Isr J Relat Sci Vol 44 No. 4 (2007) 292–300

The Blatt and the Cloninger Models of and their Relationship with

Ada H. Zohar, PhD

Behavioral Sciences Department, Ruppin Academic Center, Emek Hefer, Israel.

Abstract: This paper presents in brief the Blatt and the Cloninger theories of personality and their relationship to de- pression and to psychopathology. Each of the theories is described, the theoretical foundations of the theory are pre- sented, the theory’s view on personality stability, on the relationship between personality and psychopathology, the theory’s efficacy at predicting depression from personality measures, the theory’s explanation for sex differences in de- pression, the measures derived from the theories, and theory productivity. The paper concludes with an analysis of commonalities of, and points of disagreement between the two theories.

The choice to present and juxtapose Blatt and Depression (2004; 1), and on Cloninger’s book, Feel- Cloninger arises from a deep appreciation of both ing Good (2004; 2). theories, both new and integrative in their ap- proaches. The two theories arose in different con- texts, and in different disciplines. The Blatt theory is The Blatt Model of Personality and known mainly to psychoanalysts, clinical psycholo- Depression gists, and research psychologists with interests in de- pression and in development. The Cloninger theory Model description is known mostly to psychiatrists, and to psycholo- The Blatt model of personality posits that individu- gists and researchers who are interested in the inter- alsdevelopalongtwodimensions:thatofinterper- face between biology and behavior. There is little sonal relationships and that of identity and self interaction between these different theoretical ap- definition. The dimension of interpersonal relation- proaches; and yet the theories are different enough to ships begins with the infant’s relationship with his provide interesting contrasts and surprising com- mother and extends over the whole lifespan, though monalities. The Blatt theory originated before the the internal representation of the mother forged in Cloninger theory, but the two are currently used and infancy wields a central and enduring influence on studied without an opportunity for argument be- future relationships and their representations. The tween the two. self-enhancing aspect of the interpersonal dimen- Both Sidney Blatt and Robert Cloninger are pro- sion is intimacy and connection, and the downside is lific researchers and writers, and have given rise to a a sense of loneliness, helplessness and extreme wealth of work by others, who have examined their neediness which is difficult for others to alleviate. ideas, as well as the applications and implications of The second dimension is self-definition. It is very ac- their theories. Both are in the full swing of their sci- tive in the second year of life, and is greatly affected entific careers. This short paper does not attempt to by the emergence of the superego. Like the interper- give a complete and comprehensive presentation of sonal dimension, it is also a lifespan developmental theirwork.Rather,itshouldbeviewedasanattempt vector. The self-enhancing aspect of the self dimen- to summarize, analyze and compare some of the cur- sion is a sense of identity, of purpose and of achieve- rent, central features of both corpuses of work, ment. The downside is extreme self-criticism. The which are relevant to the issue of the relationship be- ascendancy of one of the two dimensions in any indi- tween personality and psychopathology. This dis- vidual’s life at a point in time may depend on internal cussion relies mostly on Blatt’s book, Experiences of and on external events. The dimensions are not part

Address for Correspondence: Ada H. Zohar, PhD, Behavioral Sciences Department, Ruppin Academic Center, Emek Hefer 40250, Israel. E-mail: [email protected]; [email protected] ADAH.ZOHAR 293 of an individual’s consciousness but have tremen- ria for major depressive disorder (MDD) and, vice dous power over the individual’s feelings, cognitions, versa, patients diagnosed according to the medical actions and life. model with MDD would probably be experiencing For individuals whose development is more in- profound depressive experiences of either depend- vested in the interpersonal dimension, well being is ence or self criticism. associated with issues of relatedness and depend- A second source of inspiration is developmental ency. They may be particularly vulnerable to subjec- psychopathology. Thus in Blatt’s personality model tive experiences of loss and separation. For early development and early representations are of individuals who are particularly invested in the self greatimport,butdevelopmentisviewedasanongo- dimension, well being is associated with a sense of ing process, which does not stop in early childhood, achievement, approval and freedom from inferiority andcanbeseenandinfluencedinadulthood.Itisthe and guilt. They are likely to be particularly vulnera- meeting of the person at his particular developmen- ble to perceived failure or criticism. As both dimen- tal stage with the demands reality imposes that will sions are active dimensions of development for all determine the emotional outcome. individuals, at any point in time individuals can be The Blatt theory is enriched by the wealth of de- characterized by the extent to which they are in- velopmental research, and integrates the cognitive vested in one or the other. stages described by Piaget and his students into the Psychopathology may arise when the challenges scoring of the internal representations of parental an individual faces overwhelm his or her resources, figures. primarily because the internal representations do Last but not least, there is a strong positivist sci- not lend the individual the support necessary for entific approach, so that any proposition in or arising adaptive response. The personality constellation (de- from the Blatt theory is expected to be examined and pendence and self-criticism) also shapes the individ- supported empirically. Because of this strong scien- ual’s experience and affects his or her perception of tificcomponent,theBlatttheoryofpersonalityis life events. constantly being tested, revised and refined. This feature distinguishes Blatt’s work from that of many Theoretical underpinnings psychoanalytic theorists, whose theory is mainly There are several different sources of inspiration for held up to standards of internal consistency and Blatt’s theory. First and foremost there is psychoana- therefore is unlikely be challenged, refuted, or sub- lytic theory, beginning with the work of Freud, and stantially changed. encompassing many of the psychoanalysts who fol- lowed him. It is implicit in the psychoanalytic point Stability of personality of view that depressive symptoms as described in the Personality according to Blatt’s view is always being DSM are of no clinical or theoretical interest. Behav- influenced and formed by the individual’s life experi- ioral symptoms are viewed as epiphenomena that are ences and according to his internal representations, neither specific to depression, nor universal to all pa- which are mostly stable though potentially trans- tients with depression, and are thus an idiosyncratic formable. Thus in adolescence there might be an as- expression of deeper structures. These deeper struc- cendance of the Self-criticism dimension around tures are considered to be of theoretical and clinical issues of identity and values, and ascendancy of the importance since they can be traced to early experi- Dependency dimension around peers and romantic ence, bared in the process of analysis, and changed, relationships. These might change form and empha- to produce a more adaptive, developmentally appro- sis in adulthood depending on the choices an indi- priate inner structure that will afford resilience in the vidual makes and the events of his life. Stability is face of adversity. In this context it is important to enhanced by the internal representations which are point out that while Blatt does not accept the validity formed early and are slow to change. of the medical model, patients who experience deep experiences of depression according to Blatt would Prediction of depression probably qualify by symptom count as meeting crite- Blattwasnotintentonprediction,ratherondescrib- 294 BLATT AND CLONINGER MODELS OF PERSONALITY AND THEIR RELATIONSHIP WITH PSYCHOPATHOLOGY ing, explaining and laying down the guidelines for ef- transactional process with the environment in which fective analysis or psychotherapy. Repeatedly, the those high in dependence seek social-emotional sup- dimensions of dependency and self-criticism have port and are vulnerable to rejection engendered by been found to be correlated with depressive neediness and clinging, while those high in self-criti- symptomotology. There is little evidence that they cism evoke emotional distance, suspicion, criticism directly predispose individuals to contract depres- and rejection which in turn amplifies self-criticism. sion. The prospective studies available suggest com- This approach is similar to the behavior-genetic de- plex interactions between self-criticism and scription of how genotypes construct their own envi- dependency, with other personality dimensions, ronments (10) but in Blatt’s description is free of any with psychosocial events, with age, development and genetic or biological undertones. gender (3, 4). However, high scores on self-criticism and de- Accounting for sex differences in depression pendency are not specific to depression, and have The Blatt theory is not committed to account for the been found to be associated with other disorders. So- results of epidemiological studies estimating the cial phobia but not panic disorder is associated with prevalence of disorders according to the medical high levels of self-criticism (5, 6). Speranza and col- model, be it the DSM-IV or the ICD-10, since it is leagues (7) found self-criticism and dependency to the depressive experience and not the behavior or be elevated in young women with eating disorders symptom count that need to be addressed. However, over the levels found in controls. In addition the there are suggestions that since women tend to be women diagnosed with bulimia were more self-criti- more dependent and interrelated than men, they will cal than those diagnosed with anorexia. Speranza be more vulnerable to psychosocial events of loss, and colleagues conclude that adverse early experi- whilemenwhotendtobemoreorientedtowardthe ences shaped the self-criticism and dependence of self, achievement and recognition will be more vul- these women and that these structures were not ex- nerable to events of perceived failure, criticism or plained by current levels of depression. A study of a humiliation. This is explained in psychodynamic- clinical sample of adolescents showed that developmental terms: little girls must shift their af- intrapersonal psychosocial events were associated fection from mother to father, thus making them with introjective, self-critical depression in adoles- vulnerable to the sensation of dependence and loss; cent schizophrenics, and interpersonal events with little boys must shift their identity from mother to fa- anaclitic dependent, needy depression in adolescents ther, thus making them vulnerable to threats on their with personality disorders (8). Self-criticism was as- sense of identity and self (1, pp. 226–227). So while sociated with more lethal suicide attempts and these the Blatt theory does suggest a qualitative differ- were more likely to be precipitated by an intra- ence in the experience of depression for men and psychic event, while dependence was associated with women, it does not explain the sex-ratio of preva- less lethal suicide attempts, which were more likely lence. It should be stressed that the Blatt theory al- to be precipitated by interpersonal events and to lows for women to experience self-critical have a function of communicating unhappiness to depression and for men to experience dependent de- others (9). pression; the dimensions are sex typical rather than Blatt (1, chapter 7) points out that relating to de- sex restricted. pendence and self-criticism as diathesis and to rele- vant life events as stressors is not completely Measuring personality and psychopathology supported by empirical research. While individuals The Blatt personality theory has yielded a wealth of high in dependence are more vulnerable than others measures, all self-reports, which have been shown to to interpersonal events of loss and separation, there have excellent psychometric properties and interest- is much less support specifically for events of failure ing applications First there is the depressive experi- or criticism triggering depression in individuals high ence questionnaire (DEQ), which was generated by in self-criticism. Blatt concludes that dependence collecting descriptions given by patients with de- andself-criticismarebestseenaspartofa pression, and reducing them to scales via factor anal- ADAH.ZOHAR 295 ysis. After replication and pruning out low-loading representations informs his description of best prac- items, 66 items remained which reduced to three tice. A good example is the re-analysis of the NIMH scales: dependence (later sub-divided into related- study data of the relative efficacy of various short ness and neediness) self-criticism and efficacy (11). treatment approaches to depression (13). In the A version for adolescents was also developed, the study (14), 239 patients meeting criteria for MDD DEQ-A (12). Both measures have excellent psycho- were treated at one of three sites, and randomly allo- metric properties and have been repeatedly used in cated to one of four 16-week-long treatments: brief studies of personality, depression and other disor- cognitive behavioral therapy (CBT), brief interper- ders. sonal therapy, imipramine and clinical management, In addition, a scoring system was developed by and placebo and clinical management. Zuroff and Blatt and his colleagues (1, chapter 3) for a short free- Blatt (13) showed that for patients tending more to form parental description called the Object Rela- dependency, the quality of therapist-patient alliance tions Inventory (ORI). This short written descrip- formed in the beginning of the therapeutic relation- tion is scored on three dimensions. The first, Conceptual Level, is scored on a 9-point scale, from ship was a good predictor of outcome. The self-criti- sensorimotor-preoperational in which the descrip- cal depressed patients tended not to form trusting tion relies mainly on the gratification or frustration relationships with their therapists and tended not to the other provides, to the highest conceptual level in profit as much from any form of treatment. How- which the description integrates appearance, behav- ever, over successful therapy, an important measure ior and internal dimensions of the other. The second, of improvement was the level of the internal repre- Differentiation-Relatedness dimension, is scored on a sentations that evolved in parallel to the develop- 10-point scale from the lowest level where the basic ment of the therapeutic relationship and allowed not sense of integration of the representation is lacking, only recovery but successful termination of therapy to the highest in which the self and the other are de- and maintaining the therapeutic gain over time. scribed in reciprocal and integrated relation with an These conclusions from the re-analysis of the NIMH appreciation of the complexity of the relationship. data are a good example of the open and mutual rela- The third, Qualitative-Thematic dimension, evalu- tionship between Blatt’s research and clinical prac- ates 12 potential attributes of the parental represen- tice. For successful therapy with self critical tation: affectionate, ambitious, malevolent- depressed patients, it would be necessary for the benevolent, cold-warm, constructively involved, in- therapist to identify the special transaction of the self tellectual, judgemental, negative-positive, nurturant, critical individual with others, and to address this punitive, successful, strong-weak, each on a 7-point mode of relating. scale, as well as the length of the description. This part of the ORI has been reduced via factor analysis to four major scales: benevolence, punitiveness, am- Theory productivity bition, and length of description. The ORI has excel- Blatt has collaborated widely, with colleagues in the lent psychometric qualities, has been validated in a United States, Canada, Israel, and elsewhere. This variety of clinical and non-clinical samples, and has collaborative approach, together with a long career been extended for use for respondents who are pre- school. in the Yale Department of Psychiatry, teaching and supervising professionals, has established genera- Clinical implications tions of researchers and practitioners well immersed Blatt, like Cloninger, is a practicing clinician, seeing in the Blatt approach and measures that have pro- patients and training professionals. His research and duced a large corpus of work. It is an influential the- clinical practice are profoundly connected. His un- ory, and has been a central contribution to the derstanding of the major dimension (dependence or discussion of personality development and self-criticism) around which the patients concerns psychopathology in the latter half of the 20th century are clustered and the level of his internal parental and the first decade of the 21st. 296 BLATT AND CLONINGER MODELS OF PERSONALITY AND THEIR RELATIONSHIP WITH PSYCHOPATHOLOGY

The Cloninger Biopsychosocial Model of This cube has as its eight corners all binary combina- Personality tionsofhighandlowcharactertraits,butcanalsobe considered together with the four temperament Model description scales to produce a complex and unique description The Cloninger biopsychosocial model of personality of each individual, a Temperament and Character is two-tiered. The first tier of the model is tempera- Inventory (TCI) profile (15). ment and the second character. Both temperament and character traits are considered to be by nature Theoretical bases continuous and are partitioned into high and low The descriptive medical tradition as exemplified by only for descriptive purposes. Temperament traits Kraepelin (16) suggests that disordered personality are the genetically influenced, un- or pre-conscious is the basis for the development of schizophrenia. automatic response biases that characterize the indi- This connection between personality, personality vidual and are related to individual differences in disorder,andaxisIdisordersisabasictenetofthe brain organization and function. Four temperament Cloninger model. traits are posited. Harm Avoidance (HA) which in- For the first tier of the model, temperament, be- cludes anxiety, pessimism, and shyness versus risk- havioral genetic research showing that there is a ge- taking, optimism and outgoingness, and is related to netic influence on personality traits as well as on serotonin inhibitory activity in the brain. Novelty psychopathology is central. In its turn, the genetic Seeking (NS) includes impulsivity, irritability and implications of the Cloninger model have been sub- disorderliness versus rigidity, stoicism and orderli- jected to extensive empirical research and have re- ness and is related to dopaminergic excitatory brain ceived robust validation. activity. Reward Dependence (RD) is sociability, ap- A third influence is the Washington University proval seeking and warmth, versus aloofness, de- psychiatric tradition that demands that every patient tachment and coldness. Persistence (P) is stability have a primary diagnosis that explains all or most of and dedication to achievement versus instability and presenting symptoms, rather than an array of co- lack of ambition. RD and P are posited to relate to morbid conditions. This requires a profound under- norepinephrine brain activity. The four tempera- standing of course and cause and effect in the devel- ment traits are independent and all combinations of opment of the various presenting complaints. the four are theoretically possible. The fourth theoretical emphasis is on quantita- In contrast to temperament, character is more tive rather than on qualitative measurement. Thus mature and conscious, and relates to the way in rather than making dichotomous judgements, diag- which individuals self-govern. Character guides the nostic decisions are based on continuous quantita- individual in resolving emotional conflicts. It evolves tive data. as the individual with his particular temperament profile develops in his familial, non-familial, social Stability of personality and cultural environment. Three character traits are The biopsychosocial model of personality maintains posited. Self Directedness (SD) is the executive func- that there is overriding stability of personality tion and includes responsibility, purpose, resource- throughout life, with changes in temperament or fulness, self acceptance and discipline at one pole character traits contributing to buildup of and blame, aimlessness, ineptitude, vanity and lack psychopathology under certain circumstances. It of discipline at the other. Cooperativeness (CO) is also contends that the first tier, temperament, is less the legislative function and includes helpfulness and changeable than the second tier, character. Tempera- empathy versus hostility and aggression. Self-Tran- ment is predicated on genetic and biological sub- scendence (ST) is the judicial function and includes strates, and reflects individual differences in brain imagination and originality versus control and mate- function and structure; character is the result of the rialism. The three character traits, like the four tem- transaction between the individual and his environ- perament traits are orthogonal and can thus describe ment, and thus temperament is more stable than a three-dimensional space, the personality cube. character. ADAH.ZOHAR 297

Personality and psychopathology Personality Questionnaire (TPQ) seems to provide a general vulnerability profile which is common to The Cloninger biopsychosocial model of personality many disorders; though powerful and universal it is does not focus on psychopathology, and in fact the nothighlyspecific. Cloninger book on which this paper is based is titled In addition, the model as operationalized by the “Feeling Good” (2). However, the Cloninger theory TCI has been found to predict non-psychiatric med- suggests that there are at least three possibilities for ical outcomes. For example, the temperament di- explaining the systematic relationship between per- mension of Persistence powerfully predicts sonality and psychopathology. If a personality con- reduction in body mass index (BMI) following lap- figuration is strongly associated with a certain aroscopic gastric banding a year after surgery in disorder and predates it, the personality configura- morbidly obese patients (22). tion may be a risk factor, predisposing an individual to respond to the stress and challenges he faces by Accounting for sex differences in depression developing the disorder. On the other hand, the per- There are repeated findings that women are more sonality configuration may be presyndromal, a man- harm avoidant than men, and less likely to seek nov- ifestation of the disorder predating the appearance of elty (23). These sex differences in temperament may the aggregation of symptoms that meet criteria for place women at greater risk for depression and for AxisIorAxisIIdiagnosis.Athirdpossibilitythatthe other disorders than men. It is also consistent with biopsychosocial model allows for is that both the the biopsychosocial model that genetic and hor- personality configuration and the disorder are mani- monal factors influence the sex-ratio in depression. festations of a common underlying cause or morbid- ity. There are potential personality configurations Measuring personality and psychopathology that are systemically related to most Axis I and Axis The biopsychosocial model has given rise to two II disorders, so the description of personality is very self-report measures, the Tri Dimensional Personal- comprehensive and can potentially predict any ity Questionnaire (TPQ) and the Temperament and psychopathology, including depression. Character Inventory (TCI) which includes the TPQ and extends it. The TPQ is made up of 100 items, all Prediction of depression self-descriptions which are answered either yes or The Cloninger biopsychosocial model of personality no. The items are designed to measure the three orig- is a powerful predictor of depression. In a large com- inally conceived scales of harm avoidance, novelty munity study (15) high HA and low SD contributed seeking and reward dependence each of which is to the initial level of depression in predicting the subdivided into subscales measuring related con- onsetofmajordepressionayearlater.ChangeinHA, structs. The TPQ has been translated into many lan- SD and RD over a 12 month timeframe added signif- guages, and has been shown to have high internal icantly to the prediction of depression. Altogether, consistency and test-retest reliability in a wide range initial level of depression, initial HA and SD and of cultures, languages, in clinical and non-clinical changes in HA and SD accounted for over 50% of the samples. The validity of the TPQ has been shown variance in depression in that period. In addition, in against clinical diagnosis, and by the positive associ- a treatment of depression study, changes in TCI pro- ations found between high and low activity alleles of files from pretreatment measurement to a month target genes whose products are important in the into therapy predicted favorable outcome of therapy, synthesis of neurotransmitters, or in the receptors, while no changes in TCI profiles were detected in the transporters or degraders of neurotransmitters. In patients with poor treatment outcome (17). many studies, personality tests that were designed to However,highHAandlowRDandNScontrib- measure similar constructs to those measured by the ute also to the prediction of many other disorders, TPQ did not yield positive associations in behavior including anorexia nervosa (18), obsessive-compul- genetic studies, while the TPQ did. For example, sive disorder (19), schizophrenia (20), and Cluster A Harm Avoidance (HA) temperament scale, hypothe- Axis II disorders (21). Therefore, the Tridimensional sized to be associated with the inhibitory action of 298 BLATT AND CLONINGER MODELS OF PERSONALITY AND THEIR RELATIONSHIP WITH PSYCHOPATHOLOGY serotonergic synapses, has been associated with al- dependency, self-criticism and internal representa- leles of the serotonin transporter gene, and a recent tions, or in terms of a TCI profile. meta-analytic review of 24 studies found this associ- Both approaches favor self-reports as a means of ationtoberobustwhenHAwasmeasuredbythe assessing personality. Beyond the obvious expedi- TCI, but not when using other personality measures ence of self-reports, the implication of relying on (24). The TCI includes the 100 items of the TPQ, but self-reports is placing trust in human self-knowledge also measures the second tier of the theory, charac- andhonesty.Peoplemustknowagreatdealabout ter. In all it includes 250 items that are self descrip- themselves, about their response biases, preferences tionsansweredwithayesorano.TheTCIhasbeen and behavior, to be reliable sources. translated into many languages, and found to have Both approaches include a strong scientific posi- excellent internal consistency and test-retest reliabil- tivist approach, and are thus potentially refutable. ity in many different languages, cultures and con- Rather than weaken the standing and influence of texts. It has been validated against other personality these theories their empirical positivist approach has measures such as the Rorschach (25), the MMPI made them the subject of clinical and research inter- (26), the NEO-PI, and against clinical diagnoses of est and given them salience over other less refutable personality disorders (27). It is the most widely used theories. measure of personality in biological psychiatry, in Both approaches favor a quantifying approach to behavior genetic studies, and is also used in many description over typing or dichotomizing. The idea studies of treatment efficacy. of classifying individuals into types is ancient, arising in India about 5,000 years ago in Ayurvedic medicine Theory productivity (29), and in Greece about 4,000 years ago (30), and The biopsychosocial model has produced a large has always been part of the scientific discourse. It is corpus of work and inspired many clinicians and re- essentially different from the trait used searchers. While for years twin and adoption studies by Blatt and Cloninger. Both Blatt and Cloninger can showed that considerable variance in personality describe a potentially unique profile for each indi- could be attributed to additive genetic influence and vidual; typology reduces all individuals into dichoto- to genetic epitasis, the first molecular genetic find- mous classes, e.g., “MDD” or “not MDD.” ings date from the use of the TPQ and the genetic hy- Last but not least, both approaches lend them- potheses derived from the biopsychosocial theory selves to clinical and research needs. Both ap- (28). Cloninger has traveled and collaborated widely proaches could only have been articulated by and generously and there are teams of clinicians and individuals who themselves are immersed in clinical researchers worldwide that have been inspired by his practice as well as in research, and can easily move work and have used the biopsychosocial theory and back and forth between clinical and research dis- its measures to resolve clinical or research questions. courses. There is no doubt that the biopsychosocial theory is one of the most productive and influential in the last decade of the 20th century and in the first decade of Points of Disagreement the 21st century. Blatt and Cloninger can be seen as representing two opposing sides in the important argument over the DSM and the validity of the medical model. This ar- Commonalities of the Blatt and gument has been going on for at least 100 years, since Cloninger Theories the days of Kraepelin (16) and possibly longer. The Both approaches see a continuum of human experi- medical model treats psychiatric illness as a medical ence between normal and pathological, between illness. It is thus essential to describe the symptoms normal personality and psychopathology. This that make up the syndrome, the natural course of the makes their theories applicable to all, high function- syndrome, its prevalence and known risk factors. It ing individuals and extremely compromised individ- could be argued that without such an objective mea- uals can be described either in terms of their surable description no knowledge can be accumu- ADAH.ZOHAR 299 lated about best practice. The Blatt counterargument 2. Cloninger CR. Feeling good. New York: Oxford Uni- would be against the validity of the medical model: it versity, 2004. may be precise and provide excellent inter-judge reli- 3. Henrich CC, Blatt SJ, Kuperminc GP, Zohar AH, Lead- ability, but there is no ontological basis for the phe- beater BJ. Levels of interpersonal concerns and social functioning in early adolescent boys and girls. J Pers nomena described. Depression is an experience Assess 2001;76:48–67. rather than a behavior or set of behaviors. It is true 4. Shahar G, Gallagher EF, Blatt SJ, Kuperminc GP, Lead- that in many cases there are parallels between experi- beater BJ. An interactive-synergetic approach to the as- ence and behavior, but not in all. Therefore, the most sessment of personality vulnerability to depression: crucial information for best practice is the subjective Illustration using the adolescent version of the Depres- experience of the patient current and past, and the sive Experiences Questionnaire. J Clin Psychol 2004; internal representations that shape his experiences. 60:605–625. A central disagreement between Cloninger and 5. Cox BJ, Rector NA, Bagby RM, Swinson RP, Levott AJ, Joffe RT. Is self-criticism unique for depression? A Blatt concerns Nature vs. Nurture. Cloninger be- comparison with social phobia. J Affect Disord 2000; lieves that there is considerable genetic influence on 57:223–228. personality and psychopathology, Blatt rejects the 6. Cox BJ, Fleet C, Stein MB. Self-criticism and social evidence as inconsistent and weak, and posits mainly phobia in the US national comorbidity survey. J Affect a transactional process between the individual and Disord 2004;82:227–234. his environment with extra potency to early experi- 7. Speranza M, Atger F, Corcos M, Loas G, Guilbaud O, ence. Stephan P, Perez-Diaz F, Halfon O, Venisse JL, The conscious choices that build character and Bizouard P, Lang F, Flament M, Jeammet P. Depressive are crucial to the values and behavior of the adult are psychopathology and adverse childhood experiences in childhood disorders. Eur Psychiatry 2003;18:377– much more important in the Cloninger theory than 383. in the Blatt theory. According to the Blatt theory, un- 8. Zalsman G, Posmanik S, Fischel T, Horesh N, Gothelf conscious internal structures and representations are D, Gal G, Sadeh A, Weizman A, Apter A. Psychosocial the potent motivators of adult behavior. situations, quality of depression and schizophrenia in adolescents. Psychiatry Res 2004;129:149–157. Choosing between the theories? 9. Fazaa N, Page S. Dependency and self-criticism as pre- dictors of suicidal behavior. Suicide Life Threat Behav The Blatt and Cloninger theories are different 2003;33:172–185. enough in their goals, premises, and scope to make 10. ScarrS,McCartneyM.Howpeoplemaketheirownen- the choice between them unfruitful. Under these vironment: A theory of genotype greater than environ- conditions, it is probably more constructive to sug- ment effects. Child Dev 1983;54:424–435. gest using them for different purposes and circum- 11. Zuroff DC, Quinlan DM, Blatt SJ. Psychometric prop- stances. 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