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Compartment Syndrome in Psychiatry

Compartment Syndrome in Psychiatry

I have spent a lot of time with a psychologist [in prison], which I had never done before in my life, in order to try to figure out how I could have done it. . . There are these mafia people who can kill people all day long, do terrible things, and then go home to their families. . . But the thing is that you can compartmentalise things in your life.1
–Bernard Madoff

Enron: All stressed up and no place to go.
–Daniel Scotto report, 4 months before Enron scandal

Physicians are required to fill the compartment of their neuro-crania with much in the way of thought content. Many years later, they may find the surplus of that content resurfacing. Take the example of the medical emergency known as compartment syndrome. Physicians from various disciplines will recall this striking condition which results from increased pressure in a muscle compartment.2 The compartment is surrounded by fascia which establishes the boundaries of the confined space.

Recall that fascia does not allow for significant expansion. Thus, any swelling in a compartment results in increased pressure in that area, which will compress muscles, blood vessels, and nerves. If this pressure is high enough, blood flow is blocked, leading to permanent injury. If the pressure lasts long enough, muscles may die and the limb may require amputation. Thus, the compartment syndrome amounts to “swelling out of control,” although the swelling may not be immediately visible since it occurs deep inside the limb.3

In psychiatry, we may speak of an individual separating off certain thoughts and their attendant emotions from the main, so that those thoughts do not encroach and disturb. This may be either a conscious, or an unconscious, process.4 Recollect that any given individual’s mental processes will vary dynamically according their level of sophistication and biopsychosocial constitution. Similarly, the effort required to inhibit thoughts from comingling in conscious awareness will also vary.

In a sense, the process may also be likened to invoking a mild state of dissociation in an attempt to confine and reduce anxiety.5 Incidentally, some symptoms that may suggest an impending compartment syndrome include: decreased sensation, and pain which may be enhanced when the compartment is squeezed.

But then what about our companions who, for constitutional reasons, carry less of an anxiety burden? It appears to be the case that they rely upon certain skills, such as manipulation and deception, to confine secrets.6 Regardless, they require a method for erecting mental walls of secrecy to prevent inconvenient exposure of contradictory thoughts.7 Let us remove the confounding variable of anxiety from the equation, if only for a moment.

Next, suppose that such mental processes are not fixed phenomena, but lie on a continuum. It is then possible to conclude we may be considering a common underlying mental process?

How common? In a 2005 global survey, PriceWaterhouseCoopers8 found that 45% of companies had experienced fraudulent acts (of which they were aware). Losses averaged well into the millions. Senior executives had committed a significant number of the frauds. White-collar crime costs the United States as much as $400 billion annually.9 It is interesting to note that during times of change and/or uncertainty, secrecy in organizations may increase.

This invariably results in poor communication, mistrust and mistakes because of blocked flow of timely, vital information. Here, the walls of secrecy may be compared with fascia, which contains and does not expand. Inside the compartment of secrecy, the pressure builds. Business white-collar crime, unsurprisingly, has been associated with a combination of low integrity and high conscientiousness.10 What is integrity other than the individual’s will to keep incorruptibly “whole” by keeping lies minimal, and confined to acceptable compartments?

Is this ability to compartmentalize universally condemned? There are, in fact, “situational” deceivers in society whose deceptions are acceptable and even admired.8 Consider the professional poker player, the politician, the advertiser, or any other “gamer” who must make use of subterfuge to conceal strategy. Call it impression management, deception, lying, whatever you choose—it is at base, one and the same. What ultimately keeps these individuals in the good graces of society is their ability to keep their “talents” confined to an acceptable time and place.

Perhaps at the core of compartmentalizing is how well—and how small—one confines one's lies. And how acceptable is it for us to keep them in that particular compartment? When the deception expands too much, pushes too hard against existing boundaries, the circumstances are created whereby a relatively minor injury, or continued expansion results in too much pressure. Unless something is done quickly to resolve the situation, the prognosis becomes poor.

Ultimately, surgery is the only recourse. Surgery, like legal proceedings, must be performed in a sterile environment. It's costly and carries risks. To be sure, in the operating room of the court, the secret compartment will be opened up and its contents revealed. This will be rather uncomfortable, and there will be a lengthy recovery period. And there will always be the scars.

Can you know anything other than deception? If ever the deception is annihilated, you must not look in that direction or you will turn into a pillar of salt.11
–Franz Kafka

References
1. Gelles D, Tett G. From behind bars, Madoff spins his story Available at; http://www.ft.com/cms/s/2/a29d2b4a-60b7-11e0-a182-00144feab49a.html#ixzz1J1UDPFlT. Accessed May 31, 2011.
2. Compartment syndrome. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002204/. Accessed May 31, 2011.
3. Compartment Syndrome: Swelling out of control. http://www.hughston.com/hha/a_17_2_1.htm. Accessed May 31, 2011.
4. Freud A. The Ego and the Mechanisms of Defence. New York: International Universities Press; 1966.
5. Gabbard GO. Long-Term Psychodynamic Psychotherapy: A Basic Text, 2nd Edition. Arlington, Va: American Psychiatric Publishing, Inc; 2010.
6. Hare R. The Hare Psychopathy Checklist—Revised, 2nd Edition. Toronto: Multi-Health Systems 2003.
7. Hare R, Neuman C. The PCL-R assessment of psychopathy: development, structural properties, and new directions. In: Patrick C. Handbook of Psychopathy. New York: The Guilford Press; 2006.
8. Babiak P, Hare R. Snakes in Suits: When Psychopaths Go to Work. New York: HarperCollins; 2007.
9. Maguire K, Pastore A, eds. Sourcebook of Criminal Justice Statistics. Washington, DC: U.S. Department of Justice. Bureau of Justice Statistics, 2002.
10. Blickle G, Schlegel A, Fassbender P, Klein U. Some Personality Correlates of Business White-Collar Crime. Applied Psychology: An International Revier. 2006;55:220–233. Available at: http://www.aow-bonn.de/www/doku/artikel/Blickle_et_al_2006_AP.pdf. Accessed May 31, 2011.
11. Kafka F. The Blue Octavo Notebooks. Cambridge: Exact Change; 1991.

 
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