Flat Affect After Brain Injury: How to Overcome Lack of Emotional Expressiveness

A seeming lack of emotion is a common symptom of brain injury. However, most people with this problem do not actually lack emotions. Rather, they have limited ability to show signs of emotion with their facial expressions or voice, and typically demonstrate less reaction to emotional stimuli.

This condition, also known as flat affect, is caused by damage to the frontal lobe of the brain. Depression and other emotional problems can also contribute.

You’re about to learn the causes and symptoms of flat affect and how to treat it. Let’s get started.

What Causes Flat Affect After Brain Injury?

The area of the brain most involved in emotion is called the limbic system. This system includes three important structures within the brain:

• The hypothalamus
• The amygdala
• The hippocampus

These structures help the brain control emotional responses. They are what allow us to react appropriately to emotional situations. Thus, if a brain injury damages these structures, the person may lose control of their emotions.

Another part of the brain that plays a role in emotion is the cingulate cortex, which connects to the limbic system. The cingulate cortex helps translate emotions into facial expressions.

Therefore, if this cortex becomes damaged, a person will have trouble expressing emotions with their face and voice. Psychologists call this lack of emotional expressiveness after brain injury “flat affect” because the person’s voice often has a flat, monotonous sound.

Other Reasons Why Someone May Lack Emotional Expression

Not every TBI survivor who shows a lack of emotion has flat affect. Other conditions that can cause similar symptoms after brain injury include:

• Depression. Depression is unfortunately common after brain injury and can interfere with the way the brain processes emotion. This causes people to lose interest in things that they used to enjoy, which makes them seem detached and apathetic.
• PTSD (Post-traumatic stress disorder). This disorder is also common after brain injury. One of the main symptoms of PTSD is emotional suppression and withdrawal.
• Facial paralysis. Sometimes brain injury can damage the nerves that control facial expression. This can make it difficult for the person to display emotions through their facial expressions.

In addition, some medications can also impact the way a person feels and shows emotion.

Symptoms of Flat Affect

Persons who experience flat affect after brain injury often show certain symptoms, such as:

• Monotone speaking
• No change in facial expression
• Avoidance of eye contact
• Neutral body language (i.e. relaxed and staying still in a situation where they should be tense)

It’s important to realize that patients with flat affect can still experience emotions, they have simply lost the ability to express themselves.

People with brain injury can also develop a condition known as blunted affect or “emotional blunting.”  Symptoms of blunted affect are similar to flat affect, but instead of showing no emotions, the person’s expressions are simply restrained.

Blunted affect is most common in patients with PTSD.

These symptoms can make the person appear as though they do not care about anything or other people. But for most brain injury patients, this is not true. They do care, they just are having difficulty showing it.

Treating Flat Affect After Brain Injury

The best way to treat flat affect after brain injury is to address the root causes.

For example, it is possible that your depression or PTSD is causing you emotional problems. Addressing them with a therapist and medication may help lift your flat affect.

Sometimes, flat affect can occur jointly with other cognitive effects that make it difficult for patients to understand which emotions they feel. In those cases, cognitive-behavioral therapy can be useful.

Using Cognitive-Behavioral Therapy for Flat Affect

CBT therapists can teach patients how to identify their emotions and react appropriately. They do this through a series of exercises that help a person better understand their behavior and the emotions that might have caused it.

Cognitive-behavioral therapy can also retrain people to use facial expressions when interacting with others. For example, a therapist might help you learn to smile and make eye contact when you say hello to someone.

The more you practice these behaviors, the more you will rewire your brain until these actions feel natural again.

Speech Therapy

Another therapy that can help you overcome flat affect is speech therapy. Specifically, speech therapy can help you eliminate a monotone voice.

A monotone voice usually occurs after a right hemisphere injury. The brain’s right hemisphere controls a person’s awareness and appreciation of music. This awareness also plays a part in the way we speak.

When a person suffers damage to the right side of their brain, not only can their ability to appreciate music be diminished, but they may also have trouble picking up on the subtle changes in pitch or tone during speech.

This diminished musical ability can cause the person to sound monotone when speaking, giving them an almost robotic voice.

Speech therapists can help you regain the ability to control the pitch and tone of your voice. They do this through a therapy called melodic intonation therapy (a.k.a. music therapy).

Once again, the more you practice music therapy, the better you will get at controlling your voice. That’s the power of neuroplasticity! 

Caring for Someone With Flat Affect After Brain Injury

When a loved one has flat affect, it can often feel like they have become cold and withdrawn, which can put a strain on relationships.

It might help to remember that your loved one most likely is just as frustrated by their lack of emotions as you. But while they can’t translate their feelings into physical or verbal expressions, that doesn’t mean they don’t care.

Still, it’s important to take care of your own mental health too. You might want to consider talking to a therapist familiar with brain injury. They can offer more personalized advice for coping with flat affect.

Overcoming Flat Affect After Brain Injury

Flat affect can be a challenging symptom of brain injury to deal with. But fortunately, there is hope for recovery.

Whether your lack of emotions is caused by depression or brain damage, cognitive and speech therapy can help. By practicing emotional expression with a therapist, you can rewire the brain to express emotion again.

Even if you don’t feel emotions right away, learning how to better communicate non-verbally can help improve important relationships in your life.