As occupational therapists, we care about facilitating participation in meaningful occupations and improving human quality of life, especially for people with physical or mental diseases. We help patients or clients with functional restriction participate in what they want to do in daily life through the purposeful and therapeutic use of activities. Occupational therapy’s viewpoint is that human occupational performances can be categorized as social participation, daily living activities, work, leisure, etc. Social interaction has been one of the main focuses of therapy for people with impairments, such as patients with Parkinson’s disease. Patients with Parkinson’s disease often complain that, when interacting with family, age peers, or medical practitioners, they have difficulty conveying messages through facial or bodily movements, since disease symptoms have impaired their faculties. Furthermore, medical practitioners, including occupational therapists, are also likely to misjudge patients’ emotions or motivation during therapy process if practitioners disregard the possible influence of patients’ symptoms on their expression. These clinical needs motivated my one-year Fulbright research project in the U.S. Through academic exchange, I hope to generate new contributions to clinical practice of occupational therapy for patients with Parkinson’s disease. During this Fulbright research, I have been focusing on finding out whether specific facial or bodily movements can be used to detect depressive emotion in patients with Parkinson’s disease. In this past semester, I have gained deeper knowledge of relevant research results and theories, which I summarize below.
Parkinson’s disease and its negative influences on patients’ life
Parkinson’s disease is a neurodegenerative disease that is caused by dysfunctional substantia nigra of basal ganglia in the brains, leading to insufficient dopamine secretion. This neural deficit impairs the normal coordination of different motor signals in the brain and leads to inadequate control over facial and bodily muscles. The central symptoms of Parkinson’s disease include movement tremor, muscle rigidity, and slowness of movements (i.e. bradykinesia). Since muscle movements are fundamental abilities, satisfying personal and environmental needs as basic as picking up a glass of water to drink, typing words during work, or smiling when people hear a joke from friends, their impairment comprehensively influences ability to work, care for themselves, and interact socially, causing huge distress in people’s life.
Expressive behaviors in patients are adversely affected
Facial and bodily movements play a crucial role in expressing one’s emotions and personality, yet are known to be impaired in patients with Parkinson’s disease. The symptoms of rigidity and bradykinesia in facial muscles hamper spontaneous or voluntary facial movements and limit facial expressivity, which leads to so-called facial masking. Free bodily movements are also impeded by symptoms of rigidity, bradykinesia, and tremor in patients. Parkinson’s disease makes it difficult for caregivers or friends of patients, and even medical practitioners, to discern patients’ actual moods. Patients may look indifferent or angry in communication, though they are actually in a good mood. This dissociation between experienced emotion and outward expression is one of the major complaints in patients’ daily life because it is an obstacle to mutual understanding. Facial masking and stiff bodily movements severely decrease patients’ satisfaction with social participation and quality of life. Given patients’ diminished expressivity, I developed a research question: Is it still possible to detect authentic emotion in patients with Parkinson’s disease during communication? My literature review revealed a handful of research articles that answer this question in part.
Patients’ personality could be conveyed through expressive behaviors
Expressive behaviors are used to convey a person’s emotion and personality. Although it is still unclear whether patients with Parkinson’s disease can display their emotion by facial or bodily movements, studies focusing on the relationship between personality and expressive behaviors in patients have shown some interesting results. A study by Lyons, Tickle-Degnen, Henry, and Cohn (2004) explored whether the personality of patients with Parkinson’s disease could be conveyed effectively by their expressive behaviors. The authors interviewed six female and six male patients with Parkinson’s disease and captured the interview process by a videocamera. The thin-sliced method was used to extract 2-minutes clip from each participant’s videotape. Observers rated 11 expressive behaviors in clips based on the gestalt of duration, frequency, and intensity, producing data about expressive behaviors in patients with Parkinson’s disease. Patients also completed a self-reported measure of personality, reflecting five personality traits: Neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness.
The important result of the correlational analysis in the study indicated that there are still some valid cues in expressive behaviors that could effectively convey patients’ personality traits. Brow furrowing is an observable cue of neuroticism, which means the lack of security, easily worrying about matters, anxiety, and emotional suffering. Less formal attire also implies the personality trait of being opener to experience, which means innovation and curiosity about the surroundings. This study revealed that even if diminished expressivity is a main symptom in patients with Parkinson’s disease, medical practitioners still have the possibility to make correct judgments on patients’ personality when relying on specific cues (brow furrowing, and formality of dress) in expressive behaviors. For patients with Parkinson’s disease, reduced expressivity due to the disease does not necessarily amount to the complete loss of expressive behaviors. On the basis of this study result, it is reasonable to hypothesize that patients’ emotional state could also be conveyed by outward expressive movements.
The relationship between the depressive emotion and expressive behaviors
Another interesting study, by Girard et al. (2014), investigated the relationship between depression severity and expressive behaviors in patients with major depressive disorder. Although this study did not focus on patients with Parkinson’s disease, it showed the possibility of distinguishing the severity of depression on the basis of observing expressive behaviors in patients. Depression has traditionally been the emotion most difficult to detect on the basis of outward behaviors because it involves the observation of “diminished” behaviors, not “increased” behaviors. The study by Girard et al. (2014) made a breakthrough by testing three extant hypotheses of depression and revealing “increased” expressive behaviors that are related to depression. The three depression hypotheses were: the Affective Dysregulation hypothesis, the Emotion Context Insensitivity hypothesis, and the Social Withdrawal hypothesis. The Affective Dysregulation hypothesis argues that the depressive state is marked by an increase in negative emotion behaviors and a decrease in positive emotion behaviors. The Emotion Context Insensitivity hypothesis states that depression represents deficient motivation, leading to complete reduction in all expressive behaviors no matter what kind of emotion is involved. These two hypotheses are the traditional ones explaining depression. The third hypothesis, the Social Withdrawal hypothesis, proposed by Girard et al. (2014), interprets that the depression state features an increase in hostile expressions and a decrease in social engagement, meaning that depression is marked by increased non-affiliative behaviors and decreased affiliative behaviors to keep or enlarge interpersonal distance.
In the study, 19 patients with major depressive disorder were evaluated. Coders in this study rated four action units of facial expressions: lip corner puller (affiliative, as a typical expression of happiness), dimpler (non-affiliative, as a typical one of contempt), lip corner depressor (affiliative, as typical of sadness and expression of empathy), and lip presser (non-affiliative, as typical of anger). Interviewers in the study also evaluated the severity of depression in patients by using the Hamilton Rating Scale for Depression. The results supported the Social Withdrawal hypothesis, indicating that under the situation of high depression severity, patients had increased occurrence of non-affiliative expressive behaviors (dimpler) and decreased occurrence of affiliative expressive behaviors (lip corner puller and lip corner depressor) compared with the situation of low depression severity. These results suggest that medical practitioners may rely on some facial cues (lip corner puller, lip corner depressor, and dimpler in particular) to judge depression severity in patients with major depressive disorder. The depressive emotion could be displayed not only in decreased expressive movements (lip corner puller and lip corner depressor), but also in increased expressive ones (dimpler) in those patients. This research result is helpful for researcher and clinical practitioners because it reduces the difficulty in judging depression in patients.
For occupational therapists, accurate judgment of patients’ emotions contributes to the establishment of practitioner-patient rapport and the design of appropriate treatments. The hypothesis I would like to test during my Fulbright research is whether it is still possible to perceive depressive emotion from facial or bodily movements among patients with Parkinson’s disease, who have limited expressivity due to motor symptoms. After my return to Taiwan, I hope to integrate this psychosocial-oriented result into original biomedical-oriented ones produced in Taiwan. This academic and cultural exchange will benefit the future collaboration and the professional development of occupational therapy in the U.S. and Taiwan.
Girard, J. M., Cohn, J. F., Mahoor, M. H., Mavadati, S. M., Hammal, Z., & Rosenwald, D. P. (2014). Nonverbal social withdrawal in depression: Evidence from manual and automatic analyses. Image and Vision Computing, 32, 641-647. doi: 10.1016/j.imavis.2013.12.007
Lyons, K. D., Tickle-Degnen, L., Henry, A., & Cohn, E. S. (2004). Behavioural cues of personality in Parkinson's disease. Disability and Rehabilitation, 26, 463-470. doi: 10.1080/09638280410001663030