Living without pleasure

People tend to think of depression as a syndrome characterized primarily by pervasive feelings of sadness.  To be depressed is to be in such despair that it becomes difficult to function.  Many of us have either known someone struggling with depression or have seen it somehow depicted by cultural media.  As a result, few of us are completely unfamiliar with what it means to be depressed.

Many of my patients struggle with depression.  For every new patient seen in our clinic, we obtain a full biopsychosocial history and perform a complete diagnostic assessment.  Ideally, the goal of this assessment is to generate an overview of the patient's "problem," preferably in the form of a clinical diagnosis.  In reality, however, I find that few patients really need me to tell them what's wrong; most of them already have an idea of what's wrong, which is the reason they've sought help in the first place.  In other words, a person struggling with depression already knows he feels depressed; he gains very little from having me slap a label on it. 

From time to time, however, I encounter patients who seem clearly depressed to me but who are quite surprised to hear me say it.  "I don't feel depressed," they say.  You see, depression doesn't always look the way we think it does.  In fact, it's quite possible for someone who doesn't necessarily feel depressed to meet the diagnostic criteria for Major Depressive Disorder.  Rather than feeling depressed, the problem for such a person might be that he doesn't feel much of anything at all. 

Anhedonia has been described, quite poetically, as the "paralysis of emotion."  It comes from a combination of the Greek a + hedone, literally meaning "not pleasure."  In mental health, it refers to an inability to experience pleasure in activities that one would typically find enjoyable. 

Patients relate how they experience it.  "I just feel 'blah," is a quite common description.  Others talk about lacking motivation.  "I don't feel like doing anything," they say.  "I can't get motivated."  Still others become distressed by what they perceive as a personal failing.  "I don't even enjoy spending time with my kids.  The whole time I'm with them I'm looking at my watch, wanting it to be over;" or perhaps, "I know I love my kids, but I just can't feel it." 

I wish I could conclude my little presentation with some wisdom about how we can all learn to experience pleasure in life.  The truth is, I let out an inward groan everytime a patient tells me he is unable to find pleasure in anything.  That's because as a symptom, anhedonia is notoriously difficult to treat. As a therapist, I can encourage you to engage in activities that should theoretically be enjoyable, but I can't make you enjoy them.  I'm not even sure I can teach you to enjoy them.  How do you teach something like that?  Treatment with antidepressant medications have very limited success as well.  It's a situation that often makes me feel helpless.

But if I feel helpless, imagine how the patient must feel.  Imagine a life without pleasure.  What kind of life would that be?