Section 1: Disorders of Mood and Affect
Introduction: Climate vs. Weather
In psychopathology, the terms 'mood' and 'affect' describe our emotional state, but they are not identical. Understanding the distinction is fundamental to an accurate mental state examination. The most effective way to remember the difference is through a simple analogy: Mood is to Affect as Climate is to Weather.
Mood refers to a sustained and pervasive emotional state that colors the individual's entire perception of the world. It is the underlying emotional "climate" of a person over a period of time (days or weeks). Mood is typically assessed by asking the patient subjective questions like, "How have your spirits been recently?" or "How is your mood in yourself?"
Affect is the moment-to-moment, observable expression of emotion. It is the fluctuating, external display of feeling—the emotional "weather" you can see on a person's face, in their voice, and through their body language. Affect is assessed through objective observation during the clinical interview.
The Examiner's Focus
The examiner expects you to understand this core distinction.
- Mood = Subjective & Sustained. (What the patient reports over time).
- Affect = Objective & Moment-to-moment. (What you observe right now).
A Important sign of pathology is a discrepancy between the two (e.g., a patient reports a low mood but has a bright, reactive affect).
The Dimensions of Affect: A Clinical Framework
When describing a patient's affect, clinicians use several dimensions to provide a precise and professional picture.
Valence
This is the quality of the affect—the specific emotion being expressed (e.g., depressed, anxious, angry, euphoric, perplexed).
Reactivity
This refers to the affect's responsiveness to environmental and conversational cues. A normal affect is reactive (e.g., smiling at a joke, showing concern when discussing sad topics). A conspicuous lack of reactivity is described as blunted affect.
Range and Intensity
This describes the breadth and intensity of emotional expression.
- Restricted/Constricted: The range of expression is reduced, but not entirely absent. This is common in depression and anxiety.
- Blunted: A significant reduction in the intensity of emotional expression.
- Flat: The virtual absence of any sign of affective expression. Both blunted and flat affect are considered hallmark negative symptoms of schizophrenia.
Congruence
This dimension assesses whether the expressed affect matches the content of the patient's thought.
- Congruent Affect: The emotional expression is appropriate for the topic being discussed (e.g., appearing sad when talking about a loss).
- Incongruent Affect (or Parathymia): There is a clear mismatch between the expressed emotion and the content of thought. This is highly suggestive of a psychotic disorder, particularly schizophrenia.
Clinical Example: A patient smiles and giggles while describing a terrifying delusion that people are trying to poison him.
The Examiner's Focus
Incongruity of affect is a powerful clinical sign. The examiner will test your ability to identify this mismatch in a clinical vignette as it points strongly towards a thought disorder rather than a primary mood disorder.
A middle-aged gentleman was noticed to be giggling inappropriately on hearing the news of his father's death. What is the term used to denote this type of pathological change in affect?
Explanation: The Important here is the mismatch between the situation (tragic news) and the emotional reaction (giggling). This is the textbook definition of incongruous affect. Options A, C, and D describe a reduction or absence of emotion, which is the opposite of what is being displayed. Apathy (B) is a lack of feeling or concern, which does not fit the active emotional expression of giggling.
Stability
This dimension refers to the persistence of an affective state.
- Stable Affect: A normal state where an emotion is maintained appropriately until a new stimulus warrants a change.
- Labile Affect: Characterized by rapid, exaggerated, and often unprovoked shifts in affect. The patient may switch from laughter to tears and back again with minimal provocation. This is seen in histrionic and borderline personality disorders, as well as some organic states.
- Emotional Incontinence: This is an extreme form of lability where there is a complete loss of control over emotional expression. It is a sign of organic brain disease, such as pseudobulbar palsy or frontal lobe damage. The emotional display is explosive and disconnected from the patient's underlying mood. The analogy is an "incontinence of the emotion-filled bladder."
The Examiner's Focus
The crucial distinction to make is between the "functional" lability seen in personality disorders and the "organic" disinhibition of emotional incontinence. If a vignette mentions a neurological context (e.g., stroke, head injury), the answer is likely emotional incontinence.
Emotional lability is least likely to be due to
Explanation: This question tests your knowledge of the common causes of emotional lability. Frontal lobe damage (A), pseudobulbar palsy (B), and delirium (E) are all classic organic causes of emotional lability/incontinence. Rapid mood swings are a core feature of some forms of bipolar disorder (C). Temporal lobe atrophy (D) is primarily associated with memory impairment (amnesia), personality change, or seizures, and is the least likely cause of emotional lability among the options.
A 64-year-old patient admitted in a stroke ward bursts out to laughter or tears within minutes with no control over these emotions. What is the psychopathology seen in this case?
Explanation: This is the definition of emotional incontinence. The patient shows rapid, uncontrolled emotional outbursts that are not congruent with their underlying mood. The context of a stroke ward is a major clue pointing directly to an organic cause, making emotional incontinence the most precise and correct term. The other options describe sustained mood states, not this specific pattern of disinhibited emotional expression.
Core Mood Syndromes and States
While mood and affect describe the emotional experience, clinical terms like "mania" and "depression" refer to broader syndromes that include disturbances in thought and will (motivation/drive) alongside the change in mood.
Mania is a state of pathologically elevated mood. However, it is not just a simple feeling of happiness. It is a syndrome comprising:
- Disturbed Emotion (Mood): The mood is typically described as euphoric (an intense feeling of well-being), ecstatic (a feeling of rapturous delight), or expansive (an overestimation of one's importance).
- Disturbed Thought (Form and Stream): Thinking becomes accelerated, leading to a pressure of speech and flight of ideas.
- Disturbed Will (Volition): There is a marked increase in drive and goal-directed activity, often leading to grandiose plans, overspending, and social disinhibition.
Melancholia is a term used to describe a severe, pervasive, and qualitatively distinct type of depressive mood. It is not just sadness; patients often describe it as a profound and painful emotional state that is different from normal grief.
- Important Features: It is typically associated with significant psychomotor retardation (slowing of thought and movement), anhedonia (the inability to experience pleasure), and somatic symptoms like early morning waking and diurnal mood variation (worse in the morning).
The Examiner's Focus
Psychomotor retardation is a highly significant clinical sign. The examiner will expect you to recognize it as a hallmark of severe, melancholic depression and to distinguish it from simple sadness or fatigue.
Psychomotor retardation is a characteristic feature of
Explanation: This is a straightforward knowledge question. While slowing can be seen in other conditions (e.g., negative symptoms of schizophrenia), psychomotor retardation is the classic and defining motor feature of a severe, melancholic depressive episode. It reflects the profound slowing of central nervous system processes that characterizes this state.
Apathy is a pathological state characterized by a lack of feeling, emotion, interest, or concern. It is a state of indifference.
- Core Feature: The primary disturbance is a subjective lack of feeling, which leads to a loss of motivation and drive (avolition).
- Associations: It is a core negative symptom of schizophrenia and a prominent feature of certain organic brain disorders, especially those affecting the frontal lobes.
Clinical Pearl
Differentiate apathy from depression. A depressed person often feels intense emotional pain (e.g., sadness, guilt), whereas an apathetic person feels an absence of emotion.
Apathy is characterised by
Explanation: The question asks for the core characteristic of apathy. While lack of eye contact (A), movement (B), and speech (E) can all be manifestations, they are not the defining feature. The fundamental state is the lack of feeling, interest, and concern (D). This subjective emotional emptiness is the essence of apathy.
Ecstasy is a mental state of intense, overwhelming happiness and joyful excitement. Phenomenologically, it has a distinct quality.
- Core Feature: A Important feature of ecstatic states is a disturbance in the boundaries of the self. The individual may feel a sense of unity with the universe or a merging with their surroundings.
- Associations: While it can be a feature of a manic episode or temporal lobe epilepsy, it can also occur in non-pathological states, such as during intense religious or meditative experiences.
Which of the following is true with regard to the mental state of ecstasy?
Explanation: The most accurate and defining feature among the options is the altered boundary of self (D). Ecstasy is not associated with negative states like persecution (A) or pain (B). It can occur in healthy individuals (C is incorrect). The feeling of "oneness" or merging is the core experience that defines this state.
Mixed Affective States
It is a clinical reality that pure manic or depressive episodes are less common than states where symptoms of both poles exist simultaneously. These are called mixed affective states. The core feature is an incongruity between mood, thought, and psychomotor activity.
Emil Kraepelin originally described six variations. Examples include:
- Manic Stupor: Elevated mood but with psychomotor retardation (low activity).
- Agitated Depression / Excited Depression: Depressed mood but with psychomotor agitation (high activity).
- Inhibited Mania: Elevated mood and rapid thoughts but with psychomotor retardation.
Clinical Pearl
The concept of mixed states is clinically vital because they are associated with a poorer prognosis, higher risk of suicide, and different treatment responses compared to "pure" mood episodes. The examiner will test your ability to recognize a clinical picture where mood and activity are incongruent.
Which of the following is not a mixed affective state?
Explanation: A mixed state requires a mismatch between mood, thought, or activity. A, B, D, and E all describe such a mismatch. Depression with poverty of thought (C) describes a state where the mood (depressed) and the thought process (slowed/impoverished) are congruent. Both are "low." This is a feature of a pure, severe depressive episode, not a mixed state.
Agitated depression is a well-recognized feature of
Explanation: This is a question of clinical epidemiology. Agitated depression, as a form of mixed state, is more commonly observed in depression presenting in later life. Historically termed 'involutional melancholia', this presentation of depressive despair combined with restless agitation is a classic feature in elderly patients and carries a high risk.
Pain and Mood
Pain is a frequent and challenging symptom in psychiatric practice, often co-existing with mood disturbances. Differentiating pain with a primary organic basis from pain that is psychogenic is a crucial skill.
| Feature | Organic Pain | Non-Organic (Psychogenic) Pain |
|---|---|---|
| Distribution | Less diffuse, follows anatomical boundaries. | More diffuse, vague, and does not conform to anatomical boundaries. |
| Chronicity | Often fluctuant, may have pain-free intervals. | Often constant, unremitting, and present for long periods. |
| Quality | Usually has a characteristic quality (e.g., burning, sharp). | Difficult for the patient to describe; may use odd metaphors. |
| Wakefulness | Can wake the patient from sleep. | Rarely wakes the patient from sleep. |
| Postural Changes | May have typical postural variation (e.g., headache worse on lying down). | Usually no clear postural variation. |
| Common Sites | Anywhere in the body. | Head, neck, and back are the most common sites. |
The Examiner's Focus
The examiner will test your ability to spot "red flag" symptoms that suggest an underlying organic cause for a physical complaint. A postural component to a headache is a classic example that should prompt further neurological investigation.
A 32-year-old shift worker presents with a history of headaches occurring in the mornings for a few months. His GP has been treating him for a diagnosis of tension headache. Which of the following features suggest a different pathology?
Explanation: The question asks you to identify the feature that points towards a more serious underlying (likely organic) pathology. A, B, C, and E are all common features of tension or psychogenic headaches. Postural worsening of pain (D) is a critical red flag. A headache that worsens when lying down, bending over, or coughing suggests the possibility of raised intracranial pressure, which requires urgent neurological assessment.
Anhedonia and Alexithymia
These two concepts describe profound disturbances in the experience and expression of emotion.
Coined by the French psychologist Théodule Ribot, anhedonia is the loss of the capacity to experience pleasure from activities that are normally found enjoyable. It is a core symptom of melancholic depression and a Important negative symptom of schizophrenia.
- Physical Anhedonia: A defect in the ability to experience physical pleasures, such as from eating, touch, or sex.
- Social Anhedonia: A defect in the ability to experience interpersonal pleasure, such as from being with friends or engaging in conversation.
The Examiner's Focus
Anhedonia is more than just feeling sad. It is a specific and profound inability to feel pleasure. You must be able to define it and differentiate it from other affective symptoms like apathy (lack of feeling) or blunting (lack of expression).
The term anhedonia was coined by
Explanation: This is a direct test of historical knowledge. Théodule Ribot introduced the term in 1896. Sifneos (D) is associated with alexithymia. Bleuler (A) and Kraepelin (C) are foundational figures in the concept of schizophrenia.
A depressed patient on the ward complained of total inability to experience pleasure. What is the term used to denote this type of pathological change in mood?
Explanation: The phrase "total inability to experience pleasure" is the textbook definition of anhedonia (D). Apathy (A) is a lack of feeling or concern, not specifically pleasure. Affective flattening (B) and blunting (C) refer to the observable expression of emotion, not the subjective experience.
First described by Peter Sifneos, the term alexithymia literally means "no words for emotion" (A- = no, lexis = word, thymos = emotion). It is a personality trait or cognitive style, not a disorder in itself.
Important Features:
- Difficulty identifying and describing one's own feelings.
- Difficulty differentiating between emotions and bodily sensations.
- Diminished fantasy life and reduced symbolic thinking.
- A cognitive style that is literal, utilitarian, and externally oriented.
Associations: Alexithymia is most strongly associated with psychosomatic and somatoform disorders, where emotional distress is believed to be expressed through physical symptoms. It is also seen in depression, PTSD, and some personality disorders.
The Examiner's Focus
The core concept of alexithymia is the cognitive inability to process and verbalize emotion, leading to an impoverished inner world and a focus on external or bodily sensations. The examiner will test both the definition and its primary clinical association with psychosomatic illness.
Alexithymia is common in those with
Explanation: While it can be seen in mood and personality disorders, alexithymia was originally described in, and is most classically associated with, psychosomatic disorders (A). The theory is that the inability to process emotions psychologically leads to their expression somatically.
Which of the following is not a feature associated with alexithymia?
Explanation: The cognitive style in alexithymia is characterized by concrete, literal, and externally focused thinking. Therefore, an increase in abstract thinking ability (A) is the opposite of what is expected. The other options are all core features.
Reduced symbolic thinking is a feature of
Explanation: This directly tests a Important component of the alexithymic cognitive style. A reduction in symbolic thinking (D), leading to a very literal interpretation of the world, is a defining feature.
Inability to verbalize one's strong emotions is termed as
Explanation: This is the most direct definition of alexithymia (D). The term's etymology ("no words for feelings") is captured perfectly by this description.
Mood and the Perception of Time
The subjective experience of time is not constant; it can be significantly altered by one's mood state.
- In depression, the subjective experience of time is often slowed down. Days feel long and drag on.
- In mania, the subjective experience of time is often sped up. Time feels as if it is passing very quickly.
Phenomenology
This concept is a good example of phenomenology—understanding the patient's subjective world. The Important is the congruence: a slowed-down mood state is associated with a slowed-down perception of time, and vice versa for mania.
A specific and measurable disturbance related to time is age disorientation. This is the phenomenon where a patient, typically with chronic institutionalized schizophrenia, misstates their own age.
- Definition: To be clinically significant, the discrepancy between the stated age and the actual chronological age must be five years or more.
- Clinical Features:
- Patients most commonly understate their age.
- It is associated with an earlier age of illness onset and a longer duration of hospitalization (i.e., a poor prognosis).
The Examiner's Focus
This is a highly specific piece of knowledge that is easily tested. You must remember the five-year threshold for defining age disorientation.
Patients with chronic schizophrenia may lose the track of their age and may state an age different from their actual age. To be called as age disorientation, the difference in stated age and actual age must be at least
Explanation: This question is a direct test of the definition. The established clinical and research criterion is a discrepancy of five years or more (C). Remembering this specific number is the Important to answering the question correctly.
Other Affective States
A panic attack is a discrete episode of intense fear or discomfort accompanied by a crescendo of physical and cognitive symptoms.
- Cognitive Feature: A core cognitive component is a catastrophic misinterpretation of bodily sensations.
- Outcome Fear: This leads to an intense and specific fear of a negative outcome, such as the belief that one is about to die, have a heart attack, "go crazy," or lose control.
The Examiner's Focus
The examiner expects you to recognize that a panic attack is not just anxiety; it is characterized by an acute, catastrophic belief about an imminent disaster.
A middle-aged woman suffers a panic attack and believes she is going to die. Which term could be used to describe this psychopathology?
Explanation: The belief of imminent death during a panic attack is a classic example of a catastrophic misinterpretation of symptoms. This intense belief in a negative outcome is best described as outcome fear (E). An overvalued idea (B) is a more persistent, solitary belief, not an acute fear state.
Grief vs. Major Depression
Distinguishing a normal grief reaction from a major depressive episode that requires clinical intervention is a crucial skill. While many symptoms overlap, certain features are more indicative of a syndromal depression.
| Feature | Normal Grief | Major Depression |
|---|---|---|
| Guilt | Specific to the loss (e.g., "I should have visited more"). | Pervasive, generalized, and disconnected from reality. A core sense of worthlessness. |
| Self-Esteem | Generally preserved. | Markedly diminished. Pervasive feelings of worthlessness and self-loathing. |
| Thought Content | Preoccupation with memories of the deceased. | Preoccupation with morbid, self-critical, and pessimistic thoughts. |
| Mood | Experienced in "waves" or "pangs." Positive feelings are still possible. | Pervasive and persistent. Anhedonia is profound. |
| Psychomotor Retardation | Not typical. | A classic biological sign of severe, melancholic depression. |
| Hallucinations | Brief, transient illusions or pseudohallucinations of the deceased are common and normal. | Sustained, true hallucinations are a sign of psychotic depression. |
The Examiner's Focus
The examiner will test your ability to identify the "red flags" that push a presentation from normal grief into a major depressive episode. The two most powerful signs are pervasive, generalized guilt and the presence of objective biological signs like psychomotor retardation.
Which helps differentiate normal grief from major depression?
Explanation: This is the key psychological differentiator. Guilt in grief is focused and related to the deceased. In depression, guilt becomes global, pervasive, and reflects a fundamental sense of worthlessness, which is a hallmark of the illness. Poor concentration, a degree of anhedonia, reduced appetite, and low mood are all common and expected features of a normal grief reaction.
A 72-year-old woman is referred for assessment by her GP. He is concerned that she is experiencing abnormal grief following the death of her husband five months previously following a long illness. Which of the following symptoms would most likely suggest that this woman is experiencing an abnormal grief reaction?
Explanation: Psychomotor retardation is a profound biological sign of a major depressive episode. Its presence indicates that the process has moved beyond uncomplicated grief into a syndromal illness. It is the most powerful indicator of pathology among the options. Specific guilt about the loss, transient hallucinations of the deceased, intense anxiety, and sleep disturbance are all recognized as potential components of a severe but normal grief reaction.