The role of psychological autopsy in investigating a case of atypical suicide in schizophrenia: a case report with a brief review of literature

Abstract

Background Self-harm typically is without lethal intent. Death can occur rarely, with suicide taking on an atypical form that raises the suspicion of hetero-aggression. Our study aimed to identify the link between self-harm and suicide intent and also to outline the positive diagnosis of an atypical suicide case which has raised the suspicion of hetero-aggression. For this purpose, the psychological autopsy method should be used regularly in suicide investigation because it not only allows a positive diagnosis of suicide but can also provide a detailed picture of mental degradation and associated suicide risk factors. Case presentation The case of a 26-year-old man from a rural area, found dead in the basement, at home, naked, barricaded inside, is described. Methods The on-site investigation and a complete forensic autopsy were performed. In addition, we apply the psychological autopsy method which gathered enough information to outline the positive diagnosis of suicide. We also made a brief literature review on the suicide risk factors and the behavioral changes that occurred during the COVID-19 pandemic in schizophrenic patients. Results The forensic autopsy revealed that he presented a complex craniofacial trauma as the cause of death (with scalp lacerations, frontal fracture, subarachnoid hemorrhage, and frontal cerebral contusions) associated with torso trauma (with self-inflicted stabbed wounds) with bruises and abrasions on the limbs. The injuries that caused death were self-inflicted and ensued repeatedly hitting his head against blunt objects. Using the psychological autopsy method, we found out that he presented multiple psychiatric hospitalizations for schizophrenia for almost 10 years, recently with reduced compliance to treatment. We also documented two previous suicide attempts and a gradual deterioration of his mental health. Conclusions We highlighted the role of the psychological autopsy (in addition to the judicial investigation and the forensic autopsy) for the diagnosis of committed suicide, for making a rigorous differential diagnosis between accident, hetero-aggression, and suicide, and also in pin-pointing the suicide risk factors.

Verbal Autopsy as a Tool for Defining Causes of Death in Specific Healthcare Contexts: Study of Applicability through a Traditional Literature Review

“…It should also be noted, in the final analysis, how verbal autopsy has the potential to become an extremely useful tool in the near future not only in the context of accidental or natural deaths but also in the context of forensic investigations, thus, clarifying cases of violent deaths resulting from suicide or homicide. This is especially true in cases of suicide, where a thorough psychological investigation conducted on family members and friends (so-called “psychological autopsy”) can clarify the circumstances of the death of a self-suppressive nature, especially in individuals with mental illness [ 28 , 29 , 30 ].…”

Failure in Medical Practice: Human Error, System Failure, or Case Severity?

“…The psycho-emotional consequences, which appear suddenly in such conditions, and which negatively affect the quality of the patient’s life, may later cause suicidal behavior. In this context, we may recall the COVID-19 pandemic, which imbalanced the medical system; increased distress in both healthcare workers and patients; and generated, in association with other suicidal risk factors, negative consequences in the mental states of some patients, especially those with depression and other psychiatric pathologies [ 20 , 21 , 22 ]. Learning from these extreme experiences should improve our understanding and patient care [ 22 ].…”

“…In this context, we may recall the COVID-19 pandemic, which imbalanced the medical system; increased distress in both healthcare workers and patients; and generated, in association with other suicidal risk factors, negative consequences in the mental states of some patients, especially those with depression and other psychiatric pathologies [ 20 , 21 , 22 ]. Learning from these extreme experiences should improve our understanding and patient care [ 22 ]. Thus, the successful management of complex medical cases, in addition to the necessary emergency measures, should be treated by means of a multidisciplinary approach and cover all aspects of medical practice.…”

Completed Suicide Linked to the COVID-19 Pandemic by Using the Psychological Autopsy Method in Sibiu County, Romania: Case Series and Literature Review

“…We consider that people with suicide risk factors are more vulnerable during a pandemic, with a greater need for mental health services. The COVID-19 pandemic has also had a negative impact on the accessibility of treatment (either psychiatric or somatic, or both), thus increasing suicide risk, as treatment continuity is crucial to prevent mental and physical deterioration in these patients [ 67 , 68 ]. Our last documented case is relevant in this regard because the inability of getting chemotherapy seems to have partly triggered the suicide act.…”

“…Out of the eleven cases, two showed none of the fifteen alarm signs in the distant antecedents but, in all cases, we documented one or more of these warning signs appearing or intensifying before the suicidal act. Alarm signs like sadness, restlessness, the tendency to isolation, insomnia and, in some cases, aggressiveness and nervousness are common and non-specific, but these were described in the literature as suicide risk factors during the COVID-19 pandemic [ 8 , 9 , 18 , 55 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ].…”