Thepolitical and policing problems of allowing hundreds of
thousands of refugees from Africa, the Middle East and
Afghanistan to plod intoWesternEurope tend to overshadow
thediiculties 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 inlux, 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 inFrontiers ofBehavioural Neuro-
science(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passive, immobile, lacks tonus, [is] withdrawn, mute, unable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 oldand 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 irst to characterise this phenom-
enon. His patients, mostly women, experienced recurring its
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 its 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 phenom-
enon. 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 relection: 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.”
MichaelCook is editor ofBioEdge,a bioethicsnewsletter.50 | APRIL 2016
QUANDARY Michael CookMake sense of science
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editions, plus additional content.A Bizarre Dilemma from Sweden
“Resignation syndrome” in refugee children and adolescents in Sweden is one of the most
bizarre medical stories of the past decade.