Schizophrenia Bulletin vol. 39 no. 2 pp. 247–250, 2013
doi:10.1093/schbul/sbs192
Advance Access publication January 17, 2013
Schizophrenia in Translation
The Emotion Paradox of Anhedonia in Schizophrenia: Or Is It?
Gregory P. Strauss*
University of Maryland School of Medicine, Department of Psychiatry and Maryland Psychiatric Research Center, Baltimore, MD
*To whom correspondence should be addressed; PO Box 21247, Baltimore, MD 21228, US; tel: 410-402-6104, fax: 410-402-7198,
e-mail: [email protected]
Key words: anhedonia/emotion/cognition/negative
symptoms/psychosocial/treatment/functional outcome
via retrospective, prospective, trait, and hypothetical
self-report formats. Some have even termed this apparent discrepancy the “emotion paradox” in schizophrenia
to reflect a violation of the commonsense notion that
reports of emotional experience obtained across different
self-report formats should converge. But is this the case?
Should one expect self-reports of current and noncurrent (eg, prospective, retrospective) positive emotion to
be similar?
A large body of research on healthy individuals
indicates that reports of current and noncurrent positive
emotion typically show low correlations23,24 and that
healthy individuals expect more pleasure in the future and
remember more pleasure in the past compared with what
they actually experience in the moment.25 Overestimation
of past and future relative to current positive emotions,
as well as low correlations between these types of selfreports, is thought to occur because self-reports of
current and noncurrent emotion require access to
different sources of emotion knowledge.26 In the field of
affective science, the sources of emotion knowledge that
are accessed when making prospective, retrospective,
and current reports of positive emotion are welldelineated. In their seminal article on the “Accessibility
Model of Emotional Self-Report,” Robinson and
Clore26 review this literature and discuss how reports of
current feelings require access to experiential emotion
knowledge, whereas reports of noncurrent feelings
(eg, retrospective, prospective, trait, and hypothetical)
require access to semantic emotion knowledge. Semantic
emotion knowledge includes beliefs about which types of
emotions are likely to be elicited by specific situations (eg,
“Social interactions are enjoyable”), as well as general
beliefs that a person holds about himself or herself (“I
am generally a happy person”). When viewed in relation
to the accessibility model, overestimation of past and
future relative to current positive emotion occurs because
healthy individuals access semantic knowledge stores
when making these noncurrent emotion reports, and
Anhedonia has long been considered a core clinical feature of schizophrenia.1–3 The most common definition of
anhedonia is that it reflects a diminished capacity to experience pleasure. Although this definition clearly applies
to many individuals diagnosed with major depression,4–7
recent empirical evidence suggests that it may not adequately describe the affective abnormalities characteristic
of schizophrenia.8 For example, individuals with schizophrenia report levels of current (ie, in the moment) positive emotion and arousal that are comparable to healthy
controls when exposed to stimuli in the laboratory (for
meta-analyses, see Cohen and Minor, 2010; Llerena et al
2012),9,10 show similar increases in positive emotion when
engaged in activities in their daily lives,11,12 and display
comparable neural activation to controls when reporting
their current positive emotions in response to pleasant
stimuli (see Taylor et al13 for a meta-analysis). Such evidence has led some to conclude that anhedonia should no
longer be viewed as a diminished capacity for pleasure in
this patient population.8,9,14,15
However, it is clear that not all aspects of emotional
experience are normal in schizophrenia. For example, compared with healthy controls, patients typically
report reductions in pleasure when queried during clinical interviews that obtain retrospective (ie, past) or prospective (ie, future) reports of pleasure,16–18 as well as
questionnaires that use trait (eg, Positive and Negative
Affect Scale19 or hypothetical (eg, Chapman Anhedonia
Scales)20 self-report formats. Experience sampling studies
also indicate that schizophrenia patients have a reduced
frequency of pleasurable experiences compared with controls,11,12,21,22 suggesting a diminution in pleasure-seeking
behavior. At first glance, findings indicating normal inthe-moment experience of positive emotion appear to be
at odds with those indicating diminished pleasure across
all types of noncurrent positive emotion reports obtained
© The Author 2013. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.
All rights reserved. For permissions, please email: [email protected]
247
G. P. Strauss
thus rely on beliefs about how they generally feel or how
specific situations make them feel. In healthy individuals,
overestimation of noncurrent positive emotion therefore
at least in part reflects that most healthy individuals
believe that they are generally in a moderately positive
mood and that specific types of situations (eg, vacations)
are pleasurable.26
in the moment, but schizophrenia patients report roughly
equivalent levels of retrospective and current positive
emotion.29 Thus, schizophrenia is characterized by a
reduction in the normative tendency to overestimate past
and future relative to current positive emotions, a psychological abnormality that is more encompassing than
an anticipatory pleasure deficit alone.
The Psychological Components of Anhedonia:
Low-Pleasure Beliefs and Reduced Overestimation
of Past and Future Pleasure
The Role of Cognitive Impairments in Retrospective
and Prospective Emotion Reports
We recently attempted to resolve the emotion paradox in
schizophrenia by drawing upon insight from Robinson
and Clore’s model of emotional self-report and presented evidence that individuals with schizophrenia display the same pattern of low relationships among reports
of current and noncurrent feelings as controls.14 Given
that discrepancies among different types of emotional
self-report are to be expected because they require individuals to access different sources of emotion knowledge,
the emotion paradox in schizophrenia is readily understandable. When the literature on anhedonia and emotional experience in schizophrenia is viewed in relation
to Robinson and Clore’s Accessibility Model,26 in tact
reports of current positive emotion suggest that individuals with schizophrenia do not have reduced hedonic
capacity and that diminished reports of noncurrent pleasure obtained via prospective, retrospective, trait, and
hypothetical measures can be interpreted as evidence for
“low-pleasure beliefs.”14 This interpretation is supported
by evidence in healthy individuals indicating that all types
of noncurrent emotion reports require access to semantic
emotion knowledge (ie, beliefs) rather than experiential
emotion knowledge.27,28 Thus, the literature on emotional
experience and anhedonia in schizophrenia indicating
normal current positive emotion and diminished noncurrent positive emotion can be taken as evidence for aberrant psychological rather than experiential processes.
In addition to acknowledging that reports of noncurrent feelings reflect dysfunctional psychological processes
such as low-pleasure beliefs, it is important to recognize
that individuals with schizophrenia also fail to overestimate past and future relative to current positive emotion
to the same extent as controls. For example, Gard et al.11
demonstrated that controls anticipated more pleasure
in the future than what they actually experienced in the
moment when engaged in activities, whereas individuals
with schizophrenia did not. Gard et al11 did not find that
patients reported expecting less pleasure in the future
than what they actually experienced in the moment, as
the finding is sometimes interpreted in the field, but rather
that patients simply did not overestimate their future relative to current pleasure to the same extent as controls.
Similarly, it has been found that controls remember more
pleasure in the past than what they actually experienced
248
An important question thus remains unanswered: why
do individuals with schizophrenia fail to display the
prototypical pattern of overestimating past and future
positive emotion? One possibility is that cognitive impairments interact with retrospective and prospective reports
to prevent normal cognitive processes from promoting
overestimation.
Retrospective Reports
In the affective science literature on healthy individuals, it is well documented that retrospective overestimation is predicted by greater reliance on peak experiences
within the timeframe in question, as well as relying on
one’s most recent experiences.30 Given the severity of
long-term memory impairments in schizophrenia,31 one
might expect that peak and recency mechanisms would
not exert as much of an effect on retrospective reports of
pleasure in patients, potentially making them less likely
to overestimate pleasure retrospectively. Consistent with
this notion, we recently reported data indicating that
long-term memory deficits differentiated patients rated
as being mild to moderately anhedonic on a retrospective clinical anhedonia rating scale32 from those patients
where anhedonia was rated as being absent.14 Thus, longterm memory impairments may play a key role in diminished overestimation of past pleasure in individuals with
schizophrenia.
Prospective Reports
Prospective emotion reports are also influenced by
cognitive processes. Predicting one’s emotional experience
in the future requires generating a mental representation
of a situation that is salient enough to elicit a hedonic
reaction in the present. The immediate hedonic reaction
to these mental simulations is then used to generate a
prospective self-report of how one would likely feel if that
situation were to come to pass. Generating simulations
that are salient enough to elicit an emotional reaction
is heavily dependent upon working-memory capacity.25
However, there are limitations to working memory and
the types of simulations we can generate. Due to these
limitations, we are required to take shortcuts when
simulating future events. For example, it is impossible
Anhedonia in Translation
to create a mental representation that depicts every
potential detail of an event. For this reason, mental
representations tend to be essentialized, including only
the most salient features of an event and omitting less
essential features. Similarly, mental representations tend
to be abbreviated. To prevent a mental representation from
lasting as long as the actual event itself, our simulations
are truncated and only include a few key features of the
situation. By generating mental representations that are
abbreviated and essentialized, healthy individuals are
prone to overestimating their future level of positive
emotion because their simulations focus only on certain
peak hedonic qualities of a potential event. Were these
mental representations to include a longer and more
detailed account of a situation, the overall net hedonic
value would be lowered and thus more consistent with
what would occur in real life. It is also important to
note that mental representations of the future are often
influenced by our memories from the past. However, the
memories that we retrieve are typically unrepresentative
of how an event usually occurs. They are based upon
peak emotional reactions we have had in such situations,
as well as our most recent experiences. As such, we tend
to overestimate our future positive emotions relative to
what actually occurs in the moment because we draw
upon unrepresentative memories when forming our
simulations.25 Cognitive deficits in working memory and
long-term memory may cause schizophrenia patients to
produce mental representations that lack the salience
needed to produce a strong hedonic reaction in the
present. Their simulations may be too abbreviated or lack
the detail needed to elicit feelings in the present, and they
may be less likely to retrieve the types of unrepresentative
peak intensity moments that result in overestimation of
future pleasure.
The Behavioral Component of Anhedonia
As previously mentioned, it is also clear that there is a
behavioral component to anhedonia. Experience sampling studies and clinical interviews indicate that patients
engage in fewer pleasurable activities than controls even
though they enjoy the activities they do engage in just as
much as controls.11,12 There is some evidence that cognitive impairments contribute to this behavioral deficit. In
healthy individuals, the motivation to pursue rewards is
highly dependent upon how well simulations of future
pleasure spur action.25 It may be that working-memory
impairments prevent patients from generating mental
representations of value that are salient enough to activate the decision-making processes needed to engage in
goal-directed behavior. Consistent with this possibility,
several studies have reported that patients have deficits
in generating and maintaining mental representations of
value and that these abnormalities are associated with
impaired decision-making and reduced goal-directed
behavior.33–35 Thus, cognitive deficits may be critically
involved with patients’ failures to engage in motivated
behaviors aimed at obtaining reward.
Conclusions
Although anhedonia has long been considered an
experiential deficit in schizophrenia, recent research
suggests that there is no diminished capacity for pleasure in schizophrenia. Rather, the self-reports typically
interpreted as anhedonia reflect abnormal psychological processes, such as low-pleasure beliefs and reduced
overestimation of past and future pleasure, as well as
dysfunctional behavioral processes such as reduced
pleasure-seeking behavior. Cognitive impairments may
play a critical role in these psychological and behavioral components of anhedonia. Despite this updated
understanding of anhedonia, the important question
still remains: how do we treat these abnormalities?
As I will review in a future issue of Schizophrenia in
Translation,36 Cognitive Behavioral Therapy and positive emotion enhancement techniques from the field of
affective science may offer some new avenues for the
treatment of anhedonia as it occurs in individuals with
schizophrenia.
References
1.Kraepelin E. Dementia Praecox and Paraphrenia (1919).
Translated by Barclay RM. Robertson GM, ed. New York:
Robert E Krieger; 1971.
2. Bleuler E. Dementia Praecox or the Group of Schizophrenias
(1911). Translated by Zinkin J. New York: International
Universities Press; 1950.
3. Rado S. Dynamics and classification of disordered behavior.
Am J Psychiatry. 1953;110:406–416.
4. Dunn BD, Dalgleish T, Lawrence AD, Cusack R, Ogilvie AD.
Categorical and dimensional reports of experienced affect to
emotion-inducing pictures in depression. J Abnorm Psychol.
2004; 113:654–660
5. Sloan DM, Strauss ME, Quirk SW, Sajatovic M. Subjective
and expressive emotional responses in depression. J Affect
Disord. 1997;46:135–141.
6.Sloan DM, Strauss ME, Wisner KL. Diminished response
to pleasant stimuli by depressed women. J Abnorm Psychol.
2001;110:488–493.
7.Rottenberg J, Kasch KL, Gross JJ, Gotlib IH. Sadness and
amusement reactivity differentially predict concurrent and
prospective functioning in major depressive disorder. Emotion.
2002;2:135–146.
8. Kring AM, Moran EK. Emotional response deficits in schizophrenia: insights from affective science. Schizophr Bull.
2008;34:819–834.
9. Cohen AS, Minor KS. Emotional experience in patients with
schizophrenia revisited: meta-analysis of laboratory studies.
Schizophr Bull. 2010;36:143–150.
10. Llerena K, Strauss GP, Cohen AS. Looking at the other side of
the coin: A meta-analysis of self-reported emotional arousal in
people with schizophrenia. Schizophr Res. 2012;142:65–70.
249
G. P. Strauss
11.Gard DE, Kring AM, Gard MG, Horan WP, Green MF.
Anhedonia in schizophrenia: distinctions between anticipatory
and consummatory pleasure. Schizophr Res. 2007;93:253–260.
12.Oorschot M, Lataster T, Thewissen V, Wichers M, MyinGermeys I. Mobile assessment in schizophrenia: a data-driven
momentary approach. Schizophr Bull. 2012;38:405–413.
13. Taylor SF, Kang J, Brege IS, Tso IF, Hosanagar A, Johnson
TD. Meta-analysis of functional neuroimaging studies of
emotion perception and experience in schizophrenia. Biol
Psychiatry. 2012;71:136–145.
14.Strauss GP, Gold JM. A new perspective on anhedonia in
schizophrenia. Am J Psychiatry. 2012;169:364–373.
15.Horan WP, Green MF, Kring AM, Nuechterlein KH.
Does anhedonia in schizophrenia reflect faulty memory
for subjectively experienced emotions? J Abnorm Psychol.
2006;115:496–508.
16. Kirkpatrick B, Strauss GP, Nguyen L, et al. The brief negative symptom scale: psychometric properties. Schizophr Bull.
2011;37:300–305.
17.Strauss GP, Wilbur RC, Warren KR, August SM, Gold
JM. Anticipatory vs. consummatory pleasure: what is the
nature of hedonic deficits in schizophrenia? Psychiatry Res.
2011;187:36–41.
18. Kring AM, Gur, RE, Blanchard JJ, Horan WP, Reise SP. The
clinical assessment interview for negative symptoms (cains):
final development and validation. Am J Psychiatry. In press.
19. Watson D, Clark LA. On traits and temperament: general and
specific factors of emotional experience and their relation to
the five-factor model. J Pers. 1992;60:441–476.
20.Chapman LJ, Chapman JP, Raulin ML. Scales for physical
and social anhedonia. J Abnorm Psychol. 1976;85:374–382.
21. Myin-Germeys I, Delespaul PA, deVries MW. Schizophrenia
patients are more emotionally active than is assumed based on
their behavior. Schizophr Bull. 2000;26:847–854.
22. Myin-Germeys I, Nicolson NA, Delespaul PA. The context of
delusional experiences in the daily life of patients with schizophrenia. Psychol Med. 2001;31:489–498.
23.Norris CJ, Larsen JT, Crawford E, Cacioppo JT. Better (or
worse) for some than others: individual differences in the positivity offset and negativity bias. J Res Pers. 2011; 45:100–111.
250
24. Ito TA, Cacioppo JT. Variations on a human universal: individual differences in positivity offset and negativity bias. Cogn
Emot. 2005; 19:1–26.
25. Gilbert DT, Wilson TD. Prospection: experiencing the future.
Science. 2007;317:1351–1354.
26.Robinson MD, Clore GL. Belief and feeling: evidence for
an accessibility model of emotional self-report. Psychol Bull.
2002;128:934–960.
27.Ready RE, Robinson MD, Weinberger M. Age differences
in the organization of emotion knowledge: effects involving
valence and time frame. Psychol Aging. 2006;21:726–736.
28. Robinson MD, Clore GL. Episodic and semantic knowledge
in emotional self-report: evidence for two judgment processes.
J Pers Soc Psychol. 2002;83:198–215.
29.Ben-Zeev D, McHugo GJ, Xie H, Dobbins K, Young MA.
Comparing retrospective reports to real-time/real-place mobile
assessments in individuals with schizophrenia and a nonclinical comparison group. Schizophr Bull. 2012;38:396–404.
30.Fredrickson BL, Kahneman D. Duration neglect in retrospective evaluations of affective episodes. J Pers Soc Psychol.
1993;65:45–55.
31. Heinrichs RW, Zakzanis KK. Neurocognitive deficit in schizophrenia: a quantitative review of the evidence. Neuropsychology.
1998;12:426–445.
32. Andreasen NC. Scale for the Assessment of Negative Symptoms.
Des Moines: University of Iowa Press; 1983.
33. Strauss GP, Robinson BM, Waltz JA, et al. Patients with schizophrenia demonstrate inconsistent preference judgments for affective and nonaffective stimuli. Schizophr Bull. 2011;37:1295–1304.
34.Strauss GP, Frank MJ, Waltz JA, Kasanova Z, Herbener
ES, Gold JM. Deficits in positive reinforcement learning
and uncertainty-driven exploration are associated with distinct aspects of negative symptoms in schizophrenia. Biol
Psychiatry. 2011;69:424–431.
35.Gold JM, Waltz JA, Matveeva TM, et al. Negative symptoms and the failure to represent the expected reward value
of actions: behavioral and computational modeling evidence.
Arch Gen Psychiatry. 2012;69:129–138.
36. Strauss GP. Translating basic emotion research into novel psychosocial interventions for anhedonia. Schizophr Bull. In press.