Seems like an important article:
https://www.sciencedirect.com/science/article/pii/S0010440X22000682
Social media as an incubator of personality and behavioral psychopathology: Symptom and disorder authenticity or psychosomatic social contagion?
Abstract
There has been an increasing recognition among both medical and psychological professionals, as well as the public media, of a concerning trend for child and adolescent users of audiovisual-based, algorithmic social media platforms (e.g., TikTok) to present with or claim functional psychiatric impairment that is inconsistent with or distinct from classic psychiatric nosology. In this short communication, we provide a detailed historical overview of this transdiagnostic phenomenon and suggest a conceptual model to organize thinking and research examining it. We then discuss the implications of our suggested model for accurate assessment, diagnosis, and medical-psychiatric treatment. We believe there is an urgent need for focused empirical research investigation into this concerning phenomenon that is related to the broader research and discourse examining social media influences on mental health.
Abbreviations
The global burden of mental illness in children and youth is a leading cause of disability globally, accounting for ∼13% of the total burden of disease in this age group [1,2]. Notably, this estimate excluded personality disorders given limited epidemiological data at the time, suggesting that the global burden of mental illness and children and youth is likely underestimated. There are robust sex differences in the expression of common clinical, personality, and behavioral traits and disorders, especially during adolescence (e.g., females:neuroticism and depressive/internalizing disorders and symptomatology; males:aggression and antisocial/externalizing disorders and symptomatology [[3], [4], [5], [6], [7], [8], [9], [10], [11], [12]]). However, greater understanding of the overlap among their symptom expression and sex-linked prevalences, as well as their social and biological correlates is needed. Recent quantitative work examining their symptom overlap has enhanced insight into the transdiagnostic dimensional structure of common clinical and personality psychopathology [[13], [14], [15]].
At the same time that our understanding of transdiagnostic relations among common clinical and personality disorders and symptomatology has progressed, there has emerged an increasingly urgent need to understand the magnitude and developmental significance of social media use on mental health [[16], [17], [18]], especially during adolescence given it is a critical developmental window during which emotion regulation capacities are unfolding [12,16,17,[19], [20], [21], [22]]. The urgency of this need has been magnified by the emergence of the COVID-19 pandemic which has been associated with increased social media use and perceived individual social isolation and psychological/psychiatric distress [[23], [24], [25], [26], [27], [28]], including suicide-related mortality [29].
One social media site that has received increasing media and research scrutiny as a potential conduit or ‘spread vector’ for mental illness symptoms and disorders is TikTok [[30], [31], [32]]. There has been a well-documented uprise in popular content creators with self-described tics or Tourette's Syndrome (TS) and other self-diagnosed mental health symptomatology on the TikTok platform [[37], [71]] leading some to characterize the phenomenon as “TikTok's sick-role subculture” [30]. This uptick has coincided with increasing numbers of youth who have presented to clinical providers or psychiatric services during the COVID-19 pandemic with what have been termed functional tic-like behaviors (FTLBs) [31,33,34]. Similar phenomenon has also been recently chronicled with respect to dissociative identity disorder (DID) [35].
These more recent examples of mental health-related issues appearing with notable penetrance in the social media ecosystem have emerged within the context of a broader fusion and coalescence of individual self-diagnosis, including anxiety, depression, eating disorders, autism, and gender identity-related conditions on social media platforms, perhaps most notably on the social media site Tumblr during the first decade of the 2000s [36], but also Instagram and most recently on TikTok as well [[37], [38], [39]]. The continued evolution of this trend underscores an urgent need for increased understanding of the influence of social media on mental health, including its phenotypic clinical presentations and the possibility that increasingly algorithmic social media platforms may serve as a vehicle of transmission for social contagion of self-diagnosed mental illness conditions. Moreover, a greater understanding of the contributions of both personality and common clinical psychopathology to the ways in which social media platforms impact, facilitate, and ultimately inform the emerging debate about the definitions and contours of what is and is not considered mental ill-health is needed.
1. Audiovisually immersive social media: TikTok
TikTok was initially launched as a platform for users to post short clips of dancing, singing and comedy. The social media app launched in 2018 and had approximately one billion active monthly users worldwide by 2021. During the COVID-19 pandemic, this number increased. TikTok has a distinct algorithm, which allows users to receive content tailored to them, based on their preferences, interests and current state of mind. Depending on the length and type of interaction on a post, TikTok algorithms curate an audiovisually entertaining, sensory-immersive stream of personalized videos to their "For You" page.
User content on TikTok has evolved from the app's launch, with more content creators advocating for awareness surrounding issues such as feminism, mental illness, body positivity, disabilities, and gender identity. Notably, there have been many accounts that have received millions of views for their journey with their disability and/or mental illness, especially TS. These accounts have grown in popularity and their content has appeared to gain widespread traction as viewers engage with the content and learn how content creators perform everyday activities, while having tics that can largely affect their functionality in day-to-day life.
2. Before TikTok: Tumblr and the origins of online identity fandoms
Tumblr is a social media network that was founded in 2007, reaching peak user popularity in early 2014 based on the number of daily blog posts [36,40]. The creation of ‘fandoms’ (fans of a particular person, team, fictional series, etc. regarded collectively as a community or subculture) provided users who typically were seen as outcasts, a sense of community and belonging, as demonstrated by its company's mission statement; “Tumblr is a place to express yourself, discover yourself and bond over the stuff you love. It's where your interests connect you with your people” [40]. Journalist and internet historian Katherine Dee has written “Tumblr became a place for people to fantasize and build upon ideas about real identities. There was an aesthetic dimension, a dimension of roleplay, a feeling of camaraderie with others—but it was often pure fiction [41].” This identity element was also noted as a feature of social media more broadly: as Moreno et al. [39] noted “Social media also allow users to create online identities that may reflect their real identity or a newly-developing identity.” Mental health content such as eating disorders and depression, along with numerous other common clinical mental disorders, were often disclosed on Tumblr [36]. Accounts promoting eating disorders, self-mutilation, and suicide became popular and with half of Tumblr's visitor base being under the age of 25, raising concern for the potentially deleterious effects of social media use on adolescent mental health. Tumblr implemented a policy against blogs of this nature in 2012. Similar issues also manifested on the social media platform Instagram where non-suicidal self-injury (NSSI) content and corresponding NSSI-related identities became a concern [39].
3. Personality and common clinical psychopathology: mental illness as identity-selection?
3.1. Tics, Tic DO, and Tourette's syndrome (TS)
An increasing number of reports from the US, UK, Germany, Canada and Australia have noted an increase in functional tic-like behaviors (FTLB) both prior to and during the COVID-19 pandemic, coinciding with an increase in social media content related to Tourette syndrome and tics [[31], [32], [33], [34],[42], [43], [44]]. These FTLBs differ from classic Tourette syndrome (TS) both neurotypically and phenotypically. Neurotypically, FTLB age of onset (typically 12–25 years) is later in development relative to classic TS with onset in early childhood and improvement of tic behavior in late adolescence. Phenotypically, FTLBs are characterized by an abrupt and explosive presentation of symptoms over hours or days of mostly complex phonic and motor tic-like behaviors with high severity, with many patients able to provide the exact date of onset or inciting event. In contrast to the rostro-caudal evolution of motor tic symptoms which develops over years in TS, FTLBs often predominantly affect the upper limbs, with complex movements of the arms and hands, including clapping, sign language, throwing objects, banging oneself on the chest, head or thigh, or hitting other people.
In TS, motor tics usually precede verbal tics, with the most common vocal tic being throat clearing, and less than 15% of those diagnosed with TS ever developing any complex vocalizations. In contrast, complex vocalizations are a prominent feature of FTLBs, including a large repertoire of random words, phrases, or offensive statements. Tourette's Syndrome is a highly prevalent disorder in youth, affecting approximately 1% of school-age boys and 0.25% of school-age girls [45]. The mean age onset of tic symptoms is approximately 6 years of age for both males and females as is the peak clinical presentation (when received at a specialist clinic) at 10 years of age. Some studies suggest there is a small but significant difference in tic severity between boys and girls, with girls having slightly more severe and more persistent tic symptoms with a higher resolution of tic symptoms in late teens for boys [46,47].
A large majority of those demonstrating FTLBs are adolescent females, which also forms a core user group of TikTok. Patients with FTLBs are also more commonly diagnosed with anxiety and depression, than those with TS which frequently co-occurs with neuropsychiatric conditions such as Attention-Deficit/Hyperactivity disorder (ADHD) and Obsessive-Compulsive Disorder (OCD) [33,34]. FTLBs are in keeping with a Functional Neurological Disorder in the context of anxiety and depressive symptoms and diagnoses, and more broadly with affective dysregulation. Many presenting to psychiatric clinics have also noted they have seen popular videos on Tourette's syndrome and have since started sharing the same tics [32].
3.2. Dissociative identity & other mental disorders
A similar phenomenon has been observed in individuals with self-diagnosed Dissociative Identity Disorder (DID) or adjacent quasi-psychiatric terms such as “person with Dissociated Identities” and “plurals” [35,48]. Indeed, the evolution of the online culture associated with DID or multiple personality disorder (MPD) has been richly chronicled [49]. The pluralist's online culture is an umbrella moniker that includes five distinct languageidentifiers regarding the etiology of Plurality defined by Plurals themselves including: (1): Traumagenic-Adaptive; (2) Traumagenic; (3) Traumagenic-Cultural; (4) Endogenic; and (5) Exogenic [35]. Notably, the endogenic and exogenic identifiers were identifiers created ‘de-novo’ and have no relation to empirical nomenclature. Based on these identifiers, three groups of plurals have been described. While the first two groups are related to conventional psychiatric clinical interpretations of and empirical research into DID (e.g., as potentially trauma-based), the third group is a pseudo-psychiatric group that includes those who identify as plurals but as not disordered [35].
Hashtags such as #DID, as well as #borderlinepersonalitydisorder and #bipolardisorderhave received millions of views, and popular content creators post videos capturing them ‘switching alters’ (i.e., plurals). Impressions from both the lay public and clinical professionals have converged in the observation that a salient feature of this emerging DID and self-diagnosed mental illness social media posting and discourse is that it has a distinct appearance of being romanticized, glamourized, and sexualized (or possibly malingered) [[48], [49], [50], [51], [52]]. Accordingly, this may be one explanation for why many users claim to have ‘rare’ disorders like DID (with prevalence estimates ranging from 0.01% to 14% depending on sample characteristics and the methodology used to assess DID; especially among children the disorder is extremely rare [[53], [54], [55], [56]]), as well as the emergence of a ‘plurals community’ for DID. Such plurals communities include non-traditional peri-psychiatric non-disordered notions of DID that community members have created on their own and are liberated from conventional psychiatric nosology. It has been noted that non-diagnosed (or undiagnosed) claims of DID can negatively impact others in the DID plurals community who have clinically diagnosed DID and are seeking functional reintegration as a therapy endpoint [35].
4. Diathesis-stress: an integrative model of vulnerability towards understanding social media, personality-identity confusion, and psychopathology
Although many social media users and online community members will be exposed to both media and community content that reflects peri-psychiatric conditions or self-diagnosed conditions, most will not adopt peri-psychiatric behaviors or conditions and/or seek professional clinical assistance. Indeed, positive effects of online social communities for coping with stress, relationship-building, and for enhancing feelings of belonging and shared experience among people experiencing mental illness, as well as other minority and marginalized groups, have been described [35,36,38,57,58]. What is needed in our view is an integrative explanatory framework for what places a seemingly increasing subset of individuals at-risk for or more vulnerable to adopting peri-psychiatric behaviors or conditions. The diathesis-stress model of individual differences to environmental context [[59], [60], [61], [62]] provides an organizing heuristic to begin to develop such an explanatory framework. Classic diathesis-stress or vulnerability-stress models postulate that poor developmental experiences (e.g., stressful or resource-poorenvironments) are most likely to impact the development of individuals who carry vulnerability factors, which are latent diatheses that result in increased risk for psychopathology when “triggered” by exposure to negative or otherwise stressful developmental experiences. Latent diatheses reflect biological or social-cognitive predispositions to react and behave in specific ways; psychopathology reflects signs, symptoms, and behaviors associated with mental illness or inconsistent with mental health in the normative range. While not inherently stressful per se, the social media environment is a relatively novel environment in evolutionary history and the negotiation of social relationships through the scopic medium of increasingly algorithmic, audiovisual social media may pose a unique set of conditions that place individuals with latent diathesis to personality and behavioral psychopathology, particularly that defined by deficits in emotion regulation and negative emotionality (NE) [63], at increased risk for the development of psychopathology [19,36,64,65].
Relative to males, adolescent females are at higher risk for depressive and anxiety-related disorders [6], along with higher levels of negative emotionality and personality trait neuroticism [7,9]. Accordingly, one possibility in the case of ‘TikTok tics’ is that the functional purpose of FTLBs—which are disproportionately prevalent in females based on empirical data to date – is to seek affirmation and/or draw attention to oneself to acquire social capital in online communities [36,66] while simultaneously maintaining an unconventional peri-psychiatric identity that may mask feelings of anxiety, depression, and possibly lower self-esteem [19,30,67]. It is also plausible that the social stress and isolation due to the COVID-19 pandemic operated in a dual-risk capacity in addition to unique personality and behavioral factors associated with social media use and participation in online communities themselves [19,64,65,68]. In any event, what seems to be clearly indicated by the preliminary clinical, empirical, and journalistic information is that for a subset of predominately adolescent-aged female youth, use of audiovisual-based social media platforms such as Instagram and TikTok, especially at moderate and high levels, is associated with the manifestation and course of FTLBs, less self-reported levels of psychological well-being [69], increased internalizing symptomatology [70], and self-diagnosis of various mental illnesses [71]. With appropriate diagnosis and intervention, particularly identification and cognitive behavioral treatment of emotional distress, social and/or generalized anxiety and affective dysregulation, youth with FTLBs have demonstrated a decrease in severity or remission of symptoms in the short-term [72]. This pattern of successful intervention in youth with FTLBs underscores the importance of widespread awareness of the possibility of social contagion influences on mental illness and identity confusion among young people, their parents, and mental health care practitioners [30,73,74].
5. Social awareness and implications for mental health assessment
Concerning the broader question of whether social media is causally related to the rise in rates of adolescent mood disorders, self-harm, and suicide since 2010 in the USA and UK, it has been pointed out that the rise paralleled the years “when American teens were obtaining smart phones and becoming daily users of social media platforms such as Instagram” [17]. The same is true of the unique clinical presentation of FTLBs which first emerged into clinical awareness in 2019 in Germany [32], as well as with the increasing recognition of the DID-plurality community and emergent discourse [35]. More broadly, there has been a recognition of vast online ‘neurodivergence’ ecosystem in which classical mental illness symptoms and diagnoses are viewed less as mental health concerns that require professional attention, but rather as consumer identities or character traits that make individuals sharper and more interesting than others around them [49,[75], [76], [77]].
The above recognition of this ostensibly heterogeneous sociogenic illness behavior, loosely bounded by classical notions of mental health diagnoses, suggests the possibility that the increasingly algorithmic [78] and audiovisually immersive social media environment is a scopic medium [79] in which various ‘neurodivergent’ or sick role [30] identities or personas can be claimed at will, at any given moment—with no antecedent biological basis or tether to empirical reality—with positive social and emotional reinforcement and resonance from the associated online community (e.g., via the use of hashtags; user-to-user sharing and amplification of content) [36]. This social and emotional resonance may amplify and reinforce identification with the persona and may even predict later behaviors in line with it [80]. Sharing emotions, feelings, and thoughts around one's self-diagnosed mental illness identity within a solely techno-mediated scopic performative milieu in which such feelings, emotions, and beliefs are amplified may increase the likelihood that the ‘self-diagnosed’ identity is reified and incorporated into one's self-concept, regardless of its correspondence to external reality and conventional taxonomies of mental illness [36,80]. Said differently, the capacity for emotion regulation around the nature of one's self -identity is increasingly being techno-mediated externally, rather than internally within the self.
Recognizing and responding to this possibility by researchers and mental health practitioners is an urgent public health priority in our view, given extant evidence suggesting that the social media environment is a mental health risk factor for adolescents and youth struggling with elevated personality psychopathology and inchoate personal identities during the transition to young adulthood [17,19,20,22]. In addition, whether and how social media technology is a contributing force in both potentially inducing sociogenic illness while simultaneously influencing how professional mental health organizations evolve with respect to understanding and defining mental illness—thus potentially immunizing current sociogenic illness from classical diagnoses of mental illness—is crucial to take stock of in order to rigorously inform public health discourse and policy [81].
