Resources and references

Anxiety and Stress Disorders: A guide to managing panic attacks, phobias,

PTSD, OCD, social anxiety disorder, and related conditions – Harvard Medical
School Special Health Report
What You Need to Know About Obsessive Compulsive Disorder (PDF) –
International OCD Foundation

Authors: Melinda Smith, M.A., and Jeanne Segal, Ph.D. Last

updated: June 2018.

Obsessive-Compulsive Disorder (OCD)

Symptoms, Treatment, and Self-Help

It’s normal, on occasion, to go back and double-check that the iron is unplugged or your car is
locked. But if you suffer from obsessive-compulsive disorder (OCD), obsessive thoughts and
compulsive behaviors become so consuming they interfere with your daily life. No matter what
you do, you can’t seem to shake them. But help is available. With treatment and self-help
strategies, you can break free of the unwanted thoughts and irrational urges and take back control
of your life.

What is obsessive-compulsive disorder (OCD)?

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by uncontrollable,
unwanted thoughts and ritualized, repetitive behaviors you feel compelled to perform. If you
have OCD, you probably recognize that your obsessive thoughts and compulsive behaviors are
irrational—but even so, you feel unable to resist them and break free.
Like a needle getting stuck on an old record, OCD causes the brain to get stuck on a particular
thought or urge. For example, you may check the stove 20 times to make sure it’s really turned
off, or wash your hands until they’re scrubbed raw. While you don't derive any sense of pleasure
from performing these repetitive behaviors, they may offer some passing relief for the anxiety
generated by the obsessive thoughts. You may try to avoid situations that trigger or worsen your
symptoms or self-medicate with alcohol or drugs. But while it can seem like there’s no escaping
your obsessions and compulsions, there are plenty of things you can do to help yourself and
regain control of your thoughts and actions.

OCD obsessions and compulsions

Obsessions are involuntary thoughts, images, or impulses that occur over and over again in your
mind. You don’t want to have these ideas, but you can’t stop them. Unfortunately, these
obsessive thoughts are often disturbing and distracting.
Compulsions are behaviors or rituals that you feel driven to act out again and again. Usually,
compulsions are performed in an attempt to make obsessions go away.
For example, if you’re afraid of contamination, you might develop elaborate cleaning rituals.
However, the relief never lasts. In fact, the obsessive thoughts usually come back stronger. And
the compulsive rituals and behaviors often end up causing anxiety themselves as they become
more demanding and time-consuming. This is the vicious cycle of OCD.
Most people with OCD fall into one of the following categories:

 Washers are afraid of contamination. They usually have cleaning or hand-washing

compulsions.
 Checkers repeatedly check things (oven turned off, door locked, etc.) that they associate
with harm or danger.
 Doubters and sinners are afraid that if everything isn’t perfect or done just right
something terrible will happen, or they will be punished.
 Counters and arrangers are obsessed with order and symmetry. They may have
superstitions about certain numbers, colors, or arrangements.
 Hoarders fear that something bad will happen if they throw anything away. They
compulsively hoard things that they don't need or use. They may also suffer from other
disorders, such as depression, PTSD, compulsive buying, kleptomania, ADHD, skin
picking, or tic disorders.

OCD signs and symptoms

Just because you have obsessive thoughts or perform compulsive behaviors does NOT mean that
you have obsessive-compulsive disorder. With OCD, these thoughts and behaviors cause
tremendous distress, take up a lot of time (at least one hour per day), and interfere with your
daily life and relationships.
Most people with obsessive-compulsive disorder have both obsessions and compulsions, but
some people experience just one or the other.
Common obsessive thoughts in OCD include:

 Fear of being contaminated by germs or dirt or contaminating others

 Fear of losing control and harming yourself or others

 Intrusive sexually explicit or violent thoughts and images

 Excessive focus on religious or moral ideas

 Fear of losing or not having things you might need

 Order and symmetry: the idea that everything must line up “just right”

 Superstitions; excessive attention to something considered lucky or unlucky

Common compulsive behaviors in OCD include:

 Excessive double-checking of things, such as locks, appliances, and switches

 Repeatedly checking in on loved ones to make sure they’re safe

 Counting, tapping, repeating certain words, or doing other senseless things to reduce
anxiety

 Spending a lot of time washing or cleaning

 Ordering or arranging things “just so”

 Praying excessively or engaging in rituals triggered by religious fear

 Accumulating “junk” such as old newspapers or empty food containers

Obsessive Compulsive
Disorder (OCD) and
Perfectionism
Coping with Your Perfectionism with OCD
By Owen Kelly, PhD | Reviewed by Steven Gans, MD
Updated June 29, 2017

Has anyone ever accused you of trying to be better than perfect? Perfectionism alone
is difficult enough to cope with, but it's also long been thought to play a role in the
development and maintenance of obsessive compulsive disorder (OCD) and other
forms of mental illness. Let’s explore the relationship between OCD and
perfectionism.

What is Perfectionism?

Before we talk about perfectionism and OCD, it's important to define what is meant
by perfectionism. Perfectionism, to some degree, is beneficial for a person in society.
When contrasted with the alternative, perfectionistic tendencies are preferable to
"slob" tendencies. How can you know what is good (and not only good, but ideal) and
what is not? Research on perfectionism has indicated that there are two main types of
perfectionism:

 Adaptive/Healthy Perfectionism: This type of perfectionism is characterized

by having high standards for yourself as well as others, persistence in the face
of adversity, and conscientiousness. Healthy perfectionism usually goes along
with goal-directed behavior and good organizational skills.
 Maladaptive/Unhealthy Perfectionism: This type of perfectionism is
characterized by excessive preoccupation with past mistakes, fears about
making new mistakes, doubts about whether you are doing something correctly
and being heavily invested in the high expectations of others, such as parents or
employers. An excessive preoccupation with control is also a hallmark feature
of maladaptive/unhealthy perfectionism.
In general, while adaptive/healthy perfectionism tends to be associated with good
psychological well-being and high achievement both at school and at work,
maladaptive/unhealthy perfectionism has been associated with distress, low-self
esteem and symptoms of mental illness.

Obsessive Compulsive Disorder (OCD) Perfectionism

The unhealthy form of perfectionism has been strongly linked to obsessive

compulsive disorder (OCD.) Perfectionism appears to be particularly strong if you
have a strong need for things to be done “just right” or require certainty. For example,
unhealthy perfectionism tends to be very high if you feel that your compulsions have
to be done exactly the right way. In these cases, it is not uncommon to believe that if
the compulsion is carried out perfectly, a feared outcome, such as death of a loved
one, will not take place.

Likewise, unhealthy perfectionism tends to be high if your OCD symptoms revolve

around checking. Specifically, if you do not feel you have perfect certainty that you
have locked the door or turned off the stove, you might return to check these items
over and over again. Tied to this is the excessive fear of making a catastrophic
mistake, such as leaving the door open all day or burning down the house by leaving
the stove on. Ironically, checking over and over again reinforces the idea that you are
not perfect or possibly even "losing your mind." This can make you feel even worse
and less self-confident which, of course, sets you up to do more checking.

Finally, unhealthy OCD perfectionism may help to perpetuate obsessions. For instance,
like many people with OCD you might believe that you must have complete control
over your thoughts. As such, when a bizarre or distressing thought pops intrusively
into your mind, you label these thoughts as dangerous because they are out of your
control. This causes you to monitor the thought even more closely, which can help to
create an obsession.

Tips for Dealing with OCD Perfectionism

What can you do to cope with OCD perfectionism? The first step is to recognize OCD
in yourself as well as your perfectionistic tendencies. Talking with a therapist is an
excellent way to gain a greater understanding of your condition, and provides the
feedback needed as you work to reduce the impact on your life. There are a few things
which can work particularly well in coping:

 Learn Cognitive-Behavioral Techniques: Techniques such as cognitive

restructuring and behavioral experiments can be helpful in learning to
objectively evaluate the likelihood and/or consequences of making catastrophic
 or even minor mistakes. Cognitive therapy can also be a useful tool for
critically examining the beliefs we hold about ourselves and others.
 Practice Giving up Control: As part of cognitive-behavior therapy
and/or exposure and response prevention therapy, you may be asked to
participate in exercises designed to build your capacity to tolerate a loss of
control. This can involve being prevented from checking something or
adjusting something until it is "just right." Although this can initially be
extremely distressing, over time you will gain more confidence in your ability
to tolerate a loss of control.
 Adopt a Mindful Stance: Mindfulness emphasizes being less “invested” in our
thoughts. Accepting that we have less control than we think over our thoughts
can be very helpful in reducing the distress that often accompanies intrusive
thoughts. Mindfulness meditation exercises can help to promote a more
objective awareness of our day-to-day thoughts and emotions.

The Developmental Neurobiology of Repetitive Behavior

Veenstra-VanderWeele, in Neural Circuit Development
and Function in the Brain, 2013

Repetitive Behavior and Environmental Restriction

 Abnormal repetitive behaviors are considered sentinel
behaviors by applied ethologists signaling poor animal
welfare. This is not surprising as a wide variety of
species of animals housed in restricted or impoverished
environments (e.g., zoo, farm, and laboratory) exhibit
abnormal repetitive behavior (Mason and Rushen, 2006).
In fact, as Wurbel (2001) has pointed out, repetitive
behaviors are the most common category of abnormal
behavior observed in confined animals. Demonstrations
of the attenuation or prevention of repetitive behavior by
rearing animals in larger, more complex environments
(environmental enrichment) provide strong evidence for
the role of environmental restriction in the induction
of repetitive behavior. Early social deprivation as a
 special case of environmental restriction has been shown
to have powerful deleterious effects on humans and
nonhuman primates including the induction of
abnormal repetitive behavior (Carlson and Earls, 1997;
Mason and Rushen, 2006).
 The authors’ own work has involved an animal model
that falls under the category of repetitive
behavior associated with environmental restriction. In this
model, deer mice (Peromyscus maniculatus) exhibit
repetitive hindlimb jumping and backward somersaulting
as a consequence of being reared in standard laboratory
caging. These behaviors occur at a high rate, persist
across much of the life of the animal, and appear
relatively early in development, sometimes as early as
weaning. The authors have shown in several studies that
environmental enrichment markedly attenuates the
development and expression of the repetitive behavior.
This outcome was associated with biochemical and
morphological changes in basal ganglia circuitry (Lewis,
2004).

An Update on the Neurobiology of Repetitive Behaviors in

Autism
Benjamin E. Yerys∗§, in International Review of Research in
Developmental Disabilities, 2015

Repetitive behaviors are cardinal symptoms of an autism

spectrum disorder (ASD). They do not comprise a unitary set
of behaviors, which has long been confusing to clinicians and
researchers alike (Leekam, Prior, & Uljarevic, 2011).
Stereotypic behaviors, insistence on sameness in
routines and sameness in the environment, and circumscribed
interests are repetitive behaviors noted in the earliest reports
of ASD (Asperger, 1944; Kanner, 1943); however, recent
conceptualizations now include self-injurious behaviors,
compulsive behaviors, and hyper-/hyposensitivity to stimuli
(American Psychiatric Association & DSM-5 Task Force,
2013; Bodfish, Symons, Parker, & Lewis, 2000; Leekam et al.,
2011). While there are extensive reviews postulating the
neurobiology of repetitive behaviors based on animal models
(Langen, Kas, Staal, van Engeland, & Durston, 2011; Lewis &
Kim, 2009; Lewis, Tanimura, Lee, & Bodfish, 2007), the
reviews from the human literature are limited in their scope by
only including studies with “positive” findings (Langen,
Durston, Kas, van Engeland, & Staal, 2011; Leekam et al.,
2011; Turner, 1999).

Paranoid-schizoid position

Definition
The term 'paranoid-schizoid position' refers to a constellation of anxieties, defences and internal and
external object relations that Klein considers to be characteristic of the earliest months of an infant's life
and to continue to a greater or lesser extent into childhood and adulthood. Contemporary understanding is
that paranoid-schizoid mental states play an important part throughout life. The chief characteristic of the
paranoid-schizoid position is the splitting of both self and object into good and bad, with at first little or
no integration between them.

Klein has the view that infants suffer a great deal of anxiety and that this is caused by the death instinct
within, by the trauma experienced at birth and by experiences of hunger and frustration. She assumes the
very young infant to have a rudimentary although unintegrated ego, that attempts to deal with
experiences, particularly anxiety, by using phantasies of splitting, projection and introjection.

The infant splits both his ego and his object and projects out separately his loving and hating feelings (life
and death instincts) into separate parts of the mother (or breast), with the result that the maternal object is
divided into a 'bad' breast (mother that is felt to be frustrating, persecutory and is hated) and a 'good'
breast (mother that is loved and felt to be loving and gratifying). Both the 'good' and the 'bad' objects are
then introjected and a cycle of re-projection and re-introjection ensues. Omnipotence and idealisation are
important aspects of this activity; bad experiences are omnipotently denied whenever possible and good
experiences are idealised and exaggerated as a protection against the fear of the persecuting breast.

This 'binary splitting' is essential for healthy development as it enables the infant to take in and hold on to
sufficient good experience to provide a central core around which to begin to integrate the contrasting
aspects of the self. The establishment of a good internal object is thought by Klein to be a prerequisite for
the later working through of the 'depressive position'.

A different kind of splitting, 'fragmentation', in which the object and/or the self are split into many and
smaller pieces is also a feature of the paranoid-schizoid position. Persistent or enduring use of
fragmentation and dispersal of the self weakens the fragile unintegrated ego and causes severe
disturbance.

Klein considers that both constitutional and environmental factors affect the course of the paranoid-
schizoid position. The central constitutional factor is the balance of life and death instincts in the infant.
The central environmental factor is the mothering that the infant receives. If development proceeds
normally, extreme paranoid anxieties and schizoid defences are largely given up during the early infantile
paranoid-schizoid position and during the working through of the depressive position.

Klein holds that schizoid ways of relating are never given up completely and her writing gives the
impression that the positions can be conceptualised as transient states of mind. The paranoid-schizoid
position can be thought of as the phase of development preceding the depressive position as a defence
against it and also as a regression from it.

(source: http://www.melanie-klein-trust.org.uk/paranoid-schizoid-position)

The Maturing Value System of Concern for the

Other: The Depressive Position
Introduction:

Melanie Klein had a hard life in many ways. She lost a sister when she was four,
her father when she was eighteen, and a brother shortly thereafter. Klein had a
moderately troubled relationship with her mother. She had loved all of the family
members who died. When she was in her fifties, she lost a son to a mountain climbing
accident, and very likely struggled with a depression, and then wrote her two classic
papers on mourning and manic depressive states.

I have the impression that it was her own self reflections regarding these losses and her
reactions to them that led her to recognize how difficult it is for the human organism to
tolerate loving feelings and the precarious uncertainty that the loved object will go on
living. Thus the anxieties attendant to separation and loss, when added to the pains of
envy, jealousy, and guilt, make it a real effort to develop and sustain a capacity for
loving feelings.
So how do we ever develop a capacity for love in the first place? If we were to stay in
the idealized states of mind that populate the paranoid-schizoid position, we could avoid
guilt because we would not have to concern ourselves with the mistreatment of a bad
object who deserves whatever misfortune we dish out. We could also have love for the
ideal object as long as it meets our needs and avoids becoming a bad object. But it
would be a world of self-interest and narcissism, and any love that was present would
be of the infantile “commercial” type in which I do something for you and expect
something of commensurate or greater value in return.

What Klein observed was that infants seemed to undergo a change in the middle of the
first year of life. They began to demonstrate a capacity for concern about the welfare of
the other and not just think about themselves. This evolutionary development in the life
of an infant seems to go hand in hand with the infant’s blossoming recognition that the
mother he loves, when the infant feels his needs are being met, is the same mother that
he hates when he is frustrated, etc.

This leads to a realization that the hateful feelings that are meant to destroy or banish
the frustrating, bad mother are actually simultaneously doing harm to the good mother
that he loves. This causes fear of loss and guilt and mobilizes a desire to restore the
loving relationship to the loved, good mother. Klein beautifully describes this type of
situation in her 1929 paper “Infantile Anxiety-Situations Reflected in a Work of Art and in
the Creative Impulse,” which uses an operetta by Maurice Ravel to highlight these
states of mind.

Key Points of the Infant’s New Value System:

1 – This new developmental orientation is ushered in as a result of neuroanatomical

developmental capacities that are met simultaneously with a good enough
environmental provision (using Donald Winnicott’s terminology). This is to say that its
timing is linked to increasing cortical and especially frontal lobe capacity for pulling
disparate experiences together in an increasingly complex and organized manner.
However, some infants never achieve this level of integration so neuroanatomical
development by itself is not enough. Infants that have a more problematic environment
that includes ongoing deprivation and/or trauma stay more in a paranoid-schizoid mode
of functioning. To this mode, they add manic defenses that can be developed and used
to cope with mental pain as a result of the developing brain capacities.

2 – Klein’s Depressive Position represents the most advanced and desirable attitudes
about human relationships of which the human organism is capable. They, however,
can be elaborated and refined with age and experience. Simply put, this means caring
for others as well as oneself, and wishing to make amends when one has done harm to
the other.

The real problem is that human life is complicated. Ongoing learning and
neuroanatomical development doesn’t improve the child’s capacity for love. Instead, he
improves his capacity to cope with the emotional pains that are attendant to love, most
notable jealousy and guilt. Really, if one thinks about it, the increasing language skills,
etc. improve one’s ability to lie and misrepresent to oneself what one feels or has done.
As Wilfred Bion famously said, and I paraphrase, “Language is better suited to telling
lies than uncovering the truth.”

3 – All human beings would be savages were it not for the depressive position. This is
because the depressive position mobilizes the one emotion that stops mankind
from being barbaric – GUILT! I have always subscribed to the humorous saying that
“civilized man” is an oxymoron.

Unfortunately, as we will see when we talk about the manic defenses against
depressive anxiety, man uses his prodigious brain power more for evasion of mental
pain than for facing pain with a goal of dealing with it constructively. The fear of
punishment with the rule of law and guilt are really the only two things that keep our
infant selves from running amok.

As you can see, we cannot emphasize enough how important this step is in the infant’s
development and how guilt – when not excessive and unbearable – is the most valuable
motivation for constructive development because it is linked to love. I am always
amazed when I hear someone say that guilt is a bad emotion – wrong! Irrational guilt,
excessive guilt, misplaced guilt, etc. are all problematic, but guilt in itself is very
desirable in that mobilizes a desire to take care of someone we have hurt.

4 – Making proper repair of someone we have injured requires three basic things:

1) Taking ownership and/or responsibility for having injured the party with our own
behavior.

2) Acknowledging the full extent of the injury and its impact on the injured person.

3) Making one’s best effort to fully restore the injured party, if possible, to their pre-injury
state.

5 – In Kleinian literature, one finds regular reference to “depressive anxieties.” This is

fundamentally a reference to the depressive position and implies, in whatever context it
is being brought up, that the person at that moment is concerned about the welfare of
his good object and fears losing that object or doing harm to it. Depressive anxieties are
in the realm of mental health, and their reference usually implies a concern about
preserving one’s internal harmony and mental health.

These elements make for what Klein meant by “reparation.” It is the recognition of one’s
love for the object that makes the desire for repair so powerful. It will be this love – and
the guilt that it can mobilize – that will be assaulted by the ‘manic defenses’ against
depressive concern and anxiety.

Disruption of Depressive Position Development:

There are several points to be made here.

1 – Excessive mental pain in infancy overloads the infant’s capacity to tolerate the pain
and try to modify it. The infant is driven by this excess to evade the pain entirely, which
undermines development as he compels an excessive use of omnipotent maneuvers for
coping, usually in the form of denial and projection. By definition, these maneuvers are
not compatible with the attitudes of the depressive position where one is taking full
ownership of one’s mental pain.

2 – In theory, it is possible for development to fail to outgrow of the paranoid-schizoid

position. This would imply that the infant’s mindset remains concrete, tends toward
living in a black and white universe where shades of grey are not recognized, relies
excessively on projective processes, etc. Clearly, this is the world of limited thinking that
is so commonplace in prejudice and bigotry.

So while we can see elements of the paranoid-schizoid position, it is not really the same
as the original, normal developmental situation. The foremost reason for the difference
is the ensuing brain development that has occurred after the first few months of life. The
infant is no longer as limited in his awareness of external reality. He does not have to
simply face the pain of the damage or run away from it in a wholesale fashion.

The infant, with its increasing awareness of external reality, can now use a host of
maneuvers and tricks to avoid the full experience of guilt – thus ushering in the universe
of ‘manic defenses.’

3 – It is a useful assumption that regression back to the paranoid-schizoid position does

not take place after the middle of the first year of life. It is really a progression away from
the pains of the depressive position and on to the universe of manic defenses.

Bion is famous for his algebraic equation style of diagrams, one of the most familiar
being a capital “PS” and capital “D” with arrows going in both directions between them.
This is usually interpreted as representing a human personality going back and forth, in
progression and regression, between the paranoid-schizoid position and the depressive
position.

It’s unclear if Bion literally meant for it to be taken that way or if he meant that humans
go back and forth between facing reality with a caring attitude at times and running
away from reality with omnipotent, magical maneuvers at others. In any case, I believe
a more useful diagram would involve a capital “MD” and a capital “D” with arrows going
in both directions. This more accurately reflects what happens moment to moment with
humans in their daily lives.

In a moment when mental pain becomes greater than an individual can or will tolerate,
defensive maneuvers step in to address the situation in an omnipotent, magical manner.
In relation to the pain of guilt, these maneuvers are usually drawn from the arsenal of
the classic ‘manic’ maneuvers.

As we will see later, these will include bogus repairs of the damaged object without
taking proper emotional ownership of the damage done, so as to evade a full
experience of guilt. Klein gave this the apt name “manic reparation.” These maneuvers
include a classic group of attitudes toward the primary object that are aimed at avoiding
the depressive concern for the welfare of the object and attendant “depressive
anxieties.” This group of attitudes is summed up as the classic triad of manic defenses:
“Contempt, control, and triumph.”

While I will not go into them in detail just yet, these defensive maneuvers all involve an
alteration of one’s emotional and actual relationship to external reality and psychic
reality in order to deny the emotions of the depressive position. We could give this a
shorthand description by saying that “the manic defenses are aimed predominantly at
the denial of psychic reality.” [Note: See Manic Defenses in a following section.]

Summary of the Depressive Position:

The emotional and neuroanatomical growth of the infant, as he moves into the middle of
the first year of life, ushers in an extraordinarily important change in the infant. He
progresses from a value system of “self-interest” to a value system that now also
includes an equal measure of “concern for the other.” This is based on the infant’s love
for his primary objects.

As he realizes that he has only one mother – not two separate ones (i.e. good and bad),
and that the one he loves is also the one he hates and wishes ill toward when angry and
frustrated, the infant then develops a new attitude. This is based on the painful, but
healthy feeling of “guilt” for harming its loved object. This ushers in a new array of
“depressive anxieties,” in addition to guilt, that revolve around the fear of losing the
loved object. In combination they lead the infant to wish to repair the damage done and
restore his object to its good, pre-damaged state. Klein gave this urge to repair the
term “reparation.”

As the infant continues his development, he adds to his arsenal of maneuvers that
defend against mental pain. These importantly include new defensive maneuvers
against the particularly painful emotions of fear of loss of one’s loved object and of guilt,
both of which have a central role in the depressive position. Klein gave this constellation
of maneuvers the term “manic defenses.”

Manic defenses have as their hallmark the denial of psychic reality and include a
triumvirate of maneuvers: “Contempt, control, and triumph.” Simultaneously, the manic
defenses include a bogus version of reparation that evades guilt and is therefore called
“manic reparation.
(source: http://minnickskleinacademy.com/module-2/the-maturing-value-system-of-concern-
for-the-other-the-depressive-position/)

Paranoid-schizoid position[edit]
In object relations theory, the paranoid-schizoid position is a state of mind of children,
from birth to four or six months of age.
Melanie Klein[2] has described the earliest stages of infantile psychic life in terms of a
successful completion of development through certain positions. A position, for Klein, is
a set of psychic functions that correspond to a given phase of development, always
appearing during the first year of life, but which are present at all times thereafter and
can be reactivated at any time. There are two major positions: the paranoid-schizoid
position and the subsequent depressive position. The earlier more primitive position is
the paranoid-schizoid position and if an individual's environment and up-bringing are
satisfactory, she or he will progress through the depressive position.
The paranoid-schizoid position is considered the state of mind of children from birth to
four or six months of age. Although this position develops into the next position, it is
normal to move back and forward between the two positions although some people
operate in the paranoid schizoid position for much of the time. As one of the originators
of Object Relations theory, Klein sees emotions as always related to other people or
objects of emotions. Relations during these first months are not to whole objects but
only to part objects, such as the breast, the mother's hands, her face etc.
Paranoid refers to the central paranoid anxiety, the fear of invasive malevolence. This is
experienced as coming from the outside, but ultimately derives from the projection out
of the death instinct. Paranoid anxiety can be understood in terms of anxiety about
imminent annihilation and derives from a sense of the destructive or death instinct of the
child. In this position before the secure internalisation of a good object to protect the
ego, the immature ego deals with its anxiety by splitting off bad feelings and projecting
them out. However, this causes paranoia. Schizoid refers to the central defense
mechanism: splitting, the vigilant separation of the good object from the bad object.
Klein posited that a healthy development implies that the infant has to split its external
world, its objects and itself into two categories: good (i.e., gratifying, loved, loving)
and bad (i.e. frustrating, hated, persecutory). This splitting makes it possible to introject
and identify with the good. In other words: splitting in this stage is useful because it
protects the good from being destroyed by the bad. Later, when the ego has developed
sufficiently, the bad can be integrated, and ambivalence and conflict can be tolerated.
Later with greater maturity and the resolution of the depressive position, the ego is able
to bring together the good and bad object thereby leading to whole object relations.
Achieving this involves mourning the loss of the idealised object, and associated
depressive anxieties.
Klein described development as proceeding through two phases: the paranoid-schizoid
position and the depressive position.[3] In the paranoid-schizoid position, the main
anxiety is paranoia and hypochondria, and the fear is for the self.
When things are going well, the mother is experienced as an all benign figure. However,
inevitably when needs or desires of the young baby are not immediately met by the
mother, because she is not there to fulfill them, the absence of the good object is
experienced as the presence of the bad object.
The bad object is then hated and in phantasie it is attacked. The hated frustrating object
quickly becomes persecutory as it is imagined to get revenge in a similar way to how it
is being treated. This is why the baby feels persecuted, hence the "paranoid" in
paranoid schizoid.
As well as the bad (aggressive, hateful) parts of the self deriving from the death instinct
being projected onto the object, goodness is also projected onto the object. It is easier
to see why badness is projected outside the self rather than it being felt to be within. It is
more difficult to understand why goodness also may be projected out. The reason is
when the person does not feel that they can sustain goodness and it is safer for it to be
put into the object. This is the basis for idealisation, and it can be useful in certain
situations, e.g. idealising a surgeon who is operating.
The projection of badness into the object is the basis of racism, homophobia, or any
other irrational hatred of another group seen as (but essentially not being) different from
the self, e.g. estate agents, liberals, conservatives, cyclists, car drivers, single mothers,
Northerners, Southerners, traffic wardens, etc.
Over time the baby becomes more able to tolerate frustration and hold onto the good
object for increasing periods, enabling the baby to tolerate its own bad impulses without
fear that these will destroy it. This enables a more realistic view of the self and object as
possessing both good and bad attributes, leading to the greater integration and maturity
of the depressive position.
Klein emphasizes that the good and bad parts of the self are projected onto or into the
object. This represents the operation of the life and death drive, of love and hate.

Depressive position[edit]
Klein saw the depressive position as an important developmental milestone that
continues to mature throughout the life span. The splitting and part object relations that
characterize the earlier phase are succeeded by the capacity to perceive that the other
who frustrates is also the one who gratifies. Schizoid defenses are still in evidence, but
feelings of guilt, grief, and the desire for reparation gain dominance in the developing
mind.
In the depressive position, the infant is able to experience others as whole, which
radically alters object relationships from the earlier phase.[2]:3 “Before the depressive
position, a good object is not in any way the same thing as a bad object. It is only in the
depressive position that polar qualities can be seen as different aspects of the same
object.”[4]:37Increasing nearness of good and bad brings a corresponding integration of
ego.
In a development which Grotstein terms the "primal split",[4]:39 the infant becomes aware
of separateness from the mother. This awareness allows guilt to arise in response to the
infant’s previous aggressive phantasies when bad was split from good. The mother’s
temporary absences allow for continuous restoration of her “as an image of
representation” in the infant mind.[4]:39 Symbolic thought may now arise, and can only
emerge once access to the depressive position has been obtained. With the awareness
of the primal split, a space is created in which the symbol, the symbolized, and the
experiencing subject coexist. History, subjectivity, interiority, and empathy all become
possible.[5]
The anxieties characteristic of the depressive position shift from a fear of being
destroyed to a fear of destroying others. In fact or phantasy, one now realizes the
capacity to harm or drive away a person who one ambivalently loves. The defenses
characteristic of the depressive position include the manic defenses, repression and
reparation. The manic defenses are the same defenses evidenced in the paranoid-
schizoid position, but now mobilized to protect the mind from depressive anxiety. As the
depressive position brings about an increasing integration in the ego, earlier defenses
change in character, becoming less intense and allow increasing awareness of psychic
reality.[6]:73
In working through depressive anxiety, projections are withdrawn, allowing the other
more autonomy, reality, and a separate existence.[7] The infant, whose destructive
phantasies were directed towards the bad mother who frustrated, now begins to realize
that bad and good, frustrating and satiating, it is always the same mother. Unconscious
guilt for destructive phantasies arises in response to the continuing love and attention
provided by caretakers.
[As] fears of losing the loved one become active, a very important step is made in the
development. These feelings of guilt and distress now enter as a new element into the
emotion of love. They become an inherent part of love, and influence it profoundly both
in quality and quantity.[8]:65
From this developmental milestone come a capacity for sympathy, responsibility to and
concern for others, and an ability to identify with the subjective experience of people
one cares about.[8]:65–66 With the withdrawal of the destructive projections, repression of
the aggressive impulses takes place.[6]:72–73 The child allows caretakers a more separate
existence, which facilitates increasing differentiation of inner and outer reality.
Omnipotence is lessened, which corresponds to a decrease in guilt and the fear of
loss.[7]:16
When all goes well, the developing child is able to comprehend that external others are
autonomous people with their own needs and subjectivity.
Previously, extended absences of the object (the good breast, the mother) was
experienced as persecutory, and, according to the theory of unconscious phantasy, the
persecuted infant phantisizes destruction of the bad object. The good object who then
arrives is not the object which did not arrive. Likewise, the infant who destroyed the bad
object is not the infant who loves the good object.
In phantasy, the good internal mother can be psychically destroyed by the aggressive
impulses. It is crucial that the real parental figures are around to demonstrate the
continuity of their love. In this way, the child perceives that what happens to good
objects in phantasy does not happen to them in reality. Psychic reality is allowed to
evolve as a place separate from the literalness of the physical world.
Through repeated experience with good enough parenting, the internal image that the
child has of external others, that is the child's internal object, is modified by experience
and the image transforms, merging experiences of good and bad which becomes more
similar to the real object (e.g. the mother, who can be both good and bad). In Freudian
terms, the pleasure principle is modified by the reality principle.
Melanie Klein saw this surfacing from the depressive position as a prerequisite for social
life. Moreover, she viewed the establishment of an inside and an outside world as the
start of interpersonal relationships.
Klein argued that people who never succeed in working through the depressive position
in their childhood will, as a result, continue to struggle with this problem in adult life. For
example: the cause that a person may maintain suffering from intense guilt feelings over
the death of a loved one, may be found in the unworked- through depressive position.
The guilt is there because of a lack of differentiation between fantasy and reality. It also
functions as a defense mechanism to defend the self against unbearable feelings of
sadness and sorrow, and the internal object of the loved one against the unbearable
rage of the self, which, it is feared, could destroy the internal object forever.

 Klein, M. (1946). Notes on Some Schizoid Mechanisms. Int. J. Psycho-Anal., 27:99-

110.