Social Media Dysmorphia

Over the past decade, greater social media utilization has paralleled a heightened focus on aesthetic standards perpetuated through social media. This phenomenon has resulted in the emergence of a newly recognized entity in cosmetic dermatology, social media dysphoria. Social media dysphoria describes dissatisfaction with body image relative to and as a result of beauty ideals portrayed on social media applications and their associated photo editing technology. In this article, we will describe trends in social media utilization, review body dysmorphic disorder, define social media dysphoria, propose screening criteria for high-risk patients, and discuss best practices in managing such cases clinically.

Key points

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Social media dysmorphia refers to body image dissatisfaction driven by idealized beauty standards on social media, amplified by filters and photo-editing tools.
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Prolonged exposure to curated images on social media fosters unhealthy self-comparisons, leading to disorted body perceptions and increased risk of body dysmorphic disorder (BDD).
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Indicators for social media dysmorphia include high social media use, presenting filtered selfies during consultations, and a history of BDD or obsessive tendencies.
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AI-powered filters, like TikTok’s Bold Glamor, create hyper-realistic effects, perpetuating unattainable beauty standards and influencing patients’ desires for cosmetic procedures.
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Dermatologists should educate patients on realistic outcomes, discourage realiance on filters, and recommend social media detox to improve self-image and mental health.

Abbreviations

AI	artificial intelligence
BDD	body dysmorphic disorder

Introduction

Over the past decade, greater social media utilization has paralleled a heightened focus on aesthetic standards perpetuated through social media platforms. This phenomenon has resulted in the emergence of a newly recognized entity in cosmetic dermatology, social media dysphoria. Social media dysphoria describes dissatisfaction with body image relative to and as a result of beauty ideals portrayed on social media applications and their associated photo editing technology. Special consideration must be taken to recognize social media dysmorphia, adapt to what is and is not appropriate in the care of these patients, and engage in counseling regarding realistic expectations and the implications of social media on the perception of one’s self. In this article, we will describe trends in social media utilization, review body dysmorphic disorder (BDD), define and characterize social media dysphoria, and discuss best practices in managing such cases clinically.

Epidemiology of social media

The earliest forms of social media, defined as interactive technologies that facilitate creating and sharing content among virtual communities and networks date back to the mid-20th century [ ]. The programmed logic for automated teaching operations system, launched in 1960 at the University of Illinois, is widely considered to be the first social media platform. It revolutionized communication through online chat rooms, instant messaging, and message forums [ ]. These online platforms have since evolved to allow users to share user-generated content, including digital photos and videos, and connect with other individuals and groups via self-created profiles. In the early 2000s, social media platforms such as Friendster and Myspace gained widespread popularity, followed by Facebook, YouTube, and Twitter. According to Statista, in 2024, over 5 billion people will be using social media worldwide. This statistical is projected to increase to over 6 billion in 2028 [ ]. As of April 2024, the most popular social networking service is Facebook, with over 3 billion monthly active users. The second, third, and fourth most popular social networking services are YouTube, WhatsApp, and Instagram, respectively, all with 2 billion or more monthly active users worldwide [ ].

Social media use varies widely based on demographic factors such as age, gender, race, income, and education level. In the United States, most adults use YouTube and Facebook, and about half use Instagram, whereas teens are far more likely to use Instagram, Snapchat, and TikTok. While some platforms have a nearly even gender split, others, such as TikTok and Instagram, are more likely to be used by females than their male counterparts. Hispanic adults are particularly likely to use TikTok, with 49% indicating usage. Hispanic and Asian adults also report using Instagram somewhat more frequently than Black and White adults. Adults with higher household incomes use X (formerly called Twitter ) at somewhat higher rates, and those with higher levels of formal education are especially likely to use LinkedIn [ ].

Users spend an average of 2 and half hours daily on social media and messaging apps [ ]. Certain personality traits may help explain which individuals are more likely to engage in social media. A 2009 study revealed that extraversion and openness to experiences were positively related to social media use, while emotional stability was a negative predictor [ ]. A 2015 study found that people with a higher social comparison orientation tend to use social media more heavily than people with a low social comparison orientation [ ].

With the growing popularity of social media across a range of demographics, its impact on mental health has become increasingly significant. A 2016 systemic review concluded that social media can trigger a negative feedback loop of viewing and uploading photos, self-comparison, and disordered body perception [ ]. The amount of time people spend on social media, coupled with individual personality traits, highlights how certain users may be more vulnerable to the effects of these platforms on self-image and mental health. For those inclined toward social comparison, exposure to idealized images online can heighten the risk of internalizing unrealistic standards. This comparison can foster body dissatisfaction and, in some cases, lead to more serious psychological conditions. One notable concern arising from this dynamic is BDD, a condition extensively linked in the literature to the pressures and imagery that dominate social media.

Body dysmorphic disorder

BDD is a psychiatric condition characterized by an excessive and persistent preoccupation with perceived flaws in physical appearance, which are often unnoticeable to others [ ]. The focus of preoccupation can be any part of the body, but skin (eg, perceived acne or scarring), hair (eg, perceived thinning or excessive body or facial hair), and nose (eg, size or shape) concerns are most common. Patients with BDD engage in repetitive behaviors such as frequent checking of mirrors, comparing their appearance with that of others, excessive grooming, skin picking, reassurance seeking, taking excessive selfies, or repeatedly assessing the perceived defect [ ]. To qualify for a diagnosis of BDD, the preoccupations must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning [ ]. Machine learning models have been shown to accurately predict the disorder, demonstrating how advancements in artificial intelligence (AI) show promise in the future of psychodermatology [ ].

Currently, it is estimated that 1.7% to 2.9% of the general population is affected by BDD [ ]. The prevalence rate rises to 11% to 13% among dermatology outpatients, 13% to 15% among general cosmetic surgery patients, and 20% in rhinoplasty settings [ ]. There is a slightly higher prevalence among females; however, meeting the criteria for BDD is notably higher among male compared to female cosmetic surgery-seekers [ ]. Age of onset most commonly occurs in early adolescence, with two-thirds of cases occurring before the age of 18 [ ].

BDD is a complex psychiatric condition with multifactorial etiology, including genetic, neurobiological, and environmental factors. Research on the genetic factors underlying BDD is limited, yet heredity and genetics seem to play a role in its development. One study demonstrated that 8% of individuals with BDD have a family member also diagnosed with BDD, which is 4 to 8 times the prevalence in the general population [ ]. A twin study in females who used self-report measures of dysmorphic concerns showed that genetic factors accounted for approximately 44% of the variance in dysmorphic concerns [ ].

Neurobiology and imaging findings in BDD reveal structural, functional, and connectivity abnormalities in brain regions involved in visual processing, emotional regulation, and cognitive control. Positive correlations were observed between the severity of BDD symptoms and the volumes of the left inferior frontal gyrus and right amygdala [ ]. These findings align with the functional hyperactivity of these regions, which are implicated in pathologic face processing. Diffusion tensor imaging studies identified fiber disorganization in white matter tracts connecting the visual and emotion/memory processing systems [ ]. The affected tracts included the inferior longitudinal fasciculus, which plays a role in object and face recognition and the forceps major, which connects the right and left visual processing areas [ , ]. Poor information integration between these regions may be linked to impaired insight and contribute to difficulties in accurately perceiving visual stimuli in individuals with BDD [ ]. Functional MRI studies have found that individuals with BDD show distinct brain activation patterns compared to healthy controls, including unique spatial frequency responses when viewing others’ faces, heightened left hemisphere activity, and increased bilateral amygdala activation [ ]. This suggests differences in visual processing that extend beyond distortions of their own appearance. Current research suggests a model for the pathophysiology of BDD that includes abnormalities in visual processing, emotional regulation, and cognitive control, correlating to dysfunction of the visual processing regions, limbic system, and frontostriatal circuits, respectively [ ]. The perceptual distortions, limited insight, obsessive thoughts, and compulsive behaviors associated with BDD may stem from these aberrant neurobiological and structural findings.

Environmental factors associated with BDD include a range of adverse experiences and sociocultural influences. A meta-analysis found that various forms of adverse childhood experiences, such as abuse, neglect, and bullying, are all positively associated with BDD symptomatology [ ]. In addition to childhood abuse and trauma, there is a well-documented association between social media use and BDD. Heavy usage of image-based social media platforms is significantly associated with increased BDD symptoms. A national survey found that individuals who spent 4 to 7 hours per day on Instagram and Snapchat had a higher prevalence of BDD than those who spent less than an hour per day [ ]. Image-based platforms that emphasize visual content foster a culture of comparison and unrealistic beauty standards. Furthermore, frequent exposure to idealized images and edited or filtered photos can lead to negative self-appraisals and a heightened preoccupation with perceived physical flaws. The following section will explore the closely related modern phenomenon of social media dysmorphia.

Social media dysmorphia, also known as selfie dysmorphia

Social media does not just influence what we look like online but may more permanently rewire our brains to alter what we think we look like in real life, leading to an altered perception of body images [ ]. With the accessibility of beauty mode on social media, filtering, contouring, and enhancing selfies is effortless. When combined with the dopamine rush from likes and shares , this can lead to withdrawal, leaving users feeling worse about themselves when they log off [ ]. Business Insider reported that in 2018, some alleged Apple had implemented a beauty filter in selfie mode across all cameras, with no option to disable it [ ]. According to the MIT Technology Review , TikTok was also suspected of applying an automatic facial feminizing filter during live streams [ ].

With the transformative filters we have today, potential cosmetic patients can predict the outcome of an aesthetic procedure. TikTok’s teenage filter removes shadow lines, boosts facial volume, and creates an even skin tone to give a youthful appearance [ ]. This filter leads to an idealized artificial version of youth applying a one size fits all template. When comparing these photos to actual photos from one’s youth, the difference between them and reality is striking. The Bold Glamor filter moves seamlessly with your face using generative adversarial networks (GAN) and smooths the skin, brightens the eyes, and sculpts facial features [ ]. Notably, these filters tend to reflect current societal beauty trends, such as plump lips, larger eyes, and a slim nose. This filter has garnered significant attention due to its hyper-realistic effects, sparking concerns among experts about its potential impact on mental health and body image [ ]. Adolescents are at particularly high risk for idealizing these filters and desiring them in real life given their developing self-image [ ].

It is not just social media filters that are contributing to the dissonance people face when viewing themselves in real life. AI in cosmetic dermatology is growing rapidly and sometimes can assist physicians in selecting the appropriate patient for specific cosmetic procedures. While a cosmetic dermatologist or plastic surgeon may have software to display potential facial augmentation, this is now in the hands of patients who do not understand the feasibility or complexity of such alterations to their facial anatomy [ ].

AI systems also play a role in social media algorithms. These algorithms personalize and curate a user’s feed by learning individual preferences based on how they interact with content online. A repetitive loop is created, which exposes users to specific beauty ideals, normalizing and popularizing a certain appearance. Consequently, patients may adjust their aesthetic preferences based on these popularized standards, seeking cosmetic procedures to align with the idealized versions of beauty determined by social media algorithms [ ]. Dermatologists should be able to recognize these influences and provide realistic advice to patients seeking potentially unrealistic outcomes. Although there are no formal criteria for social media dysmorphia, there are high-risk indicators that could be assessed through short questionnaires or interviews to help identify patients who may benefit from early intervention and counseling. We aim to present sample scenarios of high-risk behaviors to aid in establishing formal screening criteria for patients at risk of social media dysmorphia.

Screening criteria for high-risk patients for social media dysmorphia could include the following:

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Frequency and duration of social media use
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Bringing edited and filtered selfies to appointments and/or regular use of beauty filters or editing apps
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  Seeking cosmetic consultations to resemble something that is not naturally occurring
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History of BDD, eating disorders, or obsessive-compulsive tendencies
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  Preoccupation with perceived physical flaws causes impairment in social interactions
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Motivation to alter appearance to fit in with online peers, celebrities, or influencers

Clinical and practical implications of social media dysmorphia

A patient may present to the cosmetic dermatology clinic with digital photographs for reference of their desired cosmetic outcome. In the context of social media dysmorphia, these reference photographs may be highly edited or filtered photographs of the patient or perhaps social media influencers. Seeking results equivalent to the body augmentation possible with digital image filtering can lead to patients having unrealistic expectations of what is possible with cosmetic procedures. It has been suggested that patients using SnapChat beauty filters tend to have more body dysmorphic congruent behaviors [ ]. These patients may begin chasing a desired appearance that cannot be attained, or if pursued, would involve extensive interventions that may not lead to the seamless and natural appearance of these filtered images. Such impossible selfie consultations pose a significant challenge to the clinician managing these patients. Requests to remove nasolabial folds, enlarge the size of one’s eyes, or attain a smooth face devoid of texture based on filtered or edited images of the patients or others should serve as a warning sign that a patient may have social media dysmorphia.

Once the clinician has identified a patient potentially experiencing social media dysmorphia, the consultation should consider commenting on the inability of image filtering and editing software to reliably capture realistic outcomes based on available cosmetic interventions. It is imperative to reshape the patient’s goals to what is realistic based on their anatomy and which cosmetic procedures they would be appropriate candidates for. If patients express dissatisfaction with not being able to achieve results equivalent to filtering software, consider not offering cosmetic procedures to this patient as the likelihood of a satisfactory outcome for the patient is likely minimal.

Clinicians may be more likely to need to address specific requests patients may present with based on social media trends and the most commonly used filters. Enlargement of the lips with filler is a common filter enhancement, and posts regarding lip filler are highly prevalent on Instagram [ ]. Cheekbone augmentation and slimming of the face are other common filter enhancements patients may desire, evidenced by the increase in patients seeking buccal fat pad treatment [ ]. Flaws highlighted by the use of selfies and computer webcams, which tend to give a fishbowl -like appearance of the face and accentuate nose size, should also be on the cosmetic dermatologist’s radar. The increased use of video conferencing during the coronavirus disease (COVID-19) pandemic may explain the greater acceptance of cosmetic procedures among patients [ ].

Counseling the patient with social media dysmorphia should first consist of recognition, without judgment, that the patient’s cosmetic desires have been influenced by social media posts or filters. Explaining why certain results cannot be achieved ought to be accompanied by what can be achieved, such as to give the patient confidence that they are not simply being denied care due to expressing their true expectations. Another component of counseling is education regarding preventive skin care in the long-term improvement of skin appearance and texture. The use of sunscreen and other sun protective measures, emollients and active ingredients such as retinoids for antiaging and brightening of skin, and less invasive cosmetic interventions (eg, chemical peels) are important discussion points for such patients who may not be ideal candidates for more invasive cosmetic intervention due to their social media dysmorphia [ ].

Once social media dysmorphia is recognized and discussed with the patient, the clinician may recommend a social media detox , in which the patient is asked to forgo the use of filters, editing software, and engagement with social media personalities or influencers known to augment their photographs [ ]. In doing so, the patients may begin to reframe their self-image based on reality and avoid constant exposure to an artificial, augmented version of themselves. Alternatively, the clinician may recommend the BeReal app, a social media platform designed to encourage users to share unfiltered photos of themselves. According to influencer marketing hub, BeReal is an anti-influencer social media app that may potentially address the various negative impacts associated with social media [ ].

Ultimately, refusal of treatment may be necessary in patients with social media dysmorphia. It is not in the best interest of the patient nor the treating clinician to offer cosmetic procedures that cannot achieve the patients’ goals as such procedures come with medical risk, financial burden, and ultimately a strained patient-physician relationship if patients were expecting results that were not attainable. Clinicians may instead offer patients to seek out a second opinion, though such patients may be susceptible to coercive marketing of cosmetic procedures by other providers. Patients should be made aware of the influence of social media on their self-perception, the realistic and unrealistic outcomes cosmetic procedures can achieve, and the safest avenues to pursue cosmetic interventions even if not offered by the clinician himself as these patients may be highly motivated to have body augmentation performed.

Future directions

Social media users, especially those engaging with filters, editing tools, and highly edited images, should be made aware of the harmful effects these platforms can have on self-perception. Users should be educated on how the use of social media and analyzing one’s digital appearance could lead to the development of unhealthy behaviors and social media dysphoria.

Dermatologists must play an active role in promoting healthy behaviors and realistic expectations by raising awareness of the negative phenomena of social media dysmorphia. While dermatologists have a significant role in combating misinformation, social media companies can enhance collaboration with physicians to promote educational content more prominently in their algorithms, thereby increasing its reach to a broader audience. Though further qualitative research is essential to establish high-risk indicators and screening criteria for social media dysmorphia to be used among dermatologists and other aesthetic health care professionals, AI-driven algorithms also hold promise for enhancing screening, diagnosis, and treatment efforts.

The dichotomy of AI, particularly in the context of social media, reveals both its potential harm and its promise. Social media, similarly to AI, offers both benefits and drawbacks by connecting and educating but can also isolate individuals and promote harmful, idealized narratives. Ultimately, how we choose to use social media and AI will shape the trajectory of our future as an entire society.

Given the dual nature of AI and social media, dermatologists must navigate their evolving influence on patient care and address emerging ethical challenges, particularly with BDD and social media dysmorphia, to provide the best possible care for patients.

Clinics care points

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Recognize high-risk features: Assess patients’ social media use, including frequency, duration, and history of using photo-editing apps or filters. Be alert to behaviors such as bringing edited selfies to consultations.
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Screen for psychological factors: Evaluate for underlying psychiatric conditions like body dysmorphic disorder (BDD), eating disorders, or obsessive-compulsive tendencies that may contribute to unrealistic aesthetic expectations.
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Provide realistic counseling: Emphasize achievable outcomes based on anatomy and available cosmetic interventions. Avoid reinforcing unattainable ideals set by social media filters or influencers.
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Refuse unrealistic treatments: Decline cosmetic procedures where patients’ expectations are not feasible to avoid dissatisfaction and harm to the patient-provider relationship.
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Cultivate ethical awareness: Be cognizant of the influence of social media algorithms and cosmetic marketing on patients’ aesthetic preferences ensuring care decisions are patient-centered rather than trend-driven.