Dincolo de oglindă: percepția imaginii corporale în era digitală la studenți

Introduction

Body dysmorphic disorder (BDD) is a rising psychiatric condition characterized by excessive, intrusive and persistent concerns with perceived defects in physical appearance, which are often unobservable to others or minor, but perceived by the patient as real and causing significant distress and functional impairment⁽¹⁾. These concerns are often accompanied by repetitive behavioral changes, such as mirror checking, excessive grooming or seeking reassurance and mental acts such as comparison to others⁽²⁾.

Beyond its main diagnostic features, body dysmorphic disorder is increasingly recognized as a severe and often chronic condition associated with substantial psychiatric comorbidity. Studies indicate high rates of co-occurring psychiatric disorders, including major depressive disorder, social anxiety disorder, substance-use disorder and obsessive-compulsive disorder^(3-6).Furthermore, body dysmorphic disorder was strongly associated with suicide, with research indicating that a substantial proportion of afflicted patients experience suicidal ideation and an increased risk of suicide attempts compared with the general population⁽⁷⁾. These findings highlight the clinical severity of the disorder and the importance of early identification and intervention, particularly in vulnerable populations such as students.

From a biopsychosocial perspective, body dysmorphic disorder is understood as a multifactorial disorder arising from the interaction of biological vulnerability, maladaptive cognitive processes and sociocultural influences⁽⁸⁾. Neurobiological studies suggest the involvement of serotonergic dysregulation and abnormalities in visual information processing, particularly a bias toward detail-oriented perception which may contribute to the distorted evaluation of appearance^(8-10). At the psychological level, patients with BDD present cognitive distortions such as overestimation of perceived defects and flaws and excessive reliance on appearance for self-worth often accompanied by intense feelings of shame, anxiety and low self-esteem⁽⁸⁾.

In recent years, the sociocultural context in which body image develops has undergone significant transformation. The rapid expansion and evolution of digital media and social networking, as well as the convenient access to online platforms have reshaped the way individuals perceive themselves and others^(11,12). Social media platforms promote idealized and frequently edited standards of appearance, reinforcing unrealistic beauty standards and facilitating constant social comparison⁽¹³⁾. This exposure has been shown to increase body dissatisfaction, lower self-esteem and contribute to the development and maintenance of dysmorphophobia symptoms⁽¹⁴⁾.

Students represent a vulnerable population given this context. The transition to university life is characterized by identity formation, increased autonomy and exposure to multiple stressors, including academic pressure, social expectations and, in some cases, financial challenges. Furthermore, epidemiological studies indicate that the onset of many mental health disorders occurs during late adolescence and early adulthood, making this population susceptible to the development of body image disturbances^(15,16).

From an ethical perspective, body dysmorphic disorder presents important challenges in clinical practice. Patients with BDD frequently desire and undergo certain esthetic procedures, but in most cases the esthetic interventions do not solve the underlying psychopathology and can also exacerbate symptoms in severe cases^(17,18). This aspect may raise concerns related to beneficence and non-maleficence ethical principles, requiring physicians to balance the respect for patient’s autonomy with the responsibility to prevent harm. Current recommendations highlight the importance of screening for BDD and referring patients to appropriate mental health services⁽¹⁹⁾.

Given the increasing relevance of body image disturbances in the digital era and the vulnerability of the student population, the present study aims to provide a comprehensive analysis of body dysmorphic disorder among students. By integrating current scientific evidence with findings from a cross-sectional observational study, the research seeks to explore the complex interaction between biological, psychological and sociocultural factors, as well as the ethical challenges associated with the management of this condition.

Materials and method

Participants and procedure

The study followed a cross-sectional observational design, and it was conducted on a group of 100 Romanian students through an anonymous online questionnaire consisting of 40 closed-ended questions, grouped into six categories. The questionnaire was distributed online using Google Forms, and targeted students aged 18-30 enrolled in various university programs.

The inclusion criteria were: student status, age between 18 and 30, and fully completed questionnaire. The participants who did not meet the age criteria or provided incomplete responses were excluded from the analysis. The sample was based on voluntary participation.

The questionnaire was disseminated through social media platforms and student groups and targeting participants who met the inclusion criteria. All participants were informed about the purpose, as well as the objectives of the study prior to completing the questionnaire. Participation was voluntary and anonymous, and no personal identifying data were collected. Data confidentiality was ensured throughout the study. The study was approved by the Ethics Committee of Scientific Research of the “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, Târgu Mureș, Romania (approval no. 3417/21.11.2024).

Questionnaire

The questionnaire consisted of 40 closed-ended questions, structured into six main sections designed to assess the biopsychosocial and ethical dimensions associated with body dysmorphic disorder among students.

The first section (questions 1-6) included demographic characteristics such as age, gender, height, weight, residence and academic field. The second section (questions 7-22) assessed body image perception, the level of awareness regarding BDD, attitudes toward body modification and esthetic interventions and opinions regarding the accessibility and ethical implications of esthetic procedures among young populations. The third section (questions 23-26) examined social influences, focusing on the impact of social media beauty standards, perceived social pressure and marginalization. The fourth section of questions (27-30) evaluated psychological factors, including anxiety and stress related to appearance, avoidance behaviors, difficulty in self-perception and emotional responses to external feedback such as compliments. The fifth section (questions 31-34) investigated academic and institutional factors, including the impact of academic stress on body image and the perceived pressure within the academic environment. The last section of questions (35-40) referred to the accessibility to psychological counseling services, willingness to seek help, perceived barriers (stigma, accessibility) and attitudes toward mental health promotion initiatives within university settings.

Data analysis

The statistical analysis was performed using Python (version 3.12). Descriptive statistics were used to summarize the study population and questionnaire responses with categorical variables expressed as frequencies and percentages.

Nonparametric tests were applied for inferential analysis. The Mann-Whitney U test was used to compare differences between two independent groups, while the Kruskal-Wallis test was used for comparisons across multiple groups. Associations between categorical variables were assessed using the Chi-square test. Spearman’s rank correlation coefficient (ρ) was used to evaluate the relationships between ordinal variables. A p-value <0.05 was considered statistically significant. All statistical tests were two-tailed.

Results

Demographic (Table 1A) and anthropometric (Table 1B) characteristics of the studied sample indicated that the majority (63%) of the included students were aged 18-24 years old, while 37% of respondents were between 25 and 30 years old. Regarding gender distribution, 67% were female, and only 33% of the participants were male.

Most participants (68%) originated from urban areas, while 32% were from rural environments. In terms of academic background, 75% of respondents were enrolled in General Medicine, followed by General Nursing (8%) and Dentistry (5%), while other faculties had minimal representation (1-2%). Height distribution showed that most of the participants (41%) were between 1.65 and 1.75 m, 31% were below 1.65 m, and 28% were above 1.75 m. Body weight ranged between 42 and 160 kg, with a mean of 70.2 kg and a median of 65.6 kg.

The perception of body image among respondents appears predominantly positive; however, it was accompanied by a notable prevalence of concerns related to physical appearance. Most participants (88%) rated their overall body image within the moderate-to-high range (scores 3-5) indicating a generally satisfactory perception. A similar pattern was observed for height perception with 91% of respondents reporting scores ≥3, while weight perception showed slightly lower levels of satisfaction (74% scores ≥3).

Despite these favorable self-assessments, indicators of psychological vulnerability were evident. More than half of the respondents (58%) reported experiencing obsessive thoughts related to their height or weight, and a substantial proportion (73%) expressed intense dissatisfaction with specific body parts.

Social comparison behaviors were also common, with 51% of participants reporting that they occasionally compared their physical appearance to others and, in addition, 19% doing so frequently. A moderate-to-high desire to modify body image was reported by 66% of respondents. The primary motivations identified were health-related factors, social media influence and social pressure. In terms of preferred strategies for body image modification, noninvasive approaches were predominant, particularly physical exercise (47.1%) and dietary changes (39.7%). Esthetic procedures were less frequently considered (7.4%).

Openness toward esthetic procedures remains considerable, as approximately 73% of respondents did not exclude the possibility of undergoing such procedures. In this context, the majority supported the need for psychological evaluation prior to esthetic procedures, with 48% considering it mandatory and 38% recommending it in selected cases. Overall, 80% of respondents anticipated a positive impact from improving their body image.

The influence of social media on body image perception was reported as moderate to high by the majority of respondents (63%), and 34% of the participants experienced social marginalization caused by physical appearance. Behavioral adaptation to social media standards was common, 70% of the respondents attempted to modify physical appearance in order to conform to beauty standards promoted online.

Body image-related psychological distress was frequently reported, 85% of respondents experiencing anxiety or stress. Behavioral avoidance was prominent, as 73% reported concealing parts of their body. Additionally, 39% experienced difficulty with mirror exposure, while 61% reported distrust in appearance-related compliments.

Academic-related factors (Table 3) indicated a notable influence on body image perception. A high percentage of the studied population (73%) reported experiencing pressure to conform to a certain physical appearance within the academic environment. Regarding sources of this pressure, social media was identified as the primary source (56.2%).

Access to psychological counseling related to body image was limited (11% reported prior use). Perceived availability was also low (45% of the respondents were unaware of or had never used counseling services). Despite these results, interest in accessing psychological support was high (68%). The most frequently reported barriers in accessing psychological counseling and support are presented in Table 3.

Associations between sociodemographic variables, perceived social influences, body image perceptions and attitudes toward mental health and esthetic procedures were examined using Chi-square tests, Mann-Whitney U tests, Kruskal-Wallis tests and Spearman correlation coefficients, as appropriate. Statistically significant associations (p<0.05) identified in the study are presented in Table 4.

No statistically significant associations were identified between gender and the presence of obsessive thoughts related to body weight or height (χ²=0.076; p=0.783), nor between gender and dissatisfaction with specific body parts (χ²=0.080; p=0.777). Similarly, no significant differences were observed between males and females regarding self-perceived body weight evaluation (Mann-Whitney U=994.5; p=0.403), with comparable mean scores (females: 3.18; males: 3.39) and identical medians (3).

The area of residence (urban versus rural) was not significantly associated with the intention to undergo esthetic procedures (χ²=9.146; p=0.058), although the result approached the threshold of statistical significance. In addition, no significant differences were observed between urban and rural participants regarding the perceived influence of social media on body image (Mann-Whitney U=879.5; p=0.112).

A statistically significant positive correlation was identified between the perceived influence of social media and the frequency of comparing one’s physical appearance with others (Spearman ρ=0.329; p=0.001), indicating that individuals reporting stronger social media influence tend to engage more frequently in appearance-based comparisons.

However, no significant correlations were found between perceived social media influence and satisfaction with height (ρ = -0.046; p=0.652) or weight (ρ = -0.082; p=0.419).

Regarding access to psychological services, no significant differences were observed in stigma perception between individuals who had accessed such services and those who had not (Mann-Whitney U=523; p=0.700; mean scores: 2.91 versus 2.74; median=3 in both groups). Similarly, perceived accessibility of psychological services was not significantly correlated with stigma-related decision-making regarding help-seeking (ρ=0.066; p=0.634), and no differences were identified between individuals interested versus uninterested in psychological counseling (Mann-Whitney U=1062.5; p=0.845).

Stigma scores differed significantly depending on perceived barriers to accessing psychological services (Kruskal-Wallis H=14.26; p=0.0065), with the highest levels observed among participants reporting fear of stigmatization and lack of perceived confidentiality. In contrast, no significant differences in stigma perception were found based on attitudes toward university mental health initiatives (Kruskal-Wallis H=3.10; p=0.212).

No statistically significant associations were identified between opinions regarding the availability of esthetic procedures and the perceived necessity of prior psychological evaluation (χ²=9.81; p=0.366), nor between support for esthetic procedures in young individuals and perceptions of physicians’ ethical responsibility in evaluating such interventions (χ²=7.16; p=0.621).

In contrast, a statistically significant association was observed between the motivations for changing body image and the tendency to conform to beauty standards promoted on social media (χ²=9.78; p=0.020), with higher conformity reported among individuals citing social media ideals and social pressure as primary motivations.

Finally, strong associations were identified between appearance-related anxiety and avoidant behaviors. Specifically, higher levels of anxiety related to physical appearance were significantly associated with the tendency to hide certain body parts (χ²=21.857; p=0.0002) and with difficulty looking at oneself in the mirror (χ²=21.693; p=0.0002), indicating a consistent pattern of avoidance behaviors associated with increasing anxiety levels.

Discussion

The present study highlights the complex and multidimensional nature of body image perception among young adults, where a generally positive global self-image can coexist with significant body-related concerns. This apparent inconsistency aligns with current literature, which emphasizes that body image includes both cognitive evaluation and emotional distress components that may not always overlap^(20,21). Although most respondents reported moderate-to-high satisfaction with their overall body image, 58% described obsessive thoughts related to height or weight, and 73% reported intense dissatisfaction with specific body parts.

This dissociation between global body satisfaction and focal body-related preoccupation is clinically relevant, as body dysmorphic disorder is characterized not only by global dissatisfaction, but also by persistent preoccupation with perceived defects and repetitive or avoidant behaviors^(8,21).

The results indicating no statistically significant sex differences in body image evaluation, height and weight perception or in the presence of obsessive thoughts related to height or weight are noteworthy. There is evidence in literature suggesting gender-related differences in the prevalence of BDD, with studies reporting higher rates in female population, while others indicate comparable prevalence or gender-specific symptom patterns^(22-25). This heterogeneity may be explained by methodological differences, sociocultural factors and the increasing influence of digital environments on body image concerns across both sexes.

Given the limited and inconsistent evidence regarding environmental differences (rural versus urban) in body image perception, the findings of the present study suggest that such perceptions may be relatively stable across residential context, potentially reflecting the increasing influence of globalized media environments. The near-significant trend regarding the association between the area of residence and the intention to undergo esthetic procedures suggests a potential influence of contextual factors such as access and cultural norms, warranting further investigation.

The study did not identify statistically significant associations between opinions regarding the availability of esthetic procedures and the perceived necessity of prior psychological evaluation, nor between support for esthetic procedures and perceptions of physicians’ ethical responsibility. These findings may suggest that attitudes toward esthetic interventions and perceptions of medical responsibility may function as relatively independent characteristics within young populations. Additionally, it may reflect limited awareness regarding the role of psychological evaluation in esthetic practice, despite growing evidence highlighting its importance⁽²⁶⁾. Studies highlight that preprocedural psychological screening is essential in preventing unfavorable outcomes and identifying vulnerable individuals⁽²⁶⁾. Furthermore, the findings may also be interpreted in the context of normalization of esthetic procedures among young individuals, where such interventions are no longer perceived as strictly medical interventions requiring ethical scrutiny, but rather as accessible lifestyle choices. This aspect has been documented in literature, which suggests that increasing exposure to esthetic content on social media contributes to the perception of these procedures as routine and socially acceptable⁽²⁷⁾.

A key finding of this study is the role of social comparison in the relationship between social media exposure and body image-related behaviors. The significant association between perceived social media influence and appearance-based comparison (ρ=0.329; p=0.001) supports evidence that social media affects body image through comparison mechanisms. A recent meta-analysis demonstrated that social comparison on social media is significantly associated with body image concerns and disordered eating behaviors⁽²⁸⁾.

Importantly, no direct association was observed between social media influence and satisfaction with height or weight. This finding may support evidence suggesting that the impact of social media on body image perception is mediated by psychological processes such as internalization of appearance ideals and comparison processes⁽²⁹⁾.

The high prevalence of behavioral adaptation (70%) and perceived pressure to conform to beauty standards further supports the influence of sociocultural factors. The significant association between motivations for body image change and conformity to beauty standards (χ²=9.78; p=0.020) is consistent with findings that internalization of socially promoted appearance ideals predicts appearance-modifying behaviors⁽³⁰⁾.

Psychological distress was highly prevalent in the study population, with most participants reporting anxiety or stress related to physical appearance (85%). The strong associations identified between anxiety and avoidance behaviors such as body concealment (χ²=21.857; p=0.0002) and mirror avoidance (χ²=21.693; p=0.0002) are consistent with cognitive-behavioral models of body image disturbance which describe avoidance and safety behaviors as key mechanisms maintaining distress and negative self-perception⁽³¹.⁾ These behaviors are considered core maintaining factors in body image-related psychopathology⁽³²⁾.

Despite the high level of distress and interest in psychological support (68%), the utilization of counseling services was low (11%). This discrepancy between need and access has been widely reported, and structural barriers such as lack of information and service accessibility were suggested to be major determinants of help-seeking behavior^(33,34).

In the present study, stigma did not significantly differentiate individuals who accessed psychological services from those who did not. However, stigma levels varied significantly depending on perceived barriers, particularly in relation to fear of stigmatization and concerns about confidentiality. The results also indicate that the availability of mental health initiatives alone may be insufficient to reduce stigma. These findings suggest that stigma does not operate as a uniform barrier, but rather interacts with contextual factors such as perceived safety and accessibility of services⁽³⁵⁾.

The academic environment also contributed to body image-related pressure, with a majority of participants (72%) reporting expectations to conform to physical appearance standards. Social media was identified as the primary source of this pressure (56.2%), supporting evidence that digital environments amplify social comparison and reinforce appearance-related norms among young adults⁽³⁶⁾.

Conclusions

This study highlights that body image perception among students represents a complex and multidimensional concept, in which a generally positive self-evaluation coexists with significant psychological distress. Despite relatively favorable overall body image scores, a high prevalence of appearance-related anxiety, dissatisfaction with specific body parts and maladaptive behaviors were identified.

Social media emerged as a key contributor influencing body image-related processes, and was significantly associated with increased appearance-based comparison and conformity to externally imposed beauty standards. Importantly, its impact appears to be mediated by cognitive mechanisms rather than directly affecting satisfaction with specific physical attributes such as height or weight.

The findings also underline the central role of anxiety in shaping maladaptive behavioral patterns, particularly avoidance strategies such as body concealment and mirror avoidance which are known maintaining factors in body image disturbances.

From a clinical and ethical perspective, the study reveals a discrepancy between the high level of psychological distress and the low utilization of mental health services, highlighting the influence of perceived barriers especially stigma and concerns about confidentiality.

Overall, the results emphasize the need for early identification strategies, psychoeducational interventions and improvement in access to mental health services in student populations. In addition, the results support the importance of integrating psychological assessment into the management of body image concerns and esthetic interventions, particularly in the context of increasing sociocultural pressure mediated by digital environments.

Limitations

The present study has several limitations that should be considered when interpreting the results. Firstly, the cross-sectional design does not allow causal inferences regarding the relationships identified between social media influence, psychological factors and body image perception.

Secondly, the sample size was relatively limited (n=100) and predominantly composed of medical students, which may restrict the generalizability of the findings to broader populations.

Another aspect is that the use of a self-reported questionnaire introduces the possibility of response bias due to subjective interpretation of items. Also, the online recruitment method may have led to selection bias, as individuals with higher interest in body image and mental health topics may have been more likely to participate.

Additionally, the study did not include standardized diagnostic instruments for body dysmorphic disorder which limits the ability to differentiate between subclinical body image concerns and clinically significant BDD.

Future research should include larger and more diverse samples, longitudinal designs and validated clinical assessment tools, in order to better clarify the causal pathways and clinical implications of body image disturbances in young populations.

Ethics approval

The study was approved by the Ethics Committee of Scientific Research of the “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, Târgu Mureș, Romania (approval no. 3417/21.11.2024).

Autor corespondent:  Elena-Gabriela Strete E-mail: elena.buicu@umfst.ro

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.