6 months. Once social phobia has begun, it gradually becomes worse because of two factors. First, anticipatory anxiety gradually develops whenever the person is confronted with the necessity to enter a social gathering. Second, the patientÕs social performance becomes impaired by this underlying anxiety, resulting in the development of a vicious cycle. Exposure to the feared social situation will almost invariably provoke an immediate anxiety response. Some patients with social phobia will try to avoid social situations, while others will try to force themselves to endure the social situation despite their intense anxiety. Eventually, this progression toward complete social isolation will cause the patient to suffer serious social or occupational impairment. Patients with social phobia usually retain the insight to recognize that their fears are excessive or unreasonable, even in view of their disÞgurement. Therefore, these patients tend to be receptive to the suggestion that they should obtain professional help from a psychiatrist or other mental health professionals [28].

There are three general types of therapies available for the treatment of social phobia. The Þrst approach is a behavioral therapy technique involving ÒexposureÓ or Òßooding.Ó In exposure, patients are presented with increasingly anxiety-provoking social situations, initially in the form of imagery and later as real-life encounters. At each stage of exposure, care should be taken to make sure that the patientÕs anxiety level does not go out of control. Through this process known as systematic desensitization, the patient gradually learns not to fear the social situation [43]. In ßooding (also termed, ÒimplosionÓ), the patient is exposed to an enormous volume of phobic material in an attempt to overwhelm the phobic response. This technique can also be used in either imagery or real-life situations.

The second approach involves psychotherapy, in which the patient explores different psychological issues with the therapist. This approach can take many different forms, depending on the particular orientation of the therapist. Some therapists favor psychodynamic therapy (i.e., emphasizing the use of Freudian principles), while others favor a cognitive approach (i.e., actively trying to change the patientÕs thinking habits by challenging existing semiautomatic or automatic thought patterns).

The third approach is the use of pharmacotherapy. Antianxiety drugs (discussed in detail in Sect. 47.4.2) are used to treat anxiety symptoms, whereas antide-

pressants (discussed in greater detail in Sect. 47.4.3) are used to treat phobic symptoms. Several serotonin selective receptor inhibitors (SSRIs) and one serotonin norepinephrine receptor inhibitor (SNRI) are approved by the US Food and Drug Administration (FDA) as medications for social phobia. These include ßuvoxamine extended release (Luvox CR) (100-300 mg/ day), paroxetine (Paxil) (20 mg/day), paroxetine extended release (Paxil CR) (12.5-37.5 mg/day), sertraline (Zoloft) (50-200 mg/day) and venlafaxine extended release (Effexor XR) (75 mg/day), respectively. [44].

47.4.2 Generalized Anxiety Disorder

The anxiety experienced by patients with disÞgurement may extend beyond just anxiety in social situations. Patient may experience more generalized forms of anxiety and even depression [19, 45Ð47]. The study by Rumsey et al. [46] evaluated 220 patients with disÞguring conditions as a result of burns, skin conditions, or head and neck cancer. The study found that patients displayed increased levels of anxiety, depression, and social anxiety/avoidance [46].

To be diagnosed with Generalized Anxiety Disorder (GAD), a patient must have excessive anxiety and worry about everyday events and activities for at least 6 months. The patient Þnds it difÞcult to control worrying. The anxiety is associated with at least three of the following symptoms: restlessness, fatigue, difÞculty concentrating, irritability, muscle tension, or sleep disturbance. The focus of the anxiety is generalized in nature. It is not focused to any given stressor or social situation. This anxiety will inevitably cause impairments in social, occupational, or other important areas of functioning. Most patients with GAD do not initially seek psychiatric help. Instead, patients will often go to a medical specialist in hopes of alleviating the physical complaints that accompany this disorder (i.e., muscle tension or fatigue) [28].

The most effective treatment approach for GAD is the combination of psychotherapy and pharmacotherapy. Patient should be made aware of the chronic nature of the condition and the tendency of symptom severity to vary over time. Behavior therapy may be useful in teaching a patient how to control anxiety. Relaxation training, including breathing exercises and progressive muscle relaxation, may also be of beneÞt [44].

As far as medication, there are several drugs approved by the FDA for the treatment of GAD. These include the SSRIs paroxetine (20 mg/day) and excitalopram (Lexapro) (10 mg/day), the SNRI venlafaxine extended release (Effexor XR) (75-225 mg/ day), and the non-benzodiazepine anxiolytic buspirone (BuSpar) (20-30 mg/day) [44].

Buspirone is a non-sedating, nonaddictive antianxiety medication that is slow in onset of action. This medication must be taken on a regular basis (2 to 3 times per day) because it is not effective on an Òas neededÓ basis. It takes up to 4 weeks or more for the clinical effects of buspirone to become evident, and therefore it is ideal for patients with a chronic anxiety disorder 20 to 30 mg per day (divided dose 2 or 3 times per day). The oral dosage of buspirone ranges from However, this must be individualized for each patient, beginning with the lowest dosage and titrating upward until the optimal dosage is achieved. The side effects of buspirone include dizziness, nausea, headache, nervousness, lightheadedness, and excitement.

Benzodiazepines such as alprazolam (Xanax) (0.75- 1.5 mg/day, divided dose 3 times per day), lorazepam (Ativan) (2-4 mg/day, divided dose 2 or 3 times per day), and clonazepam (Klonopin) (0.5-1.5 mg/day, divided dose 2 or 3 times per day) are highly effective anti-anxiety medications. They are rapid acting, but can be highly sedating and potentially addictive. The major difference between these medications is the half-life. Medications with a shorter half-life carry a greater the risk of rebound anxiety and addiction. Alprazolam has the shortest half-life, whereas clonazepam has the longest half-life. The authors generally favor the above newer benzodiazepinas over the older benzodiazepines, such as diazepam (Valium) and chlordiazepoxide (Librium), because they have many active metabolites that can accumulate in the body and can compromise mental functioning when used longterm.

The optimal usage of benzodiazepines involves careful titration of the dosage beginning with a low starting dose. Once the anxiety is well controlled, the dosage should be gradually tapered. Abrupt discontinuation should be avoided, as it carries the risk of seizures, as well as recurrence or exacerbation of anxiety. Benzodiazepines should be reserved for shortterm use only to help overcome acute episodes of severe anxiety. A psychiatrist should be consulted if usage is required beyond 2 to 4 weeks. Patients should

be counseled regarding the risk of abuse or dependence with this class of medications [48, 49].

47.4.3 Depression

Patients with acquired surgical disÞgurement, especially those with facial disÞgurement, have a higher risk of developing clinical depression [18, 23, 46]. One of the challenges, however, is being able to distinguish clinical depression from other conditions that may mimic depression. These include normative sadness, depressant effects of certain medications (e.g., benzodiazepines), or comorbid medical conditions (e.g., hypothyroidism), just to name a few.

Patients with depression are less likely to comply with medical recommendations for wound care management. They are, therefore, more likely to have poor wound healing and potentially greater disÞgurement. Even more signiÞcantly, patients with depression are at an increased risk of attempting suicide [23]. Thus, it is essential that patients with depression be identiÞed early and provided with the necessary treatment intervention(s).

To diagnose major depressive disorder, the following DSM-IV-TR criteria apply. A major depressive episode is deÞned as having at least Þve of the following symptoms for at least a 2-week period: depressed mood, anhedonia (loss of interest or pleasure), change in appetite or body weight, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, difÞculty in concentration, and recurrent thoughts of death or suicide. At least one of these symptoms must include either depressed mood or anhedonia. Patients must have no history of a manic or hypomanic episode. The depression must cause signiÞcant social or occupational impairment [28].

There are many treatment approaches for depression. Psychotherapy can be used alone, or in combination with pharmacotherapy. Psychotherapy options include behavior therapy, cognitive therapy, supportive psychotherapy, dynamic psychotherapy, and family therapy. Hospitalization may be indicated if patients are at risk of suicide, homicide, or are unable to care for themselves [44].

Pharmacologic treatment of depression consists of SSRIs, TCAs, and MAOIs. SSRIs, such as ßuoxetine (Prozac) (20-80 mg/day), sertraline (Zoloft) (50-200 mg/day), paroxetine (Paxil) (20-50 mg/day), citalopram (Celexa) (20-60 mg/day), and escitalopram