Flat Affect and Brain Injury

Question: 

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?

Answer: 

“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.

 

Posted on BrainLine November 15, 2010

Celeste Campbell

Dr. Celeste Campbell is a neuropsychologist in the Polytrauma Program at the Washington, DC Veterans Administration Medical Center. She has a long history of providing cognitive psychotherapy and developing residential behavioral management programs for children and adults.

Comments

I have suffered a tramuatic brain injury and still going through the rehab process.
The flat affect comes from the brain injury. She might be in brain fog. Brain fog, fogs up your emotions. Plus you don't know you are in it. So you don't know how to act on top of it.
I use to be like this. I haven't been like this for 8 months now.

Does this happen throughout the life of a survivor then feel better for some time then happens again?
Its happened to me ever since i had my injury

Is your sister really depressed or does she have what's called 'pseudo depression'? ie looks like depression, but is actually other things. I had the blankness and flat affect for years and still do but not as bad. I just want to say it can help a lot if you show emotion to us as in a touch, a smile or kindness. Its almost as if it has to be initiated by someone else. Dont be put off if there seems to be a low level of response. We can be quite blunted, and not realise that smile we are giving is not as big as we think, or we might be having difficulty with coordinating our facial expressions with what we say. I always had my basic emotions but not the sort where you tell yourself to feel certain things. I had feelings even though it looked as if I didnt. Sometimes they come quite a bit after the event. Its individual and things need to be teased out as the writer says. Please be kind to her, it is very odd to be feeling so blank and not be able to connect as before, it means a lot if people can hang in there for you, and perhaps say I cant imagine what this is like for you, this is what i see, but I dont really know what you are experiencing but I do care. One woman I know said to her husband I need a hug right now and to her surprise she got one. Its learning different ways sometimes.

My daughter had flat affect (deadened emotions/feelins) for a long time after her brain injury. She is now 5 years post accident. Just like other areas of her thinking abilities, her emotions "woke up" slowly but surely. When they first "woke up' they were often overwhelming, but this has settled down a lot although she still experiences very high anxiety. The only thing I disagree with in this article is that healing continues for 6 months. We saw major changes in her for the first three years post accident - even now, after 5 years, she is still improving in certain areas. The brain is amazing in its ability to compensate and heal. My daughter did many types of therapy, so I am definitely not saying don't do that, But I also remember strongly the one doctor who said to her "You don't have to work SO hard on improving your brain. It will heal itself at its own pace even if you don't WORK at it all the time" It helped her to balance rehab and rest.

TBI ... you only know it if you live it

My depression hit hard about 5 months out. Got some help with seratonin uptake meds and a good bit of my opitmism, humor and communication began to return at about a year out. I have read many times that TBI's are all different but a combination of support, self help and professional help on meds when
needed is working for me.

Slow is good if success is what we strive for.

The information given to me in your blog has been very informative, always read your post. You get something to learn in a post done by you. Well done. It's a great example of setting a goal and creating that content. Hope you will continue to do such informative posts

I was hoping that the person with the brain injury who tried Brain State Technology could tell more info about it. My questions would be: what type of brain injury do you have, Mild TBI, Moderate or Severe? How exactly does this Brain State Technology work? and how much does it cost? I know this website is not for medical advice, but I would like to hear more about your experience with this technology. The website seamed vague and no prices were listed, which makes me skeptical. Thank you. 

I had a brain injury from a car accident. I suffered from PTSD syndrome, flat affect, couldn\'t focus or concentrate for very long, brain fog, etc. What saved me was Brain State Technology.......in a few treatments I was much better. I was so much better I decided to do more and with each successive round improved in other areas. After watching others also do this I would suggest to anyone especially those suffering with brain injury or depression or PSTD. Good Luck....it turned my life around.
I truly admire your use of these medical terms. May I suggest that though you are educated, many of the folks that do visit and have questions are NOT privy to the words you use. People that have BIs sometimes do not have the wherewithall to figure out long wordy sentences. Your language and ideas have to be simple and very easy to understand. For example; My wife suffered a TBI in 1981 and all these years later she suffers extreme emotional stress. She also cannot remember 4 sets of a number or two. Sequencing is a very big problem. Her ability to stare, read, concentrate and memorize is not there. So, finally, I appreciate your work and your presence here on the web. I will be happier if you apply what I humbly shared with you. Bye now.

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