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
- 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
For some more recent studies see the references in Muzio
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.
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