In some recent supervisions I’ve noticed a sign of excessive anxiety that students almost always miss. Here’s an example. See if you can catch it!
Th: “What is the problem you would like me to help you with?”
Pt: “My doctor told me to see you. He says I have an anxiety disorder. My mother died ten years ago. And my sister, she was there. She is really difficult. I just saw her at Thanksgiving. When I saw my mother, she was dead in the chair. She had kidney problems. She didn’t eat right. I have this anxiety.”
What is the sign of excessive anxiety here? Does she make sense, or did you have to fill in the blanks to make her statement make sense? In fact, she is demonstrating thought disorder. When hearing thought disorder we often think “there is something wrong with me that I don’t understand” rather than “there is something wrong with this patient’s thinking.”
In case you missed it, I will put in asterisk in the text each time her thought is disordered.
Pt: “My doctor told me to see you. He says I have an anxiety disorder. * My mother died ten years ago. And my sister, she was there. * She is really difficult. I just saw her at Thanksgiving. * When I saw my mother, she was dead in the chair. She had kidney problems. She didn’t eat right. * I have this anxiety.”
Notice the sudden shift from her anxiety to a memory. The next shift is from her memory of her sister in the past to her sister now, without any awareness that this might be confusing to the listener. Next she suddenly shifts from Thanksgiving in the present to her traumatic memory. Next she shifts from her memory in the past to her anxiety today, again without any awareness that her thoughts are not linked together into a coherent narrative.
Let’s contrast thought disorder with rumination: “My doctor told me to see you. He says I have an anxiety disorder. I think this probably started ten years ago when my mother died. So my sister was there with me when my mother was dying. And she was really difficult. We had a really hard time getting along then. Although things have gotten better. We even celebrated Thanksgiving together a few weeks ago. Anyway, my sister and I couldn’t reach my mom on the phone. So we went to her house. When she didn’t answer the door, I used my key, went in the house, and saw her dead in the chair. I have felt this anxiety ever since.”
Notice in this example that there are clear links between sentences. It makes a logical flow. This is in contrast to the disjointed quality of thought disorder.
Fragile patients with a traumatic past often present with soft forms of thought disorder like this. When you see it, immediately shift to anxiety regulation. If the thought disorder continues when the patient’s anxiety is regulated, you can comment on it: “I’m sorry. I’m a bit confused. Can you help me out? You are mention your mother’s death now, but a moment ago you were talking about your anxiety. I’m having trouble seeing how those are connected. Could you help me see that?” After intervening like this a number of times, many psychotic or traumatized patients will begin to see when they shift topics suddenly.
Why do patients’ thoughts become disordered? Some propose purely neurological reasons. However, psychoanalysts, following Bion, have proposed that when two thoughts come together, meaning forms, which, in turn, triggers feelings and anxiety. Thus, unconsciously, the patient “attacks the links” between those thoughts so that meaning cannot form. If the thoughts do not come together, they cannot create meaning, feeling, and anxiety. Thus, if you help the patient see the links between those thoughts, feelings and anxiety will rise. So you need to be vigilant when working with more traumatized patients so you can help them bear the rises in feeling and anxiety that will arise when you block psychotic defenses such as thought disorder.
But your first step will be to recognize this defense and regulate anxiety immediately. For thought disorder is a sign of cognitive/perceptual disruption.