*Helen S. Keeley Research Psychiatrist, National Suicide Research Foundation, 1 Perrott Avenue, College Road, Cork, Ireland and Consultant Child and Adolescent Psychiatrist, Brothers of Charity, Southern Services, Child and Adolescent Mental Health Services, Mahon, Blackrock, Cork, Ireland, Mary O'Sullivan Research Psychologist, Regional Development Unit, Limerick, Ireland, Paul Corcoran Research Statistician, National Suicide Research Foundation, Cork, Ireland
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In this study we aimed to identify negative life events, especially those associated with repetition, in the background histories of patients in a 2-year prospective monitoring study of hospital-treated deliberate self-harm (DSH). Thematic analysis of the narratives recorded during assessment was used to produce general categories of life events.
RESULTS
In 3031 DSH episodes (n=2287 individuals), women reported more life events than men. Family and interpersonal problems were most commonly reported. Reporting a dysfunctional family of origin, a history of sexual abuse and the imprisonment of self or other were associated with repetition retrospectively and prospectively.
CLINICAL IMPLICATIONS
The background history of patients who harm themselves should be explored routinely on assessment in order to help establish risk of repetition and to determine appropriate follow-up.
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Preliminary thematic analysis
During the period January to June 1995, narratives regarding each subject's
life history, where available, were transcribed from hospital case notes. Once
such information had been recorded for 200 cases, the text was read separately
by H.S.K. and M.O.S. Following clinical discussion, 20 underlying themes
regarding past stressors and life events were identified and coded into
general categories. This process followed the grounded approach
first recommended by Glaser & Strauss
(1967). These categories then
constituted a coding frame for the narratives that were transcribed over the
following 2-year period (July 1995June 1997). Throughout this period,
routine research meetings were held to discuss coding disagreements and to
monitor the suitability of the coding frame. As a consequence of these
meetings, the coding frame was revised as new categories
surfaced and original categories were merged, until eventually
there were 21 categories in total (Lincoln
& Guba, 1985).
Statistical analysis
Chi-squared and Mann-Whitney U tests were used, as appropriate, to
compare those who were asked about past stressors and life events in their
assessment and those who were not asked across a range of characteristics
relevant to the individual and his or her suicidal behaviour. Chi-squared
tests were also used to compare the male and female prevalence of the various
categories of life events. Separate logistic regression analyses were carried
out to estimate the association between each category of life event and the
risk of the individual harming him- or herself repeatedly, with adjustment for
age and gender. Effect modification by gender was also examined. Those
categories indicated as being significantly associated with repetition of DSH
were then entered with age and gender into a single logistic regression model
to determine which life event categories were significantly and independently
associated with DSH repetition in these patients. A similar series of logistic
regression analyses were carried out to assess the risk of further repetition
during the study period, with adjustment for the effects of previous DSH, age
and gender.
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2=13.235, d.f.=1,
P<0.001). |
View this table: [in a new window] | Table 1. Comparison of those asked about life events in their assessment to those who were not asked |
Prevalence of background stressors
Of those asked at the time of their index act, 12% reported no background
stressors, 48% discussed one event, 22% two events and 18% three or more
events. The maximum number of seven stressors was reported by two female
patients. On average, women reported more life events than men did
(Mann-Whitney U=266386.5, P<0.001), irrespective of
whether the index act was a first or repeat act of DSH.
Table 2 shows the prevalence
of the 14 most frequently reported life event categories. For both genders,
the most commonly reported categories of life event related to interpersonal
difficulties. Women more often reported family conflict/current problems
(
2=4.242, d.f.=1, P<0.05), pregnancy-related
problems (
2=21.439, d.f.=1, P<0.001) and a history
of abuse, both sexual (
2=27.605, d.f.=1, P<0.001)
and physical (
2=6.957, d.f.=1, P<0.05).
Legal/judicial problems were more often cited by men
(
2=16.678, d.f.=1, P<0.001), as was imprisonment
of self or other (
2=16.293, d.f.=1, P<0.001).
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View this table: [in a new window] | Table 2. The 14 most commonly reported categories of life events and their associated risk of repetition of deliberate self-harm (DSH) |
Retrospective repetition
Table 2 indicates that five
categories of self-reported life events were significantly associated with a
previous history of DSH. Those who reported work or school problems were less
likely to have a history of previous self-harm. Reporting problems related to
a dysfunctional family of origin, a history of either sexual or physical abuse
and imprisonment of self or other was associated with an increased prevalence
of DSH. There was no significant effect modification by gender except in the
case of those with a history of physical abuse. Such a history was associated
with increased prevalence of DSH in women (odds ratio (OR)=3.03, 95%
confidence interval (CI) 1.955.61) but not in men (OR=0.77, 95% CI
0.371.60).
Multivariate logistic regression indicated that, adjusting for age and gender, reporting problems related to a dysfunctional family of origin (OR=1.51, 95% CI 1.092.08), a history of sexual abuse (OR=1.96, 95% CI 1.273.02) and imprisonment of self or other (OR=4.60, 95% CI 2.0210.49) were each significantly and independently associated with an increased likelihood of a previous history of DSH, while the reporting of problems related to work or school issues remained significantly associated with a decreased likelihood of such a history (OR=0.56, 95% CI 0.350.88). The increased likelihood of previous DSH in women that was associated with a history of physical abuse remained significant in the multivariate model (OR=4.10, 95% CI 1.6410.27).
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Table 3 compares the frequency and risk of further DSH within the study period between the patients who reported each life event category and those who did not. The reported life events associated with previous DSH were the only ones associated with further hospital-treated DSH, adjusting for gender, age and previous DSH. Thus, reporting a dysfunctional family of origin, a history of either sexual or physical abuse and imprisonment of self or other were associated with significantly increased risk of repetition, whereas reporting problems relating to work and/or school was associated with a lower risk of repetition. A multivariate model including each of these factors with age, gender and previous DSH indicated that a dysfunctional family of origin (adjusted OR=1.88, 95% CI 1.322.67), a history of sexual abuse (adjusted OR=2.6, 95% CI 1.694.05) and imprisonment of self or other (adjusted OR=2.21, 95% CI 1.124.40) were independent risk factors for further DSH.
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View this table: [in a new window] | Table 3. The frequency and risk of further deliberate self-harm (DSH) associated with the 14 life event categories most commonly reported |
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Women generally reported more stressors and these were more likely to be internal family problems such as family conflict and pregnancy issues. In contrast, men more often cited problems external to the family, such as legal/judicial problems and imprisonment, although the latter may relate to the fact that the catchment area included three prisons, only one of which catered for female prisoners.
The methodology used in this study is necessarily limited, given the self-report nature of the information recorded in patient case notes. In Ireland, psychiatrists routinely acutely assess patients who have harmed themselves, making it more likely that background information is sought and, therefore, is available in the case notes. We found that life events were discussed in two-thirds of the study population, and that those asked and not asked were similar both demographically and clinically.
In general, the factors described by those for whom this was a first attempt were more likely to indicate stresses involved with recent or ongoing interpersonal relationships. They were more likely to cite family conflict, work or school-related problems, or the stress of illness in others, whether physical or psychological. Problems with school or work were more often identified by those who did not repeat DSH, emphasising the protective nature of involvement in education or gainful employment (Whelan, 1992).
The complex processes by which early experiences predispose to self-harm as a response to stress may be best understood in terms of attachment theory (Bowlby, 1980). Suicidal behaviour has been explained as extreme attachment behaviour (Adam, 1994). Dysfunctional family of origin is a general term given for a disruptive early life experience. This was often related to addiction in one or both parents, although the specific category of alcohol misuse in others was not reported frequently in this study, perhaps indicating that it is more the disturbance in family life that is remembered rather than the underlying addictive behaviour. Repeated DSH was not associated with a greater number of reported stressors, although the particular stressors cited by those repeating DSH are more likely to be long-standing. Patients who harm themselves and who present with certain life histories merit selection for services designed to reduce recurrence.
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