Improving but Not Feeling It: Anticipatory Anhedonia and Cognition

"Improving but Not Feeling It: Anticipatory Anhedonia and Cognition" takes up a question every clinician eventually faces: why doesn't the patient feel as well as the data suggests?

Erin Crown, MHS, PA-C, CAQ-Psychiatry addresses what happens when a patient reaches clinically meaningful improvement on a validated scale but does not feel successful. She traces much of this disconnect back to anhedonia, and specifically to anticipatory anhedonia, where a patient does not believe feeling better is even possible. She credits Dr. Roger McIntyre for teaching her that experiencing pleasure and joy requires first being able to anticipate that experience, and that anticipation itself depends on intact cognitive function. When patients are not noticing their own improvement, Erin Crown says she starts probing more directly for anhedonia and cognitive impairment, which can surface symptoms the patient had never previously endorsed. Identifying those symptoms can change the direction of treatment entirely, sometimes pointing her toward options with stronger evidence in anhedonia or cognitive function specifically.

Erin Crown, MHS, PA-C, CAQ-Psychiatry also emphasizes the importance of naming the improvement out loud for patients who cannot see it themselves. She returns to the example of her patient who had been surviving on canned soup for every meal: pointing out that he is now varying his meals and walking through more than one aisle at the grocery store can prompt a patient to concede, somewhat reluctantly, that things really have changed. She has watched patients visibly brighten when their own progress is reflected back to them in concrete, personal terms rather than an abstract score. At the same time, Erin Crown acknowledges that some symptoms are simply so heavy and persistent that a patient cannot register other, less bothersome improvements happening around them, particularly early in a depressive episode when the most distressing symptoms still dominate their attention and crowd out awareness of anything getting better around them.

Up next, in "The Lingering 'Blah': Residual Symptoms and Sleep as an Early Warning Sign," Dr. Harding and Dr. Citrome turn to the residual symptoms that outlast an initial response and what they signal.