Niederland has observed common features in seven creative patients treated over several years. These patients suffered a permanent injury to their infantile narcissism deriving from either a congenital (usually hidden) body defect or a physical malformation resulting from serious illness in early childhood. Unconscious restorative strivings permeated their fantasies, dreams, and aspirations, and tended to convert the original stigma into a mark of excellence. The permanency of the narcissistic injury accounts for the painter's feeling his product is never finished and can always be improved.

Drawing on the literature in addition to his clinical experiences, the author cites early object loss with restorative strivings, increased bisexuality, and heightened body sensitivity as contributing factors to creative activity. He is not certain however whether heightened body sensitivity is a constitutional factor (Greenacre) or is secondary to preoccupation with the body as a consequence of physical defect.