Introduction

Globally there are an estimated 4.63 billion people using smartphones and in India, it’s estimated to be about 750 million people (1). Taking selfies and uploading them onto social media has become a medium of self-representation, especially among young adults and adolescents (2). According to Oxford Dictionary, ‘Selfie’ refers to a self-portrait photograph of oneself (or oneself with other people), taken with a camera or a camera phone held at arm’s length or pointed at a mirror, which is usually shared through social media (3). On social media platforms, one tries to self-present or self-express by uploading selfies. The desire for admiration or validation can lead to compulsive behaviour where they feel to take selfies constantly and post them on social media. This behaviour is termed ‘selfitis’ (4). Selfitis or a selfie addiction is when a person is almost obsessively taking selfies, several times a day, and posting them to various social media sites like Snapchat, Facebook or Instagram (5). The selfie trend has become remarkably popular in India, especially among young people. Data from a study in students of a medical college in Mumbai, showed that a quarter of youths exhibited signs of selfie addiction and a vast majority of them (84%) had a belief that sharing their photos on social media helped in increasing their self-confidence (6).

Concerns have been raised concerning this trend's possible effects on personality development, self-esteem and mental health (7-10). A systematic review revealed that selfitis was associated with narcissistic personality trait, appearance anxiety and low self-esteem (11). The power of the selfie to deliver immediate gratification and approval via likes, comments and shares on social media is what makes it so appealing. However, this search for outside approval may exacerbate problems with body image, appearance anxiety and even narcissistic tendencies. Given the growing indistinctness between reality and virtual self-representation, it is imperative to comprehend the psychological foundations and possible ramifications of this contemporary fixation. The selfie phenomenon is not going away, thus more research is needed to fully understand how appearance anxiety, self-esteem, excessive selfie taking behaviour and personality factors interact. Medical students constitute a distinct demographic group of interest concerning selfitis. The strain and stress that come with being a medical student can either cause or aggravate narcissistic tendencies, appearance anxiety and low self-esteem (12). Examining these events within this particular cohort may yield important information about the possible effects on their professional development, mental health and future patient care. Literature pertaining to the effects of selfitis on mental health of medical students is scare in this part of south India. Hence this study was conducted to estimate the prevalence of selfitis and investigate its relationship with self-esteem, appearance anxiety and narcissistic personality trait among students of a private medical college in coastal Karnataka.

Methods

A cross-sectional study was conducted in 2022, among students of a private medical college in Dakshina Kannada district of Karnataka state in India. Students who were currently pursuing Bachelor of Medicine and Bachelor of Surgery [MBBS] or MD/MS courses in the college, with access to a smartphone and 18 years of age or older were eligible to be part of the study. Ethical approval was obtained from the Institutional Ethics Committee [INST.EC/EC/036/2022]. Written informed consent was obtained from the study participants and permission was obtained from the head of institute.

Sample size was calculated by considering population proportion as 70.6% based on a previous study by Nagaraju et al. (5), with confidence interval as 95%, margin of error 5% and 20% non-response rate, by which the sample size was estimated to be 403. Students were enrolled using convenient sampling technique.

A pre-tested, semi-structured questionnaire was used to collect the data. It consisted of sub-sections on socio-demographic details such as age, gender, Selfitis Behaviour Scale [SBS] (13) to detect selfitis, Rosenberg Self-Esteem Scale [RSES] (14) to assess self-esteem, Appearance Anxiety Inventory [AAI] (8) to detect appearance anxiety and Narcissistic Personality Inventory-16 [NPI-16] (15) to assess narcissistic personality trait of the students.

SBS is a validated tool, developed by Balakrishnan & Griffiths, and has been used by researchers for the assessment of selfie-taking-related behavior (13). It consists of 20 items and the responses to each item are rated on a five-point Likert scale [5 - strongly agree and 1 - strongly disagree]. Using the total score obtained, selfitis is categorised into three types - borderline, acute and chronic.

RSES is a tool which has been used extensively by researchers to assess a person’s self-esteem. It consists of ten items, with responses to each item recorded on a four-point Likert scale [1 - strongly disagree and 4 - strongly agree]. Half the items have a positive response; such as, "On the whole, I am satisfied with myself", while the other half have a negative response; such as, "At times I think I am no good at all". The total scores range from 10-40, with higher scores indicating a higher level of self-esteem (14).

AAI is a ten-item validated tool used to assess appearance or body image anxiety in general and body dysmorphic disorder in particular. It focuses on the cognitive processes and safety-seeking behaviors that are characteristic of a response to a distorted body image and associated shame. Scores range from 0-40, with a higher score indicative of severe appearance anxiety (8).

The NPI-16 is a tool developed by Ames et al. in 2006, which measures sub-clinical narcissism in individuals. It consists of 16 pairs of sentences, with each pair made up of one statement which is indicative of narcissism and the other is not (15).

Statistics:

Data was collected using Epi collect and analysed using Statistical Package for Social Sciences [SPSS] version 20.0. Data is presented in terms of descriptive statistics [frequency and percentages] and Pearson's correlation coefficient was used to investigate the relationships between selfitis and self-esteem, appearance anxiety, narcissistic personality trait.

Results

Eight students did not provide consent for the study. The demographic details of 403 students are; 63.52% (256) were females, 36.22% (146) males and 0.26% (1) was a transgender. In terms of education, 93.05% (375) were pursuing undergraduate and 6.95% (28) post-graduate medical courses. Majority of students 87.35% (352) were in the age-group of 18-24 years and 12.65% (51) were 25 years and older.

Assessment of selfitis revealed that 68.49% (276) of students had scores suggestive of selfitis, with 51.12% (206) having scores indicating borderline, 16.13% (65) acute and 1.24% (5) chronic selfitis [Table 1]. Selfitis was prevalent more commonly among females 73.05% (187) than males 60.96% (89) [Figure 1]. Selfitis was not detected in the lone transgender student.

Figure 1: Selfitis and gender distribution

We found a negligible positive correlation between selfitis and self-esteem (r = 0.146). A weakly positive correlation (r = 0.376) was observed between appearance anxiety and selfitis. The narcissistic personality trait and selfitis did not correlate with each other (r = 0.05), according to our research [Table 2].

Discussion

In this study, about two-thirds (68.49%) of students had scores suggestive of selfitis, among which 51.12% had borderline, 16.13% acute and 1.24% chronic selfitis. These findings are consistent with some previously reported studies from India. Nagaraju et al. (5) reported the prevalence of selfitis among nursing and medical students in Bengaluru as 70.6%, with 48.7% having borderline, 18.2% acute and 3.7% chronic selfitis. Behera P et al. (16) reported the prevalence as 72.3% in students at All India Institute of Medical Sciences at Bhubaneswar, with 52.6% having borderline, 18.3% acute and 1.3% chronic selfitis. But a few studies have also reported higher levels of selfie addiction, with Sreejamol et al. (17) finding selfie addiction to be as high as 81% (324) among college students in Kerala and Gawdee (18) reported the prevalence as 83% (166).

We found excessive selfie-taking behaviour more commonly among females than males, however studies by Nagaraju et al. (5) and Dutta E. et al (6) found no discernible gender difference in the selfies taken by college students.

A negligible positive correlation was found between selfitis and self-esteem (r=0.146). These findings are in line with studies of Srikumaran et al. (19) and Oppong et al. (20) who reported no relationship between selfitis and self-esteem. But a study by Lal R et al. (21) found a positive and very significant coefficient of correlation between self-esteem and selfitis behaviour (r = 0.62).

We found a mild positive correlation between selfitis and appearance anxiety (r = 0.376). This implies that people who exhibited selfitis behaviour were more likely to have appearance anxiety. This could be because one of the main goals of engaging in selfitis and posting on social media is to seek reassurance about their appearance and approval from others. However, studies by Digamon et al. (22) and Wagner et al. (23) reported no relationship between selfie taking and body image satisfaction. However, Gilliland et al. (24) found a positive correlation between social physical anxiety, which is an anticipation that one’s body image will be negatively judged by others and the number of times a person takes selfies and edits it before uploading on social media. Also Mills et al. (25) who conducted an experimental study on the causal effects of taking and posting selfies on social media among undergraduate students, reported a positive correlation between taking, posting selfies on social media and poor self-body-image. We found no correlation between selfitis and narcissistic personality trait (r = 0.05), which is in contrast to the findings of Lal et al. (21) and Puthiyakath et al. (26) who reported a significant, positive correlation between selfitis and narcissistic personality trait. A narcissistic person’s behaviour is usually aimed at keeping up their grandiose, positive self- views and the act of regularly taking selfies can help them to maintain this inflated self-view.

Limitations of this study: This study was conducted in a single institution we cannot generalise the results. Although validated questionnaires were used, utilising a mixed-method design would have given deeper insights into the motivating factors for excessive selfie taking behaviour and since this study was conducted in 2022, lockdown measures which were in place could have played a part in students relying more on their mobile phones for their social connections.

This study revealed that majority of students were indulging in excessive selfie taking behaviour, and borderline selfitis being the commonest type. Appearance anxiety played a role in selfie taking behaviour, with increased selfie addiction tendencies seen among students having apprehension about how others will judge them based on their physical appearance. But no correlation was found between selfitis and self-esteem, narcissistic personality trait. These findings underscore the need for raising awareness and educating adolescents about healthy use of smartphones, especially among the one’s in schools and colleges and thereby preventing the negative consequences associated with excessive selfie-taking. Future research can look into other details associated with selfie taking such as editing of selfie images before uploading on social-media, frequency of uploading these images on social-media and to better understand the dynamics of selfitis.

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