The Inner World, the Gut, and the Sense of Reality

This article describes a group of talented, high-functioning narcissistic patients who avoided thinking of other people when they were not actually present. They seemed unwilling or unable to allow other people to maintain a continuity of existence in their minds. This occurred in the transference as well; most patients never thought of their analyst in between sessions. These patients also experienced moderate to severe gastrointestinal disturbances so that the discontinuous transference was replaced by a continuous “gut transference” that varied as any ordinary transference might. These patients also had difficulties with feelings of reality, that is, not a cognitive defect in reality testing but rather some problem with those primitive sensory states that provide us with the clear feeling that we and other people and things are real and alive and that we all belong to the same world. Detailed examination of one patient's history led to hypotheses about the psychodynamic origins of this syndrome and about the actual processes involved. All these patients, who had suffered severe early object trauma, desperately needed yet avoided object attachments. It seemed they had made a visceral attachment to the disturbance in their gut that represented the painful absent object. Some implications of this for psychoanalytic therapy and culture are explored.