Posts tagged: mood disorder

Anhedonia

Dr. Holzmacher's Business LogoSome words are not replaceable.  There is no one word that can be used as a substitute.  One such word is anhedonia.  It is rarely used in casual conversation.  It is even rarely used by psychologists.   As the word was typed, the online dictionary underlined the word in red, indicating that it is not in their database.

The meaning is related to its Greek roots indicating a lack of happiness, yet this could be confused as sadness or a numb feeling.  Used in a clinical context, the word means a near inability to derive pleasure from activities once found enjoyable.  For example, a person who avidly collects stamps finds their books going unfilled, and a movie buff can’t recollect the last time they went to the cinema.  If the person went on to other activities they found rewarding, then the dropping of old interests would not be considered anhedonic.  The term is meant to describe a loss of enjoyment that has not found another outlet for expression.  This symptom is highly indicative of a depressive disorder, and may be the least understood of the many depressive complaints.

Patients usually associate sadness with depression, and to a lesser extent, sleep and appetite disturbances.  It is rare that depressive people have insight into how the disorder affects their daily activities.  Typically close others observe the alteration of behavior, and the patient often voices non-depressive rationalizations for the change.  The subjective experience of sadness is generally more figural than a change in behavior.  Said another way, people are generally more aware of changes in feeling than behavior.  This becomes important when someone suffers with a depressive disorder, and they lack a subjective sense of sadness.  They may feel angry or numb, but the lack of subjective sadness prevents the person from identifying the problem as Major Depression.

It is not uncommon for a person to be labeled by their family and physician as depressed, and yet have no insight into what others see as obvious.  It is common for the person to have an “ah-ha” moment when a microscope is placed on their behavior.  For example, a middle-aged man complained that his family and doctors continually labeling him as depressed, yet he didn’t feel particularly sad-let alone suicidal.  We discussed his daily activities and how they may have changed over the past year.  Subsequently, the man identified a significant loss of interest in professional sports and cooking.  He became aware of his loss of interest in activities that had given him the greatest enjoyment.  Within six months of accepting treatment, the man was again enjoying sports and cooking.  The symptom of anhedonia often serves as an excellent marker of clinical progress.

Anhedonia is a very important symptom of depression because it has little overlap with other psychological disorders.  The depressive phase of Bipolar Disorder and Schizophrenia are two areas of overlap.  Since the anhedonia only occurs during the depressive phase of Bipolar Disorder, it is still valuable in ruling out other diagnoses.  Anhedonia is not a prominent symptom of schizophrenia, and could easily be thought of as a reaction to the auditory and visual hallucinations.  Not so much a direct reaction as a depressive reaction to the effect of the delusions and hallucinations on social relationships.  It is likely that anhedonia has a much greater overlap with medical conditions, since many physical illnesses can impair a person to the point it is difficult or impossible to engage in “normal” activities.

Anhedonia is not just a nifty word to impress others at a cocktail party.  It is a word that often correctly classifies people as depressed who are suffering without insight.  It is a symptom that has little overlap with other psychological disorders, such that it is a significant help in making a correct diagnosis.  A prospective patient needs to rule out medical conditions that lead to chronic fatigue and low motivation.  If this person is deemed physically healthy, yet continues to suffer with a global loss of interest, a trip to the psychologist will help rule out a Mood Disorder.

Depression

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If you have been to informational websites on depression, then you have a sense of what psychologists consider to be depressive disorders.  The typical symptoms are well known, and discussed all the time.  Depression actually falls within the general category of  “Mood Disorders.”  Anyone who has suffered with a bout of moderate Major Depression does not have to be convinced of its impact on work and family life.  Many have no doubt run across the term “Bipolar Disorder” and its older antiquated name “Manic-depression.”  I consider this diagnosis  at greater length in another category on the blog titled “Bipolar.”

The major difference between Major Depression and Bipolar Disorder is a cycle of mania or hypomania.  This is not a trivial distinction, whatsoever.  Even its milder variant, hypomania, is alarming to others over prolonged periods, and negatively affects occupational and social functioning.  Mania is alarming to others over rather brief periods.  It is the polar opposite of Major Depression.  Often those afflicted are not aware of their expansive mood, or consider it to be a blessing.  Depressive people are aware of their symptoms, and sometimes dwell on them excessively.  Chronically irritated depressives are often not aware they are depressed, but they are aware of their anger.  Consider asking a confidant about your symptoms, since they may provide a fresh prospective.  We only know ourselves through the eyes of others.

Bipolar Disorders are less common than Major Depression.  Bipolar Disorders are often more debilitating, and with less effective long-term treatment.  Severe Major Depression is a nightmare, but add the disorganized frenzy of mania, and it sums to a complete breakdown in functioning.  People who suffer with a severe Major Depression have a willingness to commit suicide, and may even experience psychotic symptoms.  The type of delusions experienced by people with Major Depression and Bipolar Disorder are quite different, though either disorder may become self-destructive.

Most people using this site are more likely to have a mild form of  Major Depression than a Bipolar Disorder.  The Bipolar subcategory on this blog is more useful to significant others, than for those who suffer themselves.  This is not true for the hypomanic person, as they tend to maintain greater self-awareness than someone with mania.  It’s that the hypomanic tends to feel quite elated and energetic, such that a boring old computer blog is not their idea of entertainment.  Perhaps those suffering with acute mania are too frantic to web surf, and those with hypomania lack the awareness to consider their condition a problem.

Bipolar Disorder is often misdiagnosed.  Hypomania is mistaken for mania, and normal mood swings are taken for hypomania.  It is a very serious illness that has almost been reduced to a fad.  Twenty years ago, Borderline Personality Disorder was constantly diagnosed and questioned.  It is doubtful that Bipolar Disorder will be the last diagnostic fad in the fields of psychology and psychiatry.

Most people have had at least one bout of Major Depression in their lives.  Statistically, it’s almost deviant to avoid a Major Depressive Episode one’s whole life.  Whereas Bipolar Disorders are rarely aware of their problematic symptoms while manic, the chronic depressive knows they are depressed, but often under-appreciates the severity of their suffering.  The depression becomes a backdrop to their life, to the point good spirits seem strange and disconcerting.  Once the depression reaches the Moderate stage, it grabs one’s attention in a different way.  Physical symptoms rear their ugly heads.  Suddenly, you cannot sleep, or conversely, one can’t seem to rouse the whole day.  Your appetite is either nil or not capable of being appeased.  Chronic anxious rumination is not able to be suppressed.  It is not always easy to link all the cognitive symptoms of a depression together, in order for someone to realize they are depressed.  Most outpatients initially seek treatment in the moderate stage of a Major Depression, as the physical symptoms assert themselves.  It is likely that the moderate stage of depression inspires many web searches.

Generally, treatment is a combination of psychotherapy and medication.  The combined treatment is nearly four times as effective as either treatment used in isolation.  I believe this rule is most true for Moderate to Severe Major Depressions.  I recommend cognitive-behavioral or psychodynamic therapy for treatment of mild depression.  I am less concerned about attribution errors in more severe depressions than a milder depression.  For example, many of my patients are worried when antidepressant therapy is decreased or discontinued.  Often these patients had taken an antidepressant for years without positive results, or were placed on too low a dose of the antidepressant to be clinically effective.  Depressive patients often fail to give themselves credit for their hard work in psychotherapy.  This is an attribution error, and we all are prone to this sort of error.  Please share your comments regarding this post in the space provided below.

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