Evolution of the Psychological Autopsy: Fifty Years of Experience at ...

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County Chief Medical Examiner-Coroner's Office and the Los Angeles Suicide Prevention Center. It was conceptualized as a thorough retro- spective analysis of ...
J Forensic Sci, July 2013, Vol. 58, No. 4 doi: 10.1111/1556-4029.12138 Available online at: onlinelibrary.wiley.com


Timothy Botello,1 M.D., M.P.H.; Thomas Noguchi,2 M.D.; Lakshmanan Sathyavagiswaran,2 M.D.; Linda E. Weinberger,1 Ph.D.; and Bruce H. Gross,1 M.B.A., J.D., Ph.D.

Evolution of the Psychological Autopsy: Fifty Years of Experience at the Los Angeles County Chief Medical Examiner-Coroner’s Office*

ABSTRACT: The origin of the psychological autopsy was in the late 1950s and the result of a collaboration between the Los Angeles County Chief Medical Examiner-Coroner’s Office and the Los Angeles Suicide Prevention Center. It was conceptualized as a thorough retrospective analysis of the decedent’s state of mind and intention at the time of death. It was used initially in “equivocal” deaths where the manner of death was possibly either suicide or accident. Later, it was used in cases where a party (primarily family members) protested the Medical Examiner-Coroner’s suicide determination. Over the past 25 years, the University of Southern California Institute of Psychiatry, Law, and Behavioral Science has served as the psychiatric/psychological consultants to the Coroner’s Department. Research findings, the use of this approach in high-profile cases, and the most recent manner in which the psychological autopsy is conducted are discussed.

KEYWORDS: forensic science, psychological autopsy, suicide, undetermined, mode conference, equivocal deaths In 1958, the National Institute of Mental Health awarded a grant for the establishment of the Los Angeles Suicide Prevention Center. Some of the Center’s goals were to save lives, educate about suicide prevention, collect data on self-destructive behaviors, and develop and test theories on self-destructive behaviors and treatments. During this time, the term, psychological autopsy, was coined by Dr. Edwin Shneidman, who was working with Drs. Robert Litman and Norman Farberow at the Los Angeles Suicide Prevention Center. The psychological autopsy was conceptualized as a thorough retrospective analysis of the decedent’s state of mind and intention at the time of death. It focused on the psychological aspects of the death. At the same time, Dr. Theodore Curphey, the Los Angeles County Chief Medical Examiner-Coroner, was deciding deaths using the NASH criteria. The NASH criteria group deaths into categories that share similar features. These criteria categorize death as natural, accident, suicide, homicide, and undetermined. Deaths that are not clear about the mode are called “equivocal deaths,” which account for about 5–20% of deaths. Dr. Curphey was faced with a number of equivocal deaths from drug overdoses. He requested consultation from the Los Angeles Suicide Prevention Team (Drs. Litman, Shneidman, and Farberow) to


Keck School of Medicine, University of Southern California, Psychiatry and Behavioral Sciences, P.O. Box 86125, Los Angeles, CA 90086-0125. 2 Los Angeles County Chief Medical Examiner and Coroner’s Office, 1194 North Mission Road, Los Angeles, CA. *Presented at the 63rd Annual Meeting of the American Academy of Forensic Sciences, February 25, 2011, in Chicago, IL. Received 6 Feb. 2012; and in revised form 8 May 2012; accepted 2 June 2012.


assist him in determining a more definitive mode of death. As a result of this collaboration, the behavioral science team from the Los Angeles Suicide Prevention Center began to conduct psychological autopsies on equivocal cases for the Los Angeles County Chief Medical Examiner-Coroner. Dr. Curphey wrote that the handling of a suspected suicide used a multidisciplinary approach (1). It involved a review of the police report and the coroner’s investigation report, as well as an autopsy and toxicological study when indicated. If a suicide note was found, then the death was certified as suicide. If a note was not found, then the case was referred to the Los Angeles Suicide Prevention Center. In addition, if the Chief Medical Examiner-Coroner was not able to determine the mode of death (suicide, accident, natural), then the case was referred to the Los Angeles Suicide Prevention Center. The largest group referred initially was on deaths associated with drug ingestions, especially barbiturates and/or tranquilizers. The cause of death for the majority of these early undetermined cases was from barbiturate intoxication, and alcohol was present in sufficient amounts to raise the issue of whether the decedent was under the influence and may have accidentally taken an overdose. In a 1963 study, Drs. Litman, Curphey, and others reported on 100 consecutive equivocal cases; the largest category (n = 55) was from barbiturate ingestion (2). They divided the barbiturate ingestion cases into three categories. One category included 17 cases of alcoholics who were using both alcohol and barbiturates at the time of their death; if the barbiturate level was high, it was deemed a suicide (seven cases), but if the barbiturate level was low and alcohol level was high, it was deemed an accident (10 cases). The second category consisted of 14 barbiturate addicts, nine of whom were determined to be suicide. The third © 2013 American Academy of Forensic Sciences


category was composed of 24 cases of barbiturate deaths where there was no history of barbiturate addiction and negative alcohol level, of which 23 were determined to be suicide.




Mr. Prinze had a history of playing with guns and playing with his friends by faking suicide attempts. The fact that he killed himself in the presence of a witness, his business manager, gave weight to the argument that he was not intending to take his life.

The Use of Psychological Autopsies in High-Profile Cases The first high-profile death that used a psychological autopsy approach occurred in 1962 with the death of Marilyn Monroe. Dr. Thomas Noguchi was the deputy medical examiner assigned in charge of her autopsy. Ms. Monroe’s death was shocking to the public and her fans. Dr. Curphey, the Chief Medical Examiner-Coroner of Los Angeles County at the time, appointed a panel of mental health experts from the Los Angeles Suicide Prevention Center (including Dr. Robert Litman), which was dubbed the “Suicide Panel,” to conduct a psychological autopsy. The results of the physical autopsy showed no physical injury except for a small bruise on her hip. There were no needle marks, and she had intense cyanosis of the face. Her stomach revealed no grossly visible residue from drugs. Blood, stomach and its contents, small intestine, liver, kidney, and urine were saved for later analysis. The toxicological results showed pentobarbital level of 12.5 mg% in the liver (above fatal dose) and blood chloral hydrate level 8 mg% (above fatal dose). Both levels pointed overwhelmingly to suicide. Ms. Monroe’s history revealed that she was orphaned at an early age after her mother was psychiatrically committed. She was then placed in several foster home placements. As a teenager, she lived near the movie studios, and her dream was to be a movie star. She was described as conscientious and hardworking. Even though she played the role of the “dumb blonde,” she studied drama and learned quickly. Her marital history consisted of several marriages. She was married to the baseball star, Joe DiMaggio, and later to the playwright, Arthur Miller. Despite her marital problems, she maintained the image of a movie superstar. In 1962, she lost her contract with the studio and had financial problems. On May 29, 1962, she sang the “Happy Birthday” song to President John Kennedy in a public venue, which received considerable attention. About 8 weeks later, on August 5, 1962, she was found dead in a rented home in Brentwood, California, by an overdose of barbiturates and chloral hydrate. The result of the psychological autopsy was that the overdose was a “probable suicide.” Despite this ruling, there were continuous rumors about her being murdered. In 1982, the Los Angeles County District Attorney’s Office reopened the investigation of her death and reaffirmed that her death was a suicide. The next high-profile death of a movie star, in which a psychological autopsy was conducted, occurred on January 29, 1977 for the self-inflicted gunshot wound death of Freddie Prinze, stand-up comedian and star of “Chico and the Man.” Mr. Prinze suffered from depression and drug dependence. In 1976, he was arrested for driving under the influence of Quaaludes, and his wife filed for divorce. At the time of his death, he was depressed. It was reported that after talking to his estranged wife, Mr. Prinze grabbed a small semi-automatic pistol and shot himself in the head in front of his business manager, Marvin Snyder. The Chief Medical Examiner-Coroner’s Office referred the case to the Los Angeles Suicide Prevention Center for a psychological autopsy. Mr. Prinze left a note stating that the decision to take his life was “his alone.” The psychological autopsy confirmed the Chief Medical Examiner-Coroner’s initial ruling of suicide. However, in a civil case brought years later, a jury declared that his death was accidental. The jury found that

The Past 25 Years In 1989, Dr. Litman wrote an article in which he reviewed 500 consecutive psychological autopsies from 1977 to 1985 (3). Dr. Litman reviewed equivocal cases referred from the Los Angeles County Chief Medical Examiner-Coroner’s Office. He found that the most common referral was for deaths due to alcohol, drug ingestion, or both. About one-third had no obvious motive for suicide. The value of the psychological autopsy to the Chief Medical Examiner-Coroner was clearly demonstrated by the fact that as a result of the psychological autopsy, information was obtained which assisted in the final determination. Almost two-thirds of the undetermined cases were assigned as suicide, about one-third were determined as accident, and only nine cases remained undetermined. In 1985, in the landmark California case, Searle vs. Allstate Insurance Company, the California Supreme Court focused on the intention of the decedent in defining suicide (4). In this case, the wife contested the insurance company’s decision not to give her the full life insurance benefits after the suicide determination of her husband’s death by a self-inflicted gunshot wound to the head. The California Supreme Court ruled that mental capacity was very relevant to the question of whether an act of selfdestruction was committed with suicidal intent. The Court wrote that, “If the insured did not understand the physical nature and consequences of the act, whether he was sane or insane, then he did not intentionally kill himself ” (4, p. 475). Beginning in 1987 and continuing to the present, the University of Southern California Institute of Psychiatry, Law, and Behavioral Science has served in a consultant role for the Los Angeles County Chief Medical Examiner-Coroner’s Office and has performed all of the psychological autopsies for the Office. The request for a psychological autopsy may be prompted by one of two instances. It may be viewed as helpful in an equivocal or undetermined case, where the medical examiner-coroner’s office believes that further information may help in making a more definitive determination. In addition, the psychological autopsy may be used in a contested or protest case, which is made primarily by family members who argue that the decedent could not have committed suicide and that his or her death was more likely an accident. In either situation, the use of a psychological autopsy is limited to cases where the possible manner of death is either suicide or accident. The University of Southern California Institute of Psychiatry, Law, and Behavioral Science uses a team of mental health professionals comprised of the Medical Director, Chief Psychologist, and one or two forensic psychiatry/psychology fellows who conduct the psychological autopsy. After the data have been collected, the team members engage in an internal discussion and agreement regarding whether the decedent had a mental condition consistent or not with suicide. The results from the Coroner’s investigator, the physical autopsy, the toxicology tests, and the psychological autopsy are then presented at a confidential Mode Conference at the Los Angeles County Chief Medical Examiner-Coroner’s Office. The professional staff, including the Chief Medical Examiner-Coroner, deputy medical examiners, toxicologist, investigators, and the University of Southern California consultants, listens and questions the presenters about the



facts, reasoning, and/or opinion. An informal vote as to the manner of death is taken of all attendees with the final results being advisory only to the Chief Medical Examiner-Coroner. Before a psychological autopsy is conducted by the University of Southern California Institute of Psychiatry, Law, and Behavioral Science, the Los Angeles County Chief Medical ExaminerCoroner’s Office sends an indemnification and authorization form to the decedent’s next-of-kin. Among the issues addressed in the document are the risks inherent in conducting a psychological autopsy, and that the report and its contents are confidential to and the sole property of the Coroner, and will not be disclosed. This was a new development in conducting psychological autopsies for the Los Angeles County Chief Medical Examiner-Coroner’s Office. During the past 25 years, there have been unsuccessful Superior Court challenges to the confidentiality of the psychological autopsy report. In the end, the judges have agreed with the Chief Medical Examiner-Coroner, ruling in favor of maintaining the confidentiality because it is an integral part of the psychological autopsy process. Over the years, as a result of these court challenges, the indemnification and authorization form has been revised regarding the informed consent of family members so as to indicate more clearly the strict confidentiality of the process and the report. In an effort to more fully maintain confidentiality, the psychological autopsy report is kept in a confidential file in the Chief Medical Examiner-Coroner’s Office, separate from the coroner’s file of the decedent. The Centers for Disease Control and Prevention reported that from 1999 to 2009, suicide was the 11th leading cause of death

for all ages in the United States (5). Given the magnitude of this problem, many experts, including mental health professionals, have been actively involved in researching the factors that contribute to suicidal behavior. This knowledge base, which continues to grow and evolve, can contribute significantly in assisting coroner’s/medical examiner’s offices in cases when suicide is a possible manner of death determination. References 1. Curphey TJ. The role of the social scientist in the medicolegal certification of death by suicide. In: Farberow NL, Shneidman ES, editors. The cry for help. New York, NY: McGraw Hill, 1961;110–7. 2. Litman RE, Curphey T, Shneidman ES, Farberow NL, Tabachnick N. Investigations of equivocal suicides. JAMA 1963;184:924–9. 3. Litman RE. 500 psychological autopsies. J Forensic Sci 1989;34:638–46. 4. Searle vs. Allstate Life Insurance Company, 38 Cal. 3d 425 (Cal. 1985). 5. Centers for Disease Control and Prevention (CDC). Injury prevention & control: data & statistics (WISQARS). WISQARS leading causes of death reports, national and regional, 1999–2009, 2010, http://webappa.cdc.gov/ sasweb/ncipc/leadcaus10_us.html (accessed January 30, 2012). Additional information and reprint requests: Timothy Botello, M.D., M.P.H. Keck School of Medicine University of Southern California Psychiatry and Behavioral Sciences P.O. Box 86125 Los Angeles, CA 90086-0125 E-mail: [email protected]