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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)