Dysphoric about dysphoria: 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 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 Á 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. 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 DIAGNOSIS AND TERMINOLOGY Australasian Psychiatry . Vol 15, No 1 . February 2007 doi: 10.1080/10398560601083035 # 2007 The Royal Australian and New Zealand College of Psychiatrists 9