Love, Sex, and Marriage

in the Setting of Pathological Narcissism

Salman Akhtar, MD

M
ature love requires the estab-
lishment of a sustained rela-
tionship with a romantically
attractive, non-incestuous object toward
whom a certain amount of ambivalence
can be tolerated and in relationship with
whom affection and sensuality can both
be expressed and received. This concept
underscores the necessity to have mas-
tered the oedipal realities of childhood
(eg, feelings of smallness, rivalry, and ex-
clusion) and to have found a love object
that is neither a replica of the primary oe-
dipal love object nor utterly devoid of its
qualities. Besides this, capacity for separ-
ateness, respect for the lover’s autonomy,
and affects of tenderness and care need to
be brought under the spectrum of experi-
ences collectively called “love.”

Salman Akhtar, MD, is Professor of Psychia-

try, Jefferson Medical College, and Training
and Supervising Analyst, Psychoanalytic Cen-
ter of Philadelphia.
Address correspondence to: Salman Akhtar,
MD, Department of Psychiatry and Human
© 2009 iStock International Inc. /Nuno Silva

Behavior, Jefferson Medical College, 33 South

9th Street, Suite 210-C, Philadelphia, PA
19107; fax: 215-503-2851; or e-mail: Salman.
Akhtar@jefferson.edu.
Dr. Akhtar has disclosed no relevant finan-
cial relationships.

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 The individual with a narcissistic per- the ego’s desire for the object’s help- narcissistic gratifications get positively
sonality has not mastered these develop- giving qualities). He emphasized that cathected, and the ego ideal is, to some
mental tasks. Feeling deprived from the the highest phase of development of extent, projected on the very means of
earliest periods of childhood onwards, which object libido is capable is seen access to such realities; and 4) the nar-
he is seething with rage. This rage in the state of being in love. “A person cissistic pain over remnant longings for
makes tolerating limits that are inherent who loves has, so to speak, forfeited a oneness with primary objects and inces-
in oedipal realities difficult. Tenderness part of his narcissism, and it can only be tuous gratifications is compensated for
and restrained sexuality is replaced by replaced by his being loved … Loving in by the attachment to the love object and
oral greed and cocky irreverence. This, itself, insofar as it involves a longing and its sustained availability.
as can be readily imagined, has a wide- deprivation, lowers self regard; whereas Kernberg, in keeping with the im-
ranging impact upon the evolution and being loved, having one’s love returned, pressive breadth and depth of his contri-
sustenance of romantic and sexual life and possessing the love object raises butions to the study of love8-13 offered a
during adulthood. it once more.” Freud3 also noted that detailed definition of love that synthesiz-
Such multifaceted impact of patho- a synthesis of libidinal and aggressive es all its important aspects. According to
logical narcissism upon love relations aims is necessary for true love. Still lat- this definition, mature love is a complex
forms a topic of this contribution. I will er, he traced the idealization of the love emotional disposition that integrates “1)
elucidate the resulting dynamics and object to its “being treated in the same sexual excitement transformed into erot-
phenomenology under three separate way as our own ego, so that when we are ic desire for another person; 2) tender-
headings: narcissism and romantic love, in love a considerable amount of narcis- ness that derives from the integration of
narcissism and sexuality, and narcissism sistic libido overflows onto the object.”4 libidinally and aggressively invested self
and marriage. In each of these areas, I Although acknowledging the exaltation and object representations, with a pre-
will delineate observable problems and that accompanies love, Freud empha- dominance of love over aggression and
subjective areas of distress, taking gen- sized the potential of pain in it: “We are tolerance of the normal ambivalence that
der differences into account. never so defenseless as when we love.”5 characterizes all human relations; 3) an
He went on to note that many individu- identification with the other that includes
NARCISSISM AND ROMANTIC LOVE als protect themselves against the pos- both a reciprocal genital identification
Freud’s seminal statement of 19121 sibility of such pain by directing their and deep empathy with the other’s gen-
still forms the cornerstone of the psycho- love not to one person but to mankind in der identity; 4) a mature form of ideal-
analytic understanding of love. He noted general and its cultural institutions. ization along with deep commitment to
“two currents whose union is necessary Following Freud, many psychoana- the other and to the relationship; and 5)
to ensure a completely normal attitude in lysts made significant contributions to the passionate character of the love rela-
love … These two may be distinguished our understanding of love. I have else- tion in all three aspects: the sexual rela-
as the affectionate and sensual current.”1 where6 synthesized this literature. Here, tionship, the object relationship, and the
The affectionate current is ontogeneti- I will mention Chassageut-Smirgel’s7 superego investment of the couple.”8
cally the earlier one. It arises in connec- elucidation of the picture of the ego Such love leads to recovery of lost
tion with the early body and emotional ideal within the context of mature love parts of the self, dissolves sexual inhibi-
care provided by the mother. The sec- and by citing Kernberg’s8 comprehen- tions, and gives purpose to life. The initial
ond, more specifically sexual, current sive psychoanalytic definition of love. passion might be brief, but the capacity of
arrives on the scene during the oedipal Chassageut-Smirgel7 noted that the four the two partners for deep relations helps
phase and then, with full force, during elements characterize the healthy amal- them convert this burning flame into a
puberty. It has to be synthesized with the gamation of narcissism and love: 1) the lambent glow of companionship.
affectionate current. Romantic love can nostalgic search for oneness with the With this as a backdrop, let me move
then be expressed towards nonfamilial primary object is not given up, but the on to the deleterious effects of exces-
objects with whom a sexual union is ways of achieving it become different; sive narcissism upon the affectionate
permissible and possible. 2) the sexual satisfaction within the cou- and sensual dimensions of love. Freud’s
Freud2 later addressed the topic of ple and their autonomous sublimations affectionate current1 has never been ex-
love from a different perspective. He enhance secondary narcissism of the ego plicitly deconstructed into its compo-
distinguished between narcissistic love and diminish the ego-ego ideal gap; 3) nents. In my view, however, it comprises
(arising from the ego’s self-affirming those aspects of internal and external of the capacities for concern; curiosity;
needs) and anaclitic love (arising from reality that facilitate these sexual and empathic listening; optimal distance;

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 LEXAPRO® (escitalopram oxalate) TABLETS/ORAL SOLUTION forgiveness; and gratitude, which, in turn, gives rise to reci-
placebo. In two fixed-dose studies, the rate of discontinuation for adverse events in patients receiving 10 mg/day Lexapro was not significantly different from the
rate of discontinuation for adverse events in patients receiving placebo. The rate of discontinuation for adverse events in patients assigned to a fixed dose of procity and reparation. Individuals with narcissistic personal-
20 mg/day Lexapro was 10%, which was significantly different from the rate of discontinuation for adverse events in patients receiving 10 mg/day Lexapro (4%)
and placebo (3%). Adverse events that were associated with the discontinuation of at least 1% of patients treated with Lexapro, and for which the rate was at least
twice that of placebo, were nausea (2%) and ejaculation disorder (2% of male patients). Generalized Anxiety Disorder Among the 429 GAD patients who received
ity have difficulties with all these functions. They forget the
Lexapro 10-20 mg/day in placebo-controlled trials, 8% discontinued treatment due to an adverse event, as compared to 4% of 427 patients receiving placebo.
Adverse events that were associated with the discontinuation of at least 1% of patients treated with Lexapro, and for which the rate was at least twice the placebo
important dates in the lives of their lovers, fail to ask about
rate, were nausea (2%), insomnia (1%), and fatigue (1%). Incidence of Adverse Events in Placebo-Controlled Clinical Trials Major Depressive Disorder Table
2 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse events that occurred among 715 depressed patients who received their lover’s families, become strangely inarticulate when it
Lexapro at doses ranging from 10 to 20 mg/day in placebo-controlled trials. Events included are those occurring in 2% or more of patients treated with Lexapro
and for which the incidence in patients treated with Lexapro was greater than the incidence in placebo-treated patients. The prescriber should be aware that these comes to protecting their lovers in an agrument with others,
figures cannot be used to predict the incidence of adverse events in the course of usual medical practice where patient characteristics and other factors differ from
those which prevailed in the clinical trials. Similarly, the cited frequencies cannot be compared with figures obtained from other clinical investigations involving dif-
ferent treatments, uses, and investigators. The cited figures, however, do provide the prescribing physician with some basis for estimating the relative contribution
and cannot titrate their demands in tandem with their lover’s
of drug and non-drug factors to the adverse event incidence rate in the population studied. The most commonly observed adverse events in Lexapro patients
(incidence of approximately 5% or greater and approximately twice the incidence in placebo patients) were insomnia, ejaculation disorder (primarily ejaculatory changing psychophysiological states. The capacity for curios-
delay), nausea, sweating increased, fatigue, and somnolence (see TABLE 2). TABLE 2: Treatment-Emergent Adverse Events: Incidence in Placebo-Controlled
Clinical Trials for Major Depressive Disorder* (Percentage of Patients Reporting Event) Body System/Adverse Event [Lexapro (N=715) and Placebo (N=592)]: ity and attentive listening is similarly impaired.
Autonomic Nervous System Disorders: Dry Mouth (6% and 5%); Sweating Increased (5% and 2%). Central & Peripheral Nervous System Disorders: Dizziness
(5% and 3%). Gastrointestinal Disorders: Nausea (15% and 7%); Diarrhea (8% and 5%); Constipation (3% and 1%); Indigestion (3% and 1%); Abdominal Pain
(2% and 1%). General: Influenza-like Symptoms (5% and 4%); Fatigue (5% and 2%). Psychiatric Disorders: Insomnia (9% and 4%); Somnolence (6% and 2%);
Narcissistic individuals also have difficulty in maintaining
Appetite Decreased (3% and 1%); Libido Decreased (3% and 1%). Respiratory System Disorders: Rhinitis (5% and 4%); Sinusitis (3% and 2%). Urogenital:
Ejaculation Disorder1,2 (9% and <1%); Impotence2 (3% and <1%); Anorgasmia3 (2% and <1%).*Events reported by at least 2% of patients treated with Lexapro
optimal distance. The capacity to maintain optimal distance
are reported, except for the following events which had an incidence on placebo Lexapro: headache, upper respiratory tract infection, back pain, pharyngitis,
inflicted injury, anxiety. 1Primarily ejaculatory delay. 2Denominator used was for males only (N=225 Lexapro; N=188 placebo). 3Denominator used was for females is essentially based upon a paradox.14-16 On the one hand, the
only (N=490 Lexapro; N=404 placebo). Generalized Anxiety Disorder Table 3 enumerates the incidence, rounded to the nearest percent of treatment-emergent
adverse events that occurred among 429 GAD patients who received Lexapro 10 to 20 mg/day in placebo-controlled trials. Events included are those occurring in lovers have to tolerate a relative loss of autonomy and self-suf-
2% or more of patients treated with Lexapro and for which the incidence in patients treated with Lexapro was greater than the incidence in placebo-treated patients.
The most commonly observed adverse events in Lexapro patients (incidence of approximately 5% or greater and approximately twice the incidence in placebo
patients) were nausea, ejaculation disorder (primarily ejaculatory delay), insomnia, fatigue, decreased libido, and anorgasmia (see TABLE 3). TABLE 3: Treatment-
ficiency. On the other hand, they have to accept each other’s
Emergent Adverse Events: Incidence in Placebo-Controlled Clinical Trials for Generalized Anxiety Disorder* (Percentage of Patients Reporting Event) Body
System/Adverse Event [Lexapro (N=429) and Placebo (N=427)]: Autonomic Nervous System Disorders: Dry Mouth (9% and 5%); Sweating Increased (4% and
essential separateness; after all, they have been raised by dif-
1%). Central & Peripheral Nervous System Disorders: Headache (24% and 17%); Paresthesia (2% and 1%). Gastrointestinal Disorders: Nausea (18% and 8%);
Diarrhea (8% and 6%); Constipation (5% and 4%); Indigestion (3% and 2%); Vomiting (3% and 1%); Abdominal Pain (2% and 1%); Flatulence (2% and 1%); ferent sets of parents and grew up under different psychoso-
Toothache (2% and 0%). General: Fatigue (8% and 2%); Influenza-like symptoms (5% and 4%). Musculoskeletal: Neck/Shoulder Pain (3% and 1%). Psychiatric
Disorders: Somnolence (13% and 7%); Insomnia (12% and 6%); Libido Decreased (7% and 2%); Dreaming Abnormal (3% and 2%); Appetite Decreased
(3% and 1%); Lethargy (3% and 1%); Yawning (2% and 1%). Urogenital: Ejaculation Disorder1,2 (14% and 2%); Anorgasmia3 (6% and <1%); Menstrual Disorder
cial circumstances. The narcissistic individual has difficulty in
(2% and 1%). *Events reported by at least 2% of patients treated with Lexapro are reported, except for the following events which had an incidence on placebo
Lexapro: inflicted injury, dizziness, back pain, upper respiratory tract infection, rhinitis, pharyngitis. 1Primarily ejaculatory delay. 2Denominator used was for males
tolerating either side of this relational equation. He or she does
only (N=182 Lexapro; N=195 placebo). 3Denominator used was for females only (N=247 Lexapro; N=232 placebo). Dose Dependency of Adverse Events The
potential dose dependency of common adverse events (defined as an incidence rate of 5% in either the 10 mg or 20 mg Lexapro groups) was examined on the not wish to renounce total autonomy while also not permitting
basis of the combined incidence of adverse events in two fixed-dose trials. The overall incidence rates of adverse events in 10 mg Lexapro-treated patients (66%)
was similar to that of the placebo-treated patients (61%), while the incidence rate in 20 mg/day Lexapro-treated patients was greater (86%). Table 4 shows a separate mental life to the other. Under the pressure of in-
common adverse events that occurred in the 20 mg/day Lexapro group with an incidence that was approximately twice that of the 10 mg/day Lexapro group and
approximately twice that of the placebo group. TABLE 4: Incidence of Common Adverse Events* in Patients with Major Depressive Disorder Receiving Placebo
(N=311), 10 mg/day Lexapro (N=310), 20 mg/day Lexapro (N=125): Insomnia (4%, 7%, 14%); Diarrhea (5%, 6%, 14%); Dry Mouth (3%, 4%, 9%);
stinctual drives, the narcissistic individual comes too close to
Somnolence (1%, 4%, 9%); Dizziness (2%, 4%, 7%); Sweating Increased (<1%, 3%, 8%); Constipation (1%, 3%, 6%); Fatigue (2%, 2%, 6%); Indigestion
(1%, 2%, 6%).*Adverse events with an incidence rate of at least 5% in either of the Lexapro groups and with an incidence rate in the 20 mg/day Lexapro group
the other person and defending against the aggression, inevi-
that was approximately twice that of the 10 mg/day Lexapro group and the placebo group. Male and Female Sexual Dysfunction with SSRIs Although changes
in sexual desire, sexual performance, and sexual satisfaction often occur as manifestations of a psychiatric disorder, they may also be a consequence of tably mobilized by intimacy, he withdraws and becomes cold
pharmacologic treatment. In particular, some evidence suggests that SSRIs can cause such untoward sexual experiences. Reliable estimates of the incidence and
severity of untoward experiences involving sexual desire, performance, and satisfaction are difficult to obtain, however, in part because patients and physicians and aloof. In contrast with the mature relatedness in love that
may be reluctant to discuss them. Accordingly, estimates of the incidence of untoward sexual experience and performance cited in product labeling are likely to
underestimate their actual incidence. Table 5 shows the incidence rates of sexual side effects in patients with major depressive disorder and GAD in placebo-
controlled trials. TABLE 5: Incidence of Sexual Side Effects in Placebo-Controlled Clinical Trials [In Males Only: Adverse Event: Lexapro (N=407) and Placebo
gradually deepens, narcissistic relatedness is characterized by
(N=383)]: Ejaculation Disorder (primarily ejaculatory delay) (12% and 1%); Libido Decreased (6% and 2%); Impotence (2% and <1%). [In Females Only: Lexapro
(N=737) and Placebo (N=636)]: Libido Decreased (3% and 1%); Anorgasmia (3% and <1%). There are no adequately designed studies examining sexual cycles of need-based intimacy and defensive withdrawl.
dysfunction with escitalopram treatment. Priapism has been reported with all SSRIs. While it is difficult to know the precise risk of sexual dysfunction associated
with the use of SSRIs, physicians should routinely inquire about such possible side effects. Vital Sign Changes Lexapro and placebo groups were compared with In essence, the affectionate current of love (concern, curi-
respect to (1) mean change from baseline in vital signs (pulse, systolic blood pressure, and diastolic blood pressure) and (2) the incidence of patients meeting
criteria for potentially clinically significant changes from baseline in these variables. These analyses did not reveal any clinically important changes in vital signs
associated with Lexapro treatment. In addition, a comparison of supine and standing vital sign measures in subjects receiving Lexapro indicated that Lexapro
osity, empathy, optimal distance, forgiveness, and gratitude)
treatment is not associated with orthostatic changes. Weight Changes Patients treated with Lexapro in controlled trials did not differ from placebo-treated patients
with regard to clinically important change in body weight. Laboratory Changes Lexapro and placebo groups were compared with respect to (1) mean change from
requires that we allow someone to enter our hearts. In meta-
baseline in various serum chemistry, hematology, and urinalysis variables, and (2) the incidence of patients meeting criteria for potentially clinically significant
changes from baseline in these variables. These analyses revealed no clinically important changes in laboratory test parameters associated with Lexapro treatment. psychological terms, this is a major libidinal cathexis of an
ECG Changes Electrocardiograms from Lexapro (N=625), racemic citalopram (N=351), and placebo (N=527) groups were compared with respect to (1) mean
change from baseline in various ECG parameters and (2) the incidence of patients meeting criteria for potentially clinically significant changes from baseline in object. In a different psychoanalytic idiom, affection is the
these variables. These analyses revealed (1) a decrease in heart rate of 2.2 bpm for Lexapro and 2.7 bpm for racemic citalopram, compared to an increase of
0.3 bpm for placebo and (2) an increase in QTc interval of 3.9 msec for Lexapro and 3.7 msec for racemic citalopram, compared to 0.5 msec for placebo. Neither
Lexapro nor racemic citalopram were associated with the development of clinically significant ECG abnormalities. Other Events Observed During the Premarketing
provision of inner space for a co-created and affectively posi-
Evaluation of Lexapro Following is a list of WHO terms that reflect treatment-emergent adverse events, as defined in the introduction to the ADVERSE REACTIONS
section, reported by the 1428 patients treated with Lexapro for periods of up to one year in double-blind or open-label clinical trials during its premarketing tive relational dialogue. Regardless of the terminology, such
evaluation. All reported events are included except those already listed in Tables 2 & 3, those occurring in only one patient, event terms that are so general as to
be uninformative, and those that are unlikely to be drug related. It is important to emphasize that, although the events reported occurred during treatment with development is possible only when the core self-representa-
Lexapro, they were not necessarily caused by it. Events are further categorized by body system and listed in order of decreasing frequency according to the
following definitions: frequent adverse events are those occurring on one or more occasions in at least 1/100 patients; infrequent adverse events are those
occurring in less than 1/100 patients but at least 1/1000 patients. Cardiovascular - Frequent: palpitation, hypertension. Infrequent: bradycardia, tachycardia, ECG
tion of the individual does not need constant polishing and
abnormal, flushing, varicose vein. Central and Peripheral Nervous System Disorders - Frequent: light-headed feeling, migraine. Infrequent: tremor, vertigo, restless
legs, shaking, twitching, dysequilibrium, tics, carpal tunnel syndrome, muscle contractions involuntary, sluggishness, coordination abnormal, faintness,
attention. Winnicott’s17 phrase, “ordinarily devoted mother,”
hyperreflexia, muscular tone increased. Gastrointestinal Disorders - Frequent: heartburn, abdominal cramp, gastroenteritis. Infrequent: gastroesophageal
reflux, bloating, abdominal discomfort, dyspepsia, increased stool frequency, belching, gastritis, hemorrhoids, gagging, polyposis gastric, swallowing difficult. has a readymade counterpart in my profile of the ordinarily
General - Frequent: allergy, pain in limb, fever, hot flushes, chest pain. Infrequent: edema of extremities, chills, tightness of chest, leg pain, asthenia, syncope,
malaise, anaphylaxis, fall. Hemic and Lymphatic Disorders - Infrequent: bruise, anemia, nosebleed, hematoma, lymphadenopathy cervical. Metabolic and Nutritional devoted lover. The narcissistic individual is certainly not one.
Disorders - Frequent: increased weight. Infrequent: decreased weight, hyperglycemia, thirst, bilirubin increased, hepatic enzymes increased, gout, hypercholes-
terolemia. Musculoskeletal System Disorders - Frequent: arthralgia, myalgia. Infrequent: jaw stiffness, muscle cramp, muscle stiffness, arthritis, muscle weakness,
back discomfort, arthropathy, jaw pain, joint stiffness. Psychiatric Disorders - Frequent: appetite increased, lethargy, irritability, concentration impaired. Infrequent:
I must acknowledge that I have not discussed two impor-
jitteriness, panic reaction, agitation, apathy, forgetfulness, depression aggravated, nervousness, restlessness aggravated, suicide attempt, amnesia, anxiety attack,
bruxism, carbohydrate craving, confusion, depersonalization, disorientation, emotional lability, feeling unreal, tremulousness nervous, crying abnormal, tant issues here. One pertains to the sensual current of roman-
depression, excitability, auditory hallucination, suicidal tendency. Reproductive Disorders/Female* - Frequent: menstrual cramps, menstrual disorder. Infrequent:
menorrhagia, breast neoplasm, pelvic inflammation, premenstrual syndrome, spotting between menses. *% based on female subjects only: N=905 Respiratory tic love and the other to the object choice in the realm of love
System Disorders - Frequent: bronchitis, sinus congestion, coughing, nasal congestion, sinus headache. Infrequent: asthma, breath shortness, laryngitis,
pneumonia, tracheitis. Skin and Appendages Disorders - Frequent: rash. Infrequent: pruritus, acne, alopecia, eczema, dermatitis, dry skin, folliculitis, lipoma,
furunculosis, dry lips, skin nodule. Special Senses - Frequent: vision blurred, tinnitus. Infrequent: taste alteration, earache, conjunctivitis, vision abnormal, dry eyes,
and marriage. I intend to take these two topics up in the fol-
eye irritation, visual disturbance, eye infection, pupils dilated, metallic taste. Urinary System Disorders - Frequent: urinary frequency, urinary tract infection.
Infrequent: urinary urgency, kidney stone, dysuria, blood in urine. Events Reported Subsequent to the Marketing of Escitalopram - Although no causal relation-
lowing sections on narcissism and sexuality, and narcissism
ship to escitalopram treatment has been found, the following adverse events have been reported to have occurred in patients and to be temporally associated with
escitalopram treatment during postmarketing spontaneous and clinical trial experience and were not observed during the premarketing evaluation of escitalopram: and marriage, respectively.
Blood and Lymphatic System Disorders: hemolytic anemia, leukopenia, thrombocytopenia. Cardiac Disorders: atrial fibrillation, cardiac failure, myocardial
infarction, torsade de pointes, ventricular arrhythmia, ventricular tachycardia. Endocrine Disorders: diabetes mellitus, hyperprolactinemia, SIADH. Eye Disorders:
diplopia, glaucoma. Gastrointestinal Disorders: gastrointestinal hemorrhage, pancreatitis, rectal hemorrhage. General Disorders and Administration Site Conditions:
abnormal gait. Hepatobiliary Disorders: fulminant hepatitis, hepatic failure, hepatic necrosis, hepatitis. Immune System Disorders: allergic reaction. Investigations:
electrocardiogram QT prolongation, INR increased, prothrombin decreased. Metabolism and Nutrition Disorders: hypoglycemia, hypokalemia. Musculoskeletal and
NARCISSISM AND SEXUALITY
Connective Tissue Disorders: rhabdomyolysis. Nervous System Disorders: akathisia, choreoathetosis, dysarthria, dyskinesia, dystonia, extrapyramidal disorders,
grand mal seizures (or convulsions), hypoaesthesia, myoclonus, nystagmus, seizures, tardive dyskinesia. Pregnancy, Puerperium and Perinatal Conditions: The existing literature on narcissism and sexuality largely
spontaneous abortion. Psychiatric Disorders: acute psychosis, aggression, anger, delirium, delusion, nightmare, paranoia, visual hallucinations. Renal and Urinary
Disorders: acute renal failure. Reproductive System and Breast Disorders: priapism. Respiratory, Thoracic and Mediastinal Disorders: pulmonary embolism. Skin addresses sexual object choice. Among the scenarios outlined
and Subcutaneous Tissue Disorders: angioedema, ecchymosis, erythema multiforme, photosensitivity reaction, Stevens Johnson Syndrome, toxic epidermal
necrolysis, urticaria. Vascular Disorders: deep vein thrombosis, hypotension, orthostatic hypotension, phlebitis, thrombosis.
Forest Pharmaceuticals, Inc. Subsidiary of Forest Laboratories, Inc. St. Louis, MO 63045 USA Licensed from H. Lundbeck A/S Rev. 01/09 © 2009 Forest
are the search for a “heterosexual twin,”8 Don-Juan syndrome,
Laboratories, Inc.
persistent Madonna-whore dichotomy, early sexual promis-

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 cuity of the usual narcissist and the cation with the depriving mother of early Over time, such boredom might mani-
late promiscuity of the shy narcissist,18 childhood is unmistakably evident. fest through a diminution in the frequen-
narcissistically determined male homo- Similar problems characterize the ear- cy of sexual intercourse. During the in-
sexuality, narcissistic women’s gravitat- ly foreplay. The narcissist shows a pro- tercourse itself, this might be combated
ing to famous men, and some narcissis- clivity to disregard the partner’s needs, by postural gymnastics and penetrative
tic women’s totally turning away from lacks tenderness, and tends to move too experimentations of all sorts. With physi-
heterosexuality into celibacy or lesbian quickly toward the next step. The “fore- ologically plausible truisms and rational-
lifestyle. In regressed narcissistic men, play proper” involves undressing, facing izations, narcissistic men prefer entering
especially those leading socially isolat- each other naked, and stimulating each a woman from behind, and narcissistic
ed or religiously dictated celibate lives, other in ways other than genital-to-geni- women prefer performing intercourse
secret addiction to masturbation, and tal contact. Shedding one’s shame over while being on top. Both thus avoid face-
vulnerability to pedophilia is also evi- nakedness and gently overcoming the to-face closeness and seek greater physi-
dent. Although such phenomena and the partner’s shame are important tasks here. cal control over their own movements.
psychodynamics underlying them are Fears regarding the real and imaginary This search is driven by the enhanced or-
indeed important, in the following pas- blemishes of one’s body have to be put gasmic potential of such postures as well
sages I will concentrate upon the impact aside. For this, genuine self-regard and as their narcissistically stabilizing effects.
of excessive narcissism upon the actual trust in the partner’s goodness is needed. The more control the narcissists have, the
act of heterosexual intercourse since The narcissist lacks both and is there- more pleasure they draw from sex.
this has not received adequate attention fore uncomfortable with foreplay. Some Achieving orgasm, however, is dif-
in the literature. narcissistic men, however, hide such ficult for narcissistic individuals since
In order to illustrate how pathologi- discomfort by “humbly” serving their the experience requires dyscontrol and
cal narcissism impacts upon sexual in- partner’s needs — rather like the vagina a temporary loss of self. Narcissistic
tercourse, it might be worthwhile to first man described by Limentani19 or by pro- women might therefore feel compelled
recount the usual sequence of events as- longing the foreplay in a counterphobic to fake orgasms, especially if their
sociated with it. This includes: 1) subtle exhibition of their sexual prowess. partners regard that as a sexual trophy.
hints from the partners for readiness, Yet another important aspect of the Narcissistic men might transform their
2) initial foreplay while being dressed, foreplay is the emergence into conscious- difficulty in ejaculating and reaching
3) undressing and “foreplay proper,” 4) ness of pregenital-drive derivatives (eg, orgasm — based upon the identification
penetration and intercourse, 5) orgasm, sucking, biting, licking, showing, look- of their penis with a depriving maternal
6) post-orgasmic tenderness, and 7) re- ing, squeezing, smelling, inflicting small breast — into the masculine glory of
turn to conventional morality and non- amounts of pain). The narcissist, who being able to carry on intercourse for
sexual behavior by putting clothes back has kept his immense oral hunger and long lengths of time.
on and beginning to talk about other anally defiling impulses tightly tucked The post-orgasmic phase offers a
matters, with or without an interlude underneath his glittering persona now wonderful opportunity of “lying fal-
of sleep. At each step of this sequence vacillates between indulgent greed and low”20 in the presence of another indi-
(admittedly, robbed of innovation and anxious retreat. As a result, the partner vidual. Winnicott17 makes a special note
surprise for didactic ease), pathological ends up confused and frustrated. of this part of sexual act in his article on
narcissism might cause problems. Encountering the naked body of an mature aloneness: “It is perhaps fair to
Deficient in the capacity for empathic opposite sex partner also stirs up the say that after satisfactory intercourse
attunement, the narcissistic individual narcissist in other ways. According to each partner is alone, and it contented
often fails to discern signals of readiness Kernberg,8 “ … unconscious envy of to be alone. Being able to enjoy being
from the romantic partner. The narcis- the other transforms the idealization of alone along with another person who is
sist might also not feel the need to subtly the other’s body into its devaluation, also alone is in itself an experience of
convey his own desire since he assumes fosters the transformation of sexual health. Lack of id-tension may produce
that his need will automatically be met gratification into the sense of having anxiety, but time-integration of the per-
with gratification. Worse still, the nar- successfully invaded and incorporated sonality enables the individual to wait
cissist might deliberately overlook the the other, eliminates the richness of the for the natural return of id-tension, and
partner’s appeal signals in order to sadis- primitive object relations activated in to enjoy sharing solitude, that is to say,
tically withhold affection from them. At normal polymorphous perverse sexual- solitude that is relatively free from the
such moments, the narcissist’s identifi- ity, and descends into boredom.”8 property that we call ‘withdrawal.’ ”

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 Mutual tenderness, holding, and gen- NARCISSISM AND MARRIAGE oedipally re-charged, hence potentially
tle caressing characterizes this phase, The decision to marry and the subse- awkward, after the arrival of children.
which is also sprinkled with looking into quent establishment and maintenance of Ross29 underscored the spoiling effect
each others’ eyes, sleepy smiles, and an martial couplehood pose new challenges of the shadow of early parental imagos
occasional child-like laughter. All this while also offer new gratifications to the — especially of a homosexual nature
requires a resurgent dominance of the af- two individuals in the dyad. The most — upon marital sexuality. And long be-
fectionate current of love and poses prob- prominent among the challenges is the fore these contemporary formulations,
lems for the narcissistic individual. The need to renounce the ideal spouse rep- Horney declared parental transferences
closure of the sexual interlude and return resentation,23 an exalted, internal im- in marriage to be the “fundamental prob-
to conventional morality via dressing and age comprising of the most desirable lem in monogamy.”30 All in all, entering
resumption of non-sexual activities is attributes of all the consummated and into a marriage and sustaining it over
similarly hard for the narcissist. He either unrequited loves of adolescence and time are not easy.
ends it all abruptly or continues to inject young adulthood (on the preconscious At the same time, the experience can
the erotic into the post-sexual, ordinary level) and of the best qualities of the two be profoundly gratifying if the partners
behavior, and conversation. parents (on the unconscious level). This bring solid psychic structures of their
In essence, from the awakening of mobilizes frustration, mental pain,24 and own, have chosen each other thought-
desire through foreplay to orgasm and aggression, which, under fortunate cir- fully, and have the necessary forbear-
post-orgasmic states, the narcissist finds cumstances, turn out to be bearable. ance for meeting the above mentioned
matters difficult. According to Bach,21 Difficult psychological tasks do not challenges. Under such circumstances,
such an individual cannot manage nor- end with entry into marriage. Indeed, a the illusory search for perfection gives
mal sexuality, which “requires the ca- marriage is sustained by attending to in- way to the enriching pleasure of psy-
pacity to simultaneously enjoy oneself trapsychic and interpersonal challenges chic stability and depth. Favors to the
as a subject and as object by identifying that keep cropping up. It can only “sur- partner no longer seem like sacrifices;
with the object; it requires the capacity vive and thrive if the partners are cogni- they become the moral foundations of
to accept objects that differ from one- zant of difficulties, as they arise, com- the couplehood itself. Value systems of
self.”21 Bach goes on to say that narcis- municate their feelings to each other, the two partners mutually enhance each
sistic individuals “have generally made and resolve their differences. There must other, and raising children together of-
peace with reality on condition that they be a real commitment to their relation- fers possibilities of re-working remnant
don’t always have to live in it. They in- ship, which, in turn, will encourage the internal conflicts, transcending history,
habit the world without being embedded compromises that are needed.”25 and fostering the couple’s existential
in it. The interpenetration and mutual Disillusionment in oneself and the optimism. Narcissistic and anaclitic love
enrichment of inner life and reality are a partner, disagreements over childrear- become interchangeable,7 so that loving
problem for them, a problem concretely ing, the necessity to make sacrifices for the partner becomes synonymous with
exemplified by their difficulty in coor- the sake of one’s partner, firm mainte- loving oneself and taking good care of
dinating self-love and object-love … nance of the couple’s social and mon- oneself transforms into giving a gift to
They can be either “all themselves” or etary privacy, and resisting extramarital one’s partner. Even sexuality, while los-
“all somebody’s lover,” but seem to find erotic temptations are all part of this ing some of its initial magic, acquires a
it difficult or impossible to integrate or picture. The frequent decline of sexual deeper emotional anchor. The spouse’s
articulate these two apparently comple- excitement in the setting of an ongoing body becomes a depository of one’s in-
mentary views on the self.”21 marriage is a problem as well. Freud, ternal objects and the “geography of per-
The normal homeostasis in which while showing a greater optimism to- sonal meanings.”
the self experience and concern for oth- wards second marriages,26,27 held on to It should by now be clear that the
ers exist in an intermingled state is be- the idea that marriage reduces the inten- complexities of mourning and disillu-
yond the narcissistic individual. This is sity of erotic pleasure. He declared that sionment on the one hand, and mental
a major handicap in the enjoyment of “the psychical value of erotic needs is deepening and civilized interpersonal
sexuality and poses difficulties for mar- reduced as soon as their satisfaction be- merger on the other hand, are too much
ital life where development and main- comes easy.”1 Further dynamics under- for a narcissistic individual’s ego to bear.
tenance of mutuality — in Bergman’s lying this was elucidated by his follow- Marrying and staying married thus be-
terms,22 “true we/our experience” — is ers. Colarusso28 suggested that sexual come difficult. Four types of pathologi-
the central issue at stake. relations in a married couple become cal outcomes tend to result.

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 First, there might develop a severe in- internal objects. The narcissistic individ- ness does exist in the marriage. Further
hibition in the capacity to marry. Although ual lacks these qualities and thus ends up destructiveness arises from the unre-
largely based upon the preconsciously alienating the spouse. solved, unconscious envy of the oedipal
sensed inability to metabolize aggres- Fourth, narcissistic personalities couple and insofar as “the narcissist’s
sion in the crucible of a dyadic relation- might damage their marriages by hav- own marriage becomes unconsciously
ship, the inhibition might have additional ing extramarital affairs. Such damage a replica of the oedipal couple, it must
origins that differ in the two genders. In might remain contained within the mar- be destroyed.” The end result is divorce,
narcissistic men, the inability to marry ital bond, if is a one-time occurrence, followed by a life of sexual inconsola-
might arise from the unrelenting quest if the spouse has reasons and ability bility and spiritual desolation that can
for sexual encounters, rationalized on the to be forgiving, and if the narcissistic lead to suicide. Louis Begley’s32 dark
basis of male biological imperatives or as individual himself shows the capacity novel “The Man Who Was Late” offers
simply looking for a perfect partner. In for remorse. Otherwise the damage is a poignant description of such a situa-
narcissistic women, the inability to marry severe enough to result in divorce. This tion. In other cases, however, the image
might arise from their inordinate pleasure is especially the case with narcissistic of a lonely and rejected man becomes a
in self-sufficiency which, in turn, hides men who are habitual philanderers and “new nucleus around, which, through an
anxiety over attachment and dependence. whose spouses have psychically grown old pattern, the subjective experience of
In both men and women, these dynam- and become more self-respecting over grandiosity organizes itself again.33 The
ics forcefully resurface after the failure time. Occasionally, however, one comes debauch cleverly transforms himself into
of a first marriage and might delay, if not across narcissistic men who, over the a tragic hero.
thwart, finding an acceptable partner for a course of a long marriage, begin to rec-
second marriage. ognize their wife’s value to them. They CONCLUSION
Second, narcissistic personalities tend then make reparative gestures and might Excessive narcissism has a powerful
to select individuals who, rather than advance toward genuine concern and deleterious impact upon an individual’s
help diminish their pathology, aid in re- even love for the spouse. love life. I have categorized the resulting
taining their aggrandized view of them- The onset of middle age also poses phenomena as pertaining to romantic love,
selves. Marrying a socially prominent special risks for the sexual and marital sexuality, and the martial relationship. In
person helps the accomplished narcissist lives of narcissistic individuals. The un- all three realms, narcissistic individuals
via boastful sharing (in essence, steal- married philanderer finds his diminishing manifest behavioral rough edges and sub-
ing) of the partner’s talents and achieve- sexual prowess extremely disconcerting. jective distress. They have impaired capac-
ments. Marrying someone far beneath It threatens to de-link him with the sole ities for sustained affection and sensuality.
one’s socioeconomic status can, para- avenue he has had available for connect- They also frequently make marital object
doxically, also facilitate the stabilization ing with women (mother-substitutes) and choices that instead of ameliorating their
of narcissistic grandiosity; one can con- drawing sustenance from them. His ever pathology further consolidate their grandi-
stantly demonstrate one’s superiority. present subterranean inconsolability now ose and self-centered defensive stance. The
Besides, one can also satisfy the covert bubbles to the surface. For the married ordinary, admiration-seeking narcissist
masochism, which frequently accom- narcissist, too, matters are not simple. shows more problems in young adulthood
panies narcissism.31 In such narcissistic Generally speaking, the inevitable dimi- and the shy narcissist during midlife; the
marriages, “the partner is really a servant nution of sexuality during middle age is malignant narcissist34,35 has more sadomas-
or a convenient fixture, and depreciation compensated by deepening of mutual ochistic elements in his love life than either
and resentment are institutionalized in regard, respect, and affection. For nar- of the other two types. Not surprisingly, the
chronic aggressive behavior.”11 Clearly, cissistic individuals, especially men, the distress of these individuals seeps into the
masochistic tendencies on the partner’s diminution of sexual excitement is, how- soul of their partners who seek help with
part secretly collude in the stability of ever, accompanied by a loss of interest depressive symptoms and impotent rage.
such pathological marriages. in the partner. “Here, eternally youthful Narcissistic men and women differ in
Third, marriage does not only bring bodies are needed compulsively, regard- the surface manifestations of their troubled
a spouse in one’s life but also his or her less of the face, the person, and the at- love lives. Narcissistic men display sexual
family. Cultivating and maintaining a titudes with which such bodies relate to promiscuity coupled with a pronounced
receptive attitude towards the in-laws the (narcissistic individual).”11 Hunger lack of tenderness, reciprocity, and affec-
requires tact, resilience, and, ultimately, and greed of such proportions end up tion in the context of sexual relations. Nar-
a deep sense of respect for the spouse’s cannibalizing whatever emotional good- cissistic women find it difficult to renounce

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