Monday, 27 August 2012

Self-Injury - Series Introduction

This is the first in a series of articles I will be presenting here about Non-Suicidal Self-Injury, also known as self-harm, [or by some antiquated and misguided clinicians as “self-mutilation”].  The series will run throughout September and address many aspects of self-injury from who does it and how, what purpose it serves, what biological factors are involved, what treatment options have seen the greatest success, and what those who self-injure want you to know.  I have named this series after the psychoeducational presentation I created titled:

The definition of self-injury is;

“… the commission of deliberate harm to one’s own body. The injury is done to oneself, without the aid of another person, and the injury is severe enough for tissue damage (such as scarring) to result. Acts that are committed with conscious suicidal intent or are associated with sexual arousal are excluded.”
(Winchel  & Stanley, 1991)

Self-Injury is one of the most misunderstood, mythologized, and ignored mental health issues we face.  It is a topic I became passionate about while working with adolescents who self-injure and through friendships I made in the worldwide self-injury peer support community.  I can state with confidence that I have learned more about self-injury through those who do it than I ever have reading a textbook or in any post secondary course.

I suppose the first question is; “Is this a large enough problem to even bother with?”  The short answer is “Yes.”  The statistics gathered throughout North America and Europe reveal the practice of self-injury is more widespread and more complex than most people realize.

Research conducted by Dr. Mary K. Nixon and her team at the University of Victoria (Nixon, Jansson, Cloutier, 2005) indicated the following results that have been corroborated in various other studies throughout North America;

  • 16.9% of adolescents between the ages of 12 and 18 self-injured for an average of 21 months
  • 75.8% were female
  • Average age of onset was 15.3 years
  • 58% stopped self-injuring during adolescence
  • 42% continued to self-injure into adulthood
  • 83.1% stated they had not used self-injury to attempt suicide

Another more recent longitudinal study (Hawton, Zahl, Weatherall, 2011) conducted in the United Kingdom that tracked 11,583 patients who presented to hospital after deliberate self-injury between 1978 and 1997 revealed the following troubling statistics on completed suicides for people who self-injure long term;

  • Patients were 66 times more likely to complete suicide than the general population one year after onset (0.7%)
  • 5 years after onset - 160 times more likely (1.7%)
  • 10 years after onset - 226 times more likely (2.4%)
  • 15 years after onset - 283 times more likely (3.0%)

To put these numbers into a local perspective, lets look at school populations in the area where my practice is located: The Okanagan Valley in British Columbia has three school districts; Okanagan/Skaha, Kelowna, and Vernon.  Applying the statistics gathered in the above study to enrollment numbers for the 2011-2012 school year;

Vernon School District 22 had 3907 students between the ages of 12-18 years enrolled.  Of those;
  • 660 will self-injure for an average of 21 months
  • 277 will continue into adulthood
  • 8 will complete suicide within 15 years of the onset of self-injury

Okanagan/Skaha School District 67 had 4025 students between the ages of 12-18 years enrolled.  Of those;
  • 680 will self-injure for an average of 21 months
  • 286 will continue into adulthood
  • 8 will complete suicide within 15 years of the onset of self-injury

Kelowna School District 23 had 9426 students between the ages of 12-18 years enrolled.  Of those;
  • 1593 will self-injure for an average of 21 months
  • 669 will continue into adulthood
  • 20 will complete suicide within 15 years of the onset of self-injury

Looking at these numbers is tragic when – aside from the suicide risk - you also take into account the years of pain and suffering these individuals will endure.  And never doubt for a moment that those who self-injure for a prolonged period of time suffer torment as they enter into a cycle of self-loathing/shame, unbearable tension, overwhelming emotional distress, self-injury, and relief.  Relief that once again leads to self-loathing or shame and begins the cycle once more.

Aaron D. McClelland, RPCc –

Monday, 20 August 2012

Brain 1.4

Many marvel at the magnificence of the human brain and the unsurpassed cognitive ability that lies within.  It is true that our brains can accomplish great feats of reason, logic, problem-solving, and creativity, but all of that is the domain of the cortex - the higher functioning part of our brain.  If we look at the systems below the cortex, we can see that the design of our brains isn’t the greatest.

Our brains - all brains on planet Earth - developed pretty much the same way, beginning with a rudimentary organ that keeps us alive: the Brainstem

This brain organ keeps our heart beating, our lungs breathing, our temperature and blood pressure regulated, and all the other systems in our body functioning as they should to sustain life.  The Brainstem is about 300 million years old and all the little critters that moved around received one.  In modern computer operating system parlance, this would be “Brain 1.0”.

The problem was that over time some critters started eating other critters, so a way to sense danger and to ensure survival of self and species was needed - we needed to be able to distinguish between friend or foe.  Instead of redesigning the brain, nature added a new system that could take care of these more complex needs - the Limbic System - and it was plugged into the top of the Brainstem about 200 million years ago.

Within the Limbic System are organs that create the desire to mate, make offspring, sense, remember, and react to everything in our environment.  The Limbic system is our guardian - it helps us survive not only as a species, but as an individual by differentiating between those we can mate with and those who pose a danger to us.  This additional system saw our brains change from “Brain 1.0” to “Brain 1.2”.

But now that our world and our functionality was becoming more fine-tuned, we needed a way to move skillfully in it, and so the Cerebellum was plugged into the brainstem and Limbic system.

The Cerebellum [Latin for “small brain”] helps us move in a coordinated way by controlling our limbs and giving us practical motor skills.  This way we can move toward others of our kind for propagation and safety, and away from those who mean us harm.  This move saw us move to “Brain 1.3”.

Armed with these developing tools, our world became more and more complex as each critter competed to survive.  To navigate that complexity - and to survive as a species and as an individual - we needed more than the basics of a Brainstem-Limbic-Cerebellum system could provide us.  And so the Cortex developed - the realm of higher functioning in our brains.  But again, it was an addition to the existing system, not a complete overhaul.

The Cortex is comprised of different areas that control different aspects of our functioning; Visual, sensory, motor, prefrontal, speech control and interpretation, plus a great deal of area that can be used as memory storage.  It’s a complex organ that sets us apart from other creatures on the planet.  So, this addition saw us move to “Brain 1.4”.

As stated above, the problem is that as our brains developed, instead of a complete redesign at each stage, the new parts were added onto the old parts like Lego blocks.  This means that all the older parts of our brain can still function without the newer parts and that is a “good news - bad news” proposition.

The good news is that as we learn new skills, such as riding a bike; We can practice and develop the skill to ride a bike using our Cortex, then assign that skill to our Cerebellum so we no longer have to think about it - we simply hop on our bike and the Cerebellum takes over.

More good news is that this system helps keep us safe by speeding up our response to danger.  Our Cortex is a wonder of computing power, but - compared to the lower parts of our brain - it is slow.  To survive a sudden threat, we need speed that is unencumbered by the slow logical processes in our Cortex.

Within our Limbic System are a number of smaller organs that each have a particular job.  Three of the significant ones are;

  • Thalamus - relays sensory and motor signals and regulates consciousness, sleep, and alertness
  • Amygdala - performs the main role in the processing of memory and emotional reactions
  • Hippocampus - consolidates information from short-term memory to long-term memory
This system keeps us safe by monitoring our environment for danger and through other organs in the Limbic System will put us on high alert if is senses danger - and for speed, it’s connected directly to the Brainstem and Cerebellum.

When our body sends a signal up our Brainstem or through our vision or hearing, it first lands in the Limbic System.  The Amygdala immediately works with the Hippocampus to determine if this signal indicates danger by searching for memory of that same signal in the past.  If a memory matches that signal and is classified as a danger, the Amygdala triggers the release of a chemical soup that includes Cortisol [the “stress” hormone] and Norepinephrine [adrenalin] and gets the body ready for a “flight or flight” response.

What does this response look like?  Our bodies tense to get ready to run or fight for our lives - [this sometimes makes us feel weak, because groups of opposing muscles are pulling against each other]; Our heart rate increases to supply more oxygen to our muscles; Our blood pressure changes to meet the demands of our circulatory system; Our breathing rate increases to get more oxygen into our system; We may grow pale as blood is pulled deep into our bodies in case we are wounded; We may have an overwhelming need to “get out of here” or sometimes start feeling angry and aggressive as we prepare to fight for our lives depending on our nature.

This is a terrific safety system to keep us alive in dangerous situations.  Without it we would walk into traffic and pet snarling dogs.

The bad news is that because this system is designed to work on its own to make sure our response isn’t slowed down by having to consult our higher functioning brain, a fear response can cause us problems because in many cases it isn’t a real fear and our Cortex can’t stop it in time.  We end up having an “anxiety attack” without even knowing why we are feeling distress.  It would be nice to have all the systems integrated so the higher functioning parts of our brain is included in this safety system so we could consciously limit our fear responses, but it doesn’t look like “Brain 2.0” is on the horizon yet.

So, are we doomed to be ruled by a poorly designed brain system that isn’t rational and sometimes reacts to every day events with fear?

No.  There are many therapies that can address recurring anxiety problems; Our Limbic system was programmed to react to specific stimulus with fear, so we can reprogram it to recognize that many stimuli are not dangerous at all.

Therapy to reprogram our unreasonable fear responses takes courage and no small amount of effort, but until we are issued a “Brain 2.0”, we have to work with what we have.

Aaron D. McClelland, RPCc

Friday, 3 August 2012

Neural Pruning, or: "Why is my teen so impulsive?"

Almost every parent sports a few new grey hairs as their children navigate through their teen years, and many wonder why the teenage phase of development is often fraught with impulsive, reckless behaviour and raging emotional outbursts.  Rising hormone levels play their part to be sure, but a great deal of the impulsiveness we see in teens and young adults lies within how the human brain develops and organizes.  It’s all about the neurons.

Neurons are the little nerve cells in our brains that connect to each other through electrical and chemical signaling.  They comprise the circuitry of our brains and keep our heart beating, our lungs breathing, our temperature regulated and a millions other complex tasks that happen automatically to keep us alive, aware, and safe.  They are also the circuitry in our cortex that allow us to feel, learn, reason, plan, imagine, and act.

Each neuron has about 10,000 connections to other neurons.  At the time of our birth we have about 10 billion neurons, but our brains continue to grow into our teen years and will reach 80 billion to 120 billion in number.  So taking an average of 100 billion neurons, each with 10,000 connections gives us 1,000,000,000,000,000 circuits inside the confines of our brains – each capable of activating as we encounter a new stimulus or choice.  And with that many active connections, a teen’s brain is a pretty busy place.  And sometimes it’s a confusing place as the neural connections compete with each other – and this is why we often see the poor judgment, impulsiveness, and at-risk behaviour in our teens.  This is also why we see the rapidly cycling highs and lows of emotion and why some teens resort to drugs or alcohol or self-injury as a means dial back the sometimes overwhelming activity inside their head.

So why do we have so many connections that they actually seem to cause us problems?  It’s because the brain is designed around redundancy – we have two of almost everything we need and – as noted above - way more connections than we require.

Now here’s the good news; Because nature intended us to have more neural connections than we need, it also provided our brain with a means to organize those connections.  As we mature, our brain prunes excess connections.  First, little-used connections are pruned as part of a “use it or lose it” strategy.  Second, troublesome connections are pruned – connections that duplicate messages that create that impulsive behaviour or raging emotions are cut out.  Outwardly, we see this as “learning” and “maturing”.

This pruning process starts in infancy and is completed in early adulthood, which is why we see our wild teenagers gradually calm down as they approach their mid 20s.

So, knowing why our teens seem to be out of control at times won’t slow the greying of our hair, but it will hopefully help us to understand that these behaviours are a normal stage of development and will one day pass.

Aaron D. McClelland, RPCc