Life Events, Personality Profile, Psychiatric Morbidity in Self Injurious Behavior: A Cross Sectional study

LIFE EVENTS, PERSONALITY PROFILE,

PSYCHIATRIC MORBIDITY IN SELF INJURIOUS

BEHAVIOUR - A CROSS SECTIONAL STUDY

DISSERTATION SUBMITTED FOR PARTIAL FULFILLMENT OF THE RULES AND REGULATIONS

DOCTOR OF MEDICINE

THE TAMILNADU DR.MGR MEDICAL UNIVERSITY, CHENNAI,

TAMIL NADU.

CERTIFICATE

This is to certify that the dissertation titled “LIFE EVENTS, PERSONALITY PROFILE, PSYCHIATRIC MORBIDITY IN SELF INJURIOUS BEHAVIOUR- A CROSS SECTIONAL STUDY” is the bonafide work of Dr.K. ILAMARAN, in part fulfillment of the requirements for M.D (Psychiatry) (Branch–XVIII) examination of

The Tamilnadu Dr. M. G. R Medical University, to be held in APRIL 2016. The Period of study was from March 2015 toAugust 2015.

HOD DEAN

DECLARATION

I, Dr. K. ILAMARAN, solemnly declare that dissertation titled

“LIFE EVENTS, PERSONALITY PROFILE, PSYCHIATRIC MORBIDITY IN SELF INJURIOUS BEHAVIOUR - A CROSS SECTIONAL STUDY” is a bonafide work done by me at Kilpauk medical college, Chennai, during the period from March 2015 to August

2015, under the guidance and supervision of Dr. S. RAJARATHINAM M.D., DPM., HOD, Professor of Psychiatry, Kilpauk Medical College. This dissertation is submitted to The Tamilnadu Dr. M. G. R Medical University, towards part fulfillment for M. D. Branch – XVIII (Psychiatry), part- III examination.

Place: Chennai

ACKNOWLEDGEMENT

I sincerely thank Prof. Dr. R. NARAYANA BABU, MD., DEAN, Kilpauk Medical College for permitting me to do this study.

I sincerely thank Prof. Dr. S. RAJARATHINAM . M.D., DPM.,

Head of the Department, Kilpauk Medical College for his, concern, care,

guidance and help, and I would like to thank to Dr. R. SARAVANA JOTHI, MD., who has been a source of inspiration and motivation. I would like to express my sincere thanks to Assistant Professor, Dr. M. S. JAGADEESAN, who has guided me in completing this dissertation. I thank my colleagues, and others for their immense help in completing this study. I would be failing if I do not express my gratitude

to all my Teachers at the Department of Psychiatry, Kilpauk Medical College, Chennai for their support and encouragement during this study.

I thank all those patients who participated in the study, without

LIST OF ABBREVIATION

WHO - World Health Organization

SIB - Self Injurious Behaviour

SA - Suicide Attempt

DSH - Deliberate self harm

LAS - Lethality assessment scale

PSLE - Presumptive stressful life events

EPQ90 - Eysenck Personality Questionnaire 90

GHQ12 - General Health Questionnaire 12

CONTENTS

Sl.No. Page No

1. Introduction 1

2. Review of Literature 10

3. Aim and Objectives 26

4. Materials and Methods 28

5. Results 36

6. Discussion 61

7. Summary and Conclusions 75

8. Limitations 78

9. References 79

INTRODUCTION

According to World Health Organization (WHO), Suicide is the

second leading cause of death between 15 and 29 years of age groups,

globally (2012). It’s responsible for 1. 4% of all deaths world wide. WHO

defines suicide act as ‘the injury with varying degrees of lethal intent,”

and that suicide may be defined as a suicidal act with fatal outcome. The

word `suicide' has its origin in Latin; `sui', of oneself and `credere', to kill:

the act of intentionally destroying one's own life. In 2012, India

accounted for the highest suicidal rate. According to WHO report, one

person commits suicide every 40 seconds globally. In the world, most

suicides occur in the South-East Asia region.

Suicide

The term suicide is used to denote self-planned and deliberate

termination of one’s life. It is as old as mankind and is indeed a giant

puzzle. It is a paradox why humans who love to live a full life turn to self

destruction.

Para suicide :-

It is an impulsive act of self – injurious behavior without any prior

planning or intent to die. The harm to self may be done by inflicting

injury or consuming a substance. It is otherwise known as Deliberate

Attempted suicide:-

Among those who attempt suicide, a few succeed, but some

survive due to timely intervention of chance factors in spite of best

planning and clear cut intention to die. They are known as ‘Attempted

Suicide’.

Overlap :-

A person who tries to terminate his life with real intent may

survive. However, an individual who injures himself impulsively without

any real intent to die may lose his life.

Another meaning for suicide in latin word, is self murder. There

are some types of suicides. The general term used for suicide attempt is

self injurious behavior (SIB) which is further subdivided into suicidal

attempt (SA) and nonsuicidal self injury (NSSI).( Chloe A. Hamza ,

Shannon L. Stewart Teena Willoughby,2012 ). Usually the SA are with

intent and NSSI are without intent to die. Non suicidal self injury(NSSI),

which is defined as self-directed, deliberate destruction or alteration of

bodily tissue in the absence of suicidal intent (Nock & Favazza, 2009),

examples are self-cutting, head banging, self-hitting, scratching to the

point of bleeding, and interfering with wound healing. Suicidal behaviors

refer to directly self-injurious behaviors (e. g., suicide attempt, suicide)

severe slashing, and jumping from heights. NSSI and suicidal behaviors

are both forms of self injurious behavior, and therefore they are

sometimes conceptualized as falling along a single self-harm continuum

(Chloe A.et al 2012 )

The suicidal behaviors range from suicidal ideas to completed

suicide. It depends on the various factors like age, gender, socioeconomic

status, occupational status, educational status, and marital status.

Statistics on suicidal behavior varies between different nations. In

developed countries about 10% of the suicides were underestimated,

whereas in developing countries most of the suicides were underreported.

The overall mortality from suicide was underestimated according to

Charlton et al, (1992). Among the suicide attempters, about half of the

them had previous suicide attempts. Most of the suicide attempters had

previous deliberate self harm (DSH) injuries like slashing the hands, legs

and body. In the Indian context most of the individuals with a history of

DSH, are more likely to indulge in further suicidal behavior by drug

overdosages, organophosphorous poisoning , rat killer poisoning, phenol

liquid poisoning and oleander seed poisoning apart from hanging.

Among the suicide attempters, male suicide attempters were found to be

make more violent attempts, with high suicidal intention and lethality.

Most of the male suicide attempts were due to subjective lack of

attempts were due to negative interpersonal events. There are risk and

protective factors for suicide which include cultural, social, psychological

and biological factors. The suicide attempts were due to intensified

effects of risk factors or weakened effects of protective factors. The other

commonly occurring risk factors are elder by age, low socioeconomic

status, low educational status, unmarried people, divorced, widowed,

living alone, unemployment, retirement, students, prisoners, immigrants,

refugees, low social support and lack of social integration.

Suicide rate has been raising in younger males for the past 20

years because of the alcohol misuse, problem in the school and various

psychosocial stressors. Learning model is also a risk factor for suicide,

which is available in the society, culture, institution and mass media. The

relationship in the society has a significant impact in the individual, when

there is a disturbance in the relation between the individual and the

society, the suicidal tendency might occur.

Life event stressors prior to suicide attempts had a significant role.

The number of stressors were also important in determining the suicide.

Usually a combination of life event stressors would occur rather than a

single life event stressor. Persons with self injurious behavior would have

lower level of physical well being, psychological well being, social

STRESS:

Stress is a well known cause for mood disorder, mental

disorder and risk factor for suicide attempt. Negative life events lead to

depression, interpersonal problem, occupational problem and self

injurious behavior. Childhood trauma has a significant impact in suicide

behavior. Also unemployment, loss of job, financial problem contributed

towards suicide. The stressors are recent one, which might be weeks to

months prior to suicide attempt.

There was an increased suicidal behavior present in young females

and in low socioeconomic status. (King, Raskin, Gdowski, Butkus, &

Opipari 1990). Chronic physical illness also had a tendency to increase

the suicidal behavior. Stressful life events and social problem happened

in the recent time may lead to suicide (Townsend et al 2001).

There is a terminology known as ‘kindling effect’ otherwise called

Episode sensitization , in which individuals with repeated episodes of

selfharm, bring about neurobiological, cognitive and interpersonal

changes that directly increase the risk of recurrence. In multiple episode,

there is a weak association between stressful life events and suicidal

ideation than person with single attempt of suicide. One of the risk factor

in suicide attempt is job loss and unemployment. (Beautrais et at 1997).

suicide in adults associated with substance abuse. Some of the individual

with life events stressors would attempt suicide within a day of a stressor

(Kenneth R. Conner, 2011). Some other psychosocial stressors also had a

role in suicide, like interpersonal losses, legal issues or disciplinarians,

pregnancy or fear of pregnancy, loss of freedom, loss of self esteem,

physical and sexual abuse.

PERSONALITY:

Most suicide attempts were done by persons with abnormal

personality(Hanet,al;1997,).The risk factors are aggression, greater

impulsivity, substance abuse, antisocial personality disorder, depression,

Bipolar affective disorder I & II and with previous suicide attempt,

genetic factor and life event stressors. Sometimes there is an overlap

between borderline personality disorder and Bipolar affective disorders.

Most of the suicidal attempters had childhood physical abuse or sexual

abuse. The commonly encountered personality disorder in suicides are

borderline personality disorder, Narcissistic personality disorder and

Histrionic personality disorder.

Suicide in Schizotypal personality is understudied. Schizoid

personality disorder is associated with depression, anxiety and

behavior. According to previous study results 70% of the borderline

personality disorder had atleast one suicide attempt in their lifetime.

Borderline personality disorder is also called Emotionally unstable

personality disorder which is further divided into impulsive type and

borderline type, coming under cluster’ B’ personality. Impulsivity is one

of the feature of borderline personality and is frequently associated with

alcohol or any other substance abuse, eating disorder, unprotected sex,

reckless spending, reckless driving, frequent job changes, running away

and self injury and other features are unstable interpersonal relations,

anger outburst, idealization, devaluation, minimization, maximization,

sensitivity to the feeling of rejection, criticism and isolation. There were

an association between substance abuse on recurrent suicide attempts

was found in a study of Berk etal.(2007), but this finding was not

confirmed in Soloff and Chiappetta (2012).

In borderline personality disorder, the time prevalence of suicide

attempt is 3-10%. Men completing suicide in this disorder has been

underestimated being almost twice as women. The reasons for NSSI are

expressing anger, self punishment, distracting oneself from emotional

pain. NSSI is one of the feature of the borderline personality disorder.

This should be actively intervened because there is a possibility of serious

more unsuccessful treatments (Zahl and Hawton,2004; Paris,2007; Soloff

and Chiappetta,2012).

Many of the DSH would lead not only to recurrent DSH but also

to a serious suicide attempt. Personality disorders predispose to major

mental illness like depression, and substance abuse. Among the antisocial

personality disorder 5% commit suicide. Horrocks . J et al (2003) study

showed that emotionally unstable personality and impulsive type

personality trait or disorder was the commonest personality disorder in

self injurious behavior. Personality disorder itself increases the self

injurious behavior. Life events stressors in personality disorders increases

the suicidal ideations. Suicidal proneness, psychological distress have

been noted in schizoid personality, schizotypal personality, borderline

personality, depressive personality and sadistic personality.

Childhood adversity and comorbid mental illness increase the

suicidal rate. Based on the previous studies, that the presence of anxiety

and depressive disorder increases the risk of suicide attempts and

completed suicide (Angst et al., 1999; Sareen et al., 2005; Ten Have et

al., 2009).Heritability contributes 40% in borderline personality disorder.

Some of the studies found that there are some reduction of the areas in the

antisocial traits are risk factors for this personality disorder. (Black,

Blum, Pfohl Hale 2004, Oldham 2006.)

PSYCHIATRIC ILLNESS:

There are psychiatric illness like depression, anxiety, adjustment

disorder, substance use disorder, schizophrenia and bipolar disorders in

which suicide attempt can occur. Among the psychiatric illnesses the

depression is the commonest disorder. According to previous study

results, when there is a combined occurrence of depression and anxiety

the suicidal rate is more common than the depression alone. Anxious

mood may lead to negative thinking, which may be a predisposing factor

for suicide. In India the common psychiatric disorders leading to suicide

attempts are adjustment disorder, depression, substance abuse.

The rate of suicidal attempts are low in India when compared to

Western countries. In Western countries 90% of the suicides were due to

psychiatric illness. According to previous study results 60%-70 % of the

patients with depression would attempt for suicide, 15%-20% of the

Bipolar affective disorder would attempt for suicide and other mood

disorder would contribute to about 10%-15% of suicide, and patients with

REVIEW OF LITERATURE

The term attempted suicide gives a wide meaning from severe and

life threatening attempt to minor gestures. Complete suicide is relatively

uncommon. The suicide should be viewed as a symptom rather than a

disease per se.

PARASUICIDE:

Deliberate self poisoning and self injury term was proposed by

(Kessel, (1965). In the 1970s, Kreitman (1977), who introduced the term parasuicide, in which the individual would have self mutilating behavior

like cutting the skin, but they do not wish to die, the female – male ratio

was 3:1, they will be 4% of the all psychiatric patients, among them 30%

might be having substance abuse.

The parasuicide attempter’s age will be around 20 years and they

will be single or unmarried. The nature of the cut will be delicately, not

coarsely by using razor blade, knife and broken glass. The common sites

were wrist, arms, thighs and legs and the uncommon sites were face,

breast and abdomen. Most of these individuals would be suffering from

a personality disorder and also they will be neurotic and introverted.

Weissman, (1974) study showed that 1-10% of the completed

PSYCHOLOGICAL FACTORS:

The first important psychological insight into suicide came from

Sigmund Freud.

Sigmund Freud, in mourning and melancholia, wrote of aggression

turned inward when one internalizes a lost object and then turns this rage

on to oneself. Edwin Schneidman has written as victim’s unbearable

mental pain “psychache” and how terminally his or her perceptions

narrow and he or she can see only one solution-his or her death.

Contemporary suicidologists stress that people most likely to commit

suicide are those who have suffered the loss of a love object or have

sustained a narcissistic injury, who experience overwhelming moods like

rage and guilt, or who identify with a suicide victim. According to Freud,

“suicide is an aggression turned inwards against a loved person with

whom the individual has identified himself”

Psychodynamics of suicides:

• It is a plea for help.

• It is a final exit from all bonds.

• It is a threshold of peace and permanent bliss.

• It is a sacrifice and self atonement.

• It an escape from pain & misery.

• It is a beginning of new life through rebirth.

• It is a mastery over death.

• It is revenge against his persecutors.

• It is an act to punish the enmities.

• It is an act of rescue.

BIOLOGICAL FACTORS:

There are some evidence of involvement of biogenic amines in

suicides. According to Julius Axelrod’s study (1970) there is a relation

between suicide and biogenic amine metabolism. Marie Asberg’s (1975)

work on levels of serotonin and noradrenaline levels in the brains of

depressive individuals laid the ground work for a later suicide. Other

neurotransmitters involved in suicides are GABA (gamma amino butric

acid), G protein, glutamate receptors, kinases, BDNF. Some other studies

say that there was a decreased level of 5HT in depressed individuals with

suicide attempt.

SOCIOLOGICAL FACTORS:

Emile Durkheim, a French sociologist emphasized the importance

of social factors in the causation of suicide. According to him, the suicide

rate of a population varies inversely with the degree of social integration

There are 3 types of suicide:

1 . Egoistic

2. Altruistic

3. Anomic

Egoistic suicide:-

Here the individual has little concern for the community (family,

religion or community)

E. g. unmarried, widowed, unemployed, deprived, and bereaved.

Altruistic suicide:-

Here, the individual has excessive integration with to society. The

customs & rules of the society demand his death under certain condition.

Here the individual gives his life as a priced gift to answer the demands

of the society

E . g. sati in India / harakiri of Japan / mass suicide in cult

Anomic suicide:-

Here, the existing relationship between the individual and his

society is shattered all on a sudden

E . g. economic recession, loss of employment, wealth or status

In addition to social integration, status integration is also important as a

protection against suicide (social role like father, teacher, married,

employed, leader) . The more the status, better the social integration and

behaviour increases markedly during this time and the causes are more

social and interpersonal conflicts (Shaffer and Fisher, 1981; Brooksbank,

1985 & Hawton et al., 1982). Hopelessness has been identified as one of

the core characteristics of depression by Beck (1963). The features of

high hopelessness group were anxious and depressed mood, had a strong

wish to die, made a planned attempt, act was done for relief from mental

state, motivated for help and sought help. Rifai et al.,(1994), study shown

that the individuals with suicidal attempts had high scores in

hopelessness.

BIO PSYCHO SOCIAL FACTORS:

The cortico- hypothalamic pituitary adrenal axis, which regulates

adrenal cortical hormone levels and mediates reaction to stress. The

elevated corticotrophin releasing factor( CRF) concentration in CSF and

decreased number of CRF binding sites in the frontal cortices of suicide

attempters were present. Another study shows the alcohol itself decreases

the 5 HT in some areas of brain in depressed individuals. Alcohol is a

well known disinhibitor that increases the impulsivity leading to suicide

attempt.

AGE:

Holding et al., 1977). The rate of Adolescent suicide attempts are

increasing in numbers (Hawton et al. 1982; Brooksbank, 1985). Among the adolescents, suicide attempt was estimated to be about 8%-10% in

their life time. The old age also prone for suicide when they are living

alone without family support, and also if they have associated comorbid

physical and psychiatric illness.

GENDER:

There is a wide disparity about incidence of suicide and gender .

Some western countries shows higher incidence in males, and in

developing countries more incidence was seen in females. The studies by

Garfinkel B. D. et al., (1982), Otto (1972), L. Kotila et al., (1987) and Olfson et al (2005), showed that the higher incidence of suicide occurs in

adolescent females. There is Male–female disparity in completed suicides

among various nations of the world . Female suicide completion rate is

high in srilanka, china, and also in India. Suicide attempts in women are

less violent, less lethal and have less disfigurement. One theory says that

lower rate of suicide in women due to lower rate of alcohol dependence

and abuse in women . Women are more likely to seek medical attention

when they are depressed and they are more accommodative than men,

having better network with friends and family. Suicidal attempts before

MARRIAGE:

Married persons had lesser incidence of suicides while single

persons, never got married persons, divorced, and widowed had a higher

incidence of suicide. Unmarried persons had a higher percentage of

suicide according to Ponnudurai et al., (1986), Ghulam et al., (1995) and

Latha et al., (1996). Family history of suicide is a risk factor for suicide.

Homosexual men and women also had a higher suicidal tendency.

Fleishmann,et,al; (2005) study showed most of the suicide attempters

were married than single in India.

In India joint family concept is still existing, and suicidal attempts

were more common in nuclear family than in joint family. The national

crime records Bureau 2014, showed that, the number of suicides was

high in married men, widowers, than married women, and widows .

EDUCATION

There is no variation in educational level in persons attempting

suicide according to BilleBrahe et al.,(1985). Another study by

Nordentoft & Rubin (1993) alsoshowed that there is no difference

between attempters and general population based on educational levels.

attempts were present in individuals with educational level below

matriculation.

OCCUPATION :

Higher the social status increases the suicidal risk. Professional and

physician had a high risk for suicide. Also other occupations like law

enforcement, dentists, artists, mechanics, lawyers, insurance agents also

had a higher risk. At the same time unemployment also had significant

role in suicide. According to Ramdurg et al.(2012), employed individuals

had a higher suicidal rate than the unemployed persons and also the level

of stressors were more in employed persons. R.Tara e, al (2014)., study

found that, 55% of the suicide attempts were present in individuals with

unskilled workers.

INCOME STATUS:

According to previous study results, most of the suicide attempts

occurred in low socioeconomic status. Previous study by

Thirunavukarasu (1981) have shown that increased incidence of suicides

were present in the low income and social status group. According to

C.T.Sudhirkumar & R.Chandrasekaran,(2000).,58.1%of the participants

PHYSICAL ILLNESS:

There is always a correlation between suicide and physical illness.

Some studies showed if 6 months after a major medical attention, an

individual may attempt suicide. Medical illness contributes to about half

of the suicide attempts. For example if the individual had loss of mobility

which significantly impairs the occupation and disturbs their recreational

activities the risk is more. Disfigurement in females, chronic pain,

persons undergoing hemodialysis, cirrhosis also had a high risk for

suicideattempts. Importantly drugs like reserpine, Corticosteroids,

Antihypertensives, and Anticancer drugs also had a major contributing

factor for suicide in those individuals taking these drugs.

PSYCHIATRIC ILLNESS:

Adolescents can be reliable reporters of their suicide potential and

the clinician needs to be sensitive to symptoms of major depressive

disorder in assessing potentially suicidal adolescent (Robbin DR et al,

1985). Adolesent suicide attempters are likely to have mood disorder

about 7 times more than other individuals. Common mental illness prone

for suicide is depression, which is usually associated with another mental

illness. The identifiable risk factors are previous suicidal attempts,

About 15 % of the suicide was reported in depressive disorder,

(Pfeffer CR et al, 1993). There is a strong relation between adolescent suicide attempt, substance abuse and personality disorder (Marttunnen et

al, 1991). If the individual had psychiatric illness they would have 3-12

times of increased risk for suicide than general population. Previous

studies showed that 20% of the suicide attempters had panic disorder and

social phobia. The degree of risk varies in age, gender, diagnosis,

inpatient or outpatient treatment. Suicide among adolescents who had a

history of psychiatric hospitalization occurs approximately nine times

more often than among adolescents in the community (Kuperman et al.,

1988). Increased risk of suicide is present in patients getting inpatients

treatment than outpatient treatment . Major depressive disorder associated

with suicidal behavior (Robbins and Alessi,1985). More than 70% of the

adolescents reported suicide ideation or attempts among adolescent with

a diagnosis of major depressive disorder (Myers et al.,1991).

Suicide is a complex behavior in depression. It varies with age and

gender, risk factor is usually not a single factor but it is a combination of

two or more of risk factors. The high risk factor in geriatric age groups

are facing problem, loss of loved one, change in life style, loss of physical

independence and other physical illnesses. In old age the other medical

family and school pressures, hormonal changes and major life changes. In

suicide, morbidity is difficult to assess but lethality can be assessed

easily. Two third of the individuals with depression are not understanding

as depressed and not taking treatment. Only 50% of the individual with

depression take treatment. Depression is a treatable condition, 80-90% of

the patients will respond to medication . Sometimes antidepressants also

may induce suicide, especially taking medicine for first time and also

patients with age group of less than 25 years. Best way to prevent suicide

is early detection, diagnosis and treatment. Hawton et al (1982) study

shown that that 20 % of the individuals with psychiatric illness had drug

overdosages.

Occurrence of suicide in schizophrenia is similar to general

population (Hawton et al 2005,). The common causes for suicide in

schizophrenia is comorbid mood disorder, recent loss, hopelessness, drug

misuse, substance abuse, previous suicidal attempt. According to

Tiihonen et al(2006), in the first episode of schizophrenia, there is an

twelve fold increased risk of suicide. A study by Miles et al (1977)

shows, the life time risk of suicide in schizophrenia is 10%. The greatest

risk of suicide is present in post psychotic period (Siris & Collegue

2001). The other risk factors in schizophrenia are individuals associated

illness, sometimes responding to hallucinations. Suspicious ideas and

paranoid ideas increase the suicidal attempt.

SUBSTANCE ABUSE:

Substance abuse contributes to about 15% of the suicide attempts.

The factors like interpersonal losses, undesirable life events would cause

symptoms like mood disorders which may result in suicide. If the

substance abuse is associated with antisocial personality disorder and

those with multiple substance abuse, the risk for aggressive, impulsive

and criminal behavior increases leading to suicidal behavior. There is a

high correlation between mood disorder and substance abuse (Pfeffer et

al. 1988). Many a time, it is very difficult to decide whether a particular

death is due to suicide, murder or accident, particularly when there is

associated with alcohol abuse or drug abuse. ‘Psychoactive substance was

a major problem in adolescent populations’ according to Hawton et al

(1982).

Alcohol plays a crucial role in suicide attempt, due to

environmental factor and /or biochemical factors. In chronic course of

alcohol consumption, the individual has to face a various stressors and

interpersonal problem and rejection in the society leading to suicidal

behavior (Murphy GE 1990). According to previous studies they found

aggression and alcohol consumption. Heavy drinking was associated

with increased aggressive behavior, (Placidi GP, Oquendo MA et al.2001)

.According to Conner KR, Duberstein PR et al.(2004), individuals with

alcohol dependence who have completed suicide ,were characterized by

major depressive episodes, stressful life events, interpersonal problems,

poor social support, living alone, high aggression and impulsivity,

hopelessness, severe alcohol use , other substance abuse, serious

medical illness, and prior suicidal attempt. Male gender and older age

above 50, increase the risk for completed suicide. Recent study suggests

that the risk for suicide associated with alcohol dependence increases

with age. When the age increases mood disorder acts as a powerful risk

factor for suicide among problem drinkers. (Sher et al .,2005).

Alcohol dependence is a the maladaptive pattern of alcohol

use,which leads to clinically significant impairment or distress, Alcohol

dependence is manifested as (i) tolerance; (ii) withdrawal; (iii) taken in

larger amounts (iv) there is a persistent desire or unsuccessful efforts to

cut down or control alcohol use; (v) a great deal of time is spent in

activities necessary to obtain alcohol; (vi) important social, occupational,

or recreational activities are given up or reduced (vii) alcohol use is

continued despite of having a persistent or recurrent physical or

Nicotine abuse, Alcohol abuse, Drug abuse & Obesity are slowly

accelerating death by virtue of their medical complications. Hence, they

are called as chronic Suicide.

LIFE EVENTS:

The suicide attempters had four times of stressful life events six

months prior to the suicide attempts when compared to the general

population . Paykel et al., (1974). Schaffer et al (1974) found that 35% of

the suicidal atempters had recently been in trouble, in their study. Recent

life event are significant in adolescent attempters as in adults according to

Cohen et al, 1982. Broken homes are common among adolescent

self-poisoners than adolescents in the general population (Hawton et al.,

1982). Suicidal attempts most commonly follow quarrels with parents or

close partners (White, 1974 & Hawton et al., 1982).

Individuals with suicidal attempts had elevated levels of stress. The

severity of the suicide depends upon the stressors and chronic strains of

the suicidal attempters (Adams et al., 1994). Marttunen MJ et al, (1993)

reported that precipitant stressors were common in adolescent suicides. In

70% of cases stressors were reported in preceding one month.

Interpersonal separation and conflicts were the most common one.

According to Lewinsohn et al.,(1994), the major potential high risk

depression, family history of suicide attempt, long standing physical pain,

lower academic achievement. If the age group is between 20-30 years, the

amount of stresses will be more. (Helmes, Masuda1974, Dekka, Webb

1974). Childhood physical and sexual abuse and any adversity of their

life may lead to suicide attempt. Hawton et al, (1982) study showed that

the risk factors include chronic emotional problems, behavioral problems,

social isolation related to home, school and physical problem mental

illness. Adolescents with greatest risk of suicidal behavior had family

problem, marital problem, poor parent child attachment, exposure to

sexual abuse in childhood. (Fergusson DM et al, 2000)

MODE OF SUICIDE ATTEMPTS:

In India, most of the suicide attempts were done by using

Insecticides poisonings and corrosive poisonings. Easy accessibility and

unrestricted availability of the poisons are reasons for this common

occurrence. Among the insecticides, organophosporous compounds are

more fatal than other insecticides. Other common modes of poisoning are

Rat killer poisoning, phenyl poisoning, Ant killer poisoning, oleander

poisoning and multiple drugs poisonings . For an individual who has

engaged in selfharm, the risk of dying by suicide is significantly higher

Owens et al, 2002), especially during the first 12 months following

self-harm (Hawton et al, 2003).

According to Ponnudurai et al. (1986) the common causes of

suicides were organophosphorus compounds, sleeping tablet, copper

sulphate, self immolation and oleander seed poisoning in a descending

order of percentages. Previous study says that there was a high correlation

between depression scores and suicidal intent scores in individuals with

this mode of suicidal attempt.

AIM

To study the relevance of life events in individuals with self

injurious behavior.

To identify the personality problems in relation with suicide

attempts.

To know the occurrence of psychiatric illness in self injurious

OBJECTIVES

1 . To estimate the psychosocial stressors in suicidal attempters.

2. To find out the gender variation in suicide attempts

3. To find out the relation between intention and lethality of the

suicide

4. To find out the various personalities in suicides

MATERIALS AND METHODS

SETTING:

This study was conducted in Department of psychiatry at

Government Kilpauk medical college and hospital, conducted for a period

of six months from March 2015 to August 2015. All participants with

suicidal attempts, referred from other departments for opinion have been

selected for this study. The study was approved by ethical committee of

this college. Informed consent was obtained from all participants.

SAMPLE:

Hundred and ten consecutive samples were selected for this study.

STUDY DESIGN:

Cross sectional study

INCLUSION CRITERIA :

Age 15 and above

EXCLUSION CRITERIA:

Acutely ill

INTERVIEW:

All participants have been selected consecutively, written informed

consent was obtained from all the participants. For those with below 18

years, the consent was obtained from parents also. Each individual was

interviewed about half to one hour in the outpatient department..

Individuals were interviewed, and socio demographic profile was

administered, and enquired about mode of attempt, reason for attempt,

whether any intent or not, and any previous suicide attempts, history of

substance abuse if present its pattern, family history of suicide and

substance abuse, any physical and psychiatric illness of the life partner,

assessed and scales were applied to all the participants and counseled on

the same session of the day and if they needed medications were also

INSTRUMENTS USED

1. Semi-structured proforma.

2. Symptom check list scale 90(SCL 90)

3. General health questionnaire 12 (GHQ12)

4. Beck suicide intent scale (SIS)

5. Lethality assessment scale (LAS)

6. Presumptive stressful life events scale( PSLE scale)

7. Eysenck personality questionnaire (EPQ 90)

SEMISTRUCTURED PROFORMA

This proforma was prepared for this study, which consists of name,

age, sex, place, educational status, occupational status, marital status and

used in part 1 of this proforma. In the second part previous suicide

attempt, family history of suicide and substance abuse and mental illness

and physical illness of the spouse and their children were analyzed.

(APPENDIX 1).

SYMPTOMS CHECK LIST SCALE 90

Symptoms check list contains 90 questions and consists of three

domains, which consists of depressive symptoms, psychotic symptoms

and symptoms related to physical illness. Each questions to be answered,

in each question the distress level was divided into 0, 1, 2, 3, 4, as, not at

all, a little bit, moderate distress, quite a bit distress, extremely distress

respectively. Final score was obtained by summed up and divided.

GENERAL HEALTH QUESTIONNAIRE 12

General health questionnaire contains 12 questions. The authors of

this scale was Goldberg and Williams-1988. The GHQ 12 is a measure of

current mental health, which focused on two areas one is the inability to

carryout normal functions and the appearance of distressing experiences.

To be applied to participants and to be asked whether had a particular

symptom or behavior recently, and final score to be summedup . If the

score is 3 and above, is considered as a significant result.

(APPENDIX III)

BECK SUICIDE INTENT SCALE

The author of this scale was Beck et al (1974). This scale contains

3 domains, one is dealing with circumstances and precautions for suicide

another one deals with self report and risk of the suicide. Total scores

ranges from 0-21 and divided into low intent scale (0-3), medium intent

scale (4-10), high intent scale (11and above). This scale result shows

LETHALITY ASSESSMENT SCALE

This lethality assessment scale contains 5 keys ranges from no

predictable risk to very high imminent risk, depending upon the key

scale, the lethality and imminent risk of the suicide will be assessed. This

scale is adopted from Hoff, L. A (1995) (APPENDIX V).

PRESUMPTIVE STRESSFUL LIFE EVENTS SCALE

The presumptive stressful life events scale (PSLE scale) contains

51 items, the ranges of the scores are from 20 -95, most of the subjects

would have had more than one stressors . The stressors were analyzed for

the previous one year by using this scale. Each item to be scored and

finally to be summed up. Then it will be divided into low, medium, high

stress life events based on scores less than 150, 150-300, and more than

300 respectively. This scale is revised from Holmes & Rahe's Social

Readjustment Rating Schedule (SRRS), because many of the categories

EYSENCK PERSONALITY QUESTIONNAIRE 90

The Eysenck personality questionnaire (EPQ 90) contains ninety

questions, this questionnaire to be given to the participants, they should

answer each question by yes or no type and should not omit any question,

for each question they can take not more than few seconds, finally

depends upon the scoring the individual may come under any of the

category like psychotism, neurotism, introverted, extroverted and

STATISTICAL ANALYSIS

1. Chi square test: This test shows the relationship between two

categorical variables. Its value reflects the strength of this

relationship.

2. For continuous variable, t test (2 groups), one way of Analysis of

variance (ANOVA) (more than 2 groups) were used. If the values

are not following normal, Non parametric ANOVA were used.

p value

The probability that a finding has occurred randomly rather than as

a result of a treatment or other intervention. A p value p < 0.05 is often

considered a significant, but the lower this figure, the stronger the

RESULTS

TABLE 1 Age group variation

AGE Frequency Percent Valid

Percent

Cumulative Percent

15-20 30 27. 3 27. 3 27. 3

20-30 54 49. 1 49. 1 76. 4

30-40 17 15. 5 15. 5 91. 8

40 and above 9 8. 2 8. 2 100. 0

Total 110 100. 0 100. 0

Table 1 shows, that high number (n=54) of suicides were present in

age group between 20-30 years was 49. 1%, and low percentage were

Table 2 Gender variation

Gender Frequency Percent Valid

Percent

Cumulative Percent

Male 51 46. 4 46. 4 46. 4

Female 59 53. 6 53. 6 100. 0

Total 110 100. 0 100. 0

Table 2 shows, frequency of suicides (n=59) were high in female genders

,the percentage was (53.6%) than males .The male percentage was

46.4%(n=51).

Table 3 Educational status

Education Frequency Percent Valid Percent

Cumulative Percent

No formal education

13 11. 8 11. 8 11. 8

Upto twelfth 70 63. 6 63. 6 75. 5

Above twelfth 27 24. 5 24. 5 100. 0

Total 110 100. 0 100. 0

Table 3 shows, higher number of suicidal attempts were present in

percentage was 63. 6% . The individuals who had no formal education

(11. 8%), and who had higher educational level (24. 5%) both these

groups had less percentage of suicide attempts.

Table 4. Occupational status

Occupation

Frequency Percent

Valid Percent

Cumulative Percent

Student

Housewife

Employed Unemployed

Total

16 14. 5 14. 5 14. 5

12 10. 9 10. 9 25. 5

63 57. 3 57. 3 82. 7

19 17. 3 17. 3 100. 0

110 100. 0 100. 0

Table 4 shows, suicide attempts were more common in employed persons

(n-63) the percentage was 57. 3% than unemployed persons (n=19)

Table 5 Income status

Income per

month Frequency Percent

Valid Percent Cumulative Percent <10000 10000-25000 >25000 Total

72 65. 5 65. 5 65. 5

34 30. 9 30. 9 96. 4

4 3. 6 3. 6 100. 0

110 100. 0 100. 0

Table 5 shows, high percentage of suicides were present in

individuals with monthly income of less than 10000,per month, they

contribute to 65. 5% (n=72).

Table. 6 Marital status Marital status Frequency Percent Valid Percent Cumulative Percent Unmarried married

54 49. 1 49. 1 49. 1

56 50. 9 50. 9 100. 0

Total 110 100. 0 100. 0

Table 6, shows that there were a slightly higher rate of suicide

percentage in unmarried population (n=54) was 49. 1%, and percentage in

married population was (n=56) 50. 9%

FIGURE 1.

1=unmarried

2=married

Figure 1, says that married persons contributed slightly higher than the

Table 7

Relation between PSLE scale and Educational status

PSLE scale

Education _{<150 150-300 >300 Total}

Uneducated

10 2 1 13

% within education 76. 9% 15. 4% 7. 7% 100. 0% % within PSLE 12. 3% 8. 3% 20. 0% 11. 8% % of Total 9. 1% 1. 8% . 9% 11. 8% Below

twelfth std

55 11 4 70

% within education 78. 6% 15. 7% 5. 7% 100. 0% % within PSLE 67. 9% 45. 8% 80. 0% 63. 6% % of Total 50. 0% 10. 0% 3. 6% 63. 6%

Above twelfth std

16 11 0 27

% within education 59. 3% 40. 7% . 0% 100. 0% % within PSLE 19. 8% 45. 8% . 0% 24. 5% % of Total 14. 5% 10. 0% . 0% 24. 5%

Total Count 81 24 5 110

% within education 73. 6% 21. 8% 4. 5% 100. 0% % within PSLE 100. 0% 100. 0% 100.

0%

100. 0%

% of Total 73. 6% 21. 8% 4. 5% 100. 0%

Table 8

Chi-Square Tests

Value df

Asymp. Sig. (2-sided)

Pearson Chi-Square 8. 602a 4 . 072

Likelihood Ratio 9. 062 4 . 060

Linear-by-Linear Association

. 608 1 . 435

N. of Valid Cases 110

Table 7 and 8 shows, the participants were divided into, no formal

education, studied below twelfth standard and studied above twelfth

standard. They had PSLE scores like less than 150, 150-300, >300, and

the percentages were 76. 9%, 78. 6%, 59, 3% respectively and individuals

with below twelfth standard group had highest score (78. 6%) than other

groups. Even though the chi-square does not show significant statistical

result, one important think is 4 of the individuals within a group of below

Figure 1. Relation between PSLE scale and Education

1 = < 150

2 = 150-300

3 = >300

Table 9

Relation between PSLE scale and Occupational status

PSLE scale

occupation <150 150-300 >300 Total

Student

14 2 0 16

% within occupation 87. 5% 12. 5% . 0% 100. 0% % within PSLE 17. 3% 8. 3% . 0% 14. 5% % of Total 12. 7% 1. 8% . 0% 14. 5%

House wife

Count 10 2 0 12

% within occupn 83. 3% 16. 7% . 0% 100. 0% % within PSLE 12. 3% 8. 3% . 0% 10. 9% % of Total 9. 1% 1. 8% . 0% 10. 9%

Employed 46 14 3 63

% within occupn 73. 0% 22. 2% 4. 8% 100. 0% % within PSLE 56. 8% 58. 3% 60. 0% 57. 3%

% of Total 41. 8% 12. 7% 2. 7% 57. 3%

Unemployed 11 6 2 19

% within occupn 57. 9% 31. 6% 10. 5% 100. 0% % within PSLE 13. 6% 25. 0% 40. 0% 17. 3%

% of Total 10. 0% 5. 5% 1. 8% 17. 3%

Total 81 24 5 110

Table 10

Chi-Square Tests

Value df

Asymp. Sig. (2-sided)

Pearson Chi-Square 5. 605a 6 . 469

Likelihood Ratio 6. 518 6 . 368

Linear-by-Linear Association

5. 011 1 . 025

N of Valid Cases 110

Table 9 shows, employed persons had PSLE score 56. 8 % (<150),

58. 3 % (150-300), 60 % (>300), but individuals with unemployment had

PSLE score 13. 6%(<150), 25%(150- 300), 40%(>300), so employed

persons only had high psychosocial stressors than individuals with

unemployment. About 60% of the individuals with employment had

Figure 2

PSLE scale :1=<150

2=150-300

3=>300

Income: 1=<10000/ m, 2=10000-25000/m, 3=>25000/m

The figure 2 shows, highest psychosocial stressors were present in

individuals with income less than 10000 per month, but among the three

Table 11

Relation between marriage and PSLE score

Marital

status PSLE scale

<150 150-300 >300 Total

Unmarried

married

Count 45 10 0 55

% within mar. statu

81. 8% 18. 2% . 0% 100. 0%

% within PSLE 55. 6% 41. 7% . 0% 50. 0%

% of Total 40. 9% 9. 1% . 0% 50. 0%

Count 36 14 5 55

% within mar. statu

65. 5% 25. 5% 9. 1% 100. 0%

% within PSLE 44. 4% 58. 3% 100. 0% 50. 0%

% of Total 32. 7% 12. 7% 4. 5% 50. 0%

Total 81 24 5 110

% within mar. statu

73. 6% 21. 8% 4. 5% 100. 0%

% within PSLE 100. 0% 100. 0% 100. 0% 100. 0%

Table 12 Chi-Square Tests

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square 6. 667a 2 . 036

Likelihood Ratio 8. 603 2 . 014

Linear-by-Linear

Association

5. 799 1 . 016

N of Valid Cases 110

Table 11 and 12 shows, psychosocial stressors were present in both

married (65. 5%) and unmarried populations (81. 8%) but <150 scores

were more in unmarried populations and scores 150-300, (58. 3%), >300

(100%)were present in married populations, which indicates, though the

stressors were present in both groups the severity of stressors were more

in married groups. (p=. 036)

Table 13

Relation between presumptive stressful life events scale (PSLE scale) and Beck suicide intent scale (BECK)

BECK scale PSLE

scale Low medium high Total

<150 63 16 2 81

% within PSLE 77. 8% 19. 8% 2. 5% 100. 0% % within BECK 76. 8% 64. 0% 66. 7% 73. 6% % of Total 57. 3% 14. 5% 1. 8% 73. 6%

150-300 16 8 0 24

% within PSLE 66. 7% 33. 3% . 0% 100. 0% % within BECK 19. 5% 32. 0% . 0% 21. 8% % of Total 14. 5% 7. 3% . 0% 21. 8%

>300 3 1 1 5

% within PSLE 60. 0% 20. 0% 20. 0% 100. 0% % within BECK 3. 7% 4. 0% 33. 3% 4. 5% % of Total 2. 7% . 9% . 9% 4. 5%

Total Count 82 25 3 110

Table 14 Chi-Square Tests

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square 8. 119a 4 . 087

Likelihood Ratio 5. 443 4 . 245

Linear-by-Linear Association 2. 248 1 . 134

N of Valid Cases 110

Table 13 & 14 shows, if the PSLE score is low, the intent of the

suicide will be low likewise if the PSLE score is high the intent of the

suicide also will be high. In low score (<150) of PSLE, the intent in

BECK scale (76. 8%) is low, and in between 150-300 score of PSLE the

BECK scale is (32%) medium, in high score of PSLE >300, the BECK

intent is high(33. 3%). Though it is not statistically significant (p=0. 087)

Figure 3

Figure 3, shows there is no significant correlation between PSLE scores

and lethality of the suicide attempts.

lethality assessment scale-

1- nopredictable risk of immediate suicide

2-low risk of immediate suicide

3-moderate risk of immediate suicide

4-high risk of imminent suicide

Figure 4.

1=low

2=medium

3=high intent

Figure 4 shows, if the suicidal attempter had low intention, the

lethality of the suicide will have no risk and in medium intent, the

lethality will have medium risk, and in high intent the individual may

Table 14.

Relation between personality (EPQ 90) and Type of suicide

Personality SUICIDE

poisoning Hanging Total

Psychotism Count 6 2 8

% within EPQ 75. 0% 25. 0% 100. 0% % within

SUICIDE

5. 8% 28. 6% 7. 3% % of Total 5. 5% 1. 8% 7. 3%

Neurotism

Count 28 3 31

% within EPQ 90. 3% 9. 7% 100. 0% % within

SUICIDE

27. 2% 42. 9% 28. 2% % of Total 25. 5% 2. 7% 28. 2%

Ambivert

55 0 55

% within EPQ 100. 0% . 0% 100. 0% % within

SUICIDE

53. 4% . 0% 50. 0% % of Total 50. 0% . 0% 50. 0%

Introvert

Count 6 1 7

% within EPQ 85. 7% 14. 3% 100. 0% % within

SUICIDE

5. 8% 14. 3% 6. 4% % of Total 5. 5% . 9% 6. 4%

Extravert

8 1 9

% within EPQ 88. 9% 11. 1% 100. 0% % within

SUICIDE

7. 8% 14. 3% 8. 2% % of Total 7. 3% . 9% 8. 2%

Total Count 103 7 110

% within EPQ 93. 6% 6. 4% 100. 0% % within

SUICIDE

Table 14 shows, suicidal attempts were done by psychotism (n=8)

5. 8%, neurotism (n=31) 27. 2%, ambivert (n=55) 53. 4%, introvert (n=7)

5. 85, extrovert personality types (n=9) 7.8%. Suicide by poisoning was

contributed by (n=103) 93. 6%, and the percentage of hangings were

(n=7) 6.4%. Among all the personality types, commonly occurring

personality in poisonings were ambivert type, and hanging was most

commonly attempted by neurotic type personality.

Table 15

Relation between Alcohol and Personality type EPQ

Psychotism Neurotism Ambivert Introvert Extrovert

WITHOUT ALCOHOL

WITH ALCOHOL

Count 6 23 39 7 5

% within ALCOHOL

7. 5% 28. 7% 48. 8% 8. 8% 6. 3%

% within EPQ 75. 0% 74. 2% 70. 9% 100. 0% 55. 6%

% of Total 5. 5% 20. 9% 35. 5% 6. 4% 4. 5%

Count 2 8 16 4 30

% within ALCOHOL

6. 7% 26. 7% 53. 3% . 0% 13. 3%

% within EPQ 25. 0% 25. 8% 29. 1% . 0% 44. 4%

% of Total 1. 8% 7. 3% 14. 5% . 0% 3. 6%

Total Count 8 31 55 7 9

% within ALCOHOL

7. 3% 28. 2% 50. 0% 6. 4% 100. 0%

% within EPQ 100. 0% 100. 0% 100. 0% 100. 0% 27. 3%

Table 15 shows, percentage of suicide in personality wise, without

alcohol use were psychotism- 75%, neurotism- 74. 2%, ambivert -70. 9%,

introvert -100%, extrovert - 55. 6% and with alcohol use psychotism

25%, neurotism 25. 8%, ambivert 29. 1%, introvert 0 %, extrovert 44.4%.

Suicide attempt without alcohol intake, in which introvert types were

common(100%) and suicide attempt with alcohol intake, in which

extrovert types were common(44.4%).

Table 16

Relation between Suicide and Alcohol SUICIDE

poisoning Hanging Total WITHOUT

ALCOHOL

WITH ALCOHOL

Count 77 3 80

% within ALCOHOL

96. 3% 3. 8% 100. 0%

% within SUICIDE

74. 8% 42. 9% 72. 7%

% of Total 70. 0% 2. 7% 72. 7%

Count 26 4 30

% within ALCOHOL

86. 7% 13. 3% 100. 0%

% within SUICIDE

25. 2% 57. 1% 27. 3%

% of Total 23. 6% 3. 6% 27. 3% 103 7 110 % within

ALCOHOL

93. 6% 6. 4% 100. 0% % within

SUICIDE

Table 16, shows, among the participants (n=80) 72. 7% were not at

all used alcohol, and alcohol users were (n=30) 27. 3% only. Among the

non alcohol users 96. 3% were done suicide attempt by poisoning, 3. 8%

of the participants were attempted for hanging. With alcohol use 25. 2%

of the participants were done suicide attempt by poisoning, and 57. 1% of

the participants were attempted for hanging. So in this study suicidal

poisoning without was common and attempted hanging with alcohol use

was common.

Figure 5

1=poisoning

Figure 5 shows, there is no relation between scores in General

health questionnaires 12, and in individuals with suicidal attempt. In both

groups of suicidal attempts, the GHQ 12 scores were predominently less

than 3 only.

Table 17

Relation between symptom check list 90 (SCL 90) and Suicide

Suicide

N Mean

Std. Deviation

Std. Error Mean

SCL90 poisoning 103 12. 31 11. 906 1. 173

hanging 7 16. 00 13. 026 4. 923

Table 18

Independent Samples Test

Levene's Test for Equality of Variances

t-test for Equality of Means

F Sig. t df

SCL 90

Equal variances assumed

. 024 . 876 -. 789 108

Table 19

RELATION BEWEEN SYMPTOM CHECK LIST 90(SCL 90) AND RECURRENT SUICIDAL ATTEMPT

RECURRENT N Mean

Std. Deviation

Std. Error Mean

SCL 90

Recurrent 21 21. 76 13. 050 2. 848

First attempt 89 10. 37 10. 636 1. 127

Table 17, 18 and 19, shows there were no statistically significant

test result in relation to suicide and symptom check list 90 questionnaire

and also no relation between SCL 90 and recurrent suicide attempts.

(p=0. 876)

Table 20 COMORBID PSYCHIATRIC ILLNESS

Table 20, shows the only personality disorder commonly presented

with suicide attempts was borderline personality disorder (n=31)

contributing to 28%, the common psychiatric disorder associated with

suicides were depression (n=19) contributes 17% and other disorders like

adjustment disorder (n=3) 2. 7%, alcohol induced psychosis (n=2) 1. 8%,

schizophrenia (n=1) 0. 9%, acute stress reaction (n=1) 0. 9%, conduct

disorder (n=1) 0. 9%. So 52.7% of the participants was suffering from

PSYCHIATRIC

ILLNESS _{NUMBER PERCENTAGE}

Border line personality disorder

31 28 %

Depression 19 17 %

Adjustment disorder 3 2. 7 %

Alcohol induced psychosis

2 1. 8 %

Conduct disorder 1 0. 9 %

Acute stress reaction 1 0. 9 %

Schizophrenia 1 0. 9 %

psychiatric illness. Among the participants 19% (n=21) of them had

deliberate self harm scars (DSH), usually they had a recurrent suicidal

tendency, the duration between DSH to suicidal attempt varied from 6

months to many years in our study.

Among the participants, 30% (n=33) had comorbid substance use

disorder and it varies from harmful use to dependent pattern. 10% of the

participants had suicidal attempts under the influence of alcohol (n=11)

and they attempted by both in insecticide poisoning mode and hanging.

Recurrent suicidal attempts were present in 20% (n=22), in this study

recurrent suicidal attempts were commonly present in borderline

DISCUSSION

This theme is rarely discussed in Indian context. Its needed to consider the personality colouring of these individuals and know how

prone these individuals are to commit deliberate self harm and self

injurious behavior. It is also needed to consider the incidence of severe

mental illnesses in these individuals and how frequently they are prone

for self injurious behavior. In normal individuals without any

psychological disturbances many adverse life events force them for an

impulsive acts of self harm. Hence it is imperative to know about the

modifiable risk factors and the relationship between life events and

deliberate self harm. Hence this study is the need of the hour in the

present context.

AGE:

In this study, self injurious behavior was most commonly occurs

between the age groups of 20-30 years (49.1%). Most of the studies

related to suicide had shown that common age groups for suicide attempt

were between 15-30 years . R.Tara,G.V.Ramana Rao(2014), study shown

that common age group for suicides were between 15-35 years, so our

study had a similar findings as with previous studies. Lewinsohn et al,

hopelessness, recent stressful events, family violence and lower academic

achievement.

Previous study results shown that suicidal behavior increases

markedly during adolescence (Shaffer&Fisher,1981;Brooksband,1985). It

has been found across various studies that the incidence of attemptd

suicide was greatest in young adults (Morgan,et al,1976,Holding et

al.1977).

GENDER:

Our study shows, that frequency of suicidal attempts were

commonly present in females gender (53.6%). R. Tara, G. V. Ramana

Rao study(2014)., had showed that 60% of the suicidal attempters were

female in their studies. White (1974), Otto (1972) and Keith Howton et

al.,(1982), and Indian study by Sudhirkumar et al. (2000) all these studies

indicated that females were the common gender in suicide attempts.

Olfson et al (2005), this study shown that higher incidence of suicides

occur in adolescent females. In compared with previous studies, girls

outnumbered the boys in attempting suicide according to Garfinkel et al.,

(1982), Garfinkel B. D. et al., (1982), Otto (1972),L. Kotila et al., (1987).

EDUCATION:

Our study shows that educated individuals especially those who

have completed below twelfth standard had more vulnerability for

suicidal behavior (n=7) (63. 6%). Nordentoft & Rubin (1993) showed

that there were no difference between attempters and general population

in educational levels. According to previous study results, our study result

does not show any significant variation in educational level in relation to

suicide attempt.

OCCUPATION:

Our study says, compared to unemployed participants, the

participants with employment had a high suicidal rate (57.3%),and also

the level of stressors were more in employed persons. Ramdurg et al

(2012), study had shown, that more suicidal attempts were present in

employed persons than unemployed persons and they assessed the

stressor scores which were high in employed persons. When dealing with

psychosocial stressors in relation to employed persons, the level of

stressors were more in individuals with employment than individuals with

unemployment. R.Tara. G. V.Ramana rao (2014) study shown that, 55%

of the participants attempted suicides were only unskilled workers.

unemployment. So our study results had similar finding as with previous

study results.

MARRIAGE:

Our study results shows that there was a slight increase in suicide

attempts in married populations (50.9%) than in unmarried populations

(49.1%). Fleischmann A et al 2005, study says that increased frequency

of suicides were present in married than unmarried persons and Ramdurg

et al 2012, study also shown the similar findings .In which our study had

a similar finding with previous study. But Unmarried persons had a

higher percentage of suicides according to Ponnudurai et al., (1986),

Ghulam et al., (1995) and Latha et al., (1996) .

ECONOMIC STATUS:

The frequency of suicidal attempts were more common in

individuals with income of less than 10000 per month in our study.

White (1974), Morgan (1975), study shown, that most of the suicide

attempts were come under lower middle socioeconomic status not from

very low socioeconomic status, so our study also had a similar finding as

with previous studies.A study by Thirunavukarasu (1981) have shown

that, increased incidence of suicide in the low income and social status

PSYCHOSOCIAL STRESSORS:

We divided the stressors level into three types like <150, 150-300

and > 300 in PSLE scale. In this study, we found family conflict, marital

conflict and financial loss were the most common stressors in this

participants. Among the participants those who had educational level

below twelfth standard had a highest psychosocial stressors scores

(78.6%).When compared to unemployment, the participants with

employment had high scores in PSLE scale (60%). Osvath et al,(2004).,

reported that 80% of the suicides were due to life events like job problem,

financial problem, unemployment. P. N. Sureshkumar et al,(2013).,

reported in his study that suicidal behaviors were due to psychosocial

stressors like family conflict, financial conflict and marital conflicts.

Our study shows that psychosocial stressors were present in both

married and unmarried populations but high PSLE scores from 150-300,

and above 300 scores were present only in married populations but

Shivkumar et al (2003)., study shown that risk of suicide attempts were

more common in single or unmarried persons. Paykal et al,(1974) study

shown that life events in the preceding years had 4 times higher risk than

the general population. According to Fergusson DM et al (2000), that

adolescents with greatest risk of suicidal behaviour had family problem,

marital problem, poor parent child attachment, exposure to sexual abuse