Nonverbal cues play an obvious and critical role at way-stations such as engagement, data gathering, and

in understanding the person. Around 60–65% of social meaning is derived from them.

Basic Terminology of Nonverbal Behavior

1. Nonverbal Communications (Emblems)

In the first category, nonverbal communications, the patient is using a commonly accepted symbol
associated with a specific meaning (E.g. a thumbs up). Be mindful of the fact that different cultures may
have different interpretations of such symbols (e.g nodding your head indicates agreement or approval
in most cultures; however in countries such as Bulgaria or Greece it has the opposite meaning).

2. Nonverbal Activities

As oppossed to nonverbal communications, nonverbal activities do not have a single commonly agreed
upon meaning, and the sender may not be consciously trying to convey a message. Hand gesturing,
facial expressions, and even more directive acts such as chainsmoking cigarettes all represent nonverbal
activities.

Core Fields of Study in Nonverbal Behavior

1. Proxemics

Proxemics deals with the manner in which people are affected by the distances set between themselves
and objects in the environment, including other people.

a. Intimate distance (0 to 50 centimetres) - The primary sensory channels tend to be tactile and olfactory.
Vocal and visual and cues are of diminished importance.

b. Personal distance (50 to 120 centimetres) -Tactile cues continue to be used and olfactory and thermal
sensations diminish in importance. With their decline, the sense of sight begins to assume more
importance.

c. Social distance (120 to 350 centimetres) - The region where most face-to-face social interchange
occurs. Vocal and visual cues are the most commonly used here.

d. Public distance (over 350 centimetres) -Vision and audition remain the main channels of
communication. Most important, as people move further and further away, they tend to lose their
individuality and are perceived more as part of their surroundings.

2. Kinesics

Kinesics is the study of the body in movement. It includes gestures, movements of the body, limbs,
hands, head, feet, and legs, facial expressions, eye behavior (blinking, direction and length of gaze, and
pupil dilation), and posture. When interviewing a patient, it is important to be aware that specific
activities may shut down or facilitate the verbal output of any given patient. By way of example, hand
gestures and eye contact may be used to determine who should be speaking at any given moment in a
conversation.

3. Paralanguage

The study of paralanguage focuses on how words are delivered. It may include elements such as tone of
voice, loudness of voice, pitch of voice, rhythm and fluency of speech. Besides the tone of the voice,
speech is characterized by a number of other vocalizations, such as stutters, slips of the tongue,
repetitions, word omissions, and sentence incompletions, as well as familiar vocalizations such as “ah” or
“uhm".

A few clinical applications

1. Nonverbal Indicators of Anxiety

One of the most well-known indicators of increased anxiety remains the activation of the sympathetic
nervous system. This can translate into subtle signs such as sweating, damp palms, and increased
breathing rate. Acts such as smoking, twirling one's hair, picking at one's fingers, nail-biting, playing with
rings, twitching one's feet, tugging at the ear lobe, self-grooming activities, tearing at paper cups, and
twirling and biting pens can also be fairly reliable indicators of patient anxiety. Lastly auto-contact
behaviors such, the jaw support, the chin support, t hair clasp, the cheek support, the mouth touch, and
the temple support can also suggest disconfort.

2. Nonverbal Hints of Deception

The nonverbal clues that often seem to accompany deceit are less specific to deception than they are
generalized indicators that the deceiver is feeling anxious, worried, embarrassed, or frightened while
lying. As people usually tend to focus more on their facial movements when lying below-the-neck clues
are best for detecting deceit on a practical level.

Emblems can be useful indicators, usually only appearing in parts, or in an unsual placement (e.g an
angry fist will not be raised towards an antagonist but will quietly appear by the side of the patient).

Nonverbal activities such as hand gestures may tend to decrease when deceit is under way, particularly
if the patient has not had time to rehearse the lie and must focus on what is being said.

Higher pitch to the voice has been associated with deception as well as emotions such as fear. Another
possible clue to deception involves the response time latency (RTL). Deceptive subjects were found to
demonstrate a longer RTL and to give longer answers when in the act of deceiving. Be aware that,
without accounting for context, hese behaviors are usually multiply determined and do not in any way
guarantee that the patient is being deceitful.

3. Nonverbal Aspects of Recognizing Potentially Violent Patients

a. Recognizing Contextual Clues of Impending Violence

Most psychotic patients are not violent, but psychotic process as manifested in schizophrenia, bipolar
disorder, paranoid disorder, and other atypical psychoses may predispose the patient towards
aggression. Another such category of patients are those suffering from organic brain disease, as seen in
frontal lobe syndromes, deliria, and various dementias and those under the influence of various drugs
and especially those intoxicated with alcohol.

A patient who is being committed involuntarily, should always be considered as potentially violent.

In emergency rooms, a common mistake is to not separate feuding family members until it is too late. In
such situations, the clinician should attempt to determine quickly whether the family member is calming
or upsetting the patient.

b. Nonverbal Clues of Impending Violence

The early warning signs consist of behaviors that suggest emerging agitation. One may notice the patient
beginning to speak more quickly with a subtly angry tone of voice. These paralanguage clues may be
augmented by a display of sarcastic statements or challenges. Kinesic signs may include pacing and
refusing to sit down.

As a person comes closer to overt violence, specific behaviors may serve as reliable indicators that
aggression is imminent. Movements suggesting possible violence include activities such as clenching of
the fists, whitening of the knuckles while tightly grasping an inanimate object, and even a snarling as the
lips are pulled back from the teeth. Other common gestures are the raising of a closed fist over the head,
shaking the fist, assuming a boxing stance, gesturing as if strangling the opponent, and the pounding of
the fist into the opposite palm.

c. Nonverbal Techniques for Calming a Potentially Violent Patient

There exist no absolute rules for interacting with a patient on the verge of violence, but there are some
principles that can help guide the clinician. In the first place, the clinician should appear calm. The voice
should appear normal and unharried, while avoiding speaking loudly or in an authoritarian manner. Eye
contact should be decreased, and the hands should not be raised in any gesture that may signify an
intent to attack or defend oneself. To the contrary, it can be useful to keep the hands low, by the side,
and with palms upwards when gesturing. The interpersonal distance should be increased, as agitated
patients will feel that their intimate body space is being invaded at distances that are much greater than
for most people.