Psychosocial Impact of Facial Palsy

Introduction

“Societal interest in appearance has a long history,” and today this seems more important than ever. Social media, the importance of “the perfect picture,” and the desire and possibilities to change and enhance the body create more unrest and discomfort. Older studies show that physical attraction is an important predictor in entering relations and dating. Physical attraction is also associated with success, happiness, and better job prospects.

Rojas et al. believed that the face plays a crucial role in social interaction. People with facial palsy feel that their face is no longer “right” due to asymmetry and negative physical side effects such as incomplete eye closure, limited mouth movement, and synkinesis. Additionally, facial palsy is mentally burdening; patients often indicate they prefer not to look in the mirror because their face startles them. Moreover, they find it difficult when other people look at them and they cannot express their emotions. Because of the latter, emotions can often be misunderstood, resulting in miscommunication. For example, patients want to show their happiness, but due to asymmetric and paradoxical facial movements they may seem sad or angry.

It is of great importance that clinicians take into account the impact of facial palsy. Research has been performed on facial palsy patients concerning self-perception, difficulties with social encounters, and depressive disorders. Although facial palsy has been recognized to influence patient-perceived quality of life, the psychosocial disability may not be related to the severity of the condition. In 2000, evidence was found of a large individual variation in adaptation to facial palsy. At the same time, a strong relation between the degree and severity of the limitations and levels of stress was not found. Recently, the literature has shown that even a condition we qualify as minor may have severe psychosocial consequences, and that a patient with severe facial palsy or disfiguring synkinesis may not necessarily experience any problems. Health care providers need to be aware of the fact that patients are distressed but that it may not correlate with the severity of the palsy. Patients with low self-esteem, younger patients, and women suffer more from distress.

According to several studies, facial palsy is significantly correlated with not only reduced quality of life but also significant rates of depression and psychological distress. ^, Significant correlations have also been found between perception of facial palsy and level of psychological distress. The authors also found that female patients with facial palsy were more severely impacted with depression. Etiology of the facial paralysis also appears to play a part in the degree of depressive disorders. For instance, patients who develop facial paralysis secondary to a tumor are simply glad to be alive and often accept the paralysis more readily.

Coulson et al. also showed that 50% of facial palsy patients are unable to accurately express one or several emotions (happiness, anger, fear, sadness, disgust, surprise). The partners of these patients also considered their expressions more difficult to read. There were also some significant correlations between the duration and the timeline and emotional representation subscales of the Illness Perception Questionnaire-Revised (IPQ-R), as well as the Hospital Anxiety and Depression Scale. ^, This indicated that the duration of the facial palsy affected participants’ levels of distress. In a sample of patients with facial palsy, Bradbury et al. also found distress levels of 11.4% for depression and 35% for fear.

Psychosocial Consequences of Facial Palsy

The face is where all social interactions begin. Within a fraction of a second assumptions are made concerning age, gender, status, health, mood, and intentions—all by looking at a person’s face for just nanoseconds. In general, this is an efficient way of processing information, as we learn to “read” complex social stimuli from a very early age.

Facial palsy disturbs this process and changes the position of both the patient and the conversational partner in the interaction. In the literature, it is mentioned that damage to the face may also cause damage to “the self.” Various psychological mechanisms are triggered, and patients and their partners in conversation need to look for a new balance.

As described earlier, the responses of patients vary widely. Two factors play an important role: circumstances that caused the facial palsy and the existing personality traits such as self-esteem and intrinsic self-worth. Factors surrounding the facial palsy such as the etiology, age, gender, the manner in which the situation has been explained to them, and social support also have significant influence in outcome. The overall impact of a new appearance therefore is extremely diverse and the most important consequences are depression and anxiety ( Fig. 3.1 ).

Depression

The most common psychosocial response to facial palsy is depression. At the onset, feelings and complaints of depression may not be pathological per se. They can be seen as a normal way of mourning the loss of something the patient held dear—a “normal” face.

If the depressive response is out of proportion and continues for a very long time, it can become pathological. Sometimes, it may be the case that the patient was familiar with feelings of depression before the facial palsy occurred but managed to cope with them. Facial palsy then becomes an amplifier for something that had been there all along. The most obvious manifestations of depression are: worrying, loss of interest, feeling useless, being unable to make decisions, despair, and concentration problems.

Worrying

“I hardly recognize myself. Before, I never worried about anything, but now I will think about everything that might go wrong. I am no longer spontaneous; I worry about so many things now.”

Patients indicate they worry a lot more than before and they think about what other people might think of them. They may also worry excessively about their situation at school or work.

Loss of Interest

“When someone talks to me about silly things like shopping or some television program, I may think to myself: yeah right, big deal… I am extremely self-absorbed now.”

Patients indicate they are preoccupied with their own feelings and their facial palsy. They find it difficult to show an interest in other people and are mainly trying to “survive”.

Feelings of Uselessness

“I can understand my boss is reconsidering my contract. I mean, just look at my face… I am not exactly an ambassador for the company, am I?”

Patients often feel useless because they feel they can no longer function as a full member of society.

Despair

“And then this doctor just says: you’ll have to learn to live with it. Does he have any idea what he’s saying? Does he even know what he’s talking about?”

The despair of patients can not only impact their current situation but also future prospects. They will doubt if they will ever see an improvement or if they will ever be able to get better.

Concentration Problems

“I notice that since I have this condition I cannot concentrate anymore. I used to read books, but nowadays I can hardly manage.”

As a result of the events surrounding the facial palsy and the consequences for the patient, the patient may be fully preoccupied with the new situation, and concentrating on other matters may be difficult. One might say that the brain is completely preoccupied with the condition, and there is no room for other thoughts and feelings.

Dissatisfaction

Dissatisfaction can be characteristic of a patient with feelings of depression. Patients may be dissatisfied with the treatment, progress, and doctor’s statements. They may demand certain interventions that have not been recommended, such as surgical procedures, and they may decide to go and see other physicians hoping that they will give them want they want.

Anxiety

In addition to depression there may also be feelings of anxiety. It must be stated that anxiety is a perfectly normal reaction in a threatening situation. Anxiety is episodic and can be related to certain situations. Anxiety, however, can become restrictive if it is considerable and protracted. If patients develop a chronic anxiety of rejection and choose exclusion or isolation for fear, the fear may become pathological.