Newell & Marks (Reference Newell and Marks2000) highlight an important, under-researched area. They suggest treatment using cognitive-behavioural therapy, concentrating on exposure to avoided situations. However, their conclusions and recommendations appear broader than the data support.

They recruited from dermatology clinics, ex-surgery lists and media adverts. Their sample might therefore be expected to include subjects with less severe disfigurement or even a primary diagnosis of dysmorphophobia. The preponderance of women requires explanation when many conditions causing facial disfigurement affect both genders equally. The nature and severity of disfigurement should be described. Facial disfigurement can result from bone deformity, scarring, muscular paralysis or abnormal movement. It may be congenital or acquired and onset can be sudden or gradual at any age. Aetiology includes trauma, surgery, neoplasms and infections and likelihood of recovery varies greatly. All these factors are likely to influence the psychological difficulties experienced, including those manifest in social settings. Exposure would only be expected to help the phobic components of these problems.

Impaired control of functions important in social situations - including eating, drinking, speaking and facial expression - and altered self-image and differences in the reactions of others are likely to require changes to the routine advice given to people with social phobia. Repeated exposure to distressing events such as dribbling may reinforce negative thoughts about the self rather than minimise anxiety, as in typical phobic states. Specilist advice regarding make-up has improved patient's confidence and mood (Reference Kanzaki, Ohshiro and AbeKanzaki et al, 1998), which would be expected to aid social interaction despite helping patients ‘avoid’ their true appearance.

Newell & Marks' study, therefore, does not support the conclusion that all social anxiety in patients with all types of facial disfigurement has the same psychopathology as social phobia. Cognitive-behavioural interventions probably need to address more than the avoidance or beliefs typical of social phobia. The need for exposure, a range of cognitive techniques, grief work, specialist physiotherapy and speech therapy is likely to vary. Further research should describe the type, course and severity of disfigurement and associated difficulties and clarify specific concerns occurring in social settings.