Acute Decompensation 急性失代偿 Don suffered only a single decompensation in the several years of our contact with him. At the time of his acute break he was just twenty years old. The break came in the midst of a conjunction of stressful events, each of which added its burden and seemed to have contributed to his breakdown. To begin with, in the months preceding his decompensation, he had been having difficulty with his studies. He was a student at a prominent eastern university where he had come to study only that year. He had started his college career at a university in his own hometown, but had not been satisfied with things there. He had originally matriculated there because of his father's wishes. His father wanted him to stay at home, since he was the last of the children to be there. Don had complied with this demand, but felt resentful and chafed somewhat under this restriction. He had cherished a wish to come to the present university since childhood and resented his father's blocking his ambition. Finally he decided to make the break from home and to make the transfer in the face of his father's wishes. Coming to the new university was a test of his academic capacity on one side, but even more significantly a test of his capacity to function on his own away from his family. This was the first time in his life that he had lived away from home. Consequently, his academic difficulties confronted him with his own fears of his inadequacy and dependence on home and family. For him not to make it in the big university was to fulfill his father's and his family's predictions of his downfall. And so he felt the pressure of his academic slippage acutely. 在我们与唐接触的几年里，他只经历过一次失代偿。他急性疾病发作时才二十岁。他的崩溃发生在一系列压力事件中，每一件都增加了他的负担，似乎促成了他的崩溃。首先，在他失代偿之前的几个月里，他在学习上遇到了困难。他是东部一所著名大学的学生，那年才来这里学习。他在家乡的一所大学开始了他的大学生涯，但对那里的生活并不满意。他最初是按照父亲的意愿被录取的。他的父亲想让他呆在家里，因为他是最后一个到那里的孩子。唐答应了这个要求，但在这种限制之下，他感到有些怨恨和恼火。他从小就有上现在这所大学的愿望，并怨恨父亲的阻挠。最后，他决定与家决裂，不顾父亲的意愿转学。来到这所新大学一方面是对他学术能力的考验，但更重要的是对他离开家庭独立生活的能力的考验。这是他生平第一次离开家住。因此，学业上的困难使他不得不面对自己的不足和对家和家庭的依赖的恐惧。对他来说，上不了那所大大学就等于应验了他父亲和家人对他失败的预言。因此，他强烈地感受到学业下滑的压力。 In addition, shortly before his decompensation, he had broken off his relationship with his girl friend. This was particularly traumatic since he had never had a real girl friend before this, and his relationship with her was held by him as a facet of his being able to "make it" on his own. He found the disruption of this relationship—a disruption initiated by the girl—as upsetting and disturbing. He felt that it was a sign of his lack of masculinity and of his immaturity. It was another signal of defeat for him. 此外，在失代偿前不久，他和女友断绝了关系。这对他来说尤其痛苦，因为在此之前他从未有过一个真正的女朋友，他和她的关系被他视为他能够“独立”的一个方面。他发现这段关系的破裂——由女孩发起的破裂——令人心烦和不安。他觉得这是他缺乏男子气概和不成熟的表现。这是他失败的又一个信号。 A further factor was that shortly before the break Don had been elected president of his fraternity. He was well liked and rather popular among his fraternity brothers, but the election came to him as a surprise and a challenge. Not surprisingly, as we shall see, he felt that he was inadequate to handle the job and the responsibility that it imposed on him. These feelings were complicated by the fact that quite soon after he took office, Martin Luther King was murdered. Don was quite committed to liberal causes and had been actively involved in student activities for the improvement of civil rights, particularly for blacks. Martin Luther King had been one of his heroes, and Don was deeply affected by his death. He felt hurt, frustrated, angered, bitterly hateful, not only of whoever who had brought about King's death, but of all those who had opposed him and who stood in the way of all that King represented. He felt a sense of impotent rage and frustrated agony. 还有一个因素是，在发作前不久，唐被选为兄弟会的主席。他在兄弟会的兄弟中很受喜爱，也很受欢迎，但这次选举对他来说是一个意外和挑战。正如我们将要看到的那样，他感到自己不能胜任这项工作和它强加给他的责任，这并不奇怪。马丁·路德·金上任不久就被谋杀，这一事实使他的这种感觉更加复杂。唐非常致力于自由主义事业，并积极参与学生活动，以提高公民权利，特别是黑人的权利。马丁·路德·金曾是他的偶像之一，他的去世让唐深受影响。他感到受伤，沮丧，愤怒，极度仇恨，不仅憎恨那些导致马丁·路德·金死亡的人，也憎恨所有反对马丁·路德·金的人，以及那些阻碍马丁·路德·金所代表的一切的人。他感到一种无力的愤怒和沮丧的痛苦。 The response of the fraternity was to organize a daylong symposium at the university to consider the effects and implications of King's death on the civil rights movement. They wanted to organize it on a large scale and invite a number of prominent people to participate. The responsibility for organizing this program fell on Don's shoulders, and again typically he accepted this as a test of his abilities—particularly his ability to meet the responsibilities of his office. He plunged himself into this activity in a vigorous manner. He began working very hard, day and night, for several days. At this point he was on the brink of decompensation. His activity became more and more manic, he tried to do everything himself, making arrangements, setting up meetings, producing posters, running around from one thing to another in almost frantic style. His behavior became increasingly disorganized, frantic, and bizarre. His friends finally saw that his behavior was abnormal and increasingly disorganized, and thus brought him for psychiatric help. 兄弟会的反应是在大学里组织了一个为期一天的研讨会，讨论马丁·路德·金之死对民权运动的影响和影响。他们想组织一次大规模的活动，邀请一些知名人士参加。组织这个项目的责任落在了唐的肩上，他又一次典型地接受了这是对他能力的考验——尤其是他履行职责的能力。他以一种积极的方式投入到这项活动中。他开始非常努力地工作了几天，没日没夜。这个时候，他处于失代偿的边缘。他的活动变得越来越狂躁，什么事都想亲力亲为，安排事情，安排会议，制作海报，从一件事忙到另一件事，几乎是发疯似的。他的行为变得越来越混乱、疯狂和古怪。他的朋友们终于发现他的行为异常，而且越来越没有条理，于是带他去看精神病医生。 There was one other contributing feature of this decompensation. This had to do with Don's father. Several weeks prior to the events surrounding the immediate decompensation, Don's father had suffered a fairly severe stroke. The onset of the stroke was particularly disturbing to Don in that his father had the stroke while Don was talking to him on the telephone. Don went home to visit his father shortly after, and the effects of the stroke had stabilized by that time. The father was left with a partial paresis and some slurring of speech. Don became quite concerned with his father's condition—his father was also diabetic and alcoholic—and felt quite concerned and conflicted with the imminent possibility of his father's death. He had many preoccupations about his responsibility for his father's stroke and many guilt feelings about it—as we shall see in more detail later. 失代偿还有另一个诱因。这和唐的父亲有关。在急性失代偿反应发生的几个星期前，唐的父亲患了一场相当严重的中风。中风的发作尤其让唐感到不安，因为他父亲中风的时候，唐正在和他打电话。不久之后，唐回家看望他的父亲，那时中风的影响已经稳定下来了。父亲只剩下部分麻痹和说话含糊不清。唐开始非常担心父亲的病情——他的父亲也患有糖尿病和酗酒——他对父亲即将去世的可能性感到非常担忧和矛盾。他对他父亲中风的责任有很多顾虑，也有很多内疚的感觉——我们将在后面更详细地看到。 When Don came to the hospital he was frankly psychotic. His behavior was disorganized and erratic. He was disoriented and unable to concentrate even on simple clinical tests. He was suffering from almost manic excitement. He was alternately agitated and fearful. He was incredibly anxious and tremulous. He was repeatedly distracted by auditory hallucinations which seemed quite threatening and frightening to him. The physician who examined him at this time was a woman, and his responses to her were highly sexualized and erotic. Any questions put to him were interpreted in a highly sexual fashion. His associations were loose and he babbled rather incoherently at times in a classic flight of ideas. His clothing was disheveled, and he kept trying to unzip his fly, and intermittently trying to remove his pants. He expressed in a highly disorganized fashion somatic delusions and paranoid preoccupations that people were out to get him or do him in. He was afraid that his friends, or the doctor, or the people in the hospital wanted to kill him. An initial diagnosis was made of acute schizophrenic episode with homosexual panic. 当唐来到医院的时候，他已经明显精神失常了。他的行为杂乱无章，反复无常。他迷失了方向，甚至无法集中精力进行简单的临床试验。他几乎处于狂躁的兴奋状态。他时而激动，时而害怕。他极度焦虑和颤抖。他反复受到幻听的干扰，这对他来说似乎很有威胁和恐惧。当时给他做检查的医生是个女人，他对她的反应非常性感和色情。向他提出的任何问题都被解读成一种极具性意味的方式。他的联想很松散，有时语无伦次，像典型的思想狂飙。他的衣服乱糟糟的，他一直试图解开拉链，断断续续地试图脱下裤子。他以一种非常混乱的方式表达躯体妄想[患者会坚持自己有某些生理或外观上的残疾及缺憾，例如认为自己有很多体毛，或者会认为自己闻到、感受到异常的东西，更甚者会认为自己患了寄生虫或绝症，患者对此感到非常焦虑，会不断寻求治疗]和偏执的先占观念，认为人们是来抓他或把他弄死的。他害怕他的朋友、医生或医院里的人想要杀他。初步诊断为伴有同性恋恐慌的急性精神分裂发作。 With phenothiazines and environmental restriction, this disorganized picture cleared remarkably quickly. Within hours the disorganized and bizarre quality of his behavior disappeared and the hallucinations ceased. For several days his paranoid preoccupations persisted. He was suspicious and guarded, thinking that people were out to get him. Ideas of reference were prominent. After a few days, however, even these residual symptoms had evaporated and he had apparently returned to a level of premorbid functioning. 在吩噻嗪类药物和环境限制的作用下，这种杂乱无章的景象很快就消失了。几个小时后，他行为紊乱和怪异的特点消失了，幻觉也停止了。一连好几天，他的偏执先占观念一直没有平息。他很多疑，很警惕，认为人们是来抓他的。牵连观念[指将无关的外界现象解释为与本人有关，而且往往是恶意的，可成为妄想的先兆。]很突出。然而，几天后，甚至这些残留的症状都消失了，他显然已经恢复到发病前的功能水平。 Don was discharged from the hospital after a little more than two weeks. He then returned home, feeling uncertain about his future and not knowing what path to follow. His return home was obviously a defeat—a retreat from his failure. He had not been able to make it on his own, and his father's dire predictions had been verified by his breakdown. Once home, he began to get increasingly depressed. He did nothing—did not want to go to school, did not want to work. He just sat around and spent most of his time trying to piece together what had happened to him. He found little success in this effort and only became increasingly morose, withdrawn, and depressed. He began thinking of suicide and the idea grew on him with an intensity that frightened him. He finally came to the realization that he had reached the end of the road. He would either have to kill himself or try to get some help. He chose the latter course. 两周多一点后，唐出院了。然后他回到了家，对自己的未来感到不确定，不知道该走哪条路。他的返家显然是一次失败——从失败中撤退。他没能靠自己生存下来，他的崩溃证实了他父亲可怕的预言。一到家，他就开始变得越来越沮丧。他什么也没做——不想上学，不想工作。他只是坐在那里，大部分时间都在试图拼凑出发生在他身上的事情。他的努力收效甚微，只是变得越来越忧郁、孤僻和沮丧。他开始想自杀，这个念头越来越强烈，把他吓坏了。他终于意识到他已经走到了路的尽头。他要么自杀，要么寻求帮助。他选择了后者。 He began to see a private psychiatrist and was able to work through much of his depression. He was also able to make several important decisions about his future. He decided that he would leave home once again and pick up his academic work where he had left it. The effect of this phase of his therapy was that he had gained some measure of hope in himself, and a sufficient degree of confidence to permit him to try once more the path of his ambition that had once before led him to failure. He came back to the same university he had left when he decompensated and matriculated on a part-time basis. He also sought to continue the work of treatment that he had started so well at home. It was at this juncture that I undertook to continue Don's therapy. 他开始看私人精神病医生，并能够克服他的大部分抑郁。他还能就自己的未来做出几个重要的决定。他决定再次离开家，在他离开的地方继续他的学业。这一阶段治疗的效果是，他在自己身上获得了某种程度的希望，并有了足够的信心，可以再一次尝试那条曾经使他失败的雄心壮志之路。他回到了他失代偿时离开的那所大学，以兼职方式被录取。他还试图继续他在家里开始治疗工作，这工作之前进行得不错。就在这个时候，我接手了对唐的继续治疗。