1

Personality, psychopathology and health through the lens of interpersonal relatedness
and self-definition

Patrick Luyten, PhDa,ba

Faculty of Psychology and Educational Sciences, University of Leuven, Belgium
Research Department of Clinical, Educational and Health Psychology, University College
London, UKb

In press: Journal of the American Psychoanalytic Association

Contact address:
Patrick Luyten, PhD
University of Leuven
Tiensestraat 102 pobox 3722
3000 Leuven
Belgiume-mail: patrick.luyten@kuleuven.be2
Abstract
This paper reviews Sidney J. Blatt’s seminal contributions in the domain of personality
development, psychopathology, and health, which rank among the most well-researched andempirically supported psychoanalytic theories. Blatt is primarily known for his so-called twopolarities model of personality development, which argues that personality development
evolves through a dialectic synergistic interaction between two fundamental developmental
psychological processes across the life span–the development of interpersonal relatedness on
the one hand, and of self-definition on the other. Within this approach, psychopathology isviewed as an attempt to find a balance, however distorted, between relatedness and selfdefinition. Neurobiological research has confirmed the intrinsic and dialectic relationshipbetween the development of self-definition and relatedness in the development of the neuralcircuits subserving these capacities, which has also important implications for physicalhealth. Research relevant to each of these assumptions is reviewed, and the influence Blatt’s
approach has had on reintroducing the importance of psychodynamic factors in contemporary
psychology and psychiatry, including in DSM-5, is discussed.

3

Personality, Psychopathology and Health through the Lens of Interpersonal Relatedness
and Self-Definition

Faced with the task of providing a summary of Sidney J. Blatt’s extensive and monumental
contributions to our understanding of personality development in relation to mental andphysical health, spanning over 50 years of research, one can feel only trepidation. Yet, thebasic gist of his views on the relationships among normal and disrupted personality
development in relation to mental health can be relatively easy summarized and are
deceptively simple. Basically, Blatt assumed that personality development evolves through a
dialectic synergistic interaction between two fundamental developmental psychological lines
across the life span, that is, the development of interpersonal relatedness on the one hand andof self-definition on the other. Various forms of psychopathology are viewed within thisapproach as attempts to find a balance, however distorted, between issues of relatedness andself-definition, leading to a temporary or chronic excessive, distorted and often defensiveemphasis on one or the other of these two developmental lines.
In this paper, I briefly review the core assumptions of Blatt’s approach to normal anddisrupted personality development and the empirical basis of these assumptions. I also review
recently emerging findings demonstrating that the human capacity for interpersonal
relatedness and self-definition are closely intertwined at the neurobiological level. I discuss
the influence of disruptions of the dialectic interaction between relatedness and self-definitionon physical health, which appear to be primarily mediated through impairments in thedeveloping stress system and associated biological systems.

4
Blatt’s approach to normal and disrupted personality development
Although hundreds of empirical studies have led to further theoretical refinements of Blatt’s
formulations, demonstrating the progressive nature of the research program that was initiatedby these initial formulations (Lakatos, 1976), the basic assumptions of Blatt’s so-called twopolarities model of personality development appear to have withstood the test of time.
Consistent with basic psychoanalytic assumptions, for Blatt there is no neat distinction
between ―normal‖ and ―abnormal‖ or disrupted personality development (Blatt, 2008; Blattand Luyten, 2009; Blatt and Shichmann, 1983). His views also do not assume a neatdistinction between normal variations in personality development, ―symptom disorders‖, and―personality disorders.‖ As I will discuss in more detail later, mainstream psychology andpsychiatry have rediscovered the validity of both of these latter assumptions, and Blatt’s workin this context has had a profound influence, not least on the most recent formulations in
DSM-5 (American Psychiatric Association, 2013; Luyten and Blatt, 2015; Skodol and
Bender, 2009).
Briefly, Blatt viewed personality development as proceeding through a continuous
dialectic interaction between the capacities for interpersonal relatedness and self-definition—that is, the capacity to establish and maintain, respectively, (a) reciprocal, meaningful, andpersonally satisfying interpersonal relationships, and (b) a coherent, realistic, differentiated,and essentially positive sense of self or an identity (see Figure 1). Influenced by Anna
Freud’s concept of developmental lines (Freud, 1963), Blatt considered these two capacities
to be central to understanding both adaptive and disrupted human psychologicaldevelopment, and thus vulnerability to psychopathology.
As reviewed by Beebe and colleagues in this issue, from early infancy onward,
experiences of interpersonal relatedness—which include feelings of mutuality and gratifying
involvement, but also experiences of incompatibility, misunderstanding and separation—are5thought to contribute to the development of self-definition, which then in turn is expected tofoster the capacity for interpersonal relatedness, and vice versa (Blatt and Behrends, 1987).
Hence, human beings are seen as fundamentally interpersonal in nature. In Blatt’s view, evenour feelings of selfhood have their roots in experiences of mutuality as well as
incompatibilities and misunderstandings with others, typically beginning in interactions with
attachment figures. Influenced by object relations theory and attachment formulations, Blattviewed experiences of mutuality and incompatibility as instrumental in the need to develop
increasingly complex, differentiated, and integrated representations of self and others that
influence and guide beliefs and expectations about oneself, others, relationships, and theworld (Blatt, 2008).
From this perspective, both adaptive and disrupted personality are seen as modes ofadaptation that result from variations and disruptions in the synergistic interaction between
relatedness and self-definition throughout the life span (Luyten and Blatt, 2011). These
attempts to find a balance between relatedness and autonomy can be more or less adaptive forthe individual and/or his/her environment. According to Blatt (2008), the point of equilibriumthat is achieved between relatedness and self-definition depends on a complex set ofinteractions among psychological, sociological, cultural, historical, and biological factors (seeFigure 1). This leads individuals, even within the normal range, to place a somewhat greater
emphasis on one or the other of these dimensions. For instance, at least in Western cultures,
there would be a tendency for women to place somewhat greater emphasis on relatedness,while men would tend to place somewhat greater emphasis on self-definition. Withincollectivistic or interdependent cultures, relatedness would be valued more, while inindividualistic or independent cultures, self-definition is considered to be more normative(Kitayama et al., 1997; Markus and Kitayama, 1991; Triandis, 2001). Similarly, as reviewed
below, parenting styles have been shown to influence the development of a greater emphasis

6
on relatedness versus self-definition.
Blatt and colleagues (Blatt and Shichman, 1983) also used the term anaclitic to referto individuals whose personality organization was focused predominantly on interpersonal
relatedness. This notion was taken from the Greek anaklitos, meaning to rest or lean on, aterm that was used to refer to Freud’s (1905) description of individuals who have a strong
need to enter into relationships that rest on or lean on early experiences with caregivers, theso-called Anlehnungstypus der Objektwahl (―anaclitic object choice‖). The use of the notion
anaclitic was also inspired by Spitz’s (1945) description of a type of ―anaclitic depression‖,marked by feelings of lethargy and hopelessness, in infants who were separated from theirprimary caregiver(s) and who suffered emotional deprivation. In turn, Blatt and colleagues(Blatt and Shichman, 1983) used the term introjective to refer to individuals whose
personality organization primarily evolves around self-definition, building on Freud’s (1915)
notion that the self is developed through a process of introjection or identification withsignificant others.
Anaclitic and introjective personality styles are thus thought to reflect normal
variations within personality development, each with their particular experiential mode,
preferred forms of cognition, defenses, and adaptation, unique qualities of interpersonal
relatedness, and specific forms of object representation and self-representation (see Table 1).
Although these personality configurations represent normal variations, in the extreme,
they give rise to what consensually is defined as psychopathology. Yet, what is important isthat even the different forms of psychopathology that are distinguished within a given culture
cannot be considered to be static end-states but represent attempts to maintain a balance,
however maladaptive, between relatedness and self-definition. Psychopathology thus reflects
dynamic conflict-defense constellations (Luyten and Blatt, 2011; McWilliams, 2011).
According to Blatt, these maladaptive attempts at adaptation typically involve an excessive

7emphasis on one developmental line and the neglect of the other (Blatt, 2008), leading to a
distinction between anaclitic and introjective psychopathology. Anaclitic psychopathology
involves, at different developmental levels, a distorted and rigid, one-sided emphasis on
interpersonal relatedness; the development of autonomy and self-definition is defensively
neglected and/or avoided. Typical examples of anaclitic types of psychopathology include
schizophrenia, histrionic, dependent, and borderline personality disorders, and anaclitic
depression. In these disorders, relatedness is emphasized at the cost of the development ofautonomy and identity; excessive dependency on others is the common theme. Introjective
psychopathology, in contrast, is characterized, at different developmental levels, by adistorted and one-sided emphasis on self-definition; an excessive emphasis on the self andautonomy and the defensive neglect of relatedness is the common theme in these disorders.
Examples are paranoid schizophrenia and paranoid, obsessive-compulsive, self-criticaldepressive, and narcissistic personality disorders.
Finally, the more excessive the distorted and often defensive neglect of the other line,
the more the attempt at finding a balance is likely to fail, particularly in the longer term, andthe more it is associated with psychological costs for the individual and his/her environment.
As I will discuss in more detail below, recent extensions of the model have begun to outline
the biological costs associated with disruptions of the normal dialectic between relatedness
and self-definition, and their implications for physical health (Luyten and Blatt, 2013).
This so-called ―double helix theory of personality development‖ subsequently led tobroad-ranging research, particularly as similarities between Blatt’s views and those of otherprominent theorists across different theoretical orientations—ranging from philosophy topsychology and psychoanalysis—quickly became apparent (for a review, see Blatt, 2008).
Subsequent research has shown theoretical and empirical overlaps with similar theories that
propose that interpersonal relatedness and self-definition can be seen as central organizational

8features of personality development. In these theories, the respective dimensions have beenvariously referred to as surrender and autonomy (Angyal, 1951), communion and agency(Bakan, 1966; Pincus, 2005), affiliation or intimacy and achievement or power (McAdams,
1985; McClelland, 1985), relatedness and autonomy/competence (Deci and Ryan, 2012;
Ryan and Deci, 2000), attachment anxiety and attachment avoidance (Mikulincer and Shaver,2007; Sibley, 2007), and sociotropy and autonomy (Beck, 1983; Clark and Beck, 1999). Whatthese theories have in common is that they all propose that adaptive personality development
entails a balance between interpersonal relatedness and self-definition, whereas
psychopathology involves a temporary or chronic disruption of this balance (Luyten andBlatt, 2011). Within attachment theory, for instance, adaptive personality is conceptualized asa balance between relatedness and self-definition, as expressed in low levels of attachment
anxiety and avoidance (Mikulincer & Shaver, 2007). Insecure attachment styles, in turn, arethought to represent different types of imbalance between these dimensions. Avoidant
attachment, for instance, entails ―discomfort with closeness‖ and ―discomfort with depending
on others‖ (Mikulincer & Shaver, 2007, p. 87), representing an exaggerated emphasis on selfdefinition and a defensive avoidance of interpersonal relatedness. Attachment anxiety is
typically characterized by ―fear of rejection and abandonment‖ (Mikulincer & Shaver, 2007,
p. 155), representing an overemphasis on relatedness and a defensive avoidance of feelings ofautonomy and self-affirmation (i.e., self-definition).

From the clinic to the lab and backBlatt’s initial formulations were in part derived from his psychoanalytic experience withpatients, but they were also linked to his own life history (Blatt, 1974; Blatt, 2004).
Specifically, Blatt recounts how, in the treatment of two patients with depression, he wasstruck by the very different nature of the types of conflicts his patients were struggling with.

9
While the depressive experience of one of his patients seemed to primarily revolve aroundissues of relatedness, such as feelings of abandonment and rejection, the other patient seemed
to struggle mainly with issues related to self-definition, such as achievement, guilt, andcontrol. Blatt (2004) goes on to recall that while the depression of the second patient
resembled most closely the typical description of depression in much of 20th century
psychiatry, descriptions of the depressive experience of the first patient were, with some
important exceptions, remarkably absent from the psychoanalytic and psychiatric literature.
Yet, it reminded him of seeing his own father cry over his mother’s grave, seemingly feelingdesperate and abandoned. This experience, Blatt recounted, probably made him more awareof and attuned to depressive experiences related to feelings of abandonment and rejection,and thus it is likely to have influenced his theorizing about the importance of such
experiences.
What perhaps distinguished Blatt most from many of his contemporary
psychoanalytic thinkers and clinicians was that he decided to put his ideas and formulation to
the empirical test. Together with colleagues, he developed the Depressive Experiences
Questionnaire (DEQ) (Blatt et al., 1976). This 66-item self-report questionnaire was designed
to capture maladaptive expressions of relatedness, as evidenced in high levels ofDependency, and maladaptive expressions of self-definition, as captured by thequestionnaire’s Self-Criticism scale. Several other self-report measures assessing these
dimensions have emerged since (for reviews see Luyten et al., 2005; Zuroff et al., 2004), andmore recently, observer-rated scales of these dimensions have also been developed that
capture different levels of concerns with self-definition and relatedness at different
developmental levels. These include the Differentiation-Relatedness Scale (Diamond et al.,2011), the Prototype Matching of Anaclitic and Introjective Personality Orientation (Werbart
and Forsström, 2014), and the Anaclitic-Introjective Depression Assessment (Rost et al.,102016). Similarly, within interpersonal theories, various measures tapping into different facetsof relatedness and self-definition have been developed and validated (Locke, 2011), andattachment research has focused on interview-based measures, such as the Adult Attachment
Interview and the Child Attachment Interview, and experimental paradigms, including theStrange Situation (Ravitz et al., 2010).
A large body of research using these measures has provided evidence supporting themain assumptions of Blatt’s two-polarities model outlined above in understanding bothnormal and disrupted psychological development from childhood to adolescence andadulthood (for reviews see Luyten and Blatt, 2013; Luyten et al., 2005; Zuroff et al., 2004).
These views rank among the best-researched and -supported psychoanalytic theories, andhave also inspired much research on process-outcome relationships, as Blatt assumed thatsimilar processes were at work in psychotherapy as in normal human development (Blatt etal., 2010).
Overall, this research has shown the particularly destructive nature of self-criticism(Blatt, 1995; Shahar, 2015), while dependency seems to be much more of a double-edged
sword. Associations between self-criticism and psychopathology and psychological
functioning more generally are typically stronger for self-criticism than for dependency.
Studies suggest that this seems to be in large part due to the fact that highly
dependent/anaclitic individuals are able to develop and maintain, although often with much
ambivalence, supportive relationships with others, whereas highly introjective/self-criticalindividuals typically lack the capacity to turn to others—particularly in times of need. Thesefindings again appear to confirm Blatt’s intuition that human beings are fundamentallyinterpersonal, and that those individuals who show severe impairments in the capacity to turnto others in times of need (such as highly introjective individuals) often seem to fare11
particularly poorly in life, or at least pay a very heavy price for their inability to acknowledge
their connectness to others.
Studies have confirmed that high levels of dependency and self-criticism are both
associated with dysfunctional interpersonal transactional cycles (Kiesler, 1983), leading toexactly the behaviors and reactions by others that the individual fears and tends to avoid,which in turn strengthen the individual’s (distorted) expectations about him/herself andothers. Highly dependent/anaclitic individuals may be able to generate a positive social
environment, but their claiming relational style often leads to irritation, anger, and resentment
in others, which then may lead to actual rejection and abandonment, confirming these
individuals’ strong fear of being rejected and abandoned. Highly self-critical/introjective
individuals, by contrast, tend to be ambivalent, critical, and distrustful of others, because of
their fear of criticism and disapproval. Yet, this leads them to be perceived by others as cold,
distant, and aloof, which confirms the individual’s belief that others do not like them anddisapprove of them.
Studies based on Blatt’s assumptions have amply demonstrated the impact of thesedysfunctional transactional cycles on the nature of the therapeutic relationship andtherapeutic response (Blatt et al., 2010). Dependent/anaclitic and self-critical/introjective
individuals bring very different needs and expectations into therapy, and tend to perceive thetherapeutic relationship in personality-congruent ways. As demonstrated by systematic
research studies, the identification, articulation, and working through of these transference
reactions is crucial to establish a working alliance and for long-term change. Studies in thiscontext, consistent with Blatt’s assumptions, suggest that patients primarily preoccupied withissues of relatedness are responsive mainly to supportive dimensions in therapy. In contrast,
patients primarily preoccupied with issues of self-definition are more responsive tointerpretive–exploratory dimensions (Blatt et al., 2010). In this view, successful treatment,

12
regardless of the type of treatment, involves the reactivation of a normal synergistic
developmental process in which interpersonal experiences in the therapeutic relationship, as
in normal personality development, foster feelings of autonomy and self-definition, which inturn foster interpersonal relatedness.
It is important to point out that problems with relatedness and self-definition thus aretransdiagnostic vulnerability factors that are implicated in vulnerability for psychopathology
across the life span (for reviews, see Blatt, 2008; Blatt and Luyten, 2010; Egan et al., 2011;
Zuroff et al., 2004). These personality factors thus explain, at least in part, the notable
heterogeneity within and across different disorders. For instance, in depressed patients, atleast four subtypes have been distinguished based on these views: individuals with clinicaldepression falling within a higher-functioning, less maladaptive, anaclitic Needy Depression
and introjective Self-Critical Depression prototype, versus clinically depressed patients
falling into two lower-functioning, more maladaptive, anaclitic Submissive Depression andintrojective Dismissive Depression prototypes (Rost et al., 2016).
Similarly, studies suggest that personality disorders can be organized into a cluster
focused around issues of relatedness (an ―anaclitic‖ configuration) and a cluster focusedaround issues of self-definition (an ―introjective‖ configuration) (Blatt and Luyten, 2010).
The DSM dependent, histrionic, and borderline personality disorders typically fall into theformer cluster, while the antisocial, narcissistic, paranoid, schizoid, schizotypic, avoidant,
and obsessive-compulsive personality disorders typically fall within the second cluster. Thesefindings have influenced proposals for a radical change in the way personality pathology isorganized and assessed in DSM 5 and subsequent editions, emphasizing the centrality ofinterpersonal relatedness and self-definition in understanding and classifying personality
disorders (Bender et al., 2011)

13
Studies based on two-polarities models have also increased our understanding of theintergenerational transmission of vulnerability for psychopathology, suggesting that
disproportionate concerns with issues of relatedness and self-definition are transmitted fromone generation to the next. This has been demonstrated in studies of children as young as 4months (Beebe et al., 2007) to studies focusing on adolescents (Soenens et al., 2010). A study
by Besser and Priel (2005) in a community sample even showed that excessive preoccupation
with relatedness and self-definition was transmitted from mothers to their daughters andgranddaughters. Further evidence for the intergenerational transmission of preoccupation
with relatedness and self-definition has emerged from attachment research (Verhage et al.,2016).

Two polarities of experience, biology, and health
Consistent with Blatt’s emphasis on the synergistic interaction between relatedness and selfdefinition, neurobiological research has suggested considerable overlap in the neural circuitry
involved in social cognition with regard to the development of relatedness and the self
(Lombardo et al., 2010).
Neural circuits involved in the capacity for relatedness primarily consist of amesocorticolimbic dopaminergic reward circuit and hypothalamic-midbrain-limbicparalimbic-cortical circuits (Fonagy et al., 2011; Panksepp, 1998; Swain et al., 2007; Vrticka
and Vuilleumier, 2012). Key neuromodulators in these circuits, including neuropeptides suchas oxytocin and vasopressin, seem to be involved in the rewarding features of affiliative
behaviors (ranging from parental care to pair-bonding and sexual behavior), in social
cognitive capacities underpinning relationships, and in the regulation of behavioral andneuroendocrinological responses to stress (Neumann, 2008). Specifically, secure attachment
experiences seem to reinforce affiliative behavior, resulting in ―broaden and build‖14(Fredrickson, 2001) cycles: broadening results from the fact that secure attachment
experiences encourage explorative behavior; building, in turn, results from the fact that
attachment relationships are the ―playground‖ where skills and resources are developed.
Hence, in normative development, experiences of relatedness are intrinsically related to thedevelopment of feelings of autonomy, competence, and identity (Fonagy and Luyten, 2009;
Fredrickson, 2001; Mikulincer and Shaver, 2007). By contrast, disrupted development isassociated with a disturbance in the dialectic interaction in the development of neural circuits
involved in the processing information about self and others.
These assumptions are further reinforced by findings that neural circuits involved inreflecting on the self and others are closely intertwined. These circuits include cortical
midline structures such as the medial prefrontal cortex, posterior cingulate, precuneus, andtemporoparietal junction (Lieberman, 2007; Lombardo et al., 2011; Lombardo et al., 2010;
for a meta-analysis, see Northoff et al., 2006).
Consistent with these assumptions, there is now good evidence from research in bothhumans and animals that attachment experiences play a key role in programming thedevelopment of the hypothalamic–pituitary–adrenal axis, the main human stress system thatis underpins our capacity to deal with conflict and adversity, and in associated biologicalsystems such as the immune system and pain-processing systems (Lupien et al., 2009a;
Luyten et al., 2013; Sbarra and Hazan, 2008). These early programming effects are currently
thought to be implicated in explaining vulnerability not only to psychiatric but also tofunctional somatic and somatic disorders across the life span (Lupien et al., 2009b).
Consistent with these views, research has shown how both highly self-critical/introjective andhighly dependent/anaclitic individuals are more prone to develop a host of functional somatic
problems and disorders, with most of the evidence again being for the role of self-

15
critical/introjective features (Luyten et al., 2013; Shahar, 2015). Disruptions in stressregulation and associated biological systems have been shown to mediate these relationships.

Conclusions
In contrast to more static symptom- or disorder-centered approaches, Blatt’s two-polarities
model fundamentally proposes that psychopathology reflects attempts to achieve somestability in response to developmental disruptions by becoming preoccupied, at different
developmental levels, with one or the other of the developmental dimensions of interpersonal
relatedness or self-definition (Blatt, 2008; Luyten et al., 2012).
Although Blatt’s views have gone through a series of reformulations over the years,
the basic formulations of his two-polarities model continue to provide a productive
theoretical, empirical and clinical framework in conceptualizing continuities between normal
and disrupted personality development, vulnerability for psychopathology, mental andphysical health, and responsiveness to psychotherapy. Above all, they also demonstrate theability of psychoanalytic thinking to influence mainstream psychology and psychiatry
because of its dedication to systematic empirical research, while at the same time being
solidly rooted in psychoanalytic theory and experience.

16
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