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The ability to tolerate frustration and anxiety and the ability to develop a transference neurosis are essential prerequisites if a patient is to qualify for psychoanalytic treatment. Patients who do not fulfill these criteria have been considered unsuitable for treatment with standard psychoanalytic techniques. To this category of unsuitable patients belong those suffering from such narcissistic and impulse-ridden character disorders as perversion, addiction, psychopathy, and various other types of acting-out behavior. Two characteristics of these patients, their low threshold of tolerance of instinctual frustration, and their compelling need for immediate discharge of instinctual urges and for immediate gratification in reality merit closer genetic investigation.
An essential characteristic differentiating these patients from neurotic patients is an insistence not only upon immediate gratification, but also upon gratification in reality. No matter how disguised the form of this gratification may be, it has to be a gratification in reality, with the discharge of instinctual energy through some action or manipulation involving external reality and a real object, which may be an inanimate object—that is, a fetish.
Neurotic symptoms, on the other hand, do not provide gratification in reality. To the contrary, neurotic symptoms usually lead to some form of