My patient is afraid she will be poisoned!

“I am treating a young man, 24, who suffers from Lyme Disease and is afraid he will die. He had these fears before he got the Lyme Disease, but since then they have become stronger. He also fears he will be poisoned from food in restaurants or supermarkets, (Delusional thoughts), but those thoughts don’t prevent him from eating. He lives with his girlfriend and seems to have a good relationship with her. He stopped working, watches TV all day, and tries to ignore his thoughts. Since he is afraid of dying he is afraid to sleep. He uses so many defenses that I don’t see his core conflict or who he really is. This is not his first therapy and I hope it will be the last one, because he suffers a lot. We have a good relationship and I hope to help him.” Excellent questions!
Lyme disease, of course, can be a serious condition, but if treated properly it is not life threatening. And, since he had these obsessive thoughts before he got Lyme disease, we are dealing with a pre-existing condition and can leave the Lyme disease to the side. So let’s see if we can help you find out his core conflict.
In terms of defenses, we see that he obsesses about death, which could be the defense of rumination, if the patient is neurotic. But then we learn that he fears that restaurants or supermarkets will poison him. These are paranoid delusions. Thus, his ruminations about death probably are part of his paranoid delusional system and he, most likely, is severely fragile. In response to his delusions, he is not functioning well, no longer working.
All we know so far is this: life events trigger complex feelings; these feelings trigger anxiety; and he uses delusions about death and being poisoned as his primary defenses.
This is what we need to find out:
When did his delusions start? Then we may find the triggering event that evoked the feelings and anxiety that required him to use these psychotic defenses.
In that triggering event, what feelings were triggered?
When feelings are triggered in session, where does his anxiety get discharged? Does he have any access to anxiety being discharged into the striated muscles, or is his anxiety constantly discharged into cognitive/perceptual disruption? This will let us know his degree of fragility.
As you explore feelings, how does he respond? Does he immediately regress into more severe forms of paranoia (psychosis), does he begin to clear up a bit cognitively and have improved reality testing (borderline level of character structure), or does he clear up completely and begin to sigh and intellectualize (neurotic level of character structure)?
As you explore feelings, is he able to have some access to striated muscle tension? If so, what degree of feeling can he tolerate before she crosses the threshold of anxiety tolerance? That is, at what level of feeling does his anxiety shift out of the striated muscles and his resistance shift out of isolation of affect?
These questions will allow you to determine the triangle of conflict, the pathway of anxiety discharge, the system of resistance, and the threshold of anxiety tolerance, so you know what to treat and in what format.
Given the severity of his defenses and the poor level of functioning, my hypothesis is that he is severely fragile and will require the graded format to gradually build her capacity. However, only a careful exploration of the questions above will allow us to know for sure what his genuine capacity is. It’s always possible he is someone with a severe obsessional disorder whose anxiety will go into the striated muscles with sufficient invitation of feeling.
This is an excellent example of a case where we cannot make a determination just from dramatic symptoms we have read. We have to conduct a careful psychodiagnosis of the patient so we know what to treat and how.
To know what to do, you have to know what is going on.

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