While social media has been a catalyst for mental health awareness, the unregulated dissemination of information by influencers lacking mental health expertise, perpetuates misinformation. Youth commonly self-diagnose mental health conditions based on social media content, often inaccurately, risking misidentification and inappropriate treatment. Psychiatric contagion, the process by which psychiatric symptoms spread among individuals in close contact, can occur via social media. The authors explore how these issues present in clinical practice, and some intervention strategies for clinicians. They offer recommendations for parents, teachers, social media companies, and clinicians.
Key points
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Youth frequently use social media to learn about mental health and understand their own experiences.
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Mental health misinformation on social media posts is common, as entertainment is prioritized over accuracy or authoritative sources.
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The process of self-diagnosis in adolescents is complex and often misguided, and can help meet psychological needs in an unhealthy fashion.
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Clinicians evaluating youth who self-diagnose should understand the source and function of these beliefs, and verify symptoms via collateral sources.
Overview and background
Self-diagnosis is the process of identifying health conditions in oneself. Individuals compare information learned about psychiatric or medical conditions from digital resources, books, and testimonials of others to their own experiences to self-diagnose. This process can be beneficial, but misdiagnosis is common, and fraught with a myriad of potential problems including over-identification with the illness, contagion, or pursuing inappropriate and possibly harmful treatments.
In this review, we discuss clinical experience and research evidence concerning the phenomenon of adolescent self-diagnosis via social media. Adolescents increasingly go online to learn about mental health and understand their own experiences. One the one hand, social media facilitates open, semi-public discussions about mental illness which can spread awareness and reduce stigma. Mental health posts can facilitate access to valuable mental health information and resources, but related negative consequences must be considered. The growth of social media has created a platform for mass and targeted psychoeducation which is often sensationalized, misleading, or false. Claims about mental illness made on social media posts often contain misinformation, as platforms do not verify content and often fail to censor harmful posts, which perpetuates misinformation and encourages unproven treatments. Misinformation can lead vulnerable youth to incorrectly identify with specific psychiatric illness, pursue inappropriate treatments or delay seeking evidence-based treatments, and result in significant harm.
Social media & child and adolescent psychiatry
Social media can be easily accessed through smart phones and other personal electronic devices and allows for immediate connection. Research studies have shown that 96% of youth are constantly connected to the internet. Adolescents have been avid adopters of social media; most have quickly incorporated it as a fundamental part of their daily lives. One recent survey of over 1500 US adolescents found they averaged 4.8 hours per day on social media. Children and adolescents may be most susceptible to social media content due to key aspects of psychosocial development and social learning.
Social interactions are an integral part of the human experience and our success as a species. Early humans used cave paintings, petroglyphs, and hieroglyphs to communicate information and ideas, predecessors to the modern-day use of social media platforms and emojis. Social interactions allow for the division of labor and scaffolding learned experiences to create culture and pass on knowledge vital for survival. A substantial portion of our brain is devoted to language and social processing for precisely these reasons. At no point in the human lifespan is socialization more important than in childhood and adolescence. Social learning theory posits that youth learn how to behave through observation, imitation, and modeling, a process historically done in person, but increasingly through screen media. The adolescent mind is especially oriented toward the behavior and reactions of one’s peers. Social media is an increasingly important medium for social learning as teens spend as much time on social media observing interactions of peers as they do in-person. People are more likely to imitate behaviors and ideas of those of higher social status, a concept known as prestige bias.
It is important to review Erik Erikson’s model of psychosocial development to provide a conceptual framework for understanding specific vulnerability in youth. In late childhood (age 7–12), children typically develop a sense of industry, reinforcing confidence in their abilities to accomplish tasks and contribute to peer groups. Children compare their abilities and achievements to same age peers, which helps build their sense of industry. Meanwhile, adolescent years (age 12–18) are focused on identity formation. Peer influence, acceptance, and belonging are key psychosocial developmental milestones for adolescents. Prior to the advent of social media, children and adolescents developed these skills in in-person unstructured play and socializing as well as in school and through organized sports and extracurricular activities. The ability to connect with peers through social media and related applications (“apps”) has altered the arena in which these skills are developed. The psychosocial tasks during this phase of development focus on industry, identity, and role formation. Recent functional MRI studies have revealed significant developmental differences in brain regions associated with social cognition tasks of the adolescent brain compared to that of adults, providing support for Erik Erikson’s models.
Social contagion
The American Association of Psychology defines social contagion as “the spread of behaviors, attitudes, and affect through crowds and other types of social aggregates from one member to another”. It builds off observations that were made in ancient times by authors such as Plato, that behaviors can be spread from one person to another through imitation. Also known as sociogenic epidemics, epidemic hysteria, mass hysteria, or culture-bound stress reaction, they consist of a constellation of symptoms that spread between people who share beliefs related to those symptoms, for which anxiety-related symptoms have become typical in modern times. Traditionally spread by face-to-face communication, social contagion is more commonly spread via mass media, increasingly by social media. A wave of popular TikTok posts concerning Tourette’s disorder (totaling 6 billion views in 2021) were implicated in an unprecedented concurrent rise of adolescents presenting for treatment of new-onset functional tics, in an apparent case of mass social media contagion. The potential of social media as a vector for social contagion of risky behaviors appears considerable, reviewed in detail by Harness and colleagues (2022) in this issue.
Psychiatric contagion can be partially explained via emotion contagion, the social spread of feelings, and related behaviors. The potential for social media to transmit emotional contagion was demonstrated in an experiment in which the Facebook feed of participants was altered to vary the frequency of stories with a positive or negative emotional tone. Participants exposed to fewer positive expressions produced fewer positive posts and more negative posts themselves. Those exposed to fewer negative expressions posted fewer negative expressions and more positive ones. Although this study showed that social media is capable of transmitting emotions in the short-term, longitudinal research indicates that longer-lasting moods (eg, depression) can be transferred in a similar manner, the strongest effect in females.
The phenomenon of social media contagion is very difficult to study, which accounts for the general lack of scientific evidence about its epidemiology including prevalence. Limited research as suggests the existence of social media transmission of tic-like movements, eating disordered behavior, self-harm, suicidality, dissociative identity disorder, and controversially, gender dysphoria. Evidence provided by all the studies is weak, but it corresponds with the experiences of providers who work with adolescents. At the 2022 Annual Meeting of the American Academy of Child & Adolescent Psychiatry, author Weigle asked attendees “How often do you see patients who seem to believe they suffer from a psychiatric or neurologic condition because of something they saw online?” Of over 100 responders, 74% endorsed “somewhat often” or” very often.” Asked “How often do you see teens who seem to be influenced by social media in regards to their sexual and/or gender identity?”, 83% responded “somewhat often” or “very often.” Our colleagues believe that our patients’ symptoms are often a direct reflection of their individual online experiences (eg, social media).
Psychiatric contagion and conversion disorder versus malingering versus factitious disorder
Functional neurologic disorder (previously known as conversion disorder), factitious disorder, and malingering are psychiatric diagnoses that differ in involvement of consciousness and motivation. Factitious disorder, categorized under somatic symptoms and related disorders in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V), involves consciously feigning symptoms to garner medical attention or assume a sick role. Malingering involves intentionally falsifying symptoms for secondary gain, such as financial incentive, or escape from responsibility (ie, to avoid school, work, jail time). Functional neurologic disorder (ie, conversion disorder) differs from malingering and factitious disorder, due to the unconscious origin of the psychological stressor contributing to symptoms and lack of clear motive. The diagnosis of each of these conditions requires that symptoms are not explained by a known neurologic illness, and that clinical findings show clear incompatibility with neurologic symptoms reported by the patient. There is some conceptual overlap between functional neurologic disorders and psychiatric contagion.
Psychiatric contagion, the spread of psychiatric symptoms within a group, can be facilitated by social media platforms where individuals share personal experiences and narratives. Exposure to posts depicting certain symptoms or behaviors may inadvertently influence vulnerable individuals, to mimic or replicate these symptoms themselves for various reasons, demonstrating the complexity of social media and mental health interplay. It is important to understand various motivations for the replication of symptoms, as youth can present with primary, secondary, or unclear motives for self-diagnosis.
Adolescence is a period of identity exploration. Adolescents are often uncertain about their identity and seeking a sense of belonging. Assuming a sick role can provide a stable identity for those who perceive illness as a defining characteristic of self. Those who consciously feign symptoms in order to assume a sick role represent factitious disorder. Self-diagnosis of mental illness can facilitate validation and support from others, (eg, evoking sympathy and care from family, friends, teachers, and health care professionals). Self-diagnosis may also serve to avoid non-preferred tasks such as school attendance, homework, or chores. Psychiatric symptoms consciously faked to meet such a goal represent malingering. Symptoms produced unconsciously, often for unclear goals, represent a functional neurologic disorder.
Self-diagnosis
Increasingly, young people go online to learn about and address mental illness. Recent studies found that 77% to 83% of youth surveyed would use the internet to find information or support for a mental health concern. , Many adolescents prefer to learn about mental health online because of easy, anonymous access to information. Although authoritative sources such as the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry have posted a wealth of free, reliable psychoeducation online, adolescents are increasingly likely to learn about mental illness via social media. Adolescents value learning about their peers’ and admire influencers’ opinions regarding mental health issues via social media, and often enjoy the entertaining (if extreme or inaccurate) way in which mental health information is presented on social media. Popular posts of mental illness on social media are typically rewarded with “likes” and followers, as well as a myriad of comments expressing support, caring, and encouragement, a fact not lost on adolescent viewers.
Mental health is among the most popular topics for TikTok and Instagram posts. At the time of writing the 16 billion TikTok posts with the designation #mentalhealth have been collectively viewed 140 billion times. Social media algorithms target specific demographics and audiences most likely to be interested in the subject matter, effectively disseminating information and awareness of mental health issues to groups not reached by traditional outreach methods. Algorithms favor posts which are engaging and/or entertaining over those which provide complete or accurate information, so popular presentations of mental illness are often extreme, and provide a skewed model for social learning. The popularity of mental health-related social media posts and limited verification or regulation of content combine to foster the spread of related misinformation. Social media influencers typically appear credible to youth because of their popularity, charisma, endorsements, and success despite the great majority lacking any related training or education. Content creators and non-medical social media influencers contribute to the dissemination of misinformation. Social media posts concerning mental health are typically misleading. One review of videos concerning ADHD on TikTok classified 52% as misleading, while a study of 500 mental health advice videos on TikTok found 84% contained inaccuracies.
Mental health disorders are complex and influenced by a constellation of factors. Mental health providers rely on years of training and clinical experience to conduct a thorough interview, interpret mental status, compare collateral information, and often incorporate standardized interviews, assessments, and surveys to consider a broad differential before coming to a final diagnosis. Youth and parents self-diagnosing based on questionably trustworthy information from an online source, lacking impartial perspective, often results in misdiagnosis. Even trained medical professionals may misdiagnose based on familiarity and lack of objectivity, which is one reason the American Medical Association Code of Medical Ethics advises physicians against treating themselves or family members.
It has become commonplace for patients and/or parents to present to health care providers requesting confirmation of a specific diagnosis and a particular treatment intervention. This situation puts providers in a difficult position, as those who disagree with the self-diagnosis risk damaging the provider-patient relationship and eroding trust. A patient who believes they have diagnosed themselves accurately may feel invalidated or misunderstood by a provider who disagrees. Self-diagnosis of a mental disorder may divert attention away from a proper evaluation for underlying medical problems. Patients who have misdiagnosed themselves often favor a specific treatment based on what they have discovered online, which may deter appropriate treatment, hinder recovery, and worsen prognosis.
Individuals may inadvertently over-report or under-report symptoms based on information available online, and may even unconsciously take on symptoms to which they are exposed. Youth may believe they have a mental illness when they do not, leading to unnecessary treatment, medications, and/or distress. On the other hand, some under-diagnose themselves, dismissing serious mental health issues that require professional intervention.
Youth who self-diagnose may attempt to manage their symptoms with ineffective or even harmful attempts at treatment based on misinformation or personal biases. For example, the “bed-rotting” trend on social media entails staying in bed during the day, binge-watching television, and using social media for hours or days in the name of self-care for depression. This practice runs counter to the accepted principles of behavioral activation, which recommends productive, active habits to address depression. Bed-rotting can impair sleep routines, displace physical exercise and activities of daily living, and paradoxically exacerbate depression. Some social media posts encourage or advise illicit substance use, eating disordered behavior, self-harm, and even suicide. Many easily accessed posts offer advice on how to carry these out, for example, how to conceal cutting behaviors from parents. Social media platforms’ efforts to find and remove such posts are of limited effectiveness and are often evaded using coded language.
Social media can alleviate mental health stigma, but can also perpetuate stigma depending on content. The portrayal of mental illness on social media posts may contribute to misconceptions about mental illnesses, for example, that they are easily identifiable and self-treatable, or that people can simply “snap out of it.” Self-diagnosis based on social media psychoeducation can conversely lead to feelings of helplessness or problematic justification of misbehaviors, for example, statements such as “I hit my peer because I am bipolar and can’t help it” or “I can’t do homework because I am depressed.”
Should health care providers abandon social media? On the contrary, a need exists for accurate, useful psychoeducation, which providers are in a unique position to create. It is imperative for knowledgeable physicians and institutions to post positive content and to counter misinformation. Health professionals should advocate for social media companies, and the government, to recognize and address the potential for harm related to unverified mental health information available to youth online. It may be helpful to require disclaimers on posts making claims about mental health such as “I am not a health professional” or “this content is not a substitute for professional advice, diagnosis, or treatment” as indicated. Social media companies may emphasize content created by professionals, and that which focuses on wellbeing, prevention, treatment, and lifestyle interventions rather than romanticize pathology. Social media mental health posts could be required to clearly encourage viewers with questions to seek professional help and advice. Posts containing dangerous misinformation or encouraging eating disordered behaviors, self-harm, or suicide should be identified and removed, and repeat posters restricted.
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