BOOK FORUM
tween infant and mother for the development of self-regula-
tory processes. The work of Bowlby and others on attachment
is integrated with neurobiological findings. In particular, the
function of the right prefrontal cortex, parent-infant commu-
nication, and attachment disorders are discussed in detail.
When available, functional magnetic resonance imaging find-
ings are included. Section 2, Developmental Neuropsychiatry,
discusses predispositions to psychiatric disorders. Separate
chapters review how brain development, affect regulation,
and health might be affected by 1) a secure attachment, 2) re-
lational trauma, and 3) eventual affect dysregulation.
We have several suggestions for the next edition. First, we
would like to see case examples to apply the information, in-
terweave the presented theories, and “spell out” the concepts
in a more relevant manner. This change would make it more
readable and more directly applicable clinically. Second, the
chapters could benefit from a standardized format, with an in-
troduction, objectives, background information, and a sum-
mary of key points. This change would also make it more use-
ful as an educational text. Third, in this complex discussion of
the intersection of many fields and particularly neuroscience,
it is surprising that few figures or tables are used to help the
reader. Finally, particular emphasis is placed on the relation
between structure and function of the right hemisphere dur-
ing critical stages of development. Unfortunately, supporting
neurobiological evidence is weak (e.g., regarding the specific-
ity of abnormal development of the right prefrontal cortex),
and original references are sometimes overinterpreted. This
pitfall, however, surely reflects the paucity of neuroanatomical
information on the normal development of the primate brain.
This is an interesting, useful integration of data from many
fields—all intersecting in the areas of attachment, affect, and
pathology—that makes it a very unique reference for clini-
cians who want to explore the theoretical underpinnings of
these areas. It is an ambitious work written by a knowledge-
able author. It is already good, but with the changes noted it
would be outstanding in a second edition.
References
1. Schore AN: Affect Regulation and the Origin of the Self: The
Neurobiology of Emotional Development. New York, WW
Norton, 1994
2. Schore AN: Affect Regulation and the Repair of the Self. New
York, WW Norton, 2003
DONALD M. HILTY, M.D.
BLYTHE A. CORBETT, PH.D.
PIERRE LAVENEX, PH.D.
Sacramento, Calif.
Experiences of Depression: Theoretical, Clinical, and
Research Perspectives, by Sidney J. Blatt. Washington,
D.C., American Psychological Association, 2004, 400 pp.,
$49.95.
Working in the Yale Psychology Department, Sidney Blatt
has tenaciously pursued a formulation of depression for more
than 30 years. This book captures his journey and charts the
development of the model from personal sources (early wres-
tling with Freud’s “Mourning and Melancholia” [1] and ana-
Reprints are not available; however, Book Forum reviews can be downloaded at http://ajp.psychiatryonline.org.
1400 http://ajp.psychiatryonline.org
lytic observations), through years of applied research, to this
proposal of an integrated model.
The model argues for two types of depression but is not the
classic binary (i.e., endogenous versus neurotic/reactive) one.
In essence, Blatt argues for developmentally determined “an-
aclitic” or dependent depression (where the depressed indi-
vidual’s preoccupations involve themes of abandonment and
loss) and “introjective” depression (typified by punitive and
harsh self-criticism), with differential developmental factors
creating the shared vulnerability to depression. As acknowl-
edged by Blatt, the model overlaps with views of other theo-
rists, including Bowlby and Beck (the latter used concepts of
“sociotropy” and “autonomy”).
The model is multilayered. The two types are held to reflect
developmental disturbances in early parent-child relation-
ships, frame the experiential world of those who develop de-
pression, involve a stress-diathesis congruency model linking
contextual stressful events with depression onset, direct
treatment approaches, and allow “depression” to be modeled
parsimoniously. The last issue is perhaps the most worrisome
plank in Blatt’s argument. Arguing first that depressive sub-
typing has failed to be achieved by use of symptoms and that
“depression” is a continuum ranging from “transient dyspho-
ric” responses to “serious distortions of reality” (p. 29), Blatt
then argues for his dichotomous model as providing a “major
subtyping of depression” that is both reliable and has “dem-
onstrated validity” (p. 30). Such claims are not supported by
appropriately designed or definitive analyses. Reviewed anal-
yses seek to affirm the model rather than refine it by refutabil-
ity studies.
Where are the twin studies to consider the genetic and en-
vironmental contribution to such personality styles? Why two
constructs as against at least four factors of the Big Five
model? Is “anaclitic” not a component domain of neuroticism
and, as measured, weighted to the well-researched but here
essentially ignored facet of rejection sensitivity? If Blatt’s con-
tinuum model is valid, how necessary and sufficient are the
constructs to distinguish psychotic from melancholic depres-
sion as well as the depressions experienced by psychology
students from those of resilient control subjects? In chapter 8
(“Therapeutic Implications”), how does the model extrapo-
late to the world of clinical psychiatry (e.g., the perfectionistic
individual with a psychotic depression)? Here it would appear
that psychotherapy is viewed as necessary and sufficient.
There can be little doubt that developmental experiences
and personality styles increase the risk to certain depressive
disorders, shape the clinical picture to some degree, and have
some differential impact on varying treatment modalities,
and that Blatt’s contribution to developing such a matrix has
and will continue to be distinctive. However, his exposition in
this book posits the model as all-explanatory and has Pro-
crustean overtones.
Reference
1. Freud S: Mourning and melancholia (1917 [1915]), in
Complete Psychological Works, standard ed, vol 14. London,
Hogarth Press, 1957, pp 243–258
GORDON PARKER, M.D., PH.D., D.SC.
Sydney, Australia
Am J Psychiatry 162:7, July 2005