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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 36-39

Suicidality in somatization and undifferentiated somatoform disorders: A hospital-based study


1 Department of Psychiatry, SDM Medical College, Dharwad, India
2 Department and Psychiatry, Yenepoya Medical College, Mangalore, Karnataka, India

Date of Web Publication11-Jun-2018

Correspondence Address:
Dr. Anil Kakunje
Department and Psychiatry, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_41_18

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  Abstract 


Aim: The aim of this study is to examine suicidality in patients with somatization and undifferentiated somatoform disorders. Materials and Methods: Suicidality was assessed among 105 consecutive patients diagnosed with somatization disorder or undifferentiated somatoform disorder according to the ICD-10 criteria. The Mini-International Neuropsychiatric Interview-Plus and the Columbia-Suicide Severity Rating Scale were used in the study. Results: In the study sample, 68.6% reported wish to be dead, 37.1% reported of nonspecific active suicidal thoughts, and 1.9% reported active suicidal ideation with specific plan and intent. The most frequent reason for suicidal ideation was to end or stop the pain. Conclusion: This study had revealed that somatization and undifferentiated somatoform disorders have a high risk of self-harm.

Keywords: Self-harm, somatoform disorder, suicide


How to cite this article:
Shettar M, Kakunje A, Karkal R, Mendonsa RD, Kini G, Mohan Chandran V V. Suicidality in somatization and undifferentiated somatoform disorders: A hospital-based study. Arch Med Health Sci 2018;6:36-9

How to cite this URL:
Shettar M, Kakunje A, Karkal R, Mendonsa RD, Kini G, Mohan Chandran V V. Suicidality in somatization and undifferentiated somatoform disorders: A hospital-based study. Arch Med Health Sci [serial online] 2018 [cited 2018 Dec 15];6:36-9. Available from: http://www.amhsjournal.org/text.asp?2018/6/1/36/234103




  Introduction Top


Suicide is a significant public health issue. It is a complex behavior with many “causes,” several biological as well as psychosocial and cultural components.[1] Existing literature provides evidence for the fact that suicidality develops along a continuum ranging from less severe forms (thoughts of death or suicide ideation) to the most severe expressions of the intent to die (serious suicide attempts or completed suicides).[2] The suicide rate in India is one of the highest in the world and nearly 75% of the suicides happen in the lower middle-income countries.[3] Assessment of suicide is important because many patients who indulge in self-harm behavior contact health services before the act.[4] On an average, 77% of the people who commit suicide were in contact with a primary care physician in the year before their death, and about 45% came in contact with a primary care provider in the month before their death.[5] History of suicide attempt appears to be the best predictor of suicide attempts in the future.[6],[7],[8] Nearly 90% of suicide victims have a psychiatric disorder at the time of death.[9],[10],[11] Frequencies of suicidal attempts are more than fatal suicides.[12]

Various studies have reported wide variations in the prevalence of suicidal ideations among general populations.[13],[14],[15] A study which looked at prevalence and comorbidity of mental disorders in persons making serious suicide attempts, it was found that 90.1% had mental disorder at the time of the attempt. Persons had high rates of mood disorders, substance use disorders, conduct disorders/antisocial personality disorder, and nonaffective psychosis. The risk of suicide attempt increases with increase in psychiatric morbidity.[16] Persons with chronic migraine and [17] low back pain [18] have increased suicidal ideation and suicidal attempt. Hopelessness [19] and family support [20] are significant determinants of suicidal ideation. Factors associated with risk of completed suicide in major affective disorders are being male, living alone, hopelessness about the future, past suicide attempt, suicidal ideation, marital isolation, earlier onset of depression, comorbid alcoholism, and subjective depression.[6],[7],[21],[22],[23] History of suicidal behavior in first-degree relative is also an important risk factor.[24] Different studies have documented the risk for suicidality in patients with poor mental and physical health.[25],[26],[27],[28],[29],[30] Functional disability was independently associated with death wish in older adults.[31]

A study was done by Vijayakumar and Rajkumar, in India, to see for risk factors for completed suicide and found 1% of sample size who had somatoform disorder had committed suicide. Axis I disorders, family history of psychopathology, and recent life events were risk factors.[32] Suicidal intent as a precursor to suicide attempt deserves careful study, particularly among individuals suffering from chronic painful conditions. Most of these studies have concentrated on high-risk populations for suicidal acts with fatal consequences, such as patients with major depression. The literature on suicidality in patients with somatoform disorders is scarce due to its overlapping psychiatric comorbidities. We planned to look at suicidality in medically unexplained physical symptoms condition such as somatization and undifferentiated somatoform disorders without any psychiatric comorbidity.


  Materials and Methods Top


A total of 105 patients who were diagnosed with somatization disorder and undifferentiated somatoform disorder according to the ICD-10 criteria were recruited for the study. Diagnosis of hypochondriacal disorder, body dysmorphic disorder, and pain related to psychological factors were ruled out from the study as we wanted to concentrate on cases of medically unexplained symptoms seen in a general hospital setup. The study was conducted in the out-patient and in-patient services of the Department of Psychiatry at Yenepoya Medical College Hospital, Mangalore, India over a period of 1 year from April 1, 2015, to March 31, 2016. This was a cross-sectional design with serial sampling. All patients gave written informed consent. The study was conducted after obtaining institutional ethical clearance. Inclusion criteria were as follows: (1) patients satisfying ICD-10 criteria for somatization disorder (F45.0) and undifferentiated somatoform disorder (F45.1) with no other psychiatric comorbidities except tobacco dependence, (2) Patients above the age of 18 years, and (3) both males and females patients. Exclusion criteria were as follows: (1) patients with definite organic cause to explain the symptoms, (2) mental retardation, and (3) patients unable to complete the scale.

Assessment

Sociodemographic data were collected using a specially designed questionnaire. Mini-International Neuropsychiatric Interview-Plus was used to rule out psychiatric co-morbidity.[28]

The Columbia Suicide Severity Rating Scale was used to measure suicidality. Four constructs are measured. These are the severity of ideation; the intensity of ideation subscale, suicidal behavior subscale, and lethality subscale. Lethality subscale assesses actual attempts. It uses different assessment periods depending on research; the lifetime period assesses the worst-point ideation, a stronger predictor of subsequent suicide than current ideation.[33] These assessments were separate from their regular management. During the study, 117 patients who fulfilled the inclusion criteria were approached. Twelve patients refused consent for various reasons finally leading to 105 patients with somatization disorder and undifferentiated somatoform disorder in the study sample. Statistical analysis was performed using Statistical Package for Social Sciences version 18 (IBM Corporation, New York, USA).


  Results Top


In our study, a total of 105 patients were included with mean age of the patients as 41.55 years (±11.057). Among the participants majority were females (63.8%), they were educated up to primary school (50.50%). About 89.5% of the persons in the sample were married, 67.6% of the participants belonged to Islam religion, 61.9% were homemakers. About 28.5% were illiterate, 50.5% had completed primary school and only around 21% had education more than high school level. The sociodemographic details are described in [Table 1].
Table 1: Sociodemographic data of the study population

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Suicidal ideation

In the study population, 68.6% reported of wish to be dead, 37.1% reported of nonspecific active suicidal thoughts, 8.6% reported of active suicidal ideation with any methods without intent to act, 2.9% reported of active suicidal ideation with some intent to act, without specific plan, 1.9% reported active suicidal ideation with specific plans and intent as shown in [Figure 1].
Figure 1: Frequency of suicidal ideation

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Intensity of suicidal ideation of Columbia Suicide Severity Rating Scale

Among all the participants those who reported any suicidal ideation, 18.1% had the frequency of ideation between 2 and 5 times in a week. Nearly 22.9% reported of having <1 h/day. About 23.8% reported that they are easily able to control these thoughts. 56.2% reported that deterrents such as family, religion, the pain of death definitely stopped them from attempting the suicide. The most frequent reason for suicidal ideation was to get rid of the pain (27.6%), and 24.8% reported that the reason for ideation is to completely end the pain.

Suicidal behavior

Nearly 1.9% of participants had nonsuicidal self-injurious behavior, none of them had interrupted attempt, 2.9% had aborted attempt, and at the time of evaluation, none of the participants had preparatory acts or behavior as depicted in [Figure 2].
Figure 2: Suicidal behavior

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  Discussion Top


Systematic data on suicidality in somatoform disorders are scarce; the study looks at suicidality in somatization and undifferentiated somatoform disorders without psychiatric co-morbidity. Clinical experience shows that prevalence of suicidal ideation in somatoform disorder is not less common than it is for other psychiatric disorders.

Demographic variables of the study reveal that around 79% of individuals were between 31 and 60 years of age. The mean age of the study group was 41.55 years (±11.057). Although somatoform disorder generally starts an early presentation to psychiatrist is generally late.[34] The chronic course and late presentation imply patients would have been suffering from pain symptoms for a longer time which increased suicidality in the sample. Majority of participants were female (63.8%) which are in line with our current knowledge of somatoform disorders and is also reflected in other studies.[35] In a study done by Fink et al., to see for the prevalence of somatoform disorders among medical inpatients 57% of the participants were female.[7] In another study which screened for somatization and hypochondriasis in primary care and neurological in-patients 75% and 55% were female, respectively.[36] Majority of participants, i.e., around 89.5% were married and were living with family which is common in Indian culture. Majority of the sample belonged to Islam religion (67.6%) who is the usual clients of the hospital and females were mostly homemakers as expected in this culture (61.9%). Holy Quran prohibits suicide [37] which may be the reason for less number of suicide attempts in our study sample as majority of the participants were belonging to Islam religion. Most patients were staying with their family, and family support is identified as one of the most important determinants of suicide.[20]

In people who reported of suicidal ideation, 56.2% said that deterrents such as family, religion, the pain of death definitely stopped them from attempting suicide. Cross-national study found that there is 60% transition from suicidal ideation to suicide plan and attempt within the 1st year after the onset of suicidal ideation.[13] Studies have identified that female gender, younger age; less education is risk factors for suicidal ideation.[13],[38] Studies have also found out that unemployment and low income in males have strong effects with regard to suicide.[39]

In our study, 1.9% of participants had nonsuicidal self-injurious behavior, none of them had interrupted attempt which is in contrast to the results of another study which reported 27.58% of suicide attempts among patients diagnosed with the somatoform disorder.[40]

Strengths of our study are the homogenous group comprising somatization and undifferentiated somatoform disorders (both conditions having medically unexplained symptoms) without any psychiatric comorbidity. Frequency and intensity of suicidal ideation were assessed, along with suicidal behavior. The first author interviewed all the patients recruited for the study. To the best of our knowledge, we have not come across a similar study in Indian culture.

Limitations of the study are its cross-sectional design without a comparative group. An observational study carried out in a tertiary care hospital may not be generalized to community population. Personality factors and stressors were not assessed. Social support and life events can influence a study of this nature.


  Conclusion Top


The study showed that somatization and undifferentiated somatoform disorders are associated with high suicidality and needs careful assessment of self-harm.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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