|Year : 2016 | Volume
| Issue : 1 | Page : 32-35
Prevalence and profile of suicide attempters with abdominal pain as the reason of attempt: A retrospective study
Shivanand Kattimani1, Siddharth Sarkar2, Mathan Kaliaperumal1, Sreekanth Sakey1, Arun K Vivek1
1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Psychiatry, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||10-May-2016|
Department of Psychiatry, Sree Balaji Medical College and Hospital, Chromepet, Chennai - 600 044, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background and Aims: Suicide attempt is a complex human behavior with multiple determinants. Literature suggests toward abdominal pain as a risk factor for a suicide attempt, but such patients need to be characterized further. This retrospective study aimed to compare individuals with abdominal pain as the reason of suicide attempt to those reporting other reasons for such attempt. Methods: This retrospective chart review-based case-control study was conducted among individuals registered at the crisis intervention clinic of a Tertiary Care Hospital in South India. Information was extracted from the records using a structured profroma. Characteristics of those with abdominal pain as the reason of suicide attempt were compared with age- and gender-matched controls. Results: Of 427 persons registered in the clinic in the period, abdominal pain was the stated reason for the attempt in 37 (8.7% of the sample). Suicide attempters whose stated reason for attempted suicide as abdominal pain had lower education (P = 0.042), were more likely to suffer from physical illness (P < 0.001), were more likely to have a recent visit to a health care professional (P = 0.047), were less likely to give hint prior to attempt (P = 0.010), and had lesser stressful life events compared to the controls (P = 0.024). Conclusions: There seem to be certain differences between suicide attempters who report abdominal pain versus other causes for a suicide attempt.
Keywords: Abdominal pain, attempted suicide, coping behavior, psychiatric diagnosis, stressful life events
|How to cite this article:|
Kattimani S, Sarkar S, Kaliaperumal M, Sakey S, Vivek AK. Prevalence and profile of suicide attempters with abdominal pain as the reason of attempt: A retrospective study. J Mental Health Hum Behav 2016;21:32-5
|How to cite this URL:|
Kattimani S, Sarkar S, Kaliaperumal M, Sakey S, Vivek AK. Prevalence and profile of suicide attempters with abdominal pain as the reason of attempt: A retrospective study. J Mental Health Hum Behav [serial online] 2016 [cited 2020 Feb 25];21:32-5. Available from: http://www.jmhhb.org/text.asp?2016/21/1/32/182100
| Introduction|| |
Suicide is a complex human behavior with every suicide behavior proposed to be resulting from unbearable psychological pain, i.e., “psychache.” Most research suggests that suicide attempters have a psychiatric diagnosis, the presence of stressful life events or significant interpersonal problems,, although the presence of medical disorders also seems to increase suicide risk. Abdominal pain has been found to be associated with increased prevalence of lifetime suicidal ideas, attempts, and completed suicides.,,
India being one of the most populous countries in the world contributes to a large proportion of global suicides. Although studies have emerged from India reporting abdominal pain as the reason for a suicide attempt, there is a need for characterizing such suicide attempters further. Hence, this case–control study aimed to assess the prevalence and characteristics of suicide attempters who report abdominal pain as the reason of suicide attempt.
| Methods|| |
The present chart based case–control study was conducted in the Department of Psychiatry of a Tertiary Care Government Multispecialty Hospital in Southern India. Patients presenting to the hospital for management of medical/surgical condition after a suicide attempt are referred to the crisis intervention clinic (CIC) run by the Department of Psychiatry after medical stabilization. The CIC is manned by a team of psychiatrist, a clinical psychologist, and a social worker and the registered patients are evaluated in detail using a structured proforma at the first contact. Only those patients who were orientated and co-operative enough to give information are interviewed in this clinic, and the information is gathered from patients, their family members, and past medical records. Data are gathered about demographic data, the reason of attempt, the method used, substance use and other suicide risk factors. Psychiatric diagnosis is made as per ICD 10. Patients are rated on presumptive stressful life events scale (PSLES) to assess stress, and coping strategies inventory short form (CSI-SF) as a brief measure of coping. Patients are also evaluated in detail by a social worker to assess and intervene for social issues leading to a suicide attempt. A management plan is formulated after discussion with the consultant and include both pharmacological and nonpharmacological approaches.
This study included consecutive patients registered in the clinic over a period of 4 years (2010–2013). The suicide attempt was defined as per criteria suggested by Silverman et al. Patients with abdominal pain as the reported reason of suicide attempt formed the cases. Controls comprised patients registered in the clinic with “other” reasons for the present suicide attempt. The controls were age- and gender-matched in the ratio. The ratio of cases to controls was 1:2. Data were extracted from the records using a performa developed for the study and was evaluated using standard methods.
The two instruments used in the present analysis were PSLES and CSI-SF. PSLES has been developed to assess stressful life events and has been validated for Indian setting. This 51-item scale comprises both desirable and undesirable stressful events. The number of stressors as per PSLES was compared among cases and controls. The CSI-SF is a brief 16 item scale was derived from the 78-item CSI. The items are rated on a 5 item Likert scale from 1 to 5 rated as never, seldom, sometimes, often, and almost always. The different forms of self-reported coping responses that are generally used when faced with difficult situations are evaluated through this scale. Coping responses are classified into emotion focused and problem focused, which are further sub-classified as either engagement type or disengagement type of strategy.
Statistical analysis was performed using SPSS version 17 (SPSS Inc, TX). The cases with abdominal pain as the cause of suicide attempt were compared to the controls using appropriate parametric and nonparametric tests. Continuous data were compared using Student's t-test and categorical data using Chi-square test. Missing value imputation/analysis was not performed as a part of this study. All the tests were two-tailed and a P < 0.05 was considered significant.
| Results|| |
Of 442 persons who were registered in the CIC during the period of the study, 427 were classified as suicide attempts as per the adopted definition (intent of suicide was not clear in 15 patients). Of 427 persons, abdominal pain was the stated reason for the attempt in 37 (8.7% of the sample). The 37 persons were age- and gender-matched with controls. The reasons of suicide in the control group was interpersonal problems/altercation with family members or others in 60, financial issues in 6, academic problems in 3, anxiety and depressive symptoms in 3, and others in 2. The characteristics of cases and controls are shown in [Table 1]. Those with abdominal pain as stated reason for suicide had spent lower years in formal education than those with other stated reasons (P = 0.042), were more likely to suffer from a physical illness (P < 0.001), were more likely to visit a healthcare professional in recent past (P = 0.047) and were less likely to give a hint prior to attempt (P = 0.010).
The mode of the attempt, psychiatric diagnoses, stressful life events, and coping are depicted in [Table 2]. The most common method of suicide attempt was the consumption of insecticide. It was seen that the profile of diagnosis was not significantly different between cases and controls though adjustment disorder was the most frequent diagnosis in both the groups. The number of stressful life events was lower in those with abdominal pain as the reason of attempt (P = 0.024). The coping subscales scores did not significantly differ between the groups.
|Table 2: Mode of attempt, psychiatric diagnosis, stressful life events, and coping|
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| Discussion|| |
This study suggests that about 8.7% of suicide attempters report the stated reason of attempt as abdominal pain. The first question in such a scenario is: Were these individuals trying to conceal other reason? Based on popular beliefs and anecdotes, it is natural to look for some other hidden/untold reason when someone states abdominal pain as the reason for the suicide attempt. These persons were luckily alive after the suicide attempt and could be interviewed in detail. As these all cases were referred from medico-surgical wards after stabilization, the reason for suicide attempt might not have been recorded accurately. However, the screening by trained psychiatrists before referral to CIC and independent assessment by qualified social worker might have disclosed or hinted toward other reasons of suicide attempt apart from abdominal pain. However, detailed assessment did not lead to a change in the reason for suicide attempt in these cases. Most cases were referred to medicine, surgery or obstetrics and gynecology department for evaluation of abdominal pain. Hence, it can be surmised that abdominal pain may be a genuine reason for attempting suicide.
We noted that cases did not show any significant difference in sociodemographic profile compared to controls except in the years spent in formal education. Cases had significantly lower stressful life events in the past 1 year, again suggesting that suicide attempt might have been the result of endured pain, and were not a veiled manifestation of stressful life events. Cases were less likely to give a hint of suicide before the suicide attempt, suggesting that suicide attempts arising out of abdominal pain less likely due to “cry for help” to resolve problems. Patient with abdominal pain would be expected to visit healthcare services more frequently as was found in the results of thisstudy. The coping strategies were largely similar between cases and controls, suggesting that there may be a general common method of coping among suicide attempters. This study cannot, however, comment about method of coping among patients with abdominal pain who do not attempt suicide.
There seems to be genuine merit in accepting that abdominal pain could be one of the reasons for attempting suicide, and it can lead to completed suicides. There has been growing interest in the gut-brain axis and linking of mental illness with a disturbance in the gut., What factors eliciting abdominal pain are involved in increasing suicidal behavior are yet to be known. It may be possible that chronic pain may add to already existing individual suicide risk profile. Among pain patients, those with pain catastrophizing tendency may be more likely to attempt suicide. Others have suggested a framework for dealing with gastrointestinal distress which may be associated with increased suicidal ideas due to associated factors such as cognitive distortions and anticipatory anxiety.
The findings of the study should be contextualized in terms of its limitations that include a retrospective chart-review-based case–control study, a hospital-based limited sample, and absence of “healthy control group.” Follow-up records were not available to comments about re-attempts or change in the reported reasons of attempt.
| Conclusion|| |
To conclude, the study suggests that patients with abdominal pain as the reason for suicide attempt constitute a distinct group with lower education, more frequent healthcare visits, less stressful life events and less frequent hints before suicide attempt. Diagnosing and treating such patients for abdominal pain during medical visits may help to identify patients who are likely to harbor suicidal thoughts. This may be helpful in potentially reducing suicide attempts in this group of patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shneidman ES. Suicide as psychache. J Nerv Ment Dis 1993;181:145-7.
Beautrais AL. Risk factors for suicide and attempted suicide among young people. Aust N
Z J Psychiatry 2000;34:420-36.
Yoshimasu K, Kiyohara C, Miyashita K; Stress Research Group of the Japanese Society for Hygiene. Suicidal risk factors and completed suicide: Meta-analyses based on psychological autopsy studies. Environ Health Prev Med 2008;13:243-56.
Druss B, Pincus H. Suicidal ideation and suicide attempts in general medical illnesses. Arch Intern Med 2000;160:1522-6.
Ilgen MA, Zivin K, Austin KL, Bohnert AS, Czyz EK, Valenstein M, et al.
Severe pain predicts greater likelihood of subsequent suicide. Suicide Life Threat Behav 2010;40:597-608.
Magni G, Rigatti-Luchini S, Fracca F, Merskey H. Suicidality in chronic abdominal pain: An analysis of the Hispanic Health and Nutrition Examination Survey (HHANES). Pain 1998;76:137-44.
Spiegel B, Schoenfeld P, Naliboff B. Systematic review: The prevalence of suicidal behaviour in patients with chronic abdominal pain and irritable bowel syndrome. Aliment Pharmacol Ther 2007;26:183-93.
Vijayakumar L. Indian research on suicide. Indian J Psychiatry 2010;52 Suppl 1:S291-6.
Venkoba Rao A. Physical illness, pain, and suicidal behavior. Crisis 1990;11:48-56.
Silverman MM, Berman AL, Sanddal ND, O'carroll PW, Joiner TE. Rebuilding the tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors. Part 2: Suicide-related ideations, communications, and behaviors. Suicide Life Threat Behav 2007;37:264-77.
Sarkar S, Seshadri D. Conducting record review studies in clinical practice. J Clin Diagn Res 2014;8:JG01-4.
Singh G, Kaur D, Kaur H. Presumptive stressful life events scale (psles) – A new stressful life events scale for use in India. Indian J Psychiatry 1984;26:107-14.
Addison CC, Campbell-Jenkins BW, Sarpong DF, Kibler J, Singh M, Dubbert P, et al.
Psychometric evaluation of a Coping Strategies Inventory Short-Form (CSI-SF) in the Jackson Heart Study cohort. Int J Environ Res Public Health 2007;4:289-95.
Berger S, Hocke M, Bär KJ. Gastric dysmotility in healthy first-degree relatives of patients with schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2010;34:1294-9.
Peupelmann J, Quick C, Berger S, Hocke M, Tancer ME, Yeragani VK, et al.
Linear and non-linear measures indicate gastric dysmotility in patients suffering from acute schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2009;33:1236-40.
Sansone RA, Watts DA, Wiederman MW. Pain, pain catastrophizing, and history of intentional overdoses and attempted suicide. Pain Pract 2014;14:E29-32.
Spiegel BM, Khanna D, Bolus R, Agarwal N, Khanna P, Chang L. Understanding gastrointestinal distress: A framework for clinical practice. Am J Gastroenterol 2011;106:380-5.
[Table 1], [Table 2]