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The Rorschach Test for Predicting Suicide Among Depressed Adolescent Inpatients Joyanna Lee Silberg & Judith G. Armstrong Published online: 10 Jun 2010.
To cite this article: Joyanna Lee Silberg & Judith G. Armstrong (1992) The Rorschach Test for Predicting Suicide Among Depressed Adolescent Inpatients, Journal of Personality Assessment, 59:2, 290-303, DOI: 10.1207/s15327752jpa5902_6 To link to this article: http://dx.doi.org/10.1207/s15327752jpa5902_6
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JOURNAL OF PERSONALITY ASSESSMENT, 1992, 59(2), 290-303 Copyright o 1992, Lawrence Erlbaum Associates, Inc.
The Rorschach Test for Predicting Suicide Among Depressed Adolescent Inpatients Joyanna Lee Silberg The Sheppard and Enoch Pratt Hospital Baltimore, M D
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Judith G. Armstrong Towson State University and The Sheppard and Enoch Pratt Hospital Baltimore, M D
With the decreasing length of psychiatric hospitalizations, identification of test indicators of suicide risk becomes critically important. This Rorschach study was designed to model a clinical decision-making scenario concerning adolescent suicide risk. Using Psychiatric Evaluation Form (PEF) scores, we selected a sample of 25 severely depressed and suicidal adolescents; 26 severely depressed, not suicidal adolescents; and 28 not suicidal, not depressed adolescent inpatients at The Sheppard and Enoch Pratt Hospital. A Rorschach Index using the Exner (1986) Comprehensive System for scoring was developed to predict group membership. Four of six of the features on this index selected 64% of suicidal subjects. This constellation included traditional affective variables (vista responses, colorshading blends, color dominated responses, and morbid content) as well as measures of cognitive distortion (inaccurately perceived human movement responses [M-] and special scores). We discuss the implications of these findings for the diagnosis and treatment of the suicidal adolescent.
T h e alarming rate of youth suicide has been well publicized. As escalating health care costs are resulting in fewer inpatient hospital days available to adolescents, it becomes increasingly important to develop methods of predicting who is most at risk for suicidal acting out and in need of continuing hospital care. Much of the research o n adolescent suicide predictors has focussed o n developing a profiIe of psychological risk factors, such as inhibition and loneliness, and
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diagnostic risk factors, such as borderline personality and bipolar illness (Shafii, Carrigan, Whittinghill, & Derrick, 1987). However, risk ~rofilesare not tiesigned to predict suicide risk in the individual case. Accurate diagnosis, which is heavily emphasized in inpatient psychiatric facilities is also of limited utility ifor suicide prediction. This is particularly true for adolescents. Whereas in adulthood, depression and suicide are directly linked, among adolescents the relationship is more complex. In a sample of hospitalized adolescents, Ryan et al. (1987) found that only 61% of adolescents with major depression had any suicidal ideation. Conversely, in a study of child and adolescent suicide, Shaffer (1974) reported that less than half had a diagnosed depressive disorder. Clinicians who work with adolescents are familiar with the vast range of psychopathology found among suicide attemptors. Although some adolescents may attempt suicide as a reaction to profound situational stressors, others may have symptoms typical of specific diagnostic categories, such as major depression or schizophrenia. Diagnosis itself is fraught with reliability problems for adolescents as many clinicians are sensitive to the potential for labeling and therefore use diagnostic labels sparingly. The perceptions, affects, and behavioral style of the patient as revealed in a test like the Rorschach potentially provide rich material for assessment of suiciide risk in the individual case. Research into the Rorschach's utility in addressing the question of suicide has spanned 40 years. From the earliest work of Hertz (1948)and Lindner (1946) to the more recent research of Exner (1986), there has been considerable interest in isolating Rorschach features associated with self-destructive tendencies. Over the years, the following Rorschach variables have been consistently associated with suicidal behavior: color-shading blends (Applebaum & Holzman, 1962; Exner, 1986), vista or transparency responses (Blatt & Ritzler, 1974; Exner, 1986; Rierdan, 1978; Roth & Blatt, 1974),morbid imagery (Broida, 1954; Exner, 1986; Hertz, 1948; Lindner, 1946), and poor form quality (Arffa, 1982; Exner, 1986; Piotrowski, 1940). Exner's (1986) Suicide Constellation, taken from a population of patients who subsequently commit1:ed suicide, identifies 83% of completers and falsely identifies only 12%of depressed inpatients. Exner cautioned against using the adult Suicide Constellation with adolescents, and reported that efforts to validate an initial adolescent suicide const-ellation have been unsuccessful. One complicating factor in the Rorschach prediction of suicide in adolescents is the fact that some of the features present on Exner's (1986) adult Suicide Constellation are typical of adolescents in general (e-g., C CF > FC [color-dominatedresponses exceed form-dominat ed color responses] and S > 3 [responses using white space number more than :!I). The complexity of diagnosis in adolescence and the fact that suicidal behavio~ris clearly multidetermined in this age group complicates the search for an adolescent Rorschach suicide index. Tempted by the robustness and specificity of repeated consistent findings in adulthood, we hypothesized that the psycholog-
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ical state that accompanies profound self-destructive impulses can be captured by the Rorschach's sensitivity, even in adolescents. The following exploratory study was undertaken to examine the usefulness of the Rorschach in uncovering suicidal potential among hospitalized adolescents. By comparing severely depressed, not suicidal patients with severely depressed, suicidal patients, we attempted to isolate those factors unique to suicidal behavior unrelated to diagnostic variables. In addition, by comparing groups of severely depressed suicidal patients with severely depressed, not suicidal patients, we closely model situations wherein clinicians must decide which patients are most at risk and require further hospitalization.
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Subjects and Measures The subjects came from an original sample which consisting of 138 hospitalized adolescents who were consecutively admitted to the Sheppard and Enoch Pratt Hospital over a 2-year period. Subjects ranged from 12 to 18 years old and carried a wide variety of diagnoses. These patients were administered a battery of psychological tests, and their charts were reviewed for diagnostic and demographic information. This information was stored in a computer file as a data base for a series of studies on adolescent psychopathology and psychological testing. The Rorschach was administered by trained technicians within 3 to 10 days of the patient's admission. Subjects who produced less than 12 responses on the Rorschach were excluded from the subject pool to ensure structural summary validity. We independently scored the Rorschach protocols using the Exner (1986) Comprehensive System, after all identifying information had been removed from the protocols. Interrater reliability assessed on a sample of 10 protocols yielded percentage of agreement scores ranging from 91% to 95%. Percentage of agreement on special scores was 94%.' The patients' symptoms were rated from hospital records using the Psychiatric Evaluation Form (PEF). This measure includes adolescents in its normative population and has demonstrated reliability when used with retrospective data (Endicott & Spitzer, 1972). The 21 symptoms covered in the rating scale are listed in Table 1. Four research technicians who were unfamiliar with both the patients and the psychological test data reviewed chart materials to assess the presence and severity of the 21 PEF features on a 6-point scale ranging from no indication of the 'These data were collected before Exner's (1986)refinements of Level I and Level I1 special score categories.
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TABLE 1
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Variables Measured on the PEF Drug use and abuse Agitation Suicide/self-mutilation Grandiosity Somatic complaints Antisocial attitudes/acts Speech disorganization Hallucinations Social isolation Belligerence Disorientation Alcohol abuse Anxiety Inappropriate affect Suspicion Daily routine impairment Denial Depression Lack of emotion Impairment of role Overall severity
symptom (1) to extreme indication of the symptom (6). The material reviewed included psychiatrist's formulations, nursing notes, social work reports, aind activity therapy assessments (but not psychological evaluations)from the first 10 days following admission. When judging the presence and severity of symptoms, the research technicians were instructed to rely on behavioral evidence of symptoms rather than inferences. A subset of this initial sample was selected based on the presence or absence of severe suicide or depressive symptomatology on the PEF. Qualifying subjects were arranged into a 2 x 2 matrix of contrasting groups. The groups, diagnoses, and sample sizes are as follows: Group 1-suicidal/depressed, n = 25; Group 2:not suicidal/depressed, n = 26; Group 3-not suicidal/not depressed, n = ;!8; and Group 4-suicidal/not depressed, n = 3. The criterion established Sor inclusion in this matrix was a score of 4 or greater on the PEF dimensions of depression and suicidal/self-mutilation. The scoring rules for the PEF require that for a score of 4 or greater on the Depression scale, the subjects needed to report evidence of vegetative signs as well as subjective signs of depression. To receive a score of 4 or greater on the suicide/self-mutilation dimension, the patient needed to have made a serious suicide attempt preceding hospital admission. Thus, the suicidal group in this study consisted of subjects who entered the hospital after making a serious suicide attempt. In order to establish clear-cut groups, the criteria for low suicide and low
depression were minimal signs of depression and no signs of suicidal ideation (PEF < 3 for depression and PEF < 2 for suicide). We hoped that by contrasting extreme groups, differences in subject profiles would more clearly emerge in the results. These criteria resulted in only 3 subjects in Group 4, so this group was not included in the analysis. These 3 subjects who demonstrated suicidal behavior without accompanying depressive symptomatology comprise an interesting group worthy of investigation in a larger study. Thus, for the purpose of this study, depressed youngsters with and without suicidal behavior, as well as a group showing neither depression nor suicidal behavior were compared.
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Statistical Procedures The computer data base stored Rorschach information including summary scores and statistics derived from Exner's Comprehensive System. First, we used a discriminant analysis procedure to test whether Exner's (1986) established indices (the Depression Index, the Suicide Constellation, and the Schizophrenia 1ndex)' were able to discriminate between the groups. We chose the Depression Index and the Suicide Constellation developed by Exner because they include all of the features found in past research to be associated with suicidal ideation or behavior. The logic for including the Schizophrenia Index was based on our observation and reported finding (Armstrong, Silberg, & Parente, 1986) that, in our setting, thinking disorder was common among hospitalized adolescents, although few of them carried schizophrenia diagnoses. The three Rorschach indices were initially tested with discriminant analyses to assess how well each measure would predict group membership. A second set of discriminant analyses was done subsequently on the Suicide Constellation, and the Depression and Schizophrenia indices. These analyses examined which of the individual variables that made up the gross indices would discriminate the groups. Then, individual univariate analyses were done on each variable from the significant indices. The significant results of these analyses provided the variables needed to construct a new adolescent suicide index. The procedure used to develop the new index is an iterative analysis procedure described by Exner (1978, p. 203). The procedure involves repeated chi-square analyses of various constellations of significant variables to test which grouping of significant variables provides the best hit rate for identification of suicidal patients while providing the lowest false-positive rate. These repeated chi-square analyses resulted in the identification of a constellation of six variables predictive of suicidal behavior. A cutoff score was derived which described how many features of the constellation would be required to 2These data were collected before Exner's (1991)revised indices and are based o n indices reported in Exner (1986).
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consider the subject a suicidal risk. The number of variables at the cutoff point were the least number required to guarantee the best hit rate for suicide while avoiding false positives. The final constellation reported was the one with the best chi-square significance level, ~roducingthe highest hit rate, and lowest false-positive rate. Exner (1978) reported that the number of variables emerging in this type of analysis may not be yielded by a more conventional discriminant analysis. We tested the variables that emerged from the iterative analysis with a discriminant functions analysis to determine which method could produce a higher rate of prediction for suicidal behavior among the groups. Keep in mind that the purpose of these repeated analyses was to derive a clinically useful instrument that might provide a decision-making tool with hospitalized adolescents. In addition to Rorschach variables, PEF symptom profiles were contrasted with a multivariate analysis (MANOVA) procedure. Descriptive data such as IQ and age were examined with an analysis of variance (ANOVA) procedure, and sex distribution and diagnoses were compared with comparison of percentage procedures.
RESULTS Descriptive Data The analysis of the descriptive data revealed that the three groups were similar and showed no significant differences in age (M age = 15.5) or IQ (M IQ = 101.1) or sex distribution (53% girls and 47% boys). A comparison of diagnoses showed that Group 1 (suicidal/depressed) and Group 2 (not suicidal/depresse:d) did not differ on diagnosis. The most common diagnostic category in these groups was dysthymic disorder, which comprised 62% of Group 1 and 65% of Group 2. Group 3 (not suicidaVnot depressed) had a mixed diagnostic picture including drug abuse diagnoses (31%), conduct disorder (32%),and adjustment disorders (21%).
Symptom Profiles The PEF profiles on remaining symptoms were compared to determine whether the three groups differed symptomatically in addition to the differences in suicidal and depressive symptomatology. Comparison of symptom profiles of the three subject groups using a MANOVA revealed few differences. Aside from the clinical impression of severity reflected in a significantly elevated overall severity score in Group 1 (p < .05), there were no significant differences found betwejen Group 1 (suicidal/depressed) and Group 2 (not suicidal/depressed).
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Rorschach Data In contrast to these small group differences in diagnosis and sympt~matolog~, Group 1 emerged as having Rorschach scores that distinguished them from the other groups. All of the significant Rorschach differences found resulted from a unique cluster of Rorschach variables in the protocols of the suicidal/depressed adolescent (Group 1).There were no differences found between Groups 2 and 3. This highlights that these suicidal adolescents were markedly different from the depressed group as well as from the diagnostically mixed group, who showed neither suicidal nor depressive symptomatology. A quantitative analysis of these findings follows. A discriminant analysis was performed to determine if the three established Rorschach indices (the Suicide Constellation, the Depression Index, and the Schizophrenia Index; Exner, 1986) would discriminate the groups. Of the three indices only the Depression and Schizophrenia indices proved to have discriminantpower, F(4, 150) = 4.05, p < .004. The adult Suicide Constellation did not significantly discriminate the groups. These results highlight the need for the development of unique adolescent suicide indicators on the Rorschach. A separate discriminant analysis was performed on each set of individual variables from the Schizophrenia and Depression indices. The first analysis included the individual variables from the Schizophrenia Index: percentage of responses with accurate form perception (X+ %), the weighted sum of special scores (and all the individual special scores), number of responses with severely distorted perceptual accuracy (minus responses), number of unique responses (U), and number of inaccurately perceived human movement responses (M-). Of these variables, only the special scores categories of deviant verbalizations and contaminations (see Footnote 2), as well as the number of minus responses discriminated the groups, F(6, 148) = 2.46, P < .03. The same type of analysis was performed on the Depression Index's set of variables. Of the entire set of variables, which included number of responses in VF Fv), which shading is used to define depth (vista responses [V achromatic color responses (C' FC' CF), morbid responses, color-shading blends, and the egocentricity index, or three times reflection and pair responses only the vista responses, morbid responses, divided by total responses and the egocentricity index significantly discriminated the groups, F(6, 148) = 2.65, p < .02. Further ANOVAs were done on each of the individual variables from the two significant indices. These ANOVAs resulted in three additional significant findings: presence of M-, F(2, 76) = 3.5 1, p < .05; weighted special scores sum, F(2, 76) = 3.17, p < .05; and color-shading blends, F(2, 761) = 3.60, P < .05. All of the significant findings from both the MANOVAs and test the ANOVAs resulted from Rorschach differences in Group 1, the suicidal/depressed group. The significant findings from both the MANOVAs
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and the ANOVAs were combined to create a new adolescents suicide constellation. Repeated chi-square tests were ~erformedaccording to the iterative procedure described by Exner (1978), systematically adding the individual variables one by one and systematically changing the cutoff points until the most significant chi-square was found. To improve the constellation further, each individual feature of both Exner's d constella(1986) Suicide Constellation and Exner's (1978) ~ r o ~ o s eadolescent tion were added one by one in additional repeated chi-square tests. Of these CF > FC proved helpful in adding more features, only the variable C discriminant power to the index. The final Rorschach constellation that emerged consisted of the six individual features shown in Table 2. The presence of four out of six of these features produced a significant chi-square at the p < .0005 level. This new adolescent suicide index correctly selected 64% of the suicidal depressed subjects and falsely identified only 15% of the depressed subjects and 25% of the neither group, as shown in Table 3. This is a hit rate of 75% for correct selection of suicidal adolescents. Finally, a discriminant function analysis was performed to determine which of the variables from this new adolescent suicide index would discriminate the groups and whether a comparable level of accuracy would be found. The results indicate that three of the variables significantly discriminated the groups, F(3, 148) = 3.23, P < .004. The final discriminant function included only the C < FC, vista responses, and M- responses. The classification variable CF matrix showed that only 48% of the suicidal depressed patients were selected. The false-positiverate was 19%for the depressed group and 14%for the neither group (Group 3). This result was less impressive than the chi-square analysis just reported. These findings support Exner's (1986) conclusion that the most successful Rorschach predictor lists include a constellation of many significant variables with an established minimum cutoff for significance. These types of constella-
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TABLE 2 Summary of Rorschach Variables Associated With Adolescent Suicidal Behavior Rorschach Variables
l.FV+VF+V>O 2. Color-shading blends 3. MOR > 0 4. M- > 1 5. CF C > FC
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Meaning
>
1
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6. Weighted special scores > 9
Three-dimensional responses using shading; painful self-observational Emotional arousal is anxiety provoking Morbid preoccupations Distorted conceptions of people The number of form-dominated color responses exceeded by color responses with vague form; impulsivity Illogical thought processes
Note. Four out of six of these variables correctly selects 64% of suicidal subjects.
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TABLE 3 Number of Patients Identified as Suicidal Based on Rorschach Suicidal Index for Adolescents Suicidal (PEF t 4) Patient Groups Depressed
Number Identified
n
16
25
(PEF 2 4) Not depressed (PEF 2 2)
Not Suicidal (PEF = 1) %
Number Identified
n
64
4
26
(correctly identified) 2
3"
%
15 (false positive)
7
25
28
(false positive)
Note. A chi-square test compared number of patients identified as suicidal, p < .0005.
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"These patients were not included in the analysis.
tions, such as the one developed here through the iterative analysis, may be more powerful for prediction than individual variables isolated from discriminant analysis. Goldfried, Stricker, and Weiner (1971) commented on the importance of considering base rates in evaluating the utility of a predictor list for an infrequently occurring phenomenon such as suicide. Because this study is looking at a predictor list for suicide attempters rather than completed suicides, the relevant base rate is higher. In this study, the base rate could be considered the number of subjects from the total sample who made serious suicide attempts. Because the original sample was a group of consecutive admissions to the hospital, it can be used to derive a fairly representative indicator of the base rate for serious suicide attempters in an inpatient adolescent setting. This base rate is 25% (those subjects with a PEF score of 4 or greater on the suicide dimension among the total 138 admissions in the original sample). Given this base rate of occurrence of 25%, a predictor list with a hit rate of 75%, when viewed in the context of other relevant clinical information, can be seen as an important tool in the comprehensive evaluation of a ~ o t e n t i a l suicidal l~ adolescent. As demonstrated by these results, this new Rorschach suicide index was more powerful than either diagnosis or behavioral symptomatologyfor selecting serious suicide attempters.
DISCUSSION The suicidal index for adolescents that emerged from this study supports repeated trends found in the literature and presents some new and interesting findings. Although it is not as powerful as Exner's (1986) adult Suicide Constellation, it provides a unique combination of both cognitive and perceptual
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variables that may prove to be a fruitful direction in further research. Although a hit rate of 75% is modest, it provides more accurate prediction of suicide risk than diagnosis and symptomatology alone, both of which proved unable to distinguish the suicidal group in this study. The most common feature shared by the suicidal subjects was the presence of a vista response. In Exner's (1986) scoring system, vista describes responses in which a sense of depth and dimensionality are derived from the shaded features of the inkblot. The vista response is present on Exner's (1986) adult Suicide constellation3 and his (1978) proposed adolescent constellation. Exner (19'78) theorized that this variable taps a tendency toward painful introspection. Although derived from a different scoring system, the transparency response described by Blatt and Ritzler (1974) and Rierdan (1978) appears to tap a similar perception of depth and dimensionality. Perhaps the suicidal patients' sense of intense vulnerability and their desire to see another dimension of existence is captured by this projection of depth and transparency into the thrjeedimensional blot. Whatever its meaning, the robustness of the vista/ transparency-suicide relationship over time suggests that its implications be considered seriously when found in a Rorschach protocol. The second most common feature of our index was the color-shading blend. This finding is similarly rooted in past literature (Applebaum & Holzman, 1962) and is present in both Exner's (1986) adult Suicide Constellation and his (19'78) proposed adolescent constellation. The score given when both a color and shading response appear in the same percept is said to convey the painful affect experienced when any emotion is aroused. In adolescents who are normally affectively responsive, the association of affective arousal with the simultaneous experience of inner pain is ~ e r h a p sparticularly diagnostic. This study also suggests that morbid preoccupations expressed on the Rorschach should be taken seriously. The suicidal patients in this sample could be distinguished from their severely depressed counterparts by the presence of morbid images in the Rorschach. Although morbid preoccupation is commonly associated with depression, this study highlights its special diagnostic significance for suicidality. The CF C > FC variable is thought to give some indications of readiness to act on impulses. It is particularly impressive that this feature helped select our suicidal group because many of the other adolescents in this sample had conduct disorders and other impulsive behaviors severe enough to lead to an in-patient stay. This variable conveys the readiness of the suicidal adolescent to respoind behaviorally to his or her signals of inner distress. The remaining significant variables describe aspects of the adolescen,t's
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3Although in Exner's (1986) Suicide Constellation, responses showing depth perception without shading (FD) were added to W ,our index proved to be more powerful when the FD responses were excluded.
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thinking style. The M- perception is said to reflect a distorted conception of people. Clinical descriptions of adolescents who have attempted suicide suggest that frequently they may be attempting to punish or otherwise influence others with their act. Such an extreme form of making an interpersonal statement becomes more understandable in light of this finding. The emergence of the M on our index suggests that adolescents who are suicidal may profoundly misinterpret the intentions and motivations of others and that their suicidal behavior may reflect these serious misconceptions. The weighted special score was originally derived as a measure of thought disorder associated with schizophrenia. The more severe distortions, which receive higher scores in the weighted formula, include autistic logic and deviant verbalizations, which show difficulties in maintaining cognitive objectivity. Clinicians familiar with suicidal adolescents will recognize that subjective, personalized interpretations of their experiences is common. These patients' thinking style has become a focus in cognitively oriented studies. For example, Prezant and Neimeyer (1988) found that suicidal adolescents tended to show significant slips in logic on a cognitive error questionnaire. Their errors of selective abstraction, overgeneralization, and personalization are similar to special score categories on the Rorschach. The willingness to annihilate oneself in order to achieve a wished for effect on others shows all of these logical confusions. Consistent with these findings, Exner's (1991) most recent revision of the Depression Index was derived from a base of patients who were identified as having both cognitive and affective deficits. Clinical awareness of the cognitive deviations of the suicidal patient also helps to focus on intervention approaches. For example, in therapy one might emphasize interpersonal perceptions and examine the reasoning errors that may lead adolescents to perceive suicidal acting out as their only option. The clinical picture of the suicidal adolescent that emerges from this study rings true clinically for what we have observed in our setting and what has been described in the literature. These adolescents are painfully introspective (FV VF V > O), exhibit painful arousal (color-shading blends > I), are morbidly preoccupied (MOR > 0), impulsive (CF C > FC), and have misperceptions of people (M-) and distorted reasoning skills (weighted special scores > 9). Clearly adolescence is a time of flux as reorganization of the ~ e r s o n a l i tis~ occurring. The specific features found on our suicide index for adolescence reflect that sense of turmoil in the cognitive, interpersonal, and affective realm. The uniqueness of the adolescent may necessitate a suicide index for this age group that differs significantly from the adult version. The Rorschach variables that were isolated in the original discriminant analyses procedure but dropped out of the final configuration deserve further study. It is possible that these variables may be reflective of less serious disturbance and more useful in studies of out-~arients.The variable C C'F FC', though significantly elevated in the suicidal group as a whole, did not
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add selective power to the final index. This variable, thought to be related to painful affect in general, was typical of all of the hospitalized patients (though at a higher level in the suicidal group) and was not helpful for a more refined discrimination. The egocentricity index, which emerged as significant in the initial discriminant analysis, shows promise as an important feature for clinical analysis of suicidal potential. Further study is warranted on the cutoff ~ o i n tfor s clinical interpretation of the significance of this index. The final variables that do emerge in the final constellation may highlight the clinical features that make the suicidal patients unique and in need of more protective support and specifically focused intervention. In considering the conclusions from this study, it is important to keep in mind that a group of adolescents were excluded from the analysis-those who did not fit into the strict extreme categories on which the study was based. An important next step is to cross-validate these findings to include more diverse comparison groups, such as adolescents with moderate depression and moderate suicidal ideation. Also important to study are adolescents with suicidal ideation without depressive symptomatology who were excluded from this initial study because the sample was too small. Although these three subjects who were judged suicidal and not depressed were not included in the formal analysis, two out of three subjects showed four out of the six features required for significance in our new adolescent suicide index. This suggests that the new index may be sensitive to suicidal behavior even without associated depressive symptomatology. These results are suggestive and worthy of further study with a large sample. In addition, further research needs to examine whether the Rorschach features of this index represent situational responses of the suicidal adolescent or more enduring traits of suicide-prone individuals as suggested by Hansell, Lerner, Miden, and Ludolph (1988). It may be that some of the features of this index are more chronic trait indicators as Hansell et al, (1988) suggested (color-shading blending transparencies or vistas), whereas others are CF > FC and Mor > 0). situationally based (perhaps C These results have implications for suicide research in general. Exner (1978) tried to emphasize the importance of using a sample of successful suicides for data collection of suicide protocols. The fact that our results, which are taken from an attempter population, are similar to those found in other studies and in Exner's (1986) Suicide Constellation, suggests that the two populations may be similar for adolescents: Studies of attemptors may be used to help clari& further diagnostic questions about suicide completers. As financial resources for impatient mental health care become increasingly more limited, there may be increased reliance on psychological measures to determine need for hospitalization. The fact that Rorschach variables were successful in describing a group of suicidal youngsters when a constellation of behavioral features were not gives further credence to the value of projective
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psychological testing for determination of suicide risk. Through the Rorschach we enter the phenomenological world of the patient. To the extent that we can re-create how patients perceive and interpret their environment, we may also be able to ~redictself-destructive acting out.
ACKNOWLEDGMENTS We acknowledge the statistical assistance of Frederick Parente and the research assistance of Diane Brandt. Joyanna Lee Silberg is a senior psychologist at The Sheppard and Enoch Pratt Hospital.
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Rierdan, J. (1978). Suicide and transparency responses on the Rorschach: A replication. Journal of Consulting and Clinical Psychology, 46, 1162-1163. Roth, D., & Blatt, S. J. (1974). Spatial representations of transparency and the suicide potential. International Journal of Psycho-Analysis, 55, 287-293. Ryan, N. D., Puig-Antich,J., Ambrosini, P., Rabinovich, H., Robinson, D., Nelson, B., Iyengar, S., & Turomey, J. (1987). The clinical picture of major depression in children and adolescents. Archives of General Psychiatry, 44, 854-866. Shaffer, D. (1974). Suicide in childhood and early adolescence. Journal of% American Academy of Child Psychiatry, 21, 564-569. Shafii, M., Carringan, S., Whittinghill, J. R., & Derrick, A. (1985). Psychological autopsy of completed suicide in children and adolescents. American Journal of Psychiw, 142, 1061-1064.
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Joyanna Lee Silberg The Sheppard and Enoch Pratt Hospital 6501 North Charles Street Towson, MD 21204 Received October 7, 1991
Journal of Personality Assessment Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjpa20
The Rorschach Test for Predicting Suicide Among Depressed Adolescent Inpatients Joyanna Lee Silberg & Judith G. Armstrong Published online: 10 Jun 2010.
To cite this article: Joyanna Lee Silberg & Judith G. Armstrong (1992) The Rorschach Test for Predicting Suicide Among Depressed Adolescent Inpatients, Journal of Personality Assessment, 59:2, 290-303, DOI: 10.1207/s15327752jpa5902_6 To link to this article: http://dx.doi.org/10.1207/s15327752jpa5902_6
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JOURNAL OF PERSONALITY ASSESSMENT, 1992, 59(2), 290-303 Copyright o 1992, Lawrence Erlbaum Associates, Inc.
The Rorschach Test for Predicting Suicide Among Depressed Adolescent Inpatients Joyanna Lee Silberg The Sheppard and Enoch Pratt Hospital Baltimore, M D
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Judith G. Armstrong Towson State University and The Sheppard and Enoch Pratt Hospital Baltimore, M D
With the decreasing length of psychiatric hospitalizations, identification of test indicators of suicide risk becomes critically important. This Rorschach study was designed to model a clinical decision-making scenario concerning adolescent suicide risk. Using Psychiatric Evaluation Form (PEF) scores, we selected a sample of 25 severely depressed and suicidal adolescents; 26 severely depressed, not suicidal adolescents; and 28 not suicidal, not depressed adolescent inpatients at The Sheppard and Enoch Pratt Hospital. A Rorschach Index using the Exner (1986) Comprehensive System for scoring was developed to predict group membership. Four of six of the features on this index selected 64% of suicidal subjects. This constellation included traditional affective variables (vista responses, colorshading blends, color dominated responses, and morbid content) as well as measures of cognitive distortion (inaccurately perceived human movement responses [M-] and special scores). We discuss the implications of these findings for the diagnosis and treatment of the suicidal adolescent.
T h e alarming rate of youth suicide has been well publicized. As escalating health care costs are resulting in fewer inpatient hospital days available to adolescents, it becomes increasingly important to develop methods of predicting who is most at risk for suicidal acting out and in need of continuing hospital care. Much of the research o n adolescent suicide predictors has focussed o n developing a profiIe of psychological risk factors, such as inhibition and loneliness, and
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diagnostic risk factors, such as borderline personality and bipolar illness (Shafii, Carrigan, Whittinghill, & Derrick, 1987). However, risk ~rofilesare not tiesigned to predict suicide risk in the individual case. Accurate diagnosis, which is heavily emphasized in inpatient psychiatric facilities is also of limited utility ifor suicide prediction. This is particularly true for adolescents. Whereas in adulthood, depression and suicide are directly linked, among adolescents the relationship is more complex. In a sample of hospitalized adolescents, Ryan et al. (1987) found that only 61% of adolescents with major depression had any suicidal ideation. Conversely, in a study of child and adolescent suicide, Shaffer (1974) reported that less than half had a diagnosed depressive disorder. Clinicians who work with adolescents are familiar with the vast range of psychopathology found among suicide attemptors. Although some adolescents may attempt suicide as a reaction to profound situational stressors, others may have symptoms typical of specific diagnostic categories, such as major depression or schizophrenia. Diagnosis itself is fraught with reliability problems for adolescents as many clinicians are sensitive to the potential for labeling and therefore use diagnostic labels sparingly. The perceptions, affects, and behavioral style of the patient as revealed in a test like the Rorschach potentially provide rich material for assessment of suiciide risk in the individual case. Research into the Rorschach's utility in addressing the question of suicide has spanned 40 years. From the earliest work of Hertz (1948)and Lindner (1946) to the more recent research of Exner (1986), there has been considerable interest in isolating Rorschach features associated with self-destructive tendencies. Over the years, the following Rorschach variables have been consistently associated with suicidal behavior: color-shading blends (Applebaum & Holzman, 1962; Exner, 1986), vista or transparency responses (Blatt & Ritzler, 1974; Exner, 1986; Rierdan, 1978; Roth & Blatt, 1974),morbid imagery (Broida, 1954; Exner, 1986; Hertz, 1948; Lindner, 1946), and poor form quality (Arffa, 1982; Exner, 1986; Piotrowski, 1940). Exner's (1986) Suicide Constellation, taken from a population of patients who subsequently commit1:ed suicide, identifies 83% of completers and falsely identifies only 12%of depressed inpatients. Exner cautioned against using the adult Suicide Constellation with adolescents, and reported that efforts to validate an initial adolescent suicide const-ellation have been unsuccessful. One complicating factor in the Rorschach prediction of suicide in adolescents is the fact that some of the features present on Exner's (1986) adult Suicide Constellation are typical of adolescents in general (e-g., C CF > FC [color-dominatedresponses exceed form-dominat ed color responses] and S > 3 [responses using white space number more than :!I). The complexity of diagnosis in adolescence and the fact that suicidal behavio~ris clearly multidetermined in this age group complicates the search for an adolescent Rorschach suicide index. Tempted by the robustness and specificity of repeated consistent findings in adulthood, we hypothesized that the psycholog-
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ical state that accompanies profound self-destructive impulses can be captured by the Rorschach's sensitivity, even in adolescents. The following exploratory study was undertaken to examine the usefulness of the Rorschach in uncovering suicidal potential among hospitalized adolescents. By comparing severely depressed, not suicidal patients with severely depressed, suicidal patients, we attempted to isolate those factors unique to suicidal behavior unrelated to diagnostic variables. In addition, by comparing groups of severely depressed suicidal patients with severely depressed, not suicidal patients, we closely model situations wherein clinicians must decide which patients are most at risk and require further hospitalization.
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Subjects and Measures The subjects came from an original sample which consisting of 138 hospitalized adolescents who were consecutively admitted to the Sheppard and Enoch Pratt Hospital over a 2-year period. Subjects ranged from 12 to 18 years old and carried a wide variety of diagnoses. These patients were administered a battery of psychological tests, and their charts were reviewed for diagnostic and demographic information. This information was stored in a computer file as a data base for a series of studies on adolescent psychopathology and psychological testing. The Rorschach was administered by trained technicians within 3 to 10 days of the patient's admission. Subjects who produced less than 12 responses on the Rorschach were excluded from the subject pool to ensure structural summary validity. We independently scored the Rorschach protocols using the Exner (1986) Comprehensive System, after all identifying information had been removed from the protocols. Interrater reliability assessed on a sample of 10 protocols yielded percentage of agreement scores ranging from 91% to 95%. Percentage of agreement on special scores was 94%.' The patients' symptoms were rated from hospital records using the Psychiatric Evaluation Form (PEF). This measure includes adolescents in its normative population and has demonstrated reliability when used with retrospective data (Endicott & Spitzer, 1972). The 21 symptoms covered in the rating scale are listed in Table 1. Four research technicians who were unfamiliar with both the patients and the psychological test data reviewed chart materials to assess the presence and severity of the 21 PEF features on a 6-point scale ranging from no indication of the 'These data were collected before Exner's (1986)refinements of Level I and Level I1 special score categories.
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TABLE 1
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Variables Measured on the PEF Drug use and abuse Agitation Suicide/self-mutilation Grandiosity Somatic complaints Antisocial attitudes/acts Speech disorganization Hallucinations Social isolation Belligerence Disorientation Alcohol abuse Anxiety Inappropriate affect Suspicion Daily routine impairment Denial Depression Lack of emotion Impairment of role Overall severity
symptom (1) to extreme indication of the symptom (6). The material reviewed included psychiatrist's formulations, nursing notes, social work reports, aind activity therapy assessments (but not psychological evaluations)from the first 10 days following admission. When judging the presence and severity of symptoms, the research technicians were instructed to rely on behavioral evidence of symptoms rather than inferences. A subset of this initial sample was selected based on the presence or absence of severe suicide or depressive symptomatology on the PEF. Qualifying subjects were arranged into a 2 x 2 matrix of contrasting groups. The groups, diagnoses, and sample sizes are as follows: Group 1-suicidal/depressed, n = 25; Group 2:not suicidal/depressed, n = 26; Group 3-not suicidal/not depressed, n = ;!8; and Group 4-suicidal/not depressed, n = 3. The criterion established Sor inclusion in this matrix was a score of 4 or greater on the PEF dimensions of depression and suicidal/self-mutilation. The scoring rules for the PEF require that for a score of 4 or greater on the Depression scale, the subjects needed to report evidence of vegetative signs as well as subjective signs of depression. To receive a score of 4 or greater on the suicide/self-mutilation dimension, the patient needed to have made a serious suicide attempt preceding hospital admission. Thus, the suicidal group in this study consisted of subjects who entered the hospital after making a serious suicide attempt. In order to establish clear-cut groups, the criteria for low suicide and low
depression were minimal signs of depression and no signs of suicidal ideation (PEF < 3 for depression and PEF < 2 for suicide). We hoped that by contrasting extreme groups, differences in subject profiles would more clearly emerge in the results. These criteria resulted in only 3 subjects in Group 4, so this group was not included in the analysis. These 3 subjects who demonstrated suicidal behavior without accompanying depressive symptomatology comprise an interesting group worthy of investigation in a larger study. Thus, for the purpose of this study, depressed youngsters with and without suicidal behavior, as well as a group showing neither depression nor suicidal behavior were compared.
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Statistical Procedures The computer data base stored Rorschach information including summary scores and statistics derived from Exner's Comprehensive System. First, we used a discriminant analysis procedure to test whether Exner's (1986) established indices (the Depression Index, the Suicide Constellation, and the Schizophrenia 1ndex)' were able to discriminate between the groups. We chose the Depression Index and the Suicide Constellation developed by Exner because they include all of the features found in past research to be associated with suicidal ideation or behavior. The logic for including the Schizophrenia Index was based on our observation and reported finding (Armstrong, Silberg, & Parente, 1986) that, in our setting, thinking disorder was common among hospitalized adolescents, although few of them carried schizophrenia diagnoses. The three Rorschach indices were initially tested with discriminant analyses to assess how well each measure would predict group membership. A second set of discriminant analyses was done subsequently on the Suicide Constellation, and the Depression and Schizophrenia indices. These analyses examined which of the individual variables that made up the gross indices would discriminate the groups. Then, individual univariate analyses were done on each variable from the significant indices. The significant results of these analyses provided the variables needed to construct a new adolescent suicide index. The procedure used to develop the new index is an iterative analysis procedure described by Exner (1978, p. 203). The procedure involves repeated chi-square analyses of various constellations of significant variables to test which grouping of significant variables provides the best hit rate for identification of suicidal patients while providing the lowest false-positive rate. These repeated chi-square analyses resulted in the identification of a constellation of six variables predictive of suicidal behavior. A cutoff score was derived which described how many features of the constellation would be required to 2These data were collected before Exner's (1991)revised indices and are based o n indices reported in Exner (1986).
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consider the subject a suicidal risk. The number of variables at the cutoff point were the least number required to guarantee the best hit rate for suicide while avoiding false positives. The final constellation reported was the one with the best chi-square significance level, ~roducingthe highest hit rate, and lowest false-positive rate. Exner (1978) reported that the number of variables emerging in this type of analysis may not be yielded by a more conventional discriminant analysis. We tested the variables that emerged from the iterative analysis with a discriminant functions analysis to determine which method could produce a higher rate of prediction for suicidal behavior among the groups. Keep in mind that the purpose of these repeated analyses was to derive a clinically useful instrument that might provide a decision-making tool with hospitalized adolescents. In addition to Rorschach variables, PEF symptom profiles were contrasted with a multivariate analysis (MANOVA) procedure. Descriptive data such as IQ and age were examined with an analysis of variance (ANOVA) procedure, and sex distribution and diagnoses were compared with comparison of percentage procedures.
RESULTS Descriptive Data The analysis of the descriptive data revealed that the three groups were similar and showed no significant differences in age (M age = 15.5) or IQ (M IQ = 101.1) or sex distribution (53% girls and 47% boys). A comparison of diagnoses showed that Group 1 (suicidal/depressed) and Group 2 (not suicidal/depresse:d) did not differ on diagnosis. The most common diagnostic category in these groups was dysthymic disorder, which comprised 62% of Group 1 and 65% of Group 2. Group 3 (not suicidaVnot depressed) had a mixed diagnostic picture including drug abuse diagnoses (31%), conduct disorder (32%),and adjustment disorders (21%).
Symptom Profiles The PEF profiles on remaining symptoms were compared to determine whether the three groups differed symptomatically in addition to the differences in suicidal and depressive symptomatology. Comparison of symptom profiles of the three subject groups using a MANOVA revealed few differences. Aside from the clinical impression of severity reflected in a significantly elevated overall severity score in Group 1 (p < .05), there were no significant differences found betwejen Group 1 (suicidal/depressed) and Group 2 (not suicidal/depressed).
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Rorschach Data In contrast to these small group differences in diagnosis and sympt~matolog~, Group 1 emerged as having Rorschach scores that distinguished them from the other groups. All of the significant Rorschach differences found resulted from a unique cluster of Rorschach variables in the protocols of the suicidal/depressed adolescent (Group 1).There were no differences found between Groups 2 and 3. This highlights that these suicidal adolescents were markedly different from the depressed group as well as from the diagnostically mixed group, who showed neither suicidal nor depressive symptomatology. A quantitative analysis of these findings follows. A discriminant analysis was performed to determine if the three established Rorschach indices (the Suicide Constellation, the Depression Index, and the Schizophrenia Index; Exner, 1986) would discriminate the groups. Of the three indices only the Depression and Schizophrenia indices proved to have discriminantpower, F(4, 150) = 4.05, p < .004. The adult Suicide Constellation did not significantly discriminate the groups. These results highlight the need for the development of unique adolescent suicide indicators on the Rorschach. A separate discriminant analysis was performed on each set of individual variables from the Schizophrenia and Depression indices. The first analysis included the individual variables from the Schizophrenia Index: percentage of responses with accurate form perception (X+ %), the weighted sum of special scores (and all the individual special scores), number of responses with severely distorted perceptual accuracy (minus responses), number of unique responses (U), and number of inaccurately perceived human movement responses (M-). Of these variables, only the special scores categories of deviant verbalizations and contaminations (see Footnote 2), as well as the number of minus responses discriminated the groups, F(6, 148) = 2.46, P < .03. The same type of analysis was performed on the Depression Index's set of variables. Of the entire set of variables, which included number of responses in VF Fv), which shading is used to define depth (vista responses [V achromatic color responses (C' FC' CF), morbid responses, color-shading blends, and the egocentricity index, or three times reflection and pair responses only the vista responses, morbid responses, divided by total responses and the egocentricity index significantly discriminated the groups, F(6, 148) = 2.65, p < .02. Further ANOVAs were done on each of the individual variables from the two significant indices. These ANOVAs resulted in three additional significant findings: presence of M-, F(2, 76) = 3.5 1, p < .05; weighted special scores sum, F(2, 76) = 3.17, p < .05; and color-shading blends, F(2, 761) = 3.60, P < .05. All of the significant findings from both the MANOVAs and test the ANOVAs resulted from Rorschach differences in Group 1, the suicidal/depressed group. The significant findings from both the MANOVAs
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and the ANOVAs were combined to create a new adolescents suicide constellation. Repeated chi-square tests were ~erformedaccording to the iterative procedure described by Exner (1978), systematically adding the individual variables one by one and systematically changing the cutoff points until the most significant chi-square was found. To improve the constellation further, each individual feature of both Exner's d constella(1986) Suicide Constellation and Exner's (1978) ~ r o ~ o s eadolescent tion were added one by one in additional repeated chi-square tests. Of these CF > FC proved helpful in adding more features, only the variable C discriminant power to the index. The final Rorschach constellation that emerged consisted of the six individual features shown in Table 2. The presence of four out of six of these features produced a significant chi-square at the p < .0005 level. This new adolescent suicide index correctly selected 64% of the suicidal depressed subjects and falsely identified only 15% of the depressed subjects and 25% of the neither group, as shown in Table 3. This is a hit rate of 75% for correct selection of suicidal adolescents. Finally, a discriminant function analysis was performed to determine which of the variables from this new adolescent suicide index would discriminate the groups and whether a comparable level of accuracy would be found. The results indicate that three of the variables significantly discriminated the groups, F(3, 148) = 3.23, P < .004. The final discriminant function included only the C < FC, vista responses, and M- responses. The classification variable CF matrix showed that only 48% of the suicidal depressed patients were selected. The false-positiverate was 19%for the depressed group and 14%for the neither group (Group 3). This result was less impressive than the chi-square analysis just reported. These findings support Exner's (1986) conclusion that the most successful Rorschach predictor lists include a constellation of many significant variables with an established minimum cutoff for significance. These types of constella-
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TABLE 2 Summary of Rorschach Variables Associated With Adolescent Suicidal Behavior Rorschach Variables
l.FV+VF+V>O 2. Color-shading blends 3. MOR > 0 4. M- > 1 5. CF C > FC
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Meaning
>
1
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6. Weighted special scores > 9
Three-dimensional responses using shading; painful self-observational Emotional arousal is anxiety provoking Morbid preoccupations Distorted conceptions of people The number of form-dominated color responses exceeded by color responses with vague form; impulsivity Illogical thought processes
Note. Four out of six of these variables correctly selects 64% of suicidal subjects.
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TABLE 3 Number of Patients Identified as Suicidal Based on Rorschach Suicidal Index for Adolescents Suicidal (PEF t 4) Patient Groups Depressed
Number Identified
n
16
25
(PEF 2 4) Not depressed (PEF 2 2)
Not Suicidal (PEF = 1) %
Number Identified
n
64
4
26
(correctly identified) 2
3"
%
15 (false positive)
7
25
28
(false positive)
Note. A chi-square test compared number of patients identified as suicidal, p < .0005.
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"These patients were not included in the analysis.
tions, such as the one developed here through the iterative analysis, may be more powerful for prediction than individual variables isolated from discriminant analysis. Goldfried, Stricker, and Weiner (1971) commented on the importance of considering base rates in evaluating the utility of a predictor list for an infrequently occurring phenomenon such as suicide. Because this study is looking at a predictor list for suicide attempters rather than completed suicides, the relevant base rate is higher. In this study, the base rate could be considered the number of subjects from the total sample who made serious suicide attempts. Because the original sample was a group of consecutive admissions to the hospital, it can be used to derive a fairly representative indicator of the base rate for serious suicide attempters in an inpatient adolescent setting. This base rate is 25% (those subjects with a PEF score of 4 or greater on the suicide dimension among the total 138 admissions in the original sample). Given this base rate of occurrence of 25%, a predictor list with a hit rate of 75%, when viewed in the context of other relevant clinical information, can be seen as an important tool in the comprehensive evaluation of a ~ o t e n t i a l suicidal l~ adolescent. As demonstrated by these results, this new Rorschach suicide index was more powerful than either diagnosis or behavioral symptomatologyfor selecting serious suicide attempters.
DISCUSSION The suicidal index for adolescents that emerged from this study supports repeated trends found in the literature and presents some new and interesting findings. Although it is not as powerful as Exner's (1986) adult Suicide Constellation, it provides a unique combination of both cognitive and perceptual
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variables that may prove to be a fruitful direction in further research. Although a hit rate of 75% is modest, it provides more accurate prediction of suicide risk than diagnosis and symptomatology alone, both of which proved unable to distinguish the suicidal group in this study. The most common feature shared by the suicidal subjects was the presence of a vista response. In Exner's (1986) scoring system, vista describes responses in which a sense of depth and dimensionality are derived from the shaded features of the inkblot. The vista response is present on Exner's (1986) adult Suicide constellation3 and his (1978) proposed adolescent constellation. Exner (19'78) theorized that this variable taps a tendency toward painful introspection. Although derived from a different scoring system, the transparency response described by Blatt and Ritzler (1974) and Rierdan (1978) appears to tap a similar perception of depth and dimensionality. Perhaps the suicidal patients' sense of intense vulnerability and their desire to see another dimension of existence is captured by this projection of depth and transparency into the thrjeedimensional blot. Whatever its meaning, the robustness of the vista/ transparency-suicide relationship over time suggests that its implications be considered seriously when found in a Rorschach protocol. The second most common feature of our index was the color-shading blend. This finding is similarly rooted in past literature (Applebaum & Holzman, 1962) and is present in both Exner's (1986) adult Suicide Constellation and his (19'78) proposed adolescent constellation. The score given when both a color and shading response appear in the same percept is said to convey the painful affect experienced when any emotion is aroused. In adolescents who are normally affectively responsive, the association of affective arousal with the simultaneous experience of inner pain is ~ e r h a p sparticularly diagnostic. This study also suggests that morbid preoccupations expressed on the Rorschach should be taken seriously. The suicidal patients in this sample could be distinguished from their severely depressed counterparts by the presence of morbid images in the Rorschach. Although morbid preoccupation is commonly associated with depression, this study highlights its special diagnostic significance for suicidality. The CF C > FC variable is thought to give some indications of readiness to act on impulses. It is particularly impressive that this feature helped select our suicidal group because many of the other adolescents in this sample had conduct disorders and other impulsive behaviors severe enough to lead to an in-patient stay. This variable conveys the readiness of the suicidal adolescent to respoind behaviorally to his or her signals of inner distress. The remaining significant variables describe aspects of the adolescen,t's
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3Although in Exner's (1986) Suicide Constellation, responses showing depth perception without shading (FD) were added to W ,our index proved to be more powerful when the FD responses were excluded.
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thinking style. The M- perception is said to reflect a distorted conception of people. Clinical descriptions of adolescents who have attempted suicide suggest that frequently they may be attempting to punish or otherwise influence others with their act. Such an extreme form of making an interpersonal statement becomes more understandable in light of this finding. The emergence of the M on our index suggests that adolescents who are suicidal may profoundly misinterpret the intentions and motivations of others and that their suicidal behavior may reflect these serious misconceptions. The weighted special score was originally derived as a measure of thought disorder associated with schizophrenia. The more severe distortions, which receive higher scores in the weighted formula, include autistic logic and deviant verbalizations, which show difficulties in maintaining cognitive objectivity. Clinicians familiar with suicidal adolescents will recognize that subjective, personalized interpretations of their experiences is common. These patients' thinking style has become a focus in cognitively oriented studies. For example, Prezant and Neimeyer (1988) found that suicidal adolescents tended to show significant slips in logic on a cognitive error questionnaire. Their errors of selective abstraction, overgeneralization, and personalization are similar to special score categories on the Rorschach. The willingness to annihilate oneself in order to achieve a wished for effect on others shows all of these logical confusions. Consistent with these findings, Exner's (1991) most recent revision of the Depression Index was derived from a base of patients who were identified as having both cognitive and affective deficits. Clinical awareness of the cognitive deviations of the suicidal patient also helps to focus on intervention approaches. For example, in therapy one might emphasize interpersonal perceptions and examine the reasoning errors that may lead adolescents to perceive suicidal acting out as their only option. The clinical picture of the suicidal adolescent that emerges from this study rings true clinically for what we have observed in our setting and what has been described in the literature. These adolescents are painfully introspective (FV VF V > O), exhibit painful arousal (color-shading blends > I), are morbidly preoccupied (MOR > 0), impulsive (CF C > FC), and have misperceptions of people (M-) and distorted reasoning skills (weighted special scores > 9). Clearly adolescence is a time of flux as reorganization of the ~ e r s o n a l i tis~ occurring. The specific features found on our suicide index for adolescence reflect that sense of turmoil in the cognitive, interpersonal, and affective realm. The uniqueness of the adolescent may necessitate a suicide index for this age group that differs significantly from the adult version. The Rorschach variables that were isolated in the original discriminant analyses procedure but dropped out of the final configuration deserve further study. It is possible that these variables may be reflective of less serious disturbance and more useful in studies of out-~arients.The variable C C'F FC', though significantly elevated in the suicidal group as a whole, did not
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add selective power to the final index. This variable, thought to be related to painful affect in general, was typical of all of the hospitalized patients (though at a higher level in the suicidal group) and was not helpful for a more refined discrimination. The egocentricity index, which emerged as significant in the initial discriminant analysis, shows promise as an important feature for clinical analysis of suicidal potential. Further study is warranted on the cutoff ~ o i n tfor s clinical interpretation of the significance of this index. The final variables that do emerge in the final constellation may highlight the clinical features that make the suicidal patients unique and in need of more protective support and specifically focused intervention. In considering the conclusions from this study, it is important to keep in mind that a group of adolescents were excluded from the analysis-those who did not fit into the strict extreme categories on which the study was based. An important next step is to cross-validate these findings to include more diverse comparison groups, such as adolescents with moderate depression and moderate suicidal ideation. Also important to study are adolescents with suicidal ideation without depressive symptomatology who were excluded from this initial study because the sample was too small. Although these three subjects who were judged suicidal and not depressed were not included in the formal analysis, two out of three subjects showed four out of the six features required for significance in our new adolescent suicide index. This suggests that the new index may be sensitive to suicidal behavior even without associated depressive symptomatology. These results are suggestive and worthy of further study with a large sample. In addition, further research needs to examine whether the Rorschach features of this index represent situational responses of the suicidal adolescent or more enduring traits of suicide-prone individuals as suggested by Hansell, Lerner, Miden, and Ludolph (1988). It may be that some of the features of this index are more chronic trait indicators as Hansell et al, (1988) suggested (color-shading blending transparencies or vistas), whereas others are CF > FC and Mor > 0). situationally based (perhaps C These results have implications for suicide research in general. Exner (1978) tried to emphasize the importance of using a sample of successful suicides for data collection of suicide protocols. The fact that our results, which are taken from an attempter population, are similar to those found in other studies and in Exner's (1986) Suicide Constellation, suggests that the two populations may be similar for adolescents: Studies of attemptors may be used to help clari& further diagnostic questions about suicide completers. As financial resources for impatient mental health care become increasingly more limited, there may be increased reliance on psychological measures to determine need for hospitalization. The fact that Rorschach variables were successful in describing a group of suicidal youngsters when a constellation of behavioral features were not gives further credence to the value of projective
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psychological testing for determination of suicide risk. Through the Rorschach we enter the phenomenological world of the patient. To the extent that we can re-create how patients perceive and interpret their environment, we may also be able to ~redictself-destructive acting out.
ACKNOWLEDGMENTS We acknowledge the statistical assistance of Frederick Parente and the research assistance of Diane Brandt. Joyanna Lee Silberg is a senior psychologist at The Sheppard and Enoch Pratt Hospital.
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Joyanna Lee Silberg The Sheppard and Enoch Pratt Hospital 6501 North Charles Street Towson, MD 21204 Received October 7, 1991
