Thursday, April 25, 2019

Suicide survivors face grief, questions, challenges

Daytime sleepiness has become an accepted consequence of our busy lives. We overload our schedules, stay up too late, and even sleep with our smartphones, then walk around yawning and guzzling coffee to stay awake in the afternoon. But if your daytime sleepiness isn’t relieved by a few extra Zs now and then, your lifestyle may not be the culprit — it could be obstructive sleep apnea.

Obstructive sleep apnea occurs when the muscles in the back of your throat relax too much when you are asleep. This lets the tissues around your throat close in and block the airway. You stop breathing for a few seconds (this pause in breathing is called apnea). Your brain has to wake you up enough so you gasp or change positions to unblock the airway. You aren’t even aware it’s happening. These stop-breathing episodes can occur dozens of times per hour, making you feel tired the next day. Even worse, they increase blood pressure and heart rate, putting stress on the cardiovascular system and increasing your risk for a stroke.

In the United States, between 12 million and 18 million adults have obstructive sleep apnea — and the rates are rising, says the National Heart, Lung, and Blood Institute. Why? Because more and more Americans are overweight or obese. Too much fat in the neck can add to airway blockage during sleep.

Daytime sleepiness is one sign of obstructive sleep apnea. Others include:

    loud snoring, often accompanied by gasping for breath
    a bed partner observing pauses in breathing during sleep
    abrupt awakenings accompanied by shortness of breath
    waking up with a dry mouth or sore throat
    morning headache
    difficulty staying asleep

The American College ofIllustration of obstructive sleep apnea Physicians has published new guidelines for diagnosing obstructive sleep apnea. They urge doctors to recommend overnight sleep tests for people with unexplained daytime sleepiness.

Is that a little extreme? “I don’t think so, as long as it’s true sleepiness and not fatigue,” says Dr. Andrew Wellman, an assistant professor of medicine at Harvard Medical School professor and the Director of the Sleep Disordered Breathing Laboratory at Harvard-affiliated Brigham and Women’s Hospital.

Sleepiness is marked by heavy eyelids during the day, and nodding off when you want to stay awake. It can be due to a number of conditions, ranging from jet lag or working rotating shifts to restless legs syndrome and obstructive sleep apnea. To prove that sleep apnea is causing daytime sleepiness, an overnight sleep study is needed. That means spending the night in a sleep lab hooked up to machines that measure your heart rate, sleep and awake states, airflow, oxygen level, and other activity. The test is called attended polysomnography.

Many people with sleep apnea symptoms probably won’t go to a sleep lab. It may not be covered by insurance, or they may feel they don’t have time to do the overnight test. Dr. Wellman thinks that some people don’t want to deal with the treatment for sleep apnea, which often includes wearing a mask at night that uses forced air to keep your airway unblocked. This is known as continuous positive airway pressure (CPAP).

It’s possible to do a sleep study at home with a portable monitor, and the new sleep apnea guidelines recommend that as an alternative for some people. But home monitoring can be tricky. There are several different types of monitors, and they don’t all measure the same types or amounts of sleep activity as the sleep center tests. “The home tests aren’t always accurate. While they can be helpful at confirming a diagnosis of OSA, they can sometimes yield a false negative, meaning you have the disorder but the test says you don’t,” says Dr. Wellman.

Take daytime sleepiness seriously, says Dr. Wellman. Ask yourself if you have any risk factors for it:

    high blood pressure
    prior stroke
    being overweight
    a large neck circumference
    large tonsils
    a close relative with obstructive sleep apnea
    smoking
    nasal congestion.

While you’re at it, ask your sleeping partner if you have any of the obvious symptoms: loud snoring and episodes of gasping or stopping breathing at night, or others listed above.

If you have any of these symptoms or risk factors along with daytime sleepiness, it’s time to wake up to the possibility that you may have obstructive sleep apnea. So make room in that busy schedule for a visit to the doctor. If you do, treatment can make your sleep, and your health, much better.

For more information on sleep apnea, watch this video in which Dr. Laurence Epstein, instructor in medicine at Harvard Medical School and editor of Improving Sleep from Harvard Health Publishing, discusses how sleep apnea is diagnosed and treated. It also contains a clip of former Harvard Health Letter editor Peter Wehrwein having a sleep study. The recent, untimely deaths of Kate Spade, reportedly from depression-related suicide, and of Anthony Bourdain, also from apparent suicide, came as a surprise to many. How could a fashion designer and businesswoman known for her whimsical creations and a chef, author and television personality who embodied a lust for life be depressed enough to end their lives? Crushing sadness can hide behind many facades.

According to a report by the US Centers for Disease Control and Prevention (CDC), suicide rates for adults in the United States are on the rise; since 1999, suicide rates in 25 states increased by more than 30%. In the US, suicide accounted for nearly 45,000 deaths in 2016.

Each person who dies by suicide leaves behind an estimated six or more “suicide survivors” — people who’ve lost someone they care about deeply and are left grieving and struggling to understand.

The grief process is always difficult. But a loss through suicide is like no other, and grieving can be especially complex and traumatic. People coping with this kind of loss often need more support than others, but may get less. Why? Survivors may be reluctant to confide that the death was self-inflicted. And when others know the circumstances of the death, they may feel uncertain about how to offer help.
What makes suicide different

The death of a loved one is never easy to experience, whether it comes without warning or after a long struggle with illness. But several circumstances set death by suicide apart and make the process of bereavement more challenging. For example:

A traumatic aftermath. Death by suicide is sudden, sometimes violent, and usually unexpected. Depending on the situation, survivors may need to deal with the police or handle press inquiries. While still in shock, they may be asked if they want to visit the death scene. Sometimes officials discourage the visit as too upsetting; other times they encourage it. “Either may be the right decision for an individual. But it can add to the trauma if people feel that they don’t have a choice,” says Jack Jordan, Ph.D., clinical psychologist in Wellesley, MA and co-author of After Suicide Loss: Coping with Your Grief.

Recurring thoughts. A suicide survivor may have recurring thoughts of the death and its circumstances, replaying over and over the loved one’s final moments or their last encounter in an effort to understand — or simply because the thoughts won’t stop coming. Some suicide survivors develop post-traumatic stress disorder (PTSD), an anxiety disorder that can become chronic if not treated. In PTSD, the trauma is involuntarily re-lived in intrusive images that can create anxiety and a tendency to avoid anything that might trigger the memory.

Stigma, shame, and isolation. There’s a powerful stigma attached to mental illness (a factor in most suicides). Many religions specifically condemn the act as a sin, so survivors may understandably be reluctant to acknowledge or disclose the circumstances of such a death. Family differences over how to publicly discuss the death can make it difficult even for survivors who want to speak openly to feel comfortable doing so. The decision to keep the suicide a secret from outsiders, children, or selected relatives can lead to isolation, confusion, and shame that may last for years or even generations. In addition, if relatives blame one another — thinking perhaps that particular actions or a failure to act may have contributed to events — that can greatly undermine a family’s ability to provide mutual support.

Mixed emotions. After a homicide, survivors can direct their anger at the perpetrator. In a suicide, the victim is the perpetrator, so there is a bewildering clash of emotions. On one hand, a person who dies by suicide may appear to be a victim of mental illness or intolerable circumstances. On the other hand, the act may seem like an assault on, or rejection of, those left behind. So the feelings of anger, rejection, and abandonment that occur after many deaths are especially intense and difficult to sort out after a suicide.

Need for reason. “What if” questions can arise after any death. What if we’d gone to a doctor sooner? What if we hadn’t let her drive to the basketball game? After a suicide, these questions may be extreme and self-punishing — unrealistically condemning the survivor for failing to predict the death or to successfully intervene. In such circumstances, survivors tend to greatly overestimate their own contributing role — and their ability to affect the outcome.

“Suicide can shatter the things you take for granted about yourself, your relationships, and your world,” says Dr. Jordan. Some survivors conduct a psychological “autopsy,” finding out as much as they can about the circumstances and factors leading to the suicide. This can help develop a narrative that makes sense.

Sometimes a person with a disabling or terminal disease chooses suicide as a way of gaining control or hastening the end. When a suicide can be understood that way, survivors may feel relieved of much of their what-if guilt. “It doesn’t mean someone didn’t love their life,” says Holly Prigerson, Ph.D., professor of psychiatry at Harvard Medical School and Director of Psycho-Oncology Research, Psychosocial Oncology and Palliative Care at Dana-Farber Cancer Institute.
Support from other survivors

Suicide survivors often find individual counseling (see “Getting professional help”) and suicide support groups to be particularly helpful. There are many general grief support groups, but those focused on suicide appear to be much more valuable.

“Some people also find it helpful to be in a group with a similar kinship relationship, so parents are talking to other parents. On the other hand, it can be helpful for parents to be in a group where they hear from people who have lost a sibling — they may learn more about what it’s like for their other children,” says Dr. Jordan.

Some support groups are facilitated by mental health professionals; others by laypersons. “If you go and feel comfortable and safe — [feel] that you can open up and won’t be judged — that’s more important than whether the group is led by a professional or a layperson,” says Dr. Prigerson. Lay leaders of support groups are often themselves suicide survivors; many are trained by the American Foundation for Suicide Prevention.

For those who don’t have access to a group or feel uncomfortable meeting in person, Internet support groups are a growing resource. In a study comparing parents who made use of the Internet and those who used in-person groups, the Web users liked the unlimited time and 24-hour availability of Internet support. Survivors who were depressed or felt stigmatized by the suicide were more likely to gain help from Internet support services.

You can join a support group at any time: soon after the death, when you feel ready to be social, or even long after the suicide if you feel you could use support, perhaps around a holiday or an anniversary of the death.
Getting professional help

Suicide survivors are more likely than other bereaved people to seek the help of a mental health professional. Look for a skilled therapist who is experienced in working with grief after suicide. The therapist can support you in many ways, including these:

    helping you make sense of the death and better understand any psychiatric problems the deceased may have had
    treating you, if you’re experiencing PTSD
    exploring unfinished issues in your relationship with the deceased
    aiding you in coping with divergent reactions among family members
    offering support and understanding as you go through your unique grieving process.

A friend in need

Knowing what to say or how to help someone after a death is always difficult, but don’t let fear of saying or doing the wrong thing keep you from reaching out to a suicide survivor. Just as you might after any other death, express your concern, pitch in with practical tasks, and listen to whatever the person wants to tell you. Here are some special considerations:

Stay close. Families often feel stigmatized and cut off after a suicide. If you avoid contact because you don’t know what to say or do, family members may feel blamed and isolated. Ignore your doubts and make contact. Survivors learn to forgive awkward behaviors or clumsy statements, as long as your support and compassion are evident.

Avoid hollow reassurance. It’s not comforting to hear well-meant assurances that “things will get better” or “at least he’s no longer suffering.” Instead, the bereaved may feel that you don’t want to acknowledge or hear them express their pain and grief.

Don’t ask for an explanation. Survivors often feel as though they’re being grilled: Was there a note? Did you suspect anything? The survivor may be searching for answers, but your role for the foreseeable future is simply to be supportive and listen to what they have to say about the person, the death, and their feelings.

Remember his or her life. Suicide isn’t the most important thing about the person who died. Share memories and stories; use the person’s name (“Remember when Brian taught my daughter how to ride a two-wheeler?”). If suicide has come at the end of a long struggle with mental or physical illness, be aware that the family may want to recognize the ongoing illness as the true cause of death.

Acknowledge uncertainty. Survivors are not all alike. Even if you are a suicide survivor yourself, don’t assume that another person’s feelings and needs will be the same as yours. It’s fine to say you can’t imagine what this is like or how to help. Follow the survivor’s lead when broaching sensitive topics: “Would you like to talk about what happened?” (Ask only if you’re willing to listen to the details.) Even a survivor who doesn’t want to talk will appreciate that you asked.

Help with the practical things. Offer to run errands, provide rides to appointments, or watch over children. Ask if you can help with chores such as watering the garden, walking the dog, or putting away groceries. The survivor may want you to sit quietly, or perhaps pray, with him or her. Ask directly, “What can I do to help?”

Be there for the long haul. Dr. Jordan calls our culture’s standard approach to grief the “flu model”: grief is unpleasant but is relatively short-lived. After a stay at home, the bereaved person will jump back into life. Unfortunately, that means that once survivors are back at work and able to smile or socialize again, they quickly get the message that they shouldn’t talk about their continuing grief. Even if a survivor isn’t bringing up the subject, you can ask how she or he is coping with the death and be ready to listen (or respect a wish not to talk about it). Be patient and willing to hear the same stories or concerns repeatedly. Acknowledging emotional days such as a birthday or anniversary of the death — by calling or sending a card, for example — demonstrates your support and ongoing appreciation of the loss.

Helpful resources for suicide survivors are available at from the American Foundation for Suicide Prevention and the American Association of Suicidology.

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