IN THE NAME OF GOD THE COMPASSIONATE, THE MERCIFUL 1

A case-control study of psychosocial risk and protective factors of self- immolation in Iran., risk and protective factors of self-immolation; a study from Iran Alireza Ahmadi, MD 2

Objectives Overview Definition Public health approach to prevention Epidemiology Risks and protective factors 3

Definition  Self-burning (Self-immolation) is a self-directed violent act with suicidal intent.  The term immolation is used to depict a sacrificial connotation and,  It is commonly used for those admitted to burn units for deliberate self–burning. 4

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Prevalence of self-immolation worldwide 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. 7

What can be done to prevent self-immolation? 8

Method Cases: were selected from self-immolation patients who arrived at the regional Burn Centre in IKH-K (151 cases). Controls: were selected from the same community which the cases arose (302 controls). All cases and controls were matched for age, gender and living area. 12

Study instrument & data collection The study questionnaire consists of two main parts:  Structured Diagnostic Interview for DSM-IV (SCID) Persian Version.  Items measuring demographic, familial, & adverse life events. 13

Analytical Method 1. We used descriptive statistics to describe sample characteristics and the study main variables, 2. And used, Chi square, Fisher’s exact tests and OR to test the associations between exposure variables and self-immolation. 3. Logistic regression 14

 Logistic regression model: marital conflict and spouse addiction problem with parents, parents’ death and parents’ addiction  Logistic regression model: In the subgroup of married: marital conflict and spouse addiction and in the subgroup unmarried: problem with parents, parents’ death and parents’ addiction were meaningful. x2x2 p-valueOdds Ratio95% CI History of suicide in family Having problem with parents# 24.79< Death of parents# History of mental disorders in parents# Opium addiction of parents# 13.84< Marital conflict with spouse* 78.46< Conflict with other member of family 19.83< Addiction of spouse * 33.51< Socio-Economic Status of family 20.93< # In unmarried participants; * In married participants  Chi square: Familial factors differences between self-immolation (cases=151; controls=302) 21

 Chi square: adjustment disorders, major depression opium dependency  Logistic regression model: adjustment disorders, major depression and opium dependency were significant independent risk factors for self-immolation. Differences between self-immolation and psychiatric disorders (cases n =151; controls n=302) x2x2 p-valueOdds Ratio95% CI Adjustment disorders < Major depression 32.19< Opium dependence Heroin dependence 4.01< Schizophreniform Borderline personality disorders Antisocial personality disorder Differences between self-immolation and psychiatric disorders (cases n =151; controls n=302) 22

Psychiatric disorders and gender adjustment disorders major depression opium dependency major depression  Results of multivariate logistic regression model revealed that in the female subgroup, adjustment disorders and major depression and in subgroup male, opium dependency and also major depression were meaningful risk factors 23

Differences between self-immolation and Adverse life events (cases n =151; controls n=302) x2x2 p-valueOdds Ratio95% CI Homelessness Financial hardship 13.68< Problems with friends A relationship break-up Anxiety about school/university performance Sibling or parents’ history of suicide attempts : Individual’s history of suicide attempts Anxiety about school/university performance →  Logistic regression model : Individual’s history of suicide attempts → risk factor, Anxiety about school/university performance → Protective factor. Result: Adverse life events:  Chi square: 24

Results Results Potential factors for future prevention interventions Kerosene  Kerosene ; most common means of committing for SI (93%). Imitational (Copycat )  Imitational (Copycat ) self-immolation (57%). Easy access to the means of SI  Easy access to the means of SI, especially to kerosene fuel Lack of knowledge  Lack of knowledge about medical complications of burns. 25

Results Results Potential factors for future prevention interventions "consulting services"  Majority of patients had not used any "consulting 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 26

Discussion Discussion The percentage of self-immolation was highest in the 16 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 ) 27

Conclusion Conclusion Risk factors: - Adjustment disorders - Major depression - Opium dependence - Individual history of suicide attempts 28

Protective factors: -Consulting services utilization -Anxiety about school/university performance Conclusion Conclusion 29

Conclusion Conclusion Risk factors: Married subgroup - Spouse Marital Conflict - Spouse Addiction 30

Conclusion Conclusion Risk factors: Unmarried subgroup - Problem with parents - Parents’ death - Parents’ addiction 31

Conclusion Risk factors: Female subgroup - Adjustment disorders - Major depression - Individual history of suicide attempts - Spouse Addiction 32

Conclusion Conclusion Risk factors: Male subgroup - Major depression - Opium dependency 33

“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.”