Selfie use: The implications for psychopathology expression of body dysmorphic disorder

Abstract

Preoccupation with a body part can lead to indulgence in various forms of coping behavior. Users are frequently using technology as well as selfie to overcome their anxiety to relate to a body part as well as get approval from other online users. The present case highlights the excessive use of selfie to manage the distress-related body dysmorphic disorder (BDD). Psychiatric interview and assessment tools were used to elicit information about BDD, technology use, and affective states. Repeated use of selfie has been thought to manage the distress associated with appearance. It implies the need for screening excessive use of technology as comorbid condition and psychoeducation for promotion of healthy use of technology.

Adolescents with body dysmorphic disorder (BDD) have an excessive preoccupation with one or more imagined or minor flaws in their physical appearance, which causes significant distress and impairs their social and occupational functioning.[1] They engage in repetitive behaviors such as mirror checking, excessive grooming, reassurance seeking, skin picking, or cloth changing to lessen their anxiety. Though the preoccupation can involve any body part, the most common ones are the skin, hair, nose, eyes, eyelids, mouth, lips, jaw, and chin, and the preoccupation can be focused on several body parts at the same time.[2] The steep growth of smartphones coupled with various other social factors has led to an increase in the selfie phenomenon in India. The selfie phenomenon has grown to almost every brand in every sector hosting a selfie contest. For one, it is cost-effective and another it is easy to instantly share on Facebook, Twitter, or Instagram and identified with the help of hashtags. Brands have been positively leveraging the power of selfies. Selfie variants are also adding to the brand communication. The population-based estimates from community and epidemiological samples indicate a prevalence of 1.7%–2.4% of BDD.[3,4,5] Studies also showed that the gender ratio was approximately equal, with some studies suggesting a slight preponderance of BDD in women.[4,6] BDD also present with comorbid conditions of depression, anxiety, and suicidality.[7,8]

Today's youth lifestyle has a predominance of use and issues related to the use of gadgets, technology, and social network sites. Nearly 93% of youth possess internet at home,[9] while 89% of 18–29 years olds use social networking sites.[10] The theoretical models such as the behavioral model emphasized operant conditioning, social learning, and the role of relational frames in developing BDD-related beliefs. The media and internet culture has become one of the powerful sources of vicarious learning for enhancing or getting appreciation for one's beauty and attractiveness.[11]

Sociocultural theory of body image also emphasized that the messages given by the media, peers, and parents about the importance of appearance are internalized by individuals, who adopt others’ standards of beauty as their own.[12]

This is frequently seen in social networking sites, as well as selfies in mobile phone, where there is emphasis on ideal pictures and images. The quality of immediate peer feedback leads to increased body surveillance. The enhancement of one's appearance on social media is considered by adolescents to be one of the most important skills for achieving popularity online.[13] The perceived failure of the actual self to live up to the ideal and ought selves is hypothesized to result in negative affect and anxiety.[14]

In the background of availability and environmental factors, users with body image disturbance are more at risk for developing excessive use of selfie. There are few treatment seekers in formal treatment centers. The following one of its kind cases shows the expression of psychopathology of BDD through internet/mobile use. The case approached the Service for Healthy Use of Technology clinic for management of excessive use of selfie. It is India's first tech deaddiction clinic to manage issues related to technology use.

CASE REPORT

A.D., a 21-year-old single female, a graduate, currently pursuing degree in education, staying with parents, hailing from a semi-urban background, belonging to middle socioeconomic status, presented with the complaints of fear of interacting with others – since early childhood, preoccupied about her appearance, figure, nose, hair, and complexion – for the past 8 years and excessive use of mobile phone for Facebook, WhatsApp, and taking selfies for the past 3 years. The symptoms had an insidious mode of onset, with continuous course and fluctuating progress. There was no specific precipitating factor. The client was apparently doing well till 2008, when she was 14 years old and was studying in high school. Though she was always a below-average student, she became extremely sensitive to her teacher's comments in tuition classes regarding her studies. She compared herself with other students and felt inferior.

There was a decline in academic performance because she found mathematics and science difficult. She used to cry a lot at home and told her parents that she did not want to study. She stopped going to tuition classes and school. A psychiatrist counselled her in the nearby city, and prescribed medication. With this, she somehow managed to pass high school. There was not much improvement in the symptoms for the next few years as she became preoccupied with her appearance that her nose was not sharp, she was not fair, and had a lot of pimples. This led to a number of consultations with dermatologists, repeated mirror gazing, reassurance seeking, mood fluctuations and attempts at self harm. They sought consultation from us at NIMHANS in May 2013 and was diagnosed as BDD and social anxiety disorder. She was treated with clomipramine 150 mg/day with lithium, sertraline, and risperidone being tapered off. Therapy sessions focused on psychoeducation, cognitive restructuring, mirror retraining, exposure, and response prevention. They returned to their hometown so that she could appear for her examinations. She visited us again in October 2013, as the symptoms worsened. There was again excessive preoccupation with her looks, repeated mirror gazing, reassurance seeking, handwashing, face washing, and demanding behavior. Clomipramine was increased to 200 mg. Therapy was initiated again mainly focusing on cognitive restructuring, mirror retraining, and exposure and response prevention. There was improvement in 2 months’ time. Subsequently, the patient was followed up every 6 months for reviewing the medication.

On subsequent follow ups it was seen that she continued her preoccupation with her appearance (figure, nose, complexion, and hair), leading to checking the mirror every hour of the day. She avoided seeing mirrors in shops, restaurants, etc., with the fear that she might look bad in it and also avoided going out in day time. She was very particular about her clothes and wanted it to be the perfect fit. She used to spend a lot of time on changing her hairstyle throughout the day. She wanted to look good in order to gain social acceptance and also be liked on Facebook and WhatsApp (ends up using her phone most time of the day). She avoided social interactions and giving presentations as she feared negative evaluation by others over what she said. She started using Facebook when she was Class XI, but on reaching college 1^st year, there was excessive use of Facebook and WhatsApp. She had been preoccupied since then, whether others like her photograph on Facebook and whether others chat with her. She also had made a group of unknown friends. She checked her phone every 10 min for any messages or notifications on a usual day. She keeps clicking selfies every 15–20 min, till she was satisfied with a photograph, and if not she changed her hairstyle and clicks again. She clicked more selfies at night, because according to her, she looked better at night time, rather than day time, as it magnified her flaws. Whenever her net balance was over, she demanded her mother to get it recharged immediately. She preferred chatting and being with others online, rather than interacting in the real world. She avoided face-to-face conversations, giving presentations, purchasing things from a shop, eating, talking on a phone in a public place with the fear of negative evaluation by others, and being subject to the scrutiny of others. Premorbid temperament revealed that she had a lot of demands and temper tantrums as a child. She was overactive and would spend more time in extracurricular activities than academics. She had always been a below-average student in school and had difficulty in making friends. Family history revealed that the client's father had frequent anger outbursts and used to hit the client whenever she became demanding. Mother on the other hand was permissive. Assessment revealed the presence of problematic use of internet (score of 60 on Internet Addiction Test[15,16]), excessive use of mobile and Facebook on Problematic Mobile Phone Use Questionnaire[17] and Facebook Intensity Questionnaire,[18] moderate social phobia on Liebowitz Social Anxiety Scale[19,20] indicating moderate social phobia (score 58), and the patient got moderate score in the domains of anxiety (score 14) and stress (score-20) on Depression, Anxiety and Stress Scale.[21]

Therapy components in the initial phase included psychoeducation about BDD and the cognitive-behavioral aspects, tracking mirror and mobile use, monitoring her negative automatic thoughts, triggers, and identifying the cognitive errors. In the middle phase of therapy, the cognitive errors and dysfunctional negative thoughts were challenged and her beliefs about the importance of appearance were identified. She was also encouraged to participate in other recreational activities such as yoga, walking, drawing, and going to the library. Specific contract was made regarding her mirror and mobile use on a typical day. Initial goal was to delay the frequency of use. Mirror retraining was also done. Exposure and behavioral experiments were used to modify the underlying beliefs of importance of appearance and social acceptance.

The outcome of the therapy was positive. Fifteen sessions were carried out with the client. Mirror usage had reduced to 5–6 times/day though she still avoided seeing mirrors of shopping malls, vehicles, etc. Mobile use was also reduced to 2–3 h every day. The craving for the mobile phone/internet was still there, and whenever the mobile balance would get over, she wanted to recharge it immediately. She was able to challenge certain negative automatic thoughts, but practice was needed in developing more realistic alternative thoughts. She would have benefitted from exposure to various social situations which she avoids, but due to lack of time, only one or two situations could be practiced.

DISCUSSION

Millenials (as this age group individuals are popularly called) have never experienced life without digital technology. They are over engrossed in creating an online identity. This poses problems for those with body image concerns, especially girls, as society defines women more by their physical appearance than that of men.[22,23,24,25,26,27,28,29,30,31] This becomes worst in girls with BDD, as they have rigid, perfectionist beliefs regarding how they should look leading to negative self evaluation and low self esteem.[23] Researchers found that individuals with low self-esteem tend to be more involved with the trend of taking selfies, as well as the use of social media to mediate their interpersonal interaction in order to fulfil their self-esteem needs.[26] They try to boost their narcissism through selfies and getting approval on social network sites, but eventually it only leads to more misconceptions and assumptions. According to the self-verification theory,[27] selfies are used to receive self verification from others in the form of positive comments and likes, but for those with body image issues, it leads to constant seeking and comparing of others’ evaluations, ultimately leading to depressed affect.

According to psychiatrist Dr. David Veal, “Two out of three of all the patients who come to see me with Body Dysmorphic Disorder since the rise of camera phones have a compulsion to repeatedly take selfies and post it on on social media sites.”32

Studies indicate that selfies are found to be the reason among young people seeking plastic surgery with 10% increase in nose jobs, 7% increase in hair transplants and 6% increase in eyelid surgery in 2013 in comparison to previous years.[25] The study also found that girls who spend more time on Facebook were more likely to suffer from a physical self-image, and had an increased urge to lose weight.[25]

The above case report highlights the role of technology in triggering and maintaining the psychopathology of BDD, as well as the need for screening it as a comorbid condition in cases with BDD and other body image related problems.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.