Ambivalence is the simultaneous existence of opposing or conflicting feelings, attitudes, or desires toward a person, idea, or object. Individuals may experience both positive and negative emotions concurrently, such as love and hate, leading to uncertainty, indecisiveness, or emotional tension.

Pathophysiology

Ambivalence reflects dysregulation in emotional processing and cognitive integration. In typical circumstances, the prefrontal cortex modulates conflicting affective responses, allowing resolution of opposing emotions. Dysfunction or impaired connectivity in prefrontal-limbic circuits, particularly involving the anterior cingulate cortex, amygdala, and orbitofrontal cortex, can result in persistent, unresolved emotional conflict. Severe ambivalence is frequently observed in schizophrenia, mood disorders, and other psychiatric conditions, where impaired judgment or cognitive distortions exacerbate indecisiveness.

Assessment Technique

1. Patient interview: Encourage open-ended discussion about relationships, goals, or values.

2. Observation: Note hesitancy, frequent changes in expressed opinions, and emotional inconsistency.

3. Structured questions: Explore conflicting attitudes toward the same person, idea, or object.

4. Psychometric tools: Instruments such as the Ambivalence Questionnaire (AQ) or clinical scales in psychiatric assessments may quantify severity.

Clinical utility

• Psychiatric evaluation: Identifies patients at risk for decision-making difficulties or interpersonal conflict.

• Diagnostic relevance: Severe ambivalence is particularly associated with schizophrenia, but may also occur in bipolar disorder, borderline personality disorder, depression, and obsessive-compulsive disorder.

• Therapeutic planning: Understanding ambivalence helps clinicians tailor psychotherapy, motivational interviewing, and medication strategies to reduce internal conflict.

Differential diagnosis

Pediatric considerations

• Children may demonstrate ambivalence in attachment relationships or decision-making tasks.

• Careful observation is required to differentiate developmental indecisiveness from pathological ambivalence.

Geriatric considerations

• Older adults may exhibit ambivalence regarding life transitions, caregiving roles, or end-of-life decisions.

• Cognitive decline, executive dysfunction, or depression can exacerbate indecisiveness.

Limitations

• Ambivalence is subjective and may be difficult to quantify without structured assessment tools.

• Emotional conflict is not always pathological; mild ambivalence is normal in complex decision-making.

• Distinguishing ambivalence from confusion, apathy, or indecisiveness due to cognitive impairment is essential.

Patient counseling

• Educate the patient and caregivers about normal versus pathological ambivalence.

• Encourage strategies to clarify priorities, weigh pros and cons, and gradually resolve conflicting feelings.

• Recommend psychotherapy to enhance emotional regulation, insight, and decision-making skills.

Conclusion

Ambivalence is a common psychological phenomenon that becomes clinically significant when it interferes with decision-making or daily functioning. Recognition of severe ambivalence, particularly in psychiatric disorders such as schizophrenia, allows for targeted interventions, including psychotherapy and pharmacologic treatment, to improve patient outcomes.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA: APA; 2013.

2. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008:444–447.

3. Kaplan HI, Sadock BJ, Grebb JA. Kaplan & Sadock’s Synopsis of Psychiatry. 11th ed. Philadelphia, PA: Wolters Kluwer; 2015.

4. Freeman D, Garety P. Obsessive Compulsive Disorder and Schizophrenia: Ambivalence and Cognitive Bias. Psychol Med. 2004;34(5):879–889.