Notwithstanding any minor differences, this review uses the terms ‘isolation’, ‘segregation’, ‘separation’ and ‘seclusion’ interchangeably with ‘solitary confinement’, as defined above. It should be noted that in some health and disability facilities, confinement occurred in a physical setting that included more than one room, but in circumstances which still constituted isolation and segregation from other patients and members of the wider community and the usual routines of the facility. These circumstances have been considered for the purpose of this review. c. Seclusion and restraint: health effects and human rights standards Solitary confinement typically involves three elements: social isolation and limited, if any, 'meaningful human contact' (as defined in Mandela Rule 44); monotonous physical environment, offering reduced access to sensory stimulation; and, increased institutional control of all aspects of the individual's daily life, affording them limited personal autonomy. As social beings, each of these elements is potentially damaging to us. Together, they create a toxic mix which has been shown by studies dating back to the 19th century to adversely affect the health and wellbeing of those subjected to it. The reported psychological effects of solitary confinement range from acute to chronic and include anxiety, panic, chronic depression, rage, poor impulse control, cognitive disturbances including poor concentration and confused thought processes, perceptual distortions including depersonalisation and hallucinations, paranoia and psychosis.4 Studies have demonstrated physiological symptoms and effects too, including migraine headaches, heart palpitations, back and other joint pains, gastro-intestinal and genito-urinary problems, excessive sweating, insomnia, deterioration of eyesight, lethargy, dizziness, weakness and profound fatigue, feeling cold, poor appetite, weight loss, diarrhoea, tremulousness and aggravation of pre-existing medical problems. 5 Emerging research in the field of neuroscience demonstrates that solitary confinement disrupts brain activity, potentially leading to changes in the structure of the brain.6 Rates of self-harm 4 Shalev, S. (2008) A Sourcebook on Solitary Confinement, Mannheim Centre for Criminology: London; Grassian S. (2006) Psychiatric effects of solitary confinement. Journal of Law and Policy, 22:325Ð383; Haney C. (2003) Mental health issues in longterm solitary and supermax confinement. Crime & Delinquency, 49(1):124–156. 5 Shalev, S. (2014). ‘Solitary Confinement as a Prison Health Issue’. In: Enggist, S., Moller, L., Galea, G. and Udsen, C., (Eds.) Prisons and Health: a World Health Organisation (WHO) guide to the essentials in prison health (2nd edition), Copenhagen: WHO Regional Office Europe. pp27-35; Grassian S. (2006) Psychiatric effects of solitary confinement. Journal of Law and Policy, 22:325–383. 6 Pappas, S. (2012) Mystery of How Social Isolation Messes with Brain Solved. Life Science, September 13, 2012. 17