Focus on the positive to counter anhedonia

This week I started seeing a client again who had made previously made improvements in her depression but complained of ongoing inability to feel positive feelings. Anhedonia is typically a poor prognostic indicator across a number of psychiatric diagnoses. So, how timely it was that I found this study from Michelle Craske and colleagues (2019) who developed a treatment approach specifically to increase positive affect.

96 participants from the community with moderate symptoms of either stress, anxiety or depression according to the DASS-21, were randomly assigned to 15 weekly sessions of either Positive Affect Treatment (PAT) or Negative Affect Treatment (NAT). Those assigned to PAT achieved greater improvements in positive affect (d = .52) and had higher positive affect at 6-month follow-up than those receiving NAT (d = .67). Those assigned to PAT also experienced lower negative affect, depression, anxiety and stress symptoms at follow-up.

In terms of limitations, the depression levels were not as severe as might be found in many clinics (23% were in the ‘normal’ range at baseline, and the mean DASS Depression scores were 10-11 on a scale of 0-21). However, the positive affect levels were low (10-13th percentile), so PAT seems like a promising approach for clients where anhedonia is prominent but the client has other strengths. Secondly, the control condition – NAT – was artificially constrained to avoid overlap with PAT for a purer research inquiry into the relationship between specific therapy content focus and specific therapy outcomes. This meant clinicians in the NAT condition would not encourage pleasant event scheduling. In practice, clinicians and clients wouldn’t need to make this either-or choice. On the other hand, this design feature allows us to be clear that neglecting to help clients with anhedonia to increase pleasurable and meaningful activity is clearly not optimal treatment. Finally, there were a lot of interventions in the package and it is unclear yet whether some were doing the heavy lifting while others were just along for the ride (but see below the treatment description for a speculation about this!)
 
What is Positive Affect Treatment?
Essentially, PAT is a more targeted version of behavioural activation. The key features are (Craske et al., 2016):
First Module: 7 sessions focus on activity scheduling:

  1. Scheduling activities that are inherently pleasurable, provide a sense of accomplishment (mastery) or are consistent with valued action (shout-out to all the ACT fans out there).

  2. Therapist-guided imagery in session where the client relives positive activities in sensory detail, to deepen and savour the experiences.

Second Module: 3 sessions focus on training attention toward positive emotion:

  1. “finding the silver lining” = looking for positive features even in problematic situations

  2. “taking ownership” = identifying actions we can take to produce positive outcomes

  3. savouring pride, mastery and excitement

  4. reading accomplishments out in front of a mirror

  5. Imaginal rehearsal of anticipating (potentially) positive upcoming events and associated positive emotions (excitement, joy, curiosity)

Third Module: 4 sessions focus on cultivating positive feelings toward self and others

  1. Loving-kindness meditation: mentally sending happiness, health, peace and freedom-from-suffering wishes to others

  2. Generosity: Engaging in an act of generosity at least once a day without expecting anything in return

  3. Appreciative Joy meditation: mentally wishing good to self and others (happiness and good, joy and fortune)

  4. Generating a sense of gratitude.

 
One other feature of this study worth mentioning is that the authors provided a graph of weekly positive and negative affect in both treatment conditions. Although the trend of increase in positive affect was reasonably linear, the greatest improvements appeared to occur within the first module and then between end of treatment and follow-up. We could infer that module 1 activities have the most immediate impact, with module 2 and 3 activities perhaps having more gradual effects, if indeed they contribute above module 1 activities.

Take home: Clinical Implications

  • Anhedonia is a distinct depressive symptom that may not improve simply as a consequence of reducing negative emotions

  • Many psychological therapy protocols for depression orient the clinician toward analysing negative experiences. This may not be the most effective focus for relieving anhedonia.

  • There are specific activities that can increase positive emotions in people experiencing low positive affect: scheduling pleasurable, mastery or valued actions, then practising imaginally reliving these activities in sensory detail to prolong and intensify positive affect, seems especially important. These should not be neglected when treating clients with anhedonia.


This article is published in Journal of Consulting and Clinical Psychology.
Go to https://psycnet.apa.org/buy/2019-20571-003 for the article.

References

Craske, M.G., Meuret, A.E., Ritz, T., Treanor, M., & Dour, H. (2016). Treatment for anhedonia: A neuroscience driven approach. Depression and Anxiety, 33: 927-938.

Craske, M.G., Meuret, A.E., Ritz, T., Treanor, M., Dour, H., & Rosenfield, D. (2019). Positive affect treatment for depression and anxiety: A randomized clinical trial for a core feature of anhedonia. Journal of Consulting and Clinical Psychology, 87(5): 457-471.

Matthew Smout