What is Cotard’s syndrome? The rare mental illness which makes people think they are dead


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What is Cotard’s syndrome? The rare mental illness which makes people think they are dead

A rare mental illness can make the sufferer believe they are dead, partly dead or do not exist.

Chronicled in the Washington Post by Meeri Kim, Cotard’s syndrome — sometimes dubbed ‘Walking Corpse syndrome’ — is a condition where patients believe they are dead, parts of their body are dead or that they do not exist. Any evidence to support the fact they are alive is “explained away” by sufferers, according to the Post.

It is not classified under the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) but is recognised as a “disease of human health” in the International Classification of Diseases. According to Mind: “It is linked with psychosis, clinical depression and schizophrenia”.

A spokeswoman for Mind told The Independent the syndrome was “certainly rare”.

“Cotard’s syndrome is a type of delusion that is usually associated with denial of self-existence,” she said.

“The person experiencing the delusion might believe that they are dead, dying, parts of their body do not exist or they do not need to do activities to keep themselves alive (drink, eat, basic hygiene etc.)”

French neurologist Jules Cotard identified the first case in the 1800s. He described a woman suffering from the condition as affirming “she has no brain, no nerves, no chest, no stomach, no intestines… only skin and bones of a decomposing body”.

Esmé Weijun Wang spoke to the Post about her experience of the condition, which she suffered from for two months, explaining that after weeks of losing “her sense of reality” she woke up and told her husband she had actually died a month before, when she had fainted on a plane.

She said: “I was convinced that I had died on that flight and I was in the afterlife and hadn’t realised it until that moment.”

Ms Wang, who was previously diagnosed with a form of bipolar-type schizoaffective disorder, later recovered and “no longer saw herself as a rotting corpse”.

A Mind spokesperson said “in terms of prevalence, there seems to be very few studies” meaning it is difficult to assess how many people are affected by the condition.

The Washington Post says “what causes Cotard’s syndrome and other delusions is a matter of debate” and speculates on a range of possibilities including brain impairment.

Professor and clinical psychologist Peter Kinderman told The Independent: “This syndrome is extremely rare so there’s not much known about it, most literature on it is individual case studies over many years.”

He says one theory about the condition’s cause is that when “conditions exist to make someone feel confused or distressed” the individual can combine all their thoughts and beliefs – some of which may be distressing and unusual, with the feeling that they don’t recognise themselves.

He said this could mean “people come up with the best conclusion they can to explain the experiences they’re having, which may be that they’re dead.”

In 2013, a British man called Graham was interviewed in the New Scientist. He was diagnosed with Cotard’s syndrome after believing his “brain was dead”. He believed he had killed it after a suicide attempt following severe depression.

Graham said he visited a graveyard during this time as “it was the closest I could get to death”.

He said: “I didn’t need to eat, or speak, or do anything.”

Graham’s condition gradually improved with psychotherapy and drug treatment.

Why are men still ignored when we talk about miscarriage?


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Why are men still ignored when we talk about miscarriage?

“How is Julia doing?” That was the question my husband was repeatedly asked after our first miscarriage. And after our second; and third; and fourth. We had lost baby after baby, but it was my state of mind and health – the devastated mother who had lost her child – that was uppermost in the thoughts of our family and friends. Almost nobody asked my husband the other obvious question: how are you doing?

While it is couples who “are going to have a baby”, miscarriages only happen to women. Yet the emotional trauma of the overwhelming sense of loss and grief affects both parents. So it was with great courage that Facebook chief Mark Zuckerberg chose to reveal, as he announced he and his wife are expecting a baby girl, that they have suffered three miscarriages. His deeply personal words will have echoed strongly with everyone who has experienced the loss of a pregnancy: “You start making plans, and then they’re gone. Most people don’t discuss miscarriages because you worry your problems will distance you or reflect upon you. So you struggle on your own.”

And that it precisely what many men do after losing a baby. They struggle on and bottle up their own feelings of loss to keep strong for their partners. Yet, as Mark Zuckerberg explained in a poignant Facebook post, for the couple who have miscarried, it was very much a real baby, containing all their love and hopes for the future, so the grief is very real too. And it needs to be treated like any other grief.

New research by the Miscarriage Association has found that, despite their intense feelings of sadness, anger and loss, a quarter of men whose wives or girlfriends miscarried never spoke about their grief with them because they feared upsetting her or saying the wrong thing. The sheer horror and shock of a miscarriage, and all the bleeding it can entail, can be overwhelming – an emotion that is compounded by a man’s utter powerlessness to do anything to help the woman they love.
Yet – and, importantly, quite unlike women – men are simply expected to get back on with normal life straight away, with no time off to recover. They report returning to work shell-shocked but unable to talk about their loss with colleagues because the pregnancy had been kept a secret. Even when men do attempt to talk about their feelings the response can do more harm. Well-meaning but clumsy comments such as “never mind, you can try again” and “at least you aren’t shooting blanks” underestimate the grief experienced.

The best way to cope with miscarriage is for men and women to talk – to their partners, to their friends, to a counsellor. After a rich, successful man like Mark Zuckerberg publicly shared his grief about his wife’s miscarriages, it may make it easier for more men to finally open up about their own feelings of loss. There is nothing unnatural about grieving for the loss of your unborn child.

The last women in China with bound feet: ‘They thought it would give them a better life’


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The last women in China with bound feet: ‘They thought it would give them a better life’

Jo Farrell’s most recent photography project began, by chance, in the back of a cab. Her career-long interest is in documenting disappearing cultural practices, and in 2005 she got chatting to a Shanghai taxi driver about foot binding. “He mentioned that his grandmother had bound feet,” Farrell recalls. “Most people told me that it was such an old tradition, there were no women left. I went to the village of the cab driver’s grandmother, in the Shandong province, and met Zang Yun Ying. She became the first woman in my project.”

What followed was a nine-year journey across China, tracking down the last survivors of foot binding. She found just 50 women. Five of them were still completely bound and in hiding, but most had released their binds. All were from impoverished villages in the provinces of Yunnan and Shandong. The oldest, Zhang Yun Ying, was 103. Farrell’s photobook Living History: Bound Feet Women of China, contains close-up portraits of the severe deformity they suffered.

Foot binding was outlawed in China 103 years ago, following almost 10 decades of the practice. But the last factory producing “lotus shoes” – the triangular embroidered platforms used to showcase the women’s minuscule pointy feet – closed just six years ago.

After foot binding was banned it became taboo, and in 1950 Chairman Mao ordered anti foot-binding inspectors to publicly shame any bound women they found. “It was considered an old tradition that did not reflect modern China and should be stopped,” Farrell tells me from her flat in Hong Kong. “Their binding would be hung in windows so that people would laugh at them.”

Most women were bound at the age of seven. “The first year is particularly excruciating because the girls were made to walk until their toes would break under their weight,” says Farrell. “After that, the toes became numb and now, 50 or 60 years later, they don’t have any pain in their feet. It’s all quite numb.”

Farrell insists her photo series isn’t meant to sensationalise, but to educate us about a little-known custom. She admits she was surprised by her own reaction to seeing bound feet close up. “The first time I met Zang Yun Ying and held her foot in my hand it was just incredible – so soft and so incredibly formed.”

In spite of the brutality the project lays bare, its message is one of hope, survival and grit. “In Chinese society, it was the only way forward for women,” says Farrell. “They did it because they thought it would give them a better future, a better life.”

Sisters fight to save ancient African language from extinction


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Sisters fight to save ancient African language from extinction

A 95-year-old woman is helping a last ditch effort to preserve an ancient African language before it goes extinct.

Hanna Koper and her two sisters are thought to be the last remaining speakers of the San language N|uu, rated as critically endangered by Unesco. The San, also known as “bushmen”, were the first hunter-gatherers in southern Africa.

N|uu, which has 112 distinct sounds, was passed on orally down the generations but never written down. Now Koper and her siblings have worked with linguists to design alphabet charts with consonants, vowels and 45 different “clicks” that are typical of San languages, as well as rules of spelling and grammar.

Matthias Brenzinger, director of the Centre for African Language Diversity at the University of Cape Town, who is working on the project with British academic Sheena Shah, said: “It’s the most indigenous language of southern Africa.”

N|uu and related languages were spoken in most parts of southern Africa, he added, but were wiped out by white settlers, sometimes with the support of locals. “Very often they kept the young girls, but they killed all the men. Genocide is the major reason for these languages in southern Africa to be extinct now, and then forced assimilation. Farmers were taking their land so there was no subsistence for them any more.”

Brezinger has overseen the teaching of N|uu at a local school, where pupils learn basics such as greetings, body parts, animal names and short sentences. One teenage girl in particular is showing huge promise in the language but “at one stage there will be no fluent speaker any more”, he said.

That does not mean N|uu will necessarily be doomed to the archives, however. “With these languages, you never know,” said Brezinger. “Hawaiian was extinct basically, and then there was a movement 35 years ago and you have 2,000 mother tongue speakers of Hawaiian.

“This is why it’s very important now for us to record as much as possible with the speakers so we have material, spoken language on video tape and so on.”

N|uu has one of the biggest speech sound inventories in the world, he added, including more than 45 click phonemes, 30 non-click consonants and 37 vowels. “Language is the most important cultural asset, so if you lose your language, you lose your culture. In Canada, there is a clear link between those indigenous people who lose their language and suicide rates. In this globalised world, local identity is essential,” Brezinger.

Koper, who lives near Upington in Northern Cape province, told South Africa’s Sunday Times newspaper that when she was a girl in the days of white minority rule, she and her siblings were told their language was ugly. “We were told not to make noise and the baas [a Dutch word for supervisor] would shout at us if we spoke the language because they believed we were gossiping,” she was quoted as saying.

“This is my language. This is my bread. This is my milk. I didn’t learn it, but I ate it and this is how it is my language.”

Koper’s sister Katrina Esau, 82, who has received an award from President Jacob Zuma for her work to preserve San language and culture, added: “Other people have their own languages. Why must my language be allowed to die? It must go on. As long as there are people, the language must go on.”

Miscarriage misconceptions boost feelings of guilt and shame, study says


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Miscarriage misconceptions boost feelings of guilt and shame, study says

Feelings of guilt and shame in women who experience miscarriages are exacerbated by misconceptions over the causes, a US study suggests.

An online survey of 1,084 people, which formed the basis for research published in the Obstetrics & Gynecology journal on Monday, found that almost half of those who had a miscarriage felt guilty. Two in five said they felt like they had done something wrong, and the same number reported feeling alone.

A significant number of the respondents were under misapprehensions as to what caused the loss of the pregnancy. Three-quarters believed that a stressful event could bring about a miscarriage, 64% thought that lifting a heavy object could be a cause, and a fifth that previous use of oral contraceptives could induce pregnancy loss.

Coupled with the fact that 57% of those who had suffered a miscarriage said they were not given a cause for the loss, the researchers, from the Albert Einstein College of Medicine at Yeshiva University and Montefiore Medical Center, both in New York, believe such misapprehensions could contribute to the the negative feelings experienced.

Dr Zev Williams, the director of the programme for early and recurrent pregnancy loss, said: “The results of our survey indicate widespread misconceptions about the prevalence and causes of miscarriage. Because miscarriage is very common but rarely discussed, many women and couples feel very isolated and alone after suffering a miscarriage. We need to better educate people about miscarriage, which could help reduce the shame and stigma associated with it.”

The respondents, who were self-selecting, filled in a 33-question survey, which was open for three days in 2013, to assess perceptions of miscarriage, with 10 of the questions specifically directed at men or women reporting a history of miscarriage.

Of those who took part 15% said they or their partner had suffered a miscarriage, but the majority of respondents (55%) believed that miscarriages are uncommon (defined as less than 6% of all pregnancies). The truth is that miscarriages end one in four pregnancies and are by far the most common pregnancy complication, the paper says.

A fifth of people incorrectly believed that lifestyle choices during pregnancy, such as smoking or using drugs or alcohol, were the single most common cause of miscarriage, more common than genetic or medical causes. In reality, 60% of miscarriages are caused by a genetic problem.

The importance of hearing from others who have gone through the same experience was highlighted by a significant minority of those who had suffered a loss in pregnancy. Almost half said they felt less alone when friends disclosed their own miscarriage and 28% stated that celebrities’ disclosure of miscarriage had eased their feelings of isolation.

The authors concluded: “Patients who have experienced miscarriage may benefit from further counselling by healthcare providers, identification of the cause, and revelations from friends and celebrities. Healthcare providers have an important role in assessing and educating all pregnant patients about known prenatal risk factors, diminishing concerns about unsubstantiated but prevalent myths and, among those who experience a miscarriage, acknowledging and dissuading feelings of guilt and shame.”

The majority (55%) of respondents were women and all were aged 18-49. The sociodemographic distribution across gender, age, religion and geographic location and household income was consistent with 2010 national census statistics but race and ethnicity were not.

Body dysmorphic disorder: charity video reveals the image anxieties that can push people to the edge


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Body dysmorphic disorder: charity video reveals the image anxieties that can push people to the edge

It is a treatable condition suffered by at least 2% of the population, both male and female, that devastates the lives of those who have it and can lead to prolonged depression and even suicide. Now a fledgling charity, the Body Dysmorphic Disorder Foundation, hopes to raise awareness of the obsessive anxiety condition that leaves people convinced there is something flawed or “ugly” about their looks.

The foundation’s first conference, on 30 May in London, is aimed at health professionals, body dysmorphic disorder (BDD) sufferers and their carers, and is being promoted by a two-minute film, You Are Not Alone, directed by Steve Caplin, which tackles one of the greatest issues surrounding BDD: the idea that the person with it is isolated and cannot fit in.

“One of the biggest problems is that this is an under-researched disorder which is not fully understood by either professionals or laymen,” says clinical psychologist Dr Annemarie O’Connor, director of themindworks, a London-based psychology practice, who will be running a workshop at the conference. “This is not simply a case of feeling low or having to change your clothes a couple of times before you go out. It’s an obsessive anxiety disorder which can lead to huge levels of distress.”

That distress in turn can lead to prolonged bouts of depression and often suicide. “There’s such a high level of hopelessness and a real conviction among sufferers that they are ugly to look at or flawed,” explains O’Connor.

“Many sufferers turn to cosmetic intervention, but when that doesn’t change how they feel or how they see themselves. They become utterly convinced that a better way doesn’t exist, and this makes suicide a real feature of the disorder.”

Robert Pattinson, who was catapulted to fame after getting the role of vampire Edward Cullen in the Twilight films, told Australia’s Sunday Style magazine that he suffers from anxiety and BDD issues, which can become crippling before a red-carpet event.

“I get a ton of anxiety, right up until the second I get out of the car to the event, when suddenly it completely dissipates,” said Pattinson. “But up until that moment I’m a nutcase. Body dysmorphia, overall tremendous anxiety. I suppose it’s because of these tremendous insecurities that I never found a way to become egotistical. I don’t have a six-pack and I hate going to the gym. I’ve been like that my whole life. I never want to take my shirt off.”

Scarlett Bagwell’s 19-year-old daughter, Alannah, first began exhibiting signs of BDD at the age of 14. “I noticed that she had lost a lot of weight fast and at first I thought it was anorexia, but then other things began to happen – she would refuse to come out with us, didn’t want to leave her room … I still thought it might be teenage angst, but then one day she dropped out of school, despite having always loved it.

“There was so much turmoil in her head – she couldn’t get on the bus, I’d drive her to school but she wouldn’t go in. She really wanted to, but she couldn’t physically get out of the car. She’s a beautiful girl, but she was convinced there was so much wrong with her – she’d insist that her nose was too big and deformed, that she had tiny, piggy eyes and funny hair.”

As Alannah’s condition worsened, including bouts of self-harm and suicide attempts, so her family struggled to get a diagnosis. “I had to fight the system to get the proper treatment for her,” says her mother. “Just getting a diagnosis was so hard and meanwhile Alannah went from being very independent to being a baby again. At times I even had to force her to wash and I would wash her hair for her. Everything was a struggle. I felt I was failing my daughter.”

The hard-won key to her recovery was a combination of cognitive behavioural therapy (CBT) specifically tailored for BDD sufferers and anti-depression medication.

Alannah is now sitting her A/S exams at a local college and intends to go to university. Her mother hopes that the establishment of a regular conference will lead to further understanding, help and support for those with BDD. “I think that because everybody has slight issues with their appearance – they don’t like their hair, or they think a particular dress makes them look bad – they can’t understand the struggle that actual body dysmorphics go through,” she says. “It stops you functioning. People with body dysmorphia are very isolated; they often can’t bring themselves to go out, no matter how much they want to, they don’t want to be seen.

“We were lucky that Alannah has had help and the support of her family, but I wonder how many people struggle without that support because they are diagnosed later, undiagnosed or misdiagnosed,” she said.

How robots are helping children with autism


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How robots are helping children with autism

Anthony Arceri is seven and has autism. His clothes are covered in sensors, and he is standing in front of Zeno, a smiling, 2ft-tall robot. “What is your favourite food?” Zeno asks Anthony. “Chocolate milk and french fries.” “I love chocolate milk,” Zeno replies. The robot raises its arm, and Anthony copies. Zeno rubs his stomach, and so does Anthony.

It looks like fun – and for Anthony, it is. But researchers believe the interaction between Anthony and the robot also holds the key to early diagnosis and treatment of autism. Zeno is the result of a collaboration between Dr Dan Popa at the University of Texas at Arlington, Hanson RoboKind, Dallas Autism Treatment Centre, Texas Instruments and National Instruments – and is the brainchild of Hanson Robot owner and former Disney imagineer David Hanson.

Diagnosis of child autism has traditionally taken place through social interaction and speech exercises. This means that, until a child can speak, diagnosis is either a lengthy process, or can’t happen. But Zeno can interact with children through nonverbal communication such as body movements and facial expressions, speeding up diagnosis and perhaps even enabling it to be carried out before a child can talk.

Zeno isn’t just used for diagnosis. Children with autism can sometimes find social interaction threatening – making them withdraw, even from family members. Robots such as Zeno have features that look slightly human, but are obviously not human. This makes communication, with all its complex and frightening subtleties and nuances, less complicated and more comfortable for the child.

Anthony’s mother, Pamela Rainville, found out about Zeno from the Dallas Autism Treatment Centre, and thought the project might benefit Anthony. “It’s always good for him to be put in different situations, things outside his normal routine. Anytime he can be around other people, it’s a good learning and growing experience for him.”

So far, Anthony has had two therapy sessions with Zeno. Rainville believes he got more out of the second meeting than the first, and she expects he will get even more out of subsequent interactions with the robot. “This second time, Anthony fist-bumped Zeno, which was great. It shows he was a little more relaxed.”

Popa believes that Zeno is a good motivator for children as he is engaging and non-threatening: the children listen to the robot. “The idea is for the robot to instruct kids, give them some useful social skills and at the same time observe their reactions and calculate their reaction times. That calculation could form some kind of an autism scale.”

He says there are three ways in which therapists can use Zeno. “The first mode is called a scripted mode of interaction, where you pre-programme a certain sequence of motions. For the second mode, we have added a control system so we can have an operator or therapist control the robot by tele-operations. In this mode, it mirrors the motions of the instructor.”

In the third mode, the child can take control of the robot. “This can be unsafe as the child can do things – such as slap himself – that the robot will copy and possibly break. So we tend to use this third mode as entertainment only.”

Zeno now has a brother, Milo, as well as an international family. Zeno came first, and is used in research and classroom settings. Milo was created specifically to work directly with children. According to Richard Margolin, director of engineering at Hanson RoboKind and part of the team who developed both robots, some children with autism who had never spoken directly to an adult teacher spoke to Milo.

Milo looks very similar to Zeno. His expressive face is an important feature, because a characteristic of autism is the inability to read and connect with the emotions of others. Children are asked to identify the emotion shown by Milo from multiple choices on an iPad. Milo’s eyes are cameras, recording feedback. The child wears a chest monitor that records changes in heart rate and therefore emotion. A typical lesson would involve Milo and a child interacting one-to-one; the child responding to the robot with an iPad, and a therapist or teacher present to help if needed and record difficulties and progress.

One of Zeno and Milo’s international relatives is Kaspar, designed in the UK by the University of Hertfordshire’s Adaptive Systems Research Group. The size of a small child, unlike Zeno and Milo, Kaspar has a neutral expression so that children can interpret him how they wish. Research is under way to see how Kaspar’s use could support children with other developmental conditions, such as Down’s syndrome or attention deficit hyperactivity disorder, known as ADHD.

Another distant cousin is Nao, who was created in 2006 by Aldebaran Robotics and is being developed as a “house robot”. Along the way, Nao has been used as an educational tool, and the University of Birmingham’s Autism Centre for Education and Research worked with Aldebaran Robotics on a version of Nao to help children with autism. But like Kaspar, Nao has an expressionless face.

What seems to be unique about Zeno and Milo is the way that their expressiveness defies long-held robotic conventions. Designed to be the first advanced social robots in the world, they could eventually have an impact far beyond the diagnosis and treatment of autism. RoboKind envisages a broader role for its robots in educating young children. In the words of his creators, Zeno represents the future of robotics and could be “a wonderful addition to every household”.

Doctors’ new prescription: ‘Don’t just exercise, do it outside’


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Doctors’ new prescription: ‘Don’t just exercise, do it outside’

It’s become commonplace for San Francisco physician Daphne Miller to write prescriptions that look like this:

Drug: Exercise in Glen Canyon Park
Dose: 45 minutes of walking or running
Directions: Monday, Wednesday, Friday and Saturday at 7am
Refills: Unlimited

She estimates she has now written hundreds of prescriptions for outdoor activity. “For some reason, it is much easier to keep up a movement or exercise regimen when it’s outdoors,” Miller says.

Perhaps it’s because of the varying scenery, the fact that monthly dues and expensive Spandex outfits aren’t required, or even because of what she calls “the camaraderie of the trail”.

Miller’s not alone. Faced with mounting obesity rates and a stubbornly sedentary population, physicians – especially pediatricians – are refining their exhortations that patients need to get more exercise.

Nationwide, they are dispensing thousands of prescriptions with specific instructions – not just going to a gym, but exercising in nature, at a park, along a trail. They’re literally telling their patients to take a hike.

“This is a lot more than getting people physically active. This is about getting them outdoors,” says Zarnaaz Bashir, director of health initiatives for the National Recreation and Park Association, a group that melds parks, recreation, the environment and now, health.

When terms like “park prescriptions” began popping up in 2008 or so, many experts viewed it as a niche idea.

“It was a quirky, fun play on words. I don’t think a lot of people thought there was going to be much substance,” says Kristin Wheeler, program director at the nonprofit parks advocacy group, Institute at the Golden Gate, in San Francisco. “Now, it’s been validated.”

The number of programs has risen steadily. Officials have identified at least 50 specific programs in the US, Wheeler says, but smaller ones may be under their radar, and new programs are popping up all the time.

The trend is spreading to other countries as well – including Australia, where a conference was recently held to discuss the health and medical benefits the country’s natural parks can offer.

In the UK, doctors are prescribing visits to Green Gyms, outdoor sessions run by a conservation group. The idea is to not only improve health and stamina through exercise and activities, such as planting trees, but also to benefit local green spaces.

A result of the green-prescriptions movement has been the unlikely teaming up of otherwise unrelated groups. The Appalachian Mountain Club, for example, forged a partnership in 2013 with MassGeneral Hospital for Children to prescribe regular outdoor physical activity for children.

“With so many proven benefits to getting active outdoors, AMC can help families take the first step in trying out new activities, finding places to explore, and making these outings fun for kids,” club CEO John Judge says.

An early proponent was Robert Zarr, a physician with Unity Health Care in Washington DC who quizzes patients about their interests, checks a searchable database for information on parks in or near their zip code, and then writes a script for specific activities. He told one obese teen to skip one of the two buses she takes to school and walk through a park instead. She ended up losing weight and feeling happier.

“We’ve really got this down,” he told attendees at a conference last year in Philadelphia. “I see this as no different from prescribing medicine for asthma or an ear infection.”

Across the continent in San Francisco, Miller says she has learned that formalizing her recommendation to get out in nature by writing it as a prescription is highly effective. “Well over 80% of patients try it, and many stick to it,” she says.

Mounting evidence shows benefits of being out and active in green spaces: less tension and stress, lower blood pressure, improved immune system responses, and milder ADHD symptoms in children. Japanese researchers have found that adherents to Shinrin-yoku – “forest bathing” – have lower levels of the stress hormone cortisol than study subjects who walk the same distance in a lab.

Beyond that, simply spending more time outdoors – versus in front of the TV screen or computer monitor – equates to an overall increase in physical activity.

Proponents say the nature prescriptions shift the focus of medicine from illness to wellness, leading to the potential for widespread changes in medical care.

Diana Allen, chief of the US National Park Service’s “Healthy Parks, Healthy People” initiative, is seeing mergers of medical schools and parks programs. “That’s wild,” she said. “I think there are going to be some new fields of practice.”

She acknowledges possible opposition from traditional practitioners and drug companies – “this goes against the money machine.” And patients who simply want to pop pills for whatever ails them also may balk.

Other than the doubtless eye-rolling of some physicians who may view the programs as gimmicky, participants in the Philadelphia conference had more practical concerns. Were the parks they would send children to safe? Would weather be an issue? Would lack of transportation be a barrier?

While early adopters of the philosophy simply leapt in without much of plan – it made intuitive sense, after all – organizers now aim to standardize programs so other communities can basically plug and play.

In Philadelphia, more than two dozen partners, including The Children’s Hospital of Philadelphia, are developing Nature Rx, a comprehensive plan aimed at ensuring that when kids show up at a park to “fill” their prescriptions, the staff is ready to welcome them with specific activities.

Gail Farmer, director of education for the 340-acre Schuylkill Center for Environmental Education and one of the organizers, says park audits will start this spring and physicians will begin writing prescriptions come summer.

Adopting standards also will help researchers who are moving to the data-gathering stage. Is it really working? Do people follow the prescriptions? And does their health improve as a result?

Wheeler has just finished an economic benefits analysis for the parks of San Francisco, which put the figure at $1bn a year.

“A piece of it is what we’ve known for a long time. People prefer liveable, walkable communities,” she says. “The big new piece is health benefits.” Those, they pegged at $50m in avoided health care costs.

Self-harm is not just attention-seeking: it’s time to talk openly about the issue


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Self-harm is not just attention-seeking: it’s time to talk openly about the issue

Three years ago, with her parents and sisters out for dinner, then-13-year-old Lucy found herself alone in her family’s Lincolnshire home. Dressed in her pink Tinker Bell pyjamas, she began to make herself a cup of tea. Then she spotted an object on the kitchen counter that immediately diverted her attention. “Shall I do it?” Lucy asked herself. “Will it stop the pain?”

For Lucy, now 17, that evening marked the start of a two-and-a-half year struggle with self-harm. Two weeks before, she had been brutally attacked and raped (which she now describes as “the incident”). At the time, anxious they wouldn’t believe her, Lucy never fully revealed to anyone what had happened. In her mind, she tried to repress the rape. She began shutting herself in her bedroom. She told her parents she was feeling unwell. Physical pain, she decided, was the only way to purge her pent-up emotional pain.

“When you keep all your problems in, it feels like you’re screaming inside,” Lucy says. “But when you cut or burn yourself, the pain is more physical. You feel like you’re releasing that scream. After a few months, self-harming became part of my daily routine.”

Eventually, both at school or at home, Lucy was self-harming four times a day. She wore black jeans, black tops and even black gloves to conceal her scars. “I pushed everyone everyone away” Lucy says. “I stopped caring about school. My grades suffered. Self-harm became a real obsession. It took over my life.”

Today, having made a huge effort to stop, Lucy has not self-harmed for more than six months. But self-harm is still on the rise among the UK’s young population. Data published last year by a collaborate study from England Health Behaviour in School Aged Children (HBSC) revealed that up to one in five 15-year-olds across the country self-harm. During the past decade, according to the same study, there has been a three-fold increase in the total number of UK teenagers self-harming.

What drives young people to self-harm? Therapist Jenna Mutlick, who has a personal experience of it, says it is usually some form of “self-punishment”. People believe they have done something wrong – even when they haven’t – and then feel they deserve the pain. “I know a few people who self-harm because they are bullied and eventually come to believe that they then deserve to be bullied,” she says. “When you self-harm, it is so hard to escape from the [mental] space that you are in.”

“It’s a very heterogeneous group of people who self-harm, and there are a variety of reasons why people might start,” says Professor Glyn Lewis, head of psychiatry at University College London. “Clearly, there are people who self-harm because they want to take their own lives, but there are also people who want to self-harm because they are in difficult situations or want to relieve stress.

“As a long-term strategy, of course, self-harm is not very effective,” he adds, “but people do report that they get some form of relief from upsetting thoughts or emotions. Some forms of self-harm are obviously very dangerous, but there’s a continuum. Some people may only scratch themselves very superficially, for example, which won’t do any long-lasting damage.”

The causes of self-harm are likely to be complex, even if the person harming does not see the issues in that way. Kieran, from Glasgow, began self-harming after five years of “constant” physical and verbal bullying at school. His parents split up when he was seven, though he says it was the bullying – which still torments him today – that incited his self-harming. “The bullying made me feel really unbalanced,” says Kieran, now 23. “I started to self-harm when I was aged 11, and it kind of just snowballed from there. I stopped eating. I isolated myself from a lot of my friends and family. I kept it a secret for almost a decade.”

Like Lucy, Kieran says that self-harming became a secret obsession. The bullying made him feel “physically and mentally numb”. Self-harm, by contrast, made Kieran feel more alive, and he would regularly self-harm in his bedroom at night. “It brought me out of my slumber,” he says. “It made me feel normal, and I became addicted to doing it for that reason.” He says that the self-harm was like an “adrenaline shot” that brings everything back into focus.”

Kieran admits that he still has a “daily battle” with self-harm. He is significantly better than he was a few years ago, though, when he would harm himself up to 400 times in one evening. “It’s a high level of emotional distress that causes people to resort to self-harming,” he says. “People sometimes feel like they can’t cope with their emotion. It’s how they cope with life’s daily stresses.”

Chris Leaman, from the UK mental health charity YoungMinds, says it is still very much a taboo subject in British society. “Every year, we work with Childline, YouthNet and selfharmUK to try and combat these sort of stigmas for Self-Harm Awareness Day,” he says. “There is a definite problem around young men not feeling like they can talk about their issues, which can make self-harm quite a common issue among them.”

“Some people do talk about self-harm quite openly, but that’s relatively unusual,” says Professor Glyn Lewis. “A lot of people conceal self-harming behaviour from their friends and family. There are not necessarily signs to look out for; it’s more a case of often asking people how they are feeling, and keeping communication open with them. As a rule, families and friends concerned about someone self-harming always should talk to the person themselves and encourage them to seek professional help.”

Statistically, teenage girls are still more than twice as likely to self-harm than young males, and this has helped create another gender-based stigma: that self-harming girls are simply seeking attention. Fiona Brooks, professor of adolescent and child health at the University of Hertfordshire, who led the investigations for last year’s HBSC report, identifies this as a prevalent problem. “Nowadays, young people are in a much more uncertain world than before,” she says. “Instead of self-harming just being dismissed as attention seeking, it’s something that needs to be taken seriously. Equally, if young girls are self-harming for attention, that’s a different matter that needs to be taken just as seriously.”

Lucy thinks back on that evening she started self-harming, and wishes that she could tell herself to stop – and talk to someone. Talking, like with most former self-harmers, has been a significant part of Lucy’s recovery, but she also credits her own determination as a decisive factor. “If you don’t want to stop, you won’t,” she says. “In the end, a lot of it comes down to how you see yourself. I used to feel people were always judging me, but now I feel I don’t care what they think. Why should I let them control my happiness?”

Domestic violence could be stopped earlier, says study


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Domestic violence could be stopped earlier, says study

Victims of domestic violence are abused for almost three years before they get the help they need, and some are subjected to more than 50 incidents during that time, according to a study of the largest database of domestic violence victims in the UK.

The figures from the domestic abuse charity SafeLives reveal that almost a quarter of “high-risk” victims have been to an A&E with injuries sustained during violent abuse, and some went as many as 15 times before the problem was addressed.

Analysis of the SafeLives database, which has records of more than 35,000 cases of adults experiencing domestic abuse since 2009, found that 85% of victims had been in contact with an average of five professionals in the year before they got “effective” help from an independent domestic violence adviser (IDVA) or another specialist practitioner.

“Time and time again no one spots domestic abuse, even when victims and their children come into contact with many different public agencies. It’s not acceptable that victims should have to try to get help repeatedly. This leaves victims living in fear and danger and risks lifelong harm to their children,” said Diana Barran, the chief executive of SafeLives, which was previously called Co-ordinated Action Against Domestic Abuse (Caada).

Barran said the study was “more shocking evidence” that domestic violence could often be stopped earlier. “Every conversation with a professional represents a missed opportunity to get victims and their children the help they need,” she said.

SafeLives estimates that there are at least 100,000 victims at high risk of murder or serious injury in England and Wales, 94% of them women.

The study found that victims and often their children lived with abuse for an average of 2.7 years. Three-quarters reported abuse to the police, and 23% went to A&E because of violence sustained in abusive relationships.

Frances Wedgwood, a GP in Lambeth who provides training on domestic violence to health workers through the national Iris project, said a challenge for doctors was that many women did not come to them to disclose domestic violence.

“Domestic violence is still a very hidden problem and in my experience women do not disclose if they are not asked,” she said. “We need to get better at asking people directly if they need help.”

The study sheds light on the long-lasting impact of living in a family coping with domestic violence. According to the survey, in about a quarter of cases on the domestic violence database the victim has a child under the age of three. The study estimates that 130,000 children in the UK are living with domestic abuse, and that children are directly harmed in 62% of cases.

Among teenagers who suffered domestic abuse in their own relationships, almost half had grown up in households where violence was commonplace, the study found.

Vera Baird, former solicitor general and the current police and crime commissioner for Northumberland, said professionals needed help and training to have the confidence to deal with domestic violence.

“Domestic abuse is not a one-off violent attack. It is deliberate long-term use of coercion to control every part of the partner’s life. Violence, sexual abuse, financial control, constant criticism, isolating from family and friends are all familiar tools,” she said.

“People in that situation do not find it easy to speak and need those who could help to be alert. The alternative is what these figures suggest: victims and their families locked unnecessarily into cruelty and ill-treatment for years.”

Case study

Rebecca, 34, lived with domestic abuse for eight years before she sought help

One time I was having a nap in the afternoon, the baby had been teething so I’d been awake all night, and I woke up he was standing over me with a mop handle carved into a point, like a spear. He was pushing it into my throat, accusing me of cheating. Then he picked me up and threw me against the wall. I ran downstairs but he followed me, kicking and punching me and split my lip.

I locked myself in the bathroom and called 999. When the doorbell rang I heard chatting, calm talking. There was one young male officer, and my ex-partner was telling him that I was postnatal, that I’d gone mental and he was just defending himself. I started shouting at the officer: ‘Why aren’t you helping me?’ I swore and the officer said people could hear me, and it was a public disturbance so I swore again. He put handcuffs on me. He wouldn’t let me put my shoes on, so I wouldn’t move, and he lifted me up by the handcuffs and put me in the back of the car.

I was in a cell for hours asking for a solicitor. The duty sergeant finally came and when he opened the hatch he could see I’d been attacked. He got the officer to come and apologise to me and asked me if I wanted to file a complaint, or if I wanted to press charges against my partner. But I said no. I was exhausted and my baby was at home with my partner, who’d been drinking since the morning. It got worse after that. He was sort of smug, saying he could do what he wanted. I know there’s more training for police now, but that put me off calling the police for years.

By 2003/4 the abuse was worse. We had two girls by that time. I was hospitalised with concussion after he’d kicked me in the head wearing steel-toe-capped boots. The police and the paramedics came and I was patched up and sent home. They asked me if I wanted to press charges but I didn’t want to go through all that, I thought it would make it worse. I didn’t know where the support would come from, where I could get help.

Another time I went to the hospital walk-in. I had a black eye and it wasn’t getting better. A doctor asked me what had happened and I said I’d been punched in the face. He repeated what I said: ‘You were punched in the face.’ I didn’t know what he wanted me to say. I was ashamed, I didn’t want to say my husband did this to me. If he had asked, I’d have told him. But he didn’t.

Social services got in touch because of the paramedics’ reports; he got put on an anger management course. But Christmas Day night he’d been drinking. He grabbed me by the throat and I stumbled and fell; he kept kicking me over and over again. My teeth went through my lip, my nose was bleeding, I couldn’t see. He picked me up and carried me to the bathroom saying: ‘Look what you made me do. Why did you do that?’ I crawled to the living room and phoned the police before he ripped it out of the wall.

I did press charges that time. He was sentenced to four months for ABH. He served two. We were separated, but we got back together. Why? I had such low self-esteem and he was always there, always pestering me, grinding me down. He’d be so nice, helping with the children and I was exhausted, I needed the help. I thought it might be OK.

It was OK for a while. The kids had been on the at-risk register because a couple of incidents had been reported, but they came off that and social services were visiting less. His behaviour just went back to the way it had been before, and that’s when I decided to leave.

I remember the exact moment when I saw the sticker for the Women’s Aid helpline: it was on the back of the toilet door in Asda. It took me a couple of months to call but when I did they offered me refuge. I didn’t even know that existed. They organised transport when he was out. It was quite surreal, but it was such a relief.

Women’s Aid were so helpful, they gave us so much support including counselling. My eldest daughter was seven when we left, her sister was three and their brother was nine months. That was the main reason I left, I was terrified for my kids.

I do think professionals should offer support. If they can’t support victims themselves, they just need to know who can. I think if I’d had that information I would have left earlier.

I was 16 when we got together; he was 23. By the time I was 17 we had a daughter. I thought it was a good relationship, he helped with the parenting and around the house, but about a year later, in 1999, slowly controlling behaviour crept in. He wouldn’t like certain friends, or me going out without him, wearing certain clothes or makeup. It was quite subtle at first, but then when we argued there was pushing, then hair-pulling – each time it was a little worse than before.

Soon it was normal to have slapping, kicking, punching, throwing things. At first I didn’t tell anyone; my self-esteem was very low. I just tried to pretend it wasn’t happening, I didn’t know anything about domestic abuse.


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