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Flat Affect

Medically Reviewed by Neha Pathak, MD on January 24, 2023

In psychology, what's known as your "affect" refers to how you portray emotions -- through gestures, your tone of voice, facial expressions, and the like.  If you’re happy or upset, people usually can see it on your face and hear it in your voice. But sometimes your emotions and how you express them don’t match up -- there's a disconnect between the two. You may be elated or depressed, but others can’t tell. You may seem uncaring and unresponsive, but you're still feeling an emotion. This is called flat affect. Flat affect can be the result of different neurological and psychological conditions. There are varying degrees of how much emotion you don't show -- flat affect is the highest level of intensity.

Flat affect differs from "emotional blunting," which is when you feel emotionally numb or have a hard time feeling emotions.

 

 

 

Blunted Affect vs. Flat Affect

You may have heard the terms flat affect and blunted affect. They differ based on how much emotion you show. 

Flat affect is when you feel emotions but show practically nothing visually.

Blunted affect refers to feelingemotions but only showing some of what you're feeling. (It's a less intense form of the flat affect because you still show some response.)

There's another degree of flat affect, which is a lesser degree of the two above. Constricted (or restricted) affect is when you feel emotions but have some degree of showing it.

There are other types of affect related to flat affect: 

Labile affect refers to sudden shifts in how you express emotion.

Inappropriate affect is when an emotional reaction doesn't seem to fit the situation (smiling when you hear someone died).

Flat Affect Symptoms

If you have flat affect, you may have:

  • Lack of body language and gestures
  • Minimalized or absent facial expressions
  • Lack of shifts in speech tone

See a mental health professional if you think you may experience flat or blunted affect. They can utilize different tools to see if you have it and what may be causing it.

 

What Does Emotional Blunting Mean?

If you're feeling emotionally numb -- whether you show it or not -- that's referred to as "emotional blunting." It's one of the most common side effects of taking antidepressants, which causes some people not to continue on them. Emotional blunting means you may not feel positive or negative emotions.

It occurs in people with depression, schizophrenia, and posttraumatic stress disorder.  

When we are numb to positive emotions but not negative ones, that's called anhedonia. It's a common symptom of depression and other mental health conditions.

 

Flat Affect and Schizophrenia

This is a serious, long-term mental illness. Some symptoms include:

  • Believing things that aren’t real (delusions)
  • Seeing or hearing things that don’t exist (hallucinations)
  • Disorganized thinking or speech
  • Sudden agitation, confusion, and other unusual behaviors

A flat affect can be a negative symptom of schizophrenia, meaning that your emotional expressions don’t show outwardly. You may speak in a dull, flat voice and your face may not change. You also may have trouble understanding emotions in other people. You might confuse happy and sad, or misjudge just how happy or sad the other person might be.

Schizophrenia is a lifelong illness. Even if your symptoms have gone away, you’ll need to stay on medication and get therapy. If your symptoms are severe, you may need to go to the hospital for your or other people’s safety.

Social skills training can help change a flat affect. This is when you work with a therapist or other mental health expert to learn how to communicate, interact with others, and manage everyday activities.

Flat Affect and Depression

A flat affect can be one of the symptoms of this mood disorder. Researchers have used movie clips to study flat affect and depression. In one small study, they found that people who are depressed reacted less to positive scenes than people with schizophrenia did. Depressed people also reacted slightly more to negative clips.

Experts don’t exactly know why depression leads to a flat affect. They think it may be linked to things such as a problem with your brain chemistry, your genes, and physical changes to your brain.

Some people believe antidepressants lead to emotional blunting, specifically, but others say it's a symptom of depression caused by incomplete treatment. There's a lot that's still unknown about emotional blunting and antidepressants. Researchers have called for more studies to learn about the mechanisms of both and how they may impact one another. 

Flat affect and emotional blunting can have an impact on treatment, especially if people go off medication they can benefit from. In another study, nearly 75% of more than 750 people in the acute phase of depression (and about 25% of those in remission) said they had severe emotional blunting. About 56% thought depression caused the emotional blunting, while 45% said antidepressants had a negative effect on their emotions. More than one-third were thinking of stopping medication or had already done so.

Flat Affect and Traumatic Brain Injury (TBI)

This brain damage can happen after a car crash, a fall, or any other injury that causes a hard hit to the head.

The impact bounces your brain back and forth inside your skull. The trauma causes bruising and bleeding and tears the nerve fibers.

TBI can hurt a part of your brain called the frontal lobe. That’s where emotional expressions start. A damaged frontal lobe may cost you your ability to recognize or feel different emotions. The result can be a flat affect. You also may miss cues in other people’s body language. A brain injury can even change your personality.

TBI can range from mild to severe. Your symptoms may go away after a few months, or they may last for the rest of your life. 

Your doctor will recommend a combination of treatments. A speech therapist or neuropsychologist can help you manage your flat affect and improve your relationships with family and friends.

 

Flat Affect and Parkinson's Disease

A main symptom of this disease is having less facial expression. In the Parkinson's disease world, it's known as "masked face," "facial masking," or hypomimia. The lack of facial expression is a result of the symptoms of Parkinson's disease, which stiffens muscles in the face that can affect your eyebrows or smile, for example.

If you have Parkinson's disease, it can take longer to move. You may also have speech impairments. This can make it harder to communicate.

But there are treatments to help with facial masking if you or a loved one has Parkinson's disease. Speech therapy may be able to help, as can medications that can ease rigidity.

Flat Affect and Autism Spectrum Disorder (ASD)

Scientists know that autism and related disorders stem partly from genetics as well as differences in the brain.

People with ASD interact, behave, and communicate in different ways. They may experience flat affect. If you have autism and flat affect, your face often may appear blank. Your voice may not change tone or may sound robot-like. You may have a hard time reading other people’s voices and body language.

It can be difficult to diagnose conditions like anxiety or depression if you (or a loved one) has ASD, because there may not be many outward signs. That’s why it’s important for caregivers and doctors to check for changes in sleep, appetite, and overall mood.

There’s no cure for ASD. But medication can help with energy level, focus, depression, and seizures. Working with a therapist can help you better relate to other people.

Flat Affect and Blunted Affect Treatment

Treating the underlying disorder you have can help treat flat affect. That is, if you don't show emotion, trying to make yourself show emotion may not do the trick. But treating the underlying condition may help more. Some people may respond to treatment, but others may not.

Treatments for flat affect include treatments that address the causes (like depression, schizophrenia, and others mentioned above). These treatments can include medications. It can also include speech and physical therapies. Mental health treatments like cognitive behavioral therapy can also help with flat affect symptoms.

Show Sources

SOURCES:

Frontiers in Psychiatry: "Emotional Blunting in Patients With Major Depressive Disorder: A Brief Non-systematic Review of Current Research."

Shives, L. Basic Concepts of Psychiatric-Mental Health Nursing, Lippincott Williams & Wilkins, 2008. 

Mental Health America: "I Don't Have Feelings Anymore."

Brainline: “Flat Affect and Brain Injury.”

Neura: "Voice Patterns."

PLoS One: "Instruments Measuring Blunted Affect in Schizophrenia: A Systematic Review."

Treatment Advocacy Center: "Schizophrenia: Fact Sheet."

Schizophrenia Bulletin: “Flat Affect in Schizophrenia: Relation to Emotion Processing and Neurocognitive Measures.”

Mayo Clinic: “Schizophrenia,” “Depression (Major Depressive Disorder).”

Mayfield Brain & Spine: “Traumatic Brain Injury.”

CDC: “Signs and Symptoms of Autism Spectrum Disorders.”

Autism Speaks: “What's the Connection Between Autism and Depression?”

Journal of Abnormal Psychology: “Emotional Experience and Expression in Schizophrenia and Depression.”

Annals of General Psychiatry: "Emotional Blunting in Patients with Depression. Part I: Clinical Characteristics."

BMJ: "Depression in Parkinson's Disease."

Parkinson's Foundation: "Facial Masking."

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