Original article • Articolo originale Anhedonia in schizophrenia and major depression: state or trait? Review of the literature L’anedonia nella schizofrenia e nella depressione maggiore: stato o tratto? Rassegna della letteratura L. Pelizza*, S. Pupo**, A. Ferrari* * Centro di Salute Mentale di Guastalla (RE), Dipartimento di Salute Mentale di Reggio Emilia, AUSL di Reggio Emilia; ** Servizio di Anestesia, Rianimazione e Terapia Antalgica, Ospedale Civile di Guastalla, AUSL di Reggio Emilia Summary Results In both schizophrenia and major depression, anhedonia is con- Objectives sidered both as a state (symptom) and a personological trait Anhedonia, a term proposed by Ribot in 1896, is an inability (Figs. 1-4). to feel pleasure in situations or activities that are normally pleasing. In this review, the authors describe the psychopath- Conclusions ological features of anhedonia in schizophrenia and major Anhedonia cannot be considered as a specific psychopathologi- depression. cal feature of major depression (Table I), but appears to be a problematic psychological condition that is difficult to interpret Methods due to its nosographical transversality. Exhaustive review of the international literature (in Medline, PubMed, PsychINFO) on anhedonia in schizophrenia and ma- Key words jor depression. Anhedonia • Schizophrenia • Major depression Introduction cases characterized by the isolated lack of pleasure, that render these patients absolutely unable to find gratifica- … I’m like the king of a rain-soaked country, rich but impotent, tion from any sexual activity, food, relation or affection”. young in senility, who despises his tutors’ servile features, as bored with his dogs as with other creatures. His favourite fool’s The main difficulty in understanding and defining an- most grotesque antic won’t calm this brow so cruelly sick. hedonic behaviour is primarily related to its peculiar (Baudelaire, Spleen [The Flowers of Evil], 1857) 1 characteristic of nosographic transversality 2, as it can involve a number of widely-different psychiatric dis- The term “anhedonia” traditionally refers to a specific turbances in a non-specific manner. Along these lines, psychopathological condition characterized by a deficit in fact, Silverstone 5 observed that substantial anhedo- in the ability to experience pleasure in activities and situ- nia was present in more than 50% of patients with a ations usually considered gratifying 2. The condition can generic diagnosis of mental disease. In particular, the present as diffuse (and therefore relative to all aspects of inability to experience pleasure is a complex symp- existence) or can be limited to some areas, such as inter- tom of both major depression and psychopathological personal relations (social anhedonia), food, sexuality or syndromes belonging to the schizophrenic spectrum 6. somatosensorial experiences in general (physical anhe- Manna et al. 7, Koob and Le Moal 8, moreover, attrib- donia) 3. The word “anhedonia” was introduced by the uted a relevant role to anhedonia in the pathogenesis French psychologist Ribot 4 to describe a “pathological of eating and substance abuse disorders, which accord- insensibility to pleasure” seen in several severe psychiat- ing to these authors, is based on hedonic homeostatic ric diseases. “The state of anhedonia”, he wrote, “if I may dysregulation with a dopaminergic origin. Bermanzhon coin a new word to pair off with analgesia, has been very and Siris 9 argue that it may also be part of the constel- little studied, but it exists. I need not say that the employ- lation of symptoms of Parkinson’s disease (and thereby ment of anaesthetics suppresses at the same time pain predominantly neurologic), hypothesizing the existence and its contrary, […] and there are, undoubtedly, clinical of a specific extrapyramidal neuropsychiatric syndrome Correspondence Lorenzo Pelizza, CSM di Guastalla, via Salvo D’Acquisto 7, 42016 Guastalla (RE), Italia • Tel. +39 0522 837561 • Fax +39 0522 838980 • E-mail: [email protected] Journal of Psycopathology 2012;18:145-155 145 L. Pelizza et al. Major depression Eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder) Anhedonia Addiction disorders Schizophrenic spectrum disorders Parkinson’s disease (schizophrenia, schizotypal disorder and schizoid personality) FIGURE 1. Anhedonia and mental disorders. Anedonia e disturbi mentali. (characterized by hedonic inability, akinesia and cogni- pathologic state. A few years later, Kraepelin 12 included tive deficits) due to decreased turnover of dopamine in hedonic incapacity among the salient psychopathologi- basal ganglia (Fig. 1). cal characteristics of “amotivational syndrome” (as part According to Polese et al. 10, specifying what hypohe- of “dementia praecox”). He highlighted how a singular donic patients experience could help to better define and apathy towards interpersonal relationships, the extinction understand the nosographic transversality of anhedonia: of affection for family and friends, the loss of satisfaction “… the loss of intense pleasure as the lack of satisfaction in the workplace, in vocations and in worldly pleasures of desire, due to the absence of desire itself”. In other were often the first symptoms of the onset of psycho- words, anhedonic subjects are not able to find gratifica- sis. Despite the important contributions of Bleuler and tion as they are unable to find desire. Manna et al. 7 also Kraepelin, modern psychiatry is still divided about the underlined the need to overcome use of the term “an- psychopathological significance of anhedonia in schizo- hedonia” (which refers only to the absence of pleasure); phrenia. Some authors, in fact, consider anhedonia to be more suitable terms such as “dyshedonia” might be used, an important marker for schizophrenic status, especially which would allow better definition of the spectrum of from a diagnostic standpoint 13 14, while others give it lit- symptoms, and the severity of transitory, para-physiolog- tle or no consideration 15 16. Yet another group retains that ical symptoms from clinically chronic and invalidating hedonic incapacity is not a symptom of psychosis, but conditions. This would also include all possible qualita- rather a premorbid personality trait that predisposes sub- tive and quantitative variations of the capacity for gratifi- jects to development of overt schizophrenic disease 17 18. cation, including the absence of desire itself. In this review, the clinical characteristics of anhedonia a) Anhedonia as a symptom in schizophrenia and major depression will be presented Crow 19 was one of the first to sustain the concept that along with the principal psychopathological hypotheses anhedonia is a symptom of the schizophrenic state. Re- that have considered hedonic inability as a premorbid fining the dichotomic clinical approach (“positive vs. trait or as a pathologic state (symptom) of schizophrenia negative symptoms”) proposed by Hughlings-Jackson 20 and major depression. in neurology, Crow hypothesized the existence of two forms of schizophrenia: type I (“positive”), characterized Anhedonia and schizophrenia by predominance of psychotic phenomena (e.g. delu- sions, hallucinations), and type II (“negative”), dominated Scientific interest for anhedonia in schizophrenia began by defect symptoms, the most salient of which were emo- around the beginning of the 20th century when Bleuler 11, tional flattening and social withdrawal. Some years later, having observed the apparent indifference that certain Andreasen 13, with the intent to create valid psychometric psychotic subjects exhibited with regard to friends, fam- instruments to measure schizophrenic psychopathology, ily, preferences and ordinary interests, considered the in- introduced hedonic inability in the anhedonia/asociality ability to experience pleasure a fundamental symptoms subscale of the SANS (Scale for the Assessment of Nega- of schizophrenia and an outward manifestation of their tive Symptoms), which was defined as: a) loss of interest 146 Anhedonia in schizophrenia and major depression: state or trait? Review of the literature and gratification from activities and situations normally ty (overexpression of genes that regulate cerebral glu- considered pleasuring and/or; b) lack of intimacy and tamatergic neurotransmission), would disproportiona- emotional involvement in a variety of social and sexual tely operate under the influence of several environ- relations. mental stressors (e.g. toxins, drugs, infective agents, Successively, Carpenter 14, when clinically redefining elevated emotionality in a family environment) 28; symptoms of psychotic defects, placed anhedonia among 2. a secondary deficit in DA linked to: a) inhibition of the primary and enduring negative symptoms of what he synaptic release due to excess serotonin at the me- defined “Deficit Syndrome” of schizophrenia. In the SDS sencephalic level; or b) blockage of prefrontal D2 re- (Schedule for “Deficit Syndrome”) 21, specifically created ceptors associated with the administration of typical for diagnosis of this subtype of schizophrenia, hedonic antypsychotics (e.g. haloperidol) 27. The first of these inability was present in at least 3 of the 6 items proposed mechanisms could help in better understanding the ([A2] diminished emotional range (incapacity to experi- efficacy of atypical antipsychotics (e.g. clozapine) in ence pleasure and/or anger), [A4] curbing of interests and reducing the negative symptoms of schizophrenia (se- [A6] diminished