adaptive late-stage defense response, tonic immobility that continues in response to post-traumatic reminders may lead to reduced functioning and a diminished sense of well-being. At present, no validated self-report measures assess post-traumatic tonic immobility responses specifically.

METHODS

The primary objective of the present study was to evaluate the Scale for Tonic immobility Occurring Post-trauma (STOP), the first self-report measure developed to assess for the presence and severity of tonic immobility responses that persist following trauma exposure as part of post-traumatic symptomatology. Trauma-exposed clinical and non-clinical participants (N = 462) with a history of tonic immobility completed a demographic questionnaire, the STOP, and measures of post-traumatic symptoms, dissociation, anxiety, and depression.

RESULTS

STOP assessed four latent constructs, which were interpreted following the human defense cascade model. Together, these factors capture the sensorimotor and perceptual alterations, and dissociative experiences, associated with post-traumatic tonic immobility as a trauma-related altered state. Residual symptoms and the experience of negative affect following this response (including guilt and shame) are also represented. STOP scores demonstrated excellent reliability, as well as good construct and convergent validity, with other measures of dissociation and post-traumatic stress disorder. Results from the present study suggest tonic immobility is most consistent with other dissociative post-traumatic symptomatology.

CONCLUSIONS

STOP demonstrates excellent preliminary psychometric properties and may be useful for researchers and clinicians wishing to assess chronic forms of tonic immobility across trauma-exposed, clinical and community samples.

Chronic pain: a consequence of dysregulated protective action

Introduction

Pain is considered to be one of a number of idiosyncratic, context-dependent 'protective actions' projected into the conscious domain by the central nervous system (CNS), as a result of a series of complex interactions in response to perceived threat. A model is described which proposes chronic pain and a variety of long-term, systemic functional neurological conditions to be a consequence of significant dysregulation of these protection systems.

The Model

Previous research has demonstrated that a cognitive-behavioural model, first described in 1995 by Surawy et al., for chronic fatigue has been successful in predicting the transition from acute to chronic states in a number of conditions. This model includes predisposing, precipitating and perpetuating biopsychosocial factors. This article discusses the potential role of these factors in affecting descending inhibition in the CNS, significantly altering its ability to modulate the threat detection system. The development of 'central sensitisation' is considered in this context.

Conclusion

This model proposes that chronic pain, chronic fatigue and other so-called functional neurological phenomena can, perhaps, be more helpfully seen as the actions of a dysregulated neurological protection system, rather than symptoms of an untreatable and deteriorating medical condition. Recommendations are made for the development of appropriate therapeutic interventions indicated by this model.

Does persisting fear sustain catatonia?

OBJECTIVE

To examine the psychological substrate of catatonia.

METHOD

Reviewing the historical descriptions and explanations of catatonic behaviours by clinicians from its delineation in the 19th century to the present.

RESULTS

Patients with catatonia are often haunted by fears and terrors; this has not been widely appreciated, and certainly was lost from view in the days when catatonia was considered a subtype of schizophrenia. The report contributes to resolving a major question in catatonia: is the mind in stupor inactive, as the blank state that we picture in anesthetized patients, or is the mind active, so preoccupied as to exclude all other influences.

THE MAIN FINDING

Persistent fear occupies the mind of catatonic patients.

CONCLUSION

The signs of catatonia are adaptations to persistent fear, akin to tonic immobilization. The relief afforded by sedation supports this interpretation.

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.