Affect is defined as the prevailing emotional tone observed by the interviewer during a mental status examination. In contrast, mood is the client's self-reported mood state.
Affect is usually described in terms of its (a) content or type, (b) range and duration (also known as variability and duration), (c) appropriateness, and (d) depth or intensity. Each of these descriptive terms is discussed further.
Affect Content To begin, you should identify what affective state you observe in the client. Is it sadness, euphoria, anxiety, fear, anger, or something else? Affective content indicators include facial expression, body posture, movement, and your client's voice tone. For example, when you see tears in your client's eyes, accompanied by a downcast gaze and minimal movement (psychomotor retardation), you will likely conclude your client has a "sad" affect. In contrast, clenching fists, gritted teeth, and strong language will bring you to the conclusion that your client is displaying an "angry" affect.
Table 8.1. Descriptors of Client Attitude Toward the Examiner
Aggressive: The client attacks the examiner physically or verbally or through grimaces and gestures. The client may "flip off" the examiner or simply say in reply to an examiner response, "That's a stupid question" or "Of course I'm feeling angry, can't you do anything but mimic back to me what I've already said?"
Cooperative: The client responds directly to interviewer comments or questions. He or she may openly try to work with the interviewer in an effort to gather data or solve problems. Frequent head nods and receptive body posture are common.
Hostile: The client is indirectly nasty or biting. Sarcasm, rolling back one's eyes in apparent disgust over an interviewer comment or question, or staring off with a sour grimace may represent subtle, or not so subtle, hostility. This behavior pattern is especially common among delinquent teenagers (J. Sommers-Flanagan & Sommers-Flanagan, 1998).
Impatient: The client is on the edge of his or her seat. The client is not very tolerant of pauses or of times when interviewer speech becomes deliberate. He or she may make statements about wanting an answer to concerns immediately. There may be associated hostility and competitiveness in the case of Type A personality styles.
Indifferent: The client's appearance and movements suggest lack of concern or interest in the interview. The client may yawn, drum fingers, or become distracted by irrelevant issues or details. The client could also be described as apathetic.
Ingratiating: The client is obsequious and overly solicitous of approval and interviewer reinforcement. He or she may try to present self in an overly positive manner, or may agree with everything and anything the interviewer says. There may be excessive head nodding, eye contact, and smiles.
Intense: The client's eye contact is constant, or almost so; the client's body leans forward and listens intensely to the interviewer's every word. Client voice volume may be loud and voice tone forceful. The client is the opposite of indifferent.
Manipulative: The client tries to use the examiner for the client's own purpose or edification. He or she may interpret examiner statements to represent own best interests. Statements such as "His behavior isn't fair, is it Doctor?" are efforts to solicit agreement and may represent manipulation. Negativistic: The client opposes virtually everything the examiner says. The client may disagree with reflections, paraphrases, or summaries that are clearly accurate. The client may refuse to answer questions or be completely silent throughout an interview. This behavior is also called op-positional.
Open: The client openly and straightforwardly discusses problems and concerns. The client may also be open to examiner suggestions or interpretations.
Passive: The client offers little or no active opposition or participation in the interview. The client may say things like, "Whatever you think." He or she may simply sit passively until told what to do or say.
Seductive: The client may touch self in seductive or suggestive ways (e.g., rubbing body parts). He or she may expose skin or make efforts to be "too close" to or to touch the examiner. The client may make flirtatious and suggestive verbal comments.
Suspicious: The client may look around the room suspiciously (some even actively check for hidden microphones). Squinting or looking out of the corner of one's eyes also may be interpreted as suspiciousness. Questions about what the examiner is writing down or about why such information is needed may also signal suspiciousness.
Although people use a wide range of feeling words in conversation, affective content usually can be accurately described using one of the following:
Guilty or remorseful Happy or joyful Irritated Sad
Range and Duration A client's range and duration of affect, under normal conditions, varies depending on the client's current situation and the subject under discussion. Generally, the ability to experience and express a wide range of emotional states—even during the course of a clinical interview—is associated with positive mental health (Pennebaker, 1995). However, in some cases, a client's affective range may be too variable; and in others, it may be very constricted. Typically, clients with compulsive traits exhibit a constricted affect, while manic clients or clients with histrionic traits act out an excessively wide range of emotional states, from happiness to sadness and back again, rather quickly. Clients with this pattern are referred to as having a labile affect.
Sometimes clients exhibit little or no affect during the course of a clinical interviewas if their emotional life has been turned off. This absence of emotional display is commonly described as having a flat affect. The term is used to describe clients who seem unable to relate emotionally to other people. Examples include individuals diagnosed with schizophrenia, severe depression, or a neurological condition such as Parkinson's disease.
At times, when clients take antipsychotic medications, they experience and express minimal affect. This condition, which is very similar to flat affect, is often described as a blunted affect because an emotional response appears present, but in a restricted, minimal manner.
Appropriateness The appropriateness of client affect is judged in the context of his or her speech content and life situation. Most often, inappropriate affect is observed in very disturbed clients who are suffering from severe mental disorders such as schizophrenia or bipolar disorder.
Determining the appropriateness of client affect is a subjective process that is sometimes more straightforward than at other times. For example, if a client is speaking about a clearly tragic incident (e.g., the death of his child) and inexplicably giggling and laughing without rational justification, the examiner would have substantial evidence for concluding the client's affect was "inappropriate with respect to the content of his speech." Alternatively, sometimes clients have idiosyncratic reasons for smiling or laughing or crying in situations where it does not seem appropriate to do so. For example, when a loved one dies after a long and protracted illness, it may be appropriate for a client to smile or laugh, either for reasons associated with relief, religious beliefs, or some other factor. Similarly, clients from various cultures may react in ways that most mainstream North American mental health professionals find unusual. What is important is that we remain sensitive and cautious in our judgments about the appropriateness or inappropriateness of client affective expressions.
One particular form of inappropriate affect deserves further description. Specifically, some clients exhibit a striking emotional indifference to their personal situation. Although profound indifference may occur in a diverse range of client types, it is most common, as Morrison (1993) describes, in the somatizing client: "Patients with somatization disorder will sometimes talk about their physical incapacities (paralysis, blindness) with the nonchalance that usually accompanies a discussion of the weather. This special type of inappropriate mood [sic] is called la belle indifference (French for "lofty indifference")" (p. 112).
Depth or Intensity It is also typical for examiners to describe client affect in terms of depth or intensity. Some clients appear profoundly sad, while others seem to experience a more superficial sad affect. Determining the depth of client affect can be difficult, because many clients make strong efforts to "play their affective cards close to the vest." However, through close observation of client voice tone, body posture, facial expressions, and ability to quickly move (or not move) to a new topic, examiners can obtain at least some evidence regarding client affective depth or intensity. Nonetheless, we recommend limiting affective intensity ratings to situations when clients are deeply emotional or incredibly superficial.
When describing client affect in a mental status report, it is not necessary to use all of the dimensions described previously. It is most common to describe client affect content. The next most common dimension included is affective range and duration, with affective appropriateness and affective intensity included somewhat less often. A typical mental status report of affect in a depressed client who exhibited sad affective content, a narrow band of expression, and speech content consistent with sad life circumstances, might state:
Throughout the examination, Ms. Brown's affect was occasionally sad, but often constricted. Her affect was appropriate with respect to the content of her speech.
In contrast, a client who presents with symptoms of mania might have much different affective descriptors:
Euphoric (content or type): referring to behavior suggestive of mania (e.g., the client claims omnipotence, exhibits agitation or increased psychomotor activity, and has exaggerated gestures).
Labile (range and duration): referring to a wide band of affective expression over a short time period (e.g., the client shifts quickly from tears to laughter). Inappropriate with respect to speech content and life situation (appropriateness): (e.g., the client expresses euphoria over job loss and marital separation; in other words, client's affective state is not rationally justifiable).
Shallow (depth or intensity): referring to little depth or maintenance of emotion (e.g., the client claims to be happy because "I smile" and "smiling always takes care of everything").
The preceding client might be described as having a
. . . labile, primarily euphoric affect that showed signs of being inappropriate and shallow.
In a mental status exam, mood is different from affect. Mood is defined simply as the client's self-report regarding his or her prevailing emotional state. Mood should be evaluated directly through a simple, nonleading, open-ended question such as, "How have you been feeling lately?" or "Would you describe your mood for me?" rather than a closed and leading question that suggests an answer to the client: "Are you depressed?" When asked about their emotional state, some patients respond with a description of their physical condition or a description of their current life situation. If so, simply listen and then follow up with, "And how about emotionally? How are you feeling about (the physical condition or life situation)?"
It is desirable to record a client's response to your mood question verbatim. This makes it easier to compare a client's self-reported mood on one occasion with his or her self-reported mood on another occasion. In addition, it is important to compare self-reported mood with your evaluation of client affect. Self-reported mood should also be compared with self-reported thought content, because the thought content may account for the predominance of a particular mood.
Mood can be distinguished from affect on the basis of several features. Mood tends to last longer than affect. Mood changes less spontaneously than affect. Mood constitutes the emotional background. Mood is reported by the client, whereas affect is observed by the interviewer (Othmer & Othmer, 1994). Put another way (for you analogy buffs), mood is to affect as climate is to weather.
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