We live in an era of edited selfies and ever-evolving standards of beauty. The advent and popularity of image-based social media have put Photoshop and filters in everyone’s arsenal. A few swipes on Snapchat can give your selfie a crown of flowers or puppy ears. A little adjusting on Facetune can smoothen out skin, and make teeth look whiter and eyes and lips bigger. A quick share on Instagram, and the likes and comments start rolling in. These filters and edits have become the norm, altering people’s perception of beauty worldwide. ||||| Snapchat and Instagram filters are influencing how young people think about beauty.

 Alarmingly, more people are requesting plastic surgery to look better in selfies, according to the American Academy of Facial Plastic and Reconstructive Surgery.

 And in one disturbing emerging phenomenon, dubbed "Snapchat dysmorphia," some patients are getting plastic surgery to look more like their filtered selfies.

 According to Boston University researchers, digital filters are likely contributing to a rise in body dysmorphia, where people are overly anxious about their appearance.

 Instagram and Snapchat filters are the new celebrity photo, offering up unrealistic standards of beauty that might trigger people to feel unhappy with the way they look in real life.

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 That's according to three Boston University researchers, who published an article about body dysmorphia in the JAMA Facial Plastic Surgery medical journal this month. The article is not a study, but an overview of industry research and studies.

 Body dysmorphia is a mental health condition where people feel unduly worried about the way they look, and the authors wrote that Snapchat and Instagram filters were "altering people’s perception of beauty worldwide."

 They highlighted one especially disturbing phenomenon: "Snapchat dysmorphia." They characterised this as an emerging phenomenon where plastic surgery patients no longer ask to look like celebrities, but more like their own filtered selfies with "fuller lips, bigger eyes, or a thinner nose."

 Snapchat dysmorphia was first reported by The Independent earlier this year, when a cosmetic surgeon said more women were asking to look like their selfies. The Boston researchers wrote: "This is an alarming trend because those filtered selfies often present an unattainable look and are blurring the line of reality and fantasy for these patients."

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 They added: "It is known that the angle and close distance at which selfies are taken may distort facial dimensions and lead to dissatisfaction. Patients may seek surgery hoping to look better in selfies and social media."

 And according to the American Academy of Facial Plastic and Reconstructive Surgery, 55% of surgeons reported seeing plastic surgery patients who wanted procedures to improve how they looked in selfies in 2017, versus 42% the prior year.

 "Overall, social media apps, such as Snapchat and Facetune, are providing a new reality of beauty for today’s society," the Boston authors wrote. "These apps allow one to alter his or her appearance in an instant and conform to an unrealistic and often unattainable standard of beauty."

 Business Insider has previously written about how the filters that come pre-loaded on certain smartphone cameras, especially on Asian phones, whiten people's skin and airbrush features.

 According to the Boston University researchers, the ready availability of filters and self-editing on phones is an alarming problem that is likely contributing to rising body issue anxieties among young people.

 They said: "Models and actors were made to look perfect in magazines and ads, but the general public did not have easy access to methods to alter their own appearance ... Today, with apps like Snapchat and Facetune, that same level of perfection is accessible to everyone. Now, it is not just celebrities propagating beauty standards: it is a classmate, a coworker, or a friend."

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 SEE ALSO: How popular smartphones make your skin look 'whiter' in selfies ||||| Prim psychiatry . Author manuscript; available in PMC 2008 Apr 30. Published in final edited form as: PMCID: PMC2361388 NIHMSID: NIHMS37504 PMID: 18449358 Suicidality in Body Dysmorphic Disorder , MD Katharine A. Phillips Dr. Phillips is professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University and director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence, Rhode Island Find articles by Katharine A. Phillips Author information Copyright and License information Disclaimer Katharine A. Phillips, Dr. Phillips is professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University and director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence, Rhode Island; Please direct all correspondence to: Katharine A. Phillips, MD, Butler Hospital, 345 Blackstone Blvd, Providence, RI 02906; Tel: 401-455-6490; Fax: 401-455-6539; E-mail: ude.nworB@spillihP_enirahtaK Copyright notice

 Abstract Suicidal ideation, suicide attempts, and completed suicide appear common in individuals with body dysmorphic disorder (BDD). Available evidence indicates that approximately 80% of individuals with BDD experience lifetime suicidal ideation and 24% to 28% have attempted suicide. Although data on completed suicide are limited and preliminary, the suicide rate appears markedly high. These findings underscore the importance of recognizing and effectively treating BDD. However, BDD is underrecognized in clinical settings even though it is relatively common and often presents to psychiatrists and other mental health practitioners, dermatologists, surgeons, and other physicians. This article reviews available evidence on suicidality in BDD and discusses how to recognize and diagnose this often secret disorder. Efficacious treatments for BDD, ie, serotonin reuptake inhibitors (SRIs) and cognitive-behavioral therapy, are also discussed. Although data are limited, it appears that SRIs often diminish suicidality in these patients. Additional research is greatly needed on suicidality rates, characteristics, correlates, risk factors, treatment, and prevention of suicidality in BDD.

 Needs Assessment: Recent evidence indicates that individuals with body dysmorphic disorder (BDD) have high rates of suicidal ideation and behavior. However, BDD often goes undiagnosed in clinical settings, even though it is relatively common. It is important to be aware of the suicide risk for these individuals and to recognize and appropriately treat patients with BDD. Learning Objectives: Familiarize with suicidality rates in individuals with body dysmorphic disorder (BDD)

 Identify other aspects of suicidality (eg, clinical correlates) in BDD.

 Identify clinical features of BDD.

 Identify approaches to diagnosing and effectively treating BDD. Target Audience: Primary care physicians and psychiatrists. CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material. This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatryand professor of psychiatry at New York University School of Medicine. Review Date: October 25, 2007. Dr. Hollander reports no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Sussman is a consultant to and on the advisory boards of GlaxoSmithKline and Wyeth; and has received honoraria from AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, and Wyeth. To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation found on page 87. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by December 1, 2009 to be eligible for credit. Release date: December 1, 2007. Termination date: December 31, 2009. The estimated time to complete all three articles and the posttest is 3 hours.

 INTRODUCTION This article is devoted to the topic of suicidality in body dysmorphic disorder (BDD) because emerging empirical data and clinical experience indicate that individuals with BDD are often suicidal and may be at particularly high risk for completed suicide. Patients with BDD are often highly distressed, feel unacceptable to themselves and others, are often depressed and socially isolated, and have other risk factors for suicidal thinking and behavior. However, BDD often goes unrecognized in clinical settings. It is important to recognize BDD and institute appropriate treatment, which often improves BDD symptoms and may diminish suicidal thinking and behavior. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV),1 defines BDD as a preoccupation with an imagined defect in appearance; if a slight physical anomaly is present, the concern is markedly excessive. The preoccupation must cause clinically significant distress or impairment in social, occupational, or other areas of functioning. The appearance concerns cannot be better accounted for by another mental disorder such as anorexia nervosa. BDD is also referred to as “dysmorphophobia.” BDD appears to be relatively common. In the largest epidemiologic study, a nationwide survey in Germany (n=2,552), the prevalence of current BDD was 1.7% (95% CI=1.2–2.1%); BDD was somewhat more common in women (1.9%) than in men (1.4%).2 The prevalence of BDD has ranged from 0.7% to 1.1% in smaller community studies and from 2.3% to 13% in nonclinical student samples.3,4 BDD appears relatively common in clinical settings, including inpatient psychiatric settings; among patients with obsessive compulsive disorder (OCD), eating disorders, social anxiety disorder (SAD), and major depressive disorder (MDD; especially atypical depression); and in dermatology and cosmetic surgery settings.3,4 However, BDD often goes unrecognized.5–7 Many patients are too embarrassed and ashamed of their appearance concerns to raise them with a clinician.3,6 Patients with BDD can be severely disabled and suicidal. Thus, it is important to assess patients for BDD and be alert for clues to its presence.3,8,9 If the diagnosis is missed or misdiagnosed —or if only comorbid conditions such as depression are treated—BDD symptoms, psychosocial functioning, and suicidality may not improve.3,8 Because BDD may be less familiar to clinicians than other mental disorders, this article first briefly discusses some of BDD’s clinical features. Empirical evidence on suicidality in BDD is then reviewed. Finally, to manage suicidality, BDD must be detected (which is sometimes challenging), accurately diagnosed, and appropriately treated. This article, therefore, briefly discusses these topics. More comprehensive sources on BDD’s diagnosis and treatment are available elsewhere (S Wilhelm, PhD, unpublished data 2007).3,4,9,10

 CLINICAL FEATURES OF BODY DYSMORPHIC DISORDER Although individuals with BDD appear normal looking to others, they are preoccupied with distressing and time-consuming thoughts that some aspect of their physical appearance looks flawed or defective.3,5,11–15 They may worry, for example, that they have very noticeable acne, their skin is too red or terribly scarred, their hair is thinning, their nose is too large or misshapen, their head is too big, or their stomach is huge and protuberant. The appearance concerns can focus on any body area, and preoccupation with multiple body areas is common. The appearance preoccupations are obsessional, occurring on average for 3–8 hours per day. The beliefs about the perceived appearance defects are usually delusional or characterized by poor insight.3,16 In other words, most patients are completely or mostly convinced that the disliked body areas look abnormal, ugly, defective, flawed, unattractive, or deformed. Some patients describe themselves as looking like a monster, a severe burn victim, or the “Elephant Man.” Two-thirds of patients have ideas or delusions of reference, believing that other people take special notice of the “defect” (eg, stare at it, laugh at it, or recoil in horror because the defect is so ugly). Nearly all patients perform BDD-related compulsive behaviors, many of which may be observed by other people and can thus be a clue that a person has BDD.3,5,13–15 The aim of these behaviors is usually to check, fix, hide, or be reassured about the perceived defects. Common behaviors are mirror checking, excessive grooming (eg, compulsive hair styling or hair cutting, shaving, plucking eyebrows or body hair, excessive makeup application), asking other people if they look okay, skin picking, frequent clothes changing, tanning (eg, to cover perceived blemishes or “pale” skin), and compulsive shopping for beauty products and clothes. Most patients attempt to “camouflage” the perceived defects, such as by wearing a baseball cap, sunglasses, bulky clothes that cover their body, or heavy makeup, or by holding their body in certain positions (eg, turning the “bad side” of their face away from other people). The gender ratio has varied across studies but appears to be in the range of 1:1 to 3:2 (female:male).3 Comorbidity is common, with MDD, substance use disorders, OCD, and SAD most frequent.17 Functioning and quality of life are usually very poor. For example, in studies that used the 36-Item Short Form Health Survey, mental health-related quality of life was markedly poorer than for the general population, and even poorer than for patients with diabetes, a recent myocardial infarction, or clinical depression.18

 SUICIDALITY IN BODY DYSMORPHIC DISORDER Suicidal Ideation and Suicide Attempts in Body Dysmorphic Disorder Over the past century, patients with BDD have been described as being so distressed over their “ugliness” that they thought about, attempted, or committed suicide.13,19–22 For example, one young woman who obsessed about perceived lines under her eyes said, “I am constantly thinking about them, about my face and how I have changed. Makeup is just a waste of time. Life is not worth living.”19 Like this woman and other patients described in earlier reports, a patient seen by the author of this article was so distressed by her supposedly “large” nose, “ugly” hair, and “small” breasts that she considered suicide. She thought about her perceived appearance flaws “every second of every day,” and described these thoughts as “very, very distressing—an obsession. They’re so horrible I get suicidal; it is why I overdosed....” Cross-Sectional/Retrospective Data Empirical research on suicidality in BDD, while still limited, indicates that suicidal ideation and attempts are common in this disorder. summarizes data on suicidal ideation and suicide attempts from cross-sectional studies. Percentages in reflect lifetime (ie, past or current) rates, except for the Italian study which reported a current rate; the German study did not specify a period of time during which suicidality occurred. The United States sample of 307 subjects consisted of individuals seeking consultation or treatment in a BDD specialty setting (this sample is an expansion of previously reported samples).5,23 The other US study (n=200) was more broadly ascertained. Most participants were not seeking or receiving treatment in a BDD specialty setting. 24 The Italian study contained a clinical outpatient sample,15 and the study from England consisted of clinician referrals and self-referrals in response to media articles on BDD.11 The German study was a nationwide survey with participants representative of the general population; 42 individuals were diagnosed with BDD.2 The two US studies found a high rate of lifetime suicidal ideation (81% and 78%) even though the mean age of subjects was only in the early 30s. Comparisons with other groups must be made cautiously because direct comparisons were not made. However, these suicidal ideation rates are higher than reported for any mental disorder in an outpatient study and higher than reported for schizophrenia or MDD.25–27 Regarding suicidal ideation attributed primarily to BDD, both of the US studies found a high lifetime (current and past) rate, and the Italian study found a high current rate. A possible explanation for the lower rate in the German study is that the time period was not specified (this was also the case for suicide attempts). In addition, in the US studies suicidal ideation included thoughts that life was not worth living, whereas the German study asked a “higher-threshold” question about thoughts of taking one’s own life. TABLE 1 Suicidality Variable Non-Epidemiologic Samples Epidemiologic Sample US (n=307) US (n=200) Italy (n=58) England (n=50) Germany (n=42)† Suicidal ideation 81% 78% – – – Suicidal ideation due to BDD‡ 68% 55% 45% – 19% Attempted suicide 24% 28% – 24% – Attempted suicide due to BDD‡ 15% 13% – – 7% Number of suicide attempts§ 2.1±1.4 3.2±4.1 – – – Number of suicide attempts due to BDD‡,§ 1.2±1.4 1.2±3.0 – – – Open in a separate window Studies have found that 24% to 28% of individuals with BDD have attempted suicide ( ). Although here, too, comparisons with other populations should be made cautiously, these suicide attempt rates are an estimated 6–23 times higher than reported for the US population; within the range reported for depressed outpatients; and higher than that which has been reported for generalized anxiety disorder, panic disorder, or agoraphobia.25,27–32 A small chart-review study of clinic patients in Brazil (n=20) found that only 15% of subjects had a history of suicidal behavior.33 It is unclear whether the lower percentage in this study reflects numerical instability of the result due to the small sample or other factors. Taken together, these studies suggest that individuals with BDD have high rates of suicidal ideation and attempts. However, the findings vary to some extent across studies. Differences across studies may be attributable to differences in sample ascertainment. For example, somewhat lower rates might be expected in an epidemiologic sample. In addition, the studies used different questions to assess suicidality. Higher rates might be expected in the US studies, which asked about lifetime suicidality, whereas the time period covered in the German study was unspecified. Differences may also be attributable to cultural differences or other factors. Clinical Correlates of Suicidality in Body Dysmorphic Disorder One of the above studies (n=200)24 examined clinical correlates of lifetime suicidal ideation and attempts. In univariate analyses, both suicidal ideation and suicide attempts were significantly associated with more severe lifetime BDD, greater current functional impairment, lifetime bipolar disorder, any personality disorder, and borderline personality disorder. A history of suicidal ideation (but not suicide attempts) was additionally associated with comorbid lifetime MDD. A history of suicide attempts (but not ideation) was additionally associated with lifetime posttraumatic stress disorder (PTSD), an eating disorder, a substance use disorder, and delusional BDD beliefs (as opposed to non-delusional BDD beliefs). In logistic regression analyses, which examined which variables were independently associated with suicidality when controlling for other variables, lifetime suicidal ideation was independently predicted by comorbid MDD (odds ratio [OR]=2.77, P=.011) and more severe BDD (with each one-point increase on a nine-point BDD severity scale, the odds of suicidal ideation increased by 1.48; P=.003). Suicide attempts were independently predicted by PTSD (OR=6.44, P=.011), a substance use disorder (OR=3.07, P=.011), and more severe BDD (with each one-point increase on a nine-point BDD severity scale, the odds of a suicide attempt increased by 1.59; P=.005). Prospective Data One of the studies in (n=200) prospectively followed 185 subjects for up to 4 years, enabling determination of mean annual suicidality rates.34 As shown in ,34 annual suicidality rates were very high. Suicidal ideation was reported by 57.8% of subjects per year (annual weighted mean). This rate is approximately 10–25 times higher than the annual rate in the US population.29,35 Over prospective follow-up, 35.6% of subjects per year reported suicidal ideation that was attributed primarily to BDD symptoms. Among the entire sample, BDD severity was correlated r=.42 (P<.001) with the occurrence of suicidal ideation. TABLE 2 Variable Annual Weighted Mean Range (years 1–4) Subjects (%) 95% CI Subjects (%) Suicidal ideation 57.8 53.3–62.3 51.1–72.0 Suicidal ideation attributed to BDD (among entire sample) 35.6 31.2–39.9 31.0–39.8 Suicide attempt 2.6 1.1–4.0 0.0–3.7 Suicide attempt attributed to BDD (among entire sample) 1.5 0.4–2.6 0.0–1.9 Completed suicides 0.3 −0.1–0.8 0.0–0.8 Mean SD 95% CI Mean SD Among subjects with a suicide attempt Number of total attempts 2.5 2.1 1.4–3.6 1.3–4.8 0.5–3.6 Number of attempts attributed to BDD 2.0 2.9 1.0–3.0 0.8–3.5 0.8–4.5 Open in a separate window The mean annual suicide attempt rate of 2.6% in this study is an estimated 3–12 times higher than in the US population. 29,35 The medical threat of these attempts (plus those made during the month before intake into the study) was moderate or greater for 56% of the attempts. Suicidal intent was serious, very serious, or extreme for 72% of the attempts. Suicidality in Body Dysmorphic Disorder Compared to Obsessive-Compulsive Disorder Three studies that compared clinical characteristics of BDD and OCD examined suicidality (two of the studies included a subset of subjects from the previously noted US studies).36–38 A significantly higher proportion of BDD subjects than OCD subjects reported suicidal ideation (in two of three studies) as well as suicidal ideation attributed primarily to their disorder (in two of two studies).37,38 One study assessed lifetime suicide attempts that were attributed primarily to BDD or OCD, finding a higher rate among BDD subjects than OCD subjects (22% versus 8%).37 One study found a higher lifetime rate of suicide attempts (40%) among subjects with comorbid BDD plus OCD than in those with only BDD or only OCD. This appeared to be accounted for by more severe BDD symptoms in the comorbid group.38 Suicide Attempts in Other Patient Samples Other studies have examined suicide attempts in clinical samples that were not ascertained for BDD. In a study on a general psychiatric inpatient unit (n=122), BDD patients had more suicide attempts than non-BDD patients at a trend level (P=.098).6 A significant difference was not found in an outpatient study, although the sample size was small (n=16 BDD patients), which may have led to type II error.7 In an inpatient sample ascertained for anorexia nervosa (n=41), those with comorbid BDD (n=16) had a strikingly high lifetime suicide attempt rate of 63%. Anorexia inpatients with comorbid BDD were three times more likely to have attempted suicide than anorexia inpatients without comorbid BDD (P=.009).39 Among those with comorbid BDD, 69% had considered suicide specifically because of their BDD symptoms. Suicidality in Youths with Body Dysmorphic Disorder Suicide is the third leading cause of death among 15- to- 24-year-olds in the US.40 Thus, suicidality in youths with BDD is important, especially because BDD usually begins during early adolescence.14,23 In two of the previously mentioned studies, 67% and 81% of youths reported a history of suicidal ideation.41,42 Reported rates in the community are 15% to 27%.43,44 In these two BDD studies, 21% and 44% of youths reported a lifetime suicide attempt,41,42 whereas the estimated lifetime prevalence of attempted suicide among adolescents in the community ranges between 2.2% and 20%.45,46 One BDD study directly compared adolescents to adults, finding that a higher proportion of adolescents than adults had attempted suicide (44% versus 24%, P=.012).41 This finding was unexpected, given that adolescents had had fewer years over which to have attempted suicide because of their younger age. This finding did not appear to be explained by higher rates of comorbid depression, more severe depressive symptoms, current treatment status, or a cohort effect. It is possible that adolescents’ recall of suicide attempts was more accurate than adults’ recall. It is also possible that adolescents are at higher risk for suicidality than adults. In a study of adolescents in an inpatient setting,47 adolescent inpatients with BDD (n=14) scored significantly higher (P<.001) than adolescent inpatients without BDD (n=207) on the Suicide Probability Scale. Completed Suicide in Body Dysmorphic Disorder Completed suicide has been reported in numerous case reports and series.3,13,21,48 A retrospective study of suicides known to have occurred over 20 years among patients in two dermatology practices found that most of the patients who committed suicide had acne or BDD.20 The above-noted prospective BDD study found a very high rate of completed suicide—an annual weighted mean of 0.35% per year ( ).34 This annual suicide rate, adjusted for age, gender, and geographic region, is approximately 45 times higher than in the US population.49 That is, the standardized mortality ratio (SMR) for BDD in this study was 45. While SMRs for other populations vary somewhat depending on the study, an SMR of 45 is higher than that for most other mental disorders; the SMR for eating disorders is approximately 23, for MDD approximately 20, and for bipolar disorder approximately 15.50 Prospective studies of depression and panic disorder, which used methodology very similar to that used in the BDD study, found lower suicide rates than in the BDD study.30,51 While these findings suggest that the suicide rate in BDD is markedly high, they should be considered preliminary, especially given the relatively small sample size and short duration of follow up in the prospective BDD study, which limits the stability and precision of the suicide rate. Prospective studies are needed over longer follow-up periods and in other samples. Two Cases of Completed Suicide The two cases described here were participants in the previously noted prospective BDD interview study.24 Both individuals were receiving treatment at the time of their death. The first patient was a 31-year-old single white male who was receiving disability payments due to psychopathology. He had severe BDD (score of 7 on a 7-point severity scale) and BDD was his primary (ie, most problematic) diagnosis. He also met criteria for SAD and was in partial remission from MDD and alcohol dependence. He had no past hospitalizations or suicide attempts. He committed suicide by hanging. The second patient, a 54-year-old single white male, was unemployed due to psychopathology. He had severe BDD (score of 7 on a 7-point severity scale) and BDD was his primary diagnosis. He also had MDD and was in partial or full remission from dependence on alcohol and several drugs. He had four past psychiatric hospitalizations, all primarily for BDD. He also had one prior suicide attempt, which he attributed primarily to BDD. He committed suicide by stabbing himself. Suicide Risk Factors in Individuals with Body Dysmorphic Disorder Individuals with BDD have many risk factors for suicide. Risk factors include high rates of suicidal ideation, suicide attempts, psychiatric hospitalization, unemployment and disability, being single or divorced, poor social supports, and a history of abuse.11,14,15,18,23,24,52 Additional risk factors are high comorbidity with MDD, eating disorders, and substance use disorders.12,17 In addition, individuals with BDD often have poor self-esteem as well as high levels of anxiety, depression, anger/hostility, and impulsivity.53,54 From a clinical perspective, it appears that BDD symptoms may fuel suicidal thinking in several ways. BDD symptoms are about the self, as looking ugly, defective, or abnormal, and as being inadequate, unlovable, and unacceptable.3,11 Negative beliefs about appearance are often firmly held (ie, are delusional) such that patients cannot obtain relief by recognizing that the beliefs are inaccurate or senseless.17 These negative thoughts and beliefs cause distressing feelings such as depression, anxiety, shame, and low self-esteem.3 Of possible relevance to BDD, OCD obsessions that contradict important aspects of the self (as BDD obsessions do) are more upsetting than other types of obsessions.55 The obsessional and intrusive nature of negative BDD-related thoughts further fuel distress. In addition, BDD-related thoughts and distress often lead to social isolation, as many patients feel too self-conscious and ashamed of how they look to be around other people, and many believe that other people reject them, or even mock them, because of how they look.3,16 It can be postulated that BDD symptoms such as these, in combination with suicide risk factors such as those above, may lead to suicidal thinking and behavior.

 SUICIDE IN PATIENTS WHO RECEIVE COSMETIC SURGERY Six epidemiologic studies have found that women who received cosmetic breast implants have a suicide rate that is approximately twice the expected rate based on estimates in the general population.56 The largest investigation of this topic additionally found that women who had other types of cosmetic surgery also had an increased suicide rate.57 In some studies, women with breast implants who committed suicide were more likely to have had psychotherapy and more likely to have lower self-esteem and self-confidence, increased levels of depression, and an increased prevalence of mental illness as measured by psychiatric hospitalization.57 While reasons for the association between cosmetic surgery and suicide are unclear, one possible explanation is that some of these women may have had BDD, which is characterized by low self-esteem, depression, and a high rate of psychiatric hospitalization.56,58 In a recent study, breast augmentation/lift was the second most frequent cosmetic surgery received by individuals with BDD.59 The possible association of BDD with suicide in cosmetic surgery patients warrants further investigation.

 HOW TO RECOGNIZE AND DIAGNOSE BODY DYSMORPHIC DISORDER BDD usually goes undiagnosed in clinical settings.3,5–7 Patients often conceal their symptoms due to embarrassment, shame, or a worry that they will be misunderstood and considered vain.3,6 They may disclose only depression, anxiety, or discomfort in social situations. To diagnose BDD, patients must usually be asked directly about BDD symptoms.3,4,8 BDD can be diagnosed by asking questions that mirror the DSM-IV diagnostic criteria for BDD. Suggested questions are shown in .4 BDD is diagnosed if the person is excessively preoccupied with nonexistent or slight physical flaws (eg, thinks about them for at least 1 hour per day) and the preoccupation causes clinically significant distress or impairment in functioning. The appearance concerns should not be better accounted for by an eating disorder. However, if BDD and eating disorders co-occur, both disorders should be diagnosed. In depressed patients, it should not be assumed that BDD symptoms are irrelevant or simply a symptom of depression. If BDD diagnostic criteria are met, both BDD and depression should be diagnosed. BDD-related compulsive and safety behaviors such as mirror checking, excessive grooming, skin picking, and camouflaging may be clues that a person has BDD. TABLE 3 “Are you very worried about your appearance in any way?” or, “Are you unhappy with how you look?” If the patient replies affirmatively, proceed as you would with any other illness, asking the patient to tell you about his or her concern, eg, “What don’t you like about how you look?” or, “What is your concern?” Ask if there are other body areas they do not like, eg, “Are you unhappy with any other aspects of your appearance? Some people are worried about the appearance of their face, skin, hair, nose, or the shape or size of other body areas. Are these or any other body areas a concern for you?” Next, determine whether the patient is preoccupied with the perceived appearance flaws by asking, “How much time would you estimate that you spend each day thinking about your appearance, if you add up all the time you spend during the entire day?” or, “Do these concerns preoccupy you?” Thinking about the perceived flaws for a total of at least 1 hour per day is consistent with the diagnosis of BDD. Ask “How much distress do these concerns cause you?” After the patient replies, ask more specifically whether the concerns cause anxiety, anxiety around other people, anger, depression, panic, or suicidal thinking. Ask about effects of the appearance preoccupations on the patient’s life, eg, “Do these concerns interfere with your life or cause problems for you in any way?” After the patient replies, ask more specifically about effects on: Work: eg, being late, missing work, poor concentration or productivity, being unemployed or underemployed School: eg, being late, missing school, poor concentration or productivity, poor grades, dropping out of school, or not pursuing academic goals Social aspects of one’s life: eg, avoiding relationships, not dating, interference with intimacy or sexual functioning, avoiding social situations or events, becoming withdrawn from family or friends Other types of interference: eg, not caring for children, maintaining a household, paying bills, buying groceries, going shopping, or doing other household tasks Any other aspect of one’s life While BDD behaviors are not required for the diagnosis, most patients perform at least one of them (usually many), so these behaviors may be a clue that a patient has BDD. Ask, “Do you do things to check, try to fix, or hide the body areas you dislike?” Ask specifically about the most common behaviors: Camouflaging with clothing, sunglasses, hair, or body position Comparing their appearance with that of other people Checking the perceived flaws in mirrors or other reflecting surfaces Excessive grooming, eg, makeup application; face cleansing routines; or hair styling, combing, shaving, or plucking Seeking reassurance about how they look Touching the body areas Frequent clothes changing Skin picking to remove blemishes or other skin imperfections, or to “even out” one’s skin Tanning Dieting, excessive exercise, or excessive weightlifting Open in a separate window Patients should not be asked if they are concerned with an “imagined” defect in their appearance, as most have poor insight and do not think they are imagining the flaws they perceive. It is also best not to initially ask if they think they look disfigured or deformed, as words like these may be too extreme for some patients to endorse. Questions should focus specifically on physical appearance rather than bodily functioning, as patients may misinterpret the latter to apply only to physical illness.

 TREATMENT OF BODY DYSMORPHIC DISORDER Treatment of BDD is described in more detail elsewhere (S Wilhelm, PhD, unpublished data, 2007).3,9,10 Serotonin reuptake inhibitors (SRIs) and cognitive-behavioral therapy (CBT) are currently recommended as first-line treatments, which appear effective for a majority of patients. In contrast, cosmetic treatment, such as surgery and dermatologic treatment, appears to usually be ineffective for BDD.11,59 All SRI studies indicate that SRIs are often efficacious for BDD.3,9,10 These studies consist of a controlled and blinded cross-over study that compared the SRI clomipramine to the non-SRI desipramine (n=29); a placebo-controlled fluoxetine study (n=67)60; and open-label trials of fluvoxamine, citalopram, and escitalopram (n=15–30).10,61 In these studies, 53% to 73% of patients responded to the SRI. The cross-over trial found greater efficacy for clomipramine than desipramine, suggesting that SSRIs may be more efficacious than non-SRIs for BDD. Delusional BDD patients often improve with SRI monotherapy. Twelve to 14 weeks of SRI treatment appear to often be needed before a response is seen, and relatively high SSRI doses (higher than typically used for depression) often appear to be needed.3,10 If an SSRI is inadequately effective, augmentation of the SRI with another medication, or switching to another SRI, may be effective.3,10 SRIs appear to diminish suicidality in BDD. In the fluoxetine study,60 6% of fluoxetine-treated patients worsened on the Hamilton Rating Scale for Depression suicidal ideation item between baseline and endpoint, versus 30% of patients on placebo (P=.001). In the escitalopram study, suicidality significantly decreased.61 Available data suggest that CBT is often efficacious for BDD.3,9,62 In two randomized studies (n=54 and n=19), patients treated with CBT improved significantly more than patients on a waiting list. CBT was efficacious for BDD in several case series (n=5–13). The number of sessions in these reports ranged from twelve 60-minute sessions to sixty 90- minute sessions. CBT for BDD usually includes cognitive restructuring to identify cognitive errors and develop more accurate and helpful BDD-related thoughts and beliefs, as well as advanced cognitive techniques which focus on core beliefs; behavioral experiments to test the accuracy of BDD beliefs; exposure to avoided situations such as social situations; and response prevention to decrease compulsive behaviors such as mirror checking (S Wilhelm, PhD, unpublished data, 2007).3,62 Daily CBT homework should be assigned. CBT components that also appear beneficial include mirror retraining, in which patients learn to see their entire body in a nonjudgmental and “holistic” way (rather than focusing on disliked areas), while refraining from excessive mirror checking; mindfulness skills; habit reversal for skin picking and repetitive hair pulling or plucking; activity scheduling and scheduling pleasant activities for more severely ill, depressed, and inactive patients; and motivational interviewing, which is often needed to engage and keep patients in treatment (S Wilhelm, PhD, unpublished data, 2007).3

 CONCLUSION Available data indicate that individuals with BDD have high rates of suicidal ideation and suicide attempts, as well as a markedly high rate of completed suicide. These individuals appear to have many suicide risk factors. However, research on this important topic is limited. There is a pressing need for additional research on all aspects of suicidality in BDD, including rates, characteristics, correlates, risk factors, treatment, and prevention of suicidality. More specifically, studies are needed that use standard suicidality measures, and research is needed in a variety of samples— both clinical and epidemiologic—across different cultures and age groups. Longer follow-up of individuals with BDD is needed to obtain more precise estimates of the rate of completed suicide. The association between BDD and suicide in cosmetic surgery patients needs to be examined. Additional treatment research is also greatly needed, in keeping with Institute of Medicine63 and Surgeon General’s reports,64 which highlight the critical need to develop effective treatments for suicidality. More highly suicidal patients have been excluded from all BDD treatment studies to date because of the risks they pose. In this author’s clinical experience, SRIs are often effective for suicidal patients and should be prescribed for more highly suicidal patients with BDD. More highly suicidal patients also often benefit from therapy. However, there is a pressing need for research that examines the efficacy of existing BDD treatments for more highly suicidal patients and for research that develops even more effective treatments. Finally, because BDD often goes undiagnosed in clinical settings, there is a need for better recognition and diagnosis of this disorder. This will enable clinicians to provide appropriate clinical monitoring and treatment of these high-risk patients. ||||| Remember the days when people would bring photos of celebrities to the plastic surgeon’s office and ask for Angelina Jolie’s lips or Brad Pitt’s jaw line? That’s not the case anymore.

 Now, people want to look like themselves — heavily edited or filtered versions of themselves, that is.

 Doctors have spotted a trend of people bringing in their own selfies, usually edited with a smartphone application, and asking to look more like their photos, according to an article recently published in JAMA Facial Plastic Surgery by researchers from Boston University School of Medicine’s Department of Dermatology.

 The phenomenon is known as “Snapchat dysmorphia,” and it’s causing widespread concern among experts who are worried about its negative effect on people’s self-esteem and its potential to trigger body dysmorphic disorder, a mental illness classified on the obsessive-compulsive spectrum.

 “This is an alarming trend because those filtered selfies often present an unattainable look and are blurring the line of reality and fantasy for these patients,” the article states.

 Neelam Vashi, an assistant professor of dermatology at the Boston University School of Medicine and one of the article’s authors, told The Washington Post that “Snapchat dysmorphia” is a result of people now being able to edit away any imperfections with ease.

 “It’s remarkable,” said Vashi, who is also a board-certified dermatologist. “What used to lie in the hands of . . . celebrities and beautiful people who were innately beautiful made to look more beautiful, now it’s in the hands of anyone.”

 On Snapchat, for example, the picture messaging application features upward of 20 filters that users can toggle through by simply swiping across their phone screens. Aside from adding flower crowns or puppy ears, filters can give a person freckles, longer eyelashes, wider eyes and flawless skin, among other augmentations. Facebook, Instagram and Twitter also allow people to edit their photos in the application before uploading.

 Other applications such as Facetune take things a step further. For $3.99, users have access to a host of editing tools such as teeth whitening and making a person’s forehead, nose or waist smaller. The application has been lauded as “a Photoshop editing job in the palm of your hand” and even called “magical.”

 While people most often use filters or editing software for minor fixes such as clearing blemishes or plumping lips, Vashi said traditional cosmetic procedures largely can’t reproduce the “instant fix” people see in their edited photos.

 “Sometimes I have patients who say, ‘I want every single spot gone, and I want it gone by this week or I want it gone tomorrow,’ because that’s what this filtered photograph gave them,” she said. “They check off one thing, and it’s gone. That’s not realistic. I can’t do that. I can make people a lot better, but it will take me a lot more time than a week, and it won’t be 100 percent.”

 Of course, people have long obsessed about their looks, comparing themselves to the idealized images in the media, said Northwestern University psychology professor Renee Engeln during a 2013 TEDx Talk.

 “Our sense of what’s real, what’s possible when it comes to beauty, is warped by our overexposure to these images,” Engeln said. “Instead of seeing them for what they are, which is extraordinarily rare, we start to see them as typical or average.”

 Engeln described people who spend too much time worrying about their appearance as “beauty sick.”

 “When you are beauty sick, you cannot engage with the world,” she said, “because between you and the world is a mirror. It’s a mirror that travels with you everywhere. You can’t seem to put it down.”

 However, the term “Snapchat dysmorphia” was just coined this year by British cosmetic doctor Tijion Esho.

 According to the JAMA article, “Snapchat dysmorphia” is a form of body dysmorphic disorder. Also known as body dysmorphia or BDD, the condition is a mental disorder that causes people to be “extremely preoccupied with a perceived flaw in appearance that to others can’t be seen or appears minor,” according to the Mayo Clinic. People who have BDD tend to obsess over their appearance and body image, often checking the mirror, grooming or seeking reassurance for many hours a day, the clinic said. Treatments include cognitive behavioral therapy and medication.

 “Today’s generation can’t escape ‘the Truman effect’ because from birth they are born into an age of social platforms where their feelings of self-worth can be based purely on the number of likes and followers that they have, which is linked to how good they look or how great these images are,” Esho told the Independent.

 Until recently, only models and celebrities could take flawless, envy-inducing photos, the JAMA article said. However, given the accessibility of editing applications, once seemingly unattainable beauty standards now flood social media feeds daily, and the “perfect” people in the photos are your friends, classmates and family members, the article’s authors wrote.

 “Our society is becoming more and more preoccupied, obsessed with social media and images and photographs and what we look like,” Vashi said. “Now, everywhere you go people are taking selfies and then going on social media.”

 According to the annual American Academy of Facial Plastic and Reconstructive Surgery survey, selfies continue to be a driving force behind why people wish to get plastic surgery done.

 In 2017, the survey found that 55 percent of surgeons reported seeing patients who requested surgery to look better in selfies — a 13 percent increase from the previous year’s results.

 Being inundated by these edited images on a regular basis can take a toll on people, Vashi said, adding that looking at a photo of yourself and not seeing the same thing reflected in the mirror or an unedited photo can make people unhappy. In some cases, it can even lead to developing body dysmorphic disorder, she said.

 “It can bring feelings of sadness, and then if one really develops this disorder, that sadness clearly progresses to something that can be dangerous and alarming,” she said.

 A 2007 study published in Primary Psychiatry found that about 80 percent of people suffering from body dysmorphic disorder “experience lifetime suicidal ideation and 24% to 28% have attempted suicide.”

 While various experts, including plastic surgeons and psychologists, have cautioned against Snapchat dysmorphia, Vashi said it is unlikely that people will change their behavior in the near future.

 “It sounds like people are still going to do it because they like it. They like the way they look,” she said. “I’m just one small person in a big world, I can’t change everything, but I can make people aware and recognize and know that it’s not the real world. It’s like living in a fantasy.” |||||

Write a summary.

– Think you look better in your latest selfie than in real life? Then beware of "Snapchat dysmorphia," a newly dubbed term for people seeking plastic surgery to mimic their appearance in filtered selfies, the San Francisco Chronicle reports. "Sometimes I have patients who say, 'I want every single spot gone, and I want it gone by this week or I want it gone tomorrow,' because that's what this filtered photograph gave them," dermatologist Neelam Vashi tells the Washington Post. "They check off one thing, and it's gone. That's not realistic. I can't do that." Researchers say the fixation may be a new version of body dysmorphic disorder (or BDD), a mental ailment that makes people obsess over any perceived flaw in their appearance. A 2017 survey of plastic surgeons first spotted the trend, which is fueled by photo-filtering and editing technology once available only to celebrities. "This is an alarming trend because those filtered selfies often present an unattainable look and are blurring the line of reality and fantasy for these patients," according to an article in the JAMA medical journal co-written by Vashi. What's more, BDD is a serious mental disorder that can require cognitive behavioral therapy and medication—and lead to suicidal thoughts in 80% of sufferers, per a 2007 study. Just seeing an unfiltered image of oneself "can bring feelings of sadness" for some people, says Vashi, "and then if one really develops this disorder, that sadness clearly progresses to something that can be dangerous and alarming."


Focused crawls are collections of frequently-updated webcrawl data from narrow (as opposed to broad or wide) web crawls, often focused on a single domain or subdomain. ||||| Summer 2015 will forever be remembered as the season of celebrity break ups. Right before Labor Day, we can add another star couple split to the long list. Avril Lavigne & Chad Kroeger (better known as “that guy from Nickelback”) are getting divorced after two years of marriage. Lavigne broke the news via Instagram. Read more on… |||||
What is a one-paragraph summary of the above article?

– It must be pretty embarrassing to find yourself rejected by Playboy, but that's just what happened to these 10 celebrities rounded up by Fox News: Farrah Abraham: The Teen Mom star has been the source of many unspeakable headlines thanks to her recent sex tape, but multiple requests to appear in Playboy were turned down. So she did what any normal human would do and released her own nude pictures. Bridget Marquardt: Bizarrely, even one of Hugh Hefner's own girlfriends couldn't get her own solo spread in the magazine. After she failed her test shoots, Hef invited Marquardt to become one of the Girls Next Door, and she did at least end up in a group spread with her co-girlfriends. t.A.T.u.: If you've forgotten who this duo is, just recall 1990s hit "All the Things She Said." They got rejected from not one, but two editions of Playboy, the American one and the German one. LuAnn de Lesseps: She definitely seemed upset when fellow Real Housewife of NYC Kelly Bensimon was asked to pose in the mag, and responded with, "No one asked me!" She later claimed she didn't really want to be in Playboy anyway (and you'll notice she never was). Audrina Patridge: The Hills reality star reportedly had topless pictures taken to submit to Playboy, but got turned down ... and somehow, the photos were "accidentally" leaked. Click for the complete list.


Article:

He said he'll be back, and now he's keeping his promise: Arnold Schwarzenegger is plotting a movie return.

 Originally a body builder before making a transition to action movies, Schwarzenegger won the 2003 recall election to become Governor of California. Now, Schwarzenegger's time in office is over, and so he's looking to move back to film. Schwarzenegger tweeted today: "Exciting news. My friends at CAA have been asking me for 7 years when they can take offers seriously. Gave them the green light."

 CAA refers to the talent agency that represents him.

 As The Hollywood Reporter points out, Schwarzenegger, who is best known for his "Terminator" films, took on a number of bit parts in films throughout his governorship. Those included the 2004 "Around the World in 80 Days" remake, as well as summer 2010's action extravaganza "The Expendables."

 Schwarzenegger had previously mused on his film return, saying that he was reading and considering three different scripts. One would see him star as a kind hearted Nazi soldier that eschews orders to kill a group of kids, instead returning them to safety.

 That sounds action-packed, but he's realistic about his big screen limitations this time around.

 "In the future I have to adapt my roles to my age," he told an Austrian newspaper. "Clint Eastwood also has done it in the same way. Extreme fighting or shooting is not possible anymore. I want to be more encouraged as an actor and I believe that I can manage this challenge. I am like a sponge, which is absorbing all the knowledge and always be willing to learn all new things."

 WATCH a popular viral video chronicling the best of Schwarzenegger's movie lines: ||||| Exciting news. My friends at CAA have been asking me for 7 years when they can take offers seriously. Gave them the green light today.

 We all know the catchphrase that has been associated with Arnold Schwarzenegger since he starred in the 1984 movie "The Terminator." He even committed it to concrete at Grauman's Chinese Theater in Hollywood when his handprints and footprints were enshrined there as a major star of major motion pictures.Now those words may apply to him again. Schwarzenegger may return to the big screen.With the exception of some cameo roles like the one in the 2010 movie "The Expendables," Schwarzenegger has not had parts in any movies since he was elected governor of California in October 2003. In recent years, the Republican has had his hands full as California and the rest of the United States have struggled through the recession.When Schwarzenegger first took office as governor, his popularity was high and there was even chatter about the possibility of a run for the presidency. As President Barack Obama and his opponents known as "birthers" are well aware, a citizen must have been born in the United States to be eligible for the job.Although Schwarzenegger, who was born in Austria, would be ineligible for the presidency, legislation has been introduced at various times to amend the Constitution to allow residents who have lived in the United States for at least 20 or 25 years to become commander in chief, assuming they win the election. One bill, introduced by Sen. Orrin Hatch of Utah, even became known as "the Schwarzenegger amendment."But talk of higher office has subsided. Although he had favorability ratings of 79 percent in 2003, according to the Gallup Poll, his approval rating fell to 25 percent in January, according to Public Policy Polling.And Schwarzenegger has indicated that he would like to return to Hollywood. In a Twitter post on Thursday, he made a reference to the Creative Artists Agency, where his agents work, writing:Funny, he didn't think to use his catchphrase in the post. |||||
What is a summary?

– Arnold Schwarzenegger apparently meant it when he said, "I'll be back:" The ex-Governator is picking up his old day job, acting, reports the AP. "Exciting news," he tweeted. "My friends at CAA have been asking me for seven years when they can take offers seriously. Gave them the green light today." No word yet on whether any remakes of Terminator or Kindergarten Cop are in the works. Click here or here for more.


– Banks loaned Ted Cruz as much as $1 million during his first Senate campaign in Texas back in 2012, but you wouldn't know it from campaign finance reports. While Cruz eventually disclosed the loans from Citibank and Goldman Sachs—each valued at $250,000 to $500,000—to Senate officials, he failed to inform the Federal Election Commission as required, reports the New York Times. At the time, Cruz spoke of how he and his wife put "our entire net worth" into the campaign. NBC News reports he used $1.43 million in personal funds. But "a review of personal financial disclosures that Mr. Cruz filed later with the Senate does not find a liquidation of assets that would have accounted for all the money he spent on his campaign," per the Times. A Cruz rep admits the Goldman Sachs loan was used for the Senate race and a failure to disclose it was "inadvertent." She didn't comment on the Citibank loan, which the Times notes would have freed up other assets even if it wasn't used on Cruz's campaign. The Times notes, too, that disclosing the loans might have hurt Cruz's campaign, given that he was criticizing Wall Street bailouts and big banks. Cruz, who says the loans were borrowed against the couple's own assets, cites a "filing error," per NBC. "Those loans have been disclosed over and over and over again on multiple filings," he adds, per the Wall Street Journal. "If it was the case that they were not filed exactly as the FEC requires, then we'll amend the filings."

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 Ted Cruz on Wednesday night dismissed a New York Times report that he failed to properly disclose a loan from Goldman Sachs during his 2012 bid for the U.S. Senate, calling the matter merely a "filing error."

 "It is an inadvertent filing question," he told reporters at a press conference in Dorchester, S.C. "The facts of the underlying matter have been disclosed for many, many years. It is not complicated. Our finances are not complicated."

 The Times reported that the Cruz family took out a hefty low-interest loan from the bank, from which the candidate's wife took a leave of absence as a managing director at Goldman Sachs at the launch of the Texas senator's presidential run. That loan did not appear in the reports Cruz filed with the Federal Election Commission during his 2012 run.

 "If it was the case that it was not filed exactly as the FEC requires, we'll amend the filings," Cruz said. "But all of the information has been public and transparent for many years."

 Earlier Wednesday, the Cruz campaign called the charge an "issue of semantics."

 "The campaign is going to ask the FEC what to do," a campaign aide said, noting the loan was previously disclosed as part of Cruz's personal financial disclosures when he entered the Senate.

 The loan, which was for just under $500,000, was from his own assets, "not borrowed money," the campaign said.

 But a story often part of Cruz's speech on the road is his family's decision to invest in the campaign with the family's own finances.

 Cruz says on the stump that he and his wife "liquidated" their life savings to put into the Senate run.

 The campaign says he personally fronted a $1.43 million of his campaign's financing from personal savings, sold stock, and this particular loan.

 It also said on Wednesday night that Cruz ultimately repaid the loan in full but did not specify how.

 The campaign said Cruz was not aware at the time the loan was taken out that he had to file the loan with the FEC and was just made aware of it by the New York Times' inquiry. ||||| Texas Sen. Ted Cruz, shown at a rally in New Hampshire on Tuesday, helped pay for his 2012 election campaign in part by taking out personal loans from Citigroup Inc. and Goldman Sachs Group Inc.

 Texas Sen. Ted Cruz, shown at a rally in New Hampshire on Tuesday, helped pay for his 2012 election campaign in part by taking out personal loans from Citigroup Inc. and Goldman Sachs Group Inc. Photo: Ryan McBride/ Zuma Press

 WASHINGTON—Texas Sen. Ted Cruz didn’t disclose to election officials a pair of loans he took from Wall Street banks when he first ran for the Senate in 2012, an omission that could violate campaign rules.

 Mr. Cruz, a Republican, helped pay for his 2012 election campaign in part by taking out personal loans from Citigroup Inc. and Goldman Sachs Group Inc. that were eventually worth a total of between $500,001 and $1 million, according to financial disclosure forms that he filed with the Senate. Mr. Cruz’s wife, Heidi, worked for Goldman Sachs at the time. There is no indication that his wife was involved with the loan.

 Mr. Cruz disclosed those loans to Senate officials as required by congressional rules but didn’t tell federal election authorities about the loans, as required by election rules.

 The omission was first reported by the New York Times on Wednesday.

 Kenneth Gross, a campaign finance lawyer for Skadden Arps and a former Federal Election Commission general counsel, said that if a “candidate borrows funds to finance his campaign and puts those funds in his campaign, the candidate must disclose the original source of those funds.”

 Mr. Cruz told reporters late Wednesday that “those loans have been disclosed over and over and over again on multiple filings. If it was the case that they were not filed exactly as the FEC requires, then we’ll amend the filings. But all of the information has been public and transparent for many years and that’s the end of that.”

 A spokesman for Goldman Sachs declined to comment. Citigroup also declined to comment. There is no allegation that the banks did anything improper.

 Under the Senate’s financial-disclosure rules, senators and candidates for the Senate must make public information about their assets, income and debts. Under Federal Election Commission rules, candidates must disclose the source of funds for their campaigns. Mr. Cruz disclosed to the FEC at the time that he had put roughly $1 million in personal funds into his election campaign, but he didn’t disclose that the source of that money may have been the loans he received from Citigroup and Goldman Sachs at about the same time.

 At the time of the 2012 Senate race, Mr. Cruz was being outspent by Texas Lt. Gov. David Dewhurst, who was considered the favorite and spent more than $20 million of his own money on the race.

 Mr. Cruz first disclosed the loans on his congressional financial disclosure forms in July 2012, a few months before the election. Those filings show that he took out a “margin loan” of between $100,001 and $250,000 from Goldman Sachs earlier in 2012. Mr. Cruz had a brokerage account with Goldman Sachs and he told reporters Wednesday that he took out a margin loan from that account.

 Mr. Cruz’s July 2012 financial report to the Senate also shows that he took a “line of credit” from Citigroup of between $250,001 and $500,000.

 The loan from Goldman was later increased to between $250,001 and $500,000, according to subsequent financial disclosure reports for 2012 that Mr. Cruz made after being elected to the Senate.

 The senator’s financial statements for 2012 show that he paid off both the loans from Goldman Sachs and Citigroup by the end of that year. |||||


Article:
Image copyright Bellingcat / Russia Today Image caption Bellingcat released a photo of the man it says is Anatoliy Chepiga (left), while Russia Today named him as Ruslan Boshirov (right)

 A Russian man accused of the Salisbury poisoning is a military officer who received an honour from Vladimir Putin, an investigative website says.

 Following the attempted poisoning in March, UK investigators identified one of the two suspects as Ruslan Boshirov.

 President Putin claimed Boshirov was a civilian, and on Russian TV, he himself said he visited Salisbury as a tourist.

 But the website Bellingcat says he is actually an intelligence officer by the name of Colonel Anatoliy Chepiga.

 He has served in Chechnya and Ukraine and was made a "Hero of the Russian Federation" in 2014.

 British officials have not commented, but the BBC understands there is no dispute over the identification.

 Dmitry Peskov, a spokesman for the Kremlin, insisted that the suspect is a civilian. He said: "Many people look alike."

 Ex-Russian spy Sergei Skripal - who sold secrets to MI6 - and his daughter Yulia were poisoned with Novichok on 4 March.

 Both Mr Skripal and his daughter survived, but Dawn Sturgess - a local woman not connected to the original attack - died in July after being exposed to the same substance.

 It is thought Chepiga travelled to the UK on a false passport, along with another Russian national who used the name Alexander Petrov.

 Who is Colonel Anatoliy Chepiga?

 The 39-year-old trained at one of Russia's elite academies and served with a special forces unit under the command of the GRU - Russia's military intelligence service.

 He earned more than 20 military awards for his service.

 He is believed to have transferred to Moscow in about 2009, where he was given a false identity as Ruslan Boshirov. He has been working undercover for the past nine years.

 In December 2014, he was made a Hero of the Russian Federation. The medal, awarded in a secret ceremony, is typically handed out by the Russian president.

 It is only given to a handful of people each year. The timing suggests it was for operations in Ukraine.

 Media playback is unsupported on your device Media caption "Our friends had been suggesting for a long time that we visit this wonderful town" - interview from 13 September

 He and Petrov flew in to Gatwick Airport from Moscow on 2 March 2018 and visited Salisbury on two consecutive days, including 4 March, the day of the poisoning.

 Both men returned to Moscow on the same day. European arrest warrants and Interpol red notices have subsequently been issued for the pair.

 Russia does not extradite its own nationals.

 What is he accused of?

 Sergei Skripal, 67, and his daughter Yulia were poisoned by a nerve agent in Salisbury, where he lived. The attack was approved by the Russian state, according to the UK government.

 The Skripals spent several weeks in hospital, but recovered.

 The event sparked a series of accusations and denials between the UK and Russian governments, culminating in diplomatic expulsions and international sanctions.

 Police linked the attack to another poisoning in nearby Amesbury in June, in which Dawn Sturgess and her partner Charlie Rowley were exposed to Novichok after handling a contaminated perfume dispenser.

 Ms Sturgess later died.

 What does Russia say?

 When UK police identified Boshirov and Petrov, Russian President Vladimir Putin insisted the pair were innocent civilians.

 A day later, on 13 September, the pair appeared on Russian TV and claimed they were simply tourists, visiting Salisbury to see its "famous cathedral and its 123m spire".

 Boshirov - or Colonel Chepiga - said he and Mr Petrov were in the sports nutrition business, but were travelling for pleasure.

 They emphatically denied carrying any Novichok, or the modified Nina Ricci perfume bottle which UK investigators say contained the substance.

 The two men told Russia's state-run broadcaster that their lives had been "turned upside down" by the allegations.

 "We're afraid to go out, we fear for ourselves, our lives and lives of our loved ones," Boshirov said.

 Downing Street called the content of the interview "deeply offensive to the victims and loved ones of this horrific attack".

 Image caption Colonel Chepiga as the last name on the Gold Star honour list on the memorial wall of the Far Eastern Military Command School

 BBC Monitoring, which tracks foreign media, says Russian state-controlled TV has made no mention of allegations made by Bellingcat.

 However, they have been extensively covered by private media and external broadcasters.

 Writing on Facebook, Russian Foreign Ministry spokeswoman Maria Zakharova described the allegations as groundless.

 Komsomolskaya Pravda, a pro-Kremlin tabloid, published an online article listing "three reasons" why Chepiga was not involved in the Skripal poisoning, adding that he was not a Russian secret services operative.

 What has the UK government said?

 Foreign Secretary Jeremy Hunt has said he had a "frank exchange of views" with Russian foreign minister Sergei Lavrov about the incident.

 Speaking to Sky News on a visit to the United Nations General Assembly in New York, he said he had made clear to Mr Lavrov there would be a "price to pay" for the country's actions.

 "It was pretty tough because it is not acceptable for Russia to instruct two GRU agents to use chemical weapons on British soil," he said.

 "Our message to Russia is very straightforward: 'If you do this the price will be too high."

 Image caption Dawn Sturgess died in hospital on 8 July after handling a contaminated container

 Addressing world leaders at the United Nations on Wednesday, Theresa May criticised Russia for its "desperate fabrication" over the Salisbury spy poisoning.

 The prime minister accused Russia of "flagrantly breach[ing] international norms" citing "the reckless use of chemical weapons on the streets of Britain by agents of the Russian GRU".

 What is Bellingcat?

 The claims about Chepiga were made following an investigation by a firm called Bellingcat.

 Describing itself as "the home of online investigations", Bellingcat says it uses open-source computer software and social media as part of its work.

 Founded by Eliot Higgins, a British blogger and journalist, the firm has also carried out probes into the shooting down of Malaysian Airlines Flight MH17 in Ukraine, the wars in Syria and Iraq, and Mexican drug lords.

 On its work on the Skripal poisoning, Bellingcat says investigators searched images on several online search engines, contacted former Russian military officers, browsed photos of a military academy yearbook, searched specific terms online, and scoured leaked Russian databases.

 The firm says it then obtained extracts from the passport file of Anatoliy Vladimirovich Chepiga, which contained a photograph that strongly resembled a younger "Boshirov".

 A Bellingcat journalist, who writes under the pseudonym Moritz Rakuszizky, said he believed the firm was shortly going to be able to identify the second suspect in the Skripal case.

 "We believe based on the information we have gathered so far that he [Petrov] is a junior rank relative to Chepiga," he told BBC Two's Newsnight.

 "We think he is someone who is at the captain level or a senior lieutenant level." ||||| Bellingcat and its investigative partner The Insider – Russia have established conclusively the identity of one of the suspects in the poisoning of Sergey and Yulia Skripal, and in the homicide of British citizen Dawn Sturgess.

 Part 1 and Part 2 of Bellingcat’s investigation into the Skripal poisoning suspects are available for background information. In these previous two parts of the investigation, Bellingcat and the Insider concluded that the two suspects – traveling internationally and appearing on Russian television under the aliases “Ruslan Boshirov” and “Alexander Petrov” – are in fact undercover officers of the Russian Military Intelligence, widely known as GRU.

 Bellingcat has been able to confirm the actual identity of one of the two officers. The suspect using the cover identity of “Ruslan Boshirov” is in fact Colonel Anatoliy Chepiga, a highly decorated GRU officer bestowed with Russia’s highest state award, Hero of the Russian Federation. Following Bellingcat’s own identification, multiple sources familiar with the person and/or the investigation have confirmed the suspect’s identity.

 This finding eliminates any remaining doubt that the two suspects in the Novichok poisonings were in fact Russian officers operating on a clandestine government mission.

 While civilians in Russia can generally own more than one passport, no civilian – or even an intelligence service officer on a personal trip – can cross the state border under a fake identity. The discovery also highlights the extent of the effort – and public diplomacy risk – Russia has taken to protect the identities of the officers. President Putin publicly vouched that “Boshirov” and “Petrov” are civilians. As it is established practice that the awards Hero of the Russian Federation are handed out by the Russian president personally, it is highly likely that Vladimir Putin would have been familiar with the identity of Colonel Chepiga, given that only a handful of officers receive this award each year.

 Who is Colonel Chepiga?

 Anatoliy Vladimirovich Chepiga was born on 5 April 1979, in the far-eastern village of Nikolaevka in the Amur oblast, population 300, near the Russia-China border. At age 18, he enrolled at a military school just 40 kilometers from his home, the Far-Eastern Military Command Academy in Blagoveschensk, one of Russia’s elite training grounds for marine commandos and Spetsnaz officers.

 Anatoliy Chepiga graduated the academy with honors in 2001. He was then assigned to serve in the 14th Spetsnaz Brigade in Russia’s farthest-eastern city of Khabarovsk, one of the elite Spetsnaz units under GRU command. Chepiga’s unit (74854, formerly 20662) played a key role in the second Chechen War, and was also observed near the Ukrainian border in late 2014.

 Over the course of his assignment to the 14th Spetsnaz Brigade, Colonel Chepiga was deployed three times to Chechnya. The specific operations he was involved in are not known; however, a website of a far-eastern branch of a state-run military volunteer organization reports that he received over 20 military awards in the course of his service.

 At some point between 2003 (the last year we identified him at the 14th Spetsnaz Brigade in Khabarovsk) and 2010 (the year he received his first undercover passport), Anatoliy Chepiga was assigned his alter ego, “Ruslan Boshirov”, and was relocated to Moscow. Given his current rank of Colonel and function as a clandestine GRU officer, it is plausible that during this period he graduated from the Military Diplomatic Academy, also known as the “GRU Conservatory,” in Moscow.

 In December 2014, Colonel Chepiga was awarded Russia’s highest state award, Hero of the Russian Federation.This award is bestowed personally by the President of Russia “as recognition of services to the state and the people of Russia involving a heroic deed”.

 Most of the awards are handed out in public ceremonies – and accompanied by a presidential decree, such as the award in 2016 to Russian officers fighting in Syria. Other presidential decrees – when the underlying act of heroism is subject to state secrecy – are kept secret. This is the case with the award to Colonel Chepiga. While there is no publicly issued decree – or reference to him on the Kremlin website – the state-run volunteer website specifies that he received the award “in December 2014…for conducting a peace-keeping mission.”

 Indeed, the fact that Colonel Chepiga was bestowed the Hero of Russia award is announced on the website of his military school. While most other recipients of the award have a detailed description of the acts that resulted in the recognition, the last two recipients – Anatoliy Chepiga and Alexander Popov – received only a terse statement: “by decree from the Russian president.” This further implies that the mission he – or they – were awarded for was secret.

 The phrasing and timing of the award provides significant clues as to where Colonel Chepiga’s mission was. In 2014, there were no military activities in Chechnya. Russia had not engaged militarily in Syria yet. The only region in which Russia was conducting active military operations in secrecy at the time was in Eastern Ukraine, which is the most likely theatre of his mission, as suggested by the secrecy of his award.

 Anatoliy Chepiga is married and has one child.

 The Challenge of Finding Colonel Chepiga

 Bellingcat began the search with only the two targets’ photographs and their cover identities. Initially we attempted reverse image-search via several online engines, but no matches were found. Similarly, no name telephone numbers were registered in the name of “Ruslan Boshirov” in any of the reverse-searchable telephone databases usually scraped by Bellingcat.

 Having tried these initial avenues of pursuit, Bellingcat and the Insider approached the search deductively. On the assumption that the two suspects were GRU officers with a focus on West European covert operations (see our second publication about the Skripal poisoning suspects), and knowing their approximate age, we contacted former Russian military officers to inquire what specialized schools would have provided appropriate training. One of the sources we contacted suggested that the school with the best reputation for foreign-language training and overseas clandestine operations at the turn of the century – when the two suspects would have studied – was the Far Eastern Military Command Academy. The graduation years for the two were estimated between 2001 and 2003.

 We browsed through multiple (incomplete) yearbook photos and reunion galleries of the classes of 2001-2003 but did not find exact matches for either of the suspects. There were several possible – but not certain – matches for the suspect “Boshirov”. One of these was in a group photograph from a 2018 article about the history of the Academy. Near a photograph of Academy graduates deployed in Chechnya, the text referred to “seven school graduates [who] were bestowed with the Hero of Russia Award”.

 While testing the hypothesis that the unnamed person at right-most end of the photo might be “Boshirov,” we searched online for references to “DVOKU” (the Russian abbreviation for the Far Eastern Military Command Academy), “Chechnya” and “Hero of the Russian Federation.” This search landed us at the above-referenced Volunteer Union website, which described a certain Colonel Anatoliy Chepiga as linked to all three search terms.

 Online searches in both Google and via two Russian search engines found no images, or social media presence, related to a Colonel Anatoliy Chepiga, or to anyone by that name with a military connection. This appeared to be highly unusual, given the fact he had been awarded the highest state honor.

 Subsequently, the research team scoured leaked Russian databases for references to Anatoliy Chepiga. A number of leaked residential and/or telephone databases of various Russian cities and regions are freely available as torrents on the internet; data in such databases varies in recency between 2000 and 2014.

 The research team was able to find Anatoliy Chepiga in two locations and time periods in the database: in 2003, in Khabarovsk; and in 2012 in Moscow.

 In the 2003 database, a certain Anatoliy Vladimirovich Chepiga was listed with a phone number and an address only described as “в/ч 20662“, the Russian abbreviation for Military Unit 20662. 20662 is the Ministry of Defense designation number of Spetsnaz unit of GRU’s 14th Brigade in Khabarovsk.

 At press time, the telephone number listed next to the name of Anatoliy Chepiga was used by a person who has owned it for 4 years, and who was not aware of the previous owner of the number.

 Bellingcat accepted the working assumption that this person was indeed Colonel Anatoliy Chepiga, described in the publication as “Hero of the Russian Federation”.

 In the 2012 database, one person named Anatoliy Vladimirovich Chepiga were listed as residing in Moscow. This man was born on 5 April 1979.

 Using the birth date, address and family members’ names, Bellingcat searched for this man online and on social networks, to no avail. Another person with the same full name and birth year – but a different date of birth – was identified as a business owner unrelated to “Boshirov”. The birth year (1979) of the candidate from the database was one year later than the birth year in “Boshirov”s cover documents, however it corresponded to a graduation year from the military academy in 2001.

 At this point, Bellingcat accepted the working hypothesis that the man from the 2003 and 2012 databases is the same, and is in fact Colonel Chepiga, Hero of the Russian Federation.

 To establish if he is, in fact, “Boshirov,” we needed to obtain a photograph. None were available online or in open sources, even in a number of articles that referred to “Hero of Russia Colonel Chepiga.” Another graduate of DVOKU who reportedly received the same award simultaneously with Chepiga – Alexander Popov – could be seen in photos and videos, yet Chepiga was conspicuously absent. The systematic omission from photographs of an otherwise notable figure – which Bellingcat had previously observed in the case of GRU General Oleg Ivannikov, who served as Minister of Defense of South Ossetia under the cover identity of Andrey Laptev – suggested that Colonel Chepiga may also be a secret service officer.

 To validate the hypothesis that Chepiga is Skripal poisoning suspect “Boshirov,” Bellingcat and The Insider obtained extracts from the passport file of Anatoliy Vladimirovich Chepiga – the man born on 5th April 1979 – from two separate sources with access to databases dated prior to 2014.

 The passport file contained a photograph – dated approximately in 2003, when this passport was obtained – that strongly resembled a younger “Boshirov” as seen in passport photos released by the UK police, with an even stronger resemblance to the cover identity passport photo published in our previous publication on the Skripal suspects.

 A passport application form in the passport dossier listed Chepiga’s 2003 place of residence as “Military Unit 20662, Khabarovsk”, confirming this was indeed the person identified in the 2003 database. It also listed his place of birth as “village of Nikolaevka”, further linking this person to the Hero of the Russian Federation with the same name.

 The passport application form identified also Anatoliy Chepiga’s marital status and listed his military ID number.

 A Mission of Critical Importance

 Based on the array of information sources consulted – all of which were independent from each other and came from different time periods – Bellingcat was able to conclude with certainty that the person identified by UK authorities as “Ruslan Boshirov,” is in fact Colonel Anatoliy Vladimirovich Chepiga, a highly decorated senior officer from Russian military intelligence who was awarded the highest state honor in late 2014.

 This finding starkly contradicts both this man’s statements, as made in a TV interview to Russia’s state-run RT network, and President Vladimir Putin’s assertions that the person in question is merely a civilian named Ruslan Boshirov. These demonstrated falsehoods overshadow this man’s – and the Russian government’s – other denials in this respect, and corroborate the UK authorities’ allegations that this individual was a) complicit in the Skripal poisoning and b) acted on orders from a high-level government authority in Russia.

 Bellingcat has contacted confidentially a former Russian military officer of similar rank as Colonel Chepiga, in order to receive a reaction to what we found. The source, speaking on condition of anonymity, expressed surprise that at least one of the operatives engaged in the operation in Salisbury had the rank of colonel. Even more surprising was the suspects’ prior award of the highest military recognition.

 In our source’s words, an operation of this sort would have typically required a lower-ranked, “field operative” with a military rank of “no higher than captain.” The source further surmised that to send a highly decorated colonel back to a field job would be highly extraordinary, and would imply that “the job was ordered at the highest level.” |||||Summary:

– As the UK has alleged, Ruslan Boshirov is not who he says he is, at least according to an online investigative group. The Guardian reports Bellingcat and investigative partner the Insider say they have identified one of the men accused of poisoning the Skripals with novichok as a colonel with Russia's military intelligence service, the GRU. That man is Col. Anatoliy Chepiga, who fought in the war in Chechnya and in 2014 received the state's highest award: Hero of the Russian Federation. The BBC notes the award is generally given by Vladimir Putin, who has previously stated that Boshirov and companion Alexander Petrov are merely civilians; the men have said they traveled to Salisbury as tourists to see a well known cathedral there. Bellingcat suspects the mission that spurred that honor was a secret one; while most recipients' heroics are described in detail, Chepiga simply received his award "by decree from the Russian president." As for how the alleged identification came to be, Bellingcat explains a source suggested it look at whether the men could have attended the Far Eastern Military Command Academy, which had "the best reputation for foreign-language training and overseas clandestine operations." It came upon a photo that it thought could be Boshirov and continued its web searching, which ultimately led it to Chepiga's name and passport file. A 2003 photo in the file "strongly resembled a younger 'Boshirov.'" The BBC had this to say: "British officials have not commented. The BBC understands there is no dispute over the identification."