Botulinum toxin cosmetic therapy correlates with a more positive mood.

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Original Contribution ORIGIN Blackwell Publishing Inc A L C O N T R I B U T I O N Botulinum toxin cosmetic therapy correlates with a more positive mood Michael B Lewis, PhD1 & Patrick J Bowler, MB, BS2 1 2 School of Psychology, Cardiff University, Cardiff, UK Court House Clinics, London, UK Summary Background It has been suggested that botulinum toxin A (BTX-A) treatment for frown lines can also be used as a treatment for depression. A psychological mechanism for this effect is reviewed in
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   24  © 2009 Wiley Periodicals, Inc.ã   Journal of Cosmetic Dermatology   , 8  , 24–26  Original Contribution  BlackwellPublishingInc  ORIGINAL CONTRIBUTION  Botulinum toxin cosmetic therapy correlates with a morepositive mood  Michael B Lewis, PhD  1  & Patrick J Bowler, MB, BS  2   1  School of Psychology, Cardiff University, Cardiff, UK    2  Court House Clinics, London, UK    Summary   Background    It has been suggested that botulinum toxin A (BTX-A) treatment for frownlines can also be used as a treatment for depression. A psychological mechanism for thiseffect is reviewed in which paralysis of the corrugator (frown) muscles leads to less facialfeedback for negative emotions. Consequently, a negative affect is harder to maintain andso the person has a more positive mood.   Methods   In order to test this mechanism, the mood of patients who had received BTX-Atreatment for glabelar frown lines was measured and compared with patients who hadreceived other cosmetic treatments.   Results   The BTX-A–treated patients showed significantly less negative mood.   Conclusion   The results support the facial feedback view that frowning can make oneunhappier. Treatments that prevent frowning correlate with reduced negative mood.   Keywords   :   botulinum toxin A, glabelar frown lines, mood, depression, facial feedback   Introduction   Facial muscles do not just express emotions but they arealso involved in the experience or feeling of emotions:Smiling while reading a cartoon, for example, increasesamusement.   1   This feedback loop between the expressionof and experience of emotions was suggested by CharlesDarwin and there is now an accumulation of evidenceillustrating how facial-muscular action can affect ourmood and perception.   2   Failure to produce emotional expression also affectsmood: Patients with facial paralysis show symptoms of depression.   3   The severity of such patients’ depressivesymptoms has been found to correlated with the degreeto which their ability to smile was impaired.   4   Patientsunable to smile suffer from more depression. It is arguedthat the lack of positive facial feedback received from theabsent smile means that a positive mood is harder tomaintain.Localized facial muscular paralysis is a consequence of the use of botulinum toxin A (BTX-A; e.g. Botox® orDysport®) for cosmetic dermatology. One treatmentfor glabellar frown lines involves injections into thecorrugator (frown) muscles, paralyzing them for up to 6months. The cosmetic effect of this treatment is asmoother, less-lined forehead.   5   As well as being responsible for frown lines, the corruga-tor muscles are universally important in the expression of negative emotions including sadness, fear, anger anddistress.   6   The paralysis of these muscles means that theability to form facial expressions of these emotions isreduced. Indeed, it has been demonstrated that peoplewho have received BTX-A treatment for frown lines arerated as showing less negative facial expressions.   7   The facial feedback effect suggests that the paralysis of muscles associated with negative emotions may haveeffects beyond the outward appearance of emotion;  Correspondence: Michael B Lewis, PhD, School of Psychology, CardiffUniversity, Park Place, Cardiff CF10 3AT, UK. E-mail:   Accepted for publication October 2, 2008   Botulinum toxin therapy and moodã  M B Lewis & P J Bowler   © 2009 Wiley Periodicals, Inc.ã   Journal of Cosmetic Dermatology   , 8  , 24–26  25   Paralysis of the frown muscles could make it harder tomaintain negative emotions just as paralysis of smilemuscles makes happy emotions harder to maintain.Some support for this comes from a study that suggeststhat BTX-A injections into the corrugator frown musclescould be used as a treatment for depression.   8   Ten patientswith depression were treated with BTX-A and it wasfound that there was a marked reduction in negativeaffect to a degree where nine of the patients no longershowed depressive symptoms. There were many limitationsto this initial study, such as a lack of a control group orlong-term follow-up, but the size of the observed effectmeans that it is worthy of further research. The treatmentwas based on theoretical grounds, but there is alsoanecdotal evidence of a general improvement in themood of patients having received BTX-A therapy.   9   Thismood effect may help to explain why BTX-A treatmentleads to higher satisfaction ratings than other forms of cosmetic treatments.   10   If BTX-A treatment does have a large effect on moodthen it should be apparent in patients who have electedfor the treatment for cosmetic reasons. The currentexperiment evaluated this by testing the mood of patientswho had received BTX-A therapy for glabellar frown linesand comparing these with patients who had other formsof cosmetic treatment. It was hypothesized that patientswho had received the BTX-A treatment to the foreheadwould show a more positive mood than patients who hadreceived other forms of cosmetic therapy.   Method   Participants   Twenty-five participants took part (all white females).The participants were recruited through the Court HouseClinics and had all undergone some form of aestheticcosmetic treatment in the previous 7 days to 3 months.Many of these patients had received a variety of treatments,but they were categorized as either having had BTX-Atreatment to the forehead or not. Those not havingBTX-A treatment to the forehead may have had BTX-Aelsewhere (e.g. as a treatment for crows feet), but theywere still classified as the control group as it was nothypothesized that this treatment would affect mood. Theother treatments that the participants reported receivingincluded: glycolic peels, laser treatments, and Restylane.Twelve of the participants had undergone BTX-Atherapy to the forehead (including treatment for glabelarfrown lines) as well as, in several cases, some othertherapies. This group was designated as the BTX-A-treatedgroup and had a mean age of 47 years (SD = 9.2). Theremaining 13 participants had received cosmetic therapiesother than BTX-A to the forehead. This group wasdesignated as the control group and had a mean age of 44 years (SD = 16.0).   Procedure   Participants were given a questionnaire to fill in andreturn anonymously to Cardiff University, School of Psychology. This questionnaire asked for demographicdetails and for details of any cosmetic treatment they hadreceived recently and historically. The questionnaire alsoincluded a copy of the Irritability-Depression-AnxietyScale (IDAS).   11   This questionnaire consists of 14 questionswith four choices of answers. It provides three measures of mood based on three distinguishable elements (irritability,depression, and anxiety). The questionnaire also askedparticipants to provide a percentage value measure of their attractiveness now and prior to the treatment theyhad just received.   Results   The attractiveness ratings of the two sets of participantswere greater after treatment (both being 52 on a 100-point scale) than before treatment. The size of the change,however, was small: BTX-A–treated group increased by 6points (   N    = 9; SD   = 10.0), whereas the control groupincreased by 3 points (   N    = 10; SD   = 6.5). This differencedid not reach significance [   t   (17) = 1.143; P   = 0.269].The means from the three values on the IDAS measurefor the two groups are shown in Fig. 1. These data indicate Figure 1 Individual and average scores from the three measuresproduced by the IDAS questionnaire split according to whetherparticipants had received BTX-A treatment or not. Error barsrepresent 95% confidence intervals. The dotted lines represent theboundary between normal scores (below the dotted line) andborderline morbid scores (above the dotted line) for the IDASquestionnaire.   Botulinum toxin therapy and moodã  M B Lewis & P J Bowler   26  © 2009 Wiley Periodicals, Inc.ã   Journal of Cosmetic Dermatology   , 8  , 24–26   that the BTX-A–treated group scored consistently lowerthan the control group. This was significant [   t   (23) =3.382; P   = 0.003; d    = 1.410]. The P   -values for theindividual Irritability, Depression and Anxiety measureswere 0.063, 0.005, and 0.004, respectively.Participants within the BTX-A–treated group varied interms of how long they had been having this kind of treatment. For some participants, their first treatmentwas 2 weeks prior to treatment, whereas one participanthad been receiving BTX-A treatments for 6 years. Themean number of days since the first treatment was610 days, but this was highly skewed and so a bettermeasure of central tendency is the geometric mean,which was 195 days.   Discussion   The results showed a clear and significant difference inthe moods of the two patient groups. Those who hadreceived BTX-A treatment to the forehead had asignificantly more positive mood than those who had not,and this was carried mainly by lower anxiety anddepression scores. On these two measures, the controlgroup’s average score was inside the borderline morbidlevel, whereas the 95% confidence range for the BTX-A–treated group was wholly within the normal range.The fact that there was no significant difference in howattractive the participants felt after treatment meantthat we can discount an increase in attractivenessexplanation for this difference in mood.The research was observational in nature and so wecannot rule out the possibility that the differencesobserved are a result of differences in participants prior totreatment. The statistical analysis, however, reveals thatthe pattern of results is unlikely to be a result of chancevariability. We cannot, however, without further research,discount the possibility that happier patients are morelikely to choose BTX-A treatments over other treatments.In spite of the limitations of this kind of correlationalresearch, the results provide support for the researchhypothesis. That hypothesis being that the paralysis of the corrugator muscles, which makes it impossible tomake many negative facial expression, causes negativemoods to be harder to maintain: The lack of the negativemood feedback from the facial muscles leads these peopleto feel happier.Given the importance of the corrugator muscle as anorgan of communication, a smoother forehead andpossibly a happier mood might not be the only effects of BTX-A treatment. The positive and potentially negativepsychological implications of the elective paralysis of amajor muscle involved in emotional expressions havereceived little scientific attention. From what we know of the psychology of emotions and their relationship withbehavior, the treatment could potentially have effects on:risk evaluation, empathy to others, and communication.All of these warrant further psychological investigationif we are to understand the consequences of this increas-ingly popular cosmetic treatment.   References   1Strack F, Martin LL, Stepper S. Inhibiting and facilitatingconditions of human smile: a nonobtrusive test of the facialfeedback hypothesis.  J Pers Soc Psychol   1988; 54   : 768–77.2Strack F, Neumann R. Furrowing the brow may undermineperceived fame: the role of facial feedback in judgments of celebrity. Pers Soc Psychol B   , 2000; 26   : 762–8.3Twerski AJ, Twerski B. The emotional impact of facialparalysis. In: May M, ed. The Facial Nerve   . New York:Thieme; 1986.4Van Swearingen JM, Cohn JF, Bajaj-Luthra A. Specificimpairment of smiling increases the severity of depressivesymptoms in patients with facial neuromuscular disorders. Aesthet Plast Surg   , 1999; 23   : 416–23.5Carruthers JA, Lowe NJ, Menter MA et al   . A multicenter,double-blind, randomized, placebo-controlled study of theefficacy and safety of botulinum toxin type A in thetreatment of glabellar lines.  J Am Acad Dermatol   2002; 46   :840–9.6Ekman P. About brows: emotional conversational signals.In: M Cranach, K Froppa, W Lepenies, D Ploog, eds. HumanEthology, Claims and Limits of a New Discipline   . Cambridge,UK: Cambridge University Press; 1978.7Heckmann M, Teichmann B, Schröder U, Sprengelmeyer R,Ceballos-Baumann A. Pharmacologic denervation of frownmuscles enhances baseline expression of happiness anddecreases baseline expression of anger, sadness, and fear.  J Am Acad Dermatol   2002; 49   : 213–6.8Finzi E, Wasserman E. Treatment of depression withbotulinum toxin A: a case series. Dermatol Surg   2006; 32   :645–50.9Carruthers A, Hammond M. Commentary on Finzi &Wasserman (2006). Dermatol Surg   2006; 32   : 650–1.10Sommer B, Zschocke I, Bergfeld D, Sattler G, Augustin M.Satisfaction of patients after treatment with botulinumtoxin for dynamic facial lines. Dermatol Surg   2003; 29   :456–60.11Snaith RP, Zigmond AS. The Hospital Anxiety and DepressionScale with the Irritability–Depression–Anxiety Scale   . London,UK: nferNelson; 1994.
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