Facial disfigurement: a self-psychological perspective on the "hide-and-seek" fantasy of an avoidant personality

The author presents the self-psychological treatment of a patient who was born with a facial disfigurement. At the onset of treatment, the patient met the diagnostic criteria for avoidant personality disorder. The disfigurement predisposed the patient to perceive herself as defective and flawed. This sense of being flawed was exacerbated by early losses and selfobject failures. The formulation presented focuses on the patient's "hide-and-seek" fantasy, which expresses both archaic grandiosity and omnipotence. The patient's emotional hiding and seeking is an apt description of her avoidant behavior, in general, and the transference, more specifically.