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Abstract

Emotional instability refers to intense, unpredictable, and sometimes rapid changes in emotional state and mood. It is considered as a dysregulated emotional experience that profoundly affects an individual’s functioning, involving a complex interplay of cognitive, physiological, and behavioural factors. Recognizing this multifaceted aspect of psychopathology is essential, as it affects individuals across various diagnoses and age groups. The aim of the present study is to identify a clear definition of emotional instability, investigating its diagnostic, clinical and therapeutic implications. 

Introduction

Mood, affect and emotion have been historically central domains of psychology, psychopathology, and related clinical discipline such as psychiatry and psychotherapy. They serve as crucial components in assessing, diagnosing, and treating various psychopathological conditions 1. However, their semiology has not clearly contributed to diagnostic definition of mental disorders 2.

As scientific disciplines progress, there’s a growing interdisciplinary interest in understanding their impact and mutual interactions. This topic has been the target of insights from philosophy, clinical psychopathology, and cognitive neuroscience 3. Clarifying and refining definitions of concepts like emotion, affect, and mood is crucial for research and application within affective sciences. These definitions act as fundamental frameworks, ensuring consistency in communication and understanding across various fields and disciplines 4-6.

However, the complexity arises from the challenge of integrating and defining these multifaceted perspectives into a cohesive framework that accounts for the intricate dynamics between affect, emotion, and mood 7.

While definitions may evolve with new research and understanding, their centrality to affective sciences remains pivotal in fostering clear communication and advancing knowledge in this field. Changes reported in DSM 5 and ICD 11 classification renewed interest in affective science psychopathology 8,9.

We reported here some pitfalls of the current approach of emotion, affect and mood distinction relating to emotional instability.

A historical perspective and new insights of emotional instability

The concept of emotional instability has evolved alongside the development of psychological and psychiatric theories, with its roots tracing back to the late 19th century. Although Sigmund Freud’s psychoanalytic theories primarily focused on unconscious processes, these in turn influenced the understanding of emotions in psychopathology by highlighting the role of unresolved conflicts and repressed emotions.

Neuroticism, identified as a temperament dimension marked by heightened stress reactivity and frequent negative emotions, is a related construct that has informed our understanding of emotional instability10,11.

The mid-20th century marked a significant shift with the introduction of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The first two editions of the DSM reflected the psychodynamic theoretical perspectives predominant at the time. However, subsequent editions have progressively adopted a more categorical and symptom-based approach to diagnose mental health conditions, including emotional instability.

In the DSM-I and DSM-II emotional instability was a characteristic feature of Emotionally Unstable Personality and Hysterical Personality, respectively. The DSM-III marked a shift towards a symptom-based, atheoretical organization of psychiatric diagnoses, with emotional-affective instability becoming a criterion for Borderline Personality Disorder (BPD) diagnosis 12. The DSM-5 further recognizes emotional instability as a core feature of various mental disorders, including cyclothymic disorder and BPD, where it plays a crucial role in the onset and exacerbation of cognitive and behavioural symptoms 13.

The category of ‘emotionally unstable personality disorder’ has been dropped from ICD-11 and was never used in the recent DSM manuals – both manuals now use the term ‘borderline personality disorder’ 9.

Emotional instability, as currently understood, describes significant and frequent fluctuations in emotional states, extending to impairments in daily functioning. This condition is characterized by rapid and severe mood swings, difficulties in recognizing and modulating emotions, and an increased sensitivity to emotional triggers. This understanding is reflected in the modern psychiatric literature that explores the nuances of this condition 14,15.

The recognition of emotional instability as a common feature in a range of mental health disorders, including affective disorders and neurodevelopmental disorders like Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorders (ASD), underscores its importance across the psychiatric spectrum. Emotional instability could be regarded using a dimensional approach 16. Recent studies called for greater clinical and research attention to affecting instability and mood instability, suggesting that despite the complexities, it should be considered more than just a neglected component of psychopathology. These studies recognized the overlapping dimensions of the two constructs as ‘rapid oscillations of intense affect, with a difficulty in regulating these oscillations or their behavioural consequences’ 17,18.

Emotion, affect and mood: one fits all?

The emotional regulation is a complex process defined as an individual capacity to adjust an emotion or set of emotions. It is considered as the ability to respond to external stimuli with suitable emotions in a socially appropriate and flexible form 3,15.

In common speech, terms like ‘affect,’ ‘emotion,’ and ‘mood’ are often used interchangeably as their dysfunctional counterparts (i.e. affective, emotional and mood instability) 6. Unfortunately, this is true even among researchers in psychopathological and clinical disciplines. A survey conducted in the US highlighted these inconsistencies, with different perceptions of the temporal nature of mood and affect among psychiatry residents 19. To overcome these inconsistencies, a better integration of theoretical knowledge with practical clinical skills is needed as early career psychiatrists are not satisfied with the training they receive in psychopathology 20,21.

This discipline should aim at reaching a precise definition of these terms even though consensus is hard to establish, given the divergent interpretations in German and American psychopathology 1,22.

The DSM-IV TR and DSM-5 glossaries defines affect as momentary, akin to weather, while mood is a prolonged emotional state, similar to climate 23,13.

The American Psychological Association defines emotion, affect and mood as follows:

- Emotion as a complex reaction pattern, involving experiential, behavioural, and physiological elements, by which an individual attempts to deal with a personally significant matter or event. The specific quality of the emotion (e.g., fear, shame) is determined by the specific significance of the event. For example, if the significance involves threat, fear is likely to be generated; if the significance involves disapproval from another, shame is likely to be generated. Emotion typically involves feeling but differs from feeling in having an overt or implicit engagement with the world.

- Affect as any experience of feeling or emotion, ranging from suffering to elation, from the simplest to the most complex sensations of feeling, and from the most normal to the most pathological emotional reactions. Often described in terms of positive affect or negative affect, both mood and emotion are considered affective states. Along with cognition and conation, affect is one of the three traditionally identified components of the mind.

- Mood as any short-lived emotional state, usually of low intensity (e.g., a cheerful mood, an irritable mood) and a disposition to respond emotionally in a particular way that may last for hours, days, or even weeks, perhaps at a low level and without the person knowing what prompted the state. Moods differ from emotions in lacking an object; for example, the emotion of anger can be aroused by an insult, but an angry mood may arise when one does not know what one is angry about or what elicited the anger. Disturbances in mood are characteristic of mood disorders. All three - emotion, affect, and mood - can experience instability or dysregulation, but in slightly different ways 24.

Under a developmental psychopathological perspective, emotional instability is defined as the experience of significant and frequent fluctuations in an individual’s emotional state, leading to impairment in daily life and functioning. This condition is characterized by rapid and severe mood swings, difficulties in recognizing and controlling emotions, and an increased sensitivity to emotional triggers across life span from childhood to adulthood 25.

As the issue of ‘emotional and affective instability’ has gained increasing attention and diagnostic relevance in clinical psychopathology, however, the term is currently vaguely defined, particularly in aspects such as diagnostic criteria and symptomatology. The lack of a clear definition contributes to diagnostic confusion and is a challenge for clinical monitoring, also given the broad range of disorders where it is observed 22,26.

Disturbances of affect include blunted, flat, inappropriate, labile, or restricted affect 13 (DSM 5 - Glossary of Technical Terms - page 817). Affective lability, despite its significance, has often been overlooked as a distinct construct. Instead, it is typically studied within the context of broader disorders such as BPD and bipolar disorders 11.

Mood is described as a pervasive and sustained emotion that colours the perception of the world. Common examples include depression, elation, anger, and anxiety. Types of mood include dysphoric, elevated, euthymic and expansive 13 (DSM 5 – Glossary of Technical Terms - page 824).

The lack of a clear distinction between affective and mood state alterations led many psychiatrists to use these terms as synonyms 27,17,28.

In fact, “affective disorders” was a broad term encompassing conditions that primarily affect mood, including depression and bipolar disorder. This diagnostic category was retained in DSM III because of common usage and to favour ‘historical continuity’ but changed in further DSM revisions. With the evolution of diagnostic classifications, the DSM IV and ICD 10, the term “mood disorders” has gained more prominence as it specifies a narrower range of conditions focusing specifically on disturbances in mood. It refers to sustained emotional states and not merely to the external expression of the present emotional state (i.e., affects).

From a theoretical perspective, Berner, proposed a framework to reconcile these differences based on Janzarik’s model of structural-dynamic coherency 1,29. Affect is described as an external, observable emotional tone, fluctuating moment-to-moment, whereas mood is an internal, subjective, and sustained emotional state. The emotional reactivity could be called ‘affect’ when accompanied by pertinent expression; it may be absent, blunted, labile or restricted. Mood is better defined as ‘pervasive’ emotion. In states of dynamic instability, the basic mood switches spontaneously, in contrast to the reactive emotional changes observable in affective liability 1.

In a further psychopathological analysis, Rosfort and Stanghellini clearly delineated phenomenological differential features of mood vs affect. The concept of mood as opposed to affect can be better understood considering the following pairs: anxiety vs fear, sadness vs grief, euphoria vs joy, dysphoria vs anger, tedium vs boredom 21. Generally, ‘mood’ is defined as sustained and internal, whereas ‘affect’ is momentary and external, whereas affects are responses to a phenomenon that is grasped as their motivation, moods do not possess such directedness to a motivating object (Tab. I).

The direct application of this model might vary in clinical settings. While the theoretical distinction is clear, practical application can be complex due to individual variations and overlaps between mood and affect. Yet, training and discussions around these concepts could help guide younger clinicians toward more precise assessments, thereby enhancing diagnostic accuracy and treatment planning and monitoring.

ICD 11 presented the pragmatic option to number Mental and Behavioural (MB) Symptoms or signs involving mood or affect (MB 24), with their own definitions, recognizing mood and affect as distinct domains (Tab. II).

The interchanging use of terms like affective, mood, and emotional instability/lability highlights the field’s inconsistency in defining these concepts 26,17,13. This lack of consensus can impede the operationalization and implementation of clinical definitions, as similar clinical descriptions may not indicate similar developmental psychopathologies or psychobiologies.

For instance, mood instability in bipolar disorder is often treated with mood stabilizers, whereas emotional dysregulation in ADHD responds to stimulants and atomoxetine. Low doses of atypical antipsychotics may be effective for emotional dysregulation in BPD 30. This illustrates the necessity for distinct treatment approaches based on specific diagnostic criteria.

Emotional instability/dysregulation (EID): trait vs state

EID can be understood through the lens of ‘trait’ and ‘state’ psychopathological variables.

‘Traits’ are enduring characteristics that persist over time and across different situations. They manifest as consistent patterns in thoughts, feelings, or behaviors. For example, traits like extraversion or neuroticism remain relatively stable. In this context, EID as a trait represents a chronic dysfunction, characterized by persistent externalizing behaviors and intense emotional fluctuations. This ‘trait’ aspect of EID is often evident in conditions like BPD, where individuals frequently and intensely experience emotional fluctuations.

Affective instability and emotional dysregulation are often interchangeably used 31,22.

Conversely, ‘states’ are temporary conditions in nuanced by immediate circumstances, representing transient experiences rather than enduring attributes. EID as a state is represented as temporary emotional disturbances triggered by situational stressors. This doesn’t necessarily indicate a long-term trait of emotional instability but rather a situational reaction.

This distinction is crucial in both emotional instability diagnosis and treatment. Emotional instability as a trait may require long-term, structured interventions, focusing on underlying persistent patterns or medication. On the other hand, state-oriented EID might be addressed with immediate coping strategies or targeted situational interventions, addressing the specific environmental triggers and stressors.

This dual perspective enriches our understanding of EID. It acknowledges the complexity of emotional responses and guides clinicians in tailored treatment, whether it involves managing enduring personality patterns or addressing temporary emotional responses to specific events.

The ICD-11 Classification for personality Disorders shows considerable alignment with the DSM-5 In the Alternative Model for Personality Disorders 32. The term ‘negative affectivity’ – as a Trait Domain – replaced the descriptor ‘emotionally instability8. The ICD-11 domain structure suggests that the characteristics associated with BPD are distributed across three domains – negative affectivity, disinhibition, and dissociality – and there is no specific borderline domain.

Emotional dysregulation as trans-nosographic psychopathological dimension in adulthood and adolescence

Emotional regulation is a physiological step of the psychological development. Dysfunctions in developmental trajectories can impair this process, leading to psychopathological disturbances from a young age that often persist into later life 33.

A recent review suggested that emotional dysregulation (ED) is a trans-diagnostic dimension prevalent across a range of mental disorders, including bipolar disorder, ADHD, ASD, PTSD, personality disorders, and disorders in children and adolescents 34. It is a core symptom in BPD, bipolar disorder and Cyclothymic Disorder 9. Furthermore, it is largely represented in the Schizophrenic Spectrum and Neurodevelopmental Disorders.

Waltereit et al. 35 propose to differentiate ‘emotional’ from ‘affective dysregulation’ with the latter closer to excessive reactivity to negative emotional stimuli with anger and aggressive behaviour and the former with emotional instability causing inappropriate emotional response.

Affect dysregulation specific to interpersonal stressors, has been shown to be associated with BPD diagnoses as well as to account for the relationship of childhood maltreatment history and chronic negative affect with BPD 36,37.

Externalizing problems in youth, such as behavioural and emotional dysregulation, are frequently precursors to mood, anxiety, personality, and behavioural disorders in adulthood. The causal role of emotional dysregulation in the etiology of externalizing psychopathology is well-supported by scientific literature 38,25. The overlap of externalizing and internalizing behaviours complicates the identification and evaluation of ED 33. Beauchaine and Cicchetti highlighted the relationship between specific emotional responses to stimuli and persistent mood that influences behaviour patterns. They define ED as a pattern of emotional experience and/or expression that interferes with appropriate goal-directed behaviour 25.

Diagnostic, clinical, and therapeutic implications

Treatment approaches for ED, ranging from psychological counselling to medication, unveil different clinical experiences. Severe forms of ED can lead to suicidal behaviours and Non-Suicidal Self-Injury (NSSI) and to legal implications, requiring careful consideration in different clinical settings 39.

Furthermore, research suggests that maladaptive behaviours in eating disorders, similar to self-harm behaviours in BPD, may be a manifestation of ED as a dysfunctional emotional regulation. ED is central to the aetiology of NSSI behaviours, where NSSI is considered as a mean to alleviate and modulate unwanted emotions 40. Additionally, individuals with substance use disorders exhibit high levels of ED, exacerbated when coupled with NSSI 41.

This comprehensive understanding of ED across various disorders indicates the need for nuanced assessment and intervention strategies, acknowledging its multifaceted impact on mental health.

There is no consensus about definition of Emotional dysregulation outside BPD.

Conclusion and future directions

In conclusion, it is crucial to highlight the role of dysregulation as the core characteristic of EI– a state where its activation, expression, and ongoing experience occur without appropriate moderation or control. The dysregulation leads to a profound incongruence between the emotional responses and the determinants of a physiological functioning, affecting both immediate and long-term psychological health.

EID involves a complex interaction among cognitive, physiological, and behavioural components, often engaging the body’s survival systems in response to perceived threats. In individuals with EID, the systems designed to protect and help the organism adapt and cope to stressors, can undergo a dysregulation.

Understanding this intricate interplay is vital for developing effective treatment strategies for EID in clinical settings. It calls for a holistic approach that addresses not only the emotional symptoms but also the underlying cognitive, physiological, and behavioural dysfunctions. This comprehensive understanding of EID has significant implications for therapeutic interventions, guiding clinicians towards more targeted and integrative treatment interventions that provide for the complex needs of individuals with EID.

Oversimplification in psychopathological descriptions of mood vs affect instability should be avoided so that clearer definitions are needed. Even the use of these terms across diagnoses should be very cautiously adopted.

Without a precise operationalized description, there can be considerable confusion in diagnosing and planning treatment for individuals experiencing emotional dysregulation.

Development of a standardized, operationalized definition can improve communication among professionals, enhance research efforts, and ultimately ensure individuals receive the most suitable and effective care for their emotional dysregulation.

Figures and tables

Mood Affect
Unfocused Focused
Nonintentional Intentional
Not motivated Motivated
Inarticulate Articulate
Horizontal absorption No horizontal absorption
Emanated from, not by Emanated from and by
No captivation Captivation
No ‘felt causes’ ‘Felt causes’
Indefinite and indeterminate Determinate
No directedness Directedness
Sustained Instantaneous
TABLE I. Mood vs affect phenomenological features (adapted from Rosfort and Stanghellini 2009) 21.
MB24 Symptoms or signs involving mood or affect
MB24.0 Ambivalence
MB24.1 Anger
MB24.2 Anhedonia
MB24.3 Anxiety
MB24.4 Apathy
MB24.5 Depressed mood
MB24.6 Disturbance of affect
          MB24.60 Constricted affect
          MB24.61 Blunted affect
          MB24.62 Flat affect
          MB24.63 Labile affect
          MB24.64 Inappropriate affect
          MB24.6Y Other specified disturbance of affect
          MB24.6Z Disturbance of affect, unspecified
MB24.7 Dysphoria
MB24.8 Elevated mood
MB24.9 Euphoria
MB24.A Fear
MB24.B Feelings or guilt
MB24.C Irritability
MB24.D Leaden paralysis
MB24.E Mentale rumination
MB24.F Restlessness
MB24.G Tantrum
MB24.H Worry
MB24.Y Other specify symptoms and signs involving mood or affect
MB24.Z Symptoms and signs involving mood or affect, unspecified
TABLE II. ICD-11. 21 Symptoms, signs or clinical findings, not elsewhere classified.

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Authors

Alessandro Rossi - Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy

Ramona Di Stefano - Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy

How to Cite
[1]
Rossi, A. and Di Stefano, R. 2024. Emotional instability: terminological pitfalls and perspectives. Journal of Psychopathology. 30, 1 (Feb. 2024). DOI:https://doi.org/10.36148/2284-0249-N453.
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