Anxiety in the Stomach
“I recently finished reading your book, and I was surprised that you mention nausea in the stomach as a symptom of anxiety occurring in sessions. I, as a patient, have been a “victim” of it, and my therapist was unable to explain the phenomenon. Moreover, I have had a couple of patients mention this too and my supervisor was equally surprised to hear that. Could you tell me how commonly this happens in ISTDP and what has usually occurred before that symptom? Thanks so much!” Thank you for such a good question!
As you know from my book, Co-Creating Change, nausea in the stomach is a sign of anxiety being discharged primarily through the parasympathetic nervous system. That’s the anxiety piece, but your question goes further? What happens to make anxiety go there?
Any time feeling goes too high for a patient, she will shift from using isolation of affect as her system of resistance to using repression. That is, rather than detach from her feelings, she will turn her anger against herself. When people use repression, turning anger upon themselves, they usually suffer from depression, low self-esteem, weepiness, tiredness, embarrassment, and somatic problems.
When she shifts from isolation of affect to repression, you will also notice that her anxiety shifts from the striated muscles into the smooth muscles. Her sighing will stop, tension will go out of her muscles. She will start to look flat and a little depressed. If you ask about her symptoms, she will report sickness in the stomach and perhaps the beginnings of a migraine.
As you explore feelings with such a person, she may initially intellectualize or change topics to avoid her feelings. But as you keep exploring, she starts having feelings toward the therapist. She may detach from her feelings and the therapist (isolation of affect), or she may start to get weepy, depressed, anxious in the stomach, and tired because she is starting to turn anger upon herself.
At this point, we say she is going over the threshold of repression. That is, she is shifting from using isolation of affect to repression to avoid feelings toward the therapist. When she shifts out isolation of affect to repression, her anxiety also shifts out of striated muscles into the smooth muscles.
What happened before she became sick to her stomach? She was exploring an important issue or feeling a few seconds earlier. That exploration triggered feelings toward her therapist. Unconsciously, to protect her therapist from her feelings, she turned them onto herself, got nauseous, and then depressed.
Our task is to help her see her defense, then explore any feelings toward us that are getting covered by the weepiness or depression. As you do so, her weepiness will stop, anxiety will shift back into the striated muscles, and her depression will lessen. We keep asking about her feelings toward the therapist to restructure her system of resistance (resistance), her pathway of anxiety discharge (smooth muscles), and to build her affect tolerance.
When you explore feelings toward you, patients who repress are almost never aware that they had a split second feeling toward the therapist. They are aware only of their nausea and depression. That’s ok. Just keep helping her see defenses and keep asking about feelings toward you.
Your constant inquiry sends her an implicit message that she does not have to protect you from her feelings by getting depressed and turning against herself. This unconscious restructuring will build her capacity, leading to significant drops in symptoms.
So when you review a video of your session with a depressed patient, notice whenever she became weepy, depressed, self-critical, or tired. As soon as those symptoms or defenses occur, intervene. In that way, you will block a regression into depression. Through this rapid moment to moment intervening you will prevent the patient’s symptoms from worsening in treatment, you will help her see the mechanisms that have been causing her suffering, and you will be giving her a fighting chance to overcome her depression. Remember: she does not “have” depression. Her unconscious defenses are causing the depression. Help her see those mechanisms, and help her face the underlying anger toward you, and the pathway to recover opens up for her.
How commonly does this occur? With every patient who is depressed or has somatic symptoms. It will occur in every session with them in the early phases of treatment. If not addressed in the way I describe here, those symptoms will occur in every session when the therapist explores meaningful material. If addressed in the way I describe here, symptoms should drop over time, until anxiety is no longer discharged into the smooth muscles.