1. Introduction

Today's youngsters use a lot of gadgets, technology, and social network sites. Visual based social media channels like Instagram and Snapchat platforms that are on an all-time high in usage among men and women on social media [1].

Beauty filters are one of the most common content many young women and men use on Snapchat and Instagram. A beauty filter is a tool that helps in editing the user's photo by smoothing out their skin, enhance their facial features like eyes, lips, nose and also helps in altering the shape of their jawline, cheekbones etc. [2].

This level of physical perfection, traditionally seen only in celebrities or beauty magazines, can now be seen all over social media.

As the image becomes the norm, the standards of beauty of people around the world shift, which influences the self-esteem of an individual and can lead to Body Dysmorphia Disorder. As per the DSM V criteria, BDD is defined as “Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others” [3].

The theoretical models, such as the behavioural model, emphasizes operant conditioning, social learning, and the role of these tools in developing body dysmorphic-related beliefs [4].

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. 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 men [2]. Khanna A et al. (2017) studied such cases in an Indian scenario for the first time and showed the psychopathology of Body Dysmorphic syndrome through internet/mobile use [4]. However, this topic has been less dealt with in the literature but demands far-reaching attention for preventing this disorder from growing in the youth.

2. Aims and Objectives

The present study was done to determine the prevalence of Body Dysmorphic syndrome in males and females using selfie filters on social media and to assess the effects of these beauty filters and images on the self-esteem of the study participants.

3. Materials and Methods

An observational cross-sectional descriptive study was done by narrative interviews of the college students and online filling of the self-made form (Google forms) over one month (January 2021). The participants considered eligible for inclusion in the study were required to be 18-35 years to read and write in the English language and use selfie filters on Instagram / Snapchat. Any participants of age <18 or >35 years, pregnancy or who gave any history of psychiatric disease or diseases affecting the musculoskeletal system, connective tissue disorders, or any previous surgical procedure involving the spine or upper musculoskeletal extremity and severe neck/shoulder trauma were excluded from the study.

The participants were explained about the study, and written informed consent was obtained from the participants. The demographic details such as age, gender, religion, occupation, residence and education were recorded. The information regarding the frequency, duration, preferred social media platform use, use of selfie filters, and frequency of uploading selfies was noted.

The sample size was based on the study of Anisha Khanna, et al [4] who observed prevalence of BDD as 1.7% to 2.4%. Taking this value as reference, the minimum required sample size with 3% margin of error and 5% level of significance is 100 patients. To reduce margin of error, total sample size taken is 138.

The diagnosis of body dysmorphic syndrome/ body dysmorphic disorder (BDD) was made based on the Dysmorphic Concern Questionnaire (DCQ) scale questionnaire as applied in the google form.

DCQ scale was developed by Oosthuizen et al. [5], which assesses the concern for body dysmorphism based on 7-items without establishing a DSM-IV diagnosis of BDD. The participants rate the questions on a 4-point scale which is scored from 0-3. The resulting total score may range from 0-21, with higher scores indicating more concern about BDD. =A DCQ score cut-off of 9 was selected in this study to label a participant as "BDD". This was based on the study by Mancuso et al. [6], where the cut off of 9 showed good internal consistency with the correct diagnosis of 91.6% samples.

We used the Rosenberg Self-esteem scale [7] to assess the self-esteem of the participants. It is a uni-dimensional 10-item scale that is answered on a 4-point Likert scale from "strongly agree" to "strongly disagree" about positive and negative feelings about self. The total score may range from 0-40, with higher scores indicating high self-esteem. For the present study, a cut-off of more than 20 was considered high self-esteem, and a score of 20 or less was considered low self-esteem.

The primary outcome measures included the proportion of participants with BDD and low self-esteem. The secondary outcomes were risk factors affecting BDD and self-esteem.

3.1. Statistical Analysis

The data was entered in an M.S. Excel spreadsheet, and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. P <0.05 was considered significant. Categorical variables were presented in number and percentage (%), and continuous variables were presented as mean ± S.D. and median. Univariate logistic regression was used to find out significant risk factors of BDD and low self-esteem.

The comparison of quantitative variables was made through independent t-Test (for two groups) and ANOVA (for more than two groups). Qualitative variables were done using Fisher's Exact test. Pearson correlation coefficient was used to assess the correlation of total score and suicide risk assessment scale with several attempts. For statistical significance, a p-value of less than 0.05 was considered significant.

4. Results

The demographic characteristics of the study population have been shown in Table 1. The study patients' mean age was 27.73 ± 4.1 years with 65.22% females and 34.78% males. The majority of the population (72.46%) were unmarried and resided in an urban area (89.86%). Occupationally, 13.04% were students, and only 1.45% were unemployed. The rest of the population was employed like being health care providers (35.51%), business (12.32%), government employees (2.17%) and others (35.51%). The studied population were graduates (45.65%) or post-graduates (53.62%) with a single case of vocational education. The majority of the individuals were Hindu (82.61%), followed by Muslim (8.7%), Christian (4.35%) and others.

Table 1. Distribution of socio-demographic characteristics of study subjects

The DCQ scale replies and the total score has been shown in Table 2.

Table 2. Distribution of DCQ scale of study subjects

The concern about their physical appearance was the same as other people in the majority (71.74%), with 14.49% having no concern about their physical appearance. Among the study population, 17(12.32%) individuals were found to worry more about a functional body defect. While putting selfie images, 11(7.97%) individuals thought to have misshapen organs, and 14(10.14%) were concerned about their body odour and flatulence. A total of 13 (9.42%) individuals spent a lot of time covering the body defects by using selfie filters.

Overall, 14(10.14%) individuals felt to consult a medical professional for the body issues. Seven were told that by the doctors that they need not worry as they have standard bodies like others.

The mean DCQ score of the study patients were 4.21 ± 3.25, with a median (IQR) of 3.5(2-6). As per the DCQ scale, Body dysmorphic disorder was present in 17(12.32%) patients. (Figure 1)

Figure 1. Distribution of BDD of study subjects

The mean Rosenberg self-esteem scale of the study patients was 30.12 ± 4.99. As per the scale, 6(4.35%) were having low self-esteem.

Social media platform was used in 94.93% of cases, among which Facebook and Instagram were commonly used. The mean duration of use was 4.2 hours. Selfie filters were used in 70.29% of cases, among which beauty filters and sweet face cameras were commonly used. The frequency of uploading selfies were 4 per day. (Table 3)

Table 3. Digital media use

On performing univariate logistic regression, widowed individuals (OR 10.111, p=0.112) and married persons (OR 2.441, p=0.103) carried a higher risk for BDD in comparison to unmarried persons; males showed a lower risk of BDD (OR.756, p=0.620) in contrast to females; sub-urban and rural areas carried a higher risk (OR 2.54) in comparison to urban areas. However, statistically, none of the demographic factors was found to be a significant risk factor of BDD. The frequency of uploading selfies and use of selfie filters was significantly associated with higher odds of body dysmorphic disorder with an odds ratio of 27.115 and 5.466, respectively, as shown in Table 4.

Table 4. Univariate logistic regression to find out significant risk factors of BDD

On performing multivariate logistic regression, the frequency of uploading selfies was an independent risk factor of BDD with an adjusted odds ratio of 32.883(4.321 to 250.261).

For low self-esteem, males showed a lower risk (OR.362, p=0.360); Widow/ Widower/ Divorced showed a higher risk (OR 3.470, p=0.523). People residing in suburban areas had a significantly higher risk and higher risk of low self-esteem with an odds ratio of 5.821, p=0.043. The frequency of uploading selfies was significantly associated with low self-esteem with an odds ratio of 3.463 with a p-value of 0.0002; however, selfie filters did not show a statistically significant risk associated with low self-esteem (Table 5).

Table 5. Univariate logistic regression to find out significant risk factors of low self-esteem

On performing multivariate logistic regression, none of the factors was an independent risk factor of low self-esteem.

5. Discussion

The present generation has become an age of digitalization where every person is engaged in digital gadgets [4]. The demand for a clearer picture of oneself has brought many apps that may beautify your image with perfection. This has led to the continuous judgement of oneself in terms of body stature and looks. Dysmorphic concern, "an overconcern with an imagined or slight defect in physical appearance" [5], is one of the preliminary diagnostic criteria for BDD.

In the present study, among 70 participants, BDD was present in 17(12.32%) patients. The prevalence may vary among different populations with the use of different scales such as the 34-item Body Dysmorphic Disorder Examination (BDDE) [8], Body Dysmorphic Disorder Questionnaire (BDDQ) [9], Body Image Disturbance Questionnaire (BIDQ) [10] and DCQ.

In the present study, the DCQ scale used for BDD assessment in the present study has been validated as a screening tool for the general population rather than in-hospital psychology patients [6]. In corroboration with our study, Jorgensen et al. [11] reported BDD in 19(29%) patients using DCQ and BDDE. An Indian study by Dutta E et al. [12] on 92 U.G. and 103 PG students observed high mean scores of Body Image Acceptance and Action Questionnaire (BIAAQ), indicating obsession with body images while taking selfies. This has posed certain problems for those with concerns about their body image, especially girls, as our society defines women more by their physical appearance [12-14].

This was evident in the present study, where females carried a higher odds risk (though statistically not significant) of BDD in comparison to males. Even the total population studied that used selfie filters were predominated by women (65.22%). It has been proposed that the BDD becomes worst in girls because of their rigid perfectionist beliefs about their looks [4]. The findings were in line with Dutta et al. [12], where the use of selfies affected more females (undergraduates), P = 0.01, with no difference in the BIAAQ scores among males and females for the P.G. group (P = 0.843). Overall like the present study, there was no significant difference in the gender predisposition towards selfie images and BDD.

This has been confirmed in other studies where BDD Prevalence rates are similar among females and males [15,16]. The gender equivalence might be because females are more secretive about revealing selfie images and filters while participating in the surveys [6]. Grant et al. [17]. observed that 13.1% (n=122) of psychiatric patients were unwilling to disclose the concern of body dysmorphism when enquired. In another study, 16 (3.2%) individuals were reluctant to disclose body dysmorphism [18]. Though these two studies have been done only in psychiatric patients, this secretiveness has been much more pronounced in the general population, leading to statistical insignificance among males and females [19,20].

The use of selfies among young people has led to more seeking of medical professionals for BDD in terms of various surgeries and aesthetic procedures [4,6]. In our study, 14(10.14%) individuals felt to consult a medical professional for the body issues. Data shows that there has been an increase in 10% nose jobs, 7% hair transplants and 6% eyelid surgery over the years [14]. Since this perception of body image is becoming stronger with Instagram and Facebook selfie posting, plastic surgeries may observe an exponential rise in the future.

Despite this, it must be brought to attention that all individuals may not be in need of body correction surgery. It is just their misconception about themselves that is letting them be worried about their body image, thereby affecting them negatively in terms of causing anxiety, depression and other co-morbid psychiatric illnesses like a social phobia and obsessive-compulsive disorder (OCD) [21]. This may be because the concerns about body dysmorphism may be overpowered by other preoccupations that become difficult to control. The increasing belief and conviction about the negative self-perception may lead to the ideation of delusionality [22]. The delusions may include the belief that people criticize their appearance, note their defects and evaluate them negatively on social platforms, thereby leading to a negative perception of themselves [23].

This has led to the use of selfie-filters equivalent to the makeups/cosmetics that bring about camouflage in the usual life, seeking reassurance about their good body, thereby defying the flaw or the concern about the body disfigurement created in their mind.

In the present study, BDD was at higher risk among individuals residing in suburban and rural areas, which may be because of low confidence, self-image, and self-esteem among those residents compared to the urban population.

Decades of history have linked beauty with women, and the judgement over the digital world has exponentially increased the feeling of negative "self-evaluation", leading to low self-esteem [6].

In our study, we found 6(4.35%) cases of low self-esteem and females had a higher odds ratio (O.D.) for low self-esteem than males, though statistically, it failed to cross statistical boundaries. Literature shows that selfie-taking has been linked with low self-esteem [19]. It is comprehended that social media has become one of the resources to mediate interpersonal interaction to fulfil their self-esteem needs. The population try to boost their identity and morale through approval and "likes" of their selfie photos on social media which aggravates the misconceptions and assumptions. As per the self-verification theory [20], 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".

Corroborating with risk factors associated with BDD, we found that individuals staying in suburban and rural areas had significantly low self-esteem. This may be related to the education and occupational status of that population. The exact reason for this low self-esteem may be linked to the stigma of cultural and moral barriers that the rural-urban divide holds [24]. There is a certain level of discrimination that negatively impacts an individual in terms of his well-being, morale, and self-esteem. Though selfie filters and social platforms are becoming rampant in rural and urban sites, an inherent social stigma and negative discrimination may be a confounding factor causing a statistically significant difference in self-esteem and BDD in the present study.

The current study holds strength by clearly showing that the use of social media platforms and uploading of selfies with selfie filters increase the risk of body dysmorphic disorder, resulting in an overall decrease in the self-esteem of the general population. Since the frequency of uploading selfies carries a significantly higher risk of this disorder, it must be stressed here that general awareness must be created to decrease the frequency of selfie filters uploading and use.

The study had certain limitations. First, the study population was heterogeneous in terms of married-unmarried individuals, residents of rural/urban areas, students and working groups. Secondly, the study was conducted on small sample size. Third, we did not compare the type of use of gadgets (mobile/i=Pad) as this might impact the self-esteem of the participant.

6. Conclusions

The use of selfie filters on social platforms is raising concerns among individuals about their body dysmorphism. Such beliefs are intrusive, lowering the self-esteem of the individuals. The rural residents are at a significantly higher risk than the urban population, which might be due to behavioural discrimination, a fact that needs further large multi-centric trials for evidence. The regularity of uploading selfies with the use of selfie filters create more dysmorphism in the mind causing lowered self esteem.

Practical recommendations based on results: The use of selfie filters must be consciously applied without paying attention to the opinion of other person's, and one must keep oneself confidence intact about the body contour.