Forensic Issues in Cases of Diogenes Syndrome

Concealed Homicides-A Postmortem Study and Review

ABSTRACT

A study was undertaken at Forensic Science SA, Adelaide, South Australia, of all cases of homicide (January 2003-December 2022) where the victims' bodies had been concealed. Three hundred twenty-six homicides were identified, which included 27 cases where bodies had been deliberately hidden (8%) (age range, 2-82 years; ave, 34.9 years; M:F = 1.5:1). Deaths were due to blunt force trauma (n = 11), sharp force trauma (n = 4), asphyxia (n = 4), gunshot wound (n = 2), and a combination of drowning and asphyxia (n = 1). In 5 cases, the cause of death was not determinable. The methods of concealment (which were sometimes overlapping) included the following: dumping at a hidden/isolated location (n = 8), burial (n = 7), dismembering (n = 3), incinerating (n = 3), hiding in a wheeled garbage bin (n = 2), disposing in garbage resulting in the remains being located at waste disposal facilities (n = 2), hiding in a shed (n = 1), under a concrete floor (n = 1), in a suitcase (n = 1), in a river (n = 1), in a mine shaft (n = 1), and in a septic tank (n = 1). Although it has been asserted that concealed homicides are rarely encountered in forensic practice, the current study has demonstrated that the bodies in at least 8% of victims of homicide in South Australia have undergone some form of concealment.

Cat and dog scavenging at indoor forensic scenes: strategies for documentation and detection

Vertebrate scavenging on human remains is occasionally observed at indoor forensic scenes, especially when pets have access to the body and their deceased owners were socially distanced. Pets feeding on corpses have implications for the forensic investigation, e.g. for trauma analysis and the assessment of the cause of death, the estimation of the postmortem interval (PMI), or the recovery of the complete set of remains. Documentation of potential scavenging in forensic practice is tenuous and needs to be improved in order to be able to use the information for future casework. Investigators need to be aware of the alterations pets can cause to human remains and how these affect further analyses. Following a combined literature review for cat and canine scavenging, we present seven new cases from Switzerland with cat and/or dog involvement. We then created a flowchart guide for a systematic collection of data to use at indoor forensic scenes of suspected scavenging. Our literature review revealed the challenge in discriminating between scavenging by domestic cats and dogs, based on the appearance of the lesions alone. Furthermore, the information that is often routinely collected in indoor fatalities with potential scavenging activity is not sufficient to perform this separation. To provide a practical basis for cat and canine scavenging and its differentiation, we summarise strategies and present a flowchart to use in forensic casework of suspected indoor scavenging.

Premature burial

The fear of being buried alive or taphophobia remains a significant concern for a number of individuals. In previous centuries however, reports of live burials were frequently promulgated in the media fostering an industry focused around the manufacturing and selling of security coffins which either facilitated egress or enabled the recently buried to alert those on the surface to their plight. Holding mortuaries with resuscitation facilities were also established mainly in Continental Europe to permit close observation of the recently deceased until definitive signs of putrefaction had developed. Underpinning much of this panic was the inability of medical practitioners to definitely diagnose death. Although still a rare possibility, mainly in situations where qualified medical personnel are not available, the likelihood of alive burial is nowadays fortunately rare.

Major organ loss from post-mortem animal predation: Issues arising from emptied body cavities

The feeding of animals on bodies after death - so-called post-mortem animal predation - may complicate autopsy interpretations when there has been removal of significant amounts of skin and tissues. An extreme situation which sometimes arises is the complete evisceration and/or consumption of all major cavity organs. Search of autopsy files at Forensic Science South Australia was undertaken for examples of this phenomenon. Although such a finding at autopsy may suggest the actions of larger animals such as dogs or sharks, it may also occur when groups of smaller animals, such as cats, act in concert. Complete loss of organs may also occur if significant insect activity accompanies decomposition. Empty body cavities may therefore result from of a wide variety of animal activities involving a range of species in quite different environments. A significant problem once organs have been removed or consumed is in identifying or excluding natural diseases or injuries that may have played a role in the lethal episode.

Lethal giant basal cell carcinoma

Basal cell carcinomas are the most common malignancy in Caucasian populations with a very low predisposition to metastatic disease and an excellent prognosis if appropriately treated. Given the rarity of a lethal outcome two cases are reported. Case 1: A 61-year-old reclusive man who had an untreated facial basal cell carcinoma for 10 years died of hypothermia and sepsis complicating the extensively ulcerated and infected tumour. He also had underlying cardiomegaly, ischaemic heart disease and chronic obstructive pulmonary disease. Case 2: A 60-year-old man who had an untreated lower lumbar basal cell carcinoma for 14 years died of sepsis, inanition and pulmonary thromboembolism (due to a right-sided deep venous thrombosis) complicating the deeply ulcerated tumour. Untreated giant basal cell carcinoma may uncommonly present for medicolegal assessment with complex pathophysiological lethal mechanisms. The possibility of Diogenes syndrome should be considered.

Diogenes Syndrome: Identification and Distinction from Hoarding Disorder

"Severe domestic squalor" or Diogenes syndrome is characterised by extreme self-neglect of environment, health, and hygiene, excessive hoarding, squalor, social withdrawal, and a distinct lack of concern or shame regarding one's living condition. This report presents a case of a 51-year-old male admitted to the hospital psychiatric ward following the police removing him from his home. Police officers attended the man's home following the alarm being raised by his stepfather that he had not been seen or heard from in 3 weeks. His home was covered in several feet of rubbish, rotting food, and debris and smelled intensely of rotting mould, urine, and faeces. He was found lying nude on top of garbage with a rug over him. Diogenes syndrome is highly comorbid with psychiatric and somatic disorders, including depression, obsessive-compulsive disorder, personality disorder, and stress. This case report provides a rare opportunity to better understand the distinction of Diogenes syndrome from the closely related condition hoarding disorder. Furthermore, creating an agreed-upon constellation of symptoms representative of Diogenes is essential to creating a formal Diagnostic and Statistical Manual of Mental Disorders (DSM) entry, which would facilitate the much-needed development of assessment measures to enable accurate diagnosis and treatment.

The mourning process and "living with the dead": Two case reports and a review of the literature

The discovery of mummified bodies in domestic settings is not unusual in the medico-legal context. It is often a marker of social isolation, even in our urban modern society, and usually occurs among elderly people living alone or in precarious conditions. However, bereaved subjects can sometimes be found managing their grief by deliberately keeping the corpses of their loved ones at home. Investigation of these atypical cases can be challenging and often requires a multidisciplinary effort by different forensic specialists. We report two cases of people who lived for several months with the mummified remains of a relative. In both cases, the judge ordered a forensic psychiatry assessment of the survivors' competency and the reasons for this peculiar behavior, which is regarded as abnormal in our society. Case 1 describes a shared psychosis, which developed out of a condition of extreme seclusion of the entire family. Case 2 shows that even a mild personality disorder on which a series of traumatic events operates can trigger psychotic decompensation, causing extreme denial of the reality of death. The analysis of these cases contributes to our knowledge of the scantly studied phenomenon of "Living with the Dead" and raises questions about the psychopathology behind it. It is useful to identify subjects who are more prone to developing this "deviant" behavior, in order to distinguish people with mental illness from those who merely want to profit from the death of a loved one.

Postmortem predation by a clowder of domestic cats

A 69-year-old man was found lying on the floor at his home address. According to the police report every room was filled with refuse and "thirty or so cats" were resident in the house. The body showed signs of extensive post mortem animal predation with opening of the chest and abdominal cavities, loss of soft tissues of the face, loss of soft tissues and organs of the neck, loss of the lungs and heart, and injuries to the liver, right kidney, stomach, transverse colon and cecum. The cause of death could not be determined from the autopsy given the absence of certain vital organs such as the heart and lungs, and the presence of early putrefaction. The case shows that considerable soft tissue, bone and organ loss may occur when a number of animals work in concert. The collective term for such a group of cats is a clowder. The extent of post-mortem damage from animal activity therefore relies not only on the species involved, but also the numbers of participating animals.

An unusual pattern of post-mortem injury caused by Australian fresh water yabbies (Cherax destructor)

A 67-year-old woman with a history of previous cerebrovascular accidents who was confined to a wheel chair drowned in a pond in a public park. Features compatible with drowning included congestion and edema of the lungs with prominent hemolytic staining of the intima of the aortic root. Minor bruises and abrasions were identified. Toxicology was negative. An additional unusual finding was that of patterned symmetrical injuries to the earlobe and pinna of both ears. The injuries consisted of small irregular areas of skin loss that were sometimes linear and parallel and had the appearance of animal nibble marks. Given the presence in the pond of numerous Australian fresh water yabbies (Cherax destructor), and no other predators, it appeared that the injuries had been caused by post mortem feeding by these crustaceans. This case therefore extends the range of animals that may be involved in post mortem predation that may be encountered in cases of freshwater drowning/immersion in an Australian context, with a specific pattern of injury focused on the ear lobes.

Obturator hernia and the elderly

An 84-year-old woman with a history of weight loss, anorexia and episodic vomiting was admitted to hospital where she died soon afterwards. Her diagnosis was acute renal injury due to dehydration and malnutrition. At autopsy the body was cachectic with a small intestinal obstruction due to herniation through a defect at the anterolateral aspect of the obturator foramen. A poorly differentiated adenocarcinoma of the gastroesophageal junction was also identified with small peripheral pulmonary thromboemboli. Death was due to small bowel obstruction from a left obturator hernia with scattered peripheral pulmonary thromboemboli complicating cachexia due to gastroesophageal adenocarcinoma. Obturator hernias are called the "little old lady's hernia" and occur mainly in elderly, multiparous and malnourished women. The broader female pelvis and wider obturator canal with laxity of ligaments and loss of preperitoneal adipose tissue padding around the canal predispose to herniation. This rare hernia is often first identified at autopsy.

Frailty syndrome - Medicolegal considerations

The frailty syndrome refers to the concurrence of a number of specific clinical manifestations that include unintentional weight loss, decreased muscle mass (sarcopenia), exhaustion, reduced physical strength and activity, and slow ambulation. It involves multiple systems, is an increasing problem in elderly populations, and is strongly associated with increases in both morbidity and mortality. Despite its recognition clinically, the frailty syndrome is not often identified in forensic situations and is only infrequently mentioned in the associated literature. As there is a direct relationship between the frailty syndrome and significant adverse health outcomes the syndrome has clear medicolegal significance.

Antemortem and postmortem nonapposite data--a multidisciplinary identification strategy

Identification of human remains is often achieved by comparing documented reference data with the same type of evidence obtained from the remains. We present a case of a decomposed unidentified body, whose identity was presumed but because of the low validity range of the available data, the identification process could not be completed. Antemortem radiographs of the teeth found in the house of the reputed victim could not be compared to the edentulous cadaver and the kinship between the victim and the only living relative that could provide DNA for comparison was too tenuous. Isolated teeth found at the scene, were neither a source of DNA reference information nor questioned data to be compared to the antemortem radiographs. The strategy implemented by the investigators to reallocate the status of the isolated teeth from the questioned source to the reference source of DNA to be compared with the cadaver is presented.

Investigation of Deaths of Chronically Disabled Persons and Institutionalized Persons

The investigation of deaths involving chronically disabled and/or institutionalized persons represents an important challenge to the medicolegal death investigation community. For the purposes of this review, the chronically disabled and/or institutionalized are considered to include three non-mutually exclusive subcategories: the disabled elderly, the severely disabled, and psychiatric patients. Because deaths within certain of these populations tend to be common and expected, a very important goal when such deaths occur is the appropriate referral of cases to the medical examiner/coroner. Although each subcategory has distinct issues of importance regarding death investigation, there is also a reasonable amount of overlap between the three groups. This review provides an overview of the three subcategories, the reasons such persons may be at risk for premature, unexpected, or unnatural death, the many important issues of concern when investigating deaths within these vulnerable populations, and important preventative strategies within each group.

Philemon and Baucis, Diogenes and syllogomania, Wischnewski and hypothermia--gastric mucosal lesions in partially mummified bodies

We present a case of two brothers who died simultaneously, where their deaths could be considered to be a form of a Philemon and Baucis death; they also showed signs of Diogenes syndrome and syllogomania. The two brothers had been living in a socially isolated state and had not left their flat for months. They were found dead during the winter, in a flat with no heating. Taking the poor condition of the flat into consideration, it can be assumed that a draught existed and, therefore, the bodies were exposed to convection, that is, ventilation and low humidity, which is what caused partial mummification to the exposed areas of the body. The exact cause of death could not be determined due to the postmortem changes; however, there was very little to point to homicide or suicide as the manner of death. Despite these postmortem changes, the Wischnewski spots remained clearly visible, whose presence, in addition to the overall circumstances of the case, indicate that hypothermia could be a possible or at least contributing cause of death in both cases.

Diogenes syndrome in patients suffering from dementia

Diogenes syndrome (DS) is a behavioral disorder of the elderly. Symptoms include living in extreme squalor, a neglected physical state, and unhygienic conditions. This is accompanied by a self-imposed isolation, the refusal of external help, and a tendency to accumulate unusual objects. To explore the phenomenon of DS in dementia we searched for the terms: “Diogenes syndrome, self-neglect, dementia. ” It has long been understood that individuals with dementia often become shut-ins, living in squalor, in the Eastern Baltimore study, dementia was present in 15% of the elderly cases with moderate and severe social breakdown syndrome; twice as many as in the general population of the same age group. Researchers have underlined the frequent presence of DS (36%) in frontotemporal dementia (FTD): different neuropsychological modifications in FTD may contribute to symptoms of DS. The initial treatment should be a behavioral program, but there is not sufficient information regarding pharmacological treatment of the syndrome.

Animal-related fatalities--part I: characteristic autopsy findings and variable causes of death associated with blunt and sharp trauma

Animals may be responsible for an array of potentially lethal injuries. Blunt force injuries characteristically involve larger animals such as cattle or horses that may kick, crush, or trample a victim causing head and facial injuries. Farm workers in particular are at high risk of lethal injuries involving the head and torso. Significant blunt trauma may be found in vehicle occupants after collisions with large animals such as camels or moose. Rarely, zookeepers may be crushed by particularly massive animals such as elephants. Sharp force injuries usually involve carnivore bites, most often from dogs with a "hole and tear" pattern of wounding. Injuries from animals such as alligators and sharks may have a significant component of crushing. Incised wounds may result in death from exsanguination and air embolism. On occasion, blunt or sharp trauma from animal activity may be confused with postmortem damage or with inflicted injury from an assault.

[Severe domestic squalor]

BACKGROUND

People who live in domestic squalor and deny help may have a condition known as severe domestic squalor, previously Diogenes syndrome. The object of this article is to provide a review of incidence, possible etiology, clinical description and management of this condition.

MATERIAL AND METHODS

The article is based on literature retrieved through a non-systematic search in PubMed and the author's clinical experience.

RESULTS

Severe domestic squalor may affect people of all ages, but is particularly prevalent among the elderly. Those affected live in severe squalor with garbage, rotting food, rats and mice, urine and faeces in furniture. Some tend to hoard. The annual incidence among persons above 60 years of age, referred to a specialist, is approximately 0.5 per 1000. True community prevalence is unknown. More than 50 % of cases have a concomitant diagnosis of dementia, schizophrenia or substance dependency. An association between frontal dysfunction and severe domestic squalor is sparsely, but increasingly documented. Those affected do not express concern about their situation and are unwilling to be helped. Cases are complex and very difficult to handle for general practitioners and district nurses. Respect for autonomy and a wish to help contradict each other.

INTERPRETATION

It is very difficult to help persons who live in severe domestic squalor. The incidence in Norway is unknown and should be determined.

Congenital mesenteric abnormality causing death in an infant with a concurrent diaphragmatic hernia

The principle causes of infant death are natural causes [including the Sudden Infant Death Syndrome (SIDS)]. Natural deaths in infants are principally due to infections, cardiovascular anomalies and other metabolic or genetic disorders. Gastrointestinal pathology including anomalies may also cause death in this age group. This case describes a 6 month old boy who had undergone repair of a diaphragmatic hernia when aged 2 days, but who subsequently died as a result of a mesenteric abnormality with torsion of the gut and a large fibrous walled bowel containing hernial sac in the left pleural cavity.

Hypothermia as the cause of death in forensic pathology: Autopsy study

Introduction. The body cooling process goes through few clinical phases. These are followed by some morphological thanatological changes such as frost erythema and Wischnewsky's spots, which are used in diagnosis of death due to hypothermia. In such cases there is no any specific autopsy finding. Objective. To establish the frequency of hypothermia as the cause of death for a ten-year-period, and to analyze the sample according to gender and age, risk factors and autopsy findings of subjects. Methods. A retrospective autopsy study was performed for a ten-year-period (total of 12,765 forensic autopsies). The relevant data were collected from autopsy records, police reports and heteroanamnestic interviews. The sample was analyzed according to gender, age, scene of death, blood alcohol concentration, risk factors, and autopsy findings of all observed subjects. Results. The sample included 67 subjects, 42 males and 25 females (?2=4.31; p<0.05), of average age 63.9?14.7 years (min=27, max=92; med=65, mod=55). Nineteen of subjects were found at in-door places. In 13 subjects blood alcohol concentration ranged from 0.50 to 3.32 promille (average 1.81?0.93). The younger the observed subject was, the higher the blood alcohol concentration (?=-0.251; p=0.04). One third of the observed subjects were chronic alcohol abusers. Thirteen persons had psychiatric diseases. In 43 observed subjects the concomitant appearance of frost erythema and Wischniewsky's spots were established (?2=49.59; df=3; p<0.001). Conclusion. In the analyzed ten-year period hypothermia was not often the cause of death; it was disclosed only in 0.5% of the total number of the studied autopsies. The most of the deceased were older males with cardiovascular problems found in unprotected open-air places. The most frequent thanatological findings in the analyzed subjects were frost erythema and Wischnewsky's spots.

The mummified corpse in a domestic setting

A mummified body of an 86-year-old white man with a history of coronary atherosclerosis was found in the reception-room of his apartment located in a condominium of the city-center of Bari (Southern Italy) approximately 7 years after disappearance. Unpaid electricity bills caused the power stations to turn off electricity while unpaid condominium bills forced the manager of the condominium to open the apartment where the body was found. The corpse was well preserved through the mummification process and no external injuries were observed. Signs of a very low insect activity were also present, reasonably consistent with a rapid skin dehydration. The body was sitting on the carpet in front of an easy-chair, fully clothed by a woollen vest with dark paints and shoes. The head was lying face down on the easy-chair. The corpse was very light in weight, fixed in the sitting position by the brittle dehydrated tissues. The carpet on which the body was sitting and the covering tissue of the easy-chair on which the head was lying absorbed most of the early putrefactive fluids coming from the corpse. The internal organs were grossly identifiable but essentially unremarkable. On histologic examination most of the tissues were found to be autolyzed. Toxicology studies revealed only decompositional products. The cause of death was undetermined but presumed natural. Based on the ante-mortem data available the corpse was soon identified by dental comparison to be that one of the apartment owner missing 7 years before. The delayed recovery of elderly people who lived alone, incapacitated or unable to get help, or even of lonely deaths of nobody seems to miss are often explained by the isolation os such people even in urban areas in addition to a deficient family support, missing social and neighborly relationships, worsening of the health and financial conditions.

Congenital mesenteric defects and unexpected death-a rare finding at autopsy

Gastrointestinal causes of sudden and/or unexpected death in the young are uncommon and only rarely involve congenital anomalies of the mesentery. Two cases are reported of unexpected deaths following herniation of intestine through congenital mesenteric defects to illustrate the forensic issues that may arise. Case 1 involves a 2.5-year-old girl who collapsed on arrival to hospital following 18 hours of fever and apparently mildly nonspecific symptoms. Resuscitation was unsuccessful, and at autopsy a segment of gangrenous small intestine was found that had herniated through a congenital mesenteric defect. Case 2 involves a 23-year-old woman with a past history of severe mental and physical disabilities who was found dead in her bed. She had a recent history of mild diarrhea and vomiting, but had not appeared particularly ill. At autopsy the peritoneal cavity was filled with a very dilated and obstructed colon as a result of herniation of a segment of sigmoid colon through a distal small intestinal mesenteric defect. These cases demonstrate that symptoms and signs of intestinal ischemia may not be clearly manifested in early childhood and that developmental delay may also result in older individuals presenting in a nonspecific manner. Although rare, congenital mesenteric abnormalities with compromise of the intestinal vasculature remain a possibility to be considered at autopsy in all cases of unexpected death, despite the lack of a clear history of significant gastrointestinal disturbance. Death may relate to ischemic compromise of either the herniated portion of intestine (as in case 1) or to the stretched intestine bordering the hernial orifice (as in case 2).