We describe the case of a middle-aged woman, with a stable life from a family and occupational point of view, who appeared in a semi-estimated decubitus position on a bed at 30 hours.
The presence of a small puncture at the level of the right flank was determined as external signs of violence.
In the verification of the place of the facts, a vase with no content and an envelope addressed to the family were found.
In the envelope there was a box of the drug "loracepam" in which there was a lack of emotional response (loracepam), as well as a letter explaining certain aspects of personal work, a banal life);
Selected with the eye inspection, in the bathroom, 5 insulin dispensers and 5 vials were found, all of them without content and with them a prescription for "humalog" and instructions for administration
Applying the above scheme7, we find:
1.
The cause explains how the person died and if there is a relationship between autopsy findings and death, as well as if the probable substance use (insulin and psychotropic drugs) could be related to death.
In this regard, the forensic medical report is in charge of clarifying the cause of death.
The chemical-toxicological study determined the existence of insulin.
In order to establish whether insulinemia was elevated as a consequence of serum insulin secretion (1 ng blood glucose output, glucagon and C-peptide (a protein synthesised in the pancreas plus partially released from endogenous insulin fragments) no
These results led to determining the cause of death as a drug poisoning.
A brief analysis of the pathophysiological mechanism may indicate that the concentration of glucose plays a major role in the regulation of insulin release and it binds to a specific receptor of the protein-kinase type located at the adipose surface muscle.
In vivo insulin is synthesized in pancreatic beta cells as a pro-hormone that when fragmented results in C-peptide and insulin itself.
The main sites of insulin degradation are the liver (70%) and kidneys (10%).
After intravenous or subcutaneous administration of insulin, the half-life is dependent on dose and type of insulin.
Supraphysiological concentrations lead to a longer duration of the hypoglycemic effect, probably due to saturation of hepatic clearance systems.
2.
Another issue, which can also be more ambiguous, is the mode, referring to the circumstances that give rise to the cause of death.
To do so, it is necessary to resort to the classic scheme of natural, accidental, suicidal or suicidal death.
Generally, both the cause and the way of death can be established from objective evidences that appear at the moment of the cadaver's lifting, through the search for evidence that could reveal the circumstances of death.
It is an essential part, since it will determine the need to initiate judicial investigation.
In the case we present our own evidence, we are guided by a suicide, however, on other occasions it is not easy to determine how a person dies, based on the available information.
Thus, we can refer to certain doubts that arise between some accidents and suicides.
3.
Once determined that the mode is suicidal, the next step is to establish the reason why the victim actually committed suicide.
In many situations, the reason is totally unknown and should be deduced from the available evidence.
To do so and following Shneidman 5 he recommends a careful review of three questions: why did the victim do this? What were his reasons? and why did he do it at that determined time?
In these situations, it is essential to provide information about the life, behavior and psychological conditions of suicide, so that research can assess the most probable reason.
It is interesting to evaluate the clinical history of the victim determined in the clinical reports.
In these, we can determine how, for more than twenty years, they had presented retrospective diagnostic evaluations according to DSM criteria consisting of Axis I: major depressive disorder.
Axis II: mixed personality disorder.
Axis III: no medical diseases and Axis IV: good family support.
With regard to these diagnoses, it is evident that major depression is the individual mental disorder that most frequently precedes the act of suicide and therefore the most related to suicide risk.
In the case of unconscious mindset ingestion and several urgent involuntary psychiatric admissions, all of them related to self-lysis attempts, for which different more or less bloody methods were used as massive ingestion of acetaminophen (antidepressants).
Taking these clinical antecedents as a reference and, above all, the analysis of the left manuscript, they can give us an answer to the questions indicated, considering that writing is also the basis of personality.
The way he writes, the shape and size of the letters are some of the characteristics that allow us to know how our victim was and the degree of despair.
If we give a psychoanalytic view to the case, we reveal that suicide was a person with reduced and sometimes annulled capacity for creation and production.
Their subjective experience corresponded to the annulment of all desire and all pleasure that affected up to the minimum acts of daily life in all its aspects (family, labor, social).
The report reveals the existence of a state that activates both the body and thought, accompanied by a feeling of despair, manifested in an experience of absolute annihilation marked by itself.
From all this and evaluating the manuscripts the following considerations can be extracted:
- that the victim had a negative consideration of herself, showing a marked tendency to be considered disabled, inappropriate and useless and attributing her unpleasant experiences to moral or mental defects: "I have stopped being a singer,"
- I tended to reject myself, believing that others rejected it: "I do not feel understood," "you are seeing you every day worse telling you, losing or losing me."
- He had a negative view of the world: "doctors speak of what they believe, but of what they do not know there should be much because but I would not be like that.
The mind is so dark and so little known about it", "to stop trying with me".
- She felt socially defeated: "I am tired of fighting and fighting, suffering and not enjoying life," "at these times I feel the same as I think of myself."
- I considered the world to be very demanding and present obstacles that interfered with the achievement of the objectives of your life: anxiety has been more troubled for me by God than you know; "I cannot resist it all 100 years ago."
- I had a negative view of the future.
I saw the future from a negative perspective and turned it back and turned to a series of negative expectations: "although they say I have resources, it is no longer true and there is help today, no longer".
- I expected that her common problems and experiences would continue indefinitely, and that many worse ones would assemble her in her life: "hope is the last thing she loses, but I lost her last day."
- He had a tendency to deform his experiences, misinterpret concrete and irrelevant events taking them as failures, privations or personal rejection: "I know only what I have struggled and for what I have done.
Only I, the others see the bulls from the barrier", "adequate this has made me a bad person.
That's why I don't enjoy life".
- Everything always seemed contrary to itself, creating the negative until the positive facts were ruled out: "you say you're destroying life, mine is already broken.
I don't want friends, work, talk", "I was a pessimistic person, not a fan and now I am, so I know I'm not me".
4.
The next step is to determine the intention, which represents the resolution of an individual to carry out his death consciously or unconsciously.
In this section, it is necessary to analyze or objectify whether suicide had manifested or communicated its intention and whether these came to be verbalized and/or repeatedly expressed to different people or, on the contrary, the recent expression of suicide intent.
Communication of suicidal intents must be considered as an obvious sign of suicide risk.
There are many ways to make this communication either to relatives or relatives or even to the professionals themselves (physicians, psychiatrists, psychologists...).
From the review of the clinical documentation it can be affirmed that the victim had a higher degree of intention to end up with his life, as demonstrated by the fact that he had carried out five previous attempts and even the last picture of suicide dates13
In his writing, these data are revealed when he states: "All treatments I have rejected them (and I continue to do so, but I would be much better) are very important and nobody has done so much or put to you."
5.
Once the intention was determined, the lethality degree of the method used was assessed.
The degree of lethality may vary and be high, medium, low or absent.
As examples we can indicate that this is a high lethality when there is an unequivocal decision to remove life (dispatching the head or precipitating from a high height).
Lethality will be average when suicide prepares its own death through conscious or unconscious actions, such as neglecting a certain medical treatment that can save your life or potentially lethal use of drugs.
It will be low lethality when the victim plays a small but not insignificant role in the execution or preparation of his own death.
And lethality will be absent when the victim fails to play any role in causing his own death, although the objective data regarding which he wished to live are unknown.
According to the method used in this case, insulin is considered high and/or medium lethality.
6.
And finally, to determine if a death was due to a healthy suicide in front of a demented one, which is closely related to the evaluation of the person's intention to take off his life.
A "healthy" suicide indicates that the person had a rational understanding that an action he/she performed would result in his/her own death.
On the contrary, a "demente" suicide occurs when a person is so emotionally altered that he/she does not rationally appreciate the relationship of his/her actions to cause his/her death.
In the case we analyze, we qualify suicide as "healthy", because it is understood that suicide still in possession of their reasoning faculties wanted to end intentionally with their lives.
To reach this typification we understand that despite determining an anguished mental state, it is evident that suicide had carried out actions that show a sufficient capacity to understand the nature of the act that would be performed against its own life and its consequences.
