The Meta-Contrast Technique test predicting suicide Fribergh H, Traskman-Bendz L, Ojehagen A, Regni.11 G. The Meta-Contrast Technique - a projective test predicting suicide. A replication study. Acta Psychiatr Scand 1992: 86: 473-477. Sixty-nine inpatients who had attempted suicide were studied by means of the Meta-Contrast Technique (MCT), a projective test measuring personality factors, especially defensive strategies. The patients were divided into 3 subgroups, one of which was defined as stereotypy only, which denotes stereotypy (perceptual retardation) without any other coded defenses. At follow-up 7 of 8 completed suicides belonged to this subgroup and they matched various main diagnoses according to DSM-111-R. When the MCT findings of all patients were compared with 99 depressed inpatients from a previous study, the latter group more often had mature defensive strategies. In both investigations most completed suicides were found in the stereotypy only group. Our findings indicate that, regardless of psychiatric diagnosis, stereotypy without other defenses in MCT predicts suicide.
The prediction of suicide is a crucial issue, and professionals have to rely on their clinical evaluation as well as reports from patients about death wishes, suicide plans, known previous attempts and statistical risk factors. In addition, there is evidence that suicide risk scales and biochemical parameters have predictive value (1-4). From a psychoanalytic point of view, the assessment of the self, the vulnerability for separation and the affects predisposing suicide are regarded as important (5). Several studies have used standardized psychological tests, but they have often been reported to have less predictive value than rating scales (6). Obviously this is true when psychological tests are constructed either to measure suicidal disposition, depression and aggression more indirectly or to explore causalities that are not immediately observable in a clinical setting. Investigators have tried to find single or multiple signs of suicidal disposition in the Rorschach test and the Thematic Apperception Test (TAT). These studies have not been as successful as was hoped for (6). However, Rydin et al. (7) studied suicidal patients, who had been investigated biochemically. Low concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in lumbar cerebrospinal fluid (CSF) have been associated with violent suicidal behaviour. When comparing patients with low and high CSF 5-HIAA respectively, patients with low 5-HIAA had significantly more signs of anxiety and hostility in Rorschach
H. Fribergh, L. Traskman-Bendz, A. Ojehagen, G. Regnell Department of Psychiatry, University Hospital, Lund, Sweden
Key words: suicide: prediction; projective test Hans Fribergh, Department of Psychiatry, University Hospital, S-221 85 Lund, Sweden
ratings. Their anxiety tolerance was lower, and they were significantly less efficient in coping with conflicts. The Meta-Contrast Technique (MCT) is another projective test that was developed according to a percept-genetic model, measuring personality factors (8-12). MCT studies have shown that stereotypy and depressive retardation are associated (13, 14). In a 20-year follow-up study of 99 depressed psychiatric inpatients, the main risk factor for future suicide appeared to be depressive retardation (stereotypy) combined with a lack of functional defensive strateges in the MCT (14). In this study, we used the MCT in a group of patients referred to a psychiatric ward after a suicide attempt. The aims were to study the ability of suicide attempters to cope with the experimentally induced anxiety produced by the MCT and to investigate the relationship between stereotypy without other defenses and suicidal behavior. Material and methods Patients
From 1986 to 1989 patients were referred from the psychiatric emergency room, or from the intensive care unit, after having attempted suicide. They were hospitalized in a psychiatric ward specializing in suicidal behavior. The study has been approved by the Medical Eth473
Fribergh et al.
ics Committee of Lund University, and the participating subjects have given informed consent. The suicide attempters were diagnosed according to the DSM-111-R (15) by a senior psychiatrist. Our definition of a suicide attempt is in accordance with the definition stated in Suicide prevention in the seventies (16), i.e. “those situations in which a person has performed an actually or seemingly lifethreatening behavior with the intent of jeopardizing his life or to give the appearance of such an intent, but which has not resulted in death”. Information on completed suicides was obtained from the Department of Forensic Medicine in Lund. Comparison group
The patients who were hospitalized after a suicide attempt were compared with a group of 99 depressive inpatients who participated in a study during 1961-1963 (12). All patients had been subjected to the MCT before treatment. This sample was scored again according to the latest MCT manual (8). Their depression was diagnosed by a senior psychiatrist. Retrospective analyses gave the impression that almost all of these patients fulfilled the criteria of a major depression according to the DSM-III(13, 14). There was a 20-year follow-up regarding the incidence of suicide (13). In the comparison group, 21 patients had attempted suicide at least once before the initial examination. Three of them committed suicide. The Meta-Contrast Technique
The presentation of the test involves pairs of stimuli (called A and B). Two tachistoscopes are used. Stimulus B depicts a young person (the hero) sitting at a table with a small window in the background. B is first presented at short, but gradually prolonged, exposure times. Once the subject has reported B correctly, the exposure time is reduced to a standard value. Then A (an ugly ape-like face) is exposed immediately before B. The exposure time of B is kept constant, that of A is gradually prolonged until A + B have been correctly reported 3 times in a row (if possible). Subjects are told to report everything they perceive on the projection screen at each trial. The interpretations concern the subject’s defensive strategies, i.e., the strategies used to ward off, or distort the threat (stimulus A) directed at the young person (stimulus B), and also the anxiety evoked by it (8). The following dimensions of interpretation are of interest in this study: Repression. Stimulus A could be reported as immobilized, masked or disguised, a portrait, an object etc. 474
Isolation, negation. Stimulus A could be reported as white-painted, harmless or concealed by curtains, or as separated from the hero by a line or barrier or by an increased distance; it could also be negated. Depressive strategies. Inhibition is the central anxiety-reducing defensive strategy. Often there is a delayed report of the A-stimulus. These protocols contain very few words, undramatic reports (“the same”, “similar”, etc.). In severe cases, the A-stimulus is consistently seen as “dead”, “ill”, etc. Stereotypy. Stereotypy is often linked to depressive strategies, and it is scored when there are at least 5 successive and consistent interpretations of A; for example, the subject perceives an object (statue, mask or the like). In this study we were especially interested in stereotypies with an uninterpreted A (stereotypy only). In these cases, no or vague interpretations are given. For example, the subject may report subtle, though non-descriptive changes in the window: “something new”, “something different”, “no longer as before” and so on. Projective strategies. The influence of A on B can already be noted during the first exposures. Sometimes an explicit interaction between threat and hero is described, such as unconscious identification with the threat stimulus, which is reinterpreted as cheerful or familiar. A milder variety is sensitivity, i.e. absorption of A in B (at least two changes in shading, perspective, etc. before A appears as an independent percept). Regressive and primitive strategies. 1. Discontinuity and instability. The continuity of reporting is disrupted from one stage to the next (“now the picture is completely different”, etc.). 2. Psychosis and abnormality. This refers to an overall impression of the test, referring to abnormality or defect and to flagrant deviations from normal threshold values of perception. 3. Defensive maneuver, primitive repression and primitive isolation. This is often seen as a normal report in children, but is considered as a distinct sign of primitiveness in adults. The subject may look for protection with the test leader, wants to leave the room or shows somatic reactions etc. The repression is called primitive repression if the subject sees only parts of the threatening figure. Primitive isolation is connected with magical functioning and could also in some manifestations be interpreted as “splitting”. Anxiety. Signs of anxiety most often imply that the subject’s perception is darkened, broken, lost in chaos, etc. and/or strategies protecting the subject from detecting A disappear (regression) or become ineffective (leaking defenses). The patients were divided into 3 subgroups following the principles of Berglund & Smith (8). One of the subjects had been investigated with the MCT 13 years earlier.
The Meta-Contrast Technique - a projective test predicting suicide Subgroup 1: patients who had stereotypies without other signs (stereotypy only). Subgroup 2: in this group patients had various defensive strategies except repression and isolation. This includes projective, regressive, depressive and primitive strategies. Stereotypy could be present or absent. Scored signs of anxiety were also included. This group is labelled primitive strategies. Subgroup 3: in this group patients had various defensive strategies but at least one occasion of strategies reflecting functioning on the highest level, i.e., repression and/or isolation (mature strategies). Projective, regressive, depressive and primitive strategies as well as stereotypies could be present or absent. Scored signs of anxiety were also included. We performed all ratings. Independent ratings were performed by 2 psychologists who rated half of the reports each. The interrater reliability of MCT concerning defensive strategies/subgrouping was extremely high (0.97). Group comparisons were performed by using Student’s t-test and chi-square (17). Results
Sixty-nine patients participated. There were 30 men (mean age 35 years, range 20-61) and 39 women (mean age 37 years, range 19-69). According to the DSM-111-R, Axis I (main diagnoses), there were 20 major depressive disorders (MDD), 19 dysthymias, 5 psychoses (4 schizoaffective disorders and 1 schizophrenia), 10 substance use disorders, 8 adjustment disorders, 5 anxiety disorders and 2 others (bulimia nervosa and borderline personality disorder). MCT subgroups and patient characteristics
Table 1 describes the MCT subgroups in relation to sex, age, marital status and previous suicide attempt. There were no significant age differences between the 3 subgroups, but subgroup 1 tended to be older (NS). Sex distribution differed in the subgroups and
there were more women in subgroup 1 than in the other groups (P