The Rorschach Interaction Scale as a Potential

Predictor of Cancer

PIRKKO LAUSLAHTI GRAVES, MAG PHIL, P H D , LUCY ANN MEAD, S C M ,

AND THOMAS ARTHUR PEARSON, MD, P H D

In a long-term prospective study, medical students who later developed cancer, in contrast to
the rest of the cohort, gave Rorschach test responses indicating less satisfactory interpersonal
relationships as assessed by the Rorschach Interaction Scale (RIS). The scale remained as a
predictor of cancer after adjusting for smoking, serum cholesterol level, and age in medical
school, and after taking into account the date of diagnosis and length of follow-up time. An
exploration of the relationship between the RIS and specific types of cancer suggested that
cancers of the lung may be less influenced by this psychologic factor than are other cancers.
The findings were interpreted to suggest that internal self-other representations as measured
by the RIS are involved as regulators of biologic systems and manifestations of illness, such as
cancer.

INTRODUCTION representing increasingly "negative" or ag-

In a previous report (1) we described a
new method to assess individual attitudes
and expectations in relation to others ("re-
lationship potential"). Using those re-
sponses given to the Rorschach test that
involve an interaction between at least two
figures, the first author (PLG) constructed
an 11-point Rorschach Interaction Scale
(RIS). The primary aspect of the scale con-
cerned the emotional tone of the interac-
tion. Two major dimensions of emotional
relatedness were defined, one dimension
representing increasingly "positive" or
harmonious interactions and the other
From the Department of Medicine, The Johns Hop-
kins University School of Medicine, Baltimore,
Maryland
Address reprint requests to: Dr. Pirkko L. Graves,
The Precursors Study, 550 North Broadway, Balti-
more, MD 21205.
Received January 6, 1986; revision received April
9, 1986.
gressive, disharmonious interactions.
The impetus to develop this new method
derived from recent reports by Thomas and
colleagues from the Precursors Study (2,
3). This long-term prospective study col-
lected broad-based psychobiologic data on
a cohort of 1337 Johns Hopkins medical
students in classes graduating in 1948
through 1964. Annual recordings of health
since graduation have permitted the iden-
tification of those subjects, now in their
50s and 60s, who have remained in good
health as well as those who have devel-
oped a major disorder (e.g., hypertension,
coronary heart disorder, cancer, mental
disorder). One measure from the Precur-
sors Study, the Family Attitude Question-
naire (FAQ)—a 65-item adjective checklist
of attitudes between family members as
perceived retrospectively by the medical
student subjects—indicated a relative lack
of closeness to parents among the future
cancer and mental disorder groups as com-
pared with the healthy group (2-4). The
RIS scale, also measuring attitudes and ex-
pectations in relation to others, was ex-

Psychosomatic Medicine Vol. 48, No. 8 (Nov./Dec. 1986) 549

Copyright © 1986 by the American Psychosomatic
Published by Elsevier Science Publishing Co., Inc. 0033-3174/86/S3.50
52 Vanderbilt Avenue, New York, NY 10017
 P. L. GRAVES, L. A. MEAD, and T. A. PEARSON
pected to corroborate these earlier findings
regarding the role of interpersonal rela-
tionships in health and illness.
In the previous report (1), the RIS scale
was applied to the Rorschach responses
given by 319 healthy medical students. The
individual ratings were then categorized
by range of interaction as belonging to one
of six patterns that varied from a well-ad-
justed attitude (i.e., moderate degrees of
both positive and negative scores in the
rating) to less well-adjusted attitudes (i.e.,
extreme scores of both positive and neg-
ative ratings, or a lack of any interactional
ratings.]. Comparisons between the youth-
ful relationship potential thus assessed and
midlife health or illness showed that the
future cancer victims differed significantly
from their fellow students who remained
healthy but resembled those who later be-
came mentally ill or committed suicide;
both the cancer and the mental disorder
groups demonstrated, on the average, less
well-adjusted interaction patterns. The
present report, using larger numbers of
subjects and more rigorous statistical pro-
cedures, seeks to place the initial RIS find-
ings in the proper perspective by analyz-
ing them in more detail and examining
other factors which might be related.
METHODS
Subjects and Data Base
The Rorschach test, in either the individual or group
form, was administered to 1154 medical students
(86.3% of the cohort of 1337 students). At the time
of the test, the students were all in good health; the
median age was 23 years. The present inquiry has
been confined to white male subjects for the sake of
homogeneity because 88.6% of the entire cohort be-
longed to that sex/race group: Of the 1032 white male
subjects who took the Rorschach test in medical school
(527 in the individual, and 505 in the group form),
550 Psychosomatic Medicine Vol. 48, No. 8 (Nov./Dec. 1986)
nearly half has consistently reported good health
(N = 488,47.3%). Excluding all those subjects among
whom a major disorder was diagnosed before grad-
uation from medical school (N = 69), the following
disorder groups were identified as of January 1,1984.
Forty-five subjects reported major malignant neo-
plasm as defined in Rubrics 140-190 and 192-207
of the International Classification of Diseases, World
Health Organization, Seventh Revision, 1957. The
types of cancer represented were lung (seven), testis
(six), Hodgkin's disease (five), malignant melanoma,
prostate, large intestine (three cases each), pancreas,
salivary gland, lymphosarcoma, bladder, and con-
nective tissue (two cases each), and one case each of
rectum, brain, stomach, larynx, thyroid, kidney, mul-
tiple myeloma, and leukemia.
Ninety-nine subjects reported having essential hy-
pertension and being under treatment with antihy-
pertensive chemotherapeutic agents, whereas 43 had
a coronary heart disease (for the most part coronary
occlusion or angina pectoris). Thirty-seven men were
found to have a mental disorder usually severe enough
to require a period of hospitalization. Among these
were ten suicide cases, of whom five had been hos-
pitalized for mental illness while the others had been
severely emotionally disturbed. Two additional dis-
order groups were considered because of their pos-
sible etiologic connection with cancer: skin cancer
(N = 51), consisting of subjects with basal or squa-
mous cell carcinoma of the skin, but excluding mel-
anoma, which was placed under cancer, and benign
tumor (N = 78), consisting of subjects with a non-
malignant neoplasm. Finally, duodenal ulcer (N = 35)
as a separate disorder group was included. The rest
of the subjects (N = 87) reported miscellaneous dis-
orders, but the number within each disorder group
was too small for useful comparisons.
Selection of Covariates
A wide range of physiologic and metabolic mea-
sures were collected from the subjects while they
were in medical school as part of the Precursors Study
(5). Based on documented risk factors for major ill-
nesses, in particular cancer and cardiovascular dis-
eases (6-9), the effects of the following covariates
(risk factors) were statistically controlled on the RIS:
smoking (number of cigarettes smoked daily); serum
cholesterol level; systolic blood pressure; Quetelet
index (weight in kilograms divided by squared height
in meters); and age in medical school.
RORSCHACH AS A CANCER PREDICTOR

Rorschach Interaction Scale
The assumption underlying the RIS scale is that a
person projects his or her basic, enduring sense of
emotional relatedness with others on the Rorschach
responses involving human, humanlike, or animal
figures in interaction (1). Thus only those responses
that describe two or more figures in some sort of
mutual arrangement are used for scoring. Further-
more, only responses given in the spontaneous or
free association period are used without regard to
card, location, determinants, or elaborations added
during the inquiry. The bipolar 11-point scale con-
sists of scores ranging between +5 and - 5 , where
scores from 0 to + 5 represent increasingly positive
degrees of emotional involvement, whereas scores
from - 1 to - 5 represent increasingly negative de-
grees of involvement (Table 1).
computer (10,11). The printout of each protocol was
labeled only by a confidential identification number
and kept entirely separate from the subjects' medical
data. The ratings were made from the printouts of
the individual protocols and were done without
knowledge of the subjects' identities, including their
health status.
Two research assistants and the first author, work-
ing independently from the printouts, rated the pro-
tocols. A satisfactory interrater agreement between
each assistant and the first author was obtained
(r = 0.83, 0.82, respectively). However, to ensure
maximal reliability of final ratings, the first author
checked the individual ratings, and, in cases of dis-
agreement, the final ratings were made jointly fol-
lowing discussion. In all, 7312 ratings were obtained,
yielding approximately seven responses per protocol
(X = 6.51, SD = 4.80).

RIS Ratings RIS Patterns of Interaction

The medical students' handwritten Rorschach re- Besides treating the RIS scores in the usual quan-
sponses, some 40,000 in all, had been printed out by titative fashion, another approach was developed in

TABLE 1. Rorschach Interaction Scale"

Scale Emotional Tone Degree of Involvement Examples
+5 Warm, affectionate Close, intimate A young couple kissing
Two caterpillars embracing after a long separation
+4 Happy, gay Mutual enjoyment and People telling jokes together
sharing Puppies playing around with each other
+3 Friendly, congenial Sociable Two people shaking hands
Two children running hand in hand
+2 Implied goodwill Collaboration or Two girls cooking
sharing Two cows looking at each other
+1 Neutral coexistence Parallel activities Two priests kneeling
Two bats hanging from a roof
0 Undefined or neutral "Action" nouns Two dancers
associated with a Two vampires
specific activity
-1 Vague disharmony, mild Parallel activities Two young girls facing away from each other
discord Two little animals crawling in opposite directions
-2 Moderate discord Moderate aggressive Cowboys having a tug-of-war over a cow's skull
action Rat fleeing from a cat
-3 Deliberate contention Overt confrontation Two men shouting invectives at each other
and/or antagonism Two dogs snarling at each other
-4 Deliberate aggressiveness Aggressive physical Two knights on horseback striking at each other
contact Two bears fighting with bloody forepaws
-5 Extreme feelings of Physically destructive Two cannibals boiling Macbeth in a kettle
aggression, violence or violent acts Two animals fighting to tear apart another animal
a
The scale and a rating manual are available on request from the first author (PLG).

Psychosomatic Medicine Vol. 48, No. 8 (Nov./Dec. 1986) 551

 P. L. GRAVES, L. A. MEAD, and T. A. PEARSON

which each protocol was categorized by range of in-
teraction responses. To clarify, the mean RIS score
for each individual would represent the overall, or
average emotional tone of the interactions in the en-
tire Rorschach protocol. But a mean score of "0," for
example, would encompass such widely diverse pat-
terns of response as a) a subject who gave only a
single 0 response, and b) a subject who gave a single
- 5 and a single +5 response. It appeared desirable,
therefore, to consider variations in the combination
of positive and negative scores. These combinations
were conceptualized as reflecting variations in in-
dividual capacity to regulate and tolerate mutually
opposite feelings in relationships with others (12).
Two considerations guided the identification of
the ranges. First, the frequency distribution of the
scores was taken into account; for example, the pro-
portionately low occurrence of the extreme scores
(2% each) would suggest a special selectivity and
importance of a response with a +5 or - 5 rating.
Second, the qualitative differences between the score
categories, embedded in the construction of the scale,
were considered. Thus an expression of feelings of
deliberate contention or antagonism without physi-
cal contact (-3) would appear significantly different
from an expression of deliberate physical aggression
(-4) and would represent a qualitatively different
approach to angry or aggressive feelings.
Again, the patterns and their ranges were defined
without knowledge of the individual subjects' health
status. Six patterns of interaction were defined and
are described here briefly. A more extended descrip-
tion is given in the previous report (1).
Pattern 4: "Controlled." An emotionally reserved in-
volvement in relationships in that positively and
negatively toned feelings are experienced and tol-
erated in a controlled, restricted range only. Com-
prises both positive and negative scores within the
+ 3 to - 3 range, with one or both of these scores
included in the rating.
Pattern 5: "Ambivalent." A poorly balanced ap-
proach showing emotions in extreme, poorly mod-
ulated forms, either in destructive, hostile, or vi-
olent content, or in highly affectionate, intimate
content, or both. Range between - 5 and +5, in-
cluding one or both of these extreme ratings.
Pattern 6: "Avoidant." A distant, or withdrawn, ori-
entation in relationships. Subjects giving no scor-
able responses on the RIS are included in this
pattern.
The patterns were subsequently ordered according
to their postulated degree of emotional balance in
interpersonal relationships and given a simple nu-
merical weight (13). As mentioned, the Flexible pat-
tern was considered a well-adjusted approach and
was therefore given the weight of 1. The Conformist
pattern, postulated to be somewhat less balanced,
was weighted 2. Since the Emphatic Positive and
Controlled patterns appeared equally adequate, both
patterns were weighted 3. The Ambivalent and
Avoidant patterns, considered to represent the least
well-balanced patterns, were given the weights of 4
and 5, respectively.

Pattern 1: "Flexible." A well-adjusted approach to Statistical Analysis

relationships, able to experience both affectionate
and aggressive feelings, moderate in intensity. The Three different statistical procedures were used to
pattern contains both positive and negative scores explore the relationship between the RIS scores and
within the range between +4 and - 4 , including subsequent health status, namely, the univariate
one or both of these scores in the rating. analysis of variance (ANOVA) and two types of sur-
Pattern 2: "Conformist." An approach considered well- vivorship analytic techniques: Cox proportional haz-
adjusted because it closely conformed to total group ards model for survival data (14) and Kaplan—Meier
norms (as the most frequent ratings fell within the survival analysis with logrank test (15).
+ 1 to +3 range—66.8%). Range between 0 and The Cox proportional hazards model for survival
+ 3 (score 0 was defined as representing a low data was selected to calculate rates of diagnosis for
degree of positive involvement). each of the major disorders. This nonparametric mul-
Pattern 3: "Emphatic Positive." An approach in which tivariate modeling technique allows one to adjust for
relationships are experienced in emotionally har- varying lengths of follow-up time and for the effect
monious, positive tones only, with an emphasis of covariates. It thus estimates the proportion of sub-
on highly affectionate, warm emotions. Range be- jects having been diagnosed for a specific disorder
tween 0 and +5, with ratings on +4 and/or +5 in an interval-per-unit time, given that they have
specifically required. "survived" without the diagnosis to the beginning of

552 Psychosomatic Medicine Vol. 48, No. 8 (Nov./Dec. 1986)

RORSCHACH AS A CANCER PREDICTOR

that interval. (This proportion is also called the "haz-

Univariate Analyses
ard function," "conditional failure rate," or "age-spe-
All 1032 Rorschach protocols were clas-
cific failure rate.") Furthermore, the model identifies
from the independent variables a subset of variables
sified as belonging to one of the six pat-
("risk factors") that prognostically relate to the out-
terns of interaction. The patterns were then
come variable (occurrence of a major disorder).
examined using the means of the weighted
The Kaplan-Meier survival analysis is a nonpara-
scores described under Methods. (The
metric descriptive method to estimate the survivor-
weighted scale scores were transformed to
ship function. The curves showing cumulative pro-
a mean of 50 and a standard deviation of
portions of disease occurrence over the follow-up
time can be compared statistically between the ex-
10.)
posure groups using a logrank test.
As Table 2 shows, the mean RIS scores
revealed little variation for all but two dis-
order groups. For the Cancer vs. No Cancer
comparison, F 11025 = 5.28, p<0.02, and
RESULTS for the Mental Disorder vs. No Mental Dis-
order, F 11028 = 3.76, p<0.05: both disor-
der groups obtained the higher mean scores
Risk Factors indicating a less well-balanced approach
1
Kaplan-Meier life table analysis was to interpersonal relationships.
employed to select covariates to be in-
cluded in the Cox proportional hazards
analysis. For this purpose the continuous Survivorship Analyses
variables were categorized into three The Cox proportional hazards model was
groups. Serum cholesterol level was di- used to examine whether the subjects who
vided into =£219, 220-259, and 260 or eventually developed cancer by the end of
higher. Systolic blood pressure was grouped the follow-up time had significantly dif-
into =£120 mm Hg, 121-130 mm Hg, and ferent RIS scores from the remaining sub-
131 mm Hg or higher. Quetelet index was jects when the time of diagnosis and length
also divided into tertiles by rank to create of follow-up were taken into account and
three groups. adjustment made for baseline age, smok-
Systolic blood pressure (p<0.01) and ing, and serum cholesterol level in medi-
Quetelet index (p<0.01) were associated cal school. A parallel analysis was per-
with hypertension. The group with the formed for the other disorder groups as
highest blood pressures (5=131 mm Hg) and well.
the group with the highest Quetelet index As seen in Table 3, the beta coefficients
contained the largest proportion of hyper- and their corresponding p values indicate
tensives by the end of follow-up. that for cancer, the RIS score persists as a
Serum cholesterol level was signifi- predictor for that illness (p = 0.02) after
cantly associated with coronary heart dis-
ease (p<0.01) and also with cancer
(p<0.02); the highest level of cholesterol
had the largest proportion of subjects with
'Since it was possible for a subject to have more
coronary heart disease as well as of sub- than one disorder, the usual analysis of variance in-
jects with cancer. cluding all groups simultaneously could not be used.

Psychosomatic Medicine Vol. 48, No. 8 (Nov./Dec. 1986) 553

 P. L. GRAVES, L. A. MEAD, and T. A. PEARSON

TABLE 2. Number of Subjects in Seven Disorder Groups and Their Controls; Means and Standard
Deviations of Ages in Medical School and Rorschach Interaction Scale (RIS) Scores

Ag;e in Medical
School RIS-Score
Disorder N X SD X SD
Cancer 45 24.00 2.88 53.31 a 10.36
No cancer 982 23.35 2.76 49.82 9.95

Mental disorder 37 24.61 3.66 53.096 9.92

No mental disorder 993 23.32 2.72 49.85 9.99

Hypertension 99 23.84 3.12 49.15 10.39

No hypertension 931 23.32 2.73 50.05 9.96

Coronary heart disease 43 26 00 4.48 48.80 10.40

No coronary heart disease 987 23.25 2.60 50.02 9.98

Skin cancer 51 24.50 4.56 48.95 8.81

No skin cancer 979 23.31 2.62 50.02 10.06

Benign tumor 78 23.11 2.17 49.52 9.41

No benign tumor 915 23.39 2.80 50.00 10.10

Duodenal ulcer 35 23.62 3.17 50.15 11.81

No duodenal ulcer 980 23.36 2.75 49.90 9.93
"fi.icns = 5.28, p < 0.02.
b
fi,io28 = 3.76, p < 0.05.

adjusting for age, smoking, and serum cho-
lesterol level. For mental disorder, the RIS
score is marginally significant (p = 0.07),
while for the remaining six disorders, the
score fails to predict subsequent illness.
Regarding the disease-specific risk factors,
serum cholesterol showed only marginal
significance for cancer (p = 0.07), but re-
mained highly significant for coronary heart
disease (p < 0.001). Regarding this latter
disorder, both smoking and age contrib-
uted significantly as well: subjects who
subsequently developed coronary heart
disease smoked more (p = 0.01) and were
older (p < 0.001) while in medical school.
For hypertension, both of its specific risk
factors—systolic blood pressure (p < 0.001)
and Quetelet index (p = 0.01)—remained
as predictors for the illness. Furthermore,
age was shown to predict both for skin
cancer (p = 0.02) and mental disorder
(p = 0.04): subjects who later developed
either disorder were older when in med-
ical school.
Besides the contribution of the weighted
RIS scores, the predictive potential of each
separate RIS pattern for cancer was ex-
amined. The Kaplan-Meier plot (Fig. 1)
shows the cumulative proportion of sub-
jects in each RIS pattern who developed

554 Psychosomatic Medicine Vol. 48, No. 8 (Nov./Dec. 1986)

 TABLE 3. Cox Proportional Hazards Analysis for Seven Disorder Groups:
Rorschach Interaction Scale (RIS) Scores Controlled by Selected Risk Factors
Independent Risk Variables
Number of
RIS Score Smoking Age Other
outcome
Disorder events (Total N ) B x2 p B x2 p B x2 p 6 X2 p
Serum Cholesterol:
Cancer 34 (876) 0.04 5.52 0.02 0.110 0.66 0.41 0.001 0.80 0.99 0.007 3.39 0.07
Mental
disorder 34 (966) 0.031 3.30 0.07 0.127 0 93 0.35 0.086 4.27 0.04 - - -
Systol~cBP:
Hypertension 97 (1013) -0.002 0.04 0.84 0.132 2.64 0.10 0.019 0.29 0.59 0.039 37.97 <0.001
Quetelet:
0.085 6.29 0.01
Coronary heart Serum Cholesterol:
disease 35 (879) -0.005 0.07 0.79 0.335 6.53 0.01 0.148 26.11 <.001 0.014 18.79 <0.001
Skin cancer 46 (966) -0.013 0.75 0.39 - 0.009 0.01 0.94 0.086 5.54 0.02 - - -
Benign tumor 74 (933) -0.002 0.02 0.90 0.026 0.08 0.078 -0.078 2.21 0.14 - - -
Duodenal
ulcer 35 (952) 0.003 0.04 0.84

'Jl
'J
Jll
 P. L. GRAVES, L.A. MEAD, and T. A PEARSON

D FLEXI8LE
O CONFORMIST

0.00-
20 30

CANCER FOLLOW-UP TIME (Years)

Fig. 1. Cumulative proportion of subjects with cancer by Rorschach Interaction Patterns. Number of subjects
with cancer in each pattern (total number in parentheses): Flexible, 5(214); Conformist, 10(292);
Emphatic Positive, 4(120); Controlled, 11(203); Ambivalent, 12(162); Avoidant, 3(36).

cancer. By 20 years of follow-up, the pat-
tern groups begin to show a difference in
the proportion of cancer: the Avoidant
group has the highest proportion, 5.5%,
the Ambivalent group has 3.5%, while the
other groups have 2% or less.
At the end of 30 years of follow-up the
Flexible group has the lowest proportion
of cancer with 3%, and the Ambivalent
and Avoidant groups still have the highest
proportions, with 13% and 12%, respec-
tively. The other three groups are inter-
mediate, with proportions ranging from 5%
to 6.5%. The logrank test for overall dif-
ference between the six curves was sig-
nificant (x2 = l i . l l , p = 0.05).
The relative risks and 95% confidence
intervals for each RIS pattern were cal-
culated using the Cox proportional haz-
ards model and adjusting for smoking,
serum cholesterol level, and age in med-
ical school. Using the Flexible group as
a reference group, the relative risks for de-
veloping cancer ranged from 1.32 for
the Conformist group to 3.02 for the
Ambivalent and 4.10 for the Avoidant
groups (Table 4). Thus, the relative risk
of developing cancer appears to increase

556 Psychosomatic Medicine Vol. 48, No. 8 (Nov./Dec. 1986)

RORSCHACH AS A CANCER PREDICTOR

TABLE 4. Relative Risks of Developing Cancer over 19-35 Years of Follow-up

for the Six Rorschach Interaction Patterns
RIS Pattern Relative Risk3 95% Confidence Interval
Flexible 1.0
Conformist 1.32 (1.06, 1.65)
Emphatic Positive 1.76 (1.13, 2.74)
Controlled 2.33 (1.20, 4.53)
Ambivalent 3.02 (1.27, 7.51)
Avoidant 4.10 (1.35, 12.44)
s
Cox proportional hazards model adjusting for smoking, serum cholesterol level, and age in
medical school.

the higher the RIS pattern stands in the subjects would indicate a tendency to-
order where poor adjustment ranks the ward a less well-balanced approach to in-
highest. terpersonal relationships.

RIS and Types of Cancer DISCUSSION

The general findings for the cancer sub-
jects were further examined by using the This report provides further evidence
primary site of the cancer of grouping. Here, regarding the predictive potential of the
the classification of Hammond and Horn Rorschach Interaction Scale (RIS) with re-
(16) was adapted in the following manner: gard to cancer. This scale was expressly
designed to assess youthful perceptions and
1. lung, including the cancer of the lar- expectations in relation to others among
ynx, N = 8; men who later developed cancer. The find-
2. genitourinary system (bladder, kid- ings from a separate instrument that showed
ney, prostate, testis), N = 12; that later cancer victims held less close
3. digestive system (stomach, pancreas, perceptions of their youthful relationships
rectum, large intestine), N = 7; with others, specifically their families (3),
4. lymphatic and hematopoietic system
(lymphosarcoma, multiple myeloma,
leukemia, Hodgkin's disease), N = 9; and TABLE 5. Rorschach Interaction Scale (RIS)
5. other (melanoma, brain, thyroid, con- Mean Scores with Standard Deviations of Cancer
nective tissue, salivary gland), N = 9. Subjects Classified by Primary Site of Cancer
RIS
As Table 5 shows, the mean RIS scores Primary Site of Cancer N X SD
were higher for all cancer groups, except- Lung 8 47.47 8.11
ing lung, when compared with the No Can- Genitourinary system 12 51.28 10.56
cer group (N = 982). The highest mean RIS Digestive system 7 56.94 4.46
scores were among the subjects with can- Lymphatic-hematopoietic system 9 57.38 11.20
cer in the lymphatic-hematopoietic or the Other 9 54.33 12.94
digestive system; both subgroups of cancer No cancer 982 49.82 9.95

Psychosomatic Medicine Vol. 48, No. 8 (Nov./Dec. 1986) 557

 P. L. GRAVES, L. A. MEAD, and T. A. PEARSON
prompted the design of the RIS. A system-
atic examination of the role that quaJity of
human relationships exerts on health and
illness such as cancer thus appeared war-
ranted.
The present findings confirm the earlier
findings with the RIS. The findings show
that medical students who later developed
cancer, in contrast to the rest of the cohort,
gave test responses indicative of poorer re-
lationship potential. The possibility that
the RIS may indeed be a cancer-specific
predictor was strengthened by the fact that
five of the seven disorder groups studied
failed to show an association with the
measure. Mental disorder as the sixth dis-
order group showed a near-significant as-
sociation and thus corroborated the earlier
suggestion of a psychologic resemblance
between later cancer and mental disorder
subjects (1, 3).
The present findings are based on a more
rigorous examination in at least three dif-
ferent aspects. First, the study sample con-
sisted of the entire cohort of white males
who had taken the Rorschach test
(N= 1032]; also, the number of cancer pa-
tients had increased considerably since the
date of the first report in 1981, from 28 to
45 cases. Second, the previously used uni-
variate statistical analyses were supple-
mented by multivariate analyses that al-
lowed for control of the possible
confounding effects of risk factors. Third,
the use of survivorship analyses permitted
the examination of the rates of cancer oc-
currence adjusting for different lengths of
follow-up time, together with the relation-
ship between these rates and the psycho-
logic measure. Such an examination is
particularly important since other studies
have noted that the relationship between
certain psychosocial variables and inci-
dence of illness (e.g., coronary heart dis-
ease) would tend to diminish as the fol-
558 Psychosomatic Medicine Vol. 48, No. 8 (Nov./Dec. 1986)
low-up time lengthens in a cohort study
(17). The following discussion elaborates
these and other aspects with the purpose
of critically evaluating the present find-
ings.
First, it should be noted that the cancer
group under present study consisted of
subjects of whom a large part formed the
earlier study sample. As Fox (8) points out,
it cannot be ignored that the present, sim-
ilarly significant results could arise in part
"from the portion of the later case and con-
trol groups that might have been signifi-
cantly different by chance in the early
groups" (p. 97). When the disorder groups
become larger, samples independent from
those used in this study will be possible
and additional validation will result. But
it has also been pointed out that ulti-
mately, the validity and utility of any test
is an empirical question, i.e., to what ex-
tent a given test differentiates among in-
dependently defined groups or, alterna-
tively, identified or predicts important
states or outcomes (18). Using such an em-
pirical criterion, the present findings in-
dicate that the RIS is a promising psycho-
logic predictor of cancer.
A frequently noted concern, even in
prospective studies, is the possibility that
the disease may influence psychologic and
other variables even when it is not yet clin-
ically manifest. Therefore, the time inter-
val between diagnosis and the psychologic
assessment is an important consideration.
Most of the cancer group were in their early
twenties (X = 23.87, SD = 2.81) when they
took the Rorschach test, whereas the ma-
jority were in theirjriid-forties when can-
cer was diagnosed (X = 48.64, SD = 9.02).
Thus a time interval of 15-30 years was
not unusual. We may therefore be reason-
ably certain that the medical school mea-
surements reflected a premorbid condition
of functioning in our subjects.
RORSCHACH AS A CANCER PREDICTOR
Noteworthy is the fact that the present
study group has not yet reached the age at
which the occurrence of cancer starts to
increase at an accelerated rate—approxi-
mately from the sixth decade on (19). Fox
(8) has proposed that the role of psycho-
logic factors in the development of cancer
may be more evident in instances where
cancer occurs relatively early in life,
whereas the role of external factors will be
most important in cancers occurring at later
ages with long-term exposure to carcino-
gens. It may be that the RIS may lose its
predictive potential when the future can-
cer subjects develop the disease at an older
age and the effect of external factors will
have increased. At the same time, it is pos-
sible that already relatively early in life,
certain cancers are less influenced by psy-
chologic factors than others. This sugges-
tion stems from the exploratory finding in-
dicating that the mean RIS score for the
lung cancer subjects was not different from,
and was even somewhat lower than, the
mean score for subjects without cancer,
whereas the mean scores were higher
among the rest of the cancer subgroups. It
seems likely that smoking as an external
factor, as other studies have suggested (16],
is the most important determinant for this
particular type of cancer, surpassing the
effect of such psychologic factors as mea-
sured by the RIS. As an alternative con-
sideration, some investigations indicate that
lung cancer patients tend to demonstrate
a high degree of social conformity and thus
appear socially well-adapted due to strong
internal control, which blocks outlets for
emotional discharge (20, 21). It may be that
the RIS is not an appropriate measure in
efforts to differentiate this apparently so-
cially well-adjusted group of future cancer
subjects from their controls.
The present study follows a rich tradi-
tion in the use of the Rorschach test in
Psychosomatic Medicine Vol. 48, No. 8 (Nov./Dec. 1986)
cancer research (22-28). Methodologic
differences between the present and the
earlier studies, however, make direct com-
parisons difficult. For the most part, the
earlier studies are retrospective and cross-
sectional and, therefore, limited in their
efforts to determine whether the associa-
tion of psychologic factors to cancer was
a result of the disease rather than its pre-
cursor. Such limitations notwithstanding,
the earlier reports highlight distinct per-
sonality characteristics typical of cancer
patients, based on global personality de-
scriptions (22, 28), or clusters of person-
ality traits (23, 24-27). In contrast, the fo-
cus of the present work is on one single
psychologic factor, "relationship poten-
tial."
The RIS was developed to measure "re-
lationship potential," that is, variations in
individual perceptions and emotional ex-
pectations in relationship to others. Clin-
ical dynamic psychology stresses that it is
not the absence of negative feelings, but
rather the tolerance and moderation of
mutually opposite feelings (love-hate; af-
fection-aggression) in significant relation-
ships which is a mark of mature, "good"
adjustment (12). In contrast, the occur-
rence of poorly balanced, intensely nega-
tive and/or intensely positive feelings sig-
nifies poor adjustment (29). The RIS
patterns were defined in accordance with
such clinical guidelines. These patterns
showed that students who later developed
cancer or became mentally ill differed sig-
nificantly from the rest of their classmates.
In each instance, relationship potential
tended to be poorer and the predominant
RIS patterns indicated less successful ad-
justment.
These findings may not be surprising
among those subjects who later developed
a mental illness, as any mental illness rarely
develops without early, even lifelong signs
559
 P. L. GRAVES, L. A. MEAD, and T. A. PEARSON

of emotional disturbance. Thus youthful fects. Such an integration may be revealed

indicators of poor self-other relationships in images of others and self as either ex-
may readily be viewed as signals for later aggeratedly "good" or "horrible" (cf. the
mental disturbance. The idea that cancer Ambivalent pattern), or the impaired af-
may have psychologic components in its fective integration is dealt with by a lack
development is more baffling and, in fact, of investment in self-other relationships
a frequent source of skepticism (8). There (cf. the Avoidant pattern). Such impaired
is, however, a growing body of informa- representations would fail to act as pro-
tion suggesting that psychologic determi- tective regulators and, instead, would con-
nants, be they specific character traits (30, tribute to the breakdown of psychobiol-
31], coping and defense styles [32], prev- ogic equilibrium as shown in disease states
alent affective states (33), early par- such as cancer.
ent-child relationships (3, 4, 34) or indi- The above hypothesis does not address
vidual relationship potential (1) play a role the complex and profound question,
in the subsequent onset of cancer. Are there namely, why were only cancer and mental
reports that might help us to look at the illness, among the disorders studied, dif-
link between interpersonal relationships ferentiated by the RIS. Nor does it clarify
and cancer in a new way? Hofer and col- the proposed psychodynamic relationship
leagues' investigations of certain mother- between cancer and mental disorders (1,
infant rat interactions as biologic regu- 3). The present data do not provide an-
lators of the infant's development and swers to either question; however, a sub-
behavior may well provide such a basis. stantial body of research data and theo-
Based on the team's work, Hofer sug- retical propositions is available to guide
gests in a thoughtful article (35) that im- further study.
portant human relationships exert a reg- To begin with, clinical and develop-
ulatory function on biological systems. mental-theoretical writings (12, 36) dem-
Moreover, he argues, our inner experi- onstrate that the quality of internal
ences of interactions with others—our "in- self-other representations is largely molded
ternal representations of self-other rela- by early experiences in one's human care-
tionships"—serve as biologic regulators at taking milieu. Thus, the nature of early
least as effectively as do our actual sen- parent-child interaction, in particular the
sorimotor interactions. early conditions of nurturance, becomes a
If we consider individual RIS patterns logical realm of inquiry to widen our un-
as markers of internal self-other represen- derstanding of the role of internal self-other
tations, then the postulated link to bio- representations on later health and dis-
logic systems and to manifestations of ill- ease. Indirect support to the link between
ness becomes reasonable. That is, the internal representations in adult life
representations where positive and nega- and early parent-child relationship comes
tive feelings are moderated and emotion- from the rinding in our study population,
ally balanced (such as in the Flexible pat- reported earlier (1), of a modest but statis-
tern) would serve as effective regulators of tically significant correlation between the
events that may disturb biologic systems. RIS scores and the Closeness to Parents
A reverse outcome would be connected Scale, derived from the Family Attitude
with representations that indicate im- Questionnaire: students with higher RIS
paired integration of mutually opposite af- pattern scores, demonstrating less well-

560 Psychosomatic Medicine Vol. 48, No. 8 (Nov./Dec. 1986)

RORSCHACH AS A CANCER PREDICTOR

balanced interaction patterns, tended to before interpersonal affective experience

have lower scores on the Closeness to Par- as a predisposing psychologic factor for
ents Scale, indicating a lack of closeness cancer becomes clear. Foremost among
to parents. them are the affective meaning of early and
The affective meaning of interpersonal ongoing self-other relationships, the in-
relationships thus expanded appears to be dividual defensive and coping style, as well
a prominent predisposing psychological as the typical coping style of the early fam-
factor for cancer. In his recent extensive ily. The simultaneous consideration of the
reviews, Bahnson (34, 37) brings together stated factors in our study population
a wide array of research data to offer a awaits further study. Implicit in the above
conceptual framework concerning the role discussion, of course, is the notion that no
of interpersonal affective experiences in psychologic factor, including internal
the development of cancer. Based on his self-other representations as measured in
own findings, he proposes specific affec- the present study, directly causes later
tive components in the early parent-child, health or illness. What becomes clear,
in particular mother-child, relationship however, is the need to delineate and fur-
that seemingly differentiate future cancer ther define psychologic factors before their
victims from persons with other somatic linkage with physiologic and biologic sys-
illnesses. The role of early family relation- tems in such complex diseases as cancer
ships appears important in other respects can be understood.
as well. Predominant defensive and cop-
ing styles in the family influence the de-
velopment of the individual coping style. The authors would like to express their
According to him, the ego-defensive in- great appreciation to Dr. CaroJine B.
dividual style becomes an important in- Thomas, the originator of the Precursors
tervening variable between early family Study, and to Drs. John W. Shaffer and
experiences and the "choice" of the chan- I. L. Graves for their excellent advice.
nel of regression under stress later in life, This research was supported by the Na-
thus determining the choice of illness. tional Cancer Institute Grant 2 R18
Bahnson's formulations strongly sug- CA22416, The National Institute on Aging
gest that, ideally, several psychologic Grant 5 R01 AG01760, and The Johns Hop-
factors should be explored concomitantly kins University.

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