Body dysmorphic disorder among Lebanese females: A cross‐sectional study

Body dysmorphic disorder (BDD) is a mental health disorder characterized by an excessive preoccupation with perceived flaws or defects in one's appearance. This study aimed to assess the prevalence of BDD, identify the predictors of BDD, explore the associations of BDD with social anxiety and social phobia, and examine the effect of social media on BDD.

Body dysmorphic disorder (BDD) is a mental health disorder characterized by an excessive preoccupation with perceived flaws or defects in one's appearance, which are often imagined or exaggerated, and are typically accompanied by repetitive behaviors or mental acts in response to the preoccupation. 1 Individuals diagnosed with BDD often experience significant distress and impairment in their daily function. 2The appearance of the skin, hair, abdomen, and other facial features are among the body components that BDD may affect the most. 1,3e estimated prevalence for the general population diagnosed with BDD ranges from 2.4% to 8.8%. 4,5Although BDD affects both genders, several studies indicate that it is more common among females. 6[9] Based on a Literature review, risk factors including genetic, neurobiological, and environmental factors, childhood maltreatment, and comorbid psychiatric disorders were identified. 5BDD was linked to a higher risk of comorbid anxiety and depressive disorders. 2Additionally, childhood maltreatment and certain personality traits, such as perfectionism and neuroticism, were linked with an elevated risk of BDD. 10,11reover, BDD can be exacerbated due to the widespread use of social media. 12Social media platforms have become an omnipresent part of our life, where individuals use them to share their images and to contrast their appearance with others.This continuous exposure to idealized and highly curated images on social media can exacerbate the symptoms of individuals diagnosed with BDD and possibly contribute to its development. 12Additionally, social media can create an environment where people feel the need to continuously seek approval for their appearance, which can lead to an obsession with their supposed physical imperfections. 13D can have a significant negative impact on an individual's life, affecting their quality of life and impairing their ability to function socially, academically, and occupationally. 14Individuals with BDD may avoid social interactions due to their preoccupation with perceived flaws in their physical appearance, leading to social isolation and difficulties in forming close relationships. 14BDD can also impact an individual's career and academic pursuits, with negative effects on job performance and academic achievement. 14Furthermore, BDD can lead to debilitating symptoms such as shame, guilt, anxiety, depression, obsessive-compulsive disorder, substance misuse, and suicidal ideation. 2,15There are treatment options, such as cognitive-behavioral therapy, pharmacological treatments, and support from family and friends, which can effectively manage and improve the condition. 16,17However, the vast majority of individuals with BDD undergo cosmetic treatments. 17 Lebanon, there is limited research on the prevalence and impact of BDD, particularly among adult females.This knowledge gap highlights the need for a more in-depth understanding of the condition and its effects on Lebanese women.This study aimed to assess the prevalence of BDD among adult females, identify the predictors of BDD, its association with social anxiety and social phobia, and study the effect of social media on BDD as there remains a paucity of research in regard to social networking sites usage and BDD.

| Ethical approval
The institutional review board of the Lebanese International University approved this study (Ref:2023RC-005-LIUSOP).

| Procedure/setting
Through distinct social media networks, including WhatsApp, Facebook, and Instagram, the survey link was disseminated.A snowball sampling technique was employed and relied on the participation of the recipients of the survey link who were encouraged to forward the message to their network, including family, friends, and colleagues.The data collection phase of this cross-sectional study was conducted between January and March 2023, and it utilized an internet-based snowball sampling survey.

| Sample size
In a recent decision, the application of the simple equation n = 100 + 50 (i), where i represents the value of independent variables used in the logistic regression model, is recommended. 18r the statistical analysis, we predicted that a sample size of more than 500 would be sufficient because we assumed that the current study would include 10 covariates.

| Questionnaire
The data collection involved a self-administered questionnaire, which was originally drafted in English and afterward translated into Arabic by two qualified registered translators using a forwardbackward-forward translation method to ensure accuracy and clarity.To ensure the reliability of the questionnaire, a pilot study was conducted with nine selected participants, with different educational backgrounds.The questionnaire was developed using Google Forms and comprised eight sections.The first section of the survey consisted of a brief explanation of the purpose and objectives of the research to the participants, and they were reassured about the confidentiality of their data, which would only be accessible to the research team.
The second section gathered information about the participants' sociodemographic characteristics; age, height, weight, place of residence, marital status, educational level, occupation, and monthly family income.The third section included questions pertaining to the cosmetic interventions, in which the participants were asked to specify any cosmetic intervention, either for their face or body part, that they had undergone or intended to undergo.
[21] BDDQ is predicated on the DSM-5 criteria, which is a selfassessment diagnostic tool consisting of five closed-ended questions. 1 Participants were inquired about their level of concern regarding the appearance of one or more parts of their body and if these thoughts preoccupy them.A positive response to the first two questions and at least one part of the third question, which assessed the level of distress and impairment caused by the excessive focus on appearance, was necessary to diagnose BDD.The fourth question assesses the average time spent thinking about the perceived defect, with alternates of less than 1 h, 1-3 h, or more than 3 h/day.A diagnosis of BDD requires a positive response to the first three questions and spending 1-3 h or more per day thinking about their perceived defect, as indicated on the fourth question.The final question serves the purpose of excluding individuals whose primary concern is not being thin enough in order to prevent an incorrect diagnosis of BDD when an eating disorder may be the actual diagnosis.The BDDQ was scored on a scale of 0-4, with a score of 4 representing a positive BDD screening. 19,22,23ven the persistent rise of social media usage, there is a noticeable lack of direct inquiry into social media practices within existing BDD scales.The incorporating of social media questions in BDD scales is a 12 closed-ended self-assessment questionnaire, divided into three tools, which address this gap.The screening tool includes questions related to the impact of social media on a person's stress, avoidance, camouflage, and intervention behaviors. 20The score ranged from 0 to 12, with higher scores indicating a higher impact of social media (negative behavior in social media).Three questions were inversely calculated (yes = 0, no = 1); statements related to coping with anxiety.
The SPS-6 consists of six items taken from the 20-item SPS, including items 4, 7, 8, 15, 16, and 17.The 12-item two-factor model is a selfreport questionnaire created to evaluate and quantify two related dimensions of social anxiety and fear through self-rating on a 5-point Likert scale, ranging from "0 = Not at all characteristic or true of me" to "4 = Extremely characteristic or true of me".The SIAS-6 and SPS-6 both use a total score that is obtained by summing the responses to all 6 items, with a range of 0-24 for each scale.When combined, the two scales yield a total score range of 0-48.The higher the score, the more serious the degree of social anxiety, and phobia.

| RE SULTS
In this cross-sectional study, 1048 individuals agreed to participate and completed the questionnaire.The mean age of the respondents was (29.94 ± 10.01 years), 644 (61.5%) were living in rural regions, 554 (52.9%) were unmarried, 821 (78.3%) held university degrees, and 323 (30.8%) were employed.The sociodemographic characteristics of the participants are shown in Table 1.
Table 2 shows the prevalence and criteria of BDD among participants.It was shown that 141 (13.5%) female participants were diagnosed with BDD.A significant number of participants, 571 (54.5%), expressed concerns about the appearance of certain body parts.Furthermore, a substantial proportion of respondents, 718 (68.5%), reported avoiding certain activities due to concerns about their physical appearance.However, 533 (50.9%) of those who were concerned about their physical appearance had a primary concern with being not thin enough or becoming fat, indicating the presence of an eating disorder rather than BDD.Table 3 presents the body parts of concern among participants with BDD, with the upper body region, including the abdomen (waist), being the primary source of concern for 97 (68.8%) individuals, followed by the hips 70 (49.6%)and the skin 51 (36.2%).The most prevalent facial cosmetic procedures, the participants either performed or desired, included Facial Skin Care (21.02%),Teeth (19.54%),Rhinoplasty (14.09%), and Filler/Botox (10.56%), as depicted in Figure 1.Conversely, the most popular body cosmetic treatments that the majority have already undergone or expressed interest in were Lipomassage by Endermologie (LPG) (13.62%), cellulite Reduction (12.52%),Far Infrared Rays (FIR) (11.83%), and Fat Dissolving Injections (10.13%), as shown in Figure 2.
The incorporation of social media scores in BDD was explored through a set of questions presented in Table 4.The results showed that the mean Social Media score was (3.66 ± 2.60), with a significant proportion of participants expressing a preference for a "filtered look" in their pictures 352 (33.6%), with 326 (31.1%) reporting that they edit their images before posting them.Additionally, 316 (30.2%) participants compared their unfiltered pictures to the filtered ones available on social media platforms.
The mean SIAS/SPS score was (8.76 ± 10.37) and 592 (56.5%) responders did not find it difficult to make eye contact while 690 (65.8%) participants did not find it troubling to talk to others.However, 264 (25.2%) women slightly believe that they get nervous when people are staring at them.Furthermore, 241 (23%) of them worry that they will do something embarrassing which will attract people's attention and 239 (22.8%) believe that being in an elevator with people makes them nervous.

| DISCUSS ION
In Lebanon, there is limited research on the prevalence and impact of BDD, particularly among adult females.For this reason, this study was conducted to gain an in-depth understanding of BDD in Lebanon; we aimed to assess the prevalence of BDD among adult females, identify the predictors of BDD, explore the associations of BDD with social anxiety and social phobia, and to examine the effect of social media on BDD.
In contrast to the estimated prevalence rate of 2.2% in adolescents globally, our study found a significantly higher prevalence rate of 13.5% among Lebanese adult females. 24However, prevalence rates reported in different countries have varied considerably.For instance, previous research conducted in Makkah City, Saudi Arabia found a prevalence rate of 7.1%. 25Conversely, other studies found prevalence rates of 1.7%, 2.4%, and 6.3% in Germany, the United States, and Turkey, respectively. 4,26,27These varying prevalence rates may be attributed to differences in diagnostic criteria, cultural and social factors, and study designs.Moreover, it may be explained by the excessive use of social media post-COVID-19 and its detrimental effects on body image. 28,29[32] F I G U R E 1 Cosmetic interventions for the face (%).Other: keratopigmentation; face lift.Can you cope with your anxiety before posting images on social media?a 326 (31.1) 722 (68.9) Can you cope with your anxiety when not using camouflage options such as filters and makeup in your photos in social media?The heavy use of social media, together with its negative impact on body image, may explain the higher rates of BDD in the current study compared with the general population worldwide. 7In a study conducted in Jeddah, Saudi Arabia, it was found that the majority of participants with BDD expressed significant concerns regarding their skin (81.6%) and waist (68.8%), 22 whereas in our study, a substantial proportion of participants 54.5% expressed dissatisfaction with their body appearance and expressed concerns related to this matter, with the primary area of concern being the abdomen (waist) 68.8%, followed by the hips as the second-highest physical preoccupation, and then the skin.Similarly, a study conducted in the United States also reported that 20% of individuals with BDD were concerned about their abdomen. 4The constant concern about their appearance and body can stem from society's unachievable beauty standards that teach girls from a young age to hate their bodies and criticize it. 13 our study, we aimed to investigate the association between BDD and social anxiety among adult females.Our findings shed light on the significant association between BDD and social anxiety, which has been reported in previous studies. 33Social anxiety includes difficulties in initiating conversations and a persistent fear of being negatively evaluated by others. 21,33 B L E 6 Bivariate and logistic regression analysis to identify factors associated with body dysmorphic disorder (BDD) score.These features contribute to the heightened anxiety levels experienced by individuals with BDD, leading to substantial challenges in their overall quality of life. 34Furthermore, BDD is characterized by pervasive self-conscious thoughts that exacerbate social anxiety symptoms, prompting individuals to avoid social situations and interactions actively. 22This avoidance behavior serves as a coping mechanism for their insecurities and reinforces the negative impact of BDD on their social functioning. 14r study has notable limitations that should be considered when interpreting its findings.First, it does not include the experiences, views, and opinions of young adult women and teenagers, who may be at a higher risk for developing BDD due to societal pressures around body image.As a result, the prevalence and nature of BDD among this population may not be fully captured in our results.Second, the study relied on self-reported data, which may be subject to information bias and may not accurately reflect participants' experiences or attitudes.
BDD diagnosis in this study is based on self-reported symptoms without a psychiatrist's examination, which may lead to underestimation or overestimation of the number of individuals with this disorder at a certain point.Finally, it should be noted that certain assessment scales used for BDD, including the BDDQ, have not undergone validation in Lebanon.Moreover, we adopted the snowball sampling strategy which was not based on a random selection of the sample, and the findings did not represent all the Lebanese population and therefore our findings cannot be generalized.Despite these limitations, our study provides important insights into the prevalence and predictors of BDD among adult females in Lebanon.However, future research is needed to investigate BDD in younger age groups and to gather more objective data to complement self-reports.By addressing these limitations, future studies can build on the findings of our study and contribute to a more comprehensive understanding of BDD in Lebanon and beyond.

| CON CLUS ION
The present study provides important insights into the multifaceted nature of BDD among Lebanese adult females, identifying significant associations between BDD and various factors, such as living in urban areas, being unmarried, social media use, and having social phobia and social anxiety.In our study, the prevalence of BDD (13.5%) was higher compared to other regions.These findings underscore the complex interplay of social and psychological factors in the development of BDD, highlighting the need for a comprehensive and integrated approach in its assessment, prevention, and treatment.Moreover, it highlights the need for the development of preventive measures that address the negative impacts of social media on the well-being of affected individuals and promote a healthy body image.

AUTH O R CO NTR I B UTI O N S
Bahia Chahine contributed to the conception of the study, analyzing all data, and the critical revision of the paper.Aya Berjaoui contributed to data collection and writing the first draft of the paper.

A
web-based cross-sectional online study was conducted from January to March 2023 using snowball technique among adult females throughout the entirety of the Lebanese region (Beirut, Mount Lebanon [Urban], North, Akkar, Beqaa, Baalbek-Hermel, South, and Nabatieh [Rural]).Inclusion criteria were Lebanese females, aged 18-60 years, with internet access.

2. 6 |
Statistical methods/data analysisThe respondents' sociodemographic characteristics were analyzed through a descriptive analysis.The Student's t test was applied to analyze continuous variables, which were presented as means and standard deviations (SD).Categorical variables, on the other hand, were analyzed using the Chi-square test and were presented as frequencies and percentages, to identify the demographic and clinical variables associated with the BDD score.In the logistic regression model, variables that showed a p-value of <0.2 were taken into consideration.Multivariable logistic regression was performed to identify the independent variables that retained a significant association with the BDD.The regression model included a series of sociodemographic variables and scores as independent variables, with the BDD diagnosis as the dependent variable.The measure of association was represented by the adjusted odds ratio (aOR) with a 95% confidence interval (CI), and the Nagelkerke R 2 was 0.426.Statistical significance was considered at p < 0.05.The data collected from the survey was analyzed using the Statistical Package for the Social Sciences (SPSS), version 26.

12 TA B L E 4 1 )
Moreover, image-based social media platforms can put pressure on women to achieve unrealistic body images, where a significant proportion of our study participants, 353 (33.6%) reporting using filtered images and 316 (30.2%) comparing their unfiltered pictures to filtered ones found on social media.These findings support the notion that social media encourages women to compare their natural and unfiltered looks to edited and filtered ones, setting unrealistic beauty standards that influence and convince young adults and adolescents to follow them, which contributes to the development of BDD.Incorporating social media questions in body dysmorphic disorder scales.Do you find that your images need a "filtered look" in social media most of the time?696 (66.4) 352 (33.6)Are you influenced by comments on your appearance on social media?828 (79.0) 220 (21.0)Do you compare your unfiltered photos with filtered photos you see on social media?732 (69.8) 316 (30.2) Do you change your makeup and/or hairstyle before posting your photos on social media?747 (71.3) 301 (28.7)Have you sought cosmetic procedures before posting your photos on social media?938 (89.5) 110(10.5)

Table 5
If the previous question is yes, do these concerns preoccupy you?That is, do you think about them a lot and wish you could think about them less?
shows SIAS/ SPS scale results.TA B L E 1 Sociodemographic characteristics of participants.Characteristics (N = 1048) Number of subjects (%) Age in years (mean ± SD) 29.94 ± 10.01 Monthly family income in Lebanese pounds (LBP) TA B L E 2 Prevalence and criteria of body dysmorphic disorder (BDD) among included participants (N = 1048).Criteria Number of subjects (%)1.Are you concerned about the appearance of some part(s) of your body that you consider especially unattractive?aOtherparts:mouth,jaw, inner thighs, teeth.Participants' sociodemographic characteristics associated with BDD score are shown in Table6.The bivariate analysis demonstrated significant associations between BDD and factors such as BMI (p < 0.001), place of residence (p < 0.001), marital status (p = 0.003), Can you cope with your anxiety when not reaching a hairdresser or cosmetic clinic before posting your photos on social media?a a Those three questions were inversely calculated (yes = 0, no = 1).TA B L E 5 Social Interaction Anxiety Scale (SIAS) and Social Phobia Scale (SPS).

Criteria Bivariate analysis Multivariable logistic regression analysis BDD score = 0 (n = 907) (n, %) BDD score = 1 (n = 141) (n, %) p Value OR (95% CI) p Value
Note: BDD score was entered as the dependent variable in this model.The multivariate analysis included all variables that had a value of p ≤ 0.05 in the bivariate analysis.