Joe Borders, MFT
Recovering from addiction is challenging and requires a lot from people. There are many hardships that come along with recovery, some well known, and some that don’t get talked about very often. In my experience as an addiction counselor I have consistently seen a lack of discussion about a very important issue that comes up for most if not all recovering addicts: anhedonia.
What is Anhedonia?
Simply put, the word anhedonia refers to a significant reduction in a person’s ability to experience pleasure. A person who is suffering from anhedonia might not experience the same level of pleasure, or any pleasure at all from things that they used to really enjoy. People find themselves feeling kind of emotionally dull, numb, or “cloudy”. This is really hard for those in recovery because it can come to seem like life is dull without substance use.
Anhedonia is common in the early stages of recovery
Anhedonia is a major symptom of depression, but it is also something that most addicts face in the beginning stages of their recovery. After the withdrawal phase of addiction, many people experience what is called post acute withdrawal syndrome (PAWS). PAWS can last a couple of weeks to several months after the withdrawal phase and can manifest in a number of symptoms. The most common symptoms I hear people talk about in addiction counseling are difficulty sleeping, memory/concentration problems, depression, lack of energy, and anhedonia. In this post we are going to focus on anhedonia, because I’ve had far too many people come to therapy who are experiencing it and think they’re crazy because they’ve never heard about it.
Why is Anhedonia so Common in Addiction Recovery?
To understand this question we need to talk a little about how addiction works in the brain. Anytime you do something that brings you pleasure, dopamine is released in particular areas of the brain. Addiction affects multiple different neurotransmitters and areas of the brain, but the primary neurotransmitter we’re concerned about is dopamine.
When you do anything that is pleasurable; eating cookies, having sex, talking with a loved one, watching a good movie, whatever, dopamine is released in the brain. The problem that comes up in addiction is how much and how quickly dopamine is released. The following is a depiction of what might happen when a person engages in drug free pleasurable behaviors. Dopamine is released by neurons, which in turn essentially tell other neurons that something pleasurable is happening.
In the brain, the big difference between something like eating cookies and shooting up heroin, is the amount of dopamine they cause to be released. The following image depicts what it might look like if someone snorted a line of cocaine.
You can see that a lot more dopamine is being released here. This is where something called downregulation starts to happen. In general, the brain doesn’t like anything in extremes, and does its best to maintain balance. Over time, the brain responds to being flooded with dopamine by reducing the number of receptor sites for dopamine. This is called receptor downregulation.
Downregulation reduces the effects of so much dopamine in the system by reducing the number of receptors the dopamine molecules can fit into. This is tolerance in action at the neurochemistry level. When people repeatedly use substances, over time they find that they need to use more in order to get similar effects. Receptor downregulation is the reason for this. Because there are fewer receptor sites, there needs to be more and more of the drug to induce the same response.
In a way all of this is good. It’s an example of the brain adapting to changing conditions. The problem (aside from tolerance) is what happens when you decide to stop using the drug. When you’ve taken something to the extent that you experience tolerance, your brain has actually physically changed through actions like downregulation. This is why many people now consider addiction to be a disease.
Tolerance (downregulation) is why we experience withdrawal when we stop using a drug. In an effort to maintain balance, over time, the brain generally tries to counteract whatever a drug does by building up an opposite reaction. So in effect, if you take something that dulls pain, the brain is going to amp up its pain signals, if you take something to make you calmer, the brain is going to counteract with things to make you more alert, and if you take something to make you more energetic and excited, the brain is going to respond by releasing things that will make you more sedated. When tolerance occurs and you stop taking your drug, the brain continues to counteract the drug in these ways for a while after you’ve stopped. This is why withdrawal usually feels like everything that’s the opposite of what the drug made you feel.
Over time withdrawal effects subside, but our brains take a particularly long time to recover from dopamine tolerance. Like I said earlier, everything that brings you pleasure does so because it releases dopamine in key areas of the brain. When we become tolerant to dopamine we essentially become tolerant to the feeling of pleasure, joy, and to some extent, happiness. This is anhedonia in action at the neurochemistry level, and why anhedonia is such a pervasive problem among recovering addicts.
So using our poorly drawn image examples from earlier, after using a drug and becoming tolerant to it, the brain responds by reducing the number of dopamine receptors. Once the drug is gone, the brain goes back to releasing a normal amount of dopamine. This normal amount no longer produces the same effects because there are fewer receptor sites for the dopamine to fit into.
I often imagine it like this: say you’ve got a bunch of marbles and you’re standing over a board with a bunch of holes. You drop the marbles and several fall through the holes. Now you plug up a bunch of those holes, do the same thing, and you’re hardly getting any marbles through. It sounds crude and dumb…and in some ways that’s because its more complicated than I’m explaining…but in other ways it’s truly because it is this crude and dumb :-p
How Do You Get Over Anhedonia?
Because every drug, person, use pattern, and length of use is different, it is really hard to say how long anhedonia will last in any one person. Despite this, anhedonia from drug use should go away with time for most people. This is because, unlike in most cases of depression, anhedonia from drug use is due to a relatively simple cause and effect chain of events. You stop taking the drug, and over time the brain gets used to a normal amount of dopamine and starts to open up old receptor sites that were closed during drug use. This is why it’s so important for people to be aware of anhedonia. If you know that this is something normal and to be expected during recovery, then you can 1. know you’re not crazy, 2. hold the positive outlook that things can and will get better, and 3. have another piece of ammunition in your battle against relapse that tells you the drug isn’t worth it.
In addiction counseling the goals when working on anhedonia are:
- learning about anhedonia and normalizing it so you know what to expect
- building up motivation to struggle through it and hold onto the light at the end of the tunnel
- working on close, important relationships
- coming up with some alternative, healthy activities
- grabbing onto moments of possitivity
- challenging negative assumptions
- combating the idea that life would be better with the drug
- fostering healthy behaviors that help to rebuild normal pleasure circuits in the brain.
- and to eventually begin to pursue healthy activities that bring you pleasure and hold onto them rather than turning to the drug.
All of this is hard. Aside from all of the neurochemistry involved in anhedonia, it can be hard simply knowing that there is something out there that will satisfy an itch. I often use this analogy with people: Recovering from addiction is a lot like being healthy, losing weight, and going to the gym. You can go to the gym every day, eat right, lose weight, and feel good about yourself. But there are going to be days when you think about eating a couple of cheeseburgers while lounging around watching TV. Simply having had the experience of enjoying a couple cheeseburgers and watching TV makes it harder to stay consistently healthy, because in the back of your mind you’re going to remember those cheeseburgers on occasion.
When it comes to anhedonia, just like when first starting a diet with healthy exercise, it will be hard at first, and your healthy lifestyle might seem lame in comparison to the highs you got from drug use. But over time, with patience and perseverance, you will come to a place of deriving much more joy out of your healthy life than you did out of drug use.