Journal of Affectire Disorders, 25 ( 1992) 139- I46 0 1992 Elsevier Science Publishers
JAD
139
B.V. All rights resewed
016503L7/92/$05.00
00904
edonia in major Gwen016 Loas, Eliseo Salinas, Mien
D. Guelfi and Bertrand Samuel-Lajeunesse
Cliniqxe des Mahdies Mentales et de I’Ence’phale fC. M. M. E), Paris, Frame (Received (Revision
4 November
1991)
received 28 February
(Accepred
10 March
1992)
1992)
Summary Physical anhedonia, evaluated by the score on the physical anhedonia scale (PAS) of Chapman et al. [J. Abnorm. Psychol. 4 374-382 (1976)] was studied in 61 patients, who met RDC criteria for major depressive disorder and in 61 normal subjects. The depressed patients scored significantly higher than the normal group and presented a continuous distribution. Physical anhedonia of depressed patients seems related to the severity of the depression and does not appear to identify a qualitatively distinct subgroup.
Key wo&:
Physical anhedonia;
Depression;
Rating scale; Melancholia;
Introduction Anhedonia, the lowered ability to experience pleasure, is an important symptom of majirr depressive disorder, namely in the melancholia and endogenous subtypes. In the DSM-III (American Psychiatric Association, 1980) anhedonia was necessary for the diagnosis of melancholia subtype in major depressive disorder, which is not the case for the melancholia type in the DSM-IIIR (American Psychiatric Association 1987). In order to study anhedor?ia, it is important to give an operational definition to allow comparisons between the various studie:. Therefore.
Correspondence de Psychiatric,. France.
to: G. Loas. Service Hospitalo-Universitaire C.H.S
Philippe
Pinel. 80044 Amiens
Cedex.
Pleasure
Fawcett et al. (1983a) developed a pleasure scale (the Fawcett-Clark Pleasure Capacity Scale: FCPCS) in order to verify Klein’s (1974) hypotheses which claim that severe anhedonia would characterize a particular type of depression: namely, endogenomorphic depression. The authors showed that rhe FCPCS allows us to distinguish a bimodal distribution among the major depressive patients (Research Diagnostic Criteria (RDC, Spitzer et al., 1980) or DSM-III) with a severely anhedonic subgroup (12%). These results were confirmed in a study of a depressed French group (Hardy et al., 1986). In the evaluation of pleasure, Klein (1987), distinguished pleasure linked to biological drive reduction (‘consummatory pleasure’) and pleasure linked to activities (i.e., ‘searching, hunting, foraging’) called ‘appetitive pleasure’. According
to this author, absence of consummatory pleasure is always accompanied by an absence of appetitive pleasure. the absence of the first being characteristic of endogenomorphic depression. On the other hand, for Clark and Fawcett (1987) there is no theoretical basis for distinguishing different types of pleasure. Other authors. such as Chapman et al. (19761, distinguish between pleasure linked to physical and sensory stimulations and that linked to social activities and developed two scales: Physical Anhedonia Scale (PAS) and Social Anhedonia Scale (SAS). Their scales were especially used to study anhedonia in schizophrenia and schizoid personality disorder. But some authors showed the existence of severe physical anhedonia in depressed patients (Lutzenbergcr et al., 19833. In .!ddition. psychophysiological studies of healthy subjects having a high PAS score, suggests that these subjects could be predisposed to depressive disorder (Lutzenberger et al., 1983; Pierson et al., 1987, 1990). The aim of the present study is to test the hypothesis that the PAS. evaluating anhedonia similar to ‘consummatory pleasure’ loss, allows us to distinguish a subgroup of endogenomorphic depressed patients.
Srtbjects 6-l inpatients
hospitalized at the Clinique des Maladies Mentales et de I’Encephale were the object of a study conducted from June 1989-July 1990. After obtaining permission from the patients, we proceeded to their evaluation. Those studied met RDC criteria (Spitzer et al., 1980) for major depressive disorder specifying whether or not it is a bipolar depression. The subjects had to be from 18 to SO years of age. Exclusion criteria eliminated patients with: secondary depression, mental retardation, electroconvulsive therapy treatment within the previous six months. The subjects were evaluated within the first few days of their hospitalization by two different psychiatrists (G.L and E.S). All patients were undergoing treatment. 64 normal subjects were recruited among the hospital personnel and their family and acquain-
tances. The healthy subjects participated anonymously in the study. Those studied showed an absence of any current psychopathological condition or any history of psychiatric hospitalization. They were from 18-80 years of age. Depressive disorder was eliminated by passing the Beck Depression Inventory (BDI) (Beck and Beamesderfer, 1974). The control group was not matched for socio-demographic variables. The healthy subjzcts had to have a score under 10. Rating scales
The patients filled out 2 scales, the PAS (61item version) (Chapman and Chapman, unpublished data), and the FCPCS. The severity of the depression was measured by the l7-item Hamilton Scale (Hamilton Depression Rating Scale: HDRS, Hamilton 1960). The PAS includes 61 questions with yes or no answers, each question being scored 0 or 1, the total score ranging from 0 to 61. The FCPCS includes 36 items, each question having a 9-point scale answer (the original scale had only 5-p. ‘nt scale answers but the French authors have added 4 points of response in relation to the evaluation of displeasure), the total score ranging from 0 to 324. The healthy subjects filled out the same scales along with the BDI (Delay et al., 1963). In the two groups, the sex, age and profession, according to the S-point classification of the Institut National de la Statistique et des Etudes Economiques (INSEE, 19621, were determined along with the 3-category education level (I: below baccalaureat level, II: baccalaureat level, III: above baccalaureat level). The baccalaureat corresponds to the end of secondary school studies, that is 12 years of accredited education after age 6. Staiistical analysis
First, we examined the reliability of the PAS. Two methods were employed to evaluate the internal consistency of the PAS. First, the coefficient alpha (Kuder-Richarson Formula 20, KR 20) for the entire array of item responses was determined (Carmines and Zeller, 1979). Next, scores for each of the 61 scale items were correlated with the total score for each subject (point bi-serial correlation, Ferguson, 1981). The con-
141
current validity was evaluated by examining its relation to the FCPCS. For the predictive validity it was expected that subjects with diagnosis of major depression would report reduced pleasure (i.e., anhedonia) compared to normal subjects without this diagnosis, Secondly, the two groups of subjects were compared for non-specific variables (age, sex, profession, education level) by Chi-Square (x2) and Student’s t-test. In cases of statistically significant differences of these variables and in order to evaluate their influence in the test scores (PAS, FCPCS, and HDRS) two methods were employed. First, for :he qualitative specific variables, analysis of variance (ANOVA) was completed for each scale with three between-subject factors: Group (depressed vs control), Sex (male vs female). Eduration level (I vs II vs III). Secondly, for the age, analysis of covariance was determined for each scale with one between-subject factor: Group (depressed vs control), age as covariate and score of each scale as dependent variable. Thirdly, the scores on the PAS and the FCPCS were compared in two groups by a Student’s t-test and within each group by determinating correlations (Pearson correlation coefficient). We also studied the correlations between the score on each of the scales (HDRS, PAS and FCPCS) in the depressed group and determined the influence of depressive polarity (unipolar depression vs bipolar depression) on the above variables. Fourthy, the distributions of the PAS and FCPCS scores were determined for each group. We had tested the normality of each distribution by a Chi Square test (x2) which compared the observed distribution with the theoretical (normal) distribution using the same mean and standard-deviation as that of the observed distribution (Schwartz, 1963). The subjects were divided into 10 or 12 categories and if necessary regrouped if the theoretical (calculed) category had fewer than 5 subjects. All tests for significance are reported as twotailed tests. Results Of the 64 subjects in the depressed group, three were excluded: the first two because they
TABLE 1
Socio-demographiccharacteristics of the two groups Major depression (N= 61)
Normal subjects (N=61)
IS/46
14/‘47
Education level
I (3.5 subjects) a II (11 subjects) III (1.5 subjects)
I (20 subjects) II (12 subjects) III (29 subjects)
Age (mean SD)
43.9 (12) h
35.7 (14.3)
Sex (Male/Female)
“: P = 0.013; b: P = 0.001. Depressives are older than the normals (t = 3.4, df = 120, P = 0.001). Education levels I and III are, respectively, overand under-represented in the depressed group compared to the normal group (x’ = 8.59, df = 2. P = 0.013).
had a secondary depression, the third because he refused to take the tests. Of the 64 subjects ir, the control group, three were excluded because they scored 10 or over on the BDI. The socio-demographic characteristics of the two groups are different concerning age, education level, and profession. The depressed patients are older (mean = 43.9, SD = 12) than the controls (mean = 35.7, SD = 14.3) (t = 3.4, df = 120, P = 0.001). Education levels 1 and III are respectively over and under-represented in the depressed group (x2 = 8.59, df = 2, P = 0.013). The employees and intermediate professions are respectively over and under-represented in the depressed group (x’ = 13.61, df = 4, P = 0.008). See Table 1. Reliability of the PAS
The coefficient a!pha (KR 20) is 0.7 in the control group and 0.83 in the depressed group. 54 items out of 61 showed a positive and significant relationship to the total scale score (point bi-serial correlation). Scale items correlated with the total score at values between 0.18 and 0.59 in both groups. The remaining items (No. 5, No. 6, No. 14, No. 19, No. 30, No. 35, No. 45) show no significant correlation. The concurrent validity is expressed by the correlation behveen the PAS score and the FCPCS score by using the Pearson correlation
TABLE 2 Intercorrelation between PAS score. FCPCS score, HDRS score and age in the depressed group. (Pearson’s correlation coefficient)
PAS FCPCS HDRS Age
PAS
FCPCS
HDRS
Age
1
-0.53 a 1
0.33 b -0.17 1
0.03 -0.2 - 0.01 1
“: P = 0.00001; b: P = 0.009.
coefficient. It’s value is -0.31 (P = 0.014) for the control group and -0.53 (P = 0.00001) for the depressed group. See Table 2. The predictive validity can be shown by the existence of a higher score in the depressed group compared to the control group. In order to evaluate the influence of socio-demographic variables on the PAS, an analysis of variance with 3 between-subject factors (Group: depressed vs control, Sex: male vs female, Education level: I vs II vs III) was carried out. There exists a significant group factor (F(l, 110) = 18.21, P = 0.0001) but there are no significant sex factor (F(1, 110) = 0.073, n.s) and no significant education level factor (F(2, 110) = 1.56, n.s). An analysis of covariance with one betweensubject factor (Group: depressed vs control), age as covariate and PAS score as dependent variable has shown a significant group factor (F(1, 119) = 23.72, < 0.000001). Influence of sociodemographic variables
There is no significant correlation between age and the PAS score and age and the FCPCS score for each group. See Table 2. An analysis of variance with 3 between-subject factors (Group: depressed vs control, Sex: male vs female, Education level: I vs II vs III) and an analysis of covariance with one-between-subject factor (Group: depressed vs control), age as covariate and FCPCS score as dependent variable shows no significant factor for the FCPCS. Depressed us control group comparison
The PAS score of the depressed group (mean = 21.49, SD = 8.21 is significantly higher than that of the control group (mean = 14.75, SD = 5.5)
(t = 5.28, df = 120. P < 0.000001). On the FCPCS the score of the depressed group (mean = 260.22, SD = 23.1) dots not differ significantly from that of the control group (mean = 263, SD = 17.3) (t = 0.77, df = 120, n.s). Depressed group characteristics
In the depressed group, a correlation has been found between the PAS and the HDRS scores (r = 0.33, P = 0.009) but not between the FCPCS and the HDRS scores (r = - 0.17, n.s). See Table 2. The diagnoses are divided into 12 (19,6%) bipolar depressions and 49 (80.4%) unipolar depressions. The bipolars are younger (mean = 36.33, SD = 6.2) than the unipolars (mean = 45.85, SD = 12.4) (r = 2.56, df = 59, P = 0.013). The analysis of variance with 3 between-subject factors (Diagnostic: unipolar vs bipolar, Sex: male vs female, Education level: vs II vs III) show no diagnostic factor for each of the scales (PAS, FCPCS, HDRS). In the normal and depressed groups the tests of normality for PAS and FCPCS had shown for each scale that there were no significant differences between the observed distribution and the theoretical distribution. In the normal group,for the PAS the x2 was 0.7 (df = 3, P = ns) for the FCPCS the x2 was 1.25 (df = 5, P = ns). In the depressed group, for the PAS the x2 was 1.17 (df = 4, P = ns), for the FCPCS the x’ was 6.6 (df = 7, P = ns). So we can suppose that the PAS and FCPCS distributions are normally distributed or unimodal in each group. The PAS scores are shown in figure. Discussion This study using, an operational definition of physical anhedonia, examined the role of this symptom in major depressive disorder and also served to validate the PAS of a French population. The KR 20 scores found in several studies (Chapman et al., 1978, 1980; Edell and Chapman, 1979) vary between 0.78 and 0.83 for healthy subject groups of both sexes. The KR 20 scores of our study are closer to those of the American authors, Considering the recruitment method
I43
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Fig. 1. Distribution
of PAS scores: (top) depressed (bottom) normal group.
group;
used for the control group (hospital personnel and acquaintances) the non-specific variables between the groups are not matched. There is no correlatian between the PAS score and age as confirmed by Chapman et al. (1976, 1978) and Schuck et al. (1984). There is no influence of sex or level of education on the PAS, contrary to the Chapman et al. study (1976, 1978) which found a higher score among the male subjects. Also, Schuck et al. (1984) found a negative correlation between the PAS score and the education level (r = -0.29) among subjects with personality disorders or depressions. The PAS scores for the normal group show no significant differences according to sex and are close to the Chapman et al. (1980) values for male subjects (mean = 12.93) and to the Cook and Simukonda (1981) studies which found a mean score of 18.6 in the control group for both sexes. The PAS score for the depressed group is significantly higher than that of the control group, with a score close to Lutzenberger’s (1983) who found a mean score of 22.9 among 20 depressed patients. On the other hand, Schuk et al. (1984)
found no significant difference between the PAS scores for 3 groups (schizophrenia, bipolar affective disorder and personality disorder, unipolar affective disorder). The FCPCS score of the depressed group does not differ significantly from the control group contrary to the Fawcett et al. (1983a) findings but in agreement with the Hardy et al. (1986) findings. Our results are similar to the Hardy studies which found a mean score of 260.3 in the control group and 256.9 in the depressed group (DSM-III major depression). The construct validity of the French version of the FCPCS was proved by a principal component analysis. But the French authors increased the point scale from 5 to 9 points, so as to include a displeasure rating scale. This increase in the number of possible answers could be the reason for the difficulties that the depressed patients encounted when filling out the FCPCS and could explain the absence of predictive validity. Another explanation could be provided by the problem of cross-cultural validation that affects each scale. Even with careful translation, additional testings were necessary to verify the validity of the translations (Fava, 1983). Rut besides the problem of language, ethnic origin and gender can also influence the responses within any one culture (Marsella et al., 1975). In the depressed group, the HDRS score carrelates significantly with the PAS score, but not with the FCPCS score. Fawcett et al. (1983a) found in their depressed group a correlation of -0.46 between the FCPCS and BDI scores. Hardy et al. (1986) found no significant correlation between the FCPCS and the HDRS scores in their depressed group. In the depressed group, the PAS and FCPCS score distributions are normally distributed. But the absence of significant differences between the observed distribution and the theoretical distribution (same mean and standard-deviation as in the observed distribution) for each scale WAS and FCPCS) could be related to the small size of the group tested. With the above limitation the PAS distribution does not support the hypothesis that there is a qualitatively distinct subgroup of major depressive caracterised by severe physical anhedonia. On the other hand physical anhedonia
14-l
seems to be a symptom which varies according to the intensity of the depression. The FCPCS distribution was different from that found by Fawcett et al. (1983a) who had shown a bimodal distribution in their 164 depressives using Day’s mixture analysis model. The authors had 12% of severely anhedonic depressive. Hardy’s study had shown the existence of a subgroup (11 c/o) of severely anhedonic depressive (score of 2 or more SDS below the mean for normal subjects on the FCPCS), but the authors had not statisticaly tested the distribution of the FCPCS in their depressed group (N = 81). Physical anhedonia could be in relation with hospitalisation. Cole and Zarit (Cole and Zarit, 1984) had shown in a study comparing medically ill inpatients with depressed medically ill inpatients that the effect of the hospitalisation was a low frequency of solitary pleasure and that the effect of the depression was a low frequency of interpersonal pleasure. The depressed medically ill patients were also characterized by reporting lower interpersonal and solitary pleasure. Independent of the low frequency of physical pleasure (effect of hospitalisation), physical anhedonia in the depressed could be in relation to a loss of association between a physical stimulation and it’s correspondent feeling. Physical anhedonia can be insufficient, by itself. in distinguishing a subtype of depression. Oei et al. 419901 studied depressive symptomatology, PAS and SAS scores, and the dexamethasone suppression test on 46 patients with DSM-III depression (major depression, dysthymic disorder, atypical depression). The authors showed the existence of a subgroup of depressives (21.7%) characterized by suicidal ideation, high scores on the PAS and SAS, and dexamethasone nonsuppression. The studies of Fawcett et al. (1983a, 1983b) and Clark et al. (1984) offered some experimental support of the Klein (1974) hypotheses and has allowed the distinction of the melancholia type of DSM-III major depression. In fact, the studies of characteristics of DSM-III melancholia showed that biological therapies and electroconvulsivetherapy were not particularly effective (Zimmerman et al., 1989). Also, Zimmerman et al. (1986) suggested that the DSM-III melancho-
lia criteria differentiated the depressives only according to the severity of the depression. This work led to the revisicn of the criteria of DSM-III melancholia with a polythetic diagnostic approach in which anhedonia is no longer relevant. The authors who study anhedonia do not use an operational definition of anhedonia based on rating scales. They only use some items of diagnostic criteria cr depression rating scale items (Young et al., 1986; Hibbert et al., 1984). In other case, the authors use the anhedonia-asociality item of the Scale for Assessment of Negative Symptoms (SANS, Andreasen (1981), (i.e., Chaturvedi and Sarmukaddam, 1986; Kitamura and Suga, 1991). The above limitation is reinforced by the fact that anhedonia is a heterogeneous symptom. Peterson and Knudson (1983) tested the construct validity of anhedonia with a multi-varied analysis method based on answers to tests on 100 healthy subjects. The principal components procedure for analyzing multitrait-multimethod matrices has shown the existence of 5 components: pleasureless introversion, neurotic maladjustment, dependency, hedonic deficit No. 1 and No. 2, and coarctation. The importance of research on anhedonia shows the necessity of using a reliable definition of r;;is symptom. In a multi-aminergic perspective Van Praag et al. (1990) suggested that anhedonia in depression should be related to NA-ergic insufficiency. This transmission defect could be the cause of an inability to couple the experience of reward or anticipated reward to a particular activity. Fava et al. (1990) had shown that anhedonia is a prodromal symptom in primary major depressive disorder. Anhedonia was reported by eight of the fifteen patients of the Fava study. Our work needs to be confirmed on a larger, more varied depressed population (e.g., depressed outpatients). It wou!d also be interesting to study other types of anhedonia of the depressed patients (e.g., social anhedonia). Conclusions Our study, using an operational definition of physical anhedonia based on a reliable rating scale (PAS) does not allow us to distinguish a
145
subgroup of major depressed patients characterized by severe physical anhedonia. This characteristic has a continuous distribution in major depres& patients and is related to the severity of the depression. References American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders, 3 edn (DSM-III), Am. Pbychiatr. Assoc.. Washington, DC. American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. rev (DSMIII-R). ibid. Andreasen, N.C (1981) Scale for the Assessment of Negative Symptoms (SANS) 61981). University of Iowa. Iowa City. IA. Beck, A. and Beamesderfer, A. (1974) Assessment of depression: the depression inventory. Mod. Probl. Pharmacopsychiatr.. 7, 151-169. Carmines, E.G. and Zeller, R.A. (1979) Reliability and validity assessment, Sage Publications, Inc. Beverly Hills, CA. Chapman, L.J, Chapman, J.P. and Raulin. M.L. (1976) Scales for physical and social anhedonia. J. Abnorm. Psychol., 4, 374-382. Chapman, L.J.. Chapman, J.P. and Raulin. M.L. (1978) Bodyimage aberration in schizophrenia. J. Abnorm. Psychol., 87. 4, 399-407. Chapman. L.J.. Edell, W.S. and Chapman, J.P. (1980) Physical anhedonia, perceptual aberrration, and psychosis pronrness. Schizophrenia Bull. 6, 4, 639-653. Chaturvedi. SK. and Sarmukaddam, S.B. (1986) Prediction of outcome in depression by negative symptoms. Acta Psychiatr. Stand. 74, 183-186. Clark, D.C.. Fawcett, J., Salazar-Grueso. E. and Fawcet:, E. (1984) Seven-month clinical outcome of anhedonic and normally hedonic depressed inpatients. Am. J. Psychiatr.. 141, 10, 1216-1220. Clark. D.C. and Fawcett. J. (1987) Anhedonia. hypohedonia and pleasure capacity in major depressive disorders. In: DC. Clark and J. Fawcett (Eds.), Anhedonia and affect deficit states, PMA Publishing Corp. New York, pp. 5163. Cole, K.D. and Zarit. S.H. (1984) Psychological deficits in depressed medical patients. J. Ner. Ment. Dis., 172. 150155. Cook, M. and Simukonda, F. (1981) Anhedonia and schizophrenia. Br. J. Psychiat.. 139, 000-000. Delay, J., Pichot, P., Lemperiere, T. and Mirouze, R. (1963) La nosologie des etats depressifs. rapports entre I’etiologie et la semeiologie: 2. Risultats du questionnaire de Beck. L’encCphale. 6, 497-505. Edell, W.S. and Chapman, L.J. (1979) Anhedonia. perceptual aberration and the Rorschach. J. Consult. Clin. Psychol., 47. 2, 377-384. Fava, G.A. (1983) Assessing depressive symptoms across cultures: italian validation of the CES-D self rating scale. J. Clin. Psychol.. 39, 2, 249-251.
Fava, G.A.. Grandi. S.. Canestrari, R. and Molnar, G. (199pj Prodromal symptoms in primary major depressive disorder. J. Affect. Disord. 19. 149-152. Fawcett. J., Clark, D.C., Scheftner, W.A. and Gibbons, RD. (1983a) Assessing anhednnia in psychkrrlc p~~ie~i~,i>tG pleasure scale.Arch. Gen. Psychiatr., 40. 79-84. Fawcett. J.. Clark, D.C.. Scheftner, W.A. and Hedeker, D. (1983b) Differences between anhedonic and normally hedonic depressive states. .4m. J. Psychiatr., 140, 8, 10271030. Ferguson, G.A. (1981) Statistical analysis in psychology and education, McGraw-Hill Book Company, London. Hamilton. M. (1960) A rating scale for depression. J. Neural. Neurosurg. Psychiat., 23, 56-62. Hardy. P.. Jouvent, R.. Lancrenon, S., Roumengous, V. and Feline. A. (1986) L’echelle de plaisir-deplaisir: Utilisation dans I’haluation de la maladie depressive. L’Endphale, XII. 149-154. Hibbert, G.A.. Teasdale. J.D. and ? ,encer, P. (1984) Covariation of depressive symptoms over time. Psycholog. Med., 14.451-455. Institut National des Statistiques et des Etudes Economiques (INSEE) (1962) Codes des categories socio-professisnnelles, imprimerie nationale, 4 ed, Paris, Kitamura, T. and Suga. R. (1991) Depressive and negative symptoms in major psychiatric disorders. Comp. Psychiatr.. 32. 1. 88-94. Klein, D.F. (1974) Endogenomorphic depression: a conceptual and terminological revision. Arch. Gen. Psychiatr.. 31, 447-454. Klein, D.F. (1987) Depression and anhedonia. In: D.C. Clark and J. Fawcett (Eds), Anhedonia and affect d-ficit states, op tit, pp. I-14. Lutz:nberger. W., Birbaumer, N., Rockstroh, B. and Elbert, T. (1983) Evaluation of contingencies and conditional probabilities. Arch. Psychiatr. Nervenkr., 233, 471-488. Marsella. A.J.. Sanborn, K.O., Kameoka, V.. Shizuru, L. and Brennan, J. (1975) Cross-validation of self-report measures of depression among populations in Japanese, Chinese, and Caucasian ancestry. J. Clin. Psychol., 31, 281-287. Oei. T.I. Verhoeven, W.M.A., Westenberg. H.G.M.. Zwart, F.M. and Van Ree. J.M. (1990) Anhedonia, suicide ideation and dexamethasone nonsuppression in depressed patients. J. Psychiat. Res.. 24, I, 25-35. Peterson, C. and Knudson, R.M. (1983) Anhedonia: a construct validation approach. J. Personal. Assess.. 47, 5, 539-551. Pierson, A., Ragot. R., Ripoche. A. and Lesevre. N. (1987) Electrophysiological changes elicited by auditory stimuli given a positive or negative value: a study comparing anhedonic with hedonic subiects. Internat. J. Psychophysiol., 5. 107-123. Pierson, A., Loas, G. and Leskre. N. (1990) Etude de @entiels &oqu& cognitifs en fonction de la valence affective et de la signification des stimulus chez des sujets sains anhedoniques avec attitudes dysfonctionnelles. Len&phale, XVI, 209-216. Pichot, P. (1970) Traduction de I’echelle de depression d’Hamilton. Non publiee.
146 Schuck. J., Levcnthal. D., Rothstein, H. and Irizarry, V. (1984) Physical anhedonia and schizophrenia. J. Abnorm. Psychol.. 93, 3, 342-344. Schwartz. D. (1963) Mithodes statistiques i I’usage des m;detins et des biologistes, Flammarion midecine sciences, Paris. Spitzer, R.L.. Endicott. J. and Robins. E. (1980) Research Diagnostic Criteria (RDC) for a selected group of functional disorders. Biometrics Research, New York. NY. Van Praag. H.M.. Asnis. G.M., Kahn, R.S., Brown, S.L. Korn. M.. Harkavy. Friedman. J.M. and Wetzler. S. (1990) Monoamines and Abnormal bchaviour. A multi-aminergic perspective. Br. J. Psychiatr.. 157. 723-734.
Young, M.A., Scheftner. W.A. and Klerman, G.L., Andreasen, N.C. and Hirschfeld, R.M.A. (1986) The endogenous subtype of depression: a study of its internal construct validity. Br. J. Psychiatr.. 148, 257-267. Zimmerman, M.. Coryell, W. and Pfohl, B. (1986) Melancholic subtyping: a qualitative or quantitative distinction? Am. J. Psychiatr., 143, 1, 98-100. Zimmerm-n, M., Black. D.W. and Coryell. W. (1989). Diagnostic criteria for melancholia: the comparative validity of DSM-III and DSM-III-R. Arch. Gen. Psychiatr.. 46, 361368.
JAD
139
B.V. All rights resewed
016503L7/92/$05.00
00904
edonia in major Gwen016 Loas, Eliseo Salinas, Mien
D. Guelfi and Bertrand Samuel-Lajeunesse
Cliniqxe des Mahdies Mentales et de I’Ence’phale fC. M. M. E), Paris, Frame (Received (Revision
4 November
1991)
received 28 February
(Accepred
10 March
1992)
1992)
Summary Physical anhedonia, evaluated by the score on the physical anhedonia scale (PAS) of Chapman et al. [J. Abnorm. Psychol. 4 374-382 (1976)] was studied in 61 patients, who met RDC criteria for major depressive disorder and in 61 normal subjects. The depressed patients scored significantly higher than the normal group and presented a continuous distribution. Physical anhedonia of depressed patients seems related to the severity of the depression and does not appear to identify a qualitatively distinct subgroup.
Key wo&:
Physical anhedonia;
Depression;
Rating scale; Melancholia;
Introduction Anhedonia, the lowered ability to experience pleasure, is an important symptom of majirr depressive disorder, namely in the melancholia and endogenous subtypes. In the DSM-III (American Psychiatric Association, 1980) anhedonia was necessary for the diagnosis of melancholia subtype in major depressive disorder, which is not the case for the melancholia type in the DSM-IIIR (American Psychiatric Association 1987). In order to study anhedor?ia, it is important to give an operational definition to allow comparisons between the various studie:. Therefore.
Correspondence de Psychiatric,. France.
to: G. Loas. Service Hospitalo-Universitaire C.H.S
Philippe
Pinel. 80044 Amiens
Cedex.
Pleasure
Fawcett et al. (1983a) developed a pleasure scale (the Fawcett-Clark Pleasure Capacity Scale: FCPCS) in order to verify Klein’s (1974) hypotheses which claim that severe anhedonia would characterize a particular type of depression: namely, endogenomorphic depression. The authors showed that rhe FCPCS allows us to distinguish a bimodal distribution among the major depressive patients (Research Diagnostic Criteria (RDC, Spitzer et al., 1980) or DSM-III) with a severely anhedonic subgroup (12%). These results were confirmed in a study of a depressed French group (Hardy et al., 1986). In the evaluation of pleasure, Klein (1987), distinguished pleasure linked to biological drive reduction (‘consummatory pleasure’) and pleasure linked to activities (i.e., ‘searching, hunting, foraging’) called ‘appetitive pleasure’. According
to this author, absence of consummatory pleasure is always accompanied by an absence of appetitive pleasure. the absence of the first being characteristic of endogenomorphic depression. On the other hand, for Clark and Fawcett (1987) there is no theoretical basis for distinguishing different types of pleasure. Other authors. such as Chapman et al. (19761, distinguish between pleasure linked to physical and sensory stimulations and that linked to social activities and developed two scales: Physical Anhedonia Scale (PAS) and Social Anhedonia Scale (SAS). Their scales were especially used to study anhedonia in schizophrenia and schizoid personality disorder. But some authors showed the existence of severe physical anhedonia in depressed patients (Lutzenbergcr et al., 19833. In .!ddition. psychophysiological studies of healthy subjects having a high PAS score, suggests that these subjects could be predisposed to depressive disorder (Lutzenberger et al., 1983; Pierson et al., 1987, 1990). The aim of the present study is to test the hypothesis that the PAS. evaluating anhedonia similar to ‘consummatory pleasure’ loss, allows us to distinguish a subgroup of endogenomorphic depressed patients.
Srtbjects 6-l inpatients
hospitalized at the Clinique des Maladies Mentales et de I’Encephale were the object of a study conducted from June 1989-July 1990. After obtaining permission from the patients, we proceeded to their evaluation. Those studied met RDC criteria (Spitzer et al., 1980) for major depressive disorder specifying whether or not it is a bipolar depression. The subjects had to be from 18 to SO years of age. Exclusion criteria eliminated patients with: secondary depression, mental retardation, electroconvulsive therapy treatment within the previous six months. The subjects were evaluated within the first few days of their hospitalization by two different psychiatrists (G.L and E.S). All patients were undergoing treatment. 64 normal subjects were recruited among the hospital personnel and their family and acquain-
tances. The healthy subjects participated anonymously in the study. Those studied showed an absence of any current psychopathological condition or any history of psychiatric hospitalization. They were from 18-80 years of age. Depressive disorder was eliminated by passing the Beck Depression Inventory (BDI) (Beck and Beamesderfer, 1974). The control group was not matched for socio-demographic variables. The healthy subjzcts had to have a score under 10. Rating scales
The patients filled out 2 scales, the PAS (61item version) (Chapman and Chapman, unpublished data), and the FCPCS. The severity of the depression was measured by the l7-item Hamilton Scale (Hamilton Depression Rating Scale: HDRS, Hamilton 1960). The PAS includes 61 questions with yes or no answers, each question being scored 0 or 1, the total score ranging from 0 to 61. The FCPCS includes 36 items, each question having a 9-point scale answer (the original scale had only 5-p. ‘nt scale answers but the French authors have added 4 points of response in relation to the evaluation of displeasure), the total score ranging from 0 to 324. The healthy subjects filled out the same scales along with the BDI (Delay et al., 1963). In the two groups, the sex, age and profession, according to the S-point classification of the Institut National de la Statistique et des Etudes Economiques (INSEE, 19621, were determined along with the 3-category education level (I: below baccalaureat level, II: baccalaureat level, III: above baccalaureat level). The baccalaureat corresponds to the end of secondary school studies, that is 12 years of accredited education after age 6. Staiistical analysis
First, we examined the reliability of the PAS. Two methods were employed to evaluate the internal consistency of the PAS. First, the coefficient alpha (Kuder-Richarson Formula 20, KR 20) for the entire array of item responses was determined (Carmines and Zeller, 1979). Next, scores for each of the 61 scale items were correlated with the total score for each subject (point bi-serial correlation, Ferguson, 1981). The con-
141
current validity was evaluated by examining its relation to the FCPCS. For the predictive validity it was expected that subjects with diagnosis of major depression would report reduced pleasure (i.e., anhedonia) compared to normal subjects without this diagnosis, Secondly, the two groups of subjects were compared for non-specific variables (age, sex, profession, education level) by Chi-Square (x2) and Student’s t-test. In cases of statistically significant differences of these variables and in order to evaluate their influence in the test scores (PAS, FCPCS, and HDRS) two methods were employed. First, for :he qualitative specific variables, analysis of variance (ANOVA) was completed for each scale with three between-subject factors: Group (depressed vs control), Sex (male vs female). Eduration level (I vs II vs III). Secondly, for the age, analysis of covariance was determined for each scale with one between-subject factor: Group (depressed vs control), age as covariate and score of each scale as dependent variable. Thirdly, the scores on the PAS and the FCPCS were compared in two groups by a Student’s t-test and within each group by determinating correlations (Pearson correlation coefficient). We also studied the correlations between the score on each of the scales (HDRS, PAS and FCPCS) in the depressed group and determined the influence of depressive polarity (unipolar depression vs bipolar depression) on the above variables. Fourthy, the distributions of the PAS and FCPCS scores were determined for each group. We had tested the normality of each distribution by a Chi Square test (x2) which compared the observed distribution with the theoretical (normal) distribution using the same mean and standard-deviation as that of the observed distribution (Schwartz, 1963). The subjects were divided into 10 or 12 categories and if necessary regrouped if the theoretical (calculed) category had fewer than 5 subjects. All tests for significance are reported as twotailed tests. Results Of the 64 subjects in the depressed group, three were excluded: the first two because they
TABLE 1
Socio-demographiccharacteristics of the two groups Major depression (N= 61)
Normal subjects (N=61)
IS/46
14/‘47
Education level
I (3.5 subjects) a II (11 subjects) III (1.5 subjects)
I (20 subjects) II (12 subjects) III (29 subjects)
Age (mean SD)
43.9 (12) h
35.7 (14.3)
Sex (Male/Female)
“: P = 0.013; b: P = 0.001. Depressives are older than the normals (t = 3.4, df = 120, P = 0.001). Education levels I and III are, respectively, overand under-represented in the depressed group compared to the normal group (x’ = 8.59, df = 2. P = 0.013).
had a secondary depression, the third because he refused to take the tests. Of the 64 subjects ir, the control group, three were excluded because they scored 10 or over on the BDI. The socio-demographic characteristics of the two groups are different concerning age, education level, and profession. The depressed patients are older (mean = 43.9, SD = 12) than the controls (mean = 35.7, SD = 14.3) (t = 3.4, df = 120, P = 0.001). Education levels 1 and III are respectively over and under-represented in the depressed group (x2 = 8.59, df = 2, P = 0.013). The employees and intermediate professions are respectively over and under-represented in the depressed group (x’ = 13.61, df = 4, P = 0.008). See Table 1. Reliability of the PAS
The coefficient a!pha (KR 20) is 0.7 in the control group and 0.83 in the depressed group. 54 items out of 61 showed a positive and significant relationship to the total scale score (point bi-serial correlation). Scale items correlated with the total score at values between 0.18 and 0.59 in both groups. The remaining items (No. 5, No. 6, No. 14, No. 19, No. 30, No. 35, No. 45) show no significant correlation. The concurrent validity is expressed by the correlation behveen the PAS score and the FCPCS score by using the Pearson correlation
TABLE 2 Intercorrelation between PAS score. FCPCS score, HDRS score and age in the depressed group. (Pearson’s correlation coefficient)
PAS FCPCS HDRS Age
PAS
FCPCS
HDRS
Age
1
-0.53 a 1
0.33 b -0.17 1
0.03 -0.2 - 0.01 1
“: P = 0.00001; b: P = 0.009.
coefficient. It’s value is -0.31 (P = 0.014) for the control group and -0.53 (P = 0.00001) for the depressed group. See Table 2. The predictive validity can be shown by the existence of a higher score in the depressed group compared to the control group. In order to evaluate the influence of socio-demographic variables on the PAS, an analysis of variance with 3 between-subject factors (Group: depressed vs control, Sex: male vs female, Education level: I vs II vs III) was carried out. There exists a significant group factor (F(l, 110) = 18.21, P = 0.0001) but there are no significant sex factor (F(1, 110) = 0.073, n.s) and no significant education level factor (F(2, 110) = 1.56, n.s). An analysis of covariance with one betweensubject factor (Group: depressed vs control), age as covariate and PAS score as dependent variable has shown a significant group factor (F(1, 119) = 23.72, < 0.000001). Influence of sociodemographic variables
There is no significant correlation between age and the PAS score and age and the FCPCS score for each group. See Table 2. An analysis of variance with 3 between-subject factors (Group: depressed vs control, Sex: male vs female, Education level: I vs II vs III) and an analysis of covariance with one-between-subject factor (Group: depressed vs control), age as covariate and FCPCS score as dependent variable shows no significant factor for the FCPCS. Depressed us control group comparison
The PAS score of the depressed group (mean = 21.49, SD = 8.21 is significantly higher than that of the control group (mean = 14.75, SD = 5.5)
(t = 5.28, df = 120. P < 0.000001). On the FCPCS the score of the depressed group (mean = 260.22, SD = 23.1) dots not differ significantly from that of the control group (mean = 263, SD = 17.3) (t = 0.77, df = 120, n.s). Depressed group characteristics
In the depressed group, a correlation has been found between the PAS and the HDRS scores (r = 0.33, P = 0.009) but not between the FCPCS and the HDRS scores (r = - 0.17, n.s). See Table 2. The diagnoses are divided into 12 (19,6%) bipolar depressions and 49 (80.4%) unipolar depressions. The bipolars are younger (mean = 36.33, SD = 6.2) than the unipolars (mean = 45.85, SD = 12.4) (r = 2.56, df = 59, P = 0.013). The analysis of variance with 3 between-subject factors (Diagnostic: unipolar vs bipolar, Sex: male vs female, Education level: vs II vs III) show no diagnostic factor for each of the scales (PAS, FCPCS, HDRS). In the normal and depressed groups the tests of normality for PAS and FCPCS had shown for each scale that there were no significant differences between the observed distribution and the theoretical distribution. In the normal group,for the PAS the x2 was 0.7 (df = 3, P = ns) for the FCPCS the x2 was 1.25 (df = 5, P = ns). In the depressed group, for the PAS the x2 was 1.17 (df = 4, P = ns), for the FCPCS the x’ was 6.6 (df = 7, P = ns). So we can suppose that the PAS and FCPCS distributions are normally distributed or unimodal in each group. The PAS scores are shown in figure. Discussion This study using, an operational definition of physical anhedonia, examined the role of this symptom in major depressive disorder and also served to validate the PAS of a French population. The KR 20 scores found in several studies (Chapman et al., 1978, 1980; Edell and Chapman, 1979) vary between 0.78 and 0.83 for healthy subject groups of both sexes. The KR 20 scores of our study are closer to those of the American authors, Considering the recruitment method
I43
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of PAS scores: (top) depressed (bottom) normal group.
group;
used for the control group (hospital personnel and acquaintances) the non-specific variables between the groups are not matched. There is no correlatian between the PAS score and age as confirmed by Chapman et al. (1976, 1978) and Schuck et al. (1984). There is no influence of sex or level of education on the PAS, contrary to the Chapman et al. study (1976, 1978) which found a higher score among the male subjects. Also, Schuck et al. (1984) found a negative correlation between the PAS score and the education level (r = -0.29) among subjects with personality disorders or depressions. The PAS scores for the normal group show no significant differences according to sex and are close to the Chapman et al. (1980) values for male subjects (mean = 12.93) and to the Cook and Simukonda (1981) studies which found a mean score of 18.6 in the control group for both sexes. The PAS score for the depressed group is significantly higher than that of the control group, with a score close to Lutzenberger’s (1983) who found a mean score of 22.9 among 20 depressed patients. On the other hand, Schuk et al. (1984)
found no significant difference between the PAS scores for 3 groups (schizophrenia, bipolar affective disorder and personality disorder, unipolar affective disorder). The FCPCS score of the depressed group does not differ significantly from the control group contrary to the Fawcett et al. (1983a) findings but in agreement with the Hardy et al. (1986) findings. Our results are similar to the Hardy studies which found a mean score of 260.3 in the control group and 256.9 in the depressed group (DSM-III major depression). The construct validity of the French version of the FCPCS was proved by a principal component analysis. But the French authors increased the point scale from 5 to 9 points, so as to include a displeasure rating scale. This increase in the number of possible answers could be the reason for the difficulties that the depressed patients encounted when filling out the FCPCS and could explain the absence of predictive validity. Another explanation could be provided by the problem of cross-cultural validation that affects each scale. Even with careful translation, additional testings were necessary to verify the validity of the translations (Fava, 1983). Rut besides the problem of language, ethnic origin and gender can also influence the responses within any one culture (Marsella et al., 1975). In the depressed group, the HDRS score carrelates significantly with the PAS score, but not with the FCPCS score. Fawcett et al. (1983a) found in their depressed group a correlation of -0.46 between the FCPCS and BDI scores. Hardy et al. (1986) found no significant correlation between the FCPCS and the HDRS scores in their depressed group. In the depressed group, the PAS and FCPCS score distributions are normally distributed. But the absence of significant differences between the observed distribution and the theoretical distribution (same mean and standard-deviation as in the observed distribution) for each scale WAS and FCPCS) could be related to the small size of the group tested. With the above limitation the PAS distribution does not support the hypothesis that there is a qualitatively distinct subgroup of major depressive caracterised by severe physical anhedonia. On the other hand physical anhedonia
14-l
seems to be a symptom which varies according to the intensity of the depression. The FCPCS distribution was different from that found by Fawcett et al. (1983a) who had shown a bimodal distribution in their 164 depressives using Day’s mixture analysis model. The authors had 12% of severely anhedonic depressive. Hardy’s study had shown the existence of a subgroup (11 c/o) of severely anhedonic depressive (score of 2 or more SDS below the mean for normal subjects on the FCPCS), but the authors had not statisticaly tested the distribution of the FCPCS in their depressed group (N = 81). Physical anhedonia could be in relation with hospitalisation. Cole and Zarit (Cole and Zarit, 1984) had shown in a study comparing medically ill inpatients with depressed medically ill inpatients that the effect of the hospitalisation was a low frequency of solitary pleasure and that the effect of the depression was a low frequency of interpersonal pleasure. The depressed medically ill patients were also characterized by reporting lower interpersonal and solitary pleasure. Independent of the low frequency of physical pleasure (effect of hospitalisation), physical anhedonia in the depressed could be in relation to a loss of association between a physical stimulation and it’s correspondent feeling. Physical anhedonia can be insufficient, by itself. in distinguishing a subtype of depression. Oei et al. 419901 studied depressive symptomatology, PAS and SAS scores, and the dexamethasone suppression test on 46 patients with DSM-III depression (major depression, dysthymic disorder, atypical depression). The authors showed the existence of a subgroup of depressives (21.7%) characterized by suicidal ideation, high scores on the PAS and SAS, and dexamethasone nonsuppression. The studies of Fawcett et al. (1983a, 1983b) and Clark et al. (1984) offered some experimental support of the Klein (1974) hypotheses and has allowed the distinction of the melancholia type of DSM-III major depression. In fact, the studies of characteristics of DSM-III melancholia showed that biological therapies and electroconvulsivetherapy were not particularly effective (Zimmerman et al., 1989). Also, Zimmerman et al. (1986) suggested that the DSM-III melancho-
lia criteria differentiated the depressives only according to the severity of the depression. This work led to the revisicn of the criteria of DSM-III melancholia with a polythetic diagnostic approach in which anhedonia is no longer relevant. The authors who study anhedonia do not use an operational definition of anhedonia based on rating scales. They only use some items of diagnostic criteria cr depression rating scale items (Young et al., 1986; Hibbert et al., 1984). In other case, the authors use the anhedonia-asociality item of the Scale for Assessment of Negative Symptoms (SANS, Andreasen (1981), (i.e., Chaturvedi and Sarmukaddam, 1986; Kitamura and Suga, 1991). The above limitation is reinforced by the fact that anhedonia is a heterogeneous symptom. Peterson and Knudson (1983) tested the construct validity of anhedonia with a multi-varied analysis method based on answers to tests on 100 healthy subjects. The principal components procedure for analyzing multitrait-multimethod matrices has shown the existence of 5 components: pleasureless introversion, neurotic maladjustment, dependency, hedonic deficit No. 1 and No. 2, and coarctation. The importance of research on anhedonia shows the necessity of using a reliable definition of r;;is symptom. In a multi-aminergic perspective Van Praag et al. (1990) suggested that anhedonia in depression should be related to NA-ergic insufficiency. This transmission defect could be the cause of an inability to couple the experience of reward or anticipated reward to a particular activity. Fava et al. (1990) had shown that anhedonia is a prodromal symptom in primary major depressive disorder. Anhedonia was reported by eight of the fifteen patients of the Fava study. Our work needs to be confirmed on a larger, more varied depressed population (e.g., depressed outpatients). It wou!d also be interesting to study other types of anhedonia of the depressed patients (e.g., social anhedonia). Conclusions Our study, using an operational definition of physical anhedonia based on a reliable rating scale (PAS) does not allow us to distinguish a
145
subgroup of major depressed patients characterized by severe physical anhedonia. This characteristic has a continuous distribution in major depres& patients and is related to the severity of the depression. References American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders, 3 edn (DSM-III), Am. Pbychiatr. Assoc.. Washington, DC. American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. rev (DSMIII-R). ibid. Andreasen, N.C (1981) Scale for the Assessment of Negative Symptoms (SANS) 61981). University of Iowa. Iowa City. IA. Beck, A. and Beamesderfer, A. (1974) Assessment of depression: the depression inventory. Mod. Probl. Pharmacopsychiatr.. 7, 151-169. Carmines, E.G. and Zeller, R.A. (1979) Reliability and validity assessment, Sage Publications, Inc. Beverly Hills, CA. Chapman, L.J, Chapman, J.P. and Raulin. M.L. (1976) Scales for physical and social anhedonia. J. Abnorm. Psychol., 4, 374-382. Chapman, L.J.. Chapman, J.P. and Raulin. M.L. (1978) Bodyimage aberration in schizophrenia. J. Abnorm. Psychol., 87. 4, 399-407. Chapman. L.J.. Edell, W.S. and Chapman, J.P. (1980) Physical anhedonia, perceptual aberrration, and psychosis pronrness. Schizophrenia Bull. 6, 4, 639-653. Chaturvedi. SK. and Sarmukaddam, S.B. (1986) Prediction of outcome in depression by negative symptoms. Acta Psychiatr. Stand. 74, 183-186. Clark, D.C.. Fawcett, J., Salazar-Grueso. E. and Fawcet:, E. (1984) Seven-month clinical outcome of anhedonic and normally hedonic depressed inpatients. Am. J. Psychiatr.. 141, 10, 1216-1220. Clark. D.C. and Fawcett. J. (1987) Anhedonia. hypohedonia and pleasure capacity in major depressive disorders. In: DC. Clark and J. Fawcett (Eds.), Anhedonia and affect deficit states, PMA Publishing Corp. New York, pp. 5163. Cole, K.D. and Zarit. S.H. (1984) Psychological deficits in depressed medical patients. J. Ner. Ment. Dis., 172. 150155. Cook, M. and Simukonda, F. (1981) Anhedonia and schizophrenia. Br. J. Psychiat.. 139, 000-000. Delay, J., Pichot, P., Lemperiere, T. and Mirouze, R. (1963) La nosologie des etats depressifs. rapports entre I’etiologie et la semeiologie: 2. Risultats du questionnaire de Beck. L’encCphale. 6, 497-505. Edell, W.S. and Chapman, L.J. (1979) Anhedonia. perceptual aberration and the Rorschach. J. Consult. Clin. Psychol., 47. 2, 377-384. Fava, G.A. (1983) Assessing depressive symptoms across cultures: italian validation of the CES-D self rating scale. J. Clin. Psychol.. 39, 2, 249-251.
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