Understanding Inappropriate Affect

Woman with a stern and lost look.

 Getty / Klaus Vedfelt

Affect refers to the outward expression of a person's internal emotions. For most people, there is congruence between affect and circumstance; for example, if you are given the news that a friend has passed away, your reaction would be sadness and tears.

However, for a certain percentage of the population, outward affect does not match the situation that they are in. This is known as inappropriate affect and can have a variety of causes.

If you know someone who smiles during a tragedy or who does not show emotion when it would be expected, they may be experiencing inappropriate affect.

To fully understand all the ramifications of inappropriate affect, we will consider in detail symptoms, causes, related conditions, diagnosis, coping, treatment, and related issues.

Overview of Inappropriate Affect

As noted, inappropriate affect involves the display of reactions that do not match the situation that you are in or possibly even your internal state.

Emotions, actions, or overall demeanor that seem out of place in a situation all fall under the general umbrella term "inappropriate affect."

Inappropriate affect can be a symptom of different underlying physical or mental problems, but it can also be a disorder itself. Psychiatrists and other professionals have recognized inappropriate affect as a problem among patients for over 100 years, reporting events such as laughter without any cause and patients claiming to feel emotionally empty.

In 1909, Stransky referred to "intrapsychic ataxia" as a condition involving a disturbance between thoughts and affect. In 1950, Bleuler noted that the clinical prognosis of patients displaying inappropriate affect was much poorer than those who did not. In a nutshell, it was concluded that when a patient displayed inappropriate affect, it meant that their condition was likely to become chronic rather than just remain as an acute episode of mental illness.

Causes of Inappropriate Affect

There are a number of different potential causes of inappropriate affect, but they fall under four main categories as described below.

Brain Damage or Neurological Dysfunction

Inappropriate affect can result from physical damage to the brain such as that happening due to a brain tumor, brain damage, dementia, brain injury, head trauma, etc. Lack of oxygen to the brain is also a potentially reversible cause of inappropriate affect.

When inappropriate affect results from a structural brain problem, the areas that are usually involved include the limbic system, anterior cingulate cortex, brainstem, and prefrontal cortex. Inappropriate affect in certain cases can also result from a disinhibition syndrome in which pathways involving serotonin and glutamate are not working correctly.

Schizophrenia or Related Mental Disorder

A second main cause of inappropriate affect is mental disorders such as schizophrenia, bipolar disorder, schizoaffective disorder, etc. Often, these individuals have not lost the capacity for emotional reactions, but appear to have lost the ability to have them occur in a normal and expected way. This is because their affect is a reaction to their hallucinations or delusions and their assumptions about the reasons for other people's actions.

Instead, they have strange reactions that don't seem to make sense to the outside observer. In this way, they show emotions and behavior that do not seem to be consistent with the reality of the situation, but they are in fact consistent with their internal experience of the situation.

In schizophrenia, inappropriate affect is sometimes called "flat affect" when it results from a slowing of mental speed in responding.

Inappropriate affect may also be seen in persons with psychopathy, in that they fail to show consistent emotions in their dealings with other people and their personal relationships.

Other Factors

There can also be other causes of inappropriate affect that is not due to brain damage or a mental disorder. In most of these cases, the person is capable of responding in a normal way, but for one reason or another does not. For example, a person in therapy may laugh while describing a difficult situation so as to control their emotions.

Diagnosis of Inappropriate Affect

If you are concerned that you are or someone you know is living with inappropriate affect, it is important to obtain a diagnosis from a licensed mental health professional. Your doctor can refer you to the necessary professionals, such as a neurologist, psychologist, or psychiatrist.

The first step would generally be to rule out any physical or neurological condition causing the inappropriate affect. Often, inappropriate affect is a symptom of another disorder rather than a syndrome itself, so an assessment would be conducted for mental disorders that could be a potential cause as well. The severity of the problem would also be assessed, to determine where it falls in the range from mild to severe.

Given that people with inappropriate affect may also be out of touch with reality, particularly if the symptoms are related to a mental disorder, it is important to find a clinician whom you feel you can trust.

Conditions Involving Inappropriate Affect

Various conditions may be associated with inappropriate affect:

Mental Disorders

Neurological Conditions

  • brain damage

  • pseudobulbar affect

  • autism

  • dementia

  • Alzheimer's disease

  • head trauma

  • brain tumor

  • multiple sclerosis

Symptoms of Inappropriate Affect

The specific symptoms of inappropriate affect will depend on the underlying cause and show up in terms of facial expressions, the tone of your voice, and the content of what you say. Below are some potential symptoms:

  • uncontrollable crying even when not feeling sad
  • recognizing that your reactions are inappropriate
  • emotions that do not match the reality of a situation
  • showing happiness during a tragedy
  • becoming angry without any outward provocation
  • mania, depression, or irritability
  • flat affect or not showing expected emotional reactions (but not in the case of simply holding back emotions)

Clearly, the specific types of symptoms experienced will depend on the underlying cause of the inappropriate affect.

Types of Inappropriate Affect

In addition to the broad symptoms of inappropriate affect, there are a number of specific categories within which symptoms can be grouped. Remember that inappropriate affect is simply that which does not match the situation or the internal situation of the person.

The various types are listed below.

Blunted Affect

Blunted affect is a common symptom in schizophrenia and related disorders, and refers to a lowered level of the intensity of emotional expression. A person with blunted affect will show little feeling even in emotional situations. As an example, a person with blunted affect may tell a story about being in a car crash but talk little about how it made them feel, speak in a monotone, and not have many facial expressions.

Restricted Affect

Restricted affect is similar to blunted affect except that it is less severe. So, the person describing the car accident may show some feeling and emotion, but it is less than would be expected based on the content of what is being said.

Flat Affect

Flat affect refers to displaying absolutely no feeling or emotion regardless of the circumstances. This is a step below blunted affect in that it is completely devoid of emotional expression.

Labile Affect

A person with labile affect shows rapid changes in their emotions that don't seem to relate to any outside situations or seem to be inappropriate for the situation. In other words, if you have labile affect, you would display rapid and repeating shifts in mood or affect. A person with labile affect feels as though they do not have control over their emotions.

This type of affect is seen often in neurological disorders such as pseudobulbar affect, in manic episodes during bipolar disorder, and in borderline personality disorder. Labile affect can also result from fatigue, stress/anxiety, and over-stimulation.

Shallow Affect

Shallow affect has a similar meaning to blunted affect, but it is mostly used to describe the emotional experience of persons with psychopathy. A person with shallow affect will feel little emotion about situations that would expect to elicit specific feelings.

This means that things that cause most people to experience negative emotions do not have the same impact for psychopaths. As an example, American serial killer Richard Ramirez, also known as the Night Stalker, when sentenced to death, responded with, "Big deal. Death always went with the territory. See you in Disneyland."

Treatment of Inappropriate Affect

As with symptoms, the treatment for inappropriate affect depends on the underlying cause. Receiving proper treatment depends on an accurate diagnosis, which is why it is so important to visit a healthcare professional if you or someone you know is living with these types of symptoms.

Most types of inappropriate affect will be treated with some form of medication depending on the severity of the symptoms. Even if psychotherapy is used, it is usually as an add-on to medication, because therapy alone often will not help to remediate the problem.

Medications that may be used include antipsychotics (in the case of schizophrenia or psychosis), antidepressants (in the case of mood disorders or related issues), as well as a specific medication approved by the U.S. Food and Drug Administration for the treatment of pseudobulbar affect (a combination of dextromethorphan and quinidine).

Helping Someone with Inappropriate Affect

If you are a caregiver to a person experiencing inappropriate affect, it can be hard on you too. You may react negatively or defensively to the other person's behaviors, which can make the situation worse. You might also be confused by their behavior and not know how to react.

It's important as a caregiver that you take time to get help for yourself as well. Support groups or other avenues for connecting with other people going through the same issues may be helpful. You could also consider talk therapy for yourself to learn best how to manage the situation and your own needs and emotions.

Coping with Inappropriate Affect

If you are living with inappropriate affect, it may be hard to know how to cope. Below are some suggestions on ways to minimize the impact of inappropriate affect on your life.

If you have not already, visit a healthcare professional to determine the underlying cause of your inappropriate affect. This person will be able to recommend the appropriate treatment for your situation.

If you have a neurological condition that causes you to react in inappropriate ways, it may be helpful to share this with persons close to you so that they can understand better what is happening.

If you have schizophrenia or a related condition, it's important to seek social support such as though a schizophrenia support group, to manage stress (since stress raises your cortisol, which can trigger episodes), get regular exercise such as 30 minutes per day, get enough sleep each night, avoid using substances such as alcohol, and eat healthy foods that can help to balance your moods.

A Word From Verywell

Are you or someone you know living with inappropriate affect? While this can be a debilitating condition because it affects every area of your life from work to social relationships, with the help of a healthcare professional, it is possible to reduce the impact on your life. Once you have your symptoms under control, all areas of your life should improve and your sense of control will increase.

Whether you are prescribed medication and/or receive psychotherapy, it's important to follow through with the prescribed protocol to ensure the best chance of success. Remember that even if you are feeling better, most conditions that require medication will involve taking this medication for the long-term. For this reason, you should always follow your doctor's advice and never make treatment decisions on your own.

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