Flat Affect and Brain Injury Dr. Celeste Campbell, BrainLine

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My sister sustained a brain injury more than six months ago. She is making progress, but she is depressed, and often she seems to have no emotions. It’s like she’s a blank most of the time. The doctors mentioned something called “flat affect.” Can you explain to me what exactly this is and will it go away? Also, is this from the brain injury or from the depression?

“Flat affect” is a common symptom after a traumatic brain injury. Affect refers to our emotional expressiveness — the degree to which our facial expression and demeanor reflect what we are feeling. People with flat affect may not show the normal signs of emotion, may appear apathetic, may speak in a monotone, and may not change the expression of their emotions in response to varying situations as we expect them to. They may also appear nonresponsive to the emotions of others. In the brain, expression of affect occurs in the frontal lobe function, with specific localizations within the right hemisphere, cingulate cortex, limbic system, and in other areas that are involved in arousal.

For someone like your sister, flat affect may or may not occur in conjunction with deficits in her ability to actually feel different emotions and/or her ability to identify and label her emotions. A careful assessment by a neuropsychiatrist or neuropsychologist is often necessary to tease out just what the level of the person’s emotional experience is.

Flat affect can be a factor of both the depression (also a common symptom after TBI) and the brain injury itself. As the depression is treated, through therapy and/or medication, you may see some lifting of the flatness as your sister becomes more emotionally responsive. Also, recovery is still occurring at six months post injury, so you may see more improvement over time. For some people, however, flat affect can be permanent.

Depending on your sister’s level of awareness, intervention may involve teaching her to recognize what her level of emotional expressiveness is and how others may read it. She can then learn and practice varying emotional expressions to show how she is feeling and how she wants others to perceive her. As with any other cognitive function following brain injury, intervention includes a combination of psychoeducation, remedial training/rehabilitation, teaching of compensatory strategies, and family/friend participation. A cognitive rehabilitation specialist — a speech therapist or a neuropsychologist — can work with your sister and with those around her to help her better express some emotion nonverbally, a step toward ensuring improved acceptance and integration into social activities and closer interpersonal relationships.

Click here to go to About Ask the Expert.

Celeste Campbell, PsyD, Dr. Campbell is a neuropsychologist in the Polytrauma Program at the Washington, DC Veterans Administration Medical Center. She completed a postdoctoral fellowship in Rehabilitation Neuropsychology at National Rehabilitation Hospital and has served as adjunct faculty for the George Washington University Graduate Certificate Program in Special Education and Traumatic Brain Injury. Dr. Campbell has a long history of providing cognitive psychotherapy and developing residential behavioral management programs for children and adults with a variety of cognitive deficits, including learning disability, developmental disability and traumatic brain injury. She has served as adjunct faculty for the George Washington University Graduate Certificate Program in Special Education and Traumatic Brain Injury. In addition she has been a frequent presenter and workshop facilitator, addressing psychological, neuropsychological and cognitive issues following brain injury to survivors and their families and friends, rehabilitation and vocational specialists, special education teachers, and case managers. She has appeared on The Donahue Show, Taking the ‘Dis’ out of Disability, and PBS’ Exploring the Brain with Garrick Utley.

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