Behind the Mask: Emotion Recognition in Healthcare Students

Behind the mask: What the eyes can't tell: Facial emotion recognition in a sample of Italian health care students

Wearing a facemask remains a pivotal strategy to prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection even after vaccination, but one of the possible costs of this protection is that it may interfere with the ability to read emotion in facial expressions. We explored the extent to which it may be more difficult for participants to read emotions in faces when faces are covered with masks than when they are not, and whether participants' empathy, attachment style, and patient-centred orientation would affect their performance. Medical and nursing students (N = 429) were administered either a masked or unmasked set of 24 adult faces depicting anger, sadness, fear, or happiness. Participants also completed self-report measures of empathy, patient-centredness, and attachment style. As predicted, participants made more errors to the masked than the unmasked faces with the exception of the identification of fear. Of note, when participants missed happiness, they were most likely to see it as sadness, and when they missed anger, they were most likely to see it as happiness. A multiple linear regression analysis showed that more errors identifying emotions in faces was associated with faces being masked as opposed to unmasked, lower scores on the empathy fantasy scale, and higher scores on the fearful attachment style. The findings suggest that wearing facemasks is associated with a variety of negative outcomes that might interfere with the building of positive relationships between health care workers and patients. Those who teach student health care workers would benefit from bringing this finding into their curriculum and training.

Unmasking the Impact: Exploring the Role of Masks in Trauma-Informed Care Communication

INTRODUCTION

The COVID pandemic has necessitated mask-wearing by inpatient providers; however, the impact of masks on the acute care surgeon-patient relationship is unknown. We hypothesized that mask-wearing, while necessary, has a negative impact by acting as a barrier to communication, empathy, and trust between patients and surgeons.

METHODS

A cross-sectional study was performed by administering a written survey in English or Spanish to trauma, emergency general surgery, burn, and surgical critical care inpatients aged ≥18 y at a University Level 1 Trauma Center between January 2023 and June 2023. Patients were asked seven questions about their perception of mask effect on interactions with their surgery providers. Responses were scored on a five-point Likert scale and binarized for multivariable logistic regression.

RESULTS

There were 188 patients who completed the survey. The patients were 68% male, 44% Hispanic, and 17% Spanish speaking, with a median age of 45-54 y. A third of patients agreed that surgeon mask-wearing made it harder to understand the details of their surgical procedure and made them less comfortable in giving consent. Twenty three percent agreed that it was harder to trust their provider; increasing age was associated with lower levels of trust, odds ratio 1.36 (confidence interval 1.10-1.71, P = 0.006). Findings were consistent among patients of different sex, race/ethnicity, language, and pre-COVID hospital experience.

CONCLUSIONS

Mask-wearing, while important, has a negative impact on the patient-surgeon relationship in trauma and acute care surgery. Providers must be conscious of this effect while wearing masks and strive to optimize communication with patients to ensure high-quality trauma-informed care.

Recognizing and Looking at Masked Emotional Faces in Alexithymia

Alexithymia is a clinically relevant personality construct characterized by difficulties identifying and communicating one's emotions and externally oriented thinking. Alexithymia has been found to be related to poor emotion decoding and diminished attention to the eyes. The present eye tracking study investigated whether high levels of alexithymia are related to impairments in recognizing emotions in masked faces and reduced attentional preference for the eyes. An emotion recognition task with happy, fearful, disgusted, and neutral faces with face masks was administered to high-alexithymic and non-alexithymic individuals. Hit rates, latencies of correct responses, and fixation duration on eyes and face mask were analyzed as a function of group and sex. Alexithymia had no effects on accuracy and speed of emotion recognition. However, alexithymic men showed less attentional preference for the eyes relative to the mask than non-alexithymic men, which was due to their increased attention to face masks. No fixation duration differences were observed between alexithymic and non-alexithymic women. Our data indicate that high levels of alexithymia might not have adverse effects on the efficiency of emotion recognition from faces wearing masks. Future research on gaze behavior during facial emotion recognition in high alexithymia should consider sex as a moderating variable.

Accuracy and Speed of Emotion Recognition With Face Masks

Wearing face masks is one of the important actions to prevent the spread of COVID-19 among people around the world. Nevertheless, social interaction is limited via masks, and this impacts the accuracy and speed of emotional perception. In the present study, we assess the impact of mask-wearing on the accuracy and speed of emotion recognition. Fifty people (female n = 39, male n = 11) aged 19-28 participated in the study (M = 21.1 years). We used frontal photos of a Kosova woman who belonged to the same participants' age group, with a grey background. Twelve different pictures were used that showed the emotional states of fear, joy, sadness, anger, neutrality, and disgust, in masked and unmasked conditions. The experiment was conducted in a controlled laboratory setting. Participants were faster for identifying emotions like joy (1.507 ms) and neutral (1.971 ms). The participants were more accurate (emotions identification) in unmasked faces (M = 85.7%) than in masked faces (M = 73.8%), F(1,98) = 20.73, MSE = 1027.66, p ≤ .001, partial η² = 0.17. Masks make confusion and reduce the accuracy and speediness of emotional detection. This may have a notable impact on social interactions among peoples.

The COVID-19 pandemic and changes in social behavior: Protective face masks reduce deliberate social distancing preferences while leaving automatic avoidance behavior unaffected

Protective face masks were one of the central measures to counteract viral transmission in the COVID-19 pandemic. Prior research indicates that face masks impact various aspects of social cognition, such as emotion recognition and social evaluation. Whether protective masks also influence social avoidance behavior is less clear. Our project assessed direct and indirect measures of social avoidance tendencies towards masked and unmasked faces in two experiments with 311 participants during the first half of 2021. Two interventions were used in half of the participants from each sample (Experiment 1: protective face masks; Experiment 2: a disease prime video) to decrease or increase the salience of the immediate contagion threat. In the direct social avoidance measure, which asked for the deliberate decision to approach or avoid a person in a hypothetical social encounter, participants showed an increased willingness to approach masked as opposed to unmasked faces across experiments. This effect was further related to interindividual differences in pandemic threat perception in both samples. In the indirect measure, which assessed automatic social approach and avoidance tendencies, we neither observed an approach advantage towards masked faces nor an avoidance advantage for unmasked faces. Thus, while the absence of protective face masks may have led to increased deliberate social avoidance during the pandemic, no such effect was observed on automatic regulation of behavior, thus indicating the relative robustness of this latter behavior against changes in superordinate social norms.

Do masks cover more than just a face? A study on how facemasks affect the perception of emotional expressions according to their degree of intensity

Emotional facial expressions convey crucial information in nonverbal communication and serve as a mediator in face-to-face relationships. Their recognition would rely on specific facial traits depending on the perceived emotion. During the COVID-19 pandemic, wearing a facemask has thus disrupted the human ability to read emotions from faces. Yet, these effects are usually assessed across studies from faces expressing stereotypical and exaggerated emotions, which is far removed from real-life conditions. The objective of the present study was to evaluate the impact of facemasks through an emotion categorization task using morphs ranging from a neutral face and an expressive face (anger, disgust, fear, happiness, and sadness) (from 0% neutral to 100% expressive in 20% steps). Our results revealed a strong impact of facemasks on the recognition of expressions of disgust, happiness, and sadness, resulting in a decrease in performance and an increase in misinterpretations, both for low and high levels of intensity. In contrast, the recognition of anger and fear, as well as neutral expression, was found to be less impacted by mask-wearing. Future studies should address this issue from a more ecological point of view with the aim of taking concrete adaptive measures in the context of daily interactions.

Emotions behind a mask: the value of disgust

The impact of face masks on social cognition and interaction became a popular topic due to the long-lasting COVID-19 pandemic. This theme persists in the focus of attention beyond the pandemic, since face covering not only reduces the overall amount of face information available but also introduces biases and prejudices affecting social perception at large. Many questions are still open. One of them is whether gender of beholders affects inferring of emotions covered by face masks. Reading covered faces may be particularly challenging for individuals with mental disorders, most of which are gender-specific. Previous findings are not only sparse, but inconclusive because most research had been conducted online with resulting samples heavily dominated by females. Here in a face-to-face study, females and males were presented with a randomized set of faces covered by masks. In a two-alternative forced-choice paradigm, participants had to indicate facial emotions displayed by posers. In general, the outcome dovetails with earlier findings that face masks affect emotion recognition in a dissimilar way: Inferring some emotions suffers more severely than others, with the most pronounced influence of mask wearing on disgust and close to ceiling recognition of fear and neutral expressions. Contrary to our expectations, however, males were on overall more proficient in emotion recognition. In particular, males substantially excelled in inferring disgust. The findings help to understand gender differences in recognition of disgust, the forgotten emotion of psychiatry, that is of substantial value for a wide range of mental disorders including schizophrenia. Watch Prof. Marina Pavlova discussing this her work and this article: https://vimeo.com/860126397/5966610f49?share=copy .

Refraining from interaction can decrease fear of physical closeness during COVID-19

Perception of peripersonal space (PPS) and interpersonal distance (IPD) has been shown to be modified by external factors such as perceived danger, the use of tools, and social factors. Especially in times of social distancing in the context of the COVID-19 pandemic, it is vital to study factors that modify PPS and IPD. The present work addresses the question of whether wearing a face mask as a protection tool and social interaction impact the perception of IPD. We tested estimated IPD in pictures at three distances: 50 cm, 90 cm, and 150 cm in both social interaction (shaking hands) and without interaction and when the two people in the pictures wore a face mask or not. Data from 60 subjects were analyzed in a linear mixed model (on both difference in distance estimation to the depicted distance and in absolute distance estimation) and in a 3 (distance: 50, 90, 150) × 2 (interaction: no interaction, shake hands), × 2 face mask (no mask, mask) rmANOVA on distance estimation difference. All analyses showed that at a distance of 50 and 90 cm, participants generally underestimated the IPD while at an IPD of 150 cm, participants overestimated the distance. This could be grounded in perceived danger and avoidance behavior at closer distances, while the wider distance between persons was not perceived as dangerous. Our findings at an IPD of 90 cm show that social interaction has the largest effect at the border of our PPS, while the face mask did not affect social interaction at either distance. In addition, the ANOVA results indicate that when no social interaction was displayed, participants felt less unsafe when depicted persons wore a face mask at distances of 90 and 150 cm. This shows that participants are on the one hand aware of the given safety measures and internalized them; on the other hand, that refraining from physical social interaction helps to get close to other persons.

Impact of facemasks on psychotherapy: Clinician's confidence and emotion recognition

OBJECTIVES

Facial emotion recognition is a key component of human interactions, and in clinical relationships contributes to building and maintaining the therapeutic alliance with patients. The introduction of facemasks has reduced the availability of facial information in private and professional relationships. This study aimed to assess the impact of facemasks on clinicians' perception of clinical interactions as well as their ability to read facial expressions.

METHODS

In this cross-sectional study, a purposive sample of 342 clinical psychologists or psychotherapists completed an online survey including the assessment of burnout, alexithymia, emotion dysregulation, and self-perceived ability to build effective relationships and communication with patients with/without facemasks. Participants were randomly assigned to the standardized facial emotion recognition task Diagnostic Analysis of Nonverbal Accuracy FACES 2-Adult Faces including 24 faces representing anger, fear, sadness, and happiness.

RESULTS

Facemasks impaired the self-perceived ability of clinicians to build effective relationships and communicate with patients and reduced satisfaction in clinical encounters. The ability of clinicians to recognize facial emotions is significantly reduced for masked happy and angry faces, but not for sad and afraid ones. The perceived difficulty in building good relationships and communication with patients had a positive correlation with alexithymia and emotion dysregulation; higher levels of discomfort when wearing facemasks had a positive correlation with burnout and emotion dysregulation.

CONCLUSION

Facemasks reduced clinicians' self-confidence in clinical encounters with patients wearing facemasks, but their facial emotion recognition performance was only partially impaired.

The effect of masks on the recognition of facial expressions: A true-to-life study on the perception of basic emotions

Mouth-to-nose face masks became ubiquitous due to the COVID-19 pandemic. This ignited studies on the perception of emotions in masked faces. Most of these studies presented still images of an emotional face with a face mask digitally superimposed upon the nose-mouth region. A common finding of these studies is that smiles become less perceivable. The present study investigated the recognition of basic emotions in video sequences of faces. We replicated much of the evidence gathered from presenting still images with digitally superimposed masks. We also unearthed fundamental differences in comparison to existing studies with regard to the perception of smile which is less impeded than previous studies implied.

The impact of facemasks on blood donation process: The professionals' perspective

Facemasks represent an essential measure of prevention against the spread of COVID-19; however, they lessen the ability to convey and understand emotions through facial expressions. In blood donation settings, facemasks may interfere with professionals' tasks. This qualitative study aims to describe healthcare staff's experiences, beliefs, and attitudes toward facemask wearing and strategies used to overcome communication and relational barriers along the blood donation process. Semistructured qualitative interviews were conducted with 25 healthcare professionals (14 physicians and 11 nurses) working in Italian blood donation centers. The framework analysis method was used to organize the data and identify emerging themes. More than 70% of participants reported discomfort and a negative impact on communicating effectively with donors and building empathic relationships. The difficulty to detect early signs of adverse reactions was reported by almost all nurses, and physicians were concerned that facemasks limited the identification of donors and the detection of deferral criteria. Facemasks have changed the blood donation process, reducing the healthcare professionals' ability to build empathic relationships and communicate with donors effectively. New strategies should be developed to overcome these limitations.

The influence of face mask on social spaces depends on the behavioral immune system

Interacting with objects and people requires specifying localized spaces where these interactions can take place. Previous studies suggest that the space for interacting with objects (i.e., the peripersonal space) contributes to defining the space for interacting with people (i.e., personal and interpersonal spaces). Furthermore, situational factors, such as wearing a face mask, have been shown to influence social spaces, but how they influence the relation between action and social spaces and are modulated by individual factors is still not well understood. In this context, the present study investigated the relationship between action peripersonal and social personal and interpersonal spaces in participants approached by male and female virtual characters wearing or not wearing a face mask. We also measured individual factors related to the behavioral immune system, namely willingness to take risks, perceived infectability and germ aversion. The results showed that compared to peripersonal space, personal space was smaller and interpersonal space was larger, but the three spaces were positively correlated. All spaces were altered by gender, being shorter when participants faced female characters. Personal and interpersonal spaces were reduced with virtual characters wearing a face mask, especially in participants highly aversive to risks and germs. Altogether, these findings suggest that the regulation of the social spaces depends on the representation of action peripersonal space, but with an extra margin that is modulated by situational and personal factors in relation to the behavioral immune system.

How Are You Feeling? Interpretation of Emotions through Facial Expressions of People Wearing Different Personal Protective Equipment: An Observational Study

(1) Background: The perception of others’ emotions based on non-verbal cues, such as facial expressions, is fundamental for interpersonal communication and mutual support. Using personal protection equipment (PPE) in a work environment during the SAR-CoV-2 pandemic challenged health professionals’ ability to recognise emotions and expressions while wearing PPE. The working hypothesis of this study was that the increased limitation of facial visibility, due to the use of a personal protective device, would interfere with the perception of basic emotions in the participants. (2) Methods: Through a cross-sectional descriptive study, the present research aimed to analyse the identification of four basic emotions (happiness; sadness; fear/surprise; and disgust/anger) through three types of PPE (FFP2 respirator, protective overall and powered air-purifying respirator (PAPR)), by using 32 photographs. The study was conducted using volunteer participants who met the inclusion criteria (individuals older than 13 without cognitive limitations). Participants had to recognise the emotions of actors in photographs that were randomly displayed in an online form. (3) Results: In general, the 690 participants better recognised happiness and fear, independently of the PPE utilised. Women could better identify different emotions, along with university graduates and young and middle-aged adults. Emotional identification was at its worst when the participants wore protective overalls (5.42 ± 1.22), followed by the PAPR (5.83 ± 1.38); the best scores were obtained using the FFP2 masks (6.57 ± 1.20). Sadness was the least recognised emotion, regardless of age. (4) Conclusions: The personal protective devices interfere in the recognition of emotions, with the protective overalls having the greatest impact, and the FFP2 mask the least. The emotions that were best recognised were happiness and fear/surprise, while the least recognised emotion was sadness. Women were better at identifying emotions, as well as participants with higher education, and young and middle-aged adults.

Mapping the perception-space of facial expressions in the era of face masks

With the advent of the severe acute respiratory syndrome-Corona Virus type 2 (SARS-CoV-2) pandemic, the theme of emotion recognition from facial expressions has become highly relevant due to the widespread use of face masks as one of the main devices imposed to counter the spread of the virus. Unsurprisingly, several studies published in the last 2 years have shown that accuracy in the recognition of basic emotions expressed by faces wearing masks is reduced. However, less is known about the impact that wearing face masks has on the ability to recognize emotions from subtle expressions. Furthermore, even less is known regarding the role of interindividual differences (such as alexithymic and autistic traits) in emotion processing. This study investigated the perception of all the six basic emotions (anger, disgust, fear, happiness, sadness, and surprise), both as a function of the face mask and as a function of the facial expressions’ intensity (full vs. subtle) in terms of participants’ uncertainty in their responses, misattribution errors, and perceived intensity. The experiment was conducted online on a large sample of participants (N = 129). Participants completed the 20-item Toronto Alexithymia Scale and the Autistic Spectrum Quotient and then performed an emotion-recognition task that involved face stimuli wearing a mask or not, and displaying full or subtle expressions. Each face stimulus was presented alongside the Geneva Emotion Wheel (GEW), and participants had to indicate what emotion they believed the other person was feeling and its intensity using the GEW. For each combination of our variables, we computed the indices of ‘uncertainty’ (i.e., the spread of responses around the correct emotion category), ‘bias’ (i.e., the systematic errors in recognition), and ‘perceived intensity’ (i.e., the distance from the center of the GEW). We found that face masks increase uncertainty for all facial expressions of emotion, except for fear when intense, and that disgust was systematically confused with anger (i.e., response bias). Furthermore, when faces were covered by the mask, all the emotions were perceived as less intense, and this was particularly evident for subtle expressions. Finally, we did not find any evidence of a relationship between these indices and alexithymic/autistic traits.

Surgical face masks do not impair the decoding of facial expressions of negative affect more severely in older than in younger adults

Surgical face masks reduce the spread of airborne pathogens but also disturb the flow of information between individuals. The risk of getting seriously ill after infection with SARS-COV-2 during the present COVID-19 pandemic amplifies with age, suggesting that face masks should be worn especially during face-to-face contact with and between older people. However, the ability to accurately perceive and understand communication signals decreases with age, and it is currently unknown whether face masks impair facial communication more severely in older people. We compared the impact of surgical face masks on dynamic facial emotion recognition in younger (18–30 years) and older (65–85 years) adults (N = 96) in an online study. Participants watched short video clips of young women who facially expressed anger, fear, contempt or sadness. Faces of half of the women were covered by a digitally added surgical face mask. As expected, emotion recognition accuracy declined with age, and face masks reduced emotion recognition accuracy in both younger and older participants. Unexpectedly, the effect of face masks did not differ between age groups. Further analyses showed that masks also reduced the participants’ overall confidence in their emotion judgements, but not their performance awareness (the difference between their confidence ratings for correct and incorrect responses). Again, there were no mask-by-age interactions. Finally, data obtained with a newly developed questionnaire (attitudes towards face masks, atom) suggest that younger and older people do not differ in how much they feel impaired in their understanding of other people’s emotions by face masks or how useful they find face masks in confining the COVID-19 pandemic. In sum, these findings do not provide evidence that the impact of face masks on the decoding of facial signals is disproportionally larger in older people.

The effects of face coverings, own-ethnicity biases, and attitudes on emotion recognition

As a result of the COVID-19 pandemic, face coverings were introduced as a safety measure in certain environments in England and some research suggests that they can affect emotion recognition. Factors such as own-ethnicity bias (e.g. whether people perceiving and expressing emotions are of the same ethnicity) and social biases are also known to influence emotion recognition. However, it is unclear whether these factors interact with face coverings to affect emotion recognition. Therefore, this study examined the effects of face coverings, own-ethnicity biases, and attitudes on emotion recognition accuracy. In this study, 131 participants viewed masked and unmasked emotional faces varying in ethnicity and completed a questionnaire on their attitudes towards face masks. We found that emotion recognition was associated with masks and attitudes: accuracy was lower in masked than unmasked conditions and attitudes towards masks Inside and Outside were associated with emotion recognition. However, a match between perceiver and stimulus ethnicity did not have a significant effect on emotion recognition. Ultimately, our results suggest that masks, and negative attitudes towards them, were associated with poorer emotion recognition. Future research should explore different mask-wearing behaviours and possible in-group/out-group biases and their interaction with other social cues (e.g. in-group biases).

The Effects of Separate Facial Areas on Emotion Recognition in Different Adult Age Groups: A Laboratory and a Naturalistic Study

The identification of facial expressions is critical for social interaction. The ability to recognize facial emotional expressions declines with age. These age effects have been associated with differential age-related looking patterns. The present research project set out to systematically test the role of specific facial areas for emotion recognition across the adult lifespan. Study 1 investigated the impact of displaying only separate facial areas versus the full face on emotion recognition in 62 younger (20–24 years) and 65 middle-aged adults (40–65 years). Study 2 examined if wearing face masks differentially compromises younger (18–33 years, N = 71) versus middle-aged to older adults’ (51–83 years, N = 73) ability to identify different emotional expressions. Results of Study 1 suggested no general decrease in emotion recognition across the lifespan; instead, age-related performance seems to depend on the specific emotion and presented face area. Similarly, Study 2 observed only deficits in the identification of angry, fearful, and neutral expressions in older adults, but no age-related differences with regards to happy, sad, and disgusted expressions. Overall, face masks reduced participants’ emotion recognition; however, there were no differential age effects. Results are discussed in light of current models of age-related changes in emotion recognition.

Mask wearing affects emotion perception

To reduce the spread of COVID-19, mask wearing has become ubiquitous in much of the world. We studied the extent to which masks impair emotion recognition and dampen the perceived intensity of facial expressions by naturalistically inducing positive, neutral, and negative emotions in individuals while they were masked and unmasked. Two groups of online participants rated the emotional intensity of each presented image. One group rated full faces (N=104); the other (N=102) rated cropped images where only the upper face was visible. We found that masks impaired the recognition of and rated intensity of positive emotions. This happened even when the faces were cropped and the lower part of the face was not visible. Masks may thus reduce positive emotion and/or expressivity of positive emotion. However, perception of negativity was unaffected by masking, perhaps because unlike positive emotions like happiness which are signaled more in the mouth, negative emotions like anger rely more on the upper face.

Face Mask Reduces the Effect of Proposer’s (Un)Trustworthiness on Intertemporal and Risky Choices

Previous literature suggested that individuals increase temporal and risk discounting at the presence of a proposer whose face is perceived as untrustworthy, suggesting the activation of protective choice patterns. By the way, the COVID-19 pandemic has substantially transformed the way we interact with other people, even bringing us into situations where the face of the person making a proposal is not fully visible, because of the mask. With the current study, we aimed at verifying if the effect of proposer’s facial (un)trustworthiness on discounting behavior is modulated by mask wearing. In two different experiments, participants performed traditional delay and probability discounting tasks with masked proposers manipulated across trustworthiness levels. Results highlighted that, even after checking for subject-specific emotion recognition ability with masked faces, the presence of a masked untrustworthy proposer increases both delay and probability discounting parameters, although the effect is not statistically significant and smaller than the one detected at the presence of an untrustworthy proposer without a mask. These results suggest that the ability to perceive the proposer’s (un)trustworthiness is affected by the mask, with a consequent less strong effect of proposer’s (un)trustworthiness on choice behavior on both intertemporal and risky choices. Limits and possible implications are outlined and discussed.

The contribution of respiratory and hearing protection use to psychological distress in the workplace: a scoping review

OBJECTIVE

Workers from various industries use personal protective equipment (PPE) including masks, respirators, and hearing protection to reduce their exposures to workplace hazards. Many studies have evaluated the physiological impacts of PPE use, but few have assessed the psychological impacts. The aim of the present study was to carry out a scoping review to compile existing evidence and determine the extent of knowledge on workplace mask, respirator or hearing protection use as a psychosocial hazard (stressor) that could result in a stress response and potentially lead to psychological injury.

METHODS

The scoping review followed recognized methods and was conducted using Ovid Emcare, PubMed, Sage Journals, ScienceDirect, Scopus, SpringerLink, Google Scholar and preprint databases (OSF Preprints and medRxiv). Articles on the stressors associated with the use of masks, respirators, and hearing protection were included. The extracted data included author(s) name, year of publication, title of article, study design, population data, stressors assessed, and key findings.

RESULTS

We retrieved 650 articles after removal of duplicates, of which 26 were deemed eligible for inclusion for review. Identified factors associated with PPE use that could potentially create a stress response were identified: communication impacts, physical impacts, psychological illness symptoms, cognitive impacts, and perceived PPE-related impacts. Evidence for respirators suggest that there may be psychological injury associated with their use. However, hearing protection appears to have a protective effect in reducing psychological symptoms such as anxiety, depression, and aggression.

CONCLUSIONS

Mask or respirator use may lead to an increase in work-related stress. Whereas hearing protection may have protective effects against psychological symptoms and improves speech intelligibility. More research is needed to better understand potential psychosocial impacts of mask, respirator and/or hearing protection use.

Masked emotions: Do face mask patterns and colors affect the recognition of emotions?

Previous research has shown that face masks impair the ability to perceive social information and the readability of emotions. These studies mostly explored the effect of standard medical, often white, masks on emotion recognition. However, in reality, many individuals prefer masks with different styles. We investigated whether the appearance of the mask (pattern: angular vs. curvy and color: black vs. white) affected the recognition of emotional states. Participants were asked to identify the emotions on faces covered by masks with different designs. The presence of masks resulted in decreasing accuracy and confidence and increasing reaction times, indicating that masks impair emotion recognition. There were no significant effects of angularity versus curvature or color on emotion recognition, which suggests that mask design may not impair the recognition beyond the effect of mere mask wearing. Besides, we found relationships between individual difference variables such as mask wearing attitudes, mask design preferences, individual traits and emotion recognition. The majority of participants demonstrated positive attitudes toward mask wearing and preferred non-patterned black and white masks. Preferences for white masks were associated with better emotion recognition of masked faces. In contrast, those with negative attitudes toward masks showed marginally poorer performance in emotion recognition for masked faces, and preferred patterned more than plain masks, perhaps viewing masks as a fashion item rather than a necessity. Moreover, preferences to wear patterned masks were negatively related to actual wearing of masks indoors and perceived risks of COVID.

The Effect of Surgical Masks on the Featural and Configural Processing of Emotions

From the start of the COVID-19 pandemic, the use of surgical masks became widespread. However, they occlude an important part of the face and make it difficult to decode and interpret other people's emotions. To clarify the effect of surgical masks on configural and featural processing, participants completed a facial emotion recognition task to discriminate between happy, sad, angry, and neutral faces. Stimuli included fully visible faces, masked faces, and a cropped photo of the eyes or mouth region. Occlusion due to the surgical mask affects emotion recognition for sadness, anger, and neutral faces, although no significative differences were found in happiness recognition. Our findings suggest that happiness is recognized predominantly via featural processing.

“What Is Hidden behind the Mask?” Facial Emotion Recognition at the Time of COVID-19 Pandemic in Cognitively Normal Multiple Sclerosis Patients

Social cognition deficits have been described in people with multiple sclerosis (PwMS), even in absence of a global cognitive impairment, affecting predominantly the ability to adequately process emotions from human faces. The COVID-19 pandemic has forced people to wear face masks that might interfere with facial emotion recognition. Therefore, in the present study, we aimed at investigating the ability of emotion recognition in PwMS from faces wearing masks. We enrolled a total of 42 cognitively normal relapsing–remitting PwMS and a matched group of 20 healthy controls (HCs). Participants underwent a facial emotion recognition task in which they had to recognize from faces wearing or not surgical masks which of the six basic emotions (happiness, anger, fear, sadness, surprise, disgust) was presented. Results showed that face masks negatively affected emotion recognition in all participants (p < 0.001); in particular, PwMS showed a global worse accuracy than HCs (p = 0.005), mainly driven by the “no masked” (p = 0.021) than the “masked” (p = 0.064) condition. Considering individual emotions, PwMS showed a selective impairment in the recognition of fear, compared with HCs, in both the conditions investigated (“masked”: p = 0.023; “no masked”: p = 0.016). Face masks affected negatively also response times (p < 0.001); in particular, PwMS were globally hastier than HCs (p = 0.024), especially in the “masked” condition (p = 0.013). Furthermore, a detailed characterization of the performance of PwMS and HCs in terms of accuracy and response speed was proposed. Results from the present study showed the effect of face masks on the ability to process facial emotions in PwMS, compared with HCs. Healthcare professionals working with PwMS at the time of the COVID-19 outbreak should take into consideration this effect in their clinical practice. Implications in the everyday life of PwMS are also discussed.

Electrocardiogram-Based Emotion Recognition Systems and Their Applications in Healthcare-A Review

Affective computing is a field of study that integrates human affects and emotions with artificial intelligence into systems or devices. A system or device with affective computing is beneficial for the mental health and wellbeing of individuals that are stressed, anguished, or depressed. Emotion recognition systems are an important technology that enables affective computing. Currently, there are a lot of ways to build an emotion recognition system using various techniques and algorithms. This review paper focuses on emotion recognition research that adopted electrocardiograms (ECGs) as a unimodal approach as well as part of a multimodal approach for emotion recognition systems. Critical observations of data collection, pre-processing, feature extraction, feature selection and dimensionality reduction, classification, and validation are conducted. This paper also highlights the architectures with accuracy of above 90%. The available ECG-inclusive affective databases are also reviewed, and a popularity analysis is presented. Additionally, the benefit of emotion recognition systems towards healthcare systems is also reviewed here. Based on the literature reviewed, a thorough discussion on the subject matter and future works is suggested and concluded. The findings presented here are beneficial for prospective researchers to look into the summary of previous works conducted in the field of ECG-based emotion recognition systems, and for identifying gaps in the area, as well as in developing and designing future applications of emotion recognition systems, especially in improving healthcare.