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Anhedonia

What Is It, Causes, Diagnosis, and More

Author: Lily Guo

Editors: Alyssa Haag, Ian Mannarino, MD, MBA

Illustrator: Jessica Reynolds, MS

Copyeditor: David G. Walker


What is anhedonia?

Anhedonia refers to the inability to experience pleasure, often from activities that one used to enjoy. The DSM-V, or the fifth edition of The Diagnostic and Statistical Manual of Mental Disorders, defines anhedonia as “lack of enjoyment from, engagement in, or energy for life’s experiences; deficits in the capacity to feel pleasure and take interest in things.” Anhedonia is a facet of the broad personality trait domain detachment.

Anhedonia is a common symptom of major depressive disorder and other depressive disorders, including disruptive mood dysregulation disorder, dysthymia, premenstrual dysphoric disorder, and substance-induced depressive disorder. Depressive disorders can also be caused by an underlying medical condition (e.g., Parkinson’s disease, Cushing disease, or traumatic brain injury). Anhedonia may also be a symptom in those with neuropsychiatric disorders, such as schizophrenia, psychosis, and post-traumatic stress disorder (PTSD). While an individual’s interests can change over time and they may lose interest in things that once excited them, anhedonia describes an extreme loss of interest in things and activities that are generally accepted to be pleasurable (e.g., music, sex, food, and interaction with others). Generally, people who experience anhedonia will feel a sense of numbness or lack of feeling and have an overall negative outlook on life. 

How do you pronounce anhedonia?

Anhedonia is pronounced an-hee-dow-nee-uh.

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What causes anhedonia?

Anhedonia is a common symptom seen in those with major depressive disorder and is frequently linked to experiencing traumatic and stressful events; personality traits, such as pessimism or self-criticsm; and having a blood relative with a history of depression, bipolar disorder, alcoholism, suicide, or other mental illness. Other risk factors include having a personal history of other mental health disorders (e.g., anxiety disorder, eating disorders, or post-traumatic stress disorder); having a personal history of alcohol or recreational drug overuse; and having a serious or chronic illness, such as cancer, chronic pain, or heart disease. Major depressive disorder most commonly affects individuals aged 18-29 years old but can occur at any age and is diagnosed in those assigned female at birth at a frequency of 1.5-3 times higher than those assigned male at birth.

There are several structural causes of anhedonia, including reduced activity of the ventral striatum, a region of the brain that is likely involved in the reward system. The striatum also houses the nucleus accumbens, which has been referred to as the “pleasure center.” In addition to the deficit of activity in the striatum, there may also be atypical increase in activity of the prefrontal cortex, which is involved in planning and personality expression, seen in anhedonia. Other centers of the brain that are dysregulated in anhedonia include the amygdala, which processes emotions and is involved in decision-making, and the insula, which is thought to be important in consciousness and self-awareness. 

Imbalances in neurotransmitters, or chemical messengers secreted by nerves, have also been investigated in relation to anhedonia. Dopamine is a neurotransmitter involved in reward pathways and is expressed in high quantities in the nucleus accumbens. Reduced dopamine expression in the ventral striatum has been found to correlate with increased severity of anhedonia. Dopamine is also depleted in individuals recovering from substance use disorders and are suffering from post-acute withdrawal syndrome (PAWS). This occurs because the brain depends on substances for dopamine instead of producing its own. Additionally, gamma-Aminobutyric acid (GABA), an inhibitory neurotransmitter; glutamate, an excitatory neurotransmitter; and serotonin, a monoamine neurotransmitter, may also play a part in the pathophysiology of anhedonia. Those with major depressive disorder who also experience significant anhedonia are often found to have reduced GABA levels. 

Lastly, increased levels of inflammatory compounds, including C-reactive protein (CRP), have been measured in those with depression. Increased levels of CRP are associated with reduced connectivity between the ventral striatum and ventromedial prefrontal cortex (i.e., an area of the brain important in motivation) and subsequently, increased anhedonia.

How is anhedonia diagnosed?

Anhedonia can be diagnosed in various ways, including self-report after filling out a questionnaire administered by a clinician, answering questions on a scale, or diagnosis by a mental health professional after a thorough interview. The professional will likely ask questions about the individual’s symptoms and previous drug use and will generally assess the mood of the individual. It is also important to rule out other physical causes of anhedonia, such as substance use, vitamin deficiencies (e.g., Vitamin D), or an issue with the thyroid gland (e.g., hypothyroidism) as they can contribute to symptoms of depression. The mental health professional may perform a physical exam and order a blood test to assess vitamin and thyroid hormone levels. 

A clinician may use other diagnostic tools to assess anhedonia, which includes the Snaith-Hamilton Pleasure Scale (SHAPS), a brief 14-item self-reported scale. It asks individuals to rate statements on a scale from 0-3, with 0 being strongly disagree and 3 being strongly agree. Items include statements, such as “I would enjoy my favorite television or radio program,” “I would enjoy being with family or close friends,” “I would find pleasure in my hobbies and pastimes,” etc. The Positive and Negative Affect Schedule (PANAS) can also be administered as a measure of positive and negative affect. This consists of a 20-item mood inventory that measures positive affect (e.g., extent to which a person feels enthusiastic, active, or alert) and negative affect (e.g., feelings of anger, contempt, disgust, guilt, fear, or nervousness). Typically, the diagnosis of anhedonia is made at the same time as diagnosis of other mental disorders, such as major depression

How is anhedonia treated?

Currently, there are no specific treatments targeted at anhedonia. However, modifying lifestyle habits and treating the underlying causes may help. Strength training and aerobic activities (e.g., running or jogging) generate adrenaline and dopamine, which can provide both temporary relief and be an important part of a long-term treatment. This is especially important in those recovering from substance use disorder and PAWS. An individual may choose to seek help from a primary care professional to rule out a physical cause of their symptoms. If there are no underlying physical issues, the primary care doctor may recommend that the individual sees a psychiatrist, psychologist, or other mental health professional. It is common for mental health professionals to use cognitive behavioral therapy (CBT), a form of talk therapy, to help treat anhedonia. CBT allows individuals to become aware of and alter their negative thinking as well as respond to challenging situations in a more effective manner.

If other health conditions are indicated, such as Parkinson’s Disease or schizophrenia, the mental health professional may prescribe dopamine agonist medications (e.g., pramipexole, ropinirole, and rotigotine) and antipsychotic medications (e.g., risperidone, quetiapine, and olanzapine), respectively. If the anhedonia is experienced as a symptom of depression, a clinician may prescribe medications such as selective serotonin reuptake inhibitors (SSRI) (e.g., citalopram, escitalopram, and fluoxetine). However, research has shown that those with depression and anhedonia are more resistant to antidepressant medication therapy compared to those with depression who are not experiencing anhedonia. While SSRIs are still commonly used as a treatment, clinicians are currently exploring other anti-anhedonic medications, such as ketamine, a powerful analgesic and anesthetic that can overcome treatment resistance. Psychedelic microdosing, which is the practice of consuming very low, sub-hallucinogenic doses of psychedelic substances, such as psilocybin or lysergic acid diethylamide, have also been used with some success.

Another type of treatment that may be used in severe depression is electroconvulsive therapy (ECT). During ECT, a trained mental health professional places electrodes on the surface of the scalp and administers electric currents through the brain while the individual is under general anesthesia. This induces seizures, which can help overcome treatment resistant depression. Novel treatment for depression, such as Transcranial Magnetic Stimulation and Eye Movement Desensitization and Reprocessing, may also provide benefit in the treatment of anhedonia.

Can anhedonia go away?

Anhedonia may go away with the help of a trained mental health professional and by treating any underlying causes. Symptoms of anhedonia may come and go intermittently, and they are frequently not permanent. It is best to speak with a licensed professional about the best route for overcoming anhedonia.

What are the most important facts to know about anhedonia?

Anhedonia refers to the loss of ability to feel pleasure and is a common symptom of depressive disorders and substance use disorder. It may be caused by a decrease in activation of the region of the brain involved in reward and motivation, referred to as the ventral striatum. There may also be dysregulation of hormones that regulate the brain, including dopamine and GABA, in those with anhedonia. Diagnosis relies on speaking with a mental health professional and filling out a scale that gauges one’s interest in day-to-day activities. If an individual is diagnosed with anhedonia, the goal is to take part in more activities that can boost dopamine, such as attempting to engage in social situations and exercising. If anhedonia is a part of a larger underlying health condition, treating the condition can alleviate the symptoms of anhedonia. Anhedonia does not have to be permanent and can be treated with the help of a mental health professional. 

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Related links

Schizophrenia spectrum disorders: Clinical practice
Trauma- and stressor-related disorders: Clinical practice
Major depressive disorder
Mood disorders: Clinical practice
Mood disorders: Pathology review

Resources for research and reference

Destoop, M., Morrens, M., Coppens, V., & Dom, G. (2019). Addiction, anhedonia, and comorbid mood disorder. A narrative review. Frontiers in Psychiatry, 10. DOI: 10.3389/fpsyt.2019.00311 

Franken, I. H. A., Rassin, E., & Muris P. (2007). The assessment of anhedonia in clinical and non-clinical populations: further validation of the Snaith-Hamilton Pleasure Scale (SHAPS). Journal of Affective Disorders, 99(1-3): 83-89. DOI: 10.1016/j.jad.2006.08.020

Newman, T. (2018). Understanding anhedonia: What happens in the brain? In Medical News Today. Retrieved December 16, 2021, from https://www.medicalnewstoday.com/articles/320737#Treating-anhedonia

O’Neill, M. (2021) Anhedonia Makes It Hard for People to Feel Joy - Here’s What That Means, According to Experts. In Health. Retrieved December 17, 2021, from  https://www.health.com/mind-body/anhedonia