DISTURBANCES OF AFFECT

RK Chadda. Mamta Sood, Vijay Krishnan

Department of Psychiatry,
All India Institute of Medical Sciences, New Delhi

Introduction:

Emotions are a part of everyday life and colour all human experiences. Disturbances of
emotions are seen in most of the mental disorders. Mood and affect refer to how emotional
experiences are described in psychiatric assessment.

Affect and mood are one of the key domains of mental functioning and their assessment is an
integral part of clinical examination in psychiatry. Assessment of disturbances in affect could
be challenging to the trainees in psychiatry. Hence, before embarking on assessment of
affective disturbances it is important to understand the context of use and meaning of
different terms. Various terms like ‘feelings’, ‘emotions’, ‘affect’ and ‘mood’ have been used
to describe the emotional state of an individual.
Definitions:
Frank Fish defines ‘feelings’ as positive or negative reactions to an experience or an event,
which constitute the subjective experience of emotion, and are often transitory. In simple
English, the word feeling also refers to an active experience of somatic sensation, like touch
or pain, and the passive subjective experience of emotion.
Emotion has been primarily defined in terms of response to stimuli which lead to cognitive,
physiological and behavioural changes. Lange considers emotion to arise from a person’s
self-awareness of physical and bodily changes whereas Fish considers emotion as a stirred up
state caused by physiological changes. Both these definitions highlight that a stimulus leads
to changes in the body, which on being perceived by a person are experienced as emotion. On
the contrary, Cannon and Bard suggest that emotion is the first response to a stimulus and
physiological changes occur as a consequence of the emotion e.g. one feels afraid on seeing a
lion and then physiological changes such as sympathetic over activity follow.
Affect refers to the emotional state, as judged by external reactions like laughter, crying,
anger or fear. Affect is dynamic and transitory; it changes with situations, thought processes
and external environment.
Mood, on the other hand, refers to a more pervasive and sustained emotional state, which
colours the person’s perception of the world (and thus the affective responses). The
descriptive terms used for mood and affect are generally the same like sad, anxious, angry,
happy, calm, irritable, etc.
The term ‘affectivity’ refers to the total emotional life of the individual (Fish).
Thus, mood refers to an individual’s disposition to react to situations with a certain kind of
emotion, which is prolonged, and influences all other aspects of mental life; and these
emotions are generally manifested through a range of affects, which are complex but
momentary.

The studies of recognition of facial expression on tests like facial emotional expression test
have shown the existence of six basic emotions, expressed on face, which are easily
differentiated by subjects. The six basic emotions include anger, disgust, fear, happiness,
sadness and surprise, and are considered to be universally present. Curiously, these six basic
emotions are also similar to the navarasas or nine emotions such as shringara, hasya,
adbhuta, shanta, raudra, veera, karuna, bhayanaka and vibhatsa, described in studies of
ancient Indian drama such as the Natya Sastra.

Culture contributes a lot to the variations in expression of mood and affect. There may be
customary rules within a culture which determine the cultural norms for expressing emotion.
For example, there are customary rules for who can show which particular emotion to whom
and when and which events are likely to produce a particular emotion. In certain social (e.g.
mourning) and religious contexts, a particular emotion might be expressed, or even
considered desirable, which would not be considered appropriate in another culture.
Similarly, there may be cultural differences in the descriptions of various types of mood and
affect.

Normal and Abnormal Mood and Affect

It is essential to understand how to differentiate normal from abnormal mood and affect. It
becomes important while assessing psychopathology in affective domain during clinical
examination.

The difficulty in differentiating normal from abnormal affect arises because of a number of
reasons. Normal individuals often experience a variety of emotional states, which may occur
spontaneously or in reaction to stimuli and some of these may be distressing. Also, the same
terms are often used to describe normally experienced affect and abnormal affect that
warrants clinical intervention. For example, the terms ‘anxiety’ and ‘depression’ may have a
very specific technical meaning when used by a psychiatrist, but could have a very different
meaning to the patient while describing them. In addition, in certain situations like mourning
or during religious experiences, extreme emotional expressions are culturally expected and
permissible. There may be no phenomenological differences between the reactions seen
within the context of such a situation, and those seen as a psychopathology in a mental
disorder.

From phenomenological point of view, affect is considered normal when it is experienced

across the wide range of various emotions with different intensities that usually match and
change in accordance with the thoughts and feelings being verbally expressed. The emotional
changes are appropriately responsive to the environmental changes. Normal affect has been
sometimes called broad affect. Similarly, the normal mood is termed euthymic or in the
normal range. Individuals exhibiting euthymic mood appear calm, consistent in emotional
expression and comfortable. They may be appropriately concerned or anxious about their
problems, but are not overly frightened or agitated. A normal mood is usually a sign of
health.

Emotional reactions and expressions occur in a range of increasing intensity from normal
through abnormal to morbid in the context of socio-cultural norms, understandability,
excessiveness of the emotional response, and awareness by the person experiencing the
emotional response. Fish has described five levels of emotional reactions and expressions:
• Normal emotional reactions
• Abnormal emotion reactions
• Abnormal expressions of emotion
• Morbid expressions of emotion
• Morbid disorders of emotion
Normal emotional reactions occur as a result of events and are within the sanctioned socio-
cultural norms. Abnormal emotional reactions are excessive but understandable. Abnormal
expressions of emotion are both un-understandable and excessive to the context. Further,
emotional responses are considered to be morbid when the person is unaware of the
abnormality in addition to being un-understandable and excessive. Morbid disorders of
emotion include manic or depressive episode.
Emotional responses may be primary or secondary. Primary disturbances of emotion are un-
understandable and morbid in themselves. Secondary disturbances of emotions occur as
understandable reactions to some other psychological event or psychopathology e.g. persons
experiencing delusions or hallucinations may experience anger, fear, surprise or joy, related
to the content of these delusions or hallucinations.
The definition of abnormal mood and affect has to be understood exclusively within the
context of descriptive psychopathology and the clinician must also consider a multitude of
other factors before deciding that this phenomenon represents the symptom of an illness
warranting intervention. Therefore, while determining whether mood and affect is abnormal,
few points need to be considered:
• Whether there is quantitative or qualitative change in the mood and affect?
• Whether this change is associated with other symptoms?
• Whether there is functional impairment?
• Whether the change is outside the range of culturally appropriate expressions?
• Whether the change in affect has any association with cognition and/or conation
Andrew Sims brings in two other important dimensions for ascertaining abnormality viz.,
subjective distress and social appropriateness. It may be assessed:
• Does the individual’s current mood lead to subjective distress/suffering?
• Is the individual’s mood socially appropriate?
A pathological mood state should be considered only if one of the above two questions is
answered in the affirmative.
Causes of Affective Disturbances
Disturbances of mood and affect are seen not just in the disorders considered to be primary
disorders of mood, but also in many other psychiatric disorders as well as in physical
illnesses and also in psychoactive substance use disorders:
Psychiatric disorders: Affective disturbances occur in most of the psychiatric disorders and
across all age groups. The illnesses would include mood disorders, schizophrenia and related
psychotic disorders, delirium, dementia, anxiety disorders, adjustment disorders and
personality disorders and childhood psychiatric disorders.
Physical diseases: Many physical/medical diseases may cause affective symptoms like
frontal lobe syndrome, Alzheimer’s disease, brain tumours and infections, head injury,
Parkinson’s disease, diabetes, malaria, endocrinological disorders, HIV/AIDS, etc.
Medications like corticosteroids, alpha-methyldopa, reserpine, calcium channel blockers,
antiviral agents, etc. can also cause affective symptoms.
Psychoactive substance use: Psychoactive substance abuse or withdrawal after prolonged
use may be associated with affective symptoms. Psychoactive substances that are known to
trigger affective symptoms include alcohol, benzodiazepines, cocaine, opioids etc.
Clinical Assessment of Mood and Affect
The assessment of disturbances in mood and affect in routine clinical practice is often
challenging, Reasons include an indefinite characerteristic of the emotional expressions, an
overlap between them, cultural variations, and the variety of terms that the patients may use
to describe their emotional states. Because of the complex relationship of mood with
cognition and behaviour, differentiating cognitive from affective aspects of a particular
phenomenon and ascertaining their primacy may become difficult. Berrios also gives another
reason that the cognitive aspects of psychopathology has been given more importance in the
scientific literature which has resulted in less differentiated nature of affect (as compared to
cognition) with less developed psychopathology and fewer description of affective
disturbances.
The assessment of mood and affect is done on the basis of history, physical examination and
mental status examination.

Assessment of Mood:

As mood is a sustained emotional state experienced over a relatively prolonged period, it is

best assessed on history and enquiries are made about the pervasive mood state experienced
by the person. The assessment of affect is undertaken as part of the mental status
examination, and is recorded under a number of headings.

While assessing mood on history, one needs to enquire explicitly about the mood, with direct
questions. One could ask questions like:

• How have you been feeling lately?

• How do you feel right now?
• How do you feel this morning?
• How is your mood today?
• How have you felt in the last one week?
• Whether your current mood is typical for you?
 • What do you mean by the word ‘depressed’ in case person reports feeling sad or
depressed?
• What is it like to feel depressed?
• How depressed are you?
• How is it affecting you?
Encourage the person to elaborate on his/her responses and suggest synonyms to whether
he/she is experiencing the particular emotion e.g. for sadness suggest words or phrases like
‘feeling low’, ‘feel like crying’, ‘inability to enjoy or feel pleasure’, ‘not happy’. In case of
failure to elicit desired response, leading questions may be used e.g.
• Have you been afraid of something lately?
• Is there something frightening you?
• Have you been worried this weekend?
• Are you sad? Have you been crying?
• Have you felt unusually cheerful?
It is always useful to gather information from significant others as it adds to the information.
Other informants can be asked questions like:

• How has been his/her mood in general?

• Has there been any change in the recent past?
• Since when this change has been noticed?
• How the person has been reacting to the day to day events? Examples?
• Any other symptoms?
• What has been effect of the mood changes on functioning?
In addition, specific questions related to self-harm must also be asked, in order to pick up
current or past suicidality that might have a bearing upon the clinical management. It is
imperative to ask whether similar changes in mood have been experienced by any of his/her
family member or by him/herself in the past. At this juncture, it is important to take any
history of physical disease, medications used or psychoactive substance use, which might
have contributed to the causation of mood symptoms. While ascertaining premorbid
personality, it is important to enquire about the mood of the person before he/she fell sick.

Physical Examination:

Physical examination is an integral part of examination and can contribute in many ways. It
may provide clue about the emotional state of a person e.g. autonomic dysfunction in form of
moist palms and dry mouth, tachycardia, fine tremors and mild rise in blood pressure, may
indicate underlying anxiety. Sometimes, the findings on physical examination may be as a
result of disturbed mood e.g. multiple cut marks arising out of dysphoric mood. It may also
uncover signs of a physical disease like Parkinson’s disease which might be contributing to
the affective symptoms or even an independent comorbid physical disease.

Assessment of Affect:

Affect is formally assessed and recorded under a separate heading in mental status
examination. It is generally described/recorded under two headings:

 Subjective
 Objective

For assessment of subjective affect, generally a single direct question is asked from the
person, “How do you feel?” or “Aapka man kaisa hai?” Exact verbatim of the answer to this
question is noted as subjective affect.

Objective assessment of affect is made throughout the interview on the mental status
examination. Objective affect is examined in various dimensions to enable a comprehensive
assessment of affect, which include:

• Quality

• Range

• Reactivity

• Appropriateness

• Intensity/depth

However, intensity/depth is not always commented upon during routine mental status
examination.

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Objective affect is gauged by:

• Nonverbal cues, verbal content, thought process and direct questioning. Nonverbal
cues come from observation of general appearance, choice of clothing, facial
expression especially the eyes, gestures, posture, spontaneity, tone, volume and flow
 of speech, and flow and content of thought process. For example, a person with
mania, due to expansive mood and resultant pleasure seeking behavior, may exhibit
dressing in gaudy clothes, increased psychomotor activity, excessive use of gestures,
over familiarity, increased volume and tone of speech with rapid flow of thoughts
with grandiose content in addition to cheerful affect.
• Questions asked to assess higher mental status functioning may give clue to the
affect. For example, a person having severely depressed affect and depressive
cognitions, when being tested for personal judgment, may give an answer, coloured
by his/her prevailing depressed affect, that he/she would sit on a road and let passing
by vehicles hit him as there was no hope of his/her becoming alright.
• Empathic evaluation also helps in the assessment; it means that the interviewer must
imagine him/herself in the situation of the interviewee and try to understand what
he/she is feeling.
• Sometimes, the affect is infectious which means that the interviewer feels with the
person being interviewed; he/she is infected with the same emotion. This
infectiousness is generally noted while interviewing persons having mood disorder
e.g. the interviewer may feel cheerful without any reason while examining an elated
person with mania, as if the elation has rubbed on to him/her.

To decide whether a dimension of affect is abnormal, it is important to collate observations

made during the mental status examination. The abnormality is determined by establishing
mismatch between the emotion and the thought process, the context and the behaviour.

Quality of affect:

Quality of affect refers to characteristic emotional state, experiencing by a person, examples

include happiness, sadness, irritability, anger, euphoria, elation, depression, anxiety, etc
Certain emotions like euphoria and elation would definitely be labeled as abnormal while for
others a judgment is made as per the person’s situation.

Some of the common qualities of affect are described in detail as below:

Happiness: The gradients of happiness have been described as elevated affect, euphoria,
elation, exaltation and ecstasy.
Elevated affect is an air of confidence and enjoyment, experienced as being more cheerful
than normal, but may not be pathological.
Euphoria is subjective experience of over cheerfulness and heightened wellbeing. It is
characterized by increased enjoyment and a reduction in restraint imposed by the self or by
societal norms. There may be changes in activity levels and appetitive behaviours that reflect
heightened mood state. It is an exaggerated feeling of well-being and is not explicable by real
events. The affect in this state is, also noted as being ‘expansive’. On assessment, feelings are
expressed relatively easily and without restraint. Euphoria is frequently associated with an
overestimation of reality.

Elation is subjective experience of feelings of joy, euphoria, triumph and optimism, along
with intense self-satisfaction. This state is usually associated with an increase in activity
levels beyond that usually experienced by the person and is inappropriate for the context, and
not usually experienced as being uncomfortable or distressing.

When elation is associated with increasing self-esteem to the extent that it alters the person’s
ties with reality, it is referred to as exaltation.

Euphoria, elation and exaltation are usually seen in mania.

Ecstasy is emotional state lying on the same spectrum, but is somewhat different. It usually
involves a state of extreme well-being associated with a feeling of rapture, bliss and grace.
This is subjectively experienced as a transcendental state where the person feels at one with
the universe. There may be a feeling of being in tune with the whole of nature and at one with
the universe. Ecstasy is often a part of normal religious or spiritual experiences, when it is
associated with a pervasive feeling of communion with God or some religious figure. It can
also occur in mania and sometimes the result of a psychotic, dissociative or drug-induced
disorder.

Depression: It is a feeling of dejection that colours all thoughts, behaviour and activity. It
may occur in response to chronic frustration and disappointment, loss or bereavement or as a
part of depressive disorder. Depression, as an affect, may vary quantitatively from normal
sadness as associated with bereavement or qualitatively as profound gloominess as in severe
morbid depression. The state of persistent mood in depression may be sadness, decreased
emotional reactivity, a heightened experience of negative affect or irritable mood and ill-
humour. In morbid depression, there may be marked and severe inhibition of psychomotor
activity which may result in stupor. Due to severe retardation, a person with morbid
depression may appear indifferent to the events happening around him/her. This needs to be
differentiated from emotional indifference of a person with chronic schizophrenia. A person
with severe depression understands the significance of the events around him/her but is
unable to act due to his/her mental state. This inability to act is experienced as very painful
and makes him/her fell guilty. Depression, mild to morbid, may be seen in adjustment
disorders, mood disorders, schizophrenia and related psychotic disorders, anxiety disorders,
dissociative disorders and personality disorders, and has also been reported in children. It
may be difficult to diagnose depression in patients with physical disorders as symptoms of
depression like insomnia, loss of appetite, anergia may also occur because of discomfort and
pain associated with the physical illness itself. In this situation, it is useful to discern
persistent pervasive sadness and cognitive symptoms of depression for making diagnosis of
depression. Similar problem may arise while assessing depression during pregnancy and
postpartum period.

Anxiety: In day to day English language use, one hears commonly the word ‘anxiety’ which
means ‘uneasy preoccupation with some personal matter’ or ‘worrying about something’. But
in psychiatry it is used in a different way. Anxiety is ‘an unpleasant affective state with the
expectation but not the certainty of something untoward happening. It is characterized by
apprehension in anticipation of a danger (external or internal)’or ‘fear for no adequate
reason’. Anxiety is also described as an emotional reaction to a threat that is ill-defined,
internal and conflictual. This definition serves to differentiate anxiety from the state of fear,
related to the perception of a threat that is external, clear and non-conflictual. Anxiety and
fear, as with all emotional states, contain both psychic and physical concomitants. The
psychic symptoms of anxiety are feelings of inner restlessness, ‘bechaini’, ‘ghabraahat’,
apprehension or ruminations. The physical response in these states is the state of the
adrenergic “fight-or-flight” response, where autonomic and somatic symptoms like
palpitations, shortness of breath, muscular tension resulting in headache or chest pain,
diarrhoea and dryness of mouth may be seen. Morbid anxiety is often accompanied by one or
more symptoms like inability to sleep, poor concentration, irritability, etc.

Fish also describes anxious foreboding in which a person has a fear that something very bad
will occur but he/she cannot identify it. A related concept is panic. Panic attack is an episode
of severe anxiety characterized by feeling of choking, difficulty in breathing, symptoms of
sympathetic overactivity and physical weakness. Phobia is a fear restricted to a specific
object, situation or idea. Phobias are associated with physical symptoms of anxiety and
avoidance of the phobic object or situation.
Anxiety symptoms are seen in anxiety disorders including generalized anxiety disorder, panic
disorder, specific phobias, mood disorders especially depressive disorders, psychotic
disorders, adjustment disorders and psychoactive substance/alcohol intoxication or
withdrawal and many physical diseases.

Anxiety seen in patients with psychosis is usually intense and improves with the
improvement of psychosis. Sometimes, intense anxiety may be present in patients receiving
antipsychotics which may be due to akathisia, a side effect of antipsychotics.

Irritability: irritability is a liability to outbursts or a state of poor control over aggressive

impulses directed towards others. It is seen when a person’s affect is unusually excitable.
Anger, annoyance and impatience are often associated. It manifests as snapping at others,
shouting, slamming doors, throwing objects or physical assaulting others. Irritability can be
seen in almost all types of psychiatric disorders.

Perplexity: Perplexity is a state of puzzled bewilderment. When perplexed, a person is unable

to process events around him/her and may appear confused or anxious. It may be seen in
persons with delirium, initial stages of schizophrenia, acute and transient psychotic disorder
and anxiety disorders.
A number of other emotional states may be used as descriptors, but the interviewer should be
careful to use the terms since these carry specific meanings.
Reactivity of Affect:
Emotional reactivity refers to the fluctuations in emotions that occur in response to changes
in the environment or external situations which may or may not be emotion-laden. A normal
person would show varied affective responses in reaction to various stimuli. Clinical
assessment of reactivity of affect involves gauging the capacity of affect to adjust in response
to external factors. Abnormality may be seen in terms of the degree of the affective response
to a situation, ranging from large variations in response to minor stimuli (lability) down to an
affect that is not reactive even to extreme stimulation (apathy).
Excessive reactivity may be observed as the phenomenon of lability and emotional
incontinence.
Lability is a state of rapid and abrupt changes in affective response, which involves a
reduction in control over affect. It is often seen in mania. The person experiences various
intense affective states within a short period of time, often without connection to external
stimuli.
In emotional incontinence, there is a total loss of control of emotions, and spontaneous
outbursts of different emotions may occur e.g. laughter, crying. There is a discrepancy
between the subjective experience of emotion and the affective response, with the person
experiencing a subjective loss of control over affect. An extreme form of this condition,
denoted by ‘forced laughing’ or ‘forced crying’ is seen in epileptic states as part of pre-ictal
phenomena and also in multiple sclerosis.
Less extreme forms of affective hyper-reactivity may be part of depression, where the person
may react to negative stimuli in an uncharacteristically excessive fashion, and in histrionic
and borderline personalities.
Reductions in affective reactivity may be seen as part of melancholic depression, in which the
person may be unable to respond emotionally to both negative and positive stimuli. This state
is generally experienced subjectively, and the person generally reports distress at his/her
inability to experience appropriate affective reactivity.
Apathy is absence of reactivity and is observed as emotional dulling associated with
detachment or indifference. It is seen in schizophrenia, depression or organic states,
especially those involving frontal lobes.

In dissociation of affect, there is lack of expected emotional reaction to a particular fear or

anxiety provoking stimulus. This may be seen as denial of anxiety e.g. in soldiers under
bombardment. Another form of dissociation of affect is ‘la belle indifference’ seen in
conversion disorders, in which, despite grossly disabling and obvious symptoms, the person
seems emotionally indifferent to them.

Range of Affect:

The normal affect is characterised by an ability to experience and express a variety of

emotions ranging from one extreme to another, in response to different situations. This
dimension of affect is referred to as the range. Range may include a variety of emotions like
happiness, sadness, anger, surprise, fear, disgust, etc. The normal range is described as being
‘full’. When there is a reduction in the range of affect, emotional responses are not elicited in
response to different stimuli, and it is referred as restriction, constriction or flattening,
depending on severity of the restriction. Blunting refers to complete loss of reactivity to
different stimuli with a blunt or emotionless face.
Appropriateness of Affect:
Normally, affect is appropriate to the social environment, situation or the topic of
conversation e.g. laughter is expected when a joke is told and sadness is expected when
talking of a deceased person or a funeral. Affect is considered inappropriate when there is
discordance between the affective expression and the content of speech or observable
behaviour. A discrepancy between environment and affect is generally referred to as
inappropriate, whereas a discrepancy between the affect (externally observed) and the
internal mental state, as interpreted from cognition and behaviour has been, sometimes, called
incongruent affect. In recent literature, inappropriate affect implies both. Inappropriate affect
is classically observed in persons with schizophrenia. While classifying presence of psychotic
features in mood disorders, both mania and depressive disorder, it has become customary to
differentiate whether these are mood congruent or incongruent. In mood congruent psychotic
features, the content of delusions/hallucinations is consistent with the typical themes of
depression or mania and in mood incongruent type, it is not consistent with typical themes of
depression or mania.
Intensity/Depth of Affect: Intensity of affect is the ability to convey an emotion or create an
impact of the emotional state. Intensity and depth of emotion convey the same meaning. It is
evaluated in terms of strength of affective expression during the interview.
When there is reduced intensity of affect, it is called blunted and is seen in chronic
schizophrenia. The term shallow affect is described in the context of hebephrenic
schizophrenia. These patients show silly, superficial and inappropriate cheerfulness. The term
shallow affect has also been used to describe the superficial display of exaggerated emotions
in histrionic personality or the old classical hysteria. The increased intensity of the affect is
called exaggerated affect and is seen in mania.
Sometimes, on interview, the patient may complain of loss of feeling. It may pertain to all
emotions like sadness, joy, anger, fear, etc. This is seen in patients with depression. On an
objective assessment, one may not find any abnormality e.g. a mother may say that she does
not get any feeling while hugging her children. Patients presenting with depersonalization or
derealisation may also give similar complaints. Alexithymia is a related term which has been
described as subjective experience of loss of feelings that were formerly present.
Flat affect implies that there is no range, little intensity, no reactivity. There is limitation in
the usual range of emotional responses. The patient displays little emotional response in any
direction, although that which is expressed is in the appropriate direction, unlike
inappropriate affect.
Before we conclude this section it is important for young trainees to understand that the
quality and appropriateness of affect are easy to discern but at times, it becomes difficult to
differentiate whether to classify a particular abnormality under dimension of reactivity, range
or intensity as there are only subtle differences among these. To illustrate this, let us take an
example, reactivity is the fluctuations in emotion in response to the environmental changes
e.g. smiling in response to a pleasing event; range is ability to experience and express a
variety of emotions ranging from one extreme to another, in response to a situation like
happiness, anger, surprise, fear, etc; intensity is the strength of affective expression during the
interview which means how much happiness a person can convey in response to a pleasing
event. In blunting of affect, there is absence of reactivity, loss of emotional display and thus
no intensity of emotions.
Delusional mood is not primarily a disturbance of mood and affect but is disturbance of
thought process and has been described as one of the three primary delusional experiences. In
delusional mood, the patient has the knowledge that something is wrong around him, related
to him but does not know what it is.
Conclusion:

On clinical examination, the emotional state of a person is discussed under separate domain
of mood and affect. Mood is a pervasive and sustained emotion state whereas the affect is the
emotional responsiveness or state as on now. Mood is examined on history and affect on
mental status examination throughout the interview. Mood and affect may be considered
abnormal or morbid in the context of socio-cultural norms, understandability, excessiveness
of the emotional response, awareness by the person experiencing the emotional response,
association with other symptoms and functional impairment. A variety of affective
disturbances are seen in patients with psychiatric and medical disorders.

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