Person imagery in drawing tests in screening for mental disorders: a systematic review and meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

GUO Huibing ^1,2 , FENG Bin ^1,3 , LIU Tiantian ⁴ , FAN Huiyong ⁵ , DONG Zaiquan ⁶ , GONG Qiyong ^1,7 ,  CHEN Taolin ^1,8

1. Department of Radiology, Huaxi MR Research Center (HMRRC), Institution of Radiology and Medical Imaging, West China Hospital of Sichuan University, Chengdu 610041, P. R. China;
2. Department of Student Affairs Management, West China School of Medicine, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;
3. West China School of Medicine, Sichuan University, Chengdu 610041, P. R. China;
4. Teacher education college, Dali University, Dali 671003, P. R. China;
5. Institute of Education, Bohai University, Jinzhou 121013, P. R. China;
6. Mental Health Center, West China Hospital of Sichuan University, Chengdu 610041, P. R. China;
7. Department of Radiology, West China Xiamen Hospital of Sichuan University, Xiamen 361000, P. R. China;
8. College of Medical Technology, West China Hospital of Sichuan University, Chengdu 610041, P. R. China;

Corresponding author：

CHEN Taolin, Email: tlchen@scu.edu.cn

Keywords：

Drawing test; House-tree-person test; Person imagery; Mental disorders; Meta-analysis

DOI：

10.7507/1672-2531.202406069

Video：

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Objective To integrate person imagery from drawing tests in screening for mental disorders through meta-analysis to identify indicators that can effectively predict mental disorders. Methods A computerized search of CNKI, WanFang Data, VIP, PubMed, Web of Science, and EBSCO databases was conducted to collect studies related to mental disorders and drawing tests, with a search timeframe of the period from the creation of the database to May 8, 2023. Meta-analysis was performed using CMA 3.0 after two researchers independently screened the literature, extracted information, and assessed the risk of bias. Results A total of 43 studies were included, with 791 independent effect sizes and 8 444 subjects. Meta-analysis revealed that a total of 29 person imagery traits significantly predicted mental disorders, which could be categorized into 7 types according to the features: absent, bizarre, blackened, simplified, static, detailed, and holistic. The subgroup analysis revealed that the specific indicators of affective disorders included "excessive separation among items", "oversimplified person", "rigid and static person" and "hands behind the back". The specific indicators of thought disorders were "absence of limbs", "absence of facial features" and "disproportionate body proportions". Moreover, there were seven common indicators of mental disorders, including "oversimplified drawing", "very small drawing", "very small person", "weak or intermittent lines", "single line limb", "absence of hands or feet" and "no expression or dullness''. Conclusion The findings could provide a reference standard for selection and interpretation of drawing indicators, promote standardization of the drawing test, and enhance the accuracy of results in screening for mental disorders.

Citation： GUO Huibing, FENG Bin, LIU Tiantian, FAN Huiyong, DONG Zaiquan, GONG Qiyong, CHEN Taolin. Person imagery in drawing tests in screening for mental disorders: a systematic review and meta-analysis. Chinese Journal of Evidence-Based Medicine, 2024, 24(12): 1419-1427. doi: 10.7507/1672-2531.202406069 Copy

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3.	Sorge A, Saita E. Assessment of suicide and self-harm risk in foreign offenders. Evaluating the use of tree-drawing test. Med J Clin Psychol, 2001, 9(3): 135.
4.	Buck JN. The H-T-P technique a qualitative and quantitative scoring manual. J Clin Psychol, 1948, 4(1): 37.
5.	Machover K. Personality projection in the drawing of the human figure a method of personality investigation. Springfield: Charles C Thomas, 1949.
6.	Verinis JS, Lichtenberg EF, Henrich L. The draw-a-person in the rain technique its relationship to diagnostic category and other personality indicators. J Clin Psycho, 1974, 30(3): 407-414.
7.	张燕. 房树人投射测验在新生心理普查中的应用价值. 思想理论教育, 2010, (5): 70-73.
8.	Deng X, Mu T, Wang Y, et al. The application of human figure drawing as a supplementary tool for depression screening. Front Psychol, 2022, 13: 865206.
9.	Choi J, Lee K. A study on postpartum depression and reaction characteristics on the person in the rain drawing. Korean J Art Ther, 2012, (19): 113-130.
10.	Akinci E, Wieser MO, Vanscheidt S, et al. Impairments of social interaction in depressive disorder. Psychiatry Investig, 2022, 19(3): 178-189.
11.	朱梦鹃, 陈涛, 裴欢昌, 等. 自恋型人格障碍倾向青少年绘画特征评估. 中国健康心理学杂志, 2020, 28(5): 676-680.
12.	Basu J. Psychologists’ ambivalence toward ambiguity relocating the projective test debate for multiple interpretative hypotheses. SIS J Proj Psychol Ment Health, 2014, 21(1): 25-36.
13.	陈歌, 严万森. 罗夏墨迹测验在临床心理诊断中的效用. 中国健康心理学杂志, 2022, 30(3): 475-480.
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28.	Lee A, Hobson RP. Drawing self and others how do children with autism differ from those with learning difficulties. Br J Dev Psychol, 2006, 24: 547-565.
29.	Lee EJ. Correlations among depressive symptoms, personality, and synthetic house-tree-person drawings in South Korean adults. Psychologia, 2019, 61(4): 211-220.
30.	Lee EJ. Factors associated with nicotine addiction and coping skills in the synthetic house-tree-person drawing test. J Korean Acad Psychiatr Ment Health Nurs, 2020, 29(2): 185-193.
31.	Saneei A, Bahrami H, Haghegh SA. Self-esteem and anxiety in human figure drawing of Iranian children with ADHD. Arts Psychother, 2011, 38(4): 256-260.
32.	Seol JM, Lee HS. The efficiency of human figure drawing HFD test for differentiating mild dementia from geriatric depression. Korean J Psychol Gen, 2010, 29(4): 767-789.
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39.	陈涛, 项锦晶, 裴欢昌, 等. 反社会型人格偏离青少年在雨中人绘画中的压力应对特征. 中国心理卫生杂志, 2016, (3): 185-190.
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41.	邓叶, 周彩萍, 王叶飞. 绘画特征与抑郁倾向的相关探讨. 才智, 2017, (31): 197.
42.	高梦丹. 绘画投射测验在大学生抑郁评估中的应用研究. 南京: 南京中医药大学, 2019.
43.	黄赛君, 静进. 注意缺陷多动障碍学龄期儿童绘人测验特征分析. 中国儿童保健杂志, 2010, (4): 278-281.
44.	黄晓洁, 包呼格吉乐图. 自闭症儿童与正常儿童房树人图画对比研究. 语文学刊, 2016, (5): 160-162.
45.	李贺斌, 苑杰, 牛俊红, 等. 女性抑郁症患者在房树人测验中构图特点对照研究. 中国妇幼健康研究, 2016, (S2): 24-25.
46.	李晓敏. 房树人测验对评估初中生焦虑情绪的作用研究. 武汉: 江汉大学, 2020.
47.	李雪, 曹白丹, 杨文, 等. 高功能孤独症儿童的统合型房树人绘画测验特征. 中国心理卫生杂志, 2014, (4): 260-266.
48.	王求是, 项锦晶, 刘建新. 对自杀未遂者的儿时创伤和自我概念的访谈分析. 中国心理卫生杂志, 2007, (6): 407-410.
49.	王晓怡. 房树人测验在初中新生心理普查中的应用. 大众心理学, 2017, (1): 24-25.
50.	项锦晶, 廖孟莎, 裴欢昌. 房树人绘画测验对小学生注意缺陷多动倾向的评估. 少年儿童研究, 2020, (2): 33-37, 73.
51.	项锦晶, 廖孟莎, 朱梦鹃. 低年级小学生抑郁倾向的房树人绘画评估. 中国健康心理学杂志, 2020, 28(7): 1057-1061.
52.	谢丽亚, 叶秀红. 精神分裂症患者统合型"房树人绘画测验"测试结果分析. 中国心理卫生杂志, 1994, 8(6): 250-252, 282.
53.	严虎, 于慧慧, 陈晋东. 房树人测验在中学生抑郁状态调查中的应用. 中国临床心理学杂志, 2014, 22(5): 842-844, 848.
54.	赵妍, 王秋蕴, 项锦晶, 等. 有躯体化症状的小学生的房树人绘画测验特征. 中国心理卫生杂志, 2015, (2): 115-120.
55.	周慧强. 初中生反刍思维与房树人绘画特征的关系研究. 锦州: 渤海大学, 2021.
56.	朱绘霖, 项锦晶, 陈雯瑾, 等. 四川震区创伤后应激障碍青少年的房树人绘画特点. 教育导刊, 2011, (6): 39-42.
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60.	Guo H, Feng B, Ma Y, et al. Analysis of the screening and predicting characteristics of the house-tree-person drawing test for mental disorders a systematic review and meta-analysis. Front Psychiatry, 2023, 13: 1041770.
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1. World Health Organization. Mental disorders fact sheets. 2019.
2. Wetzel E, Greiff S. The world beyond rating scales why we should think more carefully about the response format in questionnaires. Eur J Psychol Assess, 2018, 34(1): 1-5.
3. Sorge A, Saita E. Assessment of suicide and self-harm risk in foreign offenders. Evaluating the use of tree-drawing test. Med J Clin Psychol, 2001, 9(3): 135.
4. Buck JN. The H-T-P technique a qualitative and quantitative scoring manual. J Clin Psychol, 1948, 4(1): 37.
5. Machover K. Personality projection in the drawing of the human figure a method of personality investigation. Springfield: Charles C Thomas, 1949.
6. Verinis JS, Lichtenberg EF, Henrich L. The draw-a-person in the rain technique its relationship to diagnostic category and other personality indicators. J Clin Psycho, 1974, 30(3): 407-414.
7. 张燕. 房树人投射测验在新生心理普查中的应用价值. 思想理论教育, 2010, (5): 70-73.
8. Deng X, Mu T, Wang Y, et al. The application of human figure drawing as a supplementary tool for depression screening. Front Psychol, 2022, 13: 865206.
9. Choi J, Lee K. A study on postpartum depression and reaction characteristics on the person in the rain drawing. Korean J Art Ther, 2012, (19): 113-130.
10. Akinci E, Wieser MO, Vanscheidt S, et al. Impairments of social interaction in depressive disorder. Psychiatry Investig, 2022, 19(3): 178-189.
11. 朱梦鹃, 陈涛, 裴欢昌, 等. 自恋型人格障碍倾向青少年绘画特征评估. 中国健康心理学杂志, 2020, 28(5): 676-680.
12. Basu J. Psychologists’ ambivalence toward ambiguity relocating the projective test debate for multiple interpretative hypotheses. SIS J Proj Psychol Ment Health, 2014, 21(1): 25-36.
13. 陈歌, 严万森. 罗夏墨迹测验在临床心理诊断中的效用. 中国健康心理学杂志, 2022, 30(3): 475-480.
14. 陈侃, 徐光兴. 抑郁倾向的绘画诊断研究. 心理科学, 2008, 3: 722-724.
15. 宁式颖, 郑璐, 李响, 等. 房树人测验用于评估青少年抑郁的应用研究. 中国临床研究, 2015, 28(3): 305-307.
16. Kato D, Suzuki M. Developing a scale to measure total impression of synthetic house-tree-person drawings. Soc Behav Pers Int J, 2016, 44(1): 19-28.
17. 李金德, 傅寒昀. 抑郁症的房树人绘画特征研究. 中国心理学前沿, 2021, 3(6): 656-663.
18. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ, 2003, 327(7414): 557-560.
19. Eisel HE. A comparative study of the house-tree-person drawings of schizoid personalities and individuals with below-average intelligence in a prison setting (unpublished doctorial dissertation). The Ohio State University, 1978.
20. Fukunishi I, Sugawara Y, Takayama T, et al. Association between pretransplant psychological assessments and posttransplant psychiatric disorders in living-related transplantation. Psychosomatics, 2002, 43(1): 49-54.
21. Guez J, Lev-Wiesel R, Valetsky S, et al. Self-figure drawings in women with anorexia, bulimia, overweight, and normal weight a possible tool for assessment. Arts Psychother, 2010, 37: 400-406.
22. Guo Q, Yu G, Wang J, et al. Characteristics of house-tree-person drawing test in junior high school students with depressive symptoms. Clin Child Psychol Psychiatr, 2023, 28(4): 1623-1634.
23. Kim J, Chung S. Drawing test form for depression the development of drawing tests for predicting depression among breast cancer patients. Psychiatry Investig, 2021, 18(9): 879-888.
24. Kim YJ, Yoo KM. A study on the response characteristics of DAPR draw a person in the rain drawing assessment according to the level of depression in college students. Korean Art Ther Assoc, 2019, 26(5): 951-966.
25. Kirchner JH, Marzolf SS. Personality of alcoholics as measured by sixteen personality factor questionnaire and house-tree-person color-choice characteristics. Psychol Rep, 1974, 35(1): 627-642.
26. Koide R, Fujihara K. A study on HTP organic signs. Jpn J Psychol, 1992, 63(4): 277-280.
27. Kwark YH, Lee KM. A comparative study on reactional characteristics of S-HTP between normal and schizophrenia patients. Korean J Art Ther, 2010, 17(2): 297-318.
28. Lee A, Hobson RP. Drawing self and others how do children with autism differ from those with learning difficulties. Br J Dev Psychol, 2006, 24: 547-565.
29. Lee EJ. Correlations among depressive symptoms, personality, and synthetic house-tree-person drawings in South Korean adults. Psychologia, 2019, 61(4): 211-220.
30. Lee EJ. Factors associated with nicotine addiction and coping skills in the synthetic house-tree-person drawing test. J Korean Acad Psychiatr Ment Health Nurs, 2020, 29(2): 185-193.
31. Saneei A, Bahrami H, Haghegh SA. Self-esteem and anxiety in human figure drawing of Iranian children with ADHD. Arts Psychother, 2011, 38(4): 256-260.
32. Seol JM, Lee HS. The efficiency of human figure drawing HFD test for differentiating mild dementia from geriatric depression. Korean J Psychol Gen, 2010, 29(4): 767-789.
33. Sheng L, Yang G, Pan Q, et al. Synthetic house-tree-person drawing test a new method for screening anxiety in cancer patients. J Oncol, 2019, 5062394.
34. Yang G, Zhao L, Sheng L. Association of synthetic house-tree-person drawing test and depression in cancer patients. Biomed Res Int, 2019, 2019: 1478634.
35. Yoo KM. Research on DAP SPED draw a person test on screening procedure for emotional disturbance response characteristics of ADHD children and normal children. J Korean Assoc Dev Disabil, 2013, 17(4): 189-210.
36. Zhou AB, Xie P, Pan CC, et al. Performance of patients with different schizophrenia subtypes on the synthetic house-tree-person test. Soc Behav Pers Int J, 2019, 47(11): 1-8.
37. 陈琳莹. 绘画心理治疗对精神分裂症患者康复作用的研究. 广州: 广州中医药大学, 2015.
38. 陈涛, 裴欢昌, 王鹏, 等. 青少年依赖型人格障碍倾向的绘画评估诊断. 中国特殊教育, 2015, (2): 59-64.
39. 陈涛, 项锦晶, 裴欢昌, 等. 反社会型人格偏离青少年在雨中人绘画中的压力应对特征. 中国心理卫生杂志, 2016, (3): 185-190.
40. 邓翠芸. 精神分裂症HTP测验与BPRS的相关性研究. 广州: 广州中医药大学, 2014.
41. 邓叶, 周彩萍, 王叶飞. 绘画特征与抑郁倾向的相关探讨. 才智, 2017, (31): 197.
42. 高梦丹. 绘画投射测验在大学生抑郁评估中的应用研究. 南京: 南京中医药大学, 2019.
43. 黄赛君, 静进. 注意缺陷多动障碍学龄期儿童绘人测验特征分析. 中国儿童保健杂志, 2010, (4): 278-281.
44. 黄晓洁, 包呼格吉乐图. 自闭症儿童与正常儿童房树人图画对比研究. 语文学刊, 2016, (5): 160-162.
45. 李贺斌, 苑杰, 牛俊红, 等. 女性抑郁症患者在房树人测验中构图特点对照研究. 中国妇幼健康研究, 2016, (S2): 24-25.
46. 李晓敏. 房树人测验对评估初中生焦虑情绪的作用研究. 武汉: 江汉大学, 2020.
47. 李雪, 曹白丹, 杨文, 等. 高功能孤独症儿童的统合型房树人绘画测验特征. 中国心理卫生杂志, 2014, (4): 260-266.
48. 王求是, 项锦晶, 刘建新. 对自杀未遂者的儿时创伤和自我概念的访谈分析. 中国心理卫生杂志, 2007, (6): 407-410.
49. 王晓怡. 房树人测验在初中新生心理普查中的应用. 大众心理学, 2017, (1): 24-25.
50. 项锦晶, 廖孟莎, 裴欢昌. 房树人绘画测验对小学生注意缺陷多动倾向的评估. 少年儿童研究, 2020, (2): 33-37, 73.
51. 项锦晶, 廖孟莎, 朱梦鹃. 低年级小学生抑郁倾向的房树人绘画评估. 中国健康心理学杂志, 2020, 28(7): 1057-1061.
52. 谢丽亚, 叶秀红. 精神分裂症患者统合型"房树人绘画测验"测试结果分析. 中国心理卫生杂志, 1994, 8(6): 250-252, 282.
53. 严虎, 于慧慧, 陈晋东. 房树人测验在中学生抑郁状态调查中的应用. 中国临床心理学杂志, 2014, 22(5): 842-844, 848.
54. 赵妍, 王秋蕴, 项锦晶, 等. 有躯体化症状的小学生的房树人绘画测验特征. 中国心理卫生杂志, 2015, (2): 115-120.
55. 周慧强. 初中生反刍思维与房树人绘画特征的关系研究. 锦州: 渤海大学, 2021.
56. 朱绘霖, 项锦晶, 陈雯瑾, 等. 四川震区创伤后应激障碍青少年的房树人绘画特点. 教育导刊, 2011, (6): 39-42.
57. Koto R, Krueger RF, Watson D, et al. The hierarchical taxonomy of psychopathology (HiTOP) a dimensional alternative to traditional nosologies. J Abnorm Psychol, 2017, 126(4): 454-477.
58. De Vaus J, Hornsey MJ, Kuppens P, et al. Exploring the east-west divide in prevalence of affective disorder a case for cultural differences in coping with negative emotion. Pers Soc Psychol Rev, 2018, 22(3): 285-304.
59. Khorshidi SZM, Mohammadipour M. Children’s drawing a way to discover their psychological disorders and problems. Int J Ment Health Addict, 2016, 14: 31-36.
60. Guo H, Feng B, Ma Y, et al. Analysis of the screening and predicting characteristics of the house-tree-person drawing test for mental disorders a systematic review and meta-analysis. Front Psychiatry, 2023, 13: 1041770.
61. Aberastury A. Child psychoanalysis theory and technique (8th edition). Porto Alegre: Artmed, 2012.
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Chinese Journal of Evidence-Based Medicine

Person imagery in drawing tests in screening for mental disorders: a systematic review and meta-analysis

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