¶ Understanding Mood and Affect in Therapy
Well , welcome to our Licensure Exams podcast . I'm Dr Linton Hutchinson from hot and sunny Florida , and I'm here with my co-host , Stacey Frost , who is still digging herself out from the snow up there in Michigan .
Oh , linton . Well , sometimes I'm not sure if winter will ever end , it's true , but come July and August I'll be enjoying a nice cool breeze on the porch and a cascarelli cashew ice cream cone , instead of sweltering in that muggy , swamp bowl of central Florida .
But you forgot to mention munching on pickled bologna and pig's feet , those delicious appetizer you guys like so much up there in Michigan . And for the weather here , well , are you kidding Stacey ? The hotter the better .
It's like a free sauna experience , right outside your front door and a lot of times inside as well . I don't buy it . You sound happy and excited , Linton , but I don't know . If only I could see your face right now to determine if your mood is congruent with your affect .
Well , speak of the devil Stacey . That's our topic for today . We'll be talking about the mental status exam , which , as you all know , is our go-to assessment tool , used to evaluate a client's current state of mind , cognitive abilities and overall psychological functioning .
The MSE assesses several areas , but today we're going to focus this episode on two specific domains that are often confused mood and effect .
All right , so let's start with mood , and mood refers to the client's self-reported , internal , pervasive and sustained emotional state Anxious , sad , overwhelmed , frustrated . It's the client's subjective experience that influences their perception of the world and their interactions with others .
On the other hand , affect and that's spelled by the way A-F-F-E-C-T is the outward expression of those emotions . Affect is objective and it's observed by you , the therapist .
So I hear you have some visitors up there . I'm wondering how your mood is these days , Stacey .
Well , is that a yes or no question ?
Of course . Well , can you observe a client's mood ? No , dear no . When you assess the client's mood , you rely on the client's own words to describe their internal emotional states . You might ask questions like how have you been feeling lately ? Can you describe your mood over the past few weeks ?
And your client may respond by reporting their feelings of being sad , anxious , irritable or even numb . Obviously not a yes or no question there , stacey .
That's true .
They may describe mood swings or a persistently low mood . What are some of the other terms used to describe the mood on the MS East ?
Well , when you ask the client to describe their mood , they'll probably use words like depressed , anxious , irritable , scared , angry , maybe feeling guilty .
On your exam , however , you might see those words , but you also need to understand how to document and interpret the client's reported experience in clinical language and what they mean when you see them on the exam . And I'm talking about words like euthymic , which is a neutral mood characterized by a sense of well-being and emotional stability .
Now , euthymic , which is a neutral mood characterized by a sense of well-being and emotional stability . Now euthymia refers to a balanced mood where the individual is neither experiencing significant depression nor elevated mood states like mania or hypomania that maybe you'd see with bipolar .
It's a good sign when clients report feeling euthymic , since it often indicates that their mood is in a healthy , stable range . So euthymia is the term that you look for in therapy and psychiatric evaluations as an indicator of emotional well-being .
Here's another one dysphoric , which is a general state of unease , dissatisfaction or unhappiness . If you see the term dysphoric , you want to be thinking about the following Major depressive disorder and bipolar disorder , because depressive episodes can cause dysphoria . No-transcript .
Funny , you mentioned that one too . Lynch and I'm working on a podcast about adjustment disorder , so tune in for that next time .
Okay .
¶ Exploring Mood and Affect in Therapy
All right . Another term is euphoric , and this is not to be confused with that first one . We mentioned euthymic . By the way , those two words are spelled with an E-U at the beginning , and that word E-U is Greek for good or well , so maybe you might be able to remember it that way . Euthymic means a stable and balanced mood , whereas euphoria means extra good .
So if euthymic is like cruising steadily down a scenic highway on a clear day , feeling calm and content , then euphoric is like flooring the gas pedal in a sports car , speeding through the same highway , feeling an intense rush of excitement and exhilaration .
Think bipolar disorders that involve mania and hypomania , where the client is really jazzed up like they're on cloud nine , and intoxication from certain drugs can also cause euphoria .
Next is anhedonia , which is mood characterized by an inability to experience pleasure or joy from which are usually enjoyable activities . We see this term a lot in the context of depression , schizophrenia , ptsd and withdrawal from certain substances .
It's essential to distinguish anhedonia from a general lack of interest or apathy , as the later may be more related to motivation than the ability to experience pleasure .
Are there any other terms that are used to describe mood Linton ?
Right , there are , and you'll need to know them . Elevated or expansive . This is similar to euphoria the client feels intensely happy and excited . Bipolar disorders , particularly bipolar 1 disorder Elevated expansive mood might be an indicator of a manic or hypermanic episode . Another is substance intoxication , withdrawal or medical use .
There can also be a medical condition like hyperthyroidism or certain neurological disorders .
And then there's ADHD , where symptoms of impulsivity and hyperactivity can sometimes be mistaken for an elevated mood , and it's really important to differentiate between the two , as ADHD is more about a persistent pattern of inattention and hyperactive impulsive behavior rather than episodic mood elevation .
And when we talk about elevated expansive mood , we also want to be thinking about schizoaffective disorder , which involves a combination of mood disorder symptoms and psychotic symptoms like delusions or hallucinations .
And lastly , certain personality disorders , such as narcissistic personality disorder Stacey . We've done a podcast on that , yet that's a good question .
Have we done a podcast on narcissistic ?
I don't think so We've done so many ? Yeah , we probably should , though you know .
That's a good idea .
Okay . They may include symptoms of grandiosity or elevated sense of self-importance that could be perceived as an expansive mood and borderline personality disorder , Although borderline personality disorder primarily characterized by instability in internal relationships , self-image and , in effect , clients may exhibit periods of elevated or expansive mood .
Yeah , all this talk about elevated or expansive mood , Linton , I'm thinking you know , is this how you feel on Tuesday night when you remember tomorrow's BOGO sushi day at Publix ? You know , is this how ?
you feel on Tuesday night when you remember tomorrow's Bogo Sushi Day at Publix , or maybe how you feel when you find that golden egg without a shell in the chicken coop , Not even close there , Linton .
A shell-less golden egg could indicate a calcium deficiency , stress , hormonal imbalance or health issues , in which case my mood would be more dysphoric . But before we go down .
How do you know all this stuff , Stacey ?
They call it a gift . But before we go down a rabbit hole about the kinds of things that I do find in the coop because there are some stories there let me point out that you wouldn't use the term elevated expansive mood to describe a client who's , you know , just feeling happy and enthusiastic .
Elevated or expansive mood is used to describe an exaggerated sense of wellbeing , self-confidence and optimism , and those people who are experiencing an expansive mood often feel on top of the world , brimming with energy and enthusiasm . They might believe they possess extraordinary abilities or they're destined for greatness , leading to an inflated sense of self-importance .
That's a good point . Now let's transition into affect , where you're looking at the client's facial expressions , tone of voice and overall emotional presentation . The client may be reporting feeling fine , but if they appear tearful , have a flat affect and are slumped over in their chair , you would say that the affect is inconsistent with the reported mood .
What are some other terms used to describe affect ?
Stacey , Well , the example you gave is a great place to start with terminology . You might use the terms congruent and incongruent to describe the relationship between the client's mood and affect , and if something is congruent it means that it matches . Conversely , if it's incongruent , it means that it doesn't match .
A few other terms that are commonly used to describe the client's affect on the mental status exam are broad , and this just means that the client can express a variety of expected affects in response to stimuli . For instance , imagine you've got a client who comes in and talks about different aspects of their week .
When they describe something sad , like maybe the loss of a pet , they show appropriate sadness and might even tear up a bit . Then when they talk about a fun outing they had with friends , their face lights up , they smile appropriate sadness and might even tear up a bit .
Then , when they talk about a fun outing they had with friends , their face lights up , they smile and maybe they even laugh Labile . This describes rapidly changing emotions where the client swings from one intense emotion to another , like they're smiling one minute and crying the next , or they're laughing one minute and yelling in anger the next .
Congruent affect this means that the client's affect is consistent with the content of what they're saying or experiencing . Their emotional expression matches what they're saying . Remember congruent matches Incongruent affect and this is interchangeable with an inappropriate affect . The client's affect does not match the content of their speech or the context of the situation .
Their emotional expression is out of sync with their verbal communication . Clients with schizophrenia often exhibit incongruent or inappropriate affect . For example , they might laugh when they're talking about something sad or appear emotionally flat when discussing something that would typically evoke a stronger emotional response .
There's also flat affect , and that's when a client shows absolutely no emotion at all . Their face appears unresponsive and emotionless and there's a lack of reactivity to any kind of emotional stimuli . Restricted , conflicted affect , where the client shows a limited range of emotional expression . Emotions are present , but less varied than what is typically expected .
And blunt affect , which is similar to constricted affect , but even more severe . There is very little emotional reactivity and the client may appear almost robotic .
Okay . So how does assessing the client's mood and affect help you as the therapist ? What clues does this provide you with ? We'll go through a few examples .
Okay , imagine you had a client who reports feeling I'm all right and I'm not too stressed , a relatively euthymic mood . But as you interact with them you notice their affect is blunted . They're not showing much facial expression , their voices lack any inflection and they're not very animated .
The discrepancy between the reported mood and the observed affect could suggest that there's more going on emotionally than they're letting on .
Yes , and that incongruence remember the word incongruence between mood and affect is a significant clinical clue . It might indicate the client is not fully aware of their emotional state , or perhaps they're defending against underlying feelings of depression or anxiety .
Here's another scenario A client who describes their mood as fantastic and euphoric , speaking in a rapid , pressured manner , and their affect is expansive and animated . They're smiling broadly , gesturing enthusiastically and seem almost giddy .
In this case , the elevated mood and the heightened affect are congruent , but they are both abnormally intense , which could be indicative of a manic or hypermanic episode .
Good one , Okay . So how about this case ? A client reports their mood as empty and detached following a recent loss . During the session , their affect is constricted , they're not showing much emotional variation , even when discussing the loss .
Their facial expressions are minimal and they're speaking in a monotone that flat , restricted affect , coupled with the anhedonic mood , could point towards a depressive disorder or prolonged grief disorder .
Of course , when considering diagnoses and treatment planning , the MSC is just the starting point to determine a clinical's mental state baseline . It's a snapshot of that particular moment in time when you're with them . You need to take into account the full clinical picture .
Exactly , and so , for the instance with the client that you described , linton , you'd want to explore the nature and duration of their grief response . Are there other symptoms present , like changes in appetite or sleep , difficulty concentrating or suicidal ideation ? Are they using any substances that might be complicating their clinical presentation ?
The flat affect and anhedonic mood are important pieces of the puzzle , but you have to gather all of the pieces to see the whole picture . How about a summary before we sign off , linton ?
Okay , you got it Stacey . The mental status exam is a critical tool for assessing a client's current mental state . Mood and affect are two key components . Mood refers to the client's self-reporting emotional experience , while affect is the therapist's observation of the client's emotional expression .
When assessing mood , you listen to the client's words describing their emotional states . Terms like euthymic , dysphoric , euphoric , expansive , elevated and anhedonic .
Why are all the clinical words so hard to pronounce ?
by the way , I don't know , they just are just something else .
It's like they come from . They're all Greek . This is all Greek to me . It's like we're teaching a different language . I know .
When assessing affect , you observe the client's facial expressions , tone of voice and overall emotional presentation . You look for congruence or , as Stacey says , incongruence with the reported mood , and you use terms like broad libel , constricted , restricted and blunted to describe the range and intensity of the observed affect .
Discrepancies between mood and affect can provide all those critical clinical clues that you need , especially on the exam . That suggests anything from a lack of emotional awareness to a mental disorder . Congruence between mood and effect is also noteworthy , especially when both are abnormally intense , as a manic episode , or abnormally low , as in a depressive episode .
So oh , we've reached the end . All right , all of you listeners out there , keep honing your mental status exam skills , as this will serve you very well on your exam and in your real life practice . And , as we always say , remember it's in there , it's in there . I got to brush up on my Greek and Latin , Linton .
You do , so do I oh my gosh Hmm .