SOME ASPECTS OF :

PATHOLOGICAL THOMAS FREEMAN,

hi.D.

NARCISSISM i

HE PURPOSE of this paper is to illustrate the operation of cer-

T tain pathologicaI mental processes which can be conceptu-

alized with the aid of the concept of narcissism. Narcissism is
a concept which belongs to the libido theory and it was elabo-
rated to describe a phase of mental development. T h e advent of
the later instinct theory with its delineation of life and death
instincts did not alter the central role of narcissism i n libidinal
growth. According to the classical theory narcissism describes the
libidinal investment of the ego. I n early infancy the ego is rudi-
mentary and not clearly differentiated from the world of objects
-the libidinal investment therefore permeates both ego and
objects. This phase is conceived of as that of primary narcissism.
Later with ego-object discrimination libidinal cathexes are with-
drawn from incestuous objects and returned to the ego simul-
taneously with the introjection of these objects into the same
structure. This reinvestment of the ego with libido is the phase
of secondary narcissism. Some of this narcissistic libido is de-
sexualized (deinstinctualized) and employed in cathecting the ob-
ject world. T h e remainder of the narcissistic libido retains its in-
stinctual character, thus contributing to the pleasure in self which
is a part of healthy mental life.
Freud (4) went to some lengths in his original contribution
to demonstrate how the libidinal processes which invest the ego
Read to the Hampstead Child-Therapy Clinic, London, February, 1964.
Acknowledgment is made to the Medical Research Council for supporting the
project which has led to some of the material reported in this paper.
Dr. Freeman is Medical Director of the Lansdowne Clinic, Glasgow, Scotland.

540
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 PATHOLOGICAL NARCISSISM 541

and constitute narcissism need not have a direct expression but

could manifest themselves i n the activity of the ego ideal. T h e
ideals and standards which an individual aspires to can be a
vehicle for the expression of narcissism. In such cases self-love is
replaced by an admiration and determination to achieve certain
goals and ambitions in either work, intellectual life, or in a sphere
of ethics or morality. Freud (4) emphasized that this ego-ideal
development must be distinguished from sublimation. I n the lat-
ter, libidinal energies are desexualized and directed to nonin-
stinctual aims, while in the former, the quality of the instinctual
drives is i n no way affected.
Narcissism does not describe a pathological state of ego libidi-
nal function. Without an adequate investment of libido the per-
sonality will not operate optimally-narcissism is an essential in-
gredient for healthy mental life. Under special circumstances,
however, alterations do occur in the ego libido-to narcissism-
which gives the processes a pathological character. What is to fol-
low consists of an account of phenomena which can be described
and understood as aspects of a pathological narcissism.

Pathological Narcissism in a Psychoneurotic Reaction

I
T h e patient to be described entered psychoanalytic treatment at
the age of twenty-eight having been ill for a period of six years.
At this time he was single and lived at home. H e had numerous
complaints which included severe headache, dizziness, feelings of
exhaustion, dyspepsia, claustrophobic symptoms, and premature
emission. H e had already been under psychiatric treatment for
the previous three to four years, having been hospitalized twice
and undergone an analytic form of psychotherapy intermittently
during that time. H e did not reveal that he was taking sedatives
which had been prescribed some years before.
T h e illness declared itself when he left home to join the
Navy a year after obtaining an engineering degree at the Univer-
sity. Prior to the onset of symptoms he had been active physically
and mentally. H e had excelled at tennis and rugby footfall and

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542 THOMAS FREEMAN

was socially popular. H e was the youngest of eight children-he

and an older sister being several years younger than the next sib-
ling. Both parents were alive when the patient began the analytic
therapy.
T h e first few weeks of the analysis provided some details of
the patient’s childhood. H e had always felt unwanted by the
parents. T h e father was an energetic businessman who was fre-
quently away from home. T h e patient recalled that his mother
was often unwell, he and his sister being put in charge of one
of the three older sisters. By the time the patient was six or seven
his older siblings were virtually adults. They referred to the pa-
tient and his sister as “the brats” and they never failed to express
their reluctance when expected to look after them.
TVhen three years old he fell ill with bronchopneumonia, but
his parents went off on a long holiday while he was left with an
aunt. H e knows that when his mother returned he failed to
recognize her. He suffered from enuresis until the age of eight
when he and his sister were evacuated from the city on account
of the war. H e lived with another aunt in the country for about
a year and while there began to suffer from severe headaches-
one of his mother’s symptoms. Prior to evacuation he slept in his
parents’ room and one outstanding memory was that of his mother
saying to his father, “Don’t hurt me.”
His behavior in the analytic session was “exemplary.” H e
knew a certain amount about psychoanalysis and about the rule
of free association. H e had also been told at various times that
unconscious aggression and latent homosexuality were the main
determinants of his symptoms. H e explained that while he could
understand the reasoning behind these explanations, they meant
nothing to him and had not helped to ease his symptoms. H e was
afraid of offending the analyst, and his compliant and submissive
attitude was thus motivated by anxiety. Repression and isolation
of affect were two defenses which rapidly became manifest. Even
when affect broke through into consciousness it was entirely di-
vorced from the stimulus. A similar state occurred within the area
of symptom formation, thus causing great confusion with respect
to the immediate stimulus for the intensification of a particular
complaint. His reaction to the first holiday break from analysis

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 PATHOLOGICAL NARCISSISM 543

which took place after three months will now be described be-
cause it typified the pattern that was to emerge in similar cir-
cumstances over the next two to three years.
T h e patient was told of the impending break about eleven
days before it was due. During these eleven sessions he made not
one reference to the coming interruption of the analytic work.
His two principal preoccupations were symptoms of which he com-
plained bitterly and the fear of loss of control regarding sexual
and aggressive outlets. JVhen he returned to the analysis he
said that if anything he had felt worse, but he had given no
thought to the treatment. H e was quiet for the first three days,
being rather suspicious and negative in his attitude. On the fourth
day he reported a dream: “I am with a woman who is bald and
her daughter. I am trying to help her-she cannot accept this help
and I find myself weeping.” He recalled that while driving his
car the day before he found himself whistling a song called “One
Night of Love”-the theme of this song concerning separation
from a loved one. H e had forgotten to mention this in the last
analytic hour. H e had no other associations, but the transference
nature of the dream was amply confirmed by the analyst’s bald-
ness. T h e next day he reported that he found himself weeping
again. His associations led to memories of a period in the hospital
when he had felt wretched and then to his mother whose love he
had always regarded somewhat suspiciously. H e never could be
sure if she was sincere in her protestations of care for him. During
the next two sessions he continued to bring memories of childhood
with an emphasis on separation experiences.
T h e affective reaction to the break was denied admission to
consciousness until three days after the resumption. Even when
it did appear the patient isolated it completely from the person
of,the analyst. Even at this early phase of the treatment the ana-
lytic situation had become a potent stimulus for reactions within
the patient, thus betraying the presence of an already developing
transference neurosis. Interpretation of the transference and his
resistance against this emerging met with no success. He immedi-
ately went on to discuss his sexual difficulties as he had before
the break. T h e immediate stimulus for this was soon forthcoming.
H e had been having coitus with a new woman friend for some

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544 THOMAS FREEMAN

weeks but could not reveal this. This too could be regarded as
a means of avoiding the transference. This pattern of acting with-
out talking about it first i n the analysis continued for several years
in spite of interpretation. I n the third year of the analysis he
suddenly announced that he had got himself engaged and arranged
the wedding date.
A somewhat different reaction followed the resumption of the
analysis after the second holiday break. H e reported a dream in
which he was with a woman therapist-she was rather untidy like
his mother-he intended to have coitus with her, but he had a
premature emission. H e feared this would spoil everything, but
she reassured him. This dream was indicative of the extent to
which the patient sexualized the analysis partly through his own
sexual conflicts, but also because of the interpretations of sexual
content which had been made to him during the previous months.
I n the following days he theorized about separation, about his
mother’s disinterest, and about being the unwanted eighth child
-again an undoubted reference to the holiday which had just
passed. As after the first break, no affective reaction occurred, but
he was again rather distant and less friendly i n manner.
As the analysis proceeded it became increasingly apparent
that this patient was incapable of accepting o r benefiting from
interpretations. T h e sources of some of his symptoms declared
themselves. His headaches, his dyspepsia, his need to lie down
before any exertion were based upon identification with his
mother and older sisters. Interpretation of this was met with the
same kind of incomprehension, and a similar reaction occurred
when efforts were made to make him aware of his feminine identi-
fications and the preference for passive sexual aims. Again he was
completely insensitive to any events or changes which occurred
either in the analytic room or immediately outside it.
Periodically the mother identification was replaced by an
identification with the father, and the patient would become
aware of an irritation with the analyst if he moved or coughed i n
the same way as his father tended to do. However, these reactions
were usually stifled at the time of their origin and reported a few
days later when the anger had disappeared.
I n the first month of the analysis he had related that his

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 PATHOLOGICAL NARCISSISM 545

father had suffered from a nervous breakdown when the patient

was about ten years old. Later during this phase of father identi-
fication he thought of a possible cause for his father’s illness-
namely, an affair with a woman friend while the patient’s mother
was abroad. A dream revealed the father identification clearly.
“I am with a married woman. I kiss her in public and everyone
criticizes me.” This dream followed by a week a memory from
childhood of seeing his father lying on the beach with his arms
around his woman friend.
T h e oedipal significance of the material with its implicit
castration anxiety seemed to be confirmed by a further dream.
I n this dream the patient is watching a woman having her foot
amputated-he feels nauseated-the amputation consisted of a
rhythmical movement which became faster and faster. H e
wakened with an erection. T h e immediate stimulus for the dream
was being with his girl friend who was menstruating. H e had felt
rather sick and was glad to avoid coitus. I n the ensuing session
he began to talk about the fact that he had for many years suffered
from a tight foreskin and how this frequently interfered with
satisfactory intercourse. Anxieties about hospitals, injuries, and
illnesses comprised the material of the next weeks.
Communications of this kind were repeated over and over
again during the first three years of the analysis. T h e transference
oscillated between the mother, father, and siblings. No improve-
ment was obtained and the analyst had by this time become natu-
rally cautious about interpreting any kind of content to the
patient. T h e analysis seemed to have reached a stalemate. How-
ever, material had been gradually appearing about the nature of
the patient’s object relations, although the significance of this for
the transference was not properly appreciated or exploited.
Dreams and associations indicated that the patient’s girl friends
were generally selected on the basis of his own physical appear-
ance, and he treated them i n much the same way as he felt his
mother had treated him. There seemed to be a transference im-
plication here also which unfortunately meant nothing to the
patient at this stage of the analysis.
After three years of analysis characterized by constant at-
tempts to resolve the defense against the emergence of transference

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546 THOMAS FREEMAN

fantasies and affects the patient was neither better nor aware of
any particular concern about the analyst. T h e day following the
announcement of the Christmas break which ended the third
year of the analysis he dreamed as follows: “I am traveling in a
van with two men which knocks a child down. I weep.” H e said
that his brothers had been to a funeral the day previously. During
the next sessions he talked about the luck of those who were fit
enough to go on holiday and about his symptoms. I t is of interest
that an affective response took place, although only i n the dream
and not in waking consciousness.
IYhen he returned to the analysis after the Christmas break
he showed many signs of depression including a loss of sexual
interest and a difficulty in having emission. H e reported a dream
i n which a dentist tells him that his teeth are bad and will all
have to come out. H e felt depressed in the dream. I n part the
depression was related to his father having taken ill, but the in-
fantile (transference) aspects appeared to be the most important
factor. A further dream supported this hypothesis. I n this dream
a man he knows dies; he finds himself waiting in the man’s house.
H e admitted reluctantly that a day or so previously he had been
with his nephew and the man who appeared in the dream. T h e
latter kept talking to his nephew and the patient was an,v and
rather jealous. H e remembered also that he had been kept waiting
before the last session. T h e man in the dream was a kind of ideal
for him and he would have liked to emulate him.
It is appropriate at this point to relate that the patient’s male
friends possessed capacities the patient would have liked to pos-
sess. One friend was a giant of a man and the patient would have
liked to have had a similar physique. I t pleased him to think what
this friend could do to people if he wanted. At one stage of the
analysis the patient reported a fantasy which he had had at a
football match of flinging aggressive football spectators onto the
field as if he were Superman. Another friend was aggressive in
manner and provocative. T h e patient admitted that he found a
pleasure in the way this second friend behaved.
There could be no denying the unconscious death wishes
against the idealized analyst, but in view of the powerful resistance
no attempt was made to interpret this material. I t seemed reason-

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 PATHOLOGICAL NARCISSISM 547

able to assume that he harbored the fantasy of having killed or

destroyed the analyst and that the depression was a reaction to
his. I t was some weeks before the depression lifted and potency
returned. There seemed to be no way through to the patient’s
feelings until some time later when he let slip the fear that he was
poisoning his wife with his illness. H e had married a year before.
Oral content was quite frequent in its appearance, but again it
was difficult to find a way to use it for therapeutic ends. As a rule
he complained of his wife’s demands upon him. H e thought her
desires for social contact, for coitus and other activities were ex-
cessive. H e said that he was too ill to undertake all these things
or that they made him much worse. I t was a t this stage that it was
possible to interpret his fear of becoming amare of his impact
upon others. Until now he had introjected both objects and
drives; this had led to a passivity which made him only aware of
himself and the effect which others had upon him. H e was quite
unconscious of others and what he did to them. This datum was
also interpreted within the transference.
At this time the underlying dynamics of the illness became
clearer. Sadistic preoccupations which had earlier made an ap-
pearance could now be regarded in a new light. This man could
not tolerate his oral-sadistic drives; they were projected and re-
introjected with the object; as a result passivity was the overriding
defense. During the middle third of the fourth year of the analysis
these anxieties were ventilated both in and outside the transference
situation. One positive effect was his becoming increasingly aware
i n a feeling sense that his wife and the analyst might leave him.
They were no longer, in his simile, like a watch which when done
could be replaced by a new one. Gradually he recognized that his
wife, other people, and particularly the analyst were human beings
with sensitivities and feelings like himself.
Although he complained about his symptoms almost as much
as before, his pattern of living had changed. H e was now doing
a full day’s work and undertaking tasks which made a demand
upon his anxiety tolerance. Frequently he had to work about 30
to 40 feet above the ground. H e produced dreams with a sadistic
content which along with associations revealed the terror of loss
of control over the destructive drives within him. H e still had a

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548 THOMAS FREEMAN

need to provoke his wife and was unable to feel much about the
analyst. At the same time he complained about his wife and about
her unpredictability. H e could not be sure that she would not
reject him. H e was stimulating her and being reacted to in a way
he was afraid to do in the analysis. H e did to her what he felt the
analyst was doing to him. He was convinced that he could never
trust his wife’s reaction and therefore he found it hard to forgive
her after a quarrel. T h e sadistic fantasies which underlay this
material emerged i n dreams and explained the resistance against
the transference neurosis. He wanted closeness but feared it be-
cause of the destructiveness which would appear if he was frus-
trated and the dread of retaliation. An advance was made when
the patient recognized his pleasure in cruelty.
It was toward the end of the fourth year of the analysis that
the patient finally came to produce transference fantasies which
explained so much of his inability to feel in the analytic situa-
tion. After the summer break in that year the patient revealed
once again his sensitivity to the analytic situation (the transference
neurosis) the significance of which was still utterly unconscious.
H e described transference dreams in which his passivity was
clearly manifest. I n one dream he was in a barber’s shop. T h e
barber was a big man and he felt apprehensive. His associations
led to a barber of school days who was bald and wore spectacles.
I n the second dream of the same night he came across a car crash
i n which a man and woman were injured. A day or so later he
had a postcoital dream i n which a woman was stabbed in the
chest, he wakened u p with a pain in that region of his body.
These passive feminine identifications continued and found
expression i n later dreams which revealed the patient’s uncon-
scious attitude i n the transference. H e dreamed that his father’s
housekeeper was going blind and deaf. H e felt sorry for her. This
exemplified his own refusal to acknowledge any perception of the
analyst as a person in much the same way as i n childhood he had
denied the sexual relationships of the parents. No attempt was
made to interpret this inverted oedipus complex which now
appeared so glaringly in the transference.
It was through material of this kind that a beginning could
be made in the analysis of his resistance against the transference

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 PATHOLOGICAL NARCISSISM 549

neurosis. A dream provided the bridgehead for progress. His wife

told him in the dream that she had had coitus with his large
friend. H e asked her about the size of his friend’s genitals and
how they affected her. H e noted a feeling of indifference in the
dream. When reIating this dream he blushed. H e came to the
idea that the analyst must be identified with the friend, because
both analyst and friend had the same belief i n the beneficial
effects of satisfactory coitus. H e also felt that if he had really been
talking about his friend’s genitals he would not have blushed.
At the next session he said that his feelings about the size and
efficiency of the analyst’s penis were of less importance to him
than whether the analyst was mentally healthy. If he was not it
would hardly be bearable. This anxiety connected with previous
ideas that his objects must be flawless and in n o way defective.
Gradually over the next few weeks he began to allow himself the
thought that he must believe that the analyst was quite healthy,
untiring, of complete integrity, and with endless patience. If he
was to come to regard him as someone with feeling, then he might
not be able to trust him any more than he could trust his wife or
mother because of their being equally inconsistent and unpre-
dictable. This in turn would liberate a hatred against the analyst
which he was recognizing from time to time i n relation to his
wife. H e had thought of a psychoanalyst as a kind of person who
when presented with a difficult puzzle would work away quietly
until it was solved. T h e harder the puzzle the more the analyst
would persevere. H e had refused to think of him as a person who
failing to solve the puzzle would fling it away in rage. This he had
to admit would be his own reaction.
It was after this revelation that he imagined himself i n the
analyst’s place wondering how the analyst must feel about him,
the patient. This led to fantasies in which he found himself com-
forting the analyst because earlier he had expressed critical
thoughts which he thought must have hurt him. H e was able to
recognize that the depressed feeling he attributed to the analyst
was the kind of depression he felt when he had been hurt i n the
past. I t was now apparent that one of the main causes for the idea
of the analyst as a perfect machine was to avoid the anxiety and
guilt which were provoked by destructive transference fantasies.

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550 THOMAS FREEMAN

As long as there was no feeling on either side both were safe.

From this time on the patient’s defense against feeling progres-
sively weakened and he became receptive to transference interpre-
tations.
I1

It is now time to examine this patient’s material i n terms of the

concept of narcissism and so consider how far this concept is
helpful in leading to a more comprehensive and unifying ex-
planation of the phenomena. Throughout this case there was a
characteristic tendency to obstruct the emergence of instinctual
drives and their fantasy representations by a reversal of aim-
active trends were replaced by passive ones. This was well exempli-
fied in one of his principal masturbatory fantasies which consisted
of his exhibiting his penis. T h e important aspect of the fantasy,
however, was not the thought of impressing a woman with his
penis but her looking at it. This was followed by the wish for the
woman to masturbate him. This passive fantasy could be traced to
childhood scoptophilic interests in both his sisters and mother.
After being evacuated to his aunt in the country he could not look
at his mother undressing. T h e pleasure in looking was replaced
by a passive exhibitionistic wish i n which he identified with the
observing woman.
Throughout the analysis feminine identifications were promi-
nent, and there could be no doubt that passive-genital wishes for
the father (the inverted oedipus complex and castration fear) were
nuclear problems. I t was particularly difficult to disentangle the
transference manifestations and to distinguish the preoedipal pas-
sive wishes directed to the mother from the passive genital de-
mands from the father. T h e patient introjected both object and
drive (in the above example, mother, sister, and scoptophilic
drive) and thus substituted passive for active instinctual aims. T h e
facility with which this patient introjected female objects ac-
counted almost entirely for his symptomatology. Nearly every
symptom was taken from either his mother or his sisters. A similar
tendency could be observed with the aggressive drives, only here
the aggression was introjected into the superego and led to de-
pression of mood and self-criticism.

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 PATHOLOGICAL NARCISSISM 55 1

A number of dreams demonstrated that i n adult life girl

friends were generally chosen on the model formed by a conden-
sation of his older sisters, mother, and himself. It is not difficult
to imagine that in early childhood, because of the absence of a
definitive object, his own self-image became merged with the
images of the disappointing but ultimately introjected sisters and
mother. T h e interesting point is that this patient showed no evi-
dence of inflated self-regard, nor did he overvalue his body other
than in the hypochondriacal preoccupations. What he valued and
admired was in others-the physique of his friend, the energy and
untiring vitality of his father, and the aggression which he con-
sidered to be a mark of virility. H e described many fantasies i n
which these idealizations appeared and which can only be re-
garded as subtle expressions of a powerful pleasure in physical
powers.
These phenomena i n the sphere of object relations can be
interpreted as evidences of his narcissistic disposition. T h e de-
fensive employment of passivity can also be thought of as being
facilitated by the same narcissism. Objects never having proved
satisfactory in infancy were eschewed in favor of the self. T h e self
had been taken as the locus to which libidinal drives were di-
rected. With this trend established the defense of passivity was
most easily favored. At the same time the processes of introjection
with the withdrawal of object-libidinal cathexes into the ego
heightened the narcissism. Superego dictates prevented the direct
expression of this narcissism which came to find an outlet through
idealizations.
I t was in the analytic situation that the narcissistic organiza-
tion was utilized as a defense in just the same way as it had been
employed by the patient throughout his life. An unconscious self-
preoccupation dominated all object relationships. This resulted
i n the establishment of barriers between the patient and his ob-
jects which avoided the emergence of unconscious conflicts present
i n this sphere. Before his illness his parents, siblings, male and
female friends had been a means of expressing different aspects
of his own personality and not objects in their own right. I n the
analytic treatment the patient repeated the same behavior. For
over three years the patient maintained an idealized fantasy of

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552 THOMAS FREEMAN

the analyst, but from time to time there were superimposed upon
this superego attitudes which again betrayed the presence of a
narcissistic ego ideal.
The patient’s narcissistic transference fantasies were used as
a defense against the emergence of the transference neurosis. This
patient provides a good example of the type of patient Glover
(5) describes in whom the transference neurosis is not a spontane-
ous manifestation which the patient gradually comes to recog-
nize in himself. This man although showing all the signs of an
existing transference neurosis was refractory to all attempts at
making this psychical constellation conscious. Interpretations were
rejected because of the narcissistic nature of the transference.
I t is worth recalling that the efficacy of interpretation is al-
ways dependent upon a transference which is object libidinal in
nature. The patient is thus willing to consider the interpretation
out of regard for the analyst; this prevents an immediate rejection
of the latter’s communication. The initial reception of an in-
terpretation is therefore dependent upon a positive relationship
between patient and analyst. I n this particular case the patient’s
self-preoccupation only permitted a narcissistic relationship with
the analyst. There was in fact no real relationship-no real wish
to please the analyst and thus give attention and interest to what
he said. Interpretation could only become effective after the analy-
sis of the resistance imposed by the patient’s narcissistic disposi-
tion.
As long as this patient could believe that the analyst was
without feeling, as long as he could dehumanize the analytic situa-
tion, he could deny the possible impact of his drives and affects
upon the analyst and their possible repercussions upon himself.
While he maintained this narcissistic defense he was completely
preoccupied with himself through the agency of his symptoms.
Self-concern protected him against an awareness of what he might
be doing to his objects-the analyst, his wife in the present, and
his parents and siblings in the past. T h e analysis of the narcissistic
defense led inevitably to the conflicts which had been internalized
through introjection. These conflicts operating at different instinc-
tual levels were libidinal and aggressive in content as the material
described above indicates. Each introjection was gradually replaced

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 PATHOLOGICAL NARCISSISM 553

by an object relationship in the transference. This followed the

pattern of the transference neurosis which is described by Glover
(5) as a selective repetition and thus may be contrasted with the
spontaneous transferences which occur at the beginning of an
analysis.

Forms of Path ol ogicaI Narcissism

I
The case described above illustrates the operation of narcissism
as a pathological process. Reference was made at the beginning of
this paper to the fact that narcissism is a concept which describes a
normal developmental phase of the ego especially in its libidinal
aspects. Pathological narcissism implies something more. It de-
scribes the situation where narcissism is employed with defensive
aims. According to Glover (6), pathological narcissism is a condi-
tion which arises when there is a “defensive exaggeration of nar-
cissism’’ which disturbs normal function and leads to mental
suffering. This criterion was fulfilled in the aforementioned clin-
ical material.
Pathological narcissism has, as Glover (6) mentions, a psy-
chotic or near-psychotic connotation, and this is a matter which
requires investigation. Are the mental processes which fall within
the concept of pathological narcissism akin or similar to those
which underlie psychoses or are they quite different? Before in-
vestigating this question further it is important to recall that the
sexual deviations are also characterized by the presence of patho-
logical narcissism. However, it would be misleading to consider
that identical processes are taking place in neuroses of the type
described above and patients with sexual deviations. T h e nar-
cissism in the latter g o u p is particularly obvious, especially in the
area of the object choice. I n these cases the sexual aberration
crystallizes the narcissism within itself. The object and the self
are not clearly discriminated at an unconscious level. Bak (2) has
shown that the narcissistic object choice in sexual deviations is
similarly defensive in aim. T h e self is loved because objects in
infancy were disappointing. Object-relation conflicts usually with

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554 THOMAS FREEMAN

a destructive content are masked by the narcissism (1). Narcissistic

transferences occur during the treatment of the sexual deviations
and act as a resistance against the transference neurosis and its
interpretation.
T h e pathological narcissism of the sexually deviant differs
from that encountered i n certain cases of neuroses particularly
with respect to its expression. While the former tend to show the
narcissism directly, i n the latter it has a more indirect manifesta-
tion. T h e heightened bodily concern, the pleasure in bodily
processes, and the obvious sexualization of object relationships in
the sexual deviations contrasts markedly with the case described
above where there was n o sign of a sexualized egotism. I n this
man’s case, as has already been mentioned, the pathological nar-
cissism made itself manifest through idealization and without any
overt sexualization. I n both groups of cases, however, there is a
basic failure in developing object relationships i n early life with
resultant destructive fantasies. Introjection and the ensuing passiv-
ity operate as defenses. I n the sexual deviations there has been in
childhood intense autoerotic activity which is employed to screen
the underlying object-relationship conflicts (3). Other factors which
must include hereditary influences and traumatizations of various
kinds will decide whether the individual develops a perversion or
a severe neurosis.
Both sexually deviant and psychoneurotic patients whose per-
sonality is characterized by pathological narcissism are capable of
object relationships. This makes it possible for them to enter, con-
tinue, and cooperate in psychoanalytic therapy. T h e dificulties of
interpretation and the manner in which the pathological nar-
cissism acts as a resistance have already been described. T h e fact
that a relationship is created suggests that either object-libidinal
cathexes are operating or that narcissistic object cathexes alone are
equally capable of providing the means of communication. I t is
more likely that the former condition operates because the result
of successful analysis is to substitute object-libidinal cathexes for
object cathexes which are narcissistic in nature.
It is only with the resolution of the narcissistic defense that
these patients become receptive to interpretation and can bene-
fit from it. T h e fact that psychotic patients are unresponsive to

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 PATHOLOGICAL NARCISSISbf 555

interpretative efforts has encouraged psychoanalysts to believe

that pathological narcissism of a type similar to that encountered
i n the neuroses and perversions functions defensively and thus as
a resistance. What is the nature of the pathological narcissism in
the psychoses? Is it identical to that found in nonpsychotic states
or is it different? How far can pathological narcissism be regarded
as a psychotic or near-psychotic process? T h e fact that cases of per-
version are encountered which show a psychotic or near-psychotic
symptomatology does not give anyone the right to maintain that
these conditions are typical of sexual deviations as a group or that
they are produced by an identical psychopathology. Similarly the
so-called “borderline” states-those patients whose judgnent and
reality testing are occasionally impaired-must be distinguished
from neurotic disorders however severe. I n the case described there
was never any indication of faulty reality testing. One method of
examining the nature of pathological narcissism in the psychoses
is by returning to clinical data. I n the case described below only
those aspects will be mentioned which seem relevant to the ques-
tion in hand. For this reason no reference will be made to the con-
tent of the unconscious fantasies which were operative in this case.

I1

T h e patient was a single woman of twenty-seven who complained

that a man she had once admired was reading her mind, talking
to her, and causing her great distress. She heard his voice in her
head. She said that she had never had any close relationship with
this man, but from the age of sixteen she had been in love with
him. She met him socially and used to attend him in his profes-
sional role of dentist. She frankly admitted that she used to think
constantly about him, dream about him, and enjoyed erotic
fantasies.
She had been hearing the voice for about a year before she
consulted a doctor. During that time it was quite a pleasurable
experience. I n all these years-till the age of twenty-three-she
had firmly believed that somehow they would come together. T h e
man was about forty-two and unmarried. At this time (when the
patient was twenty-three) she heard from friends that there was

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556 THOMAS FREEMAN

some suspicion of this man being a homosexual. From then on she

became convinced that he was reading her thoughts and what he
had to say to her had a disturbing and unpleasant quality. She had
been i n this state for three years, having had two spells of hos-
pitalization when she was treated with tranquilizers and electro-
shock therapy. These treatments had led to a brief remission of
symptoms.
This patient’s capacity to communicate verbally was i n no
way impaired, and a t the outset of psychotherapeutic contact she
was willing to discuss her experiences. She said that the man knew
everything she was thinking, but she also read his mind. She could
hear more than one voice-often it seemed as if the man was
quarreling with someone else. She insisted that he was not working
and that one voice said.he should go to the hospital because he was
mentally ill. At times the voice seemed to tell her lies, and she
would seem to be involved in a quarrel with it. After a few inter-
views she said that the man was being seen by a doctor also. What-
ever was happening to her was also happening to him. She did not
see this connection even when at a later period she expressed the
conviction that he was in the same hospital as she was.
She told the interviewer that he did not believe what she said.
This projection of her own insight continued throughout the
clinical contact. She complained that she was mentally ill. She
meant by this that she could not concentrate or remember any-
thing because the man’s voice was constantly interfering with her
mental activity. She attributed her cognition to the delusional
object in the same manner as Model1 (7) has described i n his
patients. She would forget where her cigarettes were and after
looking everywhere for them the voice would say, “They are in
your locker,” and that is where she would find them. Similarly she
attributed many of her own thoughts to the voice. After about
three to four weeks she virtually refused to say more about what
she was experiencing and whatever information became available
occurred from odd remarks and from the occasional answer to a
question. Her mental state deteriorated, she became tense and
agitated and was constantly listening to the voice during inter-
views. She would repeat, “It’s happening you know.”
I n spite of her unwillingness to communicate she did reveal

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 PATIIOLOGICAL NARCISSISM 557

her belief that the man was in the hospital. She was always expect-
ing to meet him. Quite soon after this she told the interviewer
that he was seeing this man before coming to see her. This revela-
tion was followed a little while later by the announcement that it
was really her father who was reading her mind and speaking to
her although it was through the man’s voice. This caused her acute
distress. She would become confused and mixed up, not knowing
what to believe. She usually refused to report what the voice was
saying but often muttered, “It’s all lies.”
Her distress increased; she believed that the man was in the
ward above the one in which she was resident. TYhen she walked
up and down the ward she heard his footsteps upstairs. She would
say, “What’s going on?” but would not express herself further. I t
seemed as though everything that was happening i n the ward was
significant. Any noise was meaningful-she looked for micro-
phones i n the consulting rooms and was constantly searching for
the man. One day she said that she was sure that she had seen him
at a window. Eventually the interviewer was also reading her
mind. She oscillated between the conviction that he knew every-
thing that was happening or that he did not believe that she heard
a voice at all. She became hostile but never openly accused the
interviewer of persecutory intent.

I n this case of hallucinatory psychosis the mechanisms underlying

the symptom production could be followed quite clearly. At the
outset of the illness the fantasies of the admired man reached
hallucinatory intensity probably during ‘the period before sleep
and while daydreaming. After the eventual realization of the in-
evitable disappointment the object was introjected into the ego
and literally became a part of it. This was to be seen i n the
patient’s inability to discriminate her own activity from that of
the internalized object and in her attributing some of her cognitive
functions to it. This internalization can be regarded as a restitu-
tional process in the sense that the ensuing symptoms represented
the patient’s relationships with objects. She had abandoned, par-

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558 THOMAS FREEMAN

tially at least, the world of objects and substituted the internalized

persecutor.
T h e withdrawal and loss of interest in real objects were
demonstrated in her attitude and behavior toward the interviewer.
She was for a time indifferent to him and quite uninfluenced by
his comments or interpretations. She was completely taken up
with the internalized object which was essentially oedipal in
nature. During an interview she would sit listening to the voice,
or walking about the room, obviously taken u p with what was
being said to her. She was unresponsive to other stimuli. Gradu-
ally the interviewer was drawn into the delusional complex, but
only i n so far as she could not imagine that he was not in contact
with the internalized object. T h e omnipotence and omniscience
of the persecutor, her own power to read his mind, and the even-
tual belief that the interviewer could also read her mind can be
classified as narcissistic phenomena.
Throughout the clinical material there ran an exaggerated
egocentrism in which the self was the center of all environmental
events. This data could be recognized as due to an ego regression
which reduced cognitive function to that developmental level
where thinking and perceiving are tied to the current environ-
mental context and where there is no abstraction from it. Thus
everything relates to the self and is judged according to this stand-
ard. T h e hallucinatory phenomena could similarly be regarded
as due to an ego regression rather than to a narcissistic regression,
however artificial i t may be to isolate these two processes from each
other. T h e libidinal drives were initially, at any rate, instrumental
in awakening the fantasy memories. Later these memories were
experienced as auditory percepts. I t is quite likely that the conver-
sion of feeling from love to hate resulted from rage against the
disappointing object. Certainly this patient had no hesitation in
saying how much she hated the persecutor and that she would like
to murder him.
No one will dispute the possibility that the magic thinking,
the belief in omnipotence and omniscience which characterize
psychotic narcissism play a defensive role similar to that encoun-
tered in cases of psychoneuroses like the one described. I n the
latter instance the patient employed a form of irrational thinking

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 PATHOLOGICAL NARCISSISM 559

which enabled him to maintain an unrealistic belief in the at-

tributes of the analyst. It was not accompanied, however, by the
pathological egocentrism which was typical of the psychotic patient.
T h e difficulty in equating both types of pathological narcissism
arises in part from the fact that it has been impossible for anyone
to demonstrate convincingly that a series of object-relationship
conflicts lie behind the narcissistic phenomena in psychotic states.
These conflicts can be demonstrated in nonpsychotic cases. It may
be that the differentiating factor is an ego regression which is
extensive in the psychotic reaction and minimal or absent in the
psychoneuroses.
I n the case of the young woman it was possible to observe data
which do not appear in consciousness in the psychoneurotic re-
action. I n the former the internalization of the object and the
hatred of it were apparent, while i n the latter this was a process
which could only be inferred from the patient’s symptoms, from
his dreams, and from some of his associations. Again the conflict
regarding the object was wholly manifest in the one case while
unconscious in the other. This suggests that the countercathectic
function in the psychotic patient was defective, thus permitting
the entry into consciousness of contents which at best only appear
in the dreams of the healthy or psychoneurotic subject. I t would
not be enough to say that this could be accounted for solely by a
failure of repression.
I n the neuroses failure of repression results in symptoms and
in a disguised expression of repressed contents. It does not lead to
the emergence of uncontrolled primary-process mechanisms.
T h e primary process could be identified as the cause of the
patient’s conscious experience of being fused with another indi-
vidual. This was the result of condensation. I n this patient it would
appear as if there was a return to an early phase of ego develop-
ment where condensation can occur easily because of the absence
of a definite boundary which differentiates the ego from the world
of objects (primary identification). This loss of discrimination due
to condensation could also be observed in the contents of the delu-
sions and the hallucinations. This content altered so that there
were times when the patient thought the persecutor was her father
or her brother or a former boy friend. There were times when the

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560 THOMAS FREEMAN

persecutor was a condensation of the former admired friend and

her father, Nothing of this kind made a conscious appearance in
the psychoneurotic patient in spite of the fact that he too had a
similar conflict in the sphere of object relations-mainly hatred
against internalized objects. These primitive condensations were
only apparent in dreams.
Considerations such as these make it difficult to believe that
the pathological narcissism of the psychotic patient can be equated
with that which appears in certain psychoneurotic patients and in
the sexual deviations. Although differences exist between the two
latter groups of conditions, the narcissism is essentially the same
in nature and in its function of defense, although the manifesta-
tions may be somewhat different. I n the psychoses the pathological
narcissism may have a defensive function, but it appears to be
associated with a different order of mental functioning. While the
pathological narcissism of the neuroses and sexual deviations arises
out of an advanced level of ego and instinctual development, the
narcissism of the psychotic reaction is part of a more primitive and
undifferentiated matrix of mental functioning. It is intimately
linked with the activity of an uncontrolled primary process with
the predominance of condensations and displacements. Repression,
introjection, identification, and other defense mechanisms which
are functions of an adequately operating ego seem to play a minor
role in the production of the symptoms, and thus the situation is
quite unlike that encountered in the neuroses. A selective disrup-
tion of the countercathectic barrier against the primary process
must be regarded as the main influence leading to the symptoma-
tology. T h e extent of the disruption of the cognitive functions and
thus of the adaptive capacity must depend upon the extent of the
countercathectic deterioration.
The cases described therefore lend further weight to the
hypothesis-laborated on many occasions in the past by classical
writers-that there is a fundamental distinction between the patho-
logical narcissism of the psychotic and that of the psychoneurotic
patient. I n mild cases of psychoneurosis, symptoms are simply
resolved because of the presence of well-developed object-libidinal
cathexes. It is only in the severe cases where suffering is not easily
alleviated that the pathological narcissism comes into view and

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 PATHOLOGICAL NARCISSISM 56 1

must be analyzed. Does a continuum exist extending from the mild

neuroses through the borderline states to the schizophrenias and
paranoid psychoses? This old question is no nearer solution than
it was fifty years ago. The data revealed by the analysis of “border-
line states” have not provided the answer. Perhaps an approach
which utilizes the concept of narcissism might be helpful. It ap-
pears to be so when applied to established cases of neurosis, per-
version, and psychosis.

Summary
An attempt has been made in this paper to utilize the concept of
narcissism to demonstrate the psychopathological processes envis-
aged as occurring in different mental states. The concept of patho-
logical narcissism is defined, and the forms it may assume in
neurosis, sexual perversion, and psychosis are described with the aid
of clinical data. The concept of pathological narcissism may be
useful in examining the relationship between neurosis and
psychosis.
BIBLIOGRAPHY

1. Arlow, J. A. Panel report: Perversions. This Journal, 2:336-345, 1954.

2. Bak. R. Fetishism. This Journal, 1:285298, 1953.
3. Freeman, T. The concept of narcissism in schizophrenic states. Int. 1.Psychoanal.,
44:293-303, 1963.
4. Freud, S. On narcissism: an introduction (1914). Standard Edition, 14:67-102.
London: Hogarth Press, 1957.
5. Glover. E. T h e Technique of Psycho-Analysis. New York: International Univer-
sities Press, 1955.
6. Glover. E. Ego-distortion. Int. J. Psychoanal., 39:260-264, 1958.
7 . Modell. H. A. Hallucinatory experiences in schizophrenia. This Journal, 6:442-
480, 1958.

Submitted November, 1963

Lunsdowne Clinic
4 Royal Crescent
Glusgow, C 3
Scot land

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