Case Report

A 41-year-old man was found dead by his wife in the living room of their shared apartment. Both were Japanese but had been living in Germany for a year. The woman stated that she had gone back to bed and slept after they had breakfast together around 8am. She woke up around 1:30 pm and found him dead. He was in a sitting position below the handle of the balcony door to which a ligature (a dog leash) was attached. A woolen blanket was interposed between the ligature and the neck and also covered his chest and legs. There was a toy duck on the man's lap (Fig. 1). Further statements from the decedents wife revealed that their first child had been born 9 months prior to the incident with severe disabilities and had been in the intensive care unit of a hospital ever since. They visited the child daily but the decedent had found this situation to be very stressful. He had suffered from Asperger's syndrome and depression, had frequently expressed thoughts of suicide, and had already tried to take his own life several times in the past. He was not in psychiatric/psychotherapeutic treatment at the time of his death. His illness meant that he was very withdrawn at times, but also aggressive and unpredictable (e.g. he had previously bitten his wife on the arm). In the days before his death, he had cut himself several times with household scissors. During the investigation it was assumed the man had committed suicide. A forensic inspection of the death scene was not undertaken.

Fig. 1
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Death scene after removing the ligature from the door handle

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An autopsy was carried out six days after the discovery of the body. The body was that of a 41-year-old man, with a body weight of 57.8 kg, and a body length of 178 cm. There was a three-turn dog leash with a tight knot around the decedents neck. The ligature was easily underminable and could not be pulled off over the head. A semicircular ligature mark, with a grooved pattern that corresponded to the dog leash, was present on the front and the sides of the neck, rising towards the nape. The superior cornu of the thyroid cartilage was broken but there was no hemorrhage of the surrounding soft tissue. There was hemorrhage of the paravertebral neck muscles on the right. No congestion of the facial skin was present. There was a single petechiae in the conjunctiva of the right eye. Numerous cuts, scores and incisions were present on the face and arms (Figs. 2–4). There was also a cut on the penile foreskin (Fig. 5). A bruise and swelling was present on the left cheek and bruises were observed on the extensor sides of the forearms and the insides of the knee joints. There were also incisions, lacerations and bruises of the oral vestibulum (Fig. 3) and a hematoma on the front side of the left thigh, with a shape reminiscent of a bite injury (Fig. 6, Table 1). There was brain edema (1580 g). Three semicircular scars were present on the extensor side of the left forearm, and there was a rounded scar on the flexor side of the left upper arm, which was reminiscent of a bite mark. The cause of death initially remained undetermined after the autopsy.

Fig. 2
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Hematoma, cuts and scratches on the face

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Fig. 3
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Oral and perioral cuts, scratches and lacerations

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Fig. 4
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Cuts and scratches of the left upper extremity

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Fig. 5
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Incision of the penile foreskin

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Fig. 6
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Left: bite-shaped hematoma on the anterior side of the left thigh Right: crescent-shaped scar on the inside of the left upper arm

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Table 1 Autopsy findings blunt and sharp force
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Chemico-toxicological analysis showed no findings. The blood alcohol concentration was 0.0%. Histological investigations did not reveal any relevant organ alterations. Histology/immunohistochemistry for age estimation of the skin wounds can be found in Table 2. Forensic physical examination of the decedents wife six days after the husband's death found a 33-year-old woman with an estimated body weight and height of 50 kg and 161 cm respectively. There was also a livid hematoma on the extensor side of the left lower leg that measured about 2 cm in diameter.

Table 2 Findings histological / immunohistochemical estimation of wound age
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Discussion

Self-injurious behavior is associated with various psychiatric diseases [1, 2]. For example is it one of the diagnostic criteria of borderline personality disorder (BPD) and is diagnosed in about 26% of patients with mood disorders [2,3,4]. However, self-harm is not found exclusively as a symptom of psychological disorders. Other motives for self-inflicted injuries can be the achievement of a legal advantage (e.g. pretending a criminal offense), an appellative character to obtain affection and compassion, but also sexual pleasure (masochism) [5]. By definition, there is no suicidal intention in self-harm. However, many people with self-harming behavior also show comorbid symptoms of suicidality [6]. Those affected report that they use self-harm in a targeted manner to distract from suicidal thoughts [7]. Self-injuries show typical characteristics, which usually allows a clear distinction from those inflicted by others (Table 3). In the case of unusual injury patterns, it can be difficult to distinguish between external and self-infliction.

Table 3 Characteristic features of self-inflicted injuries (according to [5, 28])
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The autopsy findings in the presented case were unusual for a suicidal hanging: no facial cyanosis and only a single petechiae above the ligature with obviously atypical hanging in a sitting position. There was no hemorrhage of the soft tissue surrounding the broken superior cornu of thyroid cartilage.

In this case numerous cuts, some of them deep, were located in atypical areas for self-infliction and in some cases typical areas for defensive injuries, whereas partly parallel courses occurred. Bruised and lacerated wounds of the oral mucosa, swelling and hematoma on the left cheek and a subdural film of blood over the right hemisphere indicated repeated blunt force against the head. A hematoma on the thigh looked like a bite mark. Furthermore, the setting of the discovered body with an interposed blanket between the skin of the neck and the ligature, covering of the body with the blanket and a toy duck on the lap (Fig. 1), seemed arranged. Combining the autopsy findings with the case history, the cause of death initially remained undetermined after the autopsy. The preliminary autopsy results led the investigating authorities to commission a forensic physical examination of the wife, which revealed a hematoma on the front of the lower leg as the only recent injury. Based on these findings, there was no evidence of a physical confrontation. The wife was questioned by the police a second time. Statements from the wife in the second interrogation indicated that there were often arguments between the couple about his sexual preferences. During sexual intercourse, he would tell her about other women he found desirable. This would arouse him, but she felt hurt by it. To compensate for the emotional injury, he directed her to bite his arm. There had been an argument about his sexual habits for several hours the night before he died. During this argument, she had bitten his forearm. He had hit himself on the cheek and mouth 100 to 200 times with his fist and the palm of his hand and bled heavily. In addition, he had cut himself with household scissors and forced the wife to injure him with the scissors, too. She had injured his cheek and arms with the scissors, while he guided her hand. The husband's mother had called around 6am and the wife had forced him to confess his sexual habits to his mother. After that, he had felt very ashamed and guilty. Later he had confessed to his wife that he had fallen in love with a woman whose child was a fellow patient of his own child in the hospital.

Histological and immunhistochemical examination was performed on several injuries in order to evaluate the woman’s statement regarding the origin of the injuries (Table 2, Fig. 7). The incision of the upper eyelid was considered to be fresh and arisen close to death. The findings of the examined hematomas corresponded to an origin within an hour to a few days before death. The ligature mark showed expression of aquaporin 3 (AQP3), which is to be assessed as a vitality marker and indicates vital hanging and thus strangulation as the cause of death [8,9,10,11].

Fig. 7
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Top left: ligature mark, AQP3, 200x. Top right: hematoma and incision of the left cheek, AQP3, 200x. Bottom left: hematoma left cheek, LCA, 400x. Bottom right: cut upper eyelid, CD 45, 200x

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The information provided by the decedents wife regarding the chronology of the injuries before the husband's death was therefore compatible with the estimation of wound age and thus could not be refuted.

Cutting tests with the scissors in question showed that this scissors could certainly be used as a cutting tool. Consequently, the wife’s credibility was considered to be proven by the investigative authorities and the investigation was terminated. Although the occasional parallel arrangement and uniform depth of the cuts represented a single criteria for self-harm, the entire injury pattern of blunt and sharp force, due to localization and severity, indicated a third-party infliction (Table 1).

As the deceased was Japanese, it is worth considering possible cultural differences towards self-harming behavior as an explanation for the observed injuries. However, Japanese studies on self-harm do not reveal any differences with regard to the typical characteristics of self-harm in affected individuals in Europe or North America [12, 13]. In cases of suicide with several different forms of violence, a possible complex suicide should also be considered. In the presented case, however, the non-strangulation related injuries were not severe enough to meet the criteria for a complex suicide [14]. Following the statement from the decedents wife, indicating that her husband asked her to hurt him as compensation for sexual humiliation, a sexually motivated component of the injuries (masochism) cannot be excluded in this case either. There were no indications of an autoerotic accident [15].

Further consideration about the possible self-infliction of the observed injuries should be given in cases where there is a background of mental illness. In the presented case, the man had Asperger's syndrome and depression. Asperger's Syndrome is a disorder of the autistic spectrum and is characterized as a severe impairment of mutual social interaction, in particular non-verbal communication difficulties, a narrow spectrum of interests, and compulsive routines. Common comorbidities are anxiety, obsessive–compulsive disorder (OCD) and depression. Specific symptoms such as eating disorders or self-harming behavior may also occur.

It is assumed that self-harming behavior takes on regulative functions for those affected, such as reducing stressful negative emotions, states of excitement and tension, or feelings of guilt [16, 17], but also the urge to punish or humiliate oneself is given as a motive [18]. Various methods are used; the most common are cutting or scratching, but biting, hitting or tearing hair may also occur.

Paquette-Smith et al. found previous suicide attempts in 36% of cases in a study of 79 adults with Asperger's autism [19]. Takara and Kondo examined 336 Japanese adults with acute depression. For those patients who also suffered from profound developmental disorders such as Asperger's syndrome, this represented, together with the classic risk factors (previous suicide attempts, agitation), a significant risk factor for suicide attempts [20].

In 2018, 9.396 people died in Germany due to suicide. The most commonly chosen methods were hanging, strangulation or suffocation (4256 people) [21]. The age-standardized mortality for suicide in 2015 was 8.5 in Germany and 14.5 in Japan [22]. In almost 90% of all suicides, those affected had a previous psychiatric illness [23]. Asukai et al. found that in 46% of the suicide cases, there were previous depressive illnesses in 26% of the cases psychoses and 18% of the affected persons had consumed psychoactive substances [24]. Particularly, psychotic illnesses can lead to unusual death scenes and injury patterns in cases of suicide. Byard reports a case of suicidal hanging with anogenital self-harm; a 51-year-old man cut his scrotum immediately before hanging and inserted a broomstick deep into his rectum, penetrating the peritoneum. The man was an inmate of a facility for insane criminals, a precise psychiatric history was not available [25].

Blunt force is rarely found in self-infliction. Austin et al. report a case of a 47-year-old woman who was found unclothed on her kitchen floor with multiple bruising all over her body and three deep head wounds in keeping with blunt force trauma. Fifty empty blisters of clozapine were found in the kitchen sink. Death was attributed to clozapine intoxication and hemorrhage due to blunt trauma. There was a history of schizophrenia as well as a previous suicide attempt. The large number of blunt force trauma initially suggested a possible homicide. With regard of the lack of signs of forced entry, the blood stain pattern on pieces of fixed furniture, the history of psychiatric illness and the lethal level of clozapine, the injuries were considered to be self-inflicted [26].

A case by Madea points out that the interpretation of fatal injuries regarding their classification in self-harm or third-party infliction is also essentially dependent on the presence of further, non-lethal injuries, on the traces at the death scene and the statements of other persons involved. A 78-year-old man with known schizophrenia died due to blood loss after penile amputation. Findings of blunt force against the head and the absence of typical tentative cuts suggested a homicide. The cutting tool and the amputated body part were not found near the body. The suspected son’s bloody clothes were found in a garbage can in front of the house. However, histological examinations of the penile wound showed advanced leukocyte emigration, which indicated a longer period of agony without any indication of self-rescue attempts, and thus did not support the occurrence of a homicidal event. Rather the investigation provided evidence that was compatible with the son's statements about the course of events [27].

In our presented case, the circumstances that led to the strangulation could not be fully clarified. From the investigating authorities’ point of view, it was considered a suicide due to the decedents known psychiatric history and current stressful situation (severely disabled child, partnership crisis). From the medical examiner’s point of view, the non-strangulation (self-)injury pattern remains unusual.