What is Snapchat Dysmorphia?

The perilous path from filters to fillers.

It has become evident that cosmetological treatments and nonsurgical procedures involving injectables are becoming increasingly more popular in recent times. Alongside this surge in demand, other patterns have emerged surrounding the trend that require consideration and even action on the part of professional practitioners. Limited surveys have found that approximately 8%-15% of cosmetic dermatology patients suffer from body dysmorphic disorder (Harris, 2022), a rate 600% greater than the general population whose incidence measures around 0.7%-2.4% (Fletcher, 2021). Despite these numbers, screening for body dysmorphia prior to treatment is rarely done due to the complexity of proper diagnosis, a lack of formal processes and supports for practitioners, and the ongoing mutability of the disorder itself. Nevertheless, consideration of the mental health of patients is important prior to administering treatment to ensure the best outcomes for both the patient and practitioner.

Defining Body Dysmorphia

Body dysmorphic disorder (BDD) is a DSM-5 psychiatric disorder defined as a preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others (American Psychiatric Association, 2013). This preoccupation can begin to affect the person’s personal, social, and professional life, and as mentioned above, often leads them toward seeking cosmetic treatments to address these perceived flaws. Comorbidities associated with BDD include depression, mania, social phobias, substance abuse, alcohol abuse, generalized anxiety disorder, suicidal tendencies, PTSD, and narcissism (Fletcher, 2021). It has been reported that 23.6% of patients use psychiatric medication at the time of seeking cosmetic treatment, a figure nearly four times higher than in the non-pursuant population, providing more evidence as to why isolating a specific diagnosis among patients is difficult.

Further characteristics can help us trace a BDD diagnosis as well as its emerging counterparts. BDD symptoms typically emerge during early adolescence. They result from a history of negative body-image related experiences in early childhood and adolescence ranging from anything between teasing by peers or family members, to even more common sociocultural influences such as unrealistic beauty ideals portrayed by the media. Both men and women can present with similar symptoms, although some gender differences have been reported, such as a preoccupation with weight and eating habits, size of breasts, buttocks, thighs, toes, and excess body hair for women, and concerns about too small or not muscular enough a body build, receding hairline, and obsession around genitalia for men (Shivakumar et al., 2021). Patients with BDD can experience distress of varying degrees, from a mild preoccupation limiting their concentration abilities, obsessive mirror checking, and grooming, to more severe symptoms such as skin picking, job loss, avoidance of relationships and social gatherings, self-harm and suicidal tendencies (Shivakumar et al., 2021).

Beyond the Smartphone Glass

The perfect storm has brewed of late with the collision of troubling circumstances. Social media, consumed most voraciously by the younger generation, is guilty of distributing unrealistic body images at a more rapid and massive scale than possible before its emergence, as well as targeting the more BDD susceptible adolescent subset. Further to distributing images, advances in artificial intelligence (AI) filters, augmented reality, and the democratisation of photo enhancement, has given rise to an intriguing new type of body image distortion, coined “Snapchat dysmorphia” (SD) by British cosmetic doctor Tijion Esho; “while data has yet to link the use of selfie filtering apps such as Snapchat […] with the rise of this particular form of body image distortion, given how recent the phenomenon is, cosmetic medicine as well as mental health professionals have started warning against what they believe is an increasing role of such applications in the way we perceive ourselves” (Tremblay et al., 2021).

The highly sophisticated morphing of the user’s reflection by AI creates more than just a simple dissatisfaction with one’s body image – it alters it beyond reality. One familiar way of doing so is via filters that affect one’s perception of one’s nose, create poreless/wrinkle-less skin, as well as correct overall facial asymmetry. But lesser known is that photos taken from a short distance also give rise to a perceived nasal distortion, called “the selfie effect”; “photographs taken at shorter distances will increase the perceived ratio of nasal breadth to bizygomatic breadth. Importantly, this distortion does not accurately reflect the three-dimensional appearance of the nose” (Tremblay et al., 2021). It is therefore not surprising that this type of imaging can be harmful to those already susceptible to body image issues, and data confirms that increased scrutiny of selfies has changed the concerns of patients, less of whom are seeking rhinoplasty to correct bumps on the dorsum of the nose, to more correcting perceived facial asymmetry (Tremblay et al., 2021). But how is it that body dysmorphia – and the even more egregious variants generated by new technology – creates a neurologically dissociative state that is so difficult to overcome?

A Computational Error

A study conducted by Simon C. Tremblay, Safae Essafi Tremblay, and Pierre Poirier uses the active inference approach to suggest that body image disorders “involve dysfunctional self-modelling which entails maladaptive internalisation of sociocultural preferences during adolescent identity formation” (Tremblay et al., 2021). The formation of identity is an active inference that arbitrates between identity exploration and commitment, and impaired self-modelling “is unable to reduce interpersonal uncertainty during identity exploration, which, over time, degenerates into uncontrollable epistemic habits that isolate the body image from corrective sensory evidence” (Tremblay et al., 2021). Going into further definition, the “self-model” posits that the self is not an entity but rather a representational process, which can be broken down into the two further subsets of “body schema” and “body image”. The body schema depends on sensorimotor processes that function without reflective intentionality; consider the notion of a “hot body map” which structures the active and global content involved in instrumental movements and self-preservation (Tremblay et al., 2021). In contrast, body image (or “cold body map”) is defined as a conscious representation of the body, “a reflective (i.e. explicit) bodily self-awareness […] involving deliberate (personal-level) processes associated with intentional states directed at the body  (i.e. perceptual experience, conceptual understanding, and emotional attitude directed toward the body)” (Tremblay et al., 2021). 

Having established the broad subsets of the self, the next crucial piece of the puzzle is understanding the directional flow of information, with self-consciousness understood as a hierarchical process that operates on a continuum between two poles. Consider the “directions of fit”, perceptual inference being about updating a hypothesis about the world in the present, and active inference being about selecting a hypothesis about the future and making it true through action, with continuous bidirectional interactions in their hierarchical continuum. 

Individuals vulnerable to identity confusion cannot achieve an adequate balance between individual and sociocultural expectations, which results in maladaptive social learning from sensory experience during perceptual inference (maladaptive internalisation); in the right sociocultural context, impaired epistemic agency may lead to the internalisation of overly precise prior beliefs about the negative body image in the higher levels of the self-model. In active inference, when prior beliefs are excessively confident and are in conflict with ascending sensory evidence, estimated precisions of the latter decrease (Tremblay et al., 2021). 

Put simply, confident prior beliefs entail high precision for consistent evidence and low precision for conflicting evidence. This compensatory decrease in sensory precision produces a reduced response to specific aspects of the sensory stimulus and, most importantly, a disregard for contradictory sensory evidence.

A Statistical Solution

In response to the increasingly compelling value of identifying patients with body dysmorphic disorder seeking cosmetic dermatology prior to treating them, Leslie Fletcher MSN, RN, AGNP-BC developed a multiphasic, cryptic screening protocol for body dysmorphic disorder in cosmetic dermatology. The method, distributed to a total of eight esthetic clinics in the United States, involved administering anonymous cryptic pre-screening questionnaires to all new patients between the ages of 18 and 65. Although the study limitations included a small data sample due to the study size, the initial findings positively support the implementation of screening protocols in identifying patients at risk of BDD and its subsets; “In total, 734 initial screenings were recorded over 16 weeks. Of these, 4.2% (31/734) proceeded to the secondary screening phase (COPS); 29% (9/31) subsequently screened positive for BDD. Practitioners refused to treat 77.8% (7/9) of positive screenings and documented patient responses. One patient became tearful but was grateful to have someone to talk to about BDD and agreed to speak with a mental health specialist. Follow-up confirmed the patient did undergo therapy for the condition. Two patients out of seven who tested positive underwent a third screening and additional discussion; both subsequently treated with positive results” (Fletcher, 2021). 

The positive results of this study paint a favourable light on the need to identify and treat patients with BDD for both the patients and practitioners sake. Patients with BDD are less likely to be satisfied with the outcomes of their treatment, and may even perceive a worsening effect, opening the door for both an exacerbation of their symptoms and retaliation against the practitioner. The literature reports that “2% of plastic surgeons have been physically threatened by a patient with BDD, […] 10% have received threats of violence and legal action, and since 1991, three plastic surgeons have been murdered by patients with BDD who were unhappy with their surgical results” (Feltcher, 2021). While patients seeking-out cosmetic treatment provide their tacit consent, a legal argument could be made that patients with BDD are not of the capacity to provide it. Treating patients with BDD without addressing the condition can be both a moral and legal liability. Proceeding with thought and deliberation is paramount.

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Washington DC: 2013.

Tremblay, Simon & Essafi Tremblay, Safae & Poirier, Pierre. (2021). From filters to fillers: an active inference approach to body image distortion in the selfie era. AI & SOCIETY. 36. 10.1007/s00146-020-01015-w. 

Harris, Steven MBBCh (SA), MSc (UK), MBCAM (UK) Alienization, Plastic and Reconstructive Surgery – Global Open: January 2022 – Volume 10 – Issue 1 – p e4025 doi: 10.1097/GOX.0000000000004025

Shivakumar S, Jafferany M, Sood S, Sushruth V. Cosmetic Presentations and Challenges of Body Dysmorphic Disorder and Its Collaborative Management. J Cutan Aesthet Surg. 2021;14(1):20-25. doi:10.4103/JCAS.JCAS_180_20

Fletcher, L. Development of a multiphasic, cryptic screening protocol for body dysmorphic disorder in cosmetic dermatology. J Cosmet Dermatol. 2021; 20: 1254– 1262. https://doi.org/10.1111/jocd.13885