Homicide-suicide denotes one or more homicides followed by the
perpetrator's suicide. To many people the term conjures images of
politically motivated acts such as the Palestinian suicide bombers,
the Japanese kamikaze pilots of World War II, or the World Trade
Center bombers. The 15 deaths at Columbine High School and 13 deaths
caused by a disgruntled Atlanta day trader illustrate the fact that
most homicide-suicides are in fact private tragedies with enormous
psychological impact on all the people they affect, including witnesses,
survivors, friends and relatives, and emergency personnel.
Just as suicidal ideation is more common than suicide, homicidal
ideation is more common than homicide. Similarly, coexisting homicidal
and suicidal ideation, which may be jointly present in about 5%
of visits to emergency departments (Feinstein & Plutchik, 1990)
is more common than homicide-suicide. Section VII members are undoubtedly
well acquainted with the various guidelines for the assessment of
suicide and violence potential (e.g., Kleespies, Deleppo, Gallagher,
& Niles, 1999; VandeCreek, & Knapp,1999). These assessment
guidelines focus solely on suicide risk or on violence risk, but
not jointly. Yet there is a dynamic relationship between the two
types of risk that current guidelines ignore. Individuals at risk
for homicide-suicide are typically so distraught and hopeless that
they want to die and also rageful at others whom they perceive as
victimizers. Assessing both risks are thus clinical activities that
need to go hand in hand. In such assessments, clinicians need to
be mindful of the fact that risk of harm to self and risk of harm
to others share some etiological factors (e.g., impulsivity) as
well as protective factors (e.g., good peer relations). The following
briefly reviews current knowledge on homicide-suicide. Interested
readers are referred to more extensive reviews by Coid (1983) for
a cross-cultural perspective, Hillbrand (2001) for theoretical and
practical considerations, and Marzuk, Tardiff, and Hirsch (1992)
for nosological considerations.
Homicide-suicides account for .03% of all deaths in the US. Rates
are similar in many other countries, though outside the US homicide-suicide
account for a much higher proportion of all homicides because homicide
rates are much lower. Most homicide-suicides involve one killer
(typically a man) and one victim (typically a woman), who are usually
acquainted. Homicide-suicides are more similar to suicides than
to homicides, in that there is usually no history of lifelong impulsivity
or violence towards others. Previous suicide ideation and attempts
are common, as are hopelessness, despair, and clinical depression.
Both homicide and suicide are usually planned events.
Aggression against self and against others coexist on a continuum
of severity. At one end of the continuum lie coexisting fantasies
of homicide and suicide without intent to harm. Next on the continuum
lie non-lethal acts of interpersonal violence and parasucidal behaviors,
which frequently coexist in violent individuals (Hillbrand, 1995).
Suicide by victim-precipitated homicide entails the use of lethal
force in order to get someone else (e.g., a police officer in "suicide
by cop") to kill the suicidal person. In attempted homicide-suicides,
one or both violent acts are thwarted. In the most common type of
homicide-suicide, a jealous individual kills his or her spouse or
consort, then suicides. At the other end of the continuum lie mass
murders, killing sprees causing three of more deaths, which typically
end in suicide (Dietz, 1986).
Clinicians cannot rely on spontaneously uttered threats of violence
in their assessments. Regardless of the referral issue, they need
to probe actively for suicidal and homicidal ideation, keeping in
mind the fact that reporting suicidal ideation has become acceptable
in our culture, but that reporting homicidal ideation is much less
acceptable. Bertram Karon (personal communication,1987) said it
most judiciously: "First deal with homicide risk. Then deal
with suicide risk. Then deal with anything else".
Coid, J. (1983). The epidemiology of abnormal homicide and murder
followed by suicide. Psychological Medicine, 13, 855-860.
Dietz, P. E. (1986). Mass, serial and sensational homicides. Bulletin
of the New York Academy of Medicine, 62, 477-491.
Feinstein, R., & Plutchik, R. (1990). Violence and suicide risk
assessment in the psychiatric emergency room. Comprehensive Psychiatry,
Hillbrand, M. (1995). Aggression against self and aggression against
others in violent psychiatric patients. Journal of Consulting and
Clinical Psychology, 63, 668-671.
Hillbrand, M. (2001). Homicide-suicide and other forms of co-occuring
aggression against self and against others. Professional Psychology:
Research and Practice, 32, 626-635.
Kleespies, P. M., Deleppo, J. D., Gallagher, P. L., & Niles,
B. L. (1999). Managing suicidal emergencies: Recommendations for
the practitioner. Professional Psychology: Research and Practice,
Marzuk, P. M., Tardiff, K., Hirsch, C. S. (1992). The epidemiology
of murder-suicide. Journal of the American Medical Association,
VandeCreek, L., & Knapp, S. (1999). Risk management and life-threatening
patient behaviors. Journal of Clinical Psychology, 56, 1335-1351.