Background
Resignation syndrome is the name given to a medical phenomenon that occurred in Sweden during the early 2000s (Sallin et. al, 2016). Cases of the syndrome started to pop up all over the country following a change in Swedish asylum policy that led to the deportation of many families (Aviv, 2017). Between the year 2000 and 2005, over four hundred cases of resignation syndrome were treated in hospitals all over Sweden (Aviv, 2017). Many patients diagnosed with resignation syndrome were of Eastern European dissent, most being from Soviet Bloc countries (Sallin et. al, 2016). A small percentage of patients were originally citizens of the Middle East and Northern Africa (Sallin et. al, 2016). The true cause of the condition is still unknown.
Resignation syndrome follows a distinct progression (Bodegård, 2005). At first, it may present itself in the form of sleep disturbances, anxiety, and social withdrawal (Bodegård, 2005). Then, it progresses into mutism, failure to participate in activities, and failure in non-verbal communication (Bodegård, 2005). Resignation syndrome, once fully developed, leads to incontinence, unresponsiveness, dependence on tube-feeding, and apparent unseeing (Bodegård, 2005). These symptoms, however, are accompanied by indications of preserved awareness and unimpressive lab results for EEGs, CTs, and toxicology (Bodegård, 2005). In remission, patients tend to experience varying degrees of amnesia, but every noted case has been capped by a full recovery without any remaining symptoms (Bodegård, 2005).
Controversy
There are two major controversies that surround the discussion of resignation syndrome: (1) what causes it, and (2) how to diagnose it properly. Each of those controversies will be briefly discussed in this section.
Perspectives on Root Causes of Resignation Syndrome
Some authors hypothesize that sustained stress is the root cause of resignation syndrome, while others argue that imposed stress is the driving force behind the development of the syndrome (Sallin et. al, 2016). Those aligning with the sustained stress hypothesis believe that a “discrepancy between what is expected and what really exists” creates a physical response in individuals that develop resignation syndrome (Ursin and Eriksen, 2010). On the other side of this controversy, those holding the opinion that imposed stress is the root cause of resignation syndrome believe that specifically the children’s mothers who had traumatic experiences in their country of origin project their stress onto their children (Bodegård, 2005). It would be difficult to prove which one of these hypotheses are correct, as is the case with most mental conditions, due to a reliance on patient reporting of their own feelings (Bodegård, 2005). In the meantime, the root cause of resignation syndrome remains a mystery.
Perspectives on Diagnosis of Resignation Syndrome
The controversy here can be defined by the question of whether or not resignation syndrome is simply the presence of an already-defined disorder, or whether it is an entirely separate entity of mental illness. Connections have been drawn between resignation syndrome and other refusal syndromes, such as pervasive refusal syndrome and pervasive arousal-withdrawal syndrome (Sallin et. al, 2016). Pervasive refusal syndrome, similarly to resignation syndrome, is a condition in which children cease walking, talking, eating, drinking, and taking care of themselves without any known neurological reason (Lask et. al, 1991). Also much like resignation syndrome, very little is known about why children suffering from pervasive refusal syndrome have entered a comatose state, but all of the patients displayed intense willful, angry, or frightened characteristics directly prior to their period of non-functioning (Lask, et. al, 1991). Pervasive arousal-withdrawal syndrome is a recommended re-definition for pervasive refusal syndrome based in neurology, rather than the psychological explanations provided at the time of the designation of pervasive refusal syndrome (Nunn, Lask, & Owen, 2013). The new definition suggests that the children more specifically experience a period of apparent helplessness, followed by withdrawal and regression, combined with a rejection of help (Nunn, Lask, & Owen, 2013). The new definition goes even further to suggest that the syndrome can be explained neurologically by shifts in activity of brain structures, specifically the amygdala and the insula (Nunn, Lask, & Owen, 2013). While tests run on patients displaying resignation syndrome have not been indicative of any neurological causes, patients were not tested specifically for amygdala and insula activity (Sallin et. al, 2016).
While the majority of literature links resignation syndrome to pervasive refusal syndrome and pervasive arousal-withdrawal syndrome, there have also been parallels drawn between resignation syndrome and stress-induced conditions, like post-traumatic stress disorder, since both PTSD and resignation syndrome deal with patients that have been drastically affected by intense trauma (Sallin et. al, 2016). Meanwhile, a committee of Swedish experts, on topics ranging from public policy to medicine, formed in the wake of this phenomenon determined that severe depression and dissociation disorder diagnoses align best with the demonstrated symptoms in resignation syndrome (Sallin et. al, 2016).
The most recent hypothesis on the diagnosis of resignation syndrome is that the syndrome is just an expression of catatonia (Sallin et. al, 2016). Catatonia is defined as “the presence of three or more symptoms” out of twelve, including “catalepsy, waxy flexibility, stupor, agitation, mutism, negativism, posturing, mannerisms, stereotypies, grimacing, echolalia, and echopraxia” (DSM-5, 2016). All of these symptoms are found in resignation syndrome patients, indicating a strong connection between the two illnesses. Resignation syndrome is not included in the Diagnostic and Statistical Manual of Mental Disorders, which is the universal manual utilized in diagnosing mental illness globally (Aviv, 2017). Meanwhile, the Swedish National Board of Health and Welfare officially recognized resignation syndrome as a unique diagnosis in 2014 and maintains that stance currently (Sallin et. al, 2016). There is no clear-cut answer at this point in time as to how resignation syndrome should be diagnosed, but as the causes of the syndrome are further investigated, the answer may become clearer in the future.
Topical Context
Cases of resignation syndrome have been constrained to only Sweden. Experts from a wide range of fields, from public policy to medicine to sociology, have all weighed in on why they believe this has been the case. In public policy, a change in the policy for the providence of asylum is the reason for the presence of resignation syndrome in Sweden (Aviv, 2017). However, in medicine, it is argued that the clinical traditions of Sweden are the reason for the presence of the syndrome (Sallin et. al, 2016). Sociologists, meanwhile, argue that the culture of the asylum-seekers in Sweden has made them susceptible to resignation syndrome (Aviv, 2017).
Public Policy
Historically, Sweden has been a “haven for refugees…accepting more asylum seekers per capita than any other European nation” (Aviv, 2017). However, in the early 2000s, Sweden underwent a policy change, redefining who would be granted asylum (Aviv, 2017). Under this new regulation, many “families fleeing countries that were not at war were often denied asylum” (Aviv, 2017). Due to this change in policy, many refugees who had lived in Sweden for much of their lives were informed that they were to be deported. A policy such as this was unprecedented in Europe, which leads experts in public policy to believe this is why the syndrome has been constrained strictly to Sweden (Aviv, 2017).
Medicine
Between countries, medical treatment can vary a significant amount (Sallin et. al, 2016). This could be the explanation for why resignation syndrome has only occurred in Sweden. While patients that were diagnosed with resignation syndrome in Sweden reached a very critical condition, it is possible that the warning signs of resignation syndrome were detected earlier in other countries, and thus, the children could be treated before they reached “the prolonged stuporous state” associated with resignation syndrome (Sallin et. al, 2016). Some examples of warning signs include: anxiety, dysphoria, sleeping disturbances, social withdrawal, mutism, failure to participate in activities, and failure to communicate verbally (Sallin et. al, 2016). These variances in clinical traditions between countries could be the difference between the comatose refugee children of resignation syndrome and the relatively healthy refugee children in other countries.
Sociology
Experts in the realm of sociology believe that the regional containment of resignation syndrome could be due to the culture of Sweden and of the home nations of Sweden’s refugees. The Swedish government has proposed that the children diagnosed with resignation syndrome have been raised in the “holistic cultures” of their home countries that blurs the lines between the individual and their family collective (Aviv, 2017). Children raised under these influences may feel the strain of their family as intense individual pressure, that leads to the development of resignation syndrome (Aviv, 2017). However, this theory alone does not fully explain the prevalence of resignation syndrome in Sweden. Sweden’s own culture, which the refugee children are also influenced by, likely comprises the missing piece of this puzzle in sociologists minds, but there has yet to be a study looking into this, to my knowledge at least. The syndrome is likely not just a cause of the home countries’ cultures because there have been no similar cases in response to family trauma in these countries (Aviv, 2017).
Relationship to Politics of Health
The topic of resignation syndrome relates to the role of politics in health in several ways. Resignation syndrome is an interesting example of what could be considered a culture-bound syndrome (Guarnaccia & Pincay, 2008). Also, it demonstrates how policy could potentially impact the health of a population, in this case refugee children. These topics were discussed in detail under the topical context section, but this section will contain more detailed information on how these concepts connect directly to the politics of health.
A culture-bound syndrome is an ailment or illness that only effects a certain cultural group due to their different religious practices, societal beliefs and constructs, and ways of life (Guarnaccia & Pincay, 2008). The concept of culture-bound syndromes has been up for debate since it was proposed in the 1960s (Guarnaccia & Pincay, 2008). Resignation syndrome contributes to this debate. While resignation syndrome has only affected patients of “holistic” beliefs, those children have also been the only ones subjected to the circumstances associated with resignation syndrome (Aviv, 2017). It is possible that resignation syndrome is an example of a culture-bound syndrome since it effects a specific population, but it is also possible that other factors aside from culture have caused the appearance of this syndrome.
As far as the relationship between policy and health, resignation syndrome offers some perspective. Some scholars in public policy draw a direct correlation between the change of Sweden’s asylum policy and the occurrence of resignation syndrome. The first case of resignation syndrome was diagnosed not long after the implementation of the new policy (Aviv, 2017). This insinuates a scenario where public policy had a real effect on the health of hundreds of individuals.
For Further Information
Cook, M. (2016). A bizarre dilemma in Sweden. Australasian Science, 37(3), 50.
Dhossche, D. M., Ross, C. A., & Stoppelbein, L. (2012). The role of deprivation, abuse, and trauma in pediatric catatonia without a clear medical cause. Acta Psychiatrica Scandinavica, 125, 25-32
Forslund, C-M., & Johansson, B. A. (2013). Pervasive refusal syndrome among inpatient asylum-seeking children and adolescents: a follow-up study. European Child & Adolescent Psychiatry, 22(4), 251-258.
References
Aviv, R. (2017). The trauma of facing deportation. The New Yorker, April 2017. Retrieved from https://www.newyorker.com/magazine/2017/04/03/the-trauma-of-facing-deportation
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington.
Bodegård, G. (2005). Pervasive loss of function in asylum-seeking children in Sweden. Acta Paediatrica, 94(12), 1706-1707.
Guarnaccia, P., & Pinacy, M. I. (2008). Culture-specific diagnoses and their relationship to mood disorders. In Loue, S., & Sajatovic, M. (Eds.), Diversity issues in the diagnosis, treatment, and research of mood disorders (32-53). New York: Oxford University Press, Inc.
Lask, B., Britten, C., Kroll, L., Magagna, J., & Tranter, M. (1991). Children with pervasive refusal. Archives of Disease in Childhood, 66, 866-869.
Nunn, K. P., Lask, B., & Owen, I. (2014). Pervasive refusal syndrome (PRS) 21 years on: A re-conceptualisation and a renaming. European Child Adolescent Psychiatry, 23, 163-172.
Sallin, K., Lagercrantz, H., Evers, K., Engstrom, I., Hjern, A., & Petrovic, P. (2016). Resignation syndrome: Catonia? Culture-Bound? Frontiers in Behavioral Neuroscience, 10(7).
Ursin, H., & Eriksen, H. R. (2010). Cognitive activation theory of stress. Neuroscience Biobehavioral Review, 34(6), 877-881.
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