The Psychological Consequences of Facial Injuries
The face is one of the most important markers of an individual’s identity. It is the “seat of recognition for a human being,” both in terms of how people perceive themselves and how they feel themselves to be perceived by others.
Anatomically speaking, the face and the head are where many of the functions central to everyday life are located, containing structures that are entirely or partly responsible for speech, taste, hearing, vision, and more. Many people use these functions to define themselves and their own personal identity in their daily lives.
As a result, facial injuries, particularly those that lead to permanent disfiguring or scarring, can have long-lasting effects on a person’s mental health. This is the case even when the disfigurement might not seem particularly severe, and research has shown that even minor facial injuries may lead to anxiety and increased self-consciousness.
These psychological consequences have to be taken into account whenever someone makes a legal claim for damages following an injury to their face. In this post, we outline some of the causes and psychological consequences of facial trauma, before highlighting some of the key legal considerations related to this issue.
What is facial trauma?
The term “facial trauma” is a catch-all for many different kinds of injuries that each have their own specific etiologies and can have different ongoing psychological consequences. Facial trauma can result from physical injuries, burns, diseases, or any other kind of damage. In medical terms, injuries to the face are often referred to as “orofacial” or “maxillofacial” trauma. Orofacial trauma is any injury to the face or mouth, whereas maxillofacial trauma is any injury to the face or jaw. In this post, we use the term “facial trauma” to cover both of these descriptors.
The causes and psychological consequences of facial trauma
While estimates about the prevalence of facial trauma differ, a global study conducted in 2017 found that more than 7.5 million people around the world had suffered facial fractures that year. Falling down was the predominant cause of these injuries, but other causes included physical violence and motor accidents. This study was only focused on fractures, so it did not account for people who suffered facial trauma as a result of burns, contact with dangerous chemicals, diseases, and more. Also, falling down can be quite an ambiguous descriptor. People who have been the victim of abuse or violence often report their injuries as being the result of a “fall,” so it may not be an accurate measurement.
Nevertheless, this does demonstrate that there are many different reasons why people suffer facial trauma. Given these different causes, it is unsurprising that people can respond to facial trauma in a variety of ways. For example, a person who suffers a fall at work and injures their face may have a very different reaction to someone who is attacked. When it comes to facial trauma, therefore, each person’s case must therefore be considered within a nexus of overlapping factors.
There are, however, certain overall trends for patients who suffer from facial trauma, as they tend to have a higher risk of developing post-traumatic stress disorder (PTSD), depression, anxiety, social phobia, and body image issues.
Post-traumatic stress disorder
PTSD can result from any kind of traumatic experience. If a person sustains facial injuries as part of a violent accident, then they may suffer PTSD as well. One of the common symptoms of PTSD is for people to experience flashbacks of the traumatic event whenever they are reminded of it. This makes PTSD a particular risk for people with facial injuries, as they bear very visible reminders of their traumatic experience. They risk being triggered simply by looking in the mirror. Moreover, as the face is such a visible part of a person’s identity, people with facial injuries can end up defining themselves almost entirely by their trauma.
In fact, researchers have found that it is very common for people who suffer facial trauma to develop symptoms of PTSD. A study conducted in 1997 found that more than a quarter of facial trauma victims went on to be diagnosed with PTSD symptoms seven weeks after their injury. Furthermore, even in cases where people do not meet the clinical threshold for a PTSD diagnosis, researchers have found that they may have what is known as subclinical PTSD, meaning that they show certain symptoms despite not rising to the threshold for a clinical diagnosis.
One of the main problems when it comes to identifying the connection between facial trauma and PTSD is the lack of documentation or follow-up research. Studies have shown that “the mental state of patients suffering from facial trauma is rarely ever recorded, let alone screening them for PTSD.” As the focus of emergency services is generally on ensuring a patient’s physical recovery, the long-lasting psychological effects of the trauma and the subsequent treatment can often go unnoticed. The studies cited above, however, suggest that a significant proportion of people who suffer a facial injury go on to live with some severe or low-level form of PTSD.
Depression and anxiety
Studies have also found that people who suffer facial injuries are more likely to develop depression and anxiety in the year following their traumatic experience. A study of 115 patients who suffered burns to their face and neck found that 95% of them had concerns about the future wellbeing of their families, and more than a quarter of them believed that their disfigurement would result in their unemployment. The study found that this was true even when there was no need for reconstructive surgery or skin grafting.
It is not just the disfigurement caused by the injury that can lead to anxiety but also the prospect of facial surgery. A study of more than 600 patients who were awaiting surgery for their face, jaw, or mouth found that they displayed significantly more anxiety than patients for other types of procedures. This was the case even if the patients had undergone facial surgery before.
Furthermore, as with PTSD, many victims of facial trauma may show some symptoms of anxiety or sadness even if they do not meet the diagnostic threshold for clinical depression or general anxiety disorder. Nevertheless, research has shown that these sub-threshold forms of depression and anxiety not only place patients at risk of developing clinical depression but also lead to poor medical interventions, which can affect the patients’ quality of life and their recovery from the trauma.
Social phobia
Given the importance that the face holds for a person’s sense of identity, they may become withdrawn or isolated after suffering facial trauma. If people feel unhappy about their appearance they may “feel inferior to others” in social settings and “feel a stigma associated with facial disfigurement.” People with facial trauma often recognize or perceive that people treat them differently following their injury or surgery, so they must learn to cope with other people’s altered responses to their new appearance. Investigations into the social interactions of facial trauma victims have found that “many disfigured individuals narrowly limit their range of social interactions to immediate family members and to those social contacts required for occupational functioning.”
In some cases, social withdrawal and isolation can develop into what is known as social anxiety disorder or social phobia. This is a pronounced fear of social situations that can cause people to worry extensively about social interactions or even avoid them altogether. The connection between facial disfigurement and social phobia is well documented, with researchers noting that facially disfigured people often have high levels of social phobia. To make matters worse, the psychological effects of facial trauma may also be compounded by other social problems, such as unemployment, lower education levels, and a lack of social support.
Body image issues
In severe instances, a person’s negative response to their new appearance may cause them to develop what is known as body dysmorphic disorder in the wake of their facial trauma. Body dysmorphic disorder is defined as a “subjective feeling of ugliness or physical defect” that a person feels is noticeable to others, and it can develop even if there is seemingly no objective or noticeable reason why the person might dislike their face. The mere fact of learning to live with a fundamentally altered image of oneself can be enough to prompt symptoms of body dysmorphia, which often include increased anxiety, neuroticism, depression, and introversion.
It is also worth noting that, in general, body image issues such as these are more prevalent among women than men. It has long been recognized in medical contexts that women who experience facial trauma are more likely than men to experience ongoing psychological problems. There is also some evidence to suggest that elderly female patients experience “greater amounts of post-traumatic pain when compared with their male counterparts.” As we discuss in more detail below, for a long time this disparity was seemingly reflected in the amount of compensation that was awarded to women in comparison with men in personal injury claims relating to facial trauma. That seems to have changed, however, in recent updates to how facial trauma claims are assessed.
How are facial trauma claims assessed in court?
Any claim for a facial injury will have to take into account both the physical and the psychological harm that has been inflicted on the claimant. In general, the assessment of the value of these claims is governed by the Judicial College Guidelines, which provide estimates for the amount of compensation that people can be expected to receive for different kinds of injuries.
In relation to facial trauma in particular, the guidelines note that “the assessment of general damages for facial injuries is an extremely difficult task.” The guidelines recommend considering the physical effects of the trauma first. They state that a claim should assess whether or not the trauma resulted in permanent facial disfigurement or cosmetic change. Subsequently, the guidelines state that, in cases where there are “severe psychological reactions” to the facial trauma, this will put the award “at the top of the bracket, or above it altogether.”
This is why a person seeking damages for an injury to their face will likely be assessed by multiple medical experts. They will probably be examined by an expert in facial scarring and disfigurement (such as a Maxillofacial Expert or a Plastic Surgeon), as well as a Psychiatrist. The Psychiatric Expert Witness will be able testify to the extent of the psychological harm caused by the physical injuries.
As mentioned above, the Judicial College Guidelines were recently updated to change the ways in which compensation for facial trauma was differentiated by gender. The 2019 edition of the guidelines stated the following:
In cases where there is a cosmetic element the courts have hitherto drawn a distinction between the awards of damages to males and females, the latter attracting significantly higher awards. That distinction, arising from cases that stretch back into the mists of time, has been reflected in succeeding editions of these Guidelines. Such distinction appears difficult to justify and has not been retained.
The guidelines make provision for the fact that this may change in the future, particularly as awards are made on a case by case basis. Given the fact that the literature seems to show that women are more likely than men to experience psychological consequences as a result of facial trauma, however, it will be necessary to monitor whether this update to the Judicial College Guidelines reflects the seemingly different experiences of men and women.
As stated in the introduction, facial injuries and their psychological consequences are highly complex and difficult to assess. Each assessment has to take into account a number of overlapping factors, with each case treated individually. A person’s response to their facial injury will vary based on their personality, their psychological vulnerability, and their social situation. Gender is a factor that has to be considered alongside each of these other elements. The task of a medico-legal Expert Witness is always to balance each of these factors when providing an assessment for the courts.
This post is provided for general information purposes and is not intended to cover every aspect of the topics with which it deals. It does not constitute medical, legal, or professional advice, nor is it necessarily an endorsement of the views of Professor Elliott, the U.K. Centre for Medico-Legal Studies, its employees, or its affiliates. Though we aim to ensure that all information is accurate at the time of posting, we make no representations, warranties or guarantees, whether express or implied, that the content in the post is complete or up to date.