Reactive attachment disorder(Attachment Disorder in Adult) part- III

                    Reactive attachment disorder

Reactive attachment disorder (RAD) is a psychiatric condition wherein people have difficulty forming attachments with others. It is usually the result of early childhood trauma. 

About Reactive attachment disorder (RAD):

 RAD is a rare condition in which a child or adolescent experiences difficulties forming attachments with others. According to the diagnostic and statistical manual 5th edition, RAD is the result of a trusted source of experiencing neglect or abuse during early childhood. 

Reactive attachment disorder (RAD) can develop in children who do to form a predictable and nurturing bond with a trusted parent or caregiver. This may happen as a result of:

- Growing up in an overcrowded orphanage

- Frequently changing foster homes

- Having a parent or caregiver who has mental or physical health issues.

- Being taken away from a primary caregiver after establishing a bond with them.

- Experiencing long periods of hospitalization. 

     Being unable to form early emotional bonds can cause a child to stop engaging with others emotionally and develop behavioral problems. 

     Reactive attachment disorder (RAD) tends to develop in early childhood and typically affects children and adolescents. However, the symptoms may also extend into adulthood for some people. 

Reactive attachment disorder (RAD) in children: 

   A child can develop RAD following early life trauma that prevents them from forming may consistent emotional bonds with others. 

 Some children may develop RAD as a result of early neglect, such as being left crying, wet, or hungry for hours and having no one to interact with. Others may develop RAD following emotional or physical abuse. 

  Neglect or abuse can cause feelings of isolation, abandonment, and fear. Children who develop RAD tend to stop trying to form consistent emotional bonds with others. 

  This can extend into adolescence and adulthood. For example, some people may have difficulty trusting others and forming close personal relationships. 

Signs and symptoms: 

 Children with RAD may display some or all of the following signs and symptoms trusted source:

- Rarely seeking comfort when distressed

- Not responding to comfort when distressed 

- Minimal emotional or social responses, such as avoiding eye contact and not smiling 

- Persistent low mood and crying 

- Unexplained episodes of irritability, anxiety, or fearfulness

- A lack of interest in interacting or playing with others.

- A lack of social skills

- Cognitive problems

- Hyperactivity 

- Repetitive movements, such as rocking back and forth or hand flapping 

 These symptoms must occur before the age of 5 years in order for the child to receive a diagnosis of RAD. 

Patterns: 

When children with RAD grow a little older, their symptoms usually fall into one of two general patterns: inhibited RAD symptoms or disinhibited RAD symptoms. 

The following sections will discuss these in more detail. 

Inhibited RAD symptoms: 

  With this pattern, children are usually aware of what happens around them, but they do not respond typically to outside stimuli. 

children showing inhibited RD symptoms are often withdrawn and emotionally unresponsive. They may not show or seek affection from caregivers or others, instead preferring to keep to themselves. 

Disinhibited RAD symptoms: 

 With this pattern, children may be overly friendly toward strangers. Also, they may not prefer their primary caregiver over other people. 

In most cases, these children act younger than others' age and may seek affection from others in a potentially unsafe way. 

Reactive attachment disorder (RAD) in adolescents and adults:

 Without treatment, a child who develops RAD may continue to experience issues throughout adolescence and adulthood. 

 These issues may include:

- Avoidance of physical contact

- Difficulty displaying affection or care for others

- A lack of empathy

- Poor social skills

- Difficulty forming stable 

- Relationships with others

- Cognitive problems, such as poor memory or problem-solving skills

- Anger problems

- Control issues

- Academic or workplace problems

- Engaging in risky behaviors, such as substance abuse

- Mental health problems, such as depression or anxiety

Complications:

RAD can cause complications in children, adolescents, and adults. 

Children with RAD may be at increased risk of developmental delays and delayed growth. 

Older children and adolescents may be at increased risk of:

- Anger management issues

- Difficulties in school

- Depression

- Anxiety 

- Eating disorders

- Drug and alcohol abuse

If a person does not receive treatment for RAD during childhood or adolescence, the above complications may occur.

Diagnosis:

 A doctor or therapist will diagnose according to the DSM-5 guidelines. These guidelines trusted source state that a child must meet the following criteria in order to receive a diagnosis of RAD:

- A consistent pattern of emotionally withdrawn behavior toward a parent or caregiver, as evidenced by the child rarely seeking or responding to comfort when distressed

- A consistent emotional or social disturbance, as characterized by at least two of the following behaviors: 

- Minimal social and emotional responsiveness to other people 

- Limited displays of positive emotion.

- Episodes of unexplained irritability, sadness, or fearfulness even during nonthreatening interactions with adult caregivers 

- A traumatic experience that consists of one or more of the following:

- Social neglect or deprivation

- Repeated changes to the child's primary caregiver

- Rearing in a setting that severely limits the child's ability to form selective attachments. 

- Not meeting the diagnostic criteria for an autism spectrum disorder

- Experiencing signs of RAD before the age of 5 years

- Having a developmental age of at least 9 months. 

     Some of the signs and symptoms of RAD overlap with those of other conditions, such as intellectual disabilities or attention deficit disorders. A doctor will want to rule out these conditions before diagnosing RAD.

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Attachment Disorder in Adults(Avoidant attachment) part- II

                      Avoidant attachment 

    An attachment style is the pattern of behaviors a person exhibits in response to relationships and bonds. Developing an avoidant attachment style as a child can lead to difficulties in forming close relationships as an adult.

  Avoidant attachment is one of three attachment styles trusted sources that Mary Ainsworth and Barbara Wittin developed in 1970. 

The Four attachment styles are:

 Secure: 

   Secure attachment develops in children with a parent or caregiver who is sensitive and responsive to their needs. Securely attached children have confidence that a parent or caregiver will be available to meet their needs and comfort them when they are distressed. 

Avoidant, or insecure-avoidant:

 

   Avoidant attachment develops in children who do not experience sensitive responses from a parent or caregiver to their needs or distress. Children with an avoidant attachment may become very independent, both physically and emotionally. 

Anxious, or insecure-anxious: 

  Children with anxious attachment do not have consistent responses to their needs from a parent or caregiver. Children with an anxious attachments may be clingy around their caregiver while insecure in themselves or in their interactions with others. 

Fearful, or Disorganized:

 Disorganized attachment occurs when a child wants love and care from their parent or caregiver but is also afraid of them. Disorganized attachment can develop if a parent or caregiver responds to a child seeking comfort by ignoring, yelling at, or punishing them in some way. 

Strange situation procedure:

  In the 1970s, Mary Ainsworth did an experiment called the " strange situation procedure". In this experiment, parents or caregivers left the room as their child played with a trained observer nearby. The researchers observed and documented the child's response to their parent or caregiver leaving the room. Children with a secure attachment style would cry when their parent or caregiver left the room but go to them and quickly become soothed on their return. 

 Children with an avoidant attachment style would be calm when their parent or caregiver left the room. Once they returned, the child would avoid or resist the child would avoid or resist having contact with them. 

Causes: 

  Infants and children generally need to form a close bond with their parents or caregiver. The repeated rejection of attempts to form this secure attachment may result in a child learning to suppress their desire for comfort when distressed or upset. 

  Avoidant attachment develops when an infant or young child has a parent or caregiver who is consistently emotionally unavailable or unresponsive to their needs. Infants with an avoidant attachment style may also have faced repeated discouragement from crying or expressing outward emotion. 

 The parent or caregiver of a child who has avoidant attachment may: 

- Lack of knowledge on how to support their child

- Lack empathy

- Feel overwhelmed by parenting 

- Responsibilities

- Not have developed a sense of commitment

- Have an avoidant attachment style themselves

 Children with an avoidant attachment may also disconnect from their own needs and feelings. These children may learn to self-soothe and feel as though they can only rely on themselves. As a result, they have little motivation or trust to seek help or support from others. 

Signs and symptoms: 

   A child with an avoidant attachment style may show no outward display of desire for closeness, affection, or love. However, internally, the child will feel the same stress and anxiety attachment when they are in stressful situations. 

 These children may also want to be near their primary caregiver but not interact with them. They may also reject physical contact with their caregiver. 

 Attachment styles and their associated behaviors can last into adulthood. As an adult, a person with an avoidant attachment style may experience the following: 

- Avoiding emotional closeness in a relationship

- Feeling as though their partners are being clingy when they simply want to get emotionally closer. 

- Withdrawing and coping with difficult situations alone

- Suppressing emotions

- Avoiding complaining, preferring to sulk or hint at what is wrong. 

- Suppressing negative memories

- Withdrawing, or tuning out, from unpleasant conversations or sights 

- Fearing rejection

- Having a strong sense of independence 

- Having feelings of high self-esteem while having a negative view of others 

- Being overly focused on their own needs and comforts. 

 Avoidant attachment can also affect older adults. A study from Hong Kong found that in older married couples, a male partner with an avoidant attachment style experienced more detrimental effects on their well-being than a female partner. 

Prevention:

  A parent or caregiver can prevent their child from developing an avoidant attachment style by being sensitive to their needs and feeling while encouraging them to express their wants and emotions. It is also important for a person to let their child know that they are safe and cared for through both actions and words. 

    Parents or caregivers should also be mindful to avoid making their children feel ashamed if they make a mistake or are afraid, Instead, they should soothe and comfort their children as often as possible when they are distressed or scared. 

   If a parent or caregiver finds that they are struggling with parenting and suspects that they may not consistently be meeting the emotional needs of their child, they should seek help from a mental health professional who specializes in working with people with these issues. 

 Anyone with concerns about how their child is developing, including their attachment style, may also find speaking with a pediatrician or child psychologist helpful.

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Attachment Disorder in Adult- Part 1

                    Attachment Disorder in Adults- Part 1

      An attachment disorder is a type of mood or behavioral disorder affecting a person's ability to form and maintain relationships. 

   These disorders typically develop in childhood. They can result when a child is unable to have a consistent emotional connection with a parent or primary caregiver. 

  There is no formal attachment disorder diagnosis for adults, but they can experience attachment issues. These can stem from untreated or undiagnosed attachment disorders in childhood. 

The Fundamentals: Attachment theory 

Attachment theory deals with how people form emotional bonds. The way that a person learns to form and maintain relationships primarily stems from their initial interactions with a parent or primary caregiver during childhood. 

 

 Psychologists initially study and categorized different types of attachment that can develop during childhood. Researchers later developed the Adult Attachment Interview to distinguish the types in adults. The questions assess the type of easy relationship that an adult had with their primary caregiver. 

 Types of attachment in adults are similar to those observed in children. They include:

Secure: An adult with secure attachments likely had a positive emotional bond with their primary caregiver. They are comfortable in their relationship and have low relationship anxiety. 

 Avoidant or dismissing: Adults with these attachments are uncomfortable with closeness and value independence in their relationship. As a child, their caregiver may not have been attuned to their needs. 

 Anxious or preoccupied: Adults with these attachments crave intimacy and do not feel secure in their relationships. A child may develop this attachment style if their caregiver has intermittent or unpredictable availability. 

 Disorganized: Adults with this attachment style may have intense or chaotic patterns of relationships, marked by seeking closeness and then pushing people away, for example. It may develop in response to childhood trauma or abuse. 

Types of attachment disorder: 

 -Reactive attachment disorder 

 -Disinhibited social engagement disorder 

- Reactive attachment disorder:

 RAD is typically a trusted source of early childhood maltreatment or neglect. 

  American academy of child and adolescent psychiatry notes that children with RAD may:

 - Have low levels of interaction with other people

- Show little or no evidence of emotion during social interactions

- Have difficulty claiming down when stressed

- Seem unhappy, irritable, sad, or scared when engaging in everyday activities with their caregivers. 

 If the child does not receive adequate treatment, the symptoms of RAD may manifest or continue into adulthood. Possible symptoms of the disorder in adults include:

- Difficulty reading emotions

- resistance to affection

- Difficulty showing affection

- Low levels of trust

- Difficulty maintaining relationships

- A negative self-image

- Anger issues

- Impulsivity

- Detachment. 

Disinhibited social engagement disorder:

 DSED may develop in response to social neglect and lack of consistent attachment to a primary caregiver during the first 2 years of life. 

Children in care often demonstrate symptoms of DSED. These may include:

- Hyperactivity

- Minimal social boundaries 

- Extreme sociability

- Readiness to approach and engage with strangers

If a child with DSED does not receive adequate treatment, the issue can manifest continuing into adulthood. An adolescent or adult with DSED may display:

- Hyperactivity

- An extreme trust in people that they do not know well

- A lack of awareness of social boundaries

- A tendency to ask intrusive questions to people that they have just met 

- Other behaviors that show a lack of inhibition 

Signs and symptoms:

- Uncertainty about their true identity

- Discontinuity in their sense of self 

- Related changes in behavior, consciousness, and memory

- A feeling of disconnectedness from 

- Memory loss relating to personal information or everyday events

- Reduced ability to feel physical pain. 

Attachment disorder and adult relationships:

 An attachment disorder that develops in childhood may affect relationships in adulthood, and more research into this area is necessary. 

 A person with an attachment disorder may have difficulty trusting others or feeling safe and secure in a relationship. As a result, they may have difficulty forming and maintaining friendships and romantic partnerships. 

Complications:

 Untreated childhood RAD or DSED can cause the following during adulthood:

 - Low self-esteem

- Emotional impairment

- Difficulty in social situations 

- Anxiety 

- Depression

- Dissociation

- Problems with substance use trusted source 

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Narcolepsy

                                    Narcolepsy

Narcolepsy is a chronic sleep disorder characterized by overwhelming daytime drowsiness and sudden attacks of sleep. People with narcolepsy often find it challenging to stay awake for long periods of time, regardless of the circumstances. 

     A chronic sleep disorder that causes overwhelming daytime drowsiness. 

   Sometimes, narcolepsy can be accompanied by a sudden loss of muscle tone(Cataplexy), which can be triggered by strong emotions. Narcolepsy that occurs with cataplexy is called type 1 narcolepsy. Narcolepsy that occurs without cataplexy is known as type 2 narcolepsy. 

     Narcolepsy is a neurological disorder that affects your ability to wake and sleep. People with narcolepsy have excessive, uncontrollable daytime sleepiness. They may also suddenly fall asleep at any time, during any type of activity. In a typical sleep cycle, we enter the early stages of sleep, then the deeper states, and finally after about 90 minutes of rapid eye movement (REM) sleep. People with narcolepsy go into REM sleep almost immediately in the sleep cycle and sometimes while awake. 

   Type 1 narcolepsy comes with a sudden loss of muscle tone that causes weakness and makes you unable to control your muscles(cataplexy). Type 2 is narcolepsy without cataplexy. 

Causes: 

    The exact cause of narcolepsy is unknown. People with type 1 narcolepsy have low levels of the chemical hypocretin. Hypocretin is an important neurochemical in your brain that helps regulate wakefulness and REM sleep. 

  Hypocretin levels are particularly low in those who experience cataplexy. Exactly what causes the loss of hypocretin-producing cells in the brain isn't known, but experts suspect it's due to an autoimmune reaction. It's also likely that genetics play a role in the development of narcolepsy, but the risk of a parent passing this disorder to a child is very low only about 1%. 

   Research also indicates a possible association between exposure to the swine flu (H1N1 FLU) virus and a certain form of H1N1 vaccine that's currently administered in Europe, though it's not yet clear why.

                             

Symptoms of Narcolepsy:

  Those symptoms may include:

 Excessive daytime sleepiness(EDS):

 In general, EDS makes it harder to do everyday activities, even if you got enough sleep at night. You have memory lapses and feel depressed or exhausted. 

Cataplexy:

   This can cause problems ranging from slurred speech to total body collapse, depending on the muscle involved. It's often triggered by intense emotions such as surprise, laughter, or anger. 

Hallucinations:

   These delusions can happen at any time and are often vivid and frightening. They're mostly visual, but any of the other senses can be involved. If they happen as you're falling asleep, they're called hypnagogic hallucinations. If they happen when you're waking up, they're called hypnopompic hallucinations. 

Sleep Paralysis:

  You may be unable to move or speak while falling asleep or waking up. These episodes usually last a few seconds to several minutes. 

Disrupted sleep:

  You might have a hard time staying asleep at night because of things like vivid dreams, breathing, problems, or body movements.

Some people with narcolepsy also have related problems, including:

  - Periodic limb movement disorder (PLMD): 

   Your leg muscles move without your control many times during the night.  

- Sleep apnea:

   Your breathing often stops and starts while you sleep.

Automatic behavior:

  You fall asleep during a regular activity like driving, walking, or talking. You continue the activity while asleep and wake up with no memory of what you did.

Narcolepsy Diagnosis:

  Symptoms of narcolepsy can look like those of other health problems. Your diagnosis might involve:

 - Physical exam and medical history:

  Sleep records:

  Your doctor might ask you to keep track of your symptoms and when you're sleeping for a couple of weeks. 

Polysomnogram(PSG):

  This is done in a sleep disorder clinic or a sleep lab. It's an overnight test that takes constant measurements while you're asleep to record problems in your sleep cycle. A PSG can help reveal whether you go into REM sleep at unusual times in your sleep cycle. It can rule out other problems that might be causing your symptoms.

Multiple sleep latency test(MSLT): 

 This is also done at a special clinic or lab. The test takes place during the day to measure your tendency to fall asleep and find out whether certain elements of REM  sleep happen at unusual times furin the day. You'll take four or five short naps, usually 2 hours apart. 

Other Characteristics:

 People with narcolepsy may have other sleep disorders, such as obstructive sleep apnea a condition in which breathing starts and stops throughout the night, restless legs syndrome, and even insomnia. 

    Some people with narcolepsy experience automatic behavior during brief episodes of narcolepsy. For example, you may fall asleep while performing a task you normally perform, such as writing, typing, or driving, and you continue to perform that task while asleep. When you awaken, you can't remember what you did, and you probably didn't do it well.

Normal sleep pattern VS. Narcolepsy:

    The normal process of falling asleep begins with a phase of non-rapid eye movement (NREM) sleep. During this phase, your brain waves slow considerably. After an hour or so of NREM sleep. Your brain activity changes and REM sleep begins, most dreaming occurs during REM sleep.

   In narcolepsy, however, you may suddenly enter into REM sleep without first experiencing NREM sleep, both at night and during the day. Some of the characteristics of narcolepsy, such as cataplexy, sleep paralysis, and hallucinations, are similar to changes that occur in REM sleep, but occur during wakefulness or drowsiness. 

Risk Factors:

  There are only a few known risk factors for narcolepsy, including:

  - Age: Narcolepsy typically in people between 10 to 30 years old. 

 - Family history: Your risk of narcolepsy is 20 to 40 times higher if you have a family member who has narcolepsy. 

Complications:

 Public misunderstanding of the condition: 

 Narcolepsy may cause serious problems for you professionally and personally. Others might see you as lazy or lethargic. Your performance may suffer at school or work. 

Interference with intimate relationships:

  Intense feelings, such as anger or joy, can trigger signs of narcolepsy such as anger or joy, can trigger signs of narcolepsy such as cataplexy, causing affected people to withdraw from emotional interactions. 

Physical harm:

 Sleep attacks may result in physical harm to people with narcolepsy, you're at increased risk of a car accident if you have an attack while driving. Your risk of cuts or burns is greater if you fall asleep while preparing food. 

Obesity:

 People with narcolepsy are more likely to be overweight. The weight gain may be related to low metabolism. 

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Hemolacria or Bloody epiphora

               Hemolacria or Bloody epiphora

 Hemolacria or bloody epiphora is the presence of blood in the

 tear. Alternative names for the condition include bloody tears,

 blood-stained tears, dacryohemorrhea, hematodacryorrhea,  

hemolacrimia, sanguineous tears, sanguineous lacrimation,

 hematic epiphora, dacryohemorrhysis, lacrimae cruenate, and

 tears of blood. 

      Hemolacria or bloody epiphora is the presence of blood in

 tears Multiple disorders can cause Hemolacria. This activity

 reviews the evaluation and management of hemolacria and

 highlights the role of interprofessional team members in

 collaborating to provide well-coordinated care and enhance

 outcomes for affected patients. 

Etiology:

 The source of blood in tears may be: 

 Bleeding from the conjunctive- conjunctiva is a vascular tissue

 with limbal, bulbar, fornical, and palpebral parts. The

 conjunctival vessels lie at the ocular surface and may bleed

 spontaneously or after eye-rubbing, usually causing

 subconjunctival hemorrhage. 

Trauma:

  Conjunctival laceration or rupture of conjunctival vessels may

 cause hemolacria. Surgery involving incision or excision of the

 conjunctiva may also cause hemolacria. The surgeries include

 small incision cataract surgery, pterygium surgery, squint

 surgery, scleral buckling, and trabeculectomy. 

Inflammation:

 Severe conjunctivitis including hemorrhagic conjunctivitis,

 membranous or pseudomembranous conjunctivitis,

follicular conjunctivitis with congested semilunar fold and caruncle, severe viral or bacterial conjunctivitis cause blood-stained tears. 

Vascular Lesions: 

  Hemangioma, lymphangioma, inflammatory papilloma of the conjunctivitis sac, telangiectasia of conjunctival vessels, and pyogenic granuloma. 

Vicarious menstruation:

  The conjunctiva may periodically/cyclically bleed(Vicarious menstruation) during menstruation or hormonal disturbances. This phenomenon is usually seen around menarche or rarely around menopause. 

- Normal conjunctiva stimulated by hormonal or other factors. 

- Estrogenic premenstrual light blood hypertension. 

Foreign body:

  Foreign body at the upper fornix can cause chronic irritation, erosion of the conjunctiva, and hemolacria. Subconjunctival metallic splinter after trauma may cause bleeding into the tear. 

- Chemical injury- application of silver nitrate over the conjunctiva is another cause of bloody tears.

- Bleeding from the lid margin- Inflammed lid margin due to blepharitis may cause erosion of the surface of the eyelid and lead to bleeding. 

  Bleeding from the lacrimal puncta- The source of the bleeding in tears may be the puncta There is one lacrimal punctum, each at the medial side of the upper and lower lid, respectively. These are situated at the inner margin of the lid. Punctum connects medically to a lacrimal canaliculus on both the upper and lower lid. 

 - Other causes of bleeding from the lacrimal punctum include:

 - Trauma

- Infection

- Tumor- angioma, meningioma of the lacrimal sac. 

- Vascular lesions including varices and dacryolith, rupture of dilated/ distended vessels within the lacrimal sac. 

• Vascular disorders may play an important role in the pathogenesis of hemolacria. Hypertension is an important factor that has been reported to cause epistaxis and retrograde haemolacria through the leak of hemorrhage via the lacrimal puncta
• Other causes of haemolacria include
• Cranial trauma
• Post-traumatic epilepsy
• In otherwise normal individuals after stooping, or muscular effort
• In children after 'copious weeping.'
• Coughing
• Hypertensive crisis
• Acute hemorrhagic edema of infancy
• Unknown cause/idiopathic - In some cases, despite a thorough search for ocular, systemic, or psychiatric causes, no obvious etiology or source is found.

Prognosis:

 Severe bleeding through tears may even be fatal in some cases, especially in a patient with coagulopathy. Identifying hemolacria from systemic causes is of utmost importance. 

Complications:

 

 Haemolacria as such will not lead to complications, but it can be a complication of a multitude of conditions, as explained in the etiology section. Identifying the cause and targeting the treatment towards it, is the most important step in the management of hemolacria. 

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