Maternal Mental Illness Attachment Dr Andrew Mayers

2 Maternal Mental Illness  Overview  Maternal mental illness  Post-natal depression  Post-natal psychosis  Effect on relationship between them

3 The importance of attachment  Why is attachment important between mother and infant?  Early mother–infant bond may have sig. impact on developing infant (e.g. Bowlby, 1953; Ainsworth, 1993)  Infant’s internal working model (IWM) is very important  Expectations about themselves in relation to others  Model of self and of other  If infant’s carer attends positively and responds to needs   Infant has positive IWM:  High self-worth, availability of others, resolution of crises  Infant’s carer inconsistent response and attention   Infant’s has negative IWM:  Low or ambivalent self-worth, unavailable others, crises not resolved

4 Post-natal depression (PND)  Baby blues  Two to four days after birth (quite normal – but not PND)  Emotional/liable to burst into tears, for no apparent reason  Difficult sleeping (even when baby permits)  Loss of appetite  Feeling anxious, sad, or guilty  Questioning maternal skills  Effects up to 75% of mums  May relate to changes in post-birth hormone levels  Or could be related to being in hospital  Key is that this doesn't last long – usually only a few days  If it persists it may develop into PND

5 PND: Features  PND needs same DSM-5 diagnosis as major depressive disorder  But relates specifically to the peripartum period  Pregnancy and/or within 4 weeks of birth  Additional features may also indicate presence  Sense of inadequacy, inability to cope  Feeling guilty  Being unusually irritable  Which makes the guilt worse  Being hostile/indifferent to husband/partner/baby  Panic attacks  Excessive unwarranted anxiety  Such as being alone in the house  Obsessive fears about the baby's health or wellbeing

6 PND: Prevalence  PND affects about 10% of new mums  Compare to baby blues  Although DSM-5 states ‘must be within 4 weeks of birth’  Quite clear that symptoms last MUCH longer  Vulnerable mums usually referred in ‘perinatal’ period  During pregnancy up until baby is 1 year  Can come on gradually or all of a sudden  Can range from being relatively mild to very hard-hitting  At LEAST 50% PND women afraid to tell health profs about it  Scared it will lead to social services taking child away  Or that they would be seen as bad mothers

7 Post-natal psychosis (PNP)  PNP needs same DSM-5 diagnosis as any psychotic disorder  Schizophrenia  Schizoaffective disorder  Brief psychotic disorder  Can also include manic stages of Bipolar disorder  But PNP is not specifically mentioned in DSM-5  Other than ‘postpartum mood (MDD or manic) with psychotic features’  Not particularly helpful  Symptoms usually immediately within few weeks of birth  But psychotic episodes can also occur during pregnancy

8 PNP - features  Prevalence  1 in 1000 mums may get post-natal psychosis (0.1%)  Contrast with baby blues and PND

9 Attachment and bonding  Research with Clinical Doctorate student (see Steadman, et al 2007)  We explored serious mental illness in mothers (vs. controls)  Bipolar disorder, schizophrenia, schizoaffective disorder, severe depression  Sample  6 ill mums; 12 healthy controls  First 8 weeks after birth  We measured a number of key aspects  Cognitive functioning (computerised tests)  Memory, speed of functioning, attention  Perceptions of parenting skills and stress (questionnaire)  Observation of interaction with baby (video)  Quality, sensitivity, appropriateness, etc.

10 Attachment and bonding  Observation of interaction with baby  Undertaken with video  From behind mother (to see baby’s face)  But in front of mirror (to see mum’s face)

11 Attachment and bonding  Observation of interaction with baby  Quality and appropriateness of interaction  Assessed via Crittenden CARE Index (Crittenden, 2004)  Aims of CARE Index  Mothers and infants rated on 7 aspects  Facial expression  Verbal expression  Position and body contact  Affection and sensitivity  Turn-taking and co-operation  Control  Choice of activity

12 Attachment and bonding  Look at these two videos…  Note that these videos are only available in the lecture. They will be not be posted on myBU. This is to protect confidentiality

13 Attachment and bonding  This interaction was warm, affectionate and rewarding for both mum and baby

14 Attachment and bonding  This interaction was not so good  Mum appeared disinterested: blank face…  Baby was unsure and uncomfortable

15 PNP and the child  Results  Significant differences found for several measures  Mothers with serious mental illness (SMI) vs. controls  Poorer mother–infant interaction  Poorer perceived maternal competence  Poorer cognitive function  But how could we extend this?  We could examine the effect of SMI on other factors  Attachment and bonding  Long term affect on child development  Social, emotional, educational, language, forensic  Studies are now at planning stage

16 Attachment and bonding  What should we do?  How can we improve bonding?  Encourage breastfeeding?  Or is there already too much pressure?  Implications with medication?  Alternatives?  Bonding classes  Mindfulness, relaxation and positive therapy?