“Anhedonia” in drug or alcohol withdrawal

Anhedonia is simply the inability to experience pleasure. It is a common feature of withdrawal from substance use, especially alcohol, opiates, cannabis, stimulants, and cocaine. It is also a common feature of a number of mental illnesses, such as mood disorders (depression, bipolar disorder, anxiety disorders, dysthymia, etc.), schizophrenia, and PTSD. This is another example of the overlap in causes and symptoms between mental illness and addictions (see "The Link Between Mental Health and Alcoholism/Addiction" Click Here).


Anhedonia is a common symptom in the immediate detox and abstinence period from substance use, but it often becomes a chronic symptom, lasting months or longer. This is especially true in crystal meth withdrawal, due to that particular drug's especially harsh and long-lasting effects on the brain chemistry involved. We will look at that brain chemistry in the next section. Research has shown that anhedonia is an important factor in making a person progress from recreational to obsessive drug use. In that case the person develops anhedonia after withdrawing from their occasional drinking or using, and begins drinking or using regularly to overcome the anhedonia. Addicts and alcoholics sometimes refer to this as "chasing the high." As well, anhedonia is a major factor involved in keeping a person addicted, and a major cause of relapse for those who are trying to end their addiction. Furthermore, anhedonia is strongly associated with craving and intensity of withdrawal symptoms. Therefore, treating anhedonia could be critical in terms of relapse prevention strategies. We know that mental illness is a very strong risk factor for substance use, and this seems to be in large part due to the anhedonia seen in many mental illnesses.

Why it happens

When a person stops using drugs or alcohol the brain chemicals (neurotransmitters) that the substances were jacking up drop to very low levels. These include the neurotransmitters that cause depression when they are low, and dopamine - the "feel good" neurotransmitter. When these are low, we feel the same as someone with depression: low energy, inability to feel pleasure, lack of desire to do anything (including fun things), etc. Our brain usually recovers and gets these neurotransmitters back up to normal levels, but it may take a while. Crystal meth, however, is notorious for causing very slow and incomplete return to normal brain chemistry (you picked a bad drug).

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Symptoms

Anhedonia is almost always accompanied by other symptoms, caused by the same low neurotransmitter levels. These are sometimes referred to as vegetative symptoms. These involve low energy, lack of desire to even try doing things that are usually pleasurable, and a depressed mood. These symptoms are sometimes so severe as to make the person unable to function normally. Living that way is very hard, and there is a natural tendency to want to relapse to resolve these symptoms, even if only temporarily. Some people end up experiencing the "pink cloud effect" (Click Here) which masks these depression symptoms very well for a while, but some don't. If the brain chemistry hasn't returned to normal by the time the "pink cloud" wears off, the person can fall hard, and very abruptly. Because of the overlap in symptoms, there is a fine line between anhedonia and clinical depression (see "Alcoholism/Addiction and Depression" Click Here).

Treatment

Treatment of anhedonia is important, because it's awful to live feeling that way. As well, treating anhedonia also reduces cravings and almost certainly reduces relapse rates. I would strongly recommend seeing your doctor if you feel you are anhedonic, or in anticipation of it if you are planning to detox. Different therapies have been developed to treat anhedonia. In general, there are two main approaches: psychotherapy, and medications that correct the abnormal brain chemistry.

Therapy (non-medication)

Among psychotherapeutic techniques, behavioral activation (BA) seems to be the most effective. BA was initially developed as a component of cognitive behavioral therapy (CBT). The goal of BA is to help patients to identify whether they are engaging in rewarding or non-rewarding behaviors, and to make behavioral choices that are likely to increase exposure to positively reinforcing experiences. Psychotherapy is only moderately successful, probably because it is not feasible for someone to think themselves out of anhedonia. It does not address the biochemical cause. It is also time-intensive and expensive. Interestingly, research has shown that recovery support groups that involve face-to-face meetings - such as Twelve Step groups (Click Here) or the SMART program (Click Here) - have a large effect on reducing anhedonia.

Medication treatment

Often a short course of a once-a-day, non-addictive medication called an SSRI is appropriate, as it returns the brain chemistry to healthy levels. Usually only about 4 months of this med are required, although usually longer in former meth users. This is something that will require close follow-up with your doctor to decide when to stop the medication. A medication closely related to these SSRI medications - called Buproprion - has proven particularly effective for anhedonia associated with withdrawal. It is used as an antidepressant medication, and is known as an "energizing" anti-depressant, because it tends to be particularly helpful with low energy and activity levels. There is some evidence that a medication called acetyl-l-carnitine (ALC) may be safe and effective for treating anhedonia and other vegetative symptoms. However, this medication must be given via IV for a period of at least 10 days, and remains in the experimental phases. Still, we will watch out for this therapy if it pans out in further studies. Some experimental evidence suggests that some of the antipsychotic medications may work well in treating anhedonia in recovery, especially the medications quetiapine and aripiprazole. These medications are very side-effect prone, and are especially sedating. I have a lot of experience prescribing these medications, and I would tend to use them only in people who require them for another reason in addition to anhedonia, or as a last resort when other treatment approaches have failed.

Final thoughts

Anhedonia and other vegetative symptoms are horrible to live with, and a major cause of drug or alcohol progression or relapse. But, they are very treatable. Please do talk to your doctor if you think you are affected. You deserve to be in recovery, feel good, and enjoy life in recovery. You are working hard for your recovery, so you deserve good things from it.



Work consulted: 
Hatzigiakoumis, D. S., Martinotti, G., Giannantonio, M. D., & Janiri, L. (2011). Anhedonia and Substance Dependence: Clinical Correlates and Treatment Options. Frontiers in Psychiatry, 2, 10. http://doi.org/10.3389/fpsyt.2011.00010