I concluded my previous post on the “Prozac debate” by noting that Aspazia (whose views I was criticizing) presents her case in three online posts (”This Is No Mother’s Little Helper“, “The Psychopharmacological Hedonist’s Orthodoxy“, and “The Autonomy Enhancer“), and that the relationship between the arguments made in the three segments was unclear to me.
Aspazia’s since informed me that her project has changed quite a bit in the two years since these pieces were posted, as would be expected with a work in progress. It would, therefore, be unfair be unfair to construe them as representing her views.1 Nonetheless, some of the claims she makes in “The Autonomy Enhancer” in particular are interest to me, and I will be responding to them in this post. There’s a second reason why my remarks here should be construed more as my own ruminations than as an examination of Aspazia’s views: she breaks off right where she gets to what (IMO) is the most interesting part: how the concept of “rejection-sensitivity” emerged out of Donald Klein’s original diagnostic label of “hysteroid dysphoria.”
With those caveats issued, on y va.
In “The Autonomy Enhancer”, Aspazia tells us:
Kramer helps sell this “postmodern” feminism-this elixir for a “masculine” self-determination in his chapter on “Sensitivity.” I want to point out two moves that Kramer makes in this chapter: (1) he offers up a new mental health diagnosis facilitated by Prozac interactions on “needy” women and then, (2) names this diagnosis “rejection-sensitivity,” which, I will argue, deemphasizes gender.
We can analyze this as consisting of the following five claims:
- There is such a thing as “postmodern” feminism.
- Kramer promotes (”sells”) postmodern feminism, particularly in Chapter 4 of Listening to Prozac.
- He does so by creating a new mental health diagnosis.
- This new diagnosis is “facilitated by Prozac interactions on women.”
- The name given the new diagnosis, “rejection-sensitivity,” deceptively deemphasizes gender, by ignoring its conceptual history in the earlier concepts of hysteria and hysteroid dysphoria.
Let’s take this piece by piece.
THIRD WAVE FEMINISM?
According to Aspazia,
Second-wavers-”modern” feminism-want to create a world that taught their daughters to see themselves as powerful and capable as men are, while the new style-”postmodern” feminism-is too impatient for this work, and opts for personal enhancement drugs that more effectively transform the female self into a powerful and autonomous self.
She refers here to two books - Jacquelyn Zita’s Body Talk: Philosophical Reflections on Sex and Gender and Jonathan Metzl’s Prozac on the Couch — which I need to read before I can address this topic in an informed manner (I’ve requested them at the library.) But ignorance seldom stops me from sounding off, so: Aspazia’s language here seems to imply, not merely that the use of personal enhancement drugs can be seen as compatible with “post modern feminism,” but that:
There is a political/cultural/social movement, self-described as “third-wave feminism”, “postmodern feminism” or “postfeminism,” and the use of psychoactive medications to enhance personal autonomy is a major part of that movement’s avowed program or ideology.
This seems to me plainly false. As for “third wave feminism,” I can’t say it’s a term that occurs in my lexicon frequently. But in an effort to inform myself, I just did a Google search on the phrase and and read through some of the stuff on the topic that’s on the Web. My immediate somewhat snarky response is: Fine. But why do y’all need to call yourselves a movement (or alternatively, to label yourselves with an “-ism?”) And nothing I saw made a single reference to prescription medications.
And since I’m skeptical that third-wave feminism has anything to do with medication, I don’t see that Kramer helps “sell” it. (You can call him a shill for the drug companies if you want, but not for any variety of feminism.)
A NEW DIAGNOSIS?
Aspazia alleges that rejection-sensitivity is a “new diagnostic category” cooked up by Peter Kramer.
First, by Kramer’s own account, it’s abundantly clear that if anyone deserves the credit or blame for the concept, it’s Donald Klein, not Peter Kramer.
As for the status of rejection sensitivity as a diagnostic category, let’s turn to page 421 of DSM-IV-TR:
Unlike the other atypical features, pathological sensitivity to perceived interpersonal rejection is a trait that has an early onset and persists throughout most of adult life. Rejection sensitivity occurs both when the person is and is not depressed, though it may be exacerbated during depressive periods. The problems that result from rejection sensitivity must be significant enough to result in functional impairment. There may be stormy relationships with frequent disruptions and an inability to sustain a longer-lasting relationship. The individual’s reaction to rebuff or criticism may be manifested by leaving work early, using substances excessively, or displaying other clinically significant maladaptive behavioral responses. There may also be avoidance of relationships due to the fear of interpersonal rejection. Being occasionally touchy or overemotional does not qualify as a manifestation of interpersonal rejection sensitivity.
Whoever thought it up, the term seems to have entered the standard lexicon of psychiatric practice. (Yes, DSM-IV was only released in 1994, the year after the publication of LtP; but it was in the works long before then.)
(BTW, any readers who’re wondering “What’s DSM?” might want to take a look at this informative New Yorker article.)
Granted, as a symptom rejection sensitivity has wandered all over the map of possible ailments that it’s supposed to be a symptom of. The passage just cited is from the description of the Atypical Features Specifier for Mood Disorders. But atypical depression does not occur as a distinct diagnosis in DSM-IV’s predecessor, the 1980 DSM-III (although the term was certainly around by then.) Instead, the following is one of DSM-III diagnostic criteria for Avoidant Personality Disorder:
A: Hypersensitivity to rejection, e.g., apprehensively alert to signs of social derogation, interprets innocuous events as ridicule.
(p.324)
However, the folks who revised DSM-III in 1987 to create DSM-III-R inform us:
The DSM-III concept of Avoidant Personality Disorder was essentially social withdrawal due to hypersensitivity to interpersonal rejection. It was distinguished from Schizoid Personality Disorder by the presence of a desire for affection and acceptance. The DSM-III-R concept of Avoidant Personality Disorder differs markedly in that it now corresponds to the clinical concept of “phobic character” and is no longer mutually exclusive with Schizoid Personality Disorder.
(p. 429)
The important point here is that, when it came time to incorporate Klein’s findings into the psychiatric nosology, they did not wind up under the category of “hysteroid dysphobia” (or under the contemporary successor to the classic “hysteria,” namely Histrionic Personality Disorder) but instead under Atypical Depression.
DRUG CARTOGRAPHY
Aspazia states that Kramer “offers up a new mental health diagnosis facilitated by Prozac interactions on “needy” women.”
First, note that the sentence is syntactically ambiguous: Is it the diagnosis that’s “facilitated by Prozac,” or the offering up thereof? I’ll try to show why it makes a difference.
Prozac clearly had nothing to do with the original formulation of any of Klein’s diagnostic categories. MAO inhibitors did. As for whether Prozac was involved in the process by which Kramer came to perceive the utility of rejection sensitivity as a diagnostic term: a close reading of the text is called for.
(Parenthetically, I realize that Aspazia finds something generally problematic about “drug cartography” or “pharmacological dissection” — the practice of defining and diagnosing maladies based on what drugs they respond to. My offhand response: given what little I know about how psychiatric diagnoses were arrived at before the advent of biological psychiatry, drug cartography seems to me to be a distinct improvement. But I need to know more about Aspazia’s views. She refers to some work by Jennifer Radden here. Yet another item for my reading list.)
But on with l’analyze de texte. Aspazia says:
We learn about rejection-sensitivity in connection with “Lucy.”Kramer finds that Lucy responds well to Prozac, and then launches into an exploration of a new mental illness category — rejection-sensitivity — that is reified by Prozac.
As a statement about Peter Kramer, the psychiatrist, treating Lucy, the patient, we have no evidence that it is true, and some that it is false. As a statement about “Peter Kramer,” the narrator of the text of “Lucy’s story,” it is plainly false, and reflects a misreading of the text. Let’s consider the latter point first. Kramer tells us about the medication he prescribed to Lucy after his 30-page digression on rejection sensitivity:
During a period of particularly disorganizing upset for Lucy, I started her on Prozac. Lucy never met Klein’s criteria for hysteroid dysphoria. . . . She was, to the contrary, quiet, cautious, self-protective, and self-effacing. But I thought she was nonetheless rejection-sensitive.
(LtP, p. 102)
Which addresses the first point: Kramer clearly found rejection-sensitivity to be useful diagnostic concept prior to meeting Lucy.
Moreover: in what sense can it be said that the concept of rejection sensitivity is “reified by Prozac?”
Lucy’s intial response to Prozac was promising. The medication interrupted her downward spiral. . . . Lucy’s brief, strong response to Prozac allowed me to consider the possibility that a good deal of her behavior, despite its obvious roots in her reaction to the murder of her mother, was now grounded in a functionally autonomous emotional sensitivity whose biological encoding had something to do with serotonergic neurons.
(ibid)
If Lucy’s response to fluoxetine changed Kramer’s thinking in any way, it had nothing to do with making him more inclined to think that she was sensitive to rejection; rather, it made him more likely to accept the “functional autonomy hypothesis“ and some version of the “serotonin hypothesis.”
REJECTION SENSITIVITY OR HYSTEROID DYSPHORIA?
Nonetheless, there’s a great deal more to be said about Aspazia’s claim that “rejection-sensitivity” deemphasizes gender, especially in light of how the concept emerges from the earlier diagnosis of “hysteroid dysphoria.” Unfortunately, the story here is complex: it’s not always clear when Kramer is reporting purely his own speculations, purely those of Donald Klein, when consensus (or minority) views among psychiatric practitioners. Moreover, much of the story probably can’t be found in print; Kramer’s account relies heavily on personal communications from Klein. If the real story can be found anywhere, it may be in David Healy’s 3-volume set of interviews with the “pioneers” of psychopharmacology. (Something else to get from the library.)
Here’s a brief account of the history involved. Kramer tells us,
In considering how to medicate horrid [sic] hysterics, Klein took into account their eating and sleeping habits. Although they generally did not suffer true, protracted depressions, these flamboyant patients tended, when upset, to overeat and oversleep, just like atypical depressives. Privy to the work of British researchers who made the case that atypical depression responds better to MAOIs . . . than to tricyclic antidepressants. . ., Klein tried an MAOI on the difficult hysterics referred him by his psychotherapeutic colleagues. He found that it sometimes smoothed the course of the patients’ lives. Klein tried to encompass these medication-responsive patients descriptively, thereby . . . carving out a group of hysterics whose disorder was after all not so much of the mind as of the brain. The patients looked hysterical, but the underlying disorder was a problem in biological regulation of mood. These were the patients Klein called “hysteroid dysphorics.”
Klein tried to distinguish such antidepressant-responsive hysterics according to their behavior. . . . What distinguished the hysteroid dysphorics was an extreme appetite for attention and a marked fear of rejection, a desperate emotional state that resulted in a constellation of behaviors that amounting to a caricature of femininity.
(pp. 73-74)
Klein’s himself reported on this work, and discussed the comparison with atypical depression, in a 1979 paper in Psychiatric Clinics of North America:
Hysteroid dysphorics also share a number of features with atypical or neurotic depressives as described by West and Dally and Sargant. These British investigators contrasted typical or endogenous depressives . . . with atypical or neurotic depressives who manifested prominent anxiety, emotional overreactivity and lability, fatigue and lethargy, irritability, a tendency to blame others, and a history of precipitating stress, which rendered the patient unable to cope despite a history of good premorbid functioning.
In our view, hysteroid dysphoria represents a subtype of atypical depression characterized by frequent depressive episodes and chronic life impairment rather than the prolonged or widely separated periods of depression with good premorbid or intermorbid functioning of the patients described in the British literature. In addition, hysteroid dysphorics are “attention junkies;” that is, they are “addicted” to approval or applause and specifically vulnerable to rejection, which are features not typically described in association with atypical depression.
A year later, Klein elaborates on the relationship between hysteroid dysphoria and atypical depression:
Sargant was one of the first to suggest that there was a group of depressed patients who did not benefit from ECT. He characterized these patients as “hysterical types of depressive reaction and some of them might just as well be diagnosed as anxiety states with depressive and hysterical features.” . . . We believe that Sargant was combining several different diagnostic subtypes, including panic disorder and hysteroid dysphoric patients.
The diagnosis of panic disorder is discussed [elsewhere]. A salient feature of the hysteroid dysphoric is the relationship of the symptoms to rejection or other interpersonal stress. There are other patients, however, whose depression is associated with such atypical features as overeating, sometimes to the point of producing obesity, oversleeping, waves of lethargy, reversed diurnal variation, and initial insomnia, who are not rejection-sensitive and whose mood does not bear an obvious relationship to interpersonal events. Many of these patients give a history of benefiting from amphetamines [!] without necessarily developing tolerance to them or abusing them. This syndrome can be observed in men. We shall refer to these patients as atypical depressives. The hysteroid dysphorics would be considered by some as a subgroup of the atypical depressives, but their syndromal stereotypy is so marked that we prefer to separate them, as we have done above.
If compare this with what winds up in DSM-IV, I think that the clear conclusion is that Klein loses this argument. In other words, his case (that rejection-sensitivity so distinguishes one group of patients from those otherwise known as atypical depressives that it should be the hallmark of a separate diagnosis) is not found persuasive by his professional colleagues. They find it more plausible to think of rejection sensitivity simply as one of the characteristics of atypical depression. The latter term doesn’t, to my mind, have the misogynistic overtones associated with “hysteria”; it would be interesting to know the statistics on how diagnoses of atypical depression break down by gender.
Klein’s original notion of “hysteroid dysphoria,” along with its parent diagnosis of “hysteria,” is clearly deeply “engendered.” But there’s nothing hidden or de-emphasized about that; it’s right there on the surface of Klein’s rhetoric, as he recognizes. At various points in his published writing, he offers quasi-psychoanalytic speculations about how cultural norms for the socialization of women produce such traits. Whether these speculations should be construed, in the context of their times, as pro-feminist or as reflecting a subtly misogyny, might be an interesting question. (Among other things, it would be interesting to know what was the gender ratio among the “hysterics” upon whom Klein performed his original research.) But it’s not a question that Aspazia addresses, or upon the answer to which she bases any of her claims about the contemporary “Prozac debate.”
Tentative conclusion: regardless of what Klein and Kramer may say in their writings, the actual history of rejection-sensitivity’s reception in psychiatric practice (insofar as that history can be reconstructed from these very limited sources) doesn’t show that the notion contains any hidden (or overt) gender bias or stereotyping.
1This touches on a host of interesting questions about the whole business of blogging vs. traditional publication, pseudonymity and scholarly integrity, but I’ll leave that for later. Perhaps we should ask: WWKD? (What would Kierkegaard do?)
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