Dysphoric about dysphoria:

DIAGNOSIS AND
TERMINOLOGY towards a greater conceptual
clarity of the term
Vladan Starcevic

Objective: The aim of this study was to conceptualize dysphoria in a way

that is clearer, better delineated and more clinically useful, after reviewing its
meanings in a variety of psychopathological contexts and the consequent
conceptual confusion.
Conclusions: The current semantic status of dysphoria is most unsatisfac-
tory. Its definitions are usually too broad or too simplistic and, therefore, not
clinically useful. There is no agreement on what the term means. In this article,
dysphoria is conceptualized primarily as a complex emotional state, consisting
of intense unhappiness/discontent and irritability. In addition, dysphoria is
often, though not invariably, accompanied by certain cognitive and behavioural
features. This article reviews relationships between dysphoria and related
emotional states and various psychiatric disorders, and proposes differentia-
tions that have implications for clinical practice. The role of dysphoria in mixed
states within bipolar disorder is particularly in need of further study.
Key words: bipolar disorder, depression, dysphoria, irritability, mixed states.

D
ysphoria is a term that is both unclear and in vogue at the same
time. Perhaps these two characteristics of dysphoria are not
unrelated. The more vague certain terms are, the more they are
used and the more likely they are to become ‘fashionable’; in turn, the
more these terms are used, the more their meaning becomes elusive.
Dysphoria owes its current status to at least four factors. The first, and
probably the most important, is an increasing use of dysphoria in the
context of bipolar disorder, especially its mixed states. The second is
derived from the popularity of the term ‘gender dysphoria’, which is one of
the key features of gender identity disorder. The third relates to pre-
menstrual dysphoric disorder, which was proposed as a new diagnostic
category in DSM-IV,1 and now seems likely to be incorporated into the
next edition of the DSM. Finally, neuroleptic dysphoria, a term introduced

Australasian Psychiatry . Vol 15, No 1 . February 2007

Vladan Starcevic
Associate Professor, Discipline of Psychological Medicine,
University of Sydney, Sydney, NSW, Australia.
Correspondence: Associate Professor Vladan Starcevic,
Nepean Hospital, Department of Psychological Medicine, PO
Box 63, Penrith, NSW 2751, Australia.
Email: starcev@wahs.nsw.gov.au
to denote various adverse effects of the first-generation antipsychotics,
recently received conceptual support and is considered to have significant
prognostic and treatment implications.2
A careful inspection of the ways in which dysphoria has been used reveals
inconsistencies and conceptual confusion. Within bipolar disorder, dys-
phoria is usually a part of mixed states. Dysphoria in that context often
means depressive manifestations that do not meet full criteria for a major
depressive episode, but occur along with manic or hypomanic features

hence the term ‘dysphoric (hypo)mania’. Gender dysphoria refers to a
discomfort about, unhappiness and discontent with, and even an ‘aver-
sion’ (DSM-IV-TR, p. 823)3 to one’s own biological sex. Premenstrual
dysphoric disorder is described in DSM-IV/DSM-IV-TR as a cluster of
symptoms similar to those of a major depressive episode, plus irritability,
mood instability, symptoms of anxiety and certain physical symptoms.

doi: 10.1080/10398560601083035
# 2007 The Royal Australian and New Zealand College of Psychiatrists 9
 Neuroleptic dysphoria has been very broadly concep-
tualized, and includes aversion to antipsychotic medi-
cation, excessive tiredness, decreased energy, reduced
interest and motivation, low mood, anxiety, slowed
thinking, hostility and anger, and various motor
symptoms. These features are thought to be related
to the extrapyramidal side effects.2
There is still another dysphoria-related term, but it
largely fell out of favour. Hysteroid dysphoria referred
to somewhat ‘atypical’ depressive features, including
irritability and anger, and was believed to be more
common in women with histrionic or other DSM
cluster B personality disorders. The concept is now
largely subsumed by the DSM-IV-TR major depressive
disorder with atypical features. It was found to lack
validity,4 but the term occasionally resurfaces in the
literature and in clinical parlance.
With so many different meanings of a commonly used
psychiatric term, the lack of clarity and confusion
regarding dysphoria seem stunning. The purpose of
this article is to contribute to the clarification of the
meaning of dysphoria and to re-examine its bound-
aries vis-à-vis related terms and concepts.
DEFINING AND CONCEPTUALIZING
DYSPHORIA
The dictionary definitions of dysphoria are vague,
broad and over-inclusive, or utterly simple. In either
case, they are not helpful. For example, the American
Heritage Dictionary defines dysphoria as ‘‘an emotional
state characterized by anxiety, depression, or unease’’.
In the Hutchinson Encyclopaedia , dysphoria is a ‘‘gen-
eralized feeling of being ill or depressed’’.
In the general psychiatric literature, there is an even
greater lack of clarity. Thus, DSM-IV-TR defines dys-
phoric mood as an ‘‘unpleasant mood, such as sadness,
anxiety, or irritability’’ (p. 825), and postulates it as one
of the key diagnostic criteria for cocaine withdrawal
and mixed anxiety
depressive disorder. In a major
psychiatric textbook, dysphoria is defined as follows:
‘‘Feeling of unpleasantness or discomfort; a mood of
general dissatisfaction and restlessness. Occurs in de-
Australasian Psychiatry . Vol 15, No 1 . February 2007
pression and anxiety’’ (p. 682).5 Another textbook
defines dysphoric mood as feeling sad, despondent,
discouraged and unhappy, but also as feeling anxious,
tense and irritable (p. 80).6 In his book on psycho-
pathology, Sims mentions dysphoria only once, defin-
ing it as a ‘‘condition of being ill at ease’’ (p. 305).7
Moving to the more ‘specialized’ psychiatric literature,
especially to the works of the members of the so-called
Vienna School, dysphoria acquires more specific
meanings. It was conceptualized as a ‘third emotional
field’ (in addition to mania and depression), and
defined as an unpleasant state, characterized by ten-
sion, irritability, hostility and proneness to aggressive
acting out.8 The Vienna School members consider
dysphoria important for understanding and develop-
10
ment of mood disorders, ‘affective psychoses’, delu-
sional syndromes and personality disorders. In a more
recent publication, they acknowledge that dysphoria is
a ‘non-specific syndrome’ and that it has ‘‘no parti-
cular place in a categorical diagnostic system’’ (p. 211),
while deploring that it is neglected and treated like an
‘orphan’.9
Other contributions to the conceptualization of dys-
phoria have been a product of research on bipolar
disorder. However, the views of various authors have
not been consistent. For example, one paper identified
six ‘dysphoric symptoms’ as depressed mood, anhedo-
nia, guilt, suicide, fatigue and anxiety.10 Another paper
defines ‘dysphoric episode’ as a type of manic episode
(besides euphoric and depressed types), with ‘dyspho-
ric mania’ then primarily referring to irritability and
paranoid feelings.11 Other researchers12 believe that
dysphoria should be defined as a syndrome, in a
manner similar to that proposed by the Vienna School;
that syndrome always includes irritability and at least
two of the four ‘associated symptoms’ are internal
tension, hostility, aggressive or destructive behaviour
and suspiciousness.
In a commentary, Swann acknowledges that dysphoria
‘‘can refer to many ways of feeling bad’’ (p. 325).13 The
examples given above confirm this observation, but
suggest that dysphoria covers a territory of psycho-
pathology that is just too large. There is a need to
narrow down the definition and to reach a consensus
on what dysphoria is.
WHAT IS DYSPHORIA?
The etymology of dysphoria can serve as a starting
point. The term is derived from Greek and denotes a
distress that is hard to bear. This distress implies
feelings of uneasiness or unhappiness. There is also
an implication of profound discontent. The nature of
distress in dysphoria seems to be ‘generic’ or non-
specific in that it pertains to very different things
(objects, matters, issues), with distress occurring in a
variety of psychopathological and even normal con-
texts. Thus, one can be intensely, unbearably dis-
tressed
and hence ‘dysphoric’
about one’s own
gender, while someone else is just as distressed and
‘dysphoric’ about the state of world affairs. The
original meaning of dysphoria as a hardly bearable
distress might have been an important reason for
the subsequently vague and broad definitions of
dysphoria, as they came to denote almost any unplea-
sant emotional state. Because the meaning of dys-
phoria as a hardly bearable distress is obviously too
broad, there appears to be some agreement that such
distress in dysphoria is accompanied by ‘something’.
But, what else characterizes dysphoria?
This is the point of divergence. For some, other
features of dysphoria are in fact symptoms of depres-
sion, and dysphoria then becomes a synonym or nearly
a synonym for depression. For example, one definition
of dysphoria is that it is a ‘milder depression’ (p. 94).14
For others
perhaps the emerging majority
distress,
unease, unhappiness and/or discontent in the concept
of dysphoria are accompanied by tension, irritability,
hostility, anger, psychomotor agitation, and even para-
noid tendencies. These two views cannot be reconciled.
They may also represent certain ‘traditions’. Schanda
suggests that dysphoria is ‘‘not very important in Anglo-
American literature’’ and that it is ‘‘used more or less as a
synonym for depression’’ (p. 207).15 By contrast, in
German literature, dysphoria has the status of a com-
plex emotional state, with its origin dating back 100
years, when dysphoria was conceptualized as a ‘mixed
affect’ leading to an ‘affect of suspicion’.16,17
Equating dysphoria with depression may be a sign of
intellectual laziness, which bolsters vagueness and lack
of clarity and leaves one wondering why there should
be two terms describing the same phenomenon or
condition. Alternatively, those who believe that dys-
phoria is a variant of depression should clearly spell
out how that variant differs from the ‘usual’ (typical,
major) depression and furnish evidence for the validity
of such a concept.
The above review supports the conceptualization of
dysphoria as a complex emotional state. In addition to
intense distress, unease, unhappiness and/or discon-
tent, dysphoria is characterized by emotional features
of the opposite polarity
inner tension, an ‘agitated
feeling’, irritability, hostility and/or anger. It is as if
some characteristics of depression and some character-
istics of mania were blended into one ‘emotional
entity’, a psychopathological contradiction of sorts.
This is what Stanghellini had in mind when he called
dysphoria a ‘nosographical disorganizer’, describing it
as a ‘‘different quality of mood which disorganises the
manic-depressive dichotomy’’ (p. 153s).18
The concept of dysphoria is often incomplete even
with the recognition that it is a complex emotional
state. As already noted, some definitions of dysphoria
also include certain patterns of thinking (e.g., ten-
dency to blame others) and certain behaviours (e.g.,
aggressive acting out), which may more appropriately
be considered the accompanying features or the con-
sequences of dysphoric mood, and are not always
present. Table 1 lists the mood aspects of dysphoria
as its essential components, and cognitive and beha-
vioural aspects of dysphoria as its accompanying,
secondary aspects.
In summary, dysphoria can be conceptualized as a
process, within a dynamic definition. It is a negative
(unpleasant) and complex emotional state, character-
ized by intense discontent and/or unhappiness and
accompanied by inner tension or a ‘driven’ feeling
to resort to some action to alleviate discontent or
unhappiness. Outwardly, the tension and ‘drivenness’
are often manifested through irritability, hostility,
anger, agitation, and a tendency to blame others for
Table 1: Components of dysphoria
Essential (defining) aspects
Specific emotional states
“
/ Intense discontent and/or unhappiness
“
/ Irritability, anger
Accompanying, secondary aspects (not invariably
present)
Cognitive features
“
/ Tendency to blame others
“
/ Suspiciousness, paranoid tendencies (or delusions)
Behavioural features
“
/ Agitation
“
/ Aggressive outbursts
one’s discontent or unhappiness; the latter can some-
times reach delusional (paranoid) proportions and/or
lead to aggressive behaviour.
BOUNDARIES OF DYSPHORIA
The conceptualization of dysphoria presented here
calls for re-examination of its boundaries because of
its obvious associations with various forms of psycho-
pathology.
Anxiety
There is no support for inclusion of anxiety into the
concept of dysphoria. Anxiety is closely related to the
perception of threat or danger, while dysphoria is a
state of discontent and unhappiness with subsequent
irritability. Dysphoria and anxiety may have tension
and the underlying hyperarousal12 in common, and
can be experienced at the same time. Dysphoria may
occur as a consequence of long-standing anxiety, and
it is not uncommon for anxiety to arise on the back-
ground of dysphoric mood.
Depression
A confusion about the boundary between dysphoria
Australasian Psychiatry . Vol 15, No 1 . February 2007
and depression stems from the still common tendency
to include various features of the depressive syndrome
into a definition of dysphoria and frequent descrip-
tions of dysphoric mood as sadness, despondence,
despair, and the like. However, there are several
differences. First, dysphoria is a complex emotional
state, which includes irritability in addition to unhap-
piness and discontent. Second, dysphoric persons are
more likely to blame others for their condition, while
depressed people tend to blame themselves and to feel
guilty. Third, dysphoria is more action-driven. This
action seems more purposeful in dysphoria because it
aims to alleviate a sense of unhappiness and discon-
tent; in contrast, action in agitated depression more
often appears to be aimless.
11
 Bipolar disorder
Dysphoria is increasingly regarded as a third ‘mood
quality’,8 third ‘dimension’12 or third ‘pole’,18 distinct
from mania and depression, and appearing in the
course of bipolar disorder. The distinction from mania
should be based on the quality of dysphoric mood, in
which unhappiness and discontent are as prominent as
irritability. Terms like ‘bad highs’ or ‘dysphoric mania’
are misleading, because there is nothing ‘high’ (or
elevated) in dysphoria, and dysphoria superimposed
on mania should no longer be designated as mania.
The mixed states within bipolar disorder are currently
a ‘hot’ research topic; the distinctions and boundaries
between various types of mixed states, many of which
involve dysphoria or dysphoria-like manifestations,
have not been well established. If further research
lends more support to the notion of distinct, dysphoric
episodes, bipolar disorder may in the future be more
appropriately called tripolar disorder.19
Personality disorders
Dysphoria can be incorporated into a description of
certain personality disorders, especially the borderline
and narcissistic ones. The characteristics of these
personality disorders (e.g., affective instability, irrit-
ability, intense anger, profound unhappiness because
one’s grandiose projects have not been met with
admiration, tendency to accuse others) are shared or
overlap with features of dysphoria. The boundary
between dysphoria and personality disturbance may
be blurred, particularly when dysphoria is chronic and
has trait-like features. However, the ‘fate’ of hysteroid
dysphoria and the conceptualization of dysthymic
disorder as a primary mood disorder rather than a
personality disturbance, suggest that chronic emo-
tional states should not be automatically attributed
to the psychopathology rooted in personality.
Delusional disorder
While dysphoria is easy to distinguish from delusional
disorder, some delusions
especially those of a
paranoid nature
may arise from chronic dysphoric
mood. This is understandable in view of the tendency
Australasian Psychiatry . Vol 15, No 1 . February 2007
of dysphoric individuals to see others as the cause of
their discontent and unhappiness. Chronic delusional
disorder and dysphoria are sometimes so intertwined
that mood disorder may seem to be a primary condi-
tion. Interestingly, dysphoric mood in delusional
disorder was found to have high stability over long
periods of time.20 This situation may have treatment
implications, with the possible benefit of adding a
mood stabilizer to antipsychotic medication.
Premenstrual dysphoric disorder
Premenstrual dysphoric disorder bears some similarity
to dysphoria in that both are characterized by irrit-
ability, tension, agitation and/or aggressive outbursts.
12
However, premenstrual dysphoric disorder is a broader
condition, because it encompasses many features of
depression and generalized anxiety. Therefore, the
term does not seem suitable; a more general term,
such as ‘premenstrual mood disorder’ may be more
appropriate.
Gender dysphoria
Gender dysphoria is defined as discontent with one’s
own gender. Beyond discontent, there is little that
gender dysphoria has in common with dysphoria. For
the sake of clarity, the term gender dysphoria should
be avoided, and terms like ‘gender discontent’ or
‘gender aversion’ used instead.
Irritability
Dysphoria is occasionally equated with irritability.
This is as unjustified as equating dysphoria with
depression. In both cases, a complex emotional state
is reduced to one of its components. Dysphoria is a
broader concept in which irritability is only one
aspect. Accordingly, a term like ‘irritable dysphoria’ is
a misnomer; ‘irritable’ becomes redundant in the
context of dysphoria.
CONCLUSION
This article has reviewed the current confusion regard-
ing the concept of dysphoria and use of the term in a
variety of psychopathological contexts. The concept
has clinical utility, but there is an obvious need to
define it more precisely. In this article, dysphoria is
conceptualized as a complex emotional state, consist-
ing of intense unhappiness and irritability, with
certain consequences in the cognitive and behavioural
domains that are often, though not invariably, pre-
sent. Relationships between dysphoria and other emo-
tional states and various psychiatric conditions were
reviewed. Dysphoria is most closely related to the
mixed states within bipolar disorder. The proposed
conceptualization of dysphoria needs to be studied
further and refined accordingly. Such studies, as well
as studies of other concepts of dysphoria, would
ultimately make it possible to reach a consensus on
the meaning of this apparently elusive but important
term.
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