Eur Child Adolesc Psychiatry (2009) 18:645–651 DOI 10.1007/s00787-009-0027-6 R E V I E W Pervasive refusal syndrome as part of the refusal–withdrawal– regression spectrum: critical review of the literature illustrated by a case report Tine Jaspers Æ G. M. J. Hanssen Æ Judith A. van der Valk Æ Johann H. Hanekom Æ Gijs Th. J. van Well Æ Jan N. M. Schieveld Received: 6 June 2008 / Accepted: 29 April 2009 / Published online: 21 May 2009 The Author(s) 2009. This article is published with open access at Springerlink.com Abstract Pervasive refusal syndrome (PRS) is a rare child psychiatric disorder characterized by pervasive refu- sal, active/angry resistance to help and social withdrawal leading to an endangered state. Little has been written about PRS. A literature search yielded only 15 relevant articles, all published between 1991 and 2006. This article presents a critical review of the published literature, illus- trated by a case report of an 11-year-old girl. PRS most often affects girls (75%). The mean age of the known population is 10.5 years. A premorbid high-achieving, perfectionist, conscientious personality seems to play an important role in the aetiology of PRS, as can a psychiatric history of parents or child and environmental stressors. G. M. J. Hanssen and J. A. van der Valk contributed equally to this paper. T. Jaspers J. N. M. Schieveld Department of Psychiatry and Neuropsychology, European Graduate School of Neuroscience, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, The Netherlands T. Jaspers (&) Department of Child and Adolescent Psychiatry, University Hospital Gasthuisberg, Herestraat 49, 3000 Louvain, Belgium e-mail: tine.jaspers@skynet.be G. M. J. Hanssen J. A. van der Valk Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands J. H. Hanekom Department of Paediatrics, Laurentius Hospital Roermond, PO Box 920, 6040 AX Roermond, The Netherlands G. Th. J. van Well Department of Paediatrics, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, The Netherlands PRS shows a symptom overlap with many other psychiatric disorders. However, none of the current DSM diagnoses can account for the full range of symptoms seen in PRS, and the active/angry resistance can be considered as the main distinguishing feature. Treatment should be multi- disciplinary and characterized by patience, gentle encour- agement and tender loving care. Hospitalization, ideally in a child and adolescent psychiatric unit, is almost always required. Although the recovery process is painfully slow (average duration of therapy 12.8 months), most children recover fully (complete recovery in 67% of known cases). In our opinion, it is important to increase knowledge of PRS, not only because of its disabling, potential life- threatening character, but also because there is hope for recovery through suitable treatment. We therefore propose an incorporation of PRS into the DSM and ICD classiﬁ- cations. However, an adaptation of the current diagnostic criteria is needed. We also consider PRS closely related to regression, which is why we introduce a new concept: ‘‘the refusal–withdrawal–regression spectrum’’. Keywords Withdrawal Pervasive refusal syndrome Refusal Regression Child psychiatry Introduction Pervasive refusal syndrome (PRS) is a rare and severe child psychiatric disorder deﬁned by clear food refusal and weight loss, social withdrawal, partial or complete refusal in two or more domains (mobilization/speech/attention to self-care) and an active/angry resistance to acts of help or encouragement [24]. The concept of PRS was ﬁrst introduced by Lask et al. [13]. A literature search on PRS yielded only 15 articles 123