Abstract

Introduction

Explaining Anhedonia

A Case Study

Nursing Interventions

Conclusion

References

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Anhedonia: A Case Study

Kristina E. Luna
The University of Texas Health Science Center
at San Antonio School of Nursing  


Abstract  

Schizophrenia is a mental disorder that plagues all cultures and is known to be present in all socioeconomic groups.  Patients exhibit a wide range of symptoms, which can be classified as either positive or negative.  Positive symptoms include hallucinations, delusions, erratic behavior, pressured speech, and looseness of associations.  Negative symptoms include flattening of affect, poor grooming, withdrawal, and poverty of speech.  The failure or inability to experience pleasure, also known as anhedonia, is a fairly common negative symptom, but one that is little understood by many in the psychiatric field.  By attempting to explain the etiology of anhedonia, I hope to increase the awareness of this often overlooked concept.



Introduction

Despite the fact that anhedonia is common in many patients with schizophrenia or depression, it not well understood by many in the psychiatric field.  By definition, anhedonia is a failure or an inability to experience pleasure.  “It may be an aspect of personality structure and it may be a specific state or symptom; it may be pervasive or it may be confined to a certain aspect of experience such as pleasure in social relationships or pleasure in food” (Snaith, 1993, p. 957).  Anhedonia is a common negative symptom in the deficit syndrome of schizophrenia.  Common defining characteristics of anhedonia in schizophrenia include: flattening of affect, poor eye contact, loss of interest or pleasure in all or almost all activities, or a lack of reactivity to normally pleasurable stimuli and marked psychomotor retardation or agitation (Lemke, Puhl, Koethe & Winkler, 1998).

In this article, I will, 1) explain anhedonia from several theoretical perspectives, 2) describe my clinical experience with a patient with an Axis I diagnosis of schizoaffective disorder, bipolar type who was currently depressed and exhibited anhedonia, and 3) discuss relevant treatment modalities and interventions that are of concern to the nurse.


Explaining Anhedonia

The psychoanalytic perspective

Several theorists have attempted to explain anhedonia, including the so-called father of psychology, Sigmund Freud.  Using his psychoanalytic theory, Freud tried to explain anhedonia in terms of the id, ego, and superego.  According to Freud, the id is the part of the personality that holds what is inherited, present at birth, and fixed in a person’s psychic constitution (Fortinash & Holoday-Worret, 2000).  It is the part of the personality that is responsible for the experience of pleasure.  It is believed that any deficits in the development of the id could therefore lead to the deficit syndrome of anhedonia.

Although Freud does make an interesting argument, several other theorists have also formulated explanations for the concept of anhedonia.  Some argue that the symptom of anhedonia is biological.  Others believe that anhedonia develops in reaction to the illness of schizophrenia.  Yet others argue that anhedonia results from the inability to adapt to the environment.

The view from social learning

Social learning theorists believe that behaviors are gradually learned and modified as a result of repeated interactions with the environment (Fortinash & Holoday-Worret, 2000).  Social learning begins at birth and continues throughout the entire life span.  After children are born, parents try to help them learn the basic skills that are needed to function in society.  As the children continue to grow, they learn through socialization.  Socialization with parents, family, and friends all play an integral role in their development.

While interacting with parents, family, and friends, children learn through observation, imitation, and positive and negative reinforcement.  Social learning can be seen when watching a group of children playing together.  A child who does not know how to play a certain game will watch and learn as the other children play the game.  As the child learns the rules of the game, he will join in and imitate the actions of the others.  Finally, the child will learn what he should and should not do during the game by positive and negative reinforcement.  When the child does something good, such as scoring a point for his team, his teammates will all clap and cheer for him.  When he accidentally passes the ball to the member of the opposite team, his fellow teammates will respond negatively with frowns and shouts of frustration (Bandura & Walters, 1963).

If social learning is this complex for a “normal,” healthy child, imagine the difficulty of social learning for someone diagnosed with the deficit syndrome of schizophrenia.  With the beginning of schizophrenia, the individual’s normal development is disrupted.  There may be prodromal behaviors before schizophrenia is diagnosed.  The young person may be deprived of participation in new experiences and activities and may be deprived of new experiences due to poor coping skills.  This deprivation leaves the individual with no means to develop a capacity for pleasure (Krupa & Thornton, 1986).  This results in the individual exhibiting the negative symptom of anhedonia and reinforces the idea that anhedonia is the result of inadequate social learning.

Assessing the severity of anhedonia

There are several scales available for use by the health care provider to assess the severity of a client’s anhedonia.  The Physical Anhedonia Scale (PAS) and the Social Anhedonia Scale (SAS) are just two of the many scales available that can measure anhedonia symptoms.  In a study done to examine the relationships between anhedonia and depression in the deficit syndrome of schizophrenia, subjects were tested using the PAS and SAS.  Each subject filled out revised versions of the PAS and SAS, both self-evaluation scales.  “These self-evaluation scales were used to avoid the bias inherent to the rating of both depression and negative symptoms by the same investigator.  Also, the use of self-report instruments is almost mandatory for the assessment of anhedonia, since it is inconceivable that the inner feeling of pleasure of a person could be assessed by an external rater” (Loas, Boyer & Legrand, 1999, p. 209).  One result of the study is consistent with the idea that anhedonia is a major feature in the definition of deficit schizophrenic patients.


Using Social Learning Theory to Understand Anhedonia:  A Case Study

A prime example of an individual who exhibits the negative symptom of anhedonia is MG, a forty-something year old male from Iran who was diagnosed with schizoaffective disorder somewhere around the time of his 15th birthday.  He was diagnosed as having schizoaffective disorder while living in Iran, and was in and out of the hospital throughout the latter half of his adolescent years.  He moved to the United States in his early 20s, claiming that he was being mistreated in his home country.  While living here in the United States, his mental health continued to decline and MG was admitted to the San Antonio State Hospital (SASH) several times.  When I first met MG, he had voluntarily admitted himself into SASH, claiming he couldn’t eat because his food was poisoned.  It was MG’s 25th admission into the hospital.

MG’s early diagnosis of schizoaffective disorder before his 15th birthday clearly disrupted his normal development.  His mental illness deprived him of pleasurable experiences and activities he could have had had he not been in the hospital.  His continual hospital visits led him to continue the “sick role”, causing him to spend years in unstimulating and undemanding institutional and community settings.  According to Krupa and Thornton (1986), continual exposure to these environments maintains the individual’s isolation from pleasurable activities and experiences, a phenomenon referred to as the “social breakdown” or “social poverty” syndrome.

Upon first meeting MG, I immediately noticed his disheveled appearance, flat affect, monotone voice, and his inability to maintain eye contact.  These symptoms led me to assess for anhedonia.  Upon interviewing MG, he admitted to not enjoying anything in life.  Prior to speaking with him, I reviewed his chart, noting that he smoked two packs of cigarettes per day.  While I was talking to MG, a smoke break was announced and everyone began moving outside to the designated area.  MG did not move from his seat.  When asked if he would like to go outside and smoke, he shrugged his shoulders and replied, “I don’t know.  I guess.  I don’t really feel like it.”  After some encouragement, MG reluctantly moved from his seat and walked towards the door.  I observed his behavior as he walked out, noticing that he just shuffled around with his eyes on the floor.  He continued to walk outside, but once out the door, turned around and returned to the day room.  He proceeded to find a corner isolated from everyone else and sat alone for the remainder of the afternoon, avoiding others’ attempts at conversation.

While I was unable to determine the severity of the client’s anhedonia, it is obvious that he was severely ambivalent.  I found it surprising that a person who was clearly addicted to nicotine would decline to go outside and smoke a cigarette when he could.  Despite MG’s lack of motivation, I was able to accomplish several objectives with him over the next few weeks.  For one, I established a therapeutic relationship with the client as we talked every week.  Secondly, while MG was still unreceptive to several others at SASH and sat alone most of the time, he had no problems interacting with me.  He willingly answered all questions during my interviews, but still seemed very depressed and unmotivated.  He revealed the fact that he rarely slept at night and could not eat, partly due to the delusion that his food was poisoned and partly because he didn’t want to.  However, before he left SASH, he was able to understand that no one was trying to poison him.


Nursing Interventions

Nurses have many opportunities to help patients overcome their inability to experience pleasure.  While change will not be immediate, over the course of time these individuals can begin to again take pleasure in activities.  One of the main objectives of any nurse is to establish a therapeutic relationship with the client.  Unfortunately, many of these patients don’t have the mental capacity to understand that the health care team is here to help them, and a building of trust takes time.  For trust to be established, the nurse can use Milieu therapy by manipulating the client’s physical and social environment to make it more comfortable and pleasant (Dawber, 1997).  Once patients feel comfortable in their environment, they are likely to be more willing to open up.  Their willingness to participate is essential if therapy is to continue any further.

When caring for patients with anhedonia, the nurse should also employ interventions used to treat the negative symptoms of schizophrenia.  Negative symptoms are often the most disabling symptoms and therefore the most resistant to change.  There are several potentially useful interventions:

·           Milieu therapy is encouraged, as well as social skills training, to help the client learn to become involved in other activities. 

·           Anhedonics should also be encouraged to partake in art or music therapy, which can both bring about feelings of pleasure. 

·           The client should also be asked what activities they enjoyed in the past.  If that activity is a safe and productive one, the client should be encouraged to participate in it again.  Encouragement is of the utmost importance so that the client may once again be motivated to take part in pleasurable activities.  The family of those suffering from schizophrenia must also be considered when planning care.  Families in particular find the negative symptoms of schizophrenia the most difficult to cope with because these symptoms are often regarded as character defects rather than manifestations of the illness.  Schizophrenia family work is based on the principle that families do not cause schizophrenia, but that they can influence the course of the illness by gaining knowledge of schizophrenia and its symptoms. Families can learn to reduce levels of expressed emotion and improve communication and problem solving.  The nurse’s aims for the family should be to, 

o       reduce the levels of expressed emotion, 

o       reduce the relapse rate of the person who has schizophrenia,

o       promote age-appropriate independence of the person who has schizophrenia to release families from full-time caring, and

o        improve the quality of life for the whole family (Dawber, 1997).


This can best be done by referring the family to a qualified therapist who can help meet the family’s needs.

·           As part of a total proper treatment plan, the nurse should also encourage the use of pharmacologic drugs to reduce some of the negative symptoms of schizophrenia.  However, before encouraging the use of the drug, the nurse must take the time to educate the patient on the positive and negative effects that the drug will have.  Once the patient fully understands these, the nurse should encourage their continuous use to avoid relapse.

·           Finally the most important thing that the nurse can do is continually assess patients to ensure that the therapy and care they are receiving is effective.  By monitoring patients’ progress, the nurse can quickly diagnose a relapse and take the appropriate steps to change therapy.  The nurse is a patient advocate, and should do all within his/her power to promote safety of the client and others.


Conclusion

In summary, the inability to experience pleasure, or anhedonia, is one of the defining negative characteristics in the deficit syndrome of schizophrenia and also depression.  I described how two different theories try to account for the origin of anhedonia.  Although the etiology of anhedonia is still unknown, its negative symptoms are quite obvious and their severity can be measured with standardized scales.  I then used social learning theory to analyze the case study of a patient with Anhedonia.   Finally, I discussed five nursing interventions that are appropriate when treating those afflicted with anhedonia and schizophrenia. 

To conclude, it is extremely important for health care providers to be aware of schizophrenia and assessing for anhedonia.  By discussing the negative symptom of anhedonia, I hope to increase the awareness of this little understood concept.  If and when I encounter schizophrenics during my nursing practice, I intend to utilize the appropriate nursing interventions, such as assessing for anhedonia, establishing a therapeutic relationship, providing a safe environment, and encouraging pleasurable and safe activities.  Most importantly, I hope to educate those who are lacking information on schizophrenia and its symptoms.


References

Bandura, A., & Walters, R.H. (1963).  Social Learning and Personality Development. New York: Holt, Rinehart and Winston, Inc.

Dawber, N. (1997).  Current approaches and interventions for schizophrenia.  Nursing Standard, 11(49), 49-56.

Fortinash, K. M., & Holoday-Worret, P. A. (2000).  Psychiatric Mental Health Nursing.  St. Louis, MO: Mosby, Inc.

Krupa, T., & Thornton, J. (1986).  The pleasure deficit in schizophrenia.  Occupational Therapy in Mental Health, 6(2), 65-78.

Lemke, M. R., Puhl, P., Koethe, N., Winkler, T. (1999).  Psychomotor retardation and anhedonia in depression.  Acta Psychiatrica Scandinavica, 99(4), 252-256.

Loas, G., Boyer, P., & Legrand, A. (1999).  Anhedonia in the deficit syndrome of schizophrenia.  Psychopathology, 32(4), 207-219.

Snaith, P. (1993).  Anhedonia: a neglected symptom of psychopathology.  Psychological Medicine, 23(4), 957-966.


Acknowledgments

I would like to acknowledge with gratitude the support and encouragement of my psychiatric clinical instructor Margaret Cole Marshall, MS, MA, RN, CS.

Copyright© by The University of Arizona College of Nursing; All rights reserved.