Seclusion-Induced Psychosis in an Adolescent Boy

Chief Complaint and Presenting Problem

CJ was a 13-year-old adolescent boy with a history of major depressive disorder with psychosis referred for emergency evaluation by police for aggressive behavior in the context of nonadherence with his medications for 2 days. He was subsequently admitted to an inpatient child and adolescent psychiatry unit.

History of Present Illness

Mother reported that CJ had been irritable as a young child, and had developed periodic anger outbursts characterized by yelling and throwing objects. CJ and his mother immigrated from their Central American homeland to the United States during the pandemic. Mother and guardian reported that CJ had been having temper outbursts that were constant since his immigration in March 2021. His guardian and mother also reported that CJ had experienced episodes in which he displayed disorganized thought process and anger outbursts, “which came from nowhere.”

He was reported to exhibit behavioral problems that worsened after immigration during which he was held in a seclusion room for 40 days. In this context, CJ's immigration-appointed guardian and mother reported that CJ became aggressive after he “refused to get dressed to get his vaccination; he started hitting and banging his head on the floor and police were called to bring him into the hospital.”

On initial mental status evaluation, CJ appeared to have poor insight into his illness and was unable to provide recent history. He reported that he had “water on his skin” and when the police came he woke up, and he was “having a dream of his friend dying.” Mental status evaluation was notable for thought blocking with disorganized thought process; CJ was suspicious when asked about his immigration process and seclusion. He maintained poor eye contact throughout the interview and endorsed paranoid ideation with depressed mood.

He also endorsed an anxious thought process when describing the “incidents in seclusion when he was by himself, missing his mother and not having anyone in the room.” He endorsed poor sleep with agitation during sleep, nightmares, and being withdrawn from family and friends. Anhedonia was present. He demonstrated poor concentration and a lack of appetite. He also endorsed feeling on edge around unfamiliar people. No flashbacks were reported. CJ denied symptoms of panic disorder, mania, hypomania, or oppositionality. He denied active suicidal or homicidal ideation at that time.

Psychiatric History

According to mother and guardian, CJ's symptoms began in May 2021 after he was secluded 40 days during immigration to the United States with his mother. His first hospitalization was in a United States–Mexico border state hospital for treatment of a single episode of major depressive disorder with psychosis. He was prescribed aripiprazole 5 mg PO daily for psychosis, fluoxetine 10 mg PO daily for mood, and hydroxyzine 25 mg PO TID for anxiety.

Developmental History

Information was provided by CJ's maternal aunt, who reported he had a normal birth and early developmental history. CJ was born and raised in a Central American country but immigrated to the United States in March 2021 with his mother. Birth weight was unknown. He reportedly met developmental milestones on time with walking by 18 months, talking at 2 years, and toilet training between ages 2 and 3 years. He was reported to have normal emotional and social development.

Educational History

CJ was in eighth grade in regular classes and had average academic performance.

Social History

CJ was reported to have had an unstable childhood; father left the home for unknown reasons when CJ was very young, and he was raised by mother. He left his home with his 16-year-old brother to follow mother to the United States and to live with his aunt. Before admission he was living with his aunt, 16-year-old brother, and mother. He had spent a few months in Mexico, then in a southern border state detention center, then to Miami to be with his aunt. He was reported to be able to socialize and make friends. There was no history of substance use.

Family History

There were no known diagnosed psychiatric conditions within the family.

Medical History

CJ's mother denied any medical conditions including seizures or head trauma. She reported a history of a fracture of the left arm in the past after a sports accident. There was no history of abuse.

Mental Status Examination on Admission

Mental status examination showed a Hispanic adolescent who appeared his stated age. He made poor eye contact and looked to the ceiling. He appeared depressed with minimal interest in answering any questions regarding his living situation and school. He had fair grooming and good hygiene. He was alert and oriented to time and place. He displayed normal posture and did not have rigidity or repetitive movements. His affect was blunted and guarded, mood was constricted, and he appeared depressed throughout the interview. He demonstrated no psychomotor retardation. His speech was slowed and minimal spontaneity was noted.

Thought process was disorganized with some thought blocking. Thought content was isolative, and he reported paranoid ideation regarding “people watching him”; he was seen responding to internal stimuli. He was not forthcoming regarding auditory or visual hallucinations, but it was evident that he was internally preoccupied. CJ denied any tactile, olfactory, or gustatory hallucinations. He had poor attention and concentration requiring repetition of questions multiple times during the examination. CJ denied any plan or thoughts to harm himself and/or others, but reported he wished to die. Insight and judgment were poor and limited.

Hospital Course

Upon admission, CJ's medications were restarted: fluoxetine 10 mg daily and hydroxyzine 25 mg daily as needed for anxiety/aggression. Aripiprazole was increased to 10 mg daily to target paranoia and psychotic symptoms. Upon further discussion during his hospitalization, CJ revealed more details about his time in seclusion and onset of symptoms. He stated that he was in a small room, alone, without any lights or windows. He was not allowed to have communication with anyone unless the guards talked to him. He was given infrequent designated times to urinate or defecate and guards would not accommodate any use outside of those times.

He reported he purposely restricted his intake so as to not have to urinate or have a bowel movement. He reported that when the guards did talk to him, it was demeaning comments. No official conversations took place. He did not have a bed or blanket. He reports he slept on the floor, and most nights were cold. He reports he started to hear voices. The onset relative to duration in seclusion was unknown. At first, his auditory hallucinations were positive in nature. They told him things such as “you will get out soon,” “you can get through this,” and “you will see your family soon.” They at first were comforting and provided him with some optimism.

After a week, the auditory hallucinations transformed into negative voices, perpetuated by hopelessness, and eventually became command hallucinations telling him to kill himself. He started banging his head on the wall and punching the wall in an attempt to kill himself. It was at this time that he was transported to another immigration facility that was described as an intermediary holding facility that included medical and psychiatric care. This was possibly a psychiatric hospital facility, however, details are unknown. There CJ was given a room, a bed, free access to the restroom, interaction with others, and first saw a psychiatrist.

It was at that point that he was started on fluoxetine 10 mg daily, hydroxyzine 25 mg daily as needed for anxiety/aggression, and aripiprazole 5 mg daily. Despite treatment and eventual transition to home with mother and aunt, CJ's auditory hallucinations and paranoia persisted. The voices were telling him to fight or act and so he yelled at mother, banged on the walls, and broke things.

During the course of hospitalization, no psychotic symptoms were observed after CJ's initial presentation to the emergency department. His symptoms improved with the increase in aripiprazole and continuation of fluoxetine and hydroxyzine. The department of children and families was engaged with the family, and he was subsequently discharged home to mother and aunt and outpatient follow-up.

Brief Formulation

In summary, CJ was a 13-year-old adolescent boy from Central America referred for aggressive behavior, depression, and psychosis. He had a psychiatric history of major depression with psychosis, first diagnosed three months before hospitalization. There was no history of substance use, and no family history of psychiatric disorders. CJ's presentation was notable for episodes of spontaneous aggression, depressed mood, anhedonia, poor sleep, and impaired concentration. He also experienced auditory hallucinations that became command in nature telling him to hurt himself and to hurt others. He endorsed symptoms consistent with post-traumatic stress disorder (PTSD).

CJ had no genetic or developmental factors that would predispose him to the development of psychotic symptoms. Precipitating factors included his history of trauma, specifically prolonged seclusion and isolation. His symptoms were perpetuated by his adjustment to a new country, new language, and physical distance from some of his close family members. His symptoms improved with uptitration of aripiprazole, and continuation of fluoxetine daily. Most notable was the role and impact that social isolation and seclusion had on the development of an early adolescent boy.

Multiaxial Diagnoses

Axis I

Axis II

Axis III

Axis IV

Axis V

Discussion

This case is unique as it presents an adolescent who experienced severe trauma in an experience of seclusion and who subsequently developed persisting psychosis. Improvement of symptoms was achieved by titrating aripiprazole, and better targeting the dopaminergic pathways with amelioration of his psychosis, anxiety, and aggression. In the setting of seclusion, treatment focusing on psychosis can be effective, especially since the association between psychosis and seclusion has been documented. The role of seclusion in the development of psychotic symptoms in youth merits greater understanding.

A meta-analysis on social networks and the onset of psychosis points at the link between the two, stating “reduced social networks and support appear to pre-date onset of psychotic disorder” (Michalska da Rocha et al. 2018). The authors hypothesized that the development of psychosis is influenced by low self-esteem caused by loneliness. The article states the need for a singular large-scale study, as a meta-analysis including 38 articles provides considerable variability. Despite this “high heterogeneity across different studies, the overall relationship was robust” (Michalska da Rocha et al. 2018).

One theory about hallucinations during long-term seclusion is that brain sensory perception, usually overloaded with information, is taking the current small amount of information and creating objects to fill in spaces that are missing (Bond 2014). Seclusion is a state in which individuals experience loss of everyone around them. Hallucinations in this context may aid the individual's survival in the same way that being around others physically would. Similarly, the auditory hallucinations that CJ originally experienced provided comfort and may have been adaptive in helping him cope with the stress of social isolation. However, with time, these hallucinations became maladaptive, as demonstrated by command hallucinations to hurt himself and others.

According to Bennett et al. (2020), social isolation in childhood leads to an increased risk of at least two psychotic events, which, in turn, lead to an increased risk of psychosis. One important hypothesis states how immature processing and interaction of neuronal pathways in the prefrontal cortex can cause risky behavior, skewed and emotional reactivity, as well as lead to behaviors consistent with schizophrenia (Sturman and Moghaddam 2011). Stroud et al. (2009) have also found that adolescents, in comparison with children, demonstrate more neuroendocrine and cardiovascular reactivity to social stressors, as well as more subcortical activation compared with adults, highlighting the unique vulnerability to social stressors in this age group.

Adolescents experience development of white matter regions that aid in inhibitory control (Sturman and Moghaddam 2011). White matter alterations have been demonstrated in prodromal adolescents (Karlsgodt et al. 2009). Other studies have shown that adolescents exposed to social isolation have changes in maturation and myelination of oligodendrocytes in the prefrontal cortex and alterations in dopamine signaling pathways, which can be potential mechanisms of the development of psychosis (Makinodan et al. 2012; Patel et al. 2021). CJ's isolation in seclusion likely had substantial impact on the development of psychosis.

The lasting effects of social isolation on neurodevelopment, rendering some individuals vulnerable to psychosis, have been studied in various animal models throughout the years. After being exposed to social isolation, rats are found to have increased dopamine release in the prefrontal cortex and nucleus accumbens, along with increased dopaminergic neuronal firing in the ventral tegmental area, consistent with the dopamine hypothesis of schizophrenia pathology (Selten et al. 2017). There is also increased high-affinity D2 receptor proportions in the striatum in these isolated animal models (King et al. 2009). The abundance of studies of animals reared in isolation during critical developmental periods and association with psychosis highlights the influence of seclusion.

A recent survey of the general population in the United Kingdom (N = 7403) demonstrated that people who experienced or perceived social isolation and lack of communication were significantly more likely to endorse paranoia, interferences in thoughts, and hallucinations (Butter et al. 2017). CJ's prolonged isolation, in the context of no psychiatric history or known predisposing factors, was considered a significant precipitating event in his development of psychotic symptoms.

Seclusion and isolation can have a significant impact on the development of psychosis. This undoubtedly played a significant role in this adolescent's illness.