Behavior in Affective Disorders

From the perspective of a family member or treating clinician, the most salient features of an affective disorder are the behavioral difficulties it drives. Most alarmingly, affective disorders often drive selfdestructive behavior. The vast majority of suicide victims can be diagnosed, in retrospect, with affective disorder. When the suicidal behavior does not result in death, it nevertheless may permanently strain relationships with those the patient intended to leave behind.

Suicide is the direst behavioral outcome of affective disorder, but not the only significant maladaptive behavior. At the core of maladaptive, affectively driven behaviors is the change in hedonic capacity that typically accompanies them. Where reward is absent, as in the anhedonic, depressed patient, experiences may seem flat and meaningless, and in many cases painful and enervating. A depressed patient may withdraw to bed, avoid family, friends, and work, and seek solace in alcohol or drugs.

When reward comes too easily or powerfully, as in mania, the impulse to spend, drive, and love recklessly, to flout the law and social mores, and to abuse alcohol and drugs is nearly irresistible. For the manic patient there is an indiscriminate sense of excitement over a world of newly perceived opportunities for enjoyment, resulting in costly, uninhibited, social and financial decisions.

It is important to note that affective disorders are not essential in such behaviors. Many people who attempt suicide, avoid work, spend recklessly, or drink heavily lack the signs and symptoms of affective disorders. Many patients with affective disorders (perhaps most) manage, somehow, to constrain their behavior.

Patients who change their behavior in the midst of an episode of affective disorder may benefit from confrontation and counseling about the consequences of their behavior. Some therapists think of the self-defeating and self-deprecating thoughts and attitudes that arise during depression as behaviors amenable to confrontation and redirection; this idea is the basis of cognitive therapy.

The degree of behavioral impairment associated with affective disorder can be a function not only of the severity of the symptoms, but also of the vulnerability of the patient to behavioral excess or instability.

A libertine when stable is more likely than a saint to engage in reckless acts when affectively ill, if only because the means to such acts are more familiar. An academically and economically marginal college student knocked out of school by affective illness may have a harder time getting back on track than a middle-class mid-career middle manager in a solid marriage.

A student not only lacks the benefit of a structured life upon which to recover, but may also have the option unavailable to the older person of re-entering a state of dependency on parents, a state that may reinforce functional debilitation. Patients and families are wisely counseled not to make major changes in career, family, or housing in the midst of an episode of mania or depression. The fewer the changes, the less the risk of serious impairment, and the easier the rehabilitation once the episode clears.