The Perfect Pretence - How social media is shaping a warped generation.

The social media phenomenon has engulfed our modern world of handphones, iPads or whatever lit screen you use. Men and women of all ages are taking to social media to gather information, follow friends’ daily lives and live vicariously through a celebrity’s online personas. It is through online apps that we get inspired, and apps also help us get validated by friends and family.

May 29, 06:37 PM

      It’s 10pm on a Friday night. A night that will soon be filled with loud music, drinks and photo taking. Fresh out the shower, I beautify my visage with an hour and a half’s worth of makeup and hair curling. Following a meticulous, precise and at times, arduous level of beautification, I shout to my partner, “Babe, you can call the cab in fifteen minutes.” As usual my partner rolls his eyes, sighs and yells in return, “Let’s go! It’s already 11.30. Why do you need so much time to get ready?”
      Not wanting to get into an argument, I shut my mouth, shut the door and begin my selfie-taking routine. This routine takes a very skilled level of finesse and patience. First, I attach a selfie ring light on my phone’s camera. Next, I gently lie back on the beanbag – as to not mess up my perfectly curled locks. Following this, I twist and turn like an alligator killing its prey underwater, looking for the perfect lighting and angles. Once I find that perfect screen shot, I snap away, taking at least ten to 15 photos until the perfect, ‘like-worthy’ image is captured. If I’m satisfied with the photo, I upload it on Instagram, but not before it’s heavily edited in order to increase likeability. This whole selfie process, albeit looking natural and unrehearsed on Instagram, actually takes 15 minutes. But it’s all worth it. Within the first hour, I would’ve achieved more than 20 likes. And those double-taps feel good. It feels good to be validated. It feels good to be liked. It feels good to be loved.
Because we live for the screen, we always portray our best selves. Our best lives.
      This social media phenomenon has engulfed our modern world of handphones, iPads or whatever lit screen you use. Men and women of all ages are taking to social media to gather information, follow friends’ daily lives and live vicariously through a celebrity’s online personas. Whether we like it or not, social media has moulded social fabric. It is through online apps that we get inspired, and apps also help us get validated by friends and family. Because we live for the screen, we always portray our best selves. Our best lives. Why would friends, acquaintances or even strangers want to donate those thumbs ups if we weren’t our prime selves?
      While living for the screen through edited, meticulously curated photos may just be a fun pastime for most, many want to bring this digitally manicured beauty beyond the screen and into reality. This has caused a shift in the demand for plastic surgery where more people are desiring to look like their Snapchat edited selves. As the need for social media gratification grows, so does the desire for physical beautification increase, leading to a new twist on body dysmorphic disorder (BDD) called Snapchat dysmorphia.

Snapchat dysmorphia – according to online data – is essentially a form of BDD triggered by seeing too many unrealistic photos on social media. But the questions are: Is Snapchat dysmorphia a real mental disorder? Does it trigger distorted, unrealistic ideas of beauty? Will it cause BDD? Clinical Psychologist Yap Chee Khong answers common BDD questions and explains how Snapchat dysmorphia exacerbates the disease. Consultant Plastic and Reconstructive Surgeon Dr. Yap Lok Huei chimes in later, revealing how social media has affected the industry, and revealing whether selfie-perfect faces are actually attainable through surgery.
Clinical Psychologist Yap Chee Khong
What is Body Dysmorphic Disorder with Psychologist, Yap Chee Khong
     
According to Chee Khong, studies show that BDD affects one to two percent of the world’s population. Distressing both males and females almost equally, the disorder often develops during adolescents, as teens become progressively aware of physical appearances. BDD is placed under the obsessive-compulsive disorder category when patients experience persistent and intrusive preoccupations with physical defects that aren’t observable to others. At some point during the course of the disorder, parties will have also performed repetitive behaviours in response to these perceived physical concerns.
      BDD comprises two components. First, there’s obsession which pertains to fixations on appearance. In response, there’s compulsion or safety behaviours like constant selfies with filters, mirror-checking, mirror avoidance, heavy makeup application and plastic surgery dependence. Due to both obsession and compulsion, patients with BDD are commonly distraught and similarly experience anxiety and depression. Correspondingly, patients may also suffer social impairment where they become recluses, choosing to only remain indoors, avoiding social interaction. Chee Khong discloses, “The problem with BDD is that patients rarely seek help because they believe their thoughts aren’t delusional.” He also reveals, “When patients do seek help, it’s common that they’ve lived with BDD for more than a decade.”

Levels of BDD
     
Although most patients are convinced BDD beliefs are true, we cannot assume all patients should be placed in one basket.  BDD patients are divided into three categories. If one has good insight, he or she recognises BDD beliefs are definitely or probably not true where they’re taking active approaches in managing symptoms. With poor insight, individuals believe BDD beliefs are probably not true but can’t help their compulsions. If patients experience absent insight, delusions are deemed to be absolutely true, where they aren’t convinced when people say they look fine.

Snapchat Dysmorphia and Risk Factors
     
Snapchat Dysmorphia could be a manifestation of BDD. Chee Khong maintains that before we classify Snapchat Dysmorphia as a modern take on the disorder, we have to look into the delusion’s two components – obsession and compulsion. When patients are obsessed with social media’s filtered images, they are practicing the disorder’s compulsive behaviours. Furthermore, we cannot assume that younger generations are at higher risk because Gen Zs are more in tune with technology. Chee Khong contends, “Before we claim a person has BDD or Snapchat dysmorphia, we must first understand risk factors or how the disorder manifests.”
      Firstly, there’s predisposing factors which increase susceptibilities to a mental disorder. This can include bullying, family values focusing on appearances, previous romantic hardships or careers demanding aesthetic perfection. Such examples may contribute to feelings of insecurity, inadequacy, or even fears of rejection and humiliation. Individuals experiencing predisposing factors may not suffer BDD as of yet. But, if high-risk individuals suffer an untoward event, the higher the chance for BDD onset. This is what is known as a precipitating risk factor where something as simple as a breakup triggers and contributes to occurrences of BDD. Once precipitation sets in, perpetuating risk factors (filtered selfie obsessions and plastic surgery) will maintain and perpetuate BDD, as likes and validation offer emotional security. “Although filtered selfies or Snapchat dysmorphia may just be symptoms of BDD, it can trigger inceptions of the disorder because patients believe such faces aren’t only attainable but also provide false senses of acceptance and approval,” Chee Khong laments.

A Vicious Cycle
     
When BDD sufferers undergo surgery to look like their filtered selves, this traps them in a vicious cycle, says Chee Khong.  For instance, if patients undergo rhinoplasties because they want perfect noses, they’ll never be satisfied with outcomes because there is not necessarily a physical flaw, but an internal perception. No matter how many surgeries one undergoes, no number of nips and tucks will fix flaws because internal delusions force patients into believing appearances haven’t improved. The issue related to such behaviours is how the more patients go under the knife, the more delusions are reinforced. Chee Khong maintains, “Thoughts, feelings and behaviours persistently feed each other, trapping patients in a vicious cycle.” He also acknowledges, “Despite such behaviours seeming like plastic surgery addiction, it may not be addiction per se but a need for perceived defect correction.” Once unreachable demands aren’t met, hopelessness creeps in, reminding patients of precipitating factors like bullying or rejection. Finally, patients are at risk of added co-morbidities like anxiety and depression, leading to reclusion, eating disorders or even suicide.

Self-screening
     
Despite trained professionals being the only people to diagnose BDD, patients can investigate possibilities of the disorder via simple online surveys. Questionnaires like the Cosmetic Procedure Screening and Appearance Anxiety Inventory help patients understand present symptoms and its severities. “If tabulated scores are high, it’s best individuals seek help as elevated numbers mean severe indications,” Chee Khong advises.

Getting Better
     
BDD patients who choose treatment are aided through pharmacological or non-pharmacological solutions, or a combination of the two. Before psychological treatment, individuals are assessed on contributing influences including predisposing, precipitating, perpetuating and protective factors. Treatment plans are formulated based on individual cases.
      Given that most BDD patients have poor insight, assessment on motivation to change is conducted to evaluate readiness for intervention. Patients will also undergo cognitive behavioural therapies, helping individuals recognise unconstructive views and changing irrational thoughts. As a result, patients learn to refocus attention away from the self, and re-engage with activities which improve moods. This therapy also guides patients to resist comparing appearances, to stop ruminating and challenge fears. Even though side effects involve severe anxiety, such by-products are transient once fears are regularly tested. In the event patients don’t respond to non-pharmacological treatments, they may be referred to psychiatrists. Chee Khong assures, “A psychiatrist’s or clinical psychologist’s ultimate aim is to help individuals live productively, instead of existing in a lifecycle of unhealthy obsession and preoccupation.”
Consultant Plastic and Reconstructive Surgeon Dr. Yap Lok Huei
Plastic Surgery and Social Media with Dr. Yap Lok Huei
     
Before the advent of social media, Dr. Yap would encounter situations where patients would walk in with photographs of models and celebrities they aspired to look like. Recently, what’s been a game-changer is instead of glossy magazine cutouts, patients are now flashing edited photographs of themselves, asking if the same facial or body type is possible through plastic surgery. “This is a new phenomenon, as there’s an increased focus on selfies where patients are snapping photos at certain angles and editing images to look like better versions of themselves,” Dr. Yap says. He adds, “This is very interesting because patients are now looking at themselves from a ‘selfie’ perspective, which gives a different yet direct avenue of assessment.”
      Dr. Yap normally discusses areas of concern with patients using a mirror, to locate, identify and confirm the points of interest on the eyes, face, chin, breasts or elsewhere. What he finds now is that an increasing number of patients prefer to present issues not through a mirror, but a front-facing camera.
      In Dr. Yap’s opinion, the modern world of social media has undoubtedly impacted the medical aesthetic industry simply because such apps are easy to use. Before the dawn of Instagram or Snapchat filters, people wanting to adjust their features had to use software like Photoshop. Photoshop skills weren’t something everyone previously acquired. Now, almost everyone can easily erase flaws with one to a few simple swipes. Dr. Yap details, “There is a significant impact on how we evaluate patient requests now because the use of images is now not just based on photos of oneself, but also on their alterations using filters and adjustment software tools. It is a good communications tool, but we have to be mindful, as desires aren’t always attainable.”

Are Demands Achievable?
     
Now, the question patients may want answered is: can one physically achieve the perfect selfie face or body? Should we base assessments of beauty according to filtered photos? Furthermore, are we comparing personal selfies to shots of Instagram models or celebrities? Dr. Yap advises, “Individuals must understand that aside from comparing themselves to a filtered image, they may also contrast themselves against another person’s selfie, which might also be highly idealised.” This means that patients may be comparing unmodified faces to an almost unachievable, perfect image of beauty. Dr. Yap comments, “If you think about it, the only face you don’t really see is your own, since we can only ever view ourselves through photographs and indirectly through mirrors.” The advent of easily available selfies has allowed us to change this somewhat, but we are now judging ourselves, our lives and lifestyles through what we see through the phone camera, and the portraits of our lives captured therein. With the addition of software and adjusted versions there is a tendency to move towards ‘picture perfect’ images and lifestyles. It’s always been a challenge for surgeons to achieve expectations, but with the advent of selfie filters, meeting the exact ideals has become even tougher. Add to the fact that self-images are always taken from the angle and in the lighting judged to be most flattering and attractive to the person taking the picture. Sometimes these features - such as a very tapered chin or elevated cheeks - may look unnatural from normal viewing angles. Such points add further to the challenges for the treating health professional.

An Insta-worthy Image
     
Dr. Yap concedes that selfies in themselves aren’t a bad thing. He does nonetheless argue there are those who identify with filtered images much better than their original faces. He also contends, “While advantageous, there are occasions where people are so uncomfortable with natural faces and bodies, they prefer the world to see them filtered, symmetrical and perfect.” Such patients, as stated by the good doctor, are hiding behind a seamless, filtered world. These risky behaviours may lead to possibilities of BDD or Snapchat Dysmorphia. Nevertheless, and while there’s some suggestion that selfie addiction may result in BDD, such compulsions may just be a symptom of the disorder. 
Patients suffering from BDD are red flags for plastic surgeons because they possess distorted and unnatural perceptions of beauty
BDD and Plastic Surgery
     
Patients suffering from BDD are red flags for plastic surgeons because they possess distorted and unnatural perceptions of beauty. As Chee Khong has pointed out, sufferers get caught in vicious cycles. If they perceive themselves fat, they’ll exhaustively lose weight, become anorexic, but still imagine an overweight reflection. Dr. Yap discloses, “BDD is an organic mental disorder where patients have significantly different views of what they look like. Indications like filtered selfies may trigger increased compulsive behaviours including cosmetic procedure dependence which further exacerbate unhealthy and distorted thoughts. As such, these individuals are those whom plastic surgeons avoid because expectations are rarely met.”

High-risk Patients
     
Many plastic surgeons acquiesce that patients with celebrity photographs are to be considered ‘red-flags’. So, what if they presented filtered selfies? In Dr. Yap’s opinion, it boils down to a matter of degree. Quite commonly, patients will display images to give doctors an idea of what’s desired. Still, patients must recognise the images and understand what they’re looking at. If they focus on small, singular regions like the eyes, lips or chin, that’s completely different to an entire bodily region. “In the event patients seek minor changes, demands may be met as long as desires are reasonable and achievable,” Dr. Yap asserts.
      Based on Dr. Yap’s experience, it’s not often easy to identify BDD in any given patient. Some may present with obvious patterns of behaviour while others act completely normal. Therefore, doctors cannot assume that all patients who want cosmetic surgery based on filtered selfies have BDD or Snapchat dysmorphia. “Because we’re now more exposed to our own faces, we’re progressively aware of beauty ideals and personal shortcomings,” he says. In addition, surgeons in the industry have also been affected because patients are similarly presenting before and after photos of other surgeons’ accomplishments, asking if another specialist’s handiwork is achievable. “This demand may be a tall order, as every patient’s natural shape and contours differ. Moreover, how can we confirm that Snapchat photos presented as examples of a doctor’s work weren’t doctored too?”

Unattainable Perfection
     
Snapchat Dysmorphia perhaps does nothing more than raise awareness regarding the different iterations of beauty where we’re now more conscious of our appearances. Still, the issue with social media is the fact we’re assaulted with images of flawless perfection and symmetry. Humans are programmed to prefer symmetrical bodies and faces because it’s an indication of good health and genetics. But, if you lean towards one end of the spectrum, flawless proportion comes off looking unnatural, and sometimes overly ‘constructed’.  Dr. Yap counsels, “Patients must recognise that perfection is never attainable even with cosmetic surgery. The ability to alter appearances through apps isn’t as easily done under the knife.” If we allow ourselves to fall into the trappings of chasing ultimate perfection, it may lead to dissatisfaction and many visits to a surgeon’s clinic. Dr. Yap advises, “Selfies are a great starting point but following this, surgeons need to advise patients on whether alterations are safe, or even possible, based on current anatomical parameters.”

A Bright and Vivid Snapchat Future
     
Having said that, the advent of technology should not be taken as an impediment to treating cosmetic patients.
      Dr. Yap views the use of selfies and Snapchat as a largely positive development. “It really does help, in most cases, the surgeon to understand the patient’s concerns and requests. Most patients have a fairly good understanding of what they like, and communicating this in a clear way to the surgeon allows both to partake in the shared responsibility of a detailed treatment plan. Many patients already take continuous progress photos throughout their recovery, and this in fact has served both as a record of their changes and also their journey towards their aesthetic goals. But for those that post their changes on their media pages, this may actually help to educate others as to the possibility and recovery patterns post surgery - something which my patients do find reassuring,” he opines.
      “The use of technology doesn’t change the principles by which we counsel patients, namely that a clear understanding of what can be achieved is paramount, and that we should only proceed if both surgeon and client are agreed on the positive changes that can be achieved.”
      Ultimately, cosmetic surgery can be enhanced and helped by correct use of social media imaging and filters in ways which would not have been imaginable even just a few years ago.
Dr. Yap looks forward to the next big development in personal tech, which he thinks may involve the use of handheld 3D viewing software, directly from the smartphone screen
      Dr. Yap looks forward to the next big development in personal tech, which he thinks may involve the use of handheld 3D viewing software, directly from the smartphone screen. He concludes, “This will create new forms of hyper-realistic imaging and assessment, but the drive towards better and safer patient management will continue, and we will always try to harness new technology for the betterment of our treatments, as we have always done.”

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