Hypomimia (Facial Masking) and Its Impact on Social Wellbeing

Parkinson’s disease (PD) is commonly recognized by its motor symptoms, such as tremor and slowness of movement. However, even though non-motor symptoms, like hypomimia, also known as facial masking, are not often publicly understood as being associated with PD, they can significantly impact an individual’s social interactions and overall wellbeing. Hypomimia refers to the reduced ability to display facial expressions due to muscle stiffness and rigidity in the face. Individuals with hypomimia often experience a decrease in spontaneous facial movements, making it difficult to convey emotions and social cues effectively. The symptom affects various facial muscles, including those responsible for smiling, frowning, and raising the eyebrows. This can be especially challenging when paired with speech changes commonly associated with PD, such as reduced voice volume (Gunnery et al., 2016).

Hypomimia can manifest in the very early stages of the disease, often becoming noticeable years before a clinical diagnosis. Despite being one of the earliest symptoms, it
is frequently misinterpreted as a lack of interest by an individual’s social circle or misdiagnosed as depression by physicians. The unique characteristics of hypomimia make it more challenging to evaluate compared to other symptoms of Parkinson’s disease. Unlike many PD symptoms, hypomimia is typically not asymmetric and exhibits variability in response to treatments like levodopa and Deep Brain Stimulation (DBS). Additionally, the lack of objective measurement tools further complicates its accurate assessment (Maycas-Cepeda et al., 2021). People with PD experiencing hypomimia are more prone to heightened interpersonal difficulties, including emotional distress, frustrations within social relationships, and feelings of disconnection from others (Clark et al., 2008).

The Impact on Social Interactions

Social interactions are built on a complex web of verbal and non-verbal communication. Facial expressions play a crucial role in conveying emotions, intentions, and social cues, enabling individuals to connect and empathize with one another. However, for those with hypomimia, these essential non-verbal cues are diminished, leading to various challenges in social interactions. Research has found a significant association between hypomimia and social wellbeing (Gunnery et al., 2016), including the following issues:

1. Emotional disconnect: Hypomimia can create an emotional disconnect between individuals with PD and their peers, as the inability to display facial expressions makes it challenging for others to gauge their emotional state accurately. It can be frustrating when others misinterpret a lack of facial expression as sadness or disinterest. This can also lead to misunderstandings, social awkwardness, and reduced emotional bonding (Clark et al., 2008).
2. Impaired communication: Facial expressions contribute significantly to effective communication. When individuals with PD experience hypomimia, their ability to convey subtle nuances and intentions is compromised. This can result in misinterpretations, confusion, and difficulties in establishing rapport during conversations. Research studies also show that individuals with hypomimia often experience challenges in recognizing and interpreting others’ facial expressions, particularly negative emotions, leading to further communication challenges and reduced empathetic responses (Clark et al., 2008).
3. Social isolation: Hypomimia can lead to social isolation, as others may find it difficult to relate to someone who appears less responsive or engaged. Over time, this can cause individuals with PD to withdraw from social activities, impacting their overall quality of life. People with Parkinson’s who experience more severe hypomimia have reported lower levels of social participation, reduced social support, and consequently decreased social wellbeing (Gunnery et al., 2016).
4. Negative perceptions: Unfortunately, hypomimia can lead to negative perceptions and stigmatization. Due to lack of facial expressiveness, others may mistakenly assume that individuals with PD are uninterested, bored, or lacking in cognitive abilities. These misconceptions can fuel self-consciousness regarding symptoms and a fear of embarrassment, resulting in the creation of social barriers that further isolate individuals with Parkinson’s disease (Prenger et al., 2020).
5. Relational changes with carepartners/caregivers: The psychological effects of hypomimia also impact the relationship between the individual with Parkinson’s and their carepartner/caregiver. According to a research study, carepartners reported challenges in interpreting and understanding the emotional state of loved ones with PD due to their reduced facial expressiveness. This indicates that the impact of hypomimia extends beyond the individual with PD, leading to communication difficulties and emotional disconnect, as well as a potentially compromised social wellbeing of both the person with PD and their carepartner (Gunnery et al., 2016).

Strategies for Coping

While hypomimia poses several challenges, there are strategies that individuals with PD and their loved ones can employ to mitigate its impact on social interactions, such as:

1. Education and awareness: A lack of awareness can act as a barrier to satisfying close relationships. Educating family members, friends, and the community about hypomimia can help dispel misunderstandings and reduce stigma. By promoting greater awareness, individuals touched by Parkinson’s can encourage empathy, patience, understanding, and inclusivity (Gunnery et al., 2016).
2. Compensatory strategies: Individuals with PD can learn compensatory strategies to enhance non-verbal communication. These may include exaggerating facial expressions where possible, using hand gestures, or employing verbal cues to convey emotions effectively. One study found that carepartners of people with Parkinson’s said that asking their partner clarifying questions about their emotional state helped them better navigate social interactions in the presence of hypomimia. They also relied on their familiarity with the person to interpret emotions based on other non-verbal cues or contextual information (Gunnery et al., 2016).
3. Supportive environments: Creating supportive environments that encourage open communication and understanding can make a significant difference. Friends, family, and colleagues can be educated about PD and its associated symptoms to foster an inclusive and accepting social atmosphere. If you feel comfortable and have a supportive network, try explaining your difficulty with muscle control and expression to your loved ones, as this can help them understand you better and increase their awareness of Parkinson’s. Discussing the challenges posed by hypomimia can help bridge the communication gap and strengthen emotional connections (Wootton et al., 2018).
4. Speech and occupational therapy: There are no known effective treatments designed to alleviate hypomimia in Parkinson’s specifically. However, research has found that speech and occupational therapy can assist those with PD in improving facial muscle control and enhancing non-verbal communication. These therapies focus on exercises and techniques that target facial expression and help individuals regain some of their natural expressiveness. The Lee Silverman Voice Treatment (LSVT LOUD®), originally designed for addressing speech-related issues in PD, has been found to have an additional positive effect of improving facial expressiveness in individuals experiencing hypomimia (Dumer et al., 2014).

Research on hypomimia in Parkinson’s disease highlights the importance of implementing interventions and providing support to tackle the social obstacles that can arise as a result of the symptom. By doing so, we can strive toward enhancing the overall quality of life for those affected by facial masking.

Recognizing the multifaceted impact of hypomimia on social interactions is crucial for individuals with PD. It is important to be aware that hypomimia is a distinct symptom of PD and not a reflection of the individual’s true emotions. By promoting education, empathy, and support, individuals with Parkinson’s can enhance their social interactions, emotional connections, and overall quality of life, despite the challenges posed by hypomimia.

It is important to remember that you are not alone in facing the challenges of hypomimia. Many individuals with PD experience similar difficulties, and resources are available to help navigate these obstacles. Seeking support from healthcare professionals, support groups, and online communities can provide a sense of connection, understanding, and practical advice.

Sources

Clark, U. S., Neargarder, S., & Cronin-Golomb, A. (2008). Specific impairments in the recognition of emotional facial expressions in Parkinson’s disease. Neuropsychologia, 46(9), 2300–2309. https://doi.org/10.1016/j.neuropsychologia.2008.03.014

Dumer, A. I., Oster, H., McCabe, D., Rabin, L. A., Spielman, J. L., Ramig, L. O., & Borod, J. C. (2014). Effects of the Lee Silverman Voice Treatment (LSVT® LOUD) on Hypomimia in Parkinson’s Disease. Journal of the International Neuropsychological Society, 20(03), 302–312. https://doi.org/10.1017/s1355617714000046

Gunnery, S. D., Habermann, B., Saint-Hilaire, M., Thomas, C. A., & Tickle-Degnen, L. (2016). The Relationship between the Experience of Hypomimia and Social Wellbeing in People with Parkinson’s Disease and their Care Partners. Journal of Parkinson’s Disease, 6(3), 625–630. https://doi.org/10.3233/jpd-160782

Maycas-Cepeda, T., López-Ruiz, P., Feliz-Feliz, C., Gómez-Vicente, L., García-Cobos, R., Arroyo, R., & García-Ruiz, P. J. (2021). Hypomimia in Parkinson’s Disease: What Is It Telling Us?. Frontiers in Neurology, 11, 603582. https://doi.org/10.3389/fneur.2020.603582

Prenger, M. T. M., Madray, R., Van Hedger, K., Anello, M., & MacDonald, P. A. (2020). Social Symptoms of Parkinson’s Disease. Parkinson’s Disease, 2020, 8846544. https://doi.org/10.1155/2020/8846544

Wootton, A., Starkey, N. J., & Barber, C. C. (2018). Unmoving and unmoved: experiences and consequences of impaired non-verbal expressivity in Parkinson’s patients and their spouses. Disability and Rehabilitation, 41(21), 2516–2527. https://doi.org/10.1080/09638288.2018.1471166

This content was published in the Fall 2023 edition of our quarterly magazine, Viewpoints. The content was accurate as of this publication date.