doi: 10.1111/j.1742-1241.2006.00960.

ORIGINAL PAPER
Graphology for the diagnosis of suicide attempts: a blind
proof of principle controlled study
S. Mouly,1 I. Mahé,1 K. Champion,1 C. Bertin,1 P. Popper,2 D. De Noblet,2 J. F. Bergmann1

SUMMARY Internal Medicine A, 1Hôpital

Lariboisière, Paris, France,
To evaluate the ability of two graphologists and two practising internists not
Société Française de
trained in graphology to differentiate letters written by subjects who have attemp- Graphologie, 2Paris, France
ted to commit suicide by self-poisoning and healthy volunteers, we performed a
maximal blind controlled study vs. healthy volunteers. Forty fully recovered patients Correspondence to:
Dr Jean-François Bergmann,
who had attempted to commit suicide and 40 healthy volunteers wrote and signed
PhD, Service de Médecine
a short letter or story not related to the parasuicide or their mental health status. Interne, Hôpital Lariboisière, 2
The evaluators classified the 80 letters as ‘suicide’ or ‘no suicide’ in an intention- rue Ambroise Paré, 75475 Paris
to-treat analysis. Letters expressing sadness were subsequently excluded for a per- Cedex 10, France
Tel.: + 33 1 4995 6341
protocol analysis. Correct diagnosis of suicide and of healthy controls was made
Fax: + 33 1 4995 8446
in, respectively, 32 of 40 and 33 of 40 letters by the graphologists and in 27 of Email: jf.bergmann@lrb.aphp.fr
40 and 34 of 40 letters by the internists. After the exclusion of 12 letters expres-
sing sadness, the sensitivity, specificity, positive predictive value and negative pre- Disclosures
The authors stated that they
dictive value were, respectively, 73, 88, 81 and 82% for the graphologists and 53,
have no interests which might
89, 80 and 71% for the internists. Both classified the letters with significantly be perceived as posing a
more effectiveness than chance (p < 0.001) with no statistically significant differ- conflict or bias.
ence between the two groups of evaluators. We concluded that graphological ana-
lysis is able to differentiate letters written by patients who attempt suicide from
those written by healthy controls. This technique shows an acceptable degree of
accuracy and could therefore become an additional discharge or decision-making
tool in Psychiatry or Internal Medicine.

patients (7). Graphologists claim to be able to deter-

Introduction
Suicide is a major public health problem, but there
is little evidence regarding the effectiveness of pre-
vention programmes (1). Predictive evaluation of the
risk of suicide is difficult both in general practice (2)
and in psychiatric units (3). The level of self-control
in a patient presenting risk factors for suicide cannot
be evaluated using a single test (4), but it is never-
theless important that this should be approached for
therapeutic decision-making, hospitalisation or dis-
charge.
Medical graphology is a subjective method of
handwriting analysis for evaluation of personality
(5). But only few psychological characteristics such
as psychoses, psychosomatic symptoms or extraver-
sions (6) have been correlated with graphological
characteristics. Because of the poor methodology of
these studies, it is not clear whether graphology is
able to determine the psychological profile of
mine pathological behaviour such as hysteria or
depression by the simple analysis of a single ‘neutral’
letter from patients and to be able to exclude these
diagnoses in a healthy control population. But the
sensitivity and specificity of graphology in the diag-
nosis of psychiatric diseases have never been prop-
erly evaluated, in particular because of the difficulty
in obtaining a definitive positive diagnosis in
patients and excluding such a diagnosis in healthy
controls (8). For graphologists, handwriting analysis
can determine suicidal behaviour before or after a
suicide attempt. Letters from patients recovering
from a recent suicide attempt are thus a good model
for evaluating graphology in a controlled study vs.
letters from healthy subjects without a history of sui-
cide. If this method proves to be efficient for a psy-
chiatric diagnosis of suicide, it could be proposed as
a part of the clinical evaluation of suicide risk in
patients.

ª 2007 The Authors

Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, March 2007, 61, 3, 411–415 411
412 Graphology for the diagnosis of suicide attempts
Methods
We asked consecutive patients hospitalised in the
intensive care unit of two large primary care Paris-
ian hospitals for deliberate self-poisoning with
drugs to write a story or a short letter relating a
childhood memory not linked to the parasuicide.
This request was made on the day of discharge
from the hospital to patients free of any prescribed
drug who were alert and who had undergone a
normal neurological clinical examination. The
patients were given sheets of white paper and var-
ious writing tools (pen, ball-point pen and pencil).
The letter had to be signed. The control group
consisted of healthy volunteers with no history of
parasuicide and no depression evaluated by a
MADRS (range 0–60) below 16. Patients and con-
trols received written information about the study
and gave written informed consent. A randomised
number was given to each letter by an investigator
(CB) not participating in the graphological evalua-
tion. The letters from the patients and controls
were then mixed. Information concerning age, sex
and left or right hand status was given with the
letters to two independent teams of evaluators
blind to the diagnosis: (i) two graphologists and
(ii) two physicians from an internal medicine unit
without any knowledge about graphology. The four
evaluators did not know any of the patients or the
control subjects. Each evaluator decided to dichoto-
mously classify each letter as suicide or control. In
the event of a discordance between the two graph-
ologists or between the two internists, an attempt
to reach a consensual diagnosis was made by
means of an open discussion.
We calculated that a sample size of 80 (40 per
group) was necessary to observe a difference of
Table 1 Number of correct graphological diagnoses (%) of parasuicide by two graphologists and two internists after reading letters from patients
following attempted suicide (n = 40) and healthy controls (n = 40)
Graphologists
Graphologist 1 Graphologist 2
ITT analysis
Suicide (n = 40) 31 (77%) 31 (77%)
Control (n = 40) 33 (83%) 31 (77%)
Per-protocol analysis
Suicide (n = 30) 21 (70%) 22 (73%)
Control (n = 38) 33 (87%) 31 (82%)
ITT, intention to treat.
Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, March 2007, 61, 3, 411–415
20% between the graphologists and chance (correct
diagnosis by chance 50%, correct diagnosis by
graphologists 70%) with b = 20%, a = 5%. Inten-
tion-to-treat analysis included the 80 letters. Per-
protocol analysis was made after the exclusion, by
an investigator blind to the diagnosis (JFB), of the
letter expressing sadness which would have orienta-
ted the final diagnosis. The v2 one-sample test was
used to compare the observed results with a chance
response of 50%.
Results
The letters were collected between April and Sep-
tember 2002. The two suicide (n = 40) and control
(n = 40) groups were similar in terms of mean age
(respectively 38.0 and 37.7), sex (male 12 and 15)
and left hand status (3,1). The mean MADRS
score in the control healthy group was 6.72 ±
3.7.
Classification of the letters as suicide or controls
by the graphologists and internists is presented in
Table 1. All 80 letters were included in the ITT
analysis. A discordance between the two grapholo-
gists was observed in 12 cases, but the consensus
discussion finally led to correct diagnosis in eight
cases. In brief, the graphological diagnosis had a
sensitivity of 80% (IC 66–90), a specificity of 82%
(IC 95%: 67–91), a positive predictive value of
82% (IC 95%: 67–91) and a negative predictive
value of 80% (IC 95%: 66–90). Their final diagno-
sis was statistically superior to a chance distribu-
tion (a2 = 15.6, df = 2, p < 0.001). For the
internists, the results were sensitivity 0.67, specifi-
city 0.85, positive predictive value 0.82 and nega-
tive predictive value 0.72, also statistically different
to chance (v2 = 12.2, df = 2, p = 0.005). There
Internists
Consensus Internist 1 Internist 2 Consensus
32 (80%) 26 (65%) 27 (68%) 27 (68%)
33 (83%) 34 (85%) 31 (77%) 34 (85%)
22 (73%) 16 (53%) 16 (53%) 16 (53%)
33 (87%) 34 (89%) 31 (82%) 34 (89%)
ª 2007 The Authors

was no statistical difference regarding the accuracy
of the diagnosis between the graphologists and int-
ernists (p = 0.45).
For the per-protocol (PP) analysis, 12 letters
expressing sadness were excluded: 10 from the sui-
cide group and two from the control group. Ele-
ven of these were classified as ‘suicide’ by both
teams of evaluators in the ITT analysis. In the PP
analysis, the characteristics of the graphological
test for graphologists and internists after confron-
tation were, respectively, sensitivity 73 and 53%,
specificity 88 and 89%, positive predictive value
81 and 80%, negative predictive value 82 and
71%. Both the graphologists and the internists
remained significantly different to chance in the
PP analysis (p < 0.001 for both evaluator groups).
After initial evaluation of the 80 letters, the two
graphologists disagreed on the diagnosis of 12 let-
ters; the consensus session led to a final correct
diagnosis in eight letters. For the internists, diver-
ging opinions were observed in 22 letters and a
consensus was obtained with a final correct diag-
nosis in 14.
Discussion
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 (5). But the correlation between the
writing and the psychological profile is essentially
based on case reports in which graphological char-
acteristics are described with full knowledge of the
psychological characteristics of the subject (9).
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 graph-
ological analysis could predict this risk with a
good level of predictive value, it could become a
tool in the decision-making process (10). 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
ª 2007 The Authors
Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, March 2007, 61, 3, 411–415
Graphology for the diagnosis of suicide attempts 413
written by subjects who had survived such an
attempt. These subjects were known to have
attempted suicide and there was no risk of diag-
nostic 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 influ-
enced their writing. We performed the study in
patients who had recovered a normal level of
alertness, on the day of discharge from the hospi-
tal. 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 differ-
ences 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 detec-
ted by practising internists who were not graphol-
ogists 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%, respect-
ively.
Our study had some limitations. The study eval-
uated 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 dis-
orders. The grounds which led the graphologists to
consider the letters to have been written by sub-
jects who had attempted suicide are not unequivo-
cal. 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 graph-
ics, 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 pre-
diction of suicide.
As we did not include a formal depression rat-
ing scale to evaluate subjects who had attempted
414 Graphology for the diagnosis of suicide attempts
suicide, it was impossible to search for a correla-
tion 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 compar-
ing the assessment of 10 graphologists in the diag-
nosis of extraversion showed good agreement
between the graphologists, but in this study, only
six subjects were evaluated without any healthy
control group (6). In another study (8), graphol-
ogy 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. How-
ever, 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 demon-
strated, using a solid methodology, that graphology
was not reliable in the diagnosis of psychiatric ill-
nesses such as suicide. Conversely, our positive
results are not sufficient to provide overall valid-
ation of this method. A future study using letters
written by foreign patients in a language unknown
by the graphologists and ⁄ or mixing several differ-
ent types of clearly differentiated psychiatric illnes-
ses 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 prin-
ciple trial.
In conclusion, we have shown that graphological
analysis is different to chance in evaluating the
presence of a suicide risk in handwriting, but fur-
ther studies are needed before the true role of this
technique in the diagnostic process can be estab-
lished.
An association between words used to describe
handwriting features and personality traits might
be a reason for our positive results (13). 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 graph-
ology but simply to evaluate the value of graphol-
ogy as a diagnostic test. Even with 27% of false
Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, March 2007, 61, 3, 411–415
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 informa-
tion 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 (14). Indeed it
should be noted that in psychiatry, many therapeu-
tic 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 (15).
We can conclude that graphology is able to differ-
entiate letters written by patients who attempt sui-
cide 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 let-
ters.
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Paper received August 2005, accepted March 2006

ª 2007 The Authors

Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, March 2007, 61, 3, 411–415