Pervasive refusal syndrome: systematic review of case reports

Abstract

Pervasive refusal syndrome (PRS) is a complex condition that affects young people leading to social withdrawal, inability or refusal to eat, drink, mobilise or speak. The affected individual regresses and is unable to self-care and quite characteristically will resist rehabilitation, worsen with praise or remain entirely passive. This systematic review was aimed at describing clinical features of PRS, current interventions and to summarise some of the nosological aspects of the condition. Without language restriction, an electronic search was conducted in Embase, PsychInfo, Medline, Cochrane library, and PubMed databases yielding 29 articles with a total of 79 cases. We performed a risk of assessment bias using an adapted Newcastle-Ottawa Scale and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 124 articles were identified, of which 29 were included and these yielded 79 cases. Seventy-six percent of the studies had a low rate of risk of assessment bias (good quality). Our results show that PRS overlaps with several conditions, mainly affects young females aged 7-15 years and has a recovery rate of 78% if diagnosed and treated early but the duration of inpatient treatment may last up to 9.44 months (8.82 SD). The patients had multiple inter-dependent risks. The major predisposing factors included vulnerable premorbid personality and pre-existing mental disorder. Precipitating factors were stressors such as infection and traumatic experiences. Enmeshed parent-child relationship served as a maintaining factor. The themes of treatment approach are essentially rehabilitative: (1) working collaboratively with patient and family, (2) having access to multidisciplinary team, and (3) peer/group supervision. This study has systematically evaluated a large sample of patients with PRS to ascertain its clinical features and the core elements of its treatment. Its key treatment approach is a multi-modal rehabilitative strategy that is compassionate, transparent and inclusive.

Pervasive refusal syndrome revisited: a conative disorder

“…Neither DSM-5 nor ICD-11 recognize PRS rendering it important to bring the syndrome to the attention of all disciplines constituting the pediatric mental health community. And that is why this month's paper by John Otasowie et al [2] entitled. Pervasive refusal syndrome: systematic review of case reports" is very welcome (2).…”

“…And that is why this month's paper by John Otasowie et al [2] entitled. Pervasive refusal syndrome: systematic review of case reports" is very welcome (2). Its strengths are its thorough critical screening and discussing of the existent literature by using the PRISMA guidelines, its clear systematic structure and its honest approach regarding all the aspects which we do not know or which we do not understand (yet).…”

Asylum-seeking children in shutdown: Neurobiological models

“…The same authors also reported that in the case series, all the parents of asylum-seeking patients had a history of mental illness (Otasowie et al, 2020).…”

“…Along the same lines, premorbid personality factors pertaining to the child—described as anxious, sensitive, perfectionist, conscientious high achiever with high self-expectation, and difficulty coping with perceived failure—have also been noted in a review of cases (asylum-seeking and civilian) (Otasowie et al, 2020).…”

Pervasive refusal syndrome or anorexia nervosa: a case report with a successful behavioural treatment

“…The pervasive refusal syndrome (PRS) was first described by Lask in 1991 [ 1 ]. A recent, systematic review of the literature by Otasowie and Collaborators in 2020 [ 2 ] shows the high attention paid to this issue. The disorder is rare but potentially life threatening.…”