_ ”F.“ V AN INVESTIGATION OF THE CAUSES OF SUICIDE IN PATIENTS DIAGNOSED AS SCHIZOPHRENIC BY Harold Dean Esler A THESIS Submitted To Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY College of Education Guidance and Personnel Services 196A ABSTRACT AN INVESTIGATION OF THE CAUSES OF SUICIDE IN PATIENTS DIAGNOSED AS SCHIZOPHRENIC By Harold Dean Esler The purpose of this study is to interpret the dynamics of suicidal patients and to devise a scale that will be valuable in differentiating suicidal from non—suicidal schizophrenic patients. A pilot was undertaken employing forty patients, twenty of whom were known suicidal and twenty non-suicidal. They were presented with miscellaneous objects consisting of two hundred varied items. Their task was to mark each ob- ject important, very important, unimportant, or very unimportant. The hypothesis that suicidal patients would choose significantly fewer important tems as compared to the non-suicidal patients was substantiated at the 1% level. A test of thirty miscellaneous and varied items was developed from among the two hundred objects used in the pilot study. By using this test, the Bender-Gestalt Test, and the Draw-A-Person Test, the major research was organ- ized. The hypotheses were: _ .a-‘il Harold Dean Esler l. Suicidal Patients will choosesignificantly fewer items as important compared with non-suicidal patients. 1A. The Test of Objects will differentiate suicidal from non-suicidal patients. 2. There will not be a significant difference in pathology between suicidal and non-suicidal patients. There were two hundred subjects in the study. One hundred of them were suicidal (50 male and 50 female),and one hundred of them were non-suicidal (50 male and 50 female). A suicidal patient was defined as one who had made actual attempts to take his life. A non-suicidal patient was one who had not made such an attempt. All the subjects were diagnosed as schizophrenic. The whole population was given the Test of Objects, the Bender-Gestalt Test, and Draw-A- Person Test. All the hypotheses were confirmed. Hypothesis 1 and 1A were confirmed at the 1% level of significance. The reliabilities of both the Bender-Gestalt and Draw-A-Person Tests in confirming hypothesis 2 were rated by two clinical psychologists with a result of .97 reliability on the Bender—Gestalt Test and .89 reliability on the Draw-A-Person Test. It was concluded that suicidal patients, as a group, are either unable to realize as many important experiences as non-suicidal patients or are unable to distinguish the relative importance of objects as well as non-suicidal - «Gil Harold Dean Esler patients. The Test of Objects might be used as a screening de- vice in helping to recognize potential suicides but more research is needed to confirm its validity. It is not regarded as a definitive instrument in the measurement of suicidal potential, but points to suicidal tendencies and can be a clue for further investigations. VITA Harold Dean Esler Candidate for the Degree of Doctor of Philosophy Final Examination: February 19, 196k Dissertation: "An Investigation of the Causes of Suicide in Patients Diagnosed as Schizophrenic" Outline of Study: Major Subject: Education (Rehabilitation Counseling). Minor Subject: Psychology, Educational Psychology. Biographical Items Born October 7, 1930, Detroit Michigan Undergraduate Studies, B.S. Psychology, Wayne State University, l95h-l957. Graduate Studies, M.A. Clinical Psychology, wayne State University, 1957-1959, Michigan State University, 1959-1963. Experience: Department of Social Welfare, Social Worker, 1957-1958. Division of Vocational Rehabilitation, Rehabilitation Counselor, 1958-1959. Northville State Hospital, Clinical Psychologist, 1959-1961. Lansing Public Schools, School Psychologist, 1961-1962. W. J. Maxey Boys Training School, Chief Clinical Psychologist and Director of Clinical Services, 1962-. Private Practice, 1959-. Member of the Michigan Psychological Association Certified as Psychological Examiner, State of Michigan. ii ACKNOWLEDGMENTS The writer wishes to express his appreciation to those who aided in the formulation and writing of this thesis. To Dr. Gregory Miller for his counsel and en- couragement during the whole graduate program and during the writing of the thesis. To Dr. Bill Kell for his interest and encouragement in the writing of this thesis. To Dr. John Jordan for his time and encouragement during the entire graduate program and during the writing of the thesis. To Dr. Louise Sause for joining the committee at a late date and for her interest in the thesis throughout its development. To the staff at Northville State Hospital, Ypsilanti State Hospital and Boy‘s Training School for their coopera- tion in obtaining this data. To the two raters, Rowena Reynolds, Clinical Psycholo- gist of Boy's Training School, and Carl Henderson, Chief Psychologist at Northville State Hospital. Their willing- ness to rate these tests and their conscientious attitude in doing so will always be appreciated. To Dr. Erich Fromm for his encouragement and sugges- tions in the formulation of the hypotheses. The writer wishes to express his gratitude to the following people for their aid with the statistical formulation: Chaitanya Swarup, Dr. Patricia Carpenter and particularly to John Derr whose encouragement, work and , ‘ r': r: I '* ‘ r. : ' - _‘ (- ; r‘fj w r g a l r r - . (“3 ”J. r . " e r . I (‘A {I _(‘ I C r“ . 1 7‘ c : ;‘ : rm ;‘ : ' r‘ ‘ . r J ‘o 'r r- . P. . ' : r ‘ : r - _: : C r" u" ” Ir . r . : ' c r : ' r *: - J ; C‘ 'c -. r r‘ .- ,- f P : :' . e : . ; r ._ :(Hw _v \t r lrr~ r ‘ r :1 ;' . ' C‘ t r f r L ~r*,( w _ q _ !. C e , r; ' r‘ e r ‘ ,,rr ’~ - ' ( (‘ .3 - . ..' :' I ‘ ; . : r I :i‘, (“P " - ”c n: ~ ~ : ~ . ~ :1 r o: I . ' ’3 _ f‘ '1’ _ _ - f" ' rn I r P 1 . r‘ e (F ‘| f‘ ' “ ’ , ' " C C " II C . "‘ ‘ ;' .'_‘ . ‘> ‘ ' . ; L. ‘3 ' ‘ ( _r w , - ' ‘ I .' - t -. (‘Vl P I ’ Q. (‘3- " ". r'. .' C“ I- 3“. friendship have been priceless throughout this graduate training. The writer wishes further to express his grati- tude to his family for their patience and understanding during this training and writing of this thesis. To his wife, Nancy, for her understanding and her work in helping type the thesis. Also, to his daughter, Pamela, who helped with the coding and copying of numbers and to little Laurie who could not yet understand, but did her best to assist in every way she could. iv VITA TABLE OF CONTENTS 0 C I o O I e O I O n O I ACKNOWLE DWN TS O I D O C I O O . I O Q C . LIS T OF TABLES O O I O O I I Q 0 O I O U I 0 LIST OF APPENDICES . . . . . . . . . . . . Chapter I. II. III. THE PROBLEM . . . . . . . . Introduction . . Pilot Study . . . . . Hypotheses . . . . . . . . . Definitions . . . . . . Summary . . . . . . . . REVIEW OF THE LITERATURE . . . . Introduction . . . . . . Psychoanalytic Theory . . . Neo- Freudian . . . . . . . Learning Theory . . . Miscellaneous Studies . . . Suicide in Schizophrenia Predication of Suicide Using Psychological Tests Summary . . . . . . . . . . . . DESIGN OF THE STUDY . . . . . . . Hypotheses . . . . . Selection of Sample . Selection of Tests . . The Test of Objects . Bender-Gestalt Test . . . . Draw-A-Person Test . . . Procedure . . . . . . . . . . . Analysis of Data . . . . . . . Page ii iii viii ix rtwwn—u U1 ..... Chapter IV. V. VI. BIBLIOGRAPHY . APPENDIX . Hypothesis One . . . . Hypothesis One A . . . . . Hypothesis Two . . . . . . Summary . . . . . . . . ANALYSIS OF DATA . . . . . Procedure . . . . . . . Population . . . . . . . Results . . . . . . Null Hypothesis One . . Alternate Hypothesis One Null Hypothesis One A . Alternate Hypothesis One Findings . . . . . . Mull Hypothesis 2. . . . DISCUSSION . . . . . . . . . Hypothesis One . . . . . . Hypothesis One A . . . . . Hypothesis Two . . . . . . SUMMARY AND CONCLUSIONS . The Problem . . . Methodology and Procedure Findings . . o 0 >0 0 I 0 Conclusions and Implications . Implications for Further Research Table 1. LIST OF TABLES Page Composition of Total Sample Grouped as Suicidal and Non-Suicidal . . . . . . . 3h Composition of Male Sample Grouped as SUI C idal and Non-$113.1! idal I e e e e e e e 3 5 Composition of Female Sample Grouped as Suicidal and Non-Suicidal . . . . . . . . 36 A Comparison of Number of Objects Chosen as Important and a Comparison of the Scores on the Test of Objects between Suicidal and Non-Suicidal Patients Using the Normal Tests for Means . . . . . . . . . . . . . 38 Comparison of Reliability of Raters on Bender-Gestalt Using the Reliability coefficient 0 e e e o a e e e e e o e e I 39 Comparison of Reliability of Raters on Draw-A-Person Test Using the Reliability Coefficient 0 O O O O O I O O O O O O O 0 1+0 A Comparative Rating of Degrees of Severity of Illness by the Two Examiners Using the Bender‘Gestalt Test a e e e o e e e 0 1+1 A Comparative Rating of Degrees of Sever- ity of Illness by the Two Examiners Using the Draw-A-Person Test . . . . . . bl Comparison of Degree of Psychopathology Between Suicidal and Non-Suicidal Subjects Using the Bender-Gestalt and Draw-A-Person Tests . . . . . . . . . . . h2 \Jl‘l// Vii-i LIST OF APPENDICES Page 72 7h A. Test Of objects 0 O O C I I C I O O 0 O B. Data Records . . . . . . . . . . . . Age; Education; No. Items Chosen: Very Important, Important, Very Unimportant, Unimportant; Bender Scores , Draw-A-Person Scores . ix CHAPTER I THE PROBLEM Introduction The problem of suicide has been with us for many years. Society has, for many thousands of years, taken various positions in relation to the subject of suicide. Some cul- tures mildly disapprove, some completely condemn, while others accept suicide and incorporate it as one of their mores of communal life (Farberow and Shneidman, 1961). The problem of suicide in the United States is increasing: the national suicide rate for 1957 was 9.8 per hundred thousand (Farberow and Shneidman, 1961). This is the actual sui- cide rate for the population of the United States and does not include suicidal attempts. A careful tabulation of suicidal attempts made by Farberow and Shneidman (1961) revealed that there were lll.h attempts per hundred thou- sand population or about eight times as many attempts as committed suicides. Patients diagnosed as schizophrenic account for 70% of actual suicides (Farberow and Shneidman, 1961) . Some have said that increase in the suicidal rate is 1 a reflection of the sickness of our society (Fromm, 1959). Others believe that the suicidal phenomenon is the result of internalized aggression and depression. There is an ap- parent lack of interest in the area of suicide as is stated clearly by Karl Menninger: "To the normal person, suicide seems too dreadful, and senseless to be conceivable. There almost seems to be a taboo on the serious discussion of it. There has never been a wide campaign against it, as there has been against less easily preventable forms of death. There is no organized public interest in it . . . In many instances, (it) could have been prevented by some of the res:of us." (Farberow and Shneidman, 1957). Research shows that the schizophrenic patients who have attempted and threatened suicide are a far greater suicidal risk than other diagnostic groups. It is also found that the hospital behavior of the schizophrenic is not a reliable indicator of suicidal potential. (Farberow and Shneidman, 1961). Most psychological tests are not adequate enough at this time to predict suicide (Hertz, 19h9, 1956 and Lindner, 1945). A few tests (Rabin, 19b6, Hertz, l9h9, 1956 and Lindner, 19L6) reflect some accuracy in demonstrating the dynamics of suicide. These tests, however, are time consuming and must be administered and interpreted by a highly skilled practi- tioner. Pilot Study A pilot study was done to test the hypothesis that sui— cidal patients will realize significantly fewer objects as important than non-suicidal patients. This pilot study was carried out at Northville State Hospital, Northville, Michi- gan. Forty patients were employed in the study, all of whom had a diagnosis of schizophrenia. The patients were placed in two groups of twenty each. There were ten males and ten females in each group. The groups were matched by age and by degree of psychopathology as closely as possible. Both groups were given the Test of Objects. The Test of Objects consisted of two hundred varied items and directions to check the relative importance of each object by the fol- lowing simple labels: important, very important, unimportant, and very unimportant. The objects used in the test were among ones previously designated as important by psychology students at Michigan State University, East Lansing, Michigan. An analysis of the results showed that the suicidal patients were reliably differentiated from non-suicidal patients at the 1p level of significance. From this study, the major research was evolved. Hypotheses The hypotheses advanced in this study are: l. Suicidal patients will choose significantly fewer'ob- jects as importantthan non-suicidal patients. A 1A. The Test of Objects will differentiate suicidal patients from non-suicidal patients. 2. There will not be a significant difference in pathology between suicidal and non-suicidal pa- tients. Definitions A suicidal patient was defined as one who had made an actual attempt to take his life, an attempt that could result in his death without medical intervention. Also included in the definition were patients who believed that they would die as a result of their suicidal attempts. The non-suici- dal patient was defined as one who had no history of a suicidal attempt. Schizophrenia in this study is understood to be a psychiatric diagnosis of a patient by the staff at the institution. Summary In this chapter, the problem is defined,the procedure is explained and the pilot study including definitions is presented. The hypotheses resulting from the pilot study are listed and clarified in the order of their significance. CHAPTER II REVIEW OF THE LITERATURE Introduction This chapter is a review of suicide literature. It includes Freudian and Nee-Freudian psychoanalytic theory, learning theory, studies on suicide, studies on suicide in schizophrenia, and prediction of suicide through psycholo- gical instruments. Psychoanalytic Thggry Psychoanalytic theory has made many contributions to the theories of suicide. Freud (l9h9, 1959) suggested the existence of instincts in man that propel him toward differ— ent goals. In Freud's later life, he suggested the existence of a death instinct. He applied this directly to many sui- cides. Freud spoke about the conflict between the life and death instinct as a constant, unresolved conflict. He said that man has often internalized his aggressive impulses. This internalization of aggression is a major part of suicide. Karl Menninger (1938, 1959) composes three main com- ponents necessary for suicide. These are: the desire to 6 die, the desire to be killed, and the desire to kill. He shows how many suicides are actually and originally aggres- sive attacks on individuals other than the person who commits the suicide. He gives many examples to show how hostility originally directed toward another individual has become directed toward the self. He shows how some people have thrown themselves into boiling lead, have con- sumed acids, have wrapped themselves around a red hot stove, and have devised many other painful and horrible methods to terminate their lives. Menninger suggested that many acci- dents in which people are killed are actually suicides; also, that people who become the victims of accidents or murders perhaps set up the situation so that they can be killed because of their inability to take their own lives. Fenichel (19h5) proposed some theories to explain the phenomena of suicide. Fenichel believes tension is pro- duced by the superego because of the ego's inability to live up to the demands of the superego. The tension is unbearable,and the ego feels it is not supported by the superego and can not live. He suggests that one of the motives of suicide is the attempt to unload an unbearable guilt tension at any cost. For Fenichel, the desire to live means that the ego is being supported and protected by the superego. When the desire to live vanishes, a feeling of annihilation which is a revival of feelings of infancy is experienced. Suicide sometimes is a matter of forcing forgiveness from the superego. The ego is punished severely by the aggression it has aroused against the self. This is an attempt to convince the superego that enough punishment has been experienced by the ego so that the superego will not exert any more punishment. Another cause of suicide, suggested by Fenichel, not involving the ego and superego conflict, is the feeling usually expressed about as follows: "The world will be sorry after I'm dead." Being dead or dying is connected with hopeful fantasies. These fantasies are more satis- fying than real life and may precipitate suicide. When the person‘s needs are supplied by an external superego, that is, a person outside of himself, now dead, the suicide may be an attempt by one to join his benefac- tor in death and again receive benefits. Suicide may be an attempt to gain oceanic feelings by Joining a deceased mother who previously provided pro- tection and nurturance and was originally one with the child. Suicide may also be an attempt to regain self esteem by Joining a deceased loved one. The pain of suffering many losses is often resolved by suicide. The patient feels that he will suffer no more losses when he is dead. Robert Lindner (l9th as well as Fenichel,demonstrates that suicide is a result of a person's inability to reduce tension. Freida Fromm-Reichmann (1959) is in essential agree- ment with Fenichel, Freud, and Menninger in the causes of suicide, and she has made some elaborations on these theories. She has suggested that in many suicides, the ego looses its boundaries and identifies itself with the ambivalence pre- viously felt toward the mother. When an individual commits suicide, he is killing the object of fear or hatred rather than himself. Dr. Fromm-Reichmann suggests that many sui- cides emanate from a poor early object relationship. This means that the person can not depend on others. The hope of suicide in these cases, is a relinquishing of a pattern. It is an attempt to resolve the unreliability of people and life by suicide. Suicide ends the unpredictability of life and anxiety. With reference to the aggressive com- ponent of suicide, Dr. Fromm-Reichmann illustrates this theory with the example of the patient who is recovering and makes an attempt to kill her doctor rather than repeat her attempt to kill herself. Edmund Bergler (l9h6) suggests that suicide is a magic gesture. He claims that people who commit suicide are ac- tually doing to themselves what they wish others would not do to them. He also says there is an element of masochism which he prefers to call psychic masochism. For him, most suicides embody these two principles. Harold Greenwald (1958) contributes some clinical evi- dence to support the psychoanalytic theory that sometimes suicide is an attempt to injure the mother or even the bal- ance between the superego and ego. Greenwald has shown that in suicide attempts by call girls, the purpose often is to produce guilt reactions in the mother because of the injustices experienced by the girls at her mother's hands. Greenwald also states that call girls often have internalized a con- demnation of society which prodices a feeling of worthless- ness. Harold Rosen (1953) Points out how many more neurotic patients are prone to suicide than might be suspected. He reveals how symptoms are frequently protections against suicidal impulses. Using hypnotherapy, he found that if the symptom is removed without removing the guilt, suicide might occur. The symptom can be an intermediary between the ego and the superego. It permits punishment by the superego, but the punishment is modified in the symptom. If the symptom is removed, the modification of the punish- ment is also removed. This, in turn, creates overwhelming 10 guilt that can not be tolerated and must be reduced; the reduction can be suicide. The aggressive component is also explained by Rosen. He shows that in hypnosis, if the con- scious and unconscious impulses are released without support by the therapist, the aggression can be exerted against the self which can result in suicide. A very interesting sug- gestion by Rosen is that surgical procedures frequently serve the purpose of punishing. He indicates that often the de- pressed patient will bring ahout surgical procedure in an attempt to experience pain, thereby bribing the superego and reducing the attacks of the superego. eo-Ereudian The Neo-Freudians (Blum, 1953) suggest that suicide is caused by the interpersonal reaction of the patient and the environment. They stress much less the reaction of the superego and ego; the major emphasis is on the interpersonal relationship. Alfred Adler (Adler, 1958, Farberow and Shneidman, 1961) indicates that interpersonal relationships are a major fac- tor in suicide, but he is not opposed to the aggressive ingredient in suicide. He believes that suicide is actually a means of hurting others by hurting oneself. He concludes that there are many predisposing factors in suicide and that suicide is a complex type of behavior. Adler suggests 11 four main factors in suicide: Pampered Life §tylez By pampered life style Adler means that the suicidal patient has been conditioned throughout his life to depend on others for achievement and support and will always try to lean on others. He expects and de- mands others to fulfill his wishes, and he expects a favorable outcome to all situations and become extremely frustrated when the outcome is not to his planning. Inferioritz Eeelings‘ggg §gl§ Centered ggglg; The suicidal patient's self esteem from childhood is very low, as can be seen from his pattern of unceasing attempts to achieve greater importance. The suicidal patient is an ambitious and vain person. The planning of suicide gives him the feeling of mastery over life and death. This feeling is the supreme expression of the goal of superiority on the useless side of life. The patient's thinking is self- centered. Degree 9; Activity: Adler finds that the greatest degree of activity is found in people who engage in antisocial behavior. He states that among neurotics and psychotics, activity is generally low, but there is a difference between the groups, and he suggests that it is lowest in the anxiety neurosis and schizophrenia; it is great among compulsive neurotics and depressives, and it is greatest in suicides. 12 Veiled Aggression: The suicidal patient believes he is hurting those he professes to dislike when he hurts himself. He dreams about this, administering punishment to himself in the belief that he will thus injure others. Sometimes suicide is combined with open aggression: for example, where suicide is preceded by murder. Suicide can be interpreted as an act of reproach or revenge. In this respect, it is not unlike depression, alcoholism or drug addiction, all of which are forms of veiled attacks on target individuals. Fromm (1959) states that our society is sick and uses as evidence the number of suicides committed in the world. He also cites the high rate of alcoholism and incidents of psychosomatic illnesses. Fromm believes that every human being potentially possesses the ability to love, but it is a difficult ability to develop, and very few actually are able to experience the real feeling of love. Fromm believes that man has alienated himself and projects power to society, machinery, and other objects with which he is afraid to deal himself. Fromm concludes that the underdeveloped ability to love and the loss of Opportunity to love can be important factors in suicide. Sullivan (Farberow and Shneidman, 1961) is in essential agreement with the other Neo-Freudians in the view of sui— cide. One of his main contributions is the treatment of suicidal patients, particularly those who are schizophrenic. 13 Sullivan considers suicide often a means of manipulation. He says that the patient is trying to control the world by using suicide as a threat. Sullivan demonstrates the im- portance of disarming the patient of this controlling mechanism if he is to be treated. e rnin Theory Dollard and Miller (1950) have observed how the reduc- tion of anxiety can be rewarding. They have demonstrated how rats will continue to behave in an apparently unre- warding or senseless way if it reduces their fear or anxiety. We can easily see how this mechanism can be used to explain the suicidal phenomena. The person who is extremely anxious or fearful will try many means to reduce the anxiety. He will first try means that have been rewarding in the past. If these means do not achieve the goal, the anxiety will increase, and the means to attempt to reduce the anxiety will become less and less rational. The ultimate method will be suicide. Skinner (1953) indicates that suicide is an attempt to remove an individual from an unacceptable situation. He indicates that this is a segmentation of behavior joined to emit the response. He is suggesting that the would—be suicide is trying to escape from an unpleasant situation by using a mechanism that he has never attempted before. He believes that the would-be suicide joins previously-learned 1h responses to emit a response with which he has had no previous experience. If we used field theory to explain suicide, it might be stated that in a person's life space, the valence that directs him towards death is stronger than the valence that directs him towards life. He is in an avoidance conflict which he can not resolve, so he chooses to leave the field (suicide). (Hilgard, l9h8) Miscellaneous Studies Farberow and Shneidman (1957) did a study using the three main components of suicide suggested by Menninger. They attempted to classify suicide notes by their content into the three groupings established by Henninger. They found the groupings varied with the age of the individual suicides. A desire to die appeared more frequently among older people, while the desire to kill appeared more fre- quently among younger ones. This is clearly seen by comparing age groups. Between the ages of twenty and thirty-nine years, thirty-one percent of the would-be suicides in the study demonstrated the desire to kill, while of those sixty years and above, only eleven per- cent demonstrated the desire to kill, as evidenced in their suicidal notes. In the age bracket of twenty to thirty- nine years, twenty-three percent demonstrated the desire 15 to die, while in the age bracket of sixty years and older, fifty-seven percent demonstrated this factor. The desire to die seems to be a more important factor in older patients than in younger ones. It is this writer's opinion that the desire to die has not been emphasized enough; it will be an important factor in this study. Spitz (19h5) has found that newborn infants often die in hospitals deepite more hygenic precautions than are found in foster homes. Spitz regards one of the reasons for this the lack of stimulation; the desire or zest for life is lacking. Spitz believes that the baby dies because of the feeling of not being wanted and because of the lack of love stimulation in the environment. William Mayer (1958) found that American prisoners of war in Korea frequently gave up. They did not want to live any longer. They, literally, crawled into a earner and died. He believed that, for them, life had no further pur- pose, and the challenge to live was too burdensome or too overwhelming. Intelligence seems to be an important factor in suicide. It has been found that chiliren with superior intelligence very rarely commit suicide (Carmichael, l95h). In compar- ing the number of suicides in gifted children to the normal population, the percentage was incredibly small. Ljungberg (1957) found that people with I. Q.'s of under ninety are 16 more prone to suicide than people with higher intelligence quotients. Ljungberg (1957) states that more unmarried and divorced people attempt suicide than married people. Farberow (1950), using mental patients as the studied group, stated that the suicidal patient, usually, is single or divorced, and if married, only married a short time and has none or few children. Helsually lives in the city, and he is usually in a higher-than—average economic level, is usually of Protestant faith, and if diagnosed by a psycholo- gist or psychiatrist would be considered insane. His efforts to adapt to his environment usually result in failure or poor adjustment. His personality is inhibited by dread, fear, conflict, spite and tension. Another study (Farberow and Shneidman, 1957) suggested that the suicidal patient is usually an ex—mental patient, and if he commits suicide, he usually does it within ninety days after leaving the hospital. An important suggestion in this study is that almost all the patients threaten suicide some time before committing it. Farberow (1950), in comparing suicidal patients with non-suicidal patients, found that some of the predominant features of the suicidal patients were hostility, aggression and agitation. suicidal patients were in poor contact with reality and had little ability to integrate with society. The aggression they experienced was mainly toward the father. 17 or father figure. They appeared not t) be bothered by frustration. They seemed to express much aggression inwardly and a suicidal attempt seemed to have an abreactive effect. Farberow and Shneidman (1957), (Farberow, 1950) have found that the patient usually feels better after he had made a suicidal attempt, but this feeling is short lived. A study done with twins showed that in eleven cases of identical twins who had been institutionalized for severe psychopathology, there were no cases in which both twins committed suicide (Jallman, Anstosic, l9h7). It was the author's conclusion that suicide is such a complicated phenomenon that it can not be duplicated, even when here- dity and pathology are held relatively constant. Some (Anon., 1947) of the means of committing suicide are firearms, hanging, asphixiation and poison. This ac- counts for about seventy—five percent of the suicides be- tween 19h1 and l9hb. Poisoning is decreasing and hanging increasing. Men use guns twice as frequently as women. There are about sixteen thousand suicides in the United States per year (Farberow and Shneidman, 1957). One study (Farberow and Shneidman, 1961) substantiated Sullivan's view. Three Army psychiatrists selected a group of patients who had threatened suicide or who had ac— tually attempted it, but who showed no evidence of depres- sion or psychotic confusion. These patients were told 18 that their various demands would not be granted. Further- more, they were told that no one would prevent them from committing suicide, but such an act, if successful, would be punished by revoking all material benefits to their respec— tive families, and if unsuccessful, would be punished by court martial. This was told to the patients by a psychia- trist without hostility, and none of the patients were hospitalized. In a follow-up study, it was found that there was only one suicide committed among the seventy- five patients. Sgicide in Schizophrenia Among the psychiatric diagnostic categories, the cate- gory of schizophrenia accounts for more suicides than all the rest put together. The schizophrenic patient accounts for about seventy percent of the total number of suicides (Farberow and Shneidman, 1961). Because of the seriousness of a suicidal threat made by a schizophrenic patient, Far- berow and Shneidman did an extensive study using sixty schizophrenic patients in thirty-seven mental hospitals throughout the United States. All sixty subjects were male and caucasian with the diagnosis of schizophrenia. The sub-categories were not considered. Thirty of the patients had actually committed suicide while thirty had not. These patients had been hospitalized during the interval of 1955 to 1958. Their records were examined extensively. The 19 control group (non-suicidal) was matched as closely as possible on a man-to-man basis in terms of religion, marital status and age. In this study, Farberow and Shneidman found that there were differences between the suicidal and non-suicidal patients. The suicidal patients were found to be persons who were under stress. Over seventy percent of them were people with a previous suicidal attempt or with suicidal ideations. In stress situations, these people were extremely tense, breathless, and impulsive. They were demanding; made many requests; and constantly suggested that there was nothing being done to relieve their tension. Their demands or requests and their manner of expressing their demands or requests varied. They appeared driven to achieve some kind of relief, even self action, if the tension con- tinued unrelieved. 0n the other hand, the characteristics found in the non-suicidal patient were: passivity, ac- ceptance, and relative indifference toward hOSpitalization and toward his environment. More than half of the non- suicidal population accepted hospitalization, not request- ing, demanding, or resisting treatment or accommodations. The non-suicidal patient did not appears to be dependent on the hospital nor did he seem to reject or resist it. He did not ask to leave the hospital nor did he leave with- out permission, nor did he feel a need to stay in the hospital. He often even seemed somewhat indifferent on 20 being discharged. This patient was frequently quite de- lusional, hallucinatory, isolated or preoccupied. This type of patient seemed able to make a passive adjustment to his psychopathology. A very distinct characteristic of the non-suicidal patient was his ability to handle stress or dis— regard it. This does not mean that he handled it in a healthy way, but he was able to develop a mechanism to pre- vent himself from experiencing a stress painful at a con- scious level. He was usually not depressed, nor restless, and did not usually have somatic complaints. He tended to be an older, single man, often alcoholic, whose degree of ill- ness did not seem so severe as in the other schizophrenic patients. He was often able to function outside of the hos— pital at a marginal level. He was often hospitalized, and this hospitalization was precipitated by unusual situations, or perhaps, occurred after a prolonged alcoholic episode. Farberow and Shneidman (1961) conclude that.there can be some distinctions made among schizophrenic patients as to their suicidal tendencies. Farberow and Shneidman have developed a check list which is included in their book: Th3 £31129; Hglp. One of the most marked characteristics of the suicidal schizophrenic patient is that he has suggested or made a suicidal attempt in the past. At the Suid.dal Preven- tion Center in Los Angeles, any suggestion of suicide by a patient diagnosed as schizophrenic is considered serious, and 21 such a suggestion from a patient diagnosed as schizophrenic with a history of suicidal attempt is considered even graver. According to Farberow and Shneidman, releasing from the hospital a patient diagnosed as schizophrenic who has made a suicidal attempt or gesture is dangerous because the problem of suicidal proclivity probably has not been treated. It is surmised that the patient was given tranquilizers; these tranquilizers mask the symptoms, and the patients do not appear as disturbed as they actually are. It is also under- stood that the stresses in the hospital are not as severe as those found on the outside. Farberow and Shneidman sug- gest that each patient who has a suicidal history be evaluated carefully before being released. They prescribe that he be evaluated psychiatrically and at a more dynamic level than is likely in the controlled, tranquil conditions of hOSpital environment. Prediction of Suicide Using Psychological Tests Work has been done toward producing the perfect pattern in psychological tests so that an accurate prediction of sui— cide can be made. Hertz (l9h9) produced ten Rorschach patterns indicative of suicide, and she states that the presence of five or more of these in a single protocol are enough to be reasonably certain of the presence of suicidal trends. In the two different validation studies, she was able to predict 22 eighty-five percent of the suicidal group and eighty-five percent of the non—suicidal group. The ten patterns are as follows: 1. Neurotic structure. Use of shading and color. Reduced B. Low M. Failure and rejection trends. Low F% behav- ior indicating insecurity and strain. Deep anxiety. Preoccupation or reaction a) shading and/or shading shock. Depressed states. Failure and/or rejection trends. Low M. Slow reaction time. Impaired mental approach. High F. Low M and c. Constriction. Narrow content. Behav- ior indicating sadness, anxiety and dejection. Constriction. High Ffi. Low M and C. Overemphasized control. Drs. High P. Low 0. Narrow interest. Eva- sive and non-commital behavior. Active conflict and deep inner struggle. Low 0. Color shock, repressed or disguised M. Flexor extensor and frozen M. Midline details. Unbalance of HzM. S. P. fail- ure. Symmetry preoccupations and Spatial characteristics. Ideational Symptomolog. Peculiar eccentric thinking. Fixed ideas. Phobias. Obs. Comp. trends. High 6-, F-, and c. Shading and/or M-. Agitation. High Dr. Low M, C and P. High S. Persev- eration and self-reference. Behavior indication rest- lessness and agitation. Resignation trends. Behavior indicating listlessness, . e u . ‘ . . . . . . n ' . a . u . 23 indifference and inertia. Flexor M. Low C. No S. Sterile, narrow content. 9. Sudden and/or inappropriate emotion. Sudden, unexpected and spasmodic C. 10. Withdrawal from the world. Lack of feeling tone, long RT. Low FC. High F-. Few H. Spaces used as holes 0—. Low P. Hertz made no attempt to find rationale for her tech- nique, and the patterns are by no means clear. It is spec- ulated that her means of predicting suicide by the Rorschach are predicated by her own past experience, her internaliza- tion of norms, and her intuitive skill. Hertz also can be criticized for defining commonly used psychological terms in her own terms and by the use of sym- bol patterns. In these ways, she adds to the already tre- mendous confusion in the field. Simmons and Hale (l9h9) tested fifty assorted suicidal patients with the MMPI. They found a consistent rise in the D and PT scales. They attempted to explain this by stating that the D is related to "appropriate effective component of suicide" and the PT "a strong, obsessive compulsive compon- ent often clinically observed by a manifestation of impul- sive tendencies." They have now attempted to devise a suicide scale, and if and when they finish it, it may well answer many questions. I . . u . - . a e . n e . u . . . e n y I . 4 a - . . CHAPTER III DESIGN OF THE STUDY Hypotheses The hypotheses advanced in this study are: l. Suicidal patients will choose significantly fewer objects as important than non-suicidal patients. 1A. The Test of Objects will differentiate suicidal patients from non-suicidal patients. 2. There will not be a significant difference in pathology be- tween suicidal and non-suicidal patients. Selection pf Sample Two hundred schizophrenic patients were chosen from three institutions. In the suicidal group, twenty-two females were chosen from Ypsilanti State Hospital, Ypsilanti, Michigan, and twenty-eight from Northville State HOSpital, Northville, Michigan. In the male sampling, twenty-one were chosen from Ypsilanti State Hospital, twenty-two from Northville State Hospital and seven from Boy's Training School, Whitmore Lake, Michigan. Among the non-suicidal group, fifty females were chosen from Northville State Hospital. In the male group, one was chosen from Ypsilanti State Hospital, forty-two from Northville State Hospital and seven from Boy's Training School. 25 24 Beck (l9h5), after analyzing one case in some detail, states that the test pattern is strongly suggestive of sui- cide when, in an individual of high intelligence, there is a marked anxiety, strenuous internal conflict, and a com- pulsive personality, accompanied by a marked preoccupation with personal life experience. Lindner (1946) sees card four on the Rorschach "as a suicide card.” Responses indicating decay, rottenness, or blackness with depression, he says, should be viewed as strong suicidal indicators. There are many and varied interpretations of psychol- ogical tests to indicate suicide. These interpretations seem to be based on individual orientation and the past clinical background of the interpreter. Up to this time, there does not seem to be an adequate psychological test to predict suickh. Farberow's and Shneidman's (1961) procedure using case his- tories and accumulation of facts about suicidal patients seems to be as good a predictor of suicide as any. Summary In this chapter the literature on suicide is reviewed. First, the psychoanalytic theories of suicide are presented both Freudian and Nee-Freudian. Then, learning theory and various studies, including studies of suicide in schizo- phrenia are covered. The chapter is concluded with a review of the prediction of suicide by psychological tests. 26 In both groups, the patients have a diagnosis of schizophrenia. All the patients were suggested by the psychiatrists, social workers, and psychologists of the institutions. A total of one hundred patients had made suicidal attempts; a total of one hundred patients had no history of suicidal attempts. In this research, it was an extremely difficult task to acquire the male suicidal samples. The research, in fact, was delayed some time because of the difficulty. Often these patients were tested individually, and frequently the examiner had to wait until an attempted male suicide was admitted to the hospital. Seven of the male suicidal patients were selected from the boys at Boy's Training School, Whitmore Lake, Michigan. There was either factual information of a suicidal attempt in their records, or they had made a suicidal attempt while at Boy's Training School. One of the boys had made five attempts while in the institution over a two-month period before being transferred to a mental hospital. In the non-suicidal group, the fifty females were chosen from Northville State Hospital and were selected fromvvards that approximated the wards from which the suicidal patients were taken. This was also true for the most part of the patients in the male non-suicidal group. (The seven suicide samples from Boy's Training School were matched by seven non-suicidal patients from the same institutionL . : _ . . I ' I . . . _ I 5 ' . 27 Selection 2; Tests The Test Q£ ijects was compiled and devised from the pilot study in which a test of two hundred objects was admin- istered to forty patients, twenty of whom were suicidal with a diagnosis of schizophrenia and twenty of whom were non-suicidal with a diagnosis of schizophrenia. A statistical analysis was done on the two hundred objects. The objects that had previously differentiated the suicidal from the non-suicidal group at the five percent level were chosen. Also, objects that were thought to have discriminative effects because they appealed to one sex more than another were removed from the list (e.g., cigars, foot- ball, baseball, etc.). Objects that it was thought might mislead a subject or cause him confusion were also removed. This kind of confusion was observed in the initial presenta- tion of the test to the patient when many questions were asked about such infinitely abstract items as social pres- tige, relationship with people, etc. When these items were carefully analyzed, many were deleted, and thirty objects were finally selected. Ihg,fiender-Gestalt was chosen as a test to measure the degree of psychopathology that the patient was experiencing. This test was selected because of its simplicity of pro- cedure in administering, its non-threatening quality, and the accuracy, ease, and clarity with which it can be inter- preted. The test is believed by many (Bender, 1938) to be 28 an accurate assessor of psychopathology. Hutt and Briskin (1960) have shown that the test can discriminate neurotics and psychotics and can point to the degree of psychopathol- ogy. This has also been suggested by Pascal and Suttell (1951). Further, the test was chosen because of the author's own clinical experience which has lead him to bd.ieve that this test is an excellent instrument for measuring psycho- pathology. lhg Mgchgver Draw-A-Person Test was chosen for many of the same reasons that the Bender-Gestalt test was chosen: ease of administering, the non-threatening quality of the instrument, and its ability to measure psychopathology. Re- search on the Machover Draw-A-Person Test produces conflict- ing results, but the implications are that this instrument can differentiate severely disturbed people from undisturbed people, and it has great value in an interpretation of per- sonality (Anastasi, 1952, Machover, 19h9, 1963). Further, the Machover Draw-A-Person Test was chosen because of the examiner's belief based upon his clinical experience that it is a valid clinical instrument in assessing personality and in differentiating severely disturbed from less dis- turbed patients. His clinical impression is a result of his service in a state hospital among psychotic patients and his experience in other institutions where this test was used suc- cessfully as a measurement of personality. ' l . . a . . . . 1 . . , . . . , _ . ... . . .' n I . ’ . . o . _ . . ., 29 grocedure The Testof Objects, Bender-Gestalt, and Draw-A-Person tests were administered to the two hundred schizophrenic patients. Most of the tests were group-administered. Us- ually, they were given in the classroom at the hospital. The patients were presented with the Test of Objects and asked to put a checkmark next to the object indicating its degree of importance. After they had completed the Test of Objects, they were given a small stack of 8%" x 11" white paper and told to draw a picture of a person. Two of the subjects would not draw a picture of a person and were con- sequently dropped from the study. After the completion of the Draw-A-Person Test, the Bender-Gestalt Test was admin- istered. No one refused to take the Bender-Gestalt Test. Two females in the suicidal group and two in the non~ suid.dal group were so disturbed (catatonic) that they could not respond to the stimulus. One non-suicidal patient was mentally retarded to the extent that die could not respond to the tests. One of the female patients in the non-suici— dal group was so paranoid that she could not cooperate in the testing situation. In the suicidal group, two of the females showed gross signs of organicity on the Bender—Ge— stalt, and upon checking their records, it was discovered that they had experienced brain injury. These eight subjects were dropped from the sample groups being tested. 30 Agglysis 9; Data mm: To test hypothesis one, the objects chosen as both very important and importait by both the suicidal and non-suicidal patients will be grouped into one classification. The ob- jects thus chosen by the male suicidal and male non-suicidal groups will be compared; then the objects thus chosen by the female suicidal group and female non—suicidal group will be ,ccmpared. After this is completed, the objects thus chosen by the suicidal group will be put into one classification and the objects thus chosen by the suicidal group into an- other, and then they will be compared. The statistics used for this comparison will be the normal test for means (McNemar, l9h9). The minimum level of acceptance of the hypothesis will be the five percent level. Hypothesis On; A; To determine whether the hypothesis that the Test of Objects differentiates suicidal from non-suicidal patients, the number of objects chosen as important by suicidal pa- tients will be compared with the number of items chcs an as important by non-suicidal patients. The comparison used will be calculated from the normal test for means. The minimum level of acceptance will be the .05 level. 31 Hypothesis Iw_: Hypothesis tWO will be tested by using the Bender-Ge- stalt and Draw-A-Person Tests. These two tests will be rated by two clinical psychologists who have had a mini- mum of five years of working experience with these instru- ments and with patients diagnosed as schizophrenic. They will rate the tests on a one to five basis as follows: 1. A person mildly disturbed. 2. A person moderately disturbed. 3. A person severely disturbed. A. A person quite severely disturbed. 5. A person very severely disturbed. Before the two psychologists judge the tests, they will be given some sample tests on which to practice so that they are well aware of the common criteria in making judgments and so that they can agree on a fixed definition and common eval- uation for the terms mild, moderate, severe, quite seven; and very severe. Following this, a test of reliability of the two examiners will be done using The Reliability 00- efficient. The minimal level of acceptance will be .70 (Super, 1957). ‘After this is completed, the scores w on the Bender-Gestalt and Draw-A-Person Tests of the male suicidal patients will be compared with the scores of the male non-suicidal patients to determine the degree of 32 psychopathology. The statistics used will be the T Test Statistic using the normal curve in a two-tailed test. The scores of the female suicidals and non-suicidals will be compared also. Then the sanple groups will be combined; that is, the combined average scores of the female and male suicidal patients will be compared with the combined aver- age sccres of the female and male non-suicidals. The statistic again will be the T Test using normal curve in a two-tailed test. §ummar1 In this chapter the design of the study is presented. The hypotheses are presented along with the means for test- ing these hypotheses. CHAPTER IV ANALYSIS 0F.DATA Procedure Each of two hundred patients diagnosed as schizophrenic was asked to complete the Test of Objects, to do the Draw- A-Person Test, and to take the Bender-Gestalt Test. Usually the patients were tested in groups of five to ten, depending on the number of patients available in a particular ward. At times it was necessary to test some patients individually, especially male suicidal patients who were notably scarce. It appears that males are more successful in their suicide attempts than females (Farberow and Shneidman, 1961), or that there are fewer suicide attempts among male schizophrenics. Two clinical psychologists, each of whom had a minimum of five years working experience with schizophrenics and with diagnostic instruments, were asked to rate the two hundred Bender-Gestalt and Draw-A-Perscn Tests. They were instructed to rate the tests on a one to five basis (See Chapter III). The two clinical psychologists worked in separate institutions. Examiner B scored the tests 33 3h independently of Examiner A. After scoring five sample tests, Examiner B gave the scored tests to Examiner A, the purpose being to establish common understanding andagreement and fixed standards as to what the examiners would consider mild, moderate, severe, quite severe and very severe forms of schizophrenia. There was no verbal communication between the examiners, nor did either examiner have access to any information other than that which has already been mentioned. Eopulgtion The subjects tested were two hundred patients diagnosed as schizophrenic, one hundred male and one hundred female. Half of each sex group were potentially suicidal and half were non-suicidal. The population was taken from Northville State Hospital, Northville, Michigan; Ypsilanti State Hospital, Ypsilanti, Michigan; and Boy's Training School, Whitmore Lake, Michigan. The samples were selected by the professional staff at the respective institutions. In order to rule out sex as a factor in suicide, the patients were grouped three different ways for statistical analysis: 1. Suicidal versus non-suicidal (TABLE 1.). 2. Male suicidal versus male non-suicidal (TABLE 2). 3. Female suicidal versus female non-suicidal (TABLE 3). 35 TABLE 1.--Composition of total sample grouped as suicidal and non-suicidal Suicidal Non-suicidal Mean Age (years) 32.10 35.50 Mean Educational (grade) Level 10.50 10.00 Number in Group 100.00 100.00 Table 1 includes the total population studied. It does not include the several cases that were removed from the study means of crane brain syndrome and mental deficiency. TABLE 2.--00mposition of male sample grouped as suicidal and non-suicidal Suicidal Non-suicidal Mean Age (years) 30.80 33.23 Mean Educational (grade) Level 10.1A 10.00 Number in Group 50.00 50.00 The male suicidal group is slightly younger in average age than the total suicidal group or the female suicidal group. The mean age of the suicidal male group is also lower than the mean age of the non-suicidal male group. 36 This male suicidal group was the most difficult to find. As a possible reason for this, it is suggested that when males attempt suicide, they are usually successful. It has been found that males use more violent means of trying to kill themselves than do females, thereby significantly increasing the likelihood of successful suicides (Ancu., 1947). TABLE 3.--Composition of Female sample grouped as suicidal and non-suicidal Suicidal Non-suicidal Mean Age (years) 34.20 38.18 Mean Educational (grade) Level 10.36 10.33 Number in Group 50.00 50.00 It was not difficult to obtain female suicidal patients. Many of their suicidal attempts are unsuccessful because they tend to be milder than male attempts and are often un- successful because of medical intervention. Overdoses of sleeping pills are frequently female suicide attempts veryr often thwarted by medical intervention. esults £21; lngthesiszl Suicidal and non-suicidal patients will choose an 37 equal number of objects as important. Alternate Hypothesis 1 Suicidal patients will choose significantly fewer objects as important than non-suicidal patients. [31; Hypothesis 1A The Test of Objects will not differentiate suicidal from non—suicidal patients. Alpepnate Hyppthesis 1A The objects will differentiate suicidal patients from non-suicidal patients. Findings Using the normal test of means, Null Hypothesis 1 was rejected at the 1% level, and the Alternate Hypothesis 1 was accepted. These hypotheses refer to the total popula: tion and a comparison between the sexes. Null Hypothesis 1A was rejected, and Alternate Hypo- thesis 1A was accepted for all three groups at the 1% level of significance using the normal test for the differences between means. There was very little difference between the three groups. The highest level of significance was between the female suicidal and female non-suicidal. The lowest level of significance was between the male suicidal and male non-suicidal. The variance was low for all of the groups. 38 TABLE 4.--A comparison of number of objects chosen as impor- tant and a comparison of the scores on the Test of Objects between suicidal and non-suicidal patients using the normal tests for means Suicidal Non-suicidal Suicidal Non-suicidal (Male) (Male) Mean No. of Items Chosen 17.17 23.79 17.9 24.2 Variance 1.80 .41 1.44 .74 Suicidal Non-suicidal (Female) (Female) Mean No. of Items Chosen 16.2 23.4 Variance 1.22 .90 Suicidal Male Suicidal Female Suicidal vs. vs. vs. Non-suicidal Male Non-suicidal Female Non-suicidal T Scores 4.5* 4.1* 4.9* *Significant at the 1% level. Results Null Hypgthesis 2 There will not be a significant difference in pathology between suicidal and non-suicidal patients. Alternate Hypothesis 2 There will be a significant difference in pathology between suicidal and non-suicidal patients. 39 Findin 8 To determine the reliability between the examiners, the reliable coefficient was done. The reliability between the two examiners was considerably above the level of acceptance required by the study. The minimum level of acceptance is .70. This level was surpassed on both the Draw-A-Person Test and the Bender-Gestalt Test (TABLE 5). TABLE 5.--Comparison of reliability of raters on Bender- Gestalt using the reliability coefficient (Guilford, 1954) Sum of Degrees of Squares Freedom Variance Raters 5 1 Persons 354 199 2.28 Remainder (error) __2 222 1.45 Total 368 400 r-97 In their earlier training, the examiners had different introductions to the Draw-A-Person Test. They were exposed to the same supervisor, however, when this test was used in the evaluation of schizophrenia. #0 TABLE 6.--COmpariscn of reliability of raters on Draw-A- Person Test using the reliability coefficient (Guilfcrd, l95h) Sum of Degrees of Squares Freedom Variance Raters 13 1 Persons 271 199 1.36 Remainder (error) _32 299 .1A Total 323 LOO r389 HELL Hypophgsis g Utilizing the two-tailed test, the hypothesis that there will not be a significant difference in psychopathology between the suicidal schizophrenic and non-suicidal schizo- phrenic patients was accepted. The difference between the psychopathology of the suicidal and non-suicidal patients, as a group, is non-significant on both tests. This was true of the male suicidal and non-suicidal as well as the female suicidal and non-suicidal groups. 41 as we on mm ca 5 a m m as we mm mm m H 4 ma mm an an Hesse Hesse -ssm Idem Inez Haddo Huddo Hdudo Hedda Hmudo Havao Maude Hedda Idsm lafim Idfim Idsm IdSM Idfim Ififim Idfim Isoz Inez Inez Inez puss somucmldlxmno on» waded macsasmwc 039 on» an mmocHHH mo hpancbom ho mooawou waapsn o>apmnmmaco ¢|I.w mamms MN HN andao Haddo IHfim Idzm Inez as mm mm m: «H ma H m mm am an as e a 4 Hesse Hesse Hesse Hesse Hesse Hesse Hesse suede uasm idem Idem Idem uasm Idem Idem nasm Iaoz Inez Inez Inez pmoB padpmoolhcenom one made: mncsasmxo or» on» an mmcsaaa mo hpdncbcm no moonwoo no mnupmn c>dponcmsoo 411.5 mqm<9 42 TABLE 9.--Comparison of degree of psychopathology between suicidal and non-suicidal subjects using the Bender-Gestalt and Draw-A-Person Tests Rater A Rater B Rater A Rater B Suicidal Suicidal Non—suicidal Non-suicidal Mean Bender-Gestalt 3.6a 3.h7 3.77 3.38 Rating Kean Draw-A-Person A.05 3.6a h.O9 3.77 Rating Suicidal Hale Suicidal Female Suicidfl. vs. vs. vs. Hon-suicidal Male Non- Female Non- suicidal suicidal T Score Rater A Bender-Gestalt 1.13 1.6 .6 T Score Rater A Draw-A-Person .6A 1.3 O. T Score Rater B Bender Gestalt .28 .55 1.6 T Score Rater B Draw-A-Person .61 .21 .005 o . u n c . t e - . - I u . . . c _ _ i . , . I ‘ CHAPTER V DISCUSSION W1 A Statistical comparison of the objects chosen by the suicidal and non-suicidal patients in the test of objects reveals that patients who are suicidal chose significantly fewer objects as important than the non-suicidal patients. Many possible reasons were not explored in this re- search as to why patients attempted suicide; but the results of the Test of Objects implies a very plausible cause. One significant difference between the suicidal and non-suicidal groups was the difference in the number of objects chosen by each group on the writer's Test of Objects. Speculation must be allowed as to the reason for this difference. Sup- port is given to the theory that as people regard fewer objects as important, their desire to live diminishes. There appears to be a need for objects in order to sustain the desire for life. Further evidence for this is seen by the number of patients (29) in the non-suicidal group who chose all the objects as important compared with the number 43 44 in the suicidal group (5) who chose all the objects as important. Often from the siicidal patients, we hear the statement, "I have nothing to live for." This research suggests that this kind of remark may have significant meaning in the motivation of suicide. The underlying theory in the development of Hypo- thesis 1 evolves from psychoanalytic theory, which states that suicidal patients withdraw their libido from objects outside themselves, tending to direct such energies in— ternally (Fenichel, l9h5). This theory is further expanded by the author because of his experience with suicidal pa- tients who state that they would die if it were not for certain objects they feel are important. The author's theory is that one will continue to have the desire to live as long as there are rewards available to him. If these rewards are taken away, either by external or in- ternal factors, the desire to live is reduced. When there are no rewards or objects available, then one wishes to die. If other dynamics such as internalized aggression are present, he may make a suicidal attempt. From Hypothesis 1, it can be concluded that suicidal patients who are diagnosed as schizophrenic find fewer objects of value than those schizophrenic patients who are non—suicidal. This statement is valid only in refer— ence to schizophrenic suicidals, and the inference should 45 not include types of suicidal patients other than schizo- phrenic. flyppthesis 15 Hypothesis 1A: The Test of Objects will differen- tiate suicidal patients from non-suicidal patients. This hypothesis was accepted at the 1% level. The test that the writer developed is able to differentiate suicidal from non-suicidal patients as a group. Some of the sui- cidal patients attached importance to all of the objects as did many of the non-suicidal patients. Thus, varia- tions in scores indicate that some suicidal patientS'will not be detected using the Test of Objects. Moreover, in discussing the protocols with the patients after they had taken the test, it was found that perseveration was a factor in some of the results. In some cases, the first response on the test was inadvertently repeated through- out, and in other cases, there was evidence of a tendency to avoid attending faithfully to the test. When the examiner questioned some subjects about this, they were unable to communicate clearly thd.r explanation because of their psychopathology. The examiner checked each participant in the non- suicidal group to make sure there was no history of sui- cide in his record. On occasion, when a patient checked 46 all or a high percentage of ocjects as unimportant, the examiner questioned him to determine if he had any history of suicide. Two of the patients who, on close investiga- tion, indicated a history of suicide were removed from the non-suicidal group and were placed in the suicidal group. Four of the patients in the non-suicidal group had chronic wishes to die, but never had made a suicidal attempt. The rest of the patients who chose many objects as unim- portant have no history of suicide nor suicidal thoughts. This provides some evidence that the Test of Objects with some revision may be useful as a screening device to help discriminate between suicidal and non-suicidal patients who are diagnosed as schizophrenic. Far more extensive re- search, however, is necessary before this test can be considered adequate as a screening device in general sui- cide. The wide variation of responses indicates that many suicidal patients would not be detected by the test as it is now composed. HEM; The hypothesis that there will not be a significant difference in the psychopathology between suicidal and non- suicidal patients was confirmed. Earlier research (Farberow, 1950) has suggested that the suicidal patient is a more severely ill patient than the non-suicidal. It 47 is the examiner's belief that this is not accurate. This is concluded from observations of suicidal and non-suicidal pa- tients. It may be that suicide is the method by which some patients choose to deal with their conflicts. The suicidal patient is often considered sicker because he suggested or attempted suicide, being possibly self destruc- i tive, and is a severe threat to the hospital staff and to ‘ the environment. : Suicidal behavior is considered by many the sickest means of adjustment. When the degree of psychopathology in suicidal and non-suicidal patients is measured by pro- jective tests, the differences in psychopathology is not significant. Certainly, this does not mean there is no difference in the psychopathology of the suicidal and non- suicidal populations; this does, however, mean that the relatively sensitive tests can not discriminate a differ- ence in psychopathology, and therefore, such differences as may exist can not be, in this study, considered very significant. The fact that two examiners, who have years of experience in testing, show such a high degree of agree- ment in their judgments, lends credence to the suggestion that there is not a significant difference in psycho- pathology of suicidal and non-suicidal patients. This hypothesis applies to the total population, and it can not be interpreted on an individual basis. 48 The highest reliability was on the Bender-Gestalt Test. It may be important to note that both examiners had their first introduction to this test by the same supervisor. This introduction occurred over five years ago but may be an important variable in the high degree of agreement. In their earlier training, the examiners had different introductions to the Draw-A-Person Test. They were exposed to the same supervisor, however, when this test was used in evaluation of schizophrenia. Some of the patients in the suicidal group were so disturbed that they would not know that they were injuring themselves. Their behavior was on an infantile level, and their capacity to differentiate their own thinking from reality was extremely impaired. These patients were judged suicidal because of injurious acts which they had inflicted upon themselves. The writer wonders, however, whether they can be judged suicidal any more than an infant could who injures himself be— cause cf poor reality testing. In the non-suicidal group, some of the patients were so severely disturbed that they would not have enough motivation or energy to inflict bodily harm. It is believed by the writer that suicide is an attempt at adjustment motivated by internal turmoil that 49 is relatively independent of the degree of psychopathology. of the patient. This statement can apply only to schizo— phrenic patients and can not be generalized to apply to other types of mental patients. AuEITFT ,CHAPTER VI SUMMARY AND CONCLUSION The Problem The purpose of this study was to investigate some of the dynamics of schizophrenic patients who have made suici- dal attempts and to compare these dynamics with patients who have not made suicidal attempts. An effort was made to develop a test that would aid significantly in screening schizophrenic patients who might be suicidal risks. The problem of suicide is a serious social problem and appears to be on the increase. There is a need for a method of recognizing the suicidal patient; such a method can mean saving the lives of many people. There are two main hypotheses and a sub-hypothesis advanced: l. Suicidal patients will choose significantly fewer objects as important than non-suicidal patients. 1A. The Test of Objects will differentiate suicidal patients from non-suicidal patients. 2. There will not be a significant difference in pathology between suicidal and non-suicidal patients. 50 51 Methodology app Procedure A pilot study was done from which the Test of Objects was developed with a list of objects named as important by psychology students at Michigan State University. From this list, two hundred items were selected, and they were devel- oped into the Test of Objects. This test was explained to schizophrenic patients. The patients were directed to determine each object's relative degree of importance, as: important, very important, unimportant, and very unimportant by placing a check mark under appropriate headings and be- side each object listed on a simple tally sheet. Forty schizophrenic patients were tested at Northville State Hospital--twenty suicidal and twenty non-suicidal. The suicidal patients were those who, according to the staff and hospital records, had made serious attempts on their lives. Non-suicidal patients were those who had no history of suicide. Twenty were male and twenty were female. The hypothesis of the study was that suicidal patients would choose significantly fewer objects as important.7 The pilot study substantiated the hypothesis at the lfi level of sig- nificance, using the Binomial Test of Proportions. The test of two hundred objects was analyzed, and thirty of them were found to be significant at the 5% level using Chi Square. The revised Test of Objects was then developed using thirty items and the major research was organiZed. 52 Two hundred patients from three institutions were used in the study. One hundred of them (fifty male and fifty fe- male) were in the suicidal group. One hundred of them (fifty male and fifty female) were in the non-suicidal group. All of the two hundred patients had been diagnosed as schizo- phrenic by the staffs of the institutions. The original hypothesis of the pilot study was retained, and one major and one minor hypothesis added. Recent research (Farberow, 1950) proposed that suicidal patients are more seriously ill than non-suicidal patients. It was the author's belief that this was not the case. For this reason, another hypo- thesis was evolved which stated that there was not a signi— ficant difference in psychopathology between the two groups. The instruments used to measure psychopathology were the Bender-Gestalt and the Draw—A—Person Tests. These tests were used because of the ease of administration and inter- pretation. Two examiners, one male and one female, who had at least five years of work experience with these instru— ments in uncovering the dynamics of schizophrenic patients, were employed to rate the degree of psychopathology. They were required to rate the protocols on a one to five range, one being Mildly disturbed and five being Very Severely disturbed. 53 Findings The hypotheses advanced were confirmed: Hypothesis 1: Suicidal patients would choose significantly fewer ob- jects as important than non-suicidal patients was confirmed at the 1% level of significance, using the normal test for means proportions. Hypothesis 1A: The Test of Objects will differentiate suicidal patients from non-suicidal patients was confirmed at the 1% level of significance, using the normal test of means. Hypothesis 2: There will be no significant difference in psychopathology between suicidal and non-suicidal patients was confirmed, using the T Test Statistic, two—tailed test. The degree of re- liability between Examiner A and Examiner B was .97 on the Bender-Gestalt and .89 on the Draw-A-Person Test. These results suggest strongly that the examiners who were rating the test agreed on standard measurements for mild, moderate, severe, quite severe, and very severe forms of schizophrenia. Qpnclusions and Implications The outcome of this research certainly suggests that one of the main causes of suicidal behavior is the inability of the patient to find objects that are of value to him in the environment. This can be considered only a general state- ment concerning schizophrenic suicidal patients as a group; “a H. I‘ ‘-'L‘.~ llll'l'lllII 54 specific implications regarding individual patients must be viewed with extreme caution. The view that the schizo- phrenic suicidal patient is sicker than the schizophrenic non-suicidal patient does not stand the test of this research. The more accurate implication is that the suicidal patient has a different method of solving his conflict.. He is a severely hazardous threat but not necessarily sicker from the standpoint of psychopathology. Research that was pre- sented after this study was begun also suggests that the suicidal patient is more dissatisfied with his treatment and is less a oonformist than the schizophrenic patient who is non-suicidal (Farberow and Shneidman, 1961). The Test of Objects does have some value in differen~ tiating suicidal from non-suicidal patients as a group. Its only implication is in reference to patients,as a group, who are diagnosed as schizophrenic, but since 70% of the pa- tients who commit suicide are in this diagnostic category, it could be, after further validation, a valuable tool in ascertaining potential suicidal patients (Farberow and Shneidman, 1961). The Test of Objects may indicate clues to suicidal tendencies and might be used as a quick screening device in the admission wards of hospitals. As the test is now composed, it is valid only in large group testing. Further investigation and revision must be made before it can apply validly and accurately to individuals. This 55 research suggests that the instrument has no face validity; therefore, it would be unlikely for the patient to be sus- picious about what the test measures. When many unimportant objects are checked by a patient, the suspicion of suicidal potential should be raised. A deep clinical interview and perhaps projective tests would give a more definitive answer to the question of suicide tendencies. Ear-:1- Another implication that this study suggests has refer- ence to the treatment of suicidal patients. It may be very important for the therapist to reward the patient so that the patient has something pleasant to which to look forward. Theoretically, it is possible that if the therapist arranges, for example, the Opportunity for a suicidal patient inter- ested in baseball to attend a baseball game, the suicide might be averted. The literature indicates that suicide can be averted by a phone call, an invitation to a dance, or other experiences that gives the patient pleasant anti- cipation (Farberow and Shneidman, 1961). The sickness of society can not be excluded as a fac- tor that influences suicide (Fromm, 1959). When the patient has no employment and can see no chances for employment, his motivation for living is reduced. Another therapeutic suggestion regarding suicidal patients is that the therapist should be keenly aware of 56 the things that the patient considers important. It is im- portant for him not to project his own values onto the pa- tient but to acquire from the patient the knowledge of things that the patient considers important. It is as important as anything else in the treatment of the suicidal patient to make sure that attention is given to what the patient val- ues. If, for any reason, the patient is disappointed,and the rapport is diminished, the chances of effective treat- E¥ ment are reduced significantly. ‘ Implicapiops £2; Further Research As a means of attempting to validate further the Test of Objects, it is suggested that a researcher administer it to a group of schizophrenic patients evenly grouped; for example, one hundred schizophrenic patients, twenty- five males and twenty-five females in the suicidal group, and twenty-five males and twenty~five females in the non- suicidal group. An important variable not used in this study might be that the scorer would not have access to the knowledge of which patients are suicidal and which pa— tients are non-suicidal. He could group the ones he considered suicidal and group the ones considered non- suicidal. He could then run a statistical analysis to determine how accurate his choices are. Another important suggestion is that the Test of Objects be given to patiaits 57 who are not diagnosed as schizophrenic but who have a his- tory of suicide and compare the results of their choices of items to the results acquired by testing a controlled group of people from the normal population. A refinement of the Test of Objects might be an im- portant contribution. This might be achieved by asking patients diagnosed as schizophrenic to list the ten most important things in life. After analysis of these ten important things is complete, a new test of objects could be compiled. A comparison between suid.dal and non-suicidal patients should then be completed. Anyone who is interested in determining whether the Bender-Gestalt and Draw-A-Person Tests can differentiate suicidal from non-suicidal patients could easily analyze these tests to see if there are any common factors that differentiate the two groups. If a common factor is found, it would be valuable to accompany the Test of Objects as an aid in differentiating suicidal from non-suicidal patients. BIBLIOGRAPHY Adler, Alfred. “Suicide,” Journal of Individual Ps cholo , Vol. 14 (1958), pp. 57.5I. Alexander, F., and French, T. N. Ps choanal tic Thera . New York: Ronald Press, 19 . Anastadi, A. Ps cholo ical Testi . New Yerk: Macmillan Company, I554. Anon. Chan es in the Method of Suicide, Statistical Bulletin, MetropoIItan LIfe Insurance, No. 25, 1947-48. Beck, S. J. Rorschach Test. 2. A Variet of Personalit Pictures. New Tbrk: Grune and Straétcn, I945. 7 Bergler, E. "Problem of Suicide,” Ps chiatric uarterl E4 Supplement, Vol. 20 (1946), pp. 251-275. 1 Blum, G. Ps choanal tic Theories of Personalit . New York: McGraw_EIII, 1553. Carmicheal, L. Manual of Child Psychology. John Wiley and Sons, 1954. Dollard, J., and Miller, N. E. Personalit and Pa chothera . New York: McGraw Hill Company, I955. Fromm, E. The Sane Society. New York: Rinehart, Inc., 1959. Fromm, E. Be and the Chains of Illusion. New York: Trident Press, I952. Farberow, N. L. “Personality Patterns of Suicidal Mental Patients,” Genetic Psychology Monograph, Vol. 42 (1950) PP- 3-79- Farberow, N. L., and Shneidman, E. S. The Cry for Help. New York: McGraw Hill, 1961. Farrar, C. B. ”Suicide," Journal of Clinical and Egperimental PazchoeathOIOEX, V01. ’ 0e , pp. - e Fenichel, 0. Ps choanal tic Theor of Neurosis. New York: N. W. Norton, I945. Freud, S. An Outline of Psychoanalysis. New York: N. W. Norton, . 58 59 Freud, 8. Be and the Pleasure Princi 1e. New York: Bantam Books, I959. Guilford, J. P. Psychometric Methods. New York: McGraw Hill, 1954. Greenwald, H. The Call Girl. New York: Ballantine Books, 1 Hertz, M. R. "Suicidal Configurations in Rorschach Records," Rorschach Research Excpgpge, Vol. 12 (1948), pp. 1-56. Hertz, M. R. ”Further Studies of Suicidal Configurations in Rorschach Records," Rorschach Research Exchapge, Vol. 1 13 (1949). pp. 44-73. L Hilgard, E. R. Theories of Learnin . New York: Appleton Century-Croft, Inc., I956. Hutt, M. L., and Briskin, G. J. The Clinical Use of the Revised Bender-Gestalt Test. New York: Grune and ra on, . Jallman, F., and Anastatia, M. "Twin Studies on the Psycho- pathology of Suicide,“ Journal of Nervous and Mental Disorders, 105 (1947), pp. 49-55. Lindner, R. M. Rebel Without a Cause. New York: Grove Press, Lindner, R. M. "Content Analysis in Rorschach Work," Rorschach Research and Exchange, Vol. 10 (1946), P e e ' Menninger, Karl. Man Against Himself. New York: Harcourt, Brace, 1938. Menninger, Karl. The Psychiatrist World. New York: Viking Press, 1959. Rabin, A. I. "Homicide and Attempted Suicide: A Rorschach Study," American Journal of Ortho s chiatr , (1946), pp. 516-524. Reichmann, F. F. Ps choanal sis and Ps chothera . Chicago: University of éHIcagc £ress, I959. Robins, E., et a1. "Some Interrelations of Social Factors and ClIfiical Diagnosis in Attempted Suicide," American Journal of Psychiatry, (1957), 114, 221, 231. 6O Rosen, H. H nothera in Clinical Ps chiatr . New York: Julian ress, . Shneidman, E. 8., and Farberow, N. L. Clues to Suicide. New York: McGraw Hill, 1957. Skinner, B. F. Science of Human Behavior. New York: Macmillan ompany, . Spitz, R. Hos italism: The Ps choanal tic Stud of the Child. Eew York: InternationaI Eress, Inc., V01. 1, Super, D. E. The Ps cholo of Careers. New York: Harper and Brothers, E957. Tiecher, J. D. “A Study of Attempted Suicide " Journal of Nervous and Mental Disorders, 105 (l9h7s, pp. 285-298. Von Andrzs, M. Suicide and Meaning of Life. William Hodge, l9 7. I l u o . 5 :. . ( I y . I i . I I c c . ( . -- u . ' I I O I ' v ,4 . . ; C C l - ' u . : i I ' ' /S/Z'>:T“r_v/~ In); [N rm. 1... 62 DIRECTIONS Please check the following items as to how important they are to you: 1.. 2- 3- 4- 5.— 6.— 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 2.0. 21. 22. Z3. Z4. 25. Z6. Z7. 28. 29. 30. VERY VERY ”E“ IMPORTANT IMPORTANT UNIMPORTANT S oft dr inks Television Peaches Pie Chocolate cake Self Summer 'Water Time active Christmas 4th Warm Summer Entertainment Ice Cream Fish life Milk Potatoe s Natur e Hot UNIMPORTANT APPENDIX B Data Records Male Suicidals Female Suicidals Total Suicidals Male Non-Suicidals Female Non-Suicidals Total Non-Suicidals 63 r‘W MALE SUICIDAL ‘5! O O U) E! O O 0) BENDEB DAP UNIMPORT. VERY TOTAL TOTAL UNIMPORT. IMPORT. VERY IMPORT. ED. AGE CODE 1? 10 18 10 12 11 10 20 1h 31 51 20 16 13 29 25 30 18 16 52 12 14 17 11 53 14 61 5a 55 56 1? 13 30 12 12 3h 18 35 23 23 23 30 12 10 57 12 18 15 11 58 15 23 59 23 60 27 27 20 16 12 61 11 12 28 25 30 62 27 27 63 30 29 10 64 65 66 23 23 10 10 31 26 26 3h AE'E ‘il' m m n m 9H H 0N 0H m N NH NH Nm N s n m m N m mN mH 0H NH mm Hm n m s e m. N m mN 0N m NH mm om : n N N mN o mN m a H NH NN on s a s m NH 0 nH 9H 0H H OH 9: mu m s s m m : NH NH nH m NH 9N an m m a m m o m 9N o “N m mm on a s m a N o N mN NN 0 NH :N mu m e a m o o 0 on mH 9H NH N: :9 s s a n o o 0 on c on 0H mm an “u .1 s a m H 9 NN m m m m 3 N9 9 s a e N m 9 mN oH nH HH HN H9 m, m e m H m 0H 0N 0H 0H 9 9N 09 ; m a a a o mN mN 9 o a m N: mm m m m n e N o :N NN N OH on we .r:. m m n m wH H 9H mH m a HH mN no . mmmmmH mmmmm .9momszo .9momszo H4909 H4909 .9momsH .9momzH .nm 904 @600 man mmnzmm 9mm> 9mm> Adofinapfloov AddHOHDm a: .r.. r. u y .1. ll . C . . i O. , O . U n l T . 1~ . . I A _ I . l I , I i . , q ,. ._ J. ._ , , I . . _ . . ., _ . — Brill... m e m m NH 0 9H NH NH 0 0H NH 3 a 4 N n m 0 m N NH 3 4H mm om m m a m 9 0H 9H NH NH H 0H NN mm m s s m 9 0 9 N N 0 H in la .3 m m H s m 0 m N NH NH 0 0m 3 ., . N m N N H 0 1. NN 0N N NH an Nm 0 m e 14 NH H NH HH HH 0 N i. Hm 1. m a s m N N NN NH 0H s HN 0N H m N n HN 0 HN N H m 0H H N % m s m s N m N HN N H m NH NN H m e n :H 0 3H NH N N 0H H N s s m 1. 0m 0 0m 0 0 0 NH 03 N H n m n N m m HN NH 0 :H on «N H n n e m on 0 0m 0 0 0 N an N if“... a a N N N 0 N HN 0N H H Hm NN mlmdmm W30“. .9N0N2H20 .33tz0 H4909 H4909 .308: .9595 .3. $4 .9000 m3 mmnzmm Hmm> Hm: Aconcapnoov gHOHDm a: 7 6 NN.N No.4 4.N m.m N.0H NH.H 0.NH N.NH N4.0H N sH.0H N.0N :Noz NNH :0N 0NH mNH Now NN HON NNN New 0mm sHm NomH Hapo9 N N n N N 0N 0 0N 0H 0 0H 0H NH 00H N s N a N o N NN NN o N NH NN : N N N N 0N H HN N N N N NH NN 111. 111. .111. mmmwm mmoom .9momtzs .9momszs H4909 H4909 .9m0mzH .9m0mxH .Hm mo4 9000 N40 mmnzmm 9mm> 9mm> Acodzduhoov dQHOHDm g O U manmddimsmtnnm: MN 0 0 U) BENDEB DAP 22 10 UNIMPORT . O s: HedoxomztchMNMr—ioaooxn mgNr—I .4 E... z :3 adémxomtxmmmmol-Ixowoooom E-GNH HNHN NHNr-l N HO EB "’ a e-cxomd-LxmcxmmmomHTH-Tmmcx g HNNu—l H 011-414 14mm cold-HTMBLxmxowmr-immwtx 141—1 HHN O E! >113: \omomoooooomdxomaoxoo EE HN H .4 H O QIONHr-IxotxmmmoxtxoxH-rmr-io trip-1.4.4.4 91911—1 149191.491 maxoommmiooxmmmmmnmox glNNmr-IHTNNMHTHTNHT-fimmm a: QIHNm-é‘nwmoooxoammsrnxo 8: 941-11-1141-11—191 H N N N N H N HN N NH HH HN NN H H N N H NH NH NH N H N NN HN H N H N HH 0 HH NH 0H N N 0N 0N N N N N NH 0 NH NH 0 NH NH NH NN . H H N H N H N N HN HN 0 0H NN NN .1 H N H N NH N NH NH NH N HH 0N NN N N H N H 0 H NN NN N N NH NN H H N N 0H N NH HH H 0H NH NN NN H H N N HH H NH NH N 0H N NN HN H N H N NH H NH HH N N N NH NN mw N H H N HH N NH NH N NH NH NN NN N H H N N 0 N NN N NN N NN HN N N N N N H H NN NH N HH NN 0N - N N H N NH N HN N N H 0H NH NH ..N N N N N NH H 0N 0H N H 0H 0N NH m N H N N HN 0 HN N N H NH NH NH 1 1.- m|1H NIIH 1.. 1| 1|. mmmmm 0mmmmm .90002920 .9mmmmwz0 H4909 H4909 .9000zH .9mmme .0m 004. 0000 Avoafidpdoov gHpom 342mm N N H N N N N HN NH N NH NN NH H H N N N H N NN NH NH NH NH HH N N H N H N N HN NH N NH NN mH H N H H N H N NN N 0N N 0N NH H H H H HH N NH HH 0 HH NH NN HH H N H N HH N NH NH N HH HH HH 0H H H H H N 0 N HN N NH NH NH NN m N N N N N N 0H N N NH HH 3 NN N H H H 0N 0 0N 0 0 0 HH 0N NN H H H N H 0 H NN N NN NH NN NN H N N N 0N 0 0N 0 0 0 N 0N NN N N N N NH H NH NH N HH N HN HN H N H N N N H NN NN 0 HH NN NN mdem Wowm .Eomfizb .33sz0 H4909 H4909 .9085 90005.. .0N 004 .0000 N40 mmnzmm Hmm> N00> AdossHpaoov AddHUHDm mudxum OI! .- II. B. ill“ .. Elaid‘fi. L . HN.N N0.H NH.N HN.N NH.0H NN.N NN.NH NH.NH N.N NN.N N.0H H.NN cams ,x. . HNN N0H NHN HNN NH0H NNN NNNH NHNH 0NN NNN 0NOH 0HNN Hm009 .. H400000N NHHHNN 0246NH42 NN.N N0.H HN.N NN.N HH.0H N.N N.NH N.NH 0H.N NH.N NN.0H N.HN 0mm: mm HNH H0N NNH NNH HHN NNH NNN NHN HOH NHH NNN N0NH Hmpo9 A1 Iml ~11 ml mm. ml. .HJNI NI ml. w1l m1 .IHNI 0N H H H H 0 0 0 0N 0 . 0N N NH NH , _ H H H H NH 0 NH HH HH 0 NH NN NH 1 h N H N N NN 0 NN N N N NH HN NH 11L1Nm N H N H HH 0 HH NH NH N NH NN NH mmmmmH mmmmm .9N0Nz020 .9N0N2H20 H4909 H4909 .9m0NzH .9N0NzH .00 m04 N000 N40 m002m0 HNN.» N0.H; “defiandoov AddHOHDm 342mm MALE NON-SUICIDAL ‘51 O O U) a O O U) E m E z ‘13 UNIMPORT . VERY TOTAL TOTAL UNIMPORT . IMPORT . VERY ED . IMPORT . AGE CODE 11 14 16 24 20 27 30 16 22 28 31 151 152 153 154 155 156 157 158 159 160 161 162 163 15 10 14 10 21 10 O O 30 28 38 23 30 14 30 12 35 42 19 11 3O 11 14 30 12 16 28 36 29 40 00 10 3O 20 28 30 14 15 3o 12 1, 13 12 42 21 3O 21 30 38 11 164 10 38 165 166 167 15 10 27 15 12 11 33 1-1 N 53 I1,- ll .11! '11 ill-1| IN‘. N N N N H 0 H NN H NN N NN NNH N N N N N 0 N NN NN 0 N NN NNH N H N H 0 0 0 0N 0 0N NH NN HNH H N N H 0 0 0 0N 0 0N N 0N 0NH N N H N H 0 H NN HN N NH NN NNH N N N N 0 0 0 0N 0 0N N HN NNH N N N N HH N NH NH NH 0 N NN NNH H N N N 0 0 0 0N HH NH 0H NN NNH H N N N 0 N N NN 0 NN N NN NNH N N H N 0 0 0 0N 0 0N N NN HNH m N N N H NH N N NH N N NH NN NNH N N H N 0 0 0 0N N NN N NH NNH N N N N 0 0 0 0N 0 0N H HN HNH H H N N 0 N N NN 0 NN NH HN 0NH H H N H NH 0 NH NH NH 0 N NN NNH H N H N 0 0 0 0N 0H 0N N NN NNH mmmmm mmmmm .9N0NsH20 .9N0Nszn H4909 H4909 .9NONzH .9NON2H .00 004 0000 m3 mmnzmm Hug Hmm> dofifidnnoov gHOHDmvzoz and: . H 1 x I. . r , H . . . . . . _ I o a .. . . H .. . o . o a . . . v I. I . . u :0. |.I. . v . a! .l .n... ... II .lv.| . . a . x r I; .l . . . .. . . . Aqr . . I I 4 . 1 I r . . a. . , ; H I . . I . . s . 4 . . I. a . 1 v . . . . v _ u H L n . 4 . I N N N N N 0 N NN NH 0H N NH NNH N H N H NH 0 NH NH NH N 0H NH NNH N N N N H H N NN NH NH N HH NNH N N N N 0 H H NN HH NH N NH NNH H H N N H H N NN H NN N HH HNH N N N N N 0 N NN HH N NH NN NNH H N N N N 0 N NN 0H NH NH NN NNH H N N N 0 NH NH NH N 0H HH NH HNH N H N H N N N NN HH HH NH NN 0NH W H H N N HH 0 HH NH NH H NH HN NNH N N N N NH 0 NH NH NH H NH NN NNH N N N N N H N NN N NH HH NN NNH N H N N N 0 N NN NH HH HH NH NNH H H H H 0 NH NH NH 0 NH H NN NNH H N N N H N N NN NN 0 N 0N HNH mmmmm mmmmm .smomsza .amomszo HHBON HNaoe .amomzH .emomzH .nm NNN N900 qu mmnzmm wmm> Nmm> Adodnapzoov gHUHDmIZOZ g .N . . I. ‘ o . I. . . I v I . I. . H. . I I. .I . II . III.» I: .I.I II-.. IIIIIvu . . . I . _ H. . . . . l N .- . , . 4 I .1 1 .. . . . .I . . I . i I l . . , . z / . i i 75 N0.H NH.H N.N NN.N NN.N N.N N.N N.HN N.NH N.NH H0N N0N NNH NNH NNH NOH HNN N0NH N0N N0N :N: :m: ~:: m:: m:: NI: m:: NMI: NH: NH: H H N N H 0 H NN NN H mmoom mmoom .amomszp .amomszp HNHoa HHHoa .amomzH .amomxH Nda mmnzmm Hmm> Hmm> Auoaannoov HHquHoNIzoz NHN: NH.N NNH NN.NN ado: NNNH Hapoa NH 00N NH NNH mod mnoo H H N H 0 0 0 0N 0 0N N NN NHH H N N N N 0 N NN NH H HH NN NHH N N H N 0 0 0 0N 0 0N N HN HHH N N N N NH 0 NH NH HH N NH NN NHH N N N N N H H NN NH NH N NH NHH H H N H NN 0 NN N N H NH NH HHH H H N N N H N HN NN N NH NN 0HH N N H N 0 0 0 0N H NN N HN NOH N H N N N N NH NH 0 NH N 0N NOH H N H N H H N NN 0H NH N NH N0H «N H H N N H N N HN N NH NH HN N0H N N N N 0H 0 0H 0N NH N NH NH NOH N H N N N o N NN NH N 0H 0N HoH N N N N HH N NH NH NH H NH NN NOH N H H H 0 0 0 0N H NN N NH N0H N N N H N N H NN NH N HH NH HOH mmmmm mmmmm .amomzHZN .emomszN H4909 H NNNN anOHDmlzoz mgmh .I‘Ivl N N N N N N HH NH N HH HH NN NNH H N H H N 0 N NN 0H NH NH NN HNH N N N N NH H HN N N H 0H NH 0NH N N H H 0 H H NN N HN HH NN NNH N N N N N H H NN N NH NH HH NNH N N H H 0 0 0 0N N NN N NH NNH N N N N H H N NN NH N NH NN NNH N H N N 0N 0 0N 0H N H N NH NNH H N H N N 0 N NN NH N N HN HNH N N N N N HH NH NH N 0H NH NN NNH W N H N H N N HH NH N N HH NN NNH H H H N 0 0 00 0N 0 0N N 0H HNH N N H N H o H NN NN o NN NH oNH N H H H 0 0 0 0N 0 0N NH NN NHH H H H H NH N NN N N 0 NH NN NHH N H N N 0 0 0 0N 0N 0 NH 0H NHH mmmmm mmmmm .amomszp .amomszp H4909 H4909 .amomzH .amomxH .nm mod Naoo NHN munzmm HNN> Hmm> Uofifldpnoov gHoHDmlzoz 3mm III: I, .‘o IIIII CI- 'IIII'I r .I N, N H H H 0 0 0 0N H NN 0H NH NHH H N H N 0 0 00 0N N NN N NH NHH N N N N 0 0 0 0N N HN NH HN NHH N H H H N 0 N HN NH N NH NN NHH N N H N 0 0 H NN NH NH NH NN HHH N H N N 0 0 0 0N NH NH NH NN NHH N H N N H 0 H NN N NN N NN NHH H N N H 0 0 0 0N 0 0N 0H NN HHH H N N N N 0 N HN 0H . HH HH NN 0HH H N N N N N HH NH HH N NH HN NNH NW N N H N N 0 N NN H NH 0H NH NNH N H N H HH N NH NH 0H N NH HH NNH H H N H N N N NN H HN NH NH NNH H H H N 0 0 0 0N 0N 0 H 0N NNH H N N H N 0 N NN HN H NH NN HNH N N N H HH 0 HH NH N NH N NH NNH mmmmm mmmmm .amomtza .amommst H4903 H4909 .amomzH .amomxH .aN NNH Naoo NHN mmnzmm Hmm> Hmm> Adogndpnoov gHUHDMIZO—a g I. I. _ a . I r N N I. .. I . I . o o .. . . . O . I.I 9. . It a I I I I I . I II I... I III: I It'l; .OlalID .I.II II II I III (I III: I III I I N I . I . . ._ . . . I I I .I . I ; I . 4 l u ; I . . . 4 . J NN.N N0.H NH.N NN.N H.H HN.H HN.N NN.NN N0.HH N0.NH 0.0H N.NN HNN: NNN NOH NNN NNN 0HH HNH HNN NNNN N0HH N0NH 000H 0NNN Hopes 9 7 HHaHoHNNIzoz NqHsz n24 NHH: NN.N 0.H NN.N NN.N H.N NN.H N.N H.NN N.0H NH.NH NN.0H NH.NN can: NNH 00N NNH NNH HNN NN 0NN HNHH N0N NNN NNN NHNH Haves 441fl fl fl QIMINI W WNWNH H H N N 0 0 0 0N 0N 0 NH NN NHH m H m 4 III III IIII mmoom mmoom .amomszN .amomszp HHgos H4909 .amomzH .amomzH .nm NNH mnoo qu mmnzmm Nmm> wmm> Adonflfipfloov gHUHDmIzoz magnum pa;- f” :3 I: II H.' l . iibuul Wm” .4 L S” III“ " All“ H mm: 7 1293 03056 43 3