Intentional self-harm – Analysis of methods and associated characteristics

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Intentional self-harm – Analysis of methods and associated characteristics

 Background

A total of 13,606 suicides were reported in Karnataka during 2022 accounting for 8.0 % of total suicides.⁽¹⁾ There are more than 20 suicide attempts for each suicide.  There is high prevalence of suicide attempts amongst people who engage in self-harm.  Both suicide attempt and history of Intentional Self-Harm can be a predictor of future suicide.⁽²⁾ People treated in hospital for self-harm are at 30–200 times higher risk of suicide in the following 12 months.⁽³⁾  Identifying self-harm behaviours and treating it early could be the first step in managing potential suicidal behaviours.

 

Intentional Self-Harm (herewith referred to as self-harm) is the term for self-injurious behaviours with or without suicidal intent that has non-fatal outcomes. Intentional self-injurious thoughts and behaviour may be suicidal or non-suicidal.⁽⁴⁾ It encompasses a broad range of behaviours, but is typically defined as deliberately self-initiated harm and includes behaviours such as hanging, poisoning, and cutting with and without suicide intent.⁽⁵⁾  Such cases are often regarded as failed suicides though majority of the patients do not try to kill themselves. They are usually in emotional turmoil and try to draw attention. These acts are often gratifying and cause minor to moderate harm and sometimes repeated acts can result in death.

 

Individuals who have prior mental disorder, previous attempts of suicide/ self-harm and stressful incidents are at high risk of attempting to harm themselves. Identifying such high risk individuals at right time and treating them would save their lives. Apart from a detailed forensic evaluation and reporting of such cases, a detailed psychiatric assessment is also essential in both in and out patients. Here we intend to explore different methods used, examine the relationship of sex and age to method chosen.  

 

 Aims & Objectives

1. To identify different methods used for self harm
2. To examine the relationship between gender/ age and method chosen

 

 

 

Methodology

Source of data:

Cases of attempted suicides admitted/ brought to Dr Chandramma Dayananda Sagar Institute of Medical Education and Research during the study period.

 

Methods of collection of data:

In this prospective, hospital-based, cross-sectional study, all cases of Intentional self-harm admitted/ brought to Dr Chandramma Dayananda Sagar Institute of Medical Education and Research during the study period was included in the study after obtaining a written informed consent. If the patient was aged between 7 years- 17 years, informed written assent was obtained from the patient along with a written informed consent from his/ her guardian.  Patient’s socio demographic details, personal and family history and past history of Intentional self-harm and psychiatric illness, the details of the circumstances under which the act of Intentional self-harm took place were obtained from the victim, family members, friends & eye witnesses if any.

 

Inclusion criteria:

1. All cases of Intentional self-harm admitted in CDSIMER
2. All cases brought with history of assault or accidental injury or with a vague history but later turned out to be self-harm after evaluation.

Exclusion criteria:

1. Cases which were brought with history of self-harm but later turned out otherwise after evaluation.
2. Patients who refused/ were unable to give consent.
3. Completed suicides

Sample size estimation

It was calculated based on a previous study by Nilamadhab Kar, in which it was found that attempted suicides were more common in the age group of 20-39 years i.e., 63.7%.⁽⁶⁾ In the present study, sample size was calculated considering relative precision of 15% and decided confidence level of 95% which worked out to be a total of 98 samples.

 

 

Statistical analysis:

Descriptive statistics for the qualitative and quantitative type of data like age group, gender, methods used & clinical data were summarised using frequency and percentage.

 

RESULTS

Study was conducted at Dr Chandramma Dayananda Sagar Institute of Medical Education and Research from October 2022 to February 2024. A total of 98 cases which fulfilled the inclusion criteria were examined. 63.27 % of them were females and 36.73 % were males. 46.94 % of them were in the age group of 25- 60 years followed by 19- 24 years (34.7 %). 43.8 % were unmarried and 87.75 % of them hailed from rural areas. 95.9 % of them were Hindus and 46.94 % of them had Diploma or Pre- University type of education. Unemployed and students constituted 17.35 % each and most of them belonged to Socio economic group Class I (34.7%) and Class II (38.78 %). More than half of them had unskilled/ semi-skilled job. (Table No 1)

 

Table No 1- Socio-demographic characteristics (n=98)

Variable	Frequency	Percentage
Age <13 years 14- 18 years 19-24 years 25-60 years > 60 years	01 12 34 46 05	01.02 12.24 34.70 46.94 05.10
Sex Male Female	36 62	36.73 63.27
Marital status Married Unmarried Widow	52 43 03	53.1 43.8 03.1
Geography Urban Rural	12 86	12.25 87.75
Religion Hindu Muslim Christian	94 03 01	95.9 03.1 01
Education Primary School Middle School High School Intermediate/ Diploma Graduate Post- Graduate Illiterate	04 08 10 46 14 01 15	04.09 08.16 10.20 46.94 14.29 01.02 15.30
Current job status Unemployed Employed Home maker Agriculturist Student	17 31 22 11 17	17.35 31.63 22.45 11.22 17.35
Socio economic status Class-1 Class-2 Class-3 Class-4 Class-5	34 38 18 06 02	34.70 38.78 18.36 06.12 02.04
Nature of Job Skilled Semi-skilled Unskilled Others	05 38 15 40	05.10 38.78 15.31 40.81

 

Table No 2- Type of methods used (n=98)

Method used	Frequency (98)	Percentage	Male	Female
Violent	11	11.22	4	7
Non violent	87	88.78	32	55
Total	98	100	36	62

 

88.78 % of them used non- violent methods and 55 of the 62 females used non- violent methods. (Table No 2)

 

Table No 3- Type of violent methods used (n=11)

Method used	Frequency	Percentage	Male (%)	Female (%)
Violent	11	100	04	07
a. Attempted Hanging	07	63.64	02	05
b. Attempted Drowning	02	18.18	00	02
e. Sharp force injury	02	18.18	02	00

 

Violent methods were used in 11 cases and attempted hanging was the common method (63.64%) and was used in 7 cases followed by near drowning and sharp force injury. (Table No 3)

 

Table No 4- Type of non-violent methods used (n=87)

Method used	Frequency	Percentage	Male (%)	Female (%)
Non violent	87	100	32	55
a. Cleaning products	6	6.90	02	04
b. Herbicides	2	2.30	00	02
c. Overdose of medication	24	27.59	05	19
d. Pesticide	55	63.21	25	30

 

Consumption of pesticide (63.31 %) was the most common non- violent method chosen followed by over dose of medication (27.59 %). (Table No 4)

 

Table No 5- Type of method and age group

Method chosen/Age Group	< 13 years	14- 18 yrs	19-24 yrs	25-60 yrs	> 60 yrs
Attempted Hanging (7)	-	5	2	-	-
Attempted Drowning (2)	-	-	2	-	-
Sharp force injury (2)	-	2	-	-	-
Cleaning products (6)	-	-	4	2	-
Herbicides (2)	-	1	-	-	1
Overdose of medication (24)	1	3	16	4	-
Pesticide (55)	-	1	10	40	4
Total (98)	1	12	34	46	5

 

Consumption of pesticide was common chosen method in the age group of 25- 60 years (40 of 46 cases) and over dose of medication in the age group of 19- 24 years (16 of 34 cases). Attempted hanging was the common method in the age group of 14 – 18 years (5 of 12 cases) (Table No 5)

Table No 6- Type of Cleaning products

Type of Cleaning products	Frequency (06)	Percentage (100)
Phenol	02	33.33
Hydrochloric acid	02	33.33
Herbal Cleaner	01	16.67
Benzalkonium Chloride	01	16.67

 

Table No 7- Type of Prescription drugs

Type of medication	Frequency (24)	Percentage (100)
Paracetamol	12	50.00
Thyroxin	04	16.68
Antibiotic	02	8.33
Anti- Diabetic- Metformin	02	8.33
Anti hypertensive- Amlodipine	02	8.33
Benzodiazepine and Barbiturates	02	8.33

Of the cleansing products, Phenol and Hydrochloric acid were used in 2 cases each. (Table No 6) Paracetamol was the most common type of overdose of medication (50%). (Table No 7) Pyrethroids constituted 47.27 % of the type of pesticide consumed followed by Organophosphorus compound (29.09 %) (Table No 8)

 

Table No 8- Type of Insecticide

Type of Pesticide	Frequency (55)	Percentage (100)
Organophosphorus	16	29.09
Pyrethroids	26	47.27
Zinc Phosphide	02	03.64
Aluminium Phosphide	08	14.55
Yellow Phosphorus	03	05.45

 

Table No 9- Possibility and Intentionality of death

Possibility of death	Frequency (98)	Percentage (100)
Unlikely	31	31.63
Likely possible	41	41.83
Certainly possible	26	26.54
Intentionality
Low- Did not want to die	38	38.78
High- Wanted to die	51	52.04
Mixed	9	09.18

 

52.04 % of them had an intention to end life. Death was likely possible in 41.83 % of the cases and certainly possible in 26.54 % of the cases. (Table No 9) This data was taken on the basis of the type of method chosen, provision of first aid, time taken to reach hospital and condition on arrival at the hospital.  

 

 

 

 

Table No 10

Time parameters

Time between incident and presentation	Frequency (98)	Percentage (100)
< 15 min	10	10.02
15-30 min	46	47.00
30-60min	17	17.40
>1hr-1day	25	25.58
Duration of stay in ICU
< 24 hrs	49	50.00
1 – 2 days	27	27.56
3- 5 days	11	11.22
> 5 days	11	11.22
Duration of hospitalisation
1- 2 days	32	32.65
3- 5 days	40	40.82
6 - 10 days	21	21.43
> 10 days	05	05.10

 

47 % of them reached the hospital between 15 to 30 minutes and 50% of them stayed in the ICU for less than 24 hours. Majority of them were discharged within 5 days (73.47 %). (Table No 10)

 

Table No 11: Reasons for Self Harm

Reasons	Number of cases	Percentage (%)
Interpersonal conflicts (41) With spouse With partner With other family members	16 20 05	(41.83) 16.32 20.41 05.10
Financial issues	18	18.37
Property issues	10	10.20
Bereavement	03	03.06
Unemployment	04	04.08
Alcohol abuse	05	05.10
Academic challenges	11	11.22
Chronic illness	06	06.12
Total	98	100

 

Interpersonal conflict was the main reason to harm themselves in 41.83 % of the cases and predominantly it was with their partners (20.41 %).  Financial issues (18.37 %) and academic challenges (11.22 %) were the other common reasons. (Table No 11) Only 20 of the cases were diagnosed to have Psychiatric illness where help was not sought. Depressive episode (8), emotionally unstable personality disorder (7) and Adjustment disorder (5) were the diagnoses made.

 

Discussion:

Intentional self harm is a global issue and now also a rising concern amongst Indians. Behaviours range from self- poisoning to use of sharp force with varying degrees of lethality. Lack of identifying people with self harm behaviour and in turn providing them proper Psychiatric care is one of the factors leading to higher suicide rates in rural Indian population.

 

The present study was a prospective review of the socio-demographic profile, types of methods, lethality, intentionality and reasons for such behaviour in subjects with intentional self-harm admitted in a rural tertiary care hospital referred to Psychiatry consultation. Here we discuss the risk factors associated with such behaviour and determine how different they are in Rural India compared to rest of the country and world.

 

A total of 98 cases which fulfilled the inclusion criteria were examined. 63.27 % of them were females and 46.94 % of them were in the age group of 25- 60 years followed by 19- 24 years (34.7 %). This is similar to a study done in Thailand where 60% were females and were predominantly patients from two age groups, 18-25 and 26-39 years of age.⁽⁷⁾ In another study done in Urban India there was a slight male preponderance in study sample.⁽⁸⁾ However the vulnerable age group of young adults and adolescents is common in most of the similar studies. This age group is more susceptible as they are more exposed to stressful environment and psychosocial problems which they not fully capable enough to cope up with.

 

53.1 % of them in our study were married; similar to a study by Tekkalaki B ⁽⁸⁾ in urban India about 70% of the patients were married, again a finding consistent with the researches from Indian subcontinent; ⁽⁹⁾ in contrast to European and Australian studies reported such behaviour in single and divorcees.⁽¹⁰⁾ Age of marriage is lower in Indians compared to the west and now it is gradually increasing in rural India too.

 

As the study centre is situated in rural India majority of the patients are from rural areas (87.75 %).  Majority of them had Pre- University type of education or lower. Graduates and above constituted only 15 %. Unemployed and students constituted 17.35 % each and most of them belonged to Socio economic group Class I (34.7%) and Class II (38.78 %). Tekkalaki B in his study in urban India reported 38 % of suicide attempters were educated up to high school, about 27% were graduates. ⁽⁸⁾  This finding is different in our study as it was done in rural India. Self harm behaviour is more commonly associated low educational status and unemployment. Inability to meet the social demands may be the reasons in educated individuals.

 

88.78 % of them used non- violent methods and 55 of the 62 females used non- violent methods.  More females chose softer method of self-harm than males. Attempted hanging was the most common violent method used (63.64%). Consumption of pesticide (63.31 %) was the most common non- violent method chosen followed by over dose of medication (27.59 %). Pyrethroids constituted 47.27 % of the type of pesticide. Paracetamol was the most common type of overdose of medication. Phenol and Hydrochloric acid were commonly used cleansing products. In a similar study done in Australia, non-violent methods constituted 80 %. Compared to our study violent methods like using sharp force was more common in Australia. Use of sharp force was the third most common method (13%). Again in contrast to Rural India pharmaceutical drug overdose was more common than other poisonous substances. ⁽⁵⁾   In another study in India, Grover et al has observed non violent methods were 89 % and very similar to our study consumption of pesticides was the most common non-violent method. However corrosives (11%) were preferred over prescription drugs as the next common non- violent method. It was also observed by Grover et al that violent methods like hanging, strangulation, jumping from height, self-stabbing and self-immolation were common in males (10.9%). ⁽¹¹⁾  Similarly in another study by Paholpak P et al in Thailand, self-poisoning behaviours were performed more commonly by women; while men tended to perform self-harming behaviours (violent methods).⁽⁷⁾  In contrast, Hansen et al. observed that nearly half of the sampled cases were drug poisoning and second largest group involves sharp force i.e. cutting or piercing. ⁽¹²⁾ Methods are chosen based on availability of it in the vicinity and males are more likely to shoes violent methods than males. Our Institution is a tertiary care centre in rural India and availability of pesticides is much easier and cheaper than prescription drugs. Moreover pesticides are stored in most of the houses in rural India as agriculture is their prime occupation. Pyrethroids a less fatal and more commonly available pesticide was used for self-harm.

 

Self-harm by poisoning is considered less painful than use of sharp force. Hence non violent methods are commonly used by females and it is also the only type of method in age group more than 25 years in both sexes.  In our study, there were no violent methods chosen by persons who are more than 25 years of age.

 

52.04 % of them had an intention to end life; in contrast it was slightly lesser (38.16%) in a study by Hansen et al. In 41.83 % of the cases death was likely possible and certainly possible in 26.54 % of the cases. Likelihood of death depends on the type of method, type and dose of poison consumed, injury to vital body structures, provision of first aid, time taken to reach hospital and condition on arrival at the hospital.  Individual’s knowledge of lethality of the type of method is also another contributing factor. Consumption of pyrethroid is the less lethal method followed by prescription drugs. Pyrethroids commonly used in mosquito repellents and they are more toxic to insects than to mammals and birds due to the more sensitive sodium channels in the insect nervous system and their lower body temperature. ⁽¹³⁾

 

Paracetamol and other pharmaceutical drugs were consumed in doses lesser than the lethal dose and are less likely to cause death. Likelihood of death is more common in consumption of organophosphorus compound, phosphides, attempted hanging, and attempted drowning. These are considered more lethal methods.

Many villages and towns nearby have easy and quick access to our Institution which makes patients reach faster and in our study about 47 % of them reached the hospital between 15 to 30 minutes.  All cases were initially admitted in intensive care unit and the stay in intensive care unit was less than 24 hours in 50% of them; Duration of hospitalisation was less than 5 days in 73.47 %. In a similar study in Thailand causes for longest hospital stay were intentional self-harm by (a) smoke fire and flames (b) intentional self-harm by jumping from a high place and (c) intentional self-harm by rifle, shotgun and larger firearms. The mean length of stay in this group varied widely between 1.6 + 0.5 and 24.9 + 37 days with 7% of admissions being longer than 2 weeks. ⁽⁷⁾ Again these are more lethal methods and likelihood of death is more. In our study there were no cases of self- harm from fire, firearms or fall from height. More lethal methods like attempted hanging, attempted drowning, and consumption of organophosphorus compounds were the type of cases which required longer hospitalisation.

 

Interpersonal conflict was the main reason to harm themselves in 41.83 % of the cases and predominantly it was with their partners (20.41 %).  Financial issues (18.37 %) and academic challenges (11.22 %) were the other common reasons. In a similar study by Tekkalaki B, interpersonal conflicts with the family members (46.34%), conflicts with spouse or partner (21.96%), and broken emotional relationship (17.08%) were the main causative factors for self-harm. ⁽⁸⁾ In another Indian study by Siwach and Gupta, it was reported that marital disharmony, economic hardships and scolding/disagreement with other family members were the major precipitating factors for self-harm. ⁽¹⁴⁾  These findings concur with our results where interpersonal problems, financial and academic performance were found to be the causes.

 

Psychiatric illness was diagnosed only in 20 % of the cases and they were not being treated for the same.   Depressive episode, emotionally unstable personality disorder and Adjustment disorder were the diagnoses made in those 20 cases. Remaining 78 cases did not have any psychiatric illness while they were hospitalised or in the past. In similar studies by Grover et al ⁽¹¹⁾, Tekkalaki B ⁽⁸⁾, Das PP et al  ⁽⁹⁾ and Paholpak P et al ⁽⁷⁾  psychiatric co-morbidity in self- harm cases were 22.8%, 40 %, 52% and 33.8 %. The majority of underlying psychiatric disorders comprised diagnoses of anxiety disorders (47.1%) and mood disorders (25.2%) as reported by Paholpak P et al. ⁽⁷⁾  Tekkalaki B observed personality and substance related disorders were most common psychiatric disorders. ⁽⁸⁾  Diagnosis of depressive episode or adjustment disorder in 40% subjects was reported by Das PP et al. ⁽⁹⁾   Diagnosis of Psychiatric illness are similar to various existing Indian literature; however the prevalence rate of psychiatric morbidity varies from 20 % to 52 %.  Possibility of Self-harm is in both people with or without psychiatric disorders. All were impulsive acts preceded by some psychosocial stressors which they could not surmount.

 

Conclusion

 Individuals in the age group less than 25 years constituted almost 47 % of the cases and they are more susceptible to self- harm. It is required to identify such individuals at the right time. Consumption of pesticides, most common method in rural India needs policy making and stringent regulations to curb sale and storage of pesticides. Majority of the females used non- violent softer methods of self-harm than males. Self-harm behaviour is present in both normal as well as people with psychiatric morbidity. Both set of people need support to grapple with their stress and curb impulsive acts. Only one fifth of the cases were diagnosed to have psychiatric illness. A registration and monitoring system for self- harm needs to start to identify, counsel and treat; there is an emphasis to involve mental health professionals in early diagnosis of mental disorders, suicide prevention, and improving access to psychiatric care for self-harm. Awareness has to be created about availability of round the clock helpline for people who have suicidal or self-harm ideation.  There is a further scope to identify the hurdles faced by susceptible individuals in accessing mental health care.

About the authors

Jayanth S Hosahally

Associate Professor
Dept of Forensic Medicine
Dr. Chandramma Dayananda Sagar
Institute of Medical Education and Research
Dayananda Sagar University
India

Author for correspondence.
Email: veejay02@gmail.com
ORCID iD: 0000-0001-5209-1133
Индия

Neeraj B Raj

Asst Professor
Department of Psychiatry
CDSIMER
Dayananda Sagar University
Devarakaggalahalli
Ramanagara Dist
Karnataka

Email: neerajraj20dec@gmail.com
ORCID iD: 0000-0003-3632-718X
Индия

K. B. Geetha

Dr Chandramma Dayananda Sagar Institute of Medical Education and Research; Dayananda Sagar University

Email: dr_geethakb@yahoo.co.uk
ORCID iD: 0000-0002-8841-1407

MD, Associate Professor

Индия, Devarakaggalahalli; Ramanagara Dist; Karnataka

References

Supplementary files