What is the management approach for Pervasive Arousal Withdrawal Syndrome?

Management Approach for Pervasive Arousal Withdrawal Syndrome (PAWS)

The management of Pervasive Arousal Withdrawal Syndrome requires a multidisciplinary rehabilitative approach that is compassionate, transparent, and inclusive, with hospitalization in a child and adolescent psychiatric unit being almost always necessary for effective treatment. 1

Understanding PAWS

Pervasive Arousal Withdrawal Syndrome (PAWS), previously known as Pervasive Refusal Syndrome (PRS), is a rare but serious psychiatric condition primarily affecting children and adolescents. It is characterized by:

• Social withdrawal
• Inability or refusal to eat, drink, mobilize, or speak
• Regression in functioning and inability to self-care
• Active resistance to rehabilitation efforts
• Worsening with praise or complete passivity

PAWS primarily affects females (75% of cases) with a mean age of 10.5 years 2. The condition has significant overlap with other psychiatric disorders but is distinguished by the active/angry resistance to help that patients exhibit 2.

Diagnostic Considerations

Before initiating treatment, it's essential to:

• Rule out organic causes for symptoms
• Identify predisposing factors:
  • Premorbid high-achieving, perfectionist personality
  • Family psychiatric history
  • Environmental stressors or traumatic experiences
  • Enmeshed parent-child relationships (which often serve as maintaining factors) 1

Treatment Framework

1. Hospitalization and Environment

• Inpatient treatment in a child/adolescent psychiatric unit is almost always required 2
• Create a safe, structured environment with clear boundaries
• Establish a consistent daily routine
• Implement a non-punitive, non-confrontational approach

2. Multidisciplinary Team Approach

The core team should include:

• Child psychiatrist
• Clinical psychologist
• Pediatrician
• Specialized nursing staff
• Occupational therapist
• Physical therapist
• Social worker
• Dietitian

3. Treatment Phases

Initial Phase:

• Focus on building therapeutic alliance and trust
• Ensure physical safety and medical stabilization
• Address nutritional needs (may require nasogastric feeding initially)
• Begin gentle encouragement without pressure
• Involve family in treatment planning

Middle Phase:

• Gradually increase expectations for self-care
• Implement graded exposure to activities
• Use behavioral techniques with positive reinforcement
• Avoid excessive praise which may paradoxically worsen symptoms
• Continue family work to address maintaining factors

Recovery Phase:

• Gradual reintegration into normal activities
• School reintegration program
• Transition planning for discharge
• Relapse prevention strategies

4. Specific Therapeutic Elements

• Psychological Interventions:

  • Cognitive-behavioral techniques
  • Family therapy to address enmeshed relationships
  • Play therapy for younger children
  • Art therapy as non-verbal communication tool

• Physical Rehabilitation:

  • Gradual mobilization program
  • Occupational therapy for activities of daily living
  • Physical therapy for strength and coordination

• Pharmacological Approaches:

  • No specific medication is indicated for PAWS itself
  • Medications may be used to target comorbid conditions (anxiety, depression)
  • Cautious use of anxiolytics or antidepressants if indicated

5. Family Involvement

• Educate parents about the condition
• Address parental anxiety and guilt
• Modify parent-child interactions that may maintain the condition
• Provide regular family sessions
• Include siblings in the treatment process when appropriate

Prognosis and Recovery

Despite the severity of symptoms, the prognosis for PAWS is generally positive:

• Complete recovery occurs in approximately 67% of cases 2
• Average duration of treatment is 12.8 months 2
• Recovery process is typically slow and gradual
• Early diagnosis and intervention improve outcomes 1

Common Pitfalls to Avoid

1. Confrontational approaches - These typically worsen resistance and withdrawal
2. Excessive praise - Can paradoxically increase symptoms
3. Inconsistent team approach - All team members must maintain the same therapeutic stance
4. Premature discharge - The slow recovery process requires patience
5. Neglecting family dynamics - These often maintain the condition
6. Focusing solely on physical symptoms - The psychological components require equal attention
7. Diagnostic confusion - Misdiagnosing as simple depression or conversion disorder can lead to inappropriate treatment

Follow-up Care

• Gradual transition to outpatient care
• Continued monitoring for relapse
• School reintegration support
• Family therapy to maintain gains
• Regular multidisciplinary review

The treatment of PAWS requires extraordinary patience and a carefully coordinated approach. While recovery is typically slow, most children can achieve full recovery with appropriate intervention.