Disfigurement: The Challenges for Identity and the Strategies for Coping

Living with disfigurement can constitute a psychologically challenging position for both adults and young people alike. The present paper explores the potential implications of living with disfigurement for identity through the novel application of identity process theory, a socio-psychological theory of identity threat, to the topic of disfigurement. The theory argues that individuals need to perceive appropriate levels of self-esteem, distinctiveness, continuity, self-efficacy, meaning, belonging and coherence, and that insufficient levels of these principles will induce identity threat. Firstly, the paper outlines those principles most susceptible to threat among individuals living with disfigurement. Secondly, it considers strategies which may be implemented by the threatened individual as a means of coping with identity threat associated with disfigurement, as well as the efficacy of these strategies. The primary focus of the paper lies within the identification of what threatens identity and how health care institutions can facilitate and encourage effective coping strategies among individuals living with disfigurement.     

Evaluations of People Depicted With Facial Disfigurement Compared to Those With Mobility Impairment

There are few extant studies of stereotyping of people with facial disfigurement. In the present study, two experiments (both within-participants) showed positive evaluations of people depicted as wheelchair users and, from the same participants, negative evaluations of people with facial disfigurements, compared to controls. The results of Experiment 2 suggested that implicit affective attitudes were more negative toward people with facial disfigurement than wheelchair users and were correlated with evaluation negativity. Social norms were perceived to permit more discrimination against people with facial disfigurement than against wheelchair users. These factors could help to explain the evaluative differences between the two disadvantaged groups.     

Facial disfigurement in patients with head and neck cancer: the role of social self-efficacy.

This study investigated the moderating role of social self-efficacy (i.e., the belief that one is capable of exercising control over the reactions and openness of other people) with respect to the link between facial disfigurement and psychological and n = 76) as well as their physicians. In line with the hypotheses, the results revealed that the degree of facial disfigurement, as judged by patients as well as their physicians, was positively related to psychological distress and distress in reaction to unpleasant behavior of others, but only when patients did not feel self-efficacious in social encounters. Furthermore, social self-efficacy mitigated the positive link between facial disfigurement as judged by patients and social isolation.     

When your face doesn't fit: employment discrimination against people with facial disfigurements

This study aimed to investigate the recruitment prospects of people with facial disfigurement and a contrasting group of wheelchair users, representing a functional impairment with little aesthetic impact. Three applications were made to each of 144 vacancies using three CVs and cover letters rotated around conditions in which one applicant was described as a wheelchair user, another had a noncontagious facial disfigurement, and the third (control condition) had neither. There was evidence of discrimination against people with facial disfigurement in jobs requiring high (but not low) levels of customer contact, and against wheelchair users for jobs entailing high or low‐customer contact. Aesthetic considerations, social norms, and the possibility of stigma by association are discussed as potential underlying factors.     

The Effect of Facial Disfigurement on the Proxemic Behavior of the General Public1

The personal space afforded to a disfigured or nondisfigured confederate by 450 pedestrians in a busy street was measured. In Condition 1, the confederate had a birthmark under the right eye (permanent disfigurement). In Condition 2, this was replaced by trauma scarring and bruising (temporary disfigurement). In the third condition, the confederate was “normal” (i.e., no disfigurement). It was found that subjects stood further away from the confederate in the disfigured conditions than in the no disfigurement condition. More specifically, pedestrians arriving first in each trial stood an average distance of 100 cms from the confederate in the birthmark condition, 78 cms in the trauma condition, and 56 cms when the confederate was not disfigured. In addition, subjects chose significantly more often to stand to the left (nondisfigured) side of the confederate in the birthmark and trauma conditions than they did in the normal condition. Those subjects who chose to stand on the right (disfigured) side of the confederate, stood further away from those subjects standing on the nondisfigured side. The implications of the results are discussed in terms of the possible psychological problems associated with facial disfigurement.     

A systematic review of self-help for disfigurement: Effectiveness,usability, and acceptability

Self-help has been found to be efficacious in treating mood disorders, however, little is known about its use, effectiveness, or user satisfaction, in reducing distress associated with disfigurement. This review describes the content and focus of self-help interventions available in this area. A systematic search and appraisal protocol facilitated identification of studies, extraction of data, and appraisal of quality. Clinical trials were included if the primary method of intervention delivery was via self-help. Other types of study were included if they investigated user perspectives of a self-help intervention. Eleven studies covering a range of populations met the inclusion criteria. There is tentative support for the use of self-help to manage anxiety associated with disfigurement but little is known about the management of other psychosocial difficulties. Further research and intervention development is required to examine the effectiveness, acceptability, and utility of self-help in managing the appearance related distress associated with disfigurement.     

The psychological impact of facial changes in scleroderma

The physical disabilities associated with scleroderma are well known but the psychological impact of the condition has received less attention. Few studies have examined appearance related issues, most notably of the face. The aim of this study is to evaluate the psychological impact of facial, aesthetic and functional changes in scleroderma. One hundred seventy-one patients with a clinical diagnosis of scleroderma were recruited into the study. Digital photographs were objectively graded into groups based on severity of disfigurement as judged by an observer. Facial movement was recorded using a modified House-Brackmann Grading Scale. Psychological evaluation comprised the Derriford Appearance Scale short-form (DAS), the Noticeability and Worry score and the Hospital Anxiety and Depression Scale (HADS). Severity of disfigurement predicted decreased mouth opening, the extent to which participants judged their appearance as noticeable to others, and the level of appearance-related concern as measured by the DAS24. There was an inverse relationship with age. Facial changes were ranked as the most worrying aspect of the condition. This study shows facial disfigurement impacts on patient with scleroderma independent of functional changes related to systemic disease. The major difficulty is with the perceived noticeably of the condition to other people and the resulting self-consciousness in social encounters.     

The role of disgust emotions in the observer response to facial disfigurement

Social intrusions by observers are commonly reported by those with disfiguring conditions. This study examined the role of disgust emotions in the observer response. A group of students (N = 48) completed quantitative questionnaires measuring extent of disfigurement, whilst viewing images of faces with varying disfigurements. Another group of students (N = 84) completed quantitative questionnaires measuring level of disgust elicited by the same images. Disgust sensitivity was measured using the Disgust Scale Revised. Observers reported greater levels of disgust (p < .01) with increasing severity of facial disfigurement. Individuals with a higher disgust sensitivity reported increased levels of disgust in response to faces of mild (p = .03), moderate (p = .02) and severe (p < .01) disfigurement compared to those with a lower disgust sensitivity. This provides an explanatory framework for the avoidance reactions of observers and may be important in understanding variability in adjustment following disfigurement.     

药物不良反应侵权诉讼问题研究

药物不良反应侵权诉讼是一种特殊的民事侵权诉讼。药品的生产者、药品经营者以及医疗机构都可能成为诉讼中的被告。药物不良反应侵权诉讼中的许多案件事实实行举证倒置。主要举证倒置事实有:药品缺陷、因果关系、免责事由、医疗过错等。     

Gender and Suicide Risk: The Role of Wound Site

That males have higher suicide rates than females is one of the most empirically documented social facts in suicidology, but the reasons for this continue to be debated. For the present paper, we tested a neglected contributing factor to the gender suicide ratio: wound site or the area of the body that is wounded in firearm suicides. Males may have a higher suicide rate, in part, due to their greater likelihood than women for shooting themselves in the head as opposed to the body. This has been related to gender differences in fear of facial disfigurement and suicide intent. Data from the Wayne County Medical examiner's office regarding 807 suicides committed with firearms was analyzed. The dependent variable was dichotomous and referred to the location of the site of the wound: gunshot to the head vs. gunshot to the body. Controls for demographic covariates of suicide included age and race of the suicide victim. The results of the multivariate logistic regression analysis determined that women were 47% less apt than men to shoot themselves in the head. Further analysis determined that women were less apt than men to use shotguns and rifles in their suicides (weapons that make head shooting more awkward). The findings are consistent with the notion that women are more concerned than men with facial disfigurement, and that women have a lower desire to die than men.     

Does marriage influence whether a facially disfigured person is considered physically unattractive?

Many recent studies have supported Dion, Berscheid, and Walster's (1972) viewpoint that "What is beautiful is good." In addition, several studies have found that an individual who is believed to be married to a facially attractive person will be perceived as attractive to other people. Few studies have examined how a disfigured or deformed face is perceived. The present study sought to determine whether perception of facial disfigurement is influenced by marriage to someone who has a normal face. Evidence to support this theory was found.     

Counselling patients with AIDS-associated Kaposi's sarcoma

Kaposi's Sarcoma is a disfiguring and feared symptom of HIV disease. Structured interviews of patients, family members and health care providers were conducted in three settings: USA (11), UK (8) and sub-Saharan Africa (20). These sought to identify: (a) contextual and cultural differences; (b) the main fears of patients and others; (c) practical ways of addressing these and coping with stigma, and (d) methods for ‘inoculating’ non-KS patients against psychological distress before there is any evidence of clinical signs or symptoms. It was found that context and culture mediated social responses to KS and disfigurement. Patients in Africa seemed to be less affected than Western patients by appearance and stigma. Issues relating to secrecy were common to both groups. Compliance with treatment was good as long as it was efficacious. When no further treatment of Kaposi's sarcoma was possible, there is greater emphasis on counselling. Patients (particularly in the West) appreciated treatment of lesions on the hands and face, and advice about cosmetic applications, even if lesions on other parts of the body could not be treated. Perceptions about being able to find a new partner were reduced among Western patients with KS. Patients with KS or an associated fear may benefit from counselling in which ideas relating to stigma, secrecy, treatment, cosmetic applications, the effects on family and fears of disfigurement are discussed.     

The cotherapy relationship: Special issues and problems in aids therapy groups

This paper examines the special issues and problems in the co-leadership relationship which arise in ongoing AIDS therapy and support groups. A brief review is given outlining some of the advantages and disadvantages of the coleader model. Specific attention is then paid to the issues/themes of physical deterioration of members, disfigurement, frequent absences, and members dying. Four particular patterns of interaction that develop between cotherapists are identified, illustrated, and discussed.The author thanks the Group Services staff and volunteer therapists for their contributions to this article.     

Women and Physical Distinction:

With few exceptions, the special concerns and status of women with physical distinctions (physical disability and facial disfigurement) have been largely ignored in the disability literature. Women with physical distinctions are perceived negatively and are devalued and marginalized in our culture. They face a double discrimination due to their gender and their disability. The situation is even more acute for ethnic minority women with physical distinctions. This paper will review the literature on women with physical distinctions and explore some of the issues for ethnic minority women with physical distinctins. Recommendations are offered for feminist therapists who work with this population.     

Body image and disfigurement: issues and interventions

Whether present at birth, congenital or acquired later in life, a visible disfigurement can have a profound psychological impact upon the individual concerned. Difficulties include adverse effects on body image, quality of life, and self-esteem. In addition, social encounters can present many challenges, however many individuals adapt to the demands placed upon them and appear relatively unaffected by their visible difference. This article reviews current literature exploring the psychosocial implications of living with a visible difference and considers the complex influence of physical, cultural, and psychosocial factors on adjustment. Attempts that have been made to theorise individual’s experiences, relevant interventions and care provision are then examined and the challenges facing researchers in this area are outlined.     

Coping with body image changes following a disfiguring burn injury.

The influence of emotion-focused coping on distress following disfiguring injury was examined. Two types of emotion-focused coping (i.e., venting emotions vs. mental disengagement) were assessed in 78 patients with burn injury at baseline during acute hospitalization. Body image dissatisfaction (BID) was assessed 1 week and 2 months following discharge. Use at baseline of both venting emotions and mental disengagement, compared with use of only one or neither of these coping methods, was associated at the 2-month postdischarge follow-up with significantly higher BID related to nonfacial aspects of appearance and with a greater negative social impact of disfigurement. D. M. Wegner's (1994) theoretical model of mental control and a proposed motivational analysis are used to interpret these findings.     

Does severity predict distress? The relationship between subjective and objective measures of appearance and psychological adjustment,during treatment for facial lipoatrophy

The intuitive or lay belief that the severity of a disfiguring condition predicts psychological distress is not demonstrated in clinical practice, nor in research studies. This within group study used standardised measures repeated at six month intervals, to investigate the relationship between subjective and objective measures of appearance and psychological adjustment in 51 patients undergoing treatment for facial lipoatrophy using a synthetic filler, Newfill^®. Results demonstrate a dissociation between objective and subjective measures with only subjective assessment predicting psychological outcomes. It is recommended that Moss's (2005) hypothesis of discrete group membership (normal/not normal) should be adapted to include an internal standard for comparison, and that all evaluations of treatment modifying disfigurement should include a standardised subjective measure of appearance.     

Testing a Model of Disfigurement: Effects of a Skin Camouflage Service on Well-being and Appearance Anxiety

This paper outlines and tests a model of disfigurement that integrates psychological and sociological viewpoints on appearance anxiety. Thirty-two clients who attended the British Red Cross Skin Camouflage Service for assistance in covering skin blemishes completed questionnaires designed to assess aspects of the model just before and four months after their appointment. As predicted, the results indicated that attendance at the Service had beneficial effects in reducing self-reported avoidance and increasing confidence. Well-being as measured by the General Health Questionnaire improved for those who found the camouflage cream effective in covering blemishes. Also as predicted, more fundamental aspects of appearance anxiety as measured by the Appearance Schema Inventory and Fear of Negative Evaluation were relatively unaffected by the use of camouflage creams. The results suggest that the model can be used to understand the social and cognitive processes involved in dealing with disfiguring conditions and to inform assessment of the effects of medical and psychological interventions.     

Injury characteristics across functional classes of self-injurious behavior

Self-injurious behavior (SIB) is inherently problematic because it can lead to injuries, including those that are quite severe and may result in loss of function or permanent disfigurement. The current study replicated and extended Rooker et al. (2018) by classifying the physical characteristics of injuries across groups of individuals with automatically maintained SIB (ASIB Subtypes 2 and 3) and socially maintained SIB. Individuals with Subtype 2 ASIB had the most frequent and severe injuries. Further, an inverse relation was found between the level of differentiation in the functional analysis and the number of injuries across groups. Studying the response products of SIB (the injuries) documents the risks associated with SIB, justifies the need for research and the intensive intervention, and advances knowledge of SIB. Additional research is needed to replicate these findings, and determine the variables that produce different characteristics of injury secondary to SIB.     

Assessing body image in patients with systemic sclerosis (scleroderma): validation of the adapted Satisfaction with Appearance Scale

People with scleroderma often experience disfiguring appearance-related changes in socially visible and interpersonally salient areas. Although disfigurement can lead to body image dissatisfaction, this phenomenon has not been well investigated due to the lack of a disfigurement-specific measure. The Satisfaction With Appearance (SWAP) scale, previously developed in burn survivors, was adapted and administered to 254 participants with scleroderma to evaluate its psychometric integrity and its validity for use in a different medical population that experiences changes in appearance. Principal component analysis revealed two factors – Subjective Dissatisfaction and Perceived Social Impact – rather than the four found in burn victims. Excellent estimates of internal consistency and temporal stability and strong evidence for the reliability of the two-factor solution were found. The resulting factor structure in a scleroderma population suggests that differing medical conditions may create alternate constellations of BID, reflects the need for body image researchers to assess psychometrics across medical populations and may have clinical implications for BID interventions.