646 (vide infra); two supplementary articles were found on the subject through the feedback of colleagues. We present a critical review of the existing literature, illustrated by a case report. Based on a comparison of our clinical expe- rience with the existing literature, we suggest adapting the current diagnostic criteria. We also introduce the concept of the refusal–withdrawal–regression spectrum, of which PRS is a part. It is important, in our opinion, to foster greater insight into PRS, not only due to its particularly incapacitating character, but also because there is hope for recovery through suitable treatment. We hope this article will con- tribute to an increased awareness of its existence. Case report Kate,1 a highly intelligent, 11-year-old Caucasian prepu- bertal female, was referred to our academic medical psy- chiatric unit for children by a local paediatrician for a second opinion. She had a 6-month history of increasing unexplainable somatic complaints, starting with acute fatigue, a sore throat and a headache. The symptoms developed into an inability to walk, nausea, eating prob- lems, joint pains, diplopia, dizziness and urinary frequency, resulting in progressive social withdrawal. Kate stayed in all day, did not go to school and became disinterested. Medical history was unremarkable, while psychiatric his- tory revealed perfectionist and overachieving personality features and a history of tantrums at the age of 7. The acute onset suggested a stressful event prior to the start of her complaints. Parent and child only described a troubled relationship with one particular teacher, who taught her for 2.5 consecutive years, shouted at her and, at times, openly ignored her. Changing school did not relieve the symptoms but was associated with a deterioration. Physical or sexual abuse was explicitly denied. The family history was irrelevant, although an enmeshed mother–child relationship was noted. During the admission, which was primarily diagnosti- cally focused and further characterized by an attitude of gentle encouragement and tender loving care, Kate’s con- dition deteriorated. Her immobility increased to the point that she stayed in bed all day and could only crawl. She refused solid food, resulting in a weight loss of 3 kg. Kate increasingly complained about headaches and feeling cold. The situation eventually led to her lying in bed with a coat on and covered with approximately ten folded bed sheets. She yawned every 30 s and crawled to the toilet every couple of minutes. This behaviour made a very forced and 1 To ensure anonymity, we selected a ﬁctitious name for the index patient. 123 Eur Child Adolesc Psychiatry (2009) 18:645–651 theatrical impression. Her complaints seemed to ﬂuctuate, particularly worsening when parents or medical/nursery staff were present. From informal remarks made by her room-mates and their visitors, we learned that Kate could walk and talk normally when we or her parents were not present. Whereas Kate underwent the medical investigations passively, she actively refused to cooperate with any of the psychological or psychiatric investigations and any attempts made by others to stimulate her. She constantly asked to be left alone when someone entered the room. If her request to leave was not directly obeyed, she turned away, began to whine and no longer responded to ques- tions, impeding any further attempts at conversation. When we gently tried to motivate her, she became aggressive. Despite many somatic multidisciplinary investigations, no organic cause of her complaints could be traced. Lab- oratory investigations of blood, urine and faeces showed no abnormalities. There were no serological markers associ- ated with beta-haemolytic streptococcus group A infection (GABHS), ruling out PANDAS (paediatric auto-immune neuropsychiatric disorders associated with streptococcal infections). An MRI of the brain showed no abnormalities. A provocation test to exclude a central hypothermia syn- drome showed no drop in core body temperature, thereby ruling out hypothermia. Given the severity, deteriorating and disabling character of her disorder, with a GAF (global assessment of func- tioning) score of 21–30, we were forced to transfer Kate to a child psychiatric hospital for what we expected might become a long-term inpatient rehabilitation programme. However, after 3 months of patient and gentle rehabil- itation, a spontaneous and nearly complete recovery occurred. There remained some fatigue, but it soon disap- peared. Kate returned to high school on a full-time basis and outpatient follow-up was discontinued by both her and her parents. Discussion Literature search Pervasive refusal syndrome was ﬁrst brought to our attention by a Dutch publication [25]. An extensive liter- ature search (Cochrane, Embase, PsychInfo, PubMed), conducted in April 2008, yielded only 20 articles for the search term pervasive refusal syndrome. Three of the articles were irrelevant because they dealt with entirely different topics, and two described eating disorders [5, 10] with PRS mentioned only marginally. The remaining 15 articles [2–4, 7–9, 11, 13, 17–19, 23, 24, 26, 27], published between 1991 and 2006, described only 23 distinct cases of