The Hidden Social Struggles of Face Blindness

Navigating a Faceless World

“Being face blind means living in a world full of strangers…It’s actually a source of constant anxiety,” writes The Washington Post’s face-blind writer, Sadie Dingelder.[1] For people with prosopagnosia, or face blindness (a rare neurological disorder affecting nearly 3% of the population), social situations are complicated to navigate as the brain’s facial recognition system is flawed.[2] In humans, the face serves as a reminder for many memories of the identity of a person: such as their favorite food and their hobbies. When someone’s brain does not properly process this key component of social behavior, social anxiety quickly results. Prosopagnosia not only affects an individual's ability to recognize faces but also poses significant mental health challenges, impacting social interactions, self-esteem, and emotional well-being. 

Being face blind leads to an impairment in the ability to form identities, while other forms of identification (i.e., non-facial) are relied upon. Prosopagnosia tends to go relatively unnoticed not only because of its rarity but also because those who have it are skillful at working around their disability[3] or hiding it.  Additionally, recruitment for research on the subject becomes difficult, as those who have it may not always be aware if they have grown accustomed to having this deficit.[4] Additional research into prosopagnosia will provide vast opportunities to learn more about the social-cognitive disorders and mechanisms of the brain (such as autism spectrum disorder).

What is Face Blindness?

The main purposes of the brain’s visual facial recognition system revolve around sorting socially-meaningful information based on familiarity, attractiveness, and emotion.[5] Lopatina et al. (2018) note that face recognition impairment has been found to be associated with problems with neurons in the temporal lobe and/or the fusiform face area, particularly in the right middle fusiform gyrus.[6] Associations made with these areas are activated with other brain areas in forming/retrieving memories (the hippocampus) and emotion (the amygdala), establishing the interaction between facial recognition and social operation.[7] Essentially, visual information about faces cannot be translated into meaning. Additionally, face-selective neurons found in the amygdala support the notion that the brain uses facial recognition for emotionally salient, or meaningful stimuli.[8] The own-race bias of having better familiarity/encoding for faces of one’s own ethnicity rather than external ones can also be attributed to the brain’s facial recognition system.[9] When this system in the fusiform face area is impaired in individuals with prosopagnosia, so are the subsequent social processes. Prosopagnosia falls into two forms:[10]

1. Associative Prosopagnosia - One can perceive a face normally, but meaning cannot be applied. Even if the person is familiar, they can only be recognized in other ways (e.g., the sound of their voice, the way they walk).

2. Apperceptive Prosopagnosia - Faces are abnormally perceived and their facial expressions or other non-verbal cues cannot be recognized.

Causes for prosopagnosia can be related to genetic variants,[11] stroke, traumatic brain injury, tumors or some neurodegenerative diseases.[12] Prosopagnosia can often be found in individuals with autism (ASD) and Asperger’s Syndrome due to similar cognitive-emotional processes being affected.[13] Due to the similarity of brain areas and social behaviors affected by these neurological disorders, research targeting prosopagnosia has led to a multitude of information on the topic that augments our understanding of neural development and socially-debilitating disorders.

The Emotional Toll 

Davis et al. (2010) found that social anxiety (fears related to social rejection and social impressions) can stem from not only an inability to recognize facial expressions, but also from that of facial identity.[14] With impaired facial identification, those with prosopagnosia experience high social stress and anxiety in situations that critically involve communication, such as with family, at work and in public settings. The impairment can be so socially debilitating that it interferes with self-esteem and emotional well-being, resulting in difficulties in forming relationships and feelings of social isolation.[15] Having face blindness may also lead to avoidance of socially-engaging situations as a coping mechanism, which can even be considered a phobia in extreme cases.[16] Dalrymple et al. (2014) note that this deficit can begin early in life, as children who experience developmental prosopagnosia (DP) report discomfort and distress.[17] Guyer et al. (2010) add that emerging depression is also associated with facial memory deficits.[18] 

Coping Strategies and Treatment

Often, those with face blindness will develop coping strategies to alleviate daily challenges. Dalrymple et al. (2014) found that strategies to mitigate distress in children included asking a person’s name and remembering non-facial elements of a person’s appearance such as jewelry or hair.[19] Behavioral strategies like this are employed in face-blind-oriented training to facilitate the memory of people’s facial shapes and features.[20] These memory practices cannot cure prosopagnosia but can provide ways for individuals to adapt to social environments that require identification, thereby reducing social stress.[21] Lopatina et al. (2018) and Bate et al. (2014) also found that administering oxytocin (a hormone that facilitates human bonding)[22] can alleviate difficulties with social communication - some effectiveness was also noted in facilitating facial recognition in people with social behavioral deficits.[23,24] In addition, psychotherapeutic modalities such as cognitive behavioral therapy (CBT) may be utilized alone or in conjunction with anti-anxiety medication to mitigate the effects of social anxiety.[25]

This rare condition provides important insight into connections between the brain and social behavior. While the deficits in the brain associated with face blindness are not curable, an effort to develop identification strategies will help those with facial recognition difficulties in reducing high stress and anxiety when interacting with other people. 

If one feels as though they are experiencing symptoms of prosopagnosia (face blindness) or forms of social anxiety, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Dingfelder, S. (2019, August 21). My Life With Face Blindness. The Washington Post Magazine. https://www.washingtonpost.com/news/magazine/wp/2019/08/21/feature/my-life-with-face-blindness/ 

2 Ibid. 

3 Ibid. 

4. Ibid. 

5. Lopatina, O. L., Komleva, Y. K., Gorina, Y. V., Higashida, H., & Salmina, A. B. (2018). Neurobiological Aspects of Face Recognition: The Role of Oxytocin. Frontiers in Behavioral Neuroscience, 12, 399601. https://doi.org/10.3389/fnbeh.2018.00195 

6 Ibid. 

7 Ibid. 

8 Ibid. 

9 Blandón-Gitlin, I., Pezdek, K., Saldivar, S., & Steelman, E. (2014). Oxytocin eliminates the own-race bias in face recognition memory. Brain Research, 1580, 180-187. https://doi.org/10.1016/j.brainres.2013.07.015 

10 Cleveland Clinic. (2022, July 7). Prosopagnosia (Face Blindness). https://my.clevelandclinic.org/health/diseases/23412-prosopagnosia-face-blindness

11 Ibid. 

12 National Institute of Neurological Disorders and Stroke. (2023) Prosopagnosia. https://www.ninds.nih.gov/health-information/disorders/prosopagnosia#:~:text=What%20is%20prosopagnosia%3F,and%20%E2%80%9Clack%20of%20knowledge.%E2%80%9D

13 Ibid. 

14 Davis, J. M., McKone, E., Dennett, H., & Palermo, R. (2010). Individual Differences in the Ability to Recognise Facial Identity Are Associated with Social Anxiety. PLoS ONE, 6(12). https://doi.org/10.1371/journal.pone.0028800

15 Ibid. 

16 Davis et al. (2010)

17 Dalrymple, K. A., Fletcher, K., Corrow, S., S. Barton, J. J., Yonas, A., & Duchaine, B. (2014). “A room full of strangers every day”: The psychosocial impact of developmental prosopagnosia on children and their families. Journal of psychosomatic research, 77(2), 144. https://doi.org/10.1016/j.jpsychores.2014.06.001

18 E. Guyer, D. A., R. Choate, M. V., J. Grimm, D. K., S. Pine, D. D., & Keenan, D. K. (2011). Emerging depression is associated with face memory deficits in adolescent girls. Journal of the American Academy of Child and Adolescent Psychiatry, 50(2), 180. https://doi.org/10.1016/j.jaac.2010.11.008

19 Dalrymple et al. (2014)

20 Cleveland Clinic

21 Ibid.

22 Jones, C., Barrera, I., Brothers, S., Ring, R., & Wahlestedt, C. (2017). Oxytocin and social functioning. Dialogues in clinical neuroscience, 19(2), 193–201. https://doi.org/10.31887/DCNS.2017.19.2/cjones 

23 Lopatina et al. (2018)

24 Bate, S., Cook, S. J., Duchaine, B., Tree, J. J., Burns, E. J., & Hodgson, T. L. (2014). Intranasal inhalation of oxytocin improves face processing in developmental prosopagnosia. Cortex, 50, 55-63. https://doi.org/10.1016/j.cortex.2013.08.006 

25 Johns Hopkins Medicine. (n.d.) Phobias. www.hopkinsmedicine.org/health/conditions-and-diseases/phobias

The Impact of Nervous System Attunement on Social Anxiety

Understanding Social Anxiety

There is a growing body of research elucidating the scientific complexity of communication and information between people in a social context.[1] Neurons transmit information throughout one’s body, but our whole selves interact with the whole selves of other people, as well. Mirror neurons are one key way in which we empathize and connect with others in social situations, and are fundamental to interpersonal connection. In The Whole Therapist podcast, psychotherapists Abby Esquivel and Kellee Clark discuss the importance of mirror neurons and explain that, “When we stick our tongue out to a baby and the baby’s at a developmental age where they stick their tongue out back at us, they’re mirroring what we just did. Those are the mirror neurons firing. And when they fire, they wire together.”[2] In addition to empathy, mirror neurons have also been shown to be involved in understanding the intentions of others.[3,4] The role of mirror neurons is relevant to the discussion of social anxiety, as they can serve as a way of spreading safety to others, while the regulation of our own physiology can signal safety to ourselves. 

Social anxiety is most-common among 18-29 year-olds and about 12.1% of U.S. adults experience social anxiety disorder at some point in their lives. While 31.3% of sufferers experience only mild severity of symptoms, 38.8% report moderate severity, and 29.9% fit into the serious severity category.[5] This disorder can cause significant impairment in daily functioning, especially for those who live in societies that demand regular interaction with others. Not only can it interfere with daily chores like talking to cashiers at the grocery store, but it can hinder participation in class or collaboration in the workplace, prevent people from initiating conversations, and inhibit cultivation of deeper friendships or romantic relationships. 

Social anxiety is experienced as a persistent fear about how one is being perceived.[6] This type of anxiety can be distressing during a social interaction, as well as before and after. People who suffer from social anxiety might try and control others’ perceptions of them by altering their behavior toward what they think is a more desirable way of being. According to Goldin, et al. (2009), people with social anxiety have less neural activation associated with cognitive regulation related to social threat stimuli.[7] In other words, people with social anxiety may struggle to regulate when they feel threatened. Due to neuroplasticity research, we know that brains change and re-shape constantly, which provides hope for those who feel chronically socially anxious.[8,9] If people with social anxiety can introduce a feeling of safety when they ordinarily feel threatened, over time their brains may adapt to react less fearfully in similar contexts. Due to the fact that we simply cannot control or ever know what goes on inside other people’s heads, there is scant evidence in the moment if we have achieved the perspective we seek. Even if others view us favorably in the moment, stress can persist about maintaining that positive regard. Therefore, we must shift our energy away from trying to control others’ perceptions and focus more on the internal responses that occur within our bodies when a threat is registered. 

Symptoms

Figure 1

Note: This figure was based on a chart produced by Trudeau, K. (2020). [10] 

Rehearsal and role-play, exposure treatments, and cognitive behavioral therapy all serve as common psychotherapeutic treatments for social anxiety. SSRIs, MAOIs, and Benzodiazepines are medications that may provide relief as well.[11] However, one type of intervention that can be implemented immediately and without professional supervision is the attunement to one’s own nervous system. Our nervous systems guide our behavior.[12] Whether we are in fight, flight, freeze, or a state of safety, the way in which we interact and function will look different depending on which state we’re in. For instance, if someone has anxiety about driving, when they merge on the freeway they may experience tunnel vision, increased blood pressure, increased muscle tension, a release of stress hormones, and be distracted and irritable to others in the car.[13] Alternatively, if one is in a state of safety when checking out at the grocery store, they may take their time bagging their food and chat with the cashier. Or, they might decide not to engage in conversation with the employee, but remain calm in the absence of discussion. Someone with social anxiety may experience rapid thoughts in the silence or a subtle tightness in their shoulders as they wonder whether they should say something. By tuning into one’s nervous system, it is possible to determine whether one is in fight-or-flight mode and then carry out an exercise to shift into a state of safety. Gaining this awareness can help with emotional regulation by following up with breathing and muscle relaxation strategies.

Neuroscientist Stephen Porges developed Polyvagal Theory (1994) to explain the relationship between the nervous system and human behavior. This theory postulates that our bodies constantly scan and survey our environments, registering different stimuli as safe or threatening.[14] When safety is detected, the parasympathetic nervous system engages; when threatening stimuli are detected, the sympathetic nervous system engages. When the latter system activates, our bodies automatically release stress hormones, heart rates increase, and digestion slows to prepare us to fight or flee for survival.[15] Through mirror neurons, when we self-regulate through intentional physiological relaxation, it is likely that we will communicate more calmness and safety subconsciously through tone of voice, posture, and gestures.[16] Not only will this decrease the felt experience of social anxiety within oneself, but there is an added benefit of spreading calmness and openness to those we are interacting with. We therefore can spread safety to others through attuning to ourselves.

By manually regulating our nervous system through mindful awareness and muscle relaxation techniques, we can train our bodies to realize that socializing is not threatening.[17,18] The repetition of this practice can eventually lead to quicker parasympathetic (rest) responses and decrease the intensity of socially-activated anxiety. Further, since social anxiety is widely experienced as the fear of rejection, it may be comforting to consider that there is a smaller likelihood of being rejected if one comes across as emotionally stable, confident, and open-minded.[19] Even if one can’t achieve a certain image of perfection in another’s mind, people remember most vividly how they felt during an experience--  including social interactions. Making others feel comfortable and safe through one’s own authenticity and comfortability can lead to trust building as well as positive regard, which is potentially helpful for the rational part of the socially anxious mind. However, the point of this article is not to encourage or reinforce the tendency or desire to control others’ perceptions about oneself. Ultimately, the only control we have is over how much we practice mindful awareness of physical sensations during an anxious moment and then intervening with the following techniques:

Paced Breathing for Nervous System Relaxation

Breathing is one simple, yet powerful, way to move our systems out of a state of fight-or-flight. Inhaling activates the sympathetic nervous system (fight-or-flight), while exhaling activates the parasympathetic nervous system (rest and digest).[20] Therefore, there is an important caveat to be aware of when taking a deep breath: to effectively calm down, the exhale should be longer than the inhale. One exercise to try is breathing in for 4 counts, holding the breath for 7 counts, and exhaling for 8 counts. Any variation on these numbers should still elicit a calming response if the exhale is noticeably longer than the inhale.[21] 

Figure 2

Note: This figure was produced by Reddy, S. (2021).[22] 

Muscle Relaxation for the Nervous System

Mindfulness of the physical body is the other critical piece of tuning into one’s nervous system.[23] Catching oneself feeling socially anxious is ideal, because one can then question: what areas of my body are tense right now? First, just notice if the shoulders, jaw, stomach, or any other area are carrying tension. Exhaling, while releasing tension in those body parts, signals safety and relaxation to the brain. This exercise can be used during a social interaction, as well as when one is alone and feeling anxiety. Both of these methods serve as ways of “hijacking” the autonomic nervous system and reducing the automatic fight-or-flight response that happens when threat and danger are subconsciously detected.

Figure 3

Note: This figure was produced by Innovasium Cam’s Kids [24]

The goal is not to be calm all the time, because stress and anxiety are important and adaptive feelings that provide necessary information about our environments. Rather, the goal is to have a flexible nervous system that can smoothly flow into a state of fight-or-flight when there is a real threat and then back to a state of safety when one is not in danger. In moments where a threat is registered by the nervous system but one knows that they are actually safe, moving the body out of a physiological panic response can 1) be rapidly calming, 2) help rewire neural associations between safety and socializing, and 3) communicate safety and openness to others. Due to mirror neurons, when we can regulate and calm our systems, other people can also pick up on that safety and regulation and feel more receptive, open, and secure. This can serve as an incentive to practice mindfulness of one’s nervous system, because effective communication usually occurs when people feel safe. 

Dr. Fallon Goodman, researcher of social anxiety at University of San Francisco, says that we must foster social courage “knowing that rejection lurks right around the corner.” Furthermore, Goodman says to “Pursue experiences knowing that the chances of rejection are not zero. In fact, the chances that you get rejected at some point in your life-- at some point this year-- are high.” We must pursue the things that are meaningful to us and remember that the successes of those pursuits do not determine our worth as human beings.[25] 

For more information, click here to access an interview with Psychologist Kevin Chapman on panic & social anxiety.

Additionally, you may click here to access an interview with Venerable Thubten Chodron on meditation & anxiety.

Contributed by: Maya Hsu

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Clark-Polner, E. & Clark, M. (2014). Understanding and accounting for relational context is critical for social neuroscience. Frontiers in Human Neuroscience. https://doi.org/10.3389/fnhum.2014.00127

2 Esquivel, A. & Clark, K. (Hosts). (2020-present). The Whole Therapist [Audio podcast]. Be and Belong Counseling PLLC. https://beandbelongcounseling.com/the-whole-therapist/

3 Iriki A. (2006). The neural origins and implications of imitation, mirror neurons and tool use. Curr. Opin. Neurobiol. 16, 660–667. 10.1016/j.conb.2006.10.008 

4 Iacoboni, M., Molnar-Szakacs, I., Gallese, V., Buccino, G., Mazziotta, J. C., & Rizzolatti, G. (2005). Grasping the intentions of others with one's own mirror neuron system. PLoS Biology, 3(3). https://doi.org/10.1371/journal.pbio.0030079 

5 U.S. Department of Health and Human Services. (n.d.). Social anxiety disorder. National Institute of Mental Health. Retrieved February 16, 2022, from https://www.nimh.nih.gov/health/statistics/social-anxiety-disorder 

6 DSM-5 definition of social anxiety disorder. DSM-IV-R Definition of Social Anxiety Disorder | Social Anxiety Institute. (n.d.). Retrieved February 16, 2022, from https://socialanxietyinstitute.org/dsm-definition-social-anxiety-disorder 

7 Goldin, P. R., Manber, T., Hakimi, S., Canli, T., & Gross, J. J. (2009). Neural bases of social anxiety disorder. Archives of General Psychiatry, 66(2), 170. https://doi.org/10.1001/archgenpsychiatry.2008.525 

8 Guimarães, D., Valério-Gomes, B., & Lent, R. (2020). Neuroplasticity: The brain changes over time! Frontiers for Young Minds. doi: 10.3389/frym.2020.522413

9 Gutchess, A. (2014). Plasticity of the aging brain: new directions in cognitive neuroscience. National Library of Medicine 346(6209). doi: 10.1126/science.1254604.

10 Trudeau, K. (2020). How to tell if you have a social anxiety disorder. Next Step 2 Mental Health. Retrieved February 16, 2022, from https://www.nextstep.doctor/how-to-tell-if-you-have-a-social-anxiety-disorder/ 

11 Behera, N., Samantaray, N., Kar, N., Nayak, M., & Chaudhury, S. (2020). Effectiveness of cognitive behavioral therapy on Social Anxiety Disorder: A comparative study. Industrial Psychiatry Journal, 29(1), 76. https://doi.org/10.4103/ipj.ipj_2_20 

12 National Academy Press. (1989). The Nervous System and Behavior. In Opportunities in Biology. 

13 Lanese, N. & Dutfield, S. (2022). Fight or flight: The sympathetic nervous system. LiveScience. https://www.livescience.com/65446-sympathetic-nervous-system.html 

14 Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. W W Norton & Co.

15 Feiner-Homer, K. (2016). Generating therapeutic attunement through mindfulness practice. SOPHIA. Retrieved February 16, 2022, from https://sophia.stkate.edu/msw_papers/579/?utm_source=sophia.stkate.edu%2Fmsw_papers%2F579&utm_medium=PDF&utm_campaign=PDFCoverPages 

16 Cerdán, A. G. (2022). Mirror neurons: The most powerful tool. learn everything they can do. CogniFit. Retrieved February 16, 2022, from https://blog.cognifit.com/en/mirror-neurons/ 

17 Nidich S. et al. A randomized controlled trial of the effects of transcendental meditation on quality of life in older breast cancer patients. Integr Cancer Ther. 2009 Sep;8(3):228-34.

18 Lee, M. (2009). Calming your nerves and your heart through meditation. Science in the News. Retrieved February 16, 2022, from https://sitn.hms.harvard.edu/flash/2009/issue61/ 

19 Krzyzaniak, S. (n.d.). Top 10 Personality Traits of Likable People. Ready Set Psych! Retrieved from https://readysetpsych.com/top-10-traits-of-likable-people/ 

20 André, C. (2019, January 15). Proper breathing brings better health. Scientific American. Retrieved February 16, 2022, from https://www.scientificamerican.com/article/proper-breathing-brings-better-health/ 

21 Bergland, C. (2019). Longer exhalations are an easy way to hack your vagus nerve. Psychology Today. Retrieved February 16, 2022, from https://www.psychologytoday.com/us/blog/the-athletes-way/201905/longer-exhalations-are-easy-way-hack-your-vagus-nerve 

22 Reddy, S. (2021). Breathing techniques for stress and anxiety. SWAA. Retrieved February 16, 2022, from https://swaafrica.org/breathing-techniques-for-stress-and-anxiety/ 

23 Lazaro, R. (2020). Progressive muscle relaxation. Progressive Muscle Relaxation - an overview . Retrieved February 16, 2022, from https://www.sciencedirect.com/topics/medicine-and-dentistry/progressive-muscle-relaxation 

24 Tips and tools: Progressive muscle relaxation technique. Cam's Kids. (n.d.). Retrieved February 16, 2022, from https://www.camskids.com/tipsandtools/progressive-muscle-relaxation-technique/ 

25 Goodman, F. (2021). Social Anxiety in the Modern World. TEDx Talks. Retrieved from https://www.youtube.com/watch?v=EFhP4wP1TzU&ab_channel=TEDxTalks