Decompensation: Psychology, a loss of ability to keep up normal psychological defenses, sometimes resulting in depression, anxiety, or delusions.

One of my favorite literary descriptions of a psychiatric decompensation is in the 1933 short story, Miss Lonely Hearts by Nathanael West. Miss Lonelyhearts is an advice columnist who slowly loses his mind from the suffering he reads. This passage is toward the close of the story:

“After a long night and morning, towards noon, Miss Lonelyhearts welcomed the arrival of fever. It promised heat and mentally unmotivated violence. The promise was soon fulfilled; the rock became a furnace.
He fastened his eyes on the Christ that hung on the wall opposite his bed.
As he stared at it, it became a bright fly, spinning with quick grace on a background of blood velvet sprinkled with tiny nerve stars.
Everything else in the room was dead–chairs, table, pencils, clothes, books. He thought of this black world of things as a fish. And he was right, for it suddenly rose to the bright bait on the wall. It rose with a splash of music and he saw its shining silver belly.
Christ is life and light.
“Christ! Christ!” This shout echoed through the innermost cells of his body.
He moved his head to a cooler spot on the pillow and the vein in his forehead became less swollen. He felt clean and fresh. His heart was a rose and in his skull another rose bloomed.
The room was full of grace. A sweet, clean grace, not washed clean, but clean as the inner sides of the inner petals of a newly forced rosebud.
Delight was also in the room. It was like a gentle wind, and his nerves rippled under it like small blue flowers in a pasture.
He was conscious of two rhythms that were slowly becoming one. When they became one, his identification with God was complete. His heart was the one heart, the heart of God. And his brain was likewise God’s.
God said, “Will you accept it, now?
And he replied, “I accept, I accept.”
He immediately began to plan a new life and his future conduct as Miss Lonelyhearts. He submitted drafts of his column to God and God approved them. God approved his every thought.”

– Miss Lonleyhearts by Nathanael West

My episodes of decompensation are less dramatic, but no less frightening. It’s frightening to lose the ability to sleep and concentrate. It’s frightening to lose the ability to distinguish between reality and fantasy. It’s frightening to wake-up tired and hopeless and thinking that it never gets better.

Decompensation is not necessarily a bad thing if it is part of the therapeutic process.

“…anxiety and panic symptoms are almost invariably “feeling flashbacks” triggered by a relatively benign event in the here-and-now, such as being alone in a room at twilight.”

The basic skills a trauma patient needs:

  • grounding and centering techniques
  • coping strategies for dealing with suicidal and self-abusive impulses
  • contracting for safety with themselves and others
  • anticipate stressful or triggering events
  • learn how to calm the body and mind
  • distinguish past from present reality and how to stay “in the present”

The Work of Stabilization in Trauma Treatment

If the trauma symptoms include dissociative alters the alters must know about and communicate with each other. This is not easy and my recent attempts to communicate broke through memory barriers and lead to this most recent period of decompensation and regression.

Regression is an unconscious defensive process by which the patient reverts to a previous level of functioning, usually to a certain infantile or juvenile stage. One of the best portrayals of regressive decompensation is in the film Repulsion by Roman PolanskiCatherine Deneuve portrays Carol, a sexually conflicted young Belgian woman. Carol lives in London with her older sister.

The film suggests that either Carol’s father or some other man sexually abused her as a child. I first saw Repulsion when I was in my 20’s. Watching it again this week during an episode of decompensation was a revelation.

Polanski shows us Carol’s anguish and her rapid decline with brilliant accuracy; when the Sister leaves for a week-long holiday we enter the dangerous territory of Carol’s mind.

“…the most common effect of sexual abuse is Post Traumatic Stress Disorder. Symptoms extend into adulthood and can include withdrawn behavior, reenactment of the traumatic event, avoidance of circumstances that remind one of the event, and physiological hyper-reactivity.” Psychology Today

We see these symptoms when Carol’s boyfriend tries to kiss her. She reacts with disgust, runs into her apartment in a panic and obsessively brushes her teeth.

Among the trauma symptoms depicted in Repulsion are the loss of time
which begins almost as soon as Carol is alone.

We see her increased sense of disconnection from her environment. Later, as her paranoia and hyper-vigilance escalates Carol re-lives her assault. By the end of the week Carol is lost to herself and the film closes with a snapshot of Carol as a child, glaring angrily at her Father.

Kim Morgan of the Huffington Post calls Repulsion one of the most frightening studies of madness
ever filmed.

My emotions were everywhere this week. My decompensation was not as dramatic as Carol’s; it certainly doesn’t have the narrative edge. It involved lost time and laying in bed watching Repulsion followed by non-stop episodes of MST3K.

Thank God for the part of me that comes out to watch to watch that show. The most difficult thing about surviving is surviving. Here are some things I do to take care of myself:

  • If you have a counselor or psychotherapist let that person know what is happening if you think you entering a crisis.
  • You can also call the National Suicide Prevention Hotline: 1-800-273-8255
    Remind yourself that memories are just memories; it is more normal to remember a  trauma than to forget it.
  • Remind yourself that panic attacks are not dangerous; if you find yourself in the middle of one stop and pace your breathing.
  • If you start to relive the past remind yourself of the present.
    When you can’t sleep don’t lie in bed thinking or worrying; get up and enjoy something soothing or pleasant.
  • If you have difficulty concentrating, give yourself time to focus on what you need to do.
    You may also have symptoms of depression; people with PTSD and CPTSD also have depressive episodes.

If the acuity lasts for more than a few days seek help. If you think you are a danger to yourself or others call 911 or go to an emergency room.

— Rob Goldstein 2016-2018