Are facial injuries really different? An observational cohort study comparing appearance concern and psychological distress in facial trauma and non-facial trauma patients

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Facial injuries are widely assumed to lead to stigma and significant psychosocial burden. Experimental studies of face perception support this idea, but there is very little empirical evidence to guide treatment. This study sought to address the gap.
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  1 Title page Are facial injuries really different? An observational cohort study comparing appearance concern and psychological distress in facial trauma and non-facial trauma patients   Authors: Rahtz, Emmylou; University of Exeter, European Centre for Environment and Human Health (corresponding author; e.rahtz@exeter.ac.uk)  Bhui, Kamaldeep; Barts and The London School of Medicine and Dentistry, Centre for Psychiatry Hutchison, Iain; St Bartholomew's and The Royal London Hospital, Oral and Maxillofacial Surgery Korszun, Ania; Barts and The London School of Medicine and Dentistry, Centre for Psychiatry  2 Summary Facial injuries are widely assumed to lead to stigma and significant psychosocial burden. Experimental studies of face perception support this idea, but there is very little empirical evidence to guide treatment. This study sought to address the gap. Data were collected from 193 patients admitted to hospital following facial or other trauma. Ninety (90) participants were successfully followed up eight months later. Participants completed measures of appearance concern and psychological distress (post-traumatic stress symptoms, depressive symptoms, anxiety symptoms). Participants were classified by site of injury (facial or non-facial injury). Overall levels of appearance concern were comparable to those of the general population, and there was no evidence of more appearance concern among people with facial injuries. Women and younger people were significantly more likely to experience appearance concern at baseline. Baseline and Eight month psychological distress, although common in the sample, did not differ according to the site of injury. Changes in appearance concern were, however, strongly associated with psychological distress at follow up. We conclude that, although appearance concern is severe among some people with facial injury it is not especially different to the those with non-facial injuries or the general public; changes in appearance concern, however, appear to correlate with psychological distress. We therefore suggest that interventions might focus on those with heightened appearance concern, and should target cognitive bias and psychological distress. Keywords : appearance concern; oral and maxillofacial surgery; facial trauma; depression; acute stress disorder; PTSD; anxiety  3 Introduction There is a widespread and commonly held assumption that injuries to the face result in greater psychosocial burden than other injuries. The face is qualitatively different from other parts of the body, as evidenced by the extensive body of psychological research into face perception 1,2 . From infancy, humans perceive faces differently from other visual stimuli, including those of comparable complexity 3 . Human infants show a systematic preference for looking at human faces rather than other (non-human) primate faces, likely due to a subcortical mechanism 4 : a preference for human bodies occurs later in development than preference for human faces 5 . Faces have a particularly important role in human interactions, communicating emotions and intentions 6  – 8 , and the neural mechanisms for ‘reading’ such information are highly specialised in humans and specific to the face 1 . More than any other part of the body, faces are closely tied to our sense of self, identity, empathy, attraction, and communication 9,10 , and faces provide official evidence of our identities on passports and driving licences. Changes to facial appearance can challenge the sense of self  11 . Changes to the face are particularly noticeable, both to the affected person and to observers, with symmetrical, ‘average’ faces –  those with less extreme characteristics  –  widely perceived as the most attractive 12 . Among the general population, appearance concerns are particularly likely to relate to facial appearance 13 . In experimental settings using manipulated photographs, people whose faces had scars or congenital abnormalities were judged as being significantly less honest, intelligent, trustworthy and employable than those with ‘normal’  faces 14 . Such findings may be acutely relevant when the face is visibly changed by injury. The suggestion is that those with facial injuries may be socially isolated, unable to engage social support, and may even be mistrusted or experience discrimination. However, there is limited empirical evidence to support the assumption that facial injuries have worse sequelae than other injuries, either in terms of appearance concern or psychological distress.  4 It is estimated that 500,000 people suffer facial trauma each year in Britain, with the most severe cases requiring treatment by oral and maxillofacial surgeons 15 . Young men are disproportionately likely to be affected 16,17 , as well as those from deprived socioeconomic groups 17 . Many have suggested that facial injury causes psychological distress specifically because facial attractions, expressions and communications have an important psychosocial role 11,18  – 21 . There is a small and growing body of research exploring psychological distress following facial injury but this particular theory does not appear to have been tested. Psychological distress is high following facial injury, in the form of post-traumatic stress symptoms (PTSS), including acute stress disorder (ASD), and symptoms of depression and anxiety. Estimates of the prevalence of distress vary widely across different studies. The prevalence of PTSS ranges from 25% to 41% in the first two months following facial injury 22  – 26 , whereas the prevalence in the general population is 5% 27 . Reports of prevalence of depressive symptoms following facial injury vary considerably, from as low as 5% 23,26  to 28% 28  or 30% 15 ; in comparison 11% of the general population experience significant symptoms at any time 29 . Clinically significant anxiety symptoms have been shown to be present in 14% 23  to 46% 26  of facial trauma patients, compared with a prevalence of 33% in the general population 29 . While prevalences are usually high compared with the general population, particularly for PTSS and depressive symptoms, we are not aware of any reports of comparisons with other trauma populations. Appearance concern is now an established concept in health research: it is associated with psychological distress and with poor health behaviours such as smoking and not exercising 30 . Having a visible disfigurement can affect an individual’s psychological wellbeing, including their quality of life, self-esteem and the quality of their social interactions 8 , and 48% of adults living with visible difference experience symptoms of anxiety 31 . The development of the widely used Derriford Appearance Scale 32  (DAS-59) and its short form 33  (DAS-24) have advanced the study of appearance concern considerably. However, there has been very little research on appearance concern in physical trauma patients, including facial trauma patients. A study of people with minor facial injuries (lacerations) reported relatively low appearance concern, but found that concern was  5 correlated with anxiety 18 . However, the study only used a reduced selection of questions from the DAS-59. Two further studies explored appearance among people with facial injury, using less recognised concepts such as attractiveness ratings 21  and satisfaction with appearance 34 . Facial trauma patients gave themselves lower attractiveness scores than a control group recruited from the general population 21 . The severity of facial trauma patients ’  facial injuries did not affect satisfaction with appearance 34 , suggesting that objective physical severity does not predict subjective levels of concern. This reflects a pattern seen in major trauma and facial trauma, where injury severity shows little association with psychological sequelae. Subjective measures of severity, i.e. judgements made by patients themselves, often have more predictive power in identifying poorer adjustment 21,33,35 . Beyond trauma, studies of people with objectively reported abnormalities have suggested that the highest levels of appearance concern affect those with concerns about visible differences to the trunk and lower limbs, with somewhat lower levels of concern about the face 33,36,37 : it has been hypothesised that having scars which are immediately visible, such as facial scars, encourages people to seek help and to adopt coping strategies sooner than if they were able to hide their scars. For women, there may be additional difficulties in coping with scars to sexuality-related body sites such as the breasts and stomach 36 . In addition, scars in the most visible ‘central triangle’ 38  of the face were not associated with poorer outcomes 18 , indicating that increased visibility does not correspond with increased concern. To our knowledge, however, there are no studies comparing appearance concerns and psychological outcomes of facial and non-facial trauma. Some studies have included trauma patients among larger heterogeneous groups 35,39 , but none have looked specifically at trauma or made comparisons between groups. We sought to address an important gap in the evidence, and thus to inform clinical practice, through the following aims: 1.   To establish the level of appearance concern following facial trauma (oral and maxillofacial trauma).
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