A Codec Moment

THOUGHT FOR THE DAY...

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People Who Cut Themselves and Why An Expert Discusses the Mysteries of Self-Harm or Cutting

Cutting with razors and other sharp objects is a troubling trend among women, especially teenagers. Disney starlet Demi Lovato sought treatment for the disorder, along with bulimia and bipolar disease. Why do young women engage in such self-destructive behavior, and are these disorders connected? One of the nation’s top psychiatrists, Mark Hyman Rapaport, M.D., explains... Often, people who cut themselves hide their injuries out of shame and embarrassment. But some of that stigma faded last year, when fresh-faced teen singer and actress Demi Lovato, then just 18, admitted she has wrestled with cutting and bulimia since she was 11 years old. "It was a way of expressing my shame on my body," she told "20/20," ABC’s newsmagazine. "There were times where my emotions were just so built up, I didn't know what to do,” she says. “[Cutting was] the only way I could get an immediate release." While undergoing treatment last winter at an Illinois rehabilitation center, Lovato was also diagnosed with bipolar disease. Now she speaks publically about all these issues. Lifescript decided to dig deeper to understand why a beautiful young woman like Lovato – who seemed to have it all – would engage in such self-destructive behavior. So we turned to Mark Hyman Rapaport, M.D., chairman of the department of Psychiatry and Behavioral Neurosciences at Cedars-Sinai Medical Center in Los Angeles. In this exclusive Lifescript interview, Rapaport explains self-harm and cutting and what may cause these painful disorders. Why would someone engage in self-harm or cutting behavior? It can be [a sign] of someone under tremendous pressure and distress. They’ve found this sort of dysfunctional behavior releases that. It’s also a behavior that some people outgrow. Are bipolar disorder, bulimia and cutting connected? There are certainly adolescent people who have bipolar disorder and manifest it by a variety of different behaviors, but cutting doesn’t mean somebody has bipolar disorder. It can be a sign of a variety of different dysfunctions. How can parents spot signs of self-harm or cutting? The first thing is to have a good enough relationship with your children that you know they’ve got a problem. [It's] important that there’s enough trust that the child is willing to work both with the family and outside experts to get help. That’s very difficult with adolescents – to have an open and non-judgmental relationship so they can come to you when they’re in distress. Should parents nose around more in their children's lives? More than nosing around, [we should develop] the best relationship we can with our children and not take things for granted. Our lives are all so busy [that] it’s easy to say, ‘There has been a change in my child’s behavior, but since it’s not creating a problem within the family now, I don’t have time to deal with it.’ We need to address [the problem]. What are the top warning signs of people who cut themselves? What questions should parents ask? 1. Has there been a precipitate change in this person’s friends, the types of people they’re hanging out with? Have they withdrawn from them? 2. School performance and grades: Has that person also withdrawn from activities they used to enjoy and be part of? Have they gotten out of playing in the band? Are they no longer interested in participating in theater at school? Has there been a change in those activities and behaviors? 3. [Has there] been a change in their sleep-wake cycle, eating patterns [or other] day-to-day behaviors? 4. Is the child much more withdrawn, aggressive or assertive? Are we seeing more angry outbursts or tearfulness? These are all [behaviors] that suggest that children are drifting [toward trouble] – whether it’s mood, eating or alcohol- or substance-use disorders. Why is it so difficult for children and teens to talk about cutting? Many times, kids, by nature, want to try and handle it on their own. They feel ashamed about it, and don’t want to be controlled by their parents at this point. They’re trying to be more independent. That’s why open communication and acceptance is good. What happens to people who cut themselves if you don’t deal with it head on? Other [harmful] behaviors are experimentation with drugs and alcohol. It's a major problem [that] can begin as early as junior high school and increase in high school. Frequently, there are issues around eating disorders, particularly with young women. That was the case [with Lovato]. She had been teased about her weight and developed eating disorders. If teen girl has bulimia, is she more likely to practice self-harm or cutting? One frequently sees [an array] of behaviors when someone has an eating disorder. It’s not just either binging or purging, food restriction or over exercising. It can be more basic or primitive behaviors, such as cutting. Is peer pressure a cause? We really don’t know how much of it is [due to] the pressure these young children are under – the pressure to grow up faster, to succeed in school [or] act more [grown up] than they may be developmentally ready to do. How tough is it for people who cut themselves to accept their diagnosis? For anyone to come to grips with this – let alone an adolescent whose body is changing, and who still doesn’t have the wisdom or experiences adults have had – is tough. Healing takes a long time. A young person needs to get used to the fact that they have a chronic disease. That is a tremendous burden to bear suddenly. Your friends don’t have a disease, but you do. You feel very different [and] stigmatized. How can adults minimize the shame people who cut themselves feel? It’s important to realize that these are disorders of circuitry in the brain. They’re the same types [disorders] we see in the rest of the body. They just manifest differently. The brain is the most complex system in the body. The mind and the body are connected – that’s why God made the neck. What sort of treatment is best for people who cut themselves? Intervention, whether through psychotherapy, medication or a combination of those approaches. Can doctors treat people who cut themselves without medication? Yes, sometimes, it can be very effectively treated by psychotherapy, depending on the reasons for the cutting, because – remember – cutting is a symptom. It’s not necessarily a disorder. What kind of psychotherapy is most effective for people who cut themselves? [Dialectical behavioral therapy or DBT] can be a very effective treatment for these types of destructive impulses. [DBT uses cognitive-behavioral techniques and meditation to teach patients to cope with stress, regulate emotions and improve relationships.] Have there been advances in drug and other treatments for these disorders? We’ve made tremendous progress and will continue to make it. Not just in terms of new compounds and medications, but even more importantly, we’re beginning to understand the basic biology behind [such self-destructive behavior]. What have you learned? We’re beginning to understand the role of stress and early-life trauma in [the development of] brain disorders later in life. We’re beginning to understand the role of chronic perceived stress in triggering events and changing the biology of people. Through our works in genetics and epigenetics [the study of how environment and choices can influence genes], we're learning individual factors that put someone at greater risk or resilience. This will allow us eventually to better tailor treatments. Should we be optimistic about the future of treating brain diseases? I want to emphasize the importance of hope. Just because somebody has a symptom of something like cutting or a brain disorder, it’s not necessarily going to negatively impact the rest of their lives. Many people with brain disorders have wonderful lives. What do people who cut themselves need to know most? If they’re cutting, they shouldn’t be ashamed – they should realize people understand that it’s because they’re in distress. They need to know it’s OK to get help. How Do You Deal with Difficult Emotions? It's natural to experience anger, jealousy, hurt - even though your mother told you that "a frown doesn't suit your pretty face!" But have you ever felt overwhelmed by these emotions, or think that you spend too much energy getting over them? Everyone could use some healthy options for dealing with difficult emotions.

More Antioxidants in Organic Tomatoes

When it comes to antioxidant levels, organic tomatoes have been shown to grind conventionally grown tomatoes to a pulp. That's the conclusion of a Spanish study published in the Journal of Agricultural Food Chemistry which found that organic tomatoes work harder for consumers as they contain higher levels of phenolic compounds, plant-based compounds that are known to carry a host of health benefits. After analyzing a species of tomatoes called Daniela, scientists from the University of Barcelona identified 34 different phenolic compounds, levels of which were higher in organically grown tomatoes compared to conventionally grown plants. Scientists explain that when tomatoes are grown without the use of fertilizers and pesticides, plants are forced to respond by activating their own defense mechanisms which increases levels of all antioxidants. "The more stress plants suffer, the more polyphenols they produce," explains study co-author Rosa M. Lamuela. Meanwhile, the jury is still out when it comes to the health benefits of organic produce versus conventionally grown fruits and vegetables. For example, a 2010 study published in the same journal found that organically grown onions, carrots, and potatoes contained about the same levels of antioxidants compared to traditionally raised crops using pesticides and fertilizers.

High-Dose Vitamin D Prevents Fractures

A new analysis of nearly a dozen studies testing vitamin D in older individuals has concluded that it takes a daily dose of at least 800 international units (IU) to consistently prevent broken bones. A dose that high was found to reduce the risk of hip fracture by 30 percent and other breaks by 14 percent. Lower doses didn't have any effect. The report, published in the New England Journal of Medicine, also suggests that too much calcium -- perhaps more than 1,000 milligrams (mg) per day -- can weaken the benefit. "These hip fractures cost a lot and are a really serious event. They are usually the end of independent life for a senior person; 50 percent do not regain their mobility. Reducing the risk by 30 percent with just a vitamin supplement would be an enormous public health opportunity," study researcher Dr. Heike Bischoff-Ferrari of University Hospital Zurich in Switzerland told Reuters Health. The Institute of Medicine recommends that most adults get 1,000 to 1,200 mg of calcium per day and 600 to 800 IU of vitamin D. It sets a recommended upper limit at 2,000 mg of calcium and 4,000 IU of vitamin D. Bischoff-Ferrari said the lack of benefit seen in other studies "may be explained by adherence to treatment and vitamin D supplements taken outside the study medication." Dr. Richard Bockman, a hormone expert at the Hospital for Special Surgery in New York, said the findings are an important counterbalance to last month's widely-reported recommendation by the U.S. Preventive Services Task Force. The government-backed task force advised against taking doses of less than 400 IU of vitamin D with 1,000 mg of calcium and concluded the evidence was unclear for higher doses. It also said the supplements carry a risk of side effects such as kidney stones. Bockman said the best trial is a 2003 study, known as the Trivedi trial, in which volunteers received an average of 800 IU per day as a single 100,000 IU dose every four months. "It clearly showed a reduction in fracture risk in people who were getting vitamin D," he said. In an editorial, Dr. Robert Heaney of Creighton University Medical Center in Omaha, Nebraska, said the problem with the conflicting studies may be that most have failed to consider each person's vitamin D levels to start with. Giving it to people who already have enough, or not giving enough to people with very low levels, may show no benefit, he said. "In this regard, as in several other respects, nutrients are unlike drugs. Once an adequate concentration has been achieved, additional intake has no effect," said Heaney. Bischoff-Ferrari said the new results came without directly including the Trivedi results. "The authors lost the data sets to a computer accident," she said. The new analysis is based on 11 trials that tested various regimens of oral vitamin D in people age 65 and older, mostly women, against an inactive placebo. Some of the trials also included calcium. Overall, there were 4,881 hip and other fractures (not including breaks of the spine) among more than 31,000 people. Vitamin D did not cut the rate of hip fracture significantly, and the drop in other fractures was small. When the researchers looked at people getting the highest doses of the vitamin, typically 800 IU daily, the benefits were clearer, with a 30-percent drop in hip fractures and 14-percent decline in other broken bones. "Notably, there was no reduction in the risk of hip fracture at any actual intake level lower than 792 IU per day," the researchers said. The benefits at the higher dose were seen regardless of age, additional calcium intake, whether the patients lived at home or in an institution, and baseline levels vitamin D. Bischoff-Ferrari said the clearest impact was seen in nursing home patients, who were given the highest doses of vitamin D and regularly took their pills because the nurses were giving them. Just as important is the discovery that too much calcium - more than 1,000 mg per day - may dilute vitamin D's benefits to bones, she said. Because many supplements contain 1,000 mg, the calcium people get in their diets may send people over the limit. "This is a very, very important public health message," Bischoff-Ferrari said. "There are still doctors around who are giving calcium without vitamin to hip fracture patients. Imagine giving a calcium supplement and increasing the fracture risk." In an earlier study, she added, fewer than 10 percent of the people coming into the hospital for a hip fracture had been taking the vitamin. And 60 percent of them had suffered another fracture in the prior decade, yet "the red flag is not coming up." "In the medical world, vitamin D seems like a very low priority. It may be the lack of lobbying for it, the fact that it costs almost nothing" and some people think it's too good to be true, she said. "But the data are impressive."

Knowing These Stroke Symptoms Could Save Your Life Read more: Knowing These Stroke Symptoms Could Save Your Life Important: At Risk For A Heart Attack? Find Out Now.

Stroke is the third leading cause of death in the United States, according to the Internet Stroke Center. Every year, about 795,000 Americans suffer a stroke, and more than 140,000 die from stroke. It's also the leading cause of long-term disability. Although strokes are associated with aging — in fact three-fourths of all strokes occur in people over the age of 65 — they can strike at any age. People who suffer a stroke often don't recognize the symptoms and signs which makes it difficult for them to get rapid, effective treatment. "People who don't know what a stroke is may lie down to sleep thinking it will get better or avoid calling 911 because of the concern that an ambulance is too expensive," said Dr. Cheryl Bushnell, associate professor of neurology at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina. "However, doing either one of these things right after the onset of stroke symptoms will delay treatment. "Recognizing the symptoms and signs is critical in order to receive treatment in the window of three to four and a half hours." A stroke is the sudden death of a portion of brain cells due to the lack of oxygen due to blood flow to the brain becoming blocked or damaged. Symptoms can vary depending on what causes the stroke — either a blood clot (ischemic stroke) or bleeding (hemorrhagic), exactly where in the brain the stroke occurs, and its severity. Stroke is a true medical emergency, and there are signs and symptoms that you need to know in order to save your own life and the lives of others. Bushnell suggests that everyone know the following signs of a stroke and what to do if someone is experiencing a stroke. Stroke signs and symptoms: • One side of the face is weak, numb or paralyzed • Inability to speak or understand clearly • Blurred vision or loss of vision • Dizziness or loss of balance • A sudden and severe headache If you suspect someone is having a stroke, remember the FAST acronym: • FACE: Ask the person to smile, and see if one side of their face droops. • ARMS: Ask the person to raise both arms to See if one arm drifts downward. • SPEECH: Listen to see if their speech is slurred or strange. • TIME: Every minute counts. If the individual is having difficulty with any of these tasks, call 911 immediately. If you are evaluated for stroke, you may undergo blood tests, such as a CBC (complete blood count), coagulation tests (such as prothrombin time to see how quickly your blood clots), blood chemistry tests (such as glucose), and blood lipid tests to measure your cholesterol. You may also specialized tests such as a CT scan or MRI that show images of the brain in order to diagnose stroke. Don't ever assume that a symptom is unimportant if it goes away on its own. Always consult with your doctor, and never try to make a diagnosis by yourself.

How to Heal Your Back Problem Top Specialist on How to Fix and Protect a Painful Back

We shell out billions of dollars a year in search of back pain relief. But which treatments are worth the money? In this exclusive Lifescript interview, a top orthopedic surgeon and sports medicine specialist explains what to do when you’re laid low by a painful back, and how to keep your spine healthy the rest of the time... Muscle and joint complaints have surpassed the common cold as the leading reason for doctor visits, and lower back problems lead the charge. An astonishing 80% of Americans are walloped off their feet with back trouble at some point in their lives, says Nicholas DiNubile, M.D., an orthopedic surgeon in Havertown, Penn., who specializes in sports medicine. In his best-selling book FrameWork (Rodale Books), DiNubile explains how to safely start, maintain and build a lifestyle and exercise program to boost muscle, bone and joint health. A follow-up book, FrameWork for the Lower Back (Rodale Books), provides common-sense advice for preventing and treating disk problems, sciatica, and other conditions that leave us with stiff, achy backs. If you’ve ever had back pain, it’s especially important to practice healthful habits, he says. Even a brief back episode can put you at risk for trouble later. “The No. 1 predictor of a [future] back problem is a previous back problem,” he says. “It’s like a warning shot.” DiNubile should know. Not only has he worked as an orthopedic consultant to the Philadelphia 76ers pro basketball team and Pennsylvania Ballet, but he’s also had his own longstanding back issues. In this edited Lifescript interview, he shatters myths about bed rest, back surgery and medical imaging techniques, and explains safe ways to stay active when you’ve literally been knocked flat on your back. How did your back problem start? I had a friend, [and] we used to clown around every year on the beach. He’d come find me, and tackle me just to say hi, and we’d laugh it off. But one year, he came from behind and just hyper-extended my back in a way it was never meant to move. I wound up on all fours and had a hard time standing up. That was the beginning of some big struggles. How did you deal with your back problem? For a while, I put up and just tried to work around it. And there are plenty of days now when I have tightness and aches, and I suck it up and carry on. You’re a surgeon – did you consider surgery for your back problem? No. I knew there wasn’t a surgical option that would apply. The majority of back problems don’t require surgery. There’s probably way too much back surgery in this country. What finally helped you? A combination of things. I changed my mattress to one that was more accommodating, with a layer of memory foam on top. And I modified my exercise routine to put the focus on core workouts. But what really helped me was a chiropractor. How did that help? For 12 years, I was the doctor for the 76ers, and we had an excellent chiropractor. At games, when the players were on the court, I would have him work on me. Because of the injury, my back is vulnerable and tightens up. He’d mobilize the affected [muscles] and get them functioning. I’d use the opportunity to do my own work on my back problems, especially core strengthening and stretching. Many people who never suffered a traumatic injury wind up with a chronic back problem and pain. Why? You don’t have to get tackled by a maniac. The spine is pretty vulnerable, and little things can get to you. People hurt themselves bending over to tie a shoe. I tell people to watch their BLT’s – bending, lifting and twisting. What are other common triggers of back problems? Sitting too much. People think it relieves stress, but it puts heavy force on the spine. Poor aerobic condition also makes you more vulnerable. Muscles need oxygen, and disks and ligaments need a good blood supply to stay healthy. That’s one reason smoking is damaging to your entire frame, especially the spine. Being overweight [can also cause a back problem]. The more your frame has to support, the harder it works and the more susceptible to injury it becomes. Are women at higher risk for a painful back? Pregnancy definitely takes a toll. Postural changes put pressure on the spine. Ob-gyns say once you deliver it will go away. Well, sometimes it does, but [it can leave them] more vulnerable [to future back problems]. Plus, now they have kids to take care of. They’re bending and lifting all the time. It’s a breeding ground for back pain. What role does stress play with back trouble? It’s like putting lighter fluid on a fire. It might not cause back pain, but it certainly keeps it going. How does aging affect our backs? Gray hairs and wrinkled skin aren’t the only consequences of getting older. There are musculoskeletal changes – cellular, chemical and mechanical. Even if you don’t have a painful back, if you take an MRI you’ll probably see disk degeneration and some arthritis. What does disk degeneration look like? The disk is like a little jelly donut between each of your vertebrae. It keeps the bones from rubbing against each other. When you’re young, they’re bright and water-filled. With age, they start darkening and shrinking. It’s like grapes turning into raisins. They’re accidents waiting to happen. We’re the first generation to try to stay active all our lives, and we’re living longer. We’re pushing our bodies. So there’s an explosion of musculoskeletal problems. There’s a mismatch between longevity and durability. We weren’t designed to go as long as we’re going. Does that mean a back problem is inevitable? Changes in the body are inevitable, but problems aren’t. You can rebuild muscle at any age. Studies involving 90-year-olds found that after a 12-week strength-building program, strength improved dramatically. Those who had used walkers were able to get around with canes, and those who had used canes walked without them. What activities are best for back health? Being more fit aerobically protects against back pain. There was a famous study of firefighters on disability claims. The people who had the worst aerobic fitness were most likely to miss work from lower back problems. How does heart and lung fitness help your back? We’re not sure. It probably helps with microcirculation, the blood supply that nourishes the nooks and crannies of your musculoskeletal system. And it keeps your weight down. But cardiovascular fitness by itself it isn’t enough. What else can help prevent a back problem? Core strength is really important. That’s not just six-pack abs. It’s your back muscles, obliques [the muscles on the sides of your abdomen], the back extenders and the muscles of the pelvis. They’re the support structure around the spine. I recommend a routine that works out all of these muscles. The exercises should be done every other day. Many “core” exercises you recommend are based on yoga – for example, the cobra and cat poses. How does yoga prevent or relieve a back problem? Yoga is great for back strength, enhanced flexibility and learning to relax. Many people are competitive about exercise. They’re out there playing hard, trying to outdo everyone else. The nice thing about yoga is it’s not a competition. What other fitness disciplines do you like for backs? A lot of the martial arts, especially the soft styles like tai chi, are great for posture and strength. What are back-friendly options for an aerobic workout? Walking. Swimming is fantastic, even if you have an acute back episode or just a run-of-the-mill chronic backache. If you’re not a swimmer, or your lower back is just too sore for you to swim, try water walking, water jogging or even water aerobics. The water supports your body, and it’s a comforting environment if you have a painful back or back spasms. You can do things that might be too uncomfortable on land, with gravity working against you. Any nutritional advice to promote back health? Vitamin D deficiency is a much bigger deal than we thought. Some studies have linked it with back pain. I make sure all my patients, men and women, [get] enough vitamin D3 [the more absorbable form] and calcium. When people have really bad back pain, shouldn’t they just rest? The old days of bed rest are over. We usually suggest a day or two off your feet, if you need that, to get into positions that are more comfortable. After that, it’s counterproductive. Why? Motion is lotion! I see a lot of people who are on disability for life – they have sedentary jobs, they’re not digging or building things or using their backs for work. If you’re staying home, hooked on soap operas and taking pain medication, you’re not getting better. If all you can do is get in a pool and move around a little, you should do that. But people often worry that movement will aggravate the problem. You need to learn the difference between hurt and harm. Many lower back problems are so painful that people get frightened and assume that movement will harm them. It’s not true. If you can deal with the hurt and work around it, you [won’t] harm yourself or make things worse. Should you get a magnetic resonance imaging [MRI] scan to figure out what’s wrong? You probably don’t need one. I had an X-ray after I was tackled, but I’ve never had an MRI. I knew it wouldn’t change my treatment. Still, spine MRIs can be very helpful in cases of [severe,] chronic back pain or if there’s significant leg weakness or numbness. It’s best to talk to your doctor. Should people take painkillers for back pain? Narcotics can help in the very short term, but they can lead to secondary problems like addiction. I’ll reluctantly prescribe them for a few days if patients need them to get comfortable and move around. I prefer the over-the-counter pain meds such as NSAIDS [non-steroidal anti-inflammatory drugs, including Advil and Aleve] for short-term use. But [drugs] won’t solve a back problem. Is massage helpful? I’m a big fan of massage for pain relief. But it [won’t] cure anything – you shouldn’t rely only on passive modalities, in which someone else does all the work. If you get some relief from it, you should use that period of improvement to do things [that] make yourself better. What are those things? It’s a lifestyle change and an attitude. You have to create new habits and stay active. You have to have the right mindset. I can tell when I walk into [an examining] room [that] if the patient is stressed out or negative, it’s going to be impossible to get them out of their back pain. Remember, you are part of the solution to any health problem you face. For more expert advice and information, visit our Chronic Pain Health Center.