Strong affect switches the cortex down, and we cannot plan or will away our feelings, so the goal is to build the capacity to observe feelings without being forced to act on them. In the room, follow the affect: dysregulation can be subtle (even freezing), a dysregulated patient does not give good information, and your first move is to take your own pulse.
What it is
The more activated the subcortical systems are during big feelings and strong arousal, the less active the cortical systems are, and the reverse is true.
“If someone is having big, big feels and really strong affective arousals, the emotional regulation literature is pretty clear. More activated the subcortical systems are, and the cortical systems are less activated, and the inverse is true”
7:51Affective Neuroscience: Understanding Patients Beyond DSM DiagnosesAug 2026Guest episode We do not plan feelings. They come and go, and there is not much control over their flow: you cannot just make yourself feel differently.
“We don't plan on feelings. They really come and go. There's not a lot of really control you have over the flow of your feelings. If someone says, just get up, feel better, let's go to a movie, you can't just make yourself feel something differently”
12:43Affective Neuroscience: Understanding Patients Beyond DSM DiagnosesAug 2026Guest episode We are not there yet for decreasing the bottom-up drive. That seems to get set early, from early experiences.
“I don't think we're there yet for decreasing the bottom-up stuff. That seems to get set pretty early from early experiences”
33:03Affective Neuroscience: Understanding Patients Beyond DSM DiagnosesAug 2026Guest episode Severe borderline personality disorder can be understood as lacking the cortical capacity to appraise and modulate intense affective arousal. These patients are pretty much fine until they are not.
“I think of it as they do not have the cortical capacity to modulate, to appraise, to handle those intense affective arousals, right? Every patient I meet that has severe borderline persona disorder, they're pretty much fine until they're not”
21:16Affective Neuroscience: Understanding Patients Beyond DSM DiagnosesAug 2026Guest episode Many patients struggle with regulation without fitting a category: real trouble controlling anger, but no overdoses, no cutting, stable relationships, and they still seek care.
“someone who has really difficulty controlling their anger, but they've never overdosed. They've never cut themselves. They They have stable relationships, yet they struggle and they seek care”
6:39Affective Neuroscience: Understanding Patients Beyond DSM DiagnosesAug 2026Guest episode
Treatment approach
The aim is not to change the primary feelings, the fear, grief or suffering. It is to build the capacity to observe them and not be forced to act on them.
“I don't need to modify the content of my primary affective experiences. I don't need to change when I feel fear or feel grief or feel suffering. I'm trying to help them build that capacity to observe these things and not be forced to act on them”
8:39Affective Neuroscience: Understanding Patients Beyond DSM DiagnosesAug 2026Guest episode Religion can work as a strong cortical module patients can send down to calm things. Whether it is true is irrelevant to that effect.
“They have a better cortical, what do we want to call it, module that they can unlock and that they can send down to their brain. It's just a very helpful little thing. You can think whether or not it's true is completely irrelevant. It helps calm things down”
53:03Affective Neuroscience: Understanding Patients Beyond DSM DiagnosesAug 2026
In the interview
Track the affect while you interview. Dysregulation and plain dissociation are easy to miss if you are not following it, dysregulation can look subtle (freezing rather than agitation), and a dysregulated patient does not give good information anyway.
“we're definitely worried about dysregulation and we're definitely worried about uh plain disassociation and that can be easy to miss if you're not following the affect”
10:35Psychodynamic Technique and Therapeutic Intervention: ContainmentApr 2026 Also said in 1 more episode
“dysregulation doesn't get you good information anyway and dysregulation can look subtle and can be freezing rather than aggressive active so you just want to be aware of that”
16:42How to Do a Psychiatric Intake | The Art and Science of the First HourSep 2025 Affect can be too hot, a patient coming on very strong, or too cold, someone describing the death of a loved one with little feeling.
“Affect can be too hot in that you see a patient, you know, really, really coming on strong. And then affect can be too cold in that someone's talking about something that cognitively is affect-related, you know, the passing of a loved one”
9:14Psychodynamic Technique and Therapeutic Intervention: ContainmentApr 2026 Unless someone is flowing with narrative and emotion, you may be missing information. They are not withholding it on purpose; they may be too closed off from themselves to access it.
“unless somebody is really flowing with narrative and emotions you may be missing information. And it's not because the patient is withholding it deliberately, but they may not even be accessing it if they're essentially too closed off from themselves”
12:25Psychodynamic Technique and Therapeutic Intervention: ContainmentApr 2026
When a patient dysregulates
Do what emergency medicine teaches: in a crisis, first take your own pulse.
“Well, the first thing you do is what they tell you in emergency medicine, right? in a crisis or emergency, first, you take your own pulse, right”
12:57Psychodynamic Technique and Therapeutic Intervention: ContainmentApr 2026 Give assurance only in ways that are true and that everyone knows are true: we are here together right now, you are feeling awful, but you are not in physical danger.
“give assurance but not in ways that aren't true right you should only say things in assurance that you know are true that everyone knows are true we're here together right now doing this you're feeling awful right now it looks like but you're not in physical danger”
17:12Psychodynamic Technique and Therapeutic Intervention: ContainmentApr 2026 You do not have to know grounding exercises well. Pull up box breathing on YouTube and do it with the patient.
“I'll search box breathing on YouTube and then do the box breathing with the patient at the same time. So you don't even have to know it that well”
15:33Psychodynamic Technique and Therapeutic Intervention: ContainmentApr 2026
When affect is too cold
In therapy, name it: 'I notice you are talking about something quite painful, but you don't seem to be feeling much emotion as you talk about it. Do you notice that?'
“I noticed you're talking about something quite painful, but I noticed that you don't seem to be feeling much emotion as you talk about that. Do you notice that”
19:18Psychodynamic Technique and Therapeutic Intervention: ContainmentApr 2026
It also comes up on
- AutismAggressive outbursts in more severe autism usually come from poor emotional regulation, often triggered by changes in routine, unexpected outcomes or secondary mood problems.
- LamotrigineWe do see it help patients with emotional dysregulation who report depression, but not MDD proper. Do not use a drug that is not indicated just because its side effect profile matches what you want.
- SSRIsFor affective dysregulation, frame it as maybe 8 out of 10 anger instead of 10. If it means one less big fight with your partner a week, it might be a good medication for you.
- ADHDMuch of what social media calls ADHD symptoms, though present in many people with true ADHD, is better attributed to depressive disorders, trauma disorders and personality. Patients arrive believing ADHD explains their emotional dysregulation and relationship conflicts too.
- AutismAutism spectrum disorder is high systemizing and low empathizing, plus a collection of associated problems (repetition, emotional regulation problems, some learning problems) downstream of genetics and neurobiology, at a level that makes it a disorder rather than traits.
- Borderline personality disorderPersonality disorders can disrupt sleep through maladaptive coping and emotional dysregulation.
- Circadian rhythmIn someone with neurodevelopmental traits but not ADHD, such as autistic traits, sleep-wake dysregulation is common. Give something that is not habit forming.
- Complex PTSDA mnemonic: PTSD is FEAR (fright, exposure, avoidance, re-experiencing). Complex PTSD is BAD FEAR, adding betrayal, affect regulation and developmental impact.
From these episodes
- Affective Neuroscience: Understanding Patients Beyond DSM DiagnosesAug 2026 · 7 points
- Psychodynamic Technique and Therapeutic Intervention: ContainmentApr 2026 · 7 points
- How to Do a Psychiatric Intake | The Art and Science of the First HourSep 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.