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A Bizarre Dilemma from Sweden

By Michael Cook

“Resignation syndrome” in refugee children and adolescents in Sweden is one of the most bizarre medical stories of the past decade.

The political and policing problems of allowing hundreds of thousands of refugees from Africa, the Middle East and Afghanistan to plod into Western Europe tend to overshadow the difficulties of settling them into a new and alien society.

On the medical front, countries in Western Europe are well prepared to cope with the massive influx, according to the World Health Organization. But inevitably there are exotic health issues. Female genital mutilation is one that has made headlines. One that hasn’t is “resignation syndrome” in refugee children and adolescents in Sweden.

This must be one of the most bizarre medical stories of the past decade, although it has received almost no publicity outside of Sweden. Hundreds of children and teenagers aged 7–19 have been diagnosed with a mysterious ailment that leaves them unable to eat, speak and move. According to an article by Dr Karl Sallin and colleagues in Frontiers of Behavioural Neuroscience (www.tinyurl.com/z5dzy6g), the typical patient is “totally passive, immobile, lacks tonus, [is] withdrawn, mute, unable to eat and drink, incontinent and not reacting to physical stimuli or pain”.

Unless they are given intensive nursing care, they will die.

And it happens only in Sweden.

In 2014, Swedish medical authorities started calling the phenomenon “resignation syndrome”, but this is just a label, not a solution. All of the affected children are members of ethnic minorities, many of them from former Soviet republics, with a disproportionate share being Uighurs. Many of them have been traumatised by domestic abuse, witnessing violence or being harassed. Only children from refugee families are affected; unaccompanied children are not.

None of the conventional explanations hold water. It could be a reaction to stress and trauma. It could be a projection of the anxieties of traumatised mothers. But there are 50 million traumatised refugees scattered all over the world. Why does “resignation syndrome” happen only in Sweden?

Sallin proposes a twofold diagnosis in his article. He argues that the affected children are actually suffering from an old and well-studied ailment: catatonia. They are conscious but unable to move or respond, even to painful stimuli.

His second theory is more controversial: that it is a kind of mass hysteria. Jean-Martin Charcot, a French neurologist in the late 19th century, was the first to characterise this phenomenon. His patients, mostly women, experienced recurring fits that seemed to follow a standard path of growing severity. After ruling out a physical cause, Charcot concluded that the cause was psychological, and that the ailment was transmitted by imitating other people’s hysterics. When the symptoms became “unfashionable”, the hysterical fits declined.

Sallin believes that symptoms of hysteria evolve over time “through the continuous negotiation between physicians and patients immersed in cultural context”. He suggests that the refugee children are suffering from a mass psychogenic illness tailored for people in their community, just as in past outbreaks:

Highly segregated groups where stress, control or obligations are evident and inescapable are predisposed and historically in particular religious settings are overrepresented. Female patients predominate. Patients below 20 years of age are overrepresented. Epidemics involve typical symptoms, including fatigue and unconsciousness, without demonstrable organic lesions. Relapse is common. ‘Compensational’ issues have been reported of importance. Media reports are known to enable transmission of illness behavior.

This leads us to the bioethical angle to this strange phenomenon. Publicising the illness in the media may make the public more aware of a pressing public health issue, but it may be spreading it at the same time. Indeed it appears that there was a peak in cases of “resignation syndrome” when it was given extensive coverage in the media.

So Sallin concludes with a morose reflection: physicians are bound to tube-feed their catatonic patients, but caring for them may cause the syndrome to spread even further: “The appeal to culture-bound psychopathology raises an ethical dilemma … by offering treatment, to which there is no alternative, we are also, on another level, causing new cases.”

Michael Cook is editor of BioEdge, a bioethics newsletter.