What is Resignation Syndrome?

Introduction

Resignation syndrome (also called traumatic withdrawal syndrome or traumatic refusal; Swedish: uppgivenhetssyndrom) is a possibly factitious, dissociative syndrome that induces a catatonic state, first described in Sweden in the 1990s. The condition affects predominately psychologically traumatised children and adolescents in the midst of a strenuous and lengthy migration process.

Refer to Pervasive Refusal Syndrome (PRS).

Young people reportedly develop depressive symptoms, become socially withdrawn, and become motionless and speechless as a reaction to stress and hopelessness. In the worst cases, children reject any food or drink and have to be fed by feeding tube; the condition can persist for years. Recovery ensues within months to years and is claimed to be dependent on the restoration of hope to the family.

More recently, this phenomenon has been called into question, with two children witnessing that they were forced by their parents to act apathetic in order to increase chances of being granted residence permits. As evidenced by medical records, healthcare professionals were aware of this scam, and witnessed parents who actively refused aid for their children but remained silent at the time. Later Sveriges Television, Sweden’s national public television broadcaster, were severely critiqued by investigative journalist Janne Josefsson for failing to uncover the truth. In March 2020, a report citing the Swedish Agency for Medical and Social Evaluation, SBU, said “There are no scientific studies that answer how to diagnose abandonment syndrome, nor what treatment works.”

Signs and Symptoms

Affected individuals (predominantly children and adolescents) first exhibit symptoms of anxiety and depression (in particular apathy, lethargy), then withdraw from others and care for themselves. Eventually their condition might progress to stupor, i.e. they stop walking, eating, talking, and grow incontinent. In this stage patients are seemingly unconscious and tube feeding is life-sustaining. The condition could persist for months or even years. Remission happens after life circumstances improve and ensues with gradual return to what appears to be normal function.

Nosology

Refusal syndrome and pervasive refusal syndrome shares common features and etiologic factors; however, the former is more clearly associated with trauma and adverse life circumstances. Neither is included in the standard psychiatric classification systems.

Pervasive refusal syndrome (also called pervasive arousal withdrawal syndrome) has been conceptualised in a variety of ways, including a form of post-traumatic stress disorder, learned helplessness, ‘lethal mothering’, loss of the internal parent, apathy or the ‘giving-up’ syndrome, depressive devitalisation, primitive ‘freeze’, severe loss of activities of daily living and ‘manipulative’ illness. It was also suggested to be on the ‘refusal-withdrawal-regression spectrum’.

Acknowledging its social importance and relevance, the Swedish National Board of Health and Welfare recognised the novel diagnostic entity resignation syndrome in 2014. While others argue that already-existing diagnostic entities should be used and are sufficient in the majority of cases, i.e. severe major depressive disorder with psychotic symptoms or catatonia, or conversion/dissociation disorder.

Currently, diagnostic criteria are undetermined, pathogenesis is uncertain, and effective treatment is lacking.

Causes

Resignation syndrome appears to be a very specialised response to the trauma of refugee limbo, in which families, many of whom have escaped dangerous circumstances in their home countries, wait to be granted legal permission to stay in their new country, often undergoing numerous refusals and appeals over a period of years.

Experts proposed multifactorial explanatory models involving individual vulnerability, traumatisation, migration, culturally conditioned reaction patterns and parental dysfunction or pathological adaption to a caregiver’s expectations to interplay in pathogenesis. Severe depression or conversion/dissociation disorder has been also suggested (as best diagnostic alternatives).

However, the currently prevailing stress hypothesis fails to account for the regional distribution (see Epidemiology) and contributes little to treatment. An asserted “questioning attitude”, in particular within the health care system, it has been claimed, may constitute a “perpetuating retraumatization possibly explaining the endemic” distribution. Furthermore, Sweden’s experience raises concerns about “contagion”. Researchers argue that culture-bound psychogenesis can accommodate the endemic distribution because children may learn that dissociation is a way to deal with trauma.

A proposed neurobiological model of the disorder suggests that the impact of overwhelming negative expectations are directly causative of the down-regulation of higher order and lower order behavioural systems in particularly vulnerable individuals.

Epidemiology

Depicted as a culture-bound syndrome, it was first observed and described in Sweden among children of asylum seekers from former Soviet and Yugoslav countries. In Sweden, hundreds of migrant children, facing the possibility of deportation, have been diagnosed since the 1990s. For example, 424 cases were reported between 2003 and 2005; and 2.8% of all 6547 asylum applications submitted for children were diagnosed in 2004.

It has also been observed in refugee children transferred from Australia to the Nauru Regional Processing Centre. The Economist wrote in 2018 that Doctors without Borders (MSF) refused to say how many of the children on Nauru may be suffering from traumatic withdrawal syndrome. A report published in August 2018 suggested there were at least 30. The National Justice Project, a legal centre, has brought 35 children from Nauru this year. It estimates that seven were suffering from refusal syndrome, and three were psychotic.

What is Pervasive Refusal Syndrome?

Introduction

Pervasive refusal syndrome (PRS), also known as pervasive arousal withdrawal syndrome (PAWS) is a rare hypothesized paediatric mental disorder. PRS is not included in the standard psychiatric classification systems; that is, PRS is not a recognised mental disorder in the World Health Organisation’s current (ICD-10) and upcoming (ICD-11) International Classification of Diseases and the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Refer to Resignation Syndrome.

Purported Signs and Symptoms

According to some authors, PRS symptoms have common characteristics with other psychiatric disorders, but (according to these authors), current psychiatric classification schemes, such as the DSM cannot account for the full scope of symptoms seen in PRS. Purported symptoms include partial or complete refusal to eat, move, talk, or care for oneself; active and angry resistance to acts of help and support; social withdrawal; and school refusal.

Hypothesized Causes

Trauma might be a causal factor because PRS is repeatedly seen in refugees and witnesses to violence. Viral infections might be a risk factor for PRS.

Mechanism

Some authors hypothesize that learned helplessness is one of the mechanisms involved in PRS. A number of cases have been reported in the context of eating disorders.

Hypothesized Epidemiology

Epidemiological studies are lacking. Pervasive refusal syndrome is reportedly more frequent in girls than boys. The average age of onset is purported to be 7-15.

On This Day … 14 April

People (Deaths)

  • 2010 – Alice Miller, Polish-French psychologist and author (b. 1923).

Alice Miller

Alice Miller, born as Alicija Englard (12 January 1923 to 14 April 2010), was a Polish-Swiss psychologist, psychoanalyst and philosopher of Jewish origin, who is noted for her books on parental child abuse, translated into several languages. She was also a noted public intellectual.

Her book The Drama of the Gifted Child caused a sensation and became an international bestseller upon the English publication in 1981. Her views on the consequences of child abuse became highly influential. In her books she departed from psychoanalysis, charging it with being similar to the poisonous pedagogies.

Life

Miller was born in Piotrków Trybunalski, Poland into a Jewish family. She was the oldest daughter of Gutta and Meylech Englard and had a sister, Irena, who was five years younger. From 1931 to 1933 the family lived in Berlin, where nine-year-old Alicija learned the German language. Due to the National Socialists’ seizure of power in Germany in 1933 the family turned back to Piotrków Trybunalski. As a young woman, Miller managed to escape the Jewish Ghetto in Piotrków Trybunalski, where all Jewish inhabitants were interned since October 1939, and survived World War II in Warsaw under the assumed name of Alicja Rostowska. While she was able to smuggle her mother and sister out, in 1941, her father died in the ghetto.

She retained her assumed name Alice Rostovska when she moved to Switzerland in 1946, where she had won a scholarship to the University of Basel.

In 1949 she married Swiss sociologist Andreas Miller, originally a Polish Catholic, with whom she had moved from Poland to Switzerland as students. They divorced in 1973. They had two children, Martin (born 1950) and Julika (born 1956). Shortly after his mother’s death Martin Miller stated in an interview with Der Spiegel that he had been beaten by his authoritarian father during his childhood – in the presence of his mother. Miller first stated that his mother intervened, but later that she did not intervene. These events happened decades before Alice Miller’s awakening about the dangers of such childrearing methods. Martin also mentioned that his mother was unable to talk with him, despite numerous lengthy conversations, about her wartime experiences, as she was severely burdened by them.

In 1953 Miller gained her doctorate in philosophy, psychology and sociology. Between 1953 and 1960, Miller studied psychoanalysis and practiced it between 1960 and 1980 in Zürich.

In 1980, after having worked as a psychoanalyst and an analyst trainer for 20 years, Miller “stopped practicing and teaching psychoanalysis in order to explore childhood systematically.” She became critical of both Sigmund Freud and Carl Jung. Her first three books originated from research she took upon herself as a response to what she felt were major blind spots in her field. However, by the time her fourth book was published, she no longer believed that psychoanalysis was viable in any respect.

In 1985 Miller wrote about the research from her time as a psychoanalyst: “For twenty years I observed people denying their childhood traumas, idealising their parents and resisting the truth about their childhood by any means.” In 1985 she left Switzerland and moved to Saint-Rémy-de-Provence in Southern France.

In 1986, she was awarded the Janusz Korczak Literary Award for her book Thou Shalt Not Be Aware: Society’s Betrayal of the Child.

In April 1987 Miller announced in an interview with the German magazine Psychologie Heute (Psychology Today) her rejection of psychoanalysis. The following year she cancelled her memberships in both the Swiss Psychoanalytic Society and the International Psychoanalytic Association, because she felt that psychoanalytic theory and practice made it impossible for former victims of child abuse to recognise the violations inflicted on them and to resolve the consequences of the abuse, as they “remained in the old tradition of blaming the child and protecting the parents”.

One of Miller’s last books, Bilder meines Lebens (“Pictures of My Life”), was published in 2006. It is an informal autobiography in which the writer explores her emotional process from painful childhood, through the development of her theories and later insights, told via the display and discussion of 66 of her original paintings, painted in the years 1973-2005.

Between 2005 and her death in 2010, she answered hundreds of readers’ letters on her website, where there are also published articles, flyers and interviews in three languages. Days before her death Alice Miller wrote: “These letters will stay as an important witness also after my death under my copyright”.

Miller died on 14 April 2010, at the age of 87, at her home in Saint-Rémy-de-Provence by suicide after severe illness and diagnosis of advanced stage of pancreatic cancer.

Work

Miller extended the trauma model to include all forms of child abuse, including those that were commonly accepted (such as spanking), which she called poisonous pedagogy, a non-literal translation of Katharina Rutschky’s Schwarze Pädagogik (black or dark pedagogy/imprinting).

Drawing upon the work of psychohistory, Miller analysed writers Virginia Woolf, Franz Kafka and others to find links between their childhood traumas and the course and outcome of their lives.

The introduction of Miller’s first book, The Drama of the Gifted Child, first published in 1979, contains a line that summarises her core views:

Experience has taught us that we have only one enduring weapon in our struggle against mental illness: the emotional discovery and emotional acceptance of the truth in the individual and unique history of our childhood.

In the 1990s, Miller strongly supported a new method developed by Konrad Stettbacher, who himself was later charged with incidents of sexual abuse. Miller came to know about Stettbacher and his method from a book by Mariella Mehr titled Steinzeit (Stone Age). Having been strongly impressed by the book, Miller contacted Mehr in order to get the name of the therapist. From that time forward, Miller refused to make therapist or method recommendations. In open letters, Miller explained her decision and how she originally became Stettbacher’s disciple, but in the end she distanced herself from him and his regressive therapies.

In her writings, Miller is careful to clarify that by “abuse” she does not only mean physical violence or sexual abuse, she is also concerned with psychological abuse perpetrated by one or both parents on their child; this is difficult to identify and deal with because the abused person is likely to conceal it from themselves and may not be aware of it until some event, or the onset of depression, requires it to be treated. Miller blamed psychologically abusive parents for the majority of neuroses and psychoses. She maintained that all instances of mental illness, addiction, crime and cultism were ultimately caused by suppressed rage and pain as a result of subconscious childhood trauma that was not resolved emotionally, assisted by a helper, which she came to term an “enlightened witness.” In all cultures, “sparing the parents is our supreme law,” wrote Miller. Even psychiatrists, psychoanalysts and clinical psychologists were unconsciously afraid to blame parents for the mental disorders of their clients, she contended. According to Miller, mental health professionals were also creatures of the poisonous pedagogy internalised in their own childhood. This explained why the Commandment “Honour thy parents” was one of the main targets in Miller’s school of psychology.

Miller called electroconvulsive therapy “a campaign against the act of remembering”. In her book Abbruch der Schweigemauer (The Demolition of Silence), she also criticised psychotherapists’ advice to clients to forgive their abusive parents, arguing that this could only hinder recovery through remembering and feeling childhood pain. It was her contention that the majority of therapists fear this truth and that they work under the influence of interpretations culled from both Western and Oriental religions, which preach forgiveness by the once-mistreated child. She believed that forgiveness did not resolve hatred, but covered it in a dangerous way in the grown adult: displacement on scapegoats, as she discussed in her psycho-biographies of Adolf Hitler and Jürgen Bartsch, both of whom she described as having suffered severe parental abuse.

A common denominator in Miller’s writings is her explanation of why human beings prefer not to know about their own victimisation during childhood: to avoid unbearable pain. She believed that the unconscious command of the individual, not to be aware of how he or she was treated in childhood, led to displacement: the irresistible drive to repeat abusive parenting in the next generation of children or direct unconsciously the unresolved trauma against others (war, terrorism, delinquency), or against him or herself (eating disorders, drug addiction, depression).

The Roots of Violence

According to Alice Miller, worldwide violence has its roots in the fact that children are beaten all over the world, especially during their first years of life, when their brains become structured. She said that the damage caused by this practice is devastating, but unfortunately hardly noticed by society. She argued that as children are forbidden to defend themselves against the violence inflicted on them, they must suppress the natural reactions like rage and fear, and they discharge these strong emotions later as adults against their own children or whole peoples: “child abuse like beating and humiliating not only produces unhappy and confused children, not only destructive teenagers and abusive parents, but thus also a confused, irrationally functioning society”. Miller stated that only through becoming aware of this dynamic can we break the chain of violence.

Refugee Children & Adolescents and PTSD

Research Paper Title

Traumatic experiences of conditional refugee children and adolescents and predictors of post-traumatic stress disorder: data from Turkey.

Background

The researchers aimed to determine traumatic events, mental health problems and predictors of PTSD in a sample of conditional refugee children.

Methods

The sociodemographic features, chief complaints, traumatic experiences and psychiatric diagnoses according to DSM-5 were evaluated retrospectively.

Results

20.7% (n = 70) of children experienced the armed conflict or exposed to firefights at their country of origin. Most common diagnoses were anxiety disorders (n = 82, 24.3%), major depressive disorder (n = 52, 15.4%) and PTSD (n = 43, 12.7%). Age, number of traumatic experiences, explosion and sexual violence are the most important predictors for PTSD.

Conclusions

The results suggest that the number of traumas exposed as well as their nature predicted PTSD diagnosis. Refugee children have increased risk for psychiatric problems after migration and resettlement underlining the importance of an adequate follow-up for mental health and ensuring social support networks.

Reference

Yektas, C., Erman, H. & Tufan, A.E. (2021) Traumatic experiences of conditional refugee children and adolescents and predictors of post-traumatic stress disorder: data from Turkey. doi: 10.1080/08039488.2021.1880634. Online ahead of print.

Book: The Post-Traumatic Stress Disorder Sourcebook

Book Title:

The Post-Traumatic Stress Disorder Sourcebook, Revised and Expanded Second Edition: A Guide to Healing, Recovery, and Growth.

Author(s): Glenn R. Schiraldi (PhD).

Year: 2016.

Edition: Second (2nd).

Publisher: McGraw-Hill Education.

Type(s): Paperback and Kindle.

Synopsis:

The Post-Traumatic Stress Disorder Sourcebook, Revised and Expanded Second Edition introduces survivors, loved ones, and helpers to the remarkable range of treatment alternatives and self-management techniques available today to break through the pain and realise recovery and growth.

This updated edition incorporates all-new diagnostics from the DSM-5 and covers the latest treatment techniques and research findings surrounding the optimisation of brain health and function, sleep disturbance, new USDA dietary guidelines and the importance of antioxidants, early childhood trauma, treating PTSD and alcoholism, the relationship between PTSD and brain injury, suicide and PTSD, somatic complaints associated with PTSD, and more.

Book: Neurobiologically Informed Trauma Therapy with Children & Adolescent

Book Title:

Neurobiologically Informed Trauma Therapy with Children and Adolescents: Understanding Mechanisms of Change (Norton Series on Interpersonal Neurobiology).

Author(s): Linda Chapman.

Year: 2014.

Edition: First (1st).

Publisher: W.W. Norton & Company.

Type(s): Paperback and Kindle.

Synopsis:

The model of treatment developed here is grounded in the physical, psychological, and cognitive reactions children have to traumatic experiences and the consequences of those experiences. The approach to treatment utilises the integrative capacity of the brain to create a self, foster insight, and produce change. Treatment strategies are based on cutting-edge understanding of neurobiology, the development of the brain, and the storage and retrieval of traumatic memory. Case vignettes illustrate specific examples of the reactions of children, families, and teens to acute and repeated exposure to traumatic events.

Also presented is the most recent knowledge of the role of the right hemisphere (RH) in development and therapy. Right brain communication, and how to recognise the non-verbal symbolic and unconscious, affective processes will be explained, along with examples of how the therapist can utilise art making, media, tools, and self to engage in a two-person biology. 30 illustrations; 8 pages of colour.

Major Depressive Disorder & Childhood Trauma

Research Paper Title

Major depressive disorder with childhood trauma: Clinical characteristics, biological mechanism, and therapeutic implications.

Background

Major depressive disorder (MDD) is a main type of mood disorder, characterised by significant and lasting depressed mood.

Until now, the pathogenesis of MDD is not clear, but it is certain that biological, psychological, and social factors are involved.

Childhood trauma is considered to be an important factor in the development of this disease.

Previous studies have found that nearly half of the patients with MDD have experienced childhood trauma, and different types of childhood trauma, gender, and age show different effects on this disease.

In addition, the clinical characteristics of MDD patients with childhood trauma are also different, which often have more severe depressive symptoms, higher risk of suicide, and more severe cognitive impairment.

The response to antidepressants is also worse.

In terms of biological mechanisms and marker characteristics, the serotonin transporter gene and the FKBP prolyl isomerase 5 have been shown to play an important role in MDD and childhood trauma.

Moreover, some brain imaging and biomarkers showed specific features, such as changes in gray matter in the dorsal lateral prefrontal cortex, and abnormal changes in hypothalamic-pituitary-adrenal axis function.

Reference

Guo, W., Liu, J. & Li, L. (2020) Major depressive disorder with childhood trauma: Clinical characteristics, biological mechanism, and therapeutic implications. Journal of South Central University. 45(4), pp.462-468. doi: 10.11817/j.issn.1672-7347.2020.190699.

Major Depressive Disorder: Childhood Trauma

Research Paper Title

Major depressive disorder with childhood trauma: Clinical characteristics, biological mechanism, and therapeutic implications.

Background

Major depressive disorder (MDD) is a main type of mood disorder, characterised by significant and lasting depressed mood.

Until now, the pathogenesis of MDD is not clear, but it is certain that biological, psychological, and social factors are involved.

Childhood trauma is considered to be an important factor in the development of this disease.

Previous studies have found that nearly half of the patients with MDD have experienced childhood trauma, and different types of childhood trauma, gender, and age show different effects on this disease.

In addition, the clinical characteristics of MDD patients with childhood trauma are also different, which often have more severe depressive symptoms, higher risk of suicide, and more severe cognitive impairment.

The response to antidepressants is also worse.

In terms of biological mechanisms and marker characteristics, the serotonin transporter gene and the FKBP prolyl isomerase 5 have been shown to play an important role in MDD and childhood trauma.

Moreover, some brain imaging and biomarkers showed specific features, such as changes in gray matter in the dorsal lateral prefrontal cortex, and abnormal changes in hypothalamic-pituitary-adrenal axis function.

Reference

Guo, W., Liu, J. & Li, L. (2020) Major depressive disorder with childhood trauma:Clinical characteristics, biological mechanism, and therapeutic implications. Zhong nan da xue xue bao. Journal of Central South University. 45(4), pp.462-468. doi: 10.11817/j.issn.1672-7347.2020.190699.

Book: The ACOA Trauma Syndrome

300300

Book Title:

The ACOA Trauma Syndrome: The The Impact of Childhood Pain on Adult Relationships.

Author(s): Tian Dayton.

Year: 2012.

Edition: First (1st).

Publisher: Health Communications.

Type(s): Paperback and Audiobook.

Synopsis:

The ACoA syndrome is a post-traumatic stress reaction in which pain from the stress of growing up with parental addiction emerges years even decades later in adult relationships.

Adult Children of Alcoholics suffer from a post-traumatic stress created by their dysfunctional family situations.

Through insightful analysis and thoughtful examination, bestselling author and renowned psychologist Tian Dayton shows ACoAs how and why this family trauma has such a profound effect on adult relationships and provides the tools for marshalling resilience and restoring health and happiness.

Dr. Dayton explores how our brains and bodies process childhood trauma and how those traumas can become the catalyst for unhealthy, self-medicating behaviours including drug and alcohol abuse, food issues, and sex, gambling, and shopping addictions.

Readers who have experienced previous trauma will learn how they developed PTSD and how they can heal both personally and interpersonally.

Book: Child Psychology & Development for Dummies

Book Title: Child Psychology & Development for Dummies

Author(s): Laura L. Smith, PhD and Charles H. Elliott, PhD.

Year: 2011.

Edition: First.

Publisher: Wiley Publishing, Inc.

Synopsis:

Grasp a child’s cognitive development, detect abnormalities, and learn what to do next.

An essential guide for parents, teachers, and caregivers, Child Psychology & Development For Dummies provides an informational guide to cognitive development at every stage of a child’s life, as well as expert tips and guidance on how to diagnose, treat, and overcome the cognitive barriers that impede learning and development.

  • The nuts and bolts – delve into the soup of kids’ development, including biology, psychology, learning, environment, and culture.
  • What makes kids tick? – discover how heredity, environment, experience, and culture interact to determine a child’s physical and emotional development.
  • Watch them grow – get an understanding of what a “normal” childhood should look like from conception through adolescence, and the types of behaviours to anticipate throughout.
  • Learn to spot trouble – find out what can go wrong during a child’s development, from physical problems like chronic illness to psychological problems like autism.
  • Ask for help – get expert guidance on the therapies and interventions that work, and how you can collaborate with professionals for an even better outcome.