Adverse life events risk factors in self-immolation

INTRODUCTION

Self-immolation (self-burning) is among the most violent and difficult acts to

understand, 1 and its etiology is as complex and multifaceted as any other suicidal act.

Although self-immolation is rare in high-income countries, 2-6 it is reported with

surprising frequency in many low- and middle-income countries. 7 Iran is among the

countries with the highest rates of self-immolation. In fact, some regions in the west

and south of Iran have the highest documented rates of self-immolation in the world

(22.4 per 100,000 person-years). 10, 11, 12

Women are the main victims of self-immolation in Iran. Suicide by self-burning is the

third leading cause of Years of Life Lost (YLL) through premature death among

women, after disasters and breast cancer. 10, 11 They account for 70% to 96% of all

self-immolation admissions to burn centers in Iran and approximately 80% of these

patients die. 1, 7-12

Subsequently, prevention of self-immolation has become a prominent public health

concern among professionals in Iran. This aim is well suited within suggested steps

for suicide prevention, using a public health approach, which includes a five phase

cycle: 13

1. Define the problem: surveillance;
2. Identify the cause: risk and protective factor research;
3. Develop and test interventions;
4. Implement interventions; and
5. Evaluate effectiveness of interventions.

The suicide literature reveals that risk factors of self-immolation differ across

different socio-demographic characteristics, psychological predispositions, psychiatric

disorders, and experience of adverse life events. 1-14 In Iran and most low and middle

income countries, young and adolescent women are over-represented among selfimmolation

cases. 15-28 In high income countries, however, the prevalence of selfimmolation

tends to be among older male individuals. 5, 16, 29-36 In a recent survey in

Iran, adjustment disorders were among the most prevalent psychiatric predisposition

factor 1, 24, 37 whereas, western studies tend to report major depressive disorder,

psychoses, and alcohol and other drug addictions as the most psychiatric condition

related to self-immolation. 16, 38

These risk factors have been reported among a wide range of age groups and types of

suicide victims, including younger individuals (e.g., late adolescents and young

adults), married individuals, school drop-outs, those will low level of literacy, the

unemployed, and housewives. 1, 7-12, 14, 19-22, 24, 28, 37, 39, 40- 45

Data on history of adverse life events among victims of self-immolation is sparse.

Among suicide victims more broadly, however, there is a pattern of high numbers of

adverse life events prior to the suicide attempt. Such events include unplanned

pregnancy, homelessness, financial hardship, relationship problems with friends,

and/or loved ones/spouses, academic problems and/or failures, work-related anxiety, a

personal history of suicide attempts, a family history of suicide attempts, diagnosed

mental disorders, and/or malignant disease. 46-55

This study aimed to investigate role of adverse life events in presentation of selfimmolation

among patients admitted to regional Burn Centre at Imam Khomeini

Hospital (BC-IKH) in Kermanshah province, in Iran.

Nearly all currently available data on self-immolation in the world is descriptive,

limiting one’s ability to establish any relationship between variables of interest.1-37, 39-

45 We therefore implemented a case-control design so that we could examine potential

associations between variables of interest.

METHODS

Participants:

Adult patients, both male and female, age 18 and older who either confessed to

deliberate self-burning or were reported to have done so by a reliable witness, and

were admitted to the BC-IKH were eligible to be enrolled in the study. Patients whose

suicide seemed suspicious (i.e., those who denied suicidal intent and for whom there

were no corroborating witnesses or data) were excluded. Thirty consecutive patients

who met the eligibility criteria were enrolled in this study.

The control group was recruited from the community and was matched by living areas

(district-county, rural/urban), gender, and age. All three of those demographic

characteristics are risk factors for self-immolation, so control of them was deemed

important 1, 7-12, 14, 19, 21, 24, 28, 37, 39, 42, 45 All the participants gave their informed consent

to participation in this study.

Protocol:

A trained clinical psychologist interviewed all enrolled patients within the first 24

hours of admission to the Burn Center to administer Adverse Life Event

questionnaire. With the exception of three patients (cases) who had severe burn

(defined as greater than 90% Total Body Surface Areas (TBSA)) self-reported data

were collected. In cases with high TBSA, the questionnaire was completed by the

patients’ spouses or parents.

The Adverse Life Events questionnaire was created for this study. It included 16

dichotomized items ranging from unplanned pregnancy to having inability and

malignant disease with the response categories; “Yes = 1”, and “No = 0” (See Table

1). Most items in the questionnaire are standard items for such measures. We also

included two items that previously have not been evaluated in suicide research but

play an important sociocultural role in Iran’s society, infertility and compulsory

marriage. 46-58

All protocols were approved by the Kermanshah University of Medical Sciences,

Local Research Ethics Committee.

Analytical method:

Data analyses proceed in two steps. First, we examined descriptive statistics for all

items in the Adverse Life Events questionnaire, for both the case and control

groups. Second, chi-square was used to estimate differences and, where appropriate,

the strength of the difference, between the outcome variable (self-immolation) and

the risk factor (items in the Adverse Life Event questionnaire) across each group.

We use a p-value ≤ 0.10 to identify trends and a p-value ≤ 0.05 and 95% CI to

identify significant differences.

Results

Table 2 shows the results of chi square analysis. Three variables emerged as having

statistically significant differences between the two groups. Financial hardship (x2 =

5.41, p = 0.02; OR = 3.45; CI = 1.19-9.90), an intimate relationship break-up (x2 =

9.02, p = 0.003; OR = 5.45; CI = 1.20-11.99), and individual history of suicide

attempts (x2 = 6.67; p = 0.01; OR = 7.00; CI = 1.38-35.48). Comparisons of other

variables were not statistically significant.

Discussion

The primary purpose of this study was to examine the association between adverse

life events and self-immolation among a sample of patients admitted to a regional

burn center in Iran. Numerous studies indicate adverse life events play an important

role in suicidal attempts and death, 46-56 but very few studies use elegant research

designs such as case-control research to reach these conclusions; most data were

collected in developed countries; 38, 57, 58 and few address self-immolation in particular

as a suicide technique. In fact, we were unable to locate any previous case-control

studies examining the impact of adverse life events on self-immolation among

patients in Iran or any other low- or middle-income country.

Findings from the present study suggest financial hardship, break-up of an intimate

relationship, and an individual history of suicide attempts are significant risk factors

for self-immolation. This finding is in line with existing suicide literature. Sunnqvist

et al., 48 for example, studied the role of stressful life events and biological stress

markers in suicide attempts among former adolescent psychiatric inpatients. They

found that patients who reported sexual abuse during childhood and feelings of

neglect during childhood had significantly higher levels of CSF-MHPG

(cerebrospinal fluid and Methoxy-4-hydroxyphenylglycole) and U-NA/A than those

who had not. In another study, Palacio et al. 49 used a case-control design with 108

adult suicide attempters and 108 controls matched for age and gender. Those who

reported adverse life events in the last six months, who had a family history of

suicide, who were amidst a major depressive episode, and or who expressed a wish to

die, had higher risk of suicide.

Another study, by Zhang et al., 50 used a matched case-control group of 215 suicide

attempters with major depression (92 male, 123 female). Hopelessness, negative lifeevents,

and family history of suicide were risk factors of attempted suicide. Renaud et

al. 51 confirmed the existence of a particular clinical profile of children and

improved understanding of the interrelationships between stressors in youth suicidal

behavior. In a study of 300 adolescent aged from 14 to 19 years. Marczyńska-

Wdówik, 52 found that suicide attempters and adolescents with suicidal ideation had

poor social support from parents and experienced more stressful situations and family

and school problems which were perceived difficult to solve.

Way et al., 53 reviewed the mental health records of all 76 suicides that occurred

between 1993 and 2001 in New York State Department of Correctional Services

prisons and that had some contact with mental health services during their

incarceration. He found common stressors preceding the suicide were inmate-toinmate

conflict, recent disciplinary action, fear, physical illness, and adverse life

events such as loss of good time or disruption of family/friendship relationships in the

community. Finally, Chiou et al. 54 demonstrated that the most common precipitating

characteristics among adolescent suicide attempters who were admitted to an acute

psychiatric ward in Taiwan were school stress, parent-child conflict, and

psychopathology, including feelings of hopelessness, psychotic symptoms, substance

abuse, or panic symptoms.

Prevention strategies

Results of this study support previous findings that self-immolation involves a

complex mix of intrapsychic, interpersonal, and environmental risk factors, including

adverse life events. Culturally sensitive interventions should be developed to target atrisk

individuals and communities for self-immolation prevention. These interventions

could develop out of community participatory research to involve key community

members and their inputs. It could focus on community outreach activities such as

media campaigns, or school-based interventions to reach adolescent population.

Local community-action groups and nongovernment organizations are also important

entities for self-immolation prevention activities. Interventions aimed at improving

mental health through cognitive-behavioral or interpersonal therapy strategies have

also shown to reduce the likelihood of suicide in other cultures 1 and are likely to be

helpful in preventing suicide by self-immolation in Iran.

Limitations and Future Directions

This study offers several strengths. Most prominently, it is among the first studies to

use a case-control design to examine risk factors associated with self-immolation.

Further, it was conducted in a region with self-immolation rate that are among the

highest in the world. Nonetheless, case-control studies have some inherent limitations.

One pertains to the issue of properly matching subjects between the case and control

groups. In this study the control group was selected from the same community and

matched by age and gender to consecutive-referral cases to obtain accurate matching.

It is unknown if other demographic factors, such as income, may have varied across

the groups. Another limitation of the study concerns generalizability. The sample for

this study was recruited from one region of Iran, and therefore results cannot

necessarily be generalized to other parts of Iran or to other nations. We view this work

to be a pilot study from which further investigation is warranted.

In Iran and much of the world, suicide is stigmatized and condemned for religious or

cultural reasons. In some countries, suicidal behavior is a criminal offence punishable

by law.1 Therefore, for various reasons, suicide often is a secretive act that is

deliberately hidden and considered taboo. Identification of at-risk populations, which

this manuscript contributes to, will provide valuable information for targeted

treatment and prevention programs. As discussed in the introduction, future work

should begin to move toward treatment and prevention programs.13

Conclusion

The results of this study suggest financial hardship, break-up of an intimate

relationship, and an individual history of suicide attempts are risk factors for selfimmolation.

Other variables, including unplanned pregnancy, homelessness, financial

hardship, relationship problems with friends, and/or loved ones/spouses, academic

problems and/or failures, work related anxiety, personal history of suicide attempts,

family history of suicide attempts, diagnosed mental disorders, and malignant disease,

did not play a role as individually protective or risk factors for self-immolation.

Intervention strategies to prevent life adverse events and educate at-risk individuals

about problem-solving approaches and coping skills should be developed and

implemented.

Acknowledgment

The authors would like to thank all people who participated in this study.

Ethical approval:

All protocols were approved by the Kermanshah University of Medical Sciences,

Local Research Ethics Committee.

Funding:

Financial support of this study was provided by Kermanshah University of Medical

Sciences.

Competing interests

None declared.

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