From sadness to depressed mood and from anhedonia to positive mood and well-being

Section of Psychiatry, Chair
University Psychiatric Center
KuLeuven, Campus Gasthuisberg

From sadness to depressed mood and from anhedonia to positive mood and well-being

by K. Demyttenaere, Belgium

Depressed mood and anhedonia are the two core symptoms of major depression as defined in the Diagnostic and Statistical Manual of Mental Disorders, but both symptoms are more complex than generally thought. The differentiation between depressed mood and sadness or between depressed mood and bereavement remains a clinically relevant question in daily practice. While the former is rather a mood or affect state and is usually considered independent from loss, the latter is an emotion and is usually considered as being linked to a loss situation. However, clinical reality shows that, especially in first episode depression (less in recurrent depression), patients frequently report stressful life events often linked to loss. Anhedonia, or lack of interest or pleasure, is a compound criterion, since loss of interest (appetitive or motivational anhedonia) and loss of pleasure (consummatory anhedonia) are different phenomena. Another clinically relevant question is whether the opposite of anhedonia is absence of anhedonia or whether it is the presence of positive mood and well-being. The tools most frequently used to assess change during antidepressant treatment give significantly more attention to depressed mood than to anhedonia. This is worrying, since it is in sharp contrast with what patients expect from treatment. Indeed, it has been documented that patients consider the restoration of positive mental health (optimism, vigor, self-confidence) to be the most important expectation. In conclusion, more careful differentiation between (normal) sadness and depressed mood could probably enhance diagnostic accuracy in depression, and a more careful taking into account of positive mood would probably be beneficial to the depressed patient.

Medicographia. 2013;35:287-291 (see French abstract on page 291)

In the more recent versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the two core symptoms of depression are depressed mood and lack of interest or pleasure.1-4 This is in contrast with the more recent versions of the International Classifications of Diseases (ICD), where three core symptoms of depression are mentioned: depressed mood, lack of interest or pleasure, and fatigue.5,6 The present paper focuses on depressed mood and how it is related to sadness, and on anhedonia and how it is related to positive mood or well-being.

In daily life, we all experience positive and negative emotions, positive and negative affect, positive and negative mood, and it is probably a lifelong challenge to find a balance between them. German E. Berrios, making an attempt to carefully order the words mood, affect, sentiment, emotion, and passion, and to help us out of the terminology confusion, cites Ribot7:

Sentiment, emotion and passion have been customarily distinguished from mood, affect and feeling in terms of criteria such as duration, polarity, intensity, insight, saliency, association with an inner or outer object, bodily sensations and motivational force. Sentiment, emotion and passion are defined as feeling states that are short-lived, intense, salient, and related to a recognizable object.…Mood and affect, on the other hand, are defined as longer lasting and objectless states capable of providing a sort of background feeling tone to the individual.

From sadness to depressed mood

Izard stated that sadness is generally considered to be a negative emotion, an emotional response to separation, death, disappointment, failure to achieve an important goal, or to the sorrow of another.8(pp185-186) But he also stated that we too often forget that sadness can be an appropriate response: for example, to the death of someone you love. Shared sadness can reunite a family or friends, can strengthen the sources of social support, can invite you to slow down the pace of your life, can communicate to the self that all is not well, can motivate one to renew and strengthen bonds with others, and can play a role in empathy. Distinguishing between sadness and depression is important, but not always easy. Both are often associated with loss (death, loss of a companion, the loss of friends or a love relationship, or even less easily definable losses), but the difference is that the depressed individual feels, and often actually is, incapable of dealing with the loss: the depression must be resolved before the individual can attempt to deal with the loss. By contrast, in simple sadness, the individual is capable of taking another look at the source of trouble and doing something about it.8(p209) It is, however, well documented that stressors (most often loss situations) are more frequently found in the months preceding a first episode depression than in the months preceding recurrent episode depression, where new episodes seem to become more and more independent of life stressors or losses.9 So from a qualitative point of view, first episode depression seems to be closer to sadness as an emotion, while recurrent depression seems to be closer to depressed mood or depressed affect. The wording of the DSM diagnostic criteria for depression seems to combine both aspects: depressed mood is defined as feeling sad or empty as indicated by selfreport or as appearing tearful as observed by others.4

If we accept that sadness is a negative emotion related to separation or loss and that depressed mood or depressed affect is a longer lasting and maybe more objectless state, the subsequent versions of psychiatric classification systems seem to have struggled with this difference. Indeed, neither the Feighner criteria nor the Research Diagnostic Criteria (RDC) contained an exclusion for bereavement or any other normal reactions, although they did require researchers to ascertain during their interview with patients whether bereavement was present.10,11 But DSM-III did contain bereavement as an exclusion criterion, where it was the single exception to defining sad or depressed mood as a depressive symptom.1 However, DSM-III overlooked the fact that reactions to other types of loss may have similar features to bereavement; for example, reactions to separation, illness, or economic reversal. Reactions to these types of loss were hence not included, perhaps because they could lack the relatively clear-cut nature of bereavement.1 An intermediate solution has been proposed to differentiate between bereavement and depression on top of bereavement: is the sadness a proportionate response to the real loss? This does not seem to solve the problem, however, since the discussion then just shifts to what is proportionate or not. Moreover, it has also been argued that the bereavement issue then becomes an etiological one that has no place in a theory-neutral manual, which DSM claims to aim to be.12 Aside from “disproportionate,” other attempts at exclusions- from-the-exclusion have been “when no close temporal relationship (eg, 3 months?) between bereavement and depression was found” and “when the bereavement reaction was too long lasting (2 months? 6 months?),” but again, these specifications are debatable and not very helpful. The additional diagnostic criteria for “adjustment disorder with depressed mood” are also not very helpful in qualitatively differentiating the two mood states.

Ghaemi takes this discussion back to Freud, who compared bereavement and depression (Mourning and Melancholia, 1917) and found that depression is phenomenologically similar to mourning and that what happens in mourning could provide the key to depression: sad at our loved one’s death, guilty about the anger toward him, we turn our anger inward, repressing its outward expression, and become even sadder. Freud hypothesized that pathological depression also involved these kinds of feelings toward others, repressed by an anger turned inward and directed at oneself.13(pp212-215) It becomes clear that sadness here can be understood as being part of a broader domain that also includes some degree of emotional emptiness, shame, humiliation, or loss of self-esteem.14(p24) In a mourning process, the world seems to be empty, while in depression, the world and the self seem to be empty.

Ghaemi then brings this discussion to two opposite models of depression, leaving the “bereavement-depression” debate and focusing more on cognitive distortions as being at the origin of depressed mood.13 It is therefore no longer the de- pressed or sad mood that specifies depression, but the cognitive distortions around it. The “learned helplessness” model indeed postulates that individuals develop depression in adulthood based on experiences earlier in life in which they suffered, but fromwhich they had nomeans of escaping. They retain these feelings even when escape routes are later offered: they learned to be helpless, and they remain so.15 Hence, depressed patients would suffer from depression because of these cognitive distortions, present in response to sadness in depressed patients, but absent in “normal” sadness. By contrast, the “depressive realism” model, based on experiments with college students that involved guessing when they did and did not have control over an outcome through their actions in a test situation, postulates that it is not the depressed individuals, but rather the healthy nondepressed individuals that have cognitive distortions, not seeing the world too much as it is, with all its pain and mortality and with all our weakness and cosmic insignificance as individuals.16 Depressed patients, hence, would suffer from depression because of their lack of cognitive distortions. Depression might seem simple, but it is definitely not.

From anhedonia to positive mood and well-being

The second core symptom in the DSM criteria for depression is lack of interest or pleasure. A more careful look at the way this symptom has been treated in different classifications reveals the ambivalence or the hesitations regarding the importance to be given to this symptom.

The Feighner criteria had only one necessary condition for the diagnosis of depression (dysphoric mood marked by symptoms such as being depressed, sad, despondent, or hopeless), and “loss of interest in usual activities” was only one of the minimum five additional symptoms needed to make the diagnosis of depression (at the same level as loss of appetite, sleep difficulty, loss of energy, agitation, guilt feelings, slow thinking, and recurrent suicidal thoughts).12

The major changes in the RDC from the Feighner criteria were stipulations that pervasive loss of interest or pleasure could be substituted for dysphoric mood as a necessary condition (reflecting a growing view that loss of capacity for pleasure is central to depression).14(p95) In other words, anhedonia became a symptom that was as important as depressed mood, and theoretically a patient could suffer from major depression with anhedonia and no depressed mood, or with depressed mood and no anhedonia, or with both core symptoms. From DSM-III onward, anhedonia (loss of interest and pleasure) became a core symptom of depression, at the same level as depressed mood.1-4

Anhedonia (lack of…, loss of…) is considered to be opposite to the notions of “positive mental health,” (“positive emotions,” “positive affect,” “positive mood”), and these notions continue to elicit conflicting opinions. Health can be seen as merely the absence of illness: illness is defined positively and health negatively.13 TheWorld Health Organization (WHO) defined “health” as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity (WHO, 1948). As Ghaemi stated, other authors are opposed to this view and reject the “unattainable wholeness of body, mind, and soul,” while arguing that it is the presence of disease that can be recognized, not the presence of health.17 In any case, the question remains as to whether the opposite of anhedonia is the absence of anhedonia or the presence of hedonia; in other words, is lack of anhedonia enough to consider somebody to be in “positive mental health” or should there be positive hedonia?

Another problem with symptoms of anhedonia is that they are considered as a compound diagnostic criterion: loss of interest (appetitive or motivational anhedonia, “wanting”) and loss of pleasure (consummatory anhedonia, “liking”) in response to stimuli that were previously perceived as rewarding. This aggregation hence lacks precision, and from a psychological as well as neurobiological point of view, these two subsymptoms are not the same.18

One could even go one step further and try to “read” other depressive symptoms as being decreased hedonic function: depressed mood as decreased positive affect, fatigue as diminished motivation and/or decreased energy to pursue enjoyable and goal-directed activities, and social withdrawal as reduced enthusiasm for interactions with others or difficulty obtaining enjoyment from these interactions. One could also differentiate between experiencing positive emotions (pride, enthusiasm, determination, strength, inspiration, joy, enjoyment, surprise, pleasure, excitement, vigor, etc) and the anticipation of responding with positive emotions to pleasurable situations (I would enjoy seeing other people’s smiling faces, I would enjoy a warm bath or refreshing shower, I would find pleasure in the scent of flowers or the smell of a fresh sea breeze or freshly baked bread, someone complimenting me would have a great effect on me, someone I am very attracted to asking me out for coffee would have a great effect on me, etc).19-21 The dysregulation of positive affect in depression could even be further differentiated between an elevated threshold for activating positive affect, a less intense response once positive affect is activated, difficulty sustaining a positive affect response, failure to activate positive affect in appropriate contexts, or insufficient devotion of cognitive resources to initiating, sustaining, or enhancing a typical internal positive affect response.

Assessment of treatment effects on sadness and depressed mood, on anhedonia, positive mood, and well-being

The assessment of change during antidepressant treatment is usually carried out with an observer rating scale: the Hamilton Depression Rating Scale (HAM-D) or the Montgomery- Asberg Depression Rating Scale (MADRS).22,23 The two core symptoms of the DSM diagnostic criteria are included in the rating scales to a different degree, but in any case lose their “privileged” position. Sad or depressed mood is well represented in both scales, but anhedonia has a more marginal position in both scales.

The 17-item HAM-D also gives more attention to negative affect items than to anhedonia: depressed mood (sadness, hopeless, helpless, worthlessness; hence, not only referring to affect, but also to cognitions), psychological anxiety (subjective tension and irritability, worrying), and somatic anxiety. Again, only one item is more or less referring to anhedonia: work and activities (thoughts and feelings of incapacity; fatigue or weakness; loss of interest in activities, hobbies, or work; decrease in actual time spent in activities or decrease in productivity; stopping working—hence, not only referring to anhedonia, but also to functioning).22

The 10-item MADRS has three negative affect items: apparent sadness (representing despondency, gloom, and despair [more than just ordinary transient low spirits]), reported sadness (representing depressed mood, low spirits, despondency, or feelings of being beyond help without hope), and inner tension (representing feelings of ill-defined discomfort, edginess, inner turmoil mounting to either panic, dread, or anguish). Only one item refers to anhedonia, although in the higher scores, there is a reference to the complete inability to feel positive as well as negative emotion: inability to feel (representing the subjective experience of reduced interest in the surroundings or in activities that normally give pleasure, up to the experience of being emotionally paralyzed, unable to feel anger, grief, or pleasure).23

The rather marginal place of anhedonia is hence somewhat in contrast with the DSM criteria. What is more worrying, however, is that this is in sharp contrast with what patients themselves expect as an outcome from treatment when suffering from depression. Zimmerman showed that from a patient perspective, the rank order of the most important expectations from antidepressant treatment are first, presence of positive mental health (optimism, vigor, self-confidence); second, feeling like your usual, normal self; third, return to usual level of functioning at work, home, or school; fourth, feeling in emotional control; fifth, participating in and enjoying relationships with family and friends; and only sixth, absence of symptoms of depression (negative affect). This indeed suggests that patients put a much larger emphasis on positive affect in their expectations. 24 The question indeed is whether cure from depression results from a decrease in (negatively defined) anhedonia or from an increase in (positively defined) interest or pleasure? Many clinicians take it for granted that a decrease in negative affect will automatically result in an increase in positive affect, but research shows that the relation between negative and positive affect is more complicated: correlation coefficients between both are reported to be only about –0.3021.

In conclusion, the difference between (normal) sadness and depression, as well as the difference between anhedonia and positive mood or well-being, has a history of reflection, debate, and hesitation, not only in terms of the classification systems, but also in the assessment of outcome in depression. A more careful differentiation between (normal) sadness and depression could probably enhance diagnostic accuracy, and amore careful taking into account of positive affect would probably be beneficial to the depressed patient. _

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed, rev. Washington, DC: Author; 1987.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
4. American PsychiatricAssociation.Diagnostic and Statistical Manual ofMental Disorders. 4th ed, text rev.Washington, DC: American Psychiatric Association; 2000.
5. World Health Organization. Mental disorders: Glossary and Guide to the Classification in Accordance with the Ninth Revision of the International Classification of Diseases. Geneva, Switzerland: World Health Organization; 1978.
6. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva, Switzerland: World Health Organization; 1992.
7. Berrios GE. The History of Mental Symptoms. Descriptive Psychopathology Since theNineteenthCentury. Cambridge, UK:CambridgeUniversityPress;1996.
8. Izard CE. The Psychology of Emotions. New York and London: Plenum Press; 1991.
9. Kendler KS, Thornton LM, Gardner CO. Stressful life events and previous episodes in the etiology of major depression in women: an evaluation of the “kindling” hypothesis. Am J Psychiatry. 2000;157(8):1243-1251.
10. Feighner JP, Robins E, Guze SB, Woodruff RA, Winokur G, Munoz R. Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry. 1972;26:57-63.
11. Spitzer RL, Endicott J, Robins E. Clinical criteria for psychiatric diagnosis and DSM-III. Am J Psychiatry. 1975;132:1187-1192.
12. Woodruff RA, Goodwin DW, Guze SB. Psychiatric Diagnosis. New York, NY: University Press; 1974.
13. Ghaemi SN. The Concepts of Psychiatry. A Pluralistic Approach to the Mind and Mental Illness.Baltimore and London: The Johns Hopkins University Press; 2003.
14. Horwitz VA, Wakefield JC. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. New York, NY: Oxford University Press; 2007.
15. Huesmann, LR. Learned Helplessness as a Model of Depression. Washington, DC: American Psychological Association; 1978.
16. Alloy LB and Abramson LY. Depressive realism: four theoretical pespectives. In: Alloy LB ed. Cognitive Processes in Depression. New York, NY: Guilford Press; 1988:223-265.
17. Lewis A. The State of Psychiatry: Essays and Addresses. New York, NY: Science House; 1967.
18. McCabe C, Mishor Z, Cowen PJ, Harmer CJ. Diminished neural processing of aversive and rewarding stimuli during selective serotonin reuptake inhibitor treatment. Biol Psychiatry. 2010;67:439-445.
19. Snaith RP, Hamilton M, Morley S, Humayan A, Hargreaves O, Trigwell P. A scale for the assessment of hedonic tone: the Snaith-Hamilton Pleasure Scale. Br J Psychiatry. 1995;167:99-103.
20. Bachorowski JA, Braaten EB. Emotional intensity: measurement and theoretical implications. Pers Individ Dif. 1994;17(2):191-199.
21. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS Scales. J Pers Soc Psychol. 1988;54 (6):1063-1070.
22. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960; 23:56-62.
23. Montgomery SA and Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134:382-389.
24. Zimmerman M, McGlinchey JB, Posternak MA, Friedman M, Attiullah N, Boerescu D. How should remission from depression be defined? The depressed patient’s perspective. Am J Psychiatry. 2006;163(1):148-150.

Keywords: anhedonia; depressed mood; DSM; Feighner criteria; HAM-D; ICD; MADRS; positive mood; Research Diagnostic Criteria; sadness