[Medicolegal aspects of witnessed suicide due to gunshot to the head. Part 1: Circumstances and psychopathology]

In the USA the frequency of witnessed suicide, i.e. suicide committed in the presence of at least one further individual, is reported to range between 5 and 15%. As up to now no detailed analysis of this special issue has been given in the medicolegal literature, this article presents and discusses a number of cases including 8 males and 1 female (age 19-58 years, mean 41.2 years) who had all committed suicide by inflicting a gunshot to the head. In 3 cases post-mortem blood alcohol concentrations of 1.73, 1.88 and 2.23 g/kg respectively were observed. Toxicological tests produced negative results. 5 cases had a medical history of psychiatric disorder with endogenous depression in 3, chronic alcohol abuse and drug abuse with concomitant psychosis in one case each. As far as the motives were known, domestic arguments were of prevailing importance. With one exception the suicides were committed at home. In 6 cases one witness was present, in 2 cases 2 individuals and in one case 22 persons witnessed the suicide. The reported cases are discussed in comparison with the psychiatric-psychological classification according to McDowell et al. with the aim to provide a solid and comprehensive medicolegal method to distinguish between homicide and suicide. Furthermore aspects of psychiatric sequelae and psychological support of the witnesses, which are also of importance for the forensic pathologist called to the scene, are discussed.

The sniper attacks and psychiatry

The three weeks of terror created by the snipers from October 2 to October 22 affected Maryland psychiatrists as it affected other Maryland citizens. Additionally, some psychiatrists provided specific responses during the crisis, and other psychiatrists had extraordinary relief when it ended. Furthermore, Maryland psychiatric programs are laying the groundwork for a more effective and humane response in case we are again, unfortunately, the object of sniper-like terror.

Acute stress disorder, alcohol use, and perception of safety among hospital staff after the sniper attacks

OBJECTIVE

This study examined emotional and behavioral effects on hospital staff after a series of sniper shootings in the Washington, D.C., area.

METHODS

Employees of a large tertiary care military hospital were anonymously surveyed about their perceptions of safety and threat, changes in activities, and peritraumatic dissociation as possible risk factors for acute stress disorder, depression, and increased alcohol use the week after the sniper suspects were captured.

RESULTS

Of 382 study participants, whose average age was 39 years, 24 (6 percent) met criteria for acute stress disorder, 13 (3 percent) reported increased alcohol use, and 31 (8 percent) met criteria for depression. Risk factors for acute stress disorder were female sex (odds ratio [OR]=2.59), increased alcohol use (OR=5.1), comorbid depression (OR=7.28), lower perceived safety, higher perceived threat, higher levels of peritraumatic dissociation, and greater numbers of decreased activities. Risk factors for increased alcohol use were comorbid depression (OR=4.02), lower perceived safety, higher perceived threat, and higher levels of peritraumatic dissociation. Risk factors for depression were lower perceived safety and higher levels of peritraumatic dissociation.

CONCLUSIONS

The sniper shootings were associated with substantial changes in perceived safety and threat assessment as well as decreased activities outside the home among highly educated hospital employees. Levels of acute stress disorder were similar to levels of posttraumatic stress disorder in New York City after the terrorist attacks of September 11, 2001. Peritraumatic dissociation was associated not only with acute stress disorder but also with depression and increased alcohol use after the attacks.

The cognitive impairments due to the occipito-parietal brain injury after gunshot. A successful neurorehabiliation case study

OBJECTIVE

The presented case study describes the beneficial results of the neuropsychological rehabilitation of a gunshot victim, even with late initialization of the therapy--over 1 year after head trauma.

DESIGN

A case study of DE, a victim with bilateral damage of the parietal-occipital regions of the brain due to a gunshot.

METHODS

Neuropsychological rehabilitation, first preceded by an initial neuropsychological examination (standard psychological tests: WAIS-R, RAVLT, Rey's CFT, BVRT and clinical experiments tailored to DE's condition), was initiated 1 year after trauma. The rehabilitation programme consisted of computer-based tasks, paper-and-pencil exercises, and occupational therapy. The patient's progress was assessed as improvement in performance in standardized tests and computer-based tasks.

RESULTS

DE was diagnosed with complex cognitive deficits syndrome, including visual associative agnosia, apraxia, visuospatial and constructive disorders and linguistic defects. After 1 year of rehabilitation the patient's functioning significantly improved as measured by psychological tests and computer-based tasks (p<0.05) as well as the evaluation of the patient's quality of life.

CONCLUSIONS

The case study demonstrates beneficial effects of neurorehabilitation even initialized at the so-called 'late stage' after a brain injury.

Comparison of family stresses, strengths, and outcomes after trauma and surgery

This study aimed to compare family stresses, strengths, and outcomes after motor vehicle crashes, gunshot wounds, and coronary artery bypass graft surgery. A multivariate descriptive design based on the resiliency model of family stress was used. A convenience sample of 127 family members participated within 2 days of admission to the intensive care unit. Family stresses were measured using the Family Inventory of Life Events and the Acute Physiology, Age, and Chronic Health Evaluation Scale (APACHE III). Family strengths were measured by the Family Hardiness Index and the Family Crisis Oriented Personal Evaluation Scale. Family outcomes were measured by the Family Member Well-Being Index and the Family Adaptation Scale. Family members ranged in age from 18 to 80 years (Mean, 42 years). Most of the participants in the study were women (64%) with previous intensive care unit experience (83%). The patients ranged in age from 19 to 78 years (Mean, 44 years). Multivariate analysis of variance was used to control for group differences in family member age, education, and income along with patient age and race. The results indicated that family members of patients who have experienced motor vehicle crashes, gunshot wounds, or coronary artery bypass graft surgery reported no significant differences in family strengths of hardiness and family outcomes of well-being and adaptation. However, families of patients with gunshot wounds reported significantly more stress (F = 7.94; P< 0.01) and less use of coping strategies (F = 4.33; P< 0.01) than families of patients who have experienced motor vehicle crashes or coronary artery bypass graft surgery. Interventions that address family stress and develop or mobilize coping are needed for selected families after admission of a family member to the intensive care unit.

Complex suicides by self-incineration

Among the few cases of suicidal self-incineration primary or secondary complex suicides are a rarity. Accordingly the number of reports on this subject in the forensic literature is small. In a retrospective analysis of the Freiburg and Berlin autopsy material, four cases were found within an observation period of 11 years. These are described together with seven other cases reported in the literature. Altogether most of these suicides are primary combinations, especially with falls from a height. Other combinations include hanging or the infliction of stabs, cuts or gunshot injuries. The sex and age distribution is similar to that found for suicide by self-incineration alone.

Physical and psychological outcomes 8 months after serious gunshot injury

BACKGROUND

The purpose of this study was to determine the health status and psychological distress of gunshot injury victims 8 months after hospital discharge.

METHODS

Sixty patients admitted to a Level I trauma center for firearm-related injuries were interviewed during their hospitalization and again 8 months postdischarge. Health status was measured using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). Symptoms of posttraumatic stress (avoidance and intrusion) were assessed using the Impact of Event Scale.

RESULTS

Subjects were predominantly young (mean age, 30 years), male (92%), and African-American (95%). Mean SF-36 scores at follow-up were significantly worse than preinjury scores for all subscales (p < 0.05). Symptoms of posttraumatic stress were common; 39% of respondents reported severe intrusive thoughts and 42% reported severe avoidance behaviors. Admission Injury Severity Scores did not predict poor health status 8 months postdischarge, but intrusion symptoms were strongly associated with lower SF-36 scores.

CONCLUSION

Many hospitalized survivors of gunshot injuries report significant long-term declines in physical and/or mental health. Injury severity at hospital admission may not be predictive of long-term health status.

Risk factors for pediatric posttraumatic stress disorder after traumatic injury

The purpose of this study was to identify risk factors that may be predictive of posttraumatic stress disorder (PTSD) in children after a traumatic injury. The study was a retrospective review of data collected from 337 pediatric trauma patients treated in a multidisicplinary outpatient clinic. Results from Chi-square and t-test analyses indicated that gender, ethnicity, age, and injury severity were not risk factors for PTSD. However, mechanism of injury, specifically a gun shot wound (p =.001), was associated with development of PTSD, as was body area of injury, specifically the abdomen (p =.001). Psychiatric screening of patients with gun shot wounds and wounds to the abdomen may help with the early identification and treatment of PTSD.

Battered women who were "being killed and survived it": straight talk from survivors

Findings from police reports and interviews with women who have survived an attempted domestic homicide revealed patterns in their experiences and sources of distress. The build-up in the year prior to the near-lethal attack involved tension from ongoing contact with an angry, controlling batterer. Most typically the perpetrator was an alcoholic or drug addict, a gun owner, and, if his victim had left him, her stalker. In the majority of cases, the victim had either left or announced that she was leaving the relationship. While he had often threatened her life and she feared him, she typically did not think him capable of killing her. She described the attack as shocking and terrifying, and she felt certain she was going to die. In the immediate aftermath, she received some support, but as time went by, she felt isolated and alone. Ultimately, the women became convinced that they must rely on their "inner strength" to get on with their lives.

Gun violence and children: factors related to exposure and trauma

The study discussed in this article investigated the relationship between access to firearms and parental monitoring on rural youths' exposure to gun violence and examined the effect of gun violence exposure on the mental health of these youths. A survey was administered to rural students who participated in a student assistance program (n = 162) that provided in-school support groups for students in grades 6 through 12. Results indicated that a substantial number of students were exposed to gun violence and exposure was significantly related to firearm access and parental monitoring. Furthermore, gun violence exposure was significantly associated with trauma among the youths. Implications for social workers include advising high-risk clients and their families on gun removal and safe storage practices.

Effect of the incident at Columbine on students' violence- and suicide-related behaviors

BACKGROUND

This study examined the impact that the violent incident at Columbine High School may have had on reports of behaviors related to violence and suicide among U.S. high school students.

METHODS

Nationally representative data from the 1999 Youth Risk Behavior Survey (YRBS) were analyzed using logistic regression analyses.

RESULTS

Students who completed the 1999 YRBS after the Columbine incident were more likely to report feeling too unsafe to go to school and less likely to report considering or planning suicide than were students who completed the 1999 YRBS before the incident.

CONCLUSIONS

These results highlight how an extreme incident of school violence can affect students nationwide.

Teaching firearm safety to children: failure of a program

The present study investigated the effectiveness of a skills-based firearm safety program on reducing children's play with firearms. In a randomized control study, 34 children aged 4 to 7 years participated in a week-long firearm safety program; the Control Group was composed of 36 children. After the program, pairs of children were observed playing in a structured setting in which they had access to a semiautomatic pistol. A total of 53% of the pairs played with the gun, and there was no difference in gun-play behavior between those children who did and did not receive the intervention. Interview data revealed significant discrepancies in parent and child reports of parental gun ownership and inaccurate parental predictions of their children's interest in guns. The results of the current study cast doubt on the potential effectiveness of skills-based gun safety programs for children.

[Continued physical capacity after head gunshot injury]

The human brain shows a very high density of functionally important structures. Even small lesions may therefore cause clinical symptoms. Penetrating gunshots to the head are presumed to cause immediate incapacitation by subsequent disturbance of cerebral functions. The authors discuss anatomical and functional principles of the terms action, capacity to act and incapacitation and report two illustrative cases with lack of incapacitation following gunshots to the head.

[Suicide with a walking cane gun: weapon, injury picture and psychopathology]

In Germany firearms camouflaged as items of daily use are forbidden. While reports on ball-point pen-guns have repeatedly been published in literature, the use of a walking-stick gun is a rarity. The report deals with the suicide of a 31-year-old schizophrenic man who inflicted a shotgun injury to his head with typical morphological characteristics. The weapon used was a normal-looking walking stick with a barrel, cal. .410. Under forensic and criminological aspects the significance of a walking-stick gun is comparable to that of ball-point pen-guns. Both weapons can be carried and used inconspicuously, but from a walking-stick gun also ammunition of larger calibres with a higher potential of injury can be fired.

Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression

OBJECTIVE

To assess the rate and correlates of compliance with clinicians' recommendations to remove firearms from the homes of depressed adolescents participating in a clinical trial.

METHOD

The parents of 106 adolescents with major depression who participated in a randomized psychotherapy clinical trial were asked systematically about firearms in the home. Those who answered affirmatively were given information about the suicide risk conveyed by guns in the home and urged to remove them. The rates of gun removal and acquisition were assessed at the end of the treatment and over the subsequent 2-year naturalistic follow-up.

RESULTS

Of those who had guns at intake, 26.9% reported removing them by the end of the acute trial. Retention was associated with urban origin, marital dissatisfaction, and paternal psychopathology. Of those who did not have guns at intake, 17.1% reported acquiring them over 2-year follow-up. Living in a 2-parent household and marital dissatisfaction were associated with gun acquisition.

CONCLUSIONS

Families of depressed adolescents may frequently be noncompliant with recommendations to remove guns from the home despite compliance with other aspects of treatment. More efficacious interventions to reduce access to guns in the homes of at-risk youths are needed.