How do I understand the anxiety symptoms in this patient?

“I have a question about the level of anxiety of one of my patients. He had a traumatic childhood, with a father who beat him regularly. He has had some jobs, but nothing stable, and he has lived a good part of his life in the criminal world. He abused various drugs, which triggered some psychotic episodes.
In therapy he has stopped using drugs while we have been building his capacity and confronting self-destructive defenses. We used to see dissociation, disturbed thinking and visual disturbance with just a low level of emotional focus. Now there is only a slight tendency to dissociation (which he is able to stop) and no disturbed thinking. He sighs and seems more solid with no regressive defenses like projection and splitting.
But he still reports visual problems at low levels of feeling, similar to what he experienced when he was beaten by his father (together with dissociation). So, I see signs of striated anxiety (sighs, tension) on the one hand and signs of C/P-disruption (the visual disturbance) on the other.
This apparent mixture of anxiety-levels confuses me. Could you could comment on that?” Great question!
Clearly, this patient has been fragile, given the dissociation, projection, visual disturbances, and disturbed thinking you saw in the initial phase of therapy. Working gradually to build his capacity, you have helped him improve. Now at low to moderate levels of feeling he sighs and, presumable, can also intellectualize.
However, when you go to higher levels of feeling you will cross the threshold of anxiety tolerance and at that moment he will begin to disrupt cognitively and resume the use of dissociation and other regressive defenses such as splitting and projection. It is not that he has these signs of striated and cognitive perceptual disruption at the same time. It is that his anxiety will move out of the striated muscles back into cognitive perceptual disruption when he crosses the threshold of anxiety tolerance. It’s just that this threshold is higher now than it used to be, and the words and feeling levels that trigger him to go over threshold are different than what they were earlier in treatment.
As an analogy, think about your work this way. Before, at 5% of feeling he would disrupt and dissociate. You regulated his anxiety, and you helped him bear 5% of feelings without dissociate. Bravo! But now, when you up to 10% or 20% of feeling, he will disrupt again and use dissociation again. Again, you will regulate anxiety and help him bear mixed feelings inside without dissociating. You will keep repeating this process at successively higher levels of feeling until he can bear 100% of his feelings without dissociating or projecting or disrupting. At that point, the resistance system of projection and the anxiety pathway of cognitive/perceptual disruption will be completely restructured.
Until that point, each time the patient crosses the threshold of anxiety tolerance, you will see the anxiety shift back into cognitive/perceptual disruption and the defenses of dissociation, projection, and splitting will occur again.
When reviewing your videos, examine the thirty seconds of video before the patient dissociates or has visual problems. Then you will learn either what you said or what the patient said that pushed him over the threshold. Now you will know the precise words or descriptions of feeling that he has to bear now without dissociating. Use bracing using those specific words until he sighs again.
When we are confused in these matters, it is because we don’t notice when the patient went over threshold and what triggered that shift. Study of your videos will allow you to analyze this in detail so that you become more attuned to the specific “dosage” of feeling he is able to manage and the “dosage” where he starts to have trouble. Then you can work at the edge of his capacity, while building it gradually.
He still has a fragile character structure, most likely. And that will remain so until he can bear 100% of his feelings without c/p or projection. Keep up the good work! Keep working slowly. Given the severity of his past symptoms and his past behaviors, I would guess that this will take a while. Be patient. Keep building capacity. He has a long way to go.
Take home point: the issue is not whether he is “in” striated or “in” cognitive/perceptual disruption. The issue is at what level of feeling does he cross the threshold of anxiety tolerance and shift into cognitive/perceptual disruption. This threshold is higher than it was, but it needs to be raised a great deal until he is able to bear 100% of his feelings.

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