Maternal Mental Illness Attachment

1. Maternal Mental IllnessAttachment Dr Andrew Mayers amayers@bournemouth.ac.uk

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?