Differentiating psychotic patients from nonpsychotic patients with the MMPI-2 and Rorschach

The goal of this study was to examine the incremental validity and the clinical utility of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and Rorschach (Rorschach, 1942) with regard to differential diagnosis in a sample of adult inpatients with a primary psychotic disorder or a primary mood disorder without psychotic features. Diagnostic efficiency statistics have suggested that the Rorschach Perceptual Thinking Index (PTI; Exner, 2000a, 2000b) was better than MMPI-2 scales in discriminating psychotic patients from nonpsychotic patients. We compared the 84% overall correct classification rate (OCC) for the PTI to an OCC of 70% for the MMPI-2 scales. Adding the MMPI-2 scales to the PTI resulted in a decrease in OCC of 1%, whereas adding the PTI to the MMPI-2 resulted in an increase in OCC of 14%. Sensitivity, specificity, positive predictive power, negative predictive power, and kappa were equal or higher with only the PTI in the model.     

The relationship of the Rorschach Schizophrenia Index to psychotic features in a child psychiatric sample

In this study we investigated the reliability and validity of the Rorschach Schizophrenia Index (SCZI) from Exner's (1978, 1993) Comprehensive System for a sample of 413 child psychiatric inpatients by examining relationships with the Personality Inventory for Children-Revised (PIC-R) and chart diagnoses. Interscorer reliability and internal consistency were acceptable. Multivariate analyses of variance results revealed significantly different PIC-R profiles for those with and without elevated SCZI scores, with significant differences emerging on the PIC-R Psychosis (PSY) scale and 2 cognitive triad scales (Intellectual Screening and Development), which have been reported to be more frequently elevated in PIC-R profiles of children with psychotic disorders. Significant differences were found across SCZI groups for the PSY scale, Reality Distortion scale, reality testing critical items and chart diagnoses of psychotic disorder. Implications for clinical interpretation of the SCZI with children and issues for further research with this population are discussed.     

Contributions of Discriminant Analysis to Differential Diagnosis by Self-Report

We used discriminant function analyses of the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1983), Millon Clinical Multiaxial inventory (MCMI; Milton, 1983), MCMI-II (Millon, 1987), and Symptom Checklist Ninety-Revised (SCL-90-R; Derogatis, 1983) profiles from a heterogenous group of 272 psychiatric inpatients to classify patients as depressed, manic, and/or psychotic, Most functions generated from these tests significantly discriminated depressed, manic (not MCMI-II), and psychotic (not MCMI) subjects from psychiatric controls. However. there was little improvement in diagnostic efficiency over the use of single scale elevations at specified cut scores. Functions derived from the MCMI for mania and the MCMI-II for psychosis show the most promise but require replication. The difficulty of using group profile differences for the diagnosis of individual psychiatric patients is discussed.     

Perception and the Rorschach

In this study we investigated the reliability and validity of the Rorschach Schizophrenia Index (SCZI) from Exner's (1978, 1993) Comprehensive System for a sample of 413 child psychiatric inpatients by examining relationships with the Personality Inventory for Children-Revised (PIC-R) and chart diagnoses. Interscorer reliability and internal consistency were acceptable. Multivariate analyses of variance results revealed significantly different PIC-R profiles for those with and without elevated SCZI scores, with significant differences emerging on the PIC-R Psychosis (PSY) scale and 2 cognitive triad scales (Intellectual Screening and Development), which have been reported to be more frequently elevated in PIC-R profiles of children with psychotic disorders. Significant differences were found across SCZI groups for the PSY scale, Reality Distortion scale, reality testing critical items and chart diagnoses of psychotic disorder. Implications for clinical interpretation of the SCZI with children and issues for further research with this population are discussed.     

Defense Mechanism Test (DMT) and Kernberg's theory of personality organization related to adolescents in psychiatric care

75 adolescent psychiatric patients were diagnosed with the perceptual projective test the Defense Mechanism Test (DMT) and also according to Kernberg's theory of personality organization (PO). The test protocols were scored in respect of 130DMT variables and analyzed by means of partial least squares (PLS) discriminant analysis. The objective was to try to separate the three types of PO, psychotic (PPO), borderline (BPO) and neurotic (NPO) by means of the DMT and also to compare the results with a similar study on adult psychiatric patients. The results showed that it is possible to separate significantly the three groups of PO. The BPO group seemed to be heterogeneous. The results were fairly similar to those obtained with adult psychiatric patients. The overall results supported the concurrent validity of Kernberg's theory of PO and for the DMT as well. The DMT seems to be a useful diagnostic method in respect of adolescent psychiatric patients.     

A Comparison of New and Revised Rorschach Measures of Schizophrenic Functioning in a Serbian Clinical Sample

We empirically evaluated indexes derived from the Rorschach Comprehensive System (CS) and the Rorschach Performance Assessment System (R–PAS) that are used for the assessment of psychotic functioning in schizophrenia. We compared the Perceptual Thinking Index (PTI) and the Ego Impairment Index (EII–2) with their revised versions: Thought and Perception Composite (TP–Comp) and EII–3. We evaluated their predictive validity for differentiating schizophrenic from nonschizophrenic patients in a Serbian sample. The sample consisted of 211 (109 men and 102 women, 18–50 years old) inpatients in Serbia who were divided into 2 groups: schizophrenic (100) and nonschizophrenic (111). Test administration, coding, and form quality classification followed CS guidelines. Logistic regression analysis indicated that the new indexes TP–Comp and EII–3 have slightly better predictive power than their counterparts, PTI and EII–2, in identification of schizophrenia, and that TP–Comp performed better than other indexes, although all 4 indexes were successful in differentiating these groups. The results supported the use of TP–Comp in diagnosis of schizophrenia and generally provided evidence for the utility of the Rorschach in evaluating psychosis and for its use in a cross-national context.     

The Last-Weiss Rorschach Ego-Strength Scale as a prognostic measure for psychiatric outpatients

This study tested the hypothesis that the Last and Weiss (1976) Rorschach Ego-Strength Scale (sigma E) would predict outcome among a representative sample of never-hospitalized psychiatric outpatients. 78 patients were assessed with structured symptom, psychiatric history, and social data interviews at the time of initial clinic contact and at 2-yr. follow-up. Outcome measures included the Menninger Health-Sickness Scale, a multidimensional variable involving social and work functioning and recent symptom level, symptom measures, and an index of diagnostic severity. sigma E, controlled for number of responses, correlated significantly with Health-Sickness, neurotic symptoms, diagnostic severity, and psychotic symptomatology. Among the components of sigma E, M+, and FC+ had significant relationships or contributed to significant relations with outcome variables. Considered with an earlier study of inpatients, in which S+ sigma E component correlated inversely with outcome, this study suggested that sigma E components have differing prognostic significance, depending on adaptational level of the patient.     

A psychometric evaluation of the Rorschach comprehensive system's perceptual thinking index

In this study, we investigated evidence for reliability and validity of the Perceptual Thinking Index (PTI; Exner, 2000a, 2000b) among an adult inpatient population. We conducted reliability and validity analyses on 107 patients who met the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, 2000) criteria for a schizophrenia-spectrum disorder (SSD) or mood disorder with no psychotic features (MD). Results provided support for interrater reliability as well as internal consistency of the PTI. Furthermore, the PTI was an effective index in differentiating SSD patients from patients diagnosed with an MD. Finally, the PTI demonstrated adequate diagnostic statistics that can be useful in the classification of patients diagnosed with SSD and MD. We discuss methodological issues, implications for assessment practice, and directions for future research.     

Models of the Mind (Book)

In this study, we investigated evidence for reliability and validity of the Perceptual Thinking Index (PTI; Exner, 2000a, 2000b) among an adult inpatient population. We conducted reliability and validity analyses on 107 patients who met the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, 2000) criteria for a schizophrenia-spectrum disorder (SSD) or mood disorder with no psychotic features (MD). Results provided support for interrater reliability as well as internal consistency of the PTI. Furthermore, the PTI was an effective index in differentiating SSD patients from patients diagnosed with an MD. Finally, the PTI demonstrated adequate diagnostic statistics that can be useful in the classification of patients diagnosed with SSD and MD. We discuss methodological issues, implications for assessment practice, and directions for future research.     

Self-report of basic symptoms among psychotic and nonpsychotic subjects

Basic symptoms, as defined and described by the Bonn Scale, were assessed by means of a new self-report inventory, the Rome Basic Disorders Scale. On all the subscales, psychiatric outpatients (n = 105; most frequent diagnoses: Schizophrenia, Anxiety Disorders, and Mood Disorders) scored significantly higher (p < .001) than nonclinical controls (n = 105). Psychiatric patients with at least one diagnosis on the psychotic sets of Foulds' hierarchical inventory (n = 45), compared with the rest of the psychiatric sample (n = 60), had significantly higher scores on nearly all subscales. Two groups of inpatients with Schizophrenia (n = 20) and Mood Disorders (n = 20) were tested on Day 2 and 9 of hospitalization in an emergency ward. Schizophrenic patients had significantly higher scores on most of the subscales, but only on Day 9; on Day 2 depressed and manic patients scored significantly higher on four subscales. Until now basic symptoms had not been studied during the intrapsychotic phase, mainly because of their transformation into first-rank symptoms; present findings suggest that basic symptoms are active also at the height of the psychotic breakdown and that they are more responsive to treatment in Depression and Mania than in Schizophrenia.     

Multivariate modelling and personality organization: A comparative study of the Defense Mechanism Test and linguistic expressions

The main aim of the study is to establish an empirical connection between perceptual defences as measured by the Defense Mechanism Test (DMT)–a projective percept-genetic method–and manifest linguistic expressions based on word pattern analyses. The subjects were 25 psychiatric patients with the diagnoses neurotic personality organization (NPO), borderline personality organization (BPO) and psychotic personality organization (PPO) in accordance with Kernberg's theory. A set of 130 DMT variables and 40 linguistic variables were analyzed by means of partial least squares (PLS) discriminant analysis separately and then pooled together. The overall hypothesis was that it would be possible to define the personality organization of the patients in terms of an amalgam of perceptual defences and word patterns, and that these two kinds of data would confirm each other. The result of the combined PLS analysis revealed a very good separation between the diagnostic groups as measured by the pooled variable sets. Among other things, it was shown that NPO patients are principally characterized by linguistic variables, whereas BPO and PPO patients are better defined by perceptual defences as measured by the DMT method.     

Assessment of disordered thinking in children and adolescents: the rorschach perceptual-thinking index.

The new Rorschach Perceptual-Thinking Index (PTI; Exner, 2000a, 2000b) was designed to assess thought disorders more accurately than the Schizophrenia Index (SCZI; Exner, 1993). Using a sample of child and adolescent inpatients, we examined the relation of Rorschach variables (PTI, SCZI, M-, and X- %) to thought disorder indexes on a behavior rating scale (Behavior Assessment System for Children; Reynolds & Kamphaus, 1992) and a self-report measure (Personality Inventory for Youth; Lachar & Gruber, 1995). Results indicate that, when used in a categorical manner, the PTI differentiated between those patients with and without elevated thought disorder scores on the other measures. Of all Rorschach variables, M- was most related to the other measures, indicating that this variable may be a particularly robust indicator of thought disorder among children and adolescents.     

Comparing the diagnostic validity of an abbreviated and standard MMPI

The diagnostic efficacy of the MMPI-168 and standard MMPI was compared with a sample of psychiatric inpatients. Using traditional psychiatric measures and projective testing as a basis for the criterion diagnoses, no significant differences were found between the two MMPI forms. Rationale for the methodology employed was discussed.     

Reactions to DMT as related to psychotic and borderline personality organization

Thirty-one inpatients in a psychiatric clinic were assessed with DMT and the Structural Interview. In order to assemble every relevant reaction that an individual might have to a percept-genesis, 130 DMT variables were formed. The results were first subjected to a quality control of the DMT-scores and then subjected to partial least squares in latent variables (PLS) discriminant analysis. The analysis showed that it is possible to separate patients with psychotic PO (PPO) from those with borderline PO (BPO) by means of the 130 variables. The BPO group is characterized by aggressive manifestations, sensitivity to threat, identity lability and various transformations of the Hero gestalt. The PPO group, on the other hand, is characterized by high threshold values for perception, lack of identity, denial and repression of the peripheral person at a late-phase level. There are other perceptual reactions that are important predictors of PO than the defence categories of the manual. These perceptual reactions do not correspond to the traditional psychodynamic defence mechanisms. Our conclusion is that principal component analysis (PCA) and PLS are useful methods of finding discriminating patterns of perceptual reactions to the DMT for patients with different PO.     

ABSTRACTS OF LITERATURE

To test the hypothesis that there would be significant differences in the families of schizophrenics, borderlines, neurotics, and non-neurotic psychiatric controls, a sample of six control families who had not had psychiatric treatment and fifty families who had had a child hospitalized for "emotional disturbance" were given the MMPI. Of the 50 patients, 23 were schizophrenic, one manic-depressive, 16 borderline, and 10 neurotic. None was hospitalized at the time of data collection. Using multivariant statistical profile similarities, there were no differences among either the fathers, mothers, or siblings of the offspring in the four diagnostic groups. It was concluded that these families could not be differentiated on the basis of self-reports of psychiatric symptoms.     

A comparison of Rorschach developmental level and form-level systems as indicators of psychosis.

Psychotic and nonpsychotic psychiatric inpatients were tested on the Rorschach. "Reality-testing" was measured by four form-level scoring systems designed by Beck, Mayman, Becker, and Wilensky. The psychotic subjects were dichotomized on three diagnostic dimensions: schizophrenia, paranoia, and premorbid social adjustment. No significant differences were found for the Beck system. With the other systems, psychotics showed significantly poorer reality testing than nonpsychotics. No differences were found for the schizophrenic and paranoid dimensions. The Phillips premorbid adjustment score was negatively correlated with all four measures of "reality-testing." The conclusion drawn was that Rorschach measures of "reality testing" are associated with psychotic and poor premorbid functioning, but do not differentiate schizophrenic from nonschizophrenic psychotics or paranoid schizophrenics from nonparanoid schizophrenics.     

Ethnic differences in psychiatric disorders among adolescent substance abusers in treatment

The present study describes the diagnostic profile of over 800 adolescents admitted to residential therapeutic community programs for treatment of drug abuse and related problems. The relationship between race/ethnicity and psychiatric disturbance is examined, and the association among these factors to outcome is investigated. Over 90% of the sample had a DSM-III-R nonsubstance diagnosis. There were significant differences among the race/ethnic groups on attention deficit-hyperactivity and the disruptive behavior and affective disorders. In general, African-American adolescents yielded the lowest rates of disturbance across all categories of disorders. There was no relationship among race/ethnicity, psychiatric disturbance, and 1-year posttreatment outcomes.     

Exploring the hand test with medically ill children and adolescents

Pediatric psychologists use the tools of assessment to evaluate the psychological functioning of youth with chronic and acute medical illnesses. This study is an exploration of the use of a performance-based measure, the Hand Test (HT; Wagner, 1983), with pediatric medical patients. A sample of medical inpatients (n = 27) and psychiatric outpatients (n = 24) were administered the HT, a self-report measure, and a parent-report behavior rating scale. Results indicate that the psychiatric group scored higher than the medical group on HT Aggression, Withdrawal, and Pathological scores. The Aggression (d = 0.90) and Pathological (d = 0.80) variables were particularly robust in differentiating between groups, but the Crippled variable did not differ between groups. Hierarchical logistic regression demonstrated the incremental validity of the HT over behavior ratings alone in the classification of clinical groups. Analyses indicated that the HT can add important information in the differentiation of medically ill children from those with psychological disturbance.     

Personality Disorders in Older Adult Inpatients with Chronic Mental Illness

It has been hypothesized that some types of personality disorders tend to remit with age whereas others may become more prominent. The present study determined the prevalence and nature of 13 personality disorders with a self-report inventory (Coolidge Axis II Inventory) in an older group of chronically mentally ill inpatients (N = 30, mean age = 63 years) and a younger group of similar patients (N = 30, mean age = 39 years). All patients met DSM-IV criteria for either Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, or recurrent severe Major Depression with psychotic features. The prevalence rate of personality disorders was high for both groups: 58% for the older sample and 66% for the younger group. The younger group was more likely to be diagnosed Antisocial, Borderline, Passive-Aggressive, Sadistic, and Schizotypal, but the groups were not different in the rates of Obsessive-Compulsive Disorder. This study supports the hypothesis that some personality disorders remit with age. However, no evidence was found to suggest that other personality disorders become more prominent in older adult psychiatric populations. Suggestions for future research are offered.     

A validity scale sign calling for caution in the interpretation of MMPIs among psychiatric inpatients

Three expert MMPI judges classified 100 psychiatric inpatients as psychotic or non-psychotic on the basis of their MMPIs. Validity scale data, as well as clinical scale scores, were included for 50 of the profiles, while the validity scale scores were withheld from the judges for the remaining 50 profiles. Within each of the above two groups, half had a "positive" validity scale sign (a defensive validity scale configuration defined as L or K greater than or equal to 70, or both greater than or equal to 60) and half had a negative validity scale sign, indicating a lack of defensiveness. Using actual diagnosis as the external criterion, results indicated that the majority of defensive psychotic patients produced clinical scale configurations which appeared nonpsychotic to the judges. Conversely, the majority of nondefensive nonpsychotics produced psychotic-appearing clinical scale configurations. These two types of test misses suggest that K corrections on MMPI scales relating to psychosis are not optimal for psychiatric inpatients. Guidelines were developed for interpreting defensive profiles.