Psychiatric Decompensation

Learn signs to watch for and actions to consider when severe mental illness (SMI) symptoms may be worsening.

What are warning signs and action steps for mental health decompensation?

Decompensation describes the onset or worsening of psychiatric symptoms. A person with a severe mental illness (SMI) may experience a change in mood, psychosis symptoms, cognitive decline, and other changes that impact their ability function.

Ideally, a relapse is prevented with consistent communication between the person with SMI and their care team, including care partners and unpaid family or friends who are consistently supportive. Tracking symptoms and medication and making minor adjustments as needed is the best way to maintain stability across time. The care team might design an individualized “relapse prevention plan,” with thoughtful lists about what to encourage and what to avoid. For the best possible outcomes, all important people should be included in planning and tracking.

Unfortunately, breakthrough symptoms and relapses are quite common with SMI. Noticing early warning signs of decompensation is the best approach to prevent hospitalization, criminalization, damage to relationships and opportunities, structural damage to the brain, and other possible harm from an untreated SMI condition.

New or worsening symptoms may appear over days, weeks, or months. Sometimes symptom onset is only identifiable in hindsight, but acting early can shorten an illness episode’s duration as well as long-term impacts, particularly if psychosis is an aspect of the brain-based condition. Here are a few priorities for a person experiencing new or worsening symptoms or for someone caring for another person in the early stages of decompensation:

• Keep routines consistent.
• Reduce conflict or overstimulation.
• Encourage sleep, nutrition, and medication adherence.

What are the signs of decompensation?

Early indicators of the onset of a worsening brain-based illness may include changes in behavior, such as:

• Sleeping much less or much more than typical.
• Increased isolation.
• Avoidance of family and/or friends.
• Decline in hygiene or self-care.
• Increased agitation, irritability, or anxiety.
• Difficulty concentrating or following conversations.

A person also might experience changes in thinking and perception, resulting in:

• Suspicion or paranoia.
• Irrational or bizarre beliefs (delusions).
• Hearing, seeing, and/or sensing things others do not (hallucinations).
• Confused or very disorganized speech.

Functional decline might look like:

• Difficulty with tasks that are typically easy to finish.
• Excessive absences from work, school, and appointments.
• Out-of-character conflicts with loved ones.

What is helpful for advance planning?

The reasons why symptoms get worse may be unknown. Tracking the illness and noting consistent precursors to relapse is one way to attempt to disrupt cycling through crises. Medication changes and interruptions are a common cause of decompensation. TAC’s medication management resource includes a medication log to help with tracking of dosages, effects, side effects, and other concerns.
In addition to medication changes, common triggers for decompensation are:

• Major stress or life changes.
• Disrupted sleep.
• Substance use.
• Loss of social support.
• Medical illness.

Unfortunately, many people with SMI lack insight, meaning they cannot see that they have a mental illness because of a symptom called anosognosia. This neurological symptom is the most frequent explanation for treatment non-adherence. For some people, anosognosia comes and goes alongside other symptoms. That can mean that a person loses self-awareness of illness at the precise moment they need to take action to stop decompensation. In those situations, people who care for them may be the first to recognize a worsening of illness symptoms. A care partner is anyone — family or friend — who consistently helps a person in need of support.

If the person who is unwell recognizes that their condition is worsening, they may seek help from medical providers and other supporters on their own. If they don’t have a full team for support, they may need other tools to track their own symptoms and notice changes. TAC’s library of multimedia resources includes some options, including a book by Katherine Ponte called “Your Mental Health Recovery Workbook.” A psychiatric advance directive (PAD) is another tool that some consumers of mental health care use to plan ahead for episodes of acute illness.

What can care partners do?

If you are a care partner for someone with SMI, you may have some influence over the situation if you can encourage your loved one to seek additional care when their symptoms are in an early stage of progression. If the situation becomes dangerous, you will be more prepared with advance planning.

Here are topics to research now:

• Communication skills for maintaining a collaborative relationship and possibly motivating treatment: Communication Tips: Talking with someone in psychosis – TAC
• Build an emergency toolkit: Emergencies: Plan for a mental health crisis – TAC
• How to advocate for involuntary services: Involuntary Treatment Toolkit for Severe Mental Illness – YouTube
• How to maintain and share mental health history with anyone providing care or making decisions about care: Mental Health History One Pager

How do I talk to my loved one who isn’t doing well?

When speaking with a loved one escalating toward a mental health crisis, your calm demeanor can be critical. Keep your hands, eyes, and voice soft and relaxed. Whenever possible, sit down instead of standing. Never try to convince someone in psychosis that their reality is wrong and do your best to side-step arguments by agreeing where you can and asking questions instead of giving directions. You might focus on what you’ve observed, using opening statements or questions like these below.

• “It seems to me that your sleep isn’t the same. Have you noticed a change in your sleep?”
• “What’s it like to be you right now?”
• “I want to help. Tell me more.”
• “I’m wondering if we might check in with your [doctor, case manager, therapist …].”
• “Can I help you make an appointment?”

Allow plenty of time for your loved one to hear you and respond before you make another point or ask another question, so as not to overwhelm them. As a care partner, you can communicate with any involved provider to report what’s happening and ask for recommendations. Federal privacy laws do not block you from sharing what you know, nor do they block a provider from giving general guidance about how to proceed, especially if there is a safety concern. TAC’s resource about HIPAA offers additional information.

What should I be writing down?

Maintaining a mental health history is one of the most useful things a care partner can do when supporting someone with an illness that can render them unable to self-report accurately about their symptoms. Family and friends involved in a person’s care also may want to keep evidence of symptoms with videos, text messages, written notes, etc. That evidence may be what a provider needs to file a court petition for involuntary treatment.

Consider keeping a journal to make regular notes that can eventually be transferred into the more concise mental health history. Items to note:

• Dates, times, locations for each noted behavior or symptom.
• Specific behaviors that are dangerous, bizarre, or out of character.
• Changes in mood.
• Sleep disruptions.
• Changes in basic functioning (hygiene, speech, reasoning, mobility, fine motor, etc.).

When is it time to take emergency action?

Call your loved one’s provider, a local crisis response service, or the 988 National Suicide & Crisis Lifeline if:

• You or your loved one needs to speak with a mental health professional right away.
• There is a risk of harm to self or others that is not immediately violent.
• Self-care for basic needs (eating, drinking, sleeping) is impossible.
• Confusion or disorganization is severe.
• Hallucinations, delusions, or paranoia are disrupting daily life.

The Right Response Directory may include a program near the person in crisis, or a county website might have information about local services.

If there is violence, a weapon, or a serious injury, call 911. Request response from officers with CIT training, which stands for crisis intervention team training.