A blog from the Centre for Research Ethics & Bioethics (CRB)

Tag: resignation syndrome

Conceptual analysis when we get stuck in thoughts

When philosophers are asked what method we use when we philosophize, we are happy to answer: our most important method is conceptual analysis. We apply conceptual analysis to answer philosophical questions such as “What is knowledge?”, “What is justice?”, “What is truth?” What we do is that we propose general definitions of the concepts, which we then fine-tune by using concrete examples to test that the definitions really capture all individual cases of the concepts and only these.

The problem is that both those who ask for the method of philosophy and those who answer “conceptual analysis” seem to assume that philosophy is not challenged by deeply disturbing problems, but defines concepts almost routinely. The general questions above are hardly even questions, other than purely grammatically. Who lies awake wondering “What is knowledge, what is justice, what is truth, what is goodness, what is…?”

In order to get insomnia from the questions, in order for the questions to become living philosophical problems, in order for us to be disturbed by them, we need more than only generally formulated questions.

Moreover, if there was such a thing as a method of answering philosophical questions, then the questions should already have been answered. I mean, if we since the days of Socrates had a method that answers philosophical “What is?”-questions by defining concepts, then there cannot be many questions left to answer. At most, we can refine the definitions, or apply the method to concepts that did not exist 2600 years ago. Basically, philosophy should not have many questions left to be challenged by. Since ancient times, we have a well-proven method!

To understand why philosophers continue to wonder, we need to understand why questions that superficially sound so uninteresting that we fall asleep can sometimes be so deeply perplexing that we lie awake thinking. Let me give you an example that gives a glimpse of the depths of philosophy, a glimpse of that disturbing “extra” that keeps philosophers awake at night.

The example is a “Swedish” disease, which has attracted attention around the world as something very strange. I am thinking of what was first called apathy in refugee children, but which later got the name resignation syndrome. The disease affects certain groups of children seeking asylum in Sweden. Children from the former Yugoslavia and from Central Asian countries of the former Soviet Union have been overrepresented. The children lose physical and mental functions and in the end can neither move nor communicate. They become bedridden, do not respond to pain and must be fed by tube. More than 1000 children have been affected by the disease in Sweden since the 1990s.

Confronted with this disease in refugee children, it may seem natural to think that the condition is reasonably caused by traumatic experiences in the home country and during the flight, as well as by the stress of living under deportation threat. It is not unreasonable to think so. Trauma and stress probably contribute to the disease. There is only one problem. If this were the cause, then resignation syndrome should occur in refugee children in other parts of the world as well. Unfortunately, refugee children with traumatic experiences and stressful deportation threats are not only found in Sweden. So why are (certain groups of) refugee children affected by the syndrome in Sweden in particular?

What is resignation syndrome? Here we have a question that on the surface does not sound more challenging than any other generally formulated “What is?”-question. But the question is today a challenging philosophical problem, at least for Karl Sallin, who is writing his dissertation on the syndrome here at CRB, within the framework of the Human Brain Project. What is that “extra” element that makes the question philosophically challenging for Karl Sallin?

It may seem natural to think that the challenging aspect of the question is simply that we do not yet know the answer. We do not know all the facts. It is not unreasonable to think so. Lack of knowledge naturally contributes to the question. Again, there is only one problem. We already consider ourselves knowing the answer! We think that this extreme form of despair in refugee children must, of course, be caused by traumatic experiences and by the stress that the threat of deportation entails. In the end, they can no longer bear it, but give up! If this reasonable answer were correct, then resignation syndrome should not exist only in Sweden. The philosophical question thus arises because the only reasonable answer conflicts with obvious facts.

That is why the question is philosophically challenging. Not because we do not know the answer. But because we consider ourselves to know what the answer must be! The answer seems so reasonable that we should hardly need to do more research on the matter before we take action by alleviating the children’s stressful situation, which we think is the only possible cause of the syndrome. And that is what happened…

For some years now, the guidelines for Swedish health care staff have emphasized the family’s role in recovery, as well as the importance of working for a residence permit. The guidelines are governed by the seemingly reasonable idea that children’s recovery depends on relieving the stress that causes the syndrome. Once again, there is only one problem. The guidelines never had a positive effect on the syndrome, despite attempts to create peace and stability in the family and work for a residence permit. The syndrome continued to be a “Swedish” disease. Why is the condition so stubbornly linked to Sweden?

Do you see the philosophical problem? It is not just about lack of knowledge. It is about the fact that we already think we have knowledge. The thought that the cause must be stress is so obvious, that we hardly notice that we are thinking it. It seems immediately real. In short, we have got stuck in our own thoughts, which we repeat again and again, even though we repeatedly clash with obvious facts. Like a mosquito trying to get out of a window, but just crashing, crashing, crashing.

When Karl Sallin treats the issue of resignation syndrome as a philosophical issue, he does something extremely unusual, for which there are no routine methods. He directs his attention not only outwards towards the disease, but also inwards towards ourselves. More empirical research alone does not solve the problem. As little as continuing to collide with the glass pane solves the mosquito’s problem. We need to stop and examine ourselves.

This post has now become so long that I have to stop before I can describe Karl Sallin’s dissolution of the mystery. Maybe it is good that we are not rushing forward. Riddles need time, which our impatient intellect rarely gives them. The point about the method of philosophy has hopefully become clear. The reason why philosophers analyse concepts is that we humans sometimes get caught up in our own concepts of reality. In this case, we get stuck in our concept of resignation syndrome as a stress disorder. Perhaps I can still mention that Karl Sallin’s conceptual analysis of our thought pattern about the syndrome dissolves the feeling of being faced with an incomprehensible mystery. The syndrome is no longer in conflict with obvious facts. He also shows that our thought patterns may have contributed to the disease becoming so prominent in Sweden. Our publically stated belief that the disease must be caused by stress, and our attempts to cure the disease by relieving stress, created a cultural context where this “Swedish” disease became possible. The cultural context affected the mind and the brain, which affected the biology of the body. In any case, that is what Karl Sallin suggests: resignation syndrome is a culture-bound disease. This unexpected possibility frees us from the thought we were stuck in as the only alternative.

So why did Socrates ask questions in Athens 2600 years ago? Because he discovered a method that could answer philosophical questions? My guess is that he did it for the same reason that Karl Sallin does it today. Because we humans have a tendency to imagine that we already know the answers. When we clearly see that we do not know what we thought we knew, we are freed from repeatedly colliding with a reality that should be obvious.

In philosophy, it is often the answer that is the question.

Pär Segerdahl

Written by…

Pär Segerdahl, Associate Professor at the Centre for Research Ethics & Bioethics and editor of the Ethics Blog.

Sallin, K., Evers, K., Jarbin, H., Joelsson, L., Petrovic, P. (2021) Separation and not Residency Permit Restores Function in Resignation Syndrome: A Retrospective Cohort Study. Eur Child Adolesc Psychiatry, 10.1007/s00787-021-01833-3

Sallin, K., Lagercrantz, H., Evers, K., Engström, I., Hjern, A., Petrovic, P. (2016) Resignation Syndrome: Catatonia? Culture-Bound? Frontiers in Behavioral Neuroscience, 10:7. 10.3389/fnbeh.2016.00007

This post in Swedish

We challenge habits of thought

Resignation syndrome in refugee children – a new hypothesis

Pär SegerdahlThere has been much discussion about the so-called “apathetic children” in families seeking asylum in Sweden. You read that right: in Sweden, not in other countries. By all accounts, these children are genuinely ill. They do not simulate total lack of willpower; like inability to eat, speak and move. They are in a life-threatening condition and show no reactions even to painful stimuli. But why do we have so many cases in Sweden and not in other countries?

Several hundred cases have been reported, which in 2014 led the Swedish National Board of Health and Welfare to introduce a new diagnosis: resignation syndrome. The “Swedish” syndrome appears to be a mystery, almost like a puzzle to crack. There are asylum seeking families all around the world: why does this syndrome occur to such an extent in a single country?

If you want to think more about this puzzling question, I recommended a new article in Frontiers in Behavioral Neuroscience, with Karl Sallin (PhD student at CRB) as first author. The article is long and technical, but for those interested, it is well worth the effort. It documents what is known about the syndrome and suggests a new hypothesis.

A common explanation of the syndrome is that it is a reaction to stress and depression. The explanation sounds intuitively reasonable, considering these children’s experiences. But if it were true, the syndrome should occur also in other countries. The mystery remains.

Another explanation is that the mother attempts to manage her trauma, her depression and her needs, by projecting her problems onto the child. The child, who experiences the mother as its only safety, adapts unconsciously and exhibits the symptoms that the mother treats the child as if it had. This explanation may also seem reasonable, especially considering another peculiarity of the syndrome: it does not affect unaccompanied refugee children, only children who arrive with their families. The problem is again: traumatized refugee families exist all around the world. So why is the syndrome common only in Sweden?

Now to Sallins’ hypothesis in the article. The hypothesis has two parts: one about the disease or diagnosis itself; and one about the cause of the disease, which may also explain the peculiar distribution.

After a review of symptoms and treatment response, Sallin suggests that we are not dealing with a new disease. The introduced diagnosis, “resignation syndrome,” is therefore inappropriate. We are dealing with a known diagnosis: catatonia, which is characterized by the same loss of motor skills. The children moreover seem to retain awareness, even though their immobility makes them seem unconscious. When they recover, they can often recall events that occurred while they were ill. They just cannot activate any motor skills. The catatonia hypothesis can be tested, Sallin suggests, by trying treatments with known responses in catatonic patients, and by performing PET scans of the brain.

The question then is: Why does catatonia arise only in refugee children in Sweden? That question brings us to the second part of the hypothesis, which has some similarities with the theory that the mother affects the child psychologically to exhibit symptoms: really have them, not only simulate them!

Here we might make a comparison with placebo and nocebo effects. If it is believed that a pill will have a certain impact on health – positive or negative – the effect can be produced even if the pill contains only a medically inactive substance. Probably, electromagnetic hypersensitivity is a phenomenon of this kind, having psychological causes: a nocebo effect.

The article enumerates cases where it can be suspected that catatonia-like conditions are caused psychologically: unexpected, unexplained sudden death after cancer diagnosis; death epidemics in situations of war and captivity characterized by hopelessness; acute or prolonged death after the utterance of magic death spells (known from several cultures).

The hypothesis is that life-threatening catatonia in refugee children is caused psychologically, in a certain cultural environment. Alternatively, one could say that catatonia is caused in the meeting between certain cultures and Swedish conditions, since it is more common in children from certain parts of the world. We are dealing with a culture bound psychogenesis.

Sallin compares with an outbreak of “hysteria” during the latter part of the 1800s, in connection with Jean-Martin Charcot’s famous demonstrations of hysterical patients, and where colorful symptom descriptions circulated in the press. Charcot first suggested that hysteria had organic causes. But when he later began to talk about psychological factors behind the symptoms, the number of cases of hysteria dropped.

(Perhaps I should point out that Sallin emphasizes that psychological causes are not to be understood in terms of a mind/body dualism.)

It remains to be examined exactly how meeting Swedish conditions contribute to psychologically caused catatonia in children in certain refugee families. But if I understand Sallin correctly, he thinks that the spread of symptom descriptions through mass media, and the ongoing practice of treating “children with resignation syndrome,” might be essential in this context.

If this is true, it creates an ethical problem mentioned in the article. There is no alternative to offering these children treatment: they cannot survive without tube feeding. But offering treatment also causes new cases.

Yes, these children must, of course, be offered care. But maybe Sallin, just by proposing psychological causes of the symptoms, has already contributed to reducing the number of cases in the future. Assuming that his hypothesis of a culture bound psychogenesis is true, of course.

What a fascinating interplay between belief and truth!

Pär Segerdahl

Sallin, K., Lagercrantz, H., Evers, K., Engström, I., Hjern, A., Petrovic, P., Resignation Syndrome: Catatonia? Culture-Bound? Frontiers in Behavioral Neuroscience 29, January 2016

This post in Swedish

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