Mind - Hamm Clinic

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Minding the mother and restoring
natural rhythms to support the
mother-baby relationship
Helen Kim, MD
Director, HCMC Mother Baby Program and
Hennepin Women’s Mental Health Program
Department of Psychiatry
Hennepin County Medical Center
www.mnwomensprogram.org
[email protected]
Outline
I. Definitions: mind, mindsight, mentalizing
II. What interferes with mindsight?
III. Psychiatric illness as brain/mind disorders that
include disruptions in energy and biological rhythms
IV. The role of psychiatrists and medication
V. Functional or integrative medicine as a lens to
interpret mind/body symptoms
Mission:
To support families by strengthening the emotional
health and parenting capacity of mothers
Mission:
To support families by strengthening the
emotional health and parenting capacity
MINDSIGHT of mothers
MIND
Definition of Mind
by Daniel Siegel, MD
Mind: “an embodied and relational
process that regulates the flow of
energy and information. ”
“An emergent process that arises from
energy and information flow within you
and between you and others”
Mindsight
•the ability to reflect on the mind or mental states
of oneself and others.
•emerges from within attachment relationships
that foster such processes.
•essential in healthy relationships
•a learnable skill
•“I am sad” vs “I feel sad”
“Mindsight is a kind of focused attention that allows us
to see the internal workings of our own minds. It helps
us to be aware of our mental processes without being
swept away by them, enables us to get ourselves off the
autopilot of ingrained behaviors and habitual
responses, and moves us beyond the reactive emotional
loops we all have a tendency to get trapped in…The
focusing skills that are part of mindsight make it
possible to see what is inside, to accept it, and in the
accepting to let it go, and, finally, to transform it.”
Dan Siegel, MD
Mindsight -- seeing the mind
1) Insight into oneself
2) Empathy for others
3) Integration within you and your nervous
system and between you and others
Intepersonal Neurobiology -- the study of
mindsight
Mentalize
• To be aware of mental states (desires, needs,
feelings, reasons, beliefs) that drive reactions and
behaviors of ourselves and others
• To feel and think about feeling at the same time
• A psychological skill that allows one to understand
the internal state of oneself and another
• Occurs on intellectual/conscious level
• Occurs on a gut/intuitive level
• An old idea --- Descartes, Theory of Mind, Fonagy
(mentalizing in the context of attachment
relationship, Arietta Slade (mentalizing in context
of parenting; reflective functioning)
Mindsight - noun
Mentalize - verb
•Nonjudmental curiosity, acceptance, compassion
•Mindfulness of the mind of self and others;
•Mind mindedness, reflective functioning,
psychological mindedness
•Empathy for self and others
Mentalizing as a Compass for Treatment
Jon G. Allen, PhD, Efrain Bleiberg, MD, and Tobias
Haslam-Hopwood, PsyD, The Menninger Clinic
http://www.menningerclinic.com/education/clinicalresources/mentalizing
•Mentalizing as conceptual compass to help patients understand
how staff approach treatment
•Shared understanding and shared goals as foundation for sense
of “we’re in this together”
Why is mentalizing important?
• Self-awareness: to reflect on and communicate our
feelings/thoughts
• Self-agency: Understanding that behavior doesn’t just
happen but is based on mental states.
“I am responsible for my behavior”
• Self-regulation: “I feel angry” vs “I am angry”
“I am not my feelings”
• Relationships: feeling felt by another provides sense of
connectedness/security;
promotes understanding, intimacy
• Finding meaning from suffering and hope
• Resilience
Mentalizing as a Compass for Treatment
Jon G. Allen,
Why is mindsight or mentalizing important?
•
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•
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Responsibility
Regulation
Relationships
Resilience
"The whole idea of thinking about thinking is
that we learn about ourselves through being
understood by other people. Babies learn about
their feelings by having their feelings
understood by someone else." ~ David Wallin
What interferes with mentalizing?
•Strong emotions: shame, anger, fear ---> flight/fight/freeze
•Defense strategies: repression, denial, avoidance, suppression
• Apathy/indifference: “I don’t care” what’s in my mind or yours
•“Psychiatric illness”: depression, anxiety, substance use, mania,
psychosis
Psychiatric illness as disruptions in biological
rhythms and energy
• Maternal depression or anxiety
• inhibit mindsight and/or the ability to mentalize
• disrupt biological rhythms and energy
• Stabilizing a mother’s biological rhythms is
essential before she can synchronize with her
baby’s rhythms.
• Parents as brain scientists or curators of the mind:
• Compassionate stance
• Non-judgmental curiosity
• Awe and wonder
“Depression is the number one complication
of childbirth” (Wisner, NEJM 2001)
• Perinatal Depression:
10% in general population
25% in high risk groups
• Perinatal Anxiety:
7-10%
• Gestational Diabetes:
5% pregnancies
Women have 1.5-2.5 x rate of depression vs. men
Lifetime prevalence: 21.3% women and 12.7% men
Kessler RC, et al. J Affect Disorders 1993;29:85-96
Psychosis
50% of women with
PPD have depressive
symptoms during
pregnancy
Risks of Untreated Depression/Anxiety
• Poor self care, nutrition, and prenatal compliance.
• Increased smoking, alcohol, drugs
• Increased ob/neonatal complications, such as
preterm delivery
• Increased attachment and behavioral problems
• More pediatric visits for behavioral problems and
injuries
Maternal Depression and Risk to Early
Parenting
Children 0-3 years old are most
vulnerable to risks of maternal
depression due to rapid brain
development and sole reliance on
caregiver
Maternal Depression and Risk to Children
Children’s Defense Fund of Minnesota. (2011). Zero to Three
Research to Policy: Maternal Depression and Early Childhood.
www.cdf-mn.org
Cost of untreated maternal depression
for mother and baby
Wilder Research, Oct 2010
• Total annual cost of not treating 1 mother
with depression = $22,647
• Cost of not treating the mother = $7,211
• Cost attributable to a child born to a
depressed mother = $15,323
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Brain/Mind Science vs “Behavioral Health”
•Waiting until behavior is a problem is not early
detection/early intervention
•Psychiatric illness -- disorders of the brain/mind that can
manifest in behavior changes*
•Mind behind the behavior as the target
•Early intervention starts prenatally and with parents/children
*Thomas Insel, MD, NIMH
http://www.ted.com/talks/thomas_insel_toward_a_new_understanding_of_mental_illness
Are psychiatrists just “prescribers” and
“behavioral health providers”?
“You need to see a psychiatrist” = “You need meds”
STRESS
STRESS affects mind/body and
ability to mentalize
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•
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•
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Difficulty sleeping
Headaches, body or joint aches
Poor energy
Poor concentration
Altered appetite
Digestion problems
Heart problems
High blood pressure
Irritability/anger/depression
Stress, Depression and Anxiety
through a Functional Medicine lens
What is Functional Medicine?
www.functionalmedicine.org
Personalized medicine that deals with primary prevention and
underlying causes instead of symptoms for serious chronic disease.
Based on these principles:
-Biochemical individuality
-Patient-centered medicine -- "patient care" vs "disease care”
-Web-like interconnections of physiological factors
-Health as a positive vitality not merely the absence of disease
Some clinical imbalances underlying
chronic medical conditions:
1) Hormone and neurotransmitter imbalances
2) Energy, mitochondria, and oxidative stress
3) Detoxification imbalances
4) Immune and inflammation imbalances
5) Gut and digestive health
6) Mind-body dysrhythms
Chronic Inflammation:
the common final pathway to
chronic disease
Is depression an inflammatory condition?
• Acute inflammatory response necessary for trauma or infection
• Overactive immune or inflammatory response harmful: autoimmune
disorders, RA, IBS, asthma, allergies, MS, celiac, thyroid
• Chronic inflammation drives some chronic diseases: heart disease,
obesity, diabetes, and depression
• Pro-inflammatory cytokines cause physical and psychological
symptoms (malaise, low mood, low energy, sleep disturbance) called
“sickness behavior” which resembles depression
• Neurotransmitter-focused theories of depression have been limited
• Depression’s connections to inflammation and immune dysregulation
offer other treatment options
• Psychoneuroimmunology: the study of the CNS and immune system
What causes chronic inflammation?
• Stress
• Toxins
• SAD diet
• Lack of exercise
• Hidden allergens/infections
What do you need to thrive?
•Safety
•Sleep
•Healthy Foods/Healthy Digestion
•Light, water, air
•Movement
•Love, community, connection
•Purpose
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Sleep
SLEEP
• Average sleep in 1900 --- 9 hours
• Study of 669 middle-aged adults found people sleep
much less than they should, and even less than they
think. (Am J Epi, 2006)
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–
White women
6.7 hrs/night
White men
6.1 hrs/night
Black women
5.9 hrs/night
Black men
5.1 hrs/night
Poor sleep less than wealthy.
National Sleep Foundation
Sleep in America Poll 2003:
% reporting <7 hrs
slept/weeknight
Ages 18 to 54
41
Ages 55-64
38
Ages 65-85
32
Sleep deprivation: the costs
•
•
•
•
•
•
Inhibits mentalizing (mind-blindedness)
Irritability
Poor concentration
Increased inflammation
Makes you fat
Increased risk of accidents
Healthy Nutrition and Digestion
Standard American Diet (SAD)
• High sugar
• High processed food -- think Twinkie’s
nutrient poor, high calorie
• High in animal fats
• High in unhealthy fats: saturated, hydrogenated
• Low in fiber
• Low in complex carbohydrates
• Low in plant-based foods
Standard American Diet to New American Diet:
From SAD to NAD
•Food Rules by Michael Pollan
1) What should I eat? -- Eat food
2) What kind of food should I eat? -- Mostly plants
3) How should I eat? -- Not too much
•NAD: Real food, fresh fruits and vegetables, lean protein,
moderate amounts of healthy fat, adequate fiber
Healthy Digestion
• Bacterial balance: Healthy gut has 3 pounds of good bacteria that
digest your food, help regulate hormones, excrete toxins.
• Immune system protected by thin layer that lines the gut. If barrier
damaged, can set off immune and and inflammatory reactions
Gut = the “second brain”
• Enteric nervous system
• 100 million neurons line the gut (more than the spinal cord)
• Butterflies, pit in your stomach, gut feeling
• 95% of the body’s serotonin is in the gut
• Irritable bowel syndrome
• Bidirectional connection between gut and brain (pit in your
stomach can be result or cause of anxiety)
• Neurogastroenterology
What sabotages healthy digestion?
• SAD diet
• Overuse of medications (NSAIDS, antibiotics, H2 blockers)
> 200 over-the-counter (OTC) remedies for digestive disorders
(GERD, irritable bowel, bloating, heartburn, ulcers)
• Chronic low-grade infections or gut imbalances with overgrowth
of bacteria in the small intestine, yeast overgrowth, parasites
• Toxins
• Digestive enzyme dysfunction – such as from acid blocking meds
or zinc deficiency.
• Stress -- alters the gut nervous system, contributes to leaky gut
and changing the normal bacterial flora in the gut.
Stabilizing a mother’s biological
rhythms to help her synchronize with
her baby’s rhythms.
Mind-Body Strategies
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Relax: breathing, yoga, meditation, prayer
Sleep
Address the stressors
Gut health: Pollan’s “Food Rules”
Get moving!
Purposeful, meaningful activity
Tend and Befriend
Community
How to engage psychiatrist or other medical provider:
• Imagine with the patient the hoped for outcome of appointment
• Encourage a family member to accompany the patient
• Send a note with your patient --- concise and specific (e.g. help
with restoring sleep)
• State what you are working on in therapy, such as “We are
working on mindsight” or “We are working on mentalizing” and
define what those terms are.
• State your understanding of the priorities:
• Safety
• Sleep/wake and daily routines
• Urgent needs/concerns
• Regulation, relationships, responsibility, resilience
• Long-term plan for addressing underlying destabilizing factors
Integrative Health Resources
• Institute for Functional Medicine
– www.functionalmedicine.org
• Dr Mark Hyman: www.drhyman.com
– Ultramind Solution or Ultrasimple Diet
• Dr. Christiane Northrup: www.drnorthrup.com
– Women's Bodies, Women's Wisdom
• Dr Margaret Christiansen: christensencenter.com
• Other Books:
– Henry Emmons (Chemistry of Joy; Chemistry of Calm)
– Michael Pollan (Food Rules, Omnivore’s Dilemma)
– James Hollis (Finding Meaning in the 2nd Half of Life)
• Articles of interest:
– Limitations of acute care approach to chronic conditions and a call for medical
education reform (Holman H. JAMA 2004;292:1057-1059)
Recovery from depression is a family affair
•CBT in depressed teens was effective,
but not if they had a parent who was
currently depressed
(JAMA. 2009;301(21):2215-2224)
•Treatment of depression in children not
effective unless addressing needs of
parents
Mother-Baby Model of Care
•Provide treatment for maternal psychiatric disorders while
maintaining and supporting MB relationship
•Specialized intensive outpatient/inpatient programs for
pregnant women or mothers and babies
•Incorporates baby into mother’s mental health treatment
•Eliminates childcare barrier
•Eliminates separation from baby and disruption in
breastfeeding
•Supports a healthy attachment relationship
Mother-Baby Model of Care
•Staffed by psychiatrists and other mental health providers
who specialize in perinatal and infant mental health
•Include expertise in meds for preg and nursing women
•Peer support
•Reduces stigma
•Assessment of MB relationship
Mother-Baby Programs in UK, Australia, US
• Australia: 4 MB inpt units just in Melbourne, Australia (15-27 night stay)
United Kingdom: 20 MB units that offer both outpt and inpt
• United States:
Outpatient MB Programs:
– Women and Infants Day Hospital Program, Rhode Island (2000)
– El Camino Hospital MOMS Program, San Francisco, CA (2008)
– Pine Rest Mother-Baby Partial Hospital, Michigan (2013)
– HCMC Mother-Baby Program, Minneapolis, (2013)
Inpatient Perinatal Program:
-- UNC Perinatal Psychiatric Inpatient Unit, (2012)
HCMC Mother-Baby Program
• Partial hospital program for pregnant and postpartum mothers
• Fills gap in service for perinatal women with moderate-severe
depression or anxiety
• Goal of treatment: to support mentalizing/mindsight capacity in
mothers and promote positive parenting practices
• 4 hours/day, 4 days/week, for 3 weeks
• Services:
– Group psychotherapy
– Medication evaluation and management
– On-site nursery for babies up to 1 year old
– Lactation consultation
Stories
• Range of backgrounds:
– Higher income mom overwhelmed with sleep
deprivation and fear driven by undiagnosed bipolar
disorder
– Low income, single mom homeless with 3 kids under 4
and struggling with depression
– Low income immigrant mom with baby in foster care
after she tried to kill herself
• I didn’t know that:
– My baby needs me to feel safe
– My baby needs me to talk to her
– My baby is not needy or greedy
Circle of Security
• Kent Hoffman, Glen Cooper, and Bert Powell
• Relationship based early intervention program
designed to enhance attachment security between
parents and children
• http://www.youtube.com/watch?v=cW2BfxsWguc&fe
ature=plcp
Shark music
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