Can we improve our mood by smiling more or frowning less? Dr Raj Persaud surveys the latest research into the use of botulinum toxin to treat depression
I work in private practice in Harley Street and take a large number of referrals from aesthetic professionals—often ostensibly due to concerns over offering a procedure to a particular client. Alarm bells have rung, the client may have unrealistic expectations of the outcome or want psychological reassurance that it’s okay to go ahead.
Another kind of client is one that has had many aesthetic procedures and the professional has concerns that they may be suffering from a condition like body dysmorphic disorder (BDD), otherwise known as “imagined ugliness syndrome”. I became interested in the aesthetics field because of these types of referrals.
A new study has been published indicating that botulinum toxins could provide a treatment for depression. This has interesting implications about the way toxins are perceived. If they can be considered as a treatment for depression, then this changes much of the economics around toxins.
I’ll tell you a very old joke: There is a middle-aged woman who has let herself go a little, who hasn’t been looking after herself and, as a result of not being particularly fit, she has a heart attack. She’s rushed to the casualty department, the cardiac surgeons are called down and they work away on her on the operating table. Unfortunately, they lose her and she dies.
However, this is actually a near-death experience. She finds herself at the pearly gates and she meets God. She says somewhat anxiously to God, “It’s not my time, is it?” and God replies, “No, don’t worry, relax, you’ve got another 49 years, 8 months, 7 weeks, 6 days, 5 hours to live.”
She’s reassured by this and the surgeons working away on her bring her back. She comes back to life and recovers in the recovery room. She’s somewhat alarmed by this near-death experience and decides that she really must take herself in hand and look after herself. While she’s in hospital recovering, she books herself in for various cosmetic surgery procedures. She has a tummy tuck, a facelift and even has her hair done. Like a shiny new button, she walks out of the hospital’s main gates a few days later, crosses the main road outside the hospital, is hit by a car and dies instantly.
She now finds herself back at the pearly gates and meets God again and, somewhat indignantly, she says, “But wait a second, I was here only a short while ago and you said I had another 49 years, 8 months, 7 weeks, what was all that about?” And God says, “I’m really sorry about that. The thing is, I just didn’t recognise you!”
Jokes relate to how laughter may be a treatment for depression. This isn’t because you’ve been cheered up by laughing, but that the facial muscle change that occurs seems to have a profound effect on mood.
Reasons for aesthetic procedures
People seem to think it’s obvious that patients go for aesthetic procedures because they want to look better and, as a result of looking better, they feel that many of life’s outcomes will be different for them.
It’s useful to consider why a particular person wants a particular procedure ‘right now’. I find that aesthetic professionals and doctors don’t ask the question enough—why this patient and why now? Very often, people have been struggling with an aspect of their appearance for many years, but decide to visit a doctor ‘right now’ because of what I like to call ‘the transition’. A transition is occurring in their life; a life event that they’ve been psychologically affected by and that’s why they want the procedure right now.
Classically in women, this often occurs around the time of a relationship breakdown. A key moment of transition is when they are interested—for the first time—in having an aesthetic procedure. Women who are newly divorced, or who are going through a divorce, seem much more likely to have an aesthetic procedure.
Reaction and behaviour
Given that patients are often going through this psychological transition, there is even more reason to think psychologically about what’s happening and who will benefit most. Another consideration is, how will improving your appearance make a difference to your life’s outcomes? This is another question aesthetic professionals don’t ask enough. A patient is going to react to an aesthetic procedure they’ve had, and the way they react to it is going to determine the impact that procedure has upon them.
Say someone has suffered from bad acne for many years and as a result, has become somewhat inhibited and socially withdrawn. They have a procedure, their acne is cured and they look marvellous now. However, if they continue to be socially withdrawn and inhibited, the procedure is unlikely to have much impact on their lives.
Considering how a patient will react to a procedure and how they will behave following treatment, is crucial in determining how much of a positive impact the procedure will have on their lives. The key psychological variable that predicts this impact is one that most aesthetic professionals seem unaware of; a spectrum in the personality dimension that psychologists refer to as internality and externality.
This is answered by a profound question that people rarely ask: “What is it that you think determines your destiny? What is it that you think determines your future? Is it you, or is it other people?” Internals in this locus of control theory of personality, tend to believe that destiny is in their hands—that if they work hard and make the right decisions, they can end up wherever they want to be. They are in control of their own destiny.
Externals, on the other hand, believe they’re a victim of circumstance and that there’s not much they can do to determine their future. This has some profound implications. Externals are much less likely to go and vote because they don’t believe they can make that much difference. Externals are less likely to believe in the benefits of hard work and tend to take short-cuts. They’re more likely to be caught or arrested for cheating or committing fraud.
If you have a patient who is more internal in orientation, they are more likely to positively react to the procedure you’ve done and do something positive about it. If they had been withdrawn and inhibited when you performed the procedure, they’re much more likely to realise they’ve got to bring something to the table to capitalise on the benefits of that treatment.
We should become much more aware of our patients in terms of the internality and externality dimension. Interestingly, doctors and professionals in general—given they’re highly motivated people—tend to be more internal in orientation and seem to assume the rest of the world is as internal as they are. It isn’t. Most of our patients are going to be a lot more external than we are.
A recent psychological finding showed that people are becoming more external with each generation. A matter analysis was carried out, whereby all the studies done measuring internality and externality since the early 1960s were grouped together. The study showed that younger generations aged between 16 and 21 are getting more external as the years go by. Your children, you will notice, are perhaps a lot more external than you are. Younger people are more external than older people.
This shift in externality in these modern times has some dramatic implications that aesthetic professionals should be thinking about.
Most people believe that when you perform a facial expression like a smile, it’s because you are cheerful. In other words, expression comes secondarily to the primary emotion. A new study shows that actually, it may be the other way around.
It may be that your expression drives the emotion—looking sad might, in fact, make you feel sad. A lot of psychological research backs up this surprising finding; studies showing that people’s expressions are manipulated without manipulating their mood.
For example, you can get people to smile by asking them to put a pen between their teeth. All the facial muscles involved in putting a pen between your teeth are the same as those involved in smiling, so you can get a subject to smile without cheering them up. You’re performing an intervention where they smile, or deploy the same muscles involved in smiling. There’s a great deal of research that indicates, depending on what measure you use, those people seem to cheer up, simply by performing that procedure.
On the other hand, if you get people to furrow their brow, deploying the same muscles on the face that we use when we frown or look sad, those people seem to be more negative in their outlook.
Botox and depression
Drawing on that research base, a team of researchers led by Dr Axel Wollmer and Dr Tillmann Kruger at the Universities of Basel and Hanover in Germany, did a very interesting experiment. They performed a study on 30 patients, randomised into 15 receiving the Botox and 15 receiving a saline injection as the control. These patients were profoundly depressed. They had, on average, a 16-year history of recurrent depression, with each episode of depression lasting an average of 13 months.
Subjects were given one injection of Botox in the glabella region—the researchers were particularly interested in the corrugator supercilii and the procerus muscles, both of which are involved in the glabella region for frowning. One injection, compared to the placebo group, resulted in an alleviation of depressive symptoms at a level of almost 50%, within six weeks of treatment. The finding continued through to the end of the study, which ended at 17 weeks.
If we were giving these patients an anti-depressant, or performing some kind of psychotherapy to get that kind of alleviation of symptoms, it would be rather astonishing. So why is it that a single Botox injection can have such a profound impact on the mood of very depressed people?
There are various theories. One suggests it might have something to do with the physiology of muscles; the alteration of blood flow around the face, following the theory that when you smile or frown, you’re altering blood flow to the brain. In that way, facial expressions could have an effect on your mood.
Another interesting theory is that when you look in the mirror, and you feel that you look depressed, that may make you depressed as well. You may get into a feedback loop; feeling low, looking into the mirror and seeing yourself not look as great as you’d like to.
The final theory suggests that depression has a very social element. Depressed people are not pleasant to be with, so people withdraw from them. Depressed people end up finding themselves isolated and, as a result, end up being more depressed. If people look more cheerful as a result of the Botox injection, it may have positive social cycle effects.
If Botox could be seen as a reliable treatment for depression, this has some profound implications. The finding might introduce new clients into considering treatment but also, given that there is still a stigma around aesthetic procedures and vanity, it could counteract that idea if it’s seen as a serious treatment for depression. It could therefore change the economics.
Dr Raj Persaud FRCPsych MSc MPhil is a consultant psychiatrist and Emeritus Visiting Gresham Professor for Public Understanding of Psychiatry.