See Table 1.
Overview of themes
Adolescents’ experiences were captured in four main themes: (1) experiencing a loss of joy and a flattening of emotion; (2) struggling with motivation and active engagement; (3) losing a sense of connection and belonging; (4) questioning sense of self, purpose, and the bigger picture (see Fig. 1). Each theme highlighted a unique aspect of adolescents’ experiences; however, there were areas of conceptual overlap. All major themes and sub-themes were expressed by both the clinical and community sub-samples.
Theme 1—Experiencing a loss of joy and a flattening of emotion: “I lost what I enjoyed doing” (Tessa, community)
This theme concerns the disruption of adolescents’ positive emotions and co-occurring negative emotions.
Sub-theme: Feeling less positive emotion and experiencing a cycle of boredom
Young people used a range of words to describe the presence or absence of positive emotions, including “enjoyment”, “interest”, “satisfaction”, “pride”, “curiosity”, “fun”, “endorphin rush”, “excitement”, “enthusiasm”, “relaxing”, “good” and “happy.” They described positive emotions as arising from being creative, active, achieving something difficult and spending time with others. A number of adolescents recruited from the clinic and the community described feeling a global loss of interest and enjoyment in anything. They described everything (or almost everything) as “boring”. This often seemed to contradict initial descriptions of hobbies and interests they took part in, or for which they expressed a liking or preference. These feelings of boredom and disinterest were closely linked with not wanting to do things. Adolescents also felt a sense of “monotony”, and described feeling like they were in a “constant loop” of mundane activities.
“I was just like completely bored with it. Like you get bored with a TV show, and you're like, okay leave it then, just move onto another one. It's quite like that with reading and sport because it was just a, I'm bored with this, let's try and find another thing and then I never really found another thing, I just try and do a lot of different things, think I was interested in them then get bored, and just get into a cycle of boredom, finding something else, bored with that, move on” (India, clinic).
Concepts such as “excitement” and “enthusiasm” were used by some participants in reference to both current enjoyment and the anticipation of future events. For example, Jayden (clinic) said “I get really excited watching TV, ‘cos I get really into what I’m watching”. For others excitement was absent, e.g. “nothing feels exciting” (Ivy, clinic), or things “sap the enthusiasm out of me” (Stuart, community). Many young people could not think of anything they were looking forward to or excited about, however, it was often unclear whether this was because they did not anticipate having fun, could not imagine future events, or had a “bad memory” for remembering what they had planned (i.e. prospective memory problems).
“If there's something new and shiny, new film or game I’ll probably be like, yeah it will come out and I’ll see it, but most stuff doesn’t get me excited, just sort of, wait for it to turn up and see how to feel about it.” (Ross, community).
While adolescents typically described a change in positive emotions; some also described feelings of sadness, anxiety and shame. These negative emotions sometimes resulted in a loss of positive feelings.
Sub-theme: Feeling dampened emotions
When asked to describe their feelings, some adolescents reported a partial or complete blunting of any emotion. They described themselves as feeling “dull”, “grey”, “flat”, “vacant”, “a blank sheet”, “empty” and “emotionless”. Some young people described a general flatness, passivity, and feeling “indifferent” or not “caring” about anything. Jacob (clinic) described special events like his birthday as feeling like “just another day”. This flatness was also displayed vocally by them talking with little intonation. Most young people’s experiences reflected a loss of both positive and negative emotion.
“I didn’t really feel anything, like, there was no like happiness or excitement, but there was also like no sadness. It was just like everything was grey.” (Carl, community).
The sense of blunted emotions was not reported all the time or by all young people. Sometimes adolescents felt strong fluctuations in mood, with their feelings shifting abruptly from happiness to sadness.
Theme 2—Struggling with motivation and active engagement: “I’m never motivated to do anything” (Jasmine, clinic)
This theme captures changes in wanting to do things, effort exerted and types of activities young people engaged in.
Sub-theme: Feeling unmotivated but maintaining long term aspirations
Adolescents described changes in how much they “wanted” or felt “motivated” to act or engage in experiences. This lack of drive often contrasted with young people’s stated long-term ambitions and goals, for example going to university, or playing in a band. Some participants’ lack of drive was related to specific experiences such as going to school or seeing friends. Others described a more global lack of drive, with them “not wanting to do anything at all” or even “not wanting to live” (Amy, community).
“Yeah like although they were the things I enjoyed, although I knew I should be enjoying them, for some reason like, I just like wouldn't have the motivation to do it.” (Ivy, clinic).
A loss of drive often occurred alongside a lack of positive emotion. Some participants, however, reported that although they had no drive at all, when they engaged in activities they did enjoy them. This was reported by young people in both the clinical and community samples.
Sub-theme: Feeling unable to gain momentum or engage in effortful activities
Many adolescents were less willing to make efforts needed to reach their goals or felt that everything required more effort. Young people often said “I just can’t be bothered” or that they had to “force” themselves to do anything. Many participants noted that making an effort to get things done was the key barrier to engaging with life and to improving their mood. Jennifer (clinic) said “it’s like if you have a wheel, starting to push the wheel is a lot of effort but the momentum will carry it forwards”. Young people sometimes linked their lack of mental and physical effort to low levels of energy and fatigue as well as to a lack of drive. When feeling unmotivated and fatigued, a number of adolescents said they did very little, often spending their free time just lying in bed.
“Most of the time it's my parents forcing me to get out of bed, other times if I actually have something planned, just sort of, force me to get out of bed…The last few days, I couldn’t even bring myself to get out of bed.” (Gary, clinic).
Some adolescents were able to identify activities that they would and would not do. For example, some could put in enough effort to engage in passive activities, for example,
“So it’s kind of, putting in effort to go and do things that will decline. I would do more, kind of, passive things, so like TV and movies, where it’s just in front of you.” (Richard, community).
Other young people continued to take part in more demanding activities because they felt compelled or obligated.
Theme 3—Losing a sense of connection and belonging: “I’ll be there but I won’t be present” (Jennifer, clinic)
This theme focuses on adolescents’ connections with others and the world around them.
Sub-theme: Feeling disconnected from others
Young people described a sense of relatedness, where they knew other people had similar feelings or shared experiences, and that helped them to feel connected. Receiving direct social support was important, with adolescents describing the significance of having a “support network”. Receiving emotional support helped to improve their mood and motivation. In the absence of connection, adolescents often felt detached from others.
“Participant: “Yeah sometimes, like sometimes when I say no to my friends a lot they’ll just go and have a fun time and then they’ll be talking about it.
Researcher: How does that make you feel?
Participant: A bit, quite more lonely.” (Alice, clinic).
Many participants found it difficult to communicate or express their feelings to others and instead kept things internalised. Some felt an internal struggle; they wanted to talk about their feelings, but did not want to be a burden to others. Putting feelings into words was especially hard for those in the community who did not routinely discuss their emotions with others. Some masked their real feelings by pretending they were happy or enjoying experiences when they were not.
“I guess, most of the time things - I probably appear as though it excites me, but then inside I'm just like going along with everyone else. Like if they find it exciting, I will just be like 'yeah that's nice,' but I’ll probably find it really boring.” (Isla, community).
Sub-theme: Feeling detached from the present reality
As well as social connections, some young people experienced a disconnection from their surroundings, and/or a disconnection from themselves. This sub-theme featured more strongly in the community sample. When describing feeling disconnected from the moment, adolescents used phrases such as, “going through the motions” or being on “autopilot”. Some adolescents described this as if they were watching things happen from afar, like in a film or without any depth. One young person described this feeling as an out-of-body experience, as if watching themselves from above.
“I just go through the normal stuff, but being more looking on than actually doing it, it's more like it's looking through a film, and just my body doing exactly what it would have done anyway, with me in my head watching somehow, rather than me just being there.” (Tylor, community).
For many young people disconnecting from the world around them was also a deliberate distraction from their feelings or situations.
Theme 4: Questioning sense of self, purpose, and the bigger picture: “What’s the point in trying anymore?” (Maddie, community)
This theme reflects adolescents’ search for meaning and understanding, and their perception and beliefs about the world.
Sub-theme: Reflecting on feelings, identity and purpose
Adolescents described a loss of purpose, questioning the meaning of life and of taking part in day to day activities. This description was closely linked to not wanting to do things. A loss of purpose was described by adolescents in both the clinical and community samples.
“When I think in the more wide sense I realise that there's really no point to any of this, GCSEs, exams all of that, eventually we're all gonna die, what use does it really have.” (Stuart, community).
In contrast to lacking purpose, feeling the need to have a meaningful life, and thinking “I won’t have anything to look back on” (Isla, community) was the driving force for some young people to change their actions.
Young people differed in their ability or interest in self-reflection. A lot of adolescents expressed uncertainty, as in feeling like “I don’t know my feelings”. Some young people were in the process of discovering their identity, saying “I just kinda didn't realise my interest” (Ivy, clinic) and “[I’m] still trying to figure out what I like more” (Mel, community). Others displayed explicit insight into their feelings, and expressed this at a deeper level, often appearing self-critical and considering what their feelings said about them. Matthew (community) said “I thought I was a bit better than that, but clearly wasn’t.”.
Sub-theme: Experiencing a lack of agency and a narrowing of perspective
As well as searching for self-discovery, young people talked about their view of the wider world and often expressed a bleak outlook and a lack of personal agency. The majority of young people described feeling “stuck”, “trapped” or “enclosed”. This sometimes resulted in a “mental battle” between how they felt, i.e. no emotion, and how they wanted to feel, i.e. excited. At other times, this was experienced as “acceptance” and resignation.
“Like you don’t feel yourself. People point it out to you, and you don’t change ‘cos that’s how you feel.” (Amy, community).
When struggling with their emotions, a number of young people described a narrowing of their perspective. Some young people felt “there’s kind of no way of getting back to the way I was” (Joanne, community) and could not see beyond their current circumstances or emotional state. This was closely linked with adolescents having a bleak outlook on the future, having “a lack of overall optimism” (Neil, community), and not wanting to think long term, or believing that nothing would change.
Connection between themes
The salience of, and connection between, themes was considered. Themes 1 and 2 encapsulated the most prominent and central components of anhedonia, and Themes 3 and 4 incorporated secondary experiences related to, or part of anhedonia. In addition, Themes 1–3 captured the feelings and behaviours that comprised adolescents’ experiences and theme 4 identified the cognitions and interpretation of feelings and behaviours (see Fig. 2).