Changes in Rorschach performance and clinical improvement schizophrenia
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The purpose of this study was to investigate the changes in indices of withdrawal on the Rorschach tests of hospitalized schizophrenic patients. This involved examining them when they were acutely ill and again when they were judged to be clinically improved. Two major assumptions underlie the plan of this study. The first is that the behavior and symptoms shown by the acutely ill schizophrenic patient reflects his withdrawal in three areas: interpersonal relations, the world, and the expression and control of emotion. The second assumption is that the Rorschach test has satisfactory indices for these three areas and that these indices are sensitive to changes within individuals. The concept of withdrawal as occurring in three areas is derived from different emphases in three psychiatric schools. Withdrawal from people is emphasized by the Sullivan group. Withdrawal from the environment is emphasized in the views of Meyer and Campbell. Withdrawal of and from emotion is emphasized by the Freudian school which relates this activity with centering libidinal energy on the self. One unstructured projective test which reveals the subject's attitudes and feelings toward others, his perception of the world, and the manner in which he handles his emotions is the Rorschach test. The patient's attitudes and feelings are communicated indirectly through his responses to the Rorsehach cards. In order to use this test to study the changes in withdrawal, clusters of Rorschach scores meaningfully associated with the three withdrawal areas were first isolated. Ten Rorschach indices were chosen and organized into constellations according to present theory and clinical practice. The scores reflecting the empathy, rapport, and feeling toward others experienced by the subject, and hence interpersonal relations, are the Movement and Human responses (M and H) patterned out according to their quality and with regard to the locations in which they appear, and the ratio of form-color responses to the sum of color-form and pure color responses ( FC : CF ≠ C ). The patient's perception of the world is reflected in four sets of Rorschach indices: an index of the perception of reality ( F≠% ), an index of conformity with the thinking of the group (the number of Popular responses), evidence that the world is a source of fear and danger (responses with destructive and tension-laden Content), and distortion in distance maintained by the individual between himself and the world (Rejections-Denials-Self-references). The expression and control of emotion are reflected in four sets of Rorschach indices: the ratio of intellectually determined responses to the total number of responses ( F% ), the index of the affective energy available for response to external stimuli ( 8-9-10% ), the index of emotional maturity and control ( FC : CF : C: ), and the ratio of the sum of the emotionally toned responses controlled out of respect for reality to the sum of the emotional responses where form is secondary or lacking (FC≠FY≠FV: CF ≠ C ≠ YF ≠ Y ≠ VF ≠ V ). It was predicted that clinical improvement and lessened withdrawal would be reflected in changes in the selected Rorschach indices. The changes in patterns and ratios would be in the direction of haalthier responses and better personality integration. Forty-five cooperative acutely ill schizophrenic patients between the ages of sixteen and forty were the subjects of this study. The forty-five cases were consecutive admissions selected only on the basis of diagnosis, age, and recency of onset of illness. Each patient in this study was tested both when he was acutely ill and when he left the hospital either as improved or nonimproved. Each individual was both an experimental subject and his own control since changes between first and second protocol were the data analyzed. A rating seale consisting of eleven items was devised to evaluate the clinical changes in each patient. Each patient was rated by two psychiatrists upon admission to the hospital and again upon discharge from the hospital. The second rating was made without reference to the earlier rating. The psychiatrists agreed that thirty-three of the forty-five cases showed clinical improvement during their stay in the hospital and that fourteen of these cases showed marked improvement. The remaining twelve cases showed no clinical change according to both psychiatrists. Those patients who improved and those who did not improve clinically were found to be not significantly different in respect to age, education, length of hospitalization, the kinds of therapeutic treatments given them, and the incidence of unhealthy responses on their initial tests. In the analysis of each pair of Rorschach records, a change in the direction which Rorschach theory considers to be healthy was called positive. If an index on the second protocol showed no change or changed in the direction of less healthy responses it was classified as showing an absence of positive change. The incidences of positive changes in Rorschach indices in the total group of the thirty-three improved cases were compared with the incidences of changes in the twelve nonimproved cases. A second analysis was made by comparing the incidences of Rorschach changes in those fourteen cases of the thirty-three improved cases who showed marked improvement with the incidences of changes in the twelve nonimproved cases. The specific hypotheses tested were that the clinically improved groups do not differ significantly from the nonimproved group with respect to the incidences of positive changes in each of the Rorschach indices studied. The null hypotheses could be rejected for all but three comparisons, and in two of these comparisons meaningful trends were evident in the data. StatisticaLly significant and disproportionately high incidences of multiple positive Rorschach changes occurred in the improved groups in comparison with the nonimproved group in the combined Rorschach indices. This was true for each of the three areas of withdrawal investigated: interpersonal relations (P<.O1), perception of the world (P<.001), and the expression and control of emotion (P<.02). The findings support the inference that the decrease in withdrawal which accompanies clinical improvement is related to changes in the direction of healthier responses in Rorschach retest protocols. The combined indices are more significantly related to clinical improvement than the separate indices except for the FC: CF: C ratio. This confirms Rorschach theory and practice which holds that individual scores must be combined for meaningful evaluation of a Rorschach protocol. Significant incidences of positive changes were found in the clinically improved cases in contrast with the nonimproved cases in the direction of increased interest in others (M and H; P<.04), greater warmth and empathy (FC: CF ≠ C; P<.04), increased ability to deal with stimulus material in reality terms (F≠%; P<.03), decrease in fears and tensions associated with a threatening environment (Content; P<.01), better balance between intellectual and non-intellectual drives (F%; P<.04), healthy use of affective energy (8-9-10%; P<.04), and more mature and controlled emotion (FC: CF: C; P<.01). On three of the ten indices the incidences of positive changes in the improved and nonimproved groups were not significantly different. However, trends toward significance were found on two of these indices: decrease in the total number of Rejections-Denials-Self-references and increase in the FC ≠ FY ≠ FV: CF ≠ C ≠ YF ≠ Y ≠ VF ≠ V ratio. However, separate analysis of Rejections and Denials and Self-references showed that Rejections and Denials each decreased significantly with clinical improvement (P<.03 and <.05 respectively), but the decrease in Self-references was not significant. An increase in the FC ≠ FY ≠ FV: CF ≠ C ≠ YF ≠ Y ≠ VF ≠ V ratio, indicating a greater control of emotion, was significantly associated with marked clinical improvement (P <.03) but not with undifferentiated improwment (P<.10). Changes on the tenth index, the Popular responses, were not associated with change in clinical condition. The incidences of positive Rorschach changes were relatively greater for cases showing marked clinical improvement than for cases showing undifferentiated improvement on five of the ten Rorschach indices (M and H, F≠%, F%, 8-9-10%, and the FC ≠ FY ≠ FV: CF ≠ C ≠ YF ≠ Y ≠ VF ≠ V ratio). This suggests that a small population of extreme cases may give as significant information in research as a larger more heterogeneous population. This study has shown that constellations of Rorschach indices selected on the basis of their theoretical significance can be treated experimentally, without isolating them from other scores, without ignoring qualitative features which are clinically significant, and without treating them as numerical units contrary to Rorschach usage. Changes in indices thus selected are significantly associated with changes in clinical condition. Healthier responses are found on clusters of Rorschach indices which deal with the three areas of withdrawal: interpersonal relations, attitude toward the world, and ability to handle emotions, with remission of an acute schizophrenic episode. The validity of the Rorschach test as sensitive to changes within the individual is corroborated by these data. One implication for clinical practice from this study is that this test should be given more than once in evaluating any patient. The areas in which he shows stability or disturbances would thus be delineated. Since this study has shown that Rorschach protocols are not greatly affected by familiarity with a test when there has been no clinical change, progress in therapy could be evaluated by studying changes in serial Rorschach records of one patient. This would permit evaluation of therapeutic progress within one frame of reference. The findings in this study suggest that the concept of withdrawal might be studied more intensively for its function in the genesis as well as remission in mental illness. The role of the three areas of withdrawal in the development and progress of a schizophrenic illness and the relative significance of these areas also need to be clarified.
Thesis (Ph.D.)--Boston University
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