SIS Journal of Projective Psychology & Mental Health

ISSN 0971 - 6610 ISSN 0971 - 6610 ISSN 0971 - 6610 ISSN 0971 - 6610 ISSN 0971 - 6610 JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH The Official Publication of the Somatic Inkblot Society Volume 14 Number 1 January, 2007 SIS

SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH is a refereed journal and published twice a year (January, July) by the SOMATIC INKBLOT SOCIETY and is devoted to the advancement of research in the areas of projective psychology, personality assessment, psychotherapy and mental health. The journal is broadly concerned with the development of inkblot tests and personality assessment in clinical, counseling, cross-cultural, organizational and health psychology settings. It aims to reach clinical psychologists, psychotherapists, psychiatrists, social workers, medical professionals and professional managers interested in the understanding and modification of human behaviour. The journal includes (a) research articles (b) book reviews (c) brief reports (d) news about conferences etc. and letters to the editor. MANUSCRIPTS PREPARATION: Manuscripts should be typewritten (double-spaced throughout) submitted through E-mail or in CD to B.L. Dubey, Ph.D. Editor Emeritus, SIS Journal, E-mail:sisdubey@rediffmail.com. or sisdubey@yahoo.com with a copy to Amool Ranjan Singh, Ph.D. Editor In Chief and Head of Clinical Psychology,RINPAS,Kanke,Ranchi-834006. E-mail:editor_sis@rediffmail.com & sisamool@yahoo.com, Mob 91-9431592734.The Editors reserve the right to refuse manuscript submitted and to make minor additions/deletions. Authors should prepare their manuscripts according to the Journal of Personality Assessment/ SIS Journal of Projective Psychology & Mental Health. SUBSCRIPTION: The journal is free to members of the Society, Annual membership fees are US $40 for foreign members and Rs. 300, for Indian members, Institutional subscriptions are US $60. for Foreign institutions and Rs. 600 for Indian institutions. Life membership is US $300. for foreign members and Rs. 2500/- for Indian members. Indian institutional life membership is Rs. 4000/-. Non-members may subscribe for $30 or Rs. 200 per issue. Cheques should be made payable to "SIS Journal of Projective Psychology and Mental Health" and should reach Amool Ranjan Singh, Ph.D. Editor In Chief. Members in foreign countries should send the cheque to B.L. Dubey, Ph.D. Editor Emeritus, 4406 Forest Road, Anchorage, AK-99517 (USA) Please add $5./Rs.60/ - if you are sending subscription through cheque. CHANGE OF ADDRESS. Society / journal members should inform B.L. Dubey Ph.D, Director SIS Centre, Email : sisdubey@rediffmail.com Copyright @ 1994. SOMATIC INKBLOT CENTRE, India/Anchorage U.S.A. Website: http://www.somaticinkblots.com

SIS Journal of Projective Psychology & Mental Health Volume 14, Number 1, January, 2007 Contents Page Nos. 1. Editorial : Historical Periods in SIS Theory and Practice 1-2 Wilfred A. Cassell 2. Body Consciousness in Exhibitionism 3-13 Wilfred A. Cassell 3. Desensitization Therapy For Body Image Anxiety 14-19 Wilfred A. Cassell 4. Restructuring Rorschach Pathological Body Symbolism in the 20-29 Somatoform Disorders with Truth Serum Behaviour Therapy Wilfred A. Cassell and Bankey L.Dubey 5. Rorschach Responses of Older Indians 30-43 Suprakash Chaudhury, S. Sudarsanan, K. Seby, S. K. Salujha, Kalpana, S. M. Kundeyawala and S. P. Rathee 6. A Comparison of Somatic Inkblot Series-I Indices in Normal Children and Adults 44-47 Rakesh Kumar and Amool R. Singh 7. Projective Techniques and the School-Based Assessment of Childhood Internalizing Disorders: A Critical Analysis 48-58 David N. Miller and Amanda B. Nickerson 8. Inter Correlations of Nine SIS-I Indices 59-63 D. Kumar, B.L. Dubey and Rakesh Kumar 9. Relationship Between Controllability Awareness And Cognitive Emotion Regulation In Selected Clinical Samples: A Psychosocial Perspective 64-75 Manisha Dasgupta and Nilanjana Sanyal 10. Emotional feelings in Eating Disorders: a Rorschach Test quantitative analysis 76-84 S. Daini and L. Bernardini

SIS Research Award The editors and editorial consultants wish to express their sincere appreciation to Dr B.L.Dubey for his insightful and dedicated leadership. We wish to announce his selection for this year’s Research Award of one thousand dollars. Also to be praised are the behind the scenes supportive efforts of his wife Padma Dwivedi. Under their loving guidance, we have witnessed the birth of a new bodymind-spirit journal for SIS workers internationally. We also wish to acknowledge the impressive contributions of their son Anand Dubey. He has elevated the journal beyond traditional paper bound words to an electronic state of the art Internet communication vehicle. We anticipate many further years of their dedication to spreading information about the power of SIS technology for assessment and healing. Wilfred A. Cassell, M.D., FAPA. Director SIS Centre 4501 East, 104th Avenue, Anchorage, Alaska - 99516 (USA). Email: siscassell@yahoo.com

Editorial Historical Periods in SIS Theory and Practice In envisioning the future, it might prove helpful to review the developmental history of the Somatic Inkblot Series (SIS). The need for an anatomically structured projective assessment procedure first became evident during my psychiatric residency training in Syracuse New York. It arose during a 1959 investigation of hormonal and body image abnormalities observed in women whose feminine appearance was marred by excessive facial hair. I was fortunate that my supervisor Professor Hollender, for a psychoanalyst was comparatively open minded to scientific research. This stimulated my life long interest in exploring various methods of investigating body-mind phenomenon. Initially several techniques for peering into the inner world of body consciousness were explored.. One involved the use of figure drawings such as the “Draw a person test” and the “The Inside of the Body Test “. While these were found to provide a rich source of body imagery, they were hard to quantify and were largely bypassed. Next consideration was given to a more quantifiable approach based upon recognition thresholds of tachistoscopic presentations of anatomy pictures. One study suggested that this body image generating approach might have validity in regard to assessing exterior versus interior awareness. Another indicated that tachistoscopic thresholds for recognition of the heart were different in subjects with psychphysiologic cardiac symptoms. Eventually by 1964 decision was made to postpone work with this technique because of technical measurement difficulties and unavailability of equipment in clinical settings. JWith advances in electronic and computer technology, it is hoped that eventually SIS investigators will reconsider this earlier approach. In any case, early on at Syracuse a decision was made to design an “Inkblot” projective technique. At the time I was fortunate in that my mentor Professor Hollender had previously been interested in body image clinical studies. Since he was head of the psychiatric department, he was able to offer Professor Fisher a position in our department. He introduced to me a Rorschach measure of body boundary awareness based upon quantifying percepts symbolizing the exterior. Expanding upon this projective principle, I developed a Rorschach scale based upon internal anatomy responses. After finding that it had a measure of validity in assessing internal symptoms, I began designing blots depicting various aspects of the body. Initially inkblots with visual color-form stimuli suggestive of the human heart were created. This area was focused on for several reasons: there are symbolic representations of the heart in many cultures, many individuals experience stress induced cardiac symptoms, emotional arousal alters measurable cardiovascular activity and subsequent sensory feedback affects heart consciousness, life threatening diseases involving the heart are prevalent and so on. Eventually after clinical trials using a variety of designs, four were selected for experimental use. Of these two remain. In the SIS-I series they are VII & VII and in SIS-II they are numbered 17A & 18A. Subsequently a study was completed in college students with histories of stress triggered psychophysiologic cardiac symptoms, such as “Palpitations”, “Heart fluttering” & “Heart pain”. A statistically significant relationship distinguished the cardiac symptom subjects from those free of such somatic symptoms. This suggested that somatic inkblots might provide a methodological opening for peering into the mysterious realm of body-mind phenomenon. In 1969 the series was extended to depict more regions in the body gestalt. Trials indicated, that as long as the artistic creations had suggestive structure, that they did not have to be symmetrical.

Eventually a series of twelve was created. Follow-up studies suggested that extending the series opened up new clinical avenues of investigation. Two used the SIS in the context of behavioral therapy: The first in 1971 was BODY CONSCIOUSNESS IN EXIBITIONISM and the second in 1977 was DESENSITIZATION THERAPY FOR BODY IMAGE ANXIETY. Since these may not be readily available to all readers, they have been reprinted in this journal.J In these the SIS was used during clinical interviews, when calming was induced, either by hypnotic doses of intravenous barbiturate, or by deep muscle relaxation training. J A third previously unpublished 1976 case history report follows using the Rorschach cards as visual stimuli for behavior therapy: RESTRUCTURING RORSCHACH PATHOLOGICAL BODY SYMBOLISM IN SOMATOFORM DISORDERS WITH TRUTH SERUM BEHAVIORAL THERAPY. It describes how in Conversion Disorder, diagnostically relevant Rorschach pathological anatomy symbolism depicting the site of pain, may be totally split off from conscious awareness. This developmental history will be brought up to the present in the next issues of our SIS journal. It will review reasons why the series was increased to permit projective image stimulation projects with wider clinical and research applications. One politically sensitive subject involves the inclusion of stimuli depicting the organs of reproduction and sexuality. Just like the invention of the telescope enabled Galileo to challenge the Pope’s erroneous notion that the earth was the center of the universe; our work has produced insights challenging conventional clinical practice. While SIS workers have not had to face the Inquisition, there has been significant criticism and resistance. Getting case history studies published has been problematic and served as a stimulus for this journal The early studies were met with suspicion by those solely invested in standard interviews and established psychological tests. More serious roadblock to scientific investigation arose when it became apparent that there was a need for designing stimuli related to reproduction. A troublesome problem arose: How could the series be created ethically without being falsely accused of displaying “Pornographic pictures”? In western cultures the public media are flooded with sexual themes; yet scientific research in the field is looked on with great suspicion. In these and other countries where there are politically powerful religious bigots, this poses a major roadblock for involving students, researchers and clinicians in the SIS adventure. Fortunately India ’s richer heritage has largely sheltered contributors to this journal from such bigoted attacks. As our knowledge becomes shared internationally have courage to face modern day equivalents of the Inquisition! Wilfred A. Cassell MD, FAPA, APC, Director, SIS Center, 4501 East, 104th Avenue, Anchorage, Alaska - 99516 (USA). E-Mail : siscassell@yahoo.com

2 Cassell

Body Consciousness in Exhibitionism Wilfred A. Cassell This presents a case history of a man suffering from Exibitionism illustrating his phobic like avoidance of somatic-inkblot structure suggestive of sexual content. A followup interview using intravenous barbiturate induced sedation combining psychotherapy and behavioral therapy is described. The need for replication with group studies-is emphasized. A previous study developed a technique for measuring an individual’s awareness of the cardiac region of his body schema (Cassell, 1969).J It employed three newly developed inkblots whose color – form configurations approximated, in various degrees, the heart.J Individuals who had experienced psychophysiologic symptoms in this region were distinguished from asymptomatic subjects on their anatomical responses to these stimuli.J This methodology is presently extended to examine the body consciousness of an exhibitionist with somatic anxiety referable to the genitalia. The research instrument consists of originally constructed anatomical pictures, which include visual clues relative to various aspects of the body.J This report will describe those, which depict primary and secondary sex characteristics.J The technique is based upon the assumption that an individual’s perceptual sensitivity to anatomical content in his external field of awareness relates to the degree of consciousness assigned specific organ systems in his own body schema (Fisher and Cleveland, 1958; Schaefer, 1960; Cassell, 1964, 1965, 1966). Background Clinical Data: Aside from exhibitionism, the patient – a 28-year-old single painter – appeared to have no other major psychological problems.J His past behavior indicated that he had considerable difficulty in relating to women.J He denied release of sexual tension through masturbation – rather, when such feelings reached a peak, he impulsively exposed himself to women.J Although he had experienced sexual intercourse on one occasion, he recalled feeling quite ashamed about this.J In fact, he distinctly remembered imagining that someone was in the room watching the sexual act.J When questioned about his he indicated the observer might be God who was there to punish him for having sex outside marriage. During interviews marked resistance was encountered in discussing body attitudes.J It was learned that he had doubts about the adequacy of his sexual functioning including fears of being sterile.J His sexual fantasies involved situations where he and a woman would undress for mutual exhibition.J However, at no time was sexual imagery in consciousness permitted to involve mental scenes of genital interaction between his own body and that of a woman.J Related to this, his past family background was characterized by a puritanical home situation and marked sexual restraint. Method of Projective Testing: The projective testing\t “_new” [1] was conducted in the presence of a second investigator who observed the patient’s general reaction to the test situation.J The study was conducted under two conditions. The first simply involved administering the anatomical pictures to the patient in a manner analogous to that employed with the Thematic Apperception Test.J The second concerned the modification of the individual’s consciousness through the use of rapid acting intravenous barbiturate sedation. This was administered in a sufficient dose to experimentally induce a state of psychic Wilfred A. Cassell, MD, FAPA, APC, Director, SIS Center, 4501 East, 104th Avenue, Anchorage, Alaska - 99516 (USA) E-mail : siscassell@yahoo.com Key Word : Exhibitionism, Body imgery

relaxation to control anxiety thereby reducing the patient’s inhibitions in mentally processing the somatic images stimulated by the pictures. Prior to viewing the pictures the patient was given the following instructions:J “I have here a series of pictures that I am going to show you one at a time.J As you look at each one, tell me everything. Prior to viewing the pictures the patient was given the following instructions:J “I have here a series of pictures that I am going to show you one at a time.J As you look at each one, tell me everything that comes to mind.J Although different things are seen by various people, I am particularly interested in what it reminds you of in viewing it.J Remember that there is lots of time.” In order to obtain accurate records both interviews were tape recorded and later transcribed to type for analysis. Descriptions of the Pictures and Projective Responses Related by Patient: In this report the results will be reviewed in terms of those, which were considered to be most immediately relevant for evaluating the patient’s ability to mentally process sexual imagery. Urogenital Card (VIII): It may be observed that this picture present visual input which facilitates the evaluation of the male patient’s propensity to permit phallic material to register in consciousness.J Although statistical parameters are not yet available, our research group with this anatomical picture series has compiled extensive clinical experience.J It has been found that with this picture virtually all patients\t “_new” [2] perceive anatomical content in viewing it.J A common response involves first responding to the upper configuration as “kidneys” and then perceiving the lower areas as “bladder and penis.” Remarkably enough, the patient when shown this picture simply responded – “It looks like a couple of potato sacks.”J Judging from his non-verbal behavior in inspecting the anatomical ‘ink-blot,’ the observer considered that this non-anatomical response represented the only imagery that registered in consciousness.J However, it must be acknowledged that it is, of course, impossible to exclude the possibility that the patient saw the sexual content, but elected to not report it. Under the drug-induced hypnotic state the patient responded as follows: “That looks like a couple of men … a couple of men’s heads … there’s an eye (black mark on left kidney shaped object) … they’ve got no hair … and this is their noses down here … I don’t know what that thing could be (lower area depicting bladder and penis) .. it looks like another person off in the distance because it is smaller than these two … another person’s head with something on his head … and these two guys are standing here talking … they could easily be a couple of potatoes or a couple of people … (patient inverts card) … it still looks like two potatoes regardless of the way you hold it.” It may be observed that the relationship between the pictorial reality (i.e., urogenital system) and the patient’s response pattern to this picture was highly remote. It is suggested that the patient’s imagery was much more dreamlike because the drug had released psychological inhibitions. Judging from the patient’s response, it may be inferred that the picture’s connotations more strongly impinged upon consciousness than in the non-drug state. Thus, the imagery was stated to resemble the facial area of “a couple of men.” However, this interpretation is complicated by the fact that previous research has shown that under barbiturate sedation, body consciousness tends to focus on the head (Cassell, 1970). Consequently, it must be recognized that a partial determinant of his response could have been a drug-induced artifact. 4 Cassell

Next, one might consider the analogy between the projective response to the lower area – which depicts, in a covert fashion, the bladder and penis – as “a man with a mask over his eyes,” and his apparent failure to “see” what is represented in that aspect of the picture.J It is suggested that at some level of consciousness there was psychic awareness that the visual input provoked anxiety.J In this sense the “mask” may be interpreted to symbolize the patient’s reluctance to “see” the phallic imagery impinging upon consciousness.J Lastly, attention might be directed to the response “candlestick with a light burning at the top.” It is of interest that when the therapist later asked the patient to associate to this word he responded as follows: “light bulb … darkness … stars … moon … lamp … funny shaped lamp like Aladdin’s lamp.” It is tempting to interpret the fact that you rub the later object in order to obtain magical effects, as symbolically reflecting the patient’s masturbation fantasies and unresolved sexual tensions. The last part of the response sequence indicates the re-emergence of non-anatomical content in awareness.J Again, it appears as though the patient failed to consciously recognize the phallic material inherent in the picture. After showing all the pictures to the patient in the drug situation, certain cards were presented for a third time. The Urogenital Card was the first of these. This phase of the case study was designed to have the therapist work with the patient until the phallic material inherent in the picture registered in consciousness.J The patient’s anxiety in this situation was constantly evaluated and maintained within a range ordinarily employed in desensitization behavior therapy techniques. When this card was presented to the patient, the therapist introduced the anatomical content at a higher level of awareness with the following comment: “You said that this picture has to do with “potato sacks” or “men.” Now, let’s suppose that it has to do with body: What do you see?” With this suggestion, the patient’s anxiety level increased and he became noticeably perplexed. After a long pause during which the phallic content more strongly impinged upon consciousness, he then asked the question “male or female?” He was then informed that it was whatever he saw in the picture.J After another lengthy pause, during which he appeared to become even more anxious, the patient reported, “that looks like a man’s penis… and that looks like his testicles… and that’s all that I can see.” This deviated from previously observed responses in our research unit.J Instead of initially referring to the upper areas as “kidneys,” and then subsequently perceiving the other areas in the male urogenital system, he first responded to the lower areas as “penis.” However, more unusual is his response “testicles.” Thus he substituted more anxiety laden somatic images in consciousness over anatomical content more clearly depicted in the picture. In a retest examination, six months later, he responded as follows: “It looks like two red things … like potatoes … it could be the shape of a person’s head … the black spot looks like an eye … the colored part hanging down looks like a stem or foot joining these together.” After having previously perceived the sexual material inherent in this picture, it is remarkable that six months later he once again failed to report seeing anatomy.J Eventually, he was reminded of the anatomical content.J In this instance, he projected the following pathological anatomy response: “It’s a man’s penis but it has a funny shape the way it hangs down … it is swollen and there is a big lump on it … it doesn’t hang straight down … it looks like the after effects of sexual intercourse … it’s aching and has syphilis or something… the testicles look swollen too.” Body Exhibitionism 5

This may be interpreted to represent a direct projection of his hypochondriacal concerns about the effects of sexual intercourse. Male figure card (X): This picture clearly depicts the outline of a man’s body.J It permits the patient to project responses related to the hands, the feet, the pelvic area, the limbs, the ribs, and the lungs. Initially, in viewing this picture the patient appeared to be markedly inhibited in that he only reported the following: “It resembles the shape of a man … but he doesn’t have a head.” Since ordinarily male subjects do not comment on the missing head, this aspect of the response seemed worthy of note. It may be postulated to reflect an upward displacement of his concern about losing his penis. Under sedation, he responded as follows: “This looks like the shape of man … two arms … and that’s his neck … and he’s still got no head.J That’s his two legs … and that could be his ribs … it looks as though somebody’s holding his hand around him because I see three fingers.J And this thing … well, that looks like two potato sacks … joined together and tied at the top. They’re narrow at the top and they’re wide at the bottom … they’re tied together.J That’s an owl or something (referring to the pelvic area) an owl or ah … bird … or a bat, something like that … with … with wings anyway.J These little pointed things look … they’re … horns on an owl … a horn owl.” Once again it is evident that the sedative-induced hypnotic state was characterized by richer flow of visual images and verbal output.J In the opening phase of the response sequence there is further evidence of the patient’s concern over the figure’s “missing head.”J Next, it may be observed that the imagery stimulated by the rib-like structures in the picture had a bizarre and threatening connotation, in that “somebody’s holding his hand around” the man in the picture.J Remarkably enough, the areas, which are ordinarily stated to represent “lungs”, are seen as “potato sacks.” Thus to complicate interpretation, there is evidence not just of perceptual inhibition of phallic imagery but other organ images as well. Lastly attention might be directed to his response to the pelvic area in the figure.J Since the symbolism is most interested, the interview will be reported in detail. P = patient T = therapist P : “That’s an owl or something … an owl or bird or bad … something like that with wings anyway … these little pointed things look like they’re horns on an owl … a horn how.” T : “Suppose that it all had to do with one man.J What do you see now?” P : “Well, that could be a belt buckle on his pants or anything.” T : “What else could it be?” P : (long pause)J “I don’t know … can’t think of anything else.” T : “You seem to think of that an awful lot.J What is that?” P : “I don’t know.J I can’t figure out what it could possibly be … what part of a man that represented … (patient shifts focus of attention from the pelvic area to the lungs) … this looks like the insides … but … that there … I can’t figure out what that could be … can’t figure out why the insides would be that low down … it’s down below his waist or something … it just doesn’t seem as though it’s not normal because he is something different than other men … something that’s there and is not supposed to be there and that’s why I can’t figure out what it is.” 6 Cassell

T : “If it’s below his waist what is it likely to be?” P : “Well, it could be his belly but I guess it’s kind of big.” T : “Anything else it could be?” P : “No … I’m afraid I can’t.” In this aspect of the interview the patient finally correctly identified the red areas as “internal tissue” – although he never labeled them as “lungs.”J However, at no time did the imagery relate to the male genitalia stimulated by viewing the pelvic area of the figure register in consciousness.J Yet, it is suggested that it strongly impinged upon awareness in that he projected concern about his own sexual organs as indicated by the response “it’s not normal, etc.” This picture was represented to the patient for a third time after his seeing phallic material in the Urogenital Card had influenced the patient’s perceptual set.J The dialogue between the patient and therapist follows: T : “Is there anything different that you see in this one now?” P : “No, I can still see the body of a man.” T : “Which body part would be represented here?” (Pointing to the pelvic area) P : “Well, it’s that part of the man … in that shape I cannot say what it could be.” T : “What kind of shape would it look better?” P : (Pause with no response). T : “Suppose that it was the shape of a candlestick, what would that make you think of?” P : “Well, there are a number of things that I could name off for a candlestick” (pause). T : “Suppose I told you that the part here is the same as in this picture (pointing to the Urogenital Card) in representation, what would you think of it?” P : “this sure looks like a man … he’s going to the bathroom or something … that looks like a penis” (patient’s anxiety high). T : “You seemed to have a lot of difficulty thinking that this is a penis.J The other thing that you said was that the guy had something wrong with him” … “Is that what you think about yourself?” P : “Yes, that’s right.” T : “There’s nothing wrong with you.” P : “I still think that I do … I don’t know why.” This aspect of the interview shows how this research technique may be used to stimulate somatic imagery more in the context of a relationship having potentially a therapeutic, as well as diagnostic implications. Under sedation, in this situation phallic imagery was activated in the patient’s unconsciousness. There was a great deal of resistance in bringing this into full awareness and considerable concomitant anxiety. However, in the state of relaxation induced by the drug, the therapist was able to interpret to the patient his psychopathologic body attitudes and partially desensitize the focal somatic anxiety. Of course, it is difficult to estimate the relative effects of visual input from the picture as opposed to verbal cues from the interviewer – in finally introducing the phallic imagery into conscious awareness.J Six months later, in a retest situation, he responded as follows: “That looks like the outline of a man … there are two arms and two legs and a neck … there is no head though … the red part … I don’t know … could be the intestines or some part of the body such as the heart or something.” Body Exhibitionism 7

This response again avoids reference to the phallic aspects of the figure.J It is also of interest in that the patient readily recognized the anatomical implications of the internal lung-like structures.J However, this visual input was not processed in a normative fashion as “lungs” but consistent with his regression to an oral theme perceived as “intestines.” Human figures card (III): This picture presents line configurations, which may be seen to represent human figures.J The bodies are in close proximity and share the same “body buffer zone”J (Horowitcz, 1967).J Ordinarily, they are seen as a man (left) and a woman (right) interacting in some way such as dancing.J The red areas represent “hearts” which are often stated to symbolize their “love.”J Normally a few subjects give non-anatomical responses such as “lights” or “red balls.” The patient’s initial response was unremarkable in that he saw the picture as representing “a couple of go-go dancers” with the red depicting “apples.”J However, under drug conditions much more clinically relevant material merged.J He responded as follows: “That looks like a couple of go-go dancers or something … this guy (left) looks as though he has a knife in his hand and she has got something too but I don’t know what it is … it looks to me as though they are going to cut those things in half … they are some kind of food or something … maybe that’s his hand hanging out there … they found a couple of apples … he’s going to cut one in half and give her one and himself one.” The fact that the patient perceived the male dancer as having a knife in his hand suggests that the theme represents a direct projection of castration anxiety and/or hostility toward women.J There is also evidence of regression to an oral rather than sexual level of interaction.J It also might be noted that when the patient’s therapist heard this response, the following question was asked.J “What does cutting an apple in half and giving it to her make you think of?”J Interestingly enough, in responding, the patient identified with the picture in a regressive fashion stating, “Well, he likes her … I used to do that when I was a boy.” In the retest situation six months later, his response was quite different: “There are two people … two pairs of legs and an arm … the red dots could be apples.” When asked the sex of the figures, he reported that they were two “men.”J Further, each of the two parts in between reminded him of a “penis.”J The one on the left man was seen to be “long and erect” and the right one as “short and soft.”J When asked what they were doing, he stated they were “standing there comparing sizes.” In interpreting this response, it is pertinent to note that in the interim since originally tested, the patient had for the first time in his life become involved on one occasion in exhibitionistic behaviour and genital manipulation with a known homosexual.J It is evident that the imagery stimulated in consciousness by this picture is much in line with this deviant behavior. Female figure card (VII): This picture was designed to evaluate the extent to which the female patient assimilates the feminine aspects of her body image into a gestalt. For the male patient, it apprises his ability to recognize and mentally process sexually evocative material related to a woman’s body. It presents two main aspects. The one of primary significance concerns the humanoid lower configuration consisting of two lines depicting the outline of the body, the hand and feet. There is a red area between these included to elicit responses related to the stomach or genitalia. The upper 8 Cassell

red area denotes the mouth, and the black, the hair, or if the picture is seen as a man, a moustache.J The second aspects refer to the top red object.J It presents additional anatomical material relating either to the head area or the heart.J Ordinarily, this picture was stated to represent “a dancing woman” with the upper object being “an apple.”J Thus the mature response involves assimilating the two lines which are separated in terms of the right – left axis of the body into a gestalt, and then assigning feminine sexual identification to the figure. In viewing this picture, the patient responded to the upper configuration in the normal fashion seeing it as “an apple.” However, consistent with his past history of aversion to women he simply saw the lower lines as representing “two animals.” The black area was stated to represent “a little black seal.”J His failure to resolve the line configurations into a gestalt representing the body of a woman, provided further evidence of his anxiety in mentally processing sexual imagery. The perceptual defense utilized in this instance, involved a breakdown of gestalt mechanisms of perception. The patient’s response sequence in the retest situation is of considerable interest because it shows how the separate components are eventually resolved into a gestalt as the patient’s anxiety is controlled.J His associations to the picture follow: “This is a fish or an apple or bell or something (top red object) … and it’s a big fish and he’s swimming after … these are a couple of snakes (lower lines) … this looks like a fish or something here swimming … this (pelvic area) could be a dead bird lying down or a lake … (long pause) … it’s something shaped like a person’s body … to legs and that looks like a guy’s moustache above the mouth (black area).” The interviewer then stated:J “You said before that looked like a little black seal.” The patient then continued as follows: “Like that’s something else in my head that I never thought of before … it looks like a man’s moustache … this is an apple on the tree and it looks as though he is reaching for it.” Finally, the therapist asked him, “is it a man or woman?” He then responded as follows: “Well, it’s a woman I’d say … looks as through she’s got lipstick on or something and that’s why I think it is a woman.” In the opening phrases of his response the patient clearly substituted non-anatomical symbolic content for the structure depicting the body.J Particularly noteworthy in regard to his past feelings of sexual inadequacy, is the response “dead bird lying down.”J Next, attention might be directed to the fact that when the human figure finally succeeded in registering in consciousness, it was assigned a masculine connotation.J This is remarkable since the picture is suggestive of the female rather than the male body. This avoidance of the feminine imagery is consistent with his past behaviour in relation to women.J Finally, he was eventually able to connect this distortion in perception.J However, six months later, he saw it as the figure of a man. Heart genitalia card (VI): This picture presents anatomical content relative to the heart.J More strongly embedded in the figure are cues relative to union of the male and female genitalia. The patient initially responded as follows:J “This is an animal standing inside a red object which could be a cloud.” Under drug conditions, he stated: Body Exhibitionism 9

“That could be a giraffe with those things sticking out of its head … they could be horns (central object) … and it looks as though he sees something coming and is standing on the other side of a bush or something … he’s standing in a bush … this is a bush (red area) … and this red thing here I don’t know what it is … I think that it could be a mop of hair hanging down but giraffes don’t have hair so I don’t know what it could be.” Again the patient substituted non-anatomical imagery when his consciousness was stimulated with material resembling the body.J However, at the termination of the drug session when informed that the picture had anatomical content, he then stated that it looked like the “vagina.”J In this situation the organ image of the more anxiety-laden female genitalia, rather than the cardiac aspects of the configuration succeeded in registering in consciousness.J It is suggested that, at this time in the study, he had been partially desensitized to mentally processing sexual imagery. In the retest situation, six months later, he initially failed to detect the anatomical content but when reminded of it reported once again seeing a “vagina.”J When it was further suggested to him that some people see the central object as a “penis,” he became markedly anxious refusing to accept this possibility.J In other words, when confronted with imagery depicting union of male and female genitalia, he totally blocked this from consciousness.J Body gestalt Card (II):? This picture evaluates an individual’s ability to organize separate components of the body into an overall image in the form of a gestalt (e.g., “A person with a big smile”).J It consists of three separate units arranged in such a fashion to depict the human form.J The top part was created to elicit projective responses related to the head.J The middle part depicts the oral region, but is sufficiently ambiguous in outline to present suggestive imagery relative to the heart.J The lower black area represents the arm, body and legs. Initially, the patient responded only to the latter seeing it as “a person with his hands up in the air.”J This failure to respond to the other aspects of the figure suggests that the patient had somatic anxiety in the regions depicted (e.g., “mouth,” “heart”). Under the drug state, he responded as follows: “There is a person … the top part is an animal … its got two heads and it only has one leg … this looks like a person in a drawing and this is his body and this is his leg … and this is somebody’s mouth.” It is apparent that in the retest situation, he fails to resolve the separate components of the image into a gestalt.J Moreover, his response to the upper black area as depicting an animal with two heads and only one leg is highly unusual.J The missing leg in the response may be interpreted to reflect his own undue “castration anxiety.”J Also, it is noteworthy that the drug released inhibitions to the extent that he could see the “mouth,” although interestingly enough, it was considered to be separate from the rest of the picture.J It might be noticed that a pattern is forming, whereby the exhibitionist failed to recognize anatomical structure in the pictures.J The other feature involves themes related to the oral region. Finally, for comparison purposes, an outline will be given of his responses to two anatomical pictures, which lack direct sexual referents. Chest Cavity Card (IX):? This picture illustrates the rib cage and heart to a very high degree and is invariably so recognized by most subjects.J Yet this patient saw this as “two people eating” failing to recognize the anatomical content which is so strongly present in the picture.J Under drug conditions, he stated this looks like: 10 Cassell

“the shape of a person’s head … that’s the girl’s hair hanging down … but the it could look like … oh, it reminds me of a couple of seahorses or something … and this is their tails … that’s their bodies and that’s their heads … and they are eating some kind of food or something … don’t know what it is … that’s the rippling of the water … oh, these are seahorses.” This card illustrates how the patient inhibited not just phallic material but other somatic imagery as well. Discussion: A projective technique employing a series of newly designed anatomical pictures has been developed to stimulate somatic imagery.J This approach has been illustrated in a patient with exhibitionism.J Marked resistance was observed in bringing sexual images into full registration in consciousness.J This finding may be appraised in the context of existing theory partially derived from more traditional psychoanalytic procedures (Fenichel, 1945).J The extreme perceptual inhibition of the phallic imagery observed in the present study has certain theoretical implications.J There is a definite parallel between this and the view that in exhibitionism the individual unconsciously says to his audience:J “Reassure me that I have a penis by reacting to the site of it.”J The subjective feeling that his penis might disappear becomes highly plausible to the outsider if one considers the excessive repression of sexual imagery noted in the exhibitionist studied.J It is quite understandable how an observer’s response to the exposed penis could well provide a useful external source of reality testing for refuting this pathologic body fantasy.J It might be noted that this perceptual defense has also been observed in tachistoscopically exposed illustrations of human anatomy to subjects with focal somatic anxiety secondary to psychophysiologic symptoms (Cassell, 1966). A further existing theoretical formulation of exhibitionism is that the patient is choosing women as observers of the deviant behavior, in a magical sense, is unconsciously saying:J “I show you what I wish you would show me.”J This is considered to deny the apparent castration of the female’s body, reducing the fear that this might happen to him.J It may be recalled that the patient’s responses to Cards II, III and VII (retest) were consistent with what is implied in the psychoanalytic construct “castration anxiety.”J His phobic-like aversion to processing imagery related to the female body was observed with Cards VI and VII. Attention might also be directed to the patient’s tendency to project oral rather than genital themes in viewing the pictures.J It’s consistent with the thesis that the exhibitionist is “an infantile individual” concerning his sexually deviant behavior (Karpman, 1948).J Along the same lines perhaps, it is pertinent to recall that Kinsey found that 20 percent of pre-adolescent boys who engage in sexual play have exhibitionism as the limit of the activity (Kinsey, 1948).J It is suggested that this regressive aspect has functional significance in that it avoids the anxiety stimulated by sexual imagery. Another subject for discussion concerns the observation that – like the present patient – exhibitionists in general are sexually inhibited (Rickles, 1950).J In this context brief attention might be given to the psychophysiologic aspects of normal sexual functioning.J Sexual arousal in the “normal” male involves the interaction between a physiologically originating drive state and mental imagery relating both to his own genitalia and evocative images pertaining to that of a woman.J For the exhibitionist under present study, it would appear that sexual tensions would have to be intense before the resultant union of male and female imagery would register in consciousness and motivate normal heterosexual behaviour.J It is suggested that abortive attempts to discharge these occurred when the patient acted out sexually in a state of excitation by impulsively exposing his genitalia.J As was evident in the retest situation, exhibitionistic behaviour of a homosexual nature was also attempted by the patient in order to provide a release for his sexual impulses. Body Exhibitionism 11

Of course, as might be expected with the introduction of a new technique, all the results do no fit the previous theoretical frame of reference. The above formulation may be seriously challenged since the patient was remarkably insensitive to detecting all anatomical content in the pictures – sexual or otherwise. Thus, there was evidence of perceptual inhibition of images depicting the lungs, mouth and heart.J While it may be contended that the oral region and the heart provide imagery during the states of sexual arousal (Schneider, 1956, 1957), it might appear that the data do not strongly support a specific defect in the patient’s perception of the genitalia.J However, since the patient did not have psychosomatic symptoms in other regions of the body schema this thesis warrants consideration.J Moreover, in the course of therapy, he was found to be made more anxious by the discussion of sexual themes – rather than those relating to other aspects of the body.J Therefore, in all likelihood, it would appear that the primary disorder involved aversion to the genitalia, which secondarily spread to involve other somatic regions. The patient’s avoidance of female anatomy in the pictures brings to mind mechanisms operating in phobic disorders (Snaith, 1968).J While the two conditions differ in that the exhibitionist also avoids material presumably related to his own body rather than an external object, the comparison has heuristic value.J Further, it has certain theoretical implications in terms of therapy.J For example, it is tempting to consider that just as certain clinicians may treat phobic disorders through desensitization procedures, the same general principles\t “_new” [3] might be applied in reducing anxiety related to conjuring up in consciousness scenes involving union of male and female genital imagery.J Indeed, the manner in which the therapist assisted the patient in mentally processing sexual images under narcotic relaxation employed insights borrowed from both behavioural and gestalt therapy procedures (Perls, Hefferline & Goodman 1951).J However, to be sure, it did not seem to have much “lasting” effect since repression still occurred in the six-month follow-up session. Summary: These overall theoretical considerations provide a conceptual background for ongoing research employing the anatomical picture series as an aid in stimulating somatic images in consciousness. It must be emphasized that until a scoring system is finally evolved and statistical norms established, the present study makes no claims, which may be generalized. This case history is reported solely to illustrate the use of a new technique- Somatic Inkblot Series. References: Cassell, W.A. (1964), “A projective index of body interior awareness,” Psychosomatic Medicine, 172-7. Cassell, W.A. (1965), “Body perception and symptom localization,” Psychosomatic Medicine, 27, 171-176. Cassell, W.A. (1966), “The tachistoscopic index of regional and personality assessment body awareness,” Journal of Projective Techniques & Personality Assessment, 30, 31-37. Cassell, W.A. and Duboczy, J. (1967), “Cardiac symptoms and tachistoscopic recognition of the heart image,” Canadian Psychiatric Association Journal, 12, 73-76. Cassell, W.A. (1969), “Responses to ink-blot configurations resembling the heart,” Journal of Projective Techniques & Personality Assessment, 33, 123-126. Cassell, W.A. and Chapman, J. (1970), “Inside Schizophrenia.”- Filmed distributed by Clinical Diagnostic Aids Ltd., Saskatchewan , 1970. Fenichel, O. (1945), “The Psychoanalytic Theory of Neurosis,” W.W. Norton & Co., Inc., New York. Fisher, S. & Cleveland, S.E. (1958), “Body Image and Personality,” Van Nostrand, Princeton , N.J. Horowitz, M.J., Duff, A. and Stratton, L. (1964), “The body buffer zone:- an exploration of personal space,” Archives of General Psychiatry, 11, 651-656. 12 Cassell

Karpman, B. (1948), “The psychopathology of exhibitionism,” J. Clinical, Psychopathology 9, 179-225. Kinsey, A.C., Pomeroy, W.B., and Martin, C.E. (1948), “Sexual behavior in the human male,” W.B. Saunders, Philadelphia. Kirkpatrick, E.A. (1900), “Individual tests for school children,” Psychological Review, 7, 274-80. Perls, F., Hefferline, R.F. and Goodman, P. (1951), “Gestalt Therapy,” Dell Publishing Co., New York . Schaefer, R.(1960), “Bodies in schizophrenic Rorschach responses,” Journal of Projective Techniques and Personality Assessment, 24, 267-281. Acknowledgement: [1] I wish to acknowledge the kind assistance of Dr. James Chapman. [2] The technique is currently under development as an aid in the early diagnosis of schizophrenia (Cassell and Chapman, 1970).- In testing over on young adult psychiatric patients in various diagnostic groups this was the first individual who manifested such extreme inability to perceive anatomical content in the picture.- Consequently the case history was considered of sufficient interest to justify reporting it separately, before statistical norms are finalized. [3] Perhaps it is pertinent to recall that in Denmark sexual crimes have dramatically fallen in incidence since removal of restrictions on pornographic literature. Body Exhibitionism 13

Desensitization Therapy For Body Image Anxiety Wilfred A. Cassell The Somatic Inkblot Series (SIS) has the capacity to activate in projective awareness regionally specific anatomical imagery underlying psychophysiologic symptoms. A case history-involving premature ejaculation using Jacobson-deep muscle relaxation to facilitate-desensitization therapy is described.- In recent years there has been a substantial growth in the application of behavioral therapy techniques in psychiatry (APA Report, 1974, Friedman, and Goldstein, 1974, Paul,1969, Wolpe,1969, Wolpe, et al 1973). Procedures involving systematic desensitization techniques have been found to have particular efficacy in the treatment of phobic disorders. In these conditions the patient is gradually de-conditioned to the feared object by repeatedly experiencing imagery related to it through a hierarchy of anxiety laden circumstances while in a state of deep muscle relaxation. He gradually learns to associate lower anxiety with images, which previously produced fear.J When this is generalized to the real life situation ordinarily substantial therapeutic effects are realized. Little is written about the application of desensitization techniques for treatment of phobic disorders when the fear producing objects are aspects of the human body. For the purposes of conceptualization it is proposed that the body is a psychological object with which the individual mentally interacts. At the more personal pole of the perceptual field exist psychological processes involving the patient’s awareness of the body. At the interpersonal sphere exist relationships pertaining to the perceptions of the bodies of other people. When psychopathologic phenomenon develops anatomical imagery becomes associated with anxiety.J This association may represent the subject’s heightened awareness of body regions resulting from his idiosyncratic cathexis of body regions (Fisher, 1970). It may represent changes in body perception arising from disturbed affectual states such as depression whereby perceptual attention is withdrawn from external objects and invested in the body (Fenichel, 1945). It may reflect the individual’s sensory perception or past interoceptive sensations arising from organs involved in automatic nervous system excitation during arousal (Adamson and Varsamis 1976). It may represent the effects of physical disease, trauma or surgical processes, which have focused attention on a particular anatomical region (Lipowski, 1974)).J The later in certain instances may involve an individual with whom the person is psychologically identified (e.g., sympathetic pains).J Lastly, it may represent for certain organs such as the mouth the fact that the subject’s attention has been focused on the oral region because of his past exposure to an orally aggressive person.J Whatever the cause, if the body anxiety is extreme the patient is prone to develop conversation somatic symptoms and at times psychophysiologic reactions. These problems are commonly seen in psychiatric practice, especially in patients with pronounced hysterical features. The conversation symptoms may involve bizarre types of somatic pain whose quality, severity and distribution pattern are distinguishable from discrete disease entities. There may also be alterations in peripheral sensation, impairment in motility, and difficulties in sexual functioning. All of these disturbances reflect the patient’s inability to mentally process in a normal fashion anxiety linked anatomical images. There is a need for new treatment procedures to resolve such anxiety. Traditional psychotherapists generally ignore the body in treatment patients. The exceptions are gestalt therapists and those working in the field of bioenergetics (Lowen, 1975) that employ exercise, massage techniques and Wilfred A. Cassell, MD, FAPA, APC,Director, SIS Center,4501 East, 104th Avenue, Anchorage, Alaska - 99516 (USA), E-Mail: siscassell@yahoo.com Key Word : Desensitization Therapy, Body Image Anxiety

other related procedures in attempting to remove body image anxiety. The present article proposes to introduce an additional technique employed psychodynamic principles in the setting of a behavior therapy technique to assist in the reduction of such anxiety. The proposed approach involves the use of the Projective Index of Body Awareness (Cassell, 1964,1977). This consists of twelve newly developed inkblots with various degrees of anatomical content. These provide an opportunity for the clinician to activate in consciousness specific anatomical images. When this is done under conditions of high relaxation it is possible to desensitize anxiety related to images of symptomatic regions. It must be emphasized that this technique is different from the Rorschach.J In employing the latter in body perceptual studies it was noted that there was a need for pictorial stimuli with more clearly depicted anatomical content.J These were subsequently created and may be distinguished from the Rorschach in that they have structure that is highly capable of evoking body images.J Also unlike the Rorschach this procedure has been shown to have definite validity. Thus a series of studies (Cassell, 1969,1971,1972,Adamson and Sterenko, 1977) have shown that relationships exist between an individual’s physical symptoms and his anatomical responses. In psychiatric studies it has been shown that the anatomical responses projected vary over the course of the patient’s illness, paralleling changes in his somatic symptom status and overall level of mental functioning (Cassell, 1972, 1977).J Moreover it has been shown that subjects while exercising project more somatic responses depicting organ systems activated in exercise. For example, consistent with increased sensory feedback from the cardiovascular respiratory systems the exercise subject has more imagery pertaining to the “heart” and “rib cage” (Cassell, 2000).J Lastly, in terms of the procedure’s reliability, it has been found that in healthy, normal subjects, that in test retest investigations comparable results are obtained (Cassell and dubey, 2003). A history will be reported to illustrate this approach. The patient selected for this study was a 29-yearold married engineer who was originally referred for psychiatric treatment because of depression. In the course of evaluation, it was found that he had hysterical features to his illness and associated sexual problems. The latter were manifested chiefly through the psychophysiologic disturbance of premature ejaculation. Briefly, his sexual history was as follows. He had been married for five years and had two children. For the preceding three years there had been a gradual development of impaired sexual functioning. Most of the time he was able to achieve intromission but he was unable to clearly identify a stage between onset of sexual excitement and orgasm. This had become a major problem for his personal pleasure as well as his wife’s sexual satisfaction. As part of the initial evaluation he was administered the Projective Test of Body Awareness. Only those pictures, which elicited psychopathologic responses, will be illustrated below. Card II :? This inkblot is usually seen as “smiling person with upraised arms.” The patient responded as follows: “A woman with a big mouth … the black is the hair … the rest is the body.” This response is deviant in that the sex characteristics projected are feminine and emphasis is placed upon “the big mouth” rather than a “smile.” Card III : These abstract forms are usually seen as “a man and woman dancing.” The patient responded as follows: “Two girls dancing … very sleek girls.” This response is again unusual in that again a feminine image was superimposed upon sensory input, which has more masculine than feminine characteristics. Desensitization Therapy 15

Card IV : This card has two opposed black figures and three smaller red figures.J The black configurations are usually seen as “animals” but may be perceived by subjects with heightened internal awareness as “lungs.”J The lower central figure usually is stated to represent the “heart.”J Responses to the upper red areas are extremely rare and, if anatomical, considered to reflect heightened awareness of the region.J The patient responded as follows:J “The red parts (upper area) are female sex organs … the black could be seals or fetuses … the rest the vagina and ovaries.”J The anatomical imagery stimulated in the patient’s consciousness by this picture more clearly depicts the female sexual theme observed in the earlier responses.J This sexual material is not unusual for a man to perceive. Card V : This has a major black figure in the center of which is a red heart-like object. In patients with sexual preoccupation the top projection has certain phallic connotations and is stated to represent a “penis.” The later red areas are usually seen as “human torsos” or “babies.” The patient responded as follows:J “The top part looks like a penis … the two red areas are babies.” This response is noteworthy in that for the first time male imagery was projected. It may be interpreted to reflect heightened awareness and anxiety concerning his own genitalia. Card VI : This card has a red heart-like ovoid shape set of a mauve configuration, which is often seen as an animal, such as a deer. More deeply buried in the stimulus array is anatomical content suggestive of the female genitalia. The patient responded simply as follows: “the vagina.” His response here is consistent with that noted on Card IV showing increased awareness of the female genitalia. Card VII : Most individuals stated that this represents a “woman dancing with an apple over here head.” The patient responded as follows: “A woman … the top is a penis.” This latter response is highly abnormal and is consistent with his previously noted accentuated awareness of the male genitalia. Card IX : This is a red mottled red picture. The upper left area is ordinarily stated to represent “lips.” The lower region was designed to evoke gastrointestinal responses. The patient responded as follows: “Lips … pictures taken by the subject from the air … air photos.” This response is unremarkable. The fact that he fails to detect the gastrointestinal connotations of the visual input indicates that he was not unduly aware of his stomach. It indicates that his preoccupation with sexual organs was specific and not just part of generalized heightened body awareness. Card XII : This has lateral mauve areas and central lung-like structures. It elicits anatomical responses such as “a huge man with lungs showing.” Problems over sexuality are also evaluated by the ambiguous “pelvic configuration.” The patient responded as follows: “A man … also a picture of the vagina (pointing to the pelvic region) and a penis (pointing to the white background between the lungs).”J His response here is unusual in that both male and female sexual organs are projected in relationship to the same figure. Desensitization Procedure : In a subsequent interview the patient was requested to rate the twelve pictures in order of ascending anxiety. He first selected the three cards for which his responses included no psychopathological anatomical content (Cards I, X and XI). Next in order was as follows: VIII, III, V, IV, VI, XII, VII, IX and II. After four training sessions in Jacobson relaxation (Jacobson, 1938,1964), the initial desensitization treatment was initiated by inducing a state of deep muscle relaxation for the patient.J He then was exposed to the pictures in ascending order of anxiety. A subjective scale of the patient’s anxiety level was kept by having him rate his anxiety while viewing the pictures. The scale created for this purpose was from zero – condition of being free of all anxiety – to one hundred, the greatest anxiety ever experienced by the subject. 16 Cassell

In the initial phase he rated his anxiety as ten. In viewing the cards for five seconds with a twenty second relaxation period in between his anxiety level rose to the twenty to twenty-five range in viewing the series. The exception was the last card (Card II), which resulted in a self-reported anxiety level of fifty. After a five-minute relaxation phase the procedure was repeated only this time and the viewing time was for thirty seconds followed by a thirty second pause. In this instance he was given the option of rejecting any card before the thirty-second exposure period if the resultant imagery was too threatening. When this was accomplished he reported he was much less anxious with the second viewing. His anxiety level did not exceed twenty. However, he accomplished this by rejecting Cards II and V after only five seconds of exposure. One week later the procedure was repeated for the third time in the relaxed state. In this instance, instructing him to view each picture only to the point of feeling mild anxiety modified the test. In this viewing situation he was found to be much less anxious. His anxiety level was rated as zero on all cards except V (15-20 anxiety), VII (10-15 anxiety) and II (0-10 anxiety).J In this regard the pictures were much less threatening and in all instances he was able to view them for thirty seconds. The procedure was repeated a week later and he was able to view all pictures in virtually an anxiety-free state. Clinically, this was correlated with an improvement in his sexual functioning. When seen six months after the desensitization therapy, he reported a marked improvement in his sexual life. He indicated that it closely approximated what he had experienced in the first two years of his marriage. Discussion: Before considering some of the general principles underlying the proposed treatment approach, certain aspects of this particular patient’s clinical history will be reviewed. In assigning an anxiety hierarchy to the anatomical pictures it was remarkable that the patient initially selected Card II as most threatening. As previously noted most individuals perceive this as a relatively pleasant picture of “a smiling person with upraised arms.” However, the patient substituted over this an image of “a woman with a big mouth.” In appraising the psychopathologic significance of this substitution certain aspects of the clinical history are pertinent. When asked to give verbal associations to this card, the patient’s anxiety level markedly rose. He stated that he wanted to tear up the picture since the large mouth strongly reminded him of his mother. He then became tearful and described at length a very conflictual relationship with her. A central theme was the contention on his part that his mother had always been verbally aggressive to him. Thus his mother’s verbal behavior had caused him to focus undue attention on her oral region. It may be inferred that oral imagery then had become very threatening to him because of its behavioral connotations. This formulation is supported by the fact that he rated Card IX as second most threatening. In this picture no imagery related to human content was elicited – just that referable to “lips.” Next, conceptual attention might be directed to the manner in which images of the sexual organs became associated with anxiety. It may be recalled that after two desensitization exposures of the pictures there still was residual anxiety for the lips (Card II) but none for the female genitalia (Cards IV and VI). Since it proved easier to remove the anxiety linked to the sexual regions, it may be inferred that this type of anxiety was at a lower level of intensity. Just as phobic reactions are readily generalized to other symbolically related objects; it is proposed that the patient’s fear of the genitalia developed secondary to a generalization of the oral anxiety to other body regions. In this context his psychophysiologic project with premature ejaculation could be conceptualized as relating to a desire to quickly complete intercourse because of a secondary anxiety associated with the sexual organs. This is quite analogous to the person with a phobia of a non-anatomical external object attempting to avoid the fear producing environmental situation. Next, consideration might be given to the fact that in the third desensitization session the residual anxiety was greatest for Cards V and VII. Since these produced responses denoting phallic imagery, Desensitization Therapy 17

it would appear that the patient’s anxiety was greater in mentally processing imagery related to its own genitalia.J This finding may simply reflect the fact that systemic desensitization is known to work best upon anxieties focused on objects external to the individual (Wolpe, 1973).J Thus it may have been easier to remove anxiety associated with female anatomical imagery because it was external and not directly related to the patient. In evaluating the results it must be recognized that the therapeutic potential of the outlined approach remains to be experimentally determined. In the case presented here for illustration purposes, the overall management involved the use of antidepressant medication, individual psychotherapy with a male therapist and a female co-therapist, along with educating his wife in the so-called “squeeze technique” (Masters and Johnson, 1970). Therefore it will require extensive study with complicated research designs involving many such patients to sort out the therapeutic potential of the separate treatment variables in order to ascertain that this type of desensitization approach has therapeutic efficacy. At this stage of the research, it would appear that there is a wide range of potential clinical applications for this new approach. Examples include sexual disorders, a spectrum of functional illnesses, which have heightened body image anxiety manifesting itself in various hypochondriacal symptoms or psychogenic pain and major psychophysiological conditions such as anorexia nervosa. In designing behavioural therapy techniques to desensitize body image anxiety in these various conditions, the therapist is encouraged to design the specific desensitization program to meet the patient’s idiosyncratic needs. Procedures involving visual imagery require special somatic aides such as the one employed in the present study. Clinicians who are interested in exploring the therapeutic potential of this procedure might note that heightened organ anxiety is not always associated with the projection of numerous anatomical responses. By contrast certain patients may employ the mental mechanisms of denial and repression in mentally processing in consciousness anxiety laden anatomical imagery (Cassell, 1964,1972 Cassell, W.A. and Duboczy, 1967). In viewing the somatic inkblots they avoid reference to highly suggestive anatomical content related to a symptomatic region. Further it has been the author’s clinical experience in evaluating body perceptual disturbances in a wide range of disorders that the inhibition is not always confined to images depicting the symptomatic region. In all such instances, it is necessary to reveal the anatomical content inherent in the inkblots prior to completing the desensitization procedure. Lastly, it might be noted that the therapist need not be restricted to the sole use of visual imagery with this behavioral therapy technique. For example, in treating a patient with a severe cardiac neurosis, in addition to employing visual procedures involving viewing somatic ink-blots or actual pictures symbolically depicting in various degrees the heart, the therapist might consider including auditory stimuli as well. In regard to exposing the patient to amplified sounds of his own heart’s action during a state of relaxation could provide an additional desensitization function. These are some of the general principles to keep in mind when designing a technique to desensitize body image anxiety. Summary: A newly devised therapy technique to desensitize individuals for body image anxiety arising from conversation symptoms and psychophysiologic disorders is outlined. One application involves the projective use of inkblots with high anatomical content, which provide a source of visual input to stimulate somatic images in consciousness. When these are activated in a state of relaxation the anxiety content of the pathologic anatomical imagery is reduced. A case history involving desensitization treatment for a psychoneurotic patient’s psychophysiologic symptom of premature ejaculation is presented for illustration purposes.- This preliminary report is primarily designed to alert interested clinical investigators to this technical innovation in treatment. 18 Cassell

References: Adamson, J., and Sterenko, R. (1977)-Personality and Cardiac Function.- British Journal of Projective Technique, 22,-41-47. Adamson, J.D. and Varsamis, J. (1976)-Somatic Symptoms in Schizophrenia.- Canadian Psychiatric Association Journal, 21:1, pp. 1-6. APA Report (1974) Behavior Therapy in Psychiatry:- A Report of the American Psychiatric Association Task Force on Behavior Therapy.- American Psychiatric Association, Washington. Cassell, W.A.-(1964) A Projective Index of Body-Interior Awareness.- Psychosomatic Medicine, 26:- 172-177. Cassell, W.A.-(1969) Responses to Ink-blot Configurations Resembling the Heart.- Journal of Projective Technique and Personality Assessment.- 123-126. Cassell, W.A.-(1971) Body Consciousness in Exhibitionism.- British Journal of Projective Technique.- 16: 21- 37. Cassell, W.A.-(1972) Individual Differences in Somatic Perception. -Adv. in Psychosomatic Medicine.- 8: 86- 104. Cassell, W.A.-(1973) Aggressive Image I Schizophrenia.- British Journal of Projective Technique, 22, 23-34. Cassell, W.A. (1977)-Eight Mental Measurements Handbook. Ed. Oscar K. Buros, The Gryphan Press.- Highland Park, New Jersey. Cassell, W.A.-(2000) Effects of Exercise in Body Perception.- (Unpublished data). Cassell,W.A. and Dubey,B.L.(2003) Interpreting Inner World through Somatic Imagery: M anual of Somatic Inkblot Test, SIS Center, Anchorage,(USA) Cassell, W.A. and Duboczy, J.(1967)- Cardiac Symptoms and Tachistoscopic Recognition of the Heart Image.- Canadian Psychiatric Association Journal, 12:- 73-76. Fenichel, O.(1945)- The Psychoanalytical Theory of Neurosis.- New York :- W.W. Norton and Company. Fisher, S. (1970)-Body Experience in Fantasy and Behaviour.- Meredith Corporation, New York. Friedman, P. and Goldstein, J.-(1974)- Phobic Reactions in Arietti, S., ed., American Handbook of Psychiatry, Vol. III, Ed. 2, Chap. 6, pp. 110, Basic Books, New York. Jacobson, E.-(1938) Progressive Relaxation.- Chicago, University of Chicago Press. Jacobson, E.-(1964) Anxiety and Tension Control:- A Psychobiologic Approach, Lippincott, Philadelphia. Lipowski, Z.J.-(1974) Physical Illness and Psychopathology.- International Journal of Psychiatry in Medicine, Vol. 5, No. 4, 483-497. Lowen, Alexander.(1975)- Bioenergetics.- Coward-McCann , New York. Masters, W. and Johnson, J. (1970)-Human Sexual Inadequacy.- Little Brown and Company, Boston. Paul, G.L. (1969)-Outcome of Systemic Desensitization in Behavior Therapy.- Appraisal and Status.- Edited by Franks, C.M.- New York, McGraw-Hill Book, Co., pp. 63-159. Wolpe, J. (1969)-The Practice of Behavior Therapy.- New York.- Pergoman Press.Wolpe, J., Brady, J.P., Serher, M., Auros, S., and Liberman, R.P.-(1973) The Current Status of Systematic Desensitization.- American Journal of Psychiatry.- 130:9, 961-965. Desensitization Therapy 19

Restructuring Rorschach Pathological Body Symbolism in the Somatoform Disorders with Truth Serum Behaviour Therapy Wilfred A. Cassell and Bankey L.Dubey When mentally disturbed individuals develop disease, their stress is mentally processed with deranged mental mechanisms. If their preexisting mental condition involves a form of the Somatoform Disorders, than it can poses confusing medical diagnostic problems. Differentiating psychophsiologic and conversion physical complaints from those secondary to physical disease can be puzzling. The diagnostic puzzle can sometimes be unraveled by assessing anatomical responses evoked by the Rorschach. A case history study involving a surgical patient with Conversion Disorder, “Pelvic pain” following successful surgery for bowel cancer is outlined. Post surgery fears of undetected metastases were denied, yet symbolized in a anxiety laden response depicting the pelvis as being attacked by bugs. This Rorschach evoked anxiety laden pathological imagery was desensitized in six subsequent interviews using pharmacologically induced relaxation. Most individuals find it highly stressful to have a physician inform them that they have a life threatening form of disease. In the patient’s mind this medical information links disturbing affect to the symbolic mental representation of the diseased region. In susceptible people, such stress may precipitate a psychological syndrome having features of Posttraumatic Stress Disorder (PTSD). One may involve the experience of terrifying dreams depicting either in real or symbolic form cancer spread and death scenes. If the disease process is visible on the surfaces of the body, memories of these may be reprocessed in PTSD dreams. Such sleep disturbing intrusive imagery may be comparable to that observed clinically, when real life traumatic visual memories are incorporated into dream affect and symbolism. Similar imagery may be activated when internal cancerous processes produce changes in appearance of body fluids or excretions. For example, the alarming sight of red blood bleeding from a body orifice can be vividly recorded in memory neurons during the day, only to reappear during disturbed sleep. When a person is informed of having cancer, a collage of threatening material may impact their ultimate response. Most medical care providers are able to intervene with support sufficient to prevent such stress from precipitating the overt clinical symptoms of PTSD. Ordinarily the traumatic imagery may only appear in disguised symbolic form in minimally disturbing poorly recalled dreams. In traditional practice medical practitioners and surgeons fail to enquire into the significance of such “Nightmares”. Sometimes a susceptible individual may experience extreme stress. This may activate the person’s mental defenses and convert unexpressed fears of death to medically inexplicable pain. Psychological consultants who are trained in projective technique are better able to decipher disease related dream imagery and symbolic specific anatomical inkblot responses. Pathological anatomical responses with the Rorschach may signify irrational fears of cancer spreading and exaggerated death anxiety. Often the symptomatic individual may be psychologically blind to their body image significance. Individuals suffering from Conversion Disorder pain frequently fall into this diagnostic category. It may be recalled that the diagnostic criteria for this condition involve the following four features: “A. One or more symptoms are present or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. Wilfred A. Cassell, MD, FAPA, APC, Director, SIS Center, 4501 East, 104th Avenue, Anchorage, Alaska - 99516 (USA), E-Mail: siscassell@yahoo.com and Bankey L.Dubey,Ph.D.,D.M.S.P. 4406 Forest Road, Anchorage, AK 99517(USA) Email:sisdubey@rediffmail.com Key Word : Behavior Therapy, pharmacologic relaxation,

C. The symptom or deficit is not consciously produced or feigned (as in Factitious Disorder or Malingering) D. The symptom or deficit cannot, after appropriate investigation, be fully explained on the basis a general medical condition”. E. The symptom or deficit causes clinically significant distress or impairment in social, occupational or other important areas of functioning or warrants medical evaluation. F. The symptom is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder. Case History: This involves a 47-year-old married woman who was originally evaluated thirty years ago on the medical ward of a general hospital. Her referring internist requested assistance in management of her “Severe pelvic pain”. She had bizarre affect characterized by apparent indifference. Her referring internist had said her totally denying any fear of recurrence was like an “Ostrich with its head in the sand”. At age forty-one she had developed Ulcerative Colitis, an inflammatory bowel condition whose etiology is poorly understood. It can result in abdominal pain, severe diarrhea, rectal bleeding and other severe health problems. In her case, it was bowel cancer. Diagnostic evaluation indicated that she had clinical features, which met all categories for a psychiatric diagnosis of Conversion Disorder: A. She had been hospitalized because of physical symptoms which could well be accounted for by recurrence of her bowel cancer. Her pain was experienced throughout the pelvis region, the rectal area, right hip and lower back. It was described as being a “very searing, hot jabbing pain” whose intensity “worked up and down”. B. Her pain had developed two years earlier shortly after the stress of cancer surgery. During the operation the tumor had been completely removed and a temporary colostomy established. The cancer had not spread to other structures in the pelvis. C. There was no evidence of her feigning illness. D. Extensive medical diagnostic evaluation revealed no metastasizes or activation of her Ulcerative colitis sufficient to account for her severe pain. E. Her symptoms restricted her domestic life and warranted hospitalization. F. Following surgery she developed a somatic delusion. In a paranoid way she persisted in complaining, “The surgeon removed my tailbone”. At age forty-one she had developed Ulcerative Colitis, an inflammatory bowel condition whose etiology is poorly understood. It can result in severe diarrhea, rectal bleeding and other severe health problems. In her case, one of these was bowel cancer. As noted what was remarkable about her overall clinical presentation was the great contrast between her extreme emphasis on pain and by contrast absence of any fear of dying from cancer. This denial is illustrated by considering as portion of a tape-recorded interview: “I had ulcerative colitis for quite a few years … and then it was … it would be four years ago … I believe it’s four years ago … five … no four … at Christmas time … all of a sudden after that I started Behaviour Therapy 21

to bleed from the rectum and I didn’t tell anybody or say anything about it until the middle of February … and they made me go see Dr. Z. and he set up a barium right away to look at things and when I was waiting for the results I flew to Vancouver and had a holiday with my sister … I was trying to forget about this for awhile but when I got back he told me that I was just like an ostrich sticking my head in the sand and not wanting to know what was the matter with me.” Doctor : What was the eventual diagnosis? Patient : It was cancer. Doctor : I see. Patient : And he (the surgeon) had a very good idea at that time that this is what it was … he just didn’t say … he wanted to be definitely sure. Doctor : How did you feel when he told you that you had cancer? Patient : You know I can’t remember him telling me this … not until after everything was over … I know my husband knew and whether they had me drugged and told me I don’t remember but I really don’t remember him telling me this until everything was over with … and it didn’t bother me because he said that he got it all … they told me I would be a new girl and everything would be fine … you know they gave me a temporary colostomy. Doctor : You say it didn’t bother you that you had cancer. Could you clarify that? Patient : Well some people would worry and think well you know I’ve had this … maybe I’ve still got it and you know … but it didn’t bother me. Doctor : Has it bothered you since? Do you ever think about it? Patient : Oh … once in a great while I’ll maybe think about it but not really. This denial mechanism also was evident when attempts were made to explore the significance of her PTSD dreams. After she learned about her cancer, she began to frequently experience dreams in which she died of some type of horrible disease. While she readily acknowledged that these “Nightmares” were upsetting, she repeatedly refused to accept that they might indicate that she was afraid of dying from cancer. Rorschach Results: Next attention might be given to her pretreatment body image as revealed by her anatomical responses evoked with Rorschach testing. Initially this projective procedure was administered in the traditional way with the following initial responses: Card I : “Bug … bat … beetle.” Card II : “X-ray of pelvis … kidneys.” Card III : “Two people … funny looking drops of blood.” Card IV : “Fee … monster lying there.” Card V : “Bat.” Card VI : “A fur rug.” Card VII : “… animals upside down sitting on their heads … pelvic shape.” Card VIII : “… two animals crawling up … rats.” Card IX : “… deer with horns.” Card X : “A bunch of bugs attacking the pelvic area.” 22 Cassell & Dubey

Three anatomical responses depicted pelvic imagery in her projective consciousness. Next the Rorschach procedure was modified prior to the detailed inquiry. This was done by placing all ten cards on a couch in front of her. She was instructed to arrange them in order from those, which were “most upsetting” to “least upsetting.” She arranged the series in the following order: X, VIII, IV, V, III, VII, IX, I, II, VI. Card X was extremely upsetting to her. Next she was told to rate the emotional threat that the series evoked on a scale from zero to one hundred. She was instructed to imagine the highest rating as being the “most upsetting thing she ever experienced in her life”. Reflecting the high degree of anxiety linked to the symbolic imagery, she assigned a value of ninety-nine to the card. Changing the order of administration undermines the applicability of statistical norms and obviously has disadvantages. However there is an overall positive tradeoff in working with somatic symptom related anatomical responses. It incorporates the relative degree of affect –image linkage. This summation can increase the Rorschach’s projective pulling power on clinically relevant, yet otherwise daytime dormant PTSD dream imagery. Essentially it treats the ten inkblots more as an overall visual gestalt. In this model, affect bonding between cards serves to supplement projective symbolic cognitive linkage in the associational chain. This administration procedure maximizes the projective “pull” of the cards. Moreover it makes for logical coherence in the associational chain to begin with projective responses associated with the highest level of arousal. The results of the detailed inquiry follow: Card X : Patient : “Well I just see all kinds of … they look like weird bugs of some sort all attacking … and it almost looks like in the pelvic region and it goes up into the lungs.” Doctor : “The pelvic region is where?” Patient : “Down here (pointing to central red configurations) … this is part of the pelvic region to me … this looks like it.” Doctor : “That’s the area in red primarily is it?” Patient : “Yes … and I always think they are just attacking … I just … it really bothers me … that picture really does.” Card VIII: Patient : “These look like rats or something like that (pointing to the red objects on the sides of the ink-blot configuration).” Doctor : “You are referring to the objects on either side of the red?” Patient : “Yes.” Doctor : “And what are those rats doing?” Patient : “Well they are attacking too … it looks like they are going in and either eat you up or do something.” Doctor : “What part of the body are they attacking?” Patient : “Well this is again the pelvic region (pointing to the lower area of the ink-blot configuration). A little bit higher up … to me this is more down here in the pelvic … they’re going up a little bit higher.” Behaviour Therapy 23

Doctor : “So the lower area is the pelvic region and they are going up into what part of the body?” Patient : “A little bit higher up into your stomach, up into your lungs kind of.” Card IV : Patient : “Well this looks like a monster of some type … it would be an immense bug or something.” Doctor : “And what is the bug doing?” Patient : “Well it just looks like it’s going … well I don’t know … it just feels like it’s going to do something bad … like it’s going to attack again.” Doctor : “What is it going to attack?” Patient : “Well again all of these pictures remind me of the pelvic area. I feel that this is where they are attacking when I look at these pictures.” Card V : Patient : “That to me looks like a great big bat … and I don’t know if it’s because of the radio and TV … I always think of vampire bats.” Doctor : “Vampire bats?” Patient : “And sucking blood out of people which I don’t really know if they do or not … that’s what bothers me about that.” Doctor : “Where would you be concerned about their sucking blood from?” Patient : “Well again … you know because of this down here … it looks again like it’s going down to the pelvic region … the bottom end of the bat … you know if you look at it in another way it still looks like it’s part of it again.” Card III: Patient : “They look like very strange people of some sort that are banging on a thing that looks like the pelvis and there is blood dripping down on either side which bothers me very much.” Doctor : “Where would the blood be coming from and what type of people would they be?” Patient : “Well they just … they … they look like something from outer space not like something real … like something unreal and it looks like they’re … whatever they’re doing it’s making this person lose blood somehow and it’s dripping down.” Doctor : “And what part of the body is bleeding would you say?” Patient : “It looks like it’s coming from a little bit higher than the pelvic region.” Doctor : “Like where would you say?” Patient : “Well I say up in the lungs.” Card VII: Patient : “Well this is a little different … in a way it looks like two animals are upside down with their heads like this … and then again when you look at it this way it looks like a … well I don’t know an awful looking person or something … something not real … that again is looking not quite down cause they’re looking sideways but I think they are going to try to look down to the pelvic region again … like they’re just going down to attack it like that.” 24 Cassell & Dubey

Card IX: Patient : “There again I see two very strange creatures up there … it almost looks like claws down here (lower green area) and again attacking down to the lower region.” Doctor : “In the lower red area?” Patient : “Yes and those (pointing to upper green areas) are attacking around the lungs … and these (lower green area) whatever they are, they’re awful looking creatures … they each have a big claw on them.” Doctor : “And where is the claw attacking?” Patient : “Well that is attacking down into the pelvic region.” Card I: Patient : “That just looks like sort of a butterfly and a moth combined … kind of all ragged and rings on it and you can see the feelers up here … it doesn’t bother me all that much … I don’t like it … as I say it is similar to that vampire bat but it is a different type of thing … it is more on the bug line.” Doctor : “Is this attacking anything?” Patient : “Well again all of these pictures are shaped to me like the pelvic area and this is why it bothers me that they would be attacking there.” Card II: Patient : “Here again they’re made to look like kind of animals up here again of some sort prancing around … and it looks like there’s pain down here in the pelvic area with the red patch hanging in there.” Doctor : “The lower red is the pelvic area?” Patient : “Yes … whether they’re causing it I don’t know but they’re up there doing something and it just … you can see it coming here (pointing to the red colors within the black areas).” Card VI: Patient : “Oh this one doesn’t bother me too much … it makes me feel like it’s a big bug … I don’t know why … just that it would be.” Before reviewing the treatment process, perhaps it would be of interest to briefly consider some further body perceptual data derived from figure drawing tests. They were obtained by requesting her to draw a picture of a person and then what she considered to be the inside of her body (Tait & Ascher,1955). Figure-1 Behaviour Therapy 25

Initially an interpretative cognitive psychotherapeutic approach was planned, using the Rorschach. In contrast to the SIS the ten inkblots have relatively little color form structure suggestive of anatomy. When there is a clear mental perception set focusing on a region, there may not be a need to followup with any more anatomically structured forms of the SIS. In any case, in interpreting her Rorschach pelvic image fixation, it was suggested to her that the “Attacking” creatures might symbolize in-depth fears that the surgeon had not succeeded in removing all the cancerous tissue. Perhaps predictably, considering the intensity with which she focused upon the pathologic body imagery and pain, she chose to reject this interpretation by saying “Well these are just pictures I am looking at like I’d buy in a store … they don’t have to do with my pelvis”. In this manner, her mental defense mechanism blocked unreported fears of recurrence and death anxiety. Since this strategy did not appear to be productive, a second treatment approach involving Behavioural therapy designed to desensitize body image anxiety was planned. This procedure involves gradually reconditioning the symptomatic individual to an anxiety laden hierarchy of anatomical images, while in a state of deep relaxation. Because of the highly threatening nature of her dream and Rorschach imagery, sedating doses of Sodium Amytal were injected intravenously in six subsequent viewing situations. On each treatment day she was exposed to the Rorschach cards, in order of ascending anxiety, for thirty seconds with a thirty second relaxation pause in between. In the latter sessions, the symbolism on Card X was much less threatening. The “attacking” organisms were portrayed as being more placid, more often lying down, and less likely to attack. This was clinically correlated with a comparable reduction in her pain and a willingness to more realistically consider her cancer free prognosis. Discussion: This case brings to mind some of the early views of conversion hysteria. In 1907 Janet originally introduced the concept “dissociation” to account for the underlying psychopathology (Janet, 1907). He referred to a “retraction of the field of consciousness and a tendency to the dissociation and emancipation of the systems of ideas and functions that constitute personality.” In this manner the individual no longer was considered to have access to the dissociated ideas, which permeated his mind. However, these were considered to be mentally active operating autonomously to create the symptoms of hysteria. Freud’s psychoanalytic work on hysteria is also of historical relevance (Freud, 1953) These would still appear to have historical merit for building a modern foundation for conceptualizing of Conversion Disorder. Janet’s formulation is particularly theoretically helpful in accounting for the discrepancy in the data obtained using interviews versus projective technique. The verbal report suggested that there was no fear in conscious awareness of cancer metastasizes. This affect void is reminiscent of what in the past was referred to as “la belle indifference”. In the classical cases manifested minimal overt anxiety but manifested bizarre and dramatic symptoms involving pain and paralysis. The history of projective technique in the diagnostic/therapeutic management of Conversion Disorder is also relevant in the present case history study. Rorschach’s original thinking about the significance of moving anatomical responses depicting movement warrants conceptual reexamination. Herman had begun to consider that these somehow might reflect a direct projection of kinesthetic sensations in the viewer’s own body. His creative thinking resulted from recalling a vivid dream experienced as a medical student (Ellenberger, 1954). 26 Cassell & Dubey

In my first clinical semester, I was for the time at an autopsy and looked at it with the well known respectful eagerness of a young student. The dissection of the brain interested me particularly, and I joined to it all kind of reflections about the localization and cutting up of the soul. The diseased had been an apoplectic; the brain was cut in transverse slices. The following night I had a dream in which I felt my own brain was being cut in transverse slices. One slice after another was cut off from the mass of the hemispheres and fell forward, exactly as it had happened at the autopsy. These bodily sensations (I lack a more precise designation0 were very clear, and the memory of that dream even now is fairly vivid. This dream shows that Rorschach early in his professional training needs to be praised for attempting to formulate a body-mind-spirit conceptual model. His attempt was modeled after the worthwhile work of early anatomists and neurophysiologists to localize brain functions in specific neural structures. While this proved immensely helpful for certain basic processes, such as those underlying movement and sensation, it has not proven nearly as successful for higher brain functions. This is especially true for formulating a brain-mind model for understanding more about the “Soul”. There now is a scientific literature reviewing the positive influence of various healing religious practices. Yet we lack nomenclature and theory. The present authors view certain types of dream imagery as arising from an energy source outside the individual’s conscious control. It would appear to have come from a natural healing spiritual source (“God”?). It is suggested that this interpretation may apply to Herman’s dream. The fact that that years later this dream kept intruding on his mind is pertinent. For one thing, it inspired him to postulate that movement imagery was based in biologic sensory roots. Remember his body-mind state that when he first viewed the imagery. He was a passive sleeper without access to his own volitional cognition. He was therefore in error when referring to it possessively as “his” own dream. It represented a symbolic message from a higher spiritual power. In reality he should have given thanks to the higher power, which inspired him. Most of us make the same ego based mistake in claiming personal credit for inspirational gifts from our spiritual source. In any case, his “vivid” recall brings to mind the features of what now we understand to be clinical characteristic of PTSD dreams. It may be inferred that the original autopsy scene witnessed as a young inexperienced medical student was highly stressful. Due to the initial shock some students actually faint during autopsies. In all likelihood Herman’s empathetic connection with the diseased had caused him to partially identify his own body gestalt with the body being dissected. At the time of the original trauma he was particularly interested in seeing the pathologist dissect the brain. When observing this, his mind was preoccupied with “reflections” about “the localization and cutting up of the soul”. His memory of the original scene’s visual imagery highlighted movement images from the dead person’s brain sections falling apart from the dissection. In the dream, he subjectively experienced these as kinesthetic “body sensations”. Of course, at that early scientific period in the last century had problems describing his subjective experience (“I lack a more precise designation”). At this stage in the twenty-first century there is available a richer language for scientific communication about body-mind-spirit processes involved in inkblot perception. One can now conceptualize of a person having an overall gestalt of the body with shifting levels of awareness for this, as compared to external objects in the external field of perception. Within this somatic field of consciousness various regions compete for registration in full awareness. Sensory feedback factors can influence this process. For example, consistent with Herman’s original view, sensory feedback of kinesthetic sensations from a moving or pulsating part elevate this region’s likelihood of being recognized in conscious awareness and/or having greater power to influence viewing of inkblot anatomical structure. Behaviour Therapy 27

Herman’s simplistic sensory feedback model still has some degree of relevance. It assists in understanding somatic symptoms arising from disease processes, which alter pain-transmitting neurons at the site of the pathology. It also has relevance to accounting for psychophysiologic symptoms arising from increased feedback secondary to stress induced body changes such as increased cardiovascular activity. The mid twentieth century Rorschach literature contains a number of studies relating anatomical responses to somatic symptoms (Ames, Learned et al 1952, Bohm, 1958, Levi, 1960, Weiss & Winnik, 1963, Barnes & Carnes 1971). However, the relationship between projected anatomy responses and somatic preoccupation is a much more complex one than the literature indicates. For example, a clinical investigator might predict that when a stressed individual with resultant increased heart rate views cardiac imagery either in a tachistoscopic or somatic inkblot-viewing situation. In the former, it would be expected that recognition times would be shorter. In the later one might expect that more heart responses would be projected. However, in the pioneering studies the data were only partially consistent with these predictions (Cassell, 1965, 1972, Adamson & Varmose, 1975, Adamson, et al 1977). In sharp contrast some subjects who reported psychophsiologic cardiac symptoms perceptually inhibited heart imagery (Cassell, 1967, 1969). This introduced the need for a revised more complex body-mind-spirit model. In this, psychological factors of organ symbolism and affect linkage to a region’s mental representation represented additional influences. These could be powerful inhibition perceptual force sufficient to trump the physiological feedback factor. This was observed in the present case history study. The frequency of pelvic Rorschach responses signified heightened projective awareness of this region to the interviewer. The pathological symbolism of “Bugs attacking the pelvis” on Card X was interpreted to indicate the presence of unreported images of nonexistent cancer metastasizes. The fact that this was split off in her mind is reminiscent of Janet’s views of conversion reaction and “Hysteria”. This is consistent with the views of Endicott and Endicott (1963) that Rorschach anatomy responses may reflect unconscious somatic preoccupation. It was noteworthy that when the anxiety-threat hierarchy was established she selected this last card as “Most upsetting”. Moreover once the triggering power of the order of administration had been used, then somatic imagery was projected onto the Rorschach stimuli on cards VIII, IV, V, III, IX, and I. In fact by this time a perceptual set for the pelvis had been established for all except Card VI, which was lowest in the rating scale. Of those cards that evoked pelvic imagery, it is significant that card II was rated as next lowest in anxiety linkage. This included reference to the presenting physical symptom in her Conversion Disorder: “It looks like there is pain down there in the pelvic area with the red patch hanging in there. “Pain” was somehow substituted for disturbing affect linked to her mental picture of the pelvis. Clearly this was a major distress. This discomfort experienced by her in conscious awareness perceptually inhibited what in all likelihood was a greater threat, namely fear of cancer spread and death. While it is not unusual for people to deny death anxiety (Becker, 1973), her conversion of it to “severe pain” represented a disabling somatic symptom. Conclusion: It was shown how a combination of cognitive and Behaviour therapy in association with the use of pharmacologic relaxation was therapeutically helpful. Further clinical investigation is warranted to determine if this approach with the SIS has practical merit in the Somatoform Disorders. 28 Cassell & Dubey

References: Adamson, J.D. & Varmose, J. Somatic Symptoms in Schizophrenia. Canadian Psychiatric Association Journal , 1976, 21, 1-6 Adamson, J.D., Greengrass. R..& Martin, R.M., Cassell’s Anatomical Pictures: Responses by Groups of Hospital Inpatients. British Journal of Projective Psychology and Personality Study 1977, 22, 2, 27-35 Barnes, R.E., and Carnes, G.D. Rorschach Anatomy Response Correlates in Rehabilitation Failure Subjects. Journal of. Personality Assessment, 1971, 35, 525-531. Becker, E. The Denial of Death. The Free Press, a Division of MacMillan Publishing Co., Inc., 1973. Bohm, E. A Textbook in Rorschach Test Diagnosis. . Green and Stratton, 1958. Cassell, W.A. Body Perception and Symptom Localization. Psychosomatic Medicine. 1965, 27, 171-176. Cassell, W.A. & Duboczy, J. 1967 Cardiac Symptoms and Tachistoscopic Recognition of The Heart Image Canadian Psychiatric Association Journal 12, 73-76. Cassell, W.A. Individual Differences in Somatic pPrception. Advances in Psychosomatic Medicine. 1972, Vo. 8, 86-1094. Cassell, W.A. Responses to Ink-blot Configuration Resembling the Heart. Journal.of Projective Techniques and Personality Assessment.1969, 123-126. Endicott N.A. & Endicot, J. Objective Measures of Somatic Preoccupation, Journal.of Nervous and Mental Disease, 1963, 137, 427-435. Ellenberger, H. The Life and Work of Herman Rorschach Bulletin of The Menninger Clinic, 1954, 18,175-218. Freud, S. Fragment of an Analysis of a Case of Hysteria Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 7, pp. 7, Hogarth Press London, 1953. Janet, P. The Major Symptoms of Hysteria. .- MacMillan , New York , 1907. Levi, J. Rorschach Patterns Predicting Success or Failure in Rehabilitation of the Physically Handicapped. Universities Press, 1960, 168-175. Tait, C.D. and Ascher, R.C. Inside The Body Test Psychosomatic Medicine 1955, 17, 139. Weiss, A.A. & Winnik, H.K. A contribution to The Meaning of Anatomy Responses in The Rorschach Test, 1963,1, 265-276. Behaviour Therapy 29

Rorschach Responses of Older Indians Suprakash Chaudhury, S Sudarsanan, K Seby, S K Salujha, Kalpana Srivastava, S M Kundeyawala and SP Rathee The Rorschach test by Klopfer’s method was administered to 442 older Indians aged 65 years or more, comprising of normal subjects and patient groups. The normal sample consisted of 282 subjects. The patient sample consisted of 160 patients with the diagnosis of dementia (n=66), alcohol dependence syndrome (n=8), schizophrenia (n=16), mania (n=5), depression (n=50) and anxiety disorders (n=15). The Rorschach protocols of normal older Indians at different age groups showed significant differences from each other and also from the Western norms. The Rorschach profiles of the various groups of patients also showed significant differences between them, from normal older Indian subjects and also from the Western norms. Interpretation of the Rorschach protocols of normal older Indian and also patients using the Western norms would be fallacious and misleading. The use of the Rorschach test to study the aging trends of normal older adults as well as an aid to clinical diagnosis was strongly supported. More than 80 years have passed since Hermann Rorschach began in earnest to show inkblots to patients being treated in the Krombach Mental Hospital in Switzerland. His “psychological experiment “ as he called it, led to the standardization of a personality assessment instrument that has been administered to hundreds of thousands of people, generated thousands of research studies, and become widely familiar to professional persons and the general public around the world. The Rorschach remains among the most commonly used tests in the clinical setting at present (Exner 2002). In India too the Rorschach test is widely used and enjoy the highest rank among the tests used for psycho diagnosis and assessment of personality (Prasad and Pareekh, 2001; Mishra et al, 1996). The clinical use of a psychological test like the Rorschach requires the existence of norms. Initially, because of the claim that the Rorschach was a culture free test, the norms established by western authors were accepted and used. However, later studies revealed that the responses were influences by variables such as age, social background and culture (James & Dana, 2004; Panek et al, 1983; Dubey 1982, Exner 2002). There is no published work done by Indian workers on the Rorschach in older Indians. Moreover, within the researches conducted abroad, the norms for older subjects established by various workers differ considerably (Ames, 1995). This might be because of the different scoring system used by the different workers and also due to the differences in the demographic characteristics of the samples. In addition most of these studies had a number of shortcomings, the most important being the relatively small sample size. Specific and reliable norms for older Indians are thus a vital necessity. The present study was undertaken to try to establish the norms of the Rorschach test for older Indians. Material and Method : Normal older Indians, patients with Dementia (Demen), Alcohol Dependence Syndrome (Alch Depen), Schizophrenia (Schiz), Mania, Depression (Depr), and Generalized Anxiety Disorder(Anx Dis), in the age group of 65 years or more, were included in the present study. Normal older adults, in the age group of 65 years or more, not suffering from any physical or mental illness and without a past or family history of mental illness were drawn on a random basis from Bareilly, Gauhati, Cannanore, Meerut, Udhampur, Pune and neighboring districts of Maharasthra, Chandimandir and neighbouring districts of Punjab and Haryana. In addition subjects were included from “Mathoshree” and “Nirmal Col Suprakash Chaudhury, Prof & Head, Dept of Psychiatry, Ranchi Institute of Neuropsychiatry & Allied Sciences, Kanke, Ranchi-834006; Brig S Sudarsanan, Consultant (Psychiatry), Base Hospital Delhi; Lt Col K. Seby, Graded Specialist (Psychiatry), Col S K Salujha Cl Spl (Psy),MH Jalandhar; Kalpana Srivastava, Scientist ‘E’; S M Kundeyawala, Psychologist, Dept of Psychiatry, AFMC, Pune. S.P. Rathee, Senior Scientific Officer (Clinical Psychologist), Command Hospital (Western Command), Chandimandir. Key Words: Rorschach test; norms for older Indians

home” which are institutions for the aged in Pune. The psychiatric patients were included from outpatients of Military Hospitals at Bareilly, Gauhati, Meerut, Udhampur, Pune, Chandimandir and inpatients from Mental Hospital, Bareilly. All patients were diagnosed as per ICD 10. While new patients were tested prior to starting treatment, patients undergoing treatment but showing active symptoms were also included. Each subject was initially interviewed to collect the personal data. Then the Rorschach test was administered following the technique of Klopfer (1954). It was ensured that there was no compulsion in undergoing the test. It was emphasized that the test was not being used to find out whether he was ill or not, but that he was participating in a research project to determine how various persons responded to the test. Statistical analysis was carried out using median test. Results: This study comprises of 442 Rorschach test records obtained from older Indians. The normal sample population consisted of 282 normal adults aged 65 or more. The patient group consisted of 160 patients. The demographic data of the various groups of subjects included in the study are presented in Table 1. Among normal subjects there was almost equal representation of males and females (male: female = 143: 139). A similar trend was also observed in patients with mania and anxiety disorders. Alcohol dependence syndrome was seen in males only. A male preponderance was seen in dementia and schizophrenia while the opposite trend was seen in depression. In the normal group more subjects from urban area were included (Urban vs. Rural = 225 vs. 57). The same trend was observed in all patient groups except schizophrenia. Since the major part of the work was carried out at Pune, subjects from western India are over- represented in the study. The vast majority of subjects were Hindus. Table 1 : Demographic characteristics of the subjects Charac- Normal subjects Psychiatric patients teristic Age Age Age Total Demen Alch Schiz Mania Depr Anx 65-<75 75-<85 ≥85 N=282 n=66 Depen N=16 n=5 n=50 Dis N=174 N=81 N=27 N=8 n=15 Age : Mean 68.48 77.51 88.48 72.99 76.02 76.13 71.06 70.6 71.6 74.73 Range 65-74 75-82 85-96 65-96 65-98 65-87 65-89 65-78 65-90 65-90 Distribution 65-<75 75-<85 >85 Sex: Male Female Education : 0-5 6-10 10+ Regional distribution: North South West East Domicile: Rural Urban Marital Status: Married Unmarried Others Religion: Hindu Sikh Muslim Christian Buddhist Parsee Rorschach in older Indians 31

Table 2 shows that among normal subjects there was an increase in mean number of responses from 65- <75 to ≥85 year. Among all the patient groups mania patients gave the maximum numbers of responses, while schizophrenia patients gave the least number of responses. Mania patients gave significantly more responses than age and sex matched normal controls. Patients with schizophrenia, dementia and anxiety disorders gave significantly less responses compared to age and sex matched normal controls. The average reaction of normal subjects showed a steady decrease from 65-<75 years up to ≥85 (Table 2). Among patient groups, the longest average reaction time was in schizophrenia while shortest was in mania. However, the quickest and the slowest individual reaction time were recorded in dementia and depression respectively. The average reaction time of patients with dementia, depression, schizophrenia and anxiety disorders was significantly more than age and sex matched normal controls. The achromatic reaction time was more than chromatic reaction time in normal subjects 65-<75 years, but not in 75-<85 ≥85. Among the patient groups, apart from schizophrenia, the chromatic reaction time was consistently more than the achromatic reaction time. However, the difference between achromatic and chromatic RT was < 10 seconds (Table 2). Table 2 : Responses, Reaction Time and Rejections on Rorschach test by Older Indians Charac- Normal subjects Psychiatric patients teristic Age Age Age Total Demen Alch Schiz Mania Depr Anx 65-<75 75-<85 ≥85 N=282 n=66 Depen N=16 n=5 n=50 Dis N=174 N=81 N=27 N=8 n=15 Total number of responses Mean 14.05 15.36 17.04 14.71 12.28 12.88 19.6 13.12 11.93 Range 9-29 9-24 10-32 9-32 9-25 9-19 9-25 15-26 9-25 9-32 Reaction Time in seconds Mean 39.88 36.93 35.29 38.87 48.1 44.15 54.9 26.87 49.73 45.5 Range 15-9016.79-69.23 21.82-52.9 15-90 10.63-90 25-73.33 28.8-151.5 14-35.38 19.2-133.3 25.7-66.7 Achromatic Reaction Time in seconds Mean 20.94 19.34 17.35 20.14 18.08 18.10 27.24 13.2 21.56 17.16 Range 4.8-49 3.4-35 4.8-27 3.4-49 7-36 7-36 1.2-121.6 5-22 5-78 6.67-27.5 Chromatic Reaction Time (CH RT) in seconds Mean 20.75 21.49 18.74 20.77 20.29 21.45 25.21 17.4 23.29 19.53 Range 3.4-55 4.8-37 4.2-32 3.4-55 6.4-36.25 8-36.25 1.248.8 7-24 5.8-98.75 4.6-36.3 Percentage response per card I 10.00 9.96 11.74 10.43 8.35 10.68 11.93 12.24 9.91 9.38 II 9.79 9.15 9.56 9.82 10.07 8.73 10.79 8.16 10.65 9.90 III 11.84 12.06 10.0 12.00 13.39 11.65 10.79 10.2 11.39 13.02 IV 7.25 7.77 6.74 7.58 7.86 8.74 9.66 6.12 7.99 6.77 V 8.07 6.88 7.17 7.81 11.79 8.74 9.66 8.16 9.32 16.66 VI 7.74 7.21 8.26 7.83 7.37 8.74 9.66 6.12 9.02 7.29 VII 7.50 7.69 9.56 7.98 7.74 5.83 9.66 8.16 6.66 6.77 VIII 13.68 13.85 12.83 13.98 14.01 17.47 13.07 12.24 13.02 14.06 IX 9.46 10.53 9.13 9.99 7.62 7.77 6.82 12.24 7.69 6.77 X 14.67 14.9 15.0 12.59 11.79 11.65 7.96 16.33 14.35 9.38 Rejection per Rorschach card : N(%) I 4(3.08) 3(9.09) 0(0) 7(4.19) 10(10.64) 1(12.5) 1(4.54) 0(0) 5(9.62) 3(13.04) II 4(3.08) 0(0) 0(0) 4(2.39) 1(1.06) 0(0) 0(0) 0(0) 1(1.92) 0(0) III 2(1.54) 1(3.03) 0(0) 3(1.79) 2(2.12) 0(0) 1(4.54) 0(0) 2(3.84) 0(0) IV 21(16.15) 4(12.12) 1(25) 26(15.57) 9(9.57) 0(0) 2(9.09) 0(0) 5(9.62) 4(17.39) V 1(0.77) 0(0) 0(0) 1(0.60) 2(2.12) 0(0) 1(4.54) 0(0) 0(0) 0(0) VI 22(16.92) 5(15.15) 1(25) 28(16.77) 15(15.96) 0(0) 3(13.64) 0(0) 5(9.62) 4(17.39) VII 28(21.53) 9(27.27) 2(50) 39(23.35) 18(19.15) 2(25) 2(9.09) 0(0) 15(28.84) 4(17.39) VIII 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) IX 34(26.15) 7(21.21) 0(0) 41(24.55) 20(21.28) 3(37.5) 7(31.82) 0(0) 12(23.07) 5(21.74) X 14(10.79) 4(12.12) 0(0) 18(10.78) 17(18.09) 2(25) 5(22.73) 0(0) 7(13.46) 3(13.04) Number of Rorschach cards rejected: N(%) 31(17.82) 9(11.11) 4(14.82) 44 (15.6) 6 (9.09) 0 (0) 4 (25.0) 0 (0) 13 (26.0) 5 (33.33) 22 (12.64) 5 (6.17) 0 (0) 27(9.57) 11(16.67) 1 (12.5) 3 (18.75) 0 (0) 10(20.0) 2 (13.33) 8 (4.60) 1 (1.23) 0 (0) 9 (3.19) 14(21.21) 2(25.0) 1(6.25) 0 (0) 2(4.0) 3(20.0) 4 and more 6 (3.45) 2 (2.47) 0 (0) 8 (2.84) 4(6.06) 0(0) 2(12.5) 0 (0) 2(4.0) 0(0) 32 Chaudhury et al

There was no significant difference in the percentage of response to each individual card of the Rorschach test in the various groups of subjects (Table 2). Among normal subject there was a decrease in the number of cards rejected with increasing age. Card VIII was not rejected by any of the normal subjects or patients. Patients with mania did not reject any card. Maximum rejections were by patients with depression, anxiety disorders and dementia in that order (Table 2). Table 3 : Mean (M), range (R) and percentage (%)of Location score Subjects Location W D d M R % M R % M R % Normal 5.90 0-12 40.11 7.65 0-18 52.01 0.29 0-8 1.97 65-<75 5.56 0-12 39.57 7.59 0-19 54.02 0.22 0-7 1.57 75-<85 6.44 0-11 41.93 7.47 2-15 48.63 0.26 0-3 1.69 ≥85 6.44 1-11 37.79 8.56 3-18 50.23 0.81 0-8 4.75 Dementia 4.81 0-9 39.17 6.79 1-17 55.29 0.46 0-4 3.75 Alch depen 5.25 3-11 40.76 7.13 4-13 55.36 0.38 0-1 2.95 Schizophrenia 3.38 0-8 30.73 5.75 2-14 52.27 0.56 0-3 5.09 Mania 6.4 3-11 32.65 11.6 5-19 59.18 1.2 0-4 6.12 Depression 5.37 2-11 40.93 7.02 1-17 53.18 0.37 0-2 2.82 Anxiety disorders 6.53 3-11 54.74 4.87 0-16 40.82 0.07 0-1 0.59 Table 3 : (Continued) Mean (M), range (R) and percentage (%) of Location score Subjects Location Dd S DW M R % M R % M R % Normal 0.73 0-10 4.96 0.14 0-2 0.95 0.004 0-1 0.027 65-<75 0.55 0-7 3.91 0.12 0-2 0.85 0.01 0-1 0.07 75-<85 1.01 0-3 6.58 0.17 0-1 1.11 0-0 ≥85 1.07 0-10 6.28 0.15 0-2 0.88 0-0 Dementia 0.16 0-3 1.30 0.04 0-1 0.33 0.04 0-1 0.33 Alch depen 0-0 0.13 0-1 1.01 0-0 Schizophrenia 0.06 0-1 0.55 0.06 0-1 0.55 1.19 0-4 10.82 Mania 0.2 0-4 0.10 0.2 0-1 0.10 0-0 Depression 0.35 0-4 2.67 0-0 0-0 Anxiety disorders 0.4 0-6 3.35 0.07 0-1 0.59 0-0 The mean and range of location categories is given in Table 3. Among normal subjects there was an increase of W, D, d, Dd & S with age. Among patient groups highest W were given by patients with mania and anxiety disorders (not significantly more than matched normal controls). Patients with dementia and schizophrenia gave confabulatory responses. Apart from a patients aged 65-<75 years, none of the normal subjects gave confabulatory responses. The frequency of the determinants of responses is given in Table 4. Among normal subjects F, M, FM and FC increased with age; m, Fk and CF increased till 75-<85 years and then declined; FK, Fc, C’ and C decreased with age. Among patient groups highest F was seen in mania, anxiety state and depression. Significantly higher CF responses were seen in patients with mania while patients with anxiety state, depression, schizophrenia and depression gave lower CF responses compared to normal subjects. Pure colour responses were seen in schizophrenia and mania. Rorschach in older Indians 33

In normal subjects F% increased with age. Patients with anxiety state and schizophrenia had highest F% (> 50%) followed by patients with alcohol dependence syndrome, dementia, and depression. Patients with mania had the lowest F%. A similar trend was seen in values of FK + F + Fc %. Among normal subjects the A % reduced with age. Patients with mania, alcohol dependence syndrome and dementia obtained the highest A% (Table 4). Proportion of (H+ A): (Hd + Ad): it was seen that the detail responses are half as frequent as H+A or much less. This is the usual state of affairs and not to be interpreted except as an absence of a highly over critical attitude. Among normal subjects there was an increase in detail responses with age. Sum C in normal subjects gradually increased till 75-<85 years after which there was a slight decrease. Among patient groups a significantly higher sum C was obtained by patients with mania. The mean FLR was the same in age group up to 65-<75 years to age group 75-<85 years after which there was a slight fall. Interestingly, however F+% and F-% decreased steadily with age while F% increased with age. Among patients groups, patients with schizophrenia obtained significantly lower Table 4 : Mean (M) and range of Determinant score and Ratios of Determinants Charac- Normal subjects Psychiatric patients teristic Age Age Age Total Demen Alch Schiz Mania Depr Anx 65-<75 75-<85 ≥85 Depen Dis Mean (M) and range of determinant scores F 6.61 (0-22) 7.21(0-14) 9.11 (1-22) 7.02 (0-22) 5.92 (0-12) 6.13 (2-11) 6.06 (1-12) 10.6(5-23) 8.18 (0-20) 7.07(4-21) M 0.94 (0-7) 0.94 (0-5) 1.41 (0-5) 0.98 (0-7) 1.17 (0-8) 1.0 (0-2) 0.81 (0-3) 0.4 (0-2) 0.43 (0-4) 1.0 (0-4) FM 3.59 (0-11) 3.80 (0-9) 3.37 (0-10) 3.63 (0-11) 2.85 (0-7) 3.25 (1-5) 1.63 (0-5) 4.4 (3-6) 2.33 (1-4) 2.47 (0-4) m 0.03 (0-2) 0.04 (0-1) 0 (0-0) 0.03 (0-2) 0.03(0-1) 0(0) 0(0) 0(0) 0.04 (0-1) 0(0) Fk 0.029 (0-1) 0.04 (0-1) 0.037 (0-1) 0.03 (0-1) 0.06 (0-1) 0(0) 0.06 (0-1) 0(0) 0.06 (0-2) 0(0) FK 0.65 (0-8) 0.52 (0-6) 0.33 (0-2) 0.58 (0-8) 0.56 (0-6) 0.5 (0-1) 0.56 (0-5) 0.6 (0-1) 0.35 (0-3) 0.47 (0-2) Fc 0.34 (0-3) 0.15 (0-1) 0.11 (0-1) 0.27 (0-3) 0.23 (0-3) 0.25 (0-2) 0.81 (0-3) 0.2 (0-1) 0.65 (0-6) 0.27 (0-1) C’ 0.18 (0-5) 0.05 (0-1) 0 (0-0) 0.12 (0-5) 0.12 (0-1) 0.13 (0-1) 0.13 (0-2) 0.0 (0-0) 0.08 (0-1) 0.00 (0-0) FC 0.99 (0-6) 1.42 (0-5) 1.67 (0-4) 1.18 (0-6) 0.67 (0-3) 0.75 (0-2) 0.63 (0-4) 1.1 (0-2) 0.61 (0-3) 0.4 (0-3) CF 0.6 (0-6) 1.01 (0-7) 1.0 (0-3) 0.84 (0-7) 0.33 (0-4) 0.88 (0-3) 0.31 (0-2) 2.1 (0-3) 0.38 (0-4) 0.27 (0-1) C 0.02(0-2) 0(0-0) 0(0-0) 0.01 (0-2) 0.06 (0-1) 0 (0-0) 0.06 (0-1) 0.2 (0-1) 0 (0-0) 0 (0-0) Ratios of determinants F% 45.01 46.71 49.75 45.95 48.62 49.12 56.18 40.49 46.74 58.24 FK+ F + Fc% 52.74 50.96 49.38 51.91 54.75 54.84 67.75 44.66 53.01 65.27 A% 57.69 55.70 46.25 56.02 59.05 61.86 40.27 69.08 55.48 53.96 H+A: Hd +Ad 9.32: 0.44 9.78:0.72 9.89:1.6 9.51: 0.64 8.27: 0.61 9.38: 0.25 4.94: 0.94 15.2: 0.6 7.84: 0.43 8.20: 0.13 Sum C 1.20 1.72 1.91 1.47 0.79 1.25 0.69 1.92 0.53 0.47 M : Sum C 0.94: 1.20 0.94:1.72 1.41:1.91 0.98: 1.47 1.17: 0.76 1: 1.25 0.81: 0.69 0.89: 1.92 1.25: 0.53 1.0: 0.47 FM+m: Fc +c+ C’ 3.60:0.57 3.84:0.21 3.37:0.11 3.65: 0.42 2.88: 0.38 3.25: 0.38 1.63: 0.75 1.14: 0.45 3.57: 0.73 2.47: 0.27 Response to VIII, IX & X% 37.12 39.36 37.48 37.80 33.50 35.30 27.64 40.72 33.00 32.50 W:M 5.62: 0.94 6.44:0.94 6.44:1.41 5.94: 0.98 4.83: 1.17 5.25: 1 3.75: 0.81 6.4:0.04 5.37: 1.25 6.53: 1.33 M:FM 0.94:3.59 0.94:3.80 1.41:3.37 0.98: 3.63 1.17: 2.85 1: 3.25 0.81: 1.63 0.4: 4.4 1.25: 3.53 1: 2.47 M: FM+m 0.94: 3.62 0.94:3.84 1.41:3.37 0.98: 3.66 1.17: 2.88 1: 3.25 0.81: 1.63 0.4: 4.4 1.25: 3.53 1: 2.47 FK + Fc / F 0.24 0.09 0.16 0.19 0.13 0.20 0.34 0.09 0.22 0.14 Achromatic: Chromatic 0.5: 1.67 0.3: 2.63 0.11:2.67 0.4: 2.04 0.42: 1.08 0.38: 1.63 1.13: 1.09 0.2: 3.4 0.49: 0.96 0.27: 0.67 Differentiated: Undifferentiated 0.9: 0.03 0.6: 0.00 0.4: 0.00 0.8: 0.02 0.9: 0.03 0.9: 0.00 1.4: 0.00 0.8: 0.00 1.1: 0.00 0.6: 0.00 FC: CF + C 0.99:0.66 1.4: 1.01 1.67:1.0 1.2: 0.87 0.7: 0.41 0.8: 0.88 0.5: 0.38 1.1: 2.3 0.6: 0.37 0.4: 0.27 FLR 0.83 0.83 0.80 0.83 0.65 0.74 0.55 0.85 0.82 0.75 F + % 58.57 51.90 46.55 55.39 45.35 51.88 34.46 46.71 50.93 52.38 F % 40.83 48.10 53.82 44.20 46.59 45.73 46.75 51.20 48.81 47.20 F- % 0.65 0.00 0.00 0.40 8.06 2.39 18.78 2.09 0.26 0.42 34 Chaudhury et al

FLR scores as compared to age and sex matched normal controls. More importantly the F-% of patients with schizophrenia, dementia alcohol dependence syndrome and mania were significantly more than matched normal controls. Table 5 indicates that among normal subjects there was a gradual increase of Human responses with age. Animal responses increased in 75-84 years and thereafter declined. Patients with mania gave highest Animal responses. Sex responses were very infrequent in normal older adults, and were absent in patient groups. Blood responses increased with age, but were seen only in dementia patients. Similarly Color naming was noted in normal subjects and also in dementia. Popular responses were less in normal subjects ≥85 years. Among patient groups patients with schizophrenia gave significantly lower popular responses. Of the popular responses of Klopfer et al (1954) only the following 6 were given by normal older Indians: Card I: W or cut off W: any creature with the body in the center D and wings at the sides. Card II: Cut off whole or D: Any animal or part of an animal of the dog, bear, bull, rhinoceros or elephant variety. Card III: Entire block area: two human figures in a bending position. Legs must be seen in side bottom D and figures in action. Card V: W or cut-off W: any winged creature with the body in the center D and the wings at the sides. Card VIII: Side D: Any kind of four-legged animal in any kind of motion. Card X: Outer blue D: Any many-legged animal, such as a spider, crab or octopus. Table 5 : Mean (M) and range of Content score Content Normal subjects Psychiatric patients Age Age Age Total Demen Alch Schiz Mania Depr Anx 65-<75 75-<85 ≥85 N=282 n=66 Depen N=16 n=5 n=50 Dis N=8 n=15 H 1.4(0-8) 1.69(0-6) 2.15(0-6) 1.56(0-8) 1.56 (0-10) 1.63 (0-3) 1.44 (0-5) 1.8 (0-3) 1.73 (0-10) 1.53 (0-4) Hd 0.29(0-3) 0.42(0-3) 0.93(0-9) 0.39 (0-9) 0.35 (0-5) 0.13 (0-1) 0.56 (0-6) 0.4 (0-1) 0.35 (0-2) 0.13 (0-1) A 7.98(0-25) 8.16(2-15) 7.67(1-25) 8 (0-25) 6.79 (0-14) 7.88 (3-12) 3.94 (0-8) 13.4 (9-26) 7.24 (2-14) 6.67 (0-10) Ad 0.14(0-3) 0.28(0-4) 0.78(0-8) 0.23(0-8) 0.24 (0-2) 0.13 (0-1) 0.31 (0-2) 0.4 (0-1) 0.18 (0-2) 0.07 (0-1) Aobj 0.09(0-2) 0.05(0-1) 0.07(0-1) 0.07(0-2) 0.09(0-2) 0.0 0.06(0-1) 0.0 0.06(0-1) 0.07(0-1) At 0.48(0-15) 0.38(0-4) 1.30(0-12) 0.53(0-15) 0.05(0-1) 0.0 0.88(0-2) 0.2(0-1) 0.02(0-1) 0.07(0-1) Sex 0.06(0-3) 0.05(0-2) 0.15(0-2) 0.07(0-3) 0.0 0.0 0.0 0.0 0.0 0.0 PI 1.4(0-7) 2.05(0-9) 1.52(0-7) 1.6 (0-9) 0.86(0-3) 1.75(0-1) 1.38(0-10) 1.22(0-3) 1.16(0-7) 0.33(0-2) N 0.71(0-7) 0.63(0-3) 0.52(0-2) 0.67(0-7) 0.73(0-6) 0.38(0-1) 0.44(0-4) 0.0 0.61(0-6) 0.6(0-2) Obj 1.05(0-6) 1.19(0-5) 1.56(0-4) 1.14(0-6) 0.8(0-10) 0.63(0-2) 1.38(0-7) 1(0-2) 1.14(0-10) 1.53(0-2) Bl 0.01(0-1) 0.04(0-1) 0.30(0-3) 0.04(0-3) 0.08(0-1) 0.0 0.0 0.0 0.02(0-1) 0.0 CI 0.05(0-2) 0.06(0-1) 0.0 0.05(0-2) 0.11(0-2) 0.13(0-1) 0.06(0-1) 0.0 0.07(0-1) 0.2(0-1) Arch 0.10(0-6) 0.16(0-6) 0.0 0.11(0-6) 0.20(0-3) 0.13(0-1) 0.25(0-4) 0.2(0-1) 0.14(0-2) 0.0 Art 0.21(0-4) 0.13(0-2) 0.03(0-1) 0.15(0-4) 0.17(0-3) 0.13(0-1) 0.0 0.2(0-1) 0.22(0-3) 0.73(0-3) AAt 0.02(0-1) 0.0 0.07(0-1) 0.02(0-1) 0.0 0.0 0.0 0.0 0.04(0-1) 0.0 Cn 0.03(0-2) 0.0 0.0 0.02(0-2) 0.06(0-2) 0.0 0.0 0.0 0.0 0.0 P 3.6 (0-7) 3.7(1-6) 3.0(1-6) 3.6 (0-7) 2.90(0-7) 3.6(2-6) 1.8(0-4) 4(2-6) 3.2(1-6) 3.0(1-6) O 0.02(0-2) 0.03(0-1) 0.30(0-3) 0.05 (0-3) 0.02(0-1) 0.0 0.0 0.0 0.12(0-1) 0.22(0-2) Rorschach in older Indians 35

Discussion: The Rorschach test is the most commonly used personality test in the clinical setting in India. However, despite its popularity and extensive use, the research output on the test in Indian older adults is very limited and we could not find a single Indian publication on the subject. Surveying the world literature it was found that apart from cultural differences, most of the studies on normal older adults are limited value due to small sample size. Another important shortcoming of all these studies was that they were all conducted at only one center and included subjects from that location. Thus it appears that, despite its limitations, this was the first Indian study of Rorschach in older Indians. Review of the literature revealed marked inter-cultural and intra-cultural differences on the various Rorschach indices. A study in Ivory Coast found a low mean number of responses and FH higher than M in normal as well as mentally ill subjects. These differences seemed to be related more to culture than to intellectual limitation or psychopathology (Trazo Grado, 1986). Similar findings have been reported earlier in the Spanish speaking countries viz Spain, Mexico and Panama (Exner & Weiner 1982) and also in Hispanic Americans (Kranau 1984). The sample of 442 subjects in the present study consisting of 282 normal older adults and 160 patients is the first study carried out so far in India, thus fulfilling a long felt need. Moreover, this is the first Indian multicentric study carried out at Bareilly, Gauhati, Cannanore, Meerut, Udhampur, Pune and Chandigarh. The demographic data show that the normal subjects sample can be considered to be representative of normal older Indians. The responses given by them can therefore be considered as the average response of normal older Indians. The Rorschach responses of the different groups of subjects are discussed in the following paragraphs. Productivity: Among normal older adults mean number of responses varied from a mean of 14.05 at 65 - <75 years, 15.36 at 75-<85 years and 17.04 at > 85 years showing an increase in productivity with age . This trend is in agreement with the findings of Ames et al (1995) but who reported much higher productivity of responses ranging from 9 to 61 with a mean of 25.9. The maximum response of our sample (32) is equal to the 75th percentile of Ames study (1995). As in normal Indian adults, the normal older Indian shows a lower productivity as compared to his western counterpart. The significantly higher productivity in Mania (mean R = 19.6) and significantly lower productivity in schizophrenia (mean R=11), dementia (mean R = 12.28) and anxiety disorders patients (mean R = 11.93) is in agreement with Rorschach (1998), Bohm (1996), and Exner (2002). Reaction time: The average reaction time of the normal subjects increased with age. This finding is in agreement with Ames et al (1995). Patients with mania had significantly less reaction time as compared to matched control subjects, while patients with depression, anxiety disorders, dementia, alcohol dependence syndrome and schizophrenia had significantly increased reaction time indicating slow mental process. The finding is consistent with Klopfer & Davidson (1962) and Bohm (1996). The difference between the average reaction time for chromatic cards and achromatic cards was within normal limits in all the groups. According to Klopfer et al (1954) a difference of more than 10 seconds is an indicator of disturbances arising out of emotional impact. Rejection of Cards: Rejection of cards is not uncommon even among normal individuals. However, it is common experience that some cards tend to evoke less number of responses and these cards may be rejected more frequently. Klopfer et al (1954) states that card IX is most frequently rejected and that rejection of cards II, IV, & VI also may not be significant. This was generally true in our normal subject sample. The percentage of refusal in the normal sample showed varying trends with age. As opposed to this Ames et al (1995) reported that the number of refusals increased with age. Among patient groups manic did not reject any card. Patients with depression and dementia rejected maximum cards followed by patients with schizophrenia, anxiety disorders and alcohol dependence syndrome 36 Chaudhury et al

in that order. This is in agreement with Klopfer et al (1954) Bohm (1996). However, in general it may be stated that normal older Indians reject more cards as compared to their Western counterparts. Location: Location of responses: The areas that a subject chooses for interpretation provide some measures for evaluating his perceptive process. His choices gave us some insight into his method of attacking a situation. Whole (W) response: Classically the W responses has been viewed a reflecting the subjects ability (and wish) to “ see life whole”. W response has been considered an index of organizing ability. Such responses demand intellectual activity of a higher order. The developmental evidence on this interpretation, however, might be an embarrassment, since mean W% is lowest at the earliest age and it increases with age. This trend is in agreement with Ames et al (1995). The reason for this is the preponderance of poor quality W responses at older age groups. Similarly patients with mania, anxiety disorders, depression and alcohol dependence syndrome also produce large number of W responses. The poor quality W responses are essentially regressive responses (Ames et al 1995). Large usual detail (D) response: D% in the normal adult record is expected to full between 50% and 70%. The mean D% in the normal subjects ranged from 54 % at 65-<75 years, decreasing to 48.63% at 75-<85 years and then increasing to 50.23% at > 85 years. The D% thus falls within the expected adult range. These findings are in agreement with Ames et al (1995). Small usual detail (d) response: In normal older adults the d response had a similar pattern as the D response, which is in agreement with Ames et al (1995). Unusual detail (Dd) response: In the normal adult Rorschach record an average of about 10% Dd response is expected. In the present study normal older adults obtained lower scores especially in the age group 65-< 75 years. The finding is contrary to the findings of Ames et al (1995). White space (S) response: The S response indicates oppositional traits (Rorschach 1998) and is expected to be more in psychiatric patients (Margot et al 1992). In agreement with this normal subjects gave very few S responses. However, higher scores were observed in patients with schizophrenia, mania and depression. Confabulatory whole (DW) response: Patients with schizophrenia and dementia, as expected, gave confabulatory responses. However, it was also seen in few normal older adults. This is in agreement with Ames et al (1995). Confabulatory responses are pathological in nature and are characteristics of schizophrenia (Rorschach, 1998, Klopfer et al 1954, Bohm 1996) but may rarely also occur in normal older adults. Determinants: Form (F) response: F responses are generally considered to reflect the degree of subject’s intellectual control. They give an indication of his intellectual ability and of his reasoning powers. It shows that in normal subjects F responses increases with increase in age. This is similar to the findings of Ames et al (1995). Though the F was within normal range for normal subjects, the values of F were much lower in older adults compared to the Western norms. Among patient high F responses were noted in mania indicating constriction of personality. Human movement (M) responses: M responses are an index to the richness of the inner life of the individual. In their quantity, they reflect the accessibility to the individual of his own inner workingshis fantasies, wishes, images and capacity to withstand environmental stress (Donahue & Tuber Rorschach in older Indians 37

1993). The average number of M responses in normal older adult Rorschach record is low and increased with age. The findings are congruent with those of Ames et al (1995). Moreover, the scores of normal older Indians are quantitatively lower than the Western norms. Animal movement (FM) response: Like M, FM responses represent the inner life of the individual, but at a more spontaneous, impulsive level. The images and impulses represented in a persons FM response come into awareness and are ordinarily recognized by the person as his own, but they play little role in planning or value formation. A Rorschach record deficient in FM usually suggests an individual lacking in spontaneity. On the other hand, an overloading of FM suggests ideational overimpulsiveness. Mean FM in normal subjects in the present study steadily increased from 65 - <75 years to 75-<85 years and then decreased in > 85 years groups. This is in agreement with Ames et al (1995). Among patient groups the low number of FM responses in schizophrenia and dementia patients is in agreement with earlier studies (Bohm, 1996). FM was high in mania. Psychologists commonly interpret a high FM as a sign of frustration and unsatisfied instinctual need. Much importance, however, cannot be assigned to this interpretation because as per Klopfer et al (1954) the FM ratio cannot be interpreted unless there are more than 3 M responses. In the present study M was not usually sufficiently large to satisfy this condition. Inanimate movement (m) response: m responses represent fantasies and partial identification. They denote inner tensions. Inanimate movement responses occurred infrequently in all the age groups. This finding is similar to those of Ames et al (1995) though quantitatively less. Shading responses: Shading responses give an indication of the subject’s emotional and intellectual sensitivity, his ability for empathy and the degree of concern with adapting to others and to the environment. Through them we have some insight concerning the anxieties of the individual (Weber et al, 1992). Shading responses in normal older adults are infrequent and gradually decrease with age. As expected among the patient groups schizophrenia and depression patients gave highest shading responses. Achromatic color (C’) responses: C responses are not frequent in normal older adults which is congruent with the findings of Ames et al (1995). Color responses: Color responses reflect the individual’s openness to stimulation from his surroundings, especially his social surroundings. Form- Color (FC) responses represent color most delayed and restrained by form. Their presence in a record suggests an affective adaptive ness. Color- Form (CF) responses suggest less delay and control, more impulsive, thoughtless, direct reactivity. In Pure Color (C) reactions the person behave (or experiences) as if his surroundings directed an onslaught on him. His reactions are likely to be non-adaptive, poorly integrated, highly “emotional“ looking but often representing quite shallow emotionality. In normal older adults the mean FC gradually increased with age, while the mean CF increased up to 75-<85 years and the decreased with age. On the other hand Pure C responses decreased up to 75- <85 years and were absent thereafter). This trend is in agreement with Ames et al (1995). Patients with depression gave very few color responses. This finding is in agreement with Klopfer et al (1954), and Bohm (1996). C responses can occur in two diverse clinical categories: on the one hand a childishly demanding, whining querulous ness and on the other hand, an aggressive destructiveness combined with attitude of hostility and surliness. Clinical experience suggests that depressed patients, whether neurotic or psychotic rarely produce C responses. On the other hand, patients with schizophrenia produce C responses most frequently. Individuals with history of “acting out” also gave C responses (Klopfer et al, 1954). In the present study we found that patients with depression, mania, anxiety disorders and 38 Chaudhury et al

alcohol dependence did not give any pure C responses. Not surprisingly C responses were frequently seen in schizophrenia and dementia. Form- Level Rating (FLR): FLR is the most important basis of the intellectual estimate. According to Klopfer et al (1954) the form level varies directly with the intellectual level. The highest form level obtained gives an indication of the level of capacity or potentiality. The “worst” responses indicate the extent and frequency with which the person loses his intellectual grip on reality and becomes incompetent in integrating the perception with the reality situation. The average form level indicates the level at which the intellectual resources are usually available- the habitual level of efficiency with which the person operates. In the present study the average FLR was seen to decrease with age in normal older adults. This trend is in agreement with Western norms but the FLR values are lower than the Western norm (Klopfer et al, 1954). Patients with schizophrenia and dementia gave the lower FLR indicating the low level at which the intellectual resources are available in these patients. F + %: Rorschach (1998) suggests an F+ % of 70 to 80 as indicative of “moderate” intelligence in adults. In older adults Ames (1995) reported similar findings. The findings of the present study with mean F + % of 58.57 at 65->75 years and 46.55 at > 85 years are similar, though quantitatively less. A number of investigations have observed that schizophrenia patients average a lower F + % than do normal subjects. Exner (2002) reports that the F+% is more sensitive than any other Rorschach factor in differentiating between these groups. In agreement with the above in present investigation schizophrenia patients obtained significantly less F+%. However, patients with dementia also obtained significantly lower F+%. On the other hand F+% was highest in patients with mania, while it was not significantly less in depression, anxiety disorders and alcohol dependence. The explanation for these findings is that in non-defective subjects F + % varies directly with manifest anxiety and inversely with the extent of psychotic disturbance. F-%: Two considerations suggest that an analysis of responses of inadequate form (F-%) may prove useful. First it has been observed that the F- responses of normal subjects characteristically deviate only slightly from the minimal requirements of F+ responses while, in contrast, the F- responses of schizophrenia patients are often grossly discrepant with this criteria. Secondly, the hypothesis is that the extent of perceptual distortion is related to the degree of behavioral disturbances. In agreement with the foregoing, in the present study in normal subjects F-% was highest in 65-< 75 years group but thereafter was absent. Among patients highest F-% was observed in schizophrenia. High F-% was also seen in dementia and alcohol dependence syndrome subjects. Ratios of Determinants: F%: A desirable F% is an adult record is generally considered to be 50% or below. According to Klopfer et al (1954), the control of any subject of more than average intelligence whose record contains more than 50% F can be called constrictive. Among presumably normal adult subjects any F% between 50-80% invariably corresponds to sign of inflexibility, or in clinical terms, constriction with compulsive elements. It further suggests that that F% of normal subjects was within Klopfer’s range of 20-50%, which is in agreement with the findings of Ames et al (1995). This is a healthy sign and indicates that the normal subjects have the ability to view the world in an impersonal way with controlled adjustment. This is confirmed by the FK+ F + Fc % which is not more than 70%. A higher figure indicates constrictions of personality (Klopfer et al, 1954). Among patient groups, F% was > 50% in schizophrenia and anxiety disorders indicating constriction of personality with compulsive elements in these subjects. However, none of the patients groups had FK+F + Fc % more than 70%. Sum C: Sum C was lower at 65-< 75 years and gradually increased with age till >75-<85 years after which there was a slight decrease. These findings are in agreement to those of Ames et al (1995). Rorschach in older Indians 39

However, the Sum C values are quantitatively lower and should not be interpreted as a sign of too little responsiveness to the influence from the environment, but are a cultural variant. Proportions relating to introversive- extratensive balance M : Sum C: When M responses outweigh the Sum C by 2:1 there is an introversive balance: whereas then Sum C outweighs M by 2:1 there is an extratensive balance. Something approaching a 1:1 ratio is perhaps most common, and seen in our normal group. Among patient groups introversive balance was seen in depression and anxiety disorders while extratensive balance occurred in mania. (FM + m) : (Fc + c + C’ ): FM + m responses indicate potential introversive tendencies while achromatic responses indicate potentially extratensive tendencies. If this ratio is in the same direction as M: Sum C it confirms and strengthens the impression given by the latter. If it is at variance with M: Sum C there are several hypothesis from which to choose: the subject is in a state of transition from introversion to extratension, and the second ratio indicates the direction in which the change is progressing. It might be that the ratio indicates the direction in which the person is retreating. Or it might indicate a persistent secondary orientation, which the person has been unable to realize. In any event a discrepancy in the direction of the ratio reflects a conflict in tendencies within the personality (Klopfer et al 1954). Among normal subjects in the present study the directions of the ratio was opposite in all age groups. Among patient groups the direction of the ratio was opposite in mania, but was in the same direction in the remaining groups. Percentage of responses to Cards VIII, IX & X: If less than 30% are given to the last 3 cards the hypotheses is that the individual is withdrawn from reactivity to emotional impact from the environment, either because he is confused or threatened and withdraws as a defense or because he has a longstanding mode of adjustment involving little emotional involvement. If more than 40% of the responses are given to the last 3 cards the hypothesis is that there is actual or potential responsiveness to the emotional implications of the environment. If the percentage of response to the last 3 cards go in the same direction as the other signs it would seem that the indicated direction of balance is of long standing (Klopfer et al 1954). In the present study the percentage of response to the last 3 cards was between 30-40 in all the normal subjects. It was above 40 in mania and less than 30 in schizophrenia. The above ratios taken together indicate that in normal subjects the extratensive balance and introversive balance are equal. Among patients introversive balance is present in depression and anxiety state while there is transition to introversive balance in schizophrenia. There is extratensive balance in mania. W : M - This ratio gives an indication of the extent to which the individual is able to mobilize his creative or productive energies to back up his intellectual interests and ambitions. When W is greater than twice M the level of aspiration is too high. In older adults at every age group W is greater than twice M. This is in conformity with Ames et al (1995). The same trend of W: M is observed in patient groups also. M : FM : When there are twice as many FM as M responses the individual is ruled by immediate needs for gratification rather than by long- range goals. This finding in our normal group is contrary to the findings of Ames et al (1995), and our earlier work on Indian adults (Chaudhury et al, 2006). This represents a cultural variation and is in agreement with the findings of Trazo Grado (1986). It must be mentioned here that an immature behavioral impulsivity cannot be inferred from M: FM ratio unless CF also exceeds FC, implying that the individual tends to act out his impulses without socialized restraints. Among patient groups, however, colour emphasis was seen only in mania and alcohol dependence syndrome indicating that these patients tend to act impulsively. 40 Chaudhury et al

Ratio of FK + Fc : F - This ratio is less than 0.25 in older adults and in all patient groups except those with schizophrenia. When the ratio is less than 0.25 it indicates denial, depression or undevelopment of the need for affection. This is believed to stern from rejection experiences serious enough to wrap personality development. Ratio of achromatic to chromatic responses: Achromatic < _ chromatic. When the chromatic responses exceed the achromatic responses by two to one or more, the individual tends to act out his emotions. This was seen in all our subjects except schizophrenia. This hypothesis applies particularly to cases where there is also a preponderance of (CF + C) over FC, as was seen in patients with mania. The explanation is that the individual feels little need for approval and affection, and is not held back by related anxieties, which might serve as a “ brake” for his strongly developed to emotional stimulation from the environment. Content: Human (H) figures: H responses were lowest at 65-<75 years and increased with age. This finding is in agreement with Ames et al (1995), but quantitatively lower. Patients with mania gave highest H responses while patients with schizophrenia gave least H responses. The human form was noted by Rorschach (1998) and identified by his followers as varying with health, maturity and intelligence. Its absence or low quantity in an otherwise intelligent individual is likely to indicate repression of this theme (Beck 1965). Ames et al (1995) proposed that those are less interested in the motivation of others tend to give low H responses. Indian older adults is general may be disinterested in the motivation of others. This appears to be a more plausible explanation than interpreting low H in terms of low intelligence. Animal (A) figures: The A% is low at 65-<75 years, and increases thereafter but does not show a definite age trend. This is consistent with Ames et al (1995), but at every age the A% is somewhat higher than Western norms and seems to be culturally determined (Trazo Gade, 1986). Anatomical (At) concepts: Anatomical concepts were infrequent in normal subjects and showed no definite age trend. These findings are consistent with Ames et al (1995). Increased At responses were seen in schizophrenia and mania. Sexual symbolism: Direct expression of sexual or reproduction activities were very few in all our subjects, which is in agreement with Ames et al (1995). Blood responses: Blood responses are indicative of uncontrolled affective reactions were only seen in few normal subjects and is in agreement with Klopfer (1954) and Ames et al (1995). In agreement with Rorschach (1998), Bohm (1996), and Klopfer et al (1954) significantly higher blood responses were seen in dementia and depression. Colour naming (Cn) responses: The person who names colours is overwhelmed by emotional impact and incapable of handling his reaction with integrated control. Cn responses were only seen in few normal subjects and reduced with age. However, patients with dementia gave higher Cn responses. The pathological nature of Cn was therefore, strongly supported and is in agreement with Rorschach (1998), Bohm (1996), Klopfer et al (1954) and Dubey (1982). Popular (P) responses: Popular responses were 3.6 and 3.7 at 65-<75 and 75-<85 respectively and tend to decrease thereafter with age. This is in agreement with Ames et al (1995). The fewer the popular responses the less able the person is to see the world in the same terms as other people do (Klopfer et al 1954). This was confirmed by the findings of few P’s in patients with schizophrenia, mania and dementia in present study. Rorschach in older Indians 41

Out of the ten responses designated as popular by Klopfer et al (1954) only six were given by normal older adults which are another reason for the low number of popular responses observed in normal subjects. The large majority of subjects saw the popular response on card V when the card was in the upright position. It is therefore felt that for Indian older adults the responses given with the card held is an inverted position should not be classified as popular. Disease Patterns: Dementia: Patients with dementia gave somewhat less responses and moderate rejections. Reaction time was extremely variable. W is slightly less. DW responses were high. Animal movement was reduced. Color responses were low. F+% and popular responses were low. Content deals largely with animals, human anatomy, plant, human details, object and color naming. These are in agreement with Klopfer & Davidson (1962) & Bohm (1996). Schizophrenia: While there is no single Rorschach picture typical of schizophrenia, there are a few signs, which tend to point to such a diagnosis. Patients with schizophrenia gave the least responses and moderate rejections. Reaction time was high. W is slightly less. DW responses were highest. Animal movement was markedly reduced. Colour responses were low. F+% and popular responses were lowest. Content deals largely with animals, human. Anatomy, plant, human details and object. However, sex, blood, fire, explosion, color naming was high. Contamination and perseveration were prominent. These are in agreement with Klopfer & Davidson (1962) & Bohm (1996) apart from W responses. Mania: Rorschach records of patients with mania vary considerably with the degree of excitement. The highest productivity, least reaction time and absence of rejections were seen. High F was seen. CF responses increased at the expense of FC. F+% and popular responses were markedly diminished. Content dealt with human, anatomy, animal, human details, animal details, plant and objects. These findings are in agreement with Bohm (1996). Depression: Productivity was reduced and reaction time was high. Maximum rejections were seen. Form and shading responses were high; movement responses intermediate; while all color responses and sum color greatly reduced. F+% was somewhat less than normal. Popular responses were increased. Content dealt with animals, anatomy, human, human details, animal details, plant and cloud. The variety of content was reduced. Apart from F+% and movement responses, these findings are in agreement with Rorschach (1998) & Bohm (1996). Anxiety disorders: Decreased productivity, with increased reaction time and rejection occurred. Whole responses increased at the expense of detail responses. Color responses were reduced. Popular responses decreased. Content usually dealt animals, anatomy, human, nature and object. Color shock and shading shock was seen. These findings are broadly in agreement with Bohm (1996). Piotrowski’s signs (Piotrowski, 1957) were not found to be very useful for the identification of organicity probably due to low productivity of the subjects. This finding is congruent with Chesrow et al (1949) but not with Ames (1995). Conclusions: From the above discussion it is obvious that there are important differences in the Rorschach protocols of normal older adults at different age levels as also patients with psychiatric disorders, though there are no pathognomonic sign of the various disorders. Given the heterogeneous nature of the various conditions under study, pathognomonic signs are unlikely. Apart from studying the personality characteristic of the individual subject, the Rorschach test can serve as an aid to clinical diagnosis, either alone or as a part of battery of 42 Chaudhury et al

psychiatric procedures. This is clearly supported by our study. One point that needs to be emphasized here is that just as the pathologist offers the opinion after knowing the clinical findings (and if required after examining the patient), the Rorschach test can be correctly interpreted only after correlating with the clinical details of the patient. A blind analysis is a stunt, which may or may not be successful; it has no place in clinical practice. References: Ames LB (1995). Rorschach responses in old age. 2nd ed. New York: Jason Aronson. Beck, S. J (1965) Psychological process in schizophrenic adaption. New York : Grune & Stratton. Bohm,E (1996) A text book in Rorschach test diagnosis. 7th ed. Berne: Hans Huber. Chaudhury,S. & Augustine M.(1990). Rorschach profile of normal army personnel. Medical Journal Armed Forces India 1990; 46: 263-266. Chaudhury, S., Augustine, M., Saldanha, D., Srivastava, K., Kundeyawala, S. M., Pawar, A. A. & Ryali, V.S.S.R. Norms of the Rorschach test for Indian subjects. Medical Journal Armed Forces India 2006: 62:153-160 Chesrow EJ, Wosika PH, and Reinitz AH. (1949). A psychometric evaluation of aged white males. Geriatrics, 4, 149-167. Dubey, B.L. (1982) A pragmatic view of the Rorschach InkblotTechnique. Agra : National Psychological Corporation. Exner, J.E (2002) The Rorschach. A comprehensive System. Vol- I. Basic Foundations. 4th Ed. New York: John Willey & Sons. Exner, J.E & Weiner, I.B (1982) The Rorschach. A Comprehensive System. Vol 3. Assessment of children & adolescents. New York: John Wiley & Sons. James J, Dana RH. (2004) Methodological Issues in Cross-Cultural and Multicultural Rorschach Research. J Pers Ass 82:189-208 Klopfer,B, Ainsworth,M, Klopfer,W, & Holt,R (1954) Developments in the Rorschach technique. 1. Technique and Theory. New York : World Book Company. Klopfer,B & Davidson, H (1962) The Rorschach Technique. New York: Harcourt. Kranau EJ (1984) Level of acculturation/biculturation and Rorschach protocols of Hispanic Americans and Anglo- Americans. Dissertation abstracts International. 44: 3200B. Margot H. Armsworth MW, Swank PR & Vincent KR (1992) Rorschach responses in traumatized children and adolescents. Journal of traumatic stress. 5: 119-129. Mishra RK, Kharkwal MK, Kilroy MA, Thapa K. (1996). Rorschach Test: Theory and Practice. New Delhi: Sage publications. Panek PE, Wagner EE, Kennedy-Zwergel K. (1983) A review of projective test findings with older adults. J Personality Ass. 47:562-582. Pershad D, Parekh S. (2001). A practical manual for the Rorschach test. Agra: HP Bhargava Book House. Piotrowski Z A (1957) Perceptanalysis. The Macmillan Company, New York. Rorschach H (1998) Psychodiagnostics. 10th ed. Berne : Hans Huber. Trazo-Grado, M T (1986) Identification of Rorschach indicators of psychopathology in the Ivory Coast. Dissertation abstracts International, 47 : 2636-8. Rorschach in older Indians 43

A Comparison of Somatic Inkblot Series-I Indices in Normal Children and Adults Rakesh Kumar and Amool R Singh Since birth, human beings progress through various stages of personality development. Accordingly inkblot variables should reflect changes in the quantum at different age levels. The present study was designed to demonstrate these changes empirically on Somatic Inkblot Series-I (SIS-I). The test was administered on 100 children and 100 adults. The results revealed significant differences on six out of nine variables: Movement, Typical, Atypical, Anatomy, Most Typical and Rejection of Images which confirmed the hypothesis. Inkblot techniques provide a unique opportunity to an individual to reveal one’s personality largely without such awareness. Because of this strength, inkblot techniques occupy special place in psycho diagnostic procedures. The data gathered through inkblots are analyzed both qualitatively and quantitatively to depict the personality and psychological functioning of the examinee. It can be administered on children from age 5 to older people. Irrespective of the attributes of an examinee, every inkblot has its own set of scoring variables. These variables correspond to one or the other aspects of human functioning. Since birth, human beings progress through various phases of the development of personality. The quantum of inkblot variables should reflect changes at different levels of personality development. Singh, Mishra and Mishra (1999) studied the effect of age and sex on the perception of total number of responses on SIS-II. They studied 480 subjects in four age groups of both the genders (n=60) – adolescents, adults, later adults and old age. They found significant differences in female groups only. Singh, Singh and Dubey (1999) also studied the effects of age and sex on SIS-II indices. Pandey, Tripathi and Tripathi (2001) investigated age related changes in SIS-II responses. Their sample consisted of 60 subjects in three age groups (n=20) - children, adolescents and adults. The comparisons of children and adults revealed significant differences on Human, Anatomical, Sex, Movement, Most Typical and Typical indices. None of the studies so far investigated age related changes on SIS-I. The present study is designed to fill the gap of earlier studies with an aim to demonstrate age related changes on SIS-I. Material and Method: The sample consisted of 100 normal children and 100 adults drawn from general population. The sample characteristics are displayed in table 1. Rakesh Kumar,Ph.D., Senior Clinical Psychologist, Institute of Mental Health and Hospital,Agra – 282002 Email: hypnoagra@gmail.com. Amool R Singh, Prof. & Head, Dept. of Clinical Psychology, RINPAS, Ranchi, INDIA. Email : sisamool@yahoo.com. Key Words: SIS-I, Inkblot Techniques, Projective Tests, SIS in Children Table 1 : Sample Characteristics Characteristics Children (n=100) Adults (n=100) Age Range 6-12 years 20-45 years Mean 8.78 33.68 S.D 1.27 4.56 Gender Male Female Education Primary Above Primary Domicile Rural Urban

SIS-I card form was individually administered on each subject. Nine scoring indices were found to be quantitatively comparable across the groups. The indices are – total number of responses, movement, typical, atypical, human, animal, anatomy, most typical and rejection of images. The scores on eight indices (except total number of responses) were transformed into percent scores taking total number of responses as denominator. Independent group t-tests were run on raw total scores and transformed percent scores of children and adults through SPSS 11.5. Results: Mean and S.D. of nine scoring indices are presented in table 2. The results of t-tests are depicted in table 3. Table 2 : Mean and S.D. on SIS-I Indices Indices Adults (n=100) Children (n=100) Mean S.D. Mean S.D. Total Number of Responses 40.01 12.64 37.24 11.06 Movement Responses 6.25 6.47 2.59 4.77 Typical Responses 72.54 13.81 61.45 16.07 Atypical Responses 15.95 13.74 32.37 15.33 Human Responses 18.53 7.99 17.91 12.31 Animal Responses 28.25 9.91 30.74 17.75 Anatomy Responses 17.12 8.55 13.40 12.87 Most Typical Responses 13.88 5.45 5.69 3.40 Image Rejection .28 .93 1.86 4.77 Table 3 : Results of t-tests Indices Value of t-tests Significance Level Total Number of Responses 1.64 n.s Movement Responses 4.55 .01 Typical Responses 5.23 .01 Atypical Responses 7.96 .01 Human Responses .423 n.s. Animal Responses 1.22 n.s. Anatomy Responses 2.40 .01 Most Typical Responses 12.73 .01 Image Rejection 3.23 .01 The values of t-tests are statistically significant on following six indices: movement, typical, atypical, anatomy, most typical and rejection of images. The inspection of mean scores of these significant indices revealed statistically lower scores for children on following indices – movement, typical, anatomy and most typical. The children scored significantly higher on atypical and rejection of images. Discussion: Total Number of Responses (R): The magnitude of R is not significant between children and adults. R is an indication of scored productivity on inkblot tests. It is simply total number of scorable associations of an examinee on all the images of an inkblot. R usually shows changes across psychopathological conditions. But in normal subjects at different age levels, R is not expected to show significant changes on SIS-I. Since SIS in Children 45

there are no previous studies on SIS-I, the results could not be compared. However, some approximate comparisons could be done with the studies on SIS-II. There is only one study of Pandey, Tripathi, and Tripathi (2001), which can serve the purpose of comparison. In this study, total number of responses was not included for statistical analysis across age groups. Movement (M): Movement responses are significantly higher in adults as compared to the movement responses of children. Rorschach (1942) suggested that M responses indicate the phenomena of “internalization”. The M responses reflect the ability of an examinee to handle more deliberate and sophisticated experience in a way that can be controlled emotionally. Beck (1944) stated that M responses indicate awareness towards the external world and reflect some conflicts or emotions, which do not get obvious expression in the world of reality. Werner (1948) developed a sensory tonic theory of motor activity to apply to the function of M responses in personality structure. Greater is the M; higher are the motor delays in expressions. In this context, M should be higher in adults as compared to the children. The significantly higher M in the adults of the index sample confirms the hypothesis. Pandey,et al (2001) also observed significantly higher M in adults on SIS-II. Human Responses (H): The human responses are not statistically significant across two age groups. Human responses indicate potentials for good relations. A low frequency of H responses is associated with delinquency (Ray, 1963). The high frequency of H responses is associated with compulsive behavior and indicates subjects’ preoccupation with interpersonal relationships (Klopfer et al. 1954). Every human being develops age appropriate human relationships. So H responses should not vary across the age groups in normal subjects. The results confirm the hypothesis. Pandey,et al (2001) observed significantly higher H responses in children on SIS-II. This is in contrast to the results of the present study. The differences in the results could be the outcome of small sample size used in their study. Typical Responses: The adults produced significantly higher typical responses as compared to the children. A typical response is scored when a particular response is commonly seen on a specific blot area or when the shape of the blot area resembles with the perceived object. Rorschach (1942) assigned typical responses a cornerstone position in his overall thinking about personality. He sets up four basic requisites (a) ability to centre attention making it possible a clear perception; (b) possession of clear mental pictures; (c) power to bring those clear memory pictures into consciousness; (d) ability to select from among the memory pictures, that resembles the stimulus most, a process that again depends on control of the perception and on critical interpretation. The processes involved in the production of typical responses obviously depend upon intellectual development, emotional states and cognitive functions in general. In this background, the matured individuals are expected to produce greater number of typical responses compared to the growing individuals. The result of the index study supports the hypothesis. Pandey,et.al. (2001) also observed the same findings on SIS-II. Animal Responses (A): There are no significant changes across groups on animal content. Animal score is scored when an examinee produces an animal or part of an animal as response to a blot area. The deviations from norm on this variable are usually observed in psychopathological conditions. The production of an animal association is not logically linked with age factor. So no significant differences are expected 46 Kumar & Singh

on this variable in two age groups. The results of the study are in expected direction. Pandey,et.al. (2001) also did not find significant difference on this variable of SIS-II. Anatomy Responses: The children produced significantly lesser anatomical content as compared to the adults. The somatic inkblot series has embedded anatomical structures in the images. Because of this, a preponderance of anatomical content is observed in the content category of the test. The cognitive representations of internal body organs are the functions of maturity, education and exposure. Since young children are still maturing and have less exposure to internal body organs, they are expected to produce lesser anatomical content on SIS. The results confirm the hypothesis. Pandey, et al. (2001) also observed significantly lower anatomical content in children on SIS-II. Most Typical Responses (Mt): MT responses are significantly lower in children as compared to the adults. MT responses are those responses, which are given by more than 75 bpercent subjects on a particular image (Dubey and Cassell, 1993). MT responses are indications of conformity to socio-cultural norms. The acquisition of societal norms is a maturity dependent phenomenon. As individual progresses towards maturity, he acquires these norms and tries to adhere to them. As such children are expected to produce lesser MT responses. The results of the index study confirm the hypothesis. Pandey,et.al. (2001) also found similar results on SIS-II. Rejection of Images: The children rejected significantly higher number of images than adults. Bohm (1958) stated that image rejection is the result of an inhibition or blocking of the flow of thoughts. It is also indication of shock phenomena. The quantum of image rejection in normal subjects is expected to be very low. The age as such does not exert any influence on image rejection. As such the rejections in both the groups are very low, however, the difference was found to be statistically significant. The finding is in contradiction to the expectation and the results of Pandey, et al. (2001). Conclusion: The results of the index study clearly demonstrated the power of SIS-I in tapping changes at different level of personality development strengthening the diagnostic value of the Somatic Inkblot Series. References: Beck, S.J. (1944) Rorschach’s Test vol I Basic process New York : Grune & Stratton. Bohm,E. (1958) A Text Book in Rorschach Test Diagnosis.(Tr. by A. Beck & S.J. Beck) New York: Grune & Stratton Dubey,B.L. and Cassell, W.A. (1993) Some experiences with Somatic Inkblot Series-II. British Journal of Projective Psychology, 38, 19-41. Klopfer, B., Ainsworth, M., Klopfer, W., and Halt, R. (1954) Development in the Rorschach technique vol.I Technique and theory. NewYork : Harcourt,Brace world. Pandey, R., Tripathi, V.R.M., and Tripathi, S. (2001). Age related changes in SIS-II response contents. SIS Journal of Projective Psychology & Mental Health, 8, 35-40. Ray Chaudhuri, M. (1963). Personality of the Indian Musicians. Rorschachiana Japonica, 6, 164-214. Rorschach, H. (1942) Psychodiagnostic, New York: Grune & Stratton. Singh, M.P., Mishra, M., and Mishra, N. (1999). Effect of age and sex on the lperception of total number of Inkblot Images. SIS Journal of Projective Psychology & Mental Health, 6(1): 52-54. Singh, M.P., Singh, A. and Dubey, B.L. (1999) Effect of age and sex on SIS-II responses. SIS Journal of Projective Psychology & Mental Health, 6(2): 51-76. Werner, H. (1948). Comparative psychology of Mental Development, Chicago: Follett. SIS in Children 47

Projective Techniques and the School-Based Assessment of Childhood Internalizing Disorders: A Critical Analysis David N. Miller and Amanda B. Nickerson School psychologists in the United States frequently conduct assessments of emotional and behavioral functioning of children and youth in schools, including the assessment of childhood internalizing disorders such as depression and anxiety. Although projective techniques have historically been and continue to be widely used by school psychologists for the assessment of childhood internalizing disorders and other emotional and behavioral problems, there have been frequent and increasing criticisms of their use. This article discusses various reliability and validity issues in the use of projective techniques with children and adolescents, with an emphasis on incremental and treatment validity, as well as problems associated with professional experience and clinical judgment. We conclude that projective techniques are typically not needed for the school-based assessment of childhood internalizing disorders, and that in most cases their combination does not reflect current best practices in school psychology. Recommendations are provided for using projective techniques with children and youth in schools sparingly, in specific circumstances, and within a problem-solving, databased framework. A primary role and function of school psychologists in the United States is to provide assessments of children and youth suspected of having emotional and/or behavioral problems (Merrell, Ervin, & Gimpel, 2006). A type of emotional and behavioral problem that is often misunderstood and frequently overlooked is internalizing disorders (Merrell, 2001). Childhood internalizing disorders refer to a class of disorders that are based on overcontrolled symptoms (Cicchetti & Toth, 1991). The term “overcontrolled” denotes that these problems occur when individuals “attempt to maintain too much or inappropriate control or regulation of their internal emotional and cognitive state – in other words, the way they think about the way they feel” (Merrell, 2001, p. 2). The term “internalizing” also indicates that these problems are developed, maintained, experienced, and exhibited largely within the individual (Merrell, 2001). Common examples of internalizing disorders include depression, anxiety, suicidal behavior, and social withdrawal. Childhood internalizing disorders are frequently underreported, largely because they are often difficult to observe directly, and as a result they have sometimes been described as a secret illness (Reynolds, 1992). Given the difficulty of identifying the presence of internalizing disorders through direct observation procedures, the use of projective techniques have been suggested as a viable and potentially useful method for assessing children and youth with suspected internalizing problems and/or disorders (Merrell, 2001; Stark, 1990). The purpose of this article is to discuss the use of projective techniques with children and youth in general, particularly as these assessments are conducted by school psychologists within public school settings, and more specifically for assessing children and youth with suspected internalizing problems. Before beginning this discussion, however, it is first necessary to provide a context for school-based social/emotional assessment in the U.S, and the role of the school psychologist in this process. Social-Emotional Assessment Practices of School Psychologists in the U.S: A central component of contemporary school psychology training and practice in the United Sates is data-based decision making and accountability (Ysseldyke et al., 2006). Current research indicates that assessment of social, emotional, and behavioral problems in children and youth is best accomplished when assessments are comprehensive, reliable, and valid, and when information is gathered from multiple measures and multiple informants (e.g., parents, teachers, students) across different settings (McConaughy & Ritter, 2002; Merrell, 2003). Moreover, assessments should be David N. Miller, Ph.D. University at Albany, State University of New York, ED 240, Albany, NY 12222. E-mail: dmiller@uamail.albany.edu and Amanda B. Nickerson, Ph.D. University at Albany, State University of New York. Key Word : Projective techniques, Childhood Internalizing Disorders.

directly linked to the development of evidence-based interventions (Ysseldyke et al.). As such, research suggests that a behavioral assessment framework may be most appropriate when assessing children and youth with emotional and/or behavioral problems (Mash & Terdal, 1997), particularly in schools (Shapiro & Kratochwill, 2000). Behavioral assessment methods (e.g., interviews, observations, informant-report measures) are generally viewed by school psychologists in the U.S. as more useful (Cheramie, Griffin, & Morgan, 2000) and acceptable (Eckert, Hintze, & Shapiro, 1997) than projective techniques for assessing students with suspected emotional and/or behavioral problems. In recent comprehensive literature reviews providing guidelines for the evidence-based assessment of childhood internalizing disorders such as depression (Klein, Dougherty, & Olino, 2005), anxiety (Silverman & Ollendick, 2005), and pediatric bipolar disorder (Youngstrom, Findling, Youngstrom, & Calabrese, 2005), none contained recommendations to use projective techniques. However, projective techniques continue to be widely used with this population in U.S. schools (Hosp & Reschly, 2002; Shapiro & Heick, 2004; Wilson & Reschly, 1996) as well as with individuals in other countries (Piotrowski, Keller, & Ogawa, 1993), and continue to be viewed as important in the assessment process (Kennedy, Faust, Willis, & Piotrowski, 1994). For example, results from a recent national survey indicated that school psychologists in the U.S. frequently use projective techniques with children and adolescents for a variety of purposes, including special education eligibility determination and intervention development (Hojnoski, Morrison, Brown, & Matthews, 2006). Despite their wide use in schools, projective techniques have been criticized throughout much of their history (Dawes, 1994; Lilienfield, Wood, & Garb, 2000). Their use with children and adolescents remains highly controversial (Merrell, 2003), with several researchers promoting the use of projective techniques with children and adolescents (e.g., Bardos, 1993; Chandler, 2003; Naglieri, 1993; Yalof, Abraham, Domingos, & Socket, 2001) and others criticizing them (e.g., Batsche & Peterson, 1983; Gittelman-Klein, 1986; Merrell et al., 2006; Motta, Little, & Tobin, 1993). Much of the criticism of projective techniques has focused on their psychometric properties (Merrell, 2003). In particular, projective techniques have been criticized for their questionable degree of reliability (e.g., test-retest reliability) and validity (e.g., construct validity), as well as their frequently inadequate norms (Knoff, 2003; Salvia & Ysseldyke, 2001). These issues, as well as the recent emphasis on evidence-based assessment practices in child and adolescent psychology (Mash & Hunsley, 2005) and the threat of legal sanction arising from decisions based on the use of questionable assessment tools (Kerr & Nelson, 2002), have led to an increased call for restricting the use of projective techniques with children and youth, particularly in American schools (Knoff, 2003; Merrell et al., 2006). A central criticism of the use of projective techniques is ultimately related to the validity of the projective hypothesis in general, and with children and youth in particular (Chandler, 2003). This issue has been discussed in many sources (e.g., Chandler, 2003; Lillienfield et al., 2000; Merrell, 2003) and it is not the focus of this article. Instead, our purpose is to review research on various reliability and validity issues in the use of projective techniques with children and adolescents, and the implications of these issues for school psychologists conducting assessments with children and youth with suspected internalizing disorders. Reliability and Validity Issues in the Use of Projective Techniques with Children and Adolescents: As with adults, a variety of projective techniques have been used with children and adolescents, including the Rorschach (Allen & Hollifield, 2003; Ornberg & Zalewski, 1994), human figure and kinetic family drawings (Knoff, 2003; Knoff & Prout, 1985), the Bender-Gestalt Test (Koppitz, 1975; Childhood Internalizing Disorders 49

Tolor & Brannigan, 1980), the Hand Test (Sivec & Hilsenroth, 1994; Wagner, 1986), sentence-completion techniques (Holt, 1980; Zlotogorski & Wiggs, 1986), and thematic storytelling techniques such as the Thematic Apperception Test, the Children’s Apperception Test, and the Roberts Apperception Test for Children (Dupree & Prevatt, 2003; Teglasi, 2001). The continuous developmental changes of children and adolescents, including variations in cognitive development, abstract thought, and language acquisition, may affect the reliability and validity of projective techniques (Chandler, 2003). Moreover, the use of projective techniques with children and adolescents has been criticized for several reasons, including the vagueness or difficulty in defining particular constructs projective techniques are purported to assess (Merrell, 2003), possibilities of illusory correlations between assessment responses and child behavior (i.e., the relationship between test responses and symptoms/ behaviors that are based on verbal associations rather than valid observations; Gresham, 1993), the subjective nature of evaluating responses (Hall, 2004), the potential for cultural bias when making projective interpretations (Paniagua, 1998), and the impossibility of disconfirmation given that one can never “prove” the null hypothesis (e.g., one cannot “prove” that small human figure drawings are not indicative of a low self-concept; Gresham, 1993). There have also been few innovations in the area of projective techniques during the last few decades, whereas numerous advances have been made in objective child and adolescent personality assessment, particularly in the area of empiricallybased multiaxial assessment techniques (Merrell, 2003). Although some individuals have suggested that projective techniques are not tests and therefore should not be subjected to the constraints normally applied to psychometric instruments (e.g., Schwartz & Lazar, 1979), it is clear that “Certain basic questions may legitimately be asked of any assessment method: Does it do what it purports to do, and does it do so with consistency?” (Chandler, 2003, p. 55). A number of researchers examining the psychometric properties of projective techniques with children and adolescents have concluded that they have questionable or even poor levels of reliability and validity, particularly as diagnostic instruments or for predicting behavior (e.g., Gittelman-Klein, 1978, 1986; Knoff, 2002, 2003; Merrell, 2003; Merrell et al., 2006). In response to this criticism, some proponents of projective techniques have suggested that their real value lies not in assisting with diagnostic decision-making or prediction, but rather in their utility for helping clinicians to better understand and describe the individual being assessed (e.g., Lerner, 2000). This perspective, however, has been challenged by individuals such as Knoff (2003), who contend that there has been too much emphasis in projective assessment on “understanding” particular problems and too little emphasis on moving from this understanding to problem analysis and intervention. In any discussion regarding aspects of assessment validity, it is worthwhile to emphasize that an assessment method can only be valid to a particular degree and for a particular purpose. These purposes may include the description of personality, to diagnose or classify, to give a prognosis or make a prediction, to identify therapeutic needs, to provide treatment goals, and/or to select and monitor appropriate interventions (Meyer et al., 2001; Nelson-Gray, 2003). To date, however, projective techniques have not convincingly demonstrated that they are valid for any of these purposes within the context of the school-based assessment of childhood internalizing disorders (Merrell, 2001). In addition to the validity issues previously described, there are two other aspects of validity that have important implications for the projective assessment of children and youth, and these are described below. Incremental and Treatment Validity: The use of projective techniques with children and adolescents has recently been criticized due to their lack of incremental and treatment validity (Miller & Nickerson, 2006). Incremental validity, which refers to the extent to which an assessment method contributes to the understanding of an individual 50 Miller & Nickerson

beyond that which is already known, as well as the degree to which it can provide information that cannot be gained in some other, easier way (Hunsley & Meyer, 2003), is particularly important, given that there are a number of other assessment procedures (e.g., direct observations of behavior; broadband and narrow-band behavior rating scales; structured diagnostic interviews) that have demonstrated clear utility for diagnostic and predictive purposes in the assessment of childhood internalizing disorders and other behavior problems, as well as for suggesting treatment goals (Shapiro & Kratochwill, 2000). Despite the importance of this issue, there has been little research focused on the incremental validity of projective techniques, either with children, adolescents, or adults (for a more comprehensive review of this issue, see Miller and Nickerson, 2006). The few studies that do exist have dealt primarily with adults and uniformly concluded that the evidence for incremental validity of projective techniques for identifying both causal variables and problem behaviors is weak (Garb, 2003; Garb, Lilienfield, Scott, & Wood, 2004; Lilienfield, Wood, & Garb, 2000). For example, Garb (2003) indicated that greater incremental validity was found for interviews, objective personality inventories, and self-report measures than for widely used projective techniques. Similarly, in a comprehensive review of the scientific status of projective techniques, Lilienfield et al. (2000) concluded that, “with a few exceptions, projective indexes have not consistently demonstrated incremental validity above and beyond other psychometric data” (p. 27). The authors found only two articles that examined incremental validity of projective techniques with children and adolescents, and neither found evidence of incremental validity when used with children and youth for diagnostic purposes (Gittelman-Klein, 1987; Hartman, 1972). One study did conclude that projective techniques were at least as valid as other measures (e.g., self-report and behavior rating scales) in predicting adolescent aggressive behavior (Graybill & Blackwood, 1996). However, the study was methodologically flawed since it only used select items from the teacher rating scale, comprimising the validity of the measure. Although it has been suggested that projective techniques may be useful for predicting overt or acting-out behavior (Wagner, 1986), there is little empirical support for this belief. For example, Gresham (1993) describes a situation in which a student with aggressive behavior is referred to the school psychologist. The psychologist asks the student to complete a human figure drawing, and the student’s drawing displays long arms and big hands (often considered indicative of acting-out behavior from a projective perspective). The drawing is then interpreted to confirm that the child exhibits aggressive tendencies. The problem, of course, is that this information is superfluous and does not provide any additional information to what was obtained through direct observation (that is, the human figure drawing did not contribute to incremental validity). Further, “Using a high-inference procedure to validate a low-inference behavioral event is logically and scientifically unjustified” (Gresham, 1993, p. 184). In the context of the assessment of childhood internalizing disorders, in which the problems of concern may not be directly observable, there is a similar lack of empirical evidence demonstrating the incremental validity of projective techniques for diagnostic or predictive purposes (Merrell, 2003). It has been argued that projective techniques possess incremental validity in the sense that they assess unconscious aspects of behavior that cannot be assessed via other, more objective personality assessment measures (Chandler, 2003). This contention, however, assumes that unconscious processes have a significant and causal impact on behavior. Although this viewpoint has been supported by some researchers (e.g., Westen, 1998), others have not found this evidence compelling (e.g., Mash & Terdal, 1997; Shapiro & Kratochwill, 2000). Moreover, it does not appear to be a view that is widely accepted among contemporary school psychologists in the U.S, given that many are increasingly adopting more behaviorally-oriented assessment techniques (Shapiro & Heick, 2004). Childhood Internalizing Disorders 51

An important aspect of incremental validity is whether information can be gathered in other, easier ways. Many projective techniques require a great deal of training to score and interpret. For example, although research suggests that the Rorschach may be a valid instrument for assessing adolescent thought disorders (Ornberg & Zalewski, 1994), other assessment methods (e.g., structured diagnostic interviews) provide equally valid assessments (Wood, Nezworski, & Garb, 2003) while having the additional advantage of frequently being quicker and easier to score and interpret. Further, given the relative rarity of schizophrenia and other thought disorders in children and youth, the practical utility of using the Rorschach in schools for this purpose is highly questionable (Miller & Nickerson, 2006). Given the existing evidence indicating that projective techniques have problematic incremental validity, it is incumbent upon proponents of these techniques to empirically and convincingly demonstrate that (a) the use of them adds necessary and useful information in assessing children and adolescents; and (b) this information cannot be gained in any other way. To date, however, neither of these goals has been realized (Miller & Nickerson, 2006). An additional criticism of projective techniques with children and youth is their lack of treatment validity. Treatment validity (also known as treatment utility) refers to “the degree to which assessment is shown to contribute to beneficial treatment outcome” (Hayes, Nelson, & Jarrett, 1987, p. 963). There are case examples describing how projective techniques could potentially be used to suggest specific treatments in the professional literature, though these cases are typically anecdotal, descriptive, non-experimental, and are often focused on adults rather than children or adolescents (e.g. Dubey & Cassell, 2000; Ruskowksi & Miller, 2006). Empirical evidence demonstrating the treatment utility of projective techniques with children and adolescents is lacking. A PsycINFO computer literature search conducted by the authors containing the words “treatment validity” and a variety of descriptors (e.g., “projective techniques,” “projective tests”, “apperception tests,” “Rorschach,” “figure drawings,” etc.) yielded no published articles in any peer-reviewed journals for children, adolescents, or adults. It should be noted that lack of treatment utility in child/adolescent personality assessment is not restricted to projective techniques; many objective child and adolescent personality assessment methods and procedures also lack treatment validity (Braden & Kratochwill, 1997; Kratochwill & McGivern, 1996). However, given that projective techniques frequently exhibit questionable or poor degrees of other forms of reliability and validity – a situation which is typically not the case with many objective personality assessment methods – their lack of treatment validity provides additional support for individuals criticizing their use with child and adolescent populations. Further, there are other assessment methods which have demonstrated treatment validity, such as functional behavioral assessment (Gresham, Watson, & Skinner, 2001). Although this assessment methodology was developed primarily in the context of assessing and treating disruptive behavior problems, particularly individuals with developmental disabilities (Iwata, Dorsey, Slifer, Bauman, & Richman, 1994), it may potentially be useful in the assessment of child and adolescent internalizing disorders, particularly in the areas of self-mutilation/self-injury (Miller & DeZolt, 2004) and school phobia/refusal (Kearney, 2001). Professional Judgment and Clinical Experience: A final criticism of projective techniques with children and youth relates to the issues of professional judgment and clinical experience. For example, because many of the projective techniques used by school psychologists do not have formal scoring systems (e.g., TAT; CAT) or are often scored by “personalized” rather than standardized scoring systems (Kennedy et al., 1994), it is likely that many school psychologists rely on their own clinical experience and professional judgment when interpreting them. Results from several studies, however, have indicated that practitioners are frequently unable to discriminate clinically unremarkable from clinically identified populations beyond a chance level when 52 Miller & Nickerson

interpreting children’s projective drawings (Cummings, 1986; Knoff, 2003). Research examining professional judgment in the context of other projective techniques has found similar results (Lilienfield et al., 2000). Although the suggestion that projective techniques can be used validly and effectively if they are employed by individuals with extensive clinical experience and skill is common among advocates of projective techniques (e.g., Lerner, 2000; Wagner, 1986), there is no empirical evidence for this assertion. Instead, research suggests that school and other applied psychologists frequently make a variety of cognitive errors in conducting assessments, including asking the wrong questions or engaging in fundamental attribution or information processing errors (Macmann & Barnett, 1999). A school psychologist’s overconfidence in his or her own judgment and clinical experience can also be problematic. There is now compelling evidence that, without clear decision rules, exercising clinical judgment typically leads to great variability in decision outcomes. Although training and experience may enable clinicians to develop more confidence in their diagnostic skills, research suggests this increased confidence does not improve the accuracy of their decisions. In fact, negative correlations between professional confidence and diagnostic accuracy have been found (Macmann & Barnett, 1999). Moreover, research suggests that psychologists are frequently overconfident in the accuracy of their clinical intuition (Myers, 2002), judgment (Meyer et al., 2001), and skill (Dawes, 1994; Garb, 1989). In fairness, it should be noted that there are some highly skilled and experienced psychologists who have stunned statisticians with their clinical acumen in interpreting projective techniques (Kaplan & Saccuzzo, 1997). However, these experts are often difficult to accurately identify (Miller & Nickerson, 2006), they frequently have difficulty teaching clinical skills to others (Butcher et al., 2007), and the processes by which they make clinical decisions have not been adequately examined (Miller & Nickerson, 2006). Projective Techniques and the School-Based Assessment of Childhood Internalizing Disorders: Implications for Practice: Given the lack of reliability and validity of projective techniques with children and youth, including lack of evidence for incremental and treatment validity, we conclude that projective techniques are not needed in most cases for the school-based assessment of internalizing disorders in children and adolescents. Other assessment methods are available for purposes of diagnosis, classification, and the identification of treatment goals (e.g., broad- and narrow-band behavior rating scales; structured diagnostic interviews; direct observations), and these methods are generally more reliable, valid, and easier to interpret without placing undue reliance on clinical judgment. There are, however, some unique situations in which projective techniques may be useful when assessing children and youth suspected of having internalizing disorders, including for purposes of establishing rapport (Merrell et al., 2006), developing an understanding of a child’s own world view and personal perspective (Merrell, 2003), and for generating hypotheses (Knoff, 2003). For example, when establishing rapport with a reticent child or adolescent who does not respond well to typical open-ended or close-ended interview questions, it may be helpful to provide sentence stems or request a kinetic family drawing. Rather than interpreting responses from a traditional projective perspective, information provided through sentence completion tasks should be used to generate hypotheses and identify themes for further questioning. Similarly, the kinetic family drawing (KFD) can be an effective way to assess a child’s perceptions of his or her family (McConaughy, 2005) and as a useful starting point for asking relevant questions in a clinical interview. Stark (1990) has also described how certain projective techniques may be useful with children who may be depressed but are resistant to directly revealing what they are thinking and/or feeling. He recommends that the content of the projective stimulus should be chosen based on the information sought. For example, if the assessor is concerned about the child’s thoughts in social situations, the Childhood Internalizing Disorders 53

assessor might choose a card from an apperception test (e.g., Roberts Apperception Test for Children; Thematic Apperception Test), or a picture from a book or magazine that would most likely elicit a useful response. The stimulus would then be used to elicit questions about what the figures in the picture might be thinking and/or feeling. Further probing can then be conducted to gain a better understanding of what the child believes is happening in the picture, what happened before, what will happen next, as well as anything else that might help clarify the child’s thoughts in such situations (Stark, 1990). Pictures can be useful in this process, as well as incomplete sentences, play, and figure drawings. In each case, however, children’s responses are interpreted as reflecting their own thinking patterns, and there is no attempt to interpret responses as representative of underlying processes (Stark, 1990). If and when projective techniques are used with children and adolescents, like any other assessment technique they should never be used in isolation. Rather, they should be used as only one component of a comprehensive, multi-dimensional, multi-method assessment (Meyer et al., 2001). Further, projective techniques should never be used as the primary data source in the assessment of children’s socialemotional-behavioral functioning or to make diagnostic or classification decisions (Merrell, 2003; Prout & Ferber, 1988). Projective techniques also should be used to generate hypotheses about children rather than to confirm them (Knoff, 2003). Such hypotheses can then be supported, modified, or even discarded based on the results from other assessment procedures that possess greater validity. It is also recommended that a very low level of inference be employed by school psychologists using projective techniques, and that psychologists consider conducting interpretations of student responses from a cognitive-behavioral framework. Although projective techniques have traditionally been interpreted from a psychodynamic or psychoanalytic orientation, the techniques themselves are essentially atheoretical (Prout & Ferber, 1988). For examples of using a cognitive-behavioral framework in the interpretation of a variety of projective techniques, see Knoff (2003), Prout and Ferber (1988), and Stark (1990). Conclusion: Over 20 years ago, Batsche and Peterson (1983) suggested that there was “a growing incompatibility” (p. 440) between projective assessment and school psychology. In the years since that time, this level of incompatibility appears to have widened. Despite the frequent use of projective techniques by school psychologists with children and adolescents, including those suspected of having internalizing disorders, the continued use of these techniques appears inconsistent with current best practices in school psychological assessment. Although some unique circumstances in which projective techniques might be useful were identified (e.g., establishing rapport; generating hypotheses), at the present time projective techniques for children and adolescents have not demonstrated a substantial degree of either reliability or validity, and there appears to be substantial problems associated with individuals who emphasize clinical experience and professional judgment in their interpretation. In his review of the empirical evidence of projective techniques with children and youth, Merrell (2003) concluded that problems “may not be in the techniques themselves, but rather in how they may be used” (p. 210). As such, school psychologists who use projective techniques to assess childhood internalizing disorders are encouraged to do so sparingly and cautiously and with full awareness of their strengths and limitations. References: Allen, J.C., and Hollifield, J. (2003). Using the Rorschach with children and adolescents: The Exner comprehensive system. In C.R. Reynolds and R.W. Kamphaus (Eds.), Handbook of psychological and educational assessment of children: Personality, behavior, and context (pp. 182-197). New York: Guilford. Bardos, A.N. (1993). Human figure drawings: Abusing the abused. School Psychology,Quarterly, 8, 177-181. 54 Miller & Nickerson

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Inter Correlations of Nine SIS-I Indices D. Kumar, B.L. Dubey and Rakesh Kumar The present study aims at delineating inter-correlations in nine indices of the Somatic Inkblot Series-I (SIS-I). The test was administered on a sample of 50 subjects screened through PGI Health Questionnaire. The results of product moment correlations revealed significant and positive correlations. Somatic Inkblot Series is an innovative addition to the family of projective techniques. It was developed in 1980(Cassell, 1980). It has renewed the research interest of professionals and has been serving as diagnostic and therapeutic aid. The SIS-I consists 20 images in card form like Rorschach test. SIS-I involves the presentation of ambiguous and semi-ambiguous inkblot stimuli in response to which the subject is presumed to reveal the inner core of his personality. For physicians, therapist and researchers, the body, its organ system and its perceived functions are “doorways to the minds”. Observing and assessing how people perceive or misperceive body and organ function can give clues about their innermost thoughts and feelings. What they see in ambiguous and semi-ambiguous inkblots show how they see themselves, the quality of their life and lifestyle, their adjustment to conflict, their coping skills and their view towards the reality of life . The somatic Inkblot Series can help therapist more sensitively to “hear” the inner cry of the suffering individual for help , the “ inner cry” that is not only hidden from others, but often hidden from one’s own conscious awareness as well. This is the “magic” the unique and distinguishing feature of projective testing (Cassell and Dubey,2003). SIS-I adopts simple scoring system and has only eleven indices such as – Total number of Responses, Human Responses, Animal Responses, Anatomical Responses, Movement Responses, Sex Responses, Most typical Responses, Typical Responses, Atypical Responses, Rejection of images and Pathological Responses. The present study aims at delineating correlation pattern in SIS=I indices. Material and Method: The sample consisted of 50 normal subjects drawn from general population. The subjects were screened on PGI Health Questionnaire (Verma and Pershad, 1985). The SIS-I was administered individually on all the subjects. Product moment correlations were computed among the nine indices of SIS-I. Results and Discussion: Table 1 depicts the inter correlations in nine variables i.e. – Total number of Responses, Human Responses, Animal Responses, Anatomical Responses, Movement Responses, Most typical Responses, Typical Responses, Atypical Responses, Rejection of images. Out of 36 inter correlations, 21 were found to be significant at .05 levels and above. Total number of Responses significantly correlated with Human Responses (r=.88), Animal Responses (r=.83), Anatomical Responses(r=. 50), Movement Responses(r=.52), Typical Responses (r=.91) and Atypical Responses (r=.91). It means increasing or decreasing Total number of Responses D. Kumar, Ph.D. Lecturer, National College of Girls, Alwar (Rajasthan), B.L. Dubey, Ph.D. Director, SIS Centre, Anchorage,USA Email:sisdubey@rediffmail.com) and Rakesh kumar, Ph.D. Senior Clinical Psychologist, Institute of Mental Health and Hospital, Agra – 282002 Key Words: Inter-Correlations of SIS Indices

affects the Human Responses, Animal Responses, Anatomical Responses, Movement Responses, Typical Responses and Atypical Responses. Human Responses were found to be significantly correlated with Animal Responses (r = .65), Anatomical Responses(r =.47), Movement Responses (r=.69), Typical Responses (r=.76) and Atypical Responses (r=.80).All the correlations were found to be significant at .05 level. It suggests that one who gives more Human Responses is also likely to give high Animal Responses, Anatomical Responses, Movement Responses, Typical Responses and Atypical Responses. Animal Responses were found to be significantly correlated with Movement Responses (r= .62), Typical Responses (r=.87) and Atypical Responses (r=.75). Anatomical Responses were also found to be significantly correlated with Movement Responses(r = .39), Typical Responses(r =.48) and Atypical Responses(r =.41). Table 1 : Correlation matrix of Total Sample on Nine SIS-I Indices Variables Total no. of Human Animal Anatomical Movement Rejection Most Typical Atypical Responses typical Total no. of Responses Human .879* Animal .825* .652* Anatomical .504* .475* .282* Movement .523* .697* .244 .392* Rejection -.182 -.153 -.170 -.261 -.147 Most typical .115 .220 .113 .216 .254 -.090 Typical .906* .769* .761* .483* .444* -.273* .223 Atypical .911* .801* .739* .411* .465* -.072 -.166 .667* * Significant at .05 level and above Table 2 indicates positive correlations between Total number of Responses and Human Responses (r= .97), Total number of Responses and Animal Responses (r=.86), Total number of Responses and Anatomical Responses (r=.52), Total number of Responses and Movement Responses (r=.79), Total number of Responses and Typical Responses (r=.95) Total number of Responses and Atypical Responses (r=.93). The negative correlation was observed between Rejection of images and Most typical Responses. Human Responses showed significant correlation with Animal Responses (r =.85), Anatomical Responses (r =.55), Movement Responses(r =.81), Typical Responses (r=.90) and Atypical Responses (r =.89). Animal Responses were found positively correlated with Movement Responses (r=.54), Typical Responses (r=.87) and Atypical Responses (r=.75). Rejection of Images was found to be negatively correlated with all the indices. Table 2 : Correlation Matrix of Male Subjects on Nine SIS-I Indices Variables Total no. of Human Animal Anatomical Movement Rejection Most Typical Atypical Responses typical Total no. of Responses Human .968* Animal .860* .848* Anatomical .518* .548* .295* Movement .796* .808* .623* .547* Rejection -.231 -.182 -.180 -.181 -.167 Most typical .175 .251 .218 .314 .277 -.051 Typical .947* .903* .870* .484* .712* -.282 .287 Atypical .933* .898* .746* .449* .752* -.162 -.102 .779* * Significant at .05 level and above 60 Kumar et al

Table 3 indicates the correlation matrix of nine indices of SIS-I on the responses given by 25 female subjects. Significant correlations were found between Total number of Responses and Human Responses (r= .54), Total number of Responses and Animal Responses (r =.82), Total number of Responses and Anatomical Responses (r =.47), Total number of Responses and Typical Responses (r =.76) Total number of Responses and Atypical Responses (r =.87). Significant correlation were also found between Human Responses and Movement Responses (r =.62), Human Responses and Atypical Responses (r=.55). Animal Responses were found significantly correlated with Typical Responses (r=.58) and Atypical Responses (r=.74). Anatomical Responses and Typical Responses were found to be significantly correlated (r =.48), and Anatomical Responses were negatively correlated with Movement Responses (r =.56). Table 3 : Correlation Matrix of Female subjects on Nine SIS-I Indices Variables Total no. of Human Animal Anatomical Movement Rejection Most Typical Atypical Responses typical Total no. of Responses Human .537* Animal .823* .286 Anatomical .470* .237 .275 Movement .089* .615* -.184 .177 Rejection -.001 -.100 -.129 -.560* -.145 Most typical .021 .081 .006 -.000 .244 -.363 Typical .759* .253 .582* .487* .009 -.233 .114 Atypical .871* .551* .741* .325 .069 .219 -.288 .366 * Significant at .05 level and above Table 4 shows the responses given by 25 adult (age 18-35years) subjects. Positive correlation was found between Total number of Responses and Human Responses ( r= .52), Total number of Responses and Animal Responses (r =.57), Total number of Responses and Typical Responses (r =.78), and Total number of Responses and Atypical Responses (r =.66).but negatively correlated with Rejection of images (r = -.13).Human Responses were significantly correlated with Anatomical responses (r =.40) and Movement Responses (r =.62) . Significant positive correlation was observed between Animal Responses and Typical Responses (r =.59). Table 4 : Correlation matrix of 18-35 year age group subjects on nine SIS-I Indices Variables Total no. of Human Animal Anatomical Movement Rejection Most Typical Atypical Responses typical Total no. of Responses Human .527* Animal .573* .227 Anatomical .352 .401* -.049 Movement .078 .628* -.245 .293 Rejection -.136 -.177 -.103 -.100 -.184 Most typical .117 .379 .114 .385 .349 .040 Typical .780* .345 .596* .244 -.087 -.326 .186 Atypical .659* .307 .211 .149 .087 .113 -.344 .088 * Significant at .05 level and above Table 5 reveals that the correlation matrix of nine variables found out on 25 subjects in bthe age group of 18-35 years (adult group). Total number of Responses were significantly correlated with Human Responses (r=.95), Animal Responses (r=.88), Anatomical Responses(r=.67), Movement Responses(r=.78), Typical Responses (r=.94) and Atypical Responses(r =.95). Human Responses Inter Correlations of SIS Indices 61

were also found to be positively correlated with Animal Responses (r =.78), Movement Responses (r=.79), Typical Responses (r=.89) Atypical Responses(r=.89), and Anatomical Responses (r=.57). Animal Responses significantly correlated with Anatomical Responses (r =.52), Movement Responses(r=.57), Typical Responses (r =.79) and Atypical Responses(r =.87). Table 5 : Correlation matrix of above 35 year age group subjects on nine SIS-I Indices Variables Total no. of Human Animal Anatomical Movement Rejection Most Typical Atypical Responses typical Total no. of Responses Human .950* Animal .887* .783* Anatomical .665* .572* .520* Movement .780* .797* .573* .508* Rejection -.291 -.184 -.294 -.558* -.101 Most typical .098 .151 .064 .037 .184 -.287 Typical .944* .892* .798* .685* .799* -.305 .222 Atypical .949* .872* .872* .596* .680* -.217 -.140 .802* * Significant at .05 level and above Table 6 : Correlation matrix of Rural subjects on nine SIS-I indices Variables Total no. of Human Animal Anatomical Movement Rejection Most Typical Atypical Responses typical Total no. of Responses Human .965* Animal .884* .833* Anatomical .642* .626* .538* Movement .806* .849* .685* .483* Rejection -.189 -.134 -.208 -.165 -.157 Most typical .232 .304 .326 .226 .513* -.080 Typical .950* .911* .874* .592* .792* -.259 .274 Atypical .951* .909* .794* .612* .693* -.113 -.025 .819* * Significant at .05 level and above Table 6 shows the inter correlation among nine variables of rural group. Significantly positive correlations were found between Total number of Responses and Human Responses (r= .97), Total number of Responses and Animal Responses (r =.88), Total number of Responses and Anatomical Responses(r =.64), Total number of Responses and Movement Responses(r =.89), Total number of Responses and Typical Responses(r =.95) Total number of Responses and Atypical Responses(r =.95). These results indicate that one who gives more Responses is likely to give more Human Responses, Animal Responses, Anatomical Responses, Movement Responses, Typical Responses and Atypical Responses. Human Responses were found to be significantly correlated with Animal Responses (r =.83), Anatomical Responses(r =.62), Movement Responses(r =.85), Typical Responses(r =.91) and Atypical Responses(r =.90). Animal Responses were also correlated with Anatomical Responses(r =.54), Movement Responses(r =.69), Typical Responses(r =.88) and Atypical Responses(r =.79). Anatomical Responses were found to be significantly correlated with Movement Responses(r =.48), Typical Responses(r =.59) and Atypical Responses(r =.61).Movement Responses were significantly correlated with Most typical Responses (r =.51), Typical Responses(r =.79) and Atypical Responses(r =.69). Table 7 indicates that correlation matrix of nine variables given by urban group. Total number of Responses (r =.72), Typical Responses(r =.77) and Atypical Responses(r =.84). Human Responses were positively correlated with Movement Responses(r =.56), and Atypical Responses(r =.48). Animal 62 Kumar et al

Table 7 : Correlation matrix of Urban subjects on nine SIS-I Indices Variables Total no. of Human Animal Anatomical Movement Rejection Most Typical Atypical Responses typical Total no. of Responses Human .498* Animal .725* .185 Anatomical .330 .300 -.020 Movement .086 .563* -.292 .287 Rejection .072 -.139 -.012 -.284 -.073 Most typical -.194 .003 -.228 .125 -.044 .048 Typical .768* .252 .544* .264 -.089 -.065 .064 Atypical .838* .485* .635* .228 .184 .129 -.513 .318 * Significant at .05 level and above Responses significantly correlated with Typical Responses(r =.54) and Atypical Responses(r =.63). Most typical Responses were negatively correlated with Atypical Responses(r = -.52). Rejection of images was found to be negatively correlated with almost all the variables. Conclusion: Positive correlations were observed in seven indices of SIS-I except Rejection of Images and Most typical Responses But no significant correlations were found with Most typical Responses and other indices. Positive correlations were observed between Total numbers of Responses, Human Responses, Animal Responses, Anatomical Responses, Movement responses, Typical Responses and Atypical Responses. References: Cassell, W.A. (1980) Somatic Inkblot Images (SIS-I) Somatic inkblot Center. Anchorage Alaska, USA. Cassell, W.A. (1994) The Somatic Inkblot Series Containing Rorschach’s Conceptualization. SIS Journal of Projective Psychology & Mental Health, 1,13-14. Cassell, W.A. And Dubey, B.L (2003) Interpreting inner World thru Somatic Imagery: Manual of Somatic Inkblot Series: SIS Centet, 4501E, 104th Ave Anchorage, AK 99516 USA. Dubey, B.L.And Cassell, W.A. (1993) Some Experience with SIS-I British Journal of Projective Psychology. 38, 1; 19-41. Verma, S.K., Pershad, D. (1985). PGI Health Questionnaire Agra. National Psychological Corporation, INDIA. Inter Correlations of SIS Indices 63

Relationship Between Controllability Awareness And Cognitive Emotion Regulation In Selected Clinical Samples: A Psychosocial Perspective Manisha Dasgupta and Nilanjana Sanyal Probes into “why” behaviour pathologies do occur are not very common. The present attempt incorporates a probing exercise in terms of the variables of controllability awareness, cognitive emotion regulation, narcissism, life-satisfaction and self-esteem with 32 (sixteen depressive and sixteen obsessive-compulsive) patients and a comparative judgement of the same with 32 matched normals. The main objective was to examine the relationship of controllability awareness with cognitive emotion regulation as bearing etiological conditions for the selected clinical samples. Statistical analyses revealed significant profile differences between the samples with regard to all the variables. The specific findings highlighted rumination, catastrophizing and self-blame to be non-adaptive, being related to symptoms of psychopathology while a “protective” effect was suggested from refocus on planning, positive reappraisal and putting into perspective. This study would perhaps enrich the knowledge regarding their psychopathology and help design disease-specific psychotherapeutic programmes. Behavior pathologies of various dimensions are generally marked features of clinical samples. Evidences pin-point such features in their profiles but probes into “why” they have it are not that frequent. The controllability of emotion is of highest importance at this juncture that paves the way for a positive optimistic orientation in life and a positive regard for the self, thereby enabling the development of the personality into a comparatively smoother mental frame. Hence, the question of looking for the cues for “having the leash of life within my grip to adopt better modes of control in life and be happy”. Clinical samples like depression and obsessive-compulsive disorder are often characterised by gross deficits in cognitive and affective domains reflecting maladaptations in the conative spectrum as well. Thus, the importance of delving into their personality frames for better understandability of the dynamics of their pathologies. The concept of controllability awareness is of much importance at this juncture, which describes the extent to which an individual’s responses to life situations reflect attention to distinctions between controllable and uncontrollable aspects of potential outcomes. The construct recognizes four aspects of controllability, namely, personal control of outcomes, shared control of outcomes, others in responsibility and uncontrollable/ unpredictable outcomes (Heth and Somer, 2002). In fact, perceived control has been highlighted to be the basic motivation that guides all other motives, emotions, cognitions and social behaviours (Geary, 1998). The control motive has been found to be involved with a number of benefits like better coping with stressful life circumstances (Glass, McKnight and Valdimarsdoltir, 1993; Litt, 1988; Thompson, Sobolew- Shubin, Galbraith, Schwankovsky and Cruzen, 1993), being less anxious and depressed in the face of chronic illnesses (Griffin and Rabkin, 1998; Thompson, Nanni and Levine, 1994) and less traumatised by victimisation (Regehr, Codell and Jensen, 1999). Moreover, those with a stronger sense of perceived control are more likely to take needed action to improve or protect their physical health (Peterson and Stunkard, 1989; Rodin, 1986), generally have better physical health (England and Evans, 1992) and avoid stressful situations. They are also associated with better stress tolerance and less bothersome psychological symptoms regardless of the type or severity of the psychopathology (Heth and Somer, 2002). The concept of controllability awareness is intimately associated with the personality variable of cognitive emotion regulation; emotion regulation being understood as “all the extrinsic and intrinsic Manisha Dasgupta Research Fellow and Guest Lecturer and Nilanjana Sanyal, Professor, Department of Psychology, University of Calcutta , Calcutta (Correspondence to: Prof. Nilanjana Sanyal, 119, Dr. Meghnad Saha Sarani, “Greenview” 8th Floor,N/W, Kolkata-7000029 Email: sanyal_nilanjana2004rediffmail.com) Key Word:ead: Controllability awareness .

processes responsible for monitoring, evaluating and modifying emotional reactions, especially their intensive and temporal features, to accomplish one’s goals” (Thompson, 1994). Well-adjusted, regulated individuals are expected to be relatively high in the ability to voluntarily control their attention and behaviour as needed to respond in an adaptive manner. In fact, Eisenberg, Fabes and colleagues have developed a preliminary heuristic model of the ways in which emotion and regulation jointly predict social competence and adjustment (Eisenberg and Fabes, 1992; Eisenberg, Fabes, Guthrie and Reisser, 2000). Besides, cognitive emotion regulation is narrowly related to the concept of cognitive coping (Garnefski ,Kraaij and Spinhoven, 1999). Theoretical links and hypotheses: It may also be posited that coping through emotional processing and expression is an important area of inquiry for positive psychology (Stanton et al., 2000). In fact, two distinct emotional approach coping factors have been found out, namely, emotional processing and emotional expression (Hamel and Stanton, 1999). Such coping may direct one’s attention toward a goal and the expected rate of progress (Carver and Scheir, 1998) thereby motivating action. Emotional approach coping may also aid in habituation to a stressor and its associated emotions (Foa and Kozak, 1986; Hunt, 1998), either simply through repeated exposure or through concomitant altered cognitive reappraisal of the stressor. Finally, coping through expressing emotions may facilitate regulation of the social environment (Thompson, 1994). Controllability awareness is also closely related to other personality components of narcissism, lifesatisfaction and self-esteem that have been probed in the present study (Stucke and Sporer, 2002; Dethieux, Abadie, Grandjean and Raynaud, 2000; Cantor and Blanton, 1996; Emmons, 1986; Watson, Suls and Haig, 2002; Paula and Campbell, 2002). The present research endeavour is guided by the following objectives: 1. to find out the relationship of the construct, controllability awareness and its different dimensions in depressive and obsessive-compulsive patients compared to a normal group; 2. to seek for the relationship of cognitive emotion regulation in depressive and obsessivecompulsive individuals compared to a normal group and to identify non-adaptive and “protective” strategies of cognitive emotion regulation; 3. to determine the relationship of life satisfaction, self-esteem and narcissism in depressive and obsessive-compulsive patients in comparison to a control group. Thus, the ultimate aim of the research involves investigating two different clinical groups to seek for the important contributory cognitive, conative and affective factors that may pave the way for the manifestation of psychopathology, thereby providing some lead to therapeutic measures to be considered in future. Method: Participants: A total of 64 participants was selected by means of purposive sampling and divided into three groups : 1. Depressive group (N=16; which comprised 8 males and 8 females) (M = 49.6 yrs; S.D. = 9.02 yrs). 2. Obsessive-compulsive group (N=16; which comprised 9 males and 7 females) (M = 51.2 yrs; S.D. = 8.76). 3. Control group (N=32; which comprised 17 males and 15 females) (M = 48.8 yrs; S.D. = 8.17). Controllability Awareness 65

It was matched to the two experimental groups on the basis of age, sex, religion, socio-economic status and marital status. All the subjects ranged between the ages of 40 and 60 years, were Indian citizens, followed Hinduism as their religion and belonged to a middle-class family. A psychiatrist diagnosed the patients at first as being depressive or obsessive-compulsive; they were administered with the screening test of Medico Psychological Questionnaire (MPQ) and their symptoms were also checked against the diagnostic criterion given by DSM-IV (A.P.A., 1994). Thus, their selection involved a three-way stage. All the patients were also under drug treatment during the course of the study due to ethical reason. Patients with chronic physical illness or any organic involvement were excluded from the study. Measures Self report instruments or scales were used to obtain information from the subjects. The measures used in the study are described below : 1. Controllability Awareness Inventory (C.A.I.): The 20-item Controllability Awareness Inventory (C.A.I.) was developed by Heth and Somer (2002) to measure controllability awareness. Each of the statements were scored on a five-point scale from 1 (disagree strongly) to 5 (agree strongly). Anti-trait items were reversed and the responses were summed to produce a score between 20 to 100. Similarly, scores for each of the different dimensions of controllability awareness was also found out, which was found to have a range between 5 and 25. High score in a domain indicates high level of controllability with respect to that dimension. Cronbach alpha measures for the C.A.I. previously yielded 0.78 and 0.85, indicating the reliability of this inventory. The validity index was significant at a p<0.01 level (Heth and Somer, 2002). 2. Cognitive Emotion Regulation Questionnaire (C.E.R.Q.): This questionnaire was developed by Garnefski, Kraaij and Spinhoven (1999) to measure the construct of cognitive emotion regulation. It consists of a total of 36 items that reflect nine conceptually distinct scales, each comprising four items. Responses were based on a 5-point scale ranging from 1 (almost never) to 5 (almost always). Of the four items included in a scale, a sum score was made (single straight count), which can range from 4 (never used) to 20 (often used cognitive coping strategy). Not more than 1 of the 4 items included in a scale might be “missing”. In such case, the “missing” score was replaced by the average of the three remaining scores. The lowest alpha reliability of the C.E.R.Q. was reported in a recent study to be 0.68 (blaming others) and the highest to be 0.83 (rumination). In the clinical sample, Cronbach’s alpha ranged from 0.72 (acceptance) to 0.84 (selfblame). In the non-clinical population, reliabilities ranged from 0.76 (acceptance) to 0.86 (refocus on planning). 3. Narcissism Scale: The 28-item Narcissism scale was developed by Phares and Erskine (1984) to measure narcissism of the subject. Scoring was done by summing the individual item scores, each of which is on a 5-point Likert Scale, to produce a range of 28-140. The following are filler items, included to disguise the purpose of the scale, and are not scored – 1, 6, 8, 12, 15, 19, 23, 26, 30, 34, 38, 39. Split-half reliabilities were found to be 0.84 for males and 0.83 for females. 4. Life Satisfaction Index ‘A’ and ‘B’: Life satisfaction was measured with the Life Satisfaction Index A and B (Neugarten, Havighurst and Tobin, 1961), a 20-item measure in Index A and 12 open-ended questions in Index B. A score of 1 point was provided for each response marked (X) for Life Satisfaction Index (A) in the scoring key and those for life satisfaction. Index (B) were scored in accordance to the guidelines provided in the 66 Dasgupta and Sanyal

scoring key. The correlations with the ratings made by clinical psychologists were 0.39 and 0.47 respectively for LSI-(A) and LSI-(B) respectively. 5. Self-Esteem Scale: Rosenberg’s (1965) 10-item Self-Esteem Scale was used to measure self-esteem. Scoring was done on the basis of the scoring key where “positive” responses are indicated by asterisks. Where contrived items have been used, the basis for scoring the contrived items was indicated. The total number of “positive” responses was counted. The scale is internally reliable and unidimensional and appears to have face validity. The scale has been shown to have a test-retest reliability of 0.85. 6. Medico Psychological Questionnaire (M.P.Q.): A measure of general neuroticism was obtained from the 50-item Medico Psychological Questionnaire (Bharat Raj, 1960), which was used as a screening test for the study. Scores are obtained for each of the five categories, namely, hysteria, anxiety neurosis, neurasthenia, reactive depression and obsession-compulsion. Procedure: All the questionnaires were translated into Bengali version and checked by five raters for their approval to be used as standardized tools for the present study. The participants (selected by means of purposive sampling) were administered with the questionnaires one at a time, for their completion in a single session. The sequence of the administration followed a pre-determined sequence – 1. Information Schedule 2. Medico Psychological Questionnaire (M.P.Q.) 3. Controllability Awareness Inventory (C.A.I.) 4. Cognitive Emotion Regulation Questionnaire (C.E.R.Q.) 5. Life Satisfaction Index (A) and (B) 6. Self-Esteem Scale 7. Narcissism Scale Analyses: Attempts were made to test the significance of difference between the means of depressive, obsessivecompulsive and normal (unaffected) groups for each of the variables under consideration as well as the different dimensions of controllability awareness and cognitive emotion regulation. Besides, it was also examined whether there was any sex difference between the means of the above mentioned groups in the different instances. Student’s t-test was also computed so as to ascertain the general trend of the significance of difference between the different groups. Results: Table 1 summarizes the significance of difference between the means of the different selected samples for each of the different variables and any sex difference, if present. As hypothesized, controllability awareness, cognitive emotion regulation (both positive and negative), narcissism, life satisfaction, and self-esteem differed among the three groups to a significant extent. However, there was no effect of sex or its interaction with the groups for any of the variables. Controllability Awareness 67

Further analyses of data (Table 2) suggest that both depressive and O.C.D. patients have, on an average, significantly lower controllability awareness, positive cognitive emotion regulation, life satisfaction and self-esteem than their normal counterparts. In addition, depressive individuals have, on an average, significantly higher narcissism and negative cognitive emotion regulation when compared to normal subjects, while O.C.D. clients show significant similar differences with regard to only the latter. When compared among the two clinical samples, depressive patients have, on an average, significantly lower life satisfaction only. Table 1 : F-values showing the significance of groups, sex and their interaction on different variables. Variables Source of Variance F Controllability awareness Among groups 21.30** Between sex 0.48 Interaction 0.24 Positive cognitive Among groups 12.47** emotion Between sex 0.14 regulation Interaction 0.50 Negative cognitive Among groups 10.65** emotion Between sex 0.0002 regulation Interaction 0.69 Narcissism Among groups 3.68* Between sex 0.01 Interaction 0.99 Life satisfaction Among groups 51.21** Between sex 0.45 Interaction 0.18 Self-esteem Among groups 14.22 Between sex 0.24 Interaction 0.20 * p<0.05; **p<0.01. Table 2 : Means (M), Standard deviations (S.D.), and t-values of the total scores obtained by the groups of subjects among the different variables. Variables Depression O.C.D. Normal t between t between t between (1) (2) (3) (1)&(3) (2)&(3) (1)&(2) M S.D. M S.D. M S.D. Controll-ability awareness 49.37 9.37 53.75 12.32 69.72 11.25 6.36** 4.59** 1.13 Cognitive emotion regulation (positive) 52.56 8.83 55.69 10.87 67.62 11.58 4.66** 3.5* 0.89 Cognitive emotion regulation (negative) 49.31 11.31 50.81 13.64 37.25 9.37 4.03** 4.13** 0.34 Narcissism 92.31 7.60 88.75 14.04 81.69 15.27 2.67** 1.58 0.89 Life-satisfaction 10.62 3.88 18.19 7.18 28.53 6.04 5.36** 5.36** 3.71** Self-esteem 8.75 2.72 7.75 3.17 4.73 4.44 5.53** 3.80** 0.89 *p<0.05; **p<0.01. Table 3 describes the significance of difference between the means of the different selected samples for each of the different dimensions of controllability awareness and any sex difference, if present. As hypothesized, all the dimensions differed among the three selected samples significantly. No effect of sex or its interaction with the groups for any of the variables was observed. 68 Dasgupta and Sanyal

Further analyses of data (Table 4) suggest that depressive patients have, on an average, significantly lower personal control, others in control and uncontrollable dimensions of controllability awareness than normal subjects while obsessive-compulsive patients have significantly lower personal control, shared control and uncontrollable dimensions of controllability awareness when compared to normal counterparts. However, among the two clinical samples, depressive clients have, on an average, significantly lower controllability aware-ness with respect to the dimension of others in control only. Table 3 : F-values showing the significance of groups. sex and their ineraction on the different dimensions of controllability awareness (CA) Dimensions of CA Source of Variance F Personal control Among groups 14.49** Between sex 0.06 Interaction 0.02 Shared control Among groups 4.04* Between sex 0.21 Interaction 0.16 Others in control Among groups 8.21** Between sex 0.31 Interaction 0.45 Uncontrollable Among groups 23.49** Between sex 0.06 Interaction 2.08 *p<0.05; **p<0.01 Table 4 : Means (M), Standard Deviations (S.D.), and t-values of the different dimensions of controllability awareness (CA), as obtained by the groups of subjects. Variables Depression O.C.D. Normal t between t between t between (1) (2) (3) (1)&(3) (2)&(3) (1)&(2) M S.D. M S.D. M S.D. Personal control 12.19 3.83 13.81 6.02 18.75 3.30 6.31** 3.77** 0.91 Shared control 14.56 2.99 13.88 3.93 16.83 3.85 0.63 2.54* 0.42 Others in control 12.06 2.52 14.69 4.45 16.56 3.56 4.59** 1.61 2.05* Uncontrol-lable 10.56 3.95 11.37 3.81 17.56 3.52 6.36** 5.73** 0.59 *p<0.05; **p<0.01. Table 5 summarizes the significance of difference between the means of the different selected samples for each of the different scales of cognitive emotion regulation and any sex difference, if present. As hypothesized, some strategies like self-blame, rumination, catastrophizing, refocus on planning, positive reappraisal and putting into perspective differed among the three groups. No effect of sex or its interaction with the groups for any of the variables was observed except for the strategies of positive reappraisal and blaming others. Further analyses of data (Table 6) suggest that both the clinical samples have, on an average, significantly lower refocus on planning, positive reappraisal and putting into perspective strategies of cognitive emotion regulation, while they have, on the average, significantly higher self-blame, rumination and catastrophizing strategies. Among the two clinical samples, no significant differences with respect to any of the strategies was observed. Controllability Awareness 69

Table 5 : F-values showing the significance of groups, sex and their interaction on the different strategies of cognitive emotion regulation (CER) Strategies of CER Source of Variance F Self-blame Among groups 6.01** Between sex 0.38 Interaction 0.68 Acceptance Among groups 0.04 Between sex 0.79 Interaction 0.10 Rumination Among groups 7.47** Between sex 0.07 Interaction 0.17 Positive refocussing Among groups 1.94 Between sex 2.16 Interaction 0.11 Refocus on planning Among groups 3.41* Between sex 1.64 Interaction 0.69 Positive reappraisal Among groups 19.81** Between sex 1.04 Interaction 8.98** Putting into perspective Among groups 8.16** Between sex 2.06 Interaction 1.50 Catastrophizing Among groups 13.64** Between sex 0.07 Interaction 0.69 Blaming others Among groups 1.13 Between sex 0.001 Interaction 0.29** *p<0.05; **p<0.01. Table 6 : Means (M), Standard Deviations (S.D.) and t-values of the different strategies of CER as obtained by the groups of subjects. Variables Depression O.C.D. Normal t between t between t between (1) (2) (3) (1)&(3) (2)&(3) (1)&(2) M S.D. M S.D. M S.D. Self-blame 13.00 4.11 12.19 4.28 9.53 2.81 3.51** 2.63* 0.55 Acceptance 12.94 2.79 13.25 2.86 13.06 3.59 0.12 0.19 0.33 Rumination 15.25 4.16 15.44 5.01 11.44 3.21 3.59** 3.42** 0.12 Positive refocussing 9.62 4.19 10.12 4.49 11.97 4.25 1.85 1.42 0.32 Refocus on planning 12.25 3.42 12.44 3.69 14.81 4.00 2.23* 2.03* 0.15 Positive reappraisal 8.50 3.37 10.31 4.14 15.06 3.47 6.19** 4.28** 1.36 Putting into perspective 9.25 3.45 9.56 3.44 12.72 3.24 3.51** 3.19** 0.25 Catastro-phizing 13.37 5.25 13.69 5.16 7.97 3.12 4.58** 4.89** 0.17 Blaming others 7.69 3.36 9.50 3.78 8.31 3.26 0.63 1.16 1.44 *p<0.05; **p<0.01. Table 7 summarizes the bivariate relationship between the dimensions of CA and the scales / strategies of CER among depressive and obsessive-compulsive patients. The results suggest that among depressive patients, personal control tends to be significantly negatively correlated with acceptance, catastrophizing and total cognitive emotion regulation, while a significant positive correlation is found with the strategies of positive reappraisal and total positive cognitive emotion regulation. As regards the dimension of shared control, a significant positive correlation is found to exist with the strategy of 70 Dasgupta and Sanyal

refocus on planning among them. They also tend to show a significant negative correlation in between the dimension of others in control and the scales of self-blame, rumination and catastrophizing aspects of cognitive emotion regulation. As regards the uncontrollable dimension of CA, they show significantly negative correlations with regard to acceptance, rumination and catastrophizing aspects of cognitive emotion regulation. A different trend is observed among O.C.D. clients. As regards personal control, a significantly positive correlation is observed with the scale of putting into perspective. When the dimension of others in control is concerned, a significantly negative correlation is observed with the scales of acceptance, rumination, catastrophizing, while a significantly positive correlation is revealed with the scale of putting into perspective. Last but not the least, a significantly negative correlation is seen among O.C.D. patients in between uncontrollable dimension of CA and acceptance of CER. Table 7 : Pearson product moment correlations between the dimensions of CA and the scales of CER among Depressive and Obsessive-Compulsive Patients. Scales of Cognitive Emotion Regulation Psycho Dimension Self- Accep- Rumi- Posi- Refo- Posi- Putt- Catas Blam- Total Total Total pathology of CA blame tance nation ve cus tive ing trophiing positive negative CER Refoon reapp- into sing others CER CER cuss- Plannraisal Persing ing pective Depression Personal Control -0.31 -0.52* -0.36 0.28 0.34 0.54 0.30 -0.55* 0.27 0.51* -0.61* 0.07 Shared Control -0.08 0.12 0.11 -0.07 0.51* 0.14 0.39 0.13 0.39 0.39 0.38 0.39 Others in Control -0.54* 0.03 -0.63* 0.10 -0.30 0.07 0.14 -0.58* -0.06 -0.02 -0.72** -0.60* Uncontrollable -0.19 -0.52* -0.54* 0.50* 0.004 0.50* 0.50* -0.73** -0.19 0.36 -0.67** 0.33 O.C.D. Personal Control -0.20 -0.40 -0.38 -0.20 -0.02 0.21 0.50* -0.36 0.001 0.02 -0.34 -0.31 Shared Control -0.11 -0.22 -0.36 -0.10 -0.07 0.31 -0.01 -0.19 0.004 0.01 -0.24 -0.22 Others in Control -0.20 -0.50* -0.62** 0.39 0.06 0.32 0.83** -0.51* -0.17 0.31 -0.56* -0.30 Uncontrollable -0.05 -0.66** -0.02 -0.03 -0.07 0.14 0.24 -0.03 -0.05 -0.17 -0.05 -0.18 * p<0.05 **p<0.01. Discussion: A reflection of controllability awareness is clinical samples: The results suggest that members of both the clinical groups have significantly lower controllability awareness, which might indicate that they are either unaware of or the unable to distinguish between those aspects of situations that are controllable and those which are not, and are more likely to appraise environmental demands as threatening (Heth & Somer, 2002). It is perhaps because of the pathologies clouding the controllability awareness of the patients, thereby preventing them to get beyond the threat while facing any challenge and prompting them to have defensive reactivity in their behavioural patterns, which in a round-about way lowers down their degree of controllability awareness. The findings are supported by Kim and Yongseok (2002), who found that the detrimental effect of exposure to stressful circumstances in distress was welcomed by cognitive control. Role of cognitive emotion regulation in psychopathology: Members of both the clinical samples have significantly poor score on cognitive emotional control depicted through their higher scores on negative cognitive emotion regulation strategies and lower ones on positive cognitive emotion regulation strategies (Table 1). Depressive patients have been found to have significantly very high loadings of self-blaming tendencies, probably because of the play of introjection and self-evaluating negative bias (Table 6). Such an orientation makes them to have low scores on other-blame, which tallies with theories stating that both kinds of blames may Controllability Awareness 71

form an obstacle to adaptation to negative life events or trauma (Tedeschi, 1999). They also tend to ruminate their thoughts and feelings associated with the negative events to a significant extent (Nolen- Hoeksema, Parker and Larson, 1994), and have high scores on catastrophizing as well. Such a style appears to be related to maladaptation, emotional distress and depression (Sullivan, Bishop and Pivik, 1995). Their low score on positive cognitive emotion regulation is most likely because they cease to think in a constructive fashion, being pessimistic and dependent by nature. Their scores on positive reappraisal and putting into perspective are significantly low, which implies that they tend very little to mentally attribute a positive meaning to an event in terms of personal growth (Carver, Scheier and Weintraub, 1989; Allan and Gilbert, 1995). Importance of narcissism in psychopathology: The results are also indicative of high loadings of narcissism to be associated with psychopathology, with depressive patients topping the same (Table 1 & 2). Stucke and Sporer (2002) revealed that narcissism and self-concept clarity were found to be significant predictors of negative emotions and aggression after failure. Dethieux, Abadie, Grandjean and Raynaud (2000) showed that individuals suffering from a disorder in the narcissistic transition had significantly higher scores depicting the incidence of post-partum depression among them. In addition, depression has been regarded as protecting a “fragile self” in relation to narcissism (Mollon and Parry, 1984). Life satisfaction – A Limelight to Adjustment: The results further highlight that low life satisfaction tends to be associated with poor adjustment and hence indicative of psychopathology (Table 1 & 2). Depressive patients tend to be significantly less satisfied with their lives in comparison to O.C.D. patients probably because of their decline in the amount of activity engaged in, lack of motivation to attain a valued object etc. (Cantor and Blanton, 1996; Harlow and Cantor, 1996; Csikszentmihalyi, 1975). Goal researchers (Emmons, 1986; Little, 1989; McGregor and Little, 1998) agree that having important goals and pursuing them are reliable indicators of well-being that are definitely lacking in clinical groups. Self-esteem in the face of emotional clouding: Low scores of self-esteem have also been found to be positively correlated with depression along the bipolar continuum (Table 1 & 2) (Watson, Suls and Haig, 2002). This accounts for patients to be less calibrated, have lower overall levels of persistence, and higher levels of rumination that their normal counter-parts. They also tend to be less effective in self-regulatory goal-directed behaviours as compared to the normals (Paula and Campbell, 2002). Depressive patients also tend to be less motivated than normal controls to repair their negative moods (Heimpel & Wood and Marshall & Brown, 2002). A dimensional peep into controllability awareness among clinical samples: Furthermore, the results (Table 3) suggest that personal control, shared control, others in control and uncontrollable dimensions of controllability awareness differed among the three groups significantly. Depressive clients have been found to have significantly low personal control (Table 4), being very low in energy, confidence, self-esteem, poor concentration, reduced capacity to work, loss of interest/ depressed mood, pessimism and morbid thoughts. Their score in “others in control” is also significantly low, owing to their sense of hopelessness, helplessness and pessimism (Table 4). The cognitive triad and learned helpless-ness models may also have important roles to play. Their significantly low weightage with regard to “uncontrollable” aspect of controllability awareness may be explained by 72 Dasgupta and Sanyal

the fact that their ability to engage in adaptive coping by accepting the unpredictable futile outcomes is significantly lowered. O.C.D. patients depict a slightly different profile. Their “non-adaptive” perseverance and rigidity for perfection while doing any task might account for the significantly lower personal control than the normals (Table 4). Their lack of flexibility curbs their dependence on others, thereby making them reluctant to delegate tasks to others and calling for significantly lowered shared control (Table-4). It may be noted that no significant difference among the two clinical groups in their use of the different dimensions of controllability awareness has been found out except for the dimension of “others in control”, where depressive clients have lower controllability than their O.C.D. counterparts. The intricate relationship between controllability awareness & cognitive emotion regulation: Moreover, a significant positive extent of association is found between shared control and refocus on planning among depressive clients (Table 7). They can only think of the different steps to be taken up when they rely on shared control, being dependent by nature. A negative correlation in between others in control and self-blame, rumination and catastrophizing aspects of cognitive emotion regulation has also been revealed. As regards the uncontrollable dimension, a negative correlation is found with the scales of acceptance, rumination, catastrophizing and total negative aspects of cognitive emotion regulation which may be accounted for owing to their feelings of hopelessness and helplessness that marks their orientation (Table 7). A similar trend is observed among O.C.D. patients. A significantly positive extent of association between personal control and putting into perspective is found which may be understood in light of their constricted emotionality, lack of openness and efficiency and excessive focus on order, perfection and control (Table 7). As regards others in control, a significant negative correlation is found with acceptance, rumination and catastrophizing. O.C.D. patients tend to have low controllability with regard to the dimension of others in control due to their extreme lack of flexibility and their feeling that no one can do a job perfectly like themselves. As such, they are victimized by high amounts of ruminating and catastrophizing tendencies. When the uncontrollable dimension of controllability awareness is taken into consideration, a negative correction with acceptance is also found (Table 7). Hence, the expected contribution from this endeavor is addition of new knowledge to the psychopathology of the depressive and obsessive-compulsive groups particularly together with certain formulations for designing their psychotherapeutic programs. Such an understanding is hoped to improve quality of services rendered to them. References: Allan, S. and Gilbert, P. (1995). A social comparison scale : psychometric properties and relationship to psychopathology, Journal of Personality and Individual Difference, 19, 293-299. American Psychological Association (1994). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), (4th ed) Washington, D.C., Author. Bharatraj, J. (1960). The Medico Psychological Questionnaire, Swayamsiddha Prakashana, Mysore. Cantor, N. and Blanton, H. (1996). Effectful pursuit of personal goals in daily life. In J.A. Bargh and P.M. Gollwitzer (eds). The psychology of action : Linking cognition and motivation to behaviour, pp. 338-359, New York : Guildford. Carver, C.S. and Scheier, M.F. (1998). On the self regulation of behaviour, New York : Cambridge University Press. Carver, C.S., Scheier, M.F. and Weintraub, J.K. (1989). Assessing coping strategies : A theoretically based approach. Journal of Personality and Social Psychology, 56, 267-283. Controllability Awareness 73

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Neugarten, B.L., Havighurst, R.J. and Tobin, S.S. (1961). The Journal of Gerontology, 16, 134-143. Nolen-Hoeksema, S., Parker, L.E. and Larson, J. (1994). Ruminative coping with depressed mood following loss. Journal of Personality and Social Psychology, 67, 92-104. Paula, A.D. and Campbell, J.D. (2002). Self-esteem and persistence in the face of failure. Journal of Personality and Social Psychology, 83, No.3, 711-724. Peterson, C. and Stunkard, A.J. (1989). Personal control and health promotion. Social Science and Medicine, 28, 819-828. Phares, E.J. and Erskine, N. (1984). The measurement of selfism, Educational and Psychological Measurement, 44, 597-608. Regehr, C., Cadell, S. and Jensen, K. (1999). Perceptions of control and long-term recovery from rape. American Journal of Orthopsychiatry, 69, 110-115. Rodin, J. (1986). Aging and health : Effects of the sense of control. Science, 233, 1271-1276. Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, N.J. : Princeton University Press, Princeton, New Jersey. Stanton, A.L., Danoff-Burg, S., Cameron, C.L., Bishop, M.M., Collins, C.A., Kirk, S.B., Sworowski, L.A. and Twillman, R. (2000). Emotionally expressive coping predicts psychological and physical adjustment to breast cancer. Journal of Consulting and Clinical Psychology, 68, 875-882. Stuck, T.S. and Sporer, S.L. (2002). When a grandiose self-image is threatened : Narcissism and self-concept clarity as predictors of negative emotions and aggression following ego-threat. Journal of Personality, 70(4), 509-532. Sullivan, M.J.L., Bishop, S.R. and Pivik, J. (1995). The pain catastrophizing scale: Developmental and Validation. Psychological Assessment, 7, 524-532. Tedeschi, R.G. (1999). Violence transformed : Post traumatic growth in survivors and their societies. Aggression and Violent Behaviour, 4, 319-341. Thompson, R.A. (1994). Emotional regulation : a theme in search for definition. Monographs of the Society for Research in Child Development, 59, 25-52. Thompson, S.C., Nanni, C. and Levine, A. (1994). Primary versus secondary and disease versus consequencerelated control in HIV-positive men. Journal of Personality and Social Psychology, 67, 542-547. Thompson, S.C., Sobolew-Shubin, A., Galbraith, M.E., Schwankovsky, L. and Cruzen, D. (1993). Maintaining perception of control : Finding perceived control in low-control circumstances. Journal of Personality & Social Psychology, 64, 293-304. Watson, D., Suls, J., Haig, J. (2002). Global self-esteem in relation to structural models of personality and affectivity. Journal of Personality and Social Psychology, 83, No.1, 185-197. Author Notes We are grateful to Ms. Josephine Todrank Heth, Ray D. Wolfe Center for the Study of Psychology Stress, University of Haifa, Israel, Prof. (Dr.) Eli Somer, School of Social Work, University of Haifa and Dr. Nadia Garnefski, Division of Clinical and Health Psychology, University of Leiden, The Netherlands for sending the entire scales of controllability awareness and cognitive emotion regulation with much eagerness. We thank them for their constant support and encouragement in pursuing the study. Controllability Awareness 75

Emotional feelings in Eating Disorders: a Rorschach Test quantitative analysis S. Daini and L. Bernardini This study examined Rorschach protocols of 171 female subjects, belonging to Eating Disorders subgroups (anorexia, bingeingpurging anorexia and bulimia) and mood disorder and anxiety disorder diagnosis. The clinical subgroups were compared with 41 healthy controls group comparable regarding age and socio cultural characteristics. The aim of the study was to explore emotional dynamics in the projective test situation of eating disorders patients and to verify their psychopathological similarity with depressed and anxious patients. Owing to theoretical link that many authors hypothesized with affective and emotional dynamics of shade and color determinants, we have choose them as indicators in our study. Statistical analysis was performed by MANOVA and ANOVA on Rorschach scores, following Klopfer’s method. The results showed a significantly lower productivity, shade responses and color responses in anorexic group of women, similar to Rorschach profile of depressed women. Bingeing-purging group and bulimic group showed intermediate profile being between anorexic and normal controls groups. The results are interpreted in terms of object relation. The first psychopathologic descriptions of Eating Disorders underlined an excessive compliance and the absence of spontaneous expression (Bruch H., 1978) in these subjects. Among the possible genesis of such attitude, it have been referred a symbiotic attachment and some problems with regards to separation from parents (Masterson, 1977), analytic depression with neglect and anger experience (Sugarman e coll., 1981), and a particular transfer style in psychotherapy, where the therapist functions as holding (Lerner, 1983). In recent studies the psychodynamic point of view has been less represented while depression and anxiety signs in eating disorders are part of the present debate about psychopathology, both from the point of view of comorbidity, and of their influence on the clinical course of these disorders. Some authors (Gancia- Alba, 2004) distinguishing depressed and non-depressed anorexic subgroups, concluded that depression is not a core feature in this disorder, and that anxiety is not a relevant symptom. Others (Kaminska K, Rybakowsky F., 2006) underline association between bipolar spectrum disorders and eating disorders with binge episodes. Several studies underline depression in Bulimia, several epidemiological studies reported high suicide rates in anorexia (Franko, D.L.- Keel, 2006). Depression comorbidity in bulimia and anorexia purging type is more explicit, reporting higher rate of suicide attempts (25 to 35% reported by Franko). Other studies (Blinder e Coll., 2006) showed very high comorbidity in mood disorders relating all types of Eating Disorder, and a less frequent but consistent comorbidity in anxiety disorder relating all subgroup diagnoses. From a psychological point of view, an insecure attachment style and high separation anxiety could promote body dissatisfaction (Troisi and Coll., 2006). In this prospective, object relation and the ability to communicate affective states and emotions are relevant to the pathogenesis and maintenance of eating disorder and to their interpersonal and social consequences. Recent research (Skyli & Georgy, 2005) has tried to confirm through experiment that a dysfunctional pattern of interactions and a fragile self image are related to mother-child interaction dynamics. The old focus on primary relations has so gained a new actuality (Bornstein 6 Greemberg, 1991). As regards Rorschach studies on eating disorders, this projective test is one of the most used psycho diagnostic techniques for clinical purposes. The first researches were focused on the difference between Eating Disorders, other Psychiatric disorders and normal controls. More recent works failed Silvia Daini & Lucia Bernardini, Psychiatry and Psychology Institute, Università Cattolica del Sacro Cuore, Rome, Italy, Corresponding Author: Silvia Daini. Istituto di Psichiatria e Psicologia, Università Cattolica del Sacro Cuore, Roma, Largo Francesco Vito 1, 00168, Rome, Italy, Mobile Phone: 0039 339 3798428, Tel/fax (0)6 3054850, Email: daini@katamail.com Key Words: eating disorders, emotion, Rorschach test, shading, color

to identify paradigmatic structural traits of anorexia in Rorschach Test (Fagiani & Marocco Mattini, 1989). In a study on adolescents by Exner’s Comprehensive System, considerably higher depression and schizofrenia indexes were found, as aggressive contents (Smith & Coll, 1991). An analysis of contents (Bornstein & Geeenberg, 1991) noted significantly more dependent imagery in eating disordered patients and no differences between each eating disorder type. In this decade, the Rorschach test has been chosen in research works to explore single personality traits by selected indexes, rather than for personality differentiation among eating disorders. As an example, Rorschach Dependency Scale showed higher values in eating disordered patients than in healthy controls (Narduzzi & Jackson, 2000). This dependent personality trait was contrasting with self-directness, as measured by questionnaires: this work evidences the psychological area of dependence-autonomy as a central problem in these disorders. A Rorschach study on obese subjects (Elfhag & Coll., 2004), used selected composite indexes according to Exner’s Comprehensive System to assess correlation between BMI and personality traits in obese subjects. BMI was significantly and negatively correlated to body related anxiety. Moreover, the same author had previously found that some Rorschach indexes, like food contents and form dimension, could predict weight loss in treated obese subjects (positive correlation between Rorschach indexes and weight loss, (Elfhag & Coll, 2003). Rorschach indexes related to emotional feelings and depression seem an useful tool to clarify psychopathological aspects of eating disorders.In several studies these aspects were linked to shading area of Rorschach determinants (Gacono & Melony, 1991; Weber & Coll., 1992; Eells & Boswell, 1994; Kleiger, 1997). In particular, Kleiger, in a review of interpretative approaches to shading responses privileges the Rapaport’s hypothesis about shading. Diffuse shading responses were considered anxiety indicators, while form shading an expression of attention and sensitivity to the emotional overtone of human environment. This is an interpretation comparable to Klopfer’s hypothesis about shading that considers the category form shading as an index of affective dependency. Both Rapaport and Klopfer, besides, considered achromatic color responses linked to dysthymia and depressive mood. With regards to classical color-affect interpretative hypothesis, this has been discussed by some authors in recent years (Frank, 1993) and confirmed by others (Greenwald, 1991). According to these authors form color responses appear as an indicator of positive functioning and color-form as a mark of affective passive response, which is not modulated by cognitive consideration. In the last years, indeed, a relational interpretation of color responses has been proposed (Overton, 2000). This interpretation considers color area not only as a range of human emotions, from immature to mature expression, but also as an index of relationship quality between oneself and other people. In this study, we examined eating disordered subjects with this projective technique, to verify differences in each diagnosis profile within emotional and affective expression. In particular, we hypothesized the presence of different emotional patterns in eating disorders compared to normal controls, and the presence of personality traits similar to depressed and anxious patients. Methods: Participants and procedure: 212 Italian, urban subjects participated in this study. Clinical groups are constituted by consecutive samples of female patients diagnosed and treated at Policlinico Gemelli Day Hospital service in the last five years. They were diagnosed following DSM IV TR criteria and using clinical interview. Before starting treatment, they were also submitted to Rorschach Test as a part of psychodiagnostic assessment. Emotions in eating disorders 77

Group AnRt (Anorexia restricting type) consisted of 36 subjects (mean age 19.53 ± 5.06 years); Group AnPg (Anorexia binge eating/purging type) consisted of 35 women (mean age 23.11 ± 4.91 years); Group Bu (Bulimia) consisted of 27 subjects (mean age 24.3 ± 5.54 years). They were compared with two clinical Groups: Group Dep (Mood Disorders) and Group Anx (Anxiety Disorders), the first with 34 subjects (mean age 25.47 ± 7.36) and the second with 36 subjects (mean age 23.32 ± 5.91). All clinical groups were also compared to a control group of 41 subjects (mean age 22.15 ± 3.5 years.) in healthy psychophysical condition. The sample characteristics are shown in Table 1. Anorexic subject’ lower mean age can be explained by lower age that is common in the first phase of this disease. BMI (Body Mass Index) was calculated for Eating Disordered Patients: in Group AnRt mean BMI was 15.71 ± 2.74, in Group AnPg mean BMI was 18.52 ±2.02, while in group Bu mean BMI was 25.17 ± 6.60.In depressed and anxious women groups, there were not relevant weight problems. Groups Dep and Anx diagnoses are showed in Table 2. Table 1 : Sample Characteristics AnRt AnPg Bu Dep Anx Controls (N:36) (N:38) (N:27) (N:34) (N:36) (N:41) Age: (Mean±S.D) 19.53±5.06 23.11±4.91 24.3±5.54 25.47±7.36 23.32±5.91 22.15±3.5 Education Middle 58.52% 25.71% 8.00% 20.00% 35.36% 2.57% School 38.24% 71.43% 80.00% 68.57% 61.61% 84.61% Diploma Degree 2.94% 2.86% 12.00% 11.43% 3.03% 12.82% Occupation Nill/Homely 12.12% 27.28% 17.39% 15.63% 9.38% 2.45% Worker 12.12% 30.30% 21.74% 34.37% 34.37% 21.95% Student 75.76% 42.42% 60.87% 50.00% 56.25% 75.60% Marital Status Married 7.14% 3.70% 13.33% 35.00% 20.83% 5.88% Unmarried 92.86% 88.89% 80.00% 65.00% 79.17% 94.12% Divorced ------ 7.41% 6.67% ------ ------ ------ Table 2 : Diagnoses in Depression and in Anxiety Groups (DSM IV criteria) Depression group N: 34 Dysthymia 24 Subjects Cyclothymia 2 Subjects Major Depression 8 Subjects Anxiety disorders group N: 36 Generalized Anxiety Disorder Di 25 Subjects GAD with Phobia 3 Subjects Obsessive-Compulsive 4 Subjects Panic Disorder 6 Subjects Assessment Methods: We have chosen Rorschach test, which is considered the most important method in projective techniques field so far (Lerner P.M., 1983). This test took in exam the relationship between individual perception and personality, starting from the point that subjective way to organize single inkblot during perceptive process, can reflect fundamental aspects of its psychological dynamics. The subject therefore, is stimulated to reveal “his inner world, telling what he sees on the different tables, on which he projects his intentions, meanings and feelings”(Klopfer, 1971). Rorschach poorly structured material makes subject not to answer to tables ambiguous stimuli referring to social and cultural rules, so that the given answers make personality aspects emerge, which he doesn’t know completely (Daini, 1995). Moreover, according to Chabert (1993), Rorschach is an “identity proof”, as 78 Daini & Bernardini

it induces regressive dynamics and the poor definition inkblot, that is its particular configuration, represents a “border test ” to the subject, since it provokes a comparison between inside and outside, between subject and object. The Rorschach has a long tradition as a psychodiagnostic instrument, because it offers many different information on personality, especially including affects, cognition, self-perception and interpersonal aspects. It is a projective methods, that intends not to measure an individual, but to describe him on the basis of a dynamic scheme of interdependent functions or variables, and this interrelationship may be an obstacle regarding validation issue (Klopfer, 1971). Although others typical psychological tests have been used to investigate the personality nowadays, the results of several and recent studies are considered to empirical support for the validity of the Rorschach. The Rorschach was administered following Klopfer and Davidson’s procedure and it was also used as scoring system. The Test was scored for clinical purposes by one of the Authors, blind as to the object of this research. The variables considered in this study were the number of answers (R) as a productivity index, the shade determinants (Fc, shading with good form level; c , shading with poor form level, and C’, dark light) as indicators of affective tendencies and color determinants (FC, form color, CF, color form..and C, color without form) as indicators of subjects’ emotional reactivity. The sum of achromatic determinants in addition to that of color ones, and their relationship were secondarily studied. Sum of colors (FC+CF+C), the sum of shading (Fc+c+C’) and their relationship between achromatic and chromatic division was interpreted by Klopfer as a mark of affective frustration. The weighted sum of colors (ÂC= FC+2CF+C/2) was also considered. Before doing statistic analysis, all data were transformed as square root of the raw score (the frequency of each variable in the protocol) to reduce skewness and kurtosis of each distributions, as proposed by Ercolani e Coll., 2000. First, age differences effect on Rorschach variables was calculated. Then, correlations between dependent variables were calculated as Pearson’s r. The effect of group variable was analysed by MANOVA, for simple Determinants, and the post hoc differences between group means were inquired by Duncan’s test. Composite variables were analysed by ANOVA. Statistical elaboration was performed with SPSS11.0 program. Results: Age didn’t show a significant effect on Rorschach variables, including productivity, nor a significant interaction with the independent variable “groups“. It was not then considered in subsequent analyses. Table 3 : Correlation between Rorschach Variables R t/R achrom t/R chrom Fc c C’ FC CF C IR Sum Sum Achrom achrom chrom /chrom R Pearson Correlation -.126 -.157* .484** .218** .233** .440** .171* -.113 .329** .475** .426** .174* t/R achrom Pearson Correlation .690** -.121 -.042 -..219** -.098 -.120 .004 -.115 -.200** -.157* -.131 t/Rcrhom Pearson Correlation -.014 -.027 -.202** -.0149* -.090 .025 -.106 -.117 -.180** -.052 Fc Pearson Correlation .202** .263** .271** .198** -.151* .252** .810** .286** .498** c Pearson Correlation .105 .068 .247** .134 .023 .340** .240** .200** C’’ Pearson Correlation .279** .275** .103 .048 .721** .438** .494** FC Pearson Correlation 1 .074 -.084 .059 .335** .740** -.005 CF Pearson Correlation .016 -.085 .318** .636** .040 C Pearson Correlation -.219** .006 .158* -.068 IR Pearson Correlation .200** -.055 .229** Sum achrom Pearson Correlation .462** .643** Sum chrom Pearson Correlation .062 Achrom/chrom Pearson Correlation * Correlation is significant at the 0.05 level (2-tailed) ** Correlation is significant at the 0.01 level (2-tailed) Emotions in eating disorders 79

In Table 3 correlations between Rorschach variables in the whole sample are reported. The Rorschach variables are significantly interrelated, and almost all of them show a correlation with productivity. In fact, R show a relevant or very significant positive correlation with determinants, allowing us to hypothesize that subjects with higher productivity will probably score higher in all determinants. A significant negative correlation appears with reaction time to chromatic cards (T/R chrom.), underlying that less responsive subjects tend to hesitate in front of stimuli with higher emotional value. Reaction times show a positive correlation between each other, while a longer reaction time to achromatic cards shows a significant negative correlation with C’, sum of achromatic and sum of chromatic determinants. Reaction time to chromatic tables, indeed, shows significant negative correlation with both C’ and Fc determinants sum C. In the shading area of determinants, Fc, c and C’ show an highly significant correlation, but also a significant positive correlation with color determinants (FC, CF and sumC). The same occurs to c determinant. C’, one of depression indexes according to Klopfer, is positively related to R, Fc, but also with FC and CF and their sum. MANOVA results are reported in table 4, regarding to differences between groups ( Wilk’s Lambda 0.680, p < .008). Table 4 : MANOVA Diagnosis (AnRt, AnPg, Bu, Dep, Anx, Controls) Productivity Scores, Reaction Times and Determinants AnRt AnPg Bu Dep Anx Controls F Duncan (N:36) (N:38) (N:27) (N:34) (N:36) (N:41) Post-honc Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD Test R 3.94±0.5 4.33±0.7 4.14±0.6 3.92±0.6 4.23±0.7 4.90±0.9 9.16*** C>AnRt* C>AnPg* C>Bu* C>Dep* C>Anx* AnRt<Bu* Dep<Bu Dep<C* t//R achrom 3.17±0.9 3.28±1.3 3.28±1.3 3.66±1.1 3.54±1.0 3.31±1.2 0.42 t//R chrom 4.16±1.3 3.77±1.4 3.87±1.2 4.04±1.5 4.19±1.2 3.49±1.1 1.51 Fc 0.94±0.7 1.37±0.7 1.17±0.8 0.99±0.7 0.97±0.8 1.57±0.7 4.25** C>AnRt* C>Bu* C>Dep* C>Anx* AnPg>AnRt* AnPg>Dep* AnPg>Anx* c 0.15±0.4 0.36±0.5 0.34±0.4 0.24±0.4 0.23±0.3 0.27±0.5 0.74 C’ 0.92±0.7 1.11±0.6 1.10±0.8 1.07±0.8 1.03±0.7 1.25±0.6 0.78 FC 0.95±0.7 1.06±0.7 1.07±0.7 1.24±0.6 1.04±0.7 1.64±0.8 6.77** C>AnRt* C>AnPg* C>Bu* C>Dep* C>Anx* CF 0.85±0.7 0.92±0.6 1.16±0.5 0.96±0.7 0.90±0.6 0.98±0.8 0.56 C 0.16±0.5 0.11±0.4 0.14±0.3 0.12±0.4 0.13±0.3 0.02±0.1 0.74 -*: p<.05-; **-: p<.01-; ***-: p<.001 80 Daini & Bernardini

In depression group there is the lower number of responses, while controls show a significantly higher production than almost all clinical groups except anxious patients. The means of Fc determinant are higher in control group than in all clinical groups, while restrictive anorexic show the lowest ones. The other two sub groups of eating disordered patients show an intermediate mean value between restrictive and healthy subject. FC determinants show significantly higher values in normal subjects, as expected . The Duncan’s posthoc test shows that differences between clinical groups are not significant (Table 4) The variable C shows lower mean in controls and the highest mean in restrictive anorexia group, but it is not significant according to Duncan’s test ANOVAs didn’t emphasize significant differences between diagnostic groups and between clinical subjects and controls on composite variables of shading and color. Discussion: Our data confirm both Rorschach determinants dependence from productivity and their interrelatedness. Therefore, the test should be seen as a communication flow, easier in healthy subjects than in patients with any diagnosis. With regards to the relationship between age and Rorschach variables, a non significant trend appears in older anorexics to give a lower number of answers, and in older bulimics to give an higher number of answers and an higher number of FC determinants than younger ones. This trend suggests an adjustment phenomenon, considering that younger adolescents are closer to eating disorder’s beginning. In anorexia towards a more evident narcissistic retrait and in bulimia towards a more open communication. On the whole, the productivity and selected dependent variables independency from age, despite the wide age range (12-41), allows us to consider these indicators as quite stable personality characteristics throughout the evolutional age, from adolescence to adulthood. As regards the differences between diagnostic groups, we find out a substantial resemblance between restricting anorexics and depressed patients, because of a lack of significant differences in all parameters. Depressive psychopathology in anorexia has been frequently attributed to physical condition and to metabolic changes, which are typical of this syndrome. In our observations, the analogy found in a sample of depressed patients, in good physical health and without weight problems, allows us to discuss the secondary nature of depression in anorexia. Obviously, observing depression before disorder onset and weight loss could state a different causal link with depression as primary change. However, in our samples psychological restraint which is common common to anorexia patients and depressed ones allows us to doubt that depression in anorexia is a mere consequence of global physical changes after weight loss. In this direction, in their recent study Maselle & Coll (2006) observed, after interviewing a community sample developmental course, that initial depression in adolescence is a predictor of eating disorders in older age. In fact, Rorschach test seems to put in evidence a depressive psychopathological dimension, which is characterized by a difficulty in expressing through words the emotional feelings -both with positive and negative affective value- and by refusing affective dependence from the others (low Fc levels). At various levels, these features, more evident in depression and in restricting anorexia, are present in the other eating disorders considered in this work. Anorexia bingeing purging type shows a considerably lower productivity than in controls and bulimics, but is not different from them with regards to shade determinants frequency. The same AnPt group shows higher shade means than restricting anorexics, depressed and anxious patients. Emotions in eating disorders 81

Bulimic group shows lower R and shade and color answers than normal controls, and it differences from other clinical groups only for an higher productivity than restricting and depressed subgroups. Our study results partially agree with the ones of Montebarocci & Coll (2006). Both of them show that perceived inability to experience emotional feelings is present in restricting anorexia but not in bulimia. In any case, the fundamental Rorschach shade and color variables can distinguish the features of each eating disorder. The diagnoses heterogeneity in anxious clinical sample could explain the lack of significant differences compared with the other groups. Contrarily to classical hypotheses, depressive feelings in anorexics and in depressed patients don’t result from an higher number of dark light responses. The achromatic determinants, and in particular C’, don’t produce any significant difference between normal and pathological groups, at least in a quantitative analysis context. Our observations are congruent with those underlying the absence of support of the association between C’ and depression (Frank, 1995). As to other determinant Fc, our observations agree to the interpretation, which considers shading as an index of object relation (Kleiger, 1997). Normal subjects can be more able to establish relation and be concerned about the impact of one’s emotion on others. In this sense, anorexic women and depressed patients seem to fail this ability and to be more narcissistically centred. Conclusions: Our quantitative analysis of Rorschach protocols shows a substantial resemblance between restricting anorexia and depression as to emotional expression and imaginative life compliance, with a defensive flattening of affects in both groups. Likeliness and differences between eating disorders subgroups can be cleared by this projective technique. On the contrary, anxiety disordered patients seem comparable to normal controls as to shade and color Rorschach parameters. This projective profile in restricting anorexia points out the importance of addressing psychotherapeutic work with these patients to depressive core of this pathology. Acknowledgement: We wish to thank Dr. Paolo Iliceto, for data statistical analysis. References: American Psychiatric Association. (2000). DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. American Psychiatric Press. Blinder, Bj., Cumella, Ej., Sanathara, Va. (2006). Psychiatric co morbidities of female inpatiens with eating disorders. Psychosom. Medicine, 68 (3), 454-462. Bornstein, Rf., Greenberg, Rp. (1991). Dependency and eating disorders in female psychiatric inpatiens. Journal of. Nervous and Mental Disease, 179 (3), 148-52. Chabert, C. (2003). Psicopatologia e Rorschach. Milano: Raffaello Cortina. Daini, S., Ferro, F. M. (1995). Trasformazioni e silenzi del corpo. Studi sull’anoressia nervosa. Chieti: Metis. Di Nuovo, S. (1989). Il Test di Rorschach in Psicopatologia. Milano: Franco Angeli. Eells, Gregory T., Boswell, Donald L. (1994). Validity of Rorschach inanimate movement and diffuse shading responses as measures of frustration and anxiety. Perceptual and Motor Skills, 78, 1299-1302. Elfhag K., Rossner, S., Carlsson, A.M. (2004). Degree of body weight in obesity and Rorschach personality aspects of mental distress. Eating Weight Disorder, 9, 35-43. Elfhag K., Rossner, S., Carlsson, A.M., Barkeling, B. (2003). Sibutramine Treatment In Obesity: Predictors of Weight Loss Including Rorschach Personality Data. Obesity Reasearch, 11, 1391-1399. 82 Daini & Bernardini

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