Rorschach inkblot test and psychopathology among patients suffering from schizophrenia: A correlational study

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Abstract

Background:

Rorschach test has been considered a well-known and most widely used projective test for the assessment of personality and diagnostic evaluation in various psychiatric disorders. Schizophrenia is considered to be the major psychiatric illness characterized by gross distortion of reality, the disorganization and fragmentation of perception, thought, emotion, and withdrawal from social interaction. Rorschach provides both specific and general knowledge about the different areas of personality functioning, such as coping style, emotions, managing stress, mediation, ideation, self-perception, and interpersonal relationships along with correlating with the psychopathology of the schizophrenia patients.

Aim:

The aim of the present study is to assess the relationship between Rorschach response pattern different symptoms in schizophrenia patients.

Methodology:

After having informed consent, 100 patients of schizophrenia group were included as per the International Classification of Diseases 10th Revision Diagnostic Criteria for Research (ICD-10 DCR) criteria. Information about sociodemographic data and clinical details was collected using the sociodemographic and clinical data sheet from the drawn sample. For the assessment of symptoms of schizophrenia patients, Scale for the Assessment of Positive Symptom and Scale for the Assessment of Negative Symptom have been used. After that Rorschach test was administered individually to all the participants to assess the personality structure of each schizophrenia patients.

Results:

The results showed that there is a significant positive and negative correlation among positive, negative schizophrenia symptoms, and different Rorschach variables.

Conclusion:

Schizophrenia patients having positive and negative symptoms would be giving Rorschach variables indicative of moderate level of cognitive distortions, poorly controlled and disorganized affect, less conventional form of responses, poor perception and loss with reality, poor interpersonal relationships, presence of anxiety, and aggression.

Rorschach test is a personality assessment instrument having unstructured stimuli, both objective and subjective features and constituting both a perceptual-cognitive task and a stimulus to fantasy and it functions both as a measure of perception and as a measure of association. Rorschach pioneers who regarded the instrument primarily as a measure of perception tended to regard it mainly as a way of identifying states and traits, that is, structural elements of personality. Hence, in common with other complex and multifaceted personality assessment instruments, the Rorschach test serves not just as a test but as a method of generating data that identifies many different aspects of personality functioning.

Schizophrenia has been considered to be a major psychiatric illness characterized by disturbances in thought and speech disorders which include distorted thinking (thinking governed by private and illogical rules), loosening of associations (pattern of spontaneous speech in which the things said in juxtaposition lack a meaningful relationship), thought blocking (sudden interruption of stream of speech before the thought is completed), neologisms (newly formed words whose derivation cannot be understood), poverty of speech (decreased production in speech), perception which includes hallucinations (perceptions without stimuli) mostly third person auditory hallucinations and visual hallucinations, affect which include apathy, emotional blunting, emotional shallowness, anhedonia (incapability of experiencing pleasure), inappropriate emotional responses (emotional response inappropriate to thought), motor behavior which includes decrease psychomotor activity (decreased spontaneity, stupor, and inertia) or increase in activity (aggression, excitement, restlessness, and agitation), mannerisms, grimacing, stereotypies (repetitive strange behavior), and decreased self-care. The prominent negative symptoms of schizophrenia include affective flattening or blunting, attentional impairment, avolition-apathy (lack of initiative), anhedonia, asociality (social withdrawal), and alogia (lack of speech output).

Although the Rorschach test was not developed as an intelligence test, it is purported by numerous psychologists to show intellectual levels. Rorschach[1] claimed that the test is an accurate gauge of intelligence. Klopfer et al.[2] state that “It is a customary part of Rorschach analysis to estimate the levels of intellectual capacity and efficiency of the subject. This is not considered a substitute for a test of general intelligence although for some purposes such an estimate might be all that is required, thus making an intelligence test unnecessary.” Beck[3] concluded that the test offers possibilities of an excellent instrument for the diagnosis of personality in both the intellectual and affective functioning. These are only a few of the many claims made by psychologists concerning the validity of the Rorschach test as an instrument for measuring intelligence. There are many signs and constellations of signs which have been derived from the test and which are used as indices of intelligence. The ones most widely used are: W, M, F+%, A%, 0%, variety of content, and succession of responses.

There has been much research and discussion on the personality characteristics of patients with schizophrenia. Such patients have been found to have problems in different areas of personality functioning. The Rorschach test provides both specific and general knowledge about different areas of personality functioning, such as coping style, emotions, managing stress, mediation, ideation, self-perception, and interpersonal relationships. Problems in these areas mostly equate directly with psychopathology, but they may relate to difficulties and maladjustment.[4,5,6] Much of the disordered thinking in schizophrenia is related to conflicts surrounding the expression or internalization of affect.[7,8,9] Forty percent of first-episode patients have been found to show affect-modulating problems, becoming overly intense in their emotional expressions and showing emotional impulsiveness.[8] About half of psychotic patients with first-episode psychosis have been found to avoid emotional stimuli[8] and one third to experience emotional distress.[7] Patients suffering from first-episode psychosis have been found to show impoverished or unrewarding social relationships.[8,10] They also show ineffective coping and lack of coping skills.[8] They tend to show less reality-based perceptions of others,[8] leading to difficulties in interpersonal functioning.[9] Nearly half of patients with first-episode psychosis have been found to show negative sense of self-worth.[7,11] According to Exner,[8] one-third of the patients with first-episode psychosis also show an excess of focusing on the self at the expense of concern with the social environment. In his study,[12] the researcher evaluated the relationship between the Perceptual Thinking Index Criteria and the Positive and Negative Syndrome Scale (PANSS) scores in schizophrenia patients. The PTI positively correlated with the PANSS total score. The PTI1 and PTI2 criteria significantly correlated with the PANSS negative score, the PTI4 and PTI5 with the positive. The Rorschach variable X-% significantly correlated with the negative symptoms; the WSum6 with thought disorders; and the M-with delusions. PTI score, X-% and WSum6 predicted impaired judgment and insight.

Personality testing is a field that covers a vast range of tools and tests. Some of these use many questions to measure dozens of variables; others simply identify a person as belonging to a certain category. All these approaches offer the same underlying solution; they identify features of a personality in a way that's intended to be useful in understanding and predicting their behavior. It is basically a means of measuring an individual's personality in a particular situation. It is not a measure of intelligence or ability but of behavior. It provides a snapshot view of the preferred behavior that comes subconsciously to most people. Rorschach test is used for psychological evaluation and to provide data about cognition and personality variables such as motivations, response tendencies, cognitive operations, affectivity, and personal/interpersonal perceptions of an individual. Numerous studies are conducted using Rorschach test on clinical populations including schizophrenia patients as well as on normal population. However, studies relating to establishing correlation between personality variables and positive symptoms, negative symptoms are rare and negligible. Thus, present research is an attempt to study the relationship among the personality variables with the aforesaid psychopathology of schizophrenia patients.

METHODOLOGY

Sample

The present study was conducted at Ranchi Institute of Neuro-Psychiatry and Allied Sciences (RINPAS), Kanke, Ranchi, Jharkhand, India. Sample has been collected from RINPAS, Kanke, Ranchi, Jharkhand. The design used for this present study is single group design, and it is a single-center-based correlational study. One hundred schizophrenia patients were chosen from different wards and outpatient department of RINPAS, Kanke, Ranchi, on the basis of inclusion criteria. Patients were selected through the purposive sampling technique. The inclusion criteria for schizophrenia patients is patients with a diagnosis of schizophrenia according to ICD-10 DCR, aged between 25 and 45 years, duration of illness for minimum 1 year, with the education of minimum 8 th class, who are able to understand Hindi and cooperative, both males and females were included for the study. Patients with a history suggestive of substance abuse, head injury, mental retardation, other comorbid psychiatric disorders, with significant physical or neurological problems, having hearing or vision impairment were excluded from the study.

Tools used

Sociodemographic and clinical data sheet

A self-prepared semi-structured data sheet was used for the patient group. It was divided into sociodemographic and clinical data for the patient group. The sociodemographic variables were name, age, sex, marital status, education, occupation, etc. The variables in the clinical data were duration of illness, diagnosis, and duration of treatment.

Rorschach test

Rorschach test was developed by Hermann Rorschach in 1921[1]. This test was reportedly designed to reflect unconscious parts of the personality that “project” onto the stimuli. It consists of 10 cards with bilaterally symmetrical inkblots on each of them. Each of the cards is 18 cm × 24 cm in size. Five cards are of achromatic nature, two are of black and red ink, three are chromatic on a white background. Interscorer reliabilities of 0.85 or higher. Early meta-analyses indicated that validity ranged from 0.40 to 0.50.

Scale for assessment of positive symptoms

The Scale for Assessment of Positive Symptoms (SAPSs) is a 34-item scale, developed[13] for the assessment of positive symptoms in individuals with schizophrenia. The SAPS is administered through a general interview, plus a series of standardized questions. The SAPS evaluates positive symptoms in great detail (e.g., hallucinations, delusions, bizarre behavior, and formal thought disorder). Items are scored on a 0–5 (0 = no abnormality and 5 = severe) scale. It is utilized to assess the baseline clinical status and change over time in individuals with schizophrenia. This test will be used in this present study to assess positive symptoms in schizophrenia patients. There is less reliability data for SAPS. Interrater reliability for the SAPS is generally good. Weighted kappas for most items have been reported to range from 0.7 to 1.00.

Scale for assessment of negative symptoms

The Scale for Assessment of Negative Symptoms (SANS) is a 25-item scale, developed[14] for the assessment of negative symptoms in individuals with schizophrenia. The SANS items are rated on the basis of a clinical interview, direct observation, and any additional sources of information including clinical staff or family member reports. The SANS evaluates five domains of negative symptom complex including alogia, affective flattening, avolition-apathy, anhedonia-asociality, and attention. The scale is rated on a 0–5 spectrum (0 = no abnormality and 5 = severe). Strengths of the SANS include its relative ease of administration and well-researched reliability. It is utilized to assess baseline clinical status and change over time in individuals with schizophrenia. The SANS has been demonstrated to have good internal consistency, with Cronbach's alpha values from 0.67 to 0.90 for the five subscales. This test will be used to assess the negative symptoms in schizophrenia patients.

Procedure

After having informed consent, patients of schizophrenia group were selected according to the inclusion and exclusion criteria. Information about sociodemographic data and clinical details were collected using the sociodemographic and clinical data sheet from the drawn sample. Then, scales were administered to assess the positive and negative symptoms of the schizophrenia patients. After that Rorschach test was administered to assess the personality structure of each schizophrenia patient. Rorschach protocols were scored using Exner Comprehensive System. The statistical analysis was done with the help of IBM Corp. Released 2009. IBM SPSS Statistics for Windows, Version 17.0. (Armonk, NY: IBM Corp.) for windows. For the analysis of sociodemographic variables (continuous variables), t-test was applied, and for other categorical variables of sociodemographic variables, the Chi-square test was applied. For clinical details and symptom assessment of the patients with schizophrenia, mean and standard deviation (SD) was applied. For the assessment of correlation, Pearson product moment correlation was applied.

RESULTS

On assessing the sociodemographic details, it has been found that in the group of schizophrenia patients' age ranges from 27 to 45 years with a mean of 34.92 and SD of 5.47. Regarding the other sociodemographic details, it can be said that most of the schizophrenia patients were males (65%), having primary level of education (57%), from rural background (65%), married (96%), Hindu (62%), and unemployed (56%). In terms of the clinical details of the schizophrenia patients, it has been found that the age of onset of the illness ranges from 24 years to 45 years where majority of the patient falls in 36–45 years of age range (56.00%). The remaining were in the age range of 24–35 years (44.00%). The duration of illness ranges from 1.5 years to 7 years where 53.00% of the patient falls in 1–4 years of duration of illness followed by 47.00% of patients who falls in 5–7 years of duration of illness [Table ​ [Table1a 1a and ​ andb b ].

Table 1a

Sociodemographic details of patients with schizophrenia