Getting emotional about affect and mood

According to Robert C Solomon, an American professor of philosophy, emotions are the ‘meaning of life’ (Solomon, 1993). They are the driving force behind all our goal-directed activities and they are a key ingredient in the factors that determine our judgement and preferences for specific choices. Arguably, our autonomy and emotional existence are key to providing our lives a sense of meaning. Solomon goes on to say that we do not experience a neutral, objective reality but live in ‘surreality’ of purpose, value and significance (Ratcliffe, 2009).

In psychiatry, there is a need to measure and describe emotional states and to do this in a manner that is universally understood both for reliable and valid communication, but also to further research. Psychiatrists, when referring to feelings and emotions, often use the terms ‘mood’ and ‘affect’, sometimes interchangeably. This is particularly confusing because, in the psychological realm, affect is used to mean emotion. The ambiguous use of these descriptors is clinically unhelpful and can lead to misdiagnosis and thus should be avoided (Malhi and Bell, 2019).

DSM describes mood as a pervasive and sustained emotion that colours an individual’s perception of the world. It is an internal emotional state that cannot be accurately or fully inferred by a clinician from observation alone, and instead it requires the patient to verbalise their feelings. In the sphere of emotion, it can be thought of as the emotional ‘climate’ of the brain. In contrast, an individual’s affect is less consistent and more changeable and can be regarded analogously as the emotional equivalent of the ‘weather’. Even though mood tends to be a more sustained feeling state which does not change as quickly as affect, it is readily impacted by life circumstances and individual temperament and disposition. Mood is also susceptible to reporting bias by the patient.

Solomon (1993) has suggested that mood should be assessed in the context of the patient’s entire history, as emotions are holistically linked and every emotion “presupposes the entire body of previous emotional judgements to supply its context and its history” (p. 137). While thorough and comprehensive, this broad perspective is somewhat impractical for everyday psychiatric practice.

Changes in mood need to be carefully traced and the pertinent question is what is ‘unusual’ for a person, meaning, does it deviate from their baseline. For a person with a sunny disposition, having depressive symptoms deviates significantly from what is ‘normal’ for this particular person. Someone with a negative and gloomy outlook on life might remain unnoticed or, conversely, might attract a diagnosis of depression when none is warranted. Thus, careful questioning about the timeline of mood changes is necessary in order to identify change in relation to a baseline.

In contrast to mood, affect is a state that changes within seconds and minutes and the observant clinician can get a glimpse of this external expression of a person’s internal emotional state. It can serve as a guide to the underlying mood state of the person. Affect is by definition observable, versus mood which needs to be reported by the patient.

Formally, affect is described in terms of its range, reactivity, variability, intensity and the degree to which it is in keeping with a person’s expressed thoughts and topics of conversation (appropriateness). This is sometimes referred to as its congruence with mood. The assessment of affect also involves gauging the person’s tone of voice, prosody, intonation and non-verbal affective expressions like facial expressions, gesticulation, posture and overall demeanour. The range of affect can be described as normal, meaning the individual displays the emotional nuances expected. Affect can be further described as restricted (constricted), blunted or flat. Restricted affect is a clear reduction, whereas blunted affect represents a severe reduction in the intensity of affective expression (although the two are often used interchangeably), while flat affect is a complete lack of affective expressions. For example, the voice may be monotonous and the face immobile. Conversely, affect is described as labile when several rapid and abrupt shifts are observed, for example, switching from laughing to anger or being tearful. Affect may also reflect a particular mood disorder subtype, for example, a labile affect may indicate a mixed affective episode of bipolar disorder and a flat affect may suggest melancholia, while a blunted affect could be a sign of an underlying psychotic process. Affect is further described as incongruent when it is clearly discordant with the topic of conversation (Table 1).

Table 1.

Basic definitions of affect and mood.

Term	Definition
Affect
Restricted affect	A clear reduction in affective response
Blunted affect	A severe reduction in affective response
Flat affect	A lack of any affective expression
Labile affect	Rapid and dramatic shifts in affect
Mood
Euthymia	A mood neither elevated nor depressed
Dysphoria	Mood is consistently low
Expansive mood	Emotional expression unaffected by others’ reactions
Irritable mood	Prolonged state of negative and increased reactivity
Labile mood	Marked fluctuation of mood
Elevated mood	Increased feeling of success, confidence and well-being
Depressed mood	Mood which is negative and unhappy beyond reason

Affect should not be confused with affectivity and affect as used in the psychological literature where it refers to the total or whole emotional life of an individual. Expansive mood can also refer to a mood that is characterised by unrestrained emotional expression.

An important influence on both mood and affect is temperament, which is probably determined largely by genetic factors, as it is an enduring trait that remains fairly consistent throughout adulthood. In contrast, mood is a state and not an enduring trait per se. Temperament includes behavioural traits such as extroversion or introversion, emotionality (self-regulating or reactive), activity level, attention level and persistence (determined or easily discouraged) (Rettew and McKee, 2005). The heritability of temperament is complicated, and there does not appear to be a clear pattern as there are no specific genes that confer particular temperamental traits. It is postulated that the combination of many common gene variations influences individual characteristics of temperament. Environmental factors also play a role, in that they influence gene activity. Children raised in an adverse environment may have more impulsive characteristics due to activation of certain genes responsible for such behaviours, while children raised in a positive environment may have a calmer disposition because a different set of genes have been activated.

In practice, patients being assessed by a psychiatrist at a particular moment in time experience their emotions as a combination of their temperament, mood and affect all occurring at once. In other words, their experience of all three components is concurrent, and in the same moment. (Figure 1) It is up to the psychiatrist to separate the different aspects, and for this, a careful history is necessary to determine normative traits and states; specifically, what is ‘normal’ for this person and what is abnormal or out of character and at variance with respect to their past experience.

Figure 1.

Three components that contribute to emotional mental state.

For the patient, the delineation of these aspects might not be seen as important at the moment of presentation. However, the individual’s response to the development of a mood disorder and their engagement in the treatment phase can be influenced by a person’s temperament and thus can have a bearing on their recovery. For instance, a study by Bahrini et al. (2016) examined the effect of temperament on treatment adherence and found it to be poor in patients with depressive and irritable temperaments. These patients required more education concerning the necessity of medication. In addition, patients with cyclothymic, irritable and anxious temperaments were more sensitive to the negative side effects of psychotropic medication and also required more instruction regarding their medications. Therefore, consideration of a patient’s temperament can inform the clinician in anticipating barriers to treatment, and gaining as much information as possible and supporting the patient’s pathway to recovery can be aided by attention to the careful delineation of temperamental traits from more changeable mental states of mood and affect.

In summary, there are three layers in the emotional mental state examination of a patient: the immediate and observable affect, the patient’s description of their mood and the underpinning of both mood and affect by the patient’s temperament. Except for temperament, which is relatively stable, the other aspects are quite variable and change at different rates (Figure 1). They are also influenced by both internal processes and external factors in the patient’s environment. Thus, a longitudinal assessment is often necessary in order to reliably capture all three levels of a patient’s emotional mental state.