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is trying to suppress the anger they feel about

Emotions revealed: recognising facial expressions their illness, so you get just a brief glimpse of
his or her emotion.
In the first of two articles on how recognising faces and feelings can help you Subtle expressions —These are not usually as
communicate, Paul Ekman, discusses how recognising emotions can benefit brief, but they are often missed because they
you in your professional life are so faint. They occur when an emotion is
just beginning, is slight, or when a person is

here are seven emotions that are trying to conceal it.
expressed on the face in the same way While the voice is as important as the face in
in every different culture (box 1).1 conveying emotion, to my knowledge no tool
These universal facial expressions are innate; is available to help you spot subtle expres-
they are not learnt. This explains why con- sions of emotion in the voice. In contrast,
genitally blind people show the same facial some recognised tools can help you spot
expressions attached to each of these seven micro expressions and subtle expressions on
emotions as sighted people.2 If you can learn the face.4 5
to recognise these facial expressions in your
patients (and some of the expressions may be Putting it into practice
brief or subtle), you will have greater insight Here are some examples of how to spot brief
into their emotions.3 or subtle expressions of two specific emo-
tions that you will often encounter in your
How can reading faces be valuable? patients—anger and sadness. (Reference 3
In any except the most trivial relationships, discusses in detail how to spot the other
how the other person is feeling, and our universally expressed emotions.)
acknowledgment of that, can make all the
difference in the world. For example, if we Anger
can recognise that someone is feeling Have a look at photograph A, and compare it
sad—whether it’s our child, our spouse, our with the neutral face in photograph B, which
patient, or a junior doctor—it can be helpful Photograph A: a subtle expression of anger is devoid of emotion. Photograph A has two
to be able to respond to his or her sadness. If subtle signals of anger. The first is that the
we can identify people’s emotions early on, lips are slightly narrowed and pressed
we are better able to deal with people in a together, and the second is the slight tensing
variety of situations. We are also better able to of the lower eyelids.
manage our own emotional responses to In anger, the jaw is often thrust forward
their feelings. and the lips are pressed together. The lower
Patients bring a variety of emotions with and upper eyelids may be tightened, a subtle
them when they see you, but you are unlikely sign of controlled anger or it may be just
to see these emotions fully expressed. slight annoyance. It can also occur when
Because of their embarrassment, fear, guilt, there is no anger but the person is focusing
or shame, patients do not put their emotions or concentrating on something intensely.
into words or into full facial expressions. So Which expression it is will depend on the
you will usually see only subtle traces of these context.
emotions on their faces.
Brief or subtle facial expressions Compare photograph C with the neutral
You do not need to be taught how to spot full face in photograph B. Photograph C has two
facial expressions of emotion, as these are subtle signs of sadness. The first is the
easy to recognise and we already have a natu- angling upwards of the inner corners of the
ral ability to do this. For example, Charles eyebrows. This is a reliable sign of sadness
Darwin commented that when the nanny because few people can make this movement
taking care of his toddler, William, made a voluntarily, so it could rarely be deliberately
Photograph B: a neutral facial expression
crying face, William went over to her and fabricated. Even when people are attempting
patted her shoulder in sympathy. Darwin said not to show how they are feeling, these
that William had never before seen anyone obliquely positioned eyebrows will often
cry. So William could not have learnt about reveal their sadness. The second subtle sign
this facial expression. His recognition of a of sadness is the drooping eyelids.
crying face must have been instinctive.
What to do when you spot an emotion
In the real world Emotions never tell you their cause. Suppose
In clinical practice few of us have time for you see that a patient is angry. You cannot
lengthy social transactions; we are too busy know if the patient is angry with you, the
to give patients enough time to allow them to nurse, their spouse, themselves, or whoever
relax and so tell us in words what they are they blame for their situation. That is what you
feeling. You need to encourage them to have to find out. You need to acknowledge
express themselves. The first step is to be able that something is bothering the patient and
to spot the subtle signs on their faces about find out what it is. You cannot assume you
how they are feeling. know the cause. You must avoid Othello’s
There are two types of subtle signs that error (box 2). Emotions do not tell you what is
you can learn to recognise:3 generating the emotion, only that the emotion
Micro expressions —These are extremely brief, is occurring.
lasting about 0.2 seconds. Everyone who You have to be careful. If you do not know
shows a micro expression is trying, con- the patient well the best response may be to
sciously or subconsciously, to conceal an say something general. For example: “I think
emotion. For example, perhaps your patient Photograph C: a subtle expression of sadness that in the last moment or two there was


career focus
you want one, that’s fine with me.” But the
Box 1: The seven emotions urologist needs to be able to spot the fear in Box 2: Othello’s error
the first place to intervene in this way.
universally expressed on the Othello accuses his wife Desdemona of
face loving Cassio. Othello tells her to
Facial expressions and illness
confess since he is going to kill her for
+ Sadness While it is true that many diseases have a
her treachery. Desdemona asks Othello
+ Anger characteristic face—such as Turner’s syn-
to call Cassio to testify to her innocence.
+ Surprise drome or Down’s syndrome—there are no
Othello says he has already had Cassio
+ Fear emotional expressions on the face that are
murdered. Desdemona realises that she
+ Enjoyment unique to a specific disease. A patient with will not be able to prove her innocence
+ Disgust depression, for example, shows a lot more and that Othello will kill her.
+ Contempt sadness and anger than people who are not
Desdemona: Alas, he is betrayed, and I
depressed, and they show it in response to
things that most people would not be sad or
Othello: Out, strumpet! Weep’st thou for
something upsetting you. Can you tell me angry about. They do not have a facial
him to my face?
about it? Can you tell me how you’re feel- expression that is pathognomonic of Desdemona: O, banish me, my lord, but
ing?” Or you might say: “I just had the sense a depression. kill me not!
moment ago that there were a few things that But emotional facial expressions can give Othello: Down, strumpet!
flashed through your mind. Maybe I misread you a clue to a patient’s prognosis. In a study
So what was Othello’s error? Not the
you, but if there are some feelings you examining the facial expressions of people
failure to spot how Desdemona was
haven’t told me about—it would be really with established coronary artery disease we
feeling, for he knew she was anguished
helpful if you could talk about them.” found that we could predict who would have
and afraid. His error was believing that
In some situations you may know the further ischaemic episodes.6 While we all talk emotions have only one source—he
patient better and you may know about his or about frustrating events in our life (for interpreted her anguish as due to the
her fears. You can be more direct and say example, “It took me an hour to drive to work news of her supposed lover’s death and
something such as: “Everyone’s afraid of hav- today and people kept cutting in front of me”), her fear as that of an unfaithful wife
ing this biopsy,” or, “This is the kind of thing only some of us get angry when we talk about caught in betrayal. He kills her without
that gets a lot of people upset and angry.” So these frustrations. The patients with heart dis- considering that her emotions were
what you say depends on how well you know
ease who showed this anger on their faces in those of an innocent woman who knows
the person and the specific context of your
response to frustration were significantly that her intensely jealous husband is
more likely to get ischaemia. about to kill her and she cannot prove
Patients might give their doctor the right
Emotions are not at the root of heart her innocence.
to know everything about them, including
their emotions. So I would encourage doc- disease but they may aggravate physical
tors to at least take that first step in saying, “I disease, make treatment harder, or make
saw something more, I heard something cooperation between doctors and patients If you can learn to recognise these signals,
more, I sensed something more in what you more difficult. you have a powerful tool for communication.
just told me.” Your patients expect you to ask
them about their feelings. Paul Ekman professor of psychology at the
Patients bring a University of California, San Francisco, spoke to
A clinical scenario Gavin Yamey assistant editor, BMJ Learning.
variety of emotions
Here is a scenario which shows what a doctor Competing interests: Paul Ekman is the author of
might say on spotting an emotion. with them when they the book Emotions Revealed and of the two train-
A urologist says to his patient: “Your pros- see you ing tools “Micro Expression Training Tool” and
“Subtle Expression Training Tool.”
tate 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 Competition
variety of reasons—fear of prostate cancer or Facial expressions and culture Career Focus has a copy of Paul Ekman’s book
impotence and incontinence from cancer Individuals differ in what triggers their emo- Emotions Revealed and the training tool CDs
treatments. The news is a source of potential tions and in their attitudes towards doctors. “Micro Expression Training Tool” and “Subtle
shame because discussions of prostate dis- For example, some cultural groups feel it is Expression Training Tool” to share among
ease entail discussing the penis. It is far easier inappropriate ever to show their emotions to three readers who can best express what a
to see your orthopaedic surgeon about your a doctor. Some cultures will be more afraid of particular emotion looks and feels like (word
shoulder or your knees. The relationship we certain things than other cultures. Some will count 500 or less). Please send your entries to
have with our urologist or gynaecologist is a
have greater feelings of embarrassment or
sensitive one. For more information about Paul’s
shame about different parts of their body.
Even with a procedure like a prostate research see
But the same facial expressions of emotion
biopsy, what the patient usually wants to be To find out more about the tools discussed
are seen in every culture. The emotions that
able to say is: “Is this a good time to get a in this article see
register on your face are the same no matter
second opinion before proceeding with this who you are—whether you are young or old
invasive procedure?” But patients often do 1 Ekman P, ed. Charles Darwin’s The expression of the emo-
and regardless of your education or culture. tions in man and animals. 3rd ed. London: HarperCollins
not want to spoil the relationship. This fear and New York: Oxford University Press, 1998.
So learning to spot these facial expressions
may stop them from asking whether a sec- 2 Galati D, Scherer KR, Ricci-Bitti PE. Voluntary facial
can be a useful tool in working with patients expression of emotion: comparing congenitally blind
ond opinion would be a good idea. If the
in a multicultural setting. with normally sighted encoders. J Pers Soc Psychol
urologist spots the subtle signs of fear on 1997;73:1363-79.
their patient’s face, he or she should be able 3 Ekman P. Emotions revealed. New York: Times Books,
to reassure them. The doctor should be able Conclusions 2003.
Emotions are expressed on your patients’ 4 Ekman P. Micro expression training tool. CD-ROM.
to say: “I see there’s a little hesitancy on your
part—I wonder what that’s about?” or, “Look, faces, but often the expression is brief or 5 Ekman P. Subtle expression training tool. CD-ROM.
this is so routine that everyone will probably subtle. Yet the expression, however slight or
6 Rosenberg EL, Ekman P, Jiang W, et al. Linkages
suggest you have a prostate biopsy, so you subtle, is an efficient signal—clear, rapid, and between facial expressions of emotion in transient
probably don’t need a second opinion, but if universal—of what your patients are feeling. myocardial ischemia. Emotion 2001;1:107-15.