Clinical, Psychiatric and Medicolegal Issues in Non-Fatal Strangulation: A Case Report

Abstract

Introduction: on-fatal strangulation (NFS) is a dangerous mechanism that can produce injuries with varying levels of severity. NFS-related injuries can range from low severity, such as simple contusions, to very severe, with convulsions and major forms of impairment. It is often difficult to gauge the severity of injuries from external and initial manifestations alone; it is therefore necessary to assess the possibility of misdiagnosed injuries or subsequent manifestations. Case report: In this study, we describe the case of a 71-year-old man with several injuries, mainly in the craniofacial region, following an assault by his flatmate. Not only did the subject suffer a concussive head injury and a fracture of the zygomatic bone, but he was also subjected to NFS. The patient was examined three times, and the third examination was carried out directly by us 40 days after the assault. Discussion: We concluded that NFS-related injuries are not always clearly visible and recognized after some time. It would therefore be necessary to standardize the clinical investigation procedure in suspected or confirmed cases of NFS. Conclusion: Clinical investigation should be done from the first hours after the injury event, with the help of forensic experts, with the use of dedicated instrumentation and the acquisition of photographic images, all carried out in a systematic manner for use in court, and a search performed for after-effects that cannot be identified by other methods. Psychological evaluation should also be considered as part of the broader assessment process as victims of NFS often experience significant psychological trauma.

1. Introduction

Strangulation occurs when the neck is compressed by tools or by hands, arms, or elbow folds, obstructing blood flow to the brain and oxygen passage in the airways, potentially leading to asphyxia and death [1]. If death by asphyxia does not occur, it is referred to as NFS. Recently, international research findings showed that attention has focused on the prevalence and danger of NFS [2,3]. Statistical studies indicate that manual strangulations are more common than ligature strangulations, with the aggressor often being someone close to the victim. Sectoral statistical studies indicate that NFS is a significant indicator of severe domestic violence and a risk factor for homicide. Most NFS victims are women, and NFS is often perpetrated by male partners in the context of domestic violence. Women are more likely than men to experience non-fatal strangulation, especially in violent intimate relationships. About 10–15% of women who experience intimate partner violence (IPV) have been subjected to at least one episode of non-fatal strangulation [4]. Victims can vary in age, but young adult women (aged 18 to 34) are often more vulnerable to this type of violence. These data come from the Training Institute on Strangulation Prevention (TISP), which provides a wide range of resources and has conducted multiple studies on NFS, including its prevalence, clinical signs, and long-term consequences.

Death by strangulation can occur through three mechanisms: asphyxia, circulatory impairment, and nervous system dysfunction. These mechanisms also underlie injuries that can arise even without homicidal intent, as strangulation might be used to immobilize or control the victim [5]. Non-fatal strangulation may not leave visible marks on the body, and injuries can fade over time. Hence, conducting a timely medical examination and documentation is crucial [6,7,8]. This process is carried out to prevent signs that can be directly linked to the attack from disappearing or being unusable in a forensic context [6,7,8]. In many cases, NFS is related to domestic violence and sexual violence [9,10,11], but a certain prevalence has also been observed in cases of aggression against healthcare workers, often attacked during working hours and precisely because of their duties as healthcare workers, and in cases of consensual or autoerotic sexual practices [12,13,14,15]. In domestic violence cases, the consequences can be enormous, both from the physical and psychological perspectives, especially in cases where NFS is followed by further, potentially fatal, violent attacks. In fact, often in cases of NFS that come to the attention of Emergency Department (ED) healthcare workers, the risk of re-victimization is assessed with the DA5 form—Brief risk assessment for the ED, i.e., a validated tool for assessing the situation in which the violence occurred and its potential dangers. This test is designed to evaluate the risk of violent escalation, and thus constitutes a valid aid for ED healthcare workers, enabling them to identify high-risk victims [16,17,18]. It is necessary to standardize the clinical investigation procedure in suspected or confirmed cases of NFS. With this work, we want to emphasize the importance of conducting a clinical forensic examination as soon as possible in cases of non-fatal strangulation.

2. Case Report

A 71-year-old man, with a criminal record and a history of psychiatric issues including serial hoarding, was assaulted by his 33-year-old roommate, an undocumented Gambian immigrant facing deportation, who was residing rent-free in the older man’s home. The altercation began over minor matters, escalating to the assailant threatening the victim with a large knife. The victim was then physically assaulted, including being pushed to the ground, kicked, punched, and subjected to manual strangulation. Despite the attack, the victim managed to escape and seek help at a neighbor’s house, where authorities were notified. Upon arrival, the assailant was found at the victim’s residence and confessed to the assault. The scene indicated a struggle, with broken glass and blood on the floor, leading to the attacker’s arrest. Emergency services found the victim conscious but with a bloodied and swollen face, prompting an immediate transfer to the nearest hospital for medical attention. The initial diagnosis indicated “assault by a known person, non-concussive head trauma, facial trauma with widespread bruising and left hemicostal trauma”. The physical examination, conducted in the emergency room 3 h after the traumatic event, revealed several injuries, including bruising and swelling on the face, particularly around the nasal, periorbital, and left zygomatic areas, along with signs of epistaxis and blood from the left auditory meatus. Subcutaneous emphysema was noted in the zygomatic region, consistent with manual strangulation signs on the neck. The patient also experienced pain and bruising on the left ribs, abrasions on the right thigh, and femur pain. Radiological investigations (Levels I and II) identified multiple fractures: displaced fractures of the frontal process of the zygomatic bone and the zygomatic process of the left temporal bone, a multi-fragmentary and displaced fracture of the lateral and anterior wall of the left maxillary sinus involving the infraorbital nerve canal, and a displaced fracture of the coronoid process of the left mandibular bone. Additionally, there was a voluminous hematoma in the subcutaneous soft tissues of the left fronto-orbito-zygomatic region, causing compression on the ipsilateral ocular structures, along with traumatic injury to the retro-maxillo-zygomatic subcutaneous adipose tissue in the left inferolateral location. At the chest level, the patient had a displaced fracture of the anterior arch of the second, third, and fourth ribs on the left side and a fracture of the anterior arch of the second, third, and fourth ribs on the right side. Due to the severity of the injuries, maxillofacial surgery was recommended to address the orbito-zygomatic fracture using titanium plates, screws, and absorbable membrane placement under the eyelid, supraciliary, and intraorally. However, after being informed of the associated risks, the patient declined surgical treatment and requested discharge against medical advice. The clinical documentation from the emergency room admission following the traumatic event, along with iconographic evidence, allowed for the mapping of the victim’s body lesions shortly after the attack. On the left side of the face, a hematoma and eyelid swelling were observed in the periorbital region, hindering full eye opening. In the zygomatic-malar and cheek region, there were diffuse, discontinuous ecchymoses with blurred and irregular margins, particularly concentrated in the zygomatic-malar area where an irregularly rounded abrasion approximately 1 cm in diameter was found (Figure 1).

Near the auricle, a linear continuous solution, about 1 cm long, with slightly oblique margins was observed on the tragus. On the left side of the neck, bruises with oval shapes, approximately 2 × 1 cm in size, were noted, along with confluent ecchymoses in the supraclavicular fossa area and additional oval-shaped ecchymotic lesions at the jugular level (Figure 2).

The patient underwent examination eight days after the traumatic event, and additional photographic documentation was obtained to track the injury’s progression post-attack. The documentation revealed the natural change in color and gradual healing of the periorbital hematoma, as well as an abraded lesion in the zygomatic region and continuous scabbing on the tragus and cheek region, covered by a brownish bloody crust. Additionally, a large, diffuse, yellowish ecchymotic complex was observed on the neck, extending from the lower edge of the mandible to the ipsilateral supraclavicular fossa. Within this complex, three ribbon-like ecchymoses of approximately 4 × 0.8 cm in size, purplish in color, were visible, parallel to each other, with the most cranial ecchymosis separated by approximately 2 cm from the median one, which connected posteriorly to the most caudal ecchymosis (Figure 3).

However, during the medical-legal examination carried out forty days after the traumatic event as part of the preliminary inquiry, no remnants of the superficial contusive damage previously described were noted (Figure 1). The clinical examination was carried out by the Public Prosecutor’s Office and conducted by appointed forensic physicians. The photos taken during the examination, conducted 40 days after the event, were taken by the same examining forensic physician. Palpation of the left orbito-zygomatico-malar region caused severe pain, particularly around the zygomatic process and inferior orbital arch, where a bony step and depression were felt compared to the opposite side. Dysesthesia was also noted in the left hemifacial territory innervated by the second trigeminal branch. Ocular motility examination showed no abnormalities, and there was no diplopia reported. Severe pain was also elicited upon palpation of the left temporomandibular joint, with increased pain during maximum jaw opening and a creaking sensation during jaw movement, but no speech difficulties were observed. No swelling or bruising was noted at the neck level, although small abrasions were reported near the jugular due to recent shaving. Severe tenderness was experienced upon chest palpation corresponding to fracture sites in the anterior arches of the II, III, and IV ribs on both sides, particularly in the left hemithorax, without respiratory symptoms. The patient also reported persistent anxiety and occasional mental confusion following the traumatic event.

3. Discussion

3.1. Clinical and Forensic Components

In this case, it was possible to monitor the patient’s clinical improvement following an assault involving manual strangulation, which provided insights into the body’s healing process until full recovery. By correlating the victim’s account with the observed injuries, it became evident that non-fatal strangulation had occurred. Manual strangulation involves external obstruction of the airway and pressure on the neck’s vascular and nervous structures by the assailant’s hands, leading to asphyxiation. In this instance, the compression at the level of the antero-lateral regions of the neck resulted in ecchymotic lesions. Some of these lesions were figurative, particularly those in the left cervico-lateral region, where the marks resembled the shape of the assailant’s fingers. Additionally, there was an abrasion in the right cervical region consistent with a “fingernail” imprint, likely from the edge of a thumbnail. It should be noted, however, that these findings were not detectable during the medical-legal examination carried out forty days after the traumatic event but were clearly visible only on the same day of the event and in a milder form eight days later. This case presents a clear instance of non-fatal strangulation (NFS), where the lingering effects may not be readily discernible some time after the trauma. Consequently, making a definitive diagnosis solely based on a physical examination conducted some time post-event could prove challenging. Research findings support this, indicating that in many cases, signs or symptoms of NFS are not easily detectable during examinations, even when conducted shortly after the incident. A study highlighted that in over half of the cases analyzed, victims of NFS displayed either no visible signs or only mild and poorly identifiable ones, making it difficult to correlate them with the victim’s account [16]. The first signs that can be found and looked for on the victim’s body are therefore ecchymoses (50–85% of cases according to the Training Institute on Strangulation Prevention), preferably figurative, subconjunctival petechiae (30–50%) and skin abrasions–fingernails (15–50%). In addition, other more severe injuries, such as lesions of the carotid arteries (10–25%), trauma to the thyroid gland and subsequent thyroid crisis, trauma to the lymph nodes, lesions of the larynx (15–40%) with subsequent dysphonia or even loss of consciousness, convulsive crises and anoxic brain damage (10–30%), the persistence for a more or less long period of a post-traumatic confusional state, with associated retrograde amnesia, may be observed. In particular, the specific neurological sequelae of non-fatal strangulation (NFS) can be severe and varied, primarily resulting from cerebral hypoxia (reduced oxygen supply to the brain) and direct damage to the nerves or blood vessels in the neck. These sequelae include the following:

• Hypoxic brain injury: reduced oxygenation of the brain during NFS can cause permanent damage to brain tissue, leading to cognitive deterioration, memory problems, difficulty concentrating, and reduced executive function.
• Ischemic stroke: compression of the carotid arteries during NFS can lead to the formation of blood clots or damage to the arterial walls, increasing the risk of ischemic stroke, which may cause paralysis, language difficulties, and other neurological deficits.
• Paralysis or muscle weakness: damage to the cranial or spinal nerves caused by compression can result in paralysis or muscle weakness, particularly in the upper body, including the face.
• Chronic headaches: following NFS, many victims develop chronic headaches or migraines, often related to nerve damage or altered vascularization.
• Seizures: in some cases, brain damage or post-hypoxic brain scarring can predispose victims to develop seizures or epilepsy.
• Post-concussion syndrome: if NFS is associated with a head injury, the victim may experience post-concussion syndrome, which includes symptoms such as dizziness, nausea, cognitive difficulties, and sensitivity to light or sound.
• Language difficulties (aphasia): damage to the areas of the brain responsible for language can lead to difficulties in producing or understanding speech.
• Autonomic nervous system dysfunction: NFS can impair the functioning of the autonomic nervous system, causing dysfunction in the regulation of blood pressure, heart rate, and digestive processes [17,18,19,20].

These neurological sequelae can have a lasting impact on the quality of life of the victims, requiring targeted therapeutic interventions, including rehabilitative support, occupational therapy, and, in some cases, pharmacological treatment to manage chronic symptoms.

3.2. Psychiatric Components

It is widely known that aggression is characteristic of human nature. The psychological components that can lead to aggression include the following:

• Anger and frustration, especially if the individual lacks effective coping strategies.
• Low self-esteem can lead to using aggression to feel powerful or to assert control over others.
• Stress and anxiety can impair rational decision-making, leading to aggressive reactions [21].
• Past traumatic experiences, particularly related to abuse or violence, can predispose an individual to aggressive behavior.
• Mental health issues, such as borderline personality disorder, bipolar disorder, schizophrenia, and antisocial personality disorder can include aggression as a symptom [22].
• Environmental and social influences, such as dysfunctional families or dangerous neighborhoods, can foster aggressive behavior.
• Substance abuse can reduce inhibitions and increase impulsivity, leading to aggression [23,24].
• Imitation and social learning, especially during childhood, can lead to the adoption of similar behaviors [25].
• Lack of economic and social skills can lead to aggression as a means of handling difficult situations [26].
• Cognitive distortions, such as viewing violence as an acceptable way to resolve conflicts, can contribute to aggression.

The mechanisms that govern the genesis of aggression, the conditions that increase it, and the procedures that make it chronic are still the subject of analysis in the forensic psychiatric field. Genetic, environmental and neurobiological factors contribute to determining aggressive behavior [27]. Several experimental studies have shown that there are different cortical and subcortical structures with a central role in the control of aggressive behavior, both with facilitatory and inhibitory activity of the impulse; the serotonin system, which exerts inhibitory control, and the dopamine system, which instead triggers violent behavior [28,29].

In psychiatry, pathological aggressive behavior, depending on its clinical manifestations and purposes, is divided into adaptive (defensive aggressiveness) or maladaptive (pathological aggressiveness) [30]. In the first case, aggression represents the ability to defend oneself from any danger and appears directly proportional to the triggering stimulus in terms of intensity and duration. In the second, on the other hand, the reaction to external factors is disproportionate in intensity, duration, frequency, and with respect to social rules, resulting in disproportionate aggressive attitudes. In these cases, there may be a basic neurochemical alteration, as occurs for example in various mental disorders. Pathological aggression can in turn be divided into two forms: impulsive aggression (reactive or affective) and proactive aggression (premeditated or predatory) [31,32].

Violence on an emotional basis is defined as impulsive, immediate, and reactive. It may be the result of a failure in the regulation of emotions by the subject, for whom there is a decreased threshold of activation for inhibitory regulatory effects. On the contrary, predatory aggression does not seem to be preceded by activation/inhibition of the autonomic nervous system. It appears as premeditated, calculated, studied, characterized by the absence of emotion and perception of threat. Predatory aggression is defined as unprovoked behavior, aimed at offending or coercing another individual. Aggression, in the two subtypes described (affective and predatory), represents a psychiatric emergency and is often the basis of significant physical injuries in the victim [33].

In the literature, violent and aggressive behavior is often linked to several well-defined psychiatric conditions that are frequently diagnosed and documented in the perpetrator’s history. These include schizophrenia spectrum disorders, involutionary psychoses, epilepsy, manic excitations/mixed states, imbalances in personality disorders, hysterical manifestations, focal neurological pathologies, and intoxications. Each disorder can correspond to a different form of aggression. For instance, in a patient with antisocial personality disorder, aggression is typically instrumental and premeditated, with the primary goal of gaining an advantage over others [34].

In post-traumatic stress disorder, aggression is generally triggered by the reactivation or memory of a past trauma [35,36,37]. In psychosis, there can be an aggressiveness that is expressed in deviant behaviors caused by the lack of prefrontal inhibition, cognitive impairment and ideoaffective disorganization [38]. Finally, in borderline personality disorder, aggression is reactive, an indication of emotional hypersensitivity and dysregulation [39,40]. In the forensic psychiatric field, one of the most widely used tools for assessing the risk of violent aggression is the Historical Clinical Risk Management-20 (HCR) scale, in which the following are taken into consideration [41,42]:

• elements of the patient’s personal history, evaluating, for example, the age that the aggressor was at the first violent episode, presence or absence of a serious mental disorder and/or a full-blown personality disorder;
• clinical elements, the presence or absence of symptoms of a possible psychiatric pathology that is still unrecognized;
• risk assessment, which considers possible exposure to destabilizing events and lack of personal support.

Alternatively, a second scale for assessing the risk of violence is used, the MacArthur Community Violence Interview (MCVI). It is a battery of specific detailed questions about violent behavior. This scale divides violence into two levels of severity: minor violence, if the assault consists of beatings without permanent injury, or serious violence that includes the use of knives or firearms, armed threats, and/or sexual assault [43,44,45]. It is also crucial to analyze the psychological impact on the victim. The specific psychological sequelae of non-fatal strangulation include the following:

• Post-Traumatic Stress Disorder (PTSD): victims may experience flashbacks, severe anxiety, and uncontrollable thoughts about the event [46,47].
• Anxiety and depression: victims often suffer from increased anxiety, depression, and other mood disorders.
• Fear and hypervigilance: victims may develop an intense fear of similar situations or environments and become overly watchful.
• Trust issues: aggression can lead to difficulty in trusting others, impacting personal and professional relationships.
• Self-esteem issues: victims may experience lowered self-esteem and feelings of worthlessness [46].
• Physical symptoms: psychological trauma can manifest as physical symptoms such as headaches, stomach problems, and chronic pain [48]. Understanding these components helps in identifying the roots of aggression and the subsequent trauma, allowing for the development of effective prevention and intervention strategies for both perpetrators and victims.

Injuries from non-fatal strangulation (NFS) can vary from minor to severe, but the true prevalence is not fully understood due to victims often not seeking medical attention or being followed up over time for potential long-term effects. Consequently, the exact extent of NFS-related injuries remains unclear and may not be linked to their true cause. Additionally, NFS sometimes happens during consensual sexual activity, which can lead to consequences that are frequently overlooked or not investigated [49]; whenever NFS is associated with an assault, healthcare professionals must be able to recognize the signs and symptoms as soon as possible, both during hospital exams for initial treatment and during medico-legal consultations for forensic purposes. Signs of traumatic mechanical force from a non-fatal strangulation (NFS) attack typically fade within a few days. However, recent reports indicate that healthcare workers are becoming more adept at recognizing NFS, which occurs frequently. Even without visible signs, NFS can result in serious injuries. Therefore, an initial clinical examination, ideally by a forensic expert, should be promptly conducted to identify typical NFS indicators as soon as possible after the event [50]. The forensic examination should be conducted during the initial assessment upon the victim’s admission to the emergency department and should also include a concurrent psychiatric evaluation. Standardizing a pathway for evaluating NFS cases from initial ED admission, including descriptions, measurements, and comprehensive iconographic documentation, is advisable. Forensic expertise is essential for the initial assessment, as well as for the collection of biological evidence and identifying injuries that may not be clinically attributable to the attack [51]. The growing availability of forensic experts in hospital settings could facilitate systematic early detection, comprehensive iconographic documentation, and appropriate instrumental tests to detect potential sequelae not clinically evident (such as hypoxic brain damage) but suspected based on the injury mechanism [52,53]. Psychological evaluation should also be considered as part of the broader assessment process as victims of NFS often experience significant psychological trauma. This can include symptoms of post-traumatic stress disorder (PTSD), anxiety, depression, and other mental health issues that may arise from the traumatic event. Incorporating psychological support and therapy into the treatment plan is crucial for addressing the full spectrum of NFS-related harm and promoting the overall well-being of the victim [54,55,56,57]. In the future, it should be considered that the use of artificial intelligence could increasingly assist clinical and medicolegal professionals [58,59] in the recognition and interception of cases of non-fatal strangulation (NFS), thereby advancing the evaluation of those cases that might otherwise go unrecognized.

Finally, it is important to remember that during the initial examination in non-fatal strangulation (NFS) cases, forensic imaging is a crucial tool for identifying and documenting injuries that may not be immediately visible, and the most commonly used methods are represented by MRI and CT.

Magnetic Resonance Imaging (MRI) is often highlighted as a valuable tool in detecting soft tissue injuries, including damage to the neck structures, such as the larynx, hyoid bone, and cervical spine. It is particularly effective in identifying deep tissue injuries and vascular damage that might not be apparent externally. Some studies discuss how MRI can be used to identify soft tissue injuries, including those related to NFS. It emphasizes the importance of advanced imaging techniques in forensic evaluations [60]. CT scans, especially CT angiography, are commonly used to assess vascular injuries in the carotid and vertebral arteries, which are critical in cases of NFS. This imaging modality can detect dissection, thrombosis, or pseudoaneurysms [6]. Also, ultrasound can be used to assess superficial soft tissue injuries and detect fluid collections or hematomas in the neck. It is a non-invasive and readily available tool, although it is less effective for deeper structures compared to MRI or CT. Finally, high-resolution photographic documentation is critical for capturing external injuries such as bruising, petechiae, and abrasions. While not an “imaging” technique in the traditional sense, its forensic value is significant for legal purposes. The validity of forensic imaging in NFS cases also relates to its legal admissibility and the ability to support a forensic narrative. It is crucial that the imaging is performed and interpreted by trained forensic radiologists to ensure the findings are robust and defensible in court. Therefore, forensic imaging in NFS cases is a powerful tool for identifying otherwise hidden injuries. MRI and CT angiography are particularly valuable for visualizing soft tissue and vascular damage, while ultrasound and photographic documentation complement these methods for superficial injuries. Emerging techniques might further enhance the detection of subtle injuries. The integration of these imaging modalities can significantly improve the diagnosis and legal outcomes in NFS cases.

In conclusion, in our opinion, it is necessary to have an investigative algorithm for the treatment of Non-Fatal Strangulation (NFS) in the emergency department, involving a forensic pathologist and a psychiatrist, that could follow these steps:

1. Triage with immediate stabilization: Airway assessment, monitoring of vital signs, and rapid neurological evaluation.

2. Complete physical examination: Inspection and palpation of the neck, looking for visible signs of trauma and checking for fractures or abnormalities in the larynx and trachea. Ocular examination, checking for conjunctival petechiae or hemorrhages. Assessment of internal injuries through imaging to identify internal lesions.

3. Consultation with a forensic pathologist: Detailed documentation of injuries, with photographs of visible injuries, measurements, and detailed descriptions. Collection of evidence and preservation of any biological traces or marks on the body that could be relevant to a legal investigation. Examination for internal injuries and signs of struggle.

4. Psychiatric evaluation: Screening for post-traumatic stress disorder (PTSD) by evaluating the victim for signs of anxiety, depression, or other psychological disorders related to the trauma. Immediate psychological support by providing crisis intervention and planning psychological follow-up. Assessment of suicide risk by identifying any risk of self-harm or suicide and taking appropriate protective measures.

5. Advanced imaging and diagnostics: CT or MRI of the neck and head to evaluate internal injuries such as fractures, hematomas, or brain damage from hypoxia. Laryngoscopy and bronchoscopy for direct inspection of the airways and larynx.

6. Final report: Detailed medical record documentation including all injuries, treatments, and evaluations performed. Legal report prepared by the forensic pathologist for the judicial authorities and a follow-up plan that includes further medical, legal, and psychological consultations over time.

7. Coordination with law enforcement: Sharing relevant information to facilitate the investigation and protection of the victim.

This algorithm offers an integrated approach that combines medical, legal, and psychiatric aspects to manage cases of non-fatal strangulation in an emergency context.

4. Conclusions

Non-fatal strangulation (NFS) is a highly dangerous mechanism that can result in a wide range of injuries, often unrecognized due to the lack of visible symptoms. The case of the 71-year-old man discussed in this study highlights the challenges in identifying and properly diagnosing NFS-related injuries, particularly when they are not immediately apparent. To address this, it is essential to standardize clinical investigation procedures, ensuring early and thorough assessments, ideally involving forensic experts. The integration of psychological evaluation and the potential future use of artificial intelligence in detecting NFS cases could greatly enhance the accuracy and comprehensiveness of these assessments, ultimately improving outcomes for victims.