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November 17, 1980. SELF THEORY, CONFLICT THEORY, AND THE PROBLEM OF HYPOCHONDRIASIS. Arnold Richards, M.D.
In his presentation of the clinical case history of a patient with a narcissistic syndrome, hypochondriasis, Dr. Richards took issue with the new psychology of
the self and its dismissal of conflict. His patient's morbid preoccupation with self and body could not be traced simply to some evanescing self image, but had to be traced instead to those object-instinctual conflicts dealt with by classical analysis. In an earlier work Dr. Richards had questioned what he considered to be the four basic principles of Kohut's theory: 1) the concept of narcissism as evolving along a separate developmental line of object relations and drive manifestations; 2) the stress on the economic point of view and concomitantly "on contentless mental states"; 3) the reified "delineation of two specific self-object transferences"—idealizing and mirror; and 4) the emphasis on the analyst's emotional empathy to the exclusion of his powers of observation, cognition, and synthesis. According to Dr. Richards, such a constellation of views is to be faulted not because it is "revolutionary," but because the focus is too narrow to account for the data: it fails to encompass the pervasive, protean impact of unconscious conflict and the interplay of conflict and deficit as interdependent variables.
Dr. Richards's patient was referred for analysis following an unsuccessful course of psychopharmacological treatment and a subsequent year of therapy twice weekly. When he entered analysis, he was twenty-seven, married, and had one child. He presented a spectrum of bizarre somatic complaints, together with the idea, not quite of delusional proportions, that his masculinity was deteriorating. He feared that his body was becoming effeminized, that his penis was defective (necessitating masturbation before a mirror), that intercourse would prompt a heart attack, and that he was becoming premat