Journal of Psychiatry

Deliberate Self-Harm and Psychiatric Morbidities in an Egyptian Sample: Cross-sectional, Case-control Study

Dalia Hegazy Ali^*, Mohamoud Farag Soliman, Mahmoud Mamdouh el Habibi, Marwa Abdel Rahman Soltan, Ahmed Rashad Mahfouz and Mohamed Fekry Abdel Aziz Institute of psychiatry, Faculty of Medicine, Ain Shams University, Egypt
^*Correspondence: Dalia Hegazy Ali, Institute of psychiatry, Faculty of Medicine, Ain Shams University, Egypt, Tel: +966554447502, Email:

Received: 15-Jun-2020 Published: 08-Jul-2020, DOI: 10.35248/2378-5756.20.23.468

Introduction

Self-injurious behavior is one of the most serious psychiatric phenomena. Even though it is defined as intentional, deliberate destruction to body tissues, done without suicidal intentions, and occurs for purposes that are not socially sanctioned [1]. Yet it may be potentially life threatening. In a complex relation, there is a high risk of suicide in individuals who self-injured themselves, and self-injury is found in 40-60% of suicides. However, generalizing self-injury as suicidal is inaccurate [1]. The lifetime prevalence of non-suicidal self-injury (NSSI), ranging from 13.0% to 23.2%. Meta-analysis of 119 community studies assessed more than 230000 individual in Asia, Australia, Europe and North America found prevalence rates of 17% in adolescent ages from (10-17 yrs) and 13% in young adult from (18-25 yrs), 6% in adult’s ages more than 25 yrs [2].

The most common form of self-injury is using a sharp object to cut one's skin, but self-injury also covers a wide range of behaviors including burning, scratching, banging or hitting body parts, interfering with wound healing, hair-pulling and the ingestion of toxic substances or objects [3].

With many risk factors involved [4], the risk factors with the most significant effect (odds more than 3), mainly in the adolescent population that predicates this behavior were; the prior history, cluster B personality disorder and hopelessness [5].

Classified lately as "new disorder in need of further study "in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (2013),[3] highlighted the fact of our limited knowledge about those behaviors . Nevertheless, that high-functioning individuals who have no underlying mental health diagnosis and people with different mental disorders (depression, anxiety disorders, substance abuse, eating disorders, post-traumatic stress disorder, schizophrenia, and several personality disorders), can engage in self-injury [6].

In the lights of insufficient published data about deliberate selfharm behavior, worldwide and in Egypt, we designed this study to examine the possible associations between psychiatric disorders and self-injurious behavior, as our primary research outcome. Types of self-injurious behavior, patients’ motives, and suicidal profile data will increase the depth of the results and thereby, enrich our recommendations.

Methods

Study setting and design

It is a hospital based cross-sectional, comparative, case -control study. It took place at the Institute of Psychiatry, Ain- Shams University Hospitals, which is located in Eastern Cairo and serves a catchment area of about the third of Greater Cairo (around 20 million inhabitants) with urban and rural areas. The facility serves patients with different social and economic backgrounds through its inpatients (105 beds) and outpatients (4 days a week) sections.

Study Population

All patients attending to the general university hospital emergency room (ER) , for 1 yrs ( September 2017 to August 2018), with self-injurious behavior , without a prior psychiatric diagnosis, were eligible for our study .Both genders and ages range from 18 to 60yrs were included. We excluded participants with a previous psychiatric diagnosis from the initial referral sample , ending by a eligible 110 patients with self-injurious behavior for further assessment .50 subjects with no history of psychiatric disorders or self-injury behavior were matched as the control group.

Data collection

Candidates eligible for the study were assessed by trained clinicians blind to the research hypothesis's primary outcome goal to minimize bias. We gathered data about participants' age, gender, education, marital status, place of living, job and special habits, distribution of self-injury and the tools used. Structured Clinical Interview for DSM-IV axis I disorders (SCID-I) was used for broad coverage of psychiatric diagnosis according to DSM-IV [7] and SCID-II for axis II Personality Disorders diagnosis [8]. Assessment of suicide was carried out by Columbia-Suicide Severity Rating Scale (C-SSRS) which has high validity and reliability. Data Collected on Full C-SSRS presented as Suicidal Ideation (Highest Level Endorsed 1-5), Intensity of Ideation (2-25), Suicidal Behavior (present during time period) Y/N, Medical Damage for Attempt (0-5), Potential Lethality (if medical damage = 0) (0-2) [9]. Self-Punishment Questionnaire assessed self-punishment functions. According to its procedural definition of self-injurious behavior, it expresses four dimensions (physical punishment, affective punishment, selfneglect & self-deprivation), which includes manifestations and forms of self-injury through which self-injurious behavior can be measured. It scores 0-38 as mild, 39-78 as Moderate, 79-118 as above moderate, and 119-156 as severe [10].

Data analysis

IBM SPSS software package version 20.0 was used. Qualitative data was described using number and percent. Comparison of categorical variables was done using Chi-square test. Quantitative data were described using range (minimum and maximum), mean, and standard deviation for normally distributed data. Comparisons in this category, for two independent populations were done using an independent t-test; for more were analyzed using F-test (ANOVA). Significant results were quoted as two-tailed probabilities and judged at the 5% level. Adjusted odds ratio with 95% CI was calculated to determine association.

Ethical consideration

The study was approved by the Ethics research Committee of the Institute of Psychiatry, Ain Shams University .All participants signed written informed consent, clarifying study rationale and confirming their right to withdraw from the study at any time and assuring data confidently during different research processes.

Results

Out of 110 candidates, only 100 patients completed the assessments for the study .9 female patients withdrew early in the assessment phase, did not complete the needed assessments. Incomplete data were excluded from the study.

Section (A): Descriptive statistics

Socio-demographic and clinical data

Tables 1 summarize Group (A) or patient group sociodemographic data. Similar data was gathered for their matched controls with no significant statistical differences. Table 2 summarizes Group (A) Types and sites of self-injury.

Table 1: Socio-demographic data of the group (A).

Table 2: Self-injury data distribution of the group (A).

Case group (A) psychiatric diagnoses on SCID I& II Subjects were assessed for possible axis 1 and 2 psychiatric diagnosis, as shown in Table 3.

Table 3:  Axis I and II diagnosis distribution of the group (A).

Patient group (A) distribution on Columbia-Suicide Severity Rating Scale C-SSRS 54.0% (n=54) of the cases group had suicidal ideation and 46.0% (n=46) were not suicidal. 87 % (n=47) of them had their scores on intensity of ideation subscale >20, and 13% (n=7) scored ≤ 20.

On medical damage for attempt subscale 46% (n=46) had no physical damage, 3% (n=3) had minor physical damage, 21% (n=21) had moderate physical damage, 22% (n=22) had moderately severe physical damage, 4% (n=4) had severe physical damage.

On potential lethality subscale; 8.9% (n=4) had behavior not likely to result in injury, 66.7% (n=30) showed behavior likely to result in injury but not likely to cause death, 24.4% (n=11) had behavior likely to result in death despite available medical care.

Control group (B) distribution on Columbia-Suicide Severity Rating Scale C-SSRS

In the control group; 4% (n=2) had suicidal ideation and 96% (n=48) were not suicidal. In 4% (n=2), intensity of ideation scored ≤ 20. Irrelevant data were found for suicidal behavior, medical damage for attempt, and potential lethality subscale scores.

Patient group (A) scores on Self-Punishment Questionnaire

Case group had a mean ± SD of 12.11 ± 4.6 on physical abuse subscale (range 5-24),a mean ± SD of 13.7 ± 2.81 on moral abuse subscale (range 10-21), a mean ± SD of 14.94 ± 5.97 on selfneglect subscale (range 6-26), a mean ± SD of 22.7 ± 5.09 on self-deprivation subscale (range13-32). 91% (n=91) of the sample scored as moderate, 9% (n=9) scored as above moderate with total score range 41-84, (mean ± SD = 63.43 ± 9.35).

The control group scores on Self-Punishment Questionnaire

Control group had a mean ± SD of; 9.58 ± 2.59 for physical abuse subscale (range 5-17), 7.84 ± 2.21 for moral abuse subscale (range 3-13), 8.68 ± 2.13 for self-neglect subscale (range 5-16), 15.36 ± 5.45 for self-deprivation subscale (range 7-32). 68% (n=34) of the sample scored as moderate, 32% (n=16) as mild with a total score range 31-59, mean ± SD = 41.46 ± 5.93.

Section (B): Comparative statistics

On further analysis , Comparing the two groups for suicide data, there was a statistically significant increase in suicidal ideation, intensity of ideation, suicidal behavior, medical damage for attempt, and potential lethality in case group compared to control group (P < 0.01) as shown in (Table 4).

Table 4: Studied group’s comparative data on Columbia-Suicide Severity Rating Scale (C-SSRS)

Moreover comparing the two groups for self-punishment questionnaire scores showed that there was statistically significant higher; physical abuse, moral abuse, self-neglect, self-deprivation, and total scores in case group compared to control group (P < 0.01) (Table 5).

Table 5: Studied group’s comparative scores on Self-Punishment Questionnaire.

Correlations of psychiatric diagnoses and suicide data in patients group

There was a statistically significant relation between axis 1 diagnosis, and intensity of suicidal ideation. 90.9% of patients with mixed anxiety & depression and 91.4% of patients with no psychiatric diagnosis had high intensity of ideation (Score >20), as shown in table 6-A. 70.7% of patients with mixed personality traits had high suicidal ideation compared to 42.4% of patients with a borderline personality disorder.

A statistically significant relation was found between axis 2 diagnosis and medical damage for attempt.36.6% of patients with mixed personality traits had moderately severe physical damage, 14.6% had severe physical damage compared to 11.9%, and 3.4% for patients with borderline personality disorder respectively as shown in Table 6-A .

Table 6-A: Relation between (axis 1&2) diagnosis and Columbia-Suicide Severity Rating Scale (C-SSRS) of Group A.

Our results showed no statistically significant relation between axis 1 and 2 psychiatric disorders diagnosis and total self-punishment score. As shown in Table 6-B.

Table 6-B: Relation between (axis 1&2) diagnosis and Total Self-Punishment of Group A.

Discussion

Exploring the relationship between self-injury and different psychiatric phenomena, all with the motives behind this behavior, is a vibrant area for research. Several researchers have reported self-injurious behavior in a wide range of psychiatric disorders. Although suicide is not the intention of self-injury, but the relationship between the two is complicated, thereby, it should be routinely assessed [11].

In this research, we studied 100 patients with self- injurious who were referred from the general hospital ER for consultation and management, and there 50 matches. Our goal was to test the association between psychiatric disorders and self-injurious behavior as the primary research outcome. Types of self-injurious behavior, patients motives, and suicidal profile were elaborated during the research.

In this study, the mean age of the study population was 20-29 yrs [22.21±2.02], similar to Chamberlain and colleagues, communitybased study, in which Total 333 adults (mean [SD] age 22.6 (3.6) years, 61% male [12]. Younger age groups were reported in other studies [13].

100% of our participants were male .The number of females in our referred hospital-based sample was deficient, and all refused to participate in the study. Unlike studies showing higher rates of female gender, like that of Morey and colleagues [14], Claes study reported higher rate of male participants who engaged in at least one self-injurious behavior compared to women [15]. Moreover it appeared to be more prevalent in boys than previously estimated in [16]. Other studies did not found any gender differences in adolescents and young adults [17,18].

More than 70% of our participants were single and unemployed also did not have any university grades, which is similar to [19].

Case group self-injury procedure and self-punishment functions showed that the cutting was the most prevailing in 63 (63%) of the sample followed by Shooting 15 (15%), consequently the most common tools were Sharp object in 64 (64%) of the sample followed by Gun 15 (15%). Body most injured parts were the extremities in 79 (79%) of the cases followed by head and neck injuries in 14 (14%) and abdomen & trunk injuries 7 (7%) as in Table 2 .This came in agreement with Levine results [20], who reported that skin cutting was one of the most common forms of NSSI (70%–97% of cases), followed by banging or hitting (21%– 44%) and burning (15%–35). Cutting, scratching, and self-hitting were the most common forms of non-suicidal self-harm (83.2%) [20]. More extreme forms of NSSI as for genital mutilation, eye enucleation, castration, or even limb amputation are rare and mostly seen in psychotic disorders [21]. Moreover, many reported utilizing multiple methods (50-70%) [22].

Data resulted from Columbia-Suicide Severity Rating Scale of the case group showed that the majority of self-injurer had intense suicidal thoughts during the time of self-injury. However, they had no intention of suicide during the act. Again, self-injurers were prone to have more suicidal ideation, suicidal behaviors, medical damage from self-injury, and high lethality risk, which came in agreement with Bentley and colleagues results [23].

Data obtained from Self-Punishment Questionnaire revealed that self-injurers had statistically significant high scores in; Physical abuse, Moral abuse, Self-neglect, Self-deprivation, and total score compared to control (P < 0.01). This might indicate that self-injury was adopted as a punishment method. Self-punishment reasons were particularly apparent in a community sample based study of adolescent self-injurers that found support for internally-directed rather than interpersonally-directed explicit motives for self-injury [24,25]. However, support for self-punishment reasons was only modest in other studies [26].

This study revealed that persons with self-injury do not always fall into a diagnostic category .This might reflect that self-injury is one of the coping skills a person learn either for self-punishment or less commonly to regulate negative emotions.[27,28]. 36% of the case group had axis 1 psychiatric disorders; adjustment disorder 13 (13%), mixed anxiety-depressive disorder 17 (17%), schizophrenia 6 (6%).100%of them had axis 2 personality disorders or traits; BPD 59 (59%), Mixed personality traits 41 (41%). In concordance to our results came Ayodeji and Ghimire results who reported respectively [29,30] ; the association of personality disorder and higher self-harm severity, inadequate functional adjustment and more significant suicidal ideation ; the high association of psychiatric disorder ( 37%) namely adjustment disorder (13.5%) followed by mood disorder (11%) with this behavior .Also confirmed by Skegg study who reported high comorbidity of psychiatric disorders in patients with self-harm. In his study (72.0%) of cases had affective disorder and 45.9% had personality disorder in initial assessment and follow-up [31].

The result showed a statistically significant relation between intensity of suicidal ideation and axis 1 psychiatric disorders, where 90% of patients with mixed anxiety & depression had high intensity of suicidal ideation (Score >20). Nevertheless, 91% of patients with no psychiatric diagnosis also showed high intensity of suicidal ideation, which might be a predictor for further/future pathology, and these findings were in consistency with Fergusson results, who reported that suicide ideation in adolescence increases the like hood of pathology in adulthood [32].

In the study, we found a statistically significant relation between suicidal ideation, behavior and personality problems .70.7% of the patients with mixed personality traits had high suicidal ideation and behavior compared to 42.4% of patients with borderline personality disorder. Borderline personality disorder was the only obviously linked disorder with self-harm, suicidal ideation intensity, suicidal behavior, and medical damage which came in agreement with many studies [33-35].

Limitations

The study design hindered that all potential subjects were included in the study. A larger sample with suitable gender representation would help the generalization of the results. We tried to reduce all sources of bias, yet using double-blind design could have alleviated clinician bias. Follow up study for the candidates who received intervention versus who do not, would have added more depth to the results.

Conclusions

This study revealed that psychiatric diagnoses were prevalent in patients with self-injurious than controls. Mood and stress related disorders, all with personality problems, were strongly correlated to suicidal ideation and behavior. Self-punishment motives were significantly evident.

Recommendations

People who have self-injurious behavior should receive a comprehensive psychosocial and dynamic assessment for the act. In light of the high association of suicidal risks and mental disorders, clinicians in contact with this population should receive appropriate training to provide suitable services. Referral pathways should follow best practice to assure; the immediate and long term cares for those patients, the decrease of unneeded measurable and unmeasurable expenses. More research is needed in this area to cover current knowledge gap.

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