271. In addition, in the instant case, the statements made before the Court allowed it to verify that Luz Altagracia Ramírez and her children have endured great uncertainty and profound suffering and anguish to the detriment of their physical, mental and moral integrity as a result of the forced disappearance of Narciso González Medina and to the actions of the State authorities in relation to the investigation into what happened. 300 These effects were produced not only at a personal level, but also entailed a serious impairment of family life. In this regard, the Court has taken into account the opinion of the psychiatrist Secundino Palacios, who has treated them for approximately 17 years, according to which the disappearance of Narciso González Medina “has been extremely traumatic” for the whole family, and they have suffered “all the clinical symptoms characteristic of patients with depression, as well as problems due to anxiety.” 301 272. The Court recalls that it has considered the constant refusal of the State authorities to provide information on the whereabouts of victims or to open an effective investigation to clarify what happened to be a cause of increased suffering to the family. 302 In this regard, the Court has verified the additional suffering caused to Mr. González Medina’s wife and children owing to the absence of an effective and diligent investigation, as well as to the uncertainty concerning the facts and the whereabouts of their husband and father. 303 In addition, the Court takes note of the opinion of expert witness Palacios, that “[o]ne of the factors that, from a cognitive point of view, causes the greatest feelings of helplessness and the most damage and social harm is impunity.” 273. The Court also emphasizes that the testimony of the alleged victims, 304 and the expert psychiatric opinion 305 presented reveal that the State’s actions, in the context of the 300 In his statement, Ernesto González Ramírez indicated that he “experiences great anguish, and therefore […] avoid[s] the issue” and added that he has “had to remain strong outwardly, […] because [he thinks about his] mother, that if she sees [him] like that, she will break down if [he does].” For her part, Jennie Rosanna González Ramírez described an intense depression owing to the disappearance of her father with episodes of insomnia, crying, frustration and anxiety, that “with time have decreased, but have not gone away.” Rhina Yokasta González Ramírez declared that she “has emotional crises, and had to be interned each month”; in addition, currently she suffers from asthmatic crises when faced with strong emotional situations. In this regard, Luz Altagracia Ramírez declared before the Court that “the family became totally disrupted,” and her children told of the absence of family celebrations since the disappearance of their father. Cf. Statements made by Ernesto, Jennie Rosanna and Rhina Yokasta González Ramírez on June 15 and 16, 2011, supra notes 99, 106 and 111, folios 1101, 1102, 1119, 1120, 1123, 1132, and statement made by Luz Altagracia Ramírez before the Inter-American Court during the public hearing held in this case on June 28, 2011. 301 In this regard, he stressed that “they suffered from all the clinical symptoms [anxiety, fatigue, insomnia, sadness, depresión, lethargy, agitation and others] and are still suffering from them.” He indicated that Mr. González Medina’s family have revealed changes in the four clinical areas: in their feelings, and in their motor, somatic and cognitive functions. In particular, he described the clinical histories of each of the victims, underlining that they all suffered from depression, and also the effects on their academic performance, and their workplace and social relations. Testimony provided by expert witness Secundino Palacios on June 16, 2011, supra note 208, folios 1146 to 1150. 302 Cf. Case of Blake v. Guatemala. Merits, supra note 296, para. 114, and Case of Contreras et al. v. El Salvador, supra note 51, para. 123. 303 Rhina Yokasta González Ramírez declared that since her father’s disappearance she has “not had any peace or stability,” “this anguish, this uncertainty is horrible,” and she added that “at times, [she had] had nightmares and could not sleep, […] imagining torture, like a film of what they were doing to [her] father.” Also, Jennie Rossana González Ramírez stated that “[t]he worst part of this situation is that […] the anguish never ends. As if one cannot finish something; one is always waiting for something.” Statements made by Rhina Yokasta and Jennie Rosanna González Ramírez on June 16, 2011, supra notes 99 and 111, folios 1120, 1131 and 1132. 304 Supra note 300. 305 In this regard, the expert witness and family psychiatrist indicated that the “public declarations [of the State concerning the case of Mr. González Medina] are inconsiderate, outrageous and offensive, for [Luz] Altagracia and her children; all of which, has had negative emotional consequences that have affected their physical and mental well-being.” Statement by expert witness Secundino Palacios on June 16, 2011, supra note 208, folio 1153. 83