OBJETIVO: Examinar o fenômeno clínico de homicídio seguido de suicídio (HS) a partir de um caso no qual o desfecho de suicídio não ocorreu por motivos alheios à vontade e às ações do sujeito. DESCRIÇÃO DO CASO: Trata-se do caso de um homem que matou sua namorada por ciúmes, por ocasião do término do relacionamento entre ambos, tentando, a seguir, o suicídio. No presente artigo, é dada especial ênfase aos aspectos forenses do caso, avaliado para fins de determinação de responsabilidade penal e acompanhado no Instituto Psiquiátrico Forense Dr. Maurício Cardoso, Porto Alegre (RS). COMENTÁRIOS: Ressalta-se que, ao se modificar o desfecho de um caso típico de HS, por não ter se consumado o suicídio do homicida, dois aspectos assumem relevância: as consequências legais a serem enfrentadas pelo sujeito e o manejo do impacto psíquico no sobrevivente. Do ponto de vista da prevenção, o conhecimento do fenômeno HS e dos fatores descritos como associados a ele justificaria uma constante atenção ao tema por parte dos profissionais de saúde mental. O presente relato foi autorizado pelo paciente através de termo de consentimento livre e esclarecido.
Violência; psiquiatria forense; homicídio; suicídio; transtorno depressivo
OBJECTIVE: The clinical phenomenon of homicide followed by suicide (HS) is examined through a case in which suicide was avoided despite the individual's will and actions. CASE DESCRIPTION: A man killed his girlfriend at the end of the relationship because of jealousy. After that, he attempted suicide. Special emphasis is given to the forensic aspects of the case, which has been assessed to determinate the individual's criminal responsibility and has been followed up at the Forensic Psychiatric Institute Dr. Maurício Cardoso, in Porto Alegre, state of Rio Grande do Sul, Brazil. COMMENTS: When the outcome of a typical case of HS is modified and the suicide of the murderer is not accomplished, two aspects become important: the legal consequences to be faced by the murderer and the management of the psychological impact on the survivor. Regarding prevention, the knowledge of HS and its associated factors require constant attention by mental health professionals. This report was authorized by the patient by means of informed consent.
Violence; forensic psychiatry; homicide; suicide; depressive disorder
Homicide followed by suicide: case report
Helena Dias de Castro BinsI; Cíntia DölerII; Paulo Oscar TeitelbaumIII
IForensic Psychiatrist, Instituto Psiquiátrico Forense Dr. Maurício Cardoso de Porto Alegre (IPFMC), Porto Alegre, RS, Brazil
IIForensic Psychiatrist, IPFMC, Porto Alegre, RS, Brazil
IIIForensic Psychiatrist. Master's degree student, Forensic Psychiatry, Universidad Nacional de La Plata (UNLP), La Plata, Argentina. Forensic supervisor, IPFMC, Porto Alegre, RS, Brazil
OBJECTIVE: The clinical phenomenon of homicide followed by suicide (HS) is examined through a case in which suicide was avoided despite the individual's will and actions.
CASE DESCRIPTION: A man killed his girlfriend at the end of the relationship because of jealousy. After that, he attempted suicide. Special emphasis is given to the forensic aspects of the case, which has been assessed to determinate the individual's criminal responsibility and has been followed up at the Forensic Psychiatric Institute Dr. Maurício Cardoso, in Porto Alegre, state of Rio Grande do Sul, Brazil.
COMMENTS: When the outcome of a typical case of HS is modified and the suicide of the murderer is not accomplished, two aspects become important: the legal consequences to be faced by the murderer and the management of the psychological impact on the survivor. Regarding prevention, the knowledge of HS and its associated factors require constant attention by mental health professionals. This report was authorized by the patient by means of informed consent.
Keywords: Violence, forensic psychiatry, homicide, suicide, depressive disorder.
The term homicide-suicide (HS) refers to the phenomenon of homicide followed by suicide of the murderer after a certain period of time that may range from some hours to 1 week.1-6
There are five different types of HS: amorous-jealous, spousal/consortial declining health, filicide-suicide, family murder-suicide, and extrafamilial homicide-suicide.7
It is a quite rare phenomenon, ranging from 0.2 to 0.3 event per 100,000 inhabitants/year,1,6-12 but is has a great impact, and studies have demonstrated that such rates remain constant all over the world.6,10,12 In Brazil, we could not find studies on the occurrence of this phenomenon including nationwide data; however, a regional study conducted in Porto Alegre (RS)13 reviewed local cases of HS between 1996 and 2004 and found 14 cases. The results found by the authors are similar to the data described in the international literature, with male murderers and female victims in most of the cases.1,3,4,6-8,13-16 People involved were relatives, acquaintances, or people engaged in romantic relationships.3,4,6,8,10,17
The review of the literature suggests the following risk factors for the perpetration of HS: being male, young (usually older than the woman), having a history of depression,1,4,6,18 having conflicting romantic relationships, having access to firearms, and the existence of a (real or imaginary) threat of separation or actual separation. On the other hand, the use of alcohol is not a specific risk factor and, even though some authors suggest it is an important factor, it is less relevant than the incidence of alcohol in cases of homicide without suicide.1,3
According to forensic psychiatry, it is important to emphasize the risk of "pathologizing" the cases of HS, since most of them take place within a context of conflicting romantic relationships in which, in spite of the fact that the factor triggering violence is usually jealousy, it almost never has delusional characteristics and, therefore, cannot be considered a psychotic condition.19
Currently, there is not a classification system adequately validated for this phenomenon. Marzuk et al.2 have suggested a system of classification into categories based on the type of relationship established between the murderer and the victim and on the type of motivation for the crime.
The most common type of HS is triggered by jealousy, accounting for 50-75% of all cases in the USA.4,5,7 The perpetrator is usually a man between 18 and 60 years old, generally older than his partner. The main conflict is related to the victim's refusal to accept her partner's attempt of reconciling. The aggressor is usually aware or strongly suspicious of his girlfriend, wife or lover's infidelity.1,3,6 HS triggered by jealousy is prevalently a male crime (90% of the cases), since, when a woman kills her husband or lover, the crime is usually committed in self-defense caused by repeated episodes of aggression, and it is seldom followed by suicide.7,15 These conditions are usually related to the diagnosis of battering syndrome, one of the possible manifestations of posttraumatic stress disorder.20
It is important to highlight that the literature addresses cases of homicide followed by suicide attempt (H-SA) in the same way it addresses cases of HS because the dynamics and the profile of the individuals involved are considered to be similar, since the suicidal intention is evident and clearly demonstrated, "not being accomplished due to a stroke of luck."10
Furthermore, some authors have emphasized the advantages of studying cases of H-SA in comparison with cases of HS because regarding the later the murderers also died and cannot be interviewed or explain the reasons for their behavior. On the other hand, in cases such as the one investigated in our study, in which the perpetrators failed in their suicide attempt, these individuals were available to be investigated, increasing the possibility of new explanations about their motivations and psychic conditions.10,12
Our male patient was 35 years old (34 at the time of the event), white, and divorced. He had completed the elementary school and was a professional driver. He did not have remarkable previous personal morbid events and denied having a family history of alcoholism, use of illegal drugs, suicide, mental disease, or psychiatric hospitalizations.
He started working at the age of 14, keeping a satisfactory working performance until the onset of his psychiatric condition. With regard to romantic relationships with women, he reported he had only one girlfriend when he was a teenager, and she broke up with him because she moved to another city. His second girlfriend was his ex-wife.
The onset of the current disease occurred approximately 4 years before the episode (H-SA) when his wife decided she wanted to split up with him after an 11-year marriage. She moved to another city and took their only son with her. The patient is not able to provide a clear motivation for his wife's decision of splitting up. He mentioned that she "wanted to move to another city and I didn't want to; she said she was tired of living with me" (sic).
After they separated, the patient started to show a depressive state with clinical symptoms: he felt sad all the time, apathetic, did not have appetite. He also felt unmotivated and was not able to go to work regularly. He would spend several consecutive days laying on his bed and was not even able to take care of his personal hygiene. He could not see any future for his life. He started to hear voices that told him to kill himself (command auditory hallucinations). He then attempted suicide for the first time by drinking one liter of rat poison and needed emergency medical care.
After this episode (when he was 31 years old), he sought psychiatric treatment for the first time; however, he dropped out from the treatment a few months later because he "didn't feel any improvement" (sic) even though he stopped hearing the voices that told him to kill himself. This treatment consisted of an outpatient clinical psychiatric approach with the administration of antidepressives at submaximal doses. During the next 2 years, he reported never feeling "free of sadness" (sic), having attempted suicide two more times during this period by causing frontal accidents while driving the bus of the company he worked for with the conscious intention of dying. It is important to mention that during both these episodes he was the only person inside the vehicle, since the patient did not intend to hurt other people (sic). There were no psychotic symptoms (sense-perception or thought alterations) after the first suicide attempt. The patient reported he never underwent psychiatric hospitalizations.
During the 11 months before the crime, the patient had a romantic relationship with a younger woman who had expressed some doubts about dating him lately.
At the night the crime was committed, the patient saw this woman at a bar with another man. He felt very disturbed and went back home without talking to her. Some hours later, his girlfriend went to his house and told him she wanted to break up. At that moment, the patient lost his mind (sic) and strangulated the victim. Later, when he realized he had killed his girlfriend, he tried to hide her body to uncover his crime. He abandoned the body at a desert place nearby and went back home.
In the morning, after some hours, he attempted suicide by hanging, and a relative found him. He stayed in hospital for a week due to clinical risk of death. After being discharged from hospital, he was sent to Instituto Psiquiátrico Forense Dr. Maurício Cardoso (IPFMC), Porto Alegre (RS), Brazil, as a court decision, for treatment and assessment of criminal responsibility, being charged with homicide and concealment of dead body.
When the patient was admitted at IPFMC, he had an evident psychotic state and reported not remembering the details of the crime and the reasons that led him to hide the body: "I killed her and then I tried to kill myself. I'll try again, I loved her and now she is waiting for me" (sic).
During medical examination, the patient was physically weakened, with continual and deep scars on his neck (typical signs of hanging). He was clearheaded, presenting with hypovigilance and hypotenacity. In terms of sense-perception, he had auditory hallucinations (command voices that told him to kill himself). He was aware of space and time. With regard to memory, he had lacunar amnesia with respect to the crime and its related events. He also had magical thinking, containing ideas of ruin, hopelessness and depreciation, in addition to (intrusive and obsessive) suicidal ideation and suicidal plan (he planned to hang himself to meet his dead girlfriend); he had bradypsychia as well. His speech was slow and his intelligence was clinically inferred as being intermediate. His mood was evidently depressed and his behavior was apathetic and hypoactive. Laboratory and neurologic tests did not show any significant abnormalities.
Diagnostic hypothesis, at admission, was severe depressive episode with psychotic symptoms (CID-10: F32.3).
According to the forensic point of view with regards to the criminal responsibility, it is possible to conclude that the patient should be charged with the crimes he committed (homicide and concealment of dead body), considering also the presence of a severe depressive disorder with psychotic symptoms (CID-10: F32.3) when the patient was assessed, thus, related to his criminal deeds.
The patient had several risk factors defined in the literature as being responsible for favoring cases of HS (or H-SA) among which the most important are: age group compatible with higher probability of occurrence of mood disorder; history of severe depressive state lasting for longer than 1 year, with its onset after a real emotional loss; previous suicide attempts; recent threat of new emotional loss represented by the fact that he saw his girlfriend with another man and materialized by the fact that his girlfriend informed him about her intention to break up.
His crimes were committed by impulse when the patient was in a depressive state; however, the forensic assessment of criminal responsibility was not able to find signs and symptoms demonstrating that such state could be classified within the psychotic dimension. The patient's normal cognitive and volitional skills, as well as his results on the reality test, may be demonstrated by his concern about protecting himself by hiding the victim's dead body after the homicide, going back home later.
The psychotic condition had its onset some hours after the homicide, when thought and sense-perception alterations (described above) led him to a suicide attempt, which failed for reasons beyond his control.
We believe that with regard to this patient the predominant triggering factor of his crimes is not related to the loss of his sexual partner, or to the fact that he saw his girlfriend with another man, which caused a withdrawal response (he felt sad and went back home); instead, it is related to a new relationship break up, since he only reacted impulsively regarding abandonment and killed his girlfriend when she met him with the purpose of putting an end to the relationship.18,19
In spite of the severity of his condition during the forensic assessment, the patient was considered able to be chargeable when the crime was committed, considering that the condition diagnosed as severe depressive episode with psychotic symptoms had its onset after the crimes were perpetrated (homicide and concealment of dead body). According to the forensic psychiatric point of view, the annulment and mitigation of the criminal responsibility requires evident establishment of a causal link between the psychopathological condition and the criminal behavior, which was not found in this case. According to the forensic experts, when the patient committed the crimes, he had intact cognitive skills (he was aware that killing a person is a crime) and volitional skills (he was able to control his behaviors according to the idea that killing is a crime). The attempt to conceal the dead body is a strong sign that these skills were not affected. The psychotic condition only emerged after committing the crime.
We conclude that, even though the literature suggests a relatively small prevalence of HS in comparison with the occurrence of isolated cases of homicide and suicide, mental health professionals should be attentive to situations including risk factors associated with the HS outcome with the purpose of promoting preventive therapeutic measures.
The impact of cases of HS on the families involved, the aggressor and even the mental health professionals is a strong reason for giving this topic special attention, and it should include not only cases of accomplished suicide, but mainly those cases in which the aggressor survives after the suicide attempt. In such situations, the outcome brings legal consequences, resulting in the requirement of serving time in jail or safety measure, affecting in a severe and permanent manner the surviving murderer and his family.
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Helena Dias de Castro BinsRua Carlos Huber, 800CEP 91330-150, Bairro Três Figueiras, Porto Alegre, RSTel.: (51) 3387.8889, (51) 8401.3201E-mail:
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10 Mar 2010
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