IN THE NAME OF GOD THE IN THE NAME OF GOD THE COMPASSIONATE, THE MERCIFUL COMPASSIONATE, THE MERCIFUL

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A case-control study of psychosocial A case-control study of psychosocial risk and protective factors of self-risk and protective factors of self-immolation in Iran.immolation in Iran., risk and protective , risk and protective factors of self-immolation; a study from factors of self-immolation; a study from IranIran

Alireza Ahmadi, MD

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Objectives OverviewObjectives Overview

• Definition

• Public health approach to prevention

• Epidemiology

• Risks and protective factors

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DefinitionDefinition

Self-burning (Self-immolation) is a self-directed Self-burning (Self-immolation) is a self-directed violent act with suicidal intent. violent act with suicidal intent.

The term immolation is used to depict a The term immolation is used to depict a sacrificial connotation and,sacrificial connotation and,

It is commonly used for those admitted to burn It is commonly used for those admitted to burn units for deliberate self–burning.units for deliberate self–burning.

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https://www.youtube.com/watch?v=UHu_Q2e4iFU

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Prevalence of self-immolation Prevalence of self-immolation worldwide overviewworldwide overview

< 2% of all suicides are reported in High-income countries.

10-40% of all suicides are reported in Low-Middle-income countries.

1% to 40% of all admissions to burn centers worldwide, belong to SI.

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What can be done to prevent What can be done to prevent self-immolation? self-immolation?

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MethodMethod

CasesCases:: were selected from self-immolation patients were selected from self-immolation patients who arrived at the regional Burn Centre in IKH-K who arrived at the regional Burn Centre in IKH-K (151 cases).(151 cases).

ControlsControls:: were selected from the same community were selected from the same community which the cases arose (302 controls).which the cases arose (302 controls).

All All cases and controls cases and controls were matched for age, gender were matched for age, gender and living area.and living area.

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Study instrument & data collectionStudy instrument & data collection

The study questionnaire consists of two main The study questionnaire consists of two main parts:parts:Structured Diagnostic Interview for DSM-IV Structured Diagnostic Interview for DSM-IV (SCID) Persian Version.(SCID) Persian Version.

Items measuring Items measuring demographic, familial, & demographic, familial, & adverse life events.adverse life events.

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Analytical MethodAnalytical Method

1.1. We used We used descriptive statisticsdescriptive statistics to describe to describe sample characteristics and the study main sample characteristics and the study main variables,variables,

2.2. And used, And used, Chi square, Fisher’s exact tests Chi square, Fisher’s exact tests andand OROR to test the associations between to test the associations between exposure variables and self-immolation.exposure variables and self-immolation.

3.3. Logistic regression Logistic regression

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LogisticLogistic regression model: regression model: In the subgroup of married: marital conflict marital conflict and spouse addiction and spouse addiction and in the subgroup unmarried: problem with problem with parents, parents’ death and parents’ addictionparents, parents’ death and parents’ addiction were meaningful.

x2 p-value Odds Ratio 95% CI

History of suicide in familyHistory of suicide in family 11.13 0.0010.001 2.05 1.34-3.13

Having problem with parents#Having problem with parents# 24.79 <0.0001<0.0001 4.14 2.33-7.37

Death of parents#Death of parents# 5.89 0.020.02 2.45 1.17-5.12

History of mental disorders in parents#History of mental disorders in parents# 7.85 0.0050.005 2.97 1.35-6.54

Opium addiction of parents#Opium addiction of parents# 13.84 <0.0001<0.0001 2.94 1.65-5.25

Marital conflict with spouse*Marital conflict with spouse* 78.46 <0.0001<0.0001 20.37 9.52-43.59

Conflict with other member of familyConflict with other member of family 19.83 <0.001<0.001 2.67 1.72-4.13

Addiction of spouse *Addiction of spouse * 33.51 <0.0001<0.0001 5.90 3.16-11.03

Socio-Economic Status of family Socio-Economic Status of family 20.93 <0.001<0.001 2.59 1.71-3.92# In unmarried participants; * In married participants

ChiChi squaresquare: :

Familial factors differences between self-immolation Familial factors differences between self-immolation (cases=151; controls=302)(cases=151; controls=302)

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Chi square: Chi square:

Logistic regression model: adjustment disorders, major depression adjustment disorders, major depression and opiumopium

dependencydependency were significant independent risk factors for self-immolation.

Differences between self-immolation and psychiatric disorders (cases n =151; controls n=302)

x2 p-value Odds Ratio 95% CI

Adjustment disordersAdjustment disorders 153.94 <0.001<0.001 19.45 11.37-33.28

Major depressionMajor depression 32.19 <0.001<0.001 6.56 3.18-13.51

Opium dependenceOpium dependence 3.92 0.0480.048 2.67 0.98-7.32

Heroin dependenceHeroin dependence 4.01 <0.05<0.05 - -

SchizophreniformSchizophreniform 6.04 0.010.01 - -

Borderline personality disordersBorderline personality disorders 4.96 0.030.03 8.20 0.91-73.93

Antisocial personality disorderAntisocial personality disorder 8.07 0.0040.004 - -

Differences between self-immolation and psychiatric Differences between self-immolation and psychiatric disorders (cases n =151; controls n=302)disorders (cases n =151; controls n=302)

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Psychiatric disorders and genderPsychiatric disorders and gender Results of multivariate logistic regression model revealed that in the female subgroup, adjustment disordersadjustment disorders and major depression major depression and in subgroup male, opium dependencyopium dependency and also major depression major depression were meaningful risk factors

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Differences between self-immolation and Adverse life events (cases n =151; controls n=302)x2 p-value Odds Ratio 95% CI

HomelessnessHomelessness 6.04 0.01 0.00 -

Financial hardshipFinancial hardship 13.68 <0.001 2.24 1.45-3.44

Problems with friendsProblems with friends 6.87 0.009 0.23 0.07-0.76

A relationship break-upA relationship break-up 8.19 0.004 2.03 1.24-3.30

Anxiety about school/university performanceAnxiety about school/university performance 11.45 0.001 0.26 0.12-0.60

Sibling or parents’ history of suicide Sibling or parents’ history of suicide attemptsattempts

7.87 0.005 5.58 1.46-21.33

Logistic regression model:: Individual’s history of suicide attempts Individual’s history of suicide attempts → risk factor, Anxiety Anxiety about school/university performance →about school/university performance → Protective factor.

Result: Adverse life events:Result: Adverse life events: Chi square: Chi square:

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ResultsResults

Potential factors for future prevention interventions Potential factors for future prevention interventions

KeroseneKerosene; most common means of committing for SI (93%).

Imitational (Copycat )Imitational (Copycat ) self-immolation (57%).

Easy access to the means of SIEasy access to the means of SI, especially to kerosene fuel

Lack of knowledgeLack of knowledge about medical complications of burns.

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ResultsResults

Potential factors for future prevention interventions Potential factors for future prevention interventions

Majority of patients had not used any ""consulting servicesconsulting services"" to solve or manage problems, or enhance problem-solving techniques and coping skills.

Unplanned (impulsive)Unplanned (impulsive)

(unplanned self-immolation); (70-80% of all patients) 25% of male 88% of female

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DiscussionDiscussion

The percentage of self-immolation was highest in the 16 The percentage of self-immolation was highest in the 16 to 25 years age groups (60%) and females (76%). to 25 years age groups (60%) and females (76%).

Why do women in these regions resort to such a violent act of self-harm? "Cry for Help": "Cry for Help": they don’t know that the fire is a dangerous and often fatal technique to do this.

Imitational (Copycat )Imitational (Copycat )

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ConclusionConclusion Risk factors:

- Adjustment disorders- Adjustment disorders

- Major depression- Major depression

- Opium dependence- Opium dependence

- Individual history of suicide attempts- Individual history of suicide attempts28

Protective factors:

-Consulting services utilizationConsulting services utilization

-Anxiety about school/university Anxiety about school/university performanceperformance

ConclusionConclusion

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ConclusionConclusion

Risk factors: Married subgroup

- Spouse Marital Conflict - Spouse Marital Conflict

- Spouse Addiction - Spouse Addiction

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ConclusionConclusion

Risk factors: Unmarried subgroup

- Problem with parents - Problem with parents

- Parents’ death- Parents’ death

- Parents’ addiction- Parents’ addiction

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ConclusionConclusion

Risk factors: Female subgroup

- Adjustment disorders- Adjustment disorders

- Major depression- Major depression

- Individual history of suicide attempts- Individual history of suicide attempts

- Spouse Addiction- Spouse Addiction32

ConclusionConclusion

Risk factors: Male subgroup

- Major depression- Major depression - Opium dependency - Opium dependency

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““Hic locus est ubi mors gaudet succurrere vitae.”Hic locus est ubi mors gaudet succurrere vitae.”

“[This is the place where death rejoices in helping the living.]”

─ “Motto above the door of the Anatomical Institute of Vienna, where autopsy are performed.”