Aesthetic Surgery Journal Advance Access published June 4, 2015
Editorial
Mind, Mood, and Aesthetics Steven H. Dayan, MD, FACS
What comes first: the expression or the emotion? If you smile do you become happy, or are you happy so you then smile? Since Charles Darwin first observed “that even the simulation of an emotion tends to arouse it in our mind,”1 a large body of evidence has supported the facial-feedback hypothesis, which suggests that the emotion follows the expression.2,3 Volunteers forced to smile by placing a pencil in their mouths found cartoons funnier, and those forced to frown rated unpleasant photographs more negatively.4,5 But recently, thanks to more advanced neuroimaging capabilities, we are beginning to better understand the mechanism at work. Since Paul Ekman illuminated the impact of facial expressions, we have gained a detailed understanding of how facial muscle movements linked through primitive coupled neural pathways within the amygdala trigger mood and autonomic nervous system manifestations.6-8 Those who are sad tend to frown, and those who frown are more likely to be sad. The facial feedback hypothesis today is providing a framework for reevaluating and treating one of the leading causes of disability in the United States (US). Mood disorders, and depression in particular, are highly prevalent in Western society. The National Institute of Mental Health estimates 9.5% of Americans suffer from mood disorders, and in 2012 an estimated 16 million adults aged 18 or older in the US had at least one major depressive episode. This represented 6.9% of all US adults.9 The lifetime prevalence of depression is 16.2%,10 and depressive symptoms can be found in 44% of elderly people. Since 1987 there has been a 4-fold increase in the diagnosis of depression, which perhaps not surprisingly coincides with the approval of Prozac (Eli Lilly and Company, Indianapolis, Indiana). More than 10% of the US population is now taking antidepressants, spending 11 billion dollars on the second most commonly prescribed category of medication.11 Antidepressants though, are not without drawbacks. They must be taken daily to be effective, compliance can be a hurdle, and once started and taken regularly it can be problematic if they are suddenly stopped. Some of the antidepressant medications pose risks, including insomnia,
Aesthetic Surgery Journal 2015, 1–3 © 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: [email protected] DOI: 10.1093/asj/sjv032 www.aestheticsurgeryjournal.com
decreased libido, cardiac symptoms, and more. And efficacy, while proven to benefit, many anti-depressants still leave 33% of patients symptomatic, despite multiple drug trials.12 Could there be a better, more direct, safer, and nonsystemic alternative? Since Finzi first described botulinum toxin A (BtxnA) effects on depression in 2006, multiple double-blind placebo-controlled studies have shown that the injection of BtxnA (Botox; Allergan, Irvine, California; or Dysport; Galderma, Fort Worth, Texas) into the corrugators significantly improves symptoms of depression in those who suffer from major depressive disorders, with remission rates comparing favorably to traditionally prescribed antidepressants.13-16 Yes, that is right: Botox/Dysport treats depression with results that rival the most recognized antidepressants. Since BtxnA likely does not directly cause its effects from behind the blood-brain barrier, how does it affect mood? Using the facial-feedback hypothesis as a model, if a frown is inhibited then our ability to be sad is also reduced. But even prior, our ability to perceive negative emotions may also be attenuated. It is widely accepted that when attempting to empathize or understand sadness, whether from a book, movie, or story, we use our facial muscles to initiate a frown, which then prompts a mood of sadness coupled to a limbic system-triggered autonomic nervous system response resulting in the physical manifestations of sadness. This primitively driven behavior operates below our conscious mind. Havas et al showed that following placement of BtxnA in the corrugators, reading, recognition, and cognition of angry and sad sentences was decreased.17 And Hennenlotter et al reported that after placement of neurotoxin
Dr Dayan is a Clinical Assistant Professor, Department of Otolaryngology, University of Illinois, Chicago, Illinois. Corresponding Author: Dr Steven H. Dayan, 845 N. Michigan Ave, Suite 923, Chicago, Illinois 60611, USA. E-mail: [email protected]
Aesthetic Surgery Journal
2
in the corrugators when participants were asked to frown, signaling in the amygdala and its coupling with the autonomic nervous systems became attenuated.7 If we diminish corrugator activity, then we mitigate the symptoms of anger and depression; it also may protect us from feeling the extent of sadness or anger in a confederate. To understand another’s, feelings we subconsciously mimic their expression and then start to feel that emotion ourselves. This simple, yet complex version of the child’s game “copycat” works via mirror neurons thought to be located in Brodman area 44.18,19 In essence, moods are contagious. If we engage with others who are sad, we become sad. And if they are happy, we become happy. Happiness in fact seems to be highly contagious. And it has been shown to spread up through 3 degrees of people.20 Think about that: if you smile people around you smile and then they become happier. It is one of the reasons we likely are attracted to certain people. Call it the “x-factor” or what you wish but people who smile are infectious, as are their highly attractive elevated moods. How does all of this relate to aesthetic medicine? It is well established that aesthetic intervention results in our patient projecting a better first impression and experiencing an elevated self-esteem or mood.21-23 This likely indirectly leads to others around them experiencing an improvement in mood. While this line of thinking can be well deduced with BtxnA treatments, could there be other aesthetic procedures in our toolbox that also work by this curious and covert mechanism of action? Take a good look at postoperative photographs of facelifts and filler patients: they seem to look happier; are they? Could it be that we are altering the corners of their mouth and lower facial musculature into a smile like orientation? Maybe fillers stimulate happiness by physically promoting a smile? And if not directly via the mechanical alterations, perhaps facelift and filler patients who have been shown to project a more favorable impression and improved self-esteem inspire their acquaintances to smile more, be happier, and sustain a reinforcing feedback mechanism of elevated mood that benefits both. Regardless of the specific mechanism, clearly aesthetic interventions are affecting mood and this likely expands far beyond fillers, BtxnA, and facelifts. Other nonmedical aesthetic interventions from makeup to skin and hair care also have been shown to favorably alter the impression a person projects, along with elevating mood and self-esteem.24-27 And if this is the case, can these procedures be qualified, quantified, and dosed for treatment? It is well known that cancer victims and elderly gain mood elevation when treated with makeup and hair care. If we recognize that aesthetic interventions may not only improve the mood and self-esteem of patients but also extended up to 3 degrees of people from which they are associated with, then the indirect impact of aesthetic treatments on households, communities, and, dare we think, societies could be far more significant than we realize. While
admittedly this reasoning is very expansive, especially considering that the safety and efficacy of aesthetics are yet to be FDA approved for such an indication. But such a line of thinking may locally revolutionize the way we approach, treat, and engage current and future aesthetically inclined patients. The experts tell us that the potential market of people interested in medical appearance enhancement treatments is 5 times greater than the number of people actually receiving treatments.28 However, that is assuming that these prospective pursuers are interested in physically beautifying treatments. But if the question is slightly rephrased to how many are interested in improving their mood, the number of potential patients could be 20 times greater. As aesthetic medicine and surgery continues to evolve and we as aesthetic physicians better understand who we are and what we do, the future of the trade could evolve from a vanitybranded specialty focused on form and function for a few to a self-empowering trade devoted to improving mind and mood for all. And that is a mission and privilege ushering in limitless growth … are we ready for that?
Disclosures The author has/had research, speaking, and/or consulting agreements with Merz (Greensboro, North Carolina), Allergan (Irvine, California), and Galderma (Fort Worth, Texas).
Funding The author received no financial support for the research, authorship, and publication of this article.
REFERENCES 1. 2. 3. 4.
5.
6.
7.
Darwin CR. The expression of emotion in man and animals. Chicago: University of Chicago Press, 1965:365. Izard CE. Facial expressions and the regulation of emotions. J Pers Soc Psych. 1990;58(3):487-498. McIntosh DN. Facial feedback hypotheses: evidence, implications, and directions. Motiv Emot. 1996;20:121-147. Strack F, Martin LL, Stepper S. Inhibiting and facilitating conditions of facial expressions: a non-obtrusive text of the facial feedback hypothesis. J Pers Soc Psych. 1988;54 (5):768-777. Larsen RJ, Kasimatis M, Frey K. Facilitating the furrowed brow: an unobtrusive test of the facial feedback hypothesis applied to unpleasant affect. Cognition Emotion. 1992;6:321-338. Ekman P, Levenson RW, Friesen WV. Autonomic nervous system activity distinguishes among emotions. Science. 1983;221(4616):1208-1210. Hennenlotter A, Dresel C, Castrop F, Ceballos-Baumann AO, Wohlschläger AM, Haslinger B. Link between Facial Feedback and Neural Activity within Central Circuitries of Emotion—New Insights from Botulinum Toxin– Induced Denervation of Frown Muscles. Cereb Cortex. 2009;19(3):537-542.
Dayan
8.
9.
10.
11. 12.
13.
14.
15.
16.
17.
Schwartz GE, Fair PL, Salt P, Mandel MR, Klerman GL. Facial muscle patterning to affective imagery in depressed and nondepressed subjects. Science. 1976;192(4238):489-491. Major Depression Among Adults. http://www.nimh.nih. gov/health/statistics/prevalence/major-depression-amongadults.shtml. Accessed February 9, 2015. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003; 289(23):3095-3105. Smith BL. Inappropriate prescribing. Monitor on Psychology. 2012:43(6):36. Gaynes BN, Warden D, Trivedi MH, Wisniewski SR, Fava MRush AJ. What did STAR*D teach us? Results from a large-scale, practical, clinical trial for patients with depression. Psychiatr Serv. 2009;60(11):1439-1445. Finzi E, Wasserman E. Treatment of depression with botulinum toxin A: a case series. Dermatol Surg. 2006;32 (5):645-649. Wollmer MA, de Boer C, Kalak N, et al. Facing depression with botulinum toxin: a randomized controlled trial. J Psychiatr Res. 2012;46(5):574-581. Finzi E, Rosenthal NE. Treatment of depression with onabotulinumtoxinA: a randomized, double-blind, placebo controlled trial. J Psychiatr Res. 2014;52:1-6. Hexsel D, Brum C, Siega C, et al. Evaluation of selfesteem and depression symptoms in depressed and nondepressed subjects treated with onabotulinumtoxinA for glabellar lines. Dermatol Surg. 2013;39(7):1088-1096. Havas DA, Glenberg AM, Gutowski KA, Lucarelli MJ, Davidson RJ. Cosmetic use of botulinum toxin-a affects processing of emotional language. Psychol Sci. 2010;21 (7):895-900.
3
18. Fuchs T, Koch SC. Embodied affectivity: on moving and being moved. Front Psychol. 2014;5:508. 19. Niedenthal PM. Embodying emotion. Science. 2007;316 (5827):1002-1005. 20. Fowler JH, Christakis NA. Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ. 2008;337:a2338. 21. Dayan SH, Lieberman ED, Thakkar NN, Larimer KA, Anstead A. Botulinum toxin a can positively impact first impression. Dermatol Surg. 2008;34(Suppl 1):S40-S47. 22. Dayan SH. Primal medicine. In: Dayan SH, ed. Subliminally Exposed: Shocking truths about your hidden desires in mating, dating and communicating. New York, NY: Morgan James Publishing, 2013:160-180. 23. Dayan SH, Arkins JP, Gal TJ. Blinded evaluation of the effects of hyaluronic acid filler injections on first impressions. Dermatol Surg. 2010;36(Suppl 3):1866-1873. 24. Dayan SH, Arkins JP, Sharma V, Paterson E, Barnes D. A phase 2, double-blind, randomized, placebo-controlled trial of a novel nutritional supplement product to promote healthy skin. J Drugs Dermatol. 2011;10(10):1106-1114. 25. Nash R, Fieldman G, Hussey T, Lévêque JL, Pineau P. Cosmetics: They Influence More Than Caucasian Female Facial Attractiveness. J Appl Soc Psychol. 2006;36(2): 493-504. 26. Holme SA, Beattie PE, Fleming CJ. Cosmetic camouflage advice improves quality of life. Br J Dermatol. 2002;147 (5):946-949. 27. Patzer GL. Psychologic and sociologic dimensions of hair: an aspect of the physical attractiveness phenomenon. Clin Dermatol. 1988;6(4):93-101. 28. Valeant Pharmaceuticals. Aesthetics Market quantitative research Sept 2014; Commission File No. 001–14956.
Editorial
Mind, Mood, and Aesthetics Steven H. Dayan, MD, FACS
What comes first: the expression or the emotion? If you smile do you become happy, or are you happy so you then smile? Since Charles Darwin first observed “that even the simulation of an emotion tends to arouse it in our mind,”1 a large body of evidence has supported the facial-feedback hypothesis, which suggests that the emotion follows the expression.2,3 Volunteers forced to smile by placing a pencil in their mouths found cartoons funnier, and those forced to frown rated unpleasant photographs more negatively.4,5 But recently, thanks to more advanced neuroimaging capabilities, we are beginning to better understand the mechanism at work. Since Paul Ekman illuminated the impact of facial expressions, we have gained a detailed understanding of how facial muscle movements linked through primitive coupled neural pathways within the amygdala trigger mood and autonomic nervous system manifestations.6-8 Those who are sad tend to frown, and those who frown are more likely to be sad. The facial feedback hypothesis today is providing a framework for reevaluating and treating one of the leading causes of disability in the United States (US). Mood disorders, and depression in particular, are highly prevalent in Western society. The National Institute of Mental Health estimates 9.5% of Americans suffer from mood disorders, and in 2012 an estimated 16 million adults aged 18 or older in the US had at least one major depressive episode. This represented 6.9% of all US adults.9 The lifetime prevalence of depression is 16.2%,10 and depressive symptoms can be found in 44% of elderly people. Since 1987 there has been a 4-fold increase in the diagnosis of depression, which perhaps not surprisingly coincides with the approval of Prozac (Eli Lilly and Company, Indianapolis, Indiana). More than 10% of the US population is now taking antidepressants, spending 11 billion dollars on the second most commonly prescribed category of medication.11 Antidepressants though, are not without drawbacks. They must be taken daily to be effective, compliance can be a hurdle, and once started and taken regularly it can be problematic if they are suddenly stopped. Some of the antidepressant medications pose risks, including insomnia,
Aesthetic Surgery Journal 2015, 1–3 © 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: [email protected] DOI: 10.1093/asj/sjv032 www.aestheticsurgeryjournal.com
decreased libido, cardiac symptoms, and more. And efficacy, while proven to benefit, many anti-depressants still leave 33% of patients symptomatic, despite multiple drug trials.12 Could there be a better, more direct, safer, and nonsystemic alternative? Since Finzi first described botulinum toxin A (BtxnA) effects on depression in 2006, multiple double-blind placebo-controlled studies have shown that the injection of BtxnA (Botox; Allergan, Irvine, California; or Dysport; Galderma, Fort Worth, Texas) into the corrugators significantly improves symptoms of depression in those who suffer from major depressive disorders, with remission rates comparing favorably to traditionally prescribed antidepressants.13-16 Yes, that is right: Botox/Dysport treats depression with results that rival the most recognized antidepressants. Since BtxnA likely does not directly cause its effects from behind the blood-brain barrier, how does it affect mood? Using the facial-feedback hypothesis as a model, if a frown is inhibited then our ability to be sad is also reduced. But even prior, our ability to perceive negative emotions may also be attenuated. It is widely accepted that when attempting to empathize or understand sadness, whether from a book, movie, or story, we use our facial muscles to initiate a frown, which then prompts a mood of sadness coupled to a limbic system-triggered autonomic nervous system response resulting in the physical manifestations of sadness. This primitively driven behavior operates below our conscious mind. Havas et al showed that following placement of BtxnA in the corrugators, reading, recognition, and cognition of angry and sad sentences was decreased.17 And Hennenlotter et al reported that after placement of neurotoxin
Dr Dayan is a Clinical Assistant Professor, Department of Otolaryngology, University of Illinois, Chicago, Illinois. Corresponding Author: Dr Steven H. Dayan, 845 N. Michigan Ave, Suite 923, Chicago, Illinois 60611, USA. E-mail: [email protected]
Aesthetic Surgery Journal
2
in the corrugators when participants were asked to frown, signaling in the amygdala and its coupling with the autonomic nervous systems became attenuated.7 If we diminish corrugator activity, then we mitigate the symptoms of anger and depression; it also may protect us from feeling the extent of sadness or anger in a confederate. To understand another’s, feelings we subconsciously mimic their expression and then start to feel that emotion ourselves. This simple, yet complex version of the child’s game “copycat” works via mirror neurons thought to be located in Brodman area 44.18,19 In essence, moods are contagious. If we engage with others who are sad, we become sad. And if they are happy, we become happy. Happiness in fact seems to be highly contagious. And it has been shown to spread up through 3 degrees of people.20 Think about that: if you smile people around you smile and then they become happier. It is one of the reasons we likely are attracted to certain people. Call it the “x-factor” or what you wish but people who smile are infectious, as are their highly attractive elevated moods. How does all of this relate to aesthetic medicine? It is well established that aesthetic intervention results in our patient projecting a better first impression and experiencing an elevated self-esteem or mood.21-23 This likely indirectly leads to others around them experiencing an improvement in mood. While this line of thinking can be well deduced with BtxnA treatments, could there be other aesthetic procedures in our toolbox that also work by this curious and covert mechanism of action? Take a good look at postoperative photographs of facelifts and filler patients: they seem to look happier; are they? Could it be that we are altering the corners of their mouth and lower facial musculature into a smile like orientation? Maybe fillers stimulate happiness by physically promoting a smile? And if not directly via the mechanical alterations, perhaps facelift and filler patients who have been shown to project a more favorable impression and improved self-esteem inspire their acquaintances to smile more, be happier, and sustain a reinforcing feedback mechanism of elevated mood that benefits both. Regardless of the specific mechanism, clearly aesthetic interventions are affecting mood and this likely expands far beyond fillers, BtxnA, and facelifts. Other nonmedical aesthetic interventions from makeup to skin and hair care also have been shown to favorably alter the impression a person projects, along with elevating mood and self-esteem.24-27 And if this is the case, can these procedures be qualified, quantified, and dosed for treatment? It is well known that cancer victims and elderly gain mood elevation when treated with makeup and hair care. If we recognize that aesthetic interventions may not only improve the mood and self-esteem of patients but also extended up to 3 degrees of people from which they are associated with, then the indirect impact of aesthetic treatments on households, communities, and, dare we think, societies could be far more significant than we realize. While
admittedly this reasoning is very expansive, especially considering that the safety and efficacy of aesthetics are yet to be FDA approved for such an indication. But such a line of thinking may locally revolutionize the way we approach, treat, and engage current and future aesthetically inclined patients. The experts tell us that the potential market of people interested in medical appearance enhancement treatments is 5 times greater than the number of people actually receiving treatments.28 However, that is assuming that these prospective pursuers are interested in physically beautifying treatments. But if the question is slightly rephrased to how many are interested in improving their mood, the number of potential patients could be 20 times greater. As aesthetic medicine and surgery continues to evolve and we as aesthetic physicians better understand who we are and what we do, the future of the trade could evolve from a vanitybranded specialty focused on form and function for a few to a self-empowering trade devoted to improving mind and mood for all. And that is a mission and privilege ushering in limitless growth … are we ready for that?
Disclosures The author has/had research, speaking, and/or consulting agreements with Merz (Greensboro, North Carolina), Allergan (Irvine, California), and Galderma (Fort Worth, Texas).
Funding The author received no financial support for the research, authorship, and publication of this article.
REFERENCES 1. 2. 3. 4.
5.
6.
7.
Darwin CR. The expression of emotion in man and animals. Chicago: University of Chicago Press, 1965:365. Izard CE. Facial expressions and the regulation of emotions. J Pers Soc Psych. 1990;58(3):487-498. McIntosh DN. Facial feedback hypotheses: evidence, implications, and directions. Motiv Emot. 1996;20:121-147. Strack F, Martin LL, Stepper S. Inhibiting and facilitating conditions of facial expressions: a non-obtrusive text of the facial feedback hypothesis. J Pers Soc Psych. 1988;54 (5):768-777. Larsen RJ, Kasimatis M, Frey K. Facilitating the furrowed brow: an unobtrusive test of the facial feedback hypothesis applied to unpleasant affect. Cognition Emotion. 1992;6:321-338. Ekman P, Levenson RW, Friesen WV. Autonomic nervous system activity distinguishes among emotions. Science. 1983;221(4616):1208-1210. Hennenlotter A, Dresel C, Castrop F, Ceballos-Baumann AO, Wohlschläger AM, Haslinger B. Link between Facial Feedback and Neural Activity within Central Circuitries of Emotion—New Insights from Botulinum Toxin– Induced Denervation of Frown Muscles. Cereb Cortex. 2009;19(3):537-542.
Dayan
8.
9.
10.
11. 12.
13.
14.
15.
16.
17.
Schwartz GE, Fair PL, Salt P, Mandel MR, Klerman GL. Facial muscle patterning to affective imagery in depressed and nondepressed subjects. Science. 1976;192(4238):489-491. Major Depression Among Adults. http://www.nimh.nih. gov/health/statistics/prevalence/major-depression-amongadults.shtml. Accessed February 9, 2015. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003; 289(23):3095-3105. Smith BL. Inappropriate prescribing. Monitor on Psychology. 2012:43(6):36. Gaynes BN, Warden D, Trivedi MH, Wisniewski SR, Fava MRush AJ. What did STAR*D teach us? Results from a large-scale, practical, clinical trial for patients with depression. Psychiatr Serv. 2009;60(11):1439-1445. Finzi E, Wasserman E. Treatment of depression with botulinum toxin A: a case series. Dermatol Surg. 2006;32 (5):645-649. Wollmer MA, de Boer C, Kalak N, et al. Facing depression with botulinum toxin: a randomized controlled trial. J Psychiatr Res. 2012;46(5):574-581. Finzi E, Rosenthal NE. Treatment of depression with onabotulinumtoxinA: a randomized, double-blind, placebo controlled trial. J Psychiatr Res. 2014;52:1-6. Hexsel D, Brum C, Siega C, et al. Evaluation of selfesteem and depression symptoms in depressed and nondepressed subjects treated with onabotulinumtoxinA for glabellar lines. Dermatol Surg. 2013;39(7):1088-1096. Havas DA, Glenberg AM, Gutowski KA, Lucarelli MJ, Davidson RJ. Cosmetic use of botulinum toxin-a affects processing of emotional language. Psychol Sci. 2010;21 (7):895-900.
3
18. Fuchs T, Koch SC. Embodied affectivity: on moving and being moved. Front Psychol. 2014;5:508. 19. Niedenthal PM. Embodying emotion. Science. 2007;316 (5827):1002-1005. 20. Fowler JH, Christakis NA. Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ. 2008;337:a2338. 21. Dayan SH, Lieberman ED, Thakkar NN, Larimer KA, Anstead A. Botulinum toxin a can positively impact first impression. Dermatol Surg. 2008;34(Suppl 1):S40-S47. 22. Dayan SH. Primal medicine. In: Dayan SH, ed. Subliminally Exposed: Shocking truths about your hidden desires in mating, dating and communicating. New York, NY: Morgan James Publishing, 2013:160-180. 23. Dayan SH, Arkins JP, Gal TJ. Blinded evaluation of the effects of hyaluronic acid filler injections on first impressions. Dermatol Surg. 2010;36(Suppl 3):1866-1873. 24. Dayan SH, Arkins JP, Sharma V, Paterson E, Barnes D. A phase 2, double-blind, randomized, placebo-controlled trial of a novel nutritional supplement product to promote healthy skin. J Drugs Dermatol. 2011;10(10):1106-1114. 25. Nash R, Fieldman G, Hussey T, Lévêque JL, Pineau P. Cosmetics: They Influence More Than Caucasian Female Facial Attractiveness. J Appl Soc Psychol. 2006;36(2): 493-504. 26. Holme SA, Beattie PE, Fleming CJ. Cosmetic camouflage advice improves quality of life. Br J Dermatol. 2002;147 (5):946-949. 27. Patzer GL. Psychologic and sociologic dimensions of hair: an aspect of the physical attractiveness phenomenon. Clin Dermatol. 1988;6(4):93-101. 28. Valeant Pharmaceuticals. Aesthetics Market quantitative research Sept 2014; Commission File No. 001–14956.
