Deliberate self-harm (DSH) is ‘a behavior that emerges among children and adolescents in which a child/adolescent commits an act with the purpose of physically or psychologically harming himself/herself with or without a real intent of suicide’ (Greydanus, 2011). DSH is noticed across different age groups and socio-economic groups within the society on different scales (Portzky et al., 2008; Greydanus, 2011; Kokkevi et al., 2012). DSH can be dangerous in nature and can cause serious injuries and deaths (Sinha et al., 2021). The risk factors for self-inflicted harm can be classified as psychosocial conditions of the environment, individual specific characteristics of the population and their interactions with several associated determinants (Piko and Pinczés, 2014). Adolescence is a life period during which a young person often feels confused, insecure, unhappy, and burdened by different expectations and demands. It is not uncommon that these unpleasant feelings become expressed through suicidal ideas or suicidal behavior (Mitrovi et al., 2007; Maras et al., 2013).  In most countries, suicide is second or third-leading cause of death in youth (Maras et al., 2013). Suicide rate in adolescence is quite high but differs over time and from country to country (WHO, 2008). In the last three decades, the suicide rate in India has increased by 43% but the male female ratio has been stable at 1.4: 1. Majority (71%) of suicide in India are by persons below the age of 44 years which imposes a huge social, emotional and economic burden (Vijaykumar, 2010). DSH seems to reflect the degree of powerlessness and hopelessness of young people with low education, low income, unemployment, and difficulties in coping with life stress (Arensman and Kerkhof, 2020).The factors affecting attempts of DSH are complex and poorly understood. In one study two-third (68%) of the attempter had at least one psychiatric diagnosis. Nearly 75% of the suicide attempts were committed after a precipitating factor (Sahoo et al., 2018).In the present study we compared the socio-demographic variables, psychiatric morbidity, personality traits and stressful life events in patients with DSH and normal patients.

One hundred and fifteen consecutive cases of deliberate self-harm were evaluated after being referred to psychiatric evaluation with the help of semi structured proforma, PEN inventory by Menon and Verma (Hindi version, Brief psychiatric rating scale by Overall and Gorham, and Presumptive life scale by Gurmeet Singh et al). Data on socio-demographic suicide variables, psychiatric morbidity, personality traits and stressful life events was collected. They were compared with normal controls who had never deliberately self-harmed themselves.

Statistical Analysis: The statistical package SPSS version 10.0 was sued both at data entry and analysis. Analysis involved chi-square for comparison of categorical variables, t test for comparison of means and Pearson coefficient of correlations for quantifiable data. The level of significant was set at <0.05.

Socio-demographic status of DSH patients

The mean age of the DSH group was 28.02±10.83. The maximum DSH patients (both male and female) were in the age group 15-29 years. There was no difference in the incidence based on religion, caste, marital status, educational status or employment status. Majority of the subjects were of younger age  (69.6%), females (53%), married (63.5%), educated up to secondary (87%), self -employed (43.4%), housewives (59%), belonging to nuclear family (46%) and poor socio-economic status (40.5%) and came from urban background (53%). Significantly higher (P<0.05) DSH patients had 3-6 siblings in the family compared to those that had less than 3 or more than 6 siblings in the family (Table 1). Significantly higher proportion (P<0.05) of both male and female patients attempted self-harm by self- poisoning compared to other means of self-harm including self – injury, hanging, or self-burn.  None of the subjects under study attempted DSH by drowning, jumping, or shooting. Significantly higher proportion of females(P<0.05) used AI/Zinc phosphide and organophosphate poisons (rat bait) for DSH compared to males. Significantly higher (P<0.05) proportion of females attempted DSH during day hours (8 am to 4 pm) compared to males who preferred early morning (12 am to 8 am) and evening hours (4 pm to 12 am) for DSH.  Significantly higher proportion (P<0.05) of females had means of DSH at home compared to males. Two thirds of females attempted low lethal method, whereas lethality in all three dimensions was equally distributed in males attempting DSH. In 70% of DSH patients a recent precipitating event was present within the time period of few days before attempting DSH.

Table 1. Distribution of DSH Group by Number of Siblings

Medical illness and psychotic problems

History of Physical Illness (HOPI) was present in 19% of DSH patients under study. DSH patients had some or other psychiatric disorder (Table 32). Stress related neurotic disorders and affective disorders were the most common psychiatric disorders observed in patients of DSH. Past psychiatric problem was absent in a higher proportion (66.1%) of DSH affected patients. The number of patients of DSH that had a past history of psychiatric problem was either of more than one year duration (17) or less than one year duration (22). There were 15(27.8%) males and 4(6.6%) females who had history of psychiatric hospitalization present and 7(12.9%) males and 13(21.3%) females had psychiatric hospitalization absent.

Table Present Psychiatric Disorder in DSH patients

In the present study no difference was found in the incidence of DSH based on religion, caste, marital status, educational status or employment status. Although a recent study (Rosoff et al., 2020) mentioned that educational attainment reduces the risk of suicide attempts however, the study also mentioned that this can vary with different ethnic groups and locations. Similarly Min et al., (2015) in his study in Korea found that the type of employment is important and workers with precarious workers had a higher risk of suicidal ideation and suicide attempts than non-precarious workers. Patients with more number of siblings (3-6) made significantly higher attempts of DSH in the present study. This probably occurs due to less attention or facilities to every child with more siblings. A recent study (Shtayermman and Fletcher, 2022) noticed that the number of siblings increase anxiety and stress in some individuals with resultant increase attempts at self-harm.

Self-Poisoning (86%) using AI/Zinc phosphide was the commonest method used by the subjects to execute self-harm in this study. The other hospital studies from other parts of India had reported similar figuresBansal& Barman (2011) (87%), Choudhary et al (2010)(98.4%),Sharma et al., 2008 (24.7%). This is probably due to the easy accessibility of pesticides and insecticides in Asian countries specifically in rural area. Studies in other countries however report lesser incidence of self – poisoning using pesticides. In one study the proportion of all suicides using pesticides varies from 4% in the European Region to over 50% in the Western Pacific Region (Gunnell et al., 2007). However, in the United States there were 24.5% self-poisoning cases but the commonly used poisoning substances were antidepressants, OTC analgesics, antihistamines and ADHD medications (Spiller et al., 2020). Thus, the availability of substances at different locations determines the use for self-harm.

The time reported in this study by most of the DSH patients (58.3%) was 8am to 4pm which were day-time hours. Logaraj et al (2005) had reported 35.44% of patients attempted suicide between 12 noon and 6.00pm. Similar findings were reported by Satyavati and Rao,1961.Home was the most preferred location for DSH (74.8%) in this study specifically females (83.6%) who outnumbered males (64.8%) thus women made higher proportion of attempters at home than men. This finding is in concurrence with other studies (Choudhary et al 2010).

History of physical illness was reported in 19% of DSH patients in this study. Chronic physical illnesses like hypothyroidism, tuberculosis, diabetes, hypertension, seizures were the physical illnesses reported by DSH patients who require regular treatment and have variable course of illness with deteriorating health issues and hence they act out as chronic stressors which becomes difficult to cope up for such weak and vulnerable group.These findings suggest the probability of some scope for early identification of suicide risk in this population. Hirsch et al., (2009) had also previously reported that chronic medical problems might amplify suicide risk in later life.

It was found in the present study that 88.7% (n=102) of DSH patients had diagnosable psychiatric illness, but most of them had not sought treatment for the same. These results matched with other studies from India. Kar(2010) had reported 82.5% of the attempters in his study having psychiatric illness other hospital studies in India which report similar figures were Bagadia et al; (1976).

Our results indicated that 1/3rd (33.9%) DSH patients had a history of past psychiatric illness and similar number had present psychiatric disorder either less or more than 1 year. The negligence towards psychiatric care could be obvious by the fact that, only half of the DSH patients of past psychiatric illness had received treatment and had been hospitalized in the past.

The attitude towards female psychiatric patients was more grievous as only 1/3rd of females had received psychiatric care as compared to 2/3rd of male DSH patients. The differences were statistically significant and therefore are important to promote education regarding the nature ofpsychiatric disorders and their treatability across the community to allow early detection and timely treatment thereby minimizing suicide attempt/deliberate self-harm.The presence of psychiatric disorder is among the most consistently reported risk factors for suicidal behavior (Bradvik, 2018). Mood, impulse control, alcohol/substance use, psychotic and personality disorders convey the highest risks for suicide and suicidal behaviours(Pompili et al., 2010)and the presence of multiple disorders is associated with especially elevated risk (Bradvik, 2018).Consistent with present study results which reports mood of affective disorders as to be found in 29.6% of DSH patients were comparable to the studies by Sharma et al., 2008(21.4%) and Narang et al (2000) (35.4%), Kumar (1998) (32%), Kar (2010) (24.8%), Das et al 2008 (30.7%). These studies were at variance with some western studies which report mood disorders to be present 87% in nonviolent suicide attempters in Hungary (Rihmer et al., 2013).

The various studies from Western Nations reports higher percentage of mood disorders i.e. 60% in completed suicides (Greydanus, 2011; Kekkevi et al., 2012).

It was concluded that social stress of family, society or environment and psychiatric disorders are the commonest cause of deliberate self-harm attempts in individuals and an easy access to organophosphates or other poisons facilitates the same.

1. Arensman, E., and Kerkhof, J.F.M. "Deliberate Self-Harm: Epidemiology and Risk Factors." New Oxford Textbook of Psychiatry, edited by John R. Geddes, Nancy C. Andreasen, and Guy M. Goodwin, 3rd ed., Oxford University Press, 2020, pp. 958–963. Oxford Academic, https://doi.org/10.1093/med/9780198713005.001.0001. Accessed 15 Feb. 2023.
2. Greydanus, D.E. "Treating Self-Harm in Children and Adolescents." Psychiatric Times, vol. 28, no. 2, 2011, pp. 1–6.
3. Kokkevi, A., Rotsika, V., Arapaki, A., and Richardson, C. "Adolescents’ Self-Reported Suicide Attempts, Self-Harm Thoughts and Their Correlates Across 17 European Countries." Journal of Child Psychology and Psychiatry, vol. 53, no. 4, 2012, pp. 381–389.
4. Maraš, J.S., Kolundžija, K., Dukić, O., Marković, J., Okanović, P., and Stokin, B. "Some Psychological Characteristics of Adolescents Hospitalized Following a Suicide Attempt." European Review for Medical and Pharmacological Sciences, vol. 17, 2013, pp. 50–54.
5. Mitrović, D., Vasić, M., Šobot, V., Srdanović, J., and Stokin, B. Mental Health of Children and Youth. Helicon Publishing, 2007. Proceedings of the 1st International Conference on Mental Health of Children and Youth, Serbia, pp. 69.
6. Piko, B.F., and Pinczés, T. "Impulsivity, Depression and Aggression Among Adolescents." Personality and Individual Differences, vol. 69, 2014, pp. 33–37.
7. Portzky, G., De Wilde, E.J., and van Heeringen, K. "Deliberate Self-Harm in Young People: Differences in Prevalence and Risk Factors Between The Netherlands and Belgium." European Child & Adolescent Psychiatry, vol. 17, 2008, pp. 179–186.
8. Sahoo, M.K., Biswas, H., and Agarwal, S.K. "Study on Risk Factors in Adolescents Admitted with Deliberate Self-Harm in Tata Main Hospital, Jamshedpur." Indian Psychiatry Journal, vol. 27, no. 1, 2018, pp. 80–86. https://doi.org/10.4103/ipj.ipj_62_17.
9. Vijayakumar, L. "Indian Research on Suicide." Indian Journal of Psychiatry, vol. 52, no. Suppl 1, 2010, pp. S291–S296. https://doi.org/10.4103/0019-5545.69255.
10. World Health Organization. The Health of Children and Adolescents in Europe. [Last accessed on 21 Jan. 2008]. Available from: http://www.euro.who.int/document/mediacentre/fs0605e.pdf.
11. Rosoff, D.B., Kaminsky, Z.A., McIntosh, A.M., et al. "Educational Attainment Reduces the Risk of Suicide Attempt Among Individuals with and Without Psychiatric Disorders Independent of Cognition: A Bidirectional and Multivariable Mendelian Randomization Study with More Than 815,000 Participants." Translational Psychiatry, vol. 10, no. 1, 2020, p. 388. https://doi.org/10.1038/s41398-020-01047-2.
12. Min, K.B., Park, S.G., Hwang, S.H., and Min, J.Y. "Precarious Employment and the Risk of Suicidal Ideation and Suicide Attempts." Preventive Medicine, vol. 71, 2015, pp. 72–76. https://doi.org/10.1016/j.ypmed.2014.12.017.
13. Spiller, H.A., Ackerman, J.P., Smith, G.A., et al. "Suicide Attempts by Self-Poisoning in the United States Among 10–25 Year Olds from 2000 to 2018: Substances Used, Temporal Changes, and Demographics." Clinical Toxicology, vol. 58, no. 7, 2020, pp. 676–687. https://doi.org/10.1080/15563650.2019.1665182.
14. Gunnell, D., Eddleston, M., Phillips, M.R., et al. "The Global Distribution of Fatal Pesticide Self-Poisoning: Systematic Review." BMC Public Health, vol. 7, no. 357, 2007. https://doi.org/10.1186/1471-2458-7-357.
15. Rihmer, Z., Gonda, X., Kapitány, B., and Dome, P. "Suicide in Hungary—Epidemiological and Clinical Perspectives." Annals of General Psychiatry, vol. 12, no. 21, 2013. https://doi.org/10.1186/1744-859X-12-21.
16. Brådvik, L. "Suicide Risk and Mental Disorders." International Journal of Environmental Research and Public Health, vol. 15, no. 9, 2018, p. 2028. https://doi.org/10.3390/ijerph15092028.
17. Pompili, M., Serafini, G., Innamorati, M., et al. "Suicidal Behavior and Alcohol Abuse." International Journal of Environmental Research and Public Health, vol. 7, no. 4, 2010, pp. 1392–1431. https://doi.org/10.3390/ijerph7041392.
18. Bagadia, V.N., Ghadiali, H.N., and Shah, L.P. "Unemployment and Attempted Suicide." Indian Journal of Psychiatry, vol. 18, 1976, pp. 131–139.
19. Bansal, P.D., and Barman, R. "Psychiatric Morbidity and Socio-Demographic Determinants of Deliberate Self-Harm." Journal of Clinical Diagnostic Research, vol. 5, 2011.
20. Chaudhary, A.N., Banerjee, S., Brahma, A., et al. "A Prospective Study of Suicidal Behavior in Sundervan Delta West Bengal." The National Medical Journal of India, vol. 23, no. 4, 2010, pp. 201–205.
21. Das, P.P., Grover, S., Avasthi, A., et al. "Intentional Self-Harm Seen in Psychiatric Referrals in a Tertiary Care Hospital." Indian Journal of Psychiatry, vol. 50, no. 3, 2008, pp. 187–189.
22. Logaraj, M., Ethirajan, N., Felix, J., and Roseline, F. "Suicidal Attempts Reported at a Medical College Hospital in Tamil Nadu." Indian Journal of Community Medicine, vol. 30, 2005, pp. 136–137.
23. Kar, N. "Profile of Risk Factors Associated with Suicide Attempts: A Study from Orissa." Indian Journal of Psychiatry, vol. 52, no. 1, 2010, pp. 48–56.
24. Kumar, P.N.S. "Age and Gender Related Analysis of Psychosocial Factors in Attempted Suicide." Indian Journal of Psychiatry, vol. 40, no. 4, 1998, pp. 338–345.
25. Narang, R.L., Mishra, B.P., and Mohan, N. "Attempted Suicides in Ludhiana." Indian Journal of Psychiatry, vol. 42, 2000, pp. 83–87.
26. Sharma, R., Vijay, L., and Chaturvedi, S. "Suicidal Behavior Amongst Adolescent Students in South Delhi." Indian Journal of Psychiatry, vol. 50, 2008, pp. 30–33.
27. Satyavarti, M.R.D.N. "A Study of Suicide in Bangalore." Transaction Institute of Mental Health, vol. 2, 1961, pp. 1–19.