|Year : 2021 | Volume
| Issue : 1 | Page : 28-34
Suicidal thoughts, suicidal attempts, and nonsuicidal self-injury among undergraduate health professionals
Vishal Kanaiyalal Patel1, Renish Bhuperndrabhai Bhatt2, Hitarth Himanshu Raja2, Parveen Kumar2, Deepak Sachidanand Tiwari2, Disha Alkeshbhai Vasavada2
1 Departments of Psychiatry, Dr. M.K.Shah Medical College and Research Center, Ahmedabad, Gujarat, India
2 M.P. Shah Medical College, Jamnagar, Gujarat, India
|Date of Submission||08-Dec-2020|
|Date of Decision||26-Feb-2021|
|Date of Acceptance||01-Mar-2021|
|Date of Web Publication||26-Jun-2021|
Dr. Parveen Kumar
Department of Psychiatry, M.P. Shah Government Medical College & G. G. Hospital, 2nd Floor Trauma Building, Jamnagar – 361 008, Gujarat
Source of Support: None, Conflict of Interest: None
Background and Aim: Nonsuicidal selfinjury (NSSI) was observed in both males and females, with higher rate among females. NSSI could increase the risk of future suicide attempts. Adolescence is considered as stressful period because of identity crisis, physical growth, coupled with set of decision regarding future profession and personality traits. The study is aimed to find suicidal thoughts, suicidal attempts, extent of the NSSI and its impact on the undergraduate health professionals. Materials and Methods: A cross-sectional study was carried out among medical, dental, and physiotherapy undergraduate college students of Jamnagar, Gujarat. A total of 1850 students were approached, out of them 1050 medical, 500 dental and 300 were physiotherapy students. Participants were requested to fill the pro forma containing following parts: (1) Demographic details, (2) Inventory of Statements about Self-injury, (3) Impact of Non-Suicidal Self-Injury Scale. Results: A total of 1408 students completed the pro forma. Overall 13.99% prevalence rate of NSSI was reported. Female participants had higher prevalence of self-harming behavior than male participants (χ2 = 24.226, P < 0.001). NSSI was related to suicidal thoughts and suicidal attempts with (χ2 = 263.050, P < 0.001) and (χ2 = 197.777, P < 0.001), respectively. A negative correlation was observed with age of onset of NSSI behaviors with and numbers of NSSI behavior (r = −0.317, P < 0.001). Conclusions: Participants engaged in different NSSI behaviors for affect regulation, interpersonal boundaries, sensation seeking, self-punishment, revenge, and self-care. High prevalence of NSSI among young health professionals needs independent clinical attention. There is a need of crisis interventions for the management of self-harming behaviors and to prevent future fetal suicidal attempts.
Keywords: Nonsuicidal self-injury, suicidal attempts, suicidal thoughts, undergraduate students
|How to cite this article:|
Patel VK, Bhatt RB, Raja HH, Kumar P, Tiwari DS, Vasavada DA. Suicidal thoughts, suicidal attempts, and nonsuicidal self-injury among undergraduate health professionals. Arch Med Health Sci 2021;9:28-34
|How to cite this URL:|
Patel VK, Bhatt RB, Raja HH, Kumar P, Tiwari DS, Vasavada DA. Suicidal thoughts, suicidal attempts, and nonsuicidal self-injury among undergraduate health professionals. Arch Med Health Sci [serial online] 2021 [cited 2021 Sep 22];9:28-34. Available from: https://www.amhsjournal.org/text.asp?2021/9/1/28/319396
| Introduction|| |
Suicidal ideation is defined as thoughts of killing oneself, talk, or writing about suicide in varying degrees of intensity of any definite intent or performing any relevant action. Suicide attempts are defined as a set of self-initiated sequence of behaviors or actions by an individual that would lead to his or her own death. Nonsuicidal self-injury (NSSI) defined as the intentional injuring of one's body without apparent suicidal intent and not only restricted to acts such as self-cutting, burning, ingestion of a substance or medication in excess of its therapeutic/prescribed dosage and ingesting a recreational or illicit compound., Plethora of terms such as para-suicide, suicidal attempt, deliberate self-harm, and deliberate self-injury has been used for act of self-injury.
NSSI was observed in both males and females. However, a higher rate of NSSI for females was observed in several studies. The prevalence of self-harming behavior ranges from 13.4% among young adults to 17.2% among adolescents. In women, self-cutting and scratching were more observed while hitting, burning, and banging were more among the men.
Different theories have been used to explain NSSI in individuals, such as positive reinforcement may came from the act of NSSI as a form of emotional relief while negative reinforcement results from reduction of unpleasant emotions or avoiding distressing thoughts. Individuals may choose to engage in self-injury as a means of affect regulation by punishing oneself or as “means of communication.”
Various psychiatric disorders such as; affective disorders, schizophrenia, obsessive compulsive disorder, dissociative disorders, eating disorders, substance use disorders, personality disorder such as borderline personality, antisocial and histrionic personalities and ADHD in children were found to be associated with NSSI.,,
It was also reported that NSSI could increase the risk of future suicide attempts. Adolescence is considered as stressful period because of identity crisis, physical growth, intellectual attainment, coupled with set of decision regarding future profession, and personality traits. Fliege et al. observed higher risk of self-harming behavior among adolescents and young adults than other age groups in a systematic review. Hence, the present study is aimed to find suicidal thoughts, suicidal attempts, extent of the NSSI, and its impact on the undergraduate health professionals.
Materials And Methods
A cross-sectional study was carried out among medical, dental, and physiotherapy undergraduate college students of Jamnagar, Gujarat, from January 2020 to March 2020. A total of 1850 students were approached, out of them 1050 medical, 500 dental and 300 were physiotherapy students. Students were approached via prior communication to ensure maximum attendance. Participants were requested to fill the pro forma containing following parts: (1) Demographic details, (2) Inventory of Statements about Self-injury, (3) Impact of Non-Suicidal Self-Injury Scale (INS). Participants who were present on the day of study and those who gave consent were included in the study, while those diagnosed with any psychiatric illness were excluded from the study. Participants who reported NSSI were approached and advised to consult for further clinical assessment and treatment. Ethical approval was taken from the Institutional Ethics Committee.
Semi-structured Pro forma
It included demographic details such as age, gender, residential area, marital status, living with family or not, family education of the participants.
Inventory of statements about self-injury
This scale consists of two sections. The first section lifetime frequency of 12 NSSI behaviors (banging/hitting self, biting, burning, carving, cutting, wound picking, needle-sticking, pinching, hair pulling, rubbing skin against rough surfaces, severe scratching, and swallowing chemicals) performed intentionally and without suicidal intent. Five additional questions; including age of onset, the experience of pain during NSSI, whether NSSI is performed alone or around others, time between the urge to self-injure and the act, and whether the individual wants to stop self-injuring used to assess descriptive and contextual factors. The second section assesses 13 functions of NSSI: Affect-regulation, anti-dissociation, anti-suicide, autonomy, interpersonal boundaries, interpersonal influence, marking distress, peer-bonding, self-care, self-punishment, revenge, sensation seeking, and toughness. Score of each function can range from 0 to 6. The scale has excellent internal consistency with Coefficient alphas for the interpersonal and intrapersonal scales were 0.88 and 0.80. This scale shows good internal consistency and reliability for current study with a Cronbach's alpha of 0.92.
Impact of nonsuicidal self-injury scale
The 10-item Impact of NSSI Scale (INS) was used to assess the psychosocial impact of engaging in NSSI. Sample items of the INS include, “I don't look people in the eye because of my self-harming,” “I think my social life would be better if I didn't self-harm,” “I feel embarrassed because of my self-harming” and “My relationship have suffered because of my self-harming.” Participants are instructed to answer each item on a 6-point Likert scale ranging from 0 (Never) to 5 (Severe) as how they pertains to their experience over the preceding week. Total score ranging from 0 to 50, with greater scores indicating greater psychosocial impact of NSSI. This scale indicated excellent internal consistency and reliability with a Cronbach's alpha of 0.90. This scale shows good internal consistency and reliability for current study with a Cronbach's alpha of 0.84.
Data entry and analysis was done using Microsoft excel and Epi-info software. Relation of self-harming with suicidal thoughts, suicidal attempts, and participants gender was assessed using Chi square test. The gender difference of various NSSI behaviors was assessed using Chi-square test. Relation of different NSSI behavior with various functions of NSSI was assessed using independent t-test. Relation of Impact of NSSI Scale with different NSSI behavior was assessed mean and standard deviation score. Pearson correlation test was used to assess correlation between age of first onset of different NSSI behavior with and numbers of NSSI behavior used by participants. Other parameters such as; experience pain while self-harm and time to react to self-harm after urge to do self-harm were assessed using frequency and percentage.
| Results|| |
Out of 1850 undergraduate students, 1408 (798 medical, 380 dental, and 230 physiotherapy) students completed the pro forma. Participant's age ranged from 17 to 26 years with a mean age of 20.52 ± 1.52 years.
Overall 13.99% prevalence rate of self-harming behavior was reported. Mean age of onset of NSSI was 15.75 ± 3.19 years. Out of total participants who reported NSSI 58.40% (n = 115) had experienced pain, while 41.60% (n = 82) did not experience pain. Out of 197 participants who reported NSSI, 7.11% attempted within 1 week, 24.37% attempted within the last month and 61.42% attempted within the last year. While, 49.75% attempted multiple times. 87.8% (n = 173) of participants attempted NSSI when they were alone. About 45.7% of participants react to NSSI within 1 h of urge to do self-harm, followed by 18.8% (n = 37) reacted between 1 and 3 h. A statistically significant negative correlation was observed with age of onset of different NSSI behavior with and numbers of NSSI behavior used by participants as dented by Pearson correlation test (r=-0.317, P < 0.001).
Self-harming behavior was statistically significant related to suicidal thoughts and suicidal attempts [Table 1]. This may indicate that the participants with self-harming behavior have more suicidal thoughts and suicidal attempts.
|Table 1: Distribution of gender, suicidal thoughts, and suicidal attempts with nonsuicidal self-injury (n=1408)|
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[Table 1] also shows that female participants reported more prevalence of self-harming behavior (17.90%) than male participants (08.90%), which was found to be statistically significant as denoted by Chi-square test (χ2 = 24.226, P < 0.001).
[Table 2] shows that female participants have statistically significant severe scratching behavior as compared to male participants as denoted by Chi-square test (χ2 = 21.457, P < 0.001). No statistically significant difference was observed for other NSSI behavior among male and female participants.
|Table 2: Distribution of gender and types of nonsuicidal self-injury behavior (n=197)|
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[Table 3] shows that participants with Biting NSSI behavior had statistically significant higher mean score of affect regulation and autonomy functions of NSSI, as denoted by independent t-test (t = −3.275, P = 0.001) and (t = −2.991, P = 0.003), respectively. Participants reported interfering with wound healing behavior had statistically significant higher mean score of Interpersonal boundaries and sensation seeking, as denoted by independent t-test (t = −2.117, P = 0.036) and (t = −2.427, P = 0.016), respectively. Participants with cutting behavior had statistically significant higher mean score of interpersonal boundaries and self-punishment on independent t-test (t = 2.246, P = 0.026) and (t = −2.663, P = 0.008) respectively. Participants with hair pulling behavior had statistically significant higher mean score of revenge and Self-care on independent t-test (t = −0.345, P = 0.003) and (t = −3.233, P = 0.001), respectively. These correlation suggests that the participants using biting behavior for affect regulation and autonomy, interfering with wound healing behavior for interpersonal boundaries and sensation seeking, cutting behavior for interpersonal boundaries and self-punishment, while hair pulling for revenge and self-care.
|Table 3: Distribution of nonsuicidal self-injury behavior with different functions of nonsuicidal self-injury*|
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[Table 4] shows that severe scratching and banging and hitting NSSI behavior had statistically significant higher score for affect. This means that participants using severe scratching and banging and hitting for the affect regulation.
|Table 4: Distribution of affect regulation function of nonsuicidal self-injury with different nonsuicidal self-injury behaviors*|
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[Table 5] shows that participants with swallowing substances as NSSI behavior had higher mean score on INS scale followed by cutting. This means that the participants with swallowing substances and cutting as NSSI behavior feels more embarrassed, unattractive, and impairment in social life.
|Table 5: Distribution of mean score of impact of nonsuicidal self-injury with different nonsuicidal self-injury behaviors|
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There was no statistical difference of mean INS score was observed among male (13.17 ± 12.08) and female (14.57 ± 10.57) participants, as denoted by independent t-test (t = 0.799, P = 0.425).
A statistical significant negative correlation was observed with the age of onset of different NSSI behavior with and numbers of NSSI behavior used by participants as dented by Pearson correlation test (r = −0.317, P < 0.001) in [Figure 1]. This means that early age of onset of NSSI is associated with more number of NSSI behavior.
|Figure 1: Scatter plot between age of first time self-harm attempt and number of nonsuicidal self-injury behavior|
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| Discussion|| |
The present study builds on existing literature of NSSI among the young adults and college students which confirms the NSSI is prevalent and complex behavior.
The current study found 13.99% overall prevalence of nonsuicidal self-harming behavior. Kharsati and Bhola observed that 17.2% of adolescent and 13.4% young adults had lifetime prevalence of NSSI, which is consistent with the current study. A review study conducted by Thakurta also reported that 19.8% of participants engaged in moderate and severe forms of NSSI. Andover study in a community based sample reported that on an average prevalence rate between 7.5% and 46.5% among university students. Bhola et al. in a study among 1571 school and college students observed 33.8% prevalence of NSSI. A large number of studies have found that deliberate self- harm (DSH) become more prevalent in recent years and individuals from younger generations. As DSH is a complex phenomenon the growing prevalence may be due to poor verbal communication, stress tolerance, or social problems. The difference in prevalence could be due to unique cultural and other contextual factors.
In consistent with previous studies that DSH may be due to poor stress tolerance or social problems, the current study observed that participants use NSSI behavior such as biting, severe scratching and banging and hitting for affect regulation (for calming themselves), while interfering with wound healing behavior for interpersonal boundaries (creating a boundary between myself and others) and sensation seeking, cutting behavior for Interpersonal boundaries and self-punishment and hair pulling for revenge and self-care (creating a physical injury that is easier to care). Nock et al. (2006) reported that individuals choose to engage in self-injury as a means of affect regulation by punishing oneself or as means of communication. Individuals also use self-harming for emotional relief from unpleasant emotions and to avoid distressing thoughts. Hilt et al. reported individuals engage in self-harming behavior for getting attention or avoiding activities of other people and to feel more connected with people. Hence, there is a need to asses social functions of NSSI to be acknowledge adaptive self-help among adolescents.
There are gender differences in the type of NSSI behavior chosen. The current study observed that severe scratching is more common among females while no significant difference observed in other NSSI behavior such as cutting, banging or hitting self, biting and swallowing substances. Sornberger et al. reported self-cutting as most common DSH method among women. Cipriano et al. in their study reported that male participants more commonly engage in hitting, burning, and banging behavior. The difference in method chosen may be due to difference in motives or different way of handling stressful and traumatic conditions. The reason for engaging in different methods could be poor coping skills.
The current study observed high prevalence of nonsuicidal self-harming behavior among female participants (17.90%) than males (8.90%). Bhagat et al. observed three times high prevalence of self-harming among females as compared to males. Hawton et al. and Whitlock et al. also observed more prevalence of self-harming among female participants. While Muehlenkamp et al. and Fliege et al. did not found any significant difference of self-harming among male and female participants. There is increased vulnerability of affective disorders and earlier onset of puberty could be linked with gender differences in NSSI. Hence, there is a need to emphasize on both gender in understand and address the phenomenon of NSSI.
The current study observed that participants with self-harming behavior have more suicidal thoughts and suicidal attempts. Prost and Roberts reported that 40% of participants who engage in self-injury have suicidal thoughts. Peterson et al. reported that 50%–85% of people with self-harm attempted suicide at least once during their lifetime. Muehlenkamp et al. (2012) also suggested a strong correlation between suicidality and self-injurious behavior. Hargus et al. and Nock et al. (2006) also reported that 70% individuals attempted suicide at least once and 55% multiple times, among those who had previously engaged in NSSI. This could be due to that individuals who involved in self-harming behavior have difficulties in regulating their emotions, lack of emotional awareness, and limited access to emotion regulation strategies and that may turn to maladaptive methods such as self-harm. Favazza and Conterio observed that self-injurious behavior starts at an early age and most individuals often uses more than one method. The current study also found similar results; those with early age of onset of self-harming associated with more number of NSSI behavior.
The current study found that participants with NSSI behavior feel embarrassed, unattractive, and impairment in social life which is more with swallowing substances and cutting NSSI behavior. Navya et al. in a review study also reported that individual with self-harming behavior have associated shame experiences. A meta-analysis study carried out by Taylor et al. also reported that individuals with self-harm most commonly concern managing negative internal states such as shame which may be related to self-injury scars or others. These elevated negative internal states may leads to further maintenance of self-harm behavior. Turner et al. reported that individuals who self-injuring themselves have worry about possible rejection, stigmatization, and perceived isolation that can lead to decreased dense of belongingness to others. Hence, there is a need for developing contextualized knowledge regarding NSSI which may be important for public health implications.
This study was limited by an observational, cross-sectional nature. However, short- and long-term follow-up studies are needed for the course of NSSI development, severity, and its consequences. There was no control group in this study which was required in further studies for added value to the study. The study did not include different socio-demographic profiles, which are needed for individuals risk and protective factors for NSSI. In the present study, data were collected through self-administered questionnaires, no structured clinical interviews were carried out. Furthermore, community based studies were required to be more representative and to avoid referral biases.
| Conclusion|| |
High prevalence of NSSI among young health professionals needs independent clinical attention. There is a need for developing contextualized knowledge regarding NSSI which may be important for public health implications, as knowledge and awareness regarding the correlates and risk factors of NSSI are important to better predict, understand, and treat such self-harming behaviors. Participants engaged in such behaviors had more suicidal thoughts and suicidal attempts, and feels embarrassed, unattractive and shame. There is need of crisis interventions for the management of self-harming behaviors and to prevent future fetal suicidal attempts.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]