Cases camhs transcript 2 — SMP305 lecture transcript

Uh, last, last lecture. So not, not long before we're finished. Um, so we're going to talk about attachment. Now, I'm pretty sure this isn't something you'll get in any of your other lectures. Um, but I hope you'll see by the end why it's an important concept to have some idea about. Um, it will influence, um, your interactions as a doctor, um, with patients or help to inform or help you to understand what might be going on in a consultation. OK, so it's something that I guess probably a lot of you have heard something about, so we're going to have a, have a think more about it. So we'll look at the systems of emotional regulation, we've touched on them already, but we'll look a bit more and how um their disruption may affect us. We'll look at the theories of attachment and why it matters. Uh, we'll look at the clinical effects of disrupted attachment process and the clinical categories of attachment. OK, so, um, to understand attachment, we need to think about regulation in mental health. So you're used to thinking about regulation in general medicine. Any examples of where regulation's important? Just ordinary everyday things in the body that Blood pressure, absolutely, yep. Any other ones? Yeah, absolutely. So all of these we know have to be within certain limits, or we become concerned because they're going to have very significant effects on the body if they're out with these. So homeostasis, as you know, is is a balance between the internal and external factors that affect the system and keep it functioning within certain parameters. So these are some of the regulatory systems that affect mental health. Um, so emotional regulation, we've mentioned that already, is in the limbic system. Um, arousal is the autonomic nervous system, which obviously affects mental health as well, particularly anxiety, um, memory, hippocampus and median temporal lobe, perception in the temporal lobes, and the sleep-wake cycle in the pituitary and endocrine. OK, so the main one that affects a lot of things is the limbic system. So that's just a bit of a reminder. So it was right, right buried right in the middle of the brain. Um, the caudate links up with the hippocampus and the amygdala. So what does emotional dysregulation look like? We know what um hemostatic dysregulation looks like when you've got blood pressure fluctuating, pulse fluctuating, but what does it look like if that emotional regulation, um, is not working? So you get extreme emotional outbursts, uncontrolled temper, self-harm can be part of it, and difficulty maintaining relationships. So this is a model that is is useful in terms of thinking of that emotional regulation. So, um, emotional regulation is between the two black lines. So it's not, it's not a flat line. Um, if we're, I don't know, getting ready for a driving test, um, it's not much good if we're just sort of half asleep. We need to be quite alert, but if We're um relaxing or going to sleep, then we need to be more down regulated. So that up and down in the middle, we need to go up and down within our regulation, but not above or below the lines. So if you go above the line, that's hyperarousal. So that's your anxiety state, um, or perhaps a traumatic event where you go into that hyperarousal state. Um, so that's anxiety anxiety disorders of different kinds. Below the line hyperarousal, um, is what you see in people with with severe attachment disorders. And what we think is happening is a bit like a, a, a sort of engine or a system. If you keep hyper going into hyperarousal, eventually it switches off. It, it's, it's too, too much for the system. So the system goes into hyperarousal. OK, and that hyperarousal, um, people will describe feeling emotionally numb, um, and having difficulty in, in regulating and managing things. So, oops. OK, so these are some of the causes of dysregulation. So disrupted attachment, psychological trauma. So, um, when someone has a post-traumatic reaction, they can be disregulated at times, maybe not all the time, but particularly if there's a triggering event at that point, they can become disregulated. Um, and the temporary effect of the trauma. So before it's it's um, diagnosed as such. Um, if someone's had a life event, you can have what you call acute stress disorder. So at these times, people can be a bit more on edge, particularly in the situation, um, that reminds them of it, and disrupted attachment.

OK. OK, so, um, I want you to just, with the person beside you, um, tell me what you think attachment might be and some examples of it. Um, from previous, from previous colleagues, um, people who have read stuff online and done the quiz. Um, so tell me what you think, um, attachment might be. Some examples of it. he I guess you're. This Yeah. It's Of course. This is Um. For some mistake. But I don't know. That's good. It's like. That the the Yeah Maybe I haven't. For On. like Deep I It I'll leave the crutches up to protect myself. I like Very Deep breath. It's a different. So, I think this. Oh, this is a classic. It's. Oh. I still like that. That's It was Exactly. Right. So Yeah And then OK, so, um, yeah, lots of people, um, have read or heard about the different attachment styles, and we'll come on to that in a bit. But the key thing is that attachment is absolutely essential. So, um, it's a bit like if you don't have blood pressure, you're going to be in trouble. If you don't have attachment, you'll be in trouble. It's it's, it's an absolutely essential part of, um, being human, but probably being an animal. Um, and as it says there, it's, it's, um, It's how we regulate our emotional, mental and physical health. So it's, it's actually, um, there's a lot of research that is not just integral to your mental health or your emotional interactions. It it actually affects your physical health as well. OK, so examples, so a mother-child, um, friendships, relationships, um. And of course, so Bobby is probably the main name that's um. Linked to attachment in terms of research. And he's quite, quite readable. Um, so if you want to read, um, any of his books, um, separation, attachment and separation across, I've probably forgotten the title there, but across the life cycle. So he talks about how you have the attachment as an infant, um, and it changes throughout your life, and then obviously you die and that attachment is broken for the people who are remaining. So there's a cycle of it, um. So the first thinking was, um, when people began to identify attachment was that it was, um, for food. So it was back in the 1950s, and they looked at animals and saw that animals were detached to a human, whoever they first saw when they were born, um, and they thought that it was primarily or entirely. to make sure that they got fed because obviously most mammals are born not really able to do that themselves. Um, and then Harlan 58 looked and thought, well, maybe it's more than that. Um, and we'll have a look at his research now, we'll look at the actual research he did. It's one of these difficult ones. Um, the research he did wouldn't wouldn't be passed now. um. But the, the cartoon description will tell you what he found. It's always a difficult one, isn't it? If someone's done research that wasn't ethical, um, but it does help us to understand, um, How humans work in this area.

It can be really easy to look at a newborn baby and see a being that's completely incapable of, well, pretty much everything. But what we've learned from decades of scientific research is that babies are born with a lot going on in their little brains, especially when it comes to relationships. When babies are born, they immediately begin to seek out connection with the people around them. In fact, babies' earliest cries are actually bids for attention and care from their caregivers. Because they can't take care of their own needs, babies are actually born seeking out care from the adults around them in order to survive. It's actually kind of like a survival strategy that's activated at birth. Though there are changes in what those Bids for care and attention look like across development, the main goal remains the same to get care, comfort, and safety. And when caregivers are present and responsive to those bids for attention and provide comfort, care, and security, the relationship strengthens and deepens. Humans are not the only creatures to experience this kind of dependence on relationships early in life. In fact, significant research in Animals has found similar kinds of patterns of relationship seeking behaviours in ducks, goats, dogs, and monkeys. Perhaps the most well-known animal research on this concept of seeking relationships as a source of comfort comes from the studies of the effects of maternal separation on rhesus monkeys conducted by Harry Harlowe. The prevailing idea at the time was that primates were reliant on their mothers primarily as a source of food. To test these ideas about maternal care, researchers removed baby monkeys from their mothers at an early age. These baby monkeys were then given the option of spending time with a wire mother who provided milk for the monkeys, or a cloth mother who did not provide food but was covered in cloth to simulate fur. Scientists were surprised to find that the monkeys tended to spend much more time with their cloth mothers. Indeed, the monkeys seemed to only seek out the wire mother for very brief times when they were hungry, but preferred to spend most of their time with the cloth mothers as a source of comfort. And when they were frightened by a loud noise, they would cling to the cloth mother as if searching for protection and comfort. But later research with these monkeys found that those that were removed from their mother at an early age suffered severe social and functional impairments later in their lives. These studies gave researchers an important glimpse into the effects of early deprivation and also the important role of comfort, not only nutrition in mother-child interactions. But these studies raised many concerns about the ethical treatment. Animals and as such are widely considered extremely unethical today. In fact, most universities have research boards that have rigorous policies in place to review research that's conducted with animals as well as with humans that prevent this type of treatment from occurring. It should also be noted that Harry Harlow is hardly the first person to study the dynamics of relationships. Harry and others like him were inspired by the work of John Bowlby and Mary Ainsworth, who were the pioneers of what we now call attachment.

OK, um, So, so that moved things on, um, from just being food, um, and the way we thought that this attachment process is working, um, but clearly a sort of cloth thing is really very is completely different from, um, you know, a mother and a child and that sort of interaction. Um, so the different theories are, um, it protects the infant from danger. Um, it's probably also emotional connection gives meaning. Um, so I think we would, most of us would. Um, see that our relationships are incredibly important in terms of what makes life matter to us. We're social animals, so it's not particularly been, um, studied in terms of attachment, but there's something similar going on within a social group. Um, it's definitely essential for the development of the child and affects the individual through the life cycle. So this, um, video, uh, goes into a bit more detail of demonstrating to you what what is happening in that attachment. And this is obviously looking at the attachment between the mother and the child. Babies this young are extremely responsive to the emotions and the reactivity and the social interaction that they get from the world around them. This is something that we started studying 30, 40 years ago when people didn't think that infants could engage in social interaction. In the still face experiment, what the mother did was she sits down and she's playing with her baby who's about a year of age.

I my girl. And she gives a greeting to the baby. The baby gives a greeting back to her. This baby starts pointing at different places in the world, and the mother's trying to engage her and play with her. They're working to coordinate their emotions and their intentions, what they want to do in the world, and that's really what the baby is used to. And then we ask the mother. To not respond to the baby. The baby very quickly picks up on this and then she uses all of her abilities to try and get the mother back. She smiles at the mother. She points because she's used to the mother looking where she points. Yeah. The baby puts both hands up in front of her and says, what's happening here? She makes that screechy sound at the mother, like, come on, why aren't we doing this? Even in this 2 minutes when they don't get the normal reaction, they react with negative emotions. They turn away, they feel the stress of it. They actually may lose control of their posture because of the stress that they're experiencing.

OK. OK I'm here. And what are you doing? Oh yes. Oh, what a big girl. It's a little like the good, the bad, and the ugly. The good. Is that normal stuff that goes on that we all do with our kids. The bad is when something bad happens, but the infant can overcome it. After all, when you stop the still face, the mother and the baby start to play again. The ugly is when you don't give the child any chance to get back to the good. There's no reparation and they're stuck in that really ugly situation. OK, so that, that gives you a more detailed, um, sort of picture really of of what that attachment process is. Um, and it's not, you know, it's not to say that obviously a parent can't be with a child all the time and can't pay them attention all the time, but it's that, that ability to come back and the child knows over time that the parent will come back. Um, whereas obviously if you've got a parent who's maybe drug addicted, um, they may be out for the count or we are just not available for long periods of time when the child is hungry and frightened, and that creates a very different sense for the child that doesn't matter what I do, I can't, I can't get it back like it says, get, get stuck in that position. So it's not, it's not about being perfect. It's about that sort of being able to come back, um. OK, so the, the hormone, um, I'm sure a lot of you know that it that we think modulates, as far as we understand it, this, this attachment is oxytocin, and it's seemed to go up in in the mom at birth, so it seems to somehow facilitate that, um, that attachment because what you see with the mom and the child is that they're, um, almost mirroring each other, and I think he says it was a lovely phrase orientating themselves together in the world. So when people Attached, there's a bit of what are we going to do together, you know, how are we going to face this together? Um, and again, it's the limbic brain, particularly the right hemisphere. The autonomic nervous system is very seems to be very involved as well. So if people um are separated for different reasons, it's been studied that um they, they have a decrease in temperature. Um, and if prolonged, you get changes in cortisol. Um, so there's very definite physical effects of people being, um, separated from from their main attachment figures. Um, and that's going back to the window of tolerance that we looked at earlier. Um, and now we understand it a bit more in terms of how the body's working. Um, so if there's a bit of anxiety, you go up into crisis, so you're hyper aroused, your adrenaline's flowing. If that goes on for too long, you go into hyperarousal. And state where the body starts to sort of freeze. And we see that as a physical effect of um cortisol and temperature, um, and a lot of different um features. So onto the different types of attachment. So secure attachment, anxious, I love you've heard of ambivalence and avoidant. So this next chart isn't exact, but these are the sorts of situations that can lead to these attachments. So an anxious attachment might be a mom who's who's unavailable, who's depressed, and a mom with postnatal depression. So there's another video, which is a very good one you might find online where um the mom is just not responding. So the baby tries and tries like that little baby did, but then it starts to give up, because mom's just flat and isn't able to respond. Drugs and alcohol ambivalence. So the child never knows if mom's going to be there, you know, feeding them and being fun, or she's going to be flat out. And the avoidant attachment, um, tends to occur if there's a lot of abuse and neglect. So what the child tries to do then is keep close enough so that it can get fed, but not so close that it can get hurt. So secure secure attachment. And what happens with that process of mirroring is that the child learns to self-regulate. So by getting the mom regulating them, they begin to learn it internally. So by their own time, about 5, they can internally regulate and they can start to develop other bonds with other people. And someone said they have that trust. So they sort of approach people with in a hopeful way that this is going to be fun. Anxious attachment. Maintaining the attachment of the caregiver who is um unpredictable, so clingy. So again, like if you're imagining that depressed mum, the kid keeps close to the mom and it's almost trying to jolly mom along, if you like. So they're holding on and saying, come on, mom, let's let's do this. Um, Ambivalent. Um, so you sometimes see kids who seem very grown up and they say, come on, Mom, remember your coat, um, we're going, we've got to go and get that appointment soon. Um, and your first reaction is, oh, you know, what a mature child. But you often see that where the mom who's really struggling and they've taken on a parental role with the main caregiver. And, and that regulation is not so good because they've not had that experience of having somebody regulate them. So their fear and anger is not so well regulated. Um, the avoidant child, um, it's very distressing to see. I've seen it a couple of times in clinic where children were being physically abused. They tend to be very pale, they hide in corners, and they literally freeze if they pick up something from the parents where they think they might be hurt. Um, so it's, it's distressing but very, very visible when you see children who are in that situation. Um. So the Romanian orphanages, these, um, During the war, um, there were a lot of children and it was, um, a situation where the process of attachment was, um, very easily able to be looked at. Um, so Rutter, who is a big name in child psychiatry, um, he did some research. Um, American researcher Charles Nelson did a really, really interesting piece of research. So these children were in the orphanage. Um, he took some into foster care in the local area. Um, paid for all of that. Um, and he compared the foster children with the children who were the biological parents in the orphanage and matched them for age, etc. So the children in the orphanage had not just the emotional difficulties, but they had to delay in brain development, language, motor, and socioeconomics. So right across the board, they were delayed. Um, the really good bit was that the children in the foster care. Um, improved dramatically. So very quickly they started to come on in terms of their language and their motor development. Um, so one of the, um, terms that's used in attachment theory is great, well, another thing as well, but I think came from attachment. is brain plasticity. So they used to think it was up to about 18, I think it's now well into the 20s. So although this form of attachment has happened, say you have a child with an avoidant attachment, if you can provide positive experiences, that can repair. So the brain is still capable of taking on new new patterns, as it were. And but obviously they have to be consistent and persistent so the child can learn something, something new. OK, so the, the treatments that are used, um, the main one used is something called dialectic behaviour therapy. So it's quite um a a rigorous treatment. It uses a lot of group work and what it's trying to do is help the person to see. Because the person's learned ways of being very defensive, um, and so they're not approaching people in a way that will help to start a relationship or continue it. So it's a way of helping the person almost to see the mirror of what they're doing and what they could do what they could do differently. And for children. What's used is something called Theraplay. So you have, um, bits of the time where the child has a chance to play, the mom or the main caregiver has a chance to talk about how they feel, and then you bring them together and you do a lot of practical things like, um, rubbing cream in. So, so what we think is that a lot of it is to do with touch. So touch that is just calm and um Ritual so that they can begin to do that and and various trust games and that can be very effective. So the moms, there's often a lot of work with making the mums feel cared for, um, you know, a cup of tea and toast because often these moms have had very difficult experiences themselves, so they sort of need looked after to be able to look after the children. And, obviously, with people who have attachment disorders, um, if you, if you come across a patient who seems to, one presentation, they've got an eating disorder, the next one, they've got depression, then you discover they've got drug abuse problems. That's often someone who has got an attachment disorder. So it's sort of they tend to have a lot of comorbidities. And the other thing is, and there's more and more research, so the attachment research is quite far back in CAAMHS. But over time, um, there's a sort of coming together up to a point between adult mental health and CAMHS. So we're beginning to see that some of the personality disorders have come from these early attachment difficulties. Um, so particularly things, um, the ambivalence, um, when people talk about borderline, so that person who, um, It's OK for a while and then everything falls apart, um, and have these difficulties in relationships. Um, it seems to be that, um, a lot of these have come from younger people who've had very difficult attachment experiences. OK, um, I don't think we've probably got time to go into this as as an exercise, but I'll just go through it briefly. So it just it just illustrates the sort of um person that we present to CAMHS, um, who had an attachment disorder. So in trouble at school for aggressive outbursts, often in fights. Um, her mum has severe OCD. And as a result of that, she was often left crying and hungry while mum was preoccupied with with her um compulsions. Um, once this was discovered, support was sought from um grandparents and treatment was accessed for mum. So the girl presents with a 3 year history of drug misuse, self-harm and suicide attempts. She also presents with low mood and pseudo hallucinations. In addition, she presents with food restriction, vomiting, and weight loss. So as you can see, that's a very typical, really complex picture. She was admitted twice with ongoing low mood after taking overdoses and with severe weight loss and refusal to eat. Um, at the time you're seeing her, um, she's still got restricted eating, suicidal ideas, and her mood is better. She's taking fluoxetine and she's engaged in dialectic behaviour therapy. OK, so in terms of the diagnosis, it's very difficult. So, um, she may well have an eating disorder, depression, drug misuse, um, mood disorder. Um, it's likely also that she'll have an attachment disorder. Um, in CAMHS, we wouldn't generally go for personality disorder young. So we'd say it's emotional dysregulation at that point. So you guys are going to probably know as much or more than me. And which subspecialty would you refer to in adult mental health? What would people think would be the best thing? Um, um, spoiler, there isn't, there isn't an easy answer to this. Any thoughts about where you might refer? Because it is, it is a real problem in the sense that in CAMHS you would be in one department for all of these things. You're suddenly hit with adult mental health, where, you know, you might have mood disorders team, you might have an eating disorders team, a crisis team, um. And, yeah, so any thoughts? Where you you if you had to? As I say, there there isn't, it's often an individual thing. Do you have you thought of what you might do? Yes, I mean, often the highest risk one would be the one to go for. Um, if it's somebody who's going in and out of casualty, um, there's this combination of different cases I worked with, as one of them did, you might want to go for the crisis team because that's where they're going to keep going. So, um. It's about working out what the best fit is. Um, so transitioning is really important with these young people. Um, going back to what we, a lot of people talked about earlier, if someone's got difficulties with attachment, they've got difficulties with trust, um, so they will have usually by that time built up a relationship with one of the people in CAMHS, but it's very frightening. They'll feel it as a rejection, whatever you do, that they're being transferred. So going through that process, gradually, letting them know what's happening. And it's really important to introduce them to who they're going to. And that takes an awful lot of work, because people say, no, no, it's not our case. We don't want anything to do with it. But if you just transfer it cold, you'll likely have a very big crisis, because that will just feel terrifying for the young person. Um, but if you introduce them to the person and you set up the appointments, it's got a much better chance of not, um, going back to to crisis. So it's just, just being aware that, um, young people like that need, need a lot of a lot of sort of looking after, if you like, above and beyond and, um, in CAMHS, they have gotten now, but one of the things is that A lot of the time in health, the people's DNA you discharge your two DNAs and you're out. These kids, if they're DNA and you don't discharge them, you chase them up because they're in trouble. Um, so, And they also need to know that you're there for them when they do come back.

OK, so just going back over what we've learned about attachment and as I say, it, it whatever um branch of medicine you go into, you will come across, um, because when people are in health services, they're often in a very frightening situation. And somebody asked, so even if you have a secure attachment, you will have bits of anxious or ambivalent. So at that point, you will probably move into one. So it's being aware that, you know, someone's behaving ridiculously. Well, that's probably because they're so frightened. They've flipped into um not their most helpful attachment style in terms of relating to health services. And so the homeostasis of emotion is regulated by a series of complex neural systems and it's affected if attachments disrupted. Attachments, the relationship between an individual and a significant other. It's essential for the child's development and for all of us as ongoing adults, um, when disrupted, it can lead to difficulties with relationships and mental health um and there are effective treatments. OK, so thank you all for your patience. Um, any final questions? OK, well that's, that's, that's us finished then you can, we can all go. OK, thanks for your time.

pharmacy.