A New Perspective on Anhedonia in Schizophrenia
by Gregory P. Strauss, Ph.D. and James M. Gold, Ph.D.
American Journal of Psychiatry 2012 169:364-373.
Objective: Previous research provides evidence for discrepancies in various types of emotional self-report in individuals with schizophrenia; patients and healthy subjects report similar levels of positive emotion when reporting current feelings, yet patients report lower levels of positive emotion when reporting on noncurrent feelings. Such apparent discrepancies, which have come to be termed the “emotion paradox” in schizophrenia, have complicated our understanding of what anhedonia actually reflects in this patient population. The authors sought to resolve this paradox.
Method: The authors reviewed the empirical literature on anhedonia and emotional experience in schizophrenia through the lens of the accessibility model of emotional self-report, a well-validated model of emotional self-report developed in the affective science literature that clarifies the sources of emotion knowledge that individuals access when providing different types of self-report. The authors used this model to propose a resolution to the “emotion paradox” and to provide a new psychological conceptualization of anhedonia.
Results: Data are presented in support of this new perspective on anhedonia and to demonstrate how cognitive impairments may influence reports of noncurrent feelings in schizophrenia.
Conclusions: The authors conclude that anhedonia should no longer be considered an experiential deficit or a diminished “capacity” for pleasure in patients with schizophrenia. Rather, anhedonia reflects a set of beliefs related to low pleasure that surface when patients are asked to report their noncurrent feelings. Encoding and retrieval processes may serve to maintain these beliefs despite contrary real-world pleasurable experiences. Implications for assessment and treatment are discussed in relation to this new conceptualization of anhedonia.
In medical school, we taught the students Bleuler’s "4As" of Schizophrenia – Associations, Affect, Autism, and Amibivalence. And then there was the "5th A" – Anhedonia, the absence of pleasurable feelings. And it is certainly true that in taking a history, Schizophrenic patients seem to have little memory of pleasurable experience either spontaneously or on direct questioning. Long ago, when I was a resident taking night call in various hospitals, I noticed there was a particular variant of these patients I called "The Wandering Schizophrenics" or later "Schizophrenia Migrans." They were patients who were basically on the move, going from place to place. What I got from asking why was that they were looking for someplace that felt right – making wider and wider circles from "home," going back, then setting off again. Anhedonia is part of what are called negative symptoms. The authors of this perspective paper make a point that I never thought of before. It’s not that they can’t have or don’t report positive feelings. It’s that they don’t recall pleasurable feelings in the past:
Anhedonia has long been considered a core clinical feature of schizophrenia. The most common understanding of anhedonia is that it reflects a diminished experience of pleasure. Although this definition clearly applies to individuals with major depression who report experiencing less pleasure when exposed to activities or stimuli that were previously enjoyable and who rate positive stimuli as being less pleasant than do healthy comparison subjects, it is uncertain whether these notions accurately reflect anhedonia as it occurs in schizophrenia.Confusion regarding the nature of anhedonia in schizophrenia comes from a consistent set of contradictory findings in the empirical literature, which have come to be termed the “emotion paradox.” Patients report levels of positive emotion similar to those of healthy comparison subjects when providing reports of current feelings, but they report less pleasure relative to comparison subjects when reporting their noncurrent feelings. When results from these diverse methods are viewed together, it is unclear what anhedonia actually reflects in schizophrenia. In this article, we review the empirical literature on anhedonia and emotional experience in schizophrenia through the lens of a well-validated model of emotional self-report developed in the affective science literature and use this model to resolve the “emotion paradox” and provide a new conceptualization of anhedonia.
I think that’s right, though I never thought about that before. It is memories of pleasurable experiences that’s missing – and that’s a big deal. Remembered positive experience is a huge driver of mental life – something of a compass. And anticipated positive experience has a lot to do with our view of the future, our planning, etc. The distinction they’re making here is pretty important. I’m not sure I completely agree with their explanations of the why of things. I’ll leave that to your reading [available online]. But their proposal of developing specific cognitive strategies seems like a good idea. In the few instances where I’ve personally worked with Schizophrenic patients, cognitive strategies have been well accepted and helpful. I was pleased to read this in the American Journal of Psychiatry. Much preferable to some of the other stuff that fills our literature…
To what degree were the subjects medicated? Could this be contributing to “beliefs” about pleasure — i.e. emotional anesthesia from the drugs?
Neuroleptics (antipsychotics) and Electroshock (electroconvulsive therapy) destroy good memories.
The problem is largely the past “treatment”.
Duane
Duane
Pernicious anemia caused all the symptoms in me that are typical for the atypical depression that is usual for type II bipolar. Anhedonia was easily the worst symptom. I could not remember ever having done anything right or good or even particularly interesting in my life; but seemed perfectly capable of remembering mistakes. It was hellish— flat and intense at the same time. I guess you could say it was intensely invasive because it took over my thought processes so completely, though the individual negative memories didn’t have a powerful impact (because there just wasn’t enough energy for that, I think). Bad memories were my only memories at the time. It was an effort not to dwell on them and to trust that the good memories were in there somewhere, because no one could have lived a life so bereft of good feeling and good effect.
Had that “depression” twice. The second time, I fortunately found out that I had pernicious anemia and was treated for it. Two weeks on very high doses of iron and vitamin C then I was right as rain. Those are the only times I’ve ever felt anhedonia.
I can see how it would be a really good indicator to help doctors get a more detailed profile of what they’re trying to treat. “Depression” is too generic and pedestrian a word to describe having low and debilitating feelings. I know the best look for distinctions; but in my experience, those have been the exception.
Assuming that BigPharma hasn’t had an influence on the dumbing-down of the what is labeled “depression” and how automatically antidepressants are thrown at it, has got to be “lacking insight.” Instead of broadening categories for the purpose of prescribing drugs for them, perhaps psychiatrists need to fight to get paid for at least two long sessions with very thorough evaluations and some bloodwork before passing out the anti-depressants.
Folks suffering from severe antidepressant withdrawal often are most distressed about anhedonia, although they may be suffering many other bizarre symptoms.
Having experienced this myself, I can say the lack of sense of reward from anything, even prior tasks that were a joy, is very debilitating. It’s the very thing that makes life worth living.
One interesting thing to note in schizophrenia is some have social anhedonia but do not have physical anhedonia — however, I would have to say that once anti-psychotics are started, it is hard to imagine that there is much any hedonia of any sort, and that any schizophrenic who can find joy on the medications is an underutilized resource. Also, I wonder why some therapists complain about the difficulty of treating schizophrenics when they must realize that the drugs make pleasure difficult and thus learning (therapy) next to impossible. Not the patients fault.