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Mood vs. Affect

New Hyde Park, N.Y.

The August 15 article "Distinction Between Mood, Affect Eludes Many Residents" in which Michael Serby, M.D., was quoted laments the demise of the term "mood" in the mental state exam (MSE). However, the article fails to point out that mood is a clumsy phenomenological term. It is the constant comparison of mood and affect that is confusing for students who often regard them as different sides of the same coin.

Another approach is to teach residents the linkage between a triggering situation, a dysfunctional, automatic thought, and the associated emotion, as described in standard cognitive therapy. The student can then identify the major themes of the patient’s thought content. For example, a patient may have thoughts that center around seeing the world as a dangerous place or describe pervasive themes of helplessness. The student can then check to see which emotions are linked to these themes by asking a question such as, "When you have thoughts that the world is dangerous and unpredictable, how does it make you feel?"

It is the answer to this question that can be put in inverted commas as it is an example of the patient’s sustained emotional reaction (mood) to a particular trigger: "I feel panicky and worried."

Traditionally we teach that mood and affect appear sequentially on the MSE. The model of cognitive therapy is helpful as it allows "thought content" to be linked to sustained inner emotion/mood. This in turn can be connected by the clinician to diagnosis and treatment and is grounded on cognitive therapy research. Affect can then be separated off to where it belongs—the clinician’s external judgment of the patient’s inner emotional state, based on nonverbal cues.

Thus, when presenting the MSE, it may be better to place "affect" soon after "appearance." Mood is better described as the patient’s sustained emotions in relation to dysfunctional, automatic thoughts. It should be presented after "thought content" (thought themes), to which it should be integrally linked.

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