Social networks have increased in recent decades, and with them the bullying, causing difficulties in young people's mental health expressed through depressive symptoms, suicidal ideation and suicide attempts. Up next, we present a case that exemplifies this situation.
ObjectiveTo describe a case report that exemplifies this new outlook in young people and how it affects their mental health.
MethodologyCase report and non-systematic literature review.
ResultsOne case report, treated at a hospital in Medellin due to two suicide attempts related to social networks is presented.
DiscussionCurrently, there are multiple social media resources, the advent of internet and smartphones is not only a strategy for improving social interactions, but it also contributes to impair mental health of some vulnerable young people.
ConclusionThis case sensitise us, about the relationship between the growing social networking and cyberbullying as well as suicidal thoughts/attempts; thanks to this case and the available literature, we can’t establish causality but we could deduce that the internet utter a increased risk for young people who are exposed and more vulnerable.
La victimización a través de las redes sociales se ha asociado con problemas de salud mental como depresión y comportamiento suicida.
ObjetivoPresentar el caso clínico de una adolescente víctima de cyberbullying con síntomas depresivos y comportamiento suicida.
MetodologíaReporte de caso y revisión no sistemática de la literatura relevante.
ResultadosSe presenta un reporte de caso, tratado en un hospital de Medellín debido a dos intentos de suicidio relacionados con las redes sociales.
DiscusiónEn la actualidad, existen múltiples recursos de los medios sociales. El advenimiento de Internet y teléfonos inteligentes no es solo una estrategia para mejorar las interacciones sociales, sino que también contribuye a deteriorar la salud mental de algunas personas jóvenes vulnerables.
ConclusiónEste caso nos sensibiliza sobre la relación entre el crecimiento de redes sociales y el acoso cibernético. No podemos establecer la causalidad, pero podríamos deducir que algunos contenidos en la web podrían propiciar un mayor riesgo de enfermedad mental para los jóvenes que están expuestos y vulnerables.
Suicide is a public health problem and one of the leading causes of death among young people worldwide.1 Over 1 million people commit suicide each year. Attempted suicide is up to 10–40 times more frequent than completed suicide and is considered to be the most predictive clinical risk factor for subsequent suicide.2
According to the Pan American Health Organization (PAHO) ‘Health in the Americas’ report, suicides account for a significant number of deaths from external causes, and are among the leading causes of death among adolescents and young adults. In the Andean region, suicide is more frequent among the young population, and is one of the first 3 external causes of death in the 5–19 age group.3 In Colombia, the overall prevalence of attempted suicide in the previous year is 1.3%, and 0.8% in Medellín.4,5
Bullying was first described by Dan Olweus and Erling Roland in 1983, based on the first reports of school violence that began to emerge in Norway in the early 1970s. In the late 1980s and early 1990s, the phenomenon attracted public attention and sparked research in other countries, such as Japan, the United Kingdom, the Netherlands, Canada, the United States, and Australia.6 It has been estimated that 20–35% of school-age adolescents are victims of bullying, and that this affects their academic and social performance, as well as their psychological well-being.7
Bullying is defined as an aggressive behaviour that is intentional, repeated and involves a power imbalance.8 It is a major, highly prevalent, global problem that continues to exist despite the efforts made by schools and parents to prevent it.9
Bullying can be classified according to the type of intimidation: physical, verbal, social and indirect (rumours).10 Direct intimidation is more frequently observed in males, and indirect intimidation is more common in females.10,11 Being a victim of bullying has been associated with multiple negative physical and mental health outcomes,12 and repeated bullying is directly or indirectly associated with depressive symptoms and suicidal behaviour.13–15
Cyberbullying refers to typical bullying behaviours, such as verbal abuse, mocking, insults and threats, transmitted over electronic media, such as e-mail, mobile phones, text messages and internet sites, where an individual is ridiculed, insulted or ostracised.9 The aim of cyberbullying is to cause the victim harm, humiliation, fear and despair. To qualify as bullying, these behaviours must occur repeatedly and systematically against someone who is unable to defend his/herself.16 In cyberbullying, the perpetrator avoids face-to-face contact and achieves greater intimidation by engaging in the behaviour anytime and anywhere, unlike traditional bullying that only occurs in the school context.17
The following is a review of the case of a teenager in whom cyberbullying was the precipitating factor in two suicide attempts.
MethodsCase report and non-systematic review of relevant literature. The patient was treated by psychiatrists in the emergency department of a public hospital in Medellín (Colombia). The assent of the patient and the informed consent of her parents were obtained to use the patient's clinical information for academic purposes and scientific publication. The study was conducted according to the guidelines of the Belmont report18 and the Declaration of Helsinki.19 The literature search was performed on PubMed, MEDLINE and Google Scholar. Meta-analysis and cohort studies, systematic reviews and case reports published in English and Spanish over the past 20 years were included. The search criteria were: “cyberbullying”; “bullying”; “depressive symptoms” and “attempted suicide”.
Presentation of the caseA 14-year-old girl, with no previous medical or psychiatric history, was admitted to the emergency department 7h after ingesting 5 mebendazole (antiparasitic) tablets and 5 gemfibrozil (antihyperlipidaemic) tablets and inflicting superficial lacerations on her wrists and thighs with suicidal intent.
The skin lesions did not require suturing and the patient did not show signs or symptoms of toxicity due to medication intake. Vital signs and physical examination were normal. A one-on-one, unstructured psychiatric interview was performed. Personal information was verified and the patient was asked what drove her to attempt suicide. She described sadness, worry and a wish to die related to problems she was having with a 31-year-old man who she had met in person months ago, and to whom she gave her WhatsApp, Facebook and Instagram address. The patient reported that their conversations gradually began to touch on personal and intimate subjects, and at his request she began to send him personal photographs. He insisted that she send him photographs in which she appeared scantily dressed, so the patient sent him pictures in her underwear. He demanded “more revealing” photos. The patient refused and stopped responding to his WhatsApp messages, after which he began to threaten to post the photographs on social media and say things that could compromise her reputation socially, within her family and at her school. The patient, frightened and ashamed, decided not to accede to these demands, and the photographs of her in underwear were published on Facebook.
After the photographs were published on social media, the patient became the victim of bullying at school and of cyberbullying by individuals, some she knew and others she did not know, who attacked her verbally online. The perpetrator persisted with his threats, and her depression and anxiety increased in intensity, with the appearance of suicidal ideation that took shape over the following days and resulted in the first suicide attempt which, according to the patient, would allow her to end her life, and with it, the harassment, shame and humiliation she was forced to endure.
The patient received immediate, short-term psychological care (crisis intervention), and the family mobilised to help her. Suicidal ideation disappeared, and the patient was discharged and given an outpatient psychiatric appointment. Five weeks later, the patient was again brought to the emergency department by her relatives, who had seen the patient attempting to jump from a height and had held her down and sought medical help. During this time, she had not been followed up by the psychiatry department because her healthcare entity had not authorised the appointment.
In this second psychiatric interview, the patient said that she was still sad and anxious and did not want to go to school or leave her house for fear of meeting people who might know her and might have seen the photographs and messages about her that appeared on social media. She said that at school she was continuously subjected to mockery, criticism and name-calling. All this made her feel bad and embarrassed. She believed that no-one was there to help her, that she could not rely on anyone, and that the situation would never end, so she was considering ending her life and her suffering. The family knew what was happening, gave the patient their support, and was willing to take legal action against the perpetrator. The patient realised that her family would give her their unconditional support and the suicidal ideation diminished and eventually disappeared. The patient was scheduled for outpatient psychiatric follow-up, and no pharmacological treatment was started. We were unable to follow-up the patient, since the hospital does not have an outpatient psychiatric service; therefore, she was referred to another centre for treatment and we were unable to obtain information about her subsequent evolution.
Analysis of the case and literature reviewOnline social networking sites are applications that facilitate contact between people, and enable them to share information.20 There are currently a significant number of these social networks that modify the way humans interact while globalising customs.21 Adolescents use social networks for a variety of reasons, including initiating and maintaining interpersonal relationships, entertainment, finding information, and securing an emotional outlet.22 There are several types of social networks: Facebook, MySpace, Instagram, LinkedIn, Xing, Viadeo, Flickr, Pinterest, YouTube, Twitter and WhatsApp, among others. Some of them are so popular with teenagers that they have become an integral part of their lives.23,24
The development of information and communication technologies (ICT) has brought with it new forms of peer aggression,17 and traditional bullying has been joined by a new form of school bullying: “cyberbullying”.25 Studies show that between 20% and 40% of adolescents will endure at least one episode of cyberbullying during their adolescence,26,27 and 59.7% of those reporting bullying at school are also the target of cyberbullying.
The case reported here shows how a teenage patient with no psychiatric history and no risk factors for suicidal behaviour became a victim of cyberbullying that led to the onset of depressive symptoms and suicidal ideation. This led to a first suicide attempt, followed by a second when the cyberbullying continued.
Recent studies have shown that cyberbullying is more strongly associated with suicidal ideation than traditional bullying.28 Risk factors vary among studies, but most of the following are considered major risk factors: a) previous or current experiences of traditional bullying; b) use of the Internet for 3 or more hours per day; c) use of instant messaging; d) relational difficulties; e) attention deficit hyperactivity disorder; f) conduct disorder; g) poor academic performance and h) publication of personal information using a webcam.29 Our patient had three of these risk factors: hours of internet use, instant messaging and interpersonal problems with schoolmates.
Note that the patient was not treated with psychotropic drugs; instead, as the patient's symptoms were a reaction to the harassment she was enduring, psychotherapy was ordered. It should be mentioned in this regard that, despite the relatively long duration of symptoms, the source was clear, and the patient improved immediately after receiving family and clinical support. In addition, the criterion of temporality is limited by permanent exposure to the stressor, since the patient continued to be a victim of harassment.
Data from the 1999–2000 Youth Internet Safety Survey show that depressive symptoms are significantly related to online harassment, and 13.4% of cyberbullying victims reported having suffered one or more symptoms of major depression, including functional impairment in at least one area (school or work, personal hygiene or self-efficacy), without developing major depression.25 Price et al. studied the impact of cyberbullying on today's youth, and found that it had the most impact on confidence (78%), self-esteem (70%), and friendships (42%). Many respondents also reported an emotional impact.30
Although adjustment disorder31 is considered a minor diagnosis and its validity is controversial, it is important because it is highly prevalent in clinical practice, and is linked with suicide. High rates of this diagnosis have been found using psychological autopsy, and the literature shows that stressful events are related to an increase in suicidal thoughts and behaviours in young people.32
Cyberbullying in adolescents, meanwhile, has been associated in several studies with depressive symptoms (11.3%), post-traumatic stress (23.2%) and suicidal ideation (11.3%)33; it has also been associated with substance use.34,35 Some studies have reported that cyberbullying is a “predictor” of attempted suicide.34,35 The links between traditional bullying and self-harm, suicidal ideation, suicide attempts and completed suicide are well established.25 Therefore, the emerging association between suicidal ideation and cyberbullying is hardly surprising.36 Fifteen year-olds who endured bullying presented more suicide attempts (5.4–6.8%) than those who had not been victimised (1.6–1.9%), so enduring bullying at 13 years of age increases the risk of a suicide attempt two years later by 3.05 fold (odds ratio=3.05; 95% confidence interval, 1.36–6.82) after adjusting for multiple confounding variables, such as socioeconomic level, intelligence level, family functioning and history of maternal suicide.37
Adolescents subjected to bullying use different coping strategies, such as distraction (35.4%) – browsing the web, watching television, listening to music (35.4%) – isolation (33.1%), socialising with friends (27.8%) and exercising or doing sports (27.3%).38 Some of these strategies may be maladaptive, such as those used by our patient who, unable to solve the problem, isolated herself from her family and social environment – behaviours that favoured the onset of depressive symptoms and suicidal ideation. Interestingly, in this case the symptoms appeared to resolve when the patient managed to talk about what had happened to her, and reappeared when the cyberbullying resumed one month later. This raises the need for close follow-up by an interdisciplinary team, including legal experts, of these patients. In a study conducted in Cali in 2542 students in grades 6 through to 8, aged 12–13, 24.7% reported being bullied.39
ConclusionsThis case exemplifies the new therapeutic challenges faced by psychiatrists with the advent of new technologies. The literature shows that the right diagnosis and therapy have a positive impact on the prognosis of patients that suffer these new forms of violence.
Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.
Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data.
Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.
Conflicts of interestThe authors have no conflicts of interest to declare.
We would like to thank the Hospital General de Medellín for facilitating the information used in this case, and all the anonymous patients who allow us to learn so much.
Please cite this article as: Echavarría JE, Montoya González LE, Bernal DR, Rodríguez DM. Ciberacoso y comportamiento suicida. ¿Cuál es la conexión? A propósito de un caso. Rev Colomb Psiquiat. 2017;46:247–251.
