McGrouther,1 a professor of plastic surgery in the United Kingdom, described facial disfigurement as "the last bastion of discrimination." There is an unremitting multimedia and societal pressure to conform to an idealized body shape. More attractive individuals tend to do better in relationships, at work or school, and even in court.
Facial disfigurement alters body image and may cause distress. Coping depends on a complex interplay of individual and societal factors. Although body image models have been proposed, only a small body of literature relating to facial disfigurement exists. These models, although theoretical, provide a framework for managing altered body image. This article reviews the literature (PubMed, Medline, and Ovid databases) on the effect of facial burns on body image and discusses the theory and research behind normal and altered body image. Facial burns illustrate the clinical application to provide efficacious treatment strategies for people with disfigurement.
Today's media places great emphasis on celebrities, who are typically young, slim, attractive, and healthy looking.2 Likewise, society values physically attractive people, who often perform more successfully in many aspects of life, and others are more willing to please them.3
Schilder4 defined body image as "the picture of our body which we form in our mind, that is to say the way in which our body appears to ourselves." Schilder noted body image was fluctuant, varying with age, mood, or clothing.5 Price6 proposed the body image model, comprising body reality, body presentation, and body ideal. Body reality is an individual's phenotype and depends on genotype and environmental factors. Body presentation refers to an individual's dress, adornment, and behavior. Body ideal is how an individual desires to appear. It comprises various facets including physical dimensions and body function. Body reality and presentation are compared with the body ideal, consciously and subconsciously. Body ideal, in accordance with Schilder, alters with time and environment and may be emotionally influenced. These factors are suggested to be in a state of balance; altering one may cause compensatory change in the others.
Primary socialization occurs in childhood, when body ideals are initially influenced predominately by the immediate family. The degree of adaptability to body ideal variation is also determined: "acceptance from others leads to acceptance of oneself."7 Later the media, society, and culture have more influence (secondary socialization). This occurs particularly in adolescence when body ideal may change drastically. Susceptibly to such influences varies between individuals.
Gleeson and Firth8 have argued that body image research is based on many assumptions, including that it exists and can be measured. Detractors of the body image model state, although anecdotes exist, that there is no evidence that its components influence each other.5 A large amount of work on body image focuses on eating disorders. Therefore, extrapolation to other areas, such as facial disfigurement, must be done cautiously. The body image model, however, is important as it provides a framework for health care professionals involved in all aspects of body image. It also acknowledges that body image is more than the disparity between body ideal and body reality.
Slade9 described body image as "the loose mental representation of the body," which was based on various facets. These are mental representations regarding the body's physical dimensions, cultural and social norms, individual attitudes, biological variables, cognitive and affective variables, individual psychopathology, and history of weight change. Slade,9 in accordance with Schilder and Price, stated that body image alters within a "body image band." Again, this model is theoretical and developed from eating disorder research.
Developed from cognitive-behavioral work on body dysmorphic disorders, Newell10 proposed a fear-avoidance model of psychosocial difficulties following disfigurement. This was based on the fear-avoidance model of exaggerated pain perception.11 He suggested that those who confront their anxieties seem to have better psychosocial outcomes than those who avoid them. Individual and environmental factors determine where behavior will lie on this confrontation-avoidance continuum. These include life events, body image coping strategies, history of changes to body image, fear of changed body, reactions of others, and personality.5 The central tenet of this model suggests that behaviors are avoided because of the fear of anxiety rather than the anxiety itself. Such behaviors may become reinforced and evolve so that even minor social activities become avoided. However, as Newell5 admits, this model is almost entirely speculative and was developed from phobic disorders.
Price6 defined self-image as "our assessment of our social worth." Body image and our perception of other's opinions of ourselves, mediated by our respect for those people and compensatory mechanisms, influence our self-image. Body image is related to, but differs from self-image, self-esteem, and self-concept, as it refers specifically to the internal picture of the body.10 Newell argued that less physically attractive individuals receive less reinforcement from others, resulting in decreased self-esteem and positive self-image.10
Some have suggested positive and negative attitudes to self can be held simultaneously. In addition, self-esteem varies with time and environment.12 Leary et al13 described the "sociometer hypothesis," whereby self-esteem is a gauge for monitoring interpersonal relationships. If an individual perceives he or she is being excluded, low self-esteem may develop with a resultant increase in the sociometer's sensitivity. Consequently, the lower a person's self-esteem becomes, he or she will be more likely to perceive negative interactions.
Price6 referred to altered body image as "any significant alteration to body image occurring outside the realms of expected human development." For some individuals, this may constitute a crisis; whereas others seem to adapt well. Coping strategies, the cause of altered body image, the impact on lifestyle, and the degree of social support influence this adaptation.
BODY IMAGE AND FACIAL BURNS
Faces facilitate understanding of our identity and ancestry and provide clues to age and mood.2 A person's face is the main point of focus during social interaction-providing conscious and unconscious expressions.14 Approximately two-thirds of communication is nonverbal, mediated principally by facial expression.15
Facial disfigurement describes the visual effect of scars, skin grafts, asymmetry, or altered pigmentation. It may cause disruption to body image and, especially if there is loss of self-recognition, constitute a major life crisis.16 As Schilder4 and Price6 alluded, guilt may compound the body image crisis if others have died or been injured. The reaction to facial disfigurement is comparable to the stages of bereavement (denial, anger, bargaining, depression, and acceptance) described by Kubler-Ross.17 However, Partridge2 stated that he felt liberated following disfigurement. Although a personal account that could be interpreted as denial, it demonstrates that individuals can positively readjust. Using Price's body image model, disfigurement following facial burns alters body reality. Individuals may adapt to this by changing their body ideal or body presentation. Rumsey et al18argued that burns do not necessarily have any more psychopathology than acne, for example. They reported very low levels of distress in burns patients compared with elective plastic surgery patients. However, patients were seen only once, and body image is dynamic. In addition, although unsubstantiated, the burns were "minor" and not particularly disfiguring. Furthermore, in only 193 of 458 cases was a disfigurement rating performed. Comparison to elective plastic surgery patients is difficult. Such patients may have requested a plastic surgery consultation because of high distress regarding their bodies, or may feel distressed for diagnostic reasons, such as malignancy.
Wallace and Lees19 identified 30% to 40% of burn patients had psychological problems. Browne et al20 found that 10% of adults and 15% of children with burns were psychosocially maladjusted. The common problems reported by those with facial disfigurement relate to social interaction.21,22 They may feel anxious, threatened by others, and preoccupied with their appearance. Being stared at or asked awkward questions compounds these issues. Using Newell's5 fear-avoidance model for disfigured people may avoid activities that induce anxiety or conceal disfigurement. Although this potentially provides short-term psychological relief, a pattern of avoidance may ensue, thus reinforcing anxiety-avoiding behavior. This may prevent habituation to curiosity and hinder the development of adequate coping strategies and the discrediting of falsely held beliefs.23-25 Camouflage creams, hats, and prosthesis may facilitate social interaction in the short-term, but they do not address the underlying problem.26 An immobile or distorted face may impede verbal and nonverbal communication, provoking unease in others. The development of social skills may be difficult. Negative coping strategies, such as aggression, social withdrawal, or alcohol misuse, can develop, reinforced by reciprocation and discrimination in personal and working relationships.26,27
The "buffering hypothesis" argues that social support is the most powerful factor in ameliorating stressful events.28 Social support results in high self-esteem, which may buffer emotional turbulence.29 Work with burn patients concurred with this.30 Specifically, the perceived level of support seems important, with families holding greater influence than friends.20,31,32 However, others have found the converse to be true in general life events and burns in adolescents and young adults.28,33 Orr et al33 investigated the impact of burns on body image, self-esteem, and depression in a group ranging in age from 14 to 27 years, who had suffered burns in the previous decade. Only 48% of 250 patients responded, despite persistent follow-up. Nonresponders were perhaps ambivalent and unconcerned, or distressed and evasive regarding the study. This study was conducted almost 20 years ago. The mean age at injury was 12.7 years (SD, 3.5 years), with unspecified sex ratios; 55% had facial burns of differing severities and states of reconstructive surgery. Conclusions drawn to facial burns, at differing ages, sex, and background, must be calculated carefully.
Burn patients often come from lower socioeconomic backgrounds and have lower premorbid levels of self-esteem and support.34,35 Although this is a generalization, certain individuals may require extra support following disfigurement. These patients tend to derive much of their self-esteem from their appearance and believe others evaluate them largely on the basis of their looks.33
Many studies demonstrate that no correlation exists between the size or degree of disfigurement and amount of psychopathology.36 Sufficient support for this theory is found in burn patients and in those with other causes of facial disfigurement.31,37,38 This finding may be attributed to the unpredictable response of others, including the degree of support extended.39 Cahners25 suggested that those with visible burns are forced to confront their anxieties and develop more effective coping strategies compared with those with a lesser disfigurement. However, others found that the site and size of burns do correlate with self-esteem and depression levels.40
Equivocal evidence exists as to whether demographic characteristics correlate with psychosocial maladjustment following facial burns. Andreasen and Norris41 reported that females have a more negative body image than males following severe burns. Robinson et al22 found higher levels of depression in females; however, the difference was just barely significant. This might be due to a disproportionate amount of societal pressure on women to achieve a body ideal.42 Others state that this trend could occur because men consider worrying about image as a sign of weakness.43 Brown et al44 found no sex differences.
Some researchers have found more psychological problems in adolescents and persons in their early 20s.45,46 However, Robinson et al22 found no correlation of patient age or duration of disfigurement with levels of anxiety and depression, although only 13 participants younger than 27 years were included in their study. Yet, this supports other work suggesting that the development of effective coping mechanisms determines psychosocial outcomes.20 Indeed, psychopathology may arise years after suffering a burn.47 Tucker48 compared Australian burns inpatients with discharged patients and found significantly lower levels of psychopathology with time. However, those younger than 17 years were excluded; other factors, such as pain, which may alter over time, were not controlled.
Sir Archibald McIndoe made groundbreaking advances reconstructing allied air-force pilots who were burned in World War II. He noticed that the burns of the men on the ward healed better than the officers who had been kept in cubicles: "Camaraderie was the obvious answer. The officers on their own tended to fret, lose their appetite, and think too much about their disfigurement."49
Today, surgery and pharmacology may provide some physical improvement, reducing the disparity between an individual's body reality and body ideal. However, complete restoration of appearance is not possible. Partridge24 stated, "for many people, despite surgery, there is still a visible disfigurement that they have to learn to live with." Although facial transplant may become possible, it is unlikely to become routine and is entwined with complex moral and ethical dilemmas.50 Patients considering such surgery will require careful psychological analysis and counseling. Paradoxically, it is often those who are psychologically vulnerable who seek appearance-enhancing treatment and are prone to unrealistic expectations.16,51 These individuals are psychologically less equipped to deal with appearance-altering surgery, let alone a facial transplant.52
Social skills training for people with facial disfigurement has many advocates.37,53 Changing Faces, a United Kingdom charity, offers anxiety-management techniques, communication workshops, and educational sessions to those with facial disfigurement.54 Robinson et al22 assessed the impact of a 2-day communication workshop on 64 participants. At 6 weeks and 6 months, decreased anxiety and depression levels were reported (using HAD and SAD scales); 61% reported previously difficult situations now easier, and 91% found the workshop useful. Forty-two participants failed to complete the assessment, leading to potential bias. In addition, no control group was used. The study looked at a wide range of people with facial disfigurements. Conclusions made regarding facial burns and for patients over the long term must be done cautiously. Fiegenbaum55 studied the impact of ten 2-hour group therapy sessions, which included role playing. Self-confidence improved, and social anxiety reduced significantly compared with matched controls. Although psychological difficulties can arise years after burn injury, studies performed in patients with head and neck cancer showed that improvements following group therapy exercises were maintained at 2 years.47
Cognitive-behavioral therapy aims to adapt body image so individuals become less concerned with others' behavior and less absorbed by ideal-actual discrepancies. Cognitive-based therapy approaches for social anxiety include graded exposure techniques, relaxation procedures, and videotaped feedback.56 Most work has been conducted in perceived weight problems, so application to facial burns must be performed with caution. Improvements in self-esteem and body image were documented in a small number of people with vitiligo following cognitive-behavior therapy.57
The sociological argument is that the problem lies with society and not the individual. Society should modify its stereotypes and reactions to those with facial disfigurement. In the United Kingdom, for example, people are becoming better informed as disfigurement was incorporated into the Disability Discrimination Act 2005. Whether this will translate into meaningful results remains to be seen. Cline et al58 documented 9- to 11-year-old school children's attitudes to disfigurement following exposure to an informational pack regarding facial disfigurement. Four months after the intervention, the children showed greater knowledge than control groups. However, their willingness to help others with disfigurement remained largely unchanged. Whether these findings are long-term or transferable to other groups is unclear.
Body image models, although they have limitations, provide a framework for the analysis and treatment of disfigured individuals. For some, a blemish may cause huge anxiety; others with far more disfiguring burns may cope well. Experiences and levels of perceived social support sculpt an individual's self-esteem and interpretation of specific situations. This seems to alter emotional and behavioral responses more than demographic or physical characteristics. Those who do well tend to confront their anxieties, whereas those who avoid them develop negative coping strategies and fare worse.
Various modalities can be used in the management of facial disfigurement, including surgery and psychosocial therapies. Efficacious psychological interventions must target specific cognitive and behavioral elements that predispose individuals to experience distress as a consequence of their disfigurement. Future research using qualitative and longitudinal techniques needs to be conducted to rigorously evaluate these psychosocial interventions and enable the demolition of this last bastion of discrimination.
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