Category Archives: Depression

A 25-Year-Old Affirmed Male with Multiple Comorbid Conditions – Review of Case Study

This is a case study of a trans man (born female) with many serious mental health problems, including an eating disorder. He was a survivor of childhood sexual abuse and the trauma seems to have been at the root of his problems.

He had “an eating disorder with restriction and purging, substance dependence, gender dysphoria, panic disorder without agoraphobia, PTSD, dissociative disorder, learning disorder, sleep disorder, mood disorder, borderline personality disorder, and pain disorder.”

This case study does not make any connections between his eating disorder and his gender dypshoria. Given the abuse and the multiple comorbidities, it is unlikely that the gender dysphoria caused the eating disorders.

The authors suggest that both the eating disorder and the gender dysphoria were caused by the early trauma.

“the underlying foundation of these multiple diagnoses is the presence of early developmental trauma to the emotion regulation system — which manifests as physical and emotional pain with impulsive and maladaptive attempts to engage in behaviors to meet personal needs, including safety. Zanarini and colleagues performed a study examining Axis I comorbidity in patients with BPD [borderline personality disorder] and identified high rates of comorbid PTSD. They also observed that meeting criteria for multiple Axis I disorders predicted meeting criteria for BPD.”

Treatment focused on the most severe issues first; suicidal thoughts and behaviors, then purging behaviors, urges towards substance abuse, self-harm, self-care, and interpersonal behavior. The patient was treated with dialectical behavior therapy.

Medical transition came later and was not part of the recovery from the eating disorder. However, at the time the patient entered therapy, he had already taken a male name and was dressing and living as a male.

This case study has some similarities to the case of a teenage girl* who developed gender dysphoria while being treated for an eating disorder. The teenage girl was also a survivor of childhood sexual abuse with multiple mental health problems: anxiety, depression, an eating disorder, excessive exercise, and OCD-type rituals related to germs (spraying her body with Lysol and excessive hand-washing). In addition, she had a past history of PTSD, OCD, self-harm, and suicidal thoughts.

These two cases suggest that in some cases, gender dysphoria is not the main cause of an eating disorder. Rather, trauma causes multiple mental health issues.

There are two more case studies of transgender people with eating disorders who were survivors of child abuse. They suggest different possible conclusions, however.

A trans woman whose eating disorder began when she started to live as a woman. Her goal was to have a more feminine shape. Transition and hormones did not cure the eating disorder, however. She had been physically and sexually abused as a child.

A trans woman whose identical twin also had an eating disorder. Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both survived an abusive father who threatened them with assault and death. However, one was a trans woman and one was a gay man.

In the first case, the eating disorder seems to be closely connected to the gender dysphoria since it started when she began to live as a woman. She clearly describes wanting to look more female. The abuse may have affected her, but gender dysphoria was also a factor.

In the second case, the eating disorder seems to have been caused by a combination of genes and environment, since both twins had anorexia but only one had gender dysphoria.

We’re left with the possibility that the answer is different in different cases. Sometimes severe childhood trauma may cause multiple mental health problems that include an eating disorder. Sometimes a combination of gender dysphoria and early childhood trauma may contribute to an eating disorder. And sometimes the same genes and environment will produce two people with similar eating disorders but different gender identities.

Of course, these are only four case studies. We can’t draw conclusions from them about all transgender people with eating disorders. Most of the case histories I have found don’t mention child abuse. Many of them suggest connections between gender dysphoria and eating disorders.

What we can see from these cases, however, is that for some transgender people with eating disorders, gender dysphoria is not the main or only cause of their eating disorder. Therapists should keep this in mind when treating transgender patients for eating disorders.

And, as always, we need more research.

Original Source (full text):

A 25-Year-Old Affirmed Male with Multiple Comorbid Conditions by Katharine J. Nelson, MD; S. Charles Schulz, MD in Psychiatric Annals, February 2012 – Volume 42 – Issue 2: 48-51.


A few additional details of the case history:

The article provides an interesting discussion of diagnosing and treating a patient. The full text is available online without cost, but here are a few details of the case:

The trauma the trans man survived involved “repeated episodes of sexual violence perpetrated from age 4 to 9 years old by a childhood friend’s father in the neighborhood.”

“The patient believed he had suffered multiple head injuries related to physical violence and asphyxiation in the context of sexual trauma, but was unclear if he had lost consciousness because of head injury or because of psychological dissociation during these events.”

He had “a history of heavy chemical use, starting with first use of alcohol at age 7, which continued through age 23. He also used diet pills starting at age 14, followed by heavy use of cannabis at age 15, and cocaine and other narcotics, including pills and heroin, at age 18 years.”

The patient had severe pelvic floor dysfunction which caused him a great deal of pain. It took him a while to get this diagnosed correctly.

“The patient was born and raised as a female, but in retrospect realized he did not fully identify with either the male or female gender. In the previous 2 years, he had decided to openly adopt a male gender, name, and manner of dress. He had the intention of pursuing hormone therapy and, eventually, chest reconstruction.”

Treatment and afterwards:

“Suicidal thoughts and behaviors were identified as the highest-priority target; after 6 months, these thoughts and behaviors had resolved. The patient was engaged in therapy and did not require significant emphasis on therapy interfering behaviors; therefore, quality-of-life interfering behaviors could be targeted, including purging behaviors, urges to use substances, self-injury, self-care, and interpersonally effective behaviors with friends, family, and other medical professionals. He graduated phase 1 of DBT therapy and proceeded to phase 2 to continue working on healthy emotional experiencing and management of trauma sequelae.

The patient graduated college with a high grade point average and went on to pursue master’s level education. He underwent sex hormone treatment and chest reconstruction.

He developed additional medical comorbidities, including insulin resistance and adrenal insufficiency. These medical conditions necessitated moving back in with his parents, resulting in significant familial conflict. The patient’s therapist made a referral for family therapy through our department, which was coordinated among treatment providers. The patient is enthusiastic about the progress made in treatment and states he often wonders if he would be still be alive without the intervention he received. Over the course of 3 years, his medications were all tapered to discontinuation, with the exception of prazocin 10 mg at bedtime for nightmares, ramelteon 8 mg for sleep, and clonazepam 1 mg three times a day, which was continued to assist with pelvic musculature functioning.”

Depression and Gray Matter in the Brain

Depression causes gray matter in the brain to decrease. This is important to keep in mind when looking at studies of trans people’s brains as many trans people have experienced depression.

These are just a few links to studies looking at depression’s effects on the brain. A smaller hippocampus seems to be particularly related to depression, although studies have also found a link to an overall decrease in gray matter.

The bottom line is that studies of gray matter and gender identity need to take into account past and present depression in both trans people and controls.

For anyone with depression, the bad news is that it’s not good for your brain. The good news is that you can do things for your brain – exercise, meditate, and learn.

You may be able increase the volume of your hippocampus with regular exercise. Eight weeks of mindfulness meditation increases the volume of your hippocampus and may increase the gray matter volume in other areas of your brain as well. You can increase your gray matter by learning a new skill like juggling or by reading text written backwards. Going to medical school affects your gray matter.

Back to the studies and the link between gray matter volume and depression.

State-dependent changes in hippocampal grey matter in depression. 

This study found that patients who were currently depressed had lower volumes of gray matter in the hippocampus compared to both healthy controls and people who had had depression before but were not currently depressed. After taking citalopram, the patients with current depression had more gray matter in the hippocampus.

Insular and Hippocampal Gray Matter Volume Reductions in Patients with Major Depressive Disorder.

This study found that patients with major depressive disorder had “a strong gray-matter reduction in the right anterior insula. In addition, region-of-interest analyses revealed significant gray-matter reductions in the hippocampal formation.”

The effects were stronger for people who had had more episodes of depression than people who had only had one episode.

The more episodes of depression a patient had, the less gray-matter volume they had in the right hippocampus and right amygdala.

They conclude:

“The anterior insula gray matter structure appears to be strongly affected in major depressive disorder and might play an important role in the neurobiology of depression. The hippocampal and amygdala volume loss cumulating with the number of episodes might be explained either by repeated neurotoxic stress or alternatively by higher relapse rates in patients showing hippocampal atrophy.”

In other words, having depression might affect the hippocampus or having a small hippocampus might make you get depressed more often.

Association of Depression Duration With Reduction of Global Cerebral Gray Matter Volume in Female Patients With Recurrent Major Depressive Disorder

This study found that the more months the patients had spent being depressed, the less total cerebral gray matter they had. More months of depression was also linked to less frontal gray matter, less temporal gray matter, and less parietal gray matter. The study only included female patients who had recurrent depression. They did not control for the anti-depressants the patients used, so it is possible that the medicines affected their gray matter.

Gray matter volume abnormalities in individuals with cognitive vulnerability to depression: A voxel-based morphometry study.

This study looked at people who don’t have depression but who might be vulnerable to it. The “cognitively vulnerable” group was chosen by their answers to two questionnaires. The first questionnaire looked at thinking styles that may contribute to depression – people may be vulnerable to depression based on how they think about causal attributions, consequences, and self-worth characteristics. The second questionnaire asked about symptoms of depression.

Cognitively vulnerable people had less gray matter volume in the left precentral gyrus and right fusiform gyrus compared to controls. In addition their right fusiform gyrus and right thalamus were smaller compared to people who had major depressive disorder. Patients with major depressive disorder had reduced gray matter volume in the left precentral gyrus and increased gray matter volume in the right thalamus.

They conclude:

“Reductions in brain gray matter volume exist widely in individuals with CVD. In addition, there exist similar abnormalities in gray matter volume in both CVD subjects and MDD patients. Reductions of gray matter volume in the left precentral gyrus might be correlated to the negative cognitive styles, as well as an increased risk for depression.”

Of course, we don’t know which way the causality goes – is the cognitive style causing a lower gray matter volume in the left precentral gyrus or is the lower volume of gray matter causing the cognitive style?

Widespread reductions in gray matter volume in depression.

This study found that people with major depressive disorder had 4.4% less global gray matter volume than controls. This would be the decrease expected in 14 years of normal aging.

The differences were greatest in the front and temporal lobes, but there were also significant differences in the parietal and occipital lobes.

There was not a significant difference in the cerebellar volumes.

The cortex was thinner in the left medial orbitofrontal cortex for the patients with depression.

The authors conclude:

“Our data demonstrate conclusively that widespread GM volume abnormalities are present in patients with depression. These alterations are substantial, corresponding to the amount of GM volume loss that, when averaged over the whole brain, would be expected from nearly 14 years of normal aging. The GM loss is also highly regionally specific, with focal regions showing decreases in GM volumes of nearly twice the magnitude of the global measure. The distributed and regionally specific nature of these alterations provides compelling support for considering MDD as a condition that involves the impairment of networks across the brain.”

Small frontal gray matter volume in first-episode depression patients.

This study found that patients who had had their first episode of depression had less gray matter volume in the frontal lobe than healthy controls. The lower volume was not correlated with length or severity of the illness. The patients had not yet taken any medication for their depression. The authors suggest that the changes in gray matter could have occurred before the symptoms of depression. (Although they also could have been caused by the depression, we really can’t tell.)

Anomalous Gray Matter Structural Networks in Major Depressive Disorder

This study found that the gray matter in people with depression is connected differently from in controls.

They say:

“Depressed participants had significantly decreased clustering in their brain networks across a range of network densities. Compared with control subjects, depressed participants had fewer hubs primarily in medial frontal and medial temporal areas, had higher degree in the left supramarginal gyrus and right gyrus rectus, and had higher betweenness in the right amygdala and left medial orbitofrontal gyrus.”

and they conclude:

“Networks of depressed individuals are characterized by a less efficient organization involving decreased regional connectivity compared with control subjects. Regional connections in the amygdala and medial prefrontal cortex may play a role in maintaining or adapting to depressive pathology.”