This pilot study is the first controlled trial to have demonstrated the ability of graphologists to detect a particular psychiatric status, i.e. parasuicide with a sensitivity and specificity around 80%.
Graphology is based on a theory according to which the shape, rhythm, size and position of the handwritten letters and words reflect the character of the writer. But the correlation between the writing and the psychological profile is essentially based on case reports in which graphological characteristics are described with full knowledge of the psychological characteristics of the subject. However, it would be very useful to be able to precisely determine the psychological status of an individual by studying his/her handwriting. If handwriting could define a dangerous situation such as, for example, a suicide risk, and if graphological analysis could predict this risk with a good level of predictive value, it could become a tool in the decision-making process. The decision to hospitalise or discharge a depressive patient is always difficult to take due to the risk of suicide which, if incorrectly assessed, can have serious consequences.[11,12] We therefore chose this parasuicide model in order to try to validate the graphological diagnosis. As graphologists believe that suicidal tendencies continue to be reflected in handwriting after a suicide attempt, it was methodologically justified to study the letters written by subjects who had survived such an attempt. These subjects were known to have attempted suicide and there was no risk of diagnostic error amongst the suicide population. We therefore preferred not to evaluate their degree of depression by asking them to complete a MADRS questionnaire, so that they did not feel the study to be a psychometric test, which might have influenced their writing. We performed the study in patients who had recovered a normal level of alertness, on the day of discharge from the hospital. To keep the study blinded, patients were asked to write a letter not related to their parasuicide or their mental health status or history. The control subjects did not show any depressive or suicidal tendencies, and we believe that the populations studied were correctly chosen for measurement of the metrological properties of graphology. Our findings show that there truly are detectable differences between the writing of subjects who have attempted suicide and healthy subjects even if both graphologists missed the suicidal intent in 23% of cases. The fact that this difference was also detected by practising internists who were not graphologists could represent an argument against the specific and rigorous nature of this technique. But one may also consider that the principles of graphological diagnosis are based on good sense and a logic which is perceptible by nonspecialists. However, the graphologists were slightly though not significantly better than the internists in this study with a sensitivity of 73 and 53%, respectively.
Our study had some limitations. The study evaluated the accuracy of only two graphologists in only one medical situation without follow-up of the patients. Our results could not be extrapolated to all graphologists and to other psychological disorders. The grounds which led the graphologists to consider the letters to have been written by subjects who had attempted suicide are not unequivocal. There is no global or composite score, but factors such as falling lines, a loss of the link between the letters, an heterogeneity of the graphics, a weak holding of the lines, a change in the disposition of the words, an unusual possession of the space of the page are taken into account. The subjective dichotomous global decision was built on the size, shape, pressure, speed and movement of the letters and words and on the signature. However, no graphic element in itself was purely significant of one definite quality leading to a prediction of suicide.
As we did not include a formal depression rating scale to evaluate subjects who had attempted suicide, it was impossible to search for a correlation between handwriting analysis and level of depression. We preferred to keep a more powerful binary primary end-point in accordance with our sample size calculation. A previous study comparing the assessment of 10 graphologists in the diagnosis of extraversion showed good agreement between the graphologists, but in this study, only six subjects were evaluated without any healthy control group. In another study, graphology was compared with results of psychological tests for vocational guidance.
The experimental conditions of our pilot study certainly do not allow definitive conclusions to be drawn as to the validity of graphology. Our design with a dichotomic answer of suicide yes-no greatly facilitates graphological analysis. The content of the letters themselves may influence analysis of the handwriting; indeed, 11 of the 12 letters expressing sadness were classified in the suicide group. However, even after the exclusion of these letters, graphological analysis still had a predictive value of about 80%. Our study should be considered as a preliminary report, a kind of go-no go study. Had our findings been negative, we would have demonstrated, using a solid methodology, that graphology was not reliable in the diagnosis of psychiatric illnesses such as suicide. Conversely, our positive results are not sufficient to provide overall validation of this method. A future study using letters written by foreign patients in a language unknown by the graphologists and/or mixing several different types of clearly differentiated psychiatric illnesses and letters written by healthy volunteers would allow our findings to be clarified. Of course, the prediction of future suicide risk is clinically more important than establishing a previous suicide attempt but needs longer and larger prospective studies and was not the goal of our proof of principle trial.
In conclusion, we have shown that graphological analysis is different to chance in evaluating the presence of a suicide risk in handwriting, but further studies are needed before the true role of this technique in the diagnostic process can be established.
An association between words used to describe handwriting features and personality traits might be a reason for our positive results. A high risk for suicide might modify the form or the position of the letters, the words or the lines in a letter and/or a signature, but the goal of our study was not to attempt to explain the theory of graphology but simply to evaluate the value of graphology as a diagnostic test. Even with 27% of false positives and 13% of false negatives, this study yielded positive results and should lead to further studies. Prospective studies with a follow-up of patients with various graphological diagnoses of psychiatric diseases would allow us to ascertain whether graphology provided additional information to the usual psychological diagnosis. In this case, graphology could act as a complement to standard methods and become an additional tool in therapeutic decision-making. Indeed it should be noted that in psychiatry, many therapeutic decisions are taken on the basis of impressions the predictive value of which has been even less well studied than the graphology in the present study.
We can conclude that graphology is able to differentiate letters written by patients who attempt suicide from those written by healthy subjects with an acceptable degree of accuracy. This difference is not due to the ideas expressed in the content of the letters.
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Dr Jean-François Bergmann, PhD, Service de Médecine Interne, Hôpital Lariboisière, 2 rue Ambroise Paré, 75475 Paris Cedex 10, France
Tel.: + 33 1 4995 6341
Fax: + 33 1 4995 8446
Int J Clin Pract. 2007;61(3):411-415. © 2007 Blackwell Publishing
Cite this: Graphology for the Diagnosis of Suicide Attempts: a Blind Proof of Principle Controlled Study - Medscape - Mar 01, 2007.