Medically reviewed by Johnny Williamson, MD
In conversations, we expect people’s faces and voices to react in certain ways in response to their (or our) emotions. If you share exciting news with a friend, you’d expect your voice to go higher, a smile to form and your face to exhibit interest and energy as you share your news. But if you don’t exhibit these nonverbal cues, and your face and voice continued to appear neutral even if you do want to convey some enthusiasm, your friend might feel a bit confused. You don’t seem excited… but are you?
This illustrates the challenge of experiencing flat affect, a symptom of mental illnesses like depression, post-traumatic stress disorder and schizophrenia, as well as brain injury and other neurological disorders. People with flat affect may speak in a monotone voice or wear the same neutral or sad facial expression even though they are experiencing other emotions. It’s little-known by people who haven’t experienced it, and can lead to misunderstandings and negative assumptions.
Flat affect can be a frustrating symptom to live with and a confusing one to interpret if your loved one is experiencing it. But by talking more about this condition, hopefully, we can reduce the stigma associated with it.
What Is Flat Affect?
Flat affect can be a symptom of several conditions, including depression, schizophrenia, post-traumatic stress disorder, and brain injury. It can also be a side effect of medications. The term describes a lack of emotional expressiveness, particularly in the face and voice. People with flat affect still have feelings, they just don’t physically express them like a typical person. Deborah Serani, Psy.D., psychologist and author of “Sometimes I’m Sad,” told The Mighty common signs are:
- Very restricted facial movements
- Low or monotone voice
- Lack of physically expressive movements
- Poor eye contact
- Disinterest in others or activities
- Appearing aloof or detached
Kathleen Kurucz told The Mighty flat affect makes it difficult for her to hold a conversation with anyone. Whether the topic is serious or not, there is no expression in her eyes and face that shows she is paying attention, even though she is.
“I just can’t respond to any verbal communication. It’s in my head and gets stuck there and won’t come out like it’s supposed to! It’s very frustrating to be like that! That just throws me deeper into my depressive state,” Kuracz said.
You may notice that your flat affect becomes stronger when your other symptoms worsen. For example, loved ones may even be able to recognize that you are going through a depressive episode because of your flat affect.
“My husband and mother could always tell when I was entering a depressive phase when my voice became dull and my answers to questions were monosyllabic,” Janet Coburn told The Mighty. “It was an important clue.”
What Causes Flat Affect?
Serani explained that apathy, which is a lack of emotions and interest in life, is a common cause of flat affect. Apathy is a common symptom of schizophrenia, depression, and other neurological conditions. In addition, antidepressants, antipsychotics and other medications can cause flat affect as a side effect. Brain injuries can also interfere with how you display emotion. Drug intoxication and withdrawal are often associated with flat affect as well.
We don’t know the exact process that causes flat affect, but Serani said it’s caused by dysfunction in the frontal lobes and associated pathways of the brain. The frontal lobe is involved in motivation, planning, attention, speech, personality, and reacting to feelings of others.
Treating Flat Affect
If your flat affect is a symptom of depression or PTSD, treating that underlying condition will likely treat the flat affect as well, Serani said. Similarly, if your medication is causing flat affect, adjusting your dosage (with the help of your doctor) may improve it.
However, Serani cautioned that if flat affect is caused by a brain injury, dementia, or schizophrenia, it’s not likely to improve.
Therapists can help you cope with the challenges of flat affect, perhaps even working with you to learn strategies that help you respond to others’ emotions.
How to Support Someone With Flat Affect
While not being able to express your emotions fully can be frustrating to live with, sometimes the bigger challenge is coping with other people’s responses to you. Friends may not realize your demeanor is a symptom of your illness, and assume you really are uninterested in them and unenthusiastic about what they’re saying.
If you have someone in your life who displays the symptoms of flat affect, remember that their lack of emotional expressiveness does not mean they don’t care about you.
“I wish people understood that I fully process what they say to me and that I am not uninterested nor insensitive,” Bastien Essono told The Mighty. “The lack of expression is not necessarily a lack of emotion or comprehension.”
Keep in mind that even though your friend may not seem like they’re struggling, that doesn’t mean they don’t want your support. Sophie Munoz pointed out that people often think she’s being brave and strong and doubt when she needs help, simply because she’s not behaving as they think she should.
“My words are more important than my facial expression and vocal tone. By ignoring my requests for help, it just makes me not want to ask for help,” Munoz said.
By reading this article and educating yourself on flat affect, you’ve already taken the first step towards better supporting your loved one. In conversations, you can also help your loved one by asking questions about their feelings if you’re uncertain, Serani suggested.
In addition, consider using physical touch in your communication, if your loved one is open to it.
“This can be a way for you to connect more deeply if your loved one experiences difficulties with emotional expression,” Serani said.
Ultimately, it’s best to simply try to be mindful of how flat affect manifests and that it’s not something your loved one can control.
“Your loved one isn’t being difficult, aloof or non-responsive on purpose,” Serani said.
For more on coping with mental health challenges, check out these stories from our Mighty community:
Erin is the former senior editor and chronic illness editor of The Mighty. She joined The Mighty in 2015 and previously worked at Inside Weddings magazine, Mic, and The Huffington Post. She was also the features editor at The California Aggie, UC Davis' student newspaper. She is honored to be a part of the Mighty community!
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