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Perinatal Psychiatry: Where Psychoanalytic Theory, Neuroscience, and Integrated Clinical Psychiatry Meet

Perinatal Psychiatry: Where Psychoanalytic Theory, Neuroscience, and Integrated Clinical Psychiatry Meet

© LIGHTSPRING/SHUTTERSTOCK.COM© LIGHTSPRING/SHUTTERSTOCK.COM

In May 2015, the American College of Obstetricians and Gynecologists recommended that all pregnant and postpartum women be screened at least once during the perinatal period (pregnancy and 12 months postpartum) for depression and anxiety.1 From the perspective of integrative care, this is a wonderful recommendation. However, from a more psychodynamic and neurobiological perspective, this recommendation falls short of what is actually needed to improve the lives of many mothers as well as their infants and children. Perinatal psychiatry is one area in psychiatry where our understanding of human growth and development requires knowledge from psychoanalytic concepts (specifically attachment theory), neuroscience (specifically the neurodevelopment of the neonate and the infant), and a sincere collaborative and integrated effort with our colleagues in obstetrics and pediatrics.

Attachment theory

Attachment theory was developed in the 1950s by John Bowlby,2 a British psychiatrist and psychoanalyst who studied children left by their parents in post-World War II England. In his work with these children, Bowlby found that they were not only attached to their parents, but indeed became depressed when they were separated from them. Attachment theory suggests that through the earliest bond with an infant’s parents, the child develops an internal working model of relationships that then becomes a model for all relationships later in life. It is significant that Bowlby suggested that this internal working model of relationships occurs during a sensitive period in the infant’s earliest years of life.

More recently, research on the neurobiology of attachment in humans as well as in other mammals has validated this idea that the first years of life are particularly sensitive to social development, specifically in interactions with the primary caretaker. In humans, the neurobiology of social bonding is forming during the first year of life, and this has significant implications for future social development if the infant is not given an appropriately nurturing environment.

Three levels of attachment

Attachment theory was further studied by Mary Ainsworth,3 John Bowlby’s collaborator, who went on to define 3 distinct and measurable levels of attachment to the primary caregiver:

• Secure attachment

• Anxious attachment

• Avoidant attachment

Anxious and avoidant attachment are classified as insecure attachments. These attachment patterns can be evaluated at 12 months of age and tend to remain consistent over time. Secure attachment is defined as the ability to carry a representational model of attachment figures as being available, responsive, and helpful. Insecure attachment is defined as not seeking out the attachment figure when distressed, or having difficulty moving away from the attachment figure, both situations likely due to having an unresponsive, rejecting, inconsistent, or insensitive caretaker.

This means that by the time the infant is 12 months of age, the internal working models have essentially been set. This has implications for the clinical care of mothers during the perinatal period.

Early brain development

The developing neurobiology of the infant supports the notion that the earliest months of development are crucial for social attachment. For instance, we know that at birth, the hypothalamus is already formed. The hypothalamus functions through the hypothalamic-pituitary-adrenal axis to produce cortisol by the adrenal glands. Cortisol at high doses acts as a neurotoxin and inhibits neural connections, while cortisol at low doses acts as a neurotrophic factor and induces neuronal development through neuroplasticity.

Modulation of cortisol at this early stage of life is extremely important for neuroplasticity and brain development. Social bonding (skin-to-skin contact) and oxytocin are significant modulators of cortisol at this stage of development.4 Hence, if the mother is severely depressed, or is not feeling motivated to hold and touch her infant, this has important effects for the early brain development of the neonate.

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