The Utility of Assessing Nonverbal Communication in the Psychiatric Evaluation

“You see, but you do not observe,” begins Sherlock Holmes in the 1891 short story A Scandal in Bohemia, by Arthur Conan Doyle. The passage that follows illustrates the idea of mindful observation, as Holmes makes a point to distinguish it from just seeing the steps that lead up to the room in which he and Watson stand (1). In fact, this concept of active observation is integral to the practice of medicine. As William Osler said, “the whole art of medicine is in observation” (2). Physicians perform evaluations based on the patient’s communication of ailments. Oxford Dictionary defines communication as “the imparting or exchanging of information” (3). This exchange can take many forms when interacting with a patient. Most commonly what physicians conceptualize as communication is that which is spoken by the patient. However, literature continues to reveal the importance of nonverbal behaviors in communication.

The Study of Nonverbal Communication

All forms of communication other than words can be considered nonverbal communication (4), including vocal tone, facial expressions, posturing, and bodily movements. In his 1882 book, The Expression of the Emotions in Man and Animals, Charles Darwin put forth the idea of bodily movements representing internal emotional states as a result of evolution and inheritance. He argued that these movements we see accompany certain emotional states are universal to our species and that they serve a purpose while in that emotional state (5). This was demonstrated by his understanding of the function of these movements, as muscular movements serve a purpose while in a certain emotional state. The “expression” is the sum of those underlying muscular movements. These expressions serve an evolutionary benefit for survival and evolve into habits that are inherited, known as “serviceable habits” (6).

An example of this can be demonstrated simply by the facial expression for “disgust.” Disgust can be defined as “a feeling of revulsion or profound disapproval aroused by something unpleasant or offensive” (7). From an evolutionary approach, this stimulus must therefore be one that threatens the individual. In the presence of such an offensive stimulus, whether it be a physical substance or a mental thought, the aim of the body is to prevent or remove it (8). The muscles of the face that contract, with the function of preventing/removing the toxin, give rise to the facial expression that represents disgust. This expression is that of a raised upper and lower lip, a raised and wrinkled nose, lowered eyebrows, and raised cheeks. The result is a functional closure of the mouth and nose, thereby preventing the inhalation or ingestion of a toxic substance (9). Over time, this facial expression has come to represent the emotional state of disgust. Thus, the presence of such a facial expression is communicating (nonverbally) disgust at the stimulus—that the stimulus is unpleasant or offensive.

Fast forward 90 years, and it was the paper by Ekman and Friesen (10), “Constants Across Cultures in the Face and Emotion,” that confirmed the universality of human expression of the core emotional states. In this study, in which Ekman and his team assessed facial expressions among isolated tribal members in New Guinea, it was shown that no difference was found in the ability to identify facial expressions when comparing them to other cultural groups. Emotions as separate, discrete entities, and the universal expression of them, have since been proven within many fields such as neuroscience and cross-cultural studies (6). In fact, 88% of experts within fields pertaining to nonverbal communication endorse the existence of “compelling evidence for universals in any aspect of emotion” (11).

Nonverbal Versus Verbal Communication

The importance of understanding nonverbal communication in isolation is of little benefit. Its utility is best served when in comparison with verbal communication. It is the assessment of congruency between the two forms of communication that yield the most valuable information. A patient who states “that’s fine” but shows the facial expression of disgust and looks away while saying it is communicating something much different than the patient who leans forward and looks directly at his or her physician and states “that’s fine” while nodding his or her head. Albert Mehrabian classically demonstrated that when inconsistencies in different forms of communication are present, tone and bodily movements are more trusted than is verbal content (words) (12, 13). This demonstrated well that the influence of tone of voice and bodily movements was stronger than that of verbal content when incongruence was present. Attentiveness to such incongruence can be of great utility to physicians when interacting with their patients.

Utility in the Psychiatric Evaluation

Mindfulness of nonverbal communication will allow a physician to better understand the patient. This understanding may come in the form of obtaining more information than is verbally volunteered, distinguishing deception from truths, and achieving better diagnostic clarity. Often, these insights can be gained from only a short time of observing the patient.

These brief samples of patient behavior are known as “thin slices,” which are defined as brief excerpts of expressive behavior that are sampled from a behavioral stream (14). That is, any sample of the patient’s behavior that is enough to predict traits of the patient. In usually less than 5 minutes—even as short as seconds—these brief excerpts provide a window into the patient’s state (14). Often, they provide information that the patient may not volunteer.

A common example of brief moments of patient behavior that are very telling, in as short as seconds, is smiling. Patients often smile habitually, as a smile is socially accepted as warm, engaging, and overall positive. But a well-attuned physician may be able to identify the type of smile. For clinical purposes, a useful distinction to make may be of enjoyment versus nonenjoyment smiles. That is, smiles that are truly representing positive emotions of happiness and are subconscious (and hence, true representations) versus smiles that are consciously created for social purposes. The “Duchenne smile,” named after French neurologist Guillaume Duchenne, involves the orbicularis oculi, pars lateralis, and zygomatic major muscles in conjunction, whereas other types of smiles do not (15). The Duchenne smile is the best smile to indicate enjoyment and positive effects of happiness. It is distinguished from other smiles by the involvement of the musculature surrounding the orbit, which can be seen as wrinkling around the lateral sides of either eye. This visible difference can help identify smiles created deliberately to conceal the experience of negative emotion, which may aid physicians in identifying deception.

Deception in the patient-physician interaction has been a long-standing challenge to physicians. Usually deception in the clinical encounter is motivated by themes of exploitation, protection, and shame (16). Often, physicians rely on inconsistencies in the story or the patient’s report of symptoms to determine deceit (17). However, as Darwin stated in 1882, “They [the movements of expression] reveal the thoughts and intentions of others more truly than do words, which may be falsified” (5). In fact, even when facial movements are attempted to be falsified, there is leakage of those muscles that cannot be consciously controlled (18).

Later, the discovery of “microexpressions,” expressions lasting 1/25 to 1/5 of a second, were shown to represent such leakage and reveal true emotional states (19, 20). The Facial Action Coding System has since been developed by Paul Ekman and his team as an objective method for quantifying facial movements, and it has been used not only in clinical settings but also in research, law enforcement, and behavioral detection settings.

Observation of the congruency of verbal and nonverbal communication provides physicians with a great amount of information that can guide their diagnostic formulation of the patient. The common “feel” of a patient within the first few moments of an encounter speaks to this and demonstrates the profound effect of nonverbal communication, even subconsciously. Studies have shown that “thin slices” can accurately predict personality disorders (21), as many psychiatrists will attest to when they speak of a patient giving off that “feel” of a personality disorder. The intuitive feel of a patient with schizophrenia, described in 1941 as “praecox feeling” by Dutch Psychiatrist H.C. Rumke, has also been associated with predicting the disorder (22). “Thin slices” also accurately predict depression (23), and even suicide risk for attempts (24) and reattempts (25). Anxiety varies based on whether it is an acute state anxiety or a chronic trait anxiety, as state anxiety is better communicated verbally, and trait anxiety is better communicated nonverbally (26). This demonstrates that even chronic states can be predicted by a momentary observation of nonverbal communication.

Conclusions

Physicians will benefit from being more mindful of nonverbal behaviors, as it allows for better diagnostic clarity in the psychiatric evaluation. Young physicians would benefit from increased education and training on the topic of nonverbal behaviors by their education and training programs. Doing so will allow for an increased emphasis on objective portions of documentation, such as the Mental Status Examination, and will also allow for more accurate assessments and evaluations.

Key Points/Clinical Pearls