European Child & Adolescent Psychiatry

, Volume 23, Issue 3, pp 163–172

Pervasive refusal syndrome (PRS) 21 years on: a re-conceptualisation and a renaming

Original Contribution


Twenty-one years ago, Lask and colleagues first described pervasive refusal syndrome (PRS) as a child’s “dramatic social withdrawal and determined refusal to walk, talk, eat, drink, or care for themselves in any way for several months” in the absence of an organic explanation. PRS has been conceptualised in a variety of ways since then. These have included a form of post-traumatic stress disorder, learnt 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, meaning the possibility that the children have been drugged to increase chances of asylum in asylum-seeking families. Others have insisted that PRS is simply depression, conversion disorder, catatonia or a factitious condition. This paper reviews these conceptualisations, explores some of the central complexities around PRS and proposes a neurobiological explanatory model, based upon autonomic system hyper-arousal. It touches upon the clinical implications and suggests a new name for the condition reflecting what we believe to be a more sophisticated understanding of the disorder than was available when it was first described.


Pervasive refusal syndrome (PRS) Pervasive arousal–withdrawal syndrome (PAWS) Asylum-seeking children Malignant countercalming Depressive devitalisation 


  1. 1.
    Lask B, Britten C, Kroll L, Magagna J, Tranter M (1991) Children with pervasive refusal. Arch Dis Child 66:866–869PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Nunn KP, Thompson SL (1996) The pervasive refusal syndrome: learned helplessness and hopelessness. Clin Child Psychol Psychiatry 1:121–132CrossRefGoogle Scholar
  3. 3.
    Von Folsach LL, Montgomery E (2006) Pervasive refusal syndrome among asylum-seeking children. Clin Child Psychol Psychiatry 11:457–473CrossRefGoogle Scholar
  4. 4.
    Jaspers T, Hanssen GM, van der Valk JA, Hanekom JH, van Well GT, Schieveld JN (2009) Pervasive refusal syndrome as part of the refusal–withdrawal–regression spectrum: critical review of the literature illustrated by a case report. Eur Child Adolesc Psychiatry 18(11):645–651PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Fink M, Klein DF (1995) An ethical dilemma in child psychiatry. Psychiatry Bull 19:650–651CrossRefGoogle Scholar
  6. 6.
    Taylor S, Dossetor DR, Kilham H, Bernard E (2000) The youngest case of pervasive refusal syndrome? Clin Child Psychol Psychiatry 5:23–29CrossRefGoogle Scholar
  7. 7.
    Thompson SL, Nunn KP (1997) The pervasive refusal syndrome: the RAHC experience. Clin Child Psychol Psychiatry 2:145–165CrossRefGoogle Scholar
  8. 8.
    Germain M (1994). Refusal in childhood. A dissertation submitted for part II of the entrance examination for the Royal Australian and New Zealand College of Psychiatrists. In Nunn and Thomson (1996)Google Scholar
  9. 9.
    Lask B (2004) Pervasive refusal syndrome. Adv Psychiatry Treat 10:153–159CrossRefGoogle Scholar
  10. 10.
    Bodegard G (2005) Life-threatening loss of function in refugee children: another expression of pervasive refusal syndrome? Clin Child Psychol Psychiatry 10:337–350CrossRefGoogle Scholar
  11. 11.
    Kiser LA, Ackerman BJ, Brown E (1988) Post-traumatic stress disorder in young children: a reaction to purported sexual abuse. Am Acad Child Adolesc Psychiatry 27:645–649CrossRefGoogle Scholar
  12. 12.
    McGowan R, Green J (1998) Pervasive refusal syndrome: a less severe variant with defined aetiology. Clin Child Psychol Psychiatry 3:583–590CrossRefGoogle Scholar
  13. 13.
    Overmeier JB, Leaf RC (1965) Effects of discriminative Pavlovian fear conditioning upon previously or subsequently acquired avoidance responding. J Comp Physiol Psychol 60(2):213–217 In Nunn and Thomson (1996)CrossRefGoogle Scholar
  14. 14.
    Abramson LY, Seligman MEP, Teasdale JD (1978) Learned helplessness in humans: critique and reformulation. J Abnorm Psychol 87:49–74 In Nunn and Thomson (1996)PubMedCrossRefGoogle Scholar
  15. 15.
    Nunn KP (2005) Pervasive refusal syndrome—concepts, causes and differential diagnosis. Paper given at: pervasive refusal syndrome conference; the royal college of physicians, LondonGoogle Scholar
  16. 16.
    Magagna J (2004) ‘I didn’t want to die, but I had to’: the pervasive refusal syndrome. In: Williams G, Williams P, Desmarais J, Ravenscroft K (eds) Exploring eating disorders in adolescents: the generosity of acceptance. Karnac Books, London, pp 107–138Google Scholar
  17. 17.
    Cytryn L, McKnew DH (1996) Growing up sad: childhood depression and its treatment. Norton, New YorkGoogle Scholar
  18. 18.
    Eriksson T (2006) Debate and letters. Läkartidningen 103:856–857Google Scholar
  19. 19.
    Montgomery E, Krogh Y, Jacobsen A, Lukman B (1992) Children of torture, victims’ reactions and coping. Child Abus Negl 16:797–805 In von Folsach et al. (2006)CrossRefGoogle Scholar
  20. 20.
    Lindberg T, Sundelin C (2005) Apatiska barn—var står vetenskapen idag? Läkartidningen 102:1338–1345PubMedGoogle Scholar
  21. 21.
    Nunn KP (2007). Pervasive refusal and withdrawal—a neurobiological formulation. Paper given at: Conference on Depressive Devitalisation; the Nordic Centre for Public Health, GoteborgGoogle Scholar
  22. 22.
    Arronson B, Wiberg C, Sandstedt P, Hjern A (2009) Asylum-seeking children with severe loss of activities of daily living: clinical signs and course during rehabilitation. Acta Paediatr 98(12):1977–1981CrossRefGoogle Scholar
  23. 23.
    Schmale AH Jr, Engel GL (1967) The giving up–given up complex illustrated on film. Arch Gen Psychiatry 17:135–145PubMedCrossRefGoogle Scholar
  24. 24.
    Nunn KP, Frampton I, Gordon I, Lask B (2008) The fault is not in her parents but in her insula—a neurobiological hypothesis of anorexia nervosa. Eur Eat Disord Rev 16:355–360PubMedCrossRefGoogle Scholar
  25. 25.
    Nunn KP, Frampton I, Fuglset TS, Törzsök-Sonnevend M, Lask B (2011) Anorexia nervosa and the insula. Med Hypotheses 76(3):353–357PubMedCrossRefGoogle Scholar
  26. 26.
    Nunn KP, Lask B and Frampton I (2011). Towards a Comprehensive, Causal and Explanatory Neuroscience Model of Anorexia Nervosa. In: (eds Lask B and Frampton I) Eating Disorders and the Brain, John Wiley & Sons, Ltd, Chichester, UKGoogle Scholar
  27. 27.
    Nunn KP, Frampton I, Lask B (2012) Anorexia nervosa—a noradrenergic dysregulation hypothesis. Med Hypotheses 78:580–584PubMedCrossRefGoogle Scholar
  28. 28.
    LeDoux J (1996) The emotional brain: the mysterious underpinnings of emotional life. Simon and Schuster, New YorkGoogle Scholar
  29. 29.
    Mesulam M (2000) Principles of behavioural and cognitive neurology. Oxford University Press, OxfordGoogle Scholar
  30. 30.
    Selye H (1955) Stress and disease. Science 122:625–631PubMedCrossRefGoogle Scholar
  31. 31.
    Sapolsky RM, Romero LM, Munck AU (2000) How do glucocorticoids influence stress responses? Integrating permissive, suppressive, stimulatory, and preparative actions. Endocr Rev 21:55–89PubMedGoogle Scholar
  32. 32.
    Porges SW (2011) The polyvagal theory: neurophysiological foundations of emotions, attachment, communication, and self-regulation. Norton, New YorkGoogle Scholar
  33. 33.
    Lenard Z, Studinger P, Mersich B, Kocsis L, Kollai M (2004) Maturation of cardiovagal autonomic function from childhood to young adult age. Circulation 110:2307–2312PubMedCrossRefGoogle Scholar
  34. 34.
    Iversen LL, Iversen SD, Bloom FE, Roth RH (2009) Introduction to neuropsychopharmacology. Oxford University Press, OxfordCrossRefGoogle Scholar
  35. 35.
    Insel T, Cuthbert B, Garvey M, Heinssen R, Pine DS, Quinn K, Sanislow CA, Wang PW (2010) Research domain criteria (RDoC): developing a valid diagnostic framework for research on mental disorders. Am J Psychiatr 167(7):748–751PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.University of New South WalesSydneyAustralia
  2. 2.Westmead Children’s HospitalSydneyAustralia
  3. 3.Care UKLondonUK
  4. 4.Great Ormond Street Hospital for ChildrenLondonUK

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