Using the Rorschach method in patients with brain damage

The study of the Rorschach test in patients with organic mental disorders has a long history, beginning with Rorschach´s own investigations of patients with dementia, Korsakoff´s psychosis, general paresis and lethargic encephalitis. Other pioneer Swiss researchers in this field include Oberholzer (1931). Piotrowski´s ten "organic signs" (Piotrowski 1937) also held early promise. A lot of research was done in the U.S.A. during the following decades to test and to improve Piotrowski´s signs but with no great success except for establishing beyond reasonable doubt that Piotrowski´s signs do have some validity in discriminating normal subjects from brain-injured ones. For reviews see Goldfried et al (1971), Velez-Diaz (1973); much of the relevant work up to about 1970 in the classical European and the American Rorschach traditions has also been summarised by Bohm (1972). During the 70´s and 80´s comparatively little research was done with the Rorschach in organic disorders (for excellent reviews see Caputo 1989, 1999), and before the very last years there were only sporadic attempts to use Exner´s Rorschach in neuropsychiatric conditions (but cf Ellis & Zahn 1985). However, after 1995 several papers have appeared applying the Comprehensive System to neuropsychiatry and/or neuropsychology; see for example the patient data and the interesting theoretical discussion in Perry et al 1997 (and cf Malmgren et al 1997, which uses Bohm's approach to a similar patient category).

As has been noted by Velez-Diaz (1973), Caputo (1989, 1999) and others there are several major methodological problems involved in any study of the Rorschach in organic mental disorders. Two well-known such problems are:

- The Rorschach test is sensitive to so many dimensions of human personality that the variability due to the organic component may easily vanish in "noise" due to other sources.
- The organic mental disorders are a very heterogeneous family of disturbances which cannot be expected to produce a unitary Rorschach picture.

To these, two others must be added the importance of which have in our opinion not been sufficiently appreciated:

- Much of the clinical psychiatric heterogeneity remains even if groups of patients with unitary aetiology are studied. Cf for example the diversity of organic mental syndromes observed in a group of 100 patients having undergone transsphenoidal hypophysectomi (Lindqvist 1966).
- Many diagnostic difficulties in organic psychiatry, especially in cases with multiple simultaneous reaction forms, can be resolved only in a longitudinal perspective. Cf the problem - within the framework of DSM-III-R, 1987 - of diagnosing Dementia or Amnestic Syndrome in a patient fulfilling the criteria for Delirium (see also Malmgren & Lindqvist 1993).

These considerations imply the following methodological criteria (cf also Malmgren et al 1997):
(i) that the diagnostic framework which is used must define the organic mental disorders in terms of psychopathology (independently of aetiology);
(ii) that the subjects studied should be carefully described with respect to the kinds, severity and time course of the organic mental disorders that they exhibit;
(iii) that a longitudinal (or mixed group/longitudinal) study design could offer great advantages, both by improving diagnostic precision and by reducing variability due to irrelevant factors.

Scientific studies which concentrate on the differences between the various organic mental syndromes are still very rare - and before there has been a lot more such research, we cannot confidently answer the question, How useful is the Rorschach for the diagnosis of organic mental disorders? But I believe that the method has a good prognosis as a neuropsychiatric instrument, even in such difficult fields as distinguishing organic from non-organic schizophrenic psychoses, deciding whether a patient has an astheno-emotional disorder caused by exposure to solvents, etc.

The above text was written in 2004, the following in 2020.

For some more recent studies see the references in Muzio (2016).

But: Apart from the difficulties stemming from the diagnostic framework, Rorschach studies with the Exner or R-PAS systems cannot use several of the criteria that are mentioned by Piotrowski and Bohm. First and foremost, low R (number of responses) is an important criterion for both Piotrowski and Bohm, as is Rejection. A high R is on the other hand typical of Korsakoff's amnestic disorder. To the limited extent that these signs can be scored in the new American systems, both measures are heavily influenced by the ambition to keep R within a "normal" range through encouragement and dissuation. Second, time per response is important for Piotrowski and Bohm but not scored in the new systems. Third, Bohm uses a large number of "special phenomena" in the diagnosis of organic disorders. Many of these have an a priori plausibility (a.k.a. "conceptual validity") but are not scored by Exner or R-PAS.

I developed these themes further in a presentation at the 22d IRS in Paris (2017) called Rorschach and the Brain. It is not yet available online but if you want to see it, please e-mail me. 

Today my view about the future of the Rorschach in brain disorders is pessimistic. Please help me change it.


Bohm, E. (1972). Lehrbuch der Rorschach-Psychodiagnostik. (4 ed.). Bern: Huber.

Caputo, J. (1989). Rorschach studies of neuropsychological groups of the past, present and future. Unpublished thesis for the degree of Psy.D., Central Michigan University, Mount Pleasant, MI.

Caputo, J. (1999). The Rorschach as a Neuropsychological Instrument: Historical Precedents and Future Use. HTML version of a paper read at the 16th IRA Congress, Amsterdam July 19-24, 1999.

Ellis, D., & Zahn, B. (1985). Psychological functioning after severe closed head injury. Journal of Personality Assessment, 49, 125-128.

Goldfried, M., Stricker, G., & Weiner, I. (Eds.). (1971). Rorschach handbook of clinical and research applications. Englewood Cliffs, NJ: Prentice-Hall.

Lindqvist, G. (1966). Mental change after transsphenoidal hypophysectomy. Acta Psychiatrica Scandinavica, 42 (Suppl. 190).

Lindqvist, G. & Malmgren, H. (1993). Classification and Diagnosis of Organic Mental Disorders.  Acta Psychiatrica Scandinavica, 88 (Suppl. 373).

Malmgren, H., Bilting, M., Fröbärj, G. & Lindqvist, G. (1997). A longitudinal pilot study of the Rorschach as a neuropsychological instrument. In: Carlsson, A.M. et al, Research into Rorschach and Projective Methods, (Swedish Rorschach Society, Stockholm). Presently unavailable due to ongoing revision.

Malmgren, H., & Lindqvist, G. (1993). The semantic status of diagnostic criteria for organic mental syndromes and disorders in DSM-III and DSM-III-R. Acta Psychiatrica Scandinavica, 88 (Suppl. 373), 33-47.

Muzio, E., Inkblots and neurons: Correlating typical cognitive performance with brain structure and function. In: Rorschachiana 37 (2016):1, Special Issue: Neuroscience and the Rorschach, 1–6. Ed. E. Muzio. Hogrefe.

Oberholzer, E. (1931). Zur Differentialdiagnose psychischer Folgezustande nach Schädeltrauma mittels des Rorschachschen Formdeutversuches. Zeitschrift für die gesamte Neurologie und Psychiatrie, 136, 596-629.

Perry, W. & Potterat, E. (1997). Beyond personality assessment: The use of the Rorschach as a neuropsychological instrument in patients with amnestic disorders. In: Meloy, J.R. et al, Contemporary Rorschach Interpretation, 557-76. Mahwah, N.J.: Erlbaum.

Piotrowski, Z. (1937). The Rorschach inkblot method in organic disturbances of the central nervous system. Journal of Nervous and Mental Disease, 86, 525-537.

Rorschach, H. (1921). Psychodiagnostik. Bern: Bircher.

Velez-Diaz, A. (1973). Rorschach test in the assessment of organic brain damage in adults: A review of the post-1954 literature. San Juan: Veterans Administration Center.

Latest update: March 12, 2020.

Main page        Previous page        Next page