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Childhood attachment and parental bonding in bipolar disorder
Kevin Clarkson, MBBS 3, King’s College London
Bipolar Disorder- 1.5% of the UK/US population diagnosed with bipolar
spectrum disorder- Lifetime prevalence of 2.1% - Reduced quality of life, stability and happiness- Suicide rate 8-19%, higher than any other psychiatric
condition- Genetic inheritance responsible for up to 80% of variance
in expression of disorder
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
Attachment behaviour
Parental bonding Parental bonding
SecureSecure
InsecureInsecure
- 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-worthCompetenceHopefulnessBehaviour of
others
Behaviours
Self-soothingExploringPlayingBuilding
relationshipsTolerating negative
experiences
Re-presentational
models
Self-worthCompetenceHopefulnessBehaviour of
others
Behaviours
Self-soothingExploringPlayingBuilding
relationshipsTolerating negative
experiences
- Early behaviour to ensure safety- Clinging, crying, sucking, smiling, pushing away…
- Responsive, warm, accepting- Unresponsive, rejecting, cold- Inconsistent/distracted- Abusive
Systematic Literature ReviewObjectives- explore and consolidate evidence on the causal, predictive and correlating relationships between attachment, parental bonding and Bipolar Disorder- identify areas of strength, weakness and ambiguity in current research, in order to direct further study- discuss the findings in the context of adult attachment research and current developmental theories
Method- Database search for peer-reviewed journal articles: Medline, PsychInfo and Scopus- Excluded non-english language publications and systematic reviews- Excluded research that observed adult (rather than childhood) attachment- Adopted a ‘best-evidence synthesis’ approach to consolidate findings
Findings
Study Attachment Parental Bonding
Insecure Low warmth rejection Control
Mat. 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 evidence Weak Weak Incon. Weak Incon. Strong Strong
Correlation with future bipolar disorder
+ve +ve +ve None 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
Discussionattachment and parental bonding in the context of behavioural theories that explore bipolar disorder
Internal models
Self-worthCompetenceHopefulnessSelf-soothingTolerance of
negative experiences
Internal models
Self-worthCompetenceHopefulnessSelf-soothingTolerance of
negative experiences
Low warmthLow 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
Behavioural Approach System
regulation
Cognitive vulnerability
Cognitive vulnerability
Manic defenceManic
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
RejectionRejection
Caregiver behaviourCaregiver behaviour
Insecure attachment
Insecure attachment