Emotional expression can be very personal, and not everyone wears their heart on their sleeve. But when you’re unable to express emotions even when you want to and know how to, you may be experiencing flat affect.

“Affect” in psychology refers to the outward expression of your emotion.

It’s different from your mood, which is a pervasive, longer-term emotional status, and it’s not the same as your affective state, which is the overarching emotional tone in the moment.

Affect is how you showcase your feelings to the world through facial expressions, hand gestures, vocal tonality, and nonverbal cues. It’s how you relay to others that you’re happy, sad, irritated, or overwhelmed.

When you live with schizophrenia, your ability to accurately display your affect can be impacted. You may find you’re almost completely unable to express emotions, an experience known as “flat affect.”

Flat affect is a symptom seen in various mental and physical health conditions. It’s defined as little to no outward emotional expression, determined by the absence of facial expressions, body language, eye contact, and speech intonations used to communicate emotion.

In schizophrenia, flat affect is a presentation of “diminished emotional expression,” one of five negative symptoms associated with the condition.

Negative symptoms of schizophrenia include:

  • alogia (diminished speech output)
  • diminished emotional expression
  • anhedonia (reduced ability to experience pleasure)
  • asociality (disinterest or withdrawal from social interactions)
  • avolition (a decrease in self-motivated purposeful activity)

Negative symptoms are those that take away from your baseline level of function, while positive symptoms, like hallucinations and delusions, add features to your current lived experience.

Flat affect in schizophrenia is a severe form of diminished emotional expression, where all or almost all your outward emotional expression is nonexistent. This doesn’t mean you don’t feel emotions — it means you lack the ability to express them.

Symptoms include:

  • not making eye contact
  • impassive or blank facial expression
  • monotone speech
  • absence of nonverbal emotional cues, like hand gestures
  • appearing unmoved or unresponsive to emotionally-stirring experiences
  • a lack of emotional reciprocity with others

Diminished emotional expression in schizophrenia, also known as affective flattening, isn’t limited to flat affect. It can occur on a continuum.

It’s also possible to experience:

  • Restricted (or constricted) affect: Emotional expression below what’s typical.
  • Blunted affect: Very little emotional expression.

Examples of flat affect in schizophrenia

Flat affect doesn’t mean not knowing how to express what you’re thinking during an emotional moment. It’s natural for most people to sometimes find it difficult to express what they’re feeling because they aren’t sure of the best way.

Instead, flat affect is the loss of your ability to outwardly express emotion.

Even if you know exactly how to convey it and have done it in the past, flat affect occurs when your brain can’t connect the emotions you’re feeling to their external expressions.

Examples of how flat affect might look in everyday life:

  • appearing stoic and unmoved during the funeral of your spouse despite significant grief and sorrow from the loss
  • showing no enthusiasm for a major promotion you’ve worked hard to achieve
  • being unable to show joy or excitement when given a thoughtful gift on your birthday
  • not laughing, smiling, or changing your facial expressions when a friend is telling a genuinely funny story

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR), diminished emotional expression and avolition are the two most prominent negative symptoms seen in schizophrenia.

The DSM-5-TR is an evidence-based, internationally used diagnostic tool with insight into trends for mental health conditions, but the exact prevalence of flat affect compared with other types of diminished emotional expression isn’t clear.

Overlapping terminology in literature, variations in self-reported symptoms, and the subjective nature of determining a universal “normal” level of emotional expression make it challenging to precisely measure flat affect in schizophrenia.

Schizophrenia is a mental health condition, but it’s also considered a chronic brain disorder.

It features structural and functional changes in areas of the brain responsible for emotional processing, and these alterations are linked to the negative symptoms seen in schizophrenia, including flat affect.

Genetics, medications, and brain chemistry may also play a role in the development and progression of diminished emotional expression, but more research is needed to fully understand the underlying causes.

Treating flat affect in schizophrenia involves treating schizophrenia as a whole. In general, antipsychotic medications, psychotherapy, and social support interventions are all part of the treatment plan.

According to a 2020 research review, however, antipsychotics, the cornerstone for positive symptoms like hallucinations, appear to be less effective on negative symptoms such as flat affect.

Authors note that some success has been seen in using antipsychotics in combination with antidepressants, but research is limited and has had mixed results.

Similarly, some early success has been reported with approaches like deep transcranial magnetic stimulation (TMS) for treating schizophrenia, but again, more studies are needed.

Ultimately, the most effective treatment for flat affect may come in the form of psychosocial approaches, which strive to help you build insight into attitudes, behaviors, and expectations in schizophrenia. Skill-based interventions can help you work to rebuild emotional communication — or find new ways to express emotion with those closest to you.

The 2020 research suggests that cognitive behavioral therapy (CBT), another gold standard treatment used for positive symptoms in schizophrenia, has also demonstrated moderate, positive effects on negative symptoms.

When a loved one lives with flat affect in schizophrenia, it’s important to remember not to take their lack of emotional responsiveness personally. They aren’t intentionally being distant or uncaring. They may lack the ability — not the desire — to express their emotions.

Once you understand what flat affect is and what it means, it can help prevent miscommunication, frustration, and hurt feelings.

Other ways you can support someone living with flat affect in schizophrenia include:

  • focusing on patience and understanding
  • encouraging continued professional treatment and support
  • allowing them to take time to express themselves
  • validating their emotions — their emotions are there, even if they can’t express them
  • avoiding making emotional demands or placing expectations for emotional responses
  • encouraging social interactions
  • offering to help with tasks or activities they may find challenging
  • working with a professional to develop new ways to communicate emotions
  • encouraging them to take part in healthy lifestyle habits
  • being a knowledgeable mediator with others who might not understand flat affect

Flat affect in schizophrenia is a presentation of “diminished emotional expression.” It describes a total or almost total (and uncontrollable) lack of external emotional cues like facial expressions, eye contact, and vocal tonality.

Flat affect isn’t deliberate, and it doesn’t mean someone lacks emotions. It may be caused by changes in brain structure, chemistry, and function, and it’s one of the two most common negative symptoms seen in schizophrenia.

Flat affect is treated by managing schizophrenia overall. Medications, psychotherapy, and social support may all help improve emotional communication skills.