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In his paper Kanzer not only points out something of which we have become increasingly aware, that the concept of the ego was present very early in Freud's thinking and writing but also that the concept of splitting of the ego was there early as a form of ego alteration or structural modification with attendant impaired functioning as a result of the institution and failure of defence mechanisms. In extreme instances the splitting and alteration of the ego can be accompanied by alterations of the representations of the ego and the object, resulting in delusional formations.
Kanzer's paper supplements Anna Freud's contribution to the Congress theme of acting out (pp. 165–170), in which she stressed that the return of the repressed, the pressure of the id for drive satisfaction, particularly if the quantitative relations are such that the token gratification offered by the transference does not satisfy them, may seek gratification in action instead of producing memories which can be analysed. She emphasized that what appeared in the transference was not the id derivative but the ego attitude, or ego alteration which appeared originally in the attempt to cope with the drive