Self-Criticism, Smooth Muscle Anxiety, and How ISTDP Helps

Man in business wear sits on bench, holding his headAnxiety can manifest in a variety of ways in the human body. It can make us tense in our large, voluntary muscles, activate the involuntary muscles of our internal organs, and even cause changes in our thinking, sensation, and perception. I want to focus here on one particular pattern of anxiety—anxiety in the smooth muscles—and the style of self-punitive thinking that is associated with it.

Smooth muscle anxiety is linked with a wide range of physical problems that are emotional in origin but can be mistaken as medical, which can lead to misspent health care dollars, lost time, and dashed hopes. It is my hope to help you identify manifestations of smooth muscle anxiety, learn about the thoughts linked with smooth muscle anxiety, and gain exposure to intensive short-term dynamic psychotherapy, a model that has demonstrated effectiveness in treating smooth muscle anxiety.

What Are the Smooth Muscles?

The smooth muscle systems of the body include the gastrointestinal system, the vascular system, the bronchi, and the urogenital system. There are also smooth muscles in our skin and eyes. The muscles are called smooth because they are made up of small, mushy, somewhat elastic cells. They differ from our skeletal muscles, which have long, striated fibers that are less flexible.

When our smooth muscles are functioning as they should, they regulate our blood pressure, digestion, sexual and excretory functions, and breathing—functions that are essential to human survival. However, the smooth muscles are linked to the emotional center of the brain by the nervous system, and they can be activated in response to anxiety (Janig, 2003). So what happens when anxiety impacts the smooth muscles? What symptoms are linked with dysregulation of the smooth muscle systems?

Conditions Linked with Smooth Muscle Activation

The following conditions are associated with involuntary tensing of the different smooth muscle systems (Abbass, 2015):

  • Vascular system: Hypertension, migraine
  • Gastrointestinal system: Irritable bowel syndrome (e.g., acid, spasms, diarrhea, nausea), ulcerative colitis
  • Bronchi: Reactive airways (e.g., asthma attacks)
  • Urogenital system: Sudden urge to urinate or defecate

Are Types of Thoughts Associated with Smooth Muscle Anxiety?

Clinical researchers, especially in the literature on intensive short-term dynamic psychotherapy, have noted an association between self-attacking thoughts and smooth muscle symptoms. While it is not clear whether the self-punitive thoughts can cause a stomachache or migraine, harsh thoughts and smooth muscle symptoms do seem to show up together.

In ISTDP, we use collaborative, exploratory questions to support people as they learn to reflect on the emotions that are making them anxious and triggering self-attack.

Here’s a smattering of thoughts I have heard lately that have shown up alongside smooth muscle symptoms in people I work with:

  • “These symptoms will never get better. I’ll be crippled by this.”
  • “The fight we had was my fault. How could I have been so stupid?”
  • “I’m a letdown.”

As these examples from my practice demonstrate, negative thoughts going against the self seem to co-occur with nausea and migraines. If you find that these kinds of thoughts co-occur with your IBS, migraine, or other physical symptoms, or seem to trigger them, you may be experiencing smooth muscle anxiety that has been diagnosed as a medical syndrome.

What Triggers Self-Attack and Smooth Muscle Anxiety?

Clinical research in ISTDP has demonstrated a link between complicated, mixed emotions toward loved ones, tendencies toward self-attacking thinking, and smooth muscle anxiety (Abbass, 2015). The theory of smooth muscle anxiety in ISTDP, which has been repeatedly supported by my experiences as a therapist as well as in case series data (Abbass, 2002) and empirical research (Creed, et al., 2003; Guthrie, et al., 1993), is that mixed emotions toward our attachment figures trigger anxiety. These mixed emotions are anxiety- and guilt-laden because it feels dangerous to have rage toward people whom we long to be close with and depend on.

Because of the anxiety and guilt associated with these feelings, the feelings are repressed—not thought about or reflected on. In fact, self-attacking thoughts seem to have the function of turning the anger toward the loved one back against the self with harsh thoughts and against the body with smooth muscle activation. The beloved person is protected from the anger, and the body and the self are punished. It is almost as though an unconscious, automatic part of the mind says, “How dare you have rage toward your beloved! You must redirect the rage toward yourself and your stomach to protect them!”

The Role of ISTDP in Healing

In ISTDP, we use collaborative, exploratory questions to support people as they learn to reflect on the emotions that are making them anxious and triggering self-attack. Increased reflective awareness of emotions seems to reduce the anxiety connected to them—if it can be thought about, talked about, and felt, it is no longer as scary or guilt-ridden. The complicated emotions we have about our loved ones are no longer unconscious (out of awareness) and frightening but can be seen and felt by the light of day and recognized for what they are—just feelings! People learn that they have been getting punished for emotions, which are mental, bodily events that are not inherently dangerous or wrong. Fear and guilt about emotions are replaced with thoughtfulness, openness, and comfort (Abbass, 2015).

If you are experiencing self-attacking thoughts and smooth muscle anxiety and are looking for systematic support in overcoming the automatic emotional factors that trigger your symptoms, ISTDP may be a useful treatment for you.


  1. Abbass, A. (2002). Office based research in ISTDP: Data from the first 6 years of practice. Ad Hoc Bulletin of Short-term Dynamic Psychotherapy, 6, 5-14.
  2. Abbass, A. (2015). Reaching through resistance: Advanced psychotherapy techniques. Kansas City, MO: Seven Leaves Press.
  3. Creed, F., Fernandes, L., Guthrie, E., Palmer, S. Ratecliffed, J., & Read, N. (2003). The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome. Gastroenterology, 124, 303-317
  4. Guthrie, E., Creed, F., Dawson, D., & Tomenson, B. (1993). A randomized controlled trial of psychotherapy in patients with refractory Irritable Bowel Syndrome. British Journal of Psychiatry, 163, 315-321.
  5. Janig, W. (2003). The autonomic nervous system and its coordination by the brain. In Davidson, R. J., Scherer, K. R., & Goldsmith, H. H. (Eds.), Handbook of affective sciences (pp. 135-187). Oxford: Oxford University Press.

© Copyright 2016 All rights reserved. Permission to publish granted by Maury Joseph, PsyD, Topic Expert Contributor

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

  • Leave a Comment
  • Yolanda

    July 13th, 2016 at 10:49 AM

    So I suppose that It is true that I carry all of my stress and anxiety in my shoulders.

  • Calleigh

    July 14th, 2016 at 8:22 AM

    Doctors it seems always want to make it about something medical, but it obviously isn’t always from that. There can be stress and anxiety that cause so many of these medical symptoms.

  • neal h

    July 14th, 2016 at 2:05 PM

    After reading this I am starting to think that what I have always thought was my IBS could very well be caused by the stress that I feel at my job. I work in a very high pressure and intense environment and I guess that the way I process all of that is unfortunately through my gut. I have even tried to seriously modify my diet and nothing seems to help.

Leave a Comment

By commenting you acknowledge acceptance of's Terms and Conditions of Use.


* Indicates required field.

GoodTherapy uses cookies to personalize content and ads to provide better services for our users and to analyze our traffic. By continuing to use this site you consent to our cookies.