The broad variety of clinical psychoanalysis situations includes a range of forms of pathogenic anxiety, reviewed by Gabbard . Freud, Melanie Klein, Winnicott, and Kohut have all dealt with the topic, and this is clearly not the place to attempt a summary. However, while supporters of the "conflict theory," including Freud and Klein, have worked to define the intrapsychic facets of anxiety, the "deficit theory," upheld by thinkers like
Winnicott and Kohut, focuses more on the relational aspect of worry and anxiety . As Mitchell and Black point out , Sullivan considered maternal anxiety a fundamental reference point in the child's development, forming a "good me," "bad me," or "non-me" depending on the mother's reactions.
Freud  saw anxiety mainly in relation to weakening of repression, under the impact of instincts. The ego emits an anxiety signal as libidinal and destructive impulses emerge from the id, incompatible with the dictates of the super-ego.
Melanie Klein  laid particular stress on the early, terrifying anxiety resulting as the constitutional destructive potential, the death instinct, emerges in the child's mind. This anxiety sets up unconscious processes of affirmation of a perfect, omnipotent identity, with denial of the internal destructive impulse, splitting off of the dangerous aspects and projection of these components onto family members, objects of the outside world, or the person's own organs. The targets of this projective identification become dangerously destructive in the mind of its author, who is not aware of the process, but who "expels" them from his mind, and they subsequently set in motion persecutory or hypochondriac anxieties. According to Klein, however, these identification processes do not change their "containers," except in the mind of the person making the identification.
Klein always considered the relation between subject and object fundamental to development and instinctual vicissitudes, though mainly in the person's internal world. Only Bion  believes the "container" of the identification is strongly influenced emotionally, and responds on the same level of exchange, or by processing the events so as to return them to the sender in better shape.
Klein [41, 42] maintains that during good development, gratifying experiences at the breast and with the mother figure as a whole, by fostering the primacy of libidinal aspects, enable the child to re-introject the "expelled" destructiveness in a way that facilitates its integration. However, this process of taking possession once more involves guilt feelings and depressive suffering, as the child becomes "conscious" of his own destructive impulses.
A stage of persecutory anxiety is then followed by a phase of depressive anxiety, linked to the fear of being overwhelmed, along with one's significant figures, by the destructive facets of the impulse. The encounter with the risk of losing a loved object arouses the instinct to repair the damage produced in the imagination, so as to rebuild self-confidence and the bond, as a sign of love and care. If something arises to stop this pro gression, for instance, excessive aggression causing intolerable frustration, the child risks regressing to the paranoid-schizoid position, or may present manic-depressive symptoms, where denial of the destruction alternates with despair for the loss of the bond. Failures during development are fixation points from which the child can subsequently regress when faced with fresh hurdles.
Once past the paranoid-schizoid and depressive phases, a person can find themselves later in a paranoid-schizoid or depressive position in any situation that revives memories of the past circumstances. This permits further work on mourning for one's own ideal identity and that of the idealized love objects, allowing re-affirmation of love of oneself and one's objects, though the gratification is always accompanied by the frustration of aspirations toward omnipotence.
Briefly, therefore, Freud and Klein defined mainly the vicissitudes of the internal, fantasy world, and Winnicott and Kohut spent more time on actual relations and the external reality of mothering. Today we can try to combine these two approaches in a unified vision that takes account of clinical experience related to the theories of conflict and deficit. A proposal put forward by Otto Kernberg  contains material derived from Kleinian theory regarding the world of internal relations, against a solid background of relational reality. Stephen Mitchell  also aims to overcome the traditional dichotomy.
Here I want to look at two major forms of anxiety: paranoid and depressive. Klein gave good descriptions of the internal aspects of mental conditions strongly linked to survival: fear of predators, of violent attack from outside, and of being abandoned by caring figures. These events can certainly cause the death of immature creatures, not just in a child's imagination. Such events actually happen in the outside world, though they can be imaginary too, and can trigger internal fear, anger and defenses very similar to those Klein describes as purely internal phenomena.
There is no point in digressing into a full exploration of the stages of development set out by Klein, but Balint  and then Bleger  and Ogden  all proposed changes to Klein's theory. Balint and Bleger defined stages of development prior to the Kleinian paranoid-schizoid phase: Balint went for primary love and Bleger for the "glischro-carica" position or agglutinate nucleus, a residue in the mind of early experiences of fragmentation and nonintegration. Ogden's strategy, on the other hand, flanks the contiguous-autistic position with the classic Kleinian paranoid-schizoid and depressive positions in a view that alternates the three conditions, or sometimes runs them simultaneously.
These are fascinating evolutionary themes but here I shall simply stress the importance, in clinical theories, of an overall view of the external and internal worlds, considering that they are inseparable in phylogenesis and ontogenesis, entwined functionally for the acquisition of the knowledge essential to survival.
According to Mancia [48-50], fear and anxiety stored in the emotional and affective implicit memory can to some extent become independent of external references that might trigger them. These memories, however, exert a constant pressure on a person's conscious psychic life and on the declarative memory, even if they are not formulated verbally and cannot easily be called up voluntarily. As Mancia points out, in psychoanalysis these nonthinkable, nonsymbolic emotional levels tend to surface in nonverbal form, in the tones and rhythms of the voice, and the structure of the language, more than the content of what the patient is saying. Dreams and the transference are other gateways through which they can irrupt in analysis. Mancia considers this level of memory as part of an unrepressed unconscious that may contain traumatic experiences. These presymbolic features, manifested in the "musicality" of the patient's language in the transference and through the figurative and symbolopoietic aspects of the dream, can thus be defined in explicit, conscious terms.
Paranoid and depressive anxieties may be powerful signals of unconscious affects in the psychoanalytical relation, sending the transference in a certain direction. The fear of being attacked or abandoned by the analyst, once dependence has set in, will influence the style of the relationship, particularly the negative side of the transference. If these processes can be shared and worked through together it will be much easier to integrate them and overcome the problem.
There may well be anxieties dating even farther back than those described by Melanie Klein: Gabbard  speaks of "disintegration anxiety" to describe this very early terror of losing one's own integrity if the fundamental relation is threatened by internal or external vicissitudes or if the line between the self and the object becomes blurred, creating a risk of merging with the other significant figure.
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