Dysphoria is a very familiar term in specialist language so much so that when we refer to it we understand each other without having to add much.
Despite this, if we pause to grasp the deeper meaning, it remains a term with non-univocal and consensual definitions. The etymology of the term – of Greek derivation – is explanatory. If eu-forìa refers to feeling good, dysphoria has that “dis” that precedes “forìa” which refers to feeling bad, an anguish and a pain that is difficult to bear.
We immediately understand that dysphoria is equivalent to feeling bad mood. The etymological clarification gives us an idea of the state of mind but does not specifically explain what is the typical peculiarity of dysphoric moodiness.
The most common definition considers dysphoria a complex and disorganized emotional state , with a protean phenomenology. It is characterized by a multitude of symptoms including irritability , discontent , interpersonal resentment and a feeling of defeat (the writer does not fully agree on this last point).
Attempts at definition are further complicated when we find the word dysphoria or the adjective dysphoric alongside other terms that give rise to other pictures. Premenstrual dysphoria, gender dysphoria, somatic dysphoria, neuroleptic dysphoria, postcoital dysphoria, hysteroid dysphoria .
Here we will limit ourselves to examining dysphoria as an affective state .
Dysphoria and bipolarity
If we consider dysphoria from an affective point of view we must necessarily examine its presence within the bipolar spectrum .
For many years there was a bipartition in the field of affective disorders that considered two poles of the dimension to be prevalent. Euphoria on the one hand and depression on the other .
These two opposite poles have monopolized the attention of researchers, leaving more in the shade that range of affective states that are in the middle or that take some elements from one extreme and the other.
In particular, those feelings of unpleasant tension characterized by an irritable , grumpy mood , which in extreme cases leads to aggressive actions .
In bipolar disorder it is possible to detect elements of irritability in “non-pure” states – defined by Kraepelin as Mixed States. In these we do not find elements of euphoria or depressive, distinct from each other, but we witness a situation in which elements of the two polarities coexist simultaneously.
Dysphoria can occur quite frequently in mixed states, although it is not to be considered pathognomonic. Feelings of malaise, anxiety, moodiness, irritability, distressing suffering, inconsolability, restlessness and oscillating sadness can in fact be found transversally in different psychopathological pictures.
Other framing of the phenomenon
An attempt has been made to define dysphoria itself, regardless of the diagnosis in which it occurs. Dayer (2000) identifies a phenomenologically distinguishable profile in dysphoria, characterized by subjective tension, irritability / hostility, aggressive behavior and suspiciousness.
According to Startevic (2007) for dysphoria we must mean an emotional state characterized by discomfort, discomfort and irritability .
One element that seems to characterize the term dysphoria is an affective state characterized by irritability . From this point of view, Dayer hypothesizes that dysphoria behaves like a third dimension of Bipolar Disorder. In fact, it describes two types of mixed state which are respectively the form with manic symptoms + dysphoria and that with depressive symptoms + dysphoria .
Clinical implications of the presence of dysphoria
In the context of affective disorders it is known that when the disorder has dysphoric elements we see a worse prognosis, with a greater number of relapses and greater functional impairment.
In the relationship between depression and dysphoria it has been found that depressed subjects with dysphoria have much more intense anger levels and are more difficult to make decisions.
The depressed-dysphoric subjects present a very intense emotional reactivity in front of negative stimuli. Unipolar depressed elderly subjects without a history of psychiatric pathologies may present dysphoric symptoms weeks or months before all the other symptoms which will then outline the full-blown picture.
The relationship with mood disorders
There are many open questions regarding the relationship between mood disorders and dysphoria.
Can we think of dysphoria as a predictor of bipolarity? Should we think of dysphoria as a third dimension of bipolarity? Does bipolar dysphoria have specific characteristic elements that differentiate it from other mental disorders? And I would add: how does pathological dysphoria differ from the “physiological” one? The one that, for example, we can feel in periods when everything goes wrong or in certain meteorological moments. Is it simply a quantitative or a qualitative question? The answers that will be provided will be interesting.
We are trying to define what dysphoria itself is and we understand that it is not easy to isolate it from the context in which it occurs.
Differences with other psychopathological pictures
Let’s examine the specificities that would make it distinguishable from other psychopathological pictures. Let’s take for example the differences with a depressive picture by analyzing the modalities of coping .
In depression , coping styles are internalizing, prevailing the tendency to blame oneself and to have experiences of guilt and shame . In dysphoria the coping modality is externalizing. The blame for one’s moods is attributed to external factors, experiencing feelings of anger rather than guilt or shame.
In dysphoria we try to alleviate the malaise with intentional behaviors – such only in appearance since the dysphoric cannot do otherwise – which are considered socially unacceptable (eg aggressive acting out). In depressed subjects there are less intentional behaviors, with an underlying passivity and activities without a specific intent (see the afinalistic agitation).
Evaluating the relationship between experiences and coping methods, dysphoria seems to be characterized by:
- negative emotions mainly concerning the interpersonal sphere;
- sense of defeat and feeling overwhelmed;
- hostility towards others;
- tendency to blame others.
Dysphoria and personality disorders
We immediately notice that we can observe these elements in other psychopathological situations ranging from personality disorders to more defined clinical pictures.
Think of the irritability of the mood that characterizes a borderline disorder when it experiences abandonment, the narcissist who does not feel confirmed, the obsessive who is hindered in his rituals, the antisocial when he is prevented from immediately satisfying his own needs.
Lately there has been a flourishing reflection on the differences between borderline personality disorder and bipolar spectrum disorders . Recent theories of the Interpersonal Model of Dysphoria hypothesize that dysphoria may represent a psychopathological organizer of borderline disorder. In bipolar disorder, only a symptomatic and non-fundamental aspect of the symptomatology that characterizes bipolar disorder is considered , especially in mixed states.
But dysphoric elements can be found in paranoid states, in drug intoxication / abstinence, in some phases of cognitive impairment or neurodegenerative disorders, in childhood (often an indicator of problems in the family rather than personal area), in intellectual disability and much more.
Induced dysphoric states
Sometimes a dysphoric state can even be induced by psychopharmacological prescriptions. In fact, in some situations the dysphoric component would not be the direct expression of the basic diagnostic picture but could be induced by treatment with antidepressant drugs .
Sometimes antidepressant drugs are used too lightly by figures who, despite having prescriptive qualifications, have no psychopathological and clinical experience. A picture defined as ACID – Antidepressant-associated Chronic Irritable Dysphoria – (El Mallakh et al, 2008) has been identified in which dysphoric worsening follows antidepressant therapies.
In these subjects, the treatment of depressive states requires more complex pharmacological therapies managed by specialists, I would add even very experienced!
The treatment of dysphoria
We don’t have specific treatments for dysphoria. We try to treat the primary disorder with adequate psychopharmacological treatments and with psychotherapy mainly aimed at cognitive behavior . This can help to recognize dysphoric states early and to implement valid strategies for mastering these states.
Surely it is one of the symptoms which, when present, should not be totally overlooked and must be treated first as they may affect the therapeutic relationship and adherence to treatment. It can also lead to self-directed aggressive actions or create situations that are very difficult to manage later on.