Flat Affect in Schizophrenia

What Is Flat Affect?

Flat affect indicates the diminished expression of emotion. While people with flat affect still experience emotion, they are unable to express emotions in typical and expected physical ways. They exhibit a lack of response to emotional stimuli such as reduced or absent facial expressions, monotone voice, and difficulty understanding the emotions of other people.

Flat affect is a hallmark symptom of schizophrenia, although it may also affect those with other conditions. It is a lack of showing emotion characterized by an apathetic and unchanging facial expression and little or no change in the strength, tone, or pitch of the voice.

This extremely limited range of expressions occurs even in situations that would normally seem very exciting or very sad. For instance, upon hearing the great news, someone with schizophrenia may not smile, laugh, or have any joy in their response.

Causes of Flat Affect

Although millions of people are affected by flat affect, scientists are not entirely sure of the exact cause. It is hypothesized that it is due to differences in brain functioning and some of the neurocognitive deficiencies that accompany schizophrenia.

More often than not, flat affect is an underlying symptom of several conditions—not just schizophrenia. It may even be a side-effect of certain medications, including antidepressants. Muscle disorders or facial paralysis, such as catalepsy and Bell's palsy, can also make it difficult to express emotions.

Other Conditions Associated With Flat Affect

In addition to schizophrenia, there are several other conditions related to flat affect. These include:

• Autism: Autism is a developmental condition that affects a person's ability to communicate and interact with others. Flat affect is common in people with this condition and may cause people to have little outward emotional response to other people and activities.
• Brain damage: Traumatic brain injury can also impact a person's ability to express emotions, leading to flat affect.
• Depression: Depression can lead to a variety of symptoms including low mood, loss of pleasure, hopelessness, emotional withdrawal, and lack of emotional expression.
• Parkinson's disease: This progressive disease impacts the central nervous system and leads to problems with movement. Some people with the condition also experience symptoms such as anxiety, dementia, and flat affect.
• Post-traumatic stress disorder (PTSD): PTSD is a condition that can occur after a person has experienced trauma. Symptoms can include flashbacks, hypervigilance, anxiety, depression, and flat affect. 

Symptoms and Impact

If you have been affected by flat affect, you may find that it negatively impacts your social functioning. People can respond negatively to the way you react in a situation or conversation, leading to the assumption that you are cold or unfeeling when that's not true.

It's important to note that while you may have trouble displaying emotion, many people with schizophrenia have no difficulty recognizing emotional responses in others. This is an important factor in working with your doctor to define a treatment plan, as it gives you a foundation to build on to create appropriate social exchanges.

Treatment for Flat Affect

Treatment for flat affect often depends on the underlying cause. A plan of action should begin by consulting with a psychologist or psychiatrist who diagnoses and treats mental health conditions.

Flat affect can be treated to some degree. It often requires comprehensive therapy, including working with a healthcare provider and taking medication. While it often cannot be completely eliminated, therapy and intervention can help you interact with others more warmly and naturally and get your other symptoms of schizophrenia under control.

Therapy and Intervention

Cognitive behavioral therapy, or CBT, is one of the most researched models of therapy used in the treatment of schizophrenia. CBT can help people with flat affect begin to recognize how their emotionless response does not match what is required in a specific situation.

Your therapist may have you practice appropriate reactions to different stimuli (like grief or celebration) so that you can learn how to react as other people do.

• Social skills training, a type of behavioral therapy, can also be used to teach people with schizophrenia to express feelings and needs, ask questions, and control their voice, body, and facial expressions.
• Speech therapy can help with tone and modulation of voice to convey more emotion.

Medication

In addition to evaluating your medication—since some meds can cause flat affect—your mental health provider can prescribe antipsychotic medications to control symptoms of schizophrenia, including delusions and hallucinations. Typical antipsychotics function by blocking receptors for dopamine.

The newer "atypical" antipsychotics also influence other neurotransmitters in the brain and may help with a flat affect. Clozaril (clozapine) is one of these agents shown to help combat flat affect in people with schizophrenia and other mental illnesses for which this is a concern.

Coping and Support for Caregivers

Caring for a loved one who is suffering from flat affect is challenging. It's much more than dealing with a loved one who tends to be "cold." It's not a personality trait. This symptom of schizophrenia makes it impossible for your loved one to translate emotion into a verbal or physical expression. The brain and body are not connecting.

While they may be unable to express their emotions, your emotions are likely in overdrive as you struggle to come to terms with this symptom of schizophrenia. Continuing to educate yourself on the condition and the experiences your loved one will face is one of the most important ways to cope.

Although your primary focus is on supporting your loved one, it's also important to remember to help yourself. This means seeking support from local or online groups, a mental health provider, or a trusted friend or family member.

Sharing your experiences and challenges can help you process your emotions and give you encouragement and hope. You may also gain helpful information about new or progressive treatment methods as well as other resources to help your loved one.