What is fetal programming?
- In utero environment influences the development of the fetus and can have long-lasting effects on the child - Fetal programming sets the trajectory BUT can be influenced later in vivo (e.g. reversible)
What is the Barker hypothesis?
- CHD, T2DM, Stroke and HTN originate in utero in response to undernutrition during fetal life
What are the risk factors according to Barker hypothesis?
- In vivo (Obesity, Smoking) | In utero (Low Birth Weight ---> Increased risk of CHD/HTN) - N.B. undernutrition = LBW in this context
What increases and decreases the risk of LBW?
- If genetically determined to be small ---> no increased risk - If babies grow less than genetically destined ---> Increased risk - Those that grow less than genetically destined have catch-up growth (accelerated weight gain) during childhood
What is the Fetal Origin of Adult Disease?
- Birth weight, Birth phenotype (size), Early postnatal growth ---> Increased risk of Adult life
What is the most common complication of Pregnancy?
- Depression (10%) - Maternal depression is often missed - Maternal anxiety and depression associated with Maternal Adverse Childhood Experience (e.g. sexual abuse)
What is Maternal anxiety associated with?
- Fetal heart rate
What are examples of Maternal Prenatal Stress associated with Development?
- Maternal anxiety and depression - Maternal daily hassles - Anxiety relating to Pregnancy - Family discord - Child has increased risk of anxiety, depression, ADHD, CD, Autism/autism spectrum symptoms
What are causes of antenatal maternal anxiety/depression?
- Early childhood trauma-adverse childhood experiences (ACES) - Maternal history of sexual abuse predicts elevated anxiety/depression from pregnancy to 33 months
Describe prenatal stress more common in low and middle income countries
- Symptoms of perinatal depression and anxiety (roughly 25% compared with roughly 15%) - Pregnancy specific anxiety (can be high levels of maternal and infant death - Interpersonal violence (in Afghanistan 92% of women thought wife beating justified) - Effects of natural disasters e.g. Nepal earthquake - War and other conflicts - Refugees
What is prenatal stress also associated with?
Increased risk of - Reduced birthweight and gestational age - Mixed handedness - Altered finger print pattern - Decreased telomere length (may be associated with decreased life expectancy - Altered microbiome - Asthma - Altered immune function
How is pregnancy related anxiety associated with microbiome pattern in newborn meconium
- Less varied pattern of different types of microbiome if the mother was more anxious
Describe animal studies of relationship between pre-natal mood and child neurodevelopment
- Role of HPA axis and cortisol | Prenatal stress affects neurodevelopment of offspring - Stress pregnant animal + follow outcomes in child (cross-fostered by control rat just given birth to reduce post-natal rearing effects) - Offspring of stressed mothers appear more anxious (Increased cortisol response to novel stressor compared with control)
What is the ALSPAC study?
- Avon Longitudinal Study of Parents and Children - Overall top 15% most anxious/depressed mothers have 2x increased rate of child's probable mental disorder at age 13 - Prenatal anxiety/depression/stress accounts for 10% attributable load of probable mental disorder in the population - Children of anxious group have increased SDQ (Strength and Difficulties Questionnaire) at all stages from Age 4-13) | High anxiety group have 12% of MD by Age 13 (compared to 7%)
What is the double-hit hypothesis in prenatal risk for future mental health problems?
- Only those with genetic disposition AND anxious/depressed mothers develop Mental Illness in later life - GG polymorphism in COMT gene + Anxious mother had worst working memory at Age 8 - shows gene-environmental interaction
Why is the placenta important?
- Filters all substances that cross mother fetus | Placenta has high levels of 11beta-HSD2 (at M-F blood interface)
What does O'Donnell et al 2012 say? (11beta-HSD2)
- The more anxious the mother, the lower the level of 11beta-HSD2
Describe ethnic differences between stress and 11beta-HSD2
- Stress ---> Decreased 11beta-HSD2 and increased Glucocorticoid receptors BUT only in Caucasians (no difference in non-Caucasians)
What's the correlation between amniotic cortisol and cognitive development score?
- Increased amniotic cortisol ---> decreased cognitive development score (at 17m) -1st shown by Bergmann, 2010 - Insecure attachment: Increased cortisol ---> decreased cognitive score - Secure attachment: Increased cortisol ---> no change in cognitive score
Describe fMRI study of antenatal stress
- Antenatal stressful life events correlated with fMRI activation during rewarded attention
Describe epigenetic modifications of prenatal problems
- Maternal prenatal depression associated with methylation pattern in infant cord blood, Teh, 2014 - Prenatal pregnancy specific anxiety associated with epigenetic changes in infant cord blood, Hompes, 2013 - Epigenetic change can transfer stress up to 3rd generation
Why is prenatal stress related to neurodevelopment?
- Evolutionary advantage: Predictive-adaptive response (e.g. child with anxiety has increased vigilance ---> more likely to detect dangers) - Sex differences: Females look after Offspring (Increased rates of anxiety), Males explore and fight (increased rate of conduct disorder) - Dose response effect between stress and risk | Not all children affected in the same way (genetic basis for natural selection)
What are roles of professionals in helping mothers?
- Detect and treat anxiety and depression both in pregnancy and postnatally - Psychological interventions (eg CBT) - Pharmacological intervention if needed - Help with relationship problems or domestic abuse - Help to create more social support - Practical help with housing etc - Help to teach sensitive mothering – video feedback
What is self-harm?
- NICE guidelines: "act of self-poisoning or self-injury, irrespective of apparent purpose of the act - E.g. cutting, burning, overdoses, punching a hand against a wall etc
What is Non-suicidal self injury (NSSI)?
- “the deliberate damage to the body in the absence of (conscious) intent to die, and commonly includes behaviours such as skin cutting and self-battery” (Nock, 2009). " - Similar to self harm
Is it important to differentiate between self-harm and NSSI?
PRO: Important to differentiate because - DIFFERENT case conceptualisation, risk assessment, treatment (e.g. hospitalisation) AGAINST: - NOT a dichotomy, but a multidimensional construct = ambiguity - Difficulty of a valid and reliable assessment of intent
What is the case for including NSSI in the DSM-5?
- condition requiring further research - transdiagnostic nature of the behaviour and not just in borderline personality disorder (BPD) - clinical and functional impairment - NSSI purely within a BPD context or as a manifestation of suicidality will hamper research and treatment of NSSI
Which demographics are mainly self-harming?
- 25.7% of 16 to 24 year old women reported having self-harmed at some point in their life - 9.7% of 16 to 24 year old men - 13.2% of women aged 25 to 34 - Report bias? May be acceptable for females to disclose self-harm than for males - Males may not associate some behaviours with self-harm e.g. punching a wall
What is the iceberg model of self-harm?
- 15–17 years females: for every suicide, 919 girls presented to hospital for self-harm and 6406 self-harmed in the community (without coming to the attention of health services) - (Geulayov et al., 2018)
Describe repetitionsof self harm
- 1 in 4 still repeating after 4 years & increased severity (Moran et al., 2012) - Almost 1/2 of hospital presentations repeat SH in the following 6 weeks (Perry et al., 2012) - In a sample of adolescents participating in psychological therapy trial for depression: - Predictors of NSSI over 28 weeks of follow-up: baseline NSSI, hopelessness, anxiety disorder, younger age, female gender - Predictors of suicide attempts over 28 weeks of follow-up: baseline high suicidality, NSSI, and poor family function (Wilkinson et al., Am J Psychiatry 2011)