Mood and affect
Two domains, routinely collapsed into one line. Kept apart they are among the most informative in the examination, because they can disagree with each other.
Mood and affect are the two domains most often collapsed into one line, usually something like "mood low, affect flat". That line contains two findings, neither described, and a reader six weeks later can do nothing with it.
Kept apart, these domains are among the most informative in the examination — precisely because they can disagree with each other.
Mood is reported, affect is observed
Mood is subjective. It is what the person tells you about their emotional state, over a period, in their own words. It is history in miniature: sustained, self-reported, and only available if you ask.
Affect is objective. It is the emotion you observed during the interview — its quality, its range, how it moved, and whether it fitted the subject. It is available whether or not the person cooperates, and it does not depend on their insight.
Mood is the climate; affect is the weather on the day you visited. Both are real, both matter, and the interesting cases are the ones where they do not match.
Recording mood
Three elements make a mood entry useful, and the third is the one most often left out.
The description
Euthymic, low, elevated, anxious, irritable, angry, or emotionally numb. More than one can be true at once, and irritability alongside low mood is common enough to be worth recording specifically.
The rating
Asking for a number out of ten is quick and gives something comparable across contacts. "If 0 is the worst you have ever felt and 10 the best, where are you today?" A rating of 8 alongside an obviously depressed presentation is a finding in itself.
The quotation
This is the part that survives. A person's own words about how they feel cannot be disputed, do not require your interpretation, and frequently convey more than a paragraph of description.
Mood was reported as low, with feelings of hopelessness about the future.
She described her mood as low and rated it 2 out of 10. She said: "There is nothing left to get up for."
The affect vocabulary
Affect has four dimensions worth describing: quality, range, stability, and congruence.
| Term | What it means | Distinguishing feature |
|---|---|---|
| Reactive | Changes appropriately with the topic | The normal finding |
| Full range | The expected breadth of expression is present | Normal |
| Constricted | Range narrowed, but variation remains | Less than expected, not absent |
| Blunted | Markedly reduced expression | Face and voice show far less than the situation calls for |
| Flat | Virtually no expression at all | Immobile face, monotonous voice — an extreme finding, use it precisely |
| Labile | Shifts rapidly and markedly | Tearful to laughing within minutes, often with little trigger |
| Expansive | Overflowing, little restraint | Associated with elevated mood |
| Perplexed | Bewildered, searching | Seen in acute psychosis and in delirium |
These lie on a continuum and are routinely used interchangeably, which is a shame because the distinction is real. Flat means almost nothing is expressed at all. If the person smiled once, it was not flat. Reserving the word for what it describes keeps it meaningful for the next reader.
Congruence, and why it is a finding
Congruence asks whether the observed affect matches the reported mood and the subject under discussion. It is a separate field, and it is where the two domains earn their keep.
Someone describing their mood as elevated while showing flat affect is displaying a marked incongruence. That is a real and meaningful finding — it appears in schizoaffective presentations and in schizophrenia — and it is not an error to be tidied away.
Equally, someone laughing while describing a bereavement, or entirely unmoved while describing a frightening experience, is telling you something. Record it as an observation rather than an interpretation.
He described his mood as elevated and rated it 8 out of 10. Affect was observed to be blunted and was incongruent with his stated mood; he showed little expression while describing plans he presented as exciting.
Questions for each direction of mood
"How would you describe your mood at the moment?"
"If 0 is the worst you have ever felt and 10 the best, where are you today?"
"How long has it been like this?"
"Does it shift through the day, or stay much the same?"
"Have you been feeling down, depressed or hopeless?"
"Are you still able to enjoy the things you usually enjoy?"
"How are you sleeping? Any early morning waking?"
"How is your appetite? Any change in weight?"
"How do you feel about yourself at the moment?"
"How does the future look to you?"
"Have you had times of feeling unusually good, or full of energy?"
"Have you needed less sleep than usual and still felt fine?"
"Have your thoughts felt faster than normal?"
"Have you been doing things you would not usually do — spending, plans, taking risks?"
"Have you been feeling worried or on edge?"
"Do you get episodes where your heart races or you cannot catch your breath?"
"Is there anything you have been avoiding because of the worry?"
The sleep question in the elevated-mood set is doing particular work. Reduced need for sleep, where the person wakes refreshed after three hours, differs from insomnia, where they lie awake exhausted. The distinction is diagnostically useful and takes one follow-up question.
Worked examples
Mood. She described her mood as low, with hopelessness and loss of interest, and rated it 2 out of 10. She said: "There is nothing left to get up for."
Affect. Affect was observed to be constricted and was congruent with her stated mood. She became tearful when her daughter was mentioned and settled quickly afterwards.
Mood. He described his mood as elevated and irritable, with a reduced need for sleep and increased energy, and rated it 8 out of 10. He said: "I have never felt sharper."
Affect. Affect was observed to be expansive and labile, and was congruent with his stated mood. He moved rapidly between amusement and irritation when his family were discussed.
Both give the reader four things: what was reported, a comparable number, one verbatim line, and what was observed with a judgement about fit.
Where notes go wrong
- One line for both domains. "Mood and affect low" records neither properly and loses any possibility of incongruence.
- Using "flat" loosely. It is the extreme of the range. If there was any expression, "blunted" or "constricted" is more accurate.
- Leaving congruence blank. It is a separate field and the most informative one when mood and affect diverge.
- No quotation. The single most reusable line in the note, routinely omitted.
- Recording affect as mood. "Mood appeared low" is an affect finding wearing the wrong label. Mood is what they told you; if they did not tell you, say it was not elicited.
- Treating incongruence as a mistake. If mood and affect genuinely disagreed, that is the finding. Do not smooth it out.
Common questions
What is the difference between mood and affect in the MSE?
Mood is subjective and reported by the person, describing their emotional state over a period, ideally in their own words. Affect is objective and observed during the interview: its quality, range, stability, and whether it fits what is being discussed. Mood is the climate, affect the weather on the day you visited.
What does incongruent affect mean?
That the observed emotional expression does not match the person's stated mood or the subject being discussed — elevated mood reported alongside blunted affect, for example, or laughter while describing something distressing. It is a genuine finding rather than an error, and should be recorded deliberately.
When should I use 'flat' rather than 'blunted' affect?
Flat means virtually no emotional expression at all: an immobile face and a monotonous voice. Blunted means markedly reduced but still present. If the person smiled once or their expression changed at any point, blunted or constricted is the accurate term. Reserving 'flat' for what it describes keeps it useful.
Is a mood rating out of ten worth recording?
Yes. It takes one question, gives something comparable across contacts, and occasionally produces the most striking finding in the note — a rating of 8 from someone who appears profoundly depressed, or of 2 from someone whose affect is unremarkable.
How do I distinguish reduced need for sleep from insomnia?
Ask how they feel the next day. In reduced need for sleep, characteristic of elevated mood, the person wakes after very little sleep feeling refreshed and energetic. In insomnia they lie awake and are exhausted the following day. One follow-up question separates them and the distinction is diagnostically useful.