"I kept wanting to go bigger and bigger until I couldn't wrap my lips around a straw properly," says Merissa Fernandes, 32. Though she was never officially diagnosed with filler dysmorphia, her tale can occur in varying degrees when a person begins injectable treatments. "I knew I had [filler dysmorphia] when I started [getting injections] at 27 years old. I went overboard on lip and facial filler. Starting fillers can be quite addictive, and you can get really big quickly," Fernandes says.

Injectable fillers are sought after to replace lost volume and/or add additional volume to areas like your lips, cheeks, and under eyes. While it's completely normal to receive filler, filler dysmorphia occurs when you are impacted by other forces and continue to get more and more in the quest for unrealistic perfection. "Social media has been shown to impact people's obsession with symmetry and desire for perfection," psychologist Marianna Strongin says. "Perfection is the general theme for dysmorphia."

While it sounds simple, the root causes of filler dysmorphia and your predisposition to it are more nuanced. Read on to learn more about what filler dysmorphia is, how it occurs, how to avoid it, and treatments available to help.

Marianna Strongin, Psy.D., PLLC, is a licensed clinical psychologist and owner of Strongin Therapy.

Sean Alemi, MD, is a double board-certified facial plastic and reconstructive surgeon.

Gabriela Soza, MD, is a board-certified dermatologist at PFrankMD by Dr. Paul Jarrod Frank in New York City.

Filler dysmorphia is closely tied to body dysmorphic disorder (BDD), which was first recognized in the 19th century and has evolved in meaning and more profound understanding since then. Classified as a psychiatric health condition, body dysmorphic disorder occurs when a person perceives something in their physical appearance as a flaw or deformity when it is actually normal. According to the National Library of Medicine, body dysmorphic disorder can be under-recognized and is "characterized by an all-consuming focus on perceived physical imperfections."

If you're wondering how BDD relates to filler dysmorphia, consider the latter a close relative of the former. New York psychiatrist Carly Snyder says that filler dysmorphia is a relatively new phenomenon because it's "linked to the use [and growing popularity] of dermal injectables to enhance the face's appearance non-surgically." Filler dysmorphia shares the same underlying issues that characterize body dysmorphia, in which "individuals become dissatisfied or obsessed with their appearance after receiving cosmetic fillers. It often leads to an unrealistic perception of their face, making them believe they need more treatments, even if they actually look OK or even overfilled. The phenomenon is tied to body dysmorphic disorder, where people fixate on perceived flaws in their appearance," Dr. Snyder says.

The prevalence of filler dysmorphia in cosmetic dermatology, which covers fillers, neurotoxin injections, topicals, nonablative lasers, chemical peels, and plastic surgeries, manifests in approximately 14 percent of patients who seek treatment.

Psychological, cultural, and individual factors can intermingle and distort a person's perception of their appearance, triggering filler dysmorphia. "Some people have pre-existing low self-esteem, obsessive tendencies, anxiety about their appearance, and/or are perfectionists. They strive to look a certain way and don't actually see themselves accurately," Dr. Snyder says. Generally, Dr. Strongin adds, "people who are already prone to body dysmorphia are most likely to be impacted by filler dysmorphia."

In the broader cultural sense, filler dysmorphia arises when people are significantly impacted by unrealistic standards of beauty that are both established and perpetuated by social media. "The use of filters and Photoshop creates an impossible standard of beauty that people try to emulate," says Dr. Synder. And if they receive positive feedback on their treatments, they may head back for more. "People are reinforced, at least initially, by other people validating their appearance and improvements. People frequently will praise someone who looks different and has clearly had work done, even if the person doesn't actually look better than before."

Psychologically speaking, Dr. Snyder says that when someone has filler dysmorphia, the brain overemphasizes perceived flaws due to heightened activity in visual processing and impaired emotional regulation. "Dysfunction in brain areas such as the amygdala and prefrontal cortex may cause anxiety and the obsessive, compulsive thoughts and behaviors associated with filler dysmorphia."

Even the physical act of receiving filler can become addictive and induce a cycle. "The brain's dopaminergic system becomes inappropriately tied to the satisfaction of fillers being injected and the fleeting joy one might feel at their new appearance," says Dr. Snyder. "This reward system dysfunction fuels the cycle of needing more procedures to transiently quell the feeling of dissatisfaction one has in their appearance."

Though it's not incredibly common to see in aesthetic practices, plastic surgeon David Shafer says that he occasionally sees patients manifesting signs of filler dysmorphia. "[I see it when patients] obsessively focus on minor imperfections, with recurrent requests for unnecessary treatments or dissatisfaction with natural-looking results," says Dr. Shafer. "Warning signs include a history of frequent treatments and a fixation on achieving 'perfect' or exaggerated results."

Plastic and reconstructive surgeon Sean Alemi says that he can spot patients with filler dysmorphia when they display abnormal levels of distress around their aesthetic treatment. "Often, patients [exhibit] a level of distress that is out of proportion to the physical trait and may even describe how this trait has affected their lives adversely."

According to Dr. Snyder, the symptoms of filler dysmorphia include:

If you have a history of BDD or hyperfixate on certain things about yourself, proceed with caution when opting for injectables. "I have seen patients with

general dysmorphia [BDD], and once they had fillers or other forms of cosmetic treatments, their dysmorphia worsened. People with obsessive tendencies can often transfer their obsessions to other parts of the body, [especially when it comes to fillers], as they change parts of your body," says Dr. Strongin.

People who constantly monitor their bodies or faces should recognize the propensity for even more post-filler fixation. "By adding more variability to your looks, you are more likely to develop dysmorphia of the very thing you have added," says Dr. Strongin. "I tell some of my obsessive patients that they have 'sticky' brains, which means that they get stuck on things and think about them too often. Those with 'sticky' brains should be more cautious when doing cosmetic procedures."

Overall, to avoid developing filler dysmorphia, Dr. Snyder stresses that it is important to stay mindful of your motivations for getting filler and to ground your expectations. It's possible to enjoy using fillers responsibly, but it becomes a problem when you fall into a cycle of dissatisfaction. "It is important to set limits from the outset, only work with ethical providers, and listen to feedback. Treating any underlying anxiety disorder(s) also reduces the risk of filler dysmorphia. Talking about one's feelings of imperfection and any unrealistic goals with a therapist can also be helpful and protective."

Treatment for filler dysmorphia is twofold - it encompasses both an internal and external approach. It's important to note that there is no cure and it requires consistent awareness and work. Internally speaking, Dr. Strongin says that filler dysmorphia is treated the same way that BDD and obsessive-compulsive disorder are treated, as they all comprise obsessive thoughts and compulsive behaviors. According to Dr. Snyder and Dr. Strongin, below are some effective treatment options for filler dysmorphia:

If you're set on getting filler, it is of the utmost importance to visit a skilled and ethical provider who can help you set realistic goals during your treatment and will tell you when enough is enough. "Patients should seek experienced injectors such as board-certified dermatologists or plastic surgeons who will focus on enhancing natural beauty rather than over-treatment," says dermatologist Gabriela Soza.

As the aesthetic industry continues to grow, the accountability for providers becomes tantamount not only for patient satisfaction but for making sure that patients are not overdoing it and hurting themselves in any way. Allergan Aesthetics (the makers of Botox Cosmetic) is prioritizing patient safety and satisfaction. The company recently launched its "Moving the Needle on Ethics" Report - an industry-first global coalition of thought-leadership essays aimed at driving positive change and ensuring patient care and satisfaction remain centered in a rapidly evolving aesthetics world. Most importantly, it highlights the industry's and providers' ethical obligation to tell patients when they've crossed the line with aesthetic treatments.

As for patient Fernandes, she recommends starting slow if you opt for fillers. "Let your real beauty shine. Let [filler] enhance, but don't let it take over. If you want filler, make sure you are choosing injectors and providers that care about you. More is not necessarily a good thing."