4.1.8 Disorders of emotion

Emotion, feeling, mood and affect

• Mood and affect are told apart by time course. Mood lasts days to weeks, while affect changes from moment to moment.

• Cognitive appraisal is the interpretation of an event that may lead to a feeling. The feeling is the experience itself.

• Clinicians record reported mood and observed affect separately and then compare them.

Abnormal mood states

• Moria is a foolish, shallow, puerile euphoria of frontal lobe disease, particularly right frontotemporal lesions and frontotemporal dementia.

Depression

• Psychomotor retardation is slowed thought and movement with a felt sense of effort, characteristic of moderate to severe depressive illness.

• Agitated depression is depressed mood with prominent psychomotor agitation in place of retardation: pacing, hand-wringing, being unable to stay seated. It is characteristically seen in later life.

• Agitated depression has no manic symptoms and no causative drug, so agitation alone does not make a mixed state.

Mixed states and mania

• A mixed depressive state is low mood with manic-spectrum activation, such as racing thoughts and restless overactivity, in the same episode, not the two poles in sequence.

• Kraepelin rated mood, thinking and psychomotor activity separately. A mixed state is any of six combinations in which they do not all move the same way, while pure mania and pure depression are congruent.

• Mania alters mood, energy, thinking, attention, self-esteem and behaviour but leaves memory intact and consciousness clear. Impaired orientation or memory is not a feature of a manic episode.

Anxiety, fear and phobias

• Panic is told from generalised anxiety by its abrupt onset and brief peak.

• Anxiety becomes a disorder through disproportion, persistence, avoidance and impairment.

Observed affect

Reduced affect

• Blunted affect describes expression, so it is recorded separately from reported mood.

• Neurological disease and medication can also reduce expression, and it is judged against culture, usual style and development.

Abnormal affect

• Incongruity of affect is displayed emotion that does not fit the thoughts being expressed or the situation, such as cheerfulness while describing distressing content.

• Labile affect is expression that changes markedly and repeatedly over a short period, with rapid unprovoked swings, as in mania, mixed states, emotionally unstable personality disorder and brain injury.

• Neither lability nor incongruity is specific to schizophrenia.

• Histrionic personality disorder shows exaggerated, theatrical, shallow, rapidly shifting affect driven by an audience, though dramatic expression alone cannot establish a personality disorder.

• Ambivalence is holding opposing feelings or wishes towards the same object at once, and Bleuler counted it among the fundamental features of schizophrenia.

Lability and pathological affect

• Emotionalism affects roughly one stroke survivor in five in the early months.

• Some lesions and disorders produce the opposite of lability: blunted, apathetic affect with reduced emotional expression.

• Depressive crying usually sits within sustained depressive symptoms, unlike emotionalism, although the two can overlap.

Emotional change after stroke

• Clinicians assess coexisting depression before treating, because apathy alone does not justify an antidepressant.

La belle indifférence

• La belle indifférence is a striking lack of concern about an apparently severe deficit that the person acknowledges.

• It is classically linked with conversion (functional neurological or dissociative) disorder, but it is neither sensitive nor specific for it.

• It is distinct from anosognosia, anosodiaphoria, blunted affect and alexithymia.

Alexithymia

• Alexithymia is a trait difficulty identifying and describing one's own emotions, so feelings are reported as bodily arousal.

• The emotional state, expression, pleasure and drive are preserved, which separates it from blunted affect, anhedonia and apathy.

• Thinking is concrete and externally oriented, with a poor fantasy life and reduced symbolic thinking.

• It was described in, and is classically linked with, psychosomatic and somatising patients.

• It is not one of the standard negative symptoms of schizophrenia.

• Emotional numbing is different: a reduced felt intensity or range, experienced as a change, as in trauma, depersonalisation, depression and medication effects.

Anhedonia, apathy and negative symptoms

• Anhedonia is loss or marked reduction of the capacity to experience pleasure from previously enjoyable activities; Ribot introduced the term in 1896.

• Anhedonia is a core symptom of a depressive episode and a negative symptom of schizophrenia.

• Anticipatory pleasure is looking forward to an activity and consummatory pleasure is enjoyment during it, so someone may enjoy an activity once engaged despite not anticipating it.

• Apathy is a dulled feeling tone with detachment or indifference, defined by lack of feeling rather than by reduced observable behaviour.

• Anhedonia is lost pleasure, apathy is lost drive, and blunted affect is lost expression.

• Apathy occurs in frontal and subcortical disease, Parkinson's disease, dementia and after stroke; guilt, hopelessness and distress point to coexisting depression.

• Negative symptoms are a loss or reduction of normal function, such as poverty of speech, while positive symptoms add abnormal experience.

• Depression in schizophrenia tracks threat from persecutors and hostile voices in the acute phase, and appraisals of loss, shame and humiliation about the illness after remission.

Models of separation, dying and grief

• In the separation model, detachment is shut-down of attachment behaviour, not recovery.

• Parkes and Bowlby describe four phases and Kübler-Ross five; the phases are neither rigidly sequential nor culturally uniform.

• In Kübler-Ross's model depression follows bargaining: the loss is acknowledged, attempts to postpone or undo it stop, and sadness, withdrawal and futility take over.

Parkes and Bowlby's phases

• Grief in children is shaped by developmental level and grasp of death, so it does not follow the adult pattern and is reworked at later stages.

• Children may show regression, repeated questions or behaviour change.

Normal grief

• Yearning for the deceased is the emotion most characteristic of normal grief over the first months.

• Sadness comes in waves triggered by reminders, and people alternate between attending to the loss and to daily life.

• Anger, including anger at the person who died, is a recognised feature, and guilt stays tied to the death.

• Brief perceptual experiences of the dead person, seeing, hearing or sensing them, are normal early in bereavement when held with insight and with function preserved.

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Grief or depression

• Grief and depression can coexist and bereavement can precipitate a depressive episode, so clinicians assess all suicidal thinking, including wishes to join the deceased.

• Once criteria for a depressive episode are met, adjustment disorder is not diagnosed.

Abnormal grief

• Delayed grief is a postponed onset of an otherwise recognisable grief reaction, classically more than about two weeks after the loss.

• Prolonged grief disorder is abnormal duration rather than delayed onset.

• In ICD-11 it is persistent yearning or preoccupation with intense emotional pain, beyond cultural norms and causing impairment, with self-worth intact.

• Dysthymic disorder is told apart by needing two years of depressive symptoms.

• Trauma-related disorder after a sudden or violent death shows intrusive re-experiencing of the manner of dying, avoidance, hypervigilance and a sense of current threat, rather than yearning.