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