Distinguishing and Addressing Gender Minority Stress and Borderline Personality Symptoms

Psychological Factors Associated with Functional Tic-like Behaviours during the COVID-19 Pandemic

Functional tic-like behaviours (FTLB) are a female predominant functional neurological disorder that escalated in incidence during the SARS CoV2 pandemic. This study compared social and adaptive functioning, social media use, pandemic experiences, and psychiatric comorbidities between FTLB (n = 35), Tourette Syndrome (TS) (n = 22), and neurotypical (NT) (n = 25) participants ages 11 to 25 years. The psychiatric comorbidity burden for participants with FTLB was formidable, with frequencies ranging from 1.5 to 10 times higher for major depressive disorder and panic disorder compared to TS and NT participants. Borderline personality disorder (BPD), agoraphobia, social anxiety disorder, and generalized anxiety disorder were also significantly more common in FTLB compared to NT participants. Vulnerable attachment scores, social phobia and social interaction anxiety symptoms were higher in participants with FTLB than NT but not TS. Overall distress tolerance, resilient coping, suggestibility, hours on social media, and exposure to tic and TS content were not significantly different between groups. FTLB participants rated their mental health declined more severely during the pandemic than both TS and NT participants and were more likely to experience trouble sleeping, loneliness, and difficulty affording housing and food than NT participants. Participants with FTLB were significantly more likely to identify as gender minority people than TS and NT, though there were no significant differences based on gender identity in the study variables within the FTLB group. The association and potential pathways explaining how psychiatric disorders may be contributing to FTLB, and why certain groups appear at particular risk are discussed.

The Role of Psychiatry for Transgender and Gender Diverse Adults

ABSTRACT

Since the inclusion of gender identity disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry and the broader medical field have made substantial alterations in their recognition of and respect for transgender and gender diverse (TGD) identities. As this recognition continues to expand, psychiatrists should be aware of both historical harm and current best care practices, especially in light of psychiatric morbidity in TGD populations relative to the general population. This article contextualizes the history of psychiatry's engagement with TGD patients and presents the gender minority stress and resilience model to frame the mental health disparities experienced by TGD people. We envision a role for psychiatry that goes beyond gatekeeping gender-affirming hormone therapy and surgeries. Instead, we should invest in equitable care across the continuum of mental health needs. We provide an overview of existing literature to help characterize psychiatric epidemiology for this population, with the goal of offering guidance on how psychiatrists can deliver responsive and high-quality care for TGD people. Some key areas of proposed clinical improvement include culturally tailoring interventions for substance use disorders, reducing medical trauma in acute psychiatric care settings, and better understanding the interplay of psychopharmacology and gender-affirming hormone therapy.

Detransition Narratives Trouble the Simple Attribution of Madness in Transantagonistic Contexts: A Qualitative Analysis of 16 Canadians' Experiences

Emerging evidence suggests that transgender individuals are more likely than cisgender peers to receive a diagnosis with a primary mental disorder. Attributions of madness, though, may serve the social function of dismissing and discrediting transgender individual's self-perceptions. The narratives of individuals who stop or reverse an initial gender transition who also identify as living with mental health conditions can sometimes amplify these socio-political discourses about transgender people. Through a critical mental health lens, this article presents a qualitative analysis of 16 individuals who stopped or reversed a gender transition and who also reported a primary mental health condition. Semi-structured, virtual interviews were conducted with people living in Canada. Applying constructivist grounded theory methodology, and following an iterative, inductive approach to analysis, we used the constant comparative method to analyse these 16 in-depth interviews. Results show rich complexity such that participants narrated madness in nuanced and complex ways while disrupting biased attitudes that madness discredited their thoughts and feelings, including prior gender dysphoria. Instead, participants incorporated madness into expanding self-awareness and narrated their thoughts and feelings as valid and worthy. Future research must consider provider's perspectives, though, in treating mad individuals who detransitioned, since alternate gender-affirming care models may better support the identification and wellness of care-seeking individuals who may be identified (in the past, present, or future) as mad.

Dialectical behaviour therapy (DBT) for high-risk transgender and gender diverse (TGD) youth: A qualitative study of youth and mental health providers' perspectives on intervention relevance

OBJECTIVES

Despite the significant mental health challenges and unique treatment needs of transgender and gender diverse (TGD) youth, research on the acceptability of evidence-based treatments for these youth is limited. To address this gap, the current study explored the perceived relevance of dialectical behaviour therapy (DBT) for high-risk TGD youth.

METHODS

Qualitative data were collected from six focus group discussions with a purposive sample of 21 TGD youth aged 18-25 years old who endorsed a history of depression, suicidality or self-harm and individual interviews with 10 mental health treatment providers with prior DBT and TGD client experience. The data were analysed inductively using thematic content analysis.

RESULTS

The results highlighted the perceived relevance of DBT in targeting chronic and acute stressors, some of which are unique to TGD youth such as issues related to gender dysphoria, hormone-related treatment and gender identity. Possible areas for treatment modifications including the adaptation of body awareness exercises and physiological-related coping techniques for youth experiencing gender dysphoria, and the reinforcement of self-care skills, were identified. While interpersonal effectiveness skills were acknowledged as important, treatment providers highlighted a need to prioritize safety over the practice of these skills. This is because TGD youth often experience more hostile and prejudiced interpersonal experiences than their cisgender peers.

CONCLUSION

The study's findings shed light on previously unexplored perspectives of TGD youth and treatment providers on the perceived relevance of DBT and provide treatment providers and implementation researchers with some critical issues to consider when working with high-risk TGD youth.

"Mental Readiness" and Gatekeeping in Trans Healthcare

Gatekeeping refers to clinicians' strict application of eligibility criteria to determine a trans patient's "fitness" to engage in medical transition, resulting in significant barriers to gender-affirming care. Gatekeeping often uses "mental readiness" as a prerequisite to medical transition, which contributes to patient distress and systemic discrimination. Changing international trans health guidelines (the new World Professional Association for Transgender Health Standards of Care version 8) recommends clinicians shift from a gatekeeping model towards an informed consent model, which improves access to care. This commentary offers recommendations on how clinicians can reconsider existing "mental readiness" frameworks around medical transition to facilitate improved access to care.

The nature of co-morbid psychopathology in adolescents with gender dysphoria

Gender-referred adolescents (GR) have been reported to present with considerable psychiatric symptomatology compared to their age-peers. There is, however, little research on how they compare to adolescents referred due to mental health problems (MHR). We set out to compare psychopathology in adolescents referred to our specialized gender identity unit (n = 84) and adolescents referred to a general adolescent psychiatric clinic (n = 293) in a university hospital setting in Finland. Of the GR adolescents, 40.9% had not received any psychiatric diagnosis during adolescence. Eating disorders were less common in the GR than in the MHR group, but otherwise the prevalences of disorders did not differ statistically significantly. At the symptom level, the GR adolescents displayed significantly more suicidal ideation and talk and less alcohol abuse and eating disorder symptoms than did the MHR adolescents, but otherwise their symptom profiles were comparable. Additionally, the GR adolescents had significantly fewer total externalizing symptoms than did the MHR adolescents. Adolescents seeking gender affirming treatments present with psychiatric symptoms and disorders comparable to those seen among adolescent psychiatric patients. Medical gender affirming care may not be a sufficient intervention for treating psychiatric comorbidities of adolescents with gender dysphoria.

Screening for borderline personality pathology on college campuses

Although borderline symptoms show a normative decline throughout adulthood, severe psychosocial impairment often remains. Identifying personality pathology in college-age students may help prevent "adaptive failure" that can occur during the critical period of development from puberty through the late 20s and thus reduce impairment later in life. The aims of the current study were to estimate the prevalence of borderline personality disorder (BPD) in a diverse college sample, determine which symptoms confer the greatest relative risk of screening positive for BPD and examine the utility of the Personality Inventory for DSM-5 brief form (PID-5-BF) in identifying BPD. Participants were 1456 undergraduate students, and 312 individuals (21.4% of the sample) screened positive for BPD. Chronic feelings of emptiness conferred the greatest relative risk of any symptom; students who endorsed this symptom were 15 times more likely to screen positive for BPD than those who did not. Scales and composite scores of the PID-5-BF demonstrated diagnostic accuracy ranging from sufficient to excellent. The current study contributes to literature concerning best practices in screening for personality pathology in young adults. Results suggest that chronic feelings of emptiness are significant for detecting at-risk students and implications for the use of the PID-5-BF are discussed.

Characteristics of Transgender Individuals With Emergency Department Visits and Hospitalizations for Mental Health

OBJECTIVE

Transgender individuals experience significant oppression resulting in mental health disparities. Factors associated with their need for acute mental health care are unknown. This study compared characteristics of transgender individuals who presented for acute mental health care with population-based comparison samples.

METHODS

This cross-sectional study examined transgender individuals who had a mental health-related emergency department (ED) visit (N=728) or hospitalization (N=454). Transgender individuals were identified, and their data were linked with health administrative data. The transgender ED and hospitalization samples were each compared with two samples: all individuals in Ontario who had an ED visit or hospitalization (unmatched) and individuals matched on age, region of residence, and mental health care utilization history. Individuals' sociodemographic and clinical factors were compared.

RESULTS

After matching, transgender individuals in the ED sample were more likely than those in the comparison group to be in the lowest neighborhood income quintile (37% versus 27%) and the highest residential instability quintile (47% versus 38%) and to be diagnosed as having a mood (26% versus 19%) or personality disorder (4% versus 1%). Transgender individuals in the hospitalization sample were more likely to be in the lowest neighborhood income quintile (36% versus 27%) and the highest residential instability quintile (45% versus 35%) and to be diagnosed as having a mood (40% versus 35%) or personality disorder (5% versus 2%).

CONCLUSIONS

Transgender individuals who accessed acute mental health care had unique sociodemographic and clinical factors associated with their presentation that persisted after matching. More research into the factors associated with their acute care presentation is warranted, including how experiences of marginalization play a role.

Sex and gender in treatment response to dialectical behaviour therapy: current knowledge, gaps, and future directions

Borderline personality disorder (BPD) is a mental health condition characterized by emotion dysregulation, interpersonal impairment, and high suicidality. Dialectical behaviour therapy (DBT) is the most widely studied psychotherapeutic treatment for BPD. To date, the vast majority of DBT research has focused on cisgender women, with a notable lack of systematic investigation of sex and/or gender differences in treatment response. In order to encourage effective, equitable treatment of BPD, further investigation into treatment targets in this population is critical. Here, we employed a systematic strategy to delineate gaps in the DBT literature pertaining to sex and gender differences and propose directions for future research. Findings demonstrate a significant discrepancy in measurement of sex and gender, particularly among gender-diverse individuals. Exploring DBT treatment response across the full spectrum of genders will facilitate the provision of more tailored, impactful care to all individuals who suffer from BPD.

Key learning aims

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Complex psychiatric comorbidities in Thai trans women: A case series

Trans women (TW) have a high prevalence of poor mental health. Gender-affirming treatments could reduce distress regarding their gender incongruity. However, psychiatric comorbidities might complicate the management or even confirmation of being transgender. We reported three TW with complex mental illnesses, including anxiety disorder with cultural explanation, neurodevelopmental disorders with cross-dressing, and severe personality disorder accompanied by major depression. All cases received both psychiatric and gender-affirming treatments, which demonstrated promising outcomes. Along with gender dysphoria (GD), psychiatric comorbidities also altered these TW's identity and manifestations. Recognition of such conditions would be beneficial in providing care for all TW, both with and without GD.

Identity Integration in Adolescents With Features of Gender Dysphoria Compared to Adolescents in General Population

Adolescence is an important period for identity formation and identity consolidation is one of the main developmental tasks. Gender identity is an essential aspect of identity but so far little is known about its development. Neither has the identity development of adolescents with features of gender dysphoria (GD) been extensively studied so far. However, adolescents with features of GD have been shown to present extensive psychiatric psychopathology and could therefore be assumed also to have more problems with identity development. We set out to compare the identity integration of adolescents with features of GD (n = 215; 186 natal females, 29 natal males) and adolescents from general population (n = 400; 244 females, 154 males and 2 who did not report their sex) using a culture-adapted Finnish version of an assessment tool for adolescents and young adults on identity in terms of personality functioning, the Assessment of Identity Development in Adolescence (AIDA). AIDA is a 58-item self-report questionnaire enabling dimensional differentiation between healthy and impaired identity development. The continuous AIDA total score (sum score) and its subscales were analyzed using MANOVA, and dichotomized T-scores differentiating identity development in impaired and healthy range using cross-tabulations with chi-square statistics. Adolescents with features of GD showed identity development similar to adolescents in general population. The slight differences seen in AIDA scores were in favor of the GD group. The proportion scoring to identity impairment was lowest among gender-referred adolescents assigned males at birth. Identity integration of the gender-referred adolescents was further compared to that of 77 adolescents in specialist level psychiatric outpatient treatment (67 females, 10 males). The adolescent psychiatric outpatients scored much higher toward impaired identity on all AIDA scales than did the adolescents with features of GD. These results suggest that features of GD are not associated with problems in identity development in adolescents at large. Adolescents with features of GD may have been required to process their identity more, thereby advancing further in their identity consolidation process than young people on average.

Personality Disorders and Personality Profiles in a Sample of Transgender Individuals Requesting Gender-Affirming Treatments

The study aims to explore the personality patterns of a group of transgender individuals who accessed an Italian gender clinic to undergo gender affirming treatments, by evaluating both dimensional personality domains proposed by the Alternative Model of Personality Disorders and categorical DSM-IV personality disorder (PD) diagnoses. Eighty-seven participants (40 transgender women and 47 transgender men) completed the Personality Inventory for DSM-5 and the Structured Clinical Interview for DSM-IV Axis II personality disorders. Scores obtained were compared to those of the normative samples of cisgender women and men. Results indicated that transgender women scored lower than cisgender women on two main domains (Negative Affectivity and Psychoticism) and on seven facets. As for transgender men, lower scores than cisgender men were found on Antagonism and on five facets. Transgender men scored higher than cisgender men on Depressivity. Nearly 50% of participants showed at least one PD diagnosis, with no gender differences in prevalence. Borderline PD was the most frequent diagnosis in the overall sample. Self-report measures provide a less maladaptive profile of personality functioning than the clinician-based categorical assessment. Results are interpreted in the light of the Minority Stress Model and support the need for a multi-method assessment of personality in medicalized transgender people.