Monthly Archives: December 2017

But attacking myself is something I deserve!

“A patient uses massive self-attack. She sees it now and the function and costs. But she is not willing to let go of it. Instead, she follows with a “but” and argues why the self-attack, in her case, is justified and appropriate. Is this just a rationalization I can interrupt and ask for feelings toward me, or is the “but” a sign of ego syntonic defense which needs more work? I thought it was transference resistance, but she is mildly fragile.” Thanks for this question!

First of all, why do patients attack themselves in session? To protect you! This is what you must always remember. If you keep this in mind you will be able to focus on her defense (which you have done very well!) and focus on the feeling toward you, which she has been warding off. I find that therapists often focus so much on the defense, that they forget to go right back to the feeling toward the therapist which is under the self-attack.

Isolation of affect

Somatic symptoms

“When are somatic symptoms due to anger turned inward (repression) versus “sympathy symptoms”, expressions of guilt and sympathy with the loved other? Are the symptoms both an attack on the self and an expression of unconscious guilt? What is the best way to understand this issue of self-attack versus guilt as seen in somatic symptoms?” Thanks to Johannes for this great question!

Somatic symptoms can result from the discharge pattern of anxiety or the defense of somatization proper.

When somatic symptoms occur due to anxiety we see dizziness, ringing ears, blurry vision (cognitive/perceptual disruption), diarrhea, migraines, sudden need to go to the bathroom (smooth muscles), back pain, vulvadynia, tension headaches, clenched jaw (striated muscles).

In somatization, the patient feels rage toward someone, and then identifies with that person’s damaged body. For instance, a patient who wanted to stab her husband in the eyes suddenly had sharp pain in her eyes. A man who wanted to chop his father’s arms off suddenly lost sensation in his arms.

Repression is the resistance system by which the patient turns anger upon the self using defenses such as self-attack, character defenses, weepiness, conversion, AND identification with the object of the rage. Identifying with the damaged or murdered figure is a way to turn that rage upon the self and to punish oneself. Why? Because the patient not only feels rage but love and other mixed feelings for that person. So these “sympathy symptoms” are mobilized by love and guilt. Self-attack is always a way to punish oneself due to guilt over rage toward others, hurting ourselves to protect loved ones from our rage.

How do we know if somatic symptoms are due to anxiety or the defense of somatization? The symptoms resulting from somatization do not fit the symptoms of the pathways of anxiety, e.g., loss of sensation in the arms does not fit striated muscles, smooth muscles, or cognitive/perceptual disruption.

How do we know if somatic symptoms are psychological? When we explore feelings and anxiety rises, somatic symptoms will increase or emerge. If symptoms do not fluctuate with a rise and fall of unconscious feelings and anxiety, the symptoms most likely are not psychogenic and require more medical evaluation.