A pandemic of perception
Virtual life has negatively affected patients’ self-perception. Dermatologists may be in a position to help.
Feature
By Allison Evans, Assistant Managing Editor, July 1, 2022
Photo editing, once associated with flawlessly airbrushed celebrities, has become not only ubiquitous but nearly a requirement of social sharing. In a highly curated digital world, the idea of sharing a photo without filters, lighting adjustments, and color enhancements may be downright anxiety-inducing. As many dermatologists may be witnessing, living in this world of perceived perfection may be negatively affecting people’s self-perception — with the pandemic adding an additional layer of complexity.
Zoom dysmorphia
We’ve seen how the COVID pandemic changed the way we interacted with one another, with many people working and socializing via Zoom and other videoconferencing platforms, said Arianne Shadi Kourosh, MD, MPH, FAAD, assistant professor of dermatology at Harvard Medical School and director of Community Health at Massachusetts General Hospital. (In this article, “Zoom” will represent videoconferencing platforms in general.)
“As reliance on video calls increased, we started seeing the consequences of how prolonged time staring back at yourself significantly impacted our patients in a phenomenon we call ‘Zoom dysmorphia.’ We are looking at a new phenomenon arising from the conditions of work and life in the pandemic that may be triggering or exacerbating body dysmorphic disorder (BDD),” Dr. Kourosh explained.
It is estimated that nearly 9.2% of cosmetic outpatients and 11.3% of dermatology outpatients have BDD. Prior to the pandemic, patients presented to their aesthetic physicians hoping to look more like their filtered Snapchat selfies, a phenomenon known as “Snapchat dysmorphia,” which caused concern for its potential to trigger BDD. Unlike Snapchat, where people knowingly change their appearance, in Zoom dysmorphia, BDD may be triggered by prolonged staring and self-reflection upon an unknowingly distorted image, Dr. Kourosh said.
Katharine Phillips, MD, professor of psychiatry at Weill Cornell Medicine, told NBC News that among her BDD patients, she observed intensified symptoms over the course of the pandemic. For those who don’t currently have BDD but are at risk of developing it, the stress of the pandemic could have triggered the onset of full-fledged BDD, she said.
Warning signs
Read about screening and treating patients with body dysmorphic disorder.
Survey says…
Dr. Kourosh and her colleagues surveyed over 100 board-certified dermatologists to inquire how the shift to remote life affected patient self-perception. “We found that over 50% of dermatologists have seen a relative rise in cosmetic consultations despite the pandemic — and even more alarming is that 86% reported that their patients referenced videoconferencing as a reason for their new cosmetic concerns,” said Dr. Kourosh, who is also the founding director of the Clinic for Pigmentary Disorders at Massachusetts General Hospital.
The most common patient concerns included features from the neck-up, such as upper face wrinkles (77%), dark circles under the eyes (64%), facial dark spots (53%), and neck sagging (50%), all of which may be exacerbated by camera angle, focal length, and shadow distortion, she explained.
The increased time on-camera, coupled with the unflattering effects of front-facing cameras, has triggered a concerning and subconscious response unique to the times we’re living in, Dr. Kourosh said. “In addition, many people were also spending more time on social media viewing highly edited photos of others — triggering unhealthy comparisons to their own images on front-facing cameras, which we know is distorted and not a true reflection. Unfortunately, this is the lens in which people are viewing themselves today, and it’s not accurate and can eventually become unhealthy.”
Other studies have come to similar conclusions, with one recent survey of the general public published in Facial Plastic Surgery & Aesthetic Medicine showing that of those who previously did not have an interest in facial cosmetic treatments, 40% now plan to pursue treatments based on concerns from their videoconferencing appearance alone.
Lingering effects of virtual life
A survey of more than 7,000 people demonstrated how increased hours spent on videoconferencing and social media platforms may lead to worsening anxiety, mental health, and self-perception, even as people began returning to in-person events. “There was a significant percentage that, when asked about their reasons for anxiety, cited their self-consciousness about their appearance,” said Arianne Shadi Kourosh, MD, MPH, FAAD.
Nearly 30% of all respondents stated that they planned to invest in their appearance as a coping strategy to deal with the anxiety of returning to in-person activities, and more than 30% planned to take action to change their appearance.
Those who spent more time staring at their faces on Zoom expressed more anxiety, and among 18- to 24-year-olds, it was those using filters who were most likely to have accessed mental health services, Dr. Kourosh said.
The number of respondents who experienced anxiety with returning to in-person life:
Yes: 71%
No: 29%
The number of respondents who sought mental health services:
Yes: 64%
No: 36%
The most frequently reported dermatologic concerns include:
Skin discoloration: 32%
Wrinkles: 25%
Acne: 14%
Hair loss: 14%
Source: Int. J. Women’s Dermatology. 2021; 7(5): 774-779.
A distorted image
Patients are often unaware of how cameras and photographs can distort and degrade image quality, leading to an inaccurate representation of their appearance. A study published in JAMA Facial Plastic Surgery described how self-photographs can create distorted appearances. Camera angle and focal distance may affect the perception of the image that appears on screen. A portrait taken from 12 inches away increases perceived nose size by approximately 30% when compared to an image taken at five feet, which results in essentially no difference in perceived size.
Additionally, Zoom displays a person’s facial expressions in real time. People watch themselves speak and react to others, which may draw greater attention to expression lines and wrinkles that may not have been noticed when simply looking in the mirror.
Webcams have been shown to have distorting effects as well. With webcams often recording at shorter focal lengths, the result is an overall more rounded face, wider-set eyes, broader nose, taller forehead, and disappearing ears obscured by cheeks (doi: https://doi.org/10.1371/journal.pone.0149313).
Authors in a study in Plastic and Reconstructive Surgery, explain how video calls condense life into a two-dimensional image, leaving a graded shadow along a curved surface, such as the nose, to appear as a flat, darkened area instead. This illusion may exacerbate the appearance of facial dark spots and bring unnecessary concern to users.
“Technology has certainly helped us navigate this pandemic in many ways, but it’s also important to be aware of its limitations and potential to impact how we feel about ourselves,” Dr. Kourosh noted. “Our hope is to encourage a discussion in the community of aesthetic medicine that will help us as physicians to be prepared to address this issue so we can take care of our patients as a whole person and support mental health and wellness.”
Help your patients combat Zoom dysmorphia
Share these tips with your patients who might be experiencing Zoom dysmorphia.
Assess your technology: Consider using an external, high-resolution camera for quality video and adding a ring light to control how you illuminate your face, which will also improve how you appear on camera.
Adjust your camera: Try positioning the screen further away from your face and keep the camera at eye level, which can help to minimize the distortion of the camera and improve appearance.
Protect your mental health: Find opportunities to reduce the amount of time spent looking into a front-facing camera by turning off your video on calls when it is not required. It can also be helpful to limit social media engagement. It may also help to talk with a mental health professional, who can offer strategies for redirecting focus away from perceived physical flaws.
See a board-certified dermatologist: If you’re concerned about your appearance, see a board-certified dermatologist, who can help identify whether a problem truly needs aesthetic intervention and if so, can recommend appropriate products or treatments to help you look and feel your best.
Assessing patients
Although both Zoom dysmorphia and BDD may lead someone to seek cosmetic enhancements, there is a difference between dislike of one’s image on Zoom and the persistent dissatisfaction with one’s physical appearance.
“I always recommend getting a reality-based assessment of the level of impairment on the person’s life,” said Evan Rieder, MD, FAAD, assistant professor of dermatology at New York University’s Grossman School of Medicine.
Dr. Rieder, who is double boarded in dermatology and psychiatry, recommends starting with a good screening question with very high sensitivity and specificity for body dysmorphic disorder, such as, “Is there an area of your face or body that you find to be especially unattractive?” This question comes from the Body Dysmorphic-Disorder Questionnaire – Dermatology Version (BDDQ-DV).
If a patient answers “yes” to this question, you could complete a BDD screening questionnaire, he continued. “However, most physicians can get a good sense of people’s illness through that initial screening question and following up with a second question: ‘How much time do you spend thinking about this issue on a daily basis? Count the hours.’ Most people without BDD or Zoom dysmorphia will see this as a weird question. People who are ill and not good aesthetic intervention candidates will have a very different response and may tell you that they are spending many hours per day obsessing over their appearance.”
“My clinical experience indicates that people who do not like their appearance on Zoom can do well with cosmetic procedures,” Dr. Rieder said. “The caveat being that it’s important to ask some screening questions to ensure that you’re not in thorny territory.”
“Dermatologists aren’t used to asking these types of questions, but they can yield a lot of useful information to help determine if someone may have BDD,” he said.
Diagnosing body dysmorphic disorder
According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, the following criteria must be met for clinical diagnosis of body dysmorphic disorder (BDD):
The patient has a preoccupation with one or more perceived deficits or flaws in physical appearance that are not observable or are slight to others.
The patient performs repetitive behaviors or mental acts (e.g., mirror checking, excessive grooming, skin picking) in response to the appearance concerns at some point during the disorder.
The preoccupation causes clinically significant distress or impairment in social, occupational, or other areas of functioning.
The preoccupation is not better explained by concerns meeting diagnostic criteria for eating disorders.
A return to normalcy
Dr. Kourosh believes that as people return to normal life, the ability to reconnect with loved ones and the decreased need to be locked into a chair staring at a front-facing camera should improve peoples’ sense of well-being.
“We hope awareness of this problem helps to avoid unnecessary procedures, especially if cosmetic concerns could be solved with simple changes such as a new webcam or ring light, or more importantly, if the patient would be better served speaking to a mental health professional,” she said.
