Deliberate self-harm (DSH) ranges from behaviors with no suicidal intent (but with the intent to communicate distress or relieve tension) through to suicide. Some 7%-14% of adolescents will self-harm at some time in their life, and 20%-45% of older adolescents report having had suicidal thoughts at some time (Hawton and James, 2005).DSH is common among children and adolescents, wherein they intentionally engage in acts that cause physical or psychological harm to themselves, with or without an actual intent to commit suicide (Greydanus, 2011). DSH can be observed across various age groups and socio-economic backgrounds within society, manifesting in different degrees (Portzky et al., 2008; Greydanus, 2011; Kokkevi et al., 2012). It is important to note that DSH can be hazardous and result in severe injuries and even fatalities (Sinha et al., 2021). The risk factors associated with self-inflicted harm can be categorized as psychosocial conditions within the individual's environment, specific characteristics of the individual themselves, and how these factors interact with various related determinants (Piko and Pinczés, 2014). Adolescence is a stage in life where young individuals often experience confusion, insecurity, unhappiness, and the weight of societal expectations and demands. It is not uncommon for these negative emotions to manifest as suicidal thoughts or behaviors (Mitrovi et al., 2007; Maras et al., 2013). In numerous countries, suicide ranks as the second or third leading cause of death among young people (Maras et al., 2013). The suicide rate during adolescence varies over time and across different countries (WHO, 2008). Over the past three decades, India has witnessed a 43% increase in the suicide rate, with a stable male-to-female ratio of 1.4:1. A significant majority (71%) of suicides in India involve individuals below the age of 44, which poses substantial social, emotional, and economic burdens (Vijaykumar, 2010). DSH appears to be an expression of powerlessness and hopelessness among young people with limited education, low income, unemployment, and difficulties in coping with life's stresses (Arensman and Kerkhof, 2020). The factors influencing DSH attempts are complex and not well understood. In one study, approximately two-thirds (68%) of attempters had at least one psychiatric diagnosis, and nearly 75% of suicide attempts occurred after a precipitating factor (Sahoo et al., 2018). The present study aims to compare psychiatric morbidity, personality traits, and stressful life events between patients with DSH and non-DSH 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 control patients 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.

There were only 14 (12.2%) patients out of 115 who had attempted suicide during their illness. Out of these 14 patients, 10 were males and 4 were females. The differences were not statistically significant. 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. The negligence towards female attempters in psychiatric hospitalization can be part of stigmatized cultural beliefs present in our society. However, the difference was statistically significant. Family history of Psychiatric disorder was present in about 1/5th patients of DSH group. However, the differences were not statistically significant. Significant highly stressed relations were seen in both the gender of DSH group. Males (44%) had higher stress in comparison to female with their parents. About half (51.9%) of the male patients has stress with their siblings where in females stress (44.3%) was present with in-laws just double in comparison to males (22.2%). The differences between both genders in other relations were statistically insignificant (Table 1).

DSH group patients had significantly high levels of (indicated by scores) neuroticism and psychoticism scores, and significantly low level of extraversion scores as compared to their respective control groups (Table 2).

Table 1 Nature of Relationship and Gender distribution of DSH Group

Table 2. Statistical analysis of PEN Inventory in Control and DSH group

It is to be noted in this study that 12.2% DSH patients attempted suicide. There is a wide variation in suicide rates within India (Vijaykumar, 2008). A higher proportion of male patients had psychiatric hospitalization. Nandi et al.[4] revealed that that there was preponderance of male suicides, the vulnerable age group being those between the ages of 18 to 30 and the most common method employed was poisoning. In contrast to these reports Shukla et al., (1990) in their study on the incidence of suicides in Jhansi city reported more suicides among women

This study results indicated that 1/3rd (33.9%) had a history of past psychiatric illness and similar number had present psychiatric disorder either less or more than 1 year equally. The negligency towards psychiatric care could be obvious by that, that only half of the DSH patients of past psychiatric illness had received treatment and had been hospitalized in the past. Satyavati, (1971) investigated attempted suicides in psychiatric in patients and reported that during a one-year period out of 1881 admissions 126 had made suicidal attempts with drowning being the most commonly employed method. Patients with schizophrenia accounted for 64% of the attempted suicides. Gupta et al. (1992) in their two-year follow-up study of patients who had attempted suicide with schizophrenia and depression reported that 51.8% of the suicide attempters had a personality disorder, 42% had neurotic symptoms during childhood and 23.5% had a history of drug dependence. During the follow-up period 17.1% of the schizophrenia patients had attempted suicide again with one completing suicide, compared to 19% of the depressed patients.

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 of psychiatric disorders and their treatability across the community to allow early detection and timely treatment thereby minimizing suicide attempt/deliberate self-harm. Similar findings have been previously reported (Sarkar et al., 2006; Das et al., 2008)

The presence of psychiatric disorder is among the most consistently reported risk factors for suicidal behavior (Vijaykumar, 2010). Mood, impulse control, alcohol/substance use, psychotic and personality disorders convey the highest risks for suicide and suicidal behaviors (Vijaykumar, 2008; Vijaykumar, 2010) and the presence of multiple disorders is associated with especially elevated risk.

The present study reports the frequency and severity of stressful life events (n=684) specifically undesirable events (n=398) occurring more in DSH patients. The differences were statistically highly significant when compared to the number of events occurred in control group (n=286).

Adverse stressful life events acts as an inflammatory substance in fire when happen in the lives of vulnerable DSH group suffering from underlying psychopathology this leading to severe consequences.

As noted in the present study that DSH patients had significantly higher neuroticism and psycotism previous studies also recorded similar findings. There is strong evidence that neuroticism is robustly correlated with many Axis I and II mental disorders from childhood through adulthood (Clark et al., 1994; Krueger and Markon, 2001; Khan et al., 2005).

It was concluded that patients of DSH have some or other psychiatric problem and stressful relations and must be handled with care to prevent suicide.

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