Bullying; A Psychosocial Stressor

Background: The bullying incidences have been increasing in the past few years resulting in a number of psychosocial traumas including depression, anxiety, violence and many other health concerns. Despite being a global issue, not a large number of studies have addressed this distressing act. This social threat causes negativity on both sides whether the victim or the perpetrator. The aim of the study was to evaluate the prevalence of this psychosocial stressor, its associated characteristics and bullying perceptions among the study population. Methodology: A cross-sectional observational study was conducted for 5 months from July 2017 to December 2017. Data was collected from 399 victims between the age of 15-27 years via a structured questionnaire inquiring victim’s demographics and its associated psychosocial outcomes. Collected data was then analyzed using SPSS ver. 22. Results: Out of the total study subjects there were 204 females and 195 males with the mean age of 25.10 + 5.70 years. Around 76% participants reported daily bullying events. Bullying incidences were found more common in females i.e. 48.6% of the females were bullied by called out with mean names while only 45.8% males reported so. Majority of the bullying cases were reported from educational institutes. The most prominent psychological outcomes observed and reported by the victims in response to bullying was getting revengeful thoughts for the bully. Conclusion: In conclusion, the study evaluated the psychological distress resulting from bullying incidences. Our study indicated a high prevalence of this public health concern in both genders and majorly in educational sectors.


Introduction
Bullying has become a psychosocial stressor worldwide, with greater prevalence among the school aged children and young adults (Nansel et al., 2004). It is a repetitive imbalanced behavior depicted with aggression and using power for suppression and to hurt others (Carroll, 2014). The negative actions of the perpetrator can be either verbal, physical, social or racial and may include teasing, hitting, threatening and abusing (Carroll, 2014& Nansel et al., 2004. The increasing incidences of bullying have been reported in numerous studies, and it has been proved that this destructive act is linked with adverse outcomes for both the victim and the committer as it greatly affects one's mental and physical health (CDC, 2017). Being a social threat, global bullying statistics have shown that it is becoming a chronic stressor for all age groups (CDC, 2017). Moreover, the victims especially adolescents rate bullying to be a stressful stimulator of depression and self-hate (Carroll, 2014).
If these stress events resolve over time there may be a chance for early recovery and retrieval of self-esteem and confidence but those who undergo through such events Yusra Saleem 18 continuously are more likely to develop stress-related disorders (Hjern et al., 2008;Laftman et al., 2006& Due et al., 2005 like post-traumatic stress disorder (PTSD) (Crosbyet al., 2010& Mynard et al., 2000. However, there are different coping strategies and resources that might be helpful for the victim on an individual level as well as collectively in managing such stressors (Compas et al., 2001). It is evident from the previous literature that social support plays a significant role in dealing with bullying (Grant et al., 2006). The bullied victim is mostly lacking in social circles and is much likely to be introvert (Östberg et al., 2018(Östberg et al., & O'Brennan et al., 2009. Additionally, people who are bullied are actually less convinced with seeking support (Barchia & Bussey, 2010).
The health hazards caused by bullying include poor adjustments, declined selfconfidence, increased hesitations, social isolation, suicidal thoughts, anxiety, sleep difficulties, lack of concentration and vengeful thoughts and activities are also expected from the victim (CDC, 2015). According to the National Center for Educational Statistics 1 out of every 5, students report bullying at least once or twice in a month (National Center for Educational Statistics, 2016). Victimized students gradually involve in self-blaming for such an event and undergo severe depression and prolonged maladjustments (Perren et al., 2013;Shelley & Craig, 2010).
With the advancement in technology and increased prominence and use of these electronic media by the young population has given a new direction to bullying. Cyber or electronic bullying has given a way to propagate aggression via emails, messages, and victimization on social media (Smith et al., 2008). The cyberbullying incidences have nearly doubled overtime and the victim merely knows the identity of the perpetrator (Patchin & Hinduja, 2016).
Among all the adverse effects related to bullying suicidal tendencies and attempts have been the fatalist (Reed et al., 2015). Previous studies suggest that there exist a strong inter-connection between bullying and suicide related behaviors (Reed et al., 2015). The victims, bullies and even the observers are likely to develop these suicidal tendencies due to affected mental health (CDC, 2015). It is evident that this psychosocial stressor not only causes adverse impacts on the victim but also the bully (Espelage & Holt, 2013). According to a meta-analysis students are 2.2 times more prone to suicide ideation when facing peer-victimization as compared to those who are not exposed to such an event and such students are 2.6 times more likely to attempt suicide (Gini & Espelage, 2014). A false concept has been promoted in the society that has made suicide as a general response to being bullied and hence, generating an imitating behavior among youth (CDC, 2014).
The current study aims to investigate the association of bullying with the resulting health hazards and psychosocial responses. And to prompt different aspects and perception regarding this psychosocial trauma. Despite, of being globally escalating issue there are still many undiscovered facts about bullying, specifically about what factors are actually motivating this aggressive behavior and also the related coping interventions.

Methodology
This Cross-sectional, observational study was conducted from July 2017 to December 2017. Data was collected with informed consent from study population by structured questionnaire inquiring participant's demographics (age and gender, etc.) and factors assessing bullying (previous bullying events, the frequency of bullying and its impacts, etc. (educational institutes, hostels, home and public places) of Karachi, Pakistan were enrolled in the study. All victims were included while we did not include any of the perpetrators. The collected data was then analyzed using SPSS ver. 22. All quantitative variables are presented as Mean+SD while all qualitative variables with frequency and percentages. Chisquare test was used to depict the association of bullying with various sociodemographic variables among the study subjects. P<0.05 was considered significant.

Result
Out of 399, 195 males and 204 females were included in the study with the mean age of 25.10 + 5.70 years i.e. around 57.6% participants were >25 years of age while 42.4% were <25 years. The frequency of bullying among these participants was also assessed. According to the results, as shown in table 1, 4.76% participants reported daily bullying events while 3.8% reported it for 5-10 times a week. Around 40% of the study population complained about vivid memories and nightmares associated with previous bullying experience. Moreover, 188 out of total 195 males were bullying victims while 195 out of 204 females also reported being bullied.  Figure 1: Nature of bullying reported by study participants Figure 1 shows gender wise variation in bullying nature. It is quite clear that no matter what the nature ,of bullying is, these incidences are more common among females as compared to males. 48.6% of the females and 45.8% males were bullied by called out with mean names, 36.5% females and 33.3% males opted for ignorance while 14.2% females and 15.20% males voted for physical bullying.

Figure 2: Form of bullying reported by study participants
Out of all, 52.06% of the study subjects reported being bullied verbally, 29.73% opted genderbased bullying while a few cases of physical and racial bullying were also observed. Cyberbullying despite being very common nowadays was rarely reported.

Figure 3: Major reported sites of victimization
Educational institutes remain the major site for bullying, the results in figure 4 show that 79% of the study subjects reported being bullied at school while 17% at home followed by hostels and public places. Figure 4 shows that 19.5% of victims believed that they were mostly bullied due to their appearance, 17.3% thought that they were bullied for their activities, 5.3% said that they were bullied for their way of talking while a huge number of participants gave several different reasons for them being bullied.  As shown in above figure, 16.8% of the study subjects agreed that they usually get revengeful thoughts for the bully, 12.8% faced social isolation, and 9.8% reported that they feel to bully others in response to past victimization followed by poor academic achievements and health issues.

Discussion
It has been established from the previous research that bullying is a strong risk factor for the development of adolescence depression (Klomek et al., 2007). It is evident that the depressive symptoms are more common among the bullying victims as compared to those who are not exposed to any such events. The aim of this study was to evaluate the overall occurrence of bullying events locally among different sectors of Karachi and also to highlight the forms and sites of bullying and the resulting psychosocial symptoms.
One of the most prominent outcomes of bullying is suicide that is the victims of bullying are more likely to consider suicide as the best way out as compared to nonvictims. The recent literature regarding suicide suggests that bullying has become the third leading cause of adolescence and adult deaths worldwide. According to Center of disease control and Prevention (CDC), around 14% of the school going students usually consider suicide and 7 % out of them attempted it due to high psychological distress and declined coping capabilities (CDC, 2017). Reports of International research network Health Behavior in School-aged Children (HBSC) suggest bullying as the global mental health problem especially affecting youth i.e. 11% of the school aged children complained of being bullied more than 2 to 3 times/month (Inchley & Currie, 2013). Our findings were in parallel to the reports i.e. a major proportion of our study population belonged to the educational sector ( Figure  3). Moreover, 91.5% of them complained of being bullied twice a month (Table 1).
Moreover, the statistics provided by ABC News shows that around 30% of the teenage students are involved in bullying either being victim or bullies i.e. 160,000 kids mostly skip going school just to avoid bullying (Matt, 2010). Around 96% of study participants reported bullying as a common issue according to our results and of them, more than 50% were usually involved in rushing away from routine activities (Table 1).
When comparing the nature of bullying and its variation between the two genders the most prevalent were called with mean names and left out or ignored (Figure 1). Similar results have been revealed in a previous study reporting that the most common type of victimization was calling out mean names and in contrast to our findings spreading rumors was the second leading bullying behavior (Wang et al., 2009). Moreover, according to the bullying statistics by National Bullying Prevention Center, 13% of all bullying victims report being insulted, called mean names and made fun of followed by false rumors regarding the victim and 5% get physically hurt (National Center for Educational Statistics, 2016).
Among all forms of bullying, verbal bullying is the most noticeable and prevalent i.e. a previous study reported 36.5% subjects reported being bullied verbally, 41.0% for relational, and 9.8% for cyberbullying (Wang et al., 2009). Our results were parallel with the results of the mentioned study ( Figure 2).
Vast data is available on the miseries associated with bullying that leads to loneliness, social isolation, suicidal tendencies, and absenteeism (Klomek et al., 2010;Hazemba et al., 2008;Siziya, et al., 2007& Kim et al., 2005. Similar outcomes are observed in the current study, the victims reported suffering from social isolation, suicidal thoughts and associated health issues ( Figure 5). It is evident that the victims soon develop into a bully and get involve in bullying activities due to the irresistible revengeful thoughts.
The common sites for victimization as reported in a study were home and schools, 87% of the bullying victims according to their data were bullied at home while 44% reported the incidences occurring more often at school and mainly with males as compared to females (Raskauskas, 2010). In contrast, our results suggest that bullying was more common in educational institutes (either school, colleges or universities) as compared to home (Figure 3). These victims percept that they were bullied mainly for the way they look, the way they sound or for their activities while a huge proportion gave different reasons including their religion, cast, color, body structure or sexual orientation (Figure 4). That is also supported by a published study which reports that major reasons behind bullying mainly include physical appearance (National Center for Educational Statistics, 2016).
Gerlsma and his colleague demonstrated the responsiveness and behaviors of the victim totally depends upon the offense type i.e. more forgiving nature is observed in such noncriminal offenses (Gerlsma & Lugtmeyer, 2016). In contrast, our results suggested that revengeful thought was mostly reported the outcome of the bullying event followed by social isolation, health issues and suicide ideation ( Figure 5). According to a fact sheet published in 2017, among psychological suppressors of bullying anxiety, depression, decreased self-confidence, feelings of self-harm and drug abuse are the commonest. While declined academic achievements and health issues remain on the forefront (stopbullying.gov, Fact Sheet, 2017).
In addition to the evidence provided by this study regarding the increasing prevalence of bullying incidences in our society and its devastating psychological outcomes, our study had several limitations i.e. this study only focused on the victim and not the bullies, we did not consider the role of bullies and their knowledge and understanding about the issue. Moreover, we did not evaluate the role of parents, friends and school environment in preventing bullying activities in our society.
Despite of these limiting factors, the study had some strength, i.e. the data was collected from diverse groups and we didn't focus on just school based bullying incidences. The data was collected from all possible institutes, home and different public places were covered during the course of the study to get responses that can depict not whole but at least a part of the population and their perceptions regarding this psychosocial stressor.

Conclusion
It can be concluded from the study results that this distressing issue is burning up way too rapidly, especially affecting the schools and colleges and taking many life's as it promotes suicide and triggers such harming tendencies among the victims. Our study provides an overview of different aspects of bullying, results indicate that there is a dire need to address all forms of bullying victimization and the resulting health outcomes. As it is not only an issue that affects an individual on the personal level but collectively cause harm to the community and surroundings which therefore makes it a public health concern that is to be addressed on the universal level.

Conflicts of Interest
None.

Acknowledgment
I would like to acknowledge all the study participants for providing us with all beneficial information for the study.