Emotions revealed: recognising facial expressions

In the first of two articles on how recognising faces and feelings can help you communicate, Paul Ekman discusses how recognising emotions can benefit you in your professional life

There are seven emotions that are expressed on the face in the same way in every different culture (box 1).¹ These universal facial expressions are innate; they are not learnt. This explains why congenitally blind people show the same facial expressions attached to each of these seven emotions as sighted people.² If you can learn to recognise these facial expressions in your patients (and some of the expressions may be brief or subtle), you will have greater insight into their emotions.³

How can reading faces be valuable?

In any except the most trivial relationships, how the other person is feeling, and our acknowledgment of that, can make all the difference in the world. For example, if we can recognise that someone is feeling sad--whether it's our child, our spouse, our patient, or a junior doctor--it can be helpful to be able to respond to his or her sadness. If we can identify people's emotions early on, we are better able to deal with people in a variety of situations. We are also better able to manage our own emotional responses to their feelings.

Patients bring a variety of emotions with them when they see you, but you are unlikely to see these emotions fully expressed. Because of their embarrassment, fear, guilt, or shame, patients do not put their emotions into words or into full facial expressions. So you will usually see only subtle traces of these emotions on their faces.

Brief or subtle facial expressions

You do not need to be taught how to spot full facial expressions of emotion, as these are easy to recognise and we already have a natural ability to do this. For example, Charles Darwin commented that when the nanny taking care of his toddler, William, made a crying face, William went over to her and patted her shoulder in sympathy. Darwin said that William had never before seen anyone cry. So William could not have learnt about this facial expression. His recognition of a crying face must have been instinctive.

In the real world

In clinical practice few of us have time for lengthy social transactions; we are too busy to give patients enough time to allow them to relax and so tell us in words what they are feeling. You need to encourage them to express themselves. The first step is to be able to spot the subtle signs on their faces about how they are feeling.

There are two types of subtle signs that you can learn to recognise³:

1. Micro expressions--These are extremely brief, lasting about 0.2 seconds. Everyone who shows a micro expression is trying, consciously or subconsciously, to conceal an emotion. For example, perhaps your patient is trying to suppress the anger they feel about their illness, so you get just a brief glimpse of his or her emotion.
2. Subtle expressions--These are not usually as brief, but they are often missed because they are so faint. They occur when an emotion is just beginning, is slight, or when a person is trying to conceal it.

While the voice is as important as the face in conveying emotion, to my knowledge no tool is available to help you spot subtle expressions of emotion in the voice. In contrast, some recognised tools can help you spot micro expressions and subtle expressions on the face.⁴⁵

Putting it into practice

Here are some examples of how to spot brief or subtle expressions of two specific emotions that you will often encounter in your patients--anger and sadness. (Reference 3 discusses in detail how to spot the other universally expressed emotions.)

Anger

Have a look at photograph A, and compare it with the neutral face in photograph B, which is devoid of emotion. Photograph A has two subtle signals of anger. The first is that the lips are slightly narrowed and pressed together, and the second is the slight tensing of the lower eyelids.

In anger, the jaw is often thrust forward and the lips are pressed together. The lower and upper eyelids may be tightened, a subtle sign of controlled anger or it may be just slight annoyance. It can also occur when there is no anger but the person is focusing or concentrating on something intensely. Which expression it is will depend on the context.

Sadness

Compare photograph C with the neutral face in photograph B. Photograph C has two subtle signs of sadness. The first is the angling upwards of the inner corners of the eyebrows. This is a reliable sign of sadness because few people can make this movement voluntarily, so it could rarely be deliberately fabricated. Even when people are attempting not to show how they are feeling, these obliquely positioned eyebrows will often reveal their sadness. The second subtle sign of sadness is the drooping eyelids.

What to do when you spot an emotion

Emotions never tell you their cause. Suppose you see that a patient is angry. You cannot know if the patient is angry with you, the nurse, their spouse, themselves, or whoever they blame for their situation. That is what you have to find out. You need to acknowledge that something is bothering the patient and find out what it is. You cannot assume you know the cause. You must avoid Othello's error (box 2). Emotions do not tell you what is generating the emotion, only that the emotion is occurring.

You have to be careful. If you do not know the patient well the best response may be to say something general. For example: "I think that in the last moment or two there was something upsetting you. Can you tell me about it? Can you tell me how you're feeling?" Or you might say: "I just had the sense a moment ago that there were a few things that flashed through your mind. Maybe I misread you, but if there are some feelings you haven't told me about--it would be really helpful if you could talk about them."

In some situations you may know the patient better and you may know about his or her fears. You can be more direct and say something such as: "Everyone's afraid of having this biopsy," or, "This is the kind of thing that gets a lot of people upset and angry." So what you say depends on how well you know the person and the specific context of your interaction.

Patients might give their doctor the right to know everything about them, including their emotions. So I would encourage doctors to at least take that first step in saying, "I saw something more, I heard something more, I sensed something more in what you just told me." Your patients expect you to ask them about their feelings.

A: angry

A clinical scenario

Here is a scenario which shows what a doctor might say on spotting an emotion.

A urologist says to his patient: "Your prostate specific antigen was high, so we retested it and it is still high, so we want to do a biopsy." For any man this news is a source of fear for a variety of reasons--fear of prostate cancer or impotence and incontinence from cancer treatments. The news is a source of potential shame because discussions of prostate disease entail discussing the penis. It is far easier to see your orthopaedic surgeon about your shoulder or your knees. The relationship we have with our urologist or gynaecologist is a sensitive one.

Even with a procedure like a prostate biopsy, what the patient usually wants to be able to say is: "Is this a good time to get a second opinion before proceeding with this invasive procedure?" But patients often do not want to spoil the relationship. This fear may stop them from asking whether a second opinion would be a good idea. If the urologist spots the subtle signs of fear on their patient's face, he or she should be able to reassure them. The doctor should be able to say: "I see there's a little hesitancy on your part--I wonder what that's about?" or, "Look, this is so routine that everyone will probably suggest you have a prostate biopsy, so you probably don't need a second opinion, but if you want one, that's fine with me." But the urologist needs to be able to spot the fear in the first place to intervene in this way.

B: neutral

Facial expressions and illness

While it is true that many diseases have a characteristic face--such as Turner's syndrome or Down's syndrome--there are no emotional expressions on the face that are unique to a specific disease. A patient with depression, for example, shows a lot more sadness and anger than people who are not depressed, and they show it in response to things that most people would not be sad or angry about. They do not have a facial expression that is pathognomonic of depression.

But emotional facial expressions can give you a clue to a patient's prognosis. In a study examining the facial expressions of people with established coronary artery disease we found that we could predict who would have further ischaemic episodes.⁶ While we all talk about frustrating events in our life (for example,"It took me an hour to drive to work today and people kept cutting in front of me"), only some of us get angry when we talk about these frustrations. The patients with heart disease who showed this anger on their faces in response to frustration were significantly more likely to get ischaemia.

Emotions are not at the root of heart disease but they may aggravate physical disease, make treatment harder, or make cooperation between doctors and patients more difficult.

Facial expressions and culture

Individuals differ in what triggers their emotions and in their attitudes towards doctors. For example, some cultural groups feel it is inappropriate ever to show their emotions to a doctor. Some cultures will be more afraid of certain things than other cultures. Some will have greater feelings of embarrassment or shame about different parts of their body. But the same facial expressions of emotion are seen in every culture. The emotions that register on your face are the same no matter who you are--whether you are young or old and regardless of your education or culture. So learning to spot these facial expressions can be a useful tool in working with patients in a multicultural setting.

C: sad

Conclusions

Emotions are expressed on your patients' faces, but often the expression is brief or subtle. Yet the expression, however slight or subtle, is an efficient signal--clear, rapid, and universal--of what your patients are feeling. If you can learn to recognise these signals, you have a powerful tool for communication.

Gavin Yamey, assistant editor, BMJ Learning

Visit www.paulekman.com and www.emotionsrevealed.com for more information.

studentBMJ 2004;12:133-176 April ISSN 0966-6494

1. Ekman P, ed. Charles Darwin's The expression of the emotions in man and animals. 3rd ed. London: HarperCollins and New York: Oxford University Press, 1998.
2. Galati D, Scherer KR, Ricci-Bitti PE. Voluntary facial expression of emotion: comparing congenitally blind with normally sighted encoders. J Pers Soc Psychol 1997;73:1363-79.
3. Ekman P. Emotions revealed. New York: Times Books, 2003.
4. Ekman P. Micro expression training tool. CD-ROM. www.emotionsrevealed.com
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5. Ekman P. Subtle expression training tool. CD-ROM. www.emotionsrevealed.com
6. Rosenberg EL, Ekman P, Jiang W, et al. Linkages between facial expressions of emotion in transient myocardial ischemia. Emotion 2001;1:107-15.