Impulsivity in patients with attempted suicide presenting at a tertiary care hospital in Karachi
V O L .
Impulsivity in patients with attempted suicide presenting at a tertiar y care hospital in Karachi
Ayesha Abdul Hameed 0 1 2
Abbasi Shaheed Hospital 0 1 2
Karachi 0 1 2
Pakistan 0 1 2
Khairpur Medical College 0 1 2
KhairpurMirs 0 1 2
Pakistan 0 1 2
0 Ichan School of Medicine/Queens Hospital Centre , New York , USA
1 Institute of Psychiatry, Baqai Medical University , Karachi , Pakistan
2 ShaheedZulfikar Ali Bhutto Institute of Science and Technology , Karachi
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Impulsivity in patients with attempted suicide presenting at a tertiary care
hospital in Karachi
Impulsivity In Patients With Attempted Suicide Presenting
At A Tertiary Care Hospital In Karachi
1Abbasi Shaheed Hospital, Karachi, Pakistan, 2Khairpur Medical College, KhairpurMirs, Pakistan,
3ShaheedZulfikar Ali Bhutto Institute of Science and Technology, Karachi
4Institute of Psychiatry, Baqai Medical University, Karachi, Pakistan,
5Ichan School of Medicine/Queens Hospital Centre, New York, USA, 6Abbasi Shaheed Hospital, Karachi, Pakistan
Date of submission: April 21, 2017 Date of revision: May 30, 2017 Date of acceptance: June 1, 2017
OBJECTIVE: To determine the prevalence of impulsivity in patients who attempted suicide presenting at a tertiary
care hospital, Karachi.
STUDY DESIGN: Cross sectional study.
STUDY SETTING: Study was led in the Psychiatry Department,Abbasi Shaheed Hospital, Karachi.
DURATION OF STUDY:Six month after approval of synopsis.
SUBJECTS AND METHODS: Data was prospectively collected from patients after taking verbal consent.
Permission was taken from ethical review committee. 95 patients presenting to the Psychiatry Department who
met the inclusion criteria were included. A brief history about suicide attempt and demographic data was taken from
the patient and confirmed by an attendee. The researcher himself interviewed the patient in a conducive
environment assuring the patient's confidentiality. The Barratt Impulsiveness Scale (BIS-11) which consists of 30
self administered questions, marked out of 120 and rated from 0-4 was used to measure impulsivity. Demographic
data was presented as simple descriptive statistics giving mean and standard deviation and qualitative variables
was presented as frequency and percentages. Effect modifiers were controlled through the stratification of age,
gender, marital status, educational status, socioeconomic status and occupational status to see the effect of these
on the outcome variable. Post stratification chi square test was applied, taking p-value of ≤0.05 as significant.
A total of 95 patients who attempted suicide, admitted in Psychiatry Department, Abbasi Shaheed Hospital,
Karachi were included in the study. Out of 95 patients, mean and standard deviation of age and BIS-11 score was
36.47±9.13 years and 80.4±17.6 respectively. Out of 95 patients who attempted suicide, 45 (47.4%) had
impulsivity and 50 (52.6%) had no impulsivity and 28 (29.5%) were male and 67 (70.5%) were female. Impulsivity
was found to be the most common in the age group 21-30 years and those who were divorced, unemployed, less
educated and belonged to the lower class.
CONCLUSION: The present data suggest that impulsivity, as reflected by a tendency toward rapid, unplanned
responses on an immediate memory task, is a measurable characteristic of subjects with severe previous suicidal
behaviour. People who attempted suicide tend to experience higher levels of trait impulsivity.
KEY WORDS: Attempted suicide, impulsivity, marital status, occupational status, educational status and
Suicidal behaviour is a major public health problem.
Every year around 1 million people die because of
suicide around the globe (1).The World Health
O r g a n i z a t i o n e s t i m a t e s t h a t w o r l d w i d e ,
approximately 1.53 million people will pass awayby
suicide, and 10 to 20 times more people will attempt
suicide by year 2020 (2). Generally suicide is
considered 11th leading cause of death, but it is the
3rd leading cause of death for people aged 15 to 24.
Deprivation of spirit is not the sole cause of suicide,
but it also negatively affects the folks and
acquaintances of a person who attempt suicide.
Surveys showed that the prevalence of suicidal
attempts is more than committed suicide (3).
Suicidal attempt is counted an act potentially injurious
with non-fatal outcome with evidence of intent to die
while suicide is defined as an act of intentionally
ending one's life.Although the cases of suicide are
complex, but it involves environmental, biological,
social and psychological factors also including
psychiatric disorders. Socio-political factors are also
pertinent to understanding of suicide. So, historically
Durkheim defined suicide in terms of; Anomy, Egoistic
and Altruistic (3-5). Currently Joiner's interpersonal
psychological theory received considerable attention
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S 1 1
in scientific research. Agreeing to this hypothesis,
three things must be present before a mortal will pass
away by suicide; these are 1) feelings of perceived
burdensomeness 2) a sense of thwarted belongings,
and 3) an acquired capability to lethally
selfinjury.Perceived burdensomeness occurs when a
person thinks that others will be feeling better if he/she
was numb.Thwarted belongings mean that when
person's need/desire was depended on others, only
they are not satisfied. Acquired capability to lethally
self-harm is consider acquiring capability for suicide.
Thus, Joiner's explains that when a person is
repeatedly exposed to painful/or proactive stimuli
he/she will develop the capability for suicide. The study
showed that these factors are predictors of suicidal
Impulsivity has also been connected with suicide and
self-injury and is regarded one of the important risk
genes to the aetiology and predictive of suicide (8).
Impulsivity comprises of many thought constructs such
as; self-control, cognitive complexity, attention,
cognitive instability and non-planning. There is
significant role of impulsivity in suicide, merely, a
compelling mechanism for this relationship has not
been adequately documented. Yet, surveys have
shown that rate of attempted suicide tends to be higher
in impulsive individuals than non-impulsive people.
However not all people who die by suicide are
impulsive (9).The relationship between suicide
attempts and impulsivity can be considered as having
two dimensions, state impulsivity and trait impulsivity.
State impulsivity can be defined as impulsive
experience at certain situation or point and usually this
type of suicide is unplanned. Intrait suicide on the other
hand a person has impulsive personality that
influences his interest in risky behaviours and can
contribute to suicidal behaviour. These two dimensions
may not completely overlap or be equivalent and may
bear a different relationship with lethality (10-11).A
study conducted in China which included 239
consecutive suicide attempters found that 44.8%
patients were categorized as impulsive attempters.
Consistent with these findings other studies also
described a substantial link between suicidal
behaviour and impulsivity (12-13).Moreover,
Dougherty and colleagues reasoned that higher
degree of impulsivity was related to more suicide
attempts.Some mental disorders that have impulsivity
as a core feature are considered a risk of suicidal
behaviour, People with borderline personality disorder
are more likely to engage in self-mutilating behaviours
which contribute to suicide (14).Therefore, it appears
that impulsivity does play an important but distal role, in
suicidal behaviour. Researchers reasoned that people
with high impulsivity tend to hire in more painful and
risky behaviours which make them more vulnerable to
acquire capability for suicide, and less scared of death
(7,15).Suicidal attempt is an important problem in
Pakistani population because in the last few year rate
of suicidal attempts has increased due to different
causes such as unemployment, lack of resources, low
literacy rate, weak political processes and lack of
proper primary and mental health services (16).
The principle of this study is to establish local
perspective as there is a dearth of local information.On
the foundation of this study effective screening and
management plans can be built up in order to identify
and scale down the incidence of suicide attacks.
SAMPLE: The required sample size was calculated
using WHO software by taking the prevalence of
44.8% (14)confidence level 'C. I'=95%, margin of error
d=10%. The sample size came out to be 95. The
sample was gathered through non-probability
Consecutive sampling technique.
Patient with history of suicide
attempt(s) within last three months
Male or Female.
Age 20-60 years.
Non consenting patients.
Known thyroid disease.
Critically ill patients.
Congestive cardiac failure.
Post myocardial infarction.
Chronic renal failure.
Chronic liver disease.
DATA COLLECTION PROCEDURE:
This study was conducted after approval from College
of Physicians and Surgeons Pakistan and institutional
ethical review committee. Patients who met the
inclusion criteria were selected from Psychiatry
Department, Abbasi Shaheed Hospital, Karachi and
after taking informed consent, confidentiality was
assured.information about suicide attempt and
demographic data was taken from the patient and
confirmed by an attendant. The Barratt Impulsiveness
Scale (BIS-11) that consists of 30 self administered
questions, which is scored out of 120, rated from 0-4
and cutoff is ≥ 22 (calculated by the formula 30 x 75%),
was used to measure impulsivity, filled by the patients
in terms of (Yes (1) / No (0)]. The findings of outcome
variable impulsivity (yes/no) was entered in Performa.
DATA ANALYSIS PROCEDURE:
The data wasanalyzed using SPSS Version 20.
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S
Demographics were presented as simple descriptive
statistics, giving mean and standard deviation for age
and BIS-11 score. For qualitative variables like gender,
marital status, educational status, socioeconomic
condition, occupational status and impulsivity (yes/no)
were presented as frequency and percentages. Effect
modifiers were controlled through the stratification of
age, gender, marital status, educational status,
socioeconomic status and occupational status to see
the effect of these on the outcome variable. Post
stratification chi square test was applied taking the
pv a l u e o f ≤ 0 . 0 5 a s s t a t i s t i c a l l y s i g n i fi c a n t .
Table 1 shows descriptive statistics, mean and
standard deviation of age and BIS-11 score. Figure 1
shows the frequency of impulsivity in the entire
sample. The findings of Chi-square test presented in
MEAN ± SD STANDARD MIN-MAX
IMPULSIVITY DISTRIBUTION n=95
IMPULSIVITY ACCORDING TO GENDER
IMPULSIVITY ACCORDING TO AGE n=95
Suicidalbehaviour is a major public health problem all
over the world and one of the leading causes of deaths
in young people. Each year approximately one million
people perish due to suicide. Suicidal behaviour can
be considered as a continuum ranging from wish of
death or ideation in the form of views and passive plan
to harm oneself / to attempt suicide / complete suicide.
Risk analysis varies from only suicidal ideation without
a plan (low severity) to the highest severity if there is
suicidal ideation with the plan or any past suicide
attempt. Impulsivity either chronic or acute isrisk factor
for suicide, further trait impulsivity ishigher in
attempted suicide than those who have only suicidal
ideation. Nevertheless, these widely held perceptions
of the association between suicide and impulsivity
appear to have mixed findings in many researches (1,
Findings of current study indicated that out of 95
patients who attempted suicide, 45 (47.4%) had
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S
impulsivity and 50 (52.6%) had no impulsivity. The
sample consisted of28 (29.5%) male and 67 (70.5%)
female. Stratification for gender with respect to
impulsivity showed that out of 95 patients, 13 (46.4%)
males were impulsive while 15 (53.6%) were not,
Whereas 32 (47.8%) females were impulsive but 35
(52.2%) were not. Wang et al. studied impulsivity and
suicide behaviour among the scholars of China.They
reported that in total (5,265), 9.1% (n= 479) students
never thought about suicide, but 1% (n=50) had a
history of attempted suicide. Further analysis indicated
significant differences between suicidal ideates and
attempters on cognitive impulsivity and self-oriented
attacks (18). Similarly Ghaffari et al. found significant
difference between suicides ideates and non-suicide
ideates individuals in attempted, motor and
nonplanning impulsiveness. Moreover, there is high
incidence of substance abuse and significant other
suicide attempts among suicide ideates as compared
to non-suicidal ideates (19).Another survey concluded
that people with bipolar disorder score high on the
BIS11 scale as compared to normal mortals.These high
scores were associated with past suicide attempts and
a g e , b u t e d u c a t i o n h a s l e s s i n d e p e n d e n t
effect.Suicidal ideation is highly prevalent and patients
with high impulsivity score appear to be more
susceptible to committing suicide. Thus impulsivity
may be an important factor for differentially predicting
between individuals with suicide ideation and those
who have made intention to attempt suicide (20).
On contrary Berzo and colleagues found no difference
in impulsivity of suicidal ideates and suicide
attempters, same as another study showed that
suicide ideates and attempters both have the same
scores in impulsivity, but scores were higher than
people who have never been suicidal (21).It suggested
that impulsivity is moderately high in people with
suicidality either in ideas or behaviour.Suicide
attempts estimates to be impulsive range from 20% to
85% (22-23).Anestis et al examined 70 studies on
impulsivity and suicide, they concluded that impulsivity
and suicide were moderately realted. Impulsivity has
an indirect relation rather than direct and central but
there is a role of impulsivity in suicide (8).
This study began to elucidate the role of impulsivity in
suicidal behaviour. Present data suggests that
impulsivity, as reflected by a tendency toward rapid,
unplanned responses on an immediate memory task,
is a measurable characteristic of cases with severe
previous suicidal behaviour.This issue seems to be
influenced by education, socioeconomic, occupation,
married status, age and is dependent on the clinical
state at the time of testing.People who attempted
suicide tend to experience higher levels of trait
Conflict of interest: Author declares no conflict of interest.
Funding disclosure: Nil
Ayesha Abdul Hameed; concept, data collection, data analysis, manuscript writing, manuscript review
Haresh Kumar; data collection, data analysis, manuscript writing, manuscript review
Sarika Bai; data analysis, manuscript writing, manuscript review
Azra Shaheen; data analysis, manuscript writing, manuscript review
Ravi Athwani; data analysis, manuscript writing, manuscript review
Mohammad Munir Hamirani; data analysis, manuscript writing, manuscript review
24. Witte TK , Merrill KA , Stellrecht NE , et al. “ Impulsive” youth suicide attempters are not necessarily all that impulsive . J Affect Disord . 2008 ; 107 : 107 - 116 .