Resignation syndrome in hidden tears and silences

The arrival of more than 160,000 immigrants who asked asylum in Sweden in the end of 2015 corresponds to the biggest ratio per capita recorded in OECD – Organisation for Economic Co-operation and Development – countries (1.6% of the total population of 10 million), according to a report of OECD in January of 2017. At this same year, Sweden spent €6,000 millions with refugees (1.35% of gross domestic product; Expresso, 2017). A syndrome is calling attention of international community. It is spreading among refugees’ children and it is called ‘Resignation Syndrome’ – or uppgivenhetssyndrom (Casadaptada, 2017). Children affected by the condition start showing symptoms by withdrawing from social activities and speaking less, before finally closing off completely from the world around them. Experts suggest the conscious part of their brain simply shuts down, forcing their parents to feed them through tubes and put them in nappies – although no children are believed to have ever died as a result of the condition (The Sun, 2018). Elizabeth Hultcrantz, a doctor who has treated those with the illness, told The New Yorker (2017): ‘I think it is a form of protection, this coma they are in. They are like Snow White. They just fall away from the world’.

However, why do those cases only happen in Sweden? The health care professionals taking care of those children argue that the trauma is the cause of the children’s physical distancing. The most vulnerable children are precisely those who faced extreme violence episodes or children whose family fled from dangerous environments (BBC Brasil, 2017). What Swedes verified was that, in a moment, the children were healthy and, after they received the notice of deportation, they entered in a condition similar to coma – they cannot move or eat – but the tests reveal that there is no cerebral lesions (Jornal Econômico, 2017). Doctors studying the rare condition note that it tends to only affect refugees from Eastern Europe, fleeing ‘holistic’ societies where the family unit, and wider society, is always championed over the needs of the individual. A report by the Swedish government suggested that the stricken children may be acting in line with their society’s unspoken rules, subconsciously giving up the will to live without any direct encouragement in the hope that it will save their family. Because of this, with no obvious medical cure, many psychologists believe that only the security of permanent residency can bring the children back (The Sun, 2018).

The controversy starts in epidemiology. All cases of this syndrome are described in Sweden. Although 15% of population of the country are composed by immigrants – according to Census 2010 – the biggest flow of refugees of risk regions to Europe was not to Sweden but to Germany, the United Kingdom, Spain and France. Furthermore, an interesting fact is that the biggest part of the patients with the syndrome have already been living in Sweden for some years and they are more adapted to local culture and language, theoretically. Notwithstanding, most of the affected children have gypsy ascendancy or have origin in the old USSR (Union of Soviet Socialist Republics) territories. Children with African and Asian origins or the ones who arrived unaccompanied to European countries are less affected. That framework shows that, in practice, it is unlikely that the poor origin, traumas or risk zones are related with the problem core (Opinião, 2017). The so-called ‘apathetic children’ become a political question in the midst of an increasing debate about the consequences of immigration in Sweden, where, according to Census 2010, approximately 15% of population is immigrant (G1, 2017). According to National Council for Health and Wellness (Socialstyrelsen), 68 minors tried suicide between 2016 and 2017. An excessive tragic number (Expresso, 2017). There are clearly similarities between Resignation Syndrome and other unexplained illnesses, notably Chronic Fatigue Syndrome, Anorexia nervosa and perhaps some patients with severe constipation-predominant Irritable Bowel Syndrome, all of which may be instigated by trauma. Perhaps the epidemiological links with insecurity and the therapeutic influence of hope apply to all of them. The beneficial effect of removing the children from an environment that is toxic is also important. Illness is not just about medicine, politics and culture can have an important influence (Edensor Day, 2018).

We thus propose that resignation syndrome (RS) may be conceived within a predictive coding framework, as a condition where predisposing and contextual factors generate in negative expectations and beliefs instantiated in fixed priors, which drives homeostatic and behavioral effects as well as self-perception, toward the prediction, minimizing prediction error, however, at the cost of pushing the physiological, cognitive and emotional state further away from that which sustains life. The resulting behavior – described in terms of apathy, RS or catatonia – may be interpreted as, an outwardly broadcasted self-representation functioning as to minimize prediction error by extending also into the world the interocepted state in order to affect it accordingly, or, as a behavior serving to elicit support from the surrounding. In either case, the particular behavior, intended for a specific purpose, is conceivably one corresponding to culturally sanctioned expectations of what that behavior entails. Consequently, culture-bound reaction patterns are predicted by the model (Sallin et al., 2016). The most reasonable justification is that there are some types of necessaries sociocultural factors to development of that condition. Therefore, although we do not know the mechanism and the reason of this happens in Sweden, the type of symptom displayed by children is explained culturally: it would be a way of children express their trauma (Zap, 2017). In a bit, they are healthy children, after they fall in a status similar to coma. What a lot of them have in common is that between an instant and another they received the imminent deportation notice (Visão, 2017).

Until recently, Swedish authorities allowed that families with one sick child remain. However, the arrival of more than 300,000 people in the last 3 years changed that scenario. Last year, a temporary law came into force to limit the number of chances of asylum applicants to obtain permanent residence (Médium, 2017). Currently, the country authorities suffer to shelter all refugees in security conditions: hotels, defused schools and old buildings were transformed in temporary shelters to immigrants who still did not obtain an answer for their asylum request. To contain the immigration, the country adopts more restricted rules in refugees’ receipt. The control worked and decreased the immigrants’ arrival from 10,000 to 800 by week last year (Casadaptada, 2017). Nevertheless, on the hypothesis that the behavior characterizing RS is a social extension of interoceptive predictions, which serves to either sound the alarm or perpetuate inappropriate priors, the behavioral pattern represents on some level a strategy selected in a social context (which is not to say it is in any way voluntary). If this line of reasoning is correct, which indeed is implied by the phenomenon respecting barriers pertaining to language, culture, ethnicity and national borders, measures aimed at preempting the unfortunate strategy should be enforced. Certainly, a deepened understanding of the history, culture and situation of risk groups’ individuals would be necessary in order to reach out to these individuals. The appeal to culture-bound psychopathology raises an ethical dilemma. The argument we have presented, according to which cultural sanctioning contributes to the generation of specific kinds of behavioral patterns, implies that by offering treatment, to which there is no alternative, we are also, on another level, causing new cases (Sallin et al., 2016).

The physicians believe that the phenomenon is a fear manifestation of returning to their origin countries, a theory reinforced by improvements recorded months after families had obtained the authorization to stay in Sweden (Visão, 2017). A group of physicians who take care children with Resignation syndrome argue that they recover when they feel safe. Furthermore, the permanent right to domicile is what triggers recovery. Somehow, the child will need to feel that there is hope, something for which is worth to live. That is the only way to explain how, in all cases, the right to stay in the country can change the situation (Zap, 2017).

Tears and hidden silences is a metaphor that includes the social extension, the projection of a culturally sanctioned idiom of distress also interpretable in a predictive coding framework. Accommodating an extensive multilevel involvement of homeostatic, cognitive and emotional systems with deep impact on behavior influenced by cultural expectations, this analysis is compatible with RS being catatonia, culture-bound (Sallin et al., 2016).