Forensic Science International 134 (2003) 142146

Criteria for homicide and suicide on victims of extended

suicide due to sharp force injury
A. Dettlinga, L. Althausb, H.-Th. Haffnera,*
a
Department of Forensic Medicine, University of Heidelberg, Vostr. 2, 69 115 Heidelberg, Germany
b
Department of Forensic Medicine, University of Essen, Hufelandstr. 55, 45 122 Essen, Germany
Received 28 December 2001; accepted 26 March 2003

Abstract

This report is about the findings in association with the extended suicides of nine victims killed by sharp force. All victims
were killed by sharp force. The perpetrators were predominantly the parents, the victims their children. Regarding the criteria for
differentiating self-inflicted injuries from injuries inflicted by another person, the victims injuries presented patterns usually
found solely in suicides. Thus eight of nine cases presented tentative and hesitation injuries, in three of five cases areas of injury
covered by clothing had been exposed beforehand. Despite extremely narrow intercostal spaces in children, injuries to the bones
in thoracic stabbing were avoided more often than not (four of seven cases). Only the criterion defence injury occurred nearly
as often as in homicide victims (three of nine cases). The psychopathology of extended suicide can explain this pattern. The
perpetrators motive is characterised by his pseudoaltruistic belief to save the loved ones from a world that is in his opinion
unacceptable. A fusion or integration of the victim into the perpetrators own self is based on an identity problem. Physical
interrelation of forces between perpetrator and victim restricts the victim in his defence and presents an important prerequisite
for acquiring the patterns of described injuries.
# 2003 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Sharp force; Extended suicide; Criteria of homicide and suicide

1. Introduction The term extended suicide originated from Nacke in

In cases of violent death morphologic criteria should be
observed, as they can give valuable clues for differentiation
between homicides and suicides. These criteria are espe-
cially distinct in deaths which occur by means of sharp force.
Tentative and hesitation injuries as well as avoidance of
injuries to the ribs and sternum are important in suicides. In
homicides evidence of defence injuries and stab wounds
through clothing are significant [111]. Different motivation
of action is an explanation for these varied findings. Whereas
the aggression of the attacker and the self-defence of the
victim is essential in homicides, in suicides the vague death
wish in the beginning of the event is well to the fore.
*
Corresponding author. Tel.: 49-6221-568950;
fax: 49-6221-565347.
E-mail address: hans_haffner@med.uni-heidelberg.de
(H.-Th. Haffner).
1908 [17]. His current definition largely conforms to the
classic criteria of Lange [18]. According to his definition an
extended suicide is the decision to include other closely
connected persons (usually children of ones own or ones
spouse) in the suicide without obtaining their permission.
Vengeance is not the motivation for killing the other person,
no more than remorse is the motivation for the subsequent
suicide. In the pathologically altered conception of the
suicidal person the motives are more likely altruistic or
rather pseudoaltruistic. The decision to take ones own life
is made before killing the victims. Further important aspects
for determining an extended suicide are the simultaneous
occurrence of the crime, and a partially thought out and
spontaneous decision without realisation of the conse-
quences [1921].
The killing of other persons in extended suicides can
depend on even the one (aggression/self-defence) or the
other motivation of action (vague death wish) and can be
characterised by both of them regarding the morphologic

0379-0738/03/$ see front matter # 2003 Elsevier Science Ireland Ltd. All rights reserved.
doi:10.1016/S0379-0738(03)00139-7
Table 1
General information
Case Perpetrator
no.
Age/sex Psychiatric diagnosis
1 24 years/female Serious depressive syndrome
2 31 years/female Affective psychosis
3 43 years/male Depressive syndrome
(stress-reaction and
professional failure?)
4 28 years/male Acute depressive reaction
(before he stabbed his wife
after an argument)
5 37 years/male Severe personality disorder
with depressive, hysteric and
psychotic parts
6 25 years/female Depressive syndrome after
therapy with interferon
of a multiple sclerosis
Victim
Further information Age/sex Degree of relationship Cause of death
Stuporous condition after the 4 years/male Son Faint haemorrhage after incision of
crime; admission to a psychiatric large arterial and venous neck
A. Dettling et al. / Forensic Science International 134 (2003) 142146
clinic; past attempted suicide in arteries, lung stabs, air embolism
medical history
5 years/male Son Faint haemorrhage after incision of
large venous neck arteries, lung stabs
Suicide by intoxication with 10 years/female Daughter Faint haemorrhage through multiple
antidepressants and alcohol heart and lung stabs
Besides killing the children also 18 years/male Son Faint haemorrhage through multiple
killing the wife by breast shot; heart and lung stabs
farewell-letter was found in the
flat; escape to Italy, there suicide
by shot in the head 3 days
after the crime
14 years/female Daughter Faint haemorrhage after incision of
large arterial and venous neck arteries,
stabs of the chest, air embolism
Attempted suicide by neck incision 3 years/male Son Faint haemorrhage after incision of A.
and stabs; tentative and hesitation carotis dex.
injuries on the skin of the neck
Attempted suicide by intoxication 72 years/female Mother Faint haemorrhage after multiple
with antidepressants; farewell letter: heart and lung stabs
he has to put his mother out
of her misery
Compare casuistic 4.5 months/female Daughter Faint haemorrhage after neck
and artery incision
3 years/male Son Faint haemorrhage after neck and artery
incision, chest stabs
143
144 A. Dettling et al. / Forensic Science International 134 (2003) 142146
criteria. Up to the present date there have not been any
extensive studies on this subject, merely a few case reports
[3,12].
2. Methods
During the period between 1991 and 2001 six extended
suicides by means of sharp force including nine victims
(among these were three pairs of brothers and sisters) were
investigated at the Institutes of Forensic Medicine of the
Universities Essen and Heidelberg (the term victim
includes solely the victims of the homicide and not the
perpetrators). The differentiation between extended suicide
and reactive suicide after previous homicide resulted from
individual case analysis. In four cases the perpetrator sur-
vived and the differentiation was based on a psychological
examination. The two remaining cases were analysed via
previous history and police investigation. Definitions for
classifying extended suicide were a serious depressive syn-
drome combined with suicidal tendencies, close emotional
relationship to the victims without clues of conflict situa-
tions, and the exclusion of suicidal tendencies on the part of
the victims. The homicide and subsequent suicide or
attempted suicide have to be in close chronological correla-
tion.
The evaluation of the morphologic results of victims of
extended suicide was based on the autopsies and available
photographs. Standard findings were applied, which can
normally differentiate between homicide and suicide: ten-
tative and hesitation injuries, defence injuries, costal injuries
in thoracic stabbing, pattern of wounds in multiple injuries,
stab wounds through clothing or previous exposure of the
area of injury.
3. Results
In three cases men were the perpetrators and in three cases
women. In five cases the perpetrator was a parent of the
victims, in one case it was the son. All of them were
diagnosed with depressive syndrome. Three were partly
reactive, partly neurotic, one had an acute episode of an
affective psychosis, one had an organic psychosis associated
with multiple sclerosis treated with interferon. One perpe-
trator had a serious personality disorder, partly passive-
dependent, partly hysterical, partly psychotic. Two com-
mitted suicide, one by intoxication with antidepressants and
alcohol the other by shot in the head. Three attempted
suicide but it was insufficient. One was found in a stuporous
state; an attempted suicide was known in his medical history
(Table 1).
Seven victims were children aged 4.5 months to 14 years,
four boys and three girls. The two other victims were a 18-
year-old boy (killed by his father) and a 72-year-old woman
(killed by her son).
None of the victims had solitary injuries; all of them had
multiple injuries with a predominantly clustered pattern of
injury. In three cases solitary stab wounds were discovered,
six cases were combinations of stab wounds and incised
wounds.
In one case only the region of the neck was attacked, in
eight cases two or more regions of the body were affected.
These instances included injuries to the neck in combination
with injuries to the chest, arms and hands, respectively.
In seven cases there was thoracic stabbing. Only three of
the seven instances included injuries to the ribs or the
sternum.
Eight of the nine victims had tentative injuries to the neck
or pectoral region. Three predominantly older children
suffered defence injuries. Seven victims were injured in
regions of the body usually covered by clothes. Only in five
cases were these regions actually covered at the moment of
the crime. In two of these latter cases the clothing had been
damaged, in the other three the clothing had been pushed
aside (Tables 2 and 3).
One particular case will be portrayed as an example.
A 25-year-old Turkish woman diagnosed with a central
form of multiple sclerosis killed her two children aged 3
years and 4.5 months, respectively. The childrens bodies
were found in the nursery of the apartment. The body of the
3-year-old boy presented several thoracic stab wounds
including costal injuries. There was no damage to the
clothing as it had been pushed aside. Furthermore there
were incisions to the neck and radial artery. On the left the
radial artery had been cut violently, presenting itself as a
partial amputation. Tentative incisions to the skin of the neck
were also observed. The infant girl lay correctly in her cot
dressed in babys rompers, covered by bedclothes as if she
were asleep. Apart from bilateral incisions to the radial
arteries her neck showed incisions and tentative incisions.
After removing the clothes solitary tentative stabbing of the
Table 2
Criteria for injuries inflicted by another person in victims of
extended suicide
Criteria for injuries inflicted
by another person
Defence injuries Three of nine cases
Damaged clothing Two of five cases
Costal or sternal injuries Three of seven cases
Table 3
Criteria for self-inflicted injuries in victims of extended suicide
Criteria for self-inflicted injuries
Tentative or hesitation injuries Eight of nine cases
Exposure of injured region Three of five cases
 A. Dettling et al. / Forensic Science International 134 (2003) 142146
chest and faint haemorrhage of the subcutaneous fatty tissue
was observed. None of the clothing was damaged.
Days prior to the crime the perpetrator had been in
therapy in a psychiatric hospital for depression. The depres-
sion occurred in connection with treatment for multiple
sclerosis using interferon. After killing her children she
attempted suicide with an overdose of amitriptylin, giving
prior notice of her suicide via telephone. She was found in
time by the alerted rescue service and brought to hospital in a
soporous condition. In the subsequent examination she also
presented tentative incisions around the thorax and abdomen
as well as one tentative incision on the left side of the neck.
Under interrogation the mother stated the salvation of
her children from this world as motive for the killing; she
did not want to leave her children at the mercy of a
stepmother. The expert witness for psychiatry diagnosed
an organic depressive psychosis due to multiple sclerosis and
treatment with interferon. He ruled out responsibility at the
time of the crime.
4. Discussion
Morphologic criteria for differentiation of self-inflicted
injuries from injuries inflicted by another person can be
observed in several methods of violence. They are especially
diverse in deaths by sharp force. Therefore sharp force is best
suitable for this kind of study. A considerable number of
studies exist proving the diagnostic value of the criteria for
differentiation concerning deaths by penetrating violence
[1,2,5,6,911,1316]. On the other hand, it is difficult to
collect a sufficient number of victims of extended suicide
through penetrating violence. Extended suicides are rare
events, but are even rarer to find in the study, which is
restricted to one cause of death. It was not possible to include
more than nine cases into this study, based on a collective of
10,000 autopsies.
A comparison was made between the results of these nine
cases and homicides or simple suicides. Victims of extended
suicides presented findings typical of self-inflicted injuries
in suicides. These findings also had the same frequency of
occurrence. This applies to tentative or hesitation injuries,
the condition of the clothing, and the absence of costal or
sternum injuries. The prerequisite for acquiring these inju-
ries is of course a victim incapable of self-defence at the time
of the event. In most cases reasons for this are the age of the
victim or physical interrelation of forces between perpetrator
and victim. Presumably in some cases the victims were
handicapped by preceding injuries. The 18-year-old, for
instance, had also been stabbed in the back. The number
of defence injuries is close to the number of defence injuries
of homicide victims. As expected they were found more
often in older victims, being the only ones capable of
resistance, at least in the beginning.
These findings point out that victims of extended suicide
cannot be classed with victims of homicide, even though
145
they were injured by another person. On the contrary, their
findings show similarities to suicides. This central motive is
influenced and dominated by the suicide of the perpetrator.
The pathologically altered conception of the perpetrator is
often determined on depression within the scope of an
affective psychosis. Delusions can also force sick persons
to commit extended suicide. Other psychopathological syn-
dromes and psychosocial stress factors (serious personality
disorders, acute reaction to emotional stress, intoxication in
narcotics abuse) are also associated with a higher risk for
extended suicide [20,22,23].
The supposed helpless dependence of the victim on the
perpetrator, seen from the perpetrators point of view, is
characteristic for the interrelation between perpetrator and
victim. Young children are therefore more prone to become
victims of their suicidal mother [22,2427]. Somander and
Rammer [28] and Rodenburg [29] emphasise an altruistic
belief to save the child by death from a life of suffering in an
unacceptable world. Battegay [30], on the other hand, states
that depressives in a phase of deep depression long for a
fusion with closely related persons. In this narcissistic way
people can be integrated into the patients own secluded
world. Okumura and Kraus [31] believe in a psychotic
identification of the perpetrator with the victim. According
to Bischof [32] the perpetrators whole being extended
itself onto the victim, so that killing the other person
becomes synonymous with killing ones own self. Rasch
[24] also confirms that the nature of extended suicide is an
identification with the victim, including him in ones own
destiny and existence. According to DOrban [33] and
Resnick [34] especially depressive mothers view their chil-
dren as a displaced or extended part of themselves. Hence
the killing of their child represents an extension of their own
suicide.
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