Personality Traits among Psychiatric Out-patients with Suicide Attempt Attending Tertiary Care Hospital in Eastern Nepal

Background-Suicide attempt is a self-injurious behaviour with a nonfatal outcome. Studies report increasing hospital admissions due to self-inicted harm (SIH) as well as a higher likelihood of associated psychosocial factors in SIH cases. We conducted a study to explore personality traits, socio-demographic proles and psychiatric disorders among the suicide attempt cases in a tertiary care hospital setting of eastern Nepal. Methods-It was a descriptive study conducted with purposive sampling in a tertiary care hospital among suicide attempt cases who visited to out-patient department of psychiatry. A total of 113 cases (calculated sample size) were enrolled after written informed consent within study period of 1 year. Personality traits were analyzed by using ‘Personality Trait Inventory’ questionnaire. Psychiatric diagnosis was made as per the ICD-10 diagnostic criteria. Demographic variables were recorded in a semi-structured proforma.

Background 'Suicide' is derived from the Latin word for 'self-murder'. It is a fatal act that represents the person's wish to die. 1 Suicide ideation and attempts are strongly predictive of suicide deaths; can result in negative consequences such as injury, hospitalization and loss of liberty. 2 Psychiatric patients who attempt suicide have greater suicidal ideation, compared with the patients who do not attempt suicide. 3 Clinical and community researches suggest links between suicide attempts and psychological traits of aggression, anger and impulsivity. Aggressiveness has been related to suicidality in mood disorders. 4 Higher rates of lifetime aggression were observed in suicide attempters, compared to non-suicidal patients and lifetime aggression traits did correlate with suicide attempts in patients with mood disorder. 4 Evidence on the relationship between personality traits and suicide is strongly emerging. Studies on the records of psychiatric patients with and without suicide attempt show that those who committed suicide possessed anger, aggression, anxiety and depression personality pro les. 5 Depressed patients with borderline personality traits were characteristically vulnerable and had familial generalized anxiety disorder in comparison with other groups. 6 Borderline and narcissistic personality pathology are linked as unique contributors to suicide related outcomes. 7 Impulsivity and aggression have been demonstrated as important suicide risk factor, and are also typically present in patients with conduct disorder, personality disorders, substance use disorders and bipolar disorders. 8 It is logical to hypothesize that impulsivity and suicidal behavior are correlated, because impulsive individuals might be more likely to enact a suicidal ideation. 9 The personality trait of neuroticism, which is demonstrably associated with both depression and unstable mood, is also a focus of suicide research. Bowen et al. demonstrated that neuroticism could predict depression and suicidal thoughts. 10 Some personality traits could also be predictive of psychiatric disorders. For example, neuroticism has been described as linking anxiety and depressive disorders. However, the underlying mechanisms that explain why some personality traits confer greater risk for suicidality and/or psychiatric disorders are not fully understood. Previous studies reported that personality disorders associated with affective lability and impulsivity had a higher prevalence among those who attempted suicide than other types of personality disorders. 11,12 Thus, it is necessary to study and identify different aspects of personality traits, such as impulsivity or neuroticism, in people with or without psychiatric disorders who have attempted suicide.

Methods
The objective of current study was to explore personality traits, socio-demographic pro les and psychiatric disorders among the suicide attempt cases. It is a hospital based descriptive study conducted among psychiatry out-patients with history of suicide attempt, attending a tertiary care teaching hospital in eastern Nepal. We enrolled a total of 113 subjects which was sample size calculated based on the study titled 'Clinical Correlates Associated with Suicide Attempters at a Tertiary Care Centre of Eastern Nepal' by Pandey AK et al (2015) 13 where prevalence of personality disorder (the correlate with the least prevalence among the correlates studied) was 24%. Here, Prevalence (p) = 24% Compliment of prevalence We used personality trait inventory consisting of 90 items to look for different traits in suicide attempt cases. Measurement of each trait was based on the questions of 10 items assigned for those particular 9 traits. As per the questions based on the inventory: Activity trait refers to an individual's tendency as outgoing, ambitious, rigidly organized, highly status-conscious, impatient, anxious, proactive, and concerned with time management. They are often high-achieving 'workaholics'. Superego are those who generally has high internal controls or standards. Introversion is withdrawn and reclusive; an introverted person is often cautious and secretive in dealing with others. Dominance trait re ects a person's tendency to be sociable, outgoing, active and assertive.

Data Processing
The coded proforma was collected and information were entered into computer. Quantitative and qualitative data processing were used with computer processing. The output of the project was able to provide data on the percentage, mean and standard deviation and summarized using frequency distribution tables and graphical methods (Bar diagram, Pie chart).
Identifying personality disorder as risk factors for suicide attempts is an important consideration both for research and clinical care. We found that personality disorder was seen in 34% of the total cases where Emotionally unstable personality disorder and Anxious personality disorder were found in the highest number of patients. This nding corresponds to the study by Pandey et al 13 in the same setting where 24% of the cases were found to have personality disorder, mainly Emotionally unstable impulsive subtype. Also a study by Risal A et al 14 found that Personality disorder was present in 26% of the patients admitted for intentional self-harm, mainly Emotional unstable personality disorder (impulsive type).
Our nding in BPKIHS was consistent with the study by Nabi J et al 15 where most predominant type of personality disorder was Borderline personality (28%). There was also a signi cant association (P < 0.05) between personality traits and past attempts interval, i.e. patients with Borderline personality traits were signi cantly associated with re-attempt suicide. Our nding also corresponds with Ansell Emily B et al 16 where Borderline personality disorder was a signi cant predictor of any attempt in the presence of all personality disorders. Another study by Bhatt M et al 17 found that impulsivity and borderline personality symptoms were signi cantly associated with attempted suicide. This suggests that symptoms of impulsivity in personality are strong predictors of suicide and may act in many ways by impairing the ability to cope with any situation and by drawing a person into con icts with family members and others.
The mean age of our subjects was 28.27 years and the age range was 13-75 years. This nding corresponds with the study by Shakya DR 18

Conclusion
Emotional instability trait was found in highest number of patients 70 (61.9%), followed by Depressive tendency 46 (40.7%) while personality trait was assessed using Personality Trait Inventory Questionnaire.
Personality disorder was present in 34%; most common being Emotionally unstable personality disorder. Among the suicide attempters; most common ICD-10 psychiatric diagnosis as was Substance use disorder, followed by Adjustment and Mood disorders. Majority of the psychiatric out patients with suicide attempters were female, married and literate, with the most common age group of 20-29 and < 20 years. Most of them were homemakers and from urban setting. 403/074/075 and Code: IRC/1216/018). Cases were enrolled after informed written consent from the subject. Strict con dentiality of information was maintained and the results were utilized for management of the problem concerned and similar problems in general.
Consent for publication-Not applicable.
Availability of data and materials-All data generated during this study are included in this published article.
Competing interests-The authors declare that they have no competing interests.
Funding-None. The authors, however, declare that they received logistic support from BPKIHS research committee.
Authors' contributions-DRS and SSB were involved in all steps. NS, RGJ and MB were involved in research designing, assisting data collection and editing. BKD analyzed and interpreted the subjects' response regarding personality traits. All authors read and approved the nal manuscript.