Understanding and Using the Rorschach Inkblot Test to Assess Post-Traumatic Conditions

Hypervigilance or shutdown? Electrophysiological processing of trauma-unrelated aversive stimuli after traumatic life events

Post-Traumatic Stress Disorder (PTSD) research indicates that hyper-reactivity to trauma-related stimuli reflects reduced prefrontal cortex (PFC) modulation of amygdala reactivity. However, other studies indicate a dissociative "shutdown" reaction to overwhelming aversive stimuli, possibly reflecting PFC over-modulation. To explore this, we used an Event-Related Potential (ERP) oddball paradigm to study P3 responses in the presence of the following: 1. Trauma-unrelated morbid distractors (e.g., "injured bear") related to the Rorschach inkblot test, and 2. Negative distractors (e.g., "significant failure"), among participants with high post-traumatic stress symptoms (PTS; n = 20), low PTS (n = 17), and controls (n = 15). Distractors were presented at 20% frequency amongst the more frequent (60%) neutral standard stimuli (e.g., "desk lamp") and the equally frequent (20%) neutral trauma-unrelated target stimulus ("golden fish"). P3 amplitudes were high in the presence of morbid distractors and low in the presence of negative distractors only amongst the control group. Possible mechanisms underlying the lack of P3 amplitude modulation after trauma are discussed.

Traumatized Refugees in Psychotherapy: Long-Term Changes in Personality, Mental Health, Well-Being, and Exile Life Functioning

ABSTRACT

This pre- and posttreatment study of 22 severely traumatized adult refugees spanned a mean of 6.5 years. Changes in personality functioning, mental health, and well-being were examined using the Rorschach Performance Assessment System, Harvard Trauma Questionnaire, Hopkins Symptom Checklist-25, and the World Health Organization's Quality of Life-BREF questionnaire. A paired samples t-test revealed significant improvement after psychotherapy in traumatic ideation and initial severe disruptions in thought processes, reality testing, perception, self and other representations, and relational capacity (Cohen's d = 0.46-0.59). Symptoms of anxiety, depression, and posttraumatic stress were significantly reduced (d = 0.54-0.84), quality of life in the physical health and psychological health domains increased significantly (d = 0.87 and 0.97), and percentage of participants with exile language proficiency and work/study status increased significantly. The findings demonstrate the potential of psychotherapy to contribute to normalizing perceptual, cognitive, and relational capacities in severely traumatized refugees, paramount to well-being and functioning in exile.

Complexity and Cognitive Engagement in the Rorschach Task: An Eye-Tracking Study

This study investigated whether complexity and the other related Rorschach Performance Assessment System (R-PAS) variables in the engagement and cognitive processing domain would associate with eye-tracking measures reflecting increased cognitive engagement and effort while visually scanning the Rorschach inkblots. A nonclinical sample of 71 adult volunteers were administered the Rorschach task while their eye movements were recorded using an eye tracker. Then, the average duration of fixations, the average number of fixations, the average amplitude of saccades, and the average maximum pupil size recorded during the response phase (RP) of the Rorschach administration were correlated with protocol-level, R-PAS variables located in the engagement and cognitive processing. As expected, complexity correlated, with a large effect size (r = .526, p < .01), with the number of fixations occurring during the RP of Rorschach administration. Some other variables related to complexity (e.g., Synthesis, Sy) also produced similar associations. The other eye-tracking variables under examination, however, produced weak or nonsignificant correlations.

Rorschach Assessment of Two Distinctive Personality States of a Person With Dissociative Identity Disorder

This case study used test data from a patient with Dissociative Identity Disorder (DID; American Psychiatric Association, 2013 ) to illustrate how two main personality states of the patient ("Ann" and "Ben") seemed to function. The Rorschach Performance Assessment System (R-PAS; Meyer, Viglione, Mihura, Erard, & Erdberg, 2011 ) and the Inventory of Interpersonal Problems-Circumplex (IIP-64; Horowitz, Alden, Wiggins, & Pincus, 2000 ), administered to Ann and Ben in separate settings, exposed two diverse R-PAS and IIP-64 profiles. Ann's R-PAS profile suggested an intellectualized style of information processing with few indications of psychological problems. Ben's profile indicated severe perceptual, cognitive, and interpersonal difficulties combined with suspicion and anxiety. Ann's IIP-64 profile suggested minor interpersonal problems, whereas Ben's indicated serious relational difficulties. The findings were discussed in relation to the theory of trauma-related structural dissociation of the personality (van der Hart, Nijenhuis, & Steele, 2006 ), which implies an enduring split in the organization of the personality with more or less separate entities with their own sense of self, perception of the world, and ways of organizing emotional, cognitive, and social functions. The DID personality structure is seen as a defense strategy and as a pathway in the personality development producing serious psychological pain and symptoms.

Relationship of Pretreatment Rorschach Factors to Symptoms, Quality of Life, and Real-Life Functioning in a 3-Year Follow-Up of Traumatized Refugee Patients

Response to mental health treatment varies highly among refugee patients. Research has not established which factors relate to differences in outcome. This study is a follow-up of Opaas and Hartmann's (2013) Rorschach Inkblot Method (RIM; Exner, 2003) pretreatment study of traumatized refugees, where 2 RIM principal components, Trauma Response and Reality Testing, were found descriptive of participants’ trauma-related personality functioning. This study's aims were to examine relationships of the RIM components with measures of anxiety, depression, posttraumatic stress, quality of life (QOL), employment, and exile language skills throughout 3 years. We found that impaired Reality Testing was related to more mental health symptoms and poorer QOL; furthermore, individuals with adequate Reality Testing improved in posttraumatic stress symptoms the first year and retained their improvement. Individuals with impaired Reality Testing deteriorated the first year and improved only slightly the next 2 years. The results of this study imply that traumatized refugee patients with impaired Reality Testing might need specific treatment approaches. Research follow-up periods should be long enough to detect changes. The reality testing impairment revealed by the RIM, mainly perceptual in quality, might not be easily detected by diagnostic interviews and self-report.

The impact of exposure to Internet-based information about the Rorschach and the MMPI-2 on psychiatric outpatients' ability to simulate mentally healthy test performance

To examine the impact of Internet-based information about how to simulate being mentally healthy on the Rorschach (Exner, 2003) and the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989), 87 psychiatric outpatients completed the tests under 4 conditions: uncoached and Internet-coached outpatients under faking healthy instructions (faking patients and Internet-faking patients) and patients and nonpatients under standard instructions (standard patients and standard nonpatients). On the Rorschach, faking patients and Internet-faking patients did not manage to portray healthy test performance and, like standard patients, revealed a significantly greater number of perceptual and cognitive disturbances than standard nonpatients. Faking patients scored in the psychopathological direction on most variables. Internet-faking patients produced constricted protocols with significantly higher F% (57%) and lower use of provoking and aggressive contents than the other groups. On the MMPI-2, faking patients and Internet-faking patients were able to conceal symptoms and, like standard nonpatients, scored in the normal range on the clinical scales. The validity scale L successfully detected the faking patients and the Internet-faking patients, whereas the F scale only distinguished the Internet-faking patients and K only the faking patients. We conclude that Internet-based information could threaten test validity.