Am I missing signs of anxiety?

“I have a patient, who voices his anger towards loved ones, but I rarely see any signs of anxiety and have never seen him sigh. At times he shifts in his chair, and sometimes he has dry mouth. But most of the time there is no sighing. What should what I do if the patient voices his anger without any signs of anxiety. Am I missing some signs of anxiety?” Great question!
If a patient voices his anger but is not sighing, either the anger is a defensive affect or the patient is using one of the systems of resistance. For instance, he might say he is angry, split off his positive feelings, and feel only rage toward someone, so no anxiety would rise. Remember that anger by itself does not trigger anxiety. Anger plus love mobilizes guilt which triggers anxiety.
Or he might feel angry and then turn it on himself. Then his anxiety would go into the smooth muscles, not the striated muscles. He feels only love toward you because he turns the rage back onto himself.
Or he might detach and intellectualize and detach from you. His detachment his feelings and from you would prevent feelings and anxiety from rising. Thus, we would not see a rise in unconscious anxiety in the form of sighing
So the question becomes this: when the patient does not sigh, which system of resistance does he use? 1) isolation of affect (detaching from you); 2) repression (turning anger upon himself); or 3) projection and splitting (splitting off loving feelings, feeling only rage, thus no anxiety rises).
When he does not sigh, notice what his next verbal response is. That defense will tell you the system of resistance you need to treat. If he looks away and detaches, that is isolation of affect. If he becomes depressed and weepy, engages in self-attack, or somatizes, that is the system of repression. If he projects onto you or others or views others as all good or all bad, then he is using the resistance system of projection and splitting.
Take home point: if you see no sighing, ask for feelings, notice the defenses, and then determine the system of resistance that is preventing a rise of complex mixed feelings. Now you will know why unconscious anxiety is not rising in the body.

Why is she becoming more paranoid?

“One of my patients (fragile/depressed/very self-critical) started a new relationship. However, her paranoid ideation increased at the same time. She believes others wish her ill, want to humiliate her, and hope her relationship will fail. She is afraid of being rejected. How does this tally with the increase of projected punitive super-ego? Can unconscious anger be triggered just by getting into a relationship again? Or is she criticizing herself for being afraid? I’m a bit uncertain!” Thanks for a great question!
A new relationship always triggers mixed feelings if our earlier relationships were painful. So the questions for assessment begin. How much trauma did she suffer in the past? How much feelings are mobilized by a new relationship? When these feelings rise, how does the patient deal with them? Can she detach from them (isolation of affect)? Does she turn the anger onto herself and the love toward you (repression)? Or does she project her feelings onto you and other people (projection)?
In this case, the patient experiences mixed feelings toward her new boyfriend. After all, a new love reminds her of the past loves who hurt her. She can split her loving and rageful feelings apart and project the rage onto other people to protect herself as the loving girlfriend and her boyfriend as the all-good boyfriend.
Once the anger is projected onto others, people are viewed as angry: 1) they are angry with me (wish me ill); 2) they want to hurt and humiliate me; 3) they will reject me; and 4) they hope the relationship will end.
Since the patient is also depressed, she either projects anger onto others and fears them (projection), or she turns the rage against herself (repression). Your first task is to help her face mixed feelings inside without projecting them outside. That is known as restructuring the resistance system of projection.
Pt: I’m afraid they wish me ill.
Th: Insofar as you are afraid of how people wish you ill, I wonder what thoughts you might be having about me? [If she projects onto others, she projects onto you too.]
Pt: I wondered if you thought I shouldn’t be in this relationship. [projection]
Th: Is there any evidence for that?
Pt: No. But I wonder about it.
Th: So you are aware of this thought. [cognizing about the projection]
Pt: Yes.
Th: So I wonder what feelings might be coming up here toward me that could be underneath that idea? What feelings are getting stirred up here with me?
Having clarified the projection, ask about feelings. Build the patient’s capacity to bear mixed feelings toward you without projecting those feelings onto you or other people. Building her affect tolerance in this way helps her eventually tolerate 100% of her feelings without projection. This tolerance has to be built initially almost entirely within the therapy relationship. Why? The patient’s projection onto others means that examples in past or current relationships are seen through the lens of projection. Thus, they are nearly always distorted.
With fragile patients we expect that a new relationship will trigger a rise of mixed feelings based on her past. As her feelings rise, they will exceed her integrative capacities, and she will eventually split off and project her feelings onto others. The greater the rise of feelings, the more feelings she has to project onto others. Thus, the more paranoid she will become.
That’s why we focus on feelings in the session to build her capacity to bear them internally without projection. Otherwise, without an internal “storage tank” for her feelings, they will get projected, and she will become increasingly paranoid. And, if we don’t address these feelings with the therapist, her projections in therapy will increase until she acts out and leaves therapy.
Take home point: restructure her projections repeatedly and build her capacity to tolerate ever higher levels of mixed feelings inside her until she no longer needs to project them outside of her.