A New Intervention to Reduce Anhedonia in Schizophrenia

Meta-analyses of cognitive behavioral therapy for positive symptoms of schizophrenia have demonstrated its effectiveness in reducing hallucinations or delusions. In schizophrenia “negative symptoms’ refer to a reduction of normal functioning, and it encompasses apathy, anhedonia, flat effect, avolition, social withdrawal, and, sometimes, psychomotor retardation. The purpose of this study is the idea that Anhedonia is a challenging symptom of schizophrenia and remains largely recalcitrant to current pharmacological treatments.

The goal of this exploratory pilot study was to assess if a cognitive-sensory intervention could improve anticipatory pleasure. Results show that the patients improved on the anticipatory scale of the Temporal Experience of Pleasure Scale. Daily activities of the patients were also increased. In nursing research, it has been shown that the sense of mastery is negatively correlated with negative symptoms or even with the fact of being left alone. Two research questions were addressed in a sample of five participants. Does cognitive-sensory training in anticipatory pleasure in persons with schizophrenia?

Does cognitive-sensory training in anticipatory pleasure lead to an increase in the number and complexity of daily activities performed by persons with schizophrenia? They did not expect that anticipatory pleasure cognitive skills training would directly improve consummatory pleasure. If persons with schizophrenia show a deficit in their ability to anticipate pleasure rather than consummatory pleasure, then it becomes possible to consider cognitive training might help these individuals anticipate pleasure from foreseeable, future activities.

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I feel the author did a good job using literature to support their predictions and I was convinced by their argument. The author used well supporting concepts to prove their points as they discussed theories about Anticipatory Pleasure Skills Training: A New Intervention to Reduce Anhedonia in Schizophrenia. I particularly liked the idea that they did a two year comprehensive program including assertive community treatment, social skills training, and multifamily therapy groups that led to significantly less positive and negative symptoms, less comorbid substance buse, and significantly greater satisfaction with treatment. The author thought a more specific and symptom-centered approach because they felt it might lead to specific improvement in a shorter period of time. This symptom-specific strategy has been used in other studies for positive symptoms, allowing the development of successful specific therapeutic techniques. The case studies presented in this article highlight the use of this specific symptom approach for Anhedonia. Anhedonia has been defined as a reduction in the ability to experience pleasure. It has been regarded as a core clinical feature of schizophrenia.

Research has produced a paradoxical set of findings, raising questions about its nature. Individuals with schizophrenia typically report experiencing lower levels of pleasure in their daily lives than non-patients on self-report measures of trait social and physical Anhedonia. Anticipatory pleasure is linked to motivational processes that promote goal-directed behaviors; consummatory pleasure is associated with satiety. The Temporal Experience of Pleasure Scale is a trait measure of pleasure that distinguishes between “momentary pleasure” and “anticipation of future pleasure activities. The illumination of a new way of conceptualizing Anhedonia in schizophrenia permits redefinition and calibration of the symptom complex as a target for treatment. If persons with schizophrenia show a deficit in their ability to anticipate pleasure rather than consummatory pleasure, then it becomes possible to consider that cognitive training might help these individuals anticipate pleasure from foreseeable, future activities. Greater ability to anticipate pleasure would lead to a meaningful increase in spontaneous daily activities performed.

Five participants were included in this pilot study. The participants were recruited from the regular clinical practices of the authors. The first and second authors were working in a mobile team of a community psychiatry outpatient service. The different members of this team worked as clinical case managers and were specialized in engaging difficult-to-reach patients in a comprehensive recovery program including therapeutic, occupational, and vocational services. The third author was working in a nursing home for psychiatric patients.

The intervention was proposed to the patient when Anhedonia was reported as a challenging behavior impeding improvement in the care of the patient. To be included, participants had to be on a moderate dose of maintenance antipsychotic medication, with stable dosage for at least the past 3 months, and not be suffering from a major depression (score less than 12 on the Calgary Depression Scale for Schizophrenia [CDSS]). As the intervention was delivered in the routine care, signed informed consent to use the gathered data was obtained retrospectively for patients 1, 2, and 3.

The internal review board of the nursing home approved the study, and patients 4 and 5 signed the informed consent form before their participation in the study. The participants were four men and one woman. All participants met the Diagnostic and Statistical Manual of Mental Disorders (4th edition, Text Revision) criteria for schizophrenia (American Psychiatric Association, 2000). Diagnosis was obtained at the referral time with discussion with the referring psychiatrist. Participant 1 left school by the age of 16 and had no further education or training.

He had been housebound for 3 years except during acute somatic or psychiatric care. Participants 2 and 3 were working part time in competitive employment. Participants 1 and 2 lived at home with their parents; participant 3 lived alone in her own apartment. Participants 4 and 5 had been institutionalized in a nursing home for 14 years and 30 years, respectively, and did not work. Participants 1, 4, and 5 had a history of alcohol abuse. Participant 1 used cannabis when friends visited him at home. The intervention is a cognitive-sensory intervention that aims at increasing anticipatory pleasure.

Participants are trained in state of relaxation to anticipate pleasure from potential enjoyable activities and to get the sensation of the pleasure in their bodies. The different steps of the program are described below. 1. Building the rationale for the intervention. The rationale is built by asking questions to participants in order to elicit the importance of being able to anticipate pleasure from future activities, and the links between desire and motivation. Examples of these questions are: How do you prompt yourself to engage in activities?

What makes an activity more or less attractive? What are your criteria to assess if the effort to engage in an activity is worthwhile? 2. List of pleasant activities. The therapist and the patient will list past enjoyable activities that the person would like to resume, actual activities that the person would like to increase, and novel activities associated with new roles that the person would like to assume. For example, a participant who wants to be closer to his/her sister could engage in the activity of preparing a dinner for his/her sister and her boyfriend. . Classifying activities according to their difficulty. These listed activities are then classified according to the difficulty and complexity of the task. The classification is done from easy-to-do to difficult-to-do. Examples of simple activities are (a) going to the corner of the street and having a kebab, (b) taking a walk with a good friend, (c) taking a shower, etc. Complex activities related to social or professional roles are split in smaller reachable units before engaging in a more challenging activity.

For example, going to the stadium to support one's favorite hockey team could be split in a more achievable goal such as inviting a friend to watch one's team on TV if going to a crowded sports arena is an obstacle to engaging in the activity. 4. Anticipating pleasure. During the first sessions, the therapist uses standardized material to teach the anticipatory skills. The material is composed of attractive picture-viewing activities such as biting an appetizing apple, drinking a frothy coffee presented in a lovely cup, or walking in a beautiful park.

In subsequent sessions, the training focuses on the activities listed with the patient. At the beginning of each session, as patients may be "contaminated" by co-occurring unpleasant emotions (Horan, Green, Kring, & Nuechterlein, 2006), the therapist will start with a mindfulness or relaxation exercise to help the patient be in a comfortable, pleasant emotional state. Then, the patient is asked to imagine doing the chosen activity. The therapist guides the patient to imagine the sensations linked to the activity through the senses involved (sight, hearing, touch, smell, and taste).

The patient is invited to remember past positive experiences of the activity (e. g. , Imagine that you are smelling the odor of the best kebab you have ever eaten . . . Feel the smell of the grilled meat in your nose . . . Concentrate on this odor . . . Try to feel it as vividly as possible). The patient is asked to anticipate pleasant emotions (e. g. , Feel the sensations associated with the joy of being with your friend . . . You told me that this friend is funny . . . Imagine the sensations that go with laughing. Scan your body and remember how it is to laugh . . . ).

According to the anticipated activity, the patient may be guided to anticipate the feeling of accomplishment (e. g. , Feel the contentment of getting out of the shower. . . How is it to feel clean and fresh? Try to get this feeling fully . . . Anticipate the sensation of reward. . . How is it? ). If the patient shows difficulty in imagining sensations and feelings, pictures can be presented. Patients have to assess their desire to perform the activity on a 5-point scale before and after each exercise. 5. Prescribing homework exercises. As participants develop anticipatory pleasure skills, the therapist prescribes homework exercises.

After participants accomplish single activities in daily living, more difficult activities are trained. Participant 1 received 10 hours of training at home, aimed at giving him the desire to go outside. Participants 2 and 3 received, respectively, 25 hours and 20 hours of training at the therapist's office. Participants 4 and 5 received 11 sessions of 1. 5 hours of training each in a weekly group session. Instruments: The therapists have administrated the instruments as clinical tools to assess anticipatory and consummatory pleasure, time budget, negative symptoms, and depression.

The TEPS. The TEPS measures momentary pleasure and pleasure in anticipation of future activities. It is an 18-item self-report measure of trait, and anticipatory (10 items) and consummatory (8 items) pleasure (Gard et al. , 2006). The validation of the French version of the TEPS shows psychometric characteristics similar to the original version (Favrod et al. , 2009) with a satisfactory internal and external validity. The mean theoretical range of the two scales goes from 1 to 6; higher scores indicate more pleasure. The scale was administrated in pretests and posttests.

The Time Budget Measure: The measure developed by Jolley et al. (2005, 2006) takes the form of a weekly diary completed retrospectively during a structured interview with the participant. In completing the measure, interviewers probe for activities, degree of independence in activities, and number and nature of social contacts. They also check that the week is a typical or average week, and, if not, complete the time budget on a different occasion to assess an average week. Each day is divided into four time blocks (morning, lunchtime, afternoon, evening).

Each time period or block is then rated from 0 to 4 as below: 0 = nothing - lying, thinking, sleeping, sitting, etc. , 1 = predominantly passive activity (e. g. , watching TV, listening to the radio), 2 = an independent activity requiring some planning and motivation, but relatively simple or brief (e. g. , a walk to the local shops to get cigarettes, tidying room, washing up, preparing a simple meal for oneself), 3 = several two-rated activities completely filling a time period, sounding 'busy', or a more complex and demanding, but unvaried or shorter activity (e. g. a visit involving public transport, prolonged social contact with others), and 4 = time period filled with a variety of demanding independent activities requiring significant motivation and planning, and with some variation in tasks (e. g. , work, a course of study, a trip out requiring organization). When more than one activity is present, the highest scoring activity is rated. There are 28 time blocks for the week, and the total possible score ranges from 0 to 112. The time budget was not used for the patients in the nursing home because the time-budget of these patients depended on the institutional routine.

The week assessed should be a typical or average week, and if not, the time budget is completed in relation to a week chosen to be more representative. Time budget has a satisfactory criterion and construct validity, and shows good inter-rater reliability and test-retest reliability (Jolley et al. , 2005, 2006). In the present study, the participants were interviewed on their time budget starting from the day before the assessment meeting until 7 days before this meeting. The time budget was assessed in pretests and posttests.

The CDSS. The CDSS was used to assess depressive symptoms (Addington, Addington, Maticka-Tyndale, & Joyce, 1992). The CDSS is a largely validated interview-based measure that has been shown to assess depression rather than positive, negative, or extrapyramidal symptoms (Addington, Addington, & Maticka-Tyndale, 1993, 1994; Addington et al. , 1992). The scale is validated in French (Lan?on, Auquier, Reine, Bernard, & Toumi, 2000; Lan?on, Auquier, Reine, Toumi, & Addington, 1999). The CDSS was administrated in pretest only to assess the severity of depression.

Depression defined by the Diagnostic and Statistical Manual of Mental Disorders (4th edition, Text Revision) criteria for major depressive episode corresponds to a mean score of 11. 8 (standard deviation [SD] = 3. 8) on the CDSS (Kim et al. , 2006). The Scale for the Assessment of Negative Symptoms Anhedonia/ Asociality. The Scale for the Assessment of Negative Symptoms (SANS) assesses five symptom complexes to obtain clinical ratings of negative symptoms in patients with schizophrenia. They are affective blunting, alogia (impoverished thinking), avolition/apathy, anhedonia /asociality, and disturbance of attention.

The final symptom complexes seem to have less obvious relevance to negative symptoms compared with the other four complexes. Assessments are conducted on a 6-point scale (0 = not at all to 5 = severe; Andreasen, 1989). The SANS is a valid instrument (Peralta & Cuesta, 1995); however, interrater reliability is reduced when clinicians use it in comparison to highly trained research assistants (Norman, Malia, Cortese, & Diaz, 1996). In the present study, only the anhedonia /asociality scale of the SANS was administrated in the pretest to assess the severity of Anhedonia.

I feel the researchers can test their predictions using these methods because of what lengths they went to in presenting their techniques. They incorporated a lot of various useful ideas when testing their participants. Many angles were used to go into full detail in what steps were taken to evaluate each participant in this study. The authors I feel gave a very detail analysis of each step that was taken as to not leave out any variables in each case scenario. A cognitive-sensory training package focusing on anticipating future pleasant feelings about performing activities appears to improve anticipatory pleasure as measured by the TEPS.

The high RCI indicates that the posttest scores of the anticipatory pleasure scale are reflecting important change for the five participants. These results, although preliminary, are very interesting because Anhedonia remains a particularly challenging symptom. Our second question related to whether an increase in anticipatory pleasure would be accompanied by an increase in daily activities. Concurrently, change in anticipatory pleasure, as measured by the scale, was accompanied by an increase in activity for the three participants for whom it was possible to fulfill the time budget.

Participant 4 had been ritually visiting his mother once a week for years before training. At the end of the training, the nursing home team observed that the patient had added in every week a new spontaneous activity such as going to town to do shopping, planning a little trip, or spontaneously organizing an appointment with the hairdresser outside of the nursing home. Participant 5 had been accomplishing five household chores a day for many years and did not change his program at the end of the training. The participant had been institutionalized for a great part of his life.

In previous work, we found a significant negative correlation between anticipatory pleasure and the avolition/apathy of the SANS (Favrod et al. , 2009). This correlation was lower than the one with the Anhedonia/asociality scale of the SANS, indicating a weaker link between these two variables. Apathy and avolition are probably associated with anticipatory pleasure. However, several other variables may affect activity and willingness, such as planning skills, motor skills, reinforcements provided by the environment, etc.

The results indicated that the training did not seem to improve consummatory pleasure as a consequence of an increase in anticipatory pleasure. The lack of follow-up assessment did not allow observation of an eventual delay for improvement in consummatory pleasure as a consequence of improvement of anticipatory pleasure and engagement in new activities. Another explanation could be that both kinds of pleasure have some independence between them. Anticipatory pleasure is linked to motivational processes and consummatory pleasure with satiety processes. I feel the researchers did a very good job in describing every detail of their research.

My reaction to this article is that I think Pleasure Skills Training can really help people with schizophrenia if done properly over an extended period of time under the right conditions. I as well sense that the article does contribute something interesting and important to the field. Individuals with schizophrenia already have a hard enough time in life and to go on living without experiencing a sense of pleasure is disheartening. This study shows that people living with schizophrenia if trained with the right circumstances can eventually learn how to experience pleasure.

I felt this article was presented well and easy to read with what was presented. Going through this article it was clear where each step was and what was going on. The authors used wording appropriate to this article without using too much technical jargon where it was not needed. The readability for me was quite familiar because I have had to do assignments like this before. I think when any author presents an empirical article to the world where others besides advanced Psychologists read it; they indeed try and make it easily readable so that their ideas presented get across in the best way possible.

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