Clinical Context

Body dysmorphic disorder occurs in approximately 2% of adolescents and adults and is associated with a high risk for serious pathology such as eating disorders, substance use disorders, and mood disorders. Yet many individuals with body dysmorphic disorder go unrecognized in clinical practice, and this is particularly important in the pediatric population, as the traits of body dysmorphic disorder are often first manifest during childhood.

To promote greater recognition of characteristics of body dysmorphic disorders among adolescents, Rautio and colleagues assessed a cohort of 172 young people referred to 2 specialty centers in Europe. This study was published in the January 2022 issue of European Child and Adolescent Psychiatry.^[1]

A total of 79.1% of the cohort was female and 2.3% were transgender. In general, the symptoms of body dysmorphic disorder were moderate to severe, and the majority of the cohort had poor or absent insight into their pathology or delusional beliefs. A total of 71.5% had psychiatric comorbidity, 52.1% had a history of current or past self harm, 53.7% wanted cosmetic procedures, and nearly one third had dropped out of school. Overall, female gender was associated with greater severity compared with male gender.

An emerging risk factor for body dysmorphic disorder is the use of social media. However, there is little evidence as to whether limiting social media is associated with improved body image outcomes.

Study Synopsis and Perspective

From movies to billboards to magazine covers, media have been pushing impossible beauty ideals for decades. But the recent rise of social media brings that exposure to new levels, particularly for young people.

“Youth spend, on average, between 6 and 8 hours per day on screens, much of it on social media,” says senior study author Gary S. Goldfield, PhD, senior scientist at Children’s Hospital of Eastern Ontario Research Institute in Ottawa, Canada. “Social media provides exposure to so many photo-edited pictures, including those of models, celebrities, and fitness instructors, that perpetuate an unattainable beauty standard that gets internalized by impressionable youth and young adults, leading to body dissatisfaction.”

Plenty of research has linked frequent social media use to body image issues and even eating disorders.^[2] But crucial gaps in our knowledge remain, Dr Goldfield says.

Much of that research “is correlational,” Dr Goldfield adds. And studies do not always focus on individuals who may be more vulnerable to social media’s harmful effects, such as those with ruminative or brooding cognitive styles, affecting results.

In addition, no studies have explored an obvious question: Can cutting down on social media use also diminish its potential harms?

Dr Goldfield and colleagues found an answer: Yes, it can.

Limiting social media use to 1 hour per day helped older teenagers and young adults feel much better about their weight and appearance after only 3 weeks, according to the study, published in Psychology of Popular Media, a journal of the American Psychological Association.

“Our randomized controlled design allowed us to show a stronger causal link between social media use and body image in youth, compared to previous research,” Dr Goldfield says. “To our knowledge, this is the first study to show that social media use reduction leads to enhanced body image.”

Nancy Lee Zucker, PhD, professor of psychology and neuroscience at Duke University, Durham, North Carolina, and director of the Duke Center for Eating Disorders, says the results provide needed data that could help guide young people and parents on optimal social media use. Dr Zucker was not involved in the study.

What the Researchers Did

For the study, Dr Goldfield and colleagues recruited undergraduate psychology students aged 17-25 years who averaged at least 2 hours per day of social media use on smartphones and who had symptoms of depression or anxiety.

Participants were not told the purpose of the study, and their social media use was monitored by a screen time tracking program. At the beginning and end of the study they answered questions such as “I’m pretty happy about the way I look,” and “I am satisfied with my weight,” on a 1 (never) to 5 (always) Likert scale.

During the first week all 220 participants (76% female, 23% male, and 1% other) were told to use social media on their smartphones as they usually do. During the next 3 weeks 117 students were told to limit their social media use to 1 hour per day, whereas the rest of the participants were instructed to carry on as usual. In both groups more than 70% of participants were between ages 17 and 19 years. 

The first group cut their social media use by about 50%, going from a mean of around 168 minutes per day during week 1 to around 78 minutes per day by the end of week 4, whereas the unrestricted group went from around 181 minutes per day to 189 minutes.

Cutting Use by Around Half Yielded Quick, Significant Improvements

The students who curbed their social media use saw significant improvements in their “appearance esteem” (from 2.95 to 3.15 points; P<.001) and their “weight esteem” (from 3.16 to 3.32 points; P<.001), whereas those who used social media freely saw no such changes (from 2.72 to 2.76 [P=.992] and 3.01 to 3.02 [P=.654], respectively). No gender differences between the groups were found.

The researchers are now studying possible reasons for these findings.

The changes in appearance scores “represent a small- to medium-effect size,” said child psychologist Sara R. Gould, PhD, director of the Eating Disorders Center at Children’s Mercy Kansas City in Missouri, who was not associated with the research. “As such, these are clinically meaningful results, particularly since they were achieved in only 3 weeks. Even small impacts can be added to other changes to create larger impacts or have the potential to grow over time.”

The Push to Limit Social Media

As more and more experts scrutinize the effect of social media on young people’s mental health, social media companies have responded with features designed to limit the time young users spend on their platforms.

Just this year a photo-sharing app rolled out “quiet mode,” which lets users shut down their direct messages for a specified amount of time. To turn on quiet mode, a user can navigate to their profile, select the triple line icon and then “settings,” “notifications,” and “quiet mode.” Another option is to tap the triple line icon, “your activity,” and “time spent” to set reminders to take breaks after 10, 20, or 30 minutes of use.

Video-sharing app users younger than 18 will soon have their accounts defaulted to a 1-hour daily screen-time limit. Unlike other similar features, it will require users to turn it off rather than turn it on.

Leveraging built-in controls is “a good start to being more intentional about your screen time,” suggests lead author Helen Thai, a PhD student in clinical psychology at McGill University in Montreal, Canada. “Unfortunately, users can easily bypass these settings.”

One reason for social’s magnetic pull is that “FOMO--fear of missing out on what friends are doing--can make cutting back on social media use difficult,” says Dr Zucker. To help prevent FOMO, parents may consider talking to parents of their children’s friends about reducing usage for all the children, Dr Zucker suggests.

Mary E. Romano, MD, MPH, associate professor of pediatrics-adolescent medicine at Vanderbilt University School of Medicine in Nashville, Tennessee, urges parents “to have very clear rules and expectations about social media use.” 

Dr Romano, who was also not involved in the study, recommends the website Wait Until 8th to help parents band together to commit to delaying smartphone access until at least eighth grade.

Dr Gould recommends the Family Media Plan, a tool from the American Academy of Pediatrics that lets users create a customized plan, complete with guidance tailored to each person’s age and the family’s goals. Sample tips include designating a basket for holding devices during meals and switching to audiobooks or relaxing music instead of videos to fall asleep at night.

Psychol Popular Media. Published online ahead of print 2023.

Clinical Implications

• In a previous study of adolescents with body dysmorphic disorders seen in specialized centers, 79% of the cohort was female. Overall, female gender was associated with greater severity compared with male gender. The majority of the cohort had poor or absent insight into their pathology or delusional beliefs. A total of 71.5% had psychiatric comorbidity and 52.1% had a history of current or past self-harm.
• The current study finds that a 3-week intervention to reduce social media use among university students resulted in reduced screen time and improvements in appearance and weight esteem, with similar results for women and men.
• The healthcare team should provide support for adolescents and young adults to limit social media use.

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