Main Coping Style of Self-Immolation Patients

⁴ Medical Sciences Education Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

*Corresponding author: Majid Khadem-Rezaiyan, Department of Community Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Email: khademrm@mums.ac.ir

EXTENDED ABSTRACT

Background

Self-immolation is a severe and highly lethal form of suicidal behavior that is reported more often in developing settings, including countries of the Middle East, than in many developed countries [1, 2]. Iran has been identified as a country with a substantial burden of self-immolation, and marked regional differences in incidence have been described [2, 3]. Recognition of personal, social, and sex-related patterns may help identify people at increased risk and support targeted preventive interventions [4]. Suicide prevention depends not only on treatment of psychiatric disorders and restriction of access to lethal means, but also on strengthening adaptive responses to psychological stress and improving help-seeking and problem-solving skills [5, 6].

Coping strategies are cognitive and behavioral efforts used to manage internal or external demands that are perceived as exceeding an individual's resources. In the classic framework of Lazarus and Folkman, coping may broadly involve problem-focused attempts to alter the stressful situation or emotion-focused attempts to reduce its emotional consequences [7]. Healthy coping behaviors have been reported less frequently among people who attempt suicide, while emotion-oriented patterns have been associated with greater perceived stress and suicidal ideation [8, 9]. Coping has also been studied in chronic illness, trauma, and burn survivors, but evidence specifically addressing self-immolation remains limited [10-16]. Because sociocultural context may influence both self-immolation and coping behavior, the present study evaluated coping styles among patients who attempted self-immolation and examined their relationships with demographic characteristics and burn-severity indicators.

Methods

This cross-sectional study included patients admitted to the Imam Reza Educational, Research and Treatment Center in Mashhad because of self-immolation during the period from February 2018 to February 2020. Patients who acknowledged intentional self-immolation were enrolled after informed consent. When self-immolation was initially denied but the burn distribution suggested intentional injury, including burns involving the head, neck, or upper trunk, accompanying family members were questioned; patients were included when self-immolation was confirmed and consent was obtained. Sampling was by census of eligible admitted patients.

All participants completed the 60-item Jalowiec Coping Scale. Each item is scored from 0 to 3, and the instrument evaluates eight coping styles: confrontive, evasive, optimistic, pessimistic, emotive, palliative, supportant, and self-reliant. Because the number of items differs among styles, mean scores were calculated and expressed as percentages to facilitate comparison. For each patient, the dominant coping style was defined as the style with the highest score. The validity and reliability of the questionnaire had previously been evaluated in Iranian populations [17]. Demographic variables included age, sex, ethnicity, marital status, occupation, and education. Burn-related variables included total burn percentage, burn degree, and the Abbreviated Burn Severity Index (ABSI) [18], together with hospital outcome.

Data were analyzed in SPSS version 16. Quantitative variables were compared between two groups using the independent-samples t test and among three groups using one-way ANOVA; categorical variables were assessed using the chi-square test. Relationships between quantitative variables were examined with Pearson correlation. When assumptions of normality were not satisfied, the corresponding nonparametric tests were used. All analyses were two-sided, with P<0.05 considered statistically significant. The study was approved by the Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.MEDICAL.REC.1399.385), and written informed consent was obtained from all participants.

Results

A total of 44 patients were included. Twelve patients were men (27.3%) and 32 were women (72.7%); the mean age was 30.2±13.1 years. Most participants were married (32/44, 72.7%), and Persian ethnicity was the most frequent (24/44, 54.5%), followed by Kurdish ethnicity (9/44, 20.5%). Homemakers constituted 27.3% of the sample and workers 22.7%. Educational attainment was generally low: 31.8% had primary-school education and 34.1% had middle-school education. During hospitalization, 29 patients (65.9%) were discharged and 15 (34.1%) died.

Table 1. Baseline characteristics of the study participants.

The dominant coping style was emotive in 21 patients (47.7%), pessimistic in 11 (25.0%), confrontive in 4 (9.1%), evasive in 3 (6.8%), self-reliant in 3 (6.8%), and supportant in 2 (4.5%). No participant had an optimistic or palliative style as the dominant coping pattern. Among men, emotive coping was the most frequent dominant style (58.3%), followed by self-reliant and pessimistic styles, each in approximately 16.7%. Emotive coping was also the most frequent dominant style among women. Men used the emotive coping style significantly more than women (P=0.05), whereas no significant sex differences were detected for the other coping styles.

Age showed a significant inverse correlation with the emotive coping style (r=-0.35, P=0.02), indicating greater use of emotive coping at younger ages. No significant correlations were found between age and the other coping styles. Dominant coping style was not significantly associated with ethnicity (P=0.62), marital status (P=0.82), education (P=0.76), occupation (P=0.34), or hospital outcome (P=0.22).

Table 2. Association of dominant coping style with ethnicity, marital status, education, occupation, and outcome.

The mean burn percentage was 45.3±23.3%, and the mean ABSI was 8.8±2.9. Forty-three patients had third-degree burns and only one patient had a second-degree burn; the latter patient had a pessimistic dominant coping style. The lowest mean burn percentage and the lowest mean ABSI were observed among patients with a confrontive dominant style, whereas the highest mean burn percentage occurred among those with an emotive dominant style. Nevertheless, burn percentage, ABSI, and burn degree were not significantly associated with coping style. Thus, the study's principal positive associations concerned emotive coping with male sex and younger age rather than with the anatomical or severity characteristics of the burn injury.

Conclusion

Emotive coping was the predominant coping pattern among patients admitted after self-immolation, accounting for nearly half of the sample, and pessimistic coping was the second most frequent pattern. Young men were particularly likely to use emotive coping: men used this style significantly more often than women, and increasing age was inversely associated with emotive coping. In contrast, coping style showed no significant relationship with ethnicity, marital status, education, occupation, hospital outcome, burn percentage, ABSI, or burn degree. These findings are broadly compatible with previous reports linking maladaptive or emotion-oriented coping with suicidal behavior and poorer psychological adjustment [25, 27-31]. The results support the study authors' view that training healthy coping and interpersonal problem-solving skills, particularly for younger men and other people at risk, may contribute to prevention of self-immolation and its consequences. Because no participant had optimistic or palliative coping as the dominant style and the sample was limited, the article recommends longer recruitment periods and larger samples to clarify the role of these less frequent coping patterns.

Keywords: Coping Style, Self-Immolation, Suicide

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