Childhood attachment and parental bonding in bipolar disorder

Kevin Clarkson, MBBS 3, King’s College London

kevin.clarkson@kcl.ac.uk

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