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Anhedonia: A Case
Study Kristina E.
Luna 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. The psychoanalytic
perspective 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 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. 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,
·
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. 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. 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. |