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In his paper on “Healthy and Pathological Narcissism” Paul Federn suggests several characteristics which distinguish one from the other. One of the crucial differences is the degree to which narcissism is used as a substitute for object strivings. “Healthy narcissism is employed as counter cathexis to the object strivings and for their support, but not as their substitute. The more narcissism functions as such a substitute, the more pathological it becomes” (5).
The substitute nature of pathological narcissism is retained in the derivatives of megalomanic and omnipotent wishes. With the mother as the first object, the substitute nature can be clearly observed in lesbianism, where the primary homosexual attachment of the female is acted out. Deutsch characterized the activities of homosexual women as consisting mainly in the mutual playing of “mother and child” (4). Fenichel emphasizes the empiric fact that oral eroticism usually is in the foreground in female homosexuality, consonant with its archaic nature.
In the genesis of acting out several authors stressed the oral fixation with its high narcissistic need (6). Nunberg defined the process of acting out as a “tendency to revive old ideas and perceptions and make present coincide with the past.” (10). The alternation between acting out and working through as a characteristic aspect of homosexual acting out was recently illustrated by By-chowski (3).
The homosexual syndrome—a substitute—represents an unsuccessful partial repression, leading to a partial split in the ego and a bi-sexual conflict. In the following case illustration the pathological narcissism fixated the pregenital wishes which were defended against the superego by denial and some degree of autistic thinking. In each phase of her development primary narcissistic wishes were partly sublimated, partly kept alive by repression. The repressed wishes were acted out at each successive stage of growth with substitutes until the homosexual syndrome emerged. The