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The emergence of a relational perspective in psychoanalytic thought suggests the need for new paradigms of symptom formation. In addition, biopsychosocial data on the etiology of a number of specific disorders have been accumulating. Self psychology is proposed as a relational model of psychopathology that can be incorporated into a biopsychosocial paradigm of symptom formation for Axis I disorders.
Four specific pathways to symptom formation are outlined. The first consists of a self-state of impending fragmentation that is then warded off through involvement with a substance or activity, as in addictive disorders. The second denotes a state of fragmentation without a behavioral means of self-restitution other than avoidance, seen in anxiety disorders. The third involves the use of a symptom as a compromise formation among conflicting impulses as a result of psychological trauma, as in dissociative and somatoform disorders. In the final pathway that I outline, symptoms such as depressive states and work inhibitions result from an internalized conflict between maintaining needed relationships and pursuing self-differentiation. Both internal conflict and developmental deficit are central in the genesis of symptomatic disorders.