Psychiatric Bulletin (2003) 27: 411-415. doi: 10.1192/pb.27.11.411
© 2003 The Royal College of Psychiatrists
Psychiatric Bulletin (2003) 27: 411-415
© 2003 The Royal College of Psychiatrists
Background stressors and deliberate self-harm
Prospective case note study in southern Ireland
Helen S. Keeley,
Mary O'sullivan and
Paul Corcoran
*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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Abstract
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AIMS AND METHOD
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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Introduction
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The reasons why people engage in deliberate self-harm (DSH) tend to be
complex and multiple. The immediate precipitants that people cite for harming
themselves are well-described and tend predominately to involve interpersonal
conflict and loss (Heikkinen et
al, 1994; Rubenowitz
et al, 2001). However, other factors, not necessarily
identified as immediately relevant by the person, may also predispose him or
her to self-harm when in difficulties. These include life events that can
occur at any time during the life cycle, including early childhood, and have
long-standing effects on the personal development of the subject
(Dube et al, 2001). We
aimed to describe and classify the life events, not directly precipitating the
episode, reported by a large consecutive series of patients treated in
hospital for DSH.
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Method
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Subjects
Between 1995 and 1997, the National Suicide Research Foundation
administered the two Irish centres in the World Health Organization/Euro
Multicentre Study on Suicidal Behaviour
(Platt et al, 1992).
Located in the south-west of the country, the catchment area included the
cities of Cork and Limerick, and contained 24% (863 709) of the Irish
population, almost half of whom live in urban settings
(Central Statistics Office,
1997). Ten general hospitals with accident and emergency room
facilities, five psychiatric hospitals and three prisons were monitored by
independent data collectors. Every case of DSH was identified using the
definition developed by the Working Group of the World Health
Organization/Euro Multicentre Study (Platt
et al, 1992).
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 1995–June 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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Results
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Subjects
Over the 2-year period, there were 3031 episodes of hospital-treated DSH by
2287 individuals; 1047 men (46%) and 1240 women (54%). The 1943 patients (85%)
whose previous history of DSH was known included 770 (40%) who had harmed
themselves before and 1773 (60%) for whom this was their first recorded act of
DSH. The prevalence of previous DSH was similar for men and women (41% and
38%, respectively). The opportunity to discuss life events as part of their
assessment was given to two-thirds of all patients (n=1518).
Table 1 compares those
questioned about life events with those who were not questioned across a range
of characteristics. There were fewer men among the patients asked about life
events in their assessment (
2=13.235, d.f.=1,
P<0.001).
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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Table 2. The 14 most commonly reported categories of life events and their
associated risk of repetition of deliberate self-harm (DSH)
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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) 1.95–5.61) but not in men (OR=0.77, 95% CI
0.37–1.60).
Multivariate logistic regression indicated that, adjusting for age and
gender, reporting problems related to a dysfunctional family of origin
(OR=1.51, 95% CI 1.09–2.08), a history of sexual abuse (OR=1.96, 95% CI
1.27–3.02) and imprisonment of self or other (OR=4.60, 95% CI
2.02–10.49) 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
0.35–0.88). 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 1.64–10.27).
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Prospective repetition
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Of the 2287 patients monitored, 361 (16%) presented to hospital with a
further act of DSH during the 2-year study period. Men were more likely than
women to repeat (18% v. 14%, respectively; age-adjusted OR=1.34, 95%
CI 1.07-1.69). Those with a previous history of DSH were far more likely to
repeat than those whose index act was a first occurrence of DSH (29%
v. 9%, age-adjusted OR=4.15, 95% CI 3.20–5.38).
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 1.32–2.67), a history of sexual abuse (adjusted OR=2.6,
95% CI 1.69–4.05) and imprisonment of self or other (adjusted OR=2.21,
95% CI 1.12–4.40) were independent risk factors for further DSH.
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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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Discussion
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Certain life events, particularly those of an interpersonal nature, are
associated with repeated DSH. The picture that emerges of the lives of those
who harm themselves will be familiar to those who regularly conduct clinical
assessments. A history of being sexually abused (often in childhood) was
associated with previous and future DSH, as was reporting a dysfunctional
family of origin and the imprisonment of self or other.
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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Declaration of interest
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The work of the National Suicide Research Foundation has been made possible
through the support of the Irish Government's Department of Health and
Children, the Southern and Mid-Western Health Boards and a unit grant from the
Irish Health Research Board.
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Acknowledgments
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This paper is dedicated to the late Dr Michael J. Kelleher, Founding
Director of the National Suicide Research Foundation. We thank all those who
contributed to the study. We also acknowledge the many hospital, health board
and prison personnel who have facilitated and supported the study.
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Abstract
Introduction
