Depression has multiple, sometimes conflicting features and may have multiple foundations such as illness, injury, helplessness, hibernation, familial loss, and social rejection among other possibilities. The social rejection aspect and its experiential counterpart called "rejection sensitivity" (RS) deserve special attention because of new pharmacologic tools and the impact of these tools on our culture.
Shunning and exclusion from the group are perhaps universally powerful controls on individual conduct. It makes sense (an illusory phrase in EP!) that a species, with neither claws, fangs, nor great strength but depending on group cooperation for survival, would have some physiological mechanisms for ensuring cohesion. Thus, our parents likely huddled together at first for warmth and later for cooperative success with child protection, property management, and hunting. Oddballs were cold at night and did not eat so well or were perhaps eaten themselves.
It is plausible that some regulatory mechanisms appeared early to make group demands possible and to ensure that individual members conformed to them. It also makes sense that a neurohumor, serotonin, originally associated with digestion and temperature regulation, could also serve newer systems mediating acceptance, bonding, and rejection sensitivity.
RS is a summary term for expectations of criticism by or ridicule from other people or a sense of being not quite so good nor so valuable as others. There is often a hesitancy to be assertive, to make new friends, or to try new activities. Kramer (Listening to Prozac, 1993) focused on the tentative, anxious, overly inhibited traits that erode the lives of many people who become more assertive when they take a selective serotonin reuptake inhibitor (SSRI). RS describes: (1) An enduring personality characteristic that escorts us from childhood through adult life. This cluster may be relatively unchanging for many people. It can be a pervasive weakness, when combined with anxiety, that leads to disorganization, fear, and inhibition during transitions and disagreements. In some personalities, it can be the foundation for jealousy, excess striving for approval, and even aggression towards a loved one who's loyalty is doubtful.1 Even the traditional self-regulator known as "guilt" and its externalized component, "shame," are reliably attenuated by an SSRI! (2) A class of behaviors and feelings amenable to treatment with SSRIs such as fluoxetine (Prozac), sertraline (Zoloft), or paroxetine (Paxil). (3) Many psychological feelings that appear to be identical to poor self esteem. If so, then self esteem could represent a general cluster of beliefs that is more quickly responsive to certain medications than to counseling, psychotherapy, and support groups. RS groups a range of thoughts and actions into a unit because they vary together in response to a common treatment, an SSRI. "Low self esteem" and RS describe similar attitudes and behaviors. Indeed, the overlap is so great that the terms might be used interchangeably. Treatment implications, however, are different because of social custom. Low self esteem often entails supportive counseling whereas RS (and "depression") may elicit treatment with an SSRI. Careful thought suggests, however, that a key element of supportive counseling is that of not giving the client messages of rejection. The two approaches, behavioral and pharmacological, address identical client needs but in different ways.
Because of health care costs, our cultural demands for temporal efficiency, higher population density, and a more transient lifestyle, there is a major shift in treatment from "giving hugs" to "take a pill." Hugs are ancient, comforting, and expected but unlikely in a transient culture. (Hugs are even proscribed now from ministers as well as psychologists; nearly anyone is allowed to hug a sad person except for those who are paid to do it.) However, recommending medication for fear-of-exclusion can appear to be an affirmation of that exclusion. "You don't care about me, you just want me to take a pill." Medication can also be a tool for a critical partner to use on one who has a stripe of RS in their psyche ... "I know I'm right; after all, you're the one on medication" or, "Did you take your pill?" in the middle of an argument.
Sagan & Druyan (1992) quote Sewall Wright to the effect that genetic diversity (and long-term adaptability) is most strongly associated with relatively small groups (10-100) of individuals who are geographically isolated from similar groups but periodically make trips outside of home to find a mate. This tribal arrangement could have been our most recent plateau of evolutionary growth and the context within which many of our social mechanisms (adaptive systems) were refined.2
Kramer, P. (1993) Listening to Prozac. New York: Viking.
Barkow, J., Cosmides, L., Tooby, J. (Eds.) (1992) The adapted mind: Evolutionary psychology and the generation of culture. Oxford: New York.
Sagan, C. & Druyan, A (1992) Shadows of Forgotten Ancestors. New York: Random House.