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is trying to suppress the anger they feel about
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
T
here 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 con-
genitally 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 natu-
ral 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 recognise:3
Micro expressions —These are extremely brief,
lasting about 0.2 seconds. Everyone who
shows a micro expression is trying, con-
sciously or subconsciously, to conceal an
emotion. For example, perhaps your patient
BMJ CAREERS 21 FEBRUARY 2004
Photograph A: a subtle expression of anger
Photograph B: a neutral facial expression
Photograph C: a subtle expression of sadness
their illness, so you get just a brief glimpse of
his or her emotion.
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 expres-
sions of emotion in the voice. In contrast,
some recognised tools can help you spot
micro expressions and subtle expressions on
the face.4 5
Putting it into practice
Here are some examples of how to spot brief
or subtle expressions of two specific emo-
tions 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
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 career focus
Box 1: The seven emotions
universally expressed on the
face
+ Sadness
+ Anger
+ Surprise
+ Fear
+ Enjoyment
+ Disgust
+ Contempt
something upsetting you. Can you tell me
about it? Can you tell me how you’re feel-
ing?” 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 hav-
ing 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 doc-
tors 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 clinical scenario
Here is a scenario which shows what a doctor
might say on spotting an emotion.
A urologist says to his patient: “Your pros-
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
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 dis-
ease 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 sec-
ond 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
76
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.
Facial expressions and illness
While it is true that many diseases have a
characteristic face—such as Turner’s syn-
drome 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 dis-
ease 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.
Patients bring a
variety of emotions
with them when they
see you
Facial expressions and culture
Individuals differ in what triggers their emo-
tions 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.
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.
Box 2: Othello’s error
Othello accuses his wife Desdemona of
loving Cassio. Othello tells her to
confess since he is going to kill her for
her treachery. Desdemona asks Othello
to call Cassio to testify to her innocence.
Othello says he has already had Cassio
murdered. Desdemona realises that she
will not be able to prove her innocence
and that Othello will kill her.
Desdemona: Alas, he is betrayed, and I
undone!
Othello: Out, strumpet! Weep’st thou for
him to my face?
Desdemona: O, banish me, my lord, but
kill me not!
Othello: Down, strumpet!
So what was Othello’s error? Not the
failure to spot how Desdemona was
feeling, for he knew she was anguished
and afraid. His error was believing that
emotions have only one source—he
interpreted her anguish as due to the
news of her supposed lover’s death and
her fear as that of an unfaithful wife
caught in betrayal. He kills her without
considering that her emotions were
those of an innocent woman who knows
that her intensely jealous husband is
about to kill her and she cannot prove
her innocence.
If you can learn to recognise these signals,
you have a powerful tool for communication.
Paul Ekman professor of psychology at the
University of California, San Francisco, spoke to
Gavin Yamey assistant editor, BMJ Learning.
Competing interests: Paul Ekman is the author of
the book Emotions Revealed and of the two train-
ing tools “Micro Expression Training Tool” and
“Subtle Expression Training Tool.”
Competition
Career Focus has a copy of Paul Ekman’s book
Emotions Revealed and the training tool CDs
“Micro Expression Training Tool” and “Subtle
Expression Training Tool” to share among
three readers who can best express what a
particular emotion looks and feels like (word
count 500 or less). Please send your entries to
careerfocus@bmj.com
For more information about Paul’s
research see www.paulekman.com
To find out more about the tools discussed
in this article see www.emotionsrevealed.com
1 Ekman P, ed. Charles Darwin’s The expression of the emo-
tions 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
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.
BMJ CAREERS 21 FEBRUARY 2004