Alexander Korte

Gender Identity Disorders in Childhood and Adolescence Currently Debated Concepts and Treatment Strategies

INTRODUCTION Gender identity disorders (GID) can appear even in early infancy with a variable degree of severity. Their prevalence in childhood and adolescence is below 1%. GID are often associated with emotional and behavioral problems as well as a high rate of psychiatric comorbidity. Their clinical course is highly variable. There is controversy at present over theoretical explanations of the causes of GID and over treatment approaches, particularly with respect to early hormonal intervention strategies. METHODS This review is based on a selective Medline literature search, existing national and international guidelines, and the results of a discussion among experts from multiple relevant disciplines. RESULTS As there have been no large studies to date on the course of GID, and, in particular, no studies focusing on causal factors for GID, the evidence level for the various etiological models that have been proposed is generally low. Most models of these disorders assume that they result from a complex biopsychosocial interaction. Only 2.5% to 20% of all cases of GID in childhood and adolescence are the initial manifestation of irreversible transsexualism. The current state of research on this subject does not allow any valid diagnostic parameters to be identified with which one could reliably predict whether the manifestations of GID will persist, i.e., whether transsexualism will develop with certainty or, at least, a high degree of probability. CONCLUSIONS The types of modulating influences that are known from the fields of developmental psychology and family dynamics have therapeutic implications for GID. As children with GID only rarely go on to have permanent transsexualism, irreversible physical interventions are clearly not indicated until after the individuals psychosexual development ist complete. The identity-creating experiences of this phase of development should not be restricted by the use of LHRH analogues that prevent puberty.

Body Image and Attitudinal Aspects of Eating Disorders in Rhythmic Gymnasts

Background: Aesthetic sports, especially on a competitive level, are often considered as a risk factor for the development of an eating disorder. A few studies have examined this issue in rhythmic gymnasts, but no reports on body image disturbance exist for these athletes compared to anorectic patients. Sampling and Methods: Fifty elite rhythmic gymnasts (average age 14.8 years) including the German national team, 58 female patients with anorexia nervosa (AN; average age 15.5 years), and 56 high school girls (average age 14.9 years) completed the Eating Disorder Inventory-2 and the Test for Detecting Body Image Distortion in Children and Adolescents (Test zur Erfassung der Körperbildstörung bei Kindern und Jugendlichen). Furthermore, body weight and height, body mass index, presence of amenorrhea and frequency of exercise were surveyed. Results: Body mass index was significantly lower in the elite rhythmic gymnasts than in the high school students, and significantly higher than in the AN patients. Both the elite rhythmic gymnasts and the AN patients were significantly smaller than the high school students. The elite rhythmic gymnasts trained significantly more frequently compared with the AN group and the high school group. Regarding the Eating Disorder Inventory-2 and the Test for Detecting Body Image Distortion in Children and Adolescents, AN patients scored significantly higher on all explored subscales than both the elite rhythmic gymnasts and the high school students. Conclusions: Even though some physical similarities were found for the elite rhythmic gymnasts and the AN patients, contrary to previous studies, no noticeable problems related to attitudinal aspects of eating disorders were detected in the elite rhythmic gymnasts. A mildly distorted body image of the abdomen was identified in elite rhythmic gymnasts, while AN patients expressed a broad body image distortion and students expressed no body image distortion. Our data do not allow us to draw conclusions regarding prevalence rates, long-term effects or male athletes.

Familienorientierte Gruppentherapie zur Behandlung von Patientinnen mit Anorexia und Bulimia nervosa - eine Pilotstudie

Zusammenfassung: Fragestellung: Familientherapie hat sich in der Behandlung von Anorexia (AN) und Bulimia nervosa (BN) als effektiv erwiesen. Die kognitiv-behaviorale Behandlung hat bei BN im Erwachsenenbereich gute Effekte erzielt, allerdings gibt es kaum Studien, die die Wirksamkeit psychotherapeutischer Behandlungen in der Adoleszenz untersucht haben. Da bei der Mehrzahl der Betroffenen die AN haufig wahrend der mittleren Adoleszenz auftritt und die BN wahrend der spateren Adoleszenz beginnt, ist die Entwicklung von Behandlungsprogrammen fur Essstorungen im Jugendalter dringend angezeigt. In diesem Beitrag wird ein Behandlungsprogramm dargestellt, das im Rahmen eines gruppentherapeutischen Vorgehens storungsspezifische (grostenteils psychoedukative) mit zieloffenen Therapiekomponenten verbindet. Die Patientinnen nehmen gemeinsam mit ihren Eltern an dem Gruppenangebot teil. Methodik: Es erfolgt eine Evaluation des Behandlungskonzepts anhand eines «single-group designs», und Veranderungen werden gemessen...

Psychotic episodes during menstruation in a 12-year-old girl: a case of menstrual psychosis

Short recurrent psychotic episodes during puberty and adolescence have been subject of clinical interest for decades [1]. However, their nosology and underlying biological mechanisms are still unclear. The diagnostic process is often challenging since schizophrenia and bipolar disorder, as well as severe depression, can initially present with transient psychotic symptoms [2]. Within this clinical spectrum, psychotic episodes with temporal association to the menstrual cycle, the so-called menstrual psychoses, represent a distinct and unfamiliar subgroup. They are unique for their sudden onset, short duration and complete remission. Patients show prominent affective (depressive or manic) as well as psychotic symptoms, and typical psychotic features comprise perplexity, stupor, mutism, delusion and hallucinations [3]. Symptoms can manifest in any phase of the hormonal cycle but reappear at the same time relative to menstruation [3]. Our 12-year-old patient experienced three episodes of menstrual psychosis in three subsequent menstrual cycles 7 months after her menarche. She was first referred to our clinic because of acute fears and sleep disturbances. The symptoms regressed completely, but recurred 5 weeks later. She was finally hospitalized as her mental condition deteriorated in the course of a few days. On admission she showed psychomotor retardation, cognitive disturbances and auditory hallucinations. Six weeks later, she experienced a third episode. Symptoms always began nearly isochronically with menstrual bleeding, increased to the full extent in 2–3 days, and regressed without residues after approximately 11 days (see also Table 1). Acute infection, metabolic disorders, and intoxication were ruled out by clinical and laboratory examinations. Brain MRI scans and EEG were normal. Psychological testing during the symptom-free interval revealed average intellectual functioning and minor concentration problems. Screening for anxiety and depression was negative. Regarding her medical history, delivery per caesarean without postnatal problems was reported; her mother suffered from postpartum depression. The patient’s development was both physically and mentally normative and she was not on any medication. Menarche was at age 11.6, she had slightly irregular cycles thereafter (which is not uncommon), and no abnormal fears or insecurities regarding her menses were reported. She was a single child from a good social background and well integrated in her social environment. For treatment, we administered an estrogen/progesterone combination for 21 days, followed by an estrogen preparation for 7 days [4]. She started medication on the first day of the menstrual cycle following the third episode and discontinued medication after 3 months, but has been symptom-free for further 10 months of follow-up. In our patient, the close temporal association of psychotic episodes and menstruation raised the diagnostic hypothesis of menstrual psychosis. This clinical syndrome is not recognized in standard diagnostic manuals (ICD-10, DSM-IV) and seems to be rare in children and adolescents with few case reports existing in the literature. Notably, to the best of our knowledge, our patient is among the B. D. Grünewald (&) A. Korte G. Schulte-Körne Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Munich, Nußbaumstraße 5a, 80336 Munich, Germany e-mail: barbara.gruenewald@med.uni-muenchen.de