'Psychological autopsy' can help explain death: a 16-item checklist can be used to help determine if a patient's death was accidental or self-inflicted.

MONTREAL -- A psychological autopsy can be helpful in determining the causes of a patient's death, Dr. Elena Swartz said at the annual meeting of the American Academy of Psychiatry and the Law.

The idea of a psychological autopsy began at the Los Angeles County coroner's office, said Dr. Swartz, who is a fellow in forensic psychiatry at the University of California, Davis.

It can be useful in various settings, including insurance benefit determination, product liability determination, civil malpractice cases, and criminal investigations, she said, noting that one 10-year study found that 30% of claims brought against psychiatrists involved attempted or completed suicides.

Unlike a conventional autopsy, a psychological autopsy does not focus on how a person died, but on why--which is a little more subtle, Dr. Swartz said. Take the example of "Mr. Nash," a skydiver who fell to his death. Although the cause of death was listed as "massive crush injuries," an investigation showed that he was facing indictment charges for fraud and embezzlement, and that he had been having difficulty sleeping.

"Was his death 'natural'? Did he have a heart attack [during the jump]? Was it accidental because he was so distracted that he didn't properly pack his chute? Was it suicide? Or was it homicide?" Dr. Swartz asked.

Then there are cases of "suicide by cop," she continued. "No one knows how many people induce police to kill them, but one study found that in at least 10% of cases, the victims wanted to be killed."

Motor vehicle accidents are another area in which the reason for death can be ambiguous.

"The vehicular suicide rate is unknown, but estimates are that it represents 5%-15% of fatalities," Dr. Swartz said.

To determine whether or not a person intentionally committed suicide, psychiatrists can use the Empirical Criteria for the Determination of Suicide (ECDS), a 16-item checklist containing sections on self-infliction and intention, self-infliction only, and intention only. Items on the ECDS include:

* Pathologic evidence indicates self-inflicted death.

* Evidence [exists] that decedent recognized high potential lethality of means of death, such as a pharmacist dying from a drug overdose.

* Decedent had recent and sudden changes in affect.

* Decedent had experienced general instability in immediate family.

Researchers found that these criteria had an overall ability to identify suicides in 92% of cases, Dr. Swartz said.

However, there are problems with doing a psychological autopsy, she said. For one thing, guidance on training is scant. Reliability and validity also have been questioned, as has the idea of a retrospective analysis.

Then there's bias, which can occur whenever there are secondary gains to be obtained from the autopsy as well as loved ones who are trying to color the truth to put the deceased partner or friend in a more positive light. "Despite these issues, psychological autopsies have been used in courtrooms with a great deal of success," she said.

The two main sources of information for a psychological autopsy are collateral interviews with friends, family members, neighbors, and treating physicians' and collateral records, including medical records, psychiatric records, personal notes, journals, police reports, and employment records, said Kate Warburton, D.O., a fellow in forensic psychiatry at the University of California, Davis.

Studies have shown that to increase the satisfaction of survivors, the best time to perform the collateral interviews is within the first 10 weeks of the death, Dr. Warburton said.

One thing psychological autopsies can help uncover are suicides--particularly among youth--that are the accidental result of autoerotic activities, according to Dr. Charles Scott, chief of the division of psychiatry and the law at the University of California, Davis.

For example, in autoerotic asphyxia, victims may use a rope around their necks to constrict their oxygen supply to increase pleasure while masturbating; although the rope is supposed to use a slipknot as a "self-rescue" mechanism, death can occur if that fails and the rope fails to loosen.

In one case of suspected suicide, investigators determined that the death was the result of autoerotic asphyxia by noting ligature indentations in the rafters of the bedroom, indicating that this type of "hanging" had been done more than once, he said. Often, the victim will also have pornography or other sexual aids in the room.

Other means of producing autoerotic asphyxia include a plastic bag, chest compression, and inhalation of chemicals such as nitrous oxide.

There are also deaths using means other than asphyxia to heighten pleasure, including electrocution (having a live electrical lead attached to part of the body) and "aquaeroticism" (inducing hypoxia while underwater holding one's breath), "which can look very much like drowning" if the person dies while doing it, Dr. Scott said.

Another variant on this type of game, which is not done to achieve sexual arousal, is "suffocation roulette," in which one child takes a deep breath and another comes from behind and hugs them or puts them in a choke hold until the person passes out. The idea of the game is to see who can stand the longest without passing out.

"You should suspect suffocation roulette if a child comes to you with a history of passing out for unknown reasons or unusual headaches," he said. "The 'choking game,' also called 'space monkey,' 'space cowboy,' or 'rising sun,' is close to the suffocation game, but only two people play so there are fewer people to witness it." It has also evolved into a solo choking game.

BY JOYCE FRIEDEN

Associate Editor, Practice Trends