1. Childhood attachment and parental bonding in bipolar disorder Kevin Clarkson, MBBS 3, Kings College London kevin.clarkson@kcl.ac.uk MRC Social Genetic and Developmental Psychiatry Research Centre Attachment theory and Parental Bonding - Attachment behaviour is: any form of behaviour that results in a person attaining or retaining proximity to some other differentiated and preferred individual, who is usually stronger and/or wiser (Bowlby, 1969) - Described by John Bowlby in 1969 - Developed by Mary Ainsworth and others - Attachment is influenced by the parent-child bond - warmth - Rejection/Acceptance - Control/Over-protectiveness - Early attachment shapes our representational models - Responsive caregiver - Behaviour predictably influences caregiver and environment - Secure base from which to explore Attachment behaviour Parental bonding Secure Insecure - Avoidant (deactivating) strategy minimises rejection - Ambivalent (hyper-activating) strategy maintains caregiver interest - Disorganised (dissociative) strategy in response to combined parental threat and security Re- presentational models Self-worth Competence Hopefulness Behaviour of others Behaviours Self-soothing Exploring Playing Building relationships Tolerating negative experiences Re- presentational models Self-worth Competence Hopefulness Behaviour of others Behaviours Self-soothing Exploring Playing Building relationships Tolerating negative experiences - Early behaviour to ensure safety - Clinging, crying, sucking, smiling, pushing away… - Responsive, warm, accepting - Unresponsive, rejecting, cold - Inconsistent/distracted - Abusive StudyAttachmentParental Bonding InsecureLow warmthrejectionControl Mat. Pat.Mat.Pat.Mat.Pat. Parker (1979) Joyce (1984) Perris et al. (1985) Radke-Yarrow et al. (1992) Rosenfarb et al. (1994) Carlson et al. (1998) Geller et al. (2000, 2002, 2004, 2008) Reichart et al. (2007) Neeren et al. (2008) Schenkel et al. (2008) Strength of evidenceWeak Incon.WeakIncon.Strong Correlation with future bipolar disorder +ve None Attachment - Evidence of a link between childhood attachment insecurity and later bipolar disorder - Bipolar individuals show attachment deficits earlier in childhood than depressed subjects or controls - Attachment has a modulating role on the impact of maternal psychopathology - Secure attachment increases anxiety symptoms in children of bipolar mothers - Insecure attachment reduces problem behaviour Parental Bonding - Evidence of a link between early maternal rejection, low warmth and later bipolar disorder - Low maternal warmth linked to Increased duration and severity of disease episodes in adulthood - No evidence of a link between parental controlling behaviour/over-protectiveness and later illness - Evidence for the father-child bond is inconclusive Internal models Self-worth Competence Hopefulness Self- soothing Tolerance of negative experiences Internal models Self-worth Competence Hopefulness Self- soothing Tolerance of negative experiences Low warmth - Excessive inhibition or activation of reward systems - Modulated by internal models of self-efficacy and hopefulness - Insecure vs secure attachment Behavioural Approach System regulation Cognitive vulnerability Manic defence - Models of low self-efficacy, reduced tolerance, hopelessness - Lack of effective tools in response to stress - Increased depressive ideation - Mania is a protective response to depressive cognition - Grandiose ideas counteract low self-esteem Rejection Caregiver behaviour Insecure attachment