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#anhedonia

So, I tried to make something that looked fun or pretty to help me eat. (my appetite died over 2 years ago due to depression, and putting too much effort into cooking isn’t possible due to chronic illness)

So I could only come up with this🤭:::

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Moments later, I found this on my dash and I couldn’t relate more..

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ya estoy harto de que las estrellas huelan a estiércol;
de que tenga que morir tantas veces para saber que estoy muerto;
de tener que acuchillar mi corazón para poder comprar un verso
que nunca debería ser escrito…
de que mis poemas,a veces, salgan de las cloacas de la luna.

Estoy harto de conocer todas las variedades del negro,
sin poder optar ni a un simple gris;
de ver cómo la artrosis aplasta los huesos de mi madre;
de disponer de un abanico tan amplio de soledades.

Me estoy cansando de las dulzuras tenebrosas de la vida;
de las injusticias necesarias;
de mendigarle al amor para poder comerme un trozo de cielo,
de que la ternura tenga dientes de lobo.

Qué es la vida entonces?

Un ángel carnivoro que a veces te da algunas migajas?
Una sucia perra que se orina encima tuyo?
O es un demonio ciego que reparte la suerte a tientas?

Posiblemente, las tres cosas…


Poeta volcánico

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“Najgorsze połączenie to znieczulica i anhedonia, w moim przypadku. Jestem oschła, wredna dla wszystkich bez wyjątku, jestem obojętna na każdą osobę nie ważne jak bardzo ważna i istotna dla mnie jest, a dodając do tego anhedonię (brak czerpania przyjemności z czegokolwiek) staję się po prostu ZIMNĄ S*KĄ

~Hotoke 24.10.2020

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Major Depressive Disorder (per DSM-5)

In DSM-5 (2013; p. 160–8), the American Psychiatric Association defines major depressive disorder as follows. (Since I have covered states of major depression in an earlier post, the following definition will contain only a simplified characterisation of major depressive episodes.)

One has major depressive disorder (MDD) just in case:

  • one has had a major depressive episode (as defined here), a period of mood-related distress or impairment that lasts at least two weeks, and pervasively involves at least five symptoms that must include persisting negative mood or loss of interest or pleasure (or both), together with some combination of appetite disturbance, sleep disturbance, psychomotor disturbance, fatigue, negative self-appraisal, cognitive-executive disturbance, and suicidal ideation.
  • This episode is not better explained by a schizophrenia-related or psychotic disorder.
  • One has never had a manic or hypomanic episode.

Diagnostic Features

For individuals with MDD, insomnia or fatigue are often the presenting complaints; with such presentations, failing to probe for accompanying depressive symptoms will result in underdiagnosis. Fatigue and sleep disturbance are also present in a high proportion of MDD cases. Psychomotor disturbances are much less common, but they are indicative of greater overall severity, as is the presence of delusional or near-delusional guilt.

Major depressive episodes must be accompanied by clinically significant distress or impairment in social, occupational, or other important areas of functioning. For some individuals (with milder depressive episodes), functioning may appear to be normal, but nevertheless requires disproportionate or markedly increased effort.

Per the persisting negative mood symptom, the mood in a major depressive episode is often described by the person as depressed, sad, hopeless, discouraged, or “down in the dumps”. Sadness may be denied at first, but subsequently elicited by interview (e.g. by pointing out that the individual looks as if he or she is about to cry) or inferred from facial expression and demeanour.

Moreover, in some anhedonic individuals who complain of feeling apathetic or having no feelings, and in some individuals who mainly present with anxiety, the presence of a negative mood also may be inferred from facial expression and demeanour.

Some individuals emphasise somatic complaints (e.g. bodily aches and pains) rather than reporting feelings of sadness (clinicians should determine whether the distress from such complaints is associated with specific depressive symptoms).

Many individuals with MDD report or exhibit increased irritability (e.g. persistent anger, a tendency to respond to events with angry outbursts or blaming others, or an exaggerated sense of frustration over minor matters). In depressed children and adolescents, an irritable or cranky mood may develop instead of a noticeably sad or dejected mood. Such a presentation of MDD should be differentiated from merely having a pattern of irritability in response to frustration.

Loss of interest or pleasure is nearly always present in a major depressive episode, at least to some degree. Individuals may report feeling less interested in hobbies, “not caring anymore,” or not feeling any enjoyment in activities that were previously considered pleasurable. Family members often notice social withdrawal or neglect of pleasurable avocations (e.g. a formerly avid golfer no longer plays, a child who used to enjoy soccer finds excuses not to practise). In some individuals, there is a significant reduction from previous levels of sexual interest or desire.

Appetite disturbance may consist in either a reduction or an increase. Some depressed individuals report that they have to force themselves to eat. Others may eat more and may crave specific foods (e.g. sweets or other carbohydrates). When appetite changes are severe (in either direction), there may be a significant loss or gain in weight—or, in children, a failure to make expected weight gains may be noted.

Sleep disturbance may take the form of either difficulty sleeping (insomnia) or sleeping excessively (hypersomnia). When insomnia is present, it typically takes the form of so-called middle insomnia (i.e. waking up during the night and then having difficulty returning to sleep) or terminal insomnia (i.e. waking too early and being unable to return to sleep). Although these forms of insomnia are most common, initial insomnia (i.e. difficulty falling asleep) may also occur. Individuals who present with hypersomnia may experience prolonged sleep episodes at night or increased daytime sleep. Sometimes, disturbed sleep is the reason that the individual seeks treatment.

Psychomotor disturbance potentially includes psychomotor agitation (e.g. the inability to sit still, pacing, hand-wringing; or pulling or rubbing of the skin, clothing, or other objects) or psychomotor retardation (e.g. slowed speech, thinking, and body movements; increased pauses before answering; speech that is decreased in volume, inflection, amount, or variety of content, or muteness). The psychomotor agitation or retardation must be severe enough to be observable by others and not represent merely subjective feelings of restlessness or sluggishness.

Fatigue, decreased energy, and tiredness are also common. A person may report sustained fatigue without any physical exertion. Even the smallest tasks may seem to require substantial effort. The efficiency with which tasks are accomplished may be reduced. For example, an individual may complain that washing and dressing in the morning are exhausting and take twice as long as usual.

Excessive negative self-appraisal tends to be involved in major depression. The sense of worthlessness or guilt associated with a major depressive episode may include unrealistic negative evaluations of one’s worth, or guilty preoccupations or ruminations over relatively minor past failings. Such individuals often misinterpret neutral or trivial day-to-day events as evidence of personal defects, and have an exaggerated sense of responsibility for untoward events.

In major depression, the felt sense of worthlessness or guilt may be of delusional proportions (e.g. an individual who is convinced that he or she is personally responsible for world poverty). Indeed, among major depressive episodes that have psychotic features, such delusions related to negative self-appraisal are the most common psychotic feature. For obvious reasons, such delusions are considered to be mood-congruent in the course of a major depressive episode, as opposed to mood-incongruent. (Interestingly, grandiose delusions are probably the most common psychotic feature of manic episodes, which suggests that self-appraisal delusions are the most common psychotic feature of disturbed moods in general, tending to be negative in the depressive case and positive in the manic case.)

Blaming oneself for being sick, and blaming one’s self for failing to meet occupational or interpersonal responsibilities due to illness (in this case, major depression), are both very common; unless such instances of self-blame reach the level of delusion, they are not considered to be sufficient for the negative self-appraisal symptom.

Many individuals report cognitive-executive disturbance, in the form of an impaired ability to think, concentrate, or make even minor decisions. Individuals with this symptom also may appear easily distracted, or complain of memory difficulties. Individuals engaged in cognitively demanding pursuits are often unable to function in those pursuits. In children, a precipitous drop in grades may reflect a depressive impairment of concentration. In elderly individuals, memory difficulties may be the chief complaint, and may be mistaken for early signs of a dementia (i.e. “pseudodementia”). In such cases, when the major depressive episode is successfully treated, the memory problems often fully abate. However, in some individuals, particularly elderly persons, a major depressive episode may sometimes be the initial presentation of an irreversible dementia.

Suicidal ideation, thoughts of death, and suicide attempts are common features of major depression. They range from passively wishing not to awaken in the morning, or believing that others would be better off if one were dead, to transient but recurrent thoughts of committing suicide, to having a specific suicide plan. More severely suicidal individuals may have already put their affairs in order (e.g. updated wills, settled debts), acquired needed materials (e.g. a rope or a gun), and chosen a location and time to commit suicide.

Common depressive motivations for suicide include a desire to give up in the face of perceived insurmountable obstacles (felt hopelessness), an intense wish to end what is perceived as an unending and excruciatingly painful emotional state (persistent and intense negative feelings, emotional pain), an inability to foresee any enjoyment in life (anhedonia), or the wish to not be a burden to others (negative self-appraisal). Reducing such motivations in the individual, by improving the associated patterns of thinking, seems to be a more meaningful preventative measure against suicide risk than impeding that individual’s plans for suicide.

The evaluation of the symptoms of a major depressive episode is especially difficult when they occur in an individual who also has a general medical condition (e.g. cancer, stroke, myocardial infarction, diabetes, pregnancy). For one thing, some of the criterial signs and symptoms of a major depressive episode are identical to those of general medical conditions (e.g. weight loss with untreated diabetes; fatigue with cancer; hypersomnia early in pregnancy; insomnia later in pregnancy or the postpartum). Such symptoms do count towards a major depressive diagnosis, but not when they are clearly and fully attributable to a general medical condition. In cases involving a general medical condition, particular care should be taken to assess the presence of guilt or felt worthlessness, impaired concentration or indecision, suicidal thoughts, or non-vegetative symptoms of dysphoria or anhedonia. Such symptoms are particularly central to major depression (redefinitions of major depression that include only these symptoms appear to identify nearly the same individuals as do the full criteria).

Associated Features

MDD is associated with high mortality, much of which is accounted for by suicide; however, suicide is not the only associated cause. For example, depressed individuals admitted to nursing homes have a markedly increased likelihood of death in the first year.

Depressed individuals frequently present with tearfulness, irritability, brooding, obsessive rumination, anxiety, phobias, excessive worry over physical health, and complaints of broadly somatic pain (e.g. headache, joint, abdominal, or other pains). In depressed children, separation anxiety may be more likely to occur.

Although an extensive literature exists describing neuroanatomical, neuroendocrinological, and neurophysiological correlates of MDD, no laboratory test has yielded results of sufficient sensitivity and specificity to be used as a diagnostic tool for MDD.

Until recently, hypothalamic-pituitary-adrenal (HPA) axis hyperactivity had been the most extensively investigated abnormality associated with major depressive episodes. HPA hyperactivity does appear to be associated specifically with melancholic features, psychotic features, and an increased risk for eventual suicide.

Neuro-molecular studies have implicated certain peripheral factors, including genetic variants in factors that regulate neuronal generation (i.e. neurotrophic factors) and cytokines that promote neurological inflammation. Additionally, functional magnetic resonance imaging has provided evidence for functional abnormalities in specific neural systems that support emotion processing, reward seeking, and emotion regulation.

Prevalence

  • Twelve-month overall prevalence of MDD in the United States is approximately 7%.
  • There are marked differences by age group, such that the prevalence in 18- to 29-year-old individuals is threefold higher than the prevalence in individuals age 60 years or older.
  • From early adolescence onwards, females have a 1.5- to 3-fold higher rate of MDD than males.

Development and Course

The first major depressive episode (marking the onset of MDD) may occur at any age, but the likelihood of onset increases markedly at and after puberty. In the United States, incidence appears to peak in the 20s; however, first onsets in late life are not uncommon.

The course of MDD is quite variable; some individuals rarely if ever experience remission (a period of 2 or more months without depressive symptoms, or with only one or two symptoms of mild degree), while others experience many years with few or no symptoms between discrete episodes.

Clinically, it is important to distinguish individuals who present for treatment during an exacerbation of a chronic depressive illness from those whose symptoms have developed only recently. Chronicity and pervasiveness of depressive symptoms substantially increase the likelihood of having underlying personality, anxiety, and substance use disorders, and decrease the likelihood that depressive symptoms will be fully resolved by and after treatment. It is therefore useful to ask individuals presenting with depressive symptoms to identify the last period of at least 2 months during which they were entirely free of depressive symptoms.

For four in five individuals with MDD, recovery begins within 1 year of onset; for two of those four individuals, recovery begins within 3 months of onset.

Recency of onset is a strong determinant of the likelihood of near-term recovery, and many individuals who have been depressed only for several months can be expected to recover spontaneously. Other than the duration of the current depressive episode, features associated with lower recovery rates include psychotic features, prominent anxiety, personality disorders, and symptom severity.

While longer periods of depressive symptoms decrease the likelihood of recovery, longer periods of remission also decrease the likelihood of a major depressive episode. The risk of recurrence becomes progessively lower over time as the duration of remission increases.

The risk of recurrence is higher in individuals whose preceding episode was severe, younger individuals, and individuals who have already experienced multiple episodes.

Failure to fully return to euthymic baseline after a major depressive episode—i.e. the persistence of even mild depressive symptoms during remission—is a powerful predictor of recurrence.

Many bipolar illnesses begin with one or more depressive episodes, and a substantial proportion of individuals who initially appear to have MDD will prove, in time, to instead have a bipolar disorder. This is more likely in individuals with onset of the illness in adolescence, those whose depression involves psychotic features, and those with a family history of bipolar illness. Depressive episodes with mixed features (i.e. episodes accompanied by some features of mania/hypomania) also increase the risk of having a future manic or hypomanic episode (and a corresponding bipolar diagnosis).

MDD, particularly if it involves depression with psychotic features, may transition into schizophrenia. Such a change in diagnostic symptoms is much more frequent than the reverse (i.e. it is more frequent that initially meeting the criteria for schizophrenia, then continuing to have major depressive episodes but never again having symptoms that would meet the full criteria for schizophrenia).

Despite consistent differences between genders in the prevalence rates for depressive disorders (with higher prevalence for females), there appear to be no clear differences by gender in MDD’s phenomenology, course, or treatment response.

Similarly, there are no clear effects of current age on the course or treatment response of MDD. Some symptom differences exist, though, such that hypersomnia and hyperphagia (over-eating) are more likely in younger individuals, and melancholic symptoms, particularly psychomotor retardation, are more common in older individuals. The likelihood of suicide attempts lessens in middle and late life, although the risk of completed suicide does not.

Cases of MDD that have earlier ages of onset are more likely to be familial, and more likely to involve personality disturbances.

The course of MDD does not generally change with aging. Mean times to recovery appear to be stable over long periods, and the likelihood of being in a major depressive episode does not generally increase or decrease with time.

Risk and Prognostic Factors

Temperamental

Higher trait neuroticism (negative affectivity) is a well-established risk factor for the onset of MDD, and high levels appear to render individuals more likely to develop depressive episodes in response to stressful life events.

Environmental

Adverse childhood experiences, particularly when there are multiple experiences of diverse types, constitute a set of potent risk factors for MDD.

Stressful life events are well recognised as precipitants of major depressive episodes, but the presence or absence of adverse life events near the onset of episodes does not appear to provide a useful guide to prognosis or treatment selection.

Genetic and physiological

First-degree family members of individuals with MDD have a risk for MDD that is two- to four-fold higher than that of the general population. The risk to family members appears to be higher for individuals that have early-onset and recurrent forms of MDD.

The heritability of MDD is approximately 40%, and the heritability of the personality trait neuroticism accounts for a substantial portion of this genetic liability.

Course modifiers

Essentially, all major non-mood disorders increase the risk of an individual developing symptoms of major depression.

Major depressive episodes that develop against the background of another disorder often follow a more refractory course. Substance use, anxiety, and borderline personality disorders are among the most common of these comorbid disorders, and the detection of such disorders may be obscured or delayed by presenting depressive symptoms. Nevertheless, in such cases, sustained clinical improvement in the depressive symptoms may depend on the appropriate treatment of the underlying mental illnesses.

Chronic or disabling medical conditions also increase risks for major depressive episodes. Such prevalent illnesses as diabetes, morbid obesity, and cardiovascular disease are often complicated by depressive episodes, and such episodes are more likely to become chronic than are depressive episodes in medically healthy individuals.

Culture-Related Diagnostic Issues

Surveys of MDD across diverse cultures have shown seven-fold differences in prevalence, but much more consistency in the female-to-male ratio, mean ages at onset, and the degree to which the presence of the disorder raises the likelihood of comorbid substance abuse.

While these findings suggest substantial cultural differences in the expression of MDD, they do not permit simple linkages between particular cultures and the likelihood of specific symptoms. Instead, clinicians should be aware that in most countries the majority of cases of depression go unrecognised in primary care settings, and that in many cultures somatic symptoms are much more likely to constitute the presenting complaint.

Among the possible symptoms of major depression, insomnia and loss of energy are the most uniformly reported across cultures.

Gender-Related Diagnostic Issues

The most reproducible finding in the epidemiology of MDD has been a higher prevalence in females. Despite this, there are no clear differences between genders in overall symptoms, course, treatment response, or functional consequences.

In women with depressive disorders, as compared to men with depressive disorders, the risk for suicide attempts is higher while the risk for suicide completion is lower. But these gendered disparities in suicide risk are actually independent of major depression. In fact, while depressive disorders generally increase the risks of suicide attempt and completion (for both genders), they decrease the gendered disparity in these risks. In other words, although women are more likely to attempt suicide and men are more likely to complete suicide among individuals that have depressive disorders, this difference between the genders is ever larger in the general population.

Suicide Risk

The possibility of suicidal behavior exists at all times during major depressive episodes. The most consistently described risk factor is a past history of suicide attempts or threats, but it should be remembered that most completed suicides are not preceded by unsuccessful attempts.

Overall, features associated with an increased risk for completed suicide are:

  • previous suicide attempts or threats
  • being male
  • being single or living alone
  • having prominent feelings of hopelessness.

The risk of future suicide attempts is markedly increased when there is comorbid borderline personality disorder.

Functional Consequences of MDD

Many of the functional consequences of MDD derive from the individual symptoms. Impairment can be very mild, such that many of those who interact with the affected individual are unaware of the depressive symptoms. Impairment may, however, range to complete incapacity—such that the depressed individual is unable to attend to basic self-care needs, or is mute or catatonic. Among individuals seen in general medical settings, those with MDD have more pain and physical illness, and greater decreases in physical, social, and role functioning.

Differential Diagnosis

Irritable manic episodes, mixed mood episodes

Major depressive episodes with prominent irritable mood may be difficult to distinguish from manic episodes with irritable mood, or from mixed depressive/manic episodes. This distinction requires a careful clinical evaluation of the presence of manic symptoms.

Substance/medication-induced depressive or bipolar disorder

These disorders are distinguished from MDD by the fact that their mood disturbances are directly related etiologically to a substance (e.g. a drug of abuse, a medication, or a toxin) For example, depressed mood that occurs only in the context of withdrawal from cocaine would be diagnosed as cocaine-induced depressive disorder rather than MDD.

Attention-deficit/hyperactivity disorder (ADHD)

There is some overlap in symptoms between MDD and ADHD. In particular, distractibility and low frustration tolerance are common in both ADHD and major depressive episodes. Nevertheless, if an individual meets the criteria for both MDD and ADHD, then both disorders should be diagnosed.

Relatedly, when children with ADHD present with mood disturbances characterised by irritability (rather than by sadness or loss of interest/pleasure), care must be taken not to diagnose MDD solely on the basis of such disturbances (the excessive irritability in such children may be best explained in terms of ADHD alone, in the absence of MDD).

Adjustment disorder with depressed mood

When major depressive symptoms occur in response to a psychosocial stressor, MDD is distinguished from adjustment disorder with depressed mood by the fact that in the latter disorder, full criteria for a major depressive episode are not met.

Normal Sadness

Finally, it should be noted that periods of sadness are inherent aspects of the human experience. Such periods should not be diagnosed as major depressive episodes unless criteria are met for sufficient severity (i.e. the period of sadness pervasively includes five out of the nine possible symptoms of major depression), sufficient duration (i.e. the symptoms are present most of the day, nearly every day, for at least 2 weeks), and clinically significant distress or impairment. A diagnosis of other specified depressive disorder may be appropriate for presentations of major depressive symptoms that cause clinically significant impairment but do not meet criteria for sufficient severity and duration.

Comorbidity

Other disorders with which MDD frequently co-occurs are substance-related disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, bulimia nervosa, and borderline personality disorder.

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“That’s the day I realized that there was this entire life behind things, and this incredibly benevolent force who wanted me to know there was no reason to be afraid. Ever. Video is a poor excuse, I know.  But it helps me remember … I need to remember… 

Sometimes there’s so much… beauty… in the world … I feel like I can’t take it… and my heart is just going to… cave in.“

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Anhedonia

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The first of the trilogy. So let’s do this thing…


Little did I know there was a word so fitting to go along with my feelings during usual bouts of depression and/or anxiety, combined with an existential crisis. Here we are. The thing is…how do you explain to someone you just don’t feel anymore? You have to feel something, right? Turns out you don’t. Go figure. 


It can drive you bonkers, eh? So you miss things that are in front of you. Life continues to pass you by and you continue to question why you’re even doing anything. This is all without the inclusion of suicidal ideation. Or perhaps that is what some mean when they say they rather just not be here. Maybe, perhaps, they are trying just to figure out how to be here. It’s all a similar problem but if the ideations mentioned is added to it all, I’d encourage you to hold onto the bit of light you have left and call a hotline. You’re worth it. Someone, somewhere will miss you. You just may not know it.


Not knowing is almost a non-point though. Even if you did know, would you care. The fucks are gone in every aspect. It is just you and your thoughts. What if it is someone else? How do you bring back the feels? You can’t. If someone has no desire to feel, they won’t. Now, one can always be one heck of a con artist and switch it on and off, but assuming you’re not, this is tricky for anyone to deal with.


Perhaps the country has brought upon these feelings as the majority of us now see first hand, how little we truly are. It is why we’ve always gotta have our own back. Hold onto to our own hopes, dreams, and inspirations…but how can you? Nothing pleases you any longer. You’ve all but gone hollow. Given the theme of this blog, I won’t be going anywhere. Why and for what purpose? Maybe someday I’ll find out.

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“Para mi la vida se ha detenido, sabes? Estoy como metido en un loop del que no puedo salirme. Todo es: low-high-withdrawal… depresión-medicina/alcohol/drogas-abstinencia (dolorosa, insoportable y que termina irremediablemente en depresión otra vez y se repite y se repite y se repite desde hace tres años).

En algún punto, cuando estoy en mi momento de ‘subir’ pasan cosas interesantes: viajo, me divierto, conozco gente, tengo dinero y trabajo y un plan o dos…. y luego me engancho otra vez en alguna dependencia para la cual no tengo el nivel de compromiso que se requiere para mantenerla. Ni siquiera puedo ser un buen adicto. Termino dejándolo todo porque dejo de trabajar y dejo de estudiar y dejo de querer hacer cualquier cosa, incluso intoxicarme.

Me vuelvo suicida y esa es mi alarma, es mi señal de dejar de meterme cosas.

Entonces paso por la abstinencia y es muy doloroso, sobre todo físicamente, por un rato… es casi insoportable pero cuando se termina me siento listo para volver a tratar de hacer una vida. Y luego me deprimo otra vez porque no quiero hacer nada realmente. No quiero vivir. Al menos no de esta manera en la que sigo intentando hacerlo.”

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So, if anyone would like to give me a whole lot of positive thoughts, please spread this and use the #AnhedoniaAwareness tag on twitter. 

The fact that there isn’t all that much of it yet and that people combating anhedonia tend to still focus more on their misery than on getting better for reasons that are, well, obvious due to the nature of this condition, has been very disconcerting for me for a while now, so here’s my very awkward first attempt at sharing some of my coping methods, tricks, and observations.

And I think the fact that I’ve been fighting anhedonia for 8 years now, that I’m still around, and that I have been okay for 1.5 years now despite my inability to experience positive emotions is reason enough to at least give my advice a try.

To anyone still lost, and to anyone still waiting for their positive emotions to return (like myself), don’t lose hope.

You are not alone.

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