We look upset because we feel distraught. Obvious?
Maybe the other way round? Does looking sad contribute to low
mood?
This would have revolutionary implications for understanding the
causes of depression, and indeed the treatment of mood
disorders.
How often have we intuitively felt that, if someone just tried to
look happier, it might have a positive impact on their
mood?
Now a team of researchers lead by Axel Wollmera and Tillmann
Krugerb, based at the Psychiatric Hospital of the University of
Basel, Switzerland and the Department of Psychiatry, Medical School
Hannover, Germany, have indeed turned conventional thinking on its
head. Their research, just published in the Journal
of Psychiatric Research, has found that injecting botox into
the muscles most linked with low mood, produces alleviation of
depression.
Injection of botulinum toxin to the glabellar region - just above
the nose and between the eyes, is part of one of the most common
procedures in aesthetic medicine, as the toxin inhibits the
activity of the corrugator and procerus muscles in that region.
This effect is used in the cosmetic treatment of 'frown
lines'.
The subjects recruited for this clinical trial were suffering from
long-standing low mood - on average 16 years of recurrent episodes
of depression with the current episode lasting an average of almost
30 months, and they were selected as a group unconcerned with their
facial appearance (they would not have picked 'botox' if given a
choice).
The study, 'Facing depression with botulinum toxin: A randomised controlled trial, involved patients who had not previously benefited from standard anti-depressant prescription medication.
In Wollmera, Krugerb and colleagues' clinical trial botulinum toxin
was injected just once into a specific part of the face in 15
patients, while another 15 were injected with placebo salt water.
Remarkable improvements in mood were achieved after just one
injection. Six weeks after a single treatment, scores on a standard
depression rating scale, for botulinum toxin recipients, were
reduced on average by 47.1%, while the placebo treated group
experienced only a 9.2% reduction in the measurement of their
depression.
This clinical trial involved the very specific choice of two
particular small muscles in the face, especially associated with
negative expressions, while 'botox' cosmetic treatments may target
other muscles as well.
The corrugator supercilii is a narrow muscle at the corner of the
eyebrow near the nose, and is responsible for pulling the eyebrows
downward and towards the nose, producing vertical wrinkles of the
forehead. This 'frowning' muscle and could be regarded as key in
expressing distress.
The other muscle activated when we're upset is the procerus, which
extends from the lower part of the nasal bone to the middle area in
the forehead between the eyebrows. It pulls the skin between the
eyebrows down, so it's associated with transverse forehead lines
and is usually targeted during treatment or correction of
wrinkles.
Since the Victorian era 'the omega sign' of depression, or omega
melancholicum was well known, being the facial expression where
wrinkling of the skin above the nose and between the eyebrows
resembles the Greek letter omega. The 'Omega Sign' was even
believed to be diagnostic of a depressive disorder.
A skin fold running obliquely from the lower outside to the upper inside on the upper eyelid is specifically named Veraguth's folds and was also assumed historically to be characteristic of depression.
Now it looks like modern medicine is rediscovering an ancient story
that depression writes in the face, and, vice versa, how the face
might prop up depression.
William James, a famous Professor of Psychology at Harvard
University, said in 1890, "Refuse to express a passion, and it
dies", referring to a 'facial feedback' hypothesis. Wollmera,
Krugerb and colleagues argue this suggests strong historical
support for a mutual interaction between emotions and facial muscle
activity, rather than just one way traffic.
The theory here is that expressing an emotion causes you to feel
that mood, not just the other way round.
To test this revolutionary idea a number of scientific studies
recently aimed to alter facial expression and then investigate
whether emotional experience is subsequently affected. These
studies, if they are properly scientific, have to carefully
manipulate facial displays of emotion in a manner that eliminates
the participants' awareness that they are being asked to produce an
emotional expression.
For example, one experiment involved having subjects hold a pen
between their teeth (a simulation of smiling but without the
subjects realising this was the point of the experiment). They
found cartoons funnier. In another experiment two golf tees were
attached to either side of subjects' foreheads and the participants
were asked to move the two tees together (a simulation of frowning
without the subjects realising they were being asked to glower).
When the tees were closer together, subjects rated unpleasant
photographs more negatively.
One possible implication of all these startling findings is that
you may not need 'botox' to get the same anti-depressant benefits:
relaxation techniques applied specifically to your facial muscles
might have the same effect.
The ''motion creates emotion'' theory is also reflected in the rise of 'laughter therapy'. A recent review by Ramon Mora-Ripoll, of the Laughter Research Network in Barcelona, Spain, surveys nine scientific studies which had found significant health benefits from laughing. For example in one study of eight laughter therapy weekly sessions, a 55% reduction in pain scores; a 12% increase in functional mobility; and a 50% reduction in depression symptoms and 42% in anxiety symptoms were produced by laughter in 107 chronic pain patients, who maintained these gains at 12 month follow-up.
Mora-Ripoll's review, entitled 'Potential health benefits of simulated laughter: A narrative review of the literature and recommendations for future research' published in the Academic Journal Complementary Therapies in Medicine suggests these health benefits are often being produced by 'simulated laughter' willed upon oneself, and not triggered by humour - or fun as in 'spontaneous laughter'.
Exactly why forcing yourself to laugh, just like forcibly removing frowning or a worried expression, should produce health benefits remains mysterious, but Mora-Ripoll points out that laughter itself exercises and relaxes muscles, improves respiration, stimulates circulation, decreases stress hormones, increases immune system defenses, and elevates pain threshold.
Perhaps it improves mental functioning through the release of inhibitions and promotion of sociability, and maybe frowning less and smiling more as in the botox therapy, works in similar ways.
It's possible that the botox treatment for depression was effective because a more positive facial expression improved social interaction, and this may have contributed to improved mood. Maybe looking in the mirror, and seeing they looked more cheerful, could have lead the subjects in this clinical trial to believe they were happier. This in turn, elevated mood.
However, the Wollmera, Krugerb and colleagues argue, there are many
reasons a purely aesthetic benefit can be excluded as the main cause
of mood improvement in the botox treatment of depression. Patients
in this clinical trial were not concerned about the cosmetic
appearance of their frown lines. The improvement in mood did not
turn on feeling better about a cosmetic improvement in appearance.
For example, one participant's depression remitted with the botox
treatment, but that person disliked the facial appearance it
produced.
The authors conclude that their clinical trial shows facial
expressions associated with depression are not just the
consequences of low mood. In fact, they may be integral components
of the disorder, and therefore should also be targeted.
Clinical depression is a serious and complex disorder where it's
unlikely any one treatment is going to be a magic panacea. Because
standard medical treatments work only in a proportion of patients,
exploring other possible approaches is warranted. One in 10 of the
general population suffer from clinical anxiety and depression at
any one time.
So it's good news that learning to smile and laugh more, but frown
less, may just be the latest scientifically validated treatment for
depression.