Usefulness of structural Rorschach data in identifying inpatients with depressive symptoms: a preliminary study

To explore the usefulness of various structural Rorschach data in identifying psychiatric inpatients with symptoms of depression, 54 adult inpatients were administered a Rorschach. Results indicated that the Comprehensive System, Rorschach Depression Index did not identify many of these individuals as depressed, but did identify most of the extratensive depressed individuals. Each variable included in the Depression Index and other potential, Rorschach correlations of depression were also investigated. Most of them were found to occur more often among these depressed patients than among nonpatients. Furthermore, adding other variables and using more liberal cutoffs may result in more accurate identification of patients with depressive symptoms.     

Depression in a Cancer Patient Population

The main goal of this study was to examine depression and its components in cancer patients as compared with healthy control subjects and psychiatric inpatients. The participants were 54 cancer patients (28 females with breast cancer, 26 males with prostate cancer), 59 healthy controls (33 females, 26 males), and 75 psychiatric patients (27 females, 48 males). Participants were administered the Beck Depression Inventory (BDI) and the State Trait Personality Inventory (STPI) Depression scales. Cancer patients had higher overall depression scores than did healthy controls as measured by BDI, but the difference was due primarily to the significantly higher scores of the cancer patients on the BDI Somatic–Performance subscale. No differences were found on the BDI Cognitive–Affective subscale. Cancer patients also scored significantly higher than healthy controls on the State-Trait Personality Inventory (STPI) State Depression (S-Dep) scale because of higher Euthymia subscale scores. The psychiatric inpatients scored significantly higher than the other groups on all measures of depression. The findings of this study suggest that cancer patients may be erroneously labeled as depressed because of somatic–performance difficulties they may experience, which are similar to symptoms of depressed individuals. In addition, it is essential to delineate the various components of depression in evaluating cancer patients.     

The diagnostic efficiency of the Rorschach Depression Index and the Schizophrenia Index: a review

This review focuses on the diagnostic efficiency of the new versions of the Rorschach Comprehensive System Depression Index (DEPI) and the Schizophrenia Index (SCZI). Clinical diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders was chosen as the external validation criteria. The sensitivity, specificity, and overall classification rates for the indices were presented from the studies or computed from the data when possible. The positive and negative predictive validity was estimated at three different base rates. As regards the DEPI the results showed a large variation in diagnostic performance as the index seemed to have relatively more success in identifying nonpsychotic and unipolar depression than psychotic and bipolar depression. The DEPI did not successfully identify depression among adolescent patients. As regards the SCZI the results more consistently indicated that the index effectively discriminates between psychotic and nonpsychotic patients and the predictive validity of both a positive and negative SCZI was found to be high.     

Depression and vulnerability as assessed by the Rorschach method

We examined clinically depressed (CD; n = 16), previously depressed (PD; n = 19) and never depressed (ND; n = 18) individuals on 13 theoretically selected Rorschach (Exner, 1993; Rorschach, 1942) variables and on the Beck Depression Inventory (BDI; Beck, Rush, Shaw, & Emery, 1979). The group assignment was made according to the criteria of Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994). We tested 2 contradictory models for depressive vulnerability, Beck's (Clark & Beck, 1999) and Miranda and Persons's (1988; Persons & Miranda, 1992), in a planned comparison design with focused contrasts. The CDs significantly contrasted the combined group of NDs and the PDs in a pathological direction on 8 of the 13 Rorschach variables and on the BDI. However, the combined group of CDs and PDs also significantly contrasted the NDs in a pathological direction on 3 of these Rorschach variables and on the BDI. In addition, logistic regression analyses indicated that Rorschach indexes significantly improved the prediction of major depression above and beyond that achieved by the BDI. The findings show that the Rorschach method was able to identify (a) cognitive and aggressive disturbances that are present in individuals who are actively depressed but not in individuals who have been depressed in the past or never been depressed and (b) affective and coping disturbances that are present in depressed individuals and to some degree in PD individuals but not in individuals who have not experienced depression. We discuss the scanty evidence of psychological disturbances in PD individuals, as measured with the Rorschach, in relation to the mood-state dependent hypothesis of Miranda and Persons (1988; Persons & Miranda, 1992).     

An evaluation of the effects of Rorschach EB style on the diagnostic utility of the Depression Index

Several empirical studies have found the Rorschach Depression Index (DEPI) to have questionable diagnostic utility. Studies using adolescent samples suggest that the DEPI has limited sensitivity and fails to differentiate effectively between adolescents with and without depression diagnoses. The present study was conducted to evaluate Viglione, Brager, and Haller's suggestion that the DEPI may have better discriminative ability for individuals with extratensive problem-solving styles, measured by the Rorschach EB (Erlebnistypus) variable, compared to those with introversive and ambitent styles. Comparisons were conducted between adolescents with depression-related diagnoses and adolescents with other diagnoses for each of the three EB groups. The results failed to support the hypothesized greater discriminative power of DEPI for depressed extratensives, and suggest caution in using the DEPI to evaluate adolescent depression.     

Assessment of Depression in Adolescents: Objective and Projective Measures

This study is a multimethod assessment of depressive features in a sample of 60 adolescent inpatients. The purpose of the study was to examine the relationship between self-report measures of depression and Rorschach variables commonly associated with depression. Patients represented a variety of diagnostic categories in order to determine whether information gathered through assessment instruments was related to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed. [DSM-III], American Psychiatric Association, 1980) diagnoses of depression. Findings indicated that this sample of adolescents was highly defensive and emotionally constricted. There were several significant relationships between self-report measures and Rorschach indicators of depression. However, in general, the Rorschach variables were not strongly related to depression. The self-report measures were more accurate than Rorschach variables in discriminating between depressed and nondepressed subjects.     

Assessment of depression in adolescents: objective and projective measures

This study is a multimethod assessment of depressive features in a sample of 60 adolescent inpatients. The purpose of the study was to examine the relationship between self-report measures of depression and Rorschach variables commonly associated with depression. Patients represented a variety of diagnostic categories in order to determine whether information gathered through assessment instruments was related to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed. [DSM-III], American Psychiatric Association, 1980) diagnoses of depression. Findings indicated that this sample of adolescents was highly defensive and emotionally constricted. There were several significant relationships between self-report measures and Rorschach indicators of depression. However, in general, the Rorschach variables were not strongly related to depression. The self-report measures were more accurate than Rorschach variables in discriminating between depressed and nondepressed subjects.     

Risk,Resilience, and the Rorschach: A Longitudinal Study of Children Who Experienced Sexual Abuse

Experiencing sexual abuse increases the risk that children will report or otherwise demonstrate problems with emotion, behavior, and health. This longitudinal study of 44 children who experienced sexual abuse examined whether information processing as assessed via the Rorschach Inkblot Test was associated with child-reported depression symptoms assessed via the Children's Depression Inventory (Kovacs, 1992) concurrently and an average of 15 months later. Children whose Rorschach protocols were relatively free of scores suggesting intense distress, complex processing, and sexual content were more likely to experience remission of depression symptoms at follow-up. Findings provide incremental validity for certain Rorschach indexes to inform prognosis regarding depression symptoms and perhaps their treatment.     

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.     

Multimethod assessment of depression in sexually abused girls

This study measured depression in sexually abused Black girls using the Children's Depression Inventory (Kovacs & A. T. Beck, 1977), the Internalization scale of the Child Behavior Checklist (Achenbach & Edelbrock, 1983), and the Rorschach Depression Index (Exner, 1986). There were no significant correlations between these self-report, behavior observation (by parental report), and projective measures. The abused subjects had high scores on the behavior observation and Rorschach scales. Consistent with past research, negative results were obtained with the self-report instrument. We suggest that the low scores on self-report measures of distress produced by sexually abused children may be the result of guardedness or defensiveness rather than a genuinely low level of dysphoria in this population. There were no significant relations between abuse characteristics and scores on the depression measures. Scores on Rorschach measures of organizational activity (Zf) and available coping resources (EA) were generally positively related to depression within the abuse group and negatively related to depression within the control group.     

Multimethod Assessment of Depression in Sexually Abused Girls

This study measured depression in sexually abused Black girls using the Children's Depression Inventory (Kovacs & A. T. Beck, 1977), the Internalization scale of the Child Behavior Checklist (Achenbach & Edelbrock, 1983), and the Rorschach Depression Index (Exner, 1986). There were no significant correlations between these self-report, behavior observation (by parental report), and projective measures. The abused subjects had high scores on the behavior observation and Rorschach scales. Consistent with past research, negative results were obtained with the self-report instrument. We suggest that the low scores on self-report measures of distress produced by sexually abused children may be the result of guardedness or defensiveness rather than a genuinely low level of dysphoria in this population. There were no significant relations between abuse characteristics and scores on the depression measures. Scores on Rorschach measures of organizational activity (Zf) and available coping resources (EA) were generally positively related to depression within the abuse group and negatively related to depression within the control group.     

The Rorschach Ego Impairment Index in Heterogeneous Psychiatric Patients

There is a need for test measures of ego functioning that identify treatment needs and predict treatment response. Perry and Viglione's Rorschach Ego Impairment Index (EII; Perry & Viglione, 1991) is a composite measure assessing reality testing, thought process, defensive regulation, and object relations. It has been shown to correlate with Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943) scales and subscales and other measures of psychosis in a schizophrenic sample and to predict antidepressant treatment outcome in a depressed sample. This investigation examined the EII as a measure of ego impairment in a sample of 85 heterogeneous psychiatric inpatients and outpatients. In this sample, the EII did discriminate between inpatients and outpatients; it did not discriminate between psychotic and nonpsychotic patients, though there was a trend in this direction and one of the EII's object relations variables (Good H) did so. The EII did not generally show significant relations with MMPI indices of ego impairment (Es or Scale 8), though there were some significant patterns of relation with Scale 8 subscales. The study provides some, though not unequivocal, support for the EII as measure of ego impairment and for its utility compared to other measures and adds credence to earlier suggestions of the importance of object relations measures to ego functioning assessment.     

The Rorschach Comprehensive System Egocentricity Index in psychiatric inpatients

This paper reports an exploratory study of potential correlates of Exner's Rorschach Egocentricity Index, a measure of self-focusing, in a sample of 70 psychiatric inpatients. We examined the relationship of the Index of the MMPI Ego Strength scale and to other MMPI and Exner Comprehensive System Rorschach variables, using Pearson Product-Moment correlations with partialling of the number of Rorschach responses. There were seven meaningful significant correlations between the Index and Rorschach variables: M, FM, X +%, F +%, Lambda, D, and A%. The Index-MMPI correlations were not significant. Sex differences and differences between these intercorrelations and some reported by Exner (1983) are discussed.     

Self-esteem reconsidered: unstable self-esteem outperforms level of self-esteem as vulnerability marker for depression

Previous studies have built up evidence that an unstable self-esteem is associated with vulnerability to depression and that it outperforms level of self-esteem as a predictor for symptoms of depression. However, most of these studies have used student samples exclusively to investigate the role of self-esteem instability in depression vulnerability. Our present study used samples of currently depressed inpatients, formerly depressed individuals, and never-depressed controls to investigate the relationship between self-esteem instability and depression. In addition, we examined the predictive validity of self-esteem instability in predicting future depressive symptoms. The results indicate that self-esteem instability is associated with depression and vulnerability to depression. Furthermore, self-esteem instability interacted with perceived stress variability and depressed mood variability in predicting future depressive symptomatology at six months follow-up. These results are in line with the diathesis-stress model and support the hypothesis that self-esteem instability might be more important than level of self-esteem in predicting vulnerability to depression.     

An investigation of the relationship between cognitive reactivity and rumination

Teasdale’s (Teasdale, J.D. (1988). Cognitive vulnerability to persistent depression. Cognition and Emotion, 2, 247–274) differential activation hypothesis refers to the ease with which maladaptive cognitive processes are triggered by mild dysphoria as cognitive reactivity. Supporting this model is evidence of a differential association between sad mood and dysfunctional cognitions in formerly depressed and never-depressed individuals and the finding that cognitive reactivity predicts depression recurrence in remitted depressives. The Leiden Index of Depression Sensitivity–Revised (LEIDS-R; Van der Does, A.J.W., Williams, J.M.G. (2003). Leiden Index of Depression Sensitivity–Revised (LEIDS-R). Retrieved September 4, 2007, from http://www.dousa.nl/publications_depression.htm#LEIDS) is a recently developed self-report measure that provides clinicians and researchers with a time-efficient means by which to assess cognitive reactivity. This study investigated the relationship between cognitive reactivity (indexed by the LEIDS-R) and depressive rumination in a nonclinical sample (N = 324). As predicted, partial correlations between the LEIDS-R (subscale and Total scores) and the Ruminative Response Scale (RRS; Nolen-Hoeksema, S., and Morrow, J. (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. Journal of Personality and Social Psychology, 61, 115–121) were significant after controlling for current depressive symptoms. A subsample of participants (n= 130) was administered a structured interview to determine current and past depression diagnostic status. Recovered depressed individuals scored more highly on the LEIDS-R Total and LEIDS-R Rumination subscale; however, the groups did not differ on the remaining subscales. Regression analyses indicated that (across all participants) LEIDS-R Total made a unique contribution to the prediction of depression over and above trait level of depressive rumination. Overall, the LEIDS-R is a time-efficient self-report index of cognitive reactivity that demonstrates promise in distinguishing recovered and never-depressed individuals.     

Defense Mechanisms in Mania,Bipolar Depression and Unipolar Depression

The present study compared the use of defense mechanisms in ten bipolar manic, ten bipolar depressed and ten unipolar depressed patients. The defense mechanisms were assessed by two methods: TAT stories scored by Defense Mechanism Manual and Defense Mechanism Rating Scale ratings of psychodynamic interviews. The severity of symptoms was assessed by Beck Depression Inventory for depressed patients and Young’s Manic Rating Scale for manic patients. Both bipolar manic and depressed groups used the defense mechanism of denial, borderline level defenses and immature defenses significantly more than the unipolar depression group. The manic group showed greater dependence on narcissistic level defenses as compared to the other two groups. Positive relationships were found between severity of manic symptoms and the defense mechanisms of denial as well as the narcissistic level defenses. The bipolar depression group also used more action level defenses as compared to the unipolar depression group. The unipolar depression group scored higher on the defense mechanism of identification and adaptive level defenses as compared to the manic group. A negative correlation was found between the severity of depressive symptoms for unipolar depression group and the defense mechanism of identification. The neurotic level defenses were used most frequently by unipolar depression group, followed by the bipolar depression group and manic group. Some of these findings are in consonance with the psychoanalytic understanding of mania and depression.     

Assessment of depression in patients with Alzheimer's disease: concordance among informants.

This study is an investigation of the concordance among different sources of information on ratings of depression in patients with Alzheimer's disease (AD). Informants were 75 outpatients with diagnosed AD (22 with major depressive disorder), their caregivers, and geriatric clinicians. Clinicians rated each patient on the Hamilton Rating Scale for Depression on the basis of (a) the patient's report, (b) the caregiver's report, and (c) the clinician's evaluation. Overall, patients perceived themselves as less depressed than did caregivers or clinicians; for nondepressed patients, caregivers reported patients less depressed than clinicians reported; for depressed patients, no significant differences were obtained between caregiver or clinician. Certain items were more discrepant among informants and significantly differentiated depressed from nondepressed AD patients. Level of patient dementia did not affect ratings. These findings support the need for comprehensive, accurate assessment of depression in AD patients.     

Single-Sign Rorschach Suicide Indicators: A Validity Study Using a Depressed Inpatient Population

This study attempted to test the validity of using single responses on the Rorschach as indicators of current suicidal risk. Forty-one depressed inpatients were administered the Rorschach along with a concurrent measure of depression and suicidality. Appelbaum and Holzman's (1962) color-shading sign was found to be related to low suicidal risk, whereas Blatt and Ritzler's (1974) transparency sign was found to be unrelated to current suicidal risk, but still related to a past history of suicide attempts. Patients who saw these signs while depressed were also likely to see them when recovered, suggesting that the signs may indicate a "suicidal personality" who may or may not be in any immediate danger of committing suicide.     

Single-sign Rorschach suicide indicators: a validity study using a depressed inpatient population

This study attempted to test the validity of using single responses on the Rorschach as indicators of current suicidal risk. Forty-one depressed inpatients were administered the Rorschach along with a concurrent measure of depression and suicidality. Appelbaum and Holzman's (1962) color-shading sign was found to be related to low suicidal risk, whereas Blatt and Ritzler's (1974) transparency sign was found to be unrelated to current suicidal risk, but still related to a past history of suicide attempts. Patients who saw these signs while depressed were also likely to see them when recovered, suggesting that the signs may indicate a "suicidal personality" who may or may not be in any immediate danger of committing suicide.     

Evaluating depression severity and remission with a modified Beck Depression Inventory

In an attempt to improve assessment of recovery from depression, a modified Beck Depression Inventory (mBDI) was created that permits endorsement of positive feelings in addition to depressive symptoms. In both normal and clinical samples, the mBDI showed evidence of reliability for measuring varying degrees of depression. In comparison to the original BDI, the mBDI did not significantly improve differentiation in depression severity among depressed individuals and assessment of remission of depressive symptoms. However, the mBDI was significantly better than the original BDI in detecting differences in depression level when overall depression severity was low. Clinical implications for evaluating remission of depression are discussed.