Pleasure, gratification, and the overall degree of satisfaction with one’s life are central aspects of psychiatric care. There are specific illnesses that affect the ability to think about pleasure (so-called “typical” depression), to achieve it (“atypical” depression, bipolar disorder), or to manage it (bipolar disorder, addictions). More generally, in all situations involving psychological distress, it should be kept in mind that the goal of treatment, beyond individual symptoms, is to restore as far as possible a state of well-being understood as overall satisfaction, quality of life, and the ability to derive gratification from a range of stimuli and environments.
The concept of pleasure can be understood in terms of several different stages:
having a project or a goal, and therefore having in mind where one should seek satisfaction or fulfillment;
being able to take the initiative at the right times and on the right occasions in order to move toward desired situations or create them;
being satisfied with the experience one has lived through and drawing from it the motivation to increase one’s ability to enjoy similar experiences or to enjoy them even more fully;
being able to balance the desire to feel well or enjoy something with the need to cope with its absence when it is unavailable, or with the need to devote time to other useful activities.
When a person no longer identifies anything as a pleasure worth pursuing, the term anhedonia is used (literally, “absence of gratification”). A distinction must nevertheless be made between situations in which a person appears indifferent or uninterested, without necessarily complaining about it, and situations in which the person complains about—and is indeed distressed by—the fact that they can no longer derive pleasure from their usual activities, despite still feeling some kind of urge to do so.
Anhedonia is one of the defining signs of depression and generally corresponds to outwardly visible signs as well, such as fixed facial expressions, limited responses to external stimuli, a self-focused attitude, mutism, silent and anguished reflection on negative themes, and categorical refusal of initiatives or interactions with the surrounding environment, including therapeutic ones. The anhedonic depressed person therefore tends to no longer consider pleasure possible for themselves and consequently no longer “feels” the positive, constructive value of things. They may also lose feelings of hope or desire. Even feelings of affection toward close people and spiritual points of reference may become muted or flattened, resulting in a kind of internal impoverishment that “isolates” the person from life.
The situation is different for someone who is unable to experience gratification even though they know where and how to obtain it, and therefore continues to dream of it, imagine it, or regret it if they have lost it. This is a more common experience which, when intensified, can be found in various psychiatric conditions, ranging from “atypical” depression to adjustment disorders and alcohol or substance abuse. In this case, the person feels as though they are “stuck” far away from the opportunities offered by life, excluded and rejected. They feel capable of experiencing pleasure, but only passively, without the ability, desire, or determination to go out and seek and pursue opportunities for gratification. Pleasure often remains, but in a “poor” or passive form: food, solitary entertainment, masturbation, alcohol. What is missing, in other words, is the right drive, whereas in classical anhedonia the “fuel” itself is missing. Unlike in classical anhedonia, people with “atypical” anhedonia may still have fun and experience a change in mood when the right opportunity arises, or when someone else brings them into stimulating situations.
The psychiatric disorders in which this aspect typically lies at the center of the distress, even after the most urgent symptoms have been resolved, are bipolar disorder and substance abuse (whether recent or in the past).
Within the field of substance-related disorders, various terms have been used to describe the syndromes that follow cessation of substance use (“post-withdrawal abstinence,” “reward deficiency syndrome”) or intoxication (“amotivational syndrome,” a term specifically associated with cannabis).
A substance user who loses control over the desire to use the substance does so beyond their intention to put themselves at risk, and despite rationally anticipating that the resulting pleasure will be limited and unsatisfying. In this situation, pleasure is merely anticipation—an empty expectation—or what is sometimes referred to as “salience”, meaning a mental state in which an object presents itself as the primary and urgent source of desire, even though the person is aware that the behavior is ruining their life. In fact, the behavior may no longer even be capable of producing genuine pleasure, because it occurs in a risky, unsatisfying, and indeed stressful manner, with pleasure becoming more a memory or a dream than a stable and current experience.
After stopping substance use, people who remain abstinent typically experience a kind of “gratification gap,” which may lead them to seek other sources of stimulation, including other substances or potentially addictive stimuli. Alternatively, they may not know where to look for such stimulation and remain in a state of lethargy, dullness, and grayness, without a trigger capable of providing the appropriate energy or motivation to want to live actively.
People with impulse-control disorders other than substance abuse, such as kleptomania, gambling disorder, or sexual addictions, may likewise associate a pleasure that is repeatedly pursued and acted upon but never as satisfying as it should be, with an underlying sense of boredom, emptiness, and restless or despondent dissatisfaction.
As a final variant of disorders of pleasure, there are conditions of emotional indifference, that is, states in which a person does not appear to become excited or interested in anything, without even complaining about it, but simply becomes detached from life or from their previous interests. This is characteristic of schizophrenia, but can also occur in dementing disorders. In these cases, it is more often family members who become concerned than the person themselves, who may spend hours or days without engaging in any activity and may show no particular preferences or reactions to specific stimuli. Alongside the lack of interest in stimulating activities, there may also be little or no drive to socialize, reduced talkativeness and complexity of communication, and limited emotional involvement in ongoing activities.