Psychological Autopsy

CHAPTER

Psychological Autopsy: Consultative Tool for Suicide Determination

7

Linda E. Weinberger, PhD, Timothy E. Botello, MD, MPH and Bruce H. Gross, PhD, JD, MBA University of Southern California, Los Angeles, CA, United States

INTRODUCTION Providing psychiatric and psychological consultation to one of the country’s largest Medical Examiner-Coroner’s Offices has been challenging and very interesting. Our work has been made easier by the development of a collegial relationship between the Medical Examiner’s Office and the consultation team. Each one of us has learned some basic understanding of the other’s role, resulting in an appreciation and respect for each other, which has helped the consultation process. The USC Institute of Psychiatry, Law, and Behavioral Science started providing regular psychiatric/psychological consultation to the Los Angeles County Coroner’s Office in the mid-1980s when at a local Medical Board meeting the then Chief Medical Examiner-Coroner, Dr. Ronald Kornblum, openly requested psychiatric assistance with some of his cases. Our clinical staff met with Dr. Kornblum to discuss how we could be of assistance to the Coroner’s Office, which soon led to our consultation relationship. The success of our long-term affiliation is demonstrated by the acceptance and recognition of the importance of the psychological autopsy by the Chief Medical Examiner-Coroner and his deputy medical examiners. The major purpose of a Medical Examiner-Coroner’s Office (ME/C) is to make a determination of an individual’s death as it relates to the circumstances, manner, and cause of death. The office is legally mandated to complete a death certificate and record the manner of death as natural, accident, homicide, suicide, or undetermined. In the course of determining the manner of death, the ME/C will consider a number of sources of information including pathology results, medical records, toxicology findings, investigation information, statements from family and witnesses, and psychological evidence. For those cases where a definitive manner of death cannot be determined, the category “undetermined” is entered on the death certificate. Undetermined or “equivocal” deaths are usually undecided as to whether the manner of death is suicide or accident (homicide may also be a possible Multidisciplinary Medico-Legal Death Investigation. DOI: https://doi.org/10.1016/B978-0-12-813818-2.00007-7 © 2018 Elsevier Inc. All rights reserved.

119

120

CHAPTER 7 Psychological Autopsy

determination in equivocal cases but will not be considered here). In the United States during 2015, there were 4915 undetermined injury deaths and a corresponding rate of 1.51 per 100,000 people of both sexes, and all ages and races (CDC, 2017). In such equivocal cases, the ME/C may not have sufficient information to make a definitive determination with a reasonable degree of certainty. A psychological autopsy, however, could uncover clarifying data and yield a more decisive manner of death. Another instance when a psychological autopsy may be helpful is in cases when the ME/C has enough material to make a determination of suicide; however, a family member or other relevant party may contest the determination. In contested or protested cases, a psychological autopsy may reveal psychological evidence or provide explanations for the decedent’s actions and state of mind that were not considered previously by the ME/C.

DEFINITION OF SUICIDE At present there is no uniform definition of suicide. The National Association of Medical Examiners defines suicide as “results from an injury or poisoning as a result of an intentional, self-inflicted act committed to do self-harm or cause the death of one self” (Hanzlick et al., 2002). The Centers for Disease Control and Prevention defines suicide as “death caused by self-directed injurious behavior with any intent to die as a result of the behavior” (Crosby et al., 2011a). Both definitions include the criteria of a self-inflicted act and the intent to die; however, the criterion of “intent” is not further explained. In 1872, the US Supreme Court addressed the issue of intent in a case where a widow brought an action against a life insurance company which denied her claim for recovery (Life Insurance Company v. Terry, 1872). Mr. Terry died after he consumed poison. His life insurance policy contained the condition that if the insured “dies by his own hand, the policy shall be null and void” (p. 581). Contradictory evidence was presented by the opposing sides, viz., that when he took the poison he was insane, and that when he took the poison he was “sane, and capable of knowing the consequence of the act he was about to commit” (p. 581). The Court wrote that a policy cannot be void based solely on a selfinflicted death, additional considerations must be made. If the assured, being in the possession of his ordinary reasoning faculties, from anger, pride, jealousy, or a desire to escape from the ills of life, intentionally takes his own life, the proviso attaches, and there can be no recovery. If the death is caused by the voluntary act of the assured, he knowing and intending that his death shall be the result of his act, but when his reasoning faculties are so far impaired that he is not able to understand the moral character, the general nature, consequences, and effect of the act he is about to commit, or when he is impelled thereto by an insane impulse, which he has not the power

Historical Perspective of the Psychological Autopsy

to resist, such death is not within the contemplation of the parties to the contract, and the insurer is liable. (p. 580)

A more recent court case in California defined intent in the landmark case of Searle v. Allstate Life Insurance Company (1985). Mr. Searle was a 37-year-old man who died as a result of a self-inflicted gunshot wound to the head. He had recently been experiencing depression and was described by one doctor as being in a state of rage and psychosis when he killed himself. His wife took the case to court contesting the life insurance company’s decision not to give her the full life insurance benefits because of the suicide determination of her husband’s death. The California Supreme Court recognized that, “Mental capacity is relevant to the determination of whether an act of self-destruction was committed by the insured with suicidal intent. If the insured did not understand the physical nature and consequences of the act, whether he was sane or insane, then he did not intentionally kill himself” (p. 439). These cases highlight the importance of evaluating the mental condition of the decedent and whether the individual had the ability to form the intent for suicide.

HISTORICAL PERSPECTIVE OF THE PSYCHOLOGICAL AUTOPSY A psychological autopsy is a thorough retrospective analysis of the decedent’s intent and state of mind regarding the individual’s actions close to the time of death. Although the overwhelming majority of ME/C Offices do not use psychological autopsies to assist in making “suicide” manner of death determinations, such evaluations can prove useful in protested and equivocal cases. In fact, it was the presence of so many equivocal cases in the Los Angeles County Department of Coroner that prompted the first use of a psychological autopsy for manner of death determinations. In 1958, the Los Angeles Suicide Prevention Center was established by two psychologists, Edwin Shneidman and Norman Farberow, and a psychiatrist, Robert Litman. At about that same time, Dr. Theodore Curphey, the Los Angeles County Chief Medical Examiner-Coroner, was faced with a number of equivocal deaths due to drug overdose. In an effort to determine a more definitive mode for these cases, Dr. Curphey sought the services of Drs. Shneidman, Litman, and Farberow. As a result of this collaboration, the mental health professionals developed a procedure by which to psychologically investigate an equivocal death case, with Dr. Shneidman coining the term “psychological autopsy.” In addition, a number of research studies were conducted on equivocal deaths, which led to professionals having a better understanding of suicide. Dr. Curphey recognized the important role social scientists can play when examining whether a decedent had the intention to kill him or herself in equivocal cases (Curphey, 1961), and thus the Los Angeles County Chief Medical

121

122

CHAPTER 7 Psychological Autopsy

Examiner-Coroner’s Office established a long-term association with the mental health professionals at the Los Angeles Suicide Prevention Center (Botello et al., 2013). A number of cases were referred for psychological autopsies, including those of high profile individuals whose death was shocking to the public (e.g., Marilyn Monroe, Freddie Prinze). In 1989, Dr. Litman published a paper where he reviewed 500 consecutive psychological autopsies from 1977 to 1985 (Litman, 1989). It was found that the information obtained from the psychological autopsy greatly assisted in the final manner of death determination. Almost two-thirds of the undetermined cases were assigned as suicide, about one-third were determined as accident, and only nine cases remained as undetermined. Beginning in 1987, the USC Institute of Psychiatry, Law, and Behavioral Science (USC Institute) became the psychiatric/psychological consultant to the Los Angeles County Chief Medical Examiner-Coroner’s Office, and performs all the psychological autopsies for the Office. The use of psychological autopsies is not reserved for equivocal or undetermined cases only. In fact, since the USC Institute’s involvement, the majority of psychological autopsies have been initiated because of the next-of-kin’s protest to a suicide determination, wherein they argue that the deceased’s death was more likely an accident. Regardless of whether the case is equivocal or contested, the use of a psychological autopsy is reserved only for those cases where the possible manner of death is suicide or accident.

REFERRALS FOR A PSYCHOLOGICAL AUTOPSY The USC Institute is a separate and independent agency from the Coroner’s Office, thereby avoiding a conflict of interest. The material gathered and generated from the psychological autopsies is confidential and disclosed to the Coroner’s Office ONLY and remains its property. The psychological autopsy report is kept in a confidential file in the Chief Medical Examiner-Coroner’s Office, separate from the coroner’s file of the decedent. The importance of preserving the confidentiality of the psychological autopsy report cannot be underestimated. Part of the process in conducting this type of evaluation is securing the confidence of informants (e.g., friends, coworkers, and neighbors) that the information they disclose to the mental health examiners will be not be revealed to others, including the decedent’s next-of-kin. By doing so, the informant may feel more comfortable in offering a more accurate portrayal of the decedent, without fear of having their information discovered by others they know. Several Superior Court cases have occurred where the confidentiality of the psychological autopsy report was challenged; however, in each case the judge ruled in favor of maintaining the report’s confidentiality because it is an essential component to the validity of the psychological autopsy process.

Conceptual Framework

Before the USC Institute conducts a psychological autopsy, the Los Angeles County Chief Medical Examiner-Coroner’s Office sends an “authorization and indemnification form” to the next-of-kin. A number of issues appear on the form including the risks inherent in conducting a psychological autopsy, such as psychological pain that may be felt by surviving family members (having to relive the event), prolongation of the grieving process (final death certificate delayed, lack of closure), and possible revelation of intimate details concerning the death. Once the form is signed and returned to the Coroner’s Office, the case is referred to the USC Institute and the psychological autopsy process is initiated. As mental health professionals, we recognize that many of the individuals who are contacted as sources of information may have been affected by the decedent’s death, e.g., family may still be grieving, witnesses may be experiencing some trauma, many may be confused and feel lost. As forensic consultants to the ME/C, it is important to recognize that the primary purpose of the psychological autopsy is not necessarily therapeutic, rather, it is to gather information in a sensitive manner to determine the decedent’s mental condition relative to factors associated with suicide. Nevertheless, if anyone we talk to is having problems adjusting to the death, we routinely suggest that they seek outside mental health counseling. On numerous occasions, at the conclusion of our interviews with relatives and close friends of the decedent, they spontaneously stated that they found the process to be therapeutic and thanked us for giving them an opportunity to talk about their memories and feelings with respect to the decedent’s life and death.

CONCEPTUAL FRAMEWORK USED BY THE USC INSTITUTE OF PSYCHIATRY, LAW, AND BEHAVIORAL SCIENCE Medical Examiner’s/Coroner’s offices usually do not use psychological autopsies to assist in making “suicide” and “accident” manner of death determinations (Jobes et al., 1986). There is usually enough physical evidence or psychological history obtained from law enforcement, coroner investigators, toxicologists, and pathologists that the ME/C does not need input from mental health professionals. Whenever the ME/C makes a determination of the manner of death without mental health collaboration through a psychological autopsy, assumptions are made about the decedent’s intent. A psychological autopsy may elicit material contrary to the assumptions of the ME/C, e.g., that the self-inflicted gunshot wound to the head was not intended to be a suicide, but was accidental. It is in just such cases that family members and other relevant parties contest the ME/C’s finding and may request a psychological autopsy to reject suicide as the manner of death determination.

123

124

CHAPTER 7 Psychological Autopsy

ASSUMPTIONS The experience of the ME/C and input from other professionals assisting the ME/C contribute to the ME/C’s assumptions regarding the manner of death determination. To successfully challenge the assumptions and determination, significant and persuasive evidence to the contrary must be presented to and accepted by the ME/C. The burden is on the challenger to provide significant material, offered with a sufficient degree of confidence, showing that the assumptions and determination of the ME/C were erroneous and therefore, should be rejected. If this burden cannot be met, the determination of the ME/C as to the manner of death is not rejected and stands. This approach is one that was advocated by the late Seymour Pollack, MD, the founder and former director of the USC Institute of Psychiatry, Law, and Behavioral Science, for conducting forensic psychiatric/psychological legal evaluations (Gross and Weinberger, 1982). It has an analogy in the statistical method of testing hypotheses (Fig. 7.1). For example, the great majority of adults who die by self-inflicted contact gunshot wounds to the head are clearly suicidal. If the ME/C accepts this commonly held assumption and determines that the manner of death is suicide, this could be identified as the “null hypothesis” that will be tested. However, this conclusion can be contrasted with an “alternative hypothesis,” i.e., adults who die by self-inflicted contact gunshot wounds to the head are not suicidal.

FIGURE 7.1 “Contested” cases. Example: Self-inflicted contact gunshot wound to the head.

Assumptions

In contested cases, the psychological autopsy is directed toward collecting data that reject the null hypothesis of suicide. Information and material are sought which imply that the decedent did not have a mental condition consistent with suicide (i.e., alternative hypothesis). If the psychological autopsy yields sufficient data substantiating the alternative hypothesis to an acceptable degree of confidence, the null hypothesis is rejected and the opinion by the mental health professional is that the ME/C determination of suicide should be changed. However, if data supporting the alternative hypothesis cannot challenge the null hypothesis successfully, the null hypothesis is not rejected and the opinion by the mental health professional is that the ME/C’s determination of suicide should stand. The goal of the mental health professional conducting a psychological autopsy in contested cases is to gather sufficient persuasive material that would overcome the ME/C’s “reasonable degree of certainty” that the death was a suicide. If this goal is accomplished, the manner of death is not suicide—it is something else. If the burden is not met, however, the manner of death remains suicide. In many ways, this approach is analogous to that used in criminal trials. The assumption is that the defendant is not guilty (null hypothesis); the burden of proof is on the prosecution to prove that the defendant is guilty (alternative hypothesis). The prosecuting attorney not only has the burden to prove the alternative, this burden is a very high one and requires a degree of proof of “beyond a reasonable doubt.” Thus the evidence submitted by the prosecutor must be considered valid and highly persuasive for the trier-of-fact to reject the assumption of the defendant’s nonguilt. A psychological autopsy conducted in a contested case of suicide faces a similar burden—that the data and arguments submitted must be highly persuasive so as to successfully challenge the assumption of suicide in order to change the manner of death determination. In “contested” cases of suicide, this approach of using material obtained from psychological autopsies to challenge the assumptions made by the ME/C in arriving at a manner of death determination allows the mental health professional to focus the retrospective analysis on the decedent’s intent. That is, can the mental health professional discover considerable and convincing material contradictory to a decedent having a state of mind that would lead to suicide? The task in contested cases is not to look for data supportive of a mental condition consistent with suicide, rather, it is to look for evidence that contradicts suicide. The evidence could include an impaired state of mind at the time of death (perhaps due to substantial alcohol/drug intoxication, psychotic mental illness, or marked intellectual deficits) such that the decedent could not form the intent to commit suicide. Moreover, if none or few of the significant risk factors usually associated with suicide (e.g., depression, previous suicide attempt, loss of an important interpersonal relationship, recent family pathology or discord, medical illness) were present, one could argue that the decedent did not have a mental condition consistent with suicide. This is not to say that in performing the psychological investigation, material substantiating suicide would not surface, nor should the mental health professional ignore such supportive data. The objective in contested cases,

125

126

CHAPTER 7 Psychological Autopsy

however, is to search for material that would contradict the determination of suicide by the ME/C. On the other hand, the conceptual approach used for “equivocal” or “undetermined” cases is different from that of “contested” cases (Fig. 7.2). In equivocal cases, there are no commonly held assumptions, the ME/C may not have enough material to render a manner of death determination with a reasonable degree of certainty. In these cases, both accident and suicide are plausible determinations, therefore, there is no “null” hypothesis. The objective of the psychological autopsy in equivocal cases is to probe for material that is both supportive and contradictory of a mental condition consistent with suicide. This approach varies from that in contested cases where the psychological investigation is directed only toward uncovering material refuting suicide. Consequently, in equivocal cases, if more persuasive material was obtained supporting a mental condition consistent with suicide than not consistent with suicide, then the determination derived from the psychological autopsy is “suicide.” Conversely, if the findings were reversed, the psychological investigator would opine that the manner of death is “not suicide,” i.e., “accident.”

FIGURE 7.2 “Equivocal” cases. Example: Fall from cliff.

Risk Factors and State of Mind Regarding Suicide

It is important to recognize that the burden of proof necessary in reaching a definitive manner of death determination in an equivocal case is not as high as that for overturning or rejecting the manner of death in a contested case. The material derived from the psychological autopsy only needs to tip the balance in one direction over the other, whereas in a contested case, the psychological autopsy material must tip the scale considerably to the opposing side if the original manner of death determination is to be changed. Finally, it must be underscored that the psychological autopsy is concerned only with the mental condition of the decedent, i.e., whether the decedent did or did not have a mental condition consistent with suicide at the time of the selfinflicted lethal act. It is only one of a number of sources of information that the ME/C considers in making a final death determination. For example, there may be a case where a decedent had a mental condition consistent with suicide, walked into the street, and was hit by a car. One could argue that the decedent’s mental condition may have influenced him or her to walk into traffic so as to be mortally injured. However, if other sources reveal that no cars were in the vicinity when the decedent stepped off the curb, and the car in question had just turned the corner onto the street, but was nowhere in sight previously, then it could be argued that the death was not the result of a suicidal intent but was an accident. In such cases, there is relevant evidence that outweighs a suicidal mental state, i.e., despite the decedent having a mental condition consistent with suicide, the circumstances support that the death was not the result of a suicidal intent. Therefore it is important to acknowledge that the psychological autopsy represents a tool among many to be used by the ME/C and not as the primary means for determining manner of death.

RISK FACTORS AND STATE OF MIND REGARDING SUICIDE Studies have found certain static factors that correlate highly with suicide and therefore if present, increase an individual’s risk for suicide. These factors include: gender, with males generally four times more likely to commit suicide than females (Crosby et al., 2011b); age, with highest rates found among persons aged 45 64, and then a sharp increase among those 75-years and older (CDC, 2017); and race, with the suicide rates for Whites being at least twice as high as that for Blacks, Hispanics, and Asian/Pacific Islanders (CDC, 2017). Marital status is another factor to consider. Married persons are at lowest risk, while those who are divorced or separated are at much greater risk to commit suicide, followed by those who were never married, however, a very high risk of suicide exists for males who are widowed, but not for female widows (Denny et al., 2009). Psychiatric illness is strongly related to suicidal behavior. Mood disorders, particularly depression, constitute the most prevalent diagnoses found among

127

128

CHAPTER 7 Psychological Autopsy

those who commit suicide, individuals with schizophrenia also have a high rate of suicide as do those with cooccurring substance abuse or panic disorders (Sudak, 2009; Mann and Currier, 2007; Cavanagh et al., 2003). Other risk factors are previous psychiatric hospitalization (Qin and Nordentoft, 2005), previous suicide attempts (Fowler, 2012), and family history of suicide (Qin et al., 2002). Significant interpersonal or stressful life events, including recent important losses in social relationships, health, employment, and financial status, as well as legal problems are issues that should also be examined when assessing risk (Stack and Scourfield, 2015; Wang et al., 2015; Classen and Dunn, 2011; Coope et al., 2015; Weinberger et al., 2000, 2014; Overholser et al., 2012; Cook and Davis, 2012). Demographics and psychological issues are not the only factors to be considered when conducting a psychological autopsy. Certain behaviors that the decedent may have engaged in prior to death can be used inferentially to determine the decedent’s intent. For example, individuals may give warnings, write suicide notes, dispose of their possessions, make preparations for their death, have plans for the future, or research various means of death (Rosenberg et al., 1988). The presence of any single static factor does not necessarily lead to suicidal behavior, rather, when several static and dynamic risk factors appear together, an individual’s risk for suicide is greatly increased. If none or few of the significant factors usually associated with suicide are present, then one could argue that the decedent did not have a mental condition consistent with suicide. In addition to identifying risk factors, the psychological autopsy examiners should inquire about the decedent’s state of mind at the time of death to determine if the decedent had the mental capacity to form the intent for suicide. Although suicide is generally accepted to mean the act of killing oneself intentionally, investigating the nature of that intent and whether the person had an understanding of the consequences of his or her actions is critical to the legal determination of suicide (Searle v. Allstate, 1985). That is, if a decedent were so mentally impaired, e.g., because of alcohol or drug intoxication, psychosis, or marked intellectual/cognitive deficits that he or she probably could not have understood the lethality of his or her actions, then the psychological autopsy would not support the decedent as having the necessary suicidal intent. When conducting a retrospective analysis of the risk factors and the decedent’s mental capacity to form the intent to kill himself or herself, the psychological examiners must review many sources of information (Ritchie and Gelles, 2002; Botello et al., 2003). These include the coroner investigator’s report; police reports; autopsy report; laboratory data, including toxicology results; medical and mental health records; and school records, if appropriate. The psychological examiners also should interview family, friends, employers, coworkers, neighbors, family physicians, psychotherapists, individuals who had contact with the decedent near or at the time of death, witnesses to the death, and any other relevant parties. Finally, the psychological examiners may visit the scene of death to gain a better understanding of its physical circumstances.

“Contested” or “Protest” Case Example

A full psychological autopsy report can be many pages long. Our psychological autopsy reports focus on salient factors related to suicide. The report includes detailed reasoning regarding these factors and how their presence or absence relates to a mental condition consistent with suicide. Two case examples follow. The first is a contested/protested case and the second is an equivocal/undetermined case. Although the cases are fictitious (so that the issue of confidentiality is not germane) and presented in an abbreviated form, they are reflective of the approach we use in conducting psychological autopsies.

“CONTESTED” OR “PROTEST” CASE EXAMPLE Mr. B. was a 28-year-old African-American male who was married for 4 years when he died of a self-inflicted contact gunshot wound to the head. He had a small insurance policy, issued 3 years earlier through his employer. On the evening of his death, he went to a bar with his cousin where he saw his wife’s former boyfriend. The cousin made suggestive remarks that Mr. B.’s wife might be having an affair with this man. Upon returning home, Mr. B. confronted his wife and accused her of having an affair, which she vehemently denied. Mr. B. then saw his brother-in-law’s semiautomatic pistol on the kitchen table. He picked up the gun, placed it to his temple, and said, “Is this what you want?” As his wife approached him, the gun discharged. The toxicology report at autopsy showed that the decedent had a blood alcohol level of 54.3 mmol/L. The medical examiner/coroner determined that the manner of death was suicide. Mr. B.’s wife contested the coroner’s manner of death determination of suicide and a psychological autopsy was performed. Because this was a contested case, the psychological autopsy was directed toward uncovering material contradicting suicide as the manner of death. We reiterate that the task of the mental health professional conducting a psychological autopsy in a contested case is to focus on the absence of suicide risk factors and behavioral indices that infer suicide. The mental health professional should also explore whether the decedent’s mental condition was sufficiently impaired such that he or she could not have formed the intent for suicide. The decedent was known to be a regular beer-drinker who abstained from hard liquor. On many occasions when he was intoxicated by beer, he acted hastily, and was clumsy, argumentative, and suspicious of others to the point of being somewhat paranoid. When intoxicated, he sporadically felt jealous and would accuse his wife of infidelity. This was a source of occasional marital conflict. One year earlier, while intoxicated, Mr. B. threatened to cut his wrists in a manipulative gesture to have his wife confess that she was unfaithful to him. Mr. B. put the knife down when his wife cried and pled with him to believe that she was not having an affair. The couple reconciled and on the next morning he apologized for his accusations and impulsive behavior. He said that he did not mean to hurt

129

130

CHAPTER 7 Psychological Autopsy

himself but only wanted to be reassured of her love. There were no other previous statements or attempts by Mr. B. to harm himself. The decedent never participated in mental health or alcohol treatment. There was no history of significant depression nor was there a family history of suicide, suicide attempts, or psychiatric treatment. Mr. B. was not involved in any medical treatment; at the time of his death, he was in good physical health. There were no new psychosocial stressors in his life prior to his death. He was employed fulltime and there were no financial stressors (e.g., large outstanding bills). Moreover, the decedent had not suffered any recent important losses. Mr. B. had no prior history or experience using or handling firearms. The weapon he used that night was a semiautomatic pistol that belonged to his brother-in-law, who was residing with him and his wife. Mr. B.’s brother-in-law had been cleaning the gun and left it on the kitchen table when he was called away for an emergency at his place of work. On the afternoon of his death, Mr. B. met his cousin, who suggested they go to a bar after work. At the bar, he and his cousin were drinking beer when they saw Mrs. B.’s former boyfriend, who greeted them and asked about the decedent’s wife. His cousin suggested that the former boyfriend was friendly because he was having an affair with Mrs. B. The decedent became upset upon hearing this, he finished drinking his beer and proceeded to drink shots of bourbon. He intended to drive home from the bar, but his cousin volunteered to drive instead because Mr. B. had trouble walking. When Mr. B. arrived home, he fell going up the stairs to his apartment. When he entered the apartment, he confronted his wife and claimed that she was having an affair with her former boyfriend. She denied it, however, Mr. B. did not believe her. He continued arguing and became enraged. Mrs. B. had difficulty understanding her husband because he was speaking so loudly and his speech was slurred. He then noticed the gun lying on the kitchen table. Mrs. B. stated that the magazine clip full of bullets was removed and lying next to the gun. She stated that Mr. B. displayed very agitated behavior and was having noticeable difficulty walking and talking clearly. He picked up the gun, looked into the magazine well, placed the pistol to his temple, and angrily asked her, “Is this what you want?” As she approached him, suddenly, there was a loud noise outside the house, and then the gun discharged. The following factors, derived from collateral sources when conducting the psychological autopsy, emerged and contradict the initial manner of death determination of suicide by the ME/C. The decedent had no prior psychiatric history or treatment, nor was there any family history of suicide. Mr. B. was not described as suffering from depression, nor had he experienced any recent significant losses. Prior to his death, Mr. B. did not leave a suicide note nor make any inappropriate or unexpected preparations for his death, such as giving away possessions, increasing life insurance benefits, or writing a will. He did not take any measures to avoid rescue, in fact, his wife was present when the gun discharged. He also had little familiarity with revolvers or semiautomatic guns. Mr. B. had a

“Contested” or “Protest” Case Example

history of continuing alcohol abuse as well as a history of acting impulsively when intoxicated. Although he had an earlier attempt of manipulating his wife by threatening self-injurious behavior, he had no history of suicide attempts that were directed primarily toward a desire to die. Finally, Mr. B. was AfricanAmerican and at lesser risk for suicide than Whites, he was also in an age range that is among the lowest rates for suicide. In sum, many significant risk factors and features usually associated with suicide were absent. In examining the decedent’s intent to commit suicide, a number of factors were considered. On the night of his death, Mr. B. was highly intoxicated with alcohol. He was known to have a history of becoming aggressive and suspicious when drunk. At times, his intoxication also made him paranoid and jealous. All of these factors were present on the night he died. However, he was also noted to have a great deal of difficulty with gross motor coordination and speech; these were behaviors that he had never before demonstrated. He was not known to consume hard liquor, therefore, its effect on him was unknown. It was also important to assess the effect that the sudden, loud noise may have had on him. The noise outside his house was confirmed to be a neighbor setting off fireworks. This might have startled Mr. B., and because of his agitation and poor motor coordination, the noise might have caused him to unintentionally and reflexively pull the trigger of the gun. Another factor considered was the behavior Mr. B. displayed with the firearm. Mrs. B. stated that the magazine clip full of bullets from the semiautomatic was lying next to the gun when he picked it up. She also noticed that he looked into the magazine well before he put the gun to his head. One can infer from these actions that he did not believe the weapon was loaded, i.e., being unfamiliar with semiautomatic firearms, he might not have been aware that a bullet was still in the chamber. It could be asserted that he placed the gun to his head solely as a manipulative ploy to have his wife convince him of her love and fidelity for him, rather than in a desire to kill himself. He had performed this ploy in the past, and was then convinced after doing this that his wife was telling him the truth when she denied an affair. In evaluating his state of mind at the time of death, one could argue that Mr. B. was highly intoxicated and displayed a pattern of manipulative behavior he was known to demonstrate previously for the purpose of assuring himself of his wife’s love and fidelity. Although alcohol and substance abuse problems are often associated with suicidal behavior, as are significant interpersonal problems (in this case, marital difficulties), it is believed that Mr. B.’s self-inflicted wound was not performed with the intent to end his life. He appeared to acknowledge that the magazine clip was not in the gun and even looked into the magazine well to check for bullets. It is believed that his unfamiliarity with guns and his intoxication affected his judgment, as well as his ability to accurately assess the current lethality of the firearm (i.e., not realizing or understanding that a bullet was in the chamber). In addition, he was so impaired from alcohol and anger that he may not have had control over his coordination, particularly when startled. These

131

132

CHAPTER 7 Psychological Autopsy

factors support the argument that at the time of his death he did not have the mental capacity to understand that his action of placing the gun to his head could actually result in a lethal consequence. Although the purpose of the psychological autopsy in a contested case is to uncover data contrary to a mental condition leading to suicide, data supportive of such a mental condition may surface and should be considered. Demographic and psychological factors favoring suicide in this case (e.g., male gender, previous potential self-injurious behavior, alcohol abuse, and marital difficulties) were not as convincing as those opposed to a mental state consistent with suicide. Although Mr. B. died of a self-inflicted contact gunshot wound to the head, substantial and persuasive data were found implying that Mr. B. did not have a mental condition leading to suicide. Therefore, based on the additional information gathered by the psychological autopsy, one could argue that the initial manner of death as suicide by the ME/C was successfully overcome and should be rejected.

“EQUIVOCAL” OR “UNDETERMINED” CASE EXAMPLE Mr. K. was a 32-year-old, white, single, unemployed male who lived with his parents. He was an avid jogger who regularly ran alone in the early morning. He preferred a route near his home that was on a paved bike path overlooking the ocean cliffs. A neighborhood resident saw him leave the path by climbing over a railing and walking to higher ground. In the late morning, his corpse was found on rocks below a 30-m cliff. The autopsy revealed multiple trauma and fractures of the skull, neck, arms, legs, and ribs. Toxicology findings were negative for alcohol and illegal drugs, but positive for lithium. Given the circumstances surrounding Mr. K.’s death, the ME/C did not rule on the manner of death “pending investigation,” thus prompting a psychological autopsy. Because the ME/C did not make a determination regarding the manner of death, the psychological autopsy was directed toward uncovering material that both would and would not support a mental condition consistent with suicide. Mr. K. was the youngest of three sons, both his older brothers were married and had children. Mr. K. was heterosexual but had never had a long-term romantic relationship. This was a source of emotional difficulty for him because he occasionally spoke of wanting to raise a family. He had a few close friends but they were all married or involved in serious relationships. Mr. K. was employed in the aerospace industry for several years but was laid off due to cutbacks in the company 1 year prior to his death. He talked excitedly with his friends regarding plans about returning to college for training as a computer programmer. He had no sizeable debts except for his car payments, which were paid by his unemployment checks and loans from his parents.

“Equivocal” or “Undetermined” Case Example

Mr. K. had a 7-year history of psychiatric treatment, he was diagnosed as having bipolar disorder. At the time of his death, he was stable on lithium with a therapeutic blood level of 1.0 mmol/L. Contact with the treating psychiatrist and review of psychiatric records revealed a past history of depression with suicidal ideation, but no suicide attempts. During these times, he thought about suicide when holidays approached or when he felt lonely. However, he was described by his psychiatrist as not being severely depressed and without any suicidal thoughts on his last appointment prior to his death. There was no family history of mental illness or suicide. Mr. K. consumed alcohol occasionally but was not known to abuse it. There was no history of licit or illicit drug abuse. He was described as a quiet person who was not very disclosing to friends or family about personal issues. He was noted to be impulsive and displayed poor judgment at times, i.e., he would act before he thought through a situation. His psychiatrist commented that Mr. K. was becoming more open and cheerful in the few months before his death because he was hopeful about a future with his current girlfriend as well as about his career plans. On the afternoon prior to his death, he was described as being in a pleasant mood and speaking with his family of his good fortune in acquiring tickets to a professional baseball game that weekend. On the evening before his death, he received a phone call from his girlfriend. She told him that she could not accompany him to his friend’s wedding next month because her job was relocating to another state. She also said that it was possible they would not see one another after her move. Mr. K. spoke with a friend later that evening but did not mention his girlfriend’s phone call. The friend said that Mr. K. sounded somewhat subdued, but did not seem depressed. On the night before his death, it had been raining since 6:00 p.m., on the morning of his death, there were fog and light showers. Mr. K. awoke at his usual time of 5:30 a.m. He laid out the clothes he planned to wear to an appointment he had at the college later that morning, and then put on his jogging outfit. He saw his mother, who told him that it was still raining and that he should forego jogging because he was getting over a cold. He made light of her concern and left for his usual jogging route. A resident in the area saw Mr. K. walk from the bike path and climb over a metal railing to higher ground, because of the fog, the resident could not see Mr. K. beyond that point. The coroner investigator’s report indicated that Mr. K. then walked or jogged for a short distance until he went down to a dirt path at the edge of the cliff. It was at this point that Mr. K. fell. Mr. K.’s body was found at the bottom of the cliff later that morning. When conducting a psychological autopsy where the ME/C has not ruled on the manner of death (i.e., “pending investigation,” “equivocal,” “undetermined”), it is necessary to list those factors that support an opinion of “suicide” and those that do not. In the case of Mr. K., arguments could be made for both opinions, consequently, the persuasiveness of each side must be weighed.

133

134

CHAPTER 7 Psychological Autopsy

The factors that support the opinion that Mr. K. did not have a mental condition consistent with suicide include the following: There was no recent documented history of depression or suicidal ideation. The decedent never engaged in any suicidal gestures or attempts, nor was there any such family history. While he was in psychiatric treatment for depression and taking psychiatric medication at the time of his death, his treating doctor indicated that his condition was improving. He was unemployed, yet, his financial debts were manageable. He was described by others as being cheerful and optimistic the last few months, with plans for the immediate and more distant future. The day before his death, he acquired prized tickets to an upcoming baseball game, and he had an appointment on the morning of his death at the college he hoped to attend so as to start a new career path. Although Mr. K. heard disappointing news from his girlfriend the evening before he died, he gave no indication that he was upset, depressed, or considering suicide. He did not make any preparations for his death, such as disposing of his possessions, offering final good-byes, or writing a will. It was noted that Mr. K. occasionally displayed poor judgment. One could argue that he used poor judgment on the morning of his death. He ignored his mother’s advice not to go jogging because of his cold and the rain, and he strayed from his usual jogging route to go to a hazardous location that was rendered even more dangerous because of weather and soil conditions. The psychological autopsy also revealed factors supporting that Mr. K. had a mental condition consistent with suicide. Mr. K. was a White male, these demographics correlate highly with risk for suicide. In addition, Mr. K. had a history of mental illness characterized by depression and some suicidal ideation in the past. Regarding Mr. K.’s mental condition, there were some aspects of his life that would lead to optimism, however, they could also present psychosocial stressors for him. His plan to return to college and acquire training in a new career could be anxiety arousing, e.g., he has been out of school for a few years and may have difficulty adjusting, he may incur increasing debt due to tuition costs. More importantly, his feelings of optimism were suddenly dashed when he received a disappointing telephone call from his girlfriend on the night preceding his death. Although he did not display any significant emotional upset, he was an individual who tended not to disclose emotional feelings to others. One could argue that when his girlfriend called and informed him of her impending move and possible break-up, he once again felt discouraged and lonely. His long-standing feelings of wanting to be married and have a family, along with his hope that this woman would become his wife, may have been crushed. These feelings may have been further exacerbated by her inability to attend the upcoming wedding of one of his friends, where he would once again be reminded of his “singleness” in comparison to all his friends. Given that this was his first and only romantic relationship, he may have felt even more depressed and hopeless when confronted with the loss.

Conclusion

Mr. K.’s state of mind at the time of his death could also be inferred by movements that reflect his intentions. According to a witness and the investigator’s report, Mr. K. left the paved bike path, stepped over a rail, walked up to higher ground, walked or jogged a short distance, and then went down to a dirt path near the edge of the cliff from which he fell. This series of behaviors performed in a short period of time suggests goal-directedness. If Mr. K. truly wanted to go jogging, why did he stray from his customary safe course? Mr. K. engaged in deliberate, nonlinear movements in a location and under conditions that he should have known to be dangerous. Leaving a secure paved path to approach a hazardous point implies a lack of concern for his safety. On the other hand, one could argue that Mr. K.’s impulsivity and poor judgment, in addition to the darkness and slipperiness of the area because of the fog and rain, might have created a situation whereby his death was not the product of a suicide. That is, he may not have been thinking clearly regarding the consequences of his actions. This, combined with the possibility that he could not see where he was going, could not properly assess the surroundings, and could not physically adjust to the perilous landscape, might have resulted in a death that was not intended. Mr. K, however, was not known to jog on any course other than the bike path even when there were previous foggy mornings. To leave such a familiar and secure route, given the weather conditions, was inconsistent with his past behavior. Further, Mr. K’s previous history of impulsivity and poor judgment was not of the kind or degree that placed him in dangerous situations. Finally, at the time of his death he was not under the influence of any substance that could have impaired his cognitive processes. In weighing the material that was supportive of both opinions, it was believed that the factors favoring a mental state consistent with suicide were greater and more persuasive than those arguing against suicide, and that such a manner of death determination could be made with a reasonable degree of medical certainty. Although some important factors associated with suicide were not present, many were. Moreover, it was believed that the decedent not only had a mental condition that was consistent with suicide, but that his mental capacity was not so impaired as to preclude him from understanding the nature and consequences of his actions.

CONCLUSION It has been found that although complaints about manner of death determinations are uncommon, most of those made are by family members of the deceased contesting the classification of death as suicide (Goodin and Hanzlick, 1997). Further, there are times when Medical Examiners or Coroners cannot determine a definitive manner of death based on the available material. For those contested

135

136

CHAPTER 7 Psychological Autopsy

and equivocal cases when the possible modes are either “accident” or “suicide,” a valid determination requires an understanding of the psychological dynamics for suicidal behavior. This can be a challenging task for those who are not mental health professionals with expertise in performing psychological autopsies. To make conclusive manner of death determinations in these difficult cases, mental health consultation and psychological autopsies can be a critical tool for Medical Examiner/Coroner’s Offices.

REFERENCES Botello, T.E., Weinberger, L.E., Gross, B.H., 2003. Psychological autopsy. In: Rosner, R. (Ed.), Principles and Practice of Forensic Psychiatry, second ed. Arnold, London, pp. 89 94. Botello, T., Noguchi, T., Sathyavagiswaran, L., Weinberger, L.E., Gross, B.H., 2013. Evolution of the psychological autopsy: fifty years of experience at the Los Angeles County Chief Medical Examiner-Coroner’s Office. J. Forensic Sci. 58 (4), 924 926. Available from: https://doi.org/10.1111/1556-4029.12138. Cavanagh, J.T., Carson, A.J., Sharpe, M., Lawrie, S.M., 2003. Psychological autopsy studies of suicide: a systematic review. Psychol. Med. 33 (3), 395 405. Centers for Disease Control and Prevention, 2017. Fatal injury reports, national and regional, 1981-2015. Available at: ,https://webappa.cdc.gov/sasweb/ncipc/mortrate. html. (accessed 23.05.17.). Classen, T.J., Dunn, R.A., 2011. The effect of job loss and unemployment duration on suicide risk in the United States: a new look using mass-layoffs and unemployment duration. Health Econ. 21 (3), 338 350. Available from: https://doi.org/10.1002/hec.1719. Cook, T.B., Davis, M.S., 2012. Assessing legal strains and risk of suicide using archived court data. Suicide Life Threat. Behav. 42 (5), 495 506. Available from: https://doi. org/10.1111/j.1943-278X.2012.00107.x. Coope, C., Donovan, J., Wilson, C., Barnes, M., Metcalfe, C., Hollingworth, W., et al., 2015. Characteristics of people dying by suicide after job loss, financial difficulties and other economic stressors during a period of recession (2010-2011): a review of coroners’ records. J. Affect. Disord. 183, 98 105. Available from: https://doi.org/10.1016/ j.jad.2015.04.045. Crosby, A.E., Ortega, L., Melanson, C., 2011a. Self-directed violence surveillance: Uniform definitions and recommended data elements. Centers for Disease Control and Prevention, Atlanta, p. 23. Crosby, A.E., Ortega, L., Stevens, M.R., 2011b. Suicides—United States, 1999-2007. Centers for Disease Control and Prevention, Atlanta. Available at: ,http://www.cdc. gov/mmwr/preview/mmwrhtml/su6001a11.htm. (accessed 11.12.15.). Curphey, T.J., 1961. The role of the social scientist in the medicolegal certification of death from suicide. In: Farberow, N., Shneidman, E.S. (Eds.), The Cry for Help. McGraw-Hill, New York, NY. Denny, J.T., Rogers, R.G., Krueger, P.M., Wadsworth, T., 2009. Adult suicide mortality in the Unites States: marital status, family size, socioeconomic status, and differences by

References

sex. Soc. Sci. Q. 90 (5), 1167 1185. Available from: https://doi.org/10.1111/j.15406237.2009.00652.x. Fowler, J.C., 2012. Suicide risk assessment in clinical practice: pragmatic guidelines for imperfect assessments. Psychotherapy (Chic.). 49 (1), 81 90. Goodin, J., Hanzlick, R., 1997. Mind your manners part II: general results from the National Association of Medical Examiners Manner of Death Questionnaire, 1995. Am. J. Forensic Med. Pathol. 18 (3), 224 227. Gross, B.H., Weinberger, L.E., 1982. In: Gross, B.H., Weinberger, L.E. (Eds.), The Mental Health Professional and the Legal System., vol. 16. Jossey-Bass, San Francisco, CA. Hanzlick, R., Hunsaker, J.C., Davis, G.J., 2002. A Guide for Manner of Death Classification, first ed. National Association of Medical Examiners, Atlanta, GA, p. 6. Jobes, D.A., Berman, A.L., Josselson, A.R., 1986. The impact of psychological autopsies on medical examiners’ determination of manner of death. J. Forensic Sci. 31 (1), 177 189. Life Insurance Company v. Terry, 1872, 82U.S. 580. Litman, R.E., 1989. 500 psychological autopsies. J. Forensic Sci. 34 (3), 638 646. Mann, J.J., Currier, D., 2007. Prevention of suicide. Psychiatr. Ann. 37 (5), 331 339. Overholser, J.C., Braden, A., Dieter, L., 2012. Understanding suicide risk: Identification of high-risk groups during high-risk times. J. Clin. Psychol. 68 (3), 349 361. Available from: https://doi.org/10.1002/jclp.20859. Qin, P., Nordentoft, M., 2005. Suicide risk in relation to psychiatric hospitalization: evidence on longitudinal registers. Arch. Gen. Psychiatry 62 (4), 427 432. Available from: https://doi.org/10.1001/archpsyc.62.4.427. Qin, P., Agerbo, E., Mortensen, P.B., 2002. Suicide risk in relation to family history of completed suicide and psychiatric disorders: a nested case-control study based on longitudinal registers. Lancet 360 (9340), 1126 1130. Available from: https://doi.org/ 10.1016/S0140-6736(02)11197-4. Ritchie, E.C., Gelles, M.G., 2002. Psychological autopsies: the current Department of Defense effort to standardize training and quality assurance. J. Forensic Sci. 47 (6), 1370 1372. Rosenberg, M.L., Davidson, L.E., Smith, J.C., Berman, A.L., Buzbee, H., Gantner, G., et al., 1988. Operational criteria for the determination of suicide. J. Forensic Sci. 33 (6), 1445 1456. Available from: https://doi.org/10.1520/JFS12589J. Searle v. Allstate Life Ins. Co., 1985. 38Cal. 3d 425. Stack, S., Scourfield, J., 2015. Recency of divorce, depression, and suicide risk. J. Fam. Issues 36 (6), 695 715. Available from: https://doi.org/10.1177/0192513X13494824. Sudak, H.S., 2009. Suicide. In: Sadock, B.J., Sadock, V.A., Ruiz, P. (Eds.), Comprehensive Textbook of Psychiatry, ninth ed. Lippincott Williams & Wilkins, Philadelphia, PA, pp. 2717 2732. Wang, Y., Sareen, J., Afifi, T.O., Bolton, S.L., Johnson, E.A., Bolton, J.M., 2015. A population based longitudinal study of recent stressful life events as risk factors for suicidal behavior in major depressive disorder. Arch. Suicide Res. 19 (2), 202 217. Available from: https://doi.org/10.1080/13811118.2014. Weinberger, L.E., Sreenivasan, S., Gross, E.A., Markowitz, E., Gross, B.H., 2000. Psychological factors in the determination of suicide in self-inflicted gunshot head wounds. J. Forensic Sci. 45 (4), 815 819. Weinberger, L.E., Sreenivasan, S., Garrick, T., 2014. End-of-life mental health assessments for older aged, medically ill persons with expressed desire to die. J. Am. Acad. Psychiatry Law 42 (3), 350 361.

137