ANHEDONIA AND EMOTIONAL NUMBING AND THE "OLD YOU"

I.    Introduction

I have struggled with the effects of combat trauma since I rotated out of the bush of Vietnam. I now possess information about why I feel emotionally dead in situations where other people easily express their passions positively. As we saw in the previous chapter, researchers have a greater understanding of how the battlefield introduces changes in the brain. These adjustments physically influence how you and I relate to people, particularly in neutral or negative ways.

My parents both died three days apart. I shed no tears over either of them, despite all the years I spent under their roof. Dad laid the foundation for my diagnosis of P.T.S.D. by the way he abused me growing up. I spent most of my high school years avoiding him. I have few memories of a personal relationship with my mom. I don’t miss them to this day. They were people I knew long ago.

It’s important to know why a veteran feels emotionally remote. There is a reason for it. Your husband probably behaved aloof after coming home and remains so. But that very aloofness came about not merely because of the war. What you, as a spouse, experience from him is a result of a God-given mercy that you probably prayed for many times. 

What do I mean? Specifically, as we shall see below since man sinned, he has been at war from the moment Cain picked up a rock and killed Abel, his brother. If our brains were not able to adapt to violent and dangerous situations and act accordingly, we would all die quickly. When someone yells, “Incoming!” or we hear the unmistakable sound of an AK-47, we would fail to hit the deck and return fire. Once you hear an artillery round screaming in your direction, you never forget it. This gift of memory is what our limbic system does for us. God, not impersonal evolution, made that lump of soft tissue, gray and white matter, high water content, fat, nerve cells, non-neuronal cells, and small blood vessels surrounded by bone.

These cranial adjustments’ ultimate purpose is to glorify God by giving you a way to survive danger. That is a divine gift, my friend. I want to remind you that another reason your brain does what it does in perilous times is to keep you alive so you can hear the Gospel. The Father of the Lord Jesus Christ seeks you, dear folks, to bring you into the worship of true and living God.

In the journal Healthcare Basel, I discovered an interesting study titled, “‘That Guy, Is He Really Sick at All?’ An Analysis of How Veterans with P.T.S.D. Experience Nature-Based Therapy.” The journal made the following observations and statements after attempting a different approach to P.T.S.D. therapy. Their research “examined the effects of nature-based therapy (N.B.T.) on a group of Danish veterans and showed that this form of treatment may be useful as part of the treatment offered to veterans with post-traumatic stress disorder (P.T.S.D.).”

In the first interview, most of the veterans described a feeling of loneliness after coming home, and some felt an urge to isolate themselves from their relatives and friends. They said that during service, they considered their comrades to be replacements for their families. When they first returned home, their families could not replace this relationship. The veterans described their relationships with their families as difficult and often contradictory; on the one hand, their families were the most important thing in the world to them, while on the other hand, they could not handle being together with them. All the veterans thought that they had changed and were different from how they had been before service, and they found it difficult to meet their families’ needs for affection. One veteran, when talking about his girlfriend, who used to call him or send him messages every day, said the following:

“I haven’t got the room inside me to be there for her every day… I can’t… for me feelings are just not like before.”

In the first interview, the veterans also emphasized how they had changed after serving; they were now in a constant state of alertness and unable to refrain from observing people’s behavior when in a crowd. They said they always needed to check for snipers and hide under tables when hearing the sound of airplanes. This behavior frightened other people, and they saw it as being extreme. They felt that it had a significant effect on their ability to take part in social arrangements, and it also led to unintended suspicion from their families. One veteran related the following episode about his wife coming home from work:

“I look at her…her hands, if she is carrying something, keys or… or if something looks different. If her hand is closed, I have to follow her movements until I have seen what she has got there.”

All the veterans described how both physical contact and being able to sense affection were hard after coming home. One of them was unable to pick up his little son:

“It has been terrible. Especially for my son. He has his needs… [interviewer: And you can't give this to him?] “No, I can’t take it [touching and skin-contact].”

They also said that they experienced difficulties sharing feelings and talking about how they felt, which made their emotional communication with their relatives difficult:

“It’s hard for me to express how I’m feeling and maybe also hard for them to know what to say to me [...] Not even my family knows much about how I’m doing. It stays inside me, and it’s very very hard to open up and talk about how I’m feeling and thinking.”

In the interviews conducted midway through the intervention, the veterans emphasized some changes that had occurred in the way they perceived relationships. They all experienced a positive feeling of being part of the group of veterans during the NBT. Being surrounded by people with the same background, similar experiences, and challenges was considered more comforting than being with civilians.

“If I had started in another group, where people had PTSD but for civil reasons, I don’t think it would have been the same… we have this mutual understanding [...] There are things we don’t need to say… we know what it’s like to serve abroad and be in a state of constant alertness.”

A.   Diagnosis and Effects

In dealing with the effects of numbing, a large part of the brain takes part. It is important to remember, the brain works as God intended it to in a fallen, sinful world. It is easy to label the effects of combat stress as negative and therefore the only pathway forward is through psychological therapy. But they are, only if you begin with atheistic evolution and random possibility which destroys their meaning and purpose. In other words, one hypothesis is that the aspects of the brain most affected by stress causes those areas of the brain to become underachieve, reducing “reward responsivity, positive affect, and movement toward appetitive goals.”

1.    Anhedonia

Anhedonia is the inability to feel pleasure. “Anhedonia has been conceptualized as an inability to generate emotional reactions that are sensitive to objectively positive stimuli.” It has “a unique positive relationship with PTSD’s emotional numbing symptoms and minimal relationships with other PTSD symptoms.” Anhedonia is a diverse array of deficits in hedonic function, including reduced motivation or ability to experience pleasure. The greater the extent of anhedonia, there is an increase in the likelihood of being “diagnosed with additional anxiety disorders and to a lesser extent, psychotic disorders.” The focus of one study was the overlap between lack of the sensation of pleasure and emotional numbing. To what extent did traumatic stress hinder an individual’s subjective experiences diminish a person’s “positive moods such as joy, interest, and alertness,” what is known as “appetitive functioning.” (emphasis added)

Medical News Today states: “It may even play a part in an individual’s desire to indulge in risky behaviors, such as skydiving. . . . There is evidence to suggest that the presence of anhedonia increases the risk of committing suicide, so if the link is proven, recognizing and dealing with anhedonia could save lives.” (emphasis added)

a.    What’s happening in the brain?

“The brain’s circuitry is dense, convoluted, and incredibly busy.” With Anhedonia, it’s not as if we lose our love for chocolate or ice cream. The issue is much deeper, i.e., our “reward mechanisms are impaired, which seem to include changes “in levels of interest, motivation, anticipation, expectation, and effort prediction, all of which are complex, and all of which are processed by different but overlapping neural circuits.” Something in the brain is awry, that is to say, “the reward process has come unhinged.” For reasons yet to be understood, “our brains make computations about risks, rewards, and payoffs using multiple brain regions, often without our conscious input.” (emphasis added)

In the DSM-5, anhedonia is a component of depressive disorders, substance-related disorders, psychotic disorders, and personality disorders, where it is defined by either a reduced ability to experience pleasure, or a diminished interest in engaging in pleasurable activities. (emphasis added)

The research suspected that anhedonia related minimally to P.T.S.D. but pertained most to three negative emotions: re-experiencing, avoidance, and hyperarousal. Yet anhedonia proved to have a more vital relationship to emotional numbing and the “other P.T.S.D. symptom clusters.” Scientists expected anhedonia would assist in predicting comorbid or simultaneous medical conditions such as major depression disorder (M.D.D.). When diagnosing patients with M.D.D., researchers suspected anhedonia was also present, although other research suggests there can be “distinct differences between persistently anhedonic and other clinically depressed individuals.” “Anhedonia is uniquely related to emotional numbing,” and was closely associated with the risk of increased anxiety disorder, but with psychotic disorder, the danger lessened. Anhedonia and emotional numbing are closely related to depression, whereas, anhedonia differentiates between depression and anxiety as a disorder." (emphasis added)

2.    Emotional Numbing (En)

The research suggests that the greater the emotions deprived of sensation, the greater the MDD. Thus, En diminishes a positive decrease in moods such as joy, interest, and alertness. Numbing the emotions decreases not only interest in activities but also a “detachment from others, and a restricted range of emotional expressiveness.” (emphasis added)

Relatedly, low levels of positive affect and disinterest in pleasurable activity characterize the depressive symptom of anhedonia. Both emotional numbing and anhedonia appear to reflect diminished appetitive functioning. . . . it is hypothesized that emotional numbing, an index of diminished appetitive functioning in PTSD, will be the only PTSD symptom to be uniquely related to anhedonic symptoms of depression and the presence of comorbid depressive disorders. (emphasis added)

En differentiates goal-oriented behavior due to incentives or various types of positive stimuli at the level of cognition and experience. When trauma is present, En affects behavior and expression negatively. By contrast, “persistent re-experiencing, avoidance, and increased arousal PTSD symptoms” generated negative “subjective, behavioral, and physiological experiences.” (emphasis added) Studies revealed that veterans with an aversion to an event (negative valence) and avoidance of its symptoms did not intersect at En. In other words, a person who avoids reliving an event or its symptoms doesn't have En. Anhedonia and emotional numbing are functionally related. “Emotional numbing has been shown to be the symptom that is most characteristic of chronic P.T.S.D., and is strongly associated with functional and interpersonal impairment.” (emphasis added)

a.    Other Effects on the Brain Under Traumatic Stress

The purpose of another study, “Reduced Amygdala and Ventral Striatal Activity to Happy Faces in PTSD Is Associated with Emotional Numbing,” using facial emotion perception was set forth as follows. “This study tested the predictions that (1) individuals with PTSD would display reduced responses to happy facial expressions in ventral striatal reward networks, and (2) that this reduction would be associated with emotional numbing symptoms.” (emphasis added) 

The prediction was that the ventral striatum, anterior cingulate cortex, and amygdala would activate when 240 grey-scale face stimuli pictures “depicting happy and neutral facial expressions” were viewed. 

PTSD participants revealed lower activation to happy (-neutral) faces in ventral striatum and and a trend for reduced activation in left amygdala. A significant negative correlation was found between emotional numbing symptoms in PTSD and right ventral striatal regions after controlling for depression, anxiety and PTSD severity. This study provides initial evidence that individuals with PTSD have lower reactivity to happy facial expressions, and that lower activation in ventral striatal-limbic reward networks may be associated with symptoms of emotional numbing.

Unfortunately, little is known about the neural networks that process positive stimuli dealing with P.T.S.D. The significance of understanding emotional deficits as they are related to “reward processing” and neural networks cannot be understated. Thus, “(e)motional numbing has been shown to be the symptom that is most characteristic of chronic PTSD, and is strongly associated with functional and interpersonal impairment.” (emphasis added) It was discovered that when the veterans of the study viewed the face of a beautiful woman, they were found to “have lower expectancy and satisfaction with rewards.” (emphasis added) This also occurred when involved in gambling or in tasks involved in monetary reward.

(F)or many years, a part of the basal ganglia called the nucleus accumbens has been referred to as the “pleasure center.” (Picture in the public domain)

Perception of positive signals/hedonic tone appears centered on networks encompassing the nucleus accumbens, whereas networks involved in processing stimulus-reward association are associated with wider orbitofrontal-dorsal and ventral striatal networks. Therefore, it is important to examine reward function in ventral striatal networks in PTSD in terms of reactivity to positive stimuli. Only one pilot study has examined neural reactivity to positive affective signals (animated film) in PTSD. Greater activation was found in right precentral and superior frontal gyrus, and lower activation in parahippocampal and superior temporal gyrus were found in the PTSD group. (emphasis added)

“Participants with PTSD showed lower activation in nucleus accumbens and medial prefrontal cortex (mPFC) and in dorsal (impulse control) and ventral striatal regions (reduced, caudate and putamen).”The person becomes compulsive in areas such as gambling, buying, sexual behavior, and eating yet derives little pleasure from them. Anhedonia, a result of traumatic stress, creates a lack of reactivity to pleasurable stimuli. This deficiency is the reason the ventral striatal networks are currently under examination. (emphasis added)

Critical to a higher level of emotional processing, scientists believe the prefrontal cortex relates to anhedonia. Dopamine, a compound in the body as a neurotransmitter and a precursor of other substances, including epinephrine, is involved in reward pathways. Research shows significant quantities in the nucleus accumbens. However, in the ventral striatum of people with depression (MDD), dopamine was reduced, creating severity in anhedonia, but did not affect overall depression. When dopamine levels increased in the insula, this addition affected decision-making. However, increased dopamine caused the opposite effect in the ventral striatum. “For instance, people with depression who also have pronounced anhedonia seem to have reduced GABA levels. And, depressed people with reduced opioid activity experience less pleasure during positive interactions.” (emphasis added) 

“In the healthy brain, happy faces engage a neural network involving the ventral striatum (encompassing putamen and nucleus accumbens), amygdala, orbitofrontal cortex and anterior cingulate.” (See the above cut away of the brain) It was discovered that when patients took med ication, the drugs “may have masked some amygdala effects.” What was not expected in this research was a reduction in amygdala activity when shown happy faces. The findings contrasted with previous reports “of heightened amygdala activation to fearful faces in PTSD.” (emphasis added) Formerly,

In the healthy brain, happy faces engage a neural network involving the ventral striatum (encompassing putamen and nucleus accumbens), amygdala, orbitofrontal cortex and anterior cingulate. (Picture in the public domain)

The conclusion of the study “provides novel evidence that individuals with PTSD perceive happy facial expressions as less intense and that lower activation in ventral striatal-limbic reward networks is associated with symptoms of emotional numbing in PTSD. Importantly, these blunted responses to positive facial signals are not accounted for by trauma exposure or comorbid depression. The identification of impaired functioning of reward networks in PTSD."

  Bilateral caudate.                                                             Nucleus accumbens

T2 weighted magnetic resonance scan image                   The nucleus accumbens is a major input

showing bilaterally symmetrical hyperintensities            structure of the basal ganglia and inte-

in Caudate nucleus (small, thin arrow), Putamen            grates information from cortical and

(long arrow), with sparing of Globus Pallidus                   limbic structures to mediate goal-

(broad arrow), suggestive of Extrapontine                         directed behaviors. (Pictures in the public

myelinolysis domain)

.

Even without a trauma-exposed group, the research did not clarify why a lower activation in the striatal regions manifested itself. Was the cause exposure to trauma or P.T.S.D. particularly? Studies linked anhedonia and MDD with more inadequate responses in the left nucleus accumbens and bilateral caudate.

My purpose in showing how the brain has been affected by traumatic stress is, I hope, obvious. The V.A. and its Mental Health Department are much more suited to treating traumatic stress from an after-the-fact position than a why-in-the-first-place mentality. We who struggle with this issue must understand that something significant has happened inside our brains. We cannot remain in the dark.

b.   Summary

Diagram of the basal ganglia (in red) and related structures (in blue) within the brain. (Picture in the public domain)

It is vital that you, dear reader, know why your loved one behaves and thinks as they do. You need to know how to think truthfully about traumatic stress so you can live with this person who has been traumatized. You need to know what to tell your children about why their parent is in pain; they are not mad at you, but their anger helped preserve them in combat. The traumatic experience and brain transformation occurred by divine design and under the sovereign control of the Lord of Glory. These changes are glorious to behold. However, the brain cannot revert to its former “self.” So, the LORD, in His mercy, can transform the whole person into the image of Christ. God delights to take our intransigent, broken brain and use it to drive a veteran and his wife to their knees, to seek God's mercy because they recognize they are helpless to deliver themselves. I know this first hand. God is able to bring good from these trying circumstances. Trauma is a humbling tool created by God.  

Embracing the narrow way of Christ guarantees trials and suffering. Few are those who find it. However, Christ refuses to accompany those who choose the broad path that leads to eternal destruction. Many are those who find it.

Changing some behaviors, habits, or thought patterns is not God's plan for His elect. The power of Christ overcomes the changes in the brain that appear at first glance terrible or damaging. I have experienced, to a degree, what I am talking about. Christ reveals Himself strong to the powerless. He humbles the proud who refuse to acknowledge Him and love Him.