Our first signs of illness are those that we see on our patient’s faces. Sometimes we can’t articulate exactly what it is that we perceive, but there is often a look that we recognize as illness or fatigue.

Sleep researchers have recently identified fatigue-related facial cues that tell us that a person is sleep deprived. We have seen some of them, even on our own faces, as we rise from a night that was too short. Those dark circles or bags under the eyes are clues that we haven’t had the rest we need. Perhaps your patients have even pointed out when you look tired.

In the current study, John Axelsson, PhD, of the Osher Center for Integrative Medicine at the Karolinska Institute in Stockholm, Sweden, and colleagues were able to show that people who are sleep deprived are perceived as more fatigued, less attractive and less healthy than those who get the appropriate sleep.

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The goal of this study was to see if observers could identify participants who were sleep deprived and fatigued using facial cues.

The researchers took photographs of participants on two separate occasions at the same time of day — after a normal eight hours of sleep and again after 31 hours of sleep deprivation, followed by five hours of sleep. Participants wore no make-up, wore their hair loose but away from the face and were asked to look straight into the camera with a neutral expression.

Exclusion criteria included anyone who was in poor health, had a sleep disorder, psychiatric disorder, smoked or worked night shifts.

Observers were then asked to rate the photographs based on ten facial cues. Researchers originally identified 53 potential cues associated with fatigue. About half of these were behavioral cues such as yawning. The final list consisted of six cues most commonly believed to be fatigue related. These included hanging eyelids, red eyes, swollen eyes, glazed eyes, dark circles under the eyes and pale skin.

Three additional cues were added to represent skin changes — wrinkles around the eyes, rash/eczema and droopy corners of the mouth. A design control variable, tense lips, was added, as well as expressions of sadness.

Observers were able to positively correlate cues related to eyes and skin with fatigue. In addition, sleep-deprived individuals looked sadder than after normal sleep, and sadness was related to looking fatigued (P<0.01), the researchers found.

There was no significant relationship between sleep deprivation and either tense lips or rash/eczema.

Pointing out that sleep can affect the way we are perceive individuals may be a motivating factor for patients who aren’t getting enough sleep to make appropriate behavior changes. On the other hand, patients may exhibit fatigue-related cues for other reasons, such as ptosis of the eyelids, and may mistakenly be perceived as being tired when they’re not.

Either way, take time to look for physical cues related to fatigue and sleep deprivation in your patients. Seeing a patient eye-to-eye may give you insight into their health before you even say hello.

Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.


  1. Sundelin T et al. “Cues of Fatigue: Effects of Sleep Deprivation on Facial Appearance.” Sleep. 2013 36(9):1355-1360.