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Byrne SM, Fursland A. New understandings meet old treatments: putting a contemporary face on established protocols. J Eat Disord 2024; 12:26. [PMID: 38336928 PMCID: PMC10854196 DOI: 10.1186/s40337-024-00983-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.
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Affiliation(s)
- Susan M Byrne
- University of Western Australia, Perth, WA, Australia.
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Broomfield C, Stedal K, Touyz S. The Neuropsychological Profile of Severe and Enduring Anorexia Nervosa: A Systematic Review. Front Psychol 2021; 12:708536. [PMID: 34408714 PMCID: PMC8365190 DOI: 10.3389/fpsyg.2021.708536] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/30/2021] [Indexed: 11/13/2022] Open
Abstract
Characteristics of Severe and Enduring Anorexia Nervosa (SE-AN) are being investigated to differentiate the patients experiencing SE-AN from those at earlier stages of the AN disease. The current systematic review was the first step in exploring neuropsychological functioning as a potentially identifying characteristic for long-term presentations. With a subgroup of AN patients reflecting a unique neuropsychological profile that is proportionate to the quantity of patients that go on to develop SE-AN, it was the aim of this review to assess neuropsychological functioning in the later stage of the disease. In accordance with PRISMA guidelines, a literature search was conducted using four electronic databases (PsycINFO, MEDLINE, Web of Science, and Scopus) for neuropsychological research on AN participants with a seven or more year illness duration. Datasets that met inclusion criteria were screened for SE-AN participants (N = 166) and neuropsychological data extracted together with potentially confounding variables and information required to conduct a quality assessment. In research investigating decision-making, participants with a SE-AN presentation demonstrated significantly lower functioning compared to healthy controls. There was conflicting evidence for differences in intellectual functioning and set-shifting abilities with no variability indicated in central coherence, memory, attention, reasoning, or processing speed. If findings from this preliminary analysis are confirmed through empirical research, implications include earlier identification of SE-AN patients and more effective treatment development.
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Affiliation(s)
| | - Kristin Stedal
- Regional Department for Eating Disorders, Oslo University Hospital, Ullevål, Norway
| | - Stephen Touyz
- Inside Out Institute, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
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Sternheim LC, Wickham MI, Danner UN, Maddox TW, Filoteo VJ, Shott ME, Frank GKW. Understanding implicit and explicit learning in adolescents with and without anorexia nervosa. J Eat Disord 2021; 9:77. [PMID: 34187577 PMCID: PMC8243584 DOI: 10.1186/s40337-021-00431-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 06/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cognitive disturbances such as impairments in learning are thought to play a role in adult Anorexia Nervosa (AN). It is remains unclear to what extent these disturbances result from starvation of the brain, or relate to an abnormal premorbid cognitive profile. This study investigates learning processes in adolescents with AN, hypothesizing that implicit learning is intact, as found previously in explicit learning tasks. Secondly, we hypothesized that anxiety and depression symptoms, inherent to AN, are associated to learning processes in AN. METHODS In total 46 adolescents diagnosed with AN and 44 control participants were administered an implicit category learning task in which they were asked to categorize simple perceptual stimuli (Gabor patches) based on a linear integration (i.e., an implicit task) of orientation and spatial frequency of the stimulus. A subgroup of adolescents (n = 38) also completed a task assessing explicit learning. RESULTS Model-based analyses indicated that adolescents with AN performed significantly more accurately compared to their healthy peers regardless of whether they used the optimal strategy or not. Depression and anxiety did not relate to learning performance in the AN group. CONCLUSIONS Overall, our findings of augmented implicit and explicit learning in adolescents with AN corroborate recent studies that suggested higher stimulus-response learning during prediction error paradigms. Learning disturbances in adult AN may then be at least partly due to long-term malnourishment, highlighting the importance of early recognition and refeeding in treatments for AN.
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Affiliation(s)
- Lot C Sternheim
- Department of Clinical Psychology, Universiteit Utrecht, Heidelberglaan 1, 3508, TC, Utrecht, The Netherlands.
- , Utrecht, The Netherlands.
| | - Miriam I Wickham
- Department of Social Health and Organisation Psychology, Universiteit Utrecht, Heidelberglaan 1, 3508, TC, Utrecht, The Netherlands
| | - Unna N Danner
- Department of Clinical Psychology, Universiteit Utrecht, Heidelberglaan 1, 3508, TC, Utrecht, The Netherlands
- Altrecht Eating Disorders Rintveld, Wenshoek 4, 3705, WE, Zeist, The Netherlands
| | - Todd W Maddox
- Department of Psychology, University of Texas, Austin, USA
| | - Vincent J Filoteo
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Megan E Shott
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Eating Disorders Center for Treatment and Research, University of California San Diego, San Diego, CA, USA
| | - Guido K W Frank
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Eating Disorders Center for Treatment and Research, University of California San Diego, San Diego, CA, USA
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Schilder CMT, Sternheim LC, Aarts E, van Elburg AA, Danner UN. Relationships between educational achievement, intelligence, and perfectionism in adolescents with eating disorders. Int J Eat Disord 2021; 54:794-801. [PMID: 33554341 DOI: 10.1002/eat.23482] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE High performance at school is associated with the risk of eating disorders (EDs), and perfectionism is proposed as an explanatory factor for this association. This study aims to evaluate (a) potential discrepancies between the measured IQ of adolescents with EDs and the IQ that is expected given their educational track, and (b) to what extent perfectionism was associated with educational achievement independent from IQ. METHOD WISC-III Verbal IQ, Performance IQ, and Full Scale IQ of 386 adolescent ED patients were compared with population norms for their educational track, using one-sample t tests. The association between self-oriented perfectionism (Eating Disorder Inventory-2) and educational achievement, adjusted for IQ, was determined with sequential ordinal regression analyses. RESULTS Over 50% of the patients received pre-university education, the most complex educational track. For patients receiving education in the second most complex track, IQ-scores were lower than normative data for that track. For patients receiving pre-university education, the verbal IQ was lower than the norm for that track. Self-oriented perfectionism was associated with educational achievement independent from intelligence. DISCUSSION This study suggests that high educational achievement is common in adolescents with EDs. Particularly for patients who receive education in the most complex tracks the demands at school may be higher than they can handle, based on their IQ. Self-oriented perfectionism contributed to educational achievement independent from IQ. Our results indicate that treatment for EDs should include awareness for the possibility of a too high target level of patients at school and perfectionism.
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Affiliation(s)
| | - Lot C Sternheim
- Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
| | - Emmeke Aarts
- Department of Methodology and Statistics, Utrecht University, Utrecht, The Netherlands
| | - Annemarie A van Elburg
- Altrecht Eating Disorders Rintveld, Zeist, The Netherlands.,Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
| | - Unna N Danner
- Altrecht Eating Disorders Rintveld, Zeist, The Netherlands.,Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
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Hemmingsen SD, Lichtenstein MB, Hussain AA, Sjögren JM, Støving RK. Case report: cognitive performance in an extreme case of anorexia nervosa with a body mass index of 7.7. BMC Psychiatry 2020; 20:284. [PMID: 32503476 PMCID: PMC7275539 DOI: 10.1186/s12888-020-02701-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/28/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Studies show that adult patients with anorexia nervosa display cognitive impairments. These impairments may be caused by illness-related circumstances such as low weight. However, the question is whether there is a cognitive adaptation to enduring undernutrition in anorexia nervosa. To our knowledge, cognitive performance has not been assessed previously in a patient with anorexia nervosa with a body mass index as low as 7.7 kg/m2. CASE PRESENTATION We present the cognitive profile of a 35-year-old woman with severe and enduring anorexia nervosa who was diagnosed at the age of 10 years. She was assessed with a broad neuropsychological test battery three times during a year. Her body mass index was 8.4, 9.3, and 7.7 kg/m2, respectively. Her general memory performance was above the normal range and she performed well on verbal and design fluency tasks. Her working memory and processing speed were within the normal range. However, her results on cognitive flexibility tasks (set-shifting) were below the normal range. CONCLUSIONS The case study suggests that it is possible to perform normally cognitively despite extreme and chronic malnutrition though set-shifting ability may be affected. This opens for discussion whether patients with anorexia nervosa can maintain neuropsychological performance in spite of extreme underweight and starvation. TRIAL REGISTRATION ClinicalTrials.gov, NCT02502617. Registered 20 July 2015.
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Affiliation(s)
- Simone Daugaard Hemmingsen
- Centre for Eating Disorder, Odense University Hospital, Odense, Denmark. .,Research Unit for Medical Endocrinology, Odense University Hospital, Odense, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,Open Patient data Explorative Network (OPEN), Odense, Denmark. .,The Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.
| | - Mia Beck Lichtenstein
- Centre for Telepsychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Alia Arif Hussain
- grid.466916.a0000 0004 0631 4836Eating Disorder Unit, Mental Health Centre Ballerup, Mental Health Services in the Capital Region of Denmark, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jan Magnus Sjögren
- grid.466916.a0000 0004 0631 4836Eating Disorder Unit, Mental Health Centre Ballerup, Mental Health Services in the Capital Region of Denmark, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - René Klinkby Støving
- grid.7143.10000 0004 0512 5013Centre for Eating Disorder, Odense University Hospital, Odense, Denmark ,grid.7143.10000 0004 0512 5013Research Unit for Medical Endocrinology, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Research, University of Southern Denmark, Odense, Denmark ,Open Patient data Explorative Network (OPEN), Odense, Denmark ,The Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark
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Davico C, Amianto F, Gaiotti F, Lasorsa C, Peloso A, Bosia C, Vesco S, Arletti L, Reale L, Vitiello B. Clinical and personality characteristics of adolescents with anorexia nervosa with or without non-suicidal self-injurious behavior. Compr Psychiatry 2019; 94:152115. [PMID: 31513949 DOI: 10.1016/j.comppsych.2019.152115] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/16/2019] [Accepted: 08/04/2019] [Indexed: 02/04/2023] Open
Abstract
PURPOSE About one-fifth of patients with anorexia nervosa (AN) engage in non-suicidal self-injury (NSSI). This study examined clinical and temperament profile of female adolescents with both disorders (AN+NSSI) as compared with peers with AN only. METHODS A consecutive sample of 73 female adolescents with AN (mean age: 13.77 years), who had been admitted to inpatient or day-hospital services, received clinical, cognitive, and temperament/character evaluations. Of them, 32 met DSM-5 criteria also for NSSI. Assessments included demographics, standard nutrition parameters, Youth Self-Report (YSR), Wechsler Intelligence Scale for Children IV (WISC-IV), Temperament and Character Inventory (TCI), and Global Assessment of Functioning (GAF). RESULTS No differences were detected between AN+NSSI and AN in demographics, body mass index, or age at onset of AN. AN+NSSI had higher rate of binging and purging, higher YSR scores for both internalizing and externalizing psychopathology, lower total IQ, and lower Self-directedness and Cooperativeness scores. CONCLUSIONS These data suggest that adolescents with AN+NSSI have psychopathological, cognitive and overall character features that differ from patients with AN only. These characteristics may have implications for treatment and outcome.
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Affiliation(s)
- Chiara Davico
- Department of Public Health and Pediatric Sciences, Section of Child and Adolescent Neuropsychiatry, University of Turin, Italy; Department of Pediatrics and Pediatric Sciences, Regina Margherita Pediatric Hospital, Turin, Italy
| | - Federico Amianto
- Department of Pediatrics and Pediatric Sciences, Regina Margherita Pediatric Hospital, Turin, Italy; Neurosciences Department, Psychiatry Section, University of Turin, Italy.
| | - Federica Gaiotti
- Department of Public Health and Pediatric Sciences, Section of Child and Adolescent Neuropsychiatry, University of Turin, Italy
| | - Claudia Lasorsa
- Department of Pediatrics and Pediatric Sciences, Regina Margherita Pediatric Hospital, Turin, Italy
| | - Anna Peloso
- Department of Public Health and Pediatric Sciences, Section of Child and Adolescent Neuropsychiatry, University of Turin, Italy; Department of Pediatrics and Pediatric Sciences, Regina Margherita Pediatric Hospital, Turin, Italy
| | - Chiara Bosia
- Department of Pediatrics and Pediatric Sciences, Regina Margherita Pediatric Hospital, Turin, Italy
| | - Serena Vesco
- Department of Pediatrics and Pediatric Sciences, Regina Margherita Pediatric Hospital, Turin, Italy
| | - Luca Arletti
- Department of Pediatrics and Pediatric Sciences, Regina Margherita Pediatric Hospital, Turin, Italy
| | - Laura Reale
- Department of Public Health and Pediatric Sciences, Section of Child and Adolescent Neuropsychiatry, University of Turin, Italy; Department of Pediatrics and Pediatric Sciences, Regina Margherita Pediatric Hospital, Turin, Italy
| | - Benedetto Vitiello
- Department of Public Health and Pediatric Sciences, Section of Child and Adolescent Neuropsychiatry, University of Turin, Italy; Department of Pediatrics and Pediatric Sciences, Regina Margherita Pediatric Hospital, Turin, Italy
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Grau A, Magallón-Neri E, Faus G, Feixas G. Cognitive impairment in eating disorder patients of short and long-term duration: a case-control study. Neuropsychiatr Dis Treat 2019; 15:1329-1341. [PMID: 31190837 PMCID: PMC6535667 DOI: 10.2147/ndt.s199927] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 03/11/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction: Several studies have noted the potentially negative effect of eating disorders (ED) on cognitive performance. Objective: To compare the impact of the duration of abnormal eating behaviors on cognitive performance in a sample of people with short- and long-term eating disorders and in two control groups matched for age. Method: The neuropsychological performance of 82 women diagnosed with an eating disorder were compared with two control groups from the community of 66 healthy women. Time of duration of the disorder was less than two years in half of the clinical sample, and more than 10 years in the other half. The following instruments were used to measure neuropsychological performance: the Matrix Test, the Stroop task, the Trail-Making Test, the Tower of London Test, the Posner Spatial Task, the Rey's Complex Figure, the Wechsler Vocabulary Test, and the Hayling Completion Test. Results: It showed that persons with long-term ED presented more impaired neuropsychological profiles, but not in all areas. In contrast, the short-term ED group presented similar profiles to the control groups. Discussion: This study highlights the positive association between cognitive impairment and time of evolution of ED, above all in perceptual measures and non-verbal memory. Considering the effect of the evolution of ED cognitive performance (especially in long-term patients) may further our understanding of the development of the disorder and the factors that may favor its persistence.
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Affiliation(s)
- Antoni Grau
- ITA Mental Health Specialist, Madrid, Spain.,ITA Foundation, Barcelona, Spain
| | - Ernesto Magallón-Neri
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Barcelona, Spain.,Institute of Neurosciences, University of Barcelona, Barcelona, Spain
| | - Gustavo Faus
- ITA Mental Health Specialist, Madrid, Spain.,ITA Foundation, Barcelona, Spain
| | - Guillem Feixas
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Barcelona, Spain.,Institute of Neurosciences, University of Barcelona, Barcelona, Spain
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Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLoS One 2018; 13:e0202330. [PMID: 30114286 PMCID: PMC6095578 DOI: 10.1371/journal.pone.0202330] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 08/01/2018] [Indexed: 01/06/2023] Open
Abstract
PURPOSE In on-line forums, parents have reported that their children seemed to experience a sudden or rapid onset of gender dysphoria, appearing for the first time during puberty or even after its completion. Parents describe that the onset of gender dysphoria seemed to occur in the context of belonging to a peer group where one, multiple, or even all of the friends have become gender dysphoric and transgender-identified during the same timeframe. Parents also report that their children exhibited an increase in social media/internet use prior to disclosure of a transgender identity. Recently, clinicians have reported that post-puberty presentations of gender dysphoria in natal females that appear to be rapid in onset is a phenomenon that they are seeing more and more in their clinic. Academics have raised questions about the role of social media in the development of gender dysphoria. The purpose of this study was to collect data about parents’ observations, experiences, and perspectives about their adolescent and young adult (AYA) children showing signs of an apparent sudden or rapid onset of gender dysphoria that began during or after puberty, and develop hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among this demographic group. METHODS For this descriptive, exploratory study, recruitment information with a link to a 90-question survey, consisting of multiple-choice, Likert-type and open-ended questions was placed on three websites where parents had reported sudden or rapid onsets of gender dysphoria occurring in their teen or young adult children. The study’s eligibility criteria included parental response that their child had a sudden or rapid onset of gender dysphoria and parental indication that their child’s gender dysphoria began during or after puberty. To maximize the chances of finding cases meeting eligibility criteria, the three websites (4thwavenow, transgender trend, and youthtranscriticalprofessionals) were selected for targeted recruitment. Website moderators and potential participants were encouraged to share the recruitment information and link to the survey with any individuals or communities that they thought might include eligible participants to expand the reach of the project through snowball sampling techniques. Data were collected anonymously via SurveyMonkey. Quantitative findings are presented as frequencies, percentages, ranges, means and/or medians. Open-ended responses from two questions were targeted for qualitative analysis of themes. RESULTS There were 256 parent-completed surveys that met study criteria. The AYA children described were predominantly natal female (82.8%) with a mean age of 16.4 years at the time of survey completion and a mean age of 15.2 when they announced a transgender-identification. Per parent report, 41% of the AYAs had expressed a non-heterosexual sexual orientation before identifying as transgender. Many (62.5%) of the AYAs had reportedly been diagnosed with at least one mental health disorder or neurodevelopmental disability prior to the onset of their gender dysphoria (range of the number of pre-existing diagnoses 0–7). In 36.8% of the friendship groups described, parent participants indicated that the majority of the members became transgender-identified. Parents reported subjective declines in their AYAs’ mental health (47.2%) and in parent-child relationships (57.3%) since the AYA “came out” and that AYAs expressed a range of behaviors that included: expressing distrust of non-transgender people (22.7%); stopping spending time with non-transgender friends (25.0%); trying to isolate themselves from their families (49.4%), and only trusting information about gender dysphoria from transgender sources (46.6%). Most (86.7%) of the parents reported that, along with the sudden or rapid onset of gender dysphoria, their child either had an increase in their social media/internet use, belonged to a friend group in which one or multiple friends became transgender-identified during a similar timeframe, or both. CONCLUSION This descriptive, exploratory study of parent reports provides valuable detailed information that allows for the generation of hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among AYAs. Emerging hypotheses include the possibility of a potential new subcategory of gender dysphoria (referred to as rapid-onset gender dysphoria) that has not yet been clinically validated and the possibility of social influences and maladaptive coping mechanisms. Parent-child conflict may also explain some of the findings. More research that includes data collection from AYAs, parents, clinicians and third party informants is needed to further explore the roles of social influence, maladaptive coping mechanisms, parental approaches, and family dynamics in the development and duration of gender dysphoria in adolescents and young adults.
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Affiliation(s)
- Lisa Littman
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, United States of America
- * E-mail:
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