Suicidal and Homicidal Thoughts as Psychotic Symptoms in an Adolescent: A Case Report

Abstract

The first episode of psychotic disorders often occurs in adolescence. Depressive symptoms are the most common symptoms in the prodromal period and the symptoms in this period are not specific to psychosis. Adolescence is a risky period in terms of suicidal behaviors. The risk of self-harm is further increased in the prodromal period and in the psychotic episode. Homicides in psychosis constitute a small part of all homicidal cases and homicidal thoughts have been associated with command hallucinations and delusions. In this article, an adolescent girl with psychosis who had intense homicidal and suicidal thoughts and self-harming behaviors will be presented, and homicidal thoughts in psychosis will be discussed. The symptoms of the case decreased with risperidone, and she started to socialize with the support of her teacher, who visited her house for lectures. The medical, legal, and social aspects of suicides and homicides in psychosis are discussed.

INTRODUCTION

Aggression and violence to themselves (self-harm, suicidal behaviors), others (homicidal behaviors), or both can be seen in psychiatric disorders. Although some of the risk factors were patient-centered (being in the 20s-30s, increased perception of stress, and easy access to weapons), clinical-centered factors (diagnosis, symptoms, and prognosis) were more associated with the violence risk (Woods and Ashley 2007). The only disorder in which aggression is one of the main diagnostic criteria is antisocial personality disorder (ASPD) (American Psychiatry Association 2013). When homicidal behaviors were examined retrospectively, it was found that 90% were diagnosed with a psychiatric disorder, half of which were substance abuse (SA) or personality disorder, and psychotic disorder was seen at a rate of 1/5 (Fazel and Grann 2004).

Psychotic disorders are chronic psychiatric disorders with severe loss of function and hospitalization. Homicidal thoughts and behaviors may be related to hallucinations and delusions of psychopathology. Childhood traumas, history of conduct disorder, substance use, impulsivity, and treatment non-compliance are the main risk factors associated with aggression (Faay and Sommer 2021). Suicidal thoughts and self-injury behaviors (SIB) are common in psychotic disorders; they can quickly turn into suicidal behavior (Ventriglio et al 2016). Depression, moderate to severe psychotic symptoms, and a family history of suicide are risk factors (McGirr et al 2006). The risk factors associated with suicidal behaviors differ in each stage of schizophrenia: prodrome, treatment, and remission. Initially, it is more likely to be related to the individual’s distress caused by psychotic experiences. In the post-attack period, it seems more likely to be related to the consequences of the loss of functionality. It is stated that suicidal thoughts are detected at a rate of 90% in the prodromal period, suicides are most common in the untreated psychosis period, and suicide attempts occur at a rate of 11% during treatment and 15% in the first 18 months of remission period (Ventriglio et al 2016).

Suicide is the second most common cause of death in adolescence (Shain et al 2016). On the other hand, homicidal thoughts are rare in children and adolescents (0.09%). (Vaughn et al 2020). Psychotic disorders are one of the risk factors for both. This article will discuss the clinical symptoms and follow-up of an adolescent who applied to our clinic with intense suicidal and homicidal thoughts since the prodromal period; it aims to draw attention to suicidal behaviors and raise awareness about homicidal thoughts in psychotic disorders. The patient and his family were informed that this article would be written anonymously for scientific purposes, and their consent was obtained.

CASE

A 15-year-old girl (X), who failed 9th grade, was brought by her mother with irritability, sibling jealousy, and refusal to go to school. The mother stated that for the last three years, her daughter’s self-care was low; she got angry very quickly and damaged herself and her belongings, was extremely jealous of her sister, had been reluctant to communicate with family members, spent time alone in her room, constantly asked questions, and searched on religion. She had been thinking about killing herself and others frequently for the last year and explained this as liking the thought of harming herself and dying; at first, she only cut her tongue and arm with sharp instruments such as razors, knives, and needles when she got angry. She had attempted suicide once, hated people and prepared a list of people she would kill, was reluctant to do the activities she used to enjoy, had difficulties falling and remaining asleep, and hated her sister because she was the favorite child of the family. She enjoyed playing the game of ‘assuming a completely different identity and pretending to be that persona’; each identity had a different name, age, and personality. She expressed doing this in order not to feel alone and that the fiction she played most often was ‘running away from class with her friends and killing a girl in her class’.

Due to her developmental history, she was born at thirty-two weeks by emergency cesarean section due to fetal bradycardia. Her mother’s pregnancy was planned, and she was the first of two children. The mother had a difficult pregnancy due to hyperemesis gravidarum and was followed up with the suspicion of intrauterine growth retardation because she only gained 4 kilograms. The psychomotor developmental stages were on time. She received pre-school education for three years, learned to read and write in the first year of the first grade, was very compassionate and kind to people and animals, and was loved by her surroundings. Her sister was born after an unplanned pregnancy when X was eleven months old. The mother could not take care of X enough because of the reoccurrence of the problems she had in her previous pregnancy. When X was three years old, her sister was diagnosed with acute lymphoblastic leukemia (ALL); her parents sent X to her grandfather and aunt, and they only communicated with X by phone. Three months later, his father took X with him; she could see her mother once a week. At the age of ten, X started taekwondo with the encouragement of her family. Although she initially liked it, she wanted to quit taekwondo because of strict dieting before the matches (sometimes the coach gave her a metabolism-accelerating drug to lose weight quickly), heavy training, and resorting to physical violence in her mistakes and defeats. However, her family refused. When she went to taekwondo, her interest in her lessons decreased, and her academic success gradually decreased. She left the sport after a heavy defeat in the summer qualifying matches when she was in the eighth grade. The symptoms started after that.

Family History: Father was a police officer and was described as skeptical, distrustful of people, and unpredictable by his wife and daughter. The father’s brother, who had no psychiatric diagnosis, killed himself for an unknown reason with a firearm at the age of 25.

Psychiatric Evaluation: She entered the room with her head bowed, looking around with skeptical eyes, hesitated to sit down, and talked while avoiding eye contact. She showed her age, her self-care was low, she smelled of sweat, and her hair was quite oily. Her mood was depressed, her affect was mildly blunt, memory was normal. Visual and auditory hallucinations were described; some were thought of as dissociative, because they were not persistent and resistant. Her thought process and associations were normal. Although she did not spontaneously initiated conversation, she answered the questions shortly and purposefully. Suicidal and homicidal thoughts, conflicts with her family, and nihilistic themes were found in her thought content. She was calm when talking about suicidal and homicidal thoughts. Her judgment was poor for her age. The severity of her psychomotor activity was low, and an intermittent increase in irritability due to the interview content was observed.

The themes in the Beier Sentence Completion Form were recurrent suicidal and homicidal thoughts, negative self-perception, low self-esteem, and conflict with family. The pictures she drew and the stories she wrote were about harm. (‘Once upon a time, there was a 46-year-old woman. While breastfeeding her two children, the children ripped her breast off, her veins drooped, and she died of blood loss.’ ‘While the child’s mother was cleaning the windows, the child pushed her mother, and her mother fell from the 11th floor, her bones were broken, her leg was crooked, like a puppet.’ ‘Because he does not believe in the Qur’an, Allah kills him by striking him in the head, sticking needles in his neck, burning his feet, and slowly cutting his throat. But God loves us. If God exists, let him destroy me with his wrath. I am not destroyed. Allah is an object invented by individuals who are not liars, dishonest, stupid, indifferent, incompetent.’). Her mother was afraid of the “dark and frightening theme”, so she prevented X from drawing and writing.

In Teacher Form, X was described as an unsuccessful student, was mainly absent, frequently explained her intention of harm, had physical complaints and had difficulties in focusing and maintaining attention.

Physical and neurological examination, cranial MRI, EEG, and amino acid panel were normal. Higher scores were seen in anger, hostility, and verbal aggression subscales of the Buss-Perry Aggression Scale (total score was 124, max. 150). Child Depression Scale was scored as 43 (17 and higher means depression), Rosenberg Self-Esteem Scale-Short form was scored as 6 (low self-esteem), and Difficulty in Emotion Regulation Scale was scored as 140. Emotional abuse and neglect subscales of the Childhood Trauma Scale were evaluated as above the threshold value.

Follow-up: In the first interview, frequent follow-up was planned, and risperidone 1 mg/day was started. During the second interview, X said that she had taken twelve drugs the day before and did not tell her parents. She talked about her plans to jump out of their seventh-floor house soon. Sertraline 50 mg/day was added due to depressive mood, intense feelings of worthlessness, and anhedonia. At the following interview, both her cheeks were observed to be severely scratched with her nails, and her self-care had decreased. X said that she had been controlled by an entity named ‘Muusin’ for the last year. Its gender and age were unknown, and it ordered her to harm herself and others. The dose of risperidone was increased to 2 mg/day, and hospitalization was recommended. However, the father did not accept hospitalization and said he would take a month off to care for his daughter. In the fifth interview, it was learned from the mother that X always found her nose ugly and examined it for hours in front of the mirror. Two days ago, when X got angry, she hit her head against the wall and broke her nasal bone.

In the interview after the rhinoplasty; X stated that when she went out, people constantly looked at her and wanted to hurt her, so she usually spent her time in her room, sitting in the dark because she thought that the neighbor on the opposite building was watching her through the window and trying to harm her. She stated that most people were ‘stupid ‘, that she felt different and special, and that the Illuminati had stolen her ideas. A week ago, she had made eleven medium/depth incisions on her right forearm with a razor blade. She said that when she was alone in her room in the evening, an old woman wanted her to hurt herself by saying, ‘cut off your arm’. She stated that she was afraid of being directed and harmed by the voices. The mother stated that X behaved positively to her family members until a week ago. She became withdrawn again, did not leave her room for about a week, was not interested in school, looked angry, threw things, and hurt herself with a razor blade. Risperidone was increased to 2.5 mg/day. The family was informed about thoughts of self-harm, but the father, again, refused hospitalization. After the increase in dose, the mother stated that X started to spend more time with them and that she did not harm herself and damage things even if she got angry. X also stated that she felt better, and her hallucinations had decreased considerably. Although she began to spend more time with her family, she said she still did not value her family and did not love them. The school counselor and mathematics teacher informed that X attended classes more regularly and tried to do the homework.

During follow-ups, the insight of the parents about the symptoms increased. A teacher who could support the patient socially and academically was found, and the patient’s functionality improved significantly. X started to write compositions on the subjects determined by the teacher, read books, play the guitar and interact more with her family. X started to talk less about the themes of killing herself and someone else and more often about her plans for the future. Her treatment continues.

DISCUSSION

Adolescents are developmentally impulsive and experience emotional ups and downs often. The risk of psychopathologies, such as SA, also increases, which increases the risk of suicidal behaviors and self-harm. In the literature, homicidal thoughts and behaviors in adolescents are generally discussed within the scope of the delinquent child (Price and Khubchandani 2017). In this case, severe SIB and homicidal and suicidal thoughts were associated with psychosis.

Psychotic disorders often occur in adolescence. According to the stress susceptibility model, some endogenously vulnerable individuals are sensitive to the adverse effects of stressful life events (Uher 2014). Uncle’s suicide with a firearm and father’s A-type personality traits biologically increase the risk of psychopathology in our case. It has been shown that both environment and lifestyle affect gene expression in developing a psychotic disorder, and the effect of the environment is high (Uher 2014). Prenatal stress, advanced paternal age, malnutrition, infections during pregnancy, and perinatal hypoxia are early risk factors for psychotic disorder. Traumatic life experiences during childhood, urban life, immigration, poverty, cannabis use, and being in a minority ethnic group are late risk factors (van Os et al 2004; Matheson et al 2011). In our case, stress due to hyperemesis gravidarum, malnutrition, and a history of preterm birth resulting from fetal bradycardia were early risk factors. Late risk factors were not being able to reach out to her parents emotionally during her sibling’s illness, repetitive physical and emotional abuse exposed in sports and urban life. The psychotic disorder was diagnosed because of unusual content of thought (delusional belief that she would be harmed, a delusion of control by the entity named Muusin, homicidal thoughts, feeling like a special person that can be interpreted as grandiose delusion, believing that her ideas were stolen by Illuminati); perceptual anomalies (depersonalization-derealization); visual and auditory hallucinations (hearing the voice of an older woman with a burnt face); religious-metaphysical obsessions; negative symptoms (spending time alone in her room and not going out, decrease in self-care, decrease in academic success, deterioration of relations with family, and skepticism); inconsistent mood with mild blunt affect, and damaging her tongue and nose. In addition, the symptoms of depression, social isolation, decrease in self-care, and skepticism lasting for three years were thought to be prodrome symptoms. The symptoms decreased with risperidone, while her isolation was alleviated with her private teacher as her ability to establish interpersonal relationships increased.

Dysfunctional cognitive schemas, such as ‘the world is always dangerous, the environment is threatening and unreliable, and the self is vulnerable’, result from interpersonal trauma experiences. These schemas form the basis of persecutory delusions and paranoia in psychosis by influencing the interpretation of internal and external experiences (Morrison 2009). ‘Dysfunctional cognitive schemas’ and ‘emotional dysregulation’ mediate the interaction between trauma and psychosis (Misiak et al 2017). The case may have started to perceive her environment as threatening as a consequence of her hostile dysfunctional cognitive schemas developed due recurrent traumatic experiences (‘facing injustice’, ‘injustice’ and ‘the thought that people around her deserve revenge’) and not sensing the parental warmth sufficiently; and feelings of anger, persecutory delusions and homicidal thoughts can be evaluated in this context.

Aggression in psychotic disorders is complicated due to its legal aspect and the risk of labeling (stigmatization). Despite the increased risk of violence in schizophrenia, very few of homicidal cases are associated with schizophrenia. Since the studies were conducted with people hospitalized due to the risk of harming others or who were imprisoned for the crime they committed, how much the result reflects the reality is also discussed. Moreover, it is claimed that the person with psychotic disorder is more vulnerable and in fact a victim of the violence (Adams and Yanos 2020).

The long duration of untreated time, the presence of aggressive behaviors before the onset, and ASPD characteristics are the factors that increase the risk of harming oneself and others the most in psychosis (Large and Nielssen 2011). The risk increases up to 15 times in the first psychotic episode, especially before the treatment (Nielssen et al 2012). It is stated that the violent behaviors that begin during psychosis and those that emerge in the presence of ASPD features are different from each other (Adams and Yanos 2020). Inadequate mentalization and empathy skills were detected both in schizophrenia and ASPD. However, the lack of difference in mentalization and empathy skills between patients with schizophrenia who display violent behavior and those who do not suggested that, unlike ASPD, violent behaviors are related to the psychotic process (Kristof et al 2018).

Homicidal behaviors being more frequent in males in the general population is attributed to females having higher levels of empathy while males have higher levels of aggression (Price and Khubchandani 2017). Our case was an adolescent girl. The effect of gender on violent behavior in psychosis is not consistent in studies. It is thought that the studied population and the disease phase affect violent behaviors more. The presence of more than three positive symptoms in the acute phase, non-adherence to treatment, and use of typical antipsychotics increase violent behavior. Male gender, being young, ASPD characteristics, depression, and SA were risk factors for violent behavior when positive symptoms were not dominant (Hodgins et al 2011). The symptoms in our case were attributed to the psychotic process and the active phase of the disease. Among the psychotic symptoms, persecution delusions, threat/loss of control symptoms, attack-themed command hallucinations, and religious-themed delusions have been associated with violent behaviors (Stratton et al 2017). In this case, almost all of these symptoms were present. Insight is the measure of one’s awareness of one’s illness. In schizophrenia, insight is expected to be poor. The relationship between violent behavior and insight is not clear. It is thought that other factors related to insight, such as adherence to treatment, substance use, intelligence, and cognitive flexibility, have priority (Smith et al 2020). Living alone, lack of social support, and leaving education early were more common in male schizophrenia patients who had violent behavior (Karabekiroğlu et al 2016); they were also seen in this case. It has been determined that people with schizophrenia who display homicidal behavior are more frequently traumatized in the form of emotional neglect and physical abuse in childhood (Taskaynatan and Erol 2019). Easy access to weapons increases the risk of homicide (Price and Khubchandani 2017). In our case, precautions against weapons in the house were explained to the family.

In psychotic disorders, especially in the first attack, violent behaviors towards oneself also increase. Suicidal thoughts were detected in nearly 70% of young people with homicidal thoughts (Reddy et al 2021). Severe SIB, which may result in organ loss, such as removing the eye, and amputation of a limb or a genital organ, can be seen in schizophrenia; they may be associated with religious delusions and command hallucinations (Large et al 2009). The risk of suicide in the first psychotic attack is high among people who have harmed themselves, suffered from depression, and committed violent acts in the past (Björkenstam et al 2014). This risk is highest in the first three months (Moe et al 2022), especially in the first five years (Harris and Barraclough 1997). Suicide attempts increase to 8-26% in the first attack, and those under 18 who have not started treatment are the highest risk group (Pompili et al 2011). Suicidal behavior is also common in youth at risk for psychosis; odd behavior and strange appearance increase the suicidal behavioral risk proportionally (D’Angelo et al 2017). Having a history of SIB, exposure to neglect and abuse, low number of positive symptoms, long duration of admission in the first episode, clinical deterioration, frequent presentations, and substance abuse increase the risk of SIB (Pompili et al 2011; Moe et al 2022). Body image deterioration is more common in schizophrenia, especially in youths and women (Saxon-Obada et al 2018). It is rare for a person to have the behavior of harming his/her face, and when it is observed, one of the first diagnoses that comes to mind is schizophrenia spectrum disorders (Ciorba et al 2014). Our case had cut her tongue in the past and broke her nose during follow-ups; she also talked about committing suicide. Young age, low self-esteem, hopelessness, having a family history of suicide, severe clinical deterioration, dominant-negative symptoms, traumatic experiences, and commanding hallucinations increase the risk of suicide (Pompili et al 2011). In addition, her social support decreased, and our case remained socially isolated by not going to school. Strange behaviors may increase the risk of SIB in association with social isolation and low cognitive flexibility (D’Angelo et al 2017). People with schizophrenia may want to change their physical appearance, name, and religious beliefs. This desire may be related to the psychotic process and their identity development. Here, the patient’s safety and the permanence of the results of change should be considered as much as the reason for the request (Seeman 2017). In our case, the game of imagining identities different from herself may be related to either problems/disorganization in identity development or social isolation.

The treatment of psychotic attacks with homicidal and suicidal thoughts may vary depending on the phase of the disease (Silverstein et al 2015). Antipsychotic treatment should be started as soon as possible (Langeveld et al 2014). Dopamine blockade reduces violent behaviors (Swanson et al 2008, Bo et al 2011). However, if ASPD accompanies, the response to antipsychotic treatment decreases (Bo et al 2011). Treatment of comorbid SA should also be started (Langeveld et al 2014). In the acute phase, clozapine is more effective than other antipsychotics. However, it was also stated that it is generally not preferred in the beginning of treatment because of the side effects and patient compliance problems (Hodgins et al 2011; Bo et al 2011; Silverstein et al 2015). If it is difficult to ensure the safety of the patient and those around the patient, the patient should be hospitalized. In our case, hospitalization was recommended because of intense homicidal thoughts towards herself, her sister, and her classmates. However, the father refused, stating that he would be at home by taking a leave from his work. In addition to the improvement achieved with risperidone, her social isolation decreased after she started to take private lessons from a private teacher. However, since it is not known when such a risk will recur, it is planned to inform the family frequently, pay attention to drug compliance during follow-ups, and include psychoeducation for the patient to gain insight. Since our case is in adolescence, a multidimensional, biopsychosocial approach is more critical. Identity development, career choice, and self-sufficiency skills should be emphasized. The risk of recurrence of the same symptoms in the subsequent possible attacks of the case cannot be estimated.

Homicidal and suicidal thoughts are among the emergencies of psychiatry and carry legal and medical responsibilities. Especially the period between the first attack of schizophrenia and beginning of the treatment is most critical. It is essential to follow up on high-risk individuals to intervene early and detect distinctive symptoms in the early period.