The affect is the observable feeling state of the patient during the interview. There are a number of conventions used to report aspects of the patient's affect at interview. I find it useful to break these up into five main aspects. The quality or qualities of the affect, the intensity of the qualities of affect, the dynamics of the affect, the congruity and the communicability of the affect. These categories help students think more broadly about this important aspect of mental life and are included as subcategories of the affect description. As the interview proceeds from introductory questions through the history of the presenting complaint and beyond to background history, the patient is inevitably asked about a variety of personal scenarios. While this history is being taken, the observer should observe external manifestation of the patient's feeling state. It can be useful to write these down in the margin of the record as you go to remind yourself of critical periods when the feeling state of the patient changes. It is also useful as an exercise to generate all the words you can think of of that relate to feeling states, such as sad, euphoric, elated, anxious, angry, suspicious, etc. This will be the quality of the affect or more usually the affects, as there are frequently more than one and they should be qualified with a judgment of intensity, for example, mild sadness, moderate anger, or marked euphoria. Besides the common range of feeling states noted in the community, patients with psychiatric difficulties may present with unusual affects including perplexity, fatuousity and blunting. It is important to feel confident in picking these affects, as they have significance and clinical relevance. The dynamics of the affect refers to the range of affects presented during the interview and their shifts as the interview proceeds. The range of the affect is a report of the diversity of the affective states the patient can mount. A restricted range refers to a limitation of the capacity to engage different affects, while an expansive range is the opposite. The reporting of this relies to some extent of your experience of what a normal range of affect is. The reactivity of the affect is a description of the mobility or the rapidity with which one affect shifts to another in the interview. Common examples of this are labilities seen in mania where there is a rapid shift from euphoria to despair and back again and irritability which describes the patient's sudden flight into anger or sensitivity. The congruence of the affect refers to the relationship between the quality intensity of the affect and the content of the thought. Normally, thoughts and affects are understandably associated, for example, when the patients are discussing sad events, the affect is usually sad. This is referred to as a congruent affect and is a feature of both normality but also affective disorders. Incongruence of the affect is where there is a mismatch between the tone of the affect and the content of the thought. The example might be when a patient is noted to be giggling in a fatuous manner whilst describing the suffering of their beloved mother. Incongruent affects generally raises significant concern for a psychotic disorder. The final subcategory of affect is the most mysterious and least reliable. If you're able to subtly observe your own affect, you might notice that in the presence of a depressed patient you feel heavy, sad, burdened, in the presence of an anxious person you feel jittery, in the presence of a manic person, energised, euphoric and in the presence of an angry person, tense and irritable. This is the mysterious phenomena of communication of the affect. It's as if somehow you have empathically taken on the affect of the patient. There is one notable exception to this. Frequently, in the presence of a patient with schizophrenia, you may feel none of their affect or a detachment from their affect. This is sometimes referred to as the "pane of glass" affect or non-communication of the affect. Communication of the affect should not be confused with other subjective feelings states of the examiners, such as personal feelings of anxiety related to the interview task, apprehension in the presence of threat, understandable personal judgments as a human being and the so-called counter-transference.
