Σάββατο, 27 Οκτωβρίου 2007

The impact of the loss of a loved one as a sibling

Aikaterini Samiotou, MSc

The loss of a family member has been considered as one of the most stressful experiences (Holmes & Rahe 1967 cited by Clark & Goldney 2000). In a study that tested the adolescents’ perceptions and experiences around death and grief, the loss of a loved one was considered the most distasteful aspect of death (Morin & Welsh 1996). The term bereavement refers to “all the physiological, psychological, behavioural and social response patterns displayed by an individual following the loss of a significant person or thing” (Dunne et al. 1987, cited by Cvinar 2005). Bereavement is associated with increased rates of mood disorders in children and adolescents (Weller et al. 1991).

One of the few studies that aimed to describe the characteristics of the children and adolescents after the suicide of their sibling presented them as being in a high risk for psychiatric symptomatology and social maladjustment (Pfeffer et al. 1997). According to the same study the children and adolescents survivors demonstrated a higher proportion of clinically significant depressive, anxiety symptoms and poorer school adjustment compared to a community sample. The siblings of suicide victims also reported more posttraumatic symptoms and suicidal ideation but no suicidal attempt. One important finding was that the severity of these symptoms and dysfunction was significantly related to parental psychopathology and stressful life events. Similar findings in terms of psychiatric symptoms were presented in Brent and colleagues’ study where the increase in the incidence of major depression in siblings was found to be seven times higher compared to community controls. This increase in new-onset depression was associated with personal history of psychiatric disorder and family history of psychiatric disorder and depression and remained significant even after 6 months (Brent et al. 1993). Both studies presented no excess in terms of suicidal behavior. The pervasiveness of the depressive disorder was tested in a longitudinal study that followed –up to 3 years the above sample of siblings. In contrast to the previous findings the authors concluded that although the siblings presented an increased number of severe symptoms related to grief, they appeared not to be at an increased risk for the development of depression and posttraumatic disorder over the length of follow-up and did not show elevated rates of recurrence (Brent et al. 1996). A study that evaluated the effects of bereavement group intervention on siblings of suicide victims indicated that although the children demonstrated depressive symptoms, anxiety and posttraumatic stress symptoms as well as social maladjustment, the majority did not fulfill the criteria for psychiatric disorders and had low levels of psychosocial adjustment problems (Pfeffer et al. 2002).

The body of research that focuses on the psychiatric sequelae after the loss of a sibling to suicide is restricted (Ness & Pfeffer 1990). Findings that support the increase in mood symptomatology in children and adolescents who suffer from the suicidal death are also reported in studies testing the impact of parental loss to children (Weller et al. 1991). The hypothesis that children who had experienced the suicidal death of a close relative would be more vulnerable to psychopathology, especially depression and posttraumatic disorder compared to children bereaved from paternal death not caused by suicide was tested in Cerel and colleagues’ study. The children appeared more likely to show elements of mood symptomatology, anxiety and behavioral disturbance in the first 2 years after their parent’s death compared to non suicidal bereaved children. However no differences were found in suicidality and severity of depressive symptoms between the two groups apart from that period. Interestingly, the suicidal bereaved children didn’t demonstrate more posttraumatic stress symptoms and psychosocial functioning compared to the non suicidal bereaved group (Cerel et al. 1999). The psychological consequences of the suicidal death on the close relatives were indicated in a study where depression was reported by one half of the survivors (Saarinen et al. 1999). Increased rates of depressive symptoms were reported by adolescents after the suicidal death of a close relative, in a research interested in the bereavement experiences (Harrison & Harrington 2001).

The number of studies that have been interested in the bereavement procedure and grief response especially in the sibling group is very limited. The findings regarding the bereavement expression after a suicide should be considered as associated with the whole family reaction and not only the siblings’ reaction to this type of death.

One of the most contradictory areas in bereavement research is whether the bereavement after suicide is different from other types of death. Clark and Goldney report that the bereavement process after suicide compared to other types of death presents few and not consistent quantitative differences (Clark & Goldney 2000). Quantitative studies have failed to confirm that the suicide survivors suffer more compared to survivors of other types of death (Ellenbogen & Gratton 2001). Although Ness and Pfeffer in their review did not provide conclusive evidence supporting the difference of suicide bereavement compared to other bereavement types, they suggested that there are differences in the thematic aspects of grief following a suicide (Ness & Pfeffer 1990). They have included the results of several uncontrolled studies and concluded that the grief response to suicide includes an initial shock and disbelief followed by a preoccupation with an explanation for the event. Feelings of anger and guilt were also reported in the same review. Similar findings regarding the aspects of grief after suicide are reported in an article arguing for the difference of bereavement after suicide (Jordan 2001). This article reported studies that suggest that the suicide bereavement consists of preoccupation with the meaning of suicidal death as well as guilt and blame for the act. More intensive feelings of guilt and responsibility in the suicide survivors than other survivors have been reported in different studies (Reed & Greenwald 1991). Reed in his study aiming to discriminate the factors that influence the grief procedure suggested that the survivor’s characteristics, the mode of death and the social support play a significant role. In the same study, increased feelings of rejection were experienced by the survivors (Reed 1998). Feelings of shame, rejection and stigmatization were also shown in a different study suggesting the social stigma around the suicide and the low emotional support that the suicide survivors feel (Bailley et al. 1999). Stigmatization as well as lack of comfortability was reported as elements of the reaction of the social network towards the suicide survivors (Vandongen 1993).

Friends

The event of completed suicide is considered to have deleterious psychiatric effects on the victim’s friends and peer group (Brent et al. 1992). Among the number of studies that explore the effects of the exposure to a peer’s suicide, a view that the incidence of completed suicide may lead to increased risk for subsequent suicidal behavior arises (Brent et al. 1989). This view is known as the contagion hypothesis and considers the pathway that increases the risk for suicidal behavior in peers after exposure to suicide to be the imitation (Brent et al.1989; Brent et al. 1992). This view is supported by evidence of clustering of suicides among adolescents and young adults and especially a clustering that appears two to four times commoner in the adolescent group that any other age group (Gould et al. 1990). Suicide epidemics that occur in time-place proximity also support the role of imitation in the suicidal behavior (Gould et al. 1989). The media coverage of suicide has been also related to suicide contagion and copycat suicides (Gould 2001). The possible role of imitation as a model of explaining the subsequent suicide risk after the exposure to suicide has been tested in different studies and leaded to conflicting results (Watkins & Gutierrez 2003).


Is suicide after exposure to a peer’s suicide contagious?

Findings that support the above query have been reported in Brent’s et al study where increased rates of suicidal behavior have been reported among the close friends of suicide victims (Brent et al. 1989). Differences in the friends of adolescent suicide completers in suicide ideation, behavior and disturbance compared to students with low exposure have been demonstrated in a different study (Hazell et al. 1993). Aiming to speculate the mental health of friends of suicide completers, Ho and his colleagues provided evidence of increased rates in suicidal behaviors after the exposure to suicide and they attributed this elevated risk for subsequent suicide partly to psychiatric vulnerability, underlying the causal role of the closeness with the suicide victim and the level of exposure in the increase of suicidal risk (Ho et al. 2000). The impact of friendship environment on suicidality has been investigated in a study of 13465 American adolescents where a friendship with a suicide victim was associated with increased rates of suicidal ideation and attempts both in male and female adolescents (Bearman & Moody 2004). Similar findings regarding the effect of friendship to suicidality have been reported in Gutierrez’s et al study where the exposure to a friend’s suicide was related to weaker attraction and perceptions about life and stronger attraction to death in the exposed adolescents (Gutierrez et al. 1996). Cerel et al studying a large sample of adolescents (5852) reported that the exposure to a peer’s suicidal behavior significantly increases the likelihood of suicidal ideas and attempts (Cerel et al. 2005). Results that contradicted the above findings were reported by Watkins & Gutierrez. These researchers hypothesized that the exposure to a peer’s suicide would increase the risk of suicidal behavior among the friends but their results failed to confirm the above hypothesis. In contrast they found no difference in the suicide rates between the exposed and non- exposed adolescents (Watkins & Gutierrez 2003). In a recent study that explored the relationship between the exposure to suicide –related behaviors and nearly lethal suicide attempts, the factor of exposure proved to be associated with reduced likelihood for nearly lethal suicide attempts among the friends. Interestingly, a protective association between the exposure to suicidal behavior of peers and nearly lethal suicide attempts arose when the emotional distance between the person that displayed the suicide –related behavior and the exposed friend was greater (Mercy et al. 2001). Findings supporting this view can be seen in Brent and colleagues’ research where no evidence of imitation were reported as the rates of suicidal behavior in the exposed and control group appeared similar. Anecdotal evidence was presented regarding the association of exposure with an inhibition from suicidality among the exposed adolescents (Brent et al. 1992). The possible protective role of exposure to suicidal behavior of a friend was detected in a different study. In the light of no significant differences among the suicidal rates between the exposed and non exposed adolescents, the authors argued that being exposed to the painful consequences of suicide on the family and friend environment may have inhibited the exposed friends from subsequent suicidal behavior (Brent et al. 1993). Following –up the same sample 3 years after the suicide no increased risk for suicide attempts was detected among the friends of suicide victims, providing support for the inhibition view (Brent et al. 1996).

One of the most interesting findings in the review of the research regarding the grade of the effect of a friend’s loss to suicide is the psychiatric vulnerability of the exposed adolescents (Brent et al. 1992). In the same study, among the friends the rates of a psychiatric diagnosis before exposure were high (62%) and the rates of family psychopathology were even higher (91%) (Brent et al. 1992). Although the findings regarding the contagion hypothesis may be at some level contradictory, most of the studies agree that there are pre-existing vulnerabilities in the exposed friends who develop psychiatric psychopathology and display suicidal behavior (Ho et al. 2000).



The body of research that focuses on the impact of exposure to suicide on friends of suicide victim, apart from exploring the likelihood of subsequent suicidal behavior, shows considerable attention to the psychiatric effects of the loss.

Aiming to detect the impact on the friends, Brent and colleagues interviewed the friends of suicide victims 6 months after the loss. The exposed group presented higher rates of new onset of any psychiatric disorder (major depressive disorder, anxiety, substance abuse, conduct disorder and attention deficit disorder) and especially major depression that was evident even 6 months after the death. Severe posttraumatic symptoms were observed but not posttraumatic stress disorder as a diagnosis. The authors claimed that the psychiatric effects of the exposure were consistent with pathological bereavement (Brent et al. 1992). Similar increased rates of new –onset major depression and posttraumatic stress disorder were reported in a different study. The exposure to suicide was related to a threefold increased risk for depression which was associated with vulnerability factors such as personal and family history of depression (Brent et al. 1993). The high rates of depression disorder reported in the above study were examined in study aiming to identify whether these rates could be considered as a major depression or as uncomplicated bereavement. Given the personal and family history of depression, the clinical picture of the major depression and factors associated with the relationship with the victim and the suicide exposure, the authors argued that these high rates could be considered as bereavement complicated by major depression (Brent et al. 1993). The above sample of friends of suicide victims was followed-up 3 years after suicide and presented higher rates of new –onset major depression, anxiety and posttraumatic stress disorder compared to the unexposed control group (Brent et al. 1996). Brent and colleagues identified the risk factors for the incidence of posttraumatic stress disorder after exposure to a friend’s suicide. They reported that the adolescents who developed posttraumatic stress disorder had a greater exposure to suicide, closer relationship to the victim, presented major depression simultaneously and more severe grief response. Factors as history of suicide attempt and disrupted family and social relationships were also proved associated with the incidence of posttraumatic disorder in the exposed friends (Brent et al. 1995). The incidence of traumatic grief that complicates bereavement and acts independently of depression on suicidal ideation after exposure to a friend’s suicide have been demonstrated in a study exploring the effects of the suicide on adolescents and young adults friends of suicide victims (Prigerson et al. 1999). Traumatic grief has been associated with more functional impairment, more health problems and suicidal ideas, even independently of depression and anxiety (Melhem et al. 2004). Based on the above findings regarding the traumatic grief, Melhem and colleagues aimed to describe the nature of traumatic grief in adolescent friends of suicide victims and its association with depression and posttraumatic stress disorder. Traumatic grief was described as yearning, crying, preoccupation with the suicide victim, functional impairment and difficulty in adjustment to the death. Apart from the co-morbidity of traumatic grief with depression and posttraumatic stress disorder, traumatic grief was proved to act independently and predicted the onset of these two psychiatric conditions (Melhem et al. 2004). In a recent study, one of the most interesting findings was that apart from the depressive symptoms that exposed friends presented, an elevated likelihood for this exposed group to engage in risk situations such as marijuana use, drinking and fighting was documented (Cerel et al. 2005). The adolescents exposed to suicide showed significantly increased risk for developing a new onset major depressive disorder especially one month after the suicidal death in Bridge and his colleagues’ study. The factors that proved associated to the new onset of major depression were family history of depression and feelings of responsibility and accountability for the suicide (Bridge et al. 2003).

What are the implications of the above scientific knowledge?

Regarding the siblings of an adolescent that committed suicide, an increased risk in subsequent suicidal behavior has been demonstrated as a part of the impact of the suicidal death. In respect to the above risk, different findings emerged. Different studies based on different theories were conducted in order to understand the possible factors that predispose an individual to suicidal behavior. The results of the studies are most of the times contradictory and address the familial aggregation of suicide by different perspectives. The role of psychopathology as a potential way of familial inheritance of suicide has been examined and was proved to be significant. The psychopathology and especially the affective disorders and the substance abuse have been recognized as significantly related to suicide. The familial aggregation of psychiatric illness is also well documented and is considered as a possible pathway for the transmission of suicide in the family (Bridge et al. 1997). However, this pathway is not conclusive given the evidence of familial transmission of suicide irrespectively of the psychiatric disorder (Johnson et al. 1998). Aiming to have an insight in the suicide phenomenon among the family members, the role of genetics arises as a significant predisposing factor (Roy 1991). Twin and adoption studies presented the genetic contribution in the suicide transmission. The neurobiology of suicide focuses on the serotonin disregulation but the several questions remain unanswered (Kamali et al. 2001). It is still not clear whether the levels remain stable or change in relation to the psychiatric condition and the findings regarding the serotonin contribution have been reported only in adult population above 16 year old (Shaffer & Craft 1999). The above studies demonstrate the significant role of genetics but do not provide evidence for the exclusive responsibility of genes in the familial clustering of suicide. The environmental component has been also highlighted. Shared environmental factors as poor parent-child relationships, family history of unemployment, disorganization, break up in the family and exposure to suicide in the same family contribute significantly to the familial clustering of suicide (Gould et al. 1996; Jordan 2001).
Studies that focus on the exposure to a friend’s suicide consider the increased suicide risk for the exposed friends under the spectrum of imitation and contagion. Indeed several studies have presented evidence that support a subsequent increase in suicidal behavior after a suicidal death (Hazell et al. 1993; Ho et al. 2000). The above studies attribute the increase to imitation and to the closeness of the relationship with the victim. However an interesting point in this literature review is that the evidence regarding the contagion hypothesis is contradictory and there are studies that did not support the above hypothesis, presenting no increase in the suicide rates after a suicide (Watkins & Gutierrez 2003; Brent et al. 1993). These studies discuss the possible methodological limitations that prevented them from supporting the imitation theory but also underline that the decision that leads an adolescent to end his life is complex and cannot be related to a single factor. Contrary to imitation beliefs, very interesting findings regarding the inhibitating role of the exposure to suicide from subsequent suicidal behavior, were demonstrated in this literature review. In the light of no evidence regarding imitative suicide among the exposed friends, the event of suicide was considered to cause an inhibition from the suicidal behavior due to acknowledgement of the painful effects on friends and family (Brent et al. 1992; Brent et al. 1996) and due to greater emotional and temporal distance from the victim (Mercy et al. 2001).
Apart from the different findings regarding the contagion, from the body of research that focuses on the suicide, the psychiatric vulnerability of the exposed friends arises. More specifically the exposed friends presented high rates of pre-existing psychopathology and even higher rates in family history of psychopathology (Brent et al. 1992).

The above evidence regarding the siblings and the friends of adolescent suicide victims demonstrate the complexity of the decision to display a suicide –related behavior after exposure to a suicidal death. This decision cannot be related to a single factor and a clustering of underlying factors should be present. Thus, the suicidal behavior after the loss of a sibling or friend could be viewed under a multiaxial model. An underlying psychiatric vulnerability should be present and act as predisposing factor. Precipitating conditions as stressful events, lack of support, availability of method and example of suicide in the environment can also determine the suicidal behavior (Shaffer & Craft 1999). Lack of protective factors can also play a significant role.
Based on this multiaxial model proposed for the understanding of the suicidal behavior, the prevention strategies should be formulated in a way that addresses the above complexity. Given that the population at risk is siblings and friends of adolescent victims the wiser implementation of the current scientific evidence should be in the school environment.

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