Category Archives: Anxiety

The sign of excessive anxiety we all miss

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.

Can happiness trigger anxiety?

“What do you think about fear of positive feelings? Do you notice an aversion to feeling positively in your clients? How do you think this develops, and how would ISTDP handle it? By fear of happiness, I mean avoiding happy feelings to escape negative consequences (such as being happy makes us selfish or immoral, being happy makes bad things happen, being happy makes others jealous of us, being happy draws us away from god, being happy brings sadness, etc.).” Great question! Thanks to Mohsen for posing this.

Of course, many patients avoid happiness. Happiness easily triggers anxiety and defenses. Why? To be happy is a crime because we are breaking the superego’s law that we must suffer. How dare you!!!

In ISTDP the defenses against happiness are covered in the concept: defenses against emotional closeness. To be intimate brings great happiness. Defenses against happiness can be triggered by different dynamic situations. 

If I am happy it may be a crime because I differentiate myself from my mother and our agreement to suffer, be unhappy, and be victims together: the depressive symbiosis.

If I am happy it may be a crime because I will have surpassed my father and achieved an oedipal victory. Therefore, I will become unhappy and deny or minimize my success to avoid my guilt over wanting to surpass him.

If I am happy it may be a crime because my colleagues will become envious. I will deny and minimize my happiness so we will be miserable together. Then they won’t envy me. The problem is that success will aways trigger envy in some people. You cannot avoid it. If you hold yourself back to avoid their envy, you will commit a crime to yourself and to those who would have benefitted from your success.

And finally, if I am happy, I turn against my self-punishment and face my underlying mixed feelings. Otherwise, to avoid guilt over my happiness, success, and pleasure, I will punish myself any time I feel happy to hide my forbidden wishes to succeed, to be happy, and to live a fulfilling life.

We deal with defenses against happy feelings as we would any other defenses.

Mohsen offers some common defenses. 

Pt: “Being happy makes us selfish.” [Self-attack]

Th: “Or is that how you justify punishing yourself?”

Pt: “Being happy makes us immoral.” [I must be unhappy if I am moral = Self-punishment]

Th: “You say you must be unhappy to be moral. Is this how you punish yourself?”

Pt: “Being happy makes bad things happen.” [Self-attack. Possibly a memory being misused for the purpose of self-punishment]

Th: “Being happy doesn’t make bad things happen; self-punishment is making bad things happen in your life.”

Pt: “Being happy makes others jealous. [Self-punishment to avoid envy and competition]

Th: “Yes it does. So are you willing to face that some people will envy your success?”

Pt: “Being happy draws us away from God.” [Being unhappy brings me closer to God = self-punishment + a view of God as someone who wants us to suffer for eternity (the superego masquerading as God]

Th: “So being unhappy will draw you closer to God? What kind of a God would want you to suffer for eternity?”

Pt: “Being happy brings sadness.” [If I am happy I will be sad, so I will become sad right away and beat the rush= Self-punishment]

Pt: “Being happy doesn’t bring sadness. When you are happy, you punish yourself. And this self-punishment makes you sad.”

As you can see, these defenses can develop due to varied conflicts. In ISTDP we deal with these defenses as would deal with any other defenses: identify, clarify, and confront the defenses. Turn the patient against the defenses. Help the patient face his mixed feelings as deeply as possible so he no longer needs to punish himself by avoiding happiness.

Remember that good outcome is not merely the absence of depression or anxiety. It is the presence of genuine happiness that shows the patient has processed his underlying guilt enough that he no longer has to punish himself by avoiding happiness, the birthright of every patient to seek.