Schizophrenia Flat Affect in Schizophrenia How to Recognize Impaired Emotional Functioning and Minimize Symptoms By Catherine Harrison, PhD Catherine Harrison, PhD Catherine Harrison, PhD is a former writer for Verywell Mind, covering schizophrenia. Learn about our editorial process Updated on May 25, 2022 Medically reviewed Verywell Mind articles are reviewed by board-certified physicians and mental healthcare professionals. Medical Reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. Content is reviewed before publication and upon substantial updates. Learn more. by Daniel B. Block, MD Medically reviewed by Daniel B. Block, MD LinkedIn Twitter Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania. Learn about our Medical Review Board Print David Ryle / Getty Images Table of Contents View All Table of Contents What Is Flat Affect? Causes Symptoms and Impact Treatment Coping and Support Frequently Asked Questions 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. Flat affect is more common among men than women and is often present during the onset of schizophrenia. 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. Disorganized Thinking in Schizophrenia 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. Understanding Inappropriate 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. Signs of Flat Affect Monotone or flat voice with no modulation or expressionLack of eye contactLack of discernible interest in the topic at handNo changes in facial expression regardless of the circumstance (neutral expression)Lack of verbal response to emotional stimuliBody language or non-verbal responses that are not typical to the experience, conversation, or situation at hand 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. Negative Symptoms in Schizophrenia 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. How Behavioral Therapy Works 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. Atypical Antipsychotics for Schizophrenia 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. Gathering information can help you better understand what to expect and what you can do to help. 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. Frequently Asked Questions Can flat affect be cured? Many of the conditions that cause flat affect can be treated. For some people, this can mean that their ability to express emotions can be restored. In other cases, treatment can help improve symptoms of flat affect or even prevent it from occurring. Treatments for conditions that cause flat affect vary, so talk to your healthcare practitioner or a mental health provider about which options are right for your needs. What’s the difference between blunted, constricted, and flat affect? The difference between contristed, blunted, and flat affect lies in the degree to which a person's emotional expression is affected. Constricted affect causes a diminished level of intensity and variability in how emotions are displayed. Blunted affect involves a more significant reduction in emotional expression. In flat affect, a person has minimal or absent emotional expression. What are the symptoms of schizophrenia? Schizophrenia is a brain disorder that causes problems in a person's ability to think, behave, and feel. In addition to flat affect, other symptoms of schizophrenia include delusions, hallucinations, reduced speech, disorganized speech, and lack of initiative. 6 Sources Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Li R, Ma X, Wang G, Yang J, Wang C. Why sex differences in schizophrenia?. J Transl Neurosci (Beijing). 2016;1(1):37-42. National Institute of Mental Health. Schizophrenia. Anttila V, Bulik-sullivan B, Finucane HK, et al. Analysis of shared heritability in common disorders of the brain. Science. 2018;360(6395). doi: 10.1126/science.aap8757 Evensen J, Røssberg JI, Barder H, et al. Flat affect and social functioning: a 10 year follow-up study of first episode psychosis patients. Schizophr Res. 2012;139(1-3):99-104. doi: 10.1016/j.schres.2012.04.019 Patel KR, Cherian J, Gohil K, Atkinson D. Schizophrenia: overview and treatment options. P T. 2014;39(9):638-45. Kilian S, Asmal L, Goosen A, Chiliza B, Phahladira L, Emsley R. Instruments measuring blunted affect in schizophrenia: A systematic review. PLoS One. 2015;10(6):e0127740. doi:10.1371/journal.pone.0127740 Additional Reading American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Gur, R. E., Kohler, C. G. Flat Affect in Schizophrenia: Relation to Emotion Processing and Neurocognitive Measures. Schizophrenia Bulletin. 2006. 32(2), 279–287. doi: 10.1093/schbul/sbj041. By Catherine Harrison, PhD Catherine Harrison, PhD is a former writer for Verywell Mind, covering schizophrenia. See Our Editorial Process Meet Our Review Board Share Feedback Was this page helpful? Thanks for your feedback! What is your feedback? 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