Anhedonia In Schizophrenia: How It Manifests
Anhedonia can be defined as a diminished capacity to experience pleasure or positive emotions. Anhedonia is often considered a prominent symptom in multiple mental health disorders, including major depressive disorder and schizophrenia. Anhedonia, along with other symptoms of schizophrenia, can usually be treated with a combination of doctor-prescribed medication and regular therapy sessions with a licensed mental health professional.
Anhedonia as a feature of schizophrenia
Anhedonia can be a common symptom of schizophrenia. This symptom is related to a reduced ability to experience pleasure and is typically viewed as one of the negative symptoms associated with the condition. Researchers generally view anhedonia as a "transdiagnostic symptom that is associated with deficits in neural reward and aversion functions." This can be linked with neurocognitive deficits in evaluating the value of rewards, such as perceiving the future benefit of engaging in an activity now.
Research on anhedonia in schizophrenics
Anhedonia has been described as the loss of interest in experiencing pleasure or the lack of ability to experience pleasure. This ability may be related to reward processing, decision-making, anticipatory pleasure, and motivation.
Research suggests that many people with schizophrenia can experience pleasure. When using self-reported measures of trait or physical anhedonia, many individuals with schizophrenia report experiencing less pleasure in their daily lives. However, some laboratory studies with real-life stimuli suggest an equal or greater ability to experience pleasure when compared to those without schizophrenia.
Anhedonia in this context may be more closely associated with the "inappropriate valuation of rewards." Someone with schizophrenia may be more likely to underestimate the value of future rewards, for example. This may result in them having less motivation to engage in goal-oriented activities, thus impacting their decision-making process.
Anticipatory and consummatory pleasure
Reward processes that go beyond the ability to experience pleasure can include anticipation, motivation, and reinforcement. Evidence suggests that anticipatory pleasure and consummatory pleasure may work separately. Anticipatory pleasure generally refers to the ability to experience pleasure from predicting a positive outcome or reward. Meanwhile, consummatory pleasure can refer to one's ability to feel pleasure while having an experience. For example, a person might experience anticipatory pleasure as they look forward to taking a fun trip with friends, and they might experience consummatory pleasure while enjoying the trip itself.
Patients with schizophrenia can experience pleasure
Some research indicates that people with schizophrenia may experience consummatory pleasure but have a harder time with anticipatory pleasure. Other findings suggest an "intact capacity to experience pleasure during reward anticipation in schizophrenia." This may mean that individuals with schizophrenia tend to have varying experiences with pleasure and anhedonia.
Negative symptoms of schizophrenia
Negative and positive symptoms can be seen as central features of schizophrenia. Positive features typically refer to symptoms that distort reality, such as hallucinations and delusions, as well as disorganized thinking and speech.
Effects of negative symptoms
Negative symptoms usually affect one's ability to function. They can include impaired speech (alogia), loss of motivation (avolition), and the loss of or reduced ability to experience pleasure (anhedonia). Negative symptoms are usually classified as either primary or secondary. Primary features may relate to characteristic features of schizophrenia itself, whereas secondary features are often considered temporary and contingent, such as depression or social isolation.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) characterizes negative symptoms as “restricted emotional expression and avolition.” Avolition is defined as “a decrease in motivated self-initiated purposeful activities.” Other clinical symptoms of schizophrenia may include anhedonia and asociality.
Social anhedonia in patients with schizophrenia
In general, scientists consider humans to be highly sociable as a species. Those with social anhedonia, however, tend to derive less pleasure from social engagement, which may lead to withdrawal and a reduced ability to engage with others. Extreme social isolation is often linked with feelings of loneliness.
While social anhedonia can be strongly linked with schizophrenia and related conditions, its nature and expression may vary. Some researchers note that while concepts like pleasure, reward, anhedonia, and social anhedonia can be distinct, they may also be interrelated. Studies that look at social anhedonia in people without a diagnosed mental health disorder indicate that "the capacity to attend to, and ultimately learn from, important aspects of one’s environment may be a key issue in social anhedonia." Factors like working memory and anticipatory pleasure in social engagement may play a role in this capacity.
High levels of social anhedonia tend to be linked with more severe schizophrenia symptoms and lower self-esteem, subjective recovery, and quality of life. Researchers also note that social anhedonia, rather than the presence of positive symptoms, may "be responsible for decreased social engagement across the psychosis continuum."
Physical schizophrenic anhedonia
According to the United Brain Association, some scientists believe that anhedonia can be divided into physical and social anhedonia. Physical anhedonia generally relates to a lack of or reduced interest in activities involving physical sensations, such as exercise, sex, and eating. Symptoms of anhedonia may include:
- Loss or lack of interest in activities that were previously enjoyed
- Loss or lack of interest in social activities
- Reduced interest in food
- Loss or lack of interest in having personal relationships
A potential intervention for anhedonia in schizophrenia
In one study, a “positive emotions program for schizophrenia” (PEPS) aimed to reduce "the syndrome of a diminished capacity to experience." The program used principles of positive psychology and was tested in many groups of schizophrenia patients. Intended to be a short-term, group-based intervention to improve pleasure and motivation, PEPS employed a recovery-oriented approach to schizophrenia. Studies that have examined its efficacy suggest that it may clinically improve participants' anticipatory and consummatory pleasure as measured by the Temporal Experience of Pleasure Scale (TEPS).
Therapy for addressing anhedonia or depressive disorder
Speaking to a therapist can be helpful when you're struggling to find joy and pleasure in daily life. A therapist can introduce helpful ways to manage stress and help you find ways to live in the moment, such as by practicing mindfulness. Online therapy through platforms like BetterHelp can be convenient (and affordable) for many people who would rather speak to a therapist by phone, video, or online chat.
Effectiveness of online therapy for mental health
Studies suggest that online therapy can be effective in relieving the symptoms of many mental health conditions, although individuals with schizophrenia experiencing acute psychotic symptoms may need to seek in-person care. One review and synthesis consisting of sixty-one studies looking at online interventions for individuals with psychotic disorders noted that "web-based interventions have been associated with symptom reduction" and that "increased engagement is associated with improved outcomes."
Takeaway
Can patients with schizophrenia feel pleasure?
Loss of pleasure (anhedonia) can be a common negative symptom of schizophrenia, especially for unmedicated patients. That said, people with schizophrenia may still experience pleasure, especially with the help of treatments like antidepressants, therapy, and lifestyle changes.
Other types of treatments, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) are also being studied for reducing anhedonia and other schizophrenia symptoms. A recent meta-analysis found that tDCS was effective at reducing negative symptoms of schizophrenia, although research is still ongoing.
What are the negative symptoms of anhedonia in psychosis?
Anhedonia itself (losing the ability to feel pleasure) does not have negative symptoms. Rather, anhedonia itself is a possible negative symptom of psychosis. Negative symptoms of psychosis are experiences that are present for most people, but absent for the person in psychosis. Examples of negative symptoms include reductions in speech, a lack of motivation to do tasks, and limited reactions to emotionally evocative stimuli. Symptoms of psychosis-related anhedonia include:
- A loss of interest in work and hobbies
- A lack of physical pleasure
- A lack of excitement for future events
- Social isolation
- Challenges keeping up with daily tasks like bathing, cooking, and cleaning
- Reduced emotional expression
- A lack of motivation to accomplish goals
Tools like the Positive and Negative Syndrome Scale (PANSS), self-report trait measures, and other assessment strategies can be used to assess anhedonia and other psychosis symptoms. The functional outcome of a schizophrenia patient—how well they can function in day-to-day life—is negatively correlated with negative symptom severity. In other words, people with more severe anhedonia may struggle more to manage daily tasks, maintain relationships, and look after their well-being.
What are the signs of anhedonia in psychosis versus depressive disorder?
Different people may experience anhedonia differently. That said, people with depression may have greater insight into their mental health situation than those with psychosis. They are more likely to be aware that they don’t feel pleasure in things they used to enjoy, which can lead to greater depressive symptoms like frustration and hopelessness. People with depression may also be more likely to express emotions like sadness or irritability. In contrast, people with psychosis may be more likely to show an overall lack of emotional expression. Finally, anhedonia in psychosis is often accompanied by other psychosis-related symptoms, such as hallucinations and delusions.
What is a person with schizophrenia who is experiencing anhedonia displaying?
A person with schizophrenia who is experiencing anhedonia is displaying a reduced ability to feel pleasure. As a result, they might lose interest in activities and relationships, struggle to take care of themselves, or stop working toward their goals.
Some people with schizophrenia-related anhedonia may also display something called a negative affect. “Positive” and “negative” affect are terms to describe a person’s emotional state. In someone with schizophrenia, a negative affect might include:
- Withdrawal from social interactions
- A lack of happiness about positive events
- Limited communication
- Difficulty expressing emotions that match the situation
What is a new perspective on anhedonia in schizophrenia?
“A New Perspective on Anhedonia in Schizophrenia,” published in the American Journal of Psychiatry, is a paper from 2012 that explores the so-called “schizophrenia spectrum anhedonia paradox.” The schizophrenia anhedonia paradox describes how people with schizophrenia often struggle to feel pleasure when looking forward to future events, but can often still feel pleasure from current events. The paper proposes that this paradox is due to cognitive impairments that affect patients’ beliefs and behaviors. (Keep in mind that schizophrenia research is always evolving, and older sources may have been reevaluated since their original publication date.)
What causes anhedonia in the brain?
The exact neural mechanisms underlying anhedonia are not fully understood. Studies have found that there may be a genetic factor that influences brain structure and contributes to anhedonia.
In schizophrenia patients, the dopamine dysregulation hypothesis proposes that anhedonia is due to differences in dopamine in the brain. Dopamine is a brain chemical that plays a role in reward, learning, task initiation, and pleasure. Dopamine neurons are a type of brain cell that act as a “predictive reward signal” (in other words, they cause the brain to anticipate pleasure). According to the dopamine dysregulation hypothesis, anhedonia and other schizophrenia symptoms may occur due to challenges with dopamine and dopamine neurons.
In the study “Functional neural substrates of self-reported physical anhedonia,” researchers compared the brain activity of people with schizophrenia with a group of healthy controls. They found neural correlates, or associations, between schizophrenia-related anhedonia and activity in certain key brain regions, such as the prefrontal cortex. The prefrontal cortex is an area at the front of the brain that uses dopamine for motivation and reward-seeking behavior and may play a role in anhedonia.
Other studies have shown that receiving amphetamine (a drug that boosts dopamine release) is positively correlated with the intensity of certain schizophrenia symptoms, such as hallucinations and delusions. This research suggests that anhedonia in schizophrenia patients is closely related to dopamine.
What is anhedonia after psychosis?
Some people may continue to experience anhedonia following an episode of psychosis. This may lead to challenges with motivation and pleasure, even if other psychosis symptoms have subsided. That said, studies have found that the severity of anhedonia after psychosis tends to get better with time. Proper treatment and support may help ensure positive outcomes.
What is anhedonia in schizophrenia patients?
Anhedonia is a reduced hedonic capacity, or a reduced ability to feel pleasure. People with hedonic deficits may struggle to:
- Enjoy activities they once loved
- Feel pleasure from physical sensations
- Look forward to future events
While there can be individual differences in symptoms, anhedonia is often one of the key clinical characteristics of schizophrenia spectrum disorders. In patients with schizophrenia, anhedonia may play a role in symptoms like:
- Challenges with social functioning
- A loss of interest in activities and relationships
- Feelings of numbness or indifference
- A generally depressed mood
What is an example of anhedonia?
Anticipatory and consummatory anhedonia are two examples of anhedonia that can affect people with psychiatric disorders like major depression and schizophrenia. Anticipatory anhedonia is when you don’t feel pleasure from looking forward to an experience or reward. For example, you might struggle to feel excited about an upcoming vacation, dinner with friends, or a hobby you usually enjoy. This can lead to less goal-directed behavior and a loss of interest in activities.
Consummatory anhedonia is when you don’t get enjoyment from pleasurable stimuli. For example, you might struggle to get pleasure from food, sex, massage, a hot shower, or other enjoyable physical activities. People with schizophrenia may experience consummatory anhedonia, anticipatory anhedonia, or both.
What is anhedonia and avolition in schizophrenia?
Anhedonia and avolition are affective science terms that you may have heard used in the context of schizophrenia. Anhedonia describes a type of emotional disturbance that affects people’s ability to feel pleasure. People with anhedonia might lose interest in food, sex, or activities they used to enjoy, which may in turn lead to avolition. Avolition describes a lack of motivation to do tasks, work toward goals, or initiate activities. People experiencing avolition might stop going out or struggle to take care of themselves and manage daily tasks.
Anhedonia and avolition can be symptoms of schizophrenia, central nervous system disorders, mood disorders, brain injuries, and other disorders that affect cognitive functions. Although the exact reasons for these emotional disturbances aren’t fully understood, certain areas of the brain, like the ventral striatum and the anterior cingulate cortex (located near the center of the brain), may play a role. Diffusion tensor imaging studies, which use a type of MRI to examine the brain, have found that compared to healthy control groups, people with schizophrenia who have anhedonia may also have differences in connectivity within their brains.
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