If self-inflicted wounds are not immediately lethal, then blood can be shed at various sites, indicating purposeful activity prior to death (Fig. 3; refs. 16, 22, 105, and 109). The deceased's footprints can be evident in bloodstains (60).
A suicide note may be found at the scene. In most American and international studies of self-inflicted firearm injuries, a note is found in about 10 to 40% of cases (6,16-19,21,32,35,46,49,50,110). In one English study, a note was found in 55% of cases (48). Variations include discovery of a will, funeral information, an insurance policy, or other personal papers at the scene (56,110). A note can be incorporated as part of photographic album, video presentation, or on a computer (57,111). Handwriting analysis may be required to verify that the note was written by the victim (111).
Information regarding a previous suicide attempt or threat may be lacking. In various US series of suicidal firearm injuries, prior attempts or threats have ranged from 16 to 38% (18,110). In individuals younger than 19 yr of age, this history was elicited in up to 42% of cases (6,17). Previous methods described in a Texas study included overdose (38%) and use of a gun (9% ).
A psychiatric history or disturbance is known in about one-fifth to two-thirds of cases in various series (12,17-19,26,32,46,110). Depression is the most common problem. Psychosis is seen in a small number of victims (e.g., murder-suicides involving fil-icidal mothers or family annihilator fathers ).
Similar factors motivate single victims of suicide and perpetrators of murder-suicide (28). These include relationship problems, financial/economic stresses, poor health or incurable disease, ethanol and drug abuse, legal difficulties including pending incarceration, mental illness, low self-esteem, and a past history of physical and sexual abuse (18,21,24,37,110). Perpetrators of murder-suicide, depending on the situation, are driven by jealousy, retaliation, altruism ("to save the family from the evils of the
world") or mercy (e.g., physically ailing spouse [12,24,25,27,28,38,53]). A South Carolina study of self-inflicted firearm fatalities in individuals younger than 18 yr of age showed 42% had a history of risk-taking behavior (e.g., playing with firearms, drug and alcohol abuse ). About three-fourths of victims aged 65 yr or more had a high prevalence of cancer and other chronic, debilitating illnesses that had been diagnosed while the victim was alive (18).
Self-inflicted gunshot wounds can be witnessed (16). In an Australian series, 10% of suicides were witnessed (36,46). Self-inflicted firearm wounds can be sustained during the pursuit or apprehension by police (112-114). Perpetrators of murder-suicide were witnessed shooting themselves in 15% of cases in one Texas study and in more than one-half of deaths in a New Hampshire series (26,32).
The suicide victim may attempt to create a "gun cleaning" or " hunting" accident (see Heading 21 and refs. 16, 23, and 115). Careful investigation is needed to determine whether discharge of a gun under these circumstances was an accidental death (Fig. 4; ref. 44). Suspicions are aroused when handguns are involved in a hunting incident (42). A shotgun was the most common weapon in accidental deaths, either self-inflicted or inflicted on others (42,115).
Self-inflicted firearm injuries are observed in "complex" suicides, i.e., more than one weapon or means of suicide is used (Fig. 5; refs. 16,77,116-118). These suicides can be "unplanned." Failure at one attempt (e.g., carbon monoxide poisoning, hanging) leads to use of a firearm even in a different locale (47,119). The suicide can be
"planned." Concurrent use of different firearms (e.g., air rifle followed by shotgun, simultaneous use of two guns) or a firearm and another mechanism (hanging, poisoning) to lessen the chance of failure of one method have been described (21,22,36,72,97, 116,120).
Classification of murder-suicide is based on the relationship between the perpetrator and victim (12,24,27,29). Most victims are known to the deceased (28,29,53). The most common situation is spousal/consortial (40 to 85% [24-26,29,53,121]). Common motivations in this group include jealousy and illness (52,121,122). There can be a background of domestic violence (26,29). Multiple homicide victims are seen in other types of murder-suicide scenarios (e.g., familial or "family" annihilator situation [28,53,122]).
The temporal relationship in a murder-suicide varies. The killing of one or more persons is usually followed very soon after by the suicide of the perpetrator of the homicide ("dyadic" ). Eighty percent of perpetrators killed themselves within 1 h of the murder; however, an older individual may delay suicide for up to 1 mo (12,28).
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