Expert Opinion: What Killed Anna Nicole Smith?

Dr. Welner, what can we understand from the medical examiner's findings today?

There is no evidence for Anna Nicole Smith ingesting a large amount of pills shortly before her death. This speaks against the likelihood that she intentionally ingested a heavy overdose of pills.

Does this mean that drugs could not have played a role in her death?

No, it does not. In fact, there were earlier reports that she fell in the bathroom shortly before she became unresponsive. If she did fall, intoxication involving Valium (reportedly found in her room) would explain a loss of balance. However, Valium by itself does not kill – it sedates. Over the counter medicines can carry quite sedating effects.

If drugs played a part in Anna Nicole Smith's death, did she necessarily abuse what she took?

Perhaps. But toxicology findings from yet-unfinished analysis of her body fluids will help to distinguish whether there is any higher level of a drug than might be expected. One also has to consider the possibility of the interactions of different drugs on the central nervous system or cardiac rhythm.

How do drug interactions cause death?

Drug interactions may cause death in what may even be modest doses. Sedatives may depress the arousal centers in the brain that drive the heart to beat and lungs to breathe. Medicines may also interact to prolong the impulse of the heartbeat to such a degree that an irregular heartbeat leads to stoppage of the heart altogether.

Dr. Perper mentioned something about inflammation of the heart. Is that an area that might prove to be important?

Yes, it bears watching. For Anna Nicole Smith reported flu-like symptoms in the days preceding her death. An inflammation of the heart or its lining can contribute to an unexpected death, and may follow a sickly presentation. This tragic outcome would have nothing to do with drugs or their interaction.

Folks are wondering why Anna Nicole Smith's child was being cared for by a friend while she was far away. Can you as a forensic psychiatrist explain the significance of this?

Clearly, this is not what you would expect from a mother. Nor would you expect a depressed mother to be traveling away from her daughter. On the other hand, one has to recognize how complex the emotional response to her losing her son some months ago impacted her mood and ability to parent. What we experience as her irresponsibility may reflect a woman who is more irresponsible when depressed and coping (poorly) with stress. A woman with postpartum depression may bond relatively poorly with her child. In addition, there were others around her, including Howard K. Stern, whose advice and involvement in the daughter's care, and in Anna Nicole Smith's separation from the Bahamas, has to be pursued.

Is there evidence to be gathered from the Bahamas?

Anna Nicole Smith's stresses include the untimely death of her son. Her actions in the aftermath and how others dealt with the situation, and their own interests, bear careful study. Confidantes may be found in the Bahamas, Los Angeles, and many points in between. But many interacted with her, and many will recall her thinking and reactions to the battle over her husband's estate. What did she think of how her son managed to ingest the methadone that may have contributed to his death? Did Anna Nicole Smith feel his death was suspicious? Did she ask the questions a mother would? Of whom? And if she stopped asking questions, was there any particular reason why?

You are raising points of intrigue. What does that have to do with forensic science?

The autopsy, the toxicology only provide certain information. The "what" of the death. The "how" is not always clear from the laboratory findings. Forensic psychiatry and death investigation relies heavily on interviews and confirmation of history and details. Complicating death investigation in this matter is the decedent's secret entanglements and a life with many fighting over her and fighting about her and doing so with panache, patience and the determination reserved for hundreds of millions of dollars.

If Anna Nicole Smith died by accidental overdose, does this settle the questions you would have as a forensic psychiatrist?

Maybe. Anyone observing this situation, however, witnesses a woman with many supports who profess that they love her, in the United States of America and all of its conveniences, who dropped dead at 39 with no illness yet identified. She impresses as someone for whom others made many decisions for. With others directing her, caring for her, supervising her, monitoring her, some accidents could happen. But Anna Nicole Smith was not killed by a fall. And if drugs prove to have been responsible for her death, the exact composition and drug interactions have to be laid out. How something ends up in a decedent's system speaks also to how much a role the decedent played in putting it there. If she died of drugs, was it by her own counsel, just another example of her recklessness? Or the advice of others who asserted themselves to her as concerned for her well-being?

What are the possible causes of death?

Accident, suicide or homicide. At this early stage, no one can jump to conclusions. However, it would be professionally irresponsible to not consider all three possibilities.

What is the importance of an autopsy here?

An autopsy will examine for causes of sudden death, such as heart disease, or toxicology signs of overdose, or poisoning.

In a death investigation such as this, will an autopsy yield the answers?

Not necessarily. Even if Anna Nicole Smith is found to have a toxic combination of substances in her system, the possibilities of such an event happening still include accident, homicide and suicide.

What, then, can an autopsy definitively clear up?

If Anna Nicole Smith had cardiac disease severe enough to associate with a fatal heart stoppage, heart disease may be seen. If she ingested a poison, or an exceptionally high dosage of something, toxicology analysis will show that. Even then, such a finding of excess toxin or drug only eliminates accident as a cause of death. One would still need to pursue the probability of suicide versus homicide.

How is that done?

Input from her psychiatrist and therapist is key. Input of those intimates and those closest to her is key. Tracing her movements in the period preceding her death will yield any signs of planning for her demise, whether it is as suggestive as a note or her giving away things very important to her, or her spending habits or travel decisions. The exact timing and place are important as well. Many people planning their own demise look to be alone, where they can attempt suicide without being discovered unconscious by someone who would save them.

As a very public person, her upcoming schedule would show to what degree she was planning for the future. Someone anticipating suicide would not likely be actively planning ahead. As a forensic psychiatrist performing what we call a psychological autopsy, I would want to review her e-mail correspondence, as well as her Internet activity, to see whether she was reading anything about depression or suicide that might reflect any hopelessness.

E-mail correspondence is emerging in psychological autopsy to join telephone records and eyewitness accounts as very useful instruments to ascertain despair and stresses leading to suicide, or the orchestration of her murder.

Is murder a realistic possibility?

It is a possibility that should at least be explored. The mere notion that Anna Nicole Smith had "problems," lost a son and was battling legal messes does not resolve the potential for her homicide. Marilyn Monroe was also an emotional tinderbox who died in what came to be known as a suicide but without fully resolved questions. What compounds the questions here is the death of Smith's son months earlier, under suspicious circumstances. True, her son died from an apparent combination of antidepressants and opiates. But someone with a homicidal agenda could certainly overdose him. Such was the controversy in the death of Las Vegas hotel magnate Ted Binion.

Even if tampering with a medicine or drug dose were too difficult to arrange, it is far easier to poison someone and to avoid discovery with what one is already taking than to ply someone with a foreign substance that would clearly show itself on autopsy as lethal.

As a forensic scientist, do you entertain ideas of murder simply because of the presence of medicines or chemicals that might depress the central nervous system? How do you avoid conspiracy thinking spawned by a sensational person whose death others cannot expect?

Few are wrestling, for years, over hundreds of millions of dollars. Fewer still pass away unexpectedly, and only months after her son (and heir) died perhaps even more unexpectedly. The contested will of her late husband has not yet been resolved, but there are many quite sophisticated people who are very much invested in her death. The mere occasion of her giving birth spawned a paternity … battle.

For this reason, I would explore even the most innocuous-seeming history of mishaps, collapses or other risks to her safety, including when she was recently pregnant. Untangling the legal complexities of who is entitled to her claims is a must. A forensic psychiatrist would have to also understand who would benefit under various scenarios that might follow in courts, subsequent to her death.

What about the history of Anna Nicole Smith being less than six months postpartum?

Depression is a possibility. But suicide correlates most with hopelessness, not a person being postpartum. Further investigation needs to explore how close she was to her baby, how they were together, whether she was disconnecting from the baby because she anticipated her demise. Let's not forget she was a mother mourning the loss of her son as well.

How does her weight factor into this?

Only a closer investigation will reveal her dieting habits. Many people are far heavier than Smith, and even lose more weight, without risk to their health. Some, and in particular a number of folks in the entertainment industry, give way to the pressures of appearance by developing pretty reckless weight-control habits. Some weight-control habits, either through unconventional personal remedies, or even drugs, may endanger a person's life if they are employed recklessly.

Postpartum women face significant challenges in weight control and body image. Smith's medical record will demonstrate how strong her system was, and its vulnerabilities. She had a nurse. Was that a luxury or necessity? If so, a necessity for what medical condition? Or was it a nurse for emotional reasons?

Deaths have been reported from combinations of medicines, including diet pills, that were not necessarily lethal when dosed by themselves. Changes in her emotions and medical conditions, or other items of toxicology interest, enhance the power and capability of even diet remedies to have fatal outcomes.

Does a psychological autopsy consider someone's personality when trying to distinguish between the possibility of suicide and accident?

Absolutely. Emotional instability may pitch someone into a suicidal hopelessness who was smiling to witnesses only days before. Impulsivity may lead to reckless ingestion of pills that should not be taken together; just as it may lead to a more abrupt decision to end one's life.

Is it relevant to know about her psychiatric history? Or is that just old news?

Very relevant. Someone who has had particular difficulty coping around certain issues may react with similar intensity if those stresses reawaken. Someone whose coping style may be self-endangering or self-destructive is still only likely to be that way under certain circumstances. The key is, how closely do any such circumstances resemble Anna Nicole Smith's situation at the time of her death?

Forensic psychiatrist Dr. Michael Welner has consulted on a range of cases involving questionable death, and has served as a key witness in many highly sensitive cases nationwide. He is chairman of the The Forensic Panel, a national forensic science practice of psychiatrists, pathologists, and toxicologists. He is an associate professor of psychiatry at New York University School of Medicine and a special consultant to ABC News.