Feasibility and inter-rater reliability of “Mood Differentiation Questionnaire”

in discrimination of schizophrenia spectrum disorders

Ho Taik Sung1,2, Palak A. Fichadia1,3, Sreya Kongala1, Mingxin Li1, Susan Sperry1,

Dongliang Wang1, and Luba Leontieva1

SUNY Upstate Medical University

Corresponding Author: Ho Taik Sung.

Email address: [email protected]

Abstract

1 SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210
Creighton University, 7710 Mercy Road, Suite 601, Omaha, NE 68124 (Present Address)
2
3 Icahn School of Medicine at Mout Sinai/NYC Health+Hospitals, 7901 Broadway Elmhurst, NY 11373 (Present address)
Background: Schizophrenia is widely recognized to include deficits in the expression, experience, and

recognition of emotion. “Differentiation of Moods” questionnaire, originally developed by Robert Powell,

highlights how emotional processing can vary dramatically between patients from different diagnostic

groups. The five questions inquire about hunger, anxiety, depression, anger, and fear. These questions

assess the level of ego organization, which is closely connected with thought processing. The latter tends

to be impaired in schizophrenia. The “Differentiation of Moods” has no formal scoring. This study

applies a novel scoring system which is modeled from the Positive and Negative Syndrome Scale

(PANSS) N5 new scoring guide.

Objectives: To examine the feasibility and inter-rater reliability of the Mood Differentiation

Questionnaire in schizophrenia spectrum disorders and non-schizophrenia patients. The responses were

rated based on the new scoring guide by two different raters, blind to the participants' diagnostic groups.

Method: This is an observational study of 20 patients with schizophrenia spectrum disorders as test

subjects and 20 non-schizophrenia patients as controls. The responses were analyzed according to a new

scoring guide and further classified based on the type of responses as coherent/adequate response (1),

marginal but coherent (2), concrete mode (3), and significant difficulty with abstract thinking with an

increasing inability to process emotions (4).

Results: The “Differentiation of Moods” questionnaire was well received by patients, easy to administer,

and scored according to the new guide. The inter-rater reliability was calculated using the Bland-Altman

analysis and was found to have substantial agreement, suggesting that the scores obtained had significant

inter-rater reliability.

Conclusion: Strong inter-rater reliability was achieved using the new scoring system derived from the

PANSS N5 scoring guide. Patients with schizophrenia spectrum disorder tend to have poorly

differentiated moods compared to non-schizophrenia patients. This questionnaire can be used as a

diagnostic tool for schizophrenia along with other tests to increase the accuracy of diagnosing thought

disorders.

Keywords: schizophrenia, schizophrenia spectrum disorder, thought disorder, psychological

assessment, mood differentiation, inter-rater reliability

 1. Introduction

With 13% of the total global illness burden attributable to all diseases, the burden of illness from mental

health disorders can be considered the greatest of all health issues. (Samartzis and Talias 2019) Serious

and chronic mental illnesses, like schizophrenia, carry social, health, and financial burdens for patients,

their families, and society. (Knapp et al. 2004) Research has demonstrated that early identification and

treatment of psychotic illness can lead to greater improvement in symptoms and function. (Kane et al.

2016) For example, at 5-year follow-up, 281 adults in the early detection and treatment for psychosis

program showed significant improvement in global assessment of functioning for social functioning as

well as improved scores on the negative, depressive, and cognitive factors on the Positive and Negative

Syndrome Scale. The duration of untreated psychosis of greater than a year is associated with less

response to treatment, more persistent positive symptoms, and lower global function. (Black et al. 2001)

This highlights the importance of accurate diagnoses when patients present in acute care settings.

Understanding the full individual is necessary for meaningful psychiatric and psychodiagnostic work. To

understand the complexity of the patient as a whole and have an accurate psychiatric diagnosis, the

psychological assessment can be extremely helpful. The psychological assessment in psychiatry is

similar to various diagnostic tests and scans in medicine. Most psychiatric illnesses are multifactorial, and

no biological tests have been developed that determine the illness from which a patient suffers.

Psychologists are integral to the healthcare team, especially in the inpatient unit. However, based on a

recent study, many inpatient psychologists are available on the unit only once or twice a week due to the

increasing need and chronic deficit in the outpatient setting. (Berry et al. 2022) Because of the limited

number of psychologists providing psychological assessments in inpatient settings, there is an urgent need

to develop additional means of identifying individuals with psychotic illnesses. Novel instruments that

can be administered by psychiatric residents, interns, and medical students are one way this care gap can

be addressed.
Emotional deficits in schizophrenia have been well-documented. Tremeau (2006) conducted a

comprehensive review of the literature and noted that individuals with schizophrenia display deficits in

emotional expression, experience, and recognition (Tremeau et al. 2006). A meta-analytic review has

shown that individuals with schizophrenia have deficits in facial emotion identification and

discrimination tasks. (Kohler et al. 2010) Individuals with schizophrenia are significantly less expressive

in response to a variety of emotional situations and stimuli. A recent meta-analysis demonstrated a

significant and stable effect size for deficits in the perception of emotional prosody in schizophrenia

across seventeen studies. (Hoekert et al. 2007) Regarding emotional experience, while research suggests

that individuals with schizophrenia reported their feelings as positive and negative in response to

situations and stimuli evoking those emotions as compared to those without schizophrenia, individuals

with schizophrenia may report experiencing more emotional experiences, including emotions that are

incongruent with stimuli, such as negative and at times positive emotional reactions to neutral stimuli and

negative emotions in response to positive stimuli. Differences in emotional experience may be useful in

the early identification of a psychotic illness like schizophrenia.

Deficiencies in abstraction, driven by cognitive deficits that are known to precede the development of

positive symptoms of schizophrenia, may underlie the aforementioned deficits in emotional expression,

experience, and recognition. Virtanen et al (2017) highlighted the impact of cognitive impairment on the

ability to recognize emotion in facial expressions. Another study demonstrated a significant positive

correlation between the response latency in emotion recognition (measured via the Emotion Recognition

Test of the Cambridge Neuropsychological Test Automated Battery) and difficulties in abstract thinking

(measured via PANSS) (Virtanen et al. 2017). This association could possibly be explained by the

observation that patients with schizophrenia, especially those who are cognitively impaired, increasingly

adopt maladaptively concrete thinking. For instance, Gorham demonstrated that psychotic patients

experienced a decline in abstract scores and a rise in concrete scores. To fully grasp and recognize

emotions, the individual should have undergone a cognitive process involving a level of abstraction well
beyond concrete thinking employed by many patients with schizophrenia, in which the person has

intellectualized the emotional content of their reactions to previous experiences (Zierhut et al. 2022).

The association between deficiencies in abstraction and emotional understanding could also have a

pathophysiologic basis. Per van del Heuvel MP et al (2014), patients with schizophrenia were found to

have abnormal brain connectivity in the medial temporal limbic and midline diencephalon areas (van del

Heuvel et al. 2014). In addition, Lezak et al (2004) described patients with damage to these areas who

were more likely to have memory storage and consolidation problems. Due to these deficits, these

patients found difficulty assigning meaning to the materials needed to be remembered. These findings, in

conjunction with a known role in the medial temporal limbic area in emotional regulation, may explain

the reason that individuals with schizophrenia often face difficulty in imbuing—and later retrieving—

emotional significance from their experiences (Lezak et al. 2004).

In gauging the deficits in cognition and abstraction for patients with schizophrenia, the Abstract Thinking

subscale (N5) of the Positive and Negative Syndrome Scale (PANSS) is most commonly employed in

clinical and research settings. The N5 of PANSS consists of 32 items: 16 similarities and 16 proverbs.

Scoring is based on the patient’s ability to identify similarities between items and interpret the meaning of

proverbs. Proverbs, in particular, can be highly cultural and language-specific, and both the interpretation

by subjects and the evaluation by scorers could be variable depending on their cultural background and

familiarity with the proverbs. The PANSS also does not contain a section that specifically tests for the

patient’s ability to grasp and recognize emotions, which is crucial in successful interpersonal interactions.

Robert Charles Powell, in his book “Differentiation of Moods,” noted that patients with schizophrenia

offered very specific answers in response to questions that asked them to identify their emotions. In

contrast to N5 of PANSS, these five questions conceived by Powell inquire about emotions such as

hunger, anger, fear, sadness, and anxiety, which are universal and shared across cultures. The answers to

these questions may provide information on whether the patient’s mood is well-differentiated, poorly
differentiated, or undifferentiated. In those with poorly differentiated moods, the answer might be literal

or functional in nature, for example, providing a “concrete response” in which the patient relates the

mood to recent precepts or specific examples. For those with undifferentiated moods, the answer might be

entirely incorrect or nonsensical in that they are entirely unable to address the question of how they know

that a certain mood is present (Powell R.C 2017)

Building upon the work by Powell, we devised a questionnaire and scoring system that classifies the

responses to the questions based on the degrees of “mood differentiation” and abstraction impairment.

Because the test only contains five questions, it can be quickly and easily administered by a broad group

of mental health providers, such as medical students, residents, psychiatrists, and psychologists. This

novel approach has the potential to succinctly evaluate not only deficits in abstraction but also emotional

understanding in psychotic patients—simply by posing five questions about universal feelings of anger,

anxiety, and depression. The accompanying scoring guide has also been designed to maximize ease of use

and minimize errors in interpretation. This is particularly important if the instrument is to be used

repeatedly to assess the effect of therapy on abstract thinking.

Through our study, we hope to highlight the growing importance of these tests and the promising results

we have obtained during our study.

2. Material and Methods

This observational study took place in an acute psychiatric 24-bed unit of an academic hospital located in

the city of Central New York, USA. The population of the city is 146,000. The unit admits an average of

75 patients per month from emergency rooms, medical floors, and outlying facilities. The study was

approved by the Institutional Review Board of Upstate Medical University and was carried out per the

latest version of the Declaration of Helsinki. All participants were native English speakers and belonged

to different ethnicities. Demographic and clinical characteristics of study participants are summarized in

Table 1. 21 participants with schizophrenia spectrum disorders were selected based on chart review..
Another 20 patients without schizophrenia spectrum disorders diagnoses were selected for the study as

controls.

2.1 Measures

The demographic form was administered after the patient consented, and the chart was reviewed. The

Mood Differentiation Questionnaire was administered. The study’s questionnaire draws from Robert

Powell’s essay “Differentiation of Moods: as a Reflection of Ego Organization and Personality Style.” In

the booklet, Powell discusses a heuristic diagnostic approach in which the clinician poses five questions

about emotions to patients. These five questions have been adopted into a questionnaire format which can

be readily administered in any mental health treatment setting (refer to Appendix A).

2.2 Scoring

A scoring guide has also been developed to serve as a guideline in grading the patients’ responses (refer

to Appendix B). The scoring guide borrows conceptually from Powell’s essay, which categorizes the

potential responses based on the patient’s hypothesized ego organization and personality style. Per

Powell, the responses can range from those demonstrating a clear, personal concept of each mood

(usually from patients with normal/neurotic personalities and well-differentiated moods) to those that

only indirectly address—relying on concrete examples, for example—the question of how the patient

knows when the specific mood is present (from patients with poorly differentiated mood).

These different types of responses were then grouped into four separate levels based on the connoted

degree of impairment in forming concepts and understanding emotions. This categorization borrows from

previous work by Leontieva et al. (2019), which outlined a new scoring guide for the PANSS N5

Similarities and Proverbs scale (Leontieva et al. 2019). Listed in increasing order of impairment in

abstraction, the four levels are as follows: normal/neurotic response; marginal but coherent response;
literal/functional response; and incorrect/psychotic response. If the patient’s response to a question

demonstrated components of different levels of abstraction, the higher score (i.e., the “more

differentiated” response) was given as long as it constituted a significant part of the answer. Each of the

five mood questions was scored separately and then aggregated to determine the final score for the

subject. The scoring guide could be seen in Appendix B.

A study team member conducted the interview in rooms within the unit, free from distractions and noise,

which was timed around 25-30 minutes. No follow-up was necessary. The responses were rated according

to the PANSS N5 new scoring guide by a Psychiatrist and a Psychiatry resident. The cultural backgrounds

of the raters were as follows: LL was Russian-born, fluent English speaker, American-educated, and fully

acculturated; HS was Korean-born, fluent English speaker, American-educated, and fully acculturated.

The raters were blind to the patient identifiers, such as names and diagnoses.

For inter-rater reliability, Bland-Altman analysis was performed to assess the agreement between the two

raters, and a significant agreement between the two raters was assigned as 4.098.

3. Results

The socio-demographic and clinical characteristics of study participants are presented in Table 1 and

Table 2. Briefly, Caucasians constituted the largest proportion (80.4%) of the study participants,

followed by African-Americans (14.6%). The gender distribution was about equal, with 22 male

participants and 19 females. There was also no statistical difference in the gender distribution between

test and control subjects (p value = 0.427). The majority of the patients were housed either in an assisted

living facility or living independently, with a minority of employed individuals (22%). A large fraction of

the study participants had a current disability status (51.2%).

Under the Schizophrenia category, the following diagnoses have been included - schizoaffective d/o

bipolar type (8 patients), schizophrenia (6 patients), unspecified schizophrenia spectrum (1 patient),

schizoaffective disorder (2 patients), schizoaffective depressive type (2 patients), and schizophrenia

spectrum disorder (1 patient). Under the mood disorder category, the following diagnoses have been

included - (12 patients), adjustment disorder (1 patient), borderline personality disorder (1 patient),

bipolar type 1 (1 patient), panic disorder (1 patient), unspecified depressive disorder (2 patients),

unspecified trauma and stressor-related disorder (2 patients), and unspecified anxiety disorder (1 patient).

The average ages of the study participants with schizophrenia spectrum disorders and study participants

without schizophrenia spectrum disorders diagnoses were similar at 41.4 and 38.6, respectively (Table

3). Educational level was also similar to the average number of years completed at 12.1 and 13.9,

respectively. The average number of previous hospitalizations was likewise similar at 3.8 and 4.1,

respectively.

For scorer 1, the mean aggregated score of the questionnaire per patient (refer to Methods section) was 12

with a standard deviation of 2.9. For scorer 2, the mean score was higher at 15.3 with a standard deviation

of 2.6.

In terms of correlation analysis of questions from the questionnaire (Table 4), question 1 (“hungry”) was

associated with the best correlation between the raters, with R 2 value of 0.62 (p value<0.001). In contrast,

question 2 (“anxious”) was associated with the worst correlation between the raters with R 2 value of 0.41

(p value=0.008). In terms of Bland-Altman analysis (Table 4), it was found that question 5 (“afraid”)

showed the highest agreement between raters with the mean difference between raters being 0.585 with

95% limit of agreement of -1.273 to 2.444. This was followed by question 1 (“hungry”) with a mean

difference of 0.732 with 95% limit of agreement of -1.023 to 2.486. The worst agreement between raters

was seen with questions 2 (“anxious”) and 3 ("depressed"), with a mean difference of 1.024 for both

questions.
Table 1. Socio-demographic characteristics of study participants.

DEMOGRAPHICS NUMBER %

Gender: Male 22 53.6

Female
19 46.3

Ethnicity: 33 80.4
Caucasian
6 14.6
African American
2 4.8
Others

Housing: 34 87.8
Housed
5 12.1
Unhoused

Working 9 22

Currently on disability 21 51.2

Table 2. Additional demographic and clinical characteristics of study participants.

OTHER DEMOGRAPHICS MEAN (SD) RANGE

Age (years): Control 38.6(13.7) 41.4(14.9) 19-66 18-69

Test

Education (years): Control 13.9(3.4) 12.1(1.7) 9-22 9-16

Test
 Previous Hospitalizations: Control 4.1(9.0) 3.8(5.0) 0-30 0-15
Test

Primary Diagnosis NUMBER %

Schizophrenia 20 48.7

Mood disorder 21 51.2

Table 3. Comparison of aggregated score of the questionnaire per patient between scorers

Mood differentiation questionnaire results MEAN (SD) RANGE

Scorer 1 12(2.9) 5.5,18.5

Scorer 2
15.3(2.6) 8.0,19.5

Table 4. Correlation analysis and Bland-Altman analysis for Questions from Mood

Differentiation Questionnaire

S.No Questions from the Mood R2 value p-value Bland-Altman 95% limit of
. Differentiation Questionnaire (Correlation Analysis agreements

Analysis)

1. Q1. Do you ever take a look at 0.62 <0.001 0.732 -1.023 to 2.486

yourself and say, “Gee, I guess I

must be hungry?”

If so, how would you KNOW that

you were feeling hungry or getting

hungry?

That the feeling you were feeling

must be hunger- and not something

else?

2. Q2. Do you ever take a look at 0.41 0.008 1.024 -0.959 to 3.008

yourself and say, “Gee, I guess I

must be anxious?”

If so, how would you know that

you were anxious or getting

anxious?

That the feeling you were feeling

must be anxiety- and not

something else?

3. Do you ever take a look at 0.47 0.002 1.024 -1.007 to 3.056

yourself and say, “Gee, I guess I

 must be depressed.”

If so, how would you know that

you were depressed or getting

depressed?

That the feeling you were feeling

must be depression- and not

something else?

4. Do you ever take a look at 0.55 <0.001 0.732 -1.077 to 2.54

yourself and say, “Gee, I guess I

must be angry?”

If so, how would you know that

you were angry or getting angry?

That the feeling you were feeling

must be anger- and not something

else?

5. Do you ever take a look at 0.45 0.003 0.585 -1.273 to 2.444

yourself and say, “Gee, I guess I

must be afraid?”

If so, how would you know that

you were afraid or getting afraid?

That the feeling you were feeling

must be fear- and not something

else?

N = 41

Table 5. Comparison of scores between Test and Control subjects

S.No. Questions from the mood Scores of Test Scores of p-value

differentiation subjects Control

questionnaire [Mean(SD)] subjects

[Mean(SD)]

1. Do you ever take a look at 2.8(0.9) 2.2(0.9) 0.020

yourself and say, “Gee, I

guess I must be hungry?”

If so, how would you KNOW

that you were feeling hungry

or getting hungry?

That the feeling you were

feeling must be hunger- and

not something else?

2. Do you ever take a look at 2.9(0.8) 2.1(0.6) <0.001

yourself and say, “Gee, I

guess I must be anxious?”

If so, how would you KNOW

that you were anxious or

getting anxious?
 That the feeling you were

feeling must be anxiety- and

not something else?

3. Do you ever take a look at 3.2(0.6) 2.5(0.7) 0.001

yourself and say, “Gee, I

guess I must be depressed.”

If so, how would you KNOW

that you were depressed or

getting depressed?

That the feeling you were

feeling must be depression-

and not something else?

4. Do you ever take a look at 3.2(0.8) 2.5(0.8) 0.010

yourself and say, “Gee, I

guess I must be angry?”

If so, how would you KNOW

that you were angry or getting

angry?

That the feeling you were

feeling must be anger- and not

something else?

5. Do you ever take a look at 3.3(0.8) 2.8(0.7) 0.065

yourself and say, “Gee, I

guess I must be afraid?”

If so, how would you KNOW

 that you were afraid or getting

afraid?

That the feeling you were

feeling must be fear- and not

something else?

4. Discussion

Our study aims to demonstrate the feasibility and inter-rater reliability of Mood Differentiation

Questionnaire, a novel approach of evaluating thought disorder in schizophrenia. With its ease of

use, the Mood Differentiation Questionnaire could be easily adapted by a broad group of mental

health providers to improve accuracy of diagnosing disturbances in thinking for patients with

schizophrenia.

The study demonstrated that patients with schizophrenia spectrum disorder tend to have poorly

differentiated moods compared to non-schizophrenia patients. For all 5 of the Mood

Differentiation questions, the patients with schizophrenia scored significantly higher – indicating

that they are more likely to answer in a more literal or incorrect manner which is associated with

a less differentiated mood than patients with non-schizophrenia diagnoses.

Furthermore, the Mood Differentiation Questionnaire and the accompanying scoring guide

achieved strong inter-rater reliability between two scorers, who were of different cultural and

educational backgrounds. The inter-rater reliability was calculated using the Bland-Altman

analysis which found a relatively small mean difference between the raters for the five questions,

with the highest agreement being associated with question 5 (“afraid”). In terms of correlation

analysis, the questionnaire and scoring guide also achieved a good correlation with R2 value

ranging from 0.41 to 0.62 for the five questions.

Potential future directions may involve further investigating the applicability of the questionnaire

to clinical settings, for example by devising a new test battery including the Mood

Differentiation Questionnaire (using the revised scoring guide), PANSS N5, and other modalities

such as the Pictogram test which assess disturbances in thinking for patients with schizophrenia

(Leontieva et al. 2008&2022 ). Combining three tests that alone showed good discriminant

ability against diagnoses of schizophrenia spectrum disorders will add incremental validity to

such test battery. By combining the three assessments (Mood Differentiation questions, PANSS

N5, and Pictogram test), we anticipate that this new battery of tests could improve upon the

incremental validity (vs. PANSS N5 alone) while being more widely applicable (e.g. across

different cultures) and demonstrating inter-rater reliability.

5. Limitations

A potential limitation of the study is that due to non-randomized subject selection from an

inpatient psychiatric setting, the study may be subject to a number of selection biases. This
includes the Berksonian bias because the study utilizes hospitalized patients with mood disorders

as the control group. This effect was partially mitigated by the recruitment of patients who were

deemed clinically stable. In addition, while the presence of Berksonian bias would more likely

tilt the outcome toward non-significance, our results showed patients with schizophrenia tended

to score higher compared to control patients -- a finding that was statistically significant for each

of the 5 questions.

Furthermore, it was observed that one of the raters (scorer 2) tended to score the responses

consistently higher, with the mean aggregated score of the questionnaire per patient being 12 for

scorer 1 and 15.3 scorer (Table 3). This was a trend that was noticed for each of the 5 questions.

This indicates that some raters may tend to be more stringent in evaluating that an answer is

normal/coherent versus literal/incorrect/psychotic. A more detailed scoring guide would help

mitigate some of the potential ambiguity in the interpretation of the scoring guide and improve

the consistency of scoring between different raters. To this end, a revised and more thorough

version of the scoring guide has been devised (Appendix C), which may be utilized for future

studies.

6. Conclusions

The study, which evaluated the feasibility of utilizing the Mood Differentiation Questionnaire in

patients with schizophrenia spectrum disorders and non-schizophrenia patients, demonstrated that

patients with schizophrenia spectrum disorder tend to have poorly differentiated moods

compared to non-schizophrenia patients. Furthermore, the Mood Differentiation Questionnaire

and the accompanying scoring guide achieved strong inter-rater reliability between two scorers,

who were of different cultural and educational backgrounds. With its ease of use, the Mood
Differentiation Questionnaire could be easily adapted by a broad group of mental health

providers to improve the accuracy of diagnosing disturbances in thinking for patients with

schizophrenia.

Funding statement:

No funding was used in this study.

CRediT authorship contribution statement:

Ho Taik Sung - Writing - Original draft, methodology, results, review and editing,

conceptualization

Palak A.Fichadia - Writing - Original draft, methodology, review and editing, data curation,

project administration

Sreya Kongala - Writing - review and editing,data curation, project administration

Susan Sperry - Writing - review and editing

Dongliang Wang - Formal analysis, review and editing

Luba Leontieva - Supervision, project administration, conceptualization, data curation, Writing -

original draft, review and editing

Declaration of competing interest

No funding source supported this project. None of the authors report biomedical financial

interests or potential conflicts of interest.

Acknowledgments

We thank Robert Charles Powell for inspiring the creation of the Mood Differentiation

Questionnaire based on his book, in addition to providing continued guidance for the

conceptualization of the scoring system.

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Appendix A (The Mood Differentiation Questionnaire):

These five specific questions rapidly provide valuable information suggesting the patient’s probable level

of ego-organization: normal/neurotic, borderline, or psychotic/ pre-psychotic, corresponding to well-

differentiated, poorly differentiated, and undifferentiated moods. While the time employed will vary from

patient to patient, generally it takes about seven minutes to administer the five questions and to listen

very closely to the answers. Please record the patient’s response with as much detail as possible. While

the content is important, the tone (paranoid, schizoid, antisocial, obsessive, dependent, avoidant,

narcissistic, histrionic), wording, pronouns are just as revealing.

I would like to ask you five very specific questions about your emotions. A lot of people have difficulty

with these five questions, but just do the best that you can. (Patients may be coaxed to say a bit more with

the question, “Anything else?”)

1. Do you ever take a look at yourself and say, “Gee, I guess I must be hungry?”

If so, how would you KNOW that you were feeling hungry or getting hungry?

That the feeling you were feeling must be hunger- and not something else?

2. Do you ever take a look at yourself and say, “Gee, I guess I must be anxious?”

If so, how would you KNOW that you were anxious or getting anxious?

That the feeling you were feeling must be anxiety- and not something else?
3. Do you ever take a look at yourself and say, “Gee, I guess I must be depressed.”

If so, how would you KNOW that you were depressed or getting depressed?

That the feeling you were feeling must be depression- and not something else?

4. Do you ever take a look at yourself and say, “Gee, I guess I must be angry?”

If so, how would you KNOW that you were angry or getting angry?

That the feeling you were feeling must be anger- and not something else?

5. Do you ever take a look at yourself and say, “Gee, I guess I must be afraid?”

If so, how would you KNOW that you were afraid or getting afraid?

That the feeling you were feeling must be fear- and not something else?
Appendix B (Scoring guide for grading patient’s responses to the Mood Differentiation

Questionnaire):

1. Normal/neurotic answer, demonstrating well differentiated mood:

-Directly addresses the question of how the patient personally knows when the specific

mood is present. May focus on intra-psychic or physiologic aspects of experiencing the

mood.

2-3. Marginal but coherent response:

-Not completely perfect response that may have some inaccuracy in abstraction or may

be otherwise idiosyncratic.

4-5: Literal/Functional response, demonstrating poorly differentiated mood and significant

problems with abstraction:

-Treatment response: Focuses on the action the person takes upon sensing that the mood

is present.

-Concrete response: Relates the mood to recent percepts or specific examples/anecdotes.

-Externalization response: Relies on indicators outside themselves as to how they might

be feeling.
6-7: Incorrect/psychotic response, demonstrating undifferentiated mood.

-Unable to address the question how they know that a certain mood is present. Patients

may deny experiencing the mood at all and may otherwise be too distracted or

preoccupied by internal stimuli to answer.

Appendix C (Scoring guide for grading patient’s responses to the Mood Differentiation

Questionnaire, Revised Version):

1. Normal/neurotic answer, demonstrating well differentiated mood:

Directly addresses the question of how the patient personally knows when the specific mood

is present. May focus on intra-psychic or physiologic aspects of experiencing the mood.

2. Marginal but coherent response:

Somewhat unsatisfactory answer in which the following may be present: inaccuracy or

incompleteness in abstraction; sole focus on the action the person takes upon sensing that the

mood is present (Treatment response); or idiosyncrasies in describing his or her experiences.

3: Literal/Functional response, demonstrating poorly differentiated mood:

Concrete response: Relates the mood to recent percepts or specific examples/anecdotes.

Externalization response: Relies on indicators outside themselves as to how they might be

feeling.

4: Incorrect/psychotic response, demonstrating undifferentiated mood.

Unable to address the question how they know that a certain mood is present. Patient may

say “I don’t know” or deny experiencing the mood at all. Patient also may provide
completely incoherent or unrelated answer.

*If the answer has multiple levels of response, give the higher score as long as it constitutes a

significant part of the answer. For example, if an answer demonstrates both normal/neurotic (1) and

marginal (2) components, score the answer as (1) not (2).