Fatigue, anhedonia, and active avoidance of positive experiences
When good things hurt because you are exhausted
One year ago, I was sitting cross-legged at the corner of my bed. Very still, just like that, and finally there they were: moments of nothingness. Such a relief.
One of the reasons I believe the complex hyper-inflammatory post acute disorders such as long COVID or myalgic encephalomyelitis/chronic fatigue syndrome will continue to be hard to diagnose. and harder to treat. is that the symptoms don’t necessarily correspond to measurable biomarkers, such as blood markers or image exams. The other reason is that they overlap with those characterizing conditions under the jurisdiction of the least scientific of the medical practices: psychiatry.
Psychiatry’s nosology has been considered inadequate, incomplete, and finally unsustainable by critical analysts since the late 1960s. Yet, it resists, as one of the most powerful medical specialties, offering “valuable” aid to political and cultural repression.
To this day, there is no adequate scientific model about the etiology of depression. Physicians still parroting the “chemical imbalance” hypothesis are a joke, and only taken seriously by their patients, unfortunately.
A patient suffering from long COVID, myalgic encephalomyelitis, fibromyalgia, hypothyroidism and a huge list of other physiological issues can be erroneously diagnosed as depressive and treated as such.
There is more: if depression includes several adaptive behaviors to either environmental aggression, of which social aggression is the most effective trigger, or to internal loss of homeostasis, then treating the patients with anti-depressants may not just be futile. It could be making the condition worse by not addressing the primary organic disruption.
There is no doubt, however, that disorders that cause pathological fatigue negatively affect a person’s quality of life. Some of the consequences of adjusting to the chronic conditions will produce depressive behaviors.
I enjoy several activities involving different degrees of physical effort: listening to music, lifting weights, reading fiction and non-fiction literature, practicing music, writing, engaging with plants and animals. I also enjoy outdoors activities like hiking, jogging, visiting museum expositions, and street art. Some of these activities became impossible early on. First, all the outdoor activities involve a lot of walking (the pain from the hip impingement on the left side becomes very intense. and eventually “turns off” the leg, so I fall). Jogging is just a memory from another life. I haven’t watched a show in I don’t know how long. Playing music can both cause pain, or exhaustion, during a flare up. But what about reading fiction or listening to music? I avoid both during peak stages of a flare up, but why?
The easy answer is that it is anhedonia, a loss of interest for activities and things that cause pleasure. It is a central feature in what is still currently called depression. The hypothesis is that the patient ceases to feel interest in those activities because depression affects the ability to feel pleasure.
This article is not about how this is also a problematic definition of a problematic category, but rather about how and why chronic fatigue involves moments of avoidance of positive experiences.
I can tell you right away why I avoid music - listening or playing - during peak flare-ups of chronic fatigue and pain: it’s because the emotion experienced in these activities literally hurts during these moments. The least painful and uncomfortable state during a flare up peak is immobility combined with silence and darkness. Anything disturbing that is instinctively avoided.
So it isn’t a loss of ability to feel pleasure. That ability is there, intact. It’s the expectation of more pain and discomfort.
There is not much published about this response. Avoidance of positive experiences is always an indication of disruption, but what response this is, and to what disruption, is still difficult to identify. Avoiding listening to music that I love, and not eating, sometimes not even drinking water, are things that only happen during peak fatigue or pain. Sometimes I question myself whether the fatigue I am experiencing is really fatigue, and not a “pain equivalent”. At this point, anything can happen. And sometimes the only way to push through a flare up is by avoiding feeling anything - good or bad. We don’t know exactly why this happens, but, from my subjective perception, during these moments any stimulus causes pain and discomfort.
References and further reading
Christodoulou, C., Deluca, J., Johnson, S. K., Lange, G., Gaudino, E. A., & Natelson, B. H. (1999). Examination of Cloninger's basic dimensions of personality in fatiguing illness: chronic fatigue syndrome and multiple sclerosis. Journal of psychosomatic research, 47(6), 597-607.
Lenaert, B., Boddez, Y., Vlaeyen, J. W., & van Heugten, C. M. (2018). Learning to feel tired: A learning trajectory towards chronic fatigue. Behaviour Research and Therapy, 100, 54-66.
Nikitin, J. and Freund, A.M. (2010), When wanting and fearing go together: The effect of co-occurring social approach and avoidance motivation on behavior, affect, and cognition. Eur. J. Soc. Psychol., 40: 783-804. https://doi.org/10.1002/ejsp.650
Nikitin, J. and Schoch, S. (2021). Social Approach and Avoidance Motivations. In The Handbook of Solitude (eds R.J. Coplan, J.C. Bowker and L.J. Nelson). https://doi.org/10.1002/9781119576457.ch14
Gable, S.L. (2006), Approach and Avoidance Social Motives and Goals. Journal of Personality, 74: 175-222. https://doi.org/10.1111/j.1467-6494.2005.00373.x
Asbring, P. (2001). Chronic illness–a disruption in life: identity‐transformation among women with chronic fatigue syndrome and fibromyalgia. Journal of advanced nursing, 34(3), 312-319.