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Insights and Understandings about Parental Anxiety Dr Pam Cooke Consultant Psychiatrist

Insights and Understandings about Parental Anxiety · Insights and Understandings about Parental Anxiety DrPam Cooke Consultant Psychiatrist. ... Cambridge Dictionary ... • Increase

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Page 1: Insights and Understandings about Parental Anxiety · Insights and Understandings about Parental Anxiety DrPam Cooke Consultant Psychiatrist. ... Cambridge Dictionary ... • Increase

InsightsandUnderstandingsaboutParentalAnxiety

Dr PamCookeConsultantPsychiatrist

Page 2: Insights and Understandings about Parental Anxiety · Insights and Understandings about Parental Anxiety DrPam Cooke Consultant Psychiatrist. ... Cambridge Dictionary ... • Increase

Overview

1. Whatisanxietyandhowcommonisitintheperinatalperiodandbeyond?

2. Whatimpactdoesmaternalanxietyhaveonthefetus?

3. Whatimpactdoesanxietyhaveonattachmentbehaviours?

4. Pullingitalltogether

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1.Whatisanxietyandhowcommonisitintheperinatalperiod?

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DefinitionofAnxiety

CambridgeDictionary

“anuncomfortablefeelingofnervousnessorworryaboutsomethingthatishappeningormighthappeninthefuture”

“somethingthatcausesafeelingoffearandworry”

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AnxietyDisorders

• DSM5

• “anxietydisordersdifferfromdevelopmentallynormativefearoranxietybybeingexcessiveorpersistingbeyonddevelopmentallyappropriateperiods.”

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Perinatalanxiety

Riskofananxietydisorderintheperinatalperiodis10%(Stuart2005)

Outofthis• 1.3-2.0%- PanicDisorder• 4.4-8.2%– GeneralizedAnxietyDisorder• 2.7-3.9%– OCD• 0-6.9%- PTSD

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2.Whatimpactdoesmaternalanxietyhaveonthefetus?

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Whyisitsoimportanttoidentify?

Shortandlongtermconsequencesforthepregnancy,foetus,childandsubsequently,theadult

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Pregnancyoutcomesassociatedwithprenatalstress

• Increaseincongenitalmalformationsassociatedwithseverestressinfirsttrimestere.g.deathofolderchild(HansenDetal2000)

• Lowerbirthweight(Wadhwa PDetal1993)• Prematurity• Alteredsexratio– fewermalesbeingbornthaninanunstressedpopulation(Peterka Metal2004)

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FetalOutcomes- FetalProgramming

Definition“whentheenvironmentinuteroduringspecificcriticalperiodsfordifferentoutcomes,canaffectthedevelopmentofthefetusandthechildinthelong-term”e.g.– especiallystudiedinrelationtofetalgrowthandlatervulnerabilitytocardiovasculardisease.

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Newbornsandinfants

Adversebehavioural outcomesobservablefrombeginning• more“difficult”temperament• Sleepproblems• lowercognitiveperformance• Increasedfearfulness

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Ages3-16yrs

• Increasedriskforchildemotionalproblemsespeciallyanxietyanddepression

• SymptomsofADHD• Conductdisorder(stressinlaterpregnancy)• Reductionincognitiveperfomance• Increasedriskofautisminsomestudies,withexposureinmid-lategestation(LiJetall–2009)

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• Increasedriskforschizophreniawithseverestress(e.g.invasionoftheNetherlandsin1940)(vanOs Jetal– Prenatalexposuretostressandsubsequentschizophrenia.TheMay1940invasionoftheNetherlands.BrJPsychiatry1998

• Firsttrimesterexposureappearstobethesensitiveperiod.

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Alsoarangeofalteredphysicalandphysiologicaloutcomes• Alteredfingerprintpattern(KingSetal2009)• Mixedhandedness(Obel Candothers2003)• Specificregionalreductionsinbraingrey-matterdensitylikelyresponsibleforfortheneurodevelopmental,psychiatric,cognitiveandintellectualimpairment

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• AlteredfunctioningoftheHPAaxis- altereddiurnalrhythm

• Reducedlifespan(reducedtelomerelength-linkedtoprematureaging)

• Asthmaage7years

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Ingeneral,prenatalstressincreasesanxietyanddepressivebehaviours toagreaterextentinfemaleoffspring,andimpairslearningandcognitionmoreinmaleoffsrping – whichisinkeepingwithahigherprevalenceofanxietydisordersand“neuroticism”foundinwomencomparedtomen

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PotentialUnderlyingBiologicalMechanismsforFetalProgramming

• ?Increasedexposureoffetustocortisol.Certainamountneededbutoverexposurecanpredisposetoillhealthinlaterlife

• Stressmayaffectthetransportofmaternalcortisolthroughtheplacenta,andincreasethecortisollevelinthefetus.

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3.Whatimpactdoesanxietyhaveonattachmentbehaviours?

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Anxietyandattachment

Whatmakesanemotionallyhealthyperson?

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Emotionallyhealthyhumans.

• Stemsbacktoearlyattachmenttoprimarycaregiver.Maternalanxietymayaffectthissignificantly

• AttachmentTheory- Bowlby andAinsworth-WHO1951– MaternalCareandMentalHealth“theinfantandyoungchildshouldexperienceawarm,intimate,andcontinuousrelationshipwith(his)mother(orpermanentmothersubstitute)inwhichbothfindsatisfactionandenjoyment”

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AttachmentPatterns

• Classificationbetween12-18months

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SecureAttachment

55-60%ofnon-clinicalpopulation

• good attunement between mother and baby • baby seeks out mother as secure base and

mother able to provide appropriate comfort • mother encourages appropriate exploration

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InsecureAvoidant

20-25%ofpopulation

• parent may be dismissive of child’s need for comfort, or may not notice child’s needs

• Encourages independence in child

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InsecureAmbivalent(Anxious)

10-15%ofpopulation

• child’s independence and exploration is minimised by parent

• child will seek out parent for comfort in times of distress, but will often be difficult to settle

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InsecureDisorganised

15-20%ofpopulation

• Childexperiencescaregiversaseitherfrighteningorfrightened

• Characterizedby lackofacoherent‘organized’behavioural strategyfordealingwiththestresses

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Assessment of Mother–Infant Relationship

Unsettledinsleepand/orfeedingDifficulttosettleIrritable/constantlycryingReflux/gastricdistressHyper-vigilanceDifficultyseparatingfromparent

Withdrawal/passivityFreezingGazeavoidantFailuretoThriveFlataffect/lackofcrying/limitedvocalisingEmotionallyunder-responsive

InteractiveResponsiveEngagingHoldseyegazeSmilingMirrorsparentalfacialexpressionCryingwhendistressedSettleswhencomfortedExplorestheworld

HEALTHYINFANTBEHAVIOURS BEHAVIOURSOFCONCERN

Avoidantattachmentbehaviours

Anxiousattachmentbehaviours

IndiscriminantAttachmentbehavioursInteractseasilywithstrangersAvoidsparents

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WHATARETHECONSEQUENCESOFTHESEATTACHMENTPATTERNSFORCHILDRENANDSUBSEQUENTLY, FORADULTS?

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AvoidantAttachment

Behaviours aschildren-externalizingbehaviours• Aggression• Hostility• Conductdisorders

Behaviours asadults• Denyfeelings• Hidefeelings• Denypainfulemotions• Dismisspainfulmemoriesorevents

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AmbivalentAttachment

Behaviours aschildren• Anxietydisorders• Emotional

Behaviours asadults• Anxietydisorders• Overlyemotional• Limitedassertiveness

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Disorganised AttachmentBehaviours aschildren• Aggressive• Pooremotional

regulation• Morelikelytodissociate• Lowerreflectivefunction• Lowerselfesteem• Academicproblems• Morelikelytoberejected

bypeers

Behaviours asadults• Depression• Anxiety• Substanceabuse• Excessivefocusonnew

romanticpartners“BorderlinePersonalityDisorder”

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Roleoffearinattachment

• Securechildrenfeardanger• Avoidantchildrenfearcloseness• Ambivalentchildrenfearseparation• Disorganizedchildrenfeartheircaregiver

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4.Pullingitalltogether.

Howdoesknowingallthisinfluencemypractice?

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• Some anxiety is normal in pregnancy or the post natal period, however anxiety that is persisting, significantly distressing or has associated with it a decline in functioning may be symptomatic of an anxiety disorder

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2subgroups.

- Peoplewithapre-existingcondition– eitherdiagnosedorundiagnosed

- Peopleinasituationalcrisis/adjustmentreaction/disorder

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Question

Howdoyoudecideifapregnantwomanorparentismoreanxiousthanthe“norm”?

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My“clinicalfilter”– totallyintuitiveandnon-evidencebased!

• Alotofreferencestofeelinganxiousareactuallymanifestationsofdepression- manypeopledon’tidentifywithhavingalowmood,butdoidentifywithfeelinganxious,andmoreoftenthannot,aclinicalsignificantlevelofanxietyhasacomponentofdepression

• Ifaparentcan’tgetbacktosleepafterthebaby/youngchildhasresettled,likelytobemoreclinicallysignificant.

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• Howdotheyfeeliftheyhavesometimetothemselves,e.g.abreakfromthebaby/youngchild,todosomethingthattheyusuallywouldenjoydoinge.g.goingforacoffeewithoutthechild/childrenforacoupleofhours?

• Haveotherpeoplecommentedontheirpresentationoronanychangeintheirchild?

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Issuesintreatment

• Howtoengage/educateawomanwhoispregnantandanxious,abouttheadverseoutcomesofbeinganxiousinpregnancyversusrisksfrompharmacotherapy?

• Enlistingthesupportofpartnerandfamilyifappropriate

• Knowingtheresourcesavailabletoyou–importanceoftheGPasthecoordinatorofcare

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Multifacetedapproach

• Psychoeducation aboutthecondition• Elicitingbarrierstoeffectivetreatment• Behavioural modification- especiallydietandexercise

• Psychologicaltherapies• Medicationoptions• Selfhelp/supportgroups• ParentInfantResearchInstitute

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CaseHistories

1. “Rob”– 19yr oldmaleinadultinpatientunit2. “Mary”27/40pregnantwithsevereOCD.

Cameoffsertralineat4weekspregnant,whenshediscoveredshewaspregnant.Severerelapse

3. “Anne”presentedat12monthspostpartum,withseverehealthanxietyandanxietyregardingherdeath.Hadtraumaticlabouranddelivery.

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Takehomemessages1. Anxietyiscommon.Likelythat1:10antenatal

patientswillhaveananxietydisorder2. “Pathological”maternalanxietycanresultin

adverseconsequencesforthepregnancyandchildduetofetalprogramming

3. Disturbedmaternal-infantattachmentasaresultofmaternalanxietycanexacerbatebehavioural andmentalhealthissuesinoffspring.

4. Ifindoubt,refertoGPforfurthertriageorrefertohospitalpsychiatricservices.

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Questions?