First, we need to define delusion...a term which is often misunderstood.
Delusion is defined in the DSM as irrational and fantastic beliefs that do not correlate with reality. Delusions are often associated with psychotic disorders like schizophrenia, but they can occur in persons with body dysmorphic disorder and anorexia nervosa, both of which involve delusions about body image and "dysphoric feelings" (these are feelings of discomfort or dissociation from oneself). Importantly, we aren't sure what causes delusions, but we do know a few things, like:
- persons suffering from delusions tend to believe with certainty in their delusion;
- a delusion is not the same as lying. People with delusions experience the delusion as a real thing;
- there is a fine line between "delusion" and "insight". Some persons who have been called "delusional" were instead very "insightful";
- not all delusions are the same, and not all delusions should be treated in the same way;
Now that we know a bit more about delusions, let's take schizophrenia out of the equation, since schizotypal disorders can involve distinct types of delusions, and are different from disorders like body dysmorphic disorder (BDD) and anorexia nervosa (AN), which involve feelings about own-body perception. We can also add gender dysphoria (GD) to this mix, because a key part of gender dysphoria involves similar feelings about having something wrong with your body. BUT, just because all three of these are similar, that doesn't make them the same! In fact, all three have different diagnostic criteria, and unsurprisingly, they all require different treatment.
For persons with BDD, that typically means rounds of therapy paired with antipsychotic medications like SSRIs. Through that process, the brain’s visual processing networks can be brought into alignment with the rest of the body. When that happens, delusional thinking tends to lessen or disappear.
For persons with AN, counseling and psychotherapy might involve "visual realignment", where persons are slowly helped to "see" and "recognize" their bodies. It also can include therapies that help persons overcome trauma and recognize individual agency, since adverse experiences and loss of agency may be a trigger for AN.
There is growing evidence that individuals with gender dysphoria also have irregularities in visual processing regions of the brain. However, in AN and BDD, realignment occurs by bringing the brain into alignment with the body. For persons with gender dysphoria, treatment works best when the rest of the body is brought into alignment with the brain's expectations about one’s own gender identity (remember: the brain is just as much a part of the body as anything else). We are not entirely certain why this works, but since there are many different regions of the brain, it is possible that gender identity and awareness are more strongly correlated with parts of the brain governing "gendered behavior". This also means that people with gender dysphoria are not at all delusional about their gender; instead, they probably have deep insight that the rest of us cannot see!
For transgender people, treatments like hormone replacement and gender confirmation surgery help to alleviate the distress resulting from internal conflicts.
In short, it can be said that gender dysphoria, body dysmorphic disorder, and anorexia nervosa all exhibit similarities, but for persons with BDD and AN, treatment involves aligning the brain with the rest of the body, and for persons with GD, treatment involves aligning the rest of the body with the brain.
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