Depending on jurisdiction, knowing as much detail as possible about the cause and sequence of death is instrumental to the insanity defense evaluation. The forensic psychiatrist must first diagnose an illness that includes a break with reality; psychosis may involve response to a hallucination, a fixed, false belief, or profound disorientation. The available clinical history needs to be closely correlated with crime scene findings, no easy task given the adversarial process, and often no identifiable witnesses. Knife deaths offer ample opportunity for assessing the sequence of the attack, and a clinical correlation with the defendant's history.

Case 1: The defendant reports a quick fatal strike, with no particular purpose in response to a single hallucination, "Now." Indeed, the victim's throat was cut. But two pictures tell an important story. Many wounds appeared on the victim's left hand- suggesting the right hand was being held down. The hand wounds indicate a prolonged struggle as the victim grabbed the knife repeatedly. The amount of external blood indicates that these wounds occurred early in the attack, for the body's response to the neck wound would have shunted blood from the extremities.

Case 2: The history of an offender who "blanks out." The knife inflicts a variety of wounds all over the victim, without regard for targeting vital organs, in a random manner that is evidenced even with the struggling of the victim fending off the attack. This is a pattern of a knife attack, going beyond overkill, blind to the vital targets, that best demonstrates an offender who acts out of body or in blind rage.

Case 3: This defendant gives a history only of losing control. Indeed, the victim has many stab wounds. But a closer look at the neck of the victim demonstrates thin, parallel, superficial cuts to the skin, known as hesitation marks. These wounds could only have been inflicted with the victim at close range, and with control by the offender so as to not cut very deep. Hesitation marks reflect a prelude to the attack, and one of menace to a restrained victim. Were the insanity claim to revolve around evidence of a delusion, the notion that the victim could have warranted the threat of the skimming blade might yet fit. But an out of control defendant cannot exercise the control and calculation to taunt with death's door.

Lessons: Any credible psychiatric examination of an offense leading to death must involve a trip to the coroner's office. The pathologist should be advised of as many established facts of the case as possible, and only those facts, so that he might be able to offer input on what happened based on available evidence he has not seen, as well as his autopsy pictures and slides. The forensic psychiatrist needs this input from the pathologist in order to arrive at an opinion on insanity cases following knife attacks with credibility.