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Is the grief experienced by a "survivor" (family member or friend left behind by a suicide) different from that following a natural death? Or is it a special kind of "complicated grief more severe and prolonged than normal? Complicated grief' is defined as distinct from major depressive disorder with criteria that include intrusive thoughts about and yearning for the deceased, excessive loneliness, disbelief, and excessive bitterness or anger related to the death, lasting longer than 6 months. Uncomplicated grief, on the other hand, is a depressive syndrome that incompletely meets criteria for major depressive disorder, does not go beyond 6 months, and is not associated with extreme morbidity. Not being prepared for the death (most often the case with a suicide) carries a high likelihood of complicated grief, and if the death was violent, it is often associated with the onset of major depression."
The number of people counted as survivors varies according to whether one includes only close relatives and friends or acquaintances and professional colleagues as well, but a conservative estimate counts about 6 survivors for every suicide death. Surviving suicide is more prevalent than is realized: Crosby and Sacks, researchers at the Centers for Disease Control and Prevention, surveyed more than 5000 randomly selected community adults in the United States and found that 7% had experienced the loss of someone by suicide during the previous year. In most cases, the suicides were friends or acquaintances, but in 3% they were members of their immediate family.' This seems an extraordinarily high figure. Suicide frequently happens as an unexpected, violent death. Even if it has been vaguely anticipated as a possible outcome of an individual's unrelenting depression or dysfunctional, failure ridden life trajectory, the timing of it is almost always unpredictable, and suicide comes as a surprise. Since it is an unnatural death, mental health professionals and the general public have long believed intuitively that the aftermath in survivors must be unduly prolonged, more so than that in the case of death from disease or old age.
Farberow and colleagues studied the spouses (average age 62 years) of persons who had died by suicide and compared them with unmatched spouses of those who died natural deaths and spouses who were nonbereaved.'' The groups were selected from coroners' and health systems registers, but the low acceptance rate (35% in the case of suicides' spouses, 30% for spouses of those who died natural deaths) makes it likely that the sample was not representative of the general population. Regardless, investigators found little dissimilarity between the mourning experiences of the 2 bereaved groups, both of them experiencing substantial grief, emotional distress, depression, and anxiety. Despite their suffering, they were able to adapt to and to function in their new roles as widowed persons, and by the end of 6 months the severity of symptoms had considerably subsided in the spouses of the suicide victims, although they continued to experience distress to some degree to the end of the full year. The final assessment at 2,5 years showed no measurable difference between the bereaved groups, although residual dysphoria continued to be present among some members of both.
In the Leiden Bereavement Study (a prospective longitudinal study over 14 months that compared first-degree family members of suicide victims with those of traffic victims or people who died after long-term illness), posttraumatic stress disorder (PTSD) symptoms were equally common among all groups. The degree of kinship to the deceased was the most influential factor. Parents, widowers, and sisters of the deceased were more strongly affected than adult children, brothers, or widows.
Among a sample of 343 Canadian undergraduate students who were surveyed because they experienced bereavement (at mean age 17 years) resulting from either suicide, accident, or anticipated or unexpected natural death, the suicide survivors stood out as more frequently experiencing feelings of rejection, responsibility, shame, total grief, stigmatization, and "unique reactions," So-called unique reactions of suicide survivors included pretending to others that the death was not a suicide, obsessive rumination over the motivations of the deceased for dying, and perceiving the suicide as an aggressive act directed at the survey respondent, that is, as a way of getting even,* Seguin and colleagues found that parents of young male Quebec residents who had taken their lives experienced more psychological distress at 6- and 9-month follow-up than did parents of accident victims. Shame, a reaction unique to suicide, was the central experience they reported that was different. Similarly, the primary experience of children bereaved by the suicide of a parent, as compared with those who had lost a parent by means other than suicide, was also shame. "Relatives and friends bereaved of older people dying through suicide are also likely to show the same common themes noted above—stigmatization, shame, a sense of rejection, and unique reactions specific to the survivors of a death by suicide."'
Brent and colleagues interviewed 28 high school students who witnessed a suicide by firearm on a school bus that also resulted in the serious injury by gunshot of a second student and compared them with demographically matched control subjects. The exposed students had higher rates of new-onset anxiety disorder and PTSD (18%, compared with 0% in the control group).'' In a larger, case-control study of peers of adolescent suicide victims (n = 146), 5% of the exposed group developed PTSD. The probability was increased if they were close to the suicide victim or had a history of discordant family background, substance abuse, agoraphobia, or suicide attempts and if they had been at or near or had witnessed the scene of the suicide.''' At 3-year follow-up, PTSD persisted in the originally affected subgroup, but by now 20% of the entire sample carried a current diagnosis of major depressive illness, compared with 5% of the unexposed control group. Almost one-half of the group reported a new-onset depressive episode during the 3 years, emerging subsequent to the friend's suicide.'
Surprisingly, the incidence of new suicide attempts among the exposed friends was low (3%), no higher than in the control group, suggesting that exposure to the devastating impact of suicide could be an antisuicide inhibiting influence. This finding suggests that indirect exposure to suicide may sometimes promote suicidal behavior in the short term, through contagion,"" but that over a longer time the personal pain resulting from direct exposure serves as a restraining influence.
In one study, one-quarter of teenaged siblings of adolescent suicide victims developed a new-onset major depressive illness, a higher proportion than among their friends or unexposed control subjects. The depressive illness became manifest 1 month after the suicide and was still present at 6 months. Unlike the case of friends of victims, significant emotional distress in siblings seemed not to persist long-term—a rather surprising finding. In their 3-year follow-up of 25 siblings of adolescent suicide victims,'^ Brent and colleagues found no excess of psychiatric disturbance among them, although their grief immediately following the suicide was measurably greater than among the friends. Apparently, the siblings' resilience to the event allowed them to recover their health by the end of the 3-year follow-up. Siblings who were younger than the decedent had somewhat more difficulty than those who were older, perhaps because they were at an impressionable age. The mothers of adolescent suicide victims, however, continued to struggle with prolonged depression, and it was also more likely to recur.
With regard to children bereaved by the suicide of parents. Shepherd and Barraclough"* followed up 36 children, aged 2 to 17 years at the time of their loss, after 5 to 17 years. The overall incidence of psychiatric morbidity was greater than for a comparison group. However, the children frequently came from homes that were dysfunctional because of the mental illness of the parent, and presuicide stresses were related to their functioning at follow-up. Some children were coping without serious consequences, and a few reported relief from an insupportable situation."
Despite such findings, most studies that have searched for defining differences between the experiences of survivors of suicide and comparison groups (usually accident "survivors") have concluded that survivor groups have more in common with each another than differences. Jordan argues that this conclusion stems by default from the methodological weaknesses in the studies thus far reported in the literature (Type II errors). Most studies are uncontrolled, or their follow-up has not been long enough.
Comparison with victims of accidents, a commonly used group, can be misleading. The equally sudden, violent nature of the event washes out differences that might show up if the suicide deaths were compared with natural deaths.'' In both suicide and accident deaths, relatives may blame themselves, wondering whether they could have prevented the loss had they taken some action or other. The failure to show a difference could indicate a class effect in survivors of all kinds of traumatic deaths not specific to suicides.'' However, even with this example, questioning one's actions is likely to happen more often among suicide than accident survivors. Survivors of suicide deaths persistently struggle to make sense of the reasons why the individual took his or her life, a thematic difference that is not shared with any other form of death. Suicide survivors frequently berate themselves for their self perceived mistreatment or abandonment of the decedent. In some cases, after extended periods of living with the problematic behavior of the suicide victim, survivors may feel relieved, only to punish themselves for it afterward. The families of suicide victims tend to withdraw from their social networks because of perceived or real stigmatization and the ever-present shame that dogs them. Shaky family dynamics may become even more dysfunctional, although in other cases families may knit together in the wake of their loss.
The reactions of the significant others of suicide victims, however, are influenced by their own preexisting emotional problems, more often prevalent among them than in relatives of accident victims. Postsuicide bereavement reactions represent an interaction between the circumstances of the event, the quality of the relationship between the suicide victim and the survivor, and the vulnerability or resilience of the survivor.'' Histories of psychiatric illness and family discord are more often found in the background of suicide victims: a Swedish study found a twofold probability of a family history of suicide deaths (9.4%) among relatives of suicide victims.''
Murphy and her colleagues followed 173 parents over 5 years who had lost children aged 12 to 28 years through violent means (that is, either suicide, homicide, or accident).'' The effect of the loss was clearly profound and persistent and took 3 to 4 years to resolve, with no time difference between the 3 groups. Of the group as a whole, 13% experienced suicidal ideation during follow-up. An increased level of distress, depression, PTSD, and nonacceptance of the loss were predictive of suicidal ideation. Surprisingly, having lost a child by suicide was not especially a predictor of suicidal ideation in the parents, compared with the other groups. One year after the death, only 12% of parents stated that they had found a personal meaning in the death of their child through their soul-searching; that is, they could make sense of it. This proportion rose to about one-half at the 5-year mark, leaving the remainder with their continuing perplexity.
Repressive coping strategies were liable to perpetuate the chances of PTSD.' Clearly, the resolution of complicated grief resulting from the suicide of a close person, particularly a son or daughter, takes several years to accomplish, if it occurs at all.
- Sakinofsky, I. (2007). The aftermath of suicide: managing survivors’ bereavement. Canadian Journal of Psychiatry, 52(6), 129-136.
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