SIS Journal of Projective Psychology & Mental Health

Editorial: Dissolving Death Anxiety with Yoga Empowered SIS WilfredA. Cassell Attempted Suicide in Borderline Patients: Projective Suggestions and Clinical Paths. Rossetti, R. and Silvia Daini Role of Emotion Regulation Difficulties in Predicting Mental Health andWell.being Prachl Saxena,Akanksha Dubey and Rakesh Pandey Penetrative Interpretation of the Inner Selfofa Case through Projective Imagery: A Comparative Exploration Nilanjana Sanyal, Manisha Dasgupta and SarikaAgarwal Diagnostic Indicators of 515-1 among Non Paranoid Schizophrenics Bhawna Singh, Rajni Kashyap and A. K. Srivastava Pathological Personality and Approval Motive in Smokers Archana Singh, S. K. Singh and R. K. Singh Dissociative Convulsion Disorder: ACase Study Preeti Pandey, Ajay Tiwari and Nalini Mishra Depression, Personality Characteristics and Gain among Female Patients Suffering From Somatoform Disorder and Chronic Physical Pain In Comparison to Normal Controls Damayanti Datta, Jayan!i Basu and Gautam Bandyopadhyay Coping Strategies and Psychological Defenses Used by Mentally III Criminals Vidhata Dixit, D. K. Kenswar, Jai Prakash and Amool R. Singh Assoclatlonal Contents of Rorschach and its Relationship with Verbal Intelligence in adults Shweta, R. C. Bajpai.A R. Singh and K. S. Sengar Cognitive Flexibility in Patients with Bipolar Affective Disorder: Current Episode Mania S. K. Yadav, S.Alreja, K. S. SengarandA. R. Singh 123-129 130-146 147-154 155-164 165-167 168-172 173-176 177-185 186-192 193-199 200-205 Official Publication of the Somatic Inkblot Society

Somatic Inkblot Society OFFICE BEARERS President : B, L. Dubey (USA) Vice President : Brig. D.Saldanha (India) Gen. Secretary : Masroor Jahan (India) Joint Secretary : P.K.Singh (India) Treasurer: Padma Dwivedi (USA) Executive Members : WilfredA. Cassell (USA) Rakesh Pandey (India) Nalini Mishra (India) Arcahna Singh (India) K. S. Sengar(lndia) Manisha Kiran (India) MaryCassell(USA) Asheem Dubey (USA) George Savage (S.Africa) Silvia Daini (ilaly) 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 menial 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 behavior. The journal includes (a) research articles (b) book reviews (c) brief reports (d) news about conferences and letters to the editor. MANUSCRIPTS PREPARATION : Manuscripts should be typewritten (single-spaced throughout) submitted through E-mail orin CD toB.L. Dubey. Ph.D. Editor Emeritus, SIS Journal. E-mail:bldubey@gmail.com with a copy to Amool R. Singh, Ph.D. Editor In Chief, Director, RINPAS & Prof. Clinical Psychology, RINPAS, Kanke, Ranchi-834006. E- mail:sisamool@yahoo.com. Cell: 91-9431592734. The Editors reselVe 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 $50 for foreign members and Rs. 300, for Indian members, Institutional subscriptions are US $100. for Foreign institutions and Rs.l 000 for Indian institutions. Life membership is US $400 for foreign members and Rs. 2500/- for Indian members. Indian institutional life membership is Rs. 10,000/-. Non-members may subscribe for $60 or Rs.250 per issue. Cheques should be made payable to "SIS Journal of Projective Psychology and Mental Health" at Ranchi and should reach Amool R.Singh, Ph.D. Editor In Chief, Director, RINPAS & Head, Dept. of Clinical Psychology, RINPAS, Kanke, Ranchi-834006. 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 $10IRs.501- if you are sending subscription through cheque. CHANGE OF ADDRESS. Members should inform B.l. Dubey, Ph.D, Director SIS Centre, mail:bldubey@gmail.comofanychangeofmailingaddress. Copyright@1994.SISCenter,lndia/Anchorage Website: http://www.somaticinkblots.com Online Testing: http://psyche.dubay.bz OR http://122,16096,85:1001ISISTest

Abstracted in “APA’s Psyc INFO “ Regd. No. 71632/99, RNI Delhi SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH Volume 18 Number 2 July 2011 EDITORS EMERITUS Wilfred A. Cassell, MD, Director, SIS Center, 4501E,104th Avenue, Anchorage, AK.99516 (USA). E-Mail: siscassell2@yahoo.com Bankey L. Dubey, Ph.D., Director SIS Centre,4406 Forest Rd, Anchorage, AK 99517 Cell : 907-250-8834,E-mail: bldubey@gmail.com EDITOR-IN-CHIEF Amool R. Singh, Ph.D., Director, RINPAS and Prof. Clinical Psychology, RINPAS, Kanke, Ranchi-834006 (India). Cel.:91-9431592734, E-mail:sisamool@yahoo.com EDITORS Suprakash Chaudhury, MD, Ph.D., Prof. & Head, Dept. of Psychiatry, RINPAS, Kanke, Ranchi- 834006, Mob.:91-09334386496 E-mail: suprakashch@gmail.com Rakesh Pandey, Ph.D. Professor, Dept. of Psychology, Banaras Hindu University,Varanasi-221005 Cell:91-9415812329, E-Mail: rpan_in@yahoo.com Anand Dubey. B.E., MBA, SIS Centre, 4406 Forrest Road, Anchorage, AK 99517 E-Mail: anand. dubey@gmail.com Padma Dwivedi, M.A., 4406 Forest Road, Anchorage, AK 99517 mail: sisdubey@yahoo.com Jai Prakash, Ph.D., Ass. Prof. Dept. of Cl. Psychology, RINPAS, Kanke, Ranchi-834006 E-mail: drjaiprakashrinpas@rediffmail.com Cell: 91-9934582290 Umed Singh, Ph.D., Dept. of Psychology, Kurukshetra University, Kurukshetra-136119. Cell: 91-9416511077 Email Umedsingh_78@yahoo.com. EDITORIAL CONSULTANTS Kristian Aleman, Ph.D., Sweden K.R.Banerjee. MRCP India Saugata Basu, Ph.D., India Carina Coulacoglou, Ph.D., Greece N. G. Desai, M. D., India Philip Greenway, Ph.D, Australia S. Haque, M. D., India M. Jahan, Ph.D., India Arvind Keshary, Ph.D., India Anatoly B. Khromov, Ph.D., Russia H. Kumar, Ph.D., USA R. Kumar, Ph.D., India Sudhir Kumar, M. D., India A. S. Kundu, Ph.D., India Ram Jee Lal, Ph.D., lndia Anu S. Lather, Ph.D., India Lisa Milne, Ph.D., Australia Nalini Mishra, Ph.D., India Ashok Kumar Nag, M.D., India Paola Nicolini, M.A., Italy Edward M. Petrosky, Ph.D., U.S.A. Marisa Porecca, Ph.D., Italy Kiran Rao, Ph.D., India Stefano Reschini, M.A, Italy Barry A. Ritzier, Ph.D., U.S.A. D. Saldanha, M. D., India Nilanjana Sanyal, Ph.D., India K. S. Sengar, Ph.D., India D. K. Sharma, MHA, India Radhe Shyam, Ph.D.lndia Archana Singh, Ph.D., India V. K. Sinha, M.D., India A. K. Srivastava, Ph.D., India Kalpana Srivastava, Ph.D., India Trayambak Tiwari, Ph.D., India Ailo Uhinki, Ps.D., Finland A. N. Verma, Ph.D., India Yasho V. Verma, Ph.D., India Robert B. Williams, Ph.D., Canada

SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH: ACHIEVEMENTS Journal in WHO Listing Members of Somatic Inkblot Society will be glad to know that SIS Jr. of Projective Psychology and Mental Health has been listed by World Health Organization (Global Forum for Health Research) among 25 indexed journals that have published the highest number of articles on mental health from LMICs in Latin America, Africa and Asia (Medline and PsycINFO). Extract from table-6 of “Research Capacity for Mental Health in Low - and Middle - Income Countries: Results of a Mapping Project “(www.globalforumhealth.org) is given below: Journal in Pro Quest Listing: We are glad to inform you that SIS Journal of Projective Psychology & Mental Health has been listed in academic research database ProQuest Psychology Journals™. ProQuest is a company in Michigan, United States. It is a leading provider of electronic databases for academic libraries. Databases are used in over 20,000 academic libraries around the country and around the world including some of the most prestigious higher education institutions such as Harvard, Yale, Princeton, Oxford ect. ProQuest provides abstracts and indexing for more than 640 titles, with over 540 titles available in full text. Users get access to charts, diagrams, graphs, tables, photos, and other graphical elements essential to psychological research. Rank Journal Country Language Revista de Psicoanalisis Argentina Spanish Revista de Neurologia Spain Spanish Revista Brasileria de Psiquiatria Brazil Eng.,Spani.,Portuguese, Arquivos de Neuro-psiquiatria Brazil Portuguese Acta Psiquiatrica y psicologica de Amercia Laina Argentina Spanish Journal of the Medical Association of Thailand Thailand English, Thai British Journal of Psychiatry UK English Acta Psychiatrica Scandinavica Denmark English Salud Mentale Mexico Spanish Vertex Argentina Spanish Journal of Personality and Clinical Studies India English Social Psychiatry and Psychiatric Epidemiology Germany English Revista Medica de Chile Chile Spanish South African Journal of Psychology South Africa Afrikaans, English Psychological Reports USA English South African Medical Journal South Africa Afrikaans, English The Australian & New Zealand Jr. of Psychiatry Australia English International Journal of Social Psychiatry U. K. English Psychiatry Research Ireland English Social Science & Medicine U. K. English Revista De Saude Publica Brazil Portuguese International Journal of Geriatric Psychiatry U. K. English SIS Jr. of Projective Psychology & Mental Health India English Journal Brasilerio de Psiquiatria Brazil Portuguese Psychiatry and Clinical Neurosciences Australia English

Editorial Dissolving Death Anxiety with Yoga Empowered SIS

This editorial is dedicated to the spirit of the unknown individual who eons ago accepted a monumental gift from our “Cosmic Creator”. This Divine selected person was given positive energy accompanied by enlightening insight concerning the “Body image” focusing foundation principles underlying Yoga. Because of its antiquity, there was no written record documenting the exact date yet this was a momentous event in our human history of knowledge. It provided the intellectual stimulus for all subsequent developments in mind-bodyspirit theory. Gradually over the centuries, devout practitioners refined techniques conceived to optimize the multilevel benefits from the practice of this discipline. It is anticipated that more optimal refinements may come from futuristic studies involving the blending of Yoga, dream imagery and SIS concepts. Historically, after the advent of the scientific method, many rigorous international studies have documented Yoga’s multiple positive health effects. Unfortunately, this documentation has been primarily related to physiologic/psychological functioning. Less has been scientifically accomplished with humans regarding “spirituality”. Perhaps, this is partly because of the intangible nature and remoteness from mathematical quantification of this dimension. Fortunately, fascinating progress has been made recently, in scientifically assessing higher mental/behavioral processes in other living creatures. Some scientists suggest that these may even indirectly provide a lens for viewing the primitive foundation of the human soul. In any case, I have observed instances in which projective inkblot techniques and dream data can be blended with Yoga guided somatic awareness. Pilot studies suggest that such a blending process may bring into focus the spiritual dimension for observation and modification. One fundamental spiritual/philosophical/ religious construct for introspective humans concerns our Cosmic passage through existence in a time limited biological vessel destined to die. For many people this dilemma necessarily poses an affect arousing threat, while contemplating one’s fragile “Body image”. Sometimes the negative energy surrounding their anticipation of dying is sufficiently severe to trigger mental disturbances in childhood (e.g. “Nightmares”, somatic symptoms etc.). Later in adolescence and early adulthood these may become more cognitively formulated linked with threatening affect operationally herein defined as “Death anxiety”. This was periodically experienced by my deceased psychiatrist mentor, inkblot artist Herman Rorschach. For illustration purposes, please consider the following imaginary interview: Now I invite the reader to share an imaginary conversation of mine with Rorschach’s soul involving a science- fiction- like type of Cosmic time/space travel: “Herman, please allow me to introduce myself. My name is Wilfred Cassell, a fellow inkblot designer living in the early 21st century. I know that in your short, professional career, that you did not receive much support financially. It must have been humiliating that solely for economic reasons, your publisher omitted one third of your inkblots. I want to immediately share some good news from earth: YOUR TEN REMAINING INKBLOTS TURNED OUT

124 Cassell TO BE THE BASIS FOR A HIGHLY VALUED PROJECTIVE TECHNIQUE! Please rest assured that your legacy lives on in this 21st century, especially in modern day India. Perhaps you might be interested in some historical background regarding India’s rise to prominence. After the World War that Hitler was planning at the time of your death, and thankfully lost, Indian citizens became free from British imperialism. Now, India is rapidly emerging beyond its rich heritage of Yoga based, depth psychology as an international leader in projective inkblot techniques. Unlike the study of brain anatomy, the study of central nervous system function can only be brought to full fruition in an open cultural atmosphere. In India, there is an optimal integration growing between times honored, body-mind-spirit insights, with projective knowledge, derived from modern electronic inkblot technology. India now provides a secure democratic bastion in a world still beset by evil. Many countries still live in the dark intellectual ages blinded by Hitler- emulating, authoritarian, repressive political/religious leaders. Many would, if they could “burn” all projective literature, in order to destroy all such in-depth reality testing, honest enquiry. They capitalize on the immature desires of those who were neglected /abused in their early development years, who habitually seek authoritarian parental surrogates. They cling to leaders who facilitate the projection of their own hidden inner world erotic/aggressive, sadomasochistic impulses on victims like the German prison guards did to the Jews and others during World War II. At this point, I would like to give you a brief historical review of the evolution of your technique. You may recall attempting to develop a scoring method in order to appraise and quantify responses. Of course, your untimely death prevented any significant progress in the development of an assessment system. Fortunately, several insightful psychologists took up the development of a meaningful analysis based upon an integration of both examination strategies. Of course, when culturally normative data scores are ignored, this opens up the criticism that the data reflects more what is on the examiner’s mind than that of the responder. Yet after World War II, this did not deter psychoanalysts to clinically explore the treatment applications of Rorschach Content Analysis.” Unfortunately, their promising findings are now more a part of history, than modern clinical practice. At this time, Herman, I would like to give you a brief historical review of your inkblot technique’s growth since your untimely death prevented any significant progress in developing a meaningful assessment system. Fortunately, many psychologists have made extensive contributions not only in clinical diagnostic settings, but, as well, many other test assessment applications. Yet, while of considerable statistical merit, these sometimes fail to openly declare, that their particular scoring system did not rely on basic principles of projection. In their absence, it is a misnomer for the professional examiner to refer to the results as data fundamentally derived from a “Projective test“. This categorization is only accurate when the reviewer scores responses for either direct or symbolic meaning through content analysis. Typically, in clinical practice, the response review is not an “either or situation.” Most experienced psychometricians will provide a meaningful analysis based upon an integration of both assessment strategies. Yet, the generally recognized value of your inkblots is a testimony of their “pulling power” to release in projective awareness diagnostically relevant imagery. While others have designed inkblots, our only describes the work of one psychologist, Wayne Holtzman. He made an

Dissolving Death Anxiety with Yoga Empowered SIS 125 A and B series with 45 inkblots in each form, plus two practice blots common to both forms, a total of 92 different blots, some of which are not symmetrical. He advocates counting only one response per card. He also appreciated the symbolic power of content analysis and illustrated this approach by reviewing a case history in his book. My work with your ten inkblots began in 1959. I developed two such scoring systems for assessing degrees of focal body awareness associated with somatic symptoms. These are briefly outlined in this book in the section describing “the Somatic Inkblot Series (SIS)”. The objective of my original investigation was to study the relationship between a subject’s heart awareness and the sensory feedback of cardiovascular activity. However, as you know, in your ten inkblots there is only a little colorform structure suggestive of the heart. In pilot studies, I soon found it not methodologically worthwhile using them for such “psychosomatic” research. Consequently, I designed a set suggestive of the heart. After these were found to be useful, I applied the same projective principle in designing inkblots with structure relative to a variety of somatic regions as well as common, clinical imagery themes. Exploring Rorschach’s Occupational Secondary Empathetic Stress: Next, I wish to speak more personally about your final professional years on planet earth. Your pioneering, projective studies in Switzerland also demanded mental strength because of an ever menacing evil political climate. Your views, concerning the underlying nature of mental disorders, were conceived in the intellectually repressed period prior to World War II. In that era of mental science, the racist shadow of Hitler’s genetic biases was casting a dark shadow throughout Europe. In Germany, many psychiatric patients suffering from Schizophrenic Disorder were murdered by injection. Because of your humanistic inkblot projective studies exploring the psychological distortions of the psychotic mind, no doubt you were indirectly pressured by Nazi, brain programmed Swiss hospital authorities. I empathetically understand your past suffering, prior to your untimely death at age thirtyseven. Prior to the introduction of antipsychotic medication in the second half of the 20th century, attempting to diagnose and treat catatonic, withdrawn or alternatively aggressive, delusional, hallucinating, psychotic patients, must have been highly stressful. Probably at times, like other psychiatrists working in such a psychologically toxic environment, you have suffered from what we now refer to as secondary, empathetic traumatic mental stress symptoms. Unlike your psychiatric hospital colleagues, you were much more at risk for this occupational hazard. Ironically, this was likely partially traceable to the powerful projective technique that you yourself had designed. Your secondary empathetic exposure was greatly magnified when you peered into the psychotic inner world of such suffering souls through the powerful projective lens of your inkblots. Fortunately, modern hospital psychiatrists have a variety of helpful antipsychotic drugs to reduce such disturbances. However, without these available, no doubt their tormented projected imagery vividly exposed your own brain’s visual centers and emotion linked neural networks to their tormented pathologic “nightmares,” somatic delusions, hallucinations, affect storms etc. Through the magic of this spiritual cosmic connection, let me act for a few moments as your own personal psychotherapist. In my opinion, your professional life situation was comparable to that of the early 20th century radiologists. Many of them were largely naïve about their unprotected occupational exposure to cancer inducing radiation that could subject them to cancer. Prior to this knowledge, some died prematurely. Like them, you are an inspirational historical hero in my imaginary, 21st century scientific hall of fame.

126 Cassell I would like to continue this brief therapeutic analysis by exploring the psychological significance of a stress triggered dream, which apparently you dreamt as a young medical student: “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 dissecting of the brain interested me particularly, and I joined to it all kinds of reflex ions about the localization and the cutting up of the soul. The deceased 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 HEMISPHERE AND FELL FORWARD, EXACTLY AS IT HAD HAPPENED AT THE AUTOPSY. THESE BODILY SENSATIONS (I LACK A MORE PRECISE DESIGNATION) WERE VERY CLEAR, AND THE MEMORY OF THAT DREAM IS NOW FAIRLY VIVID”. Perhaps, Herman you will still recall this body-mind-spirit, significant dream. Please understand that I have respect for your artistic creativity and courage to challenge the early 20th century clinicians, who solely relied on psychic surface phenomenon obtained from archaic, psychiatric interview techniques. So do not be offended if I attempt to assist you in bringing to your spirit’s attention its possible significance to your having experienced an exaggerated degree of Death anxiety. My help is based upon the notion that no one, no matter how symbolically sophisticated, that no mortal can comprehensively interpret his/her personal dreams. The fact that you remembered the details of the dream so accurately, many years later, suggests that it was linked with high anxiety. Next, I wish to draw attention to its possible meaning through Content analysis. Notice that the projected imagery contains content referring to two dimensions: (1) the human brain, as a physical object of the human body on the planet earth and (2) the “soul” as a spiritual dimension of Brahman consciousness connecting to the “Afterlife” in “Pre Big Bang” cosmic existence.

My interpretation is that it was the probably the latter death related connotation that activated the threatening emotions. We now know that as a result of such an occupational environment, psychiatrists have traditionally had a relatively high rate of self destructive behaviors, including what now seems like suicidal behavior. May I ask you a personal question? Did this stress play a role in neglecting to seek prompt treatment for your ruptured appendix? Also, forgive me if I seem to insult you, but I am trying to assist you in discovering the dream’s significance. Did you have an interest in finding out if various predictions about the “Afterlife” made by the world’s major religions were valid? In neglecting your ruptured appendix were you depressed, or perhaps even suicidal, wishing to escape your emotionally painful professional life? Or alternatively, were you simply curious about what it would be like to prematurely pass through the spiritual door leading to “Pre Big Bang” existence? In addition, I would like your impressions, regarding the nature of the “Afterlife.” Being seventy seven years old, I expect to be joining it soon. Many on earth anticipate that it really is a loving “Heavenly” spiritual dimension. Many believe that it is where; ultimately, after the soul exits the human body (like in SIS-II B 22), it can reunite with deceased loved ones and other meaningful souls. Sometimes, especially during the early stages of grieving, some humans periodically experience the extrasensory mystical impression, that their deceased loved one is spiritually present. In addition, such visitations reassure in dreams, during which the visitor’s loving spirit appears to be free of human cares and worldly suffering.

Dissolving Death Anxiety with Yoga Empowered SIS 127 Of course, many skeptics consider such emotionally charged mystical experiences quite irrational. They critically focus on the wishful thinking aspects of religious dogma, that promise: “Pie in the sky when you die, it’s a lie, ” for example, “Being next to the feet of God, with your sins forgiven - if you donate money to the church,” “Being sexually rewarded if you sacrifice your body in terrorist acts, ” etc. Before ending Herman may I ask one more favor? Would you please consider helping me by providing a “Second opinion” regarding a man fifty years old? He has been in treatment with me and a female psychotherapist at intervals for several years. He suffers from Chronic Recurrent Major Depression and episodically has benefited from psychotherapy and antidepressant medication. Moreover the past year, he has actively engaged in Yoga for thirty minutes in the morning and ninety in the evening. The onset of his Affective Disorder was in his childhood. It began when his father at thirty seven years old developed terminal cancer. As an eight year old boy, he had felt “incredible love” for his dad. After a long period of suffering, his father eventually died. Years later as an adult in therapy, he recalled that this had triggered “grief that was unbelievable…I still carry the grief today pretty buried inside…If I dream of him (He tended to experience such dreams around the anniversary date of his father’s death. An example follows: In my dream I wanted to visit his grave but I got lost driving…I felt sad and was crying… and had to stop to get directions but they didn’t match)…I’m able to cry…I still miss him terrible… the loss was tragic…the whole world came to an end…part of myself was torn open and left that way!” When asked about his mother‘s reaction, he said that “She was devastated…she changed…she became distant and never came back emotionally.” (His mature female psychotherapist partially functions as a surrogate mother figure assisting him in resolving maternal emotional abandonment issues.) While he was temporarily away working in a remote wilderness setting, in a follow-up telephone psychotherapy session, he was asked if he would give permission to share his clinical history. He e-mailed the following: “I typed up the dream that we talked about (in the office)…that was one of those tough ones where the grief comes out…it never is a very pleasant experience…but necessary…please feel free to use the information in any way that you would like too…if it could help anybody else going through hard times that would be great!” His dream follows: “I dreamed that I was in a room and my dad was there…he looked quite old…he was grey haired and had a lot of wrinkles…he did not say anything to me for a while…I was very excited and happy that he was there…he was moving around the room sitting on different pieces of furniture…I was just watching him…I thought that he was being kind of “stand-offish”…keeping to himself…then he got up and went into another room and I followed him… he set down on the couch and I walked up to him, stood in front of him and just looked at him for a second…then I said that I could use a hug…he smiled and looked at me and got up off the couch and gave me a big hug…when he hugged me, a warm peaceful feeling moved through my whole body…it started a the top and moved down to my feet…it felt wonderful!” When asked in the office therapy session to say more about how he felt in the dream, he said: “I was very glad to see my dad…I couldn’t take my eyes off him…I wanted to talk to him and hug him…when he hugged me it felt incredible…like something good was poured into my body… it felt warm.” Next in the e-mail, he explored the dreams symbolism as follows: “In other dreams of my dad he was young with dark hair…and very

128 Cassell smooth almost glowing skin…In this dream he was very old with grey hair and very wrinkled…I wonder if this may represent my age…like maybe I don’t have that much time left…in this dream he was stand-off-ish…I had to initiate contact…but when I did he responded happily with a smile. Now I have some questions… what was the warmth that passed through or into my body when we hugged? Was this a dream about my dad…or a spiritual visitation from my dad?”

Soon after while I was in Yoga meditation I received a clinically helpful answers that I plan to share in the next psychotherapy session. Sensed the presence of Herman’s supportive spirit caused my heart to race with great joy. Initially it was puzzling, but then creative thoughts involuntarily flashed into my mind. Herman. Apart from Herman’s clinical consultation, I realized the necessity for patience. My philosophical/religious questions could never be answered now. All mortals have to wait until death, when the soul leaves the body. However, I did appreciate that a new Yoga imagining exercise entered my mind, as if programmed by Herman. I envisioned a futuristic image activating visual exercise for enhancing spiritual communication with those in the “Afterlife.” This involved supplementing the traditional mediator’s state of Brahman consciousness. The mental change prescribed, involved changing the direction of spatial focus from introspection, to the polar opposite direction, far beyond the body into Cosmic space. To accomplish this, the following psychic steps may be initiated, once Brahman consciousness is entered: Imagery is to be conjured up in conscious awareness, by recalling memories of modern mesmerizing, astronomical photographs of remote galaxies (such as taken by the Hubble telescope). Once these mental pictures are recalled from memory storage, it becomes subjectively possible during Yoga, to fantasize traveling on a mystical space ship, to visit the deceased, located in the spiritual dimension of the “Afterlife.” This destination can be realized by fantasizing one’s spirit first leaving the body(as portrayed in SIS-II B 22) and then traveling back in time to the beginning of the universe by passing through cosmic space to ultimately arrive beyond the original site of the “Big Bang.” Such a psychic voyage could clear consciousness from negative existential personal loneliness/ grief, and restore affect positive bonds. Simultaneously it could neutralize/heal extraneous contaminating stressful memories, as well as distressing input from the modern media. If accomplished through repeated daily Yoga exercises, this would enrich those having religious faith to grow in a positive healing spirituality. This image stimulating approach will be expanded upon in a later section. However, Consistent with my mentor’s Death anxiety, for illustration purposes I will now briefly present my own personal history. Subsequently when meditating I gained insight how “Death anxiety” provided my deeper psychological determinants for designing the original cardiac “inkblots” that preceded SIS-I. When an active adolescent boy in Canada, my hockey activities were immediately stopped by an old family physician. During routine chest examination for a “Chest Cold“, he detected a heart murmur. He warned me that I would soon die, if I didn’t immediately restrict all active sports. Since I was experiencing no cardiovascular symptoms, I only followed his ominous advice for a limited period. Yet subsequently when actively competing in various sports, I constantly feared dying of a “heart attack”. Later during my medical training after I volunteered to be a control subject in a cardiac study, the cardiologist reassured me that what the family doctor has heard was a normal physiologic murmur which had absolutely no pathological significance. While his medical

Dissolving Death Anxiety with Yoga Empowered SIS 129 reassurance was helpful, my heart/death related hypochondriacally anxieties were not totally erased. In 1980 I reported in my book “Body Symbolism” that I originally designed blots resembling the heart primarily because of planning to design psychophysiology studies monitoring cardiovascular functions, while concurrently protectively assessing inkblot perception. As noted above, through introspection and meditation I realized that unresolved persistent residual Death anxiety may have played an unconscious role. I also now realize from empirical trials with SIS-II B17 depicting beautiful love filled alive beating heart may be used as a life symbol to augment positive energy during Yoga. When a meditating subject is instructed to imagine the heart stopping, a imaginary moment for the viewer to face death under supervised conditions. My adolescent onset Body image anxiety also accounted for my designing several others portraying death linked spirituality. One graphic example is B22 symbolizing the dying individual’s “soul” leaving the body. In order to convert such negative psychic affect into positive energy, the Yoga Master can instruct the viewer of B22 to identity spiritually with the flow of the soul away from the body. After this mental set is conjured up in the consciousness, the non-atheist based believer may be instructed to envision loving spiritually in the afterlife. Positive life energy may be represented symbolically by viewing the final segment, which shows peaceful, nature scenes, with joyful appearing living creatures that ends the SIS-II. Here it may be suggested that the final picture of a beautiful, shining full moon symbolically represents the first phase of the soul’s cosmic voyage back to the Divine Creator to joyfully join deceased loved ones. I encourage members of the SIS Society to collaborate with so motivated Yoga Masters to conceptualize and implement innovative somatic imaging guidance techniques.

Wilfred A Cassell, M.D., FAPA, APC. Editor Emeritus, SIS J. of Projective Psychology & Mental Health, Director, SIS Center, 4501E, 104th Avenue, Anchorage, AK - 99507 (USA) E-Mail: siscassell2@yahoo.com

data on this subject, for sure the number of suicides and attempted suicides is so high that it arouses our attention and indicates that more strategies of primary and secondary prevention need to be elaborated. In this regard it is necessary to point out from the very beginning that, in the current state of our knowledge, we have no valid indicator to predict with a good margin of certainty whether or not a patient will attempt suicide. We only have elements which are associated with an increase of risk, such as the presence of a previous suicide attempt, or a sense of complete loss of hope in the patient personal experience. Patients with a borderline personality structure often show suicidal and self-harm dynamics. Even though mortality from suicide remains relatively low in these kinds of patients (around 6-8%), the presence of these dynamics, the resulting relational modalities and the huge difficulty they have to focus on them on a psychological level, represent a serious obstacle to treatment. In the present study we have examined two clinical cases of borderline patients with a previous suicide attempt, who, after a psychodiagnostic phase, have undertaken a dynamicoriented psychotherapy. The purpose of this study is to begin a discussion on the suicidal dynamics of such patients, trying to show how these dynamics can be detected already in the diagnostic phase, how this phase plays a central role in starting a possible psychological reflection about it and how such a reflection, when conducted later in therapy, could probably reduce the desire for death in patients. Dynamics: The cause of suicide attempts should not be regarded as a homogeneous phenomenon, but as a result of several conspiring factors, which interact at different levels and generate the phenomenon itself. There can be different modalities of suicide, not so much because of their methods as for their motivations: some suicides are accidental, others represent substitutes for murder, others are requests for help, and others again stand for a failure

Attempted Suicide and Projective Suggestions 131 in working out guilt. Some of them, though, are also an expression of total helplessness, unmercifully directed toward self destruction.

On a cognitive level, both conscious and unconscious elements are part of suicidal behaviors (Hendin, 1991), whereas, in our opinion, despair should be considered as a conscious affective response to unconscious dynamics. Freud (1917) considers suicide as a part of melancholia dynamics. He says that the Ego can kill itself only if it treats itself like an object; which would allow it to direct toward itself the aggressiveness directed in the beginning toward an external object (internalization). The importance of ambivalence results from some key elements: a feeling of hatred toward another person, the lack of strongly desired libido connection; the inability to differentiate themselves from the others. Klein too, in developing the concept of death instinct, interprets suicide as an act of retaliation against oneself of the aggressiveness primitively directed toward the object. However, while Freud is still anchored to a suicide- melancholy concept, Klein begins to give of it an interpretation not necessarily related to depression. In Klein’s opinion, indeed, suicide would be the most damaging expression of persecutory guilt and it would take place in all the most regressed narcissistic states as schizophrenia, melancholia, hypochondria, when the death instinct works with the utmost virulence and it’s impossible to oppose any defense against its dominance. Later studies have led to detect different dynamics underlying the suicidal gesture that, interacting in different ways, determine the transition to the act itself. The deterioration of reality analysis skills and the lack of Ego integration often go with suicidal fantasies and behaviors. This can be extremely important when it comes to action, i.e. to the suicidal gesture itself, when the main component is the total collapse of the patient’s defenses, ineffective in taming the intense anger and pain. In the time before, such dynamics can be highlighted by fantasies beginning to be perceived as if they were real and thoughts focusing on belittling aspects. Patients often have, at a more superficial level, conscious fantasies of revenge against real rejecting objects. Even though these fantasies are often just an expression of aggressive wishes or of revenge wishes, their intensity can get to the point of bringing to action. As already pointed out by Klein, the feeling of death as desire of purification from faults, both real and imaginary, and of freedom from persecution instances is a key component in any suicidal behavior (Asch, 1980). According to Maltsberger (1980), such desire results from a persistent failure in integrating the Self which would generate in the subject suffering and loss of hope due to the feeling of being under the constant contemptuous judgment of an internal Other presence. This interior Other (killer) would not be an object but a part of themselves being separated: the body. We could schematically represent it this way: Sense of Self (‘me’) Body representation + ‘Killer’ representation Object Representation intact

132 Rossetti and Daini Suicidal behavior can be induced by the inability to bear losses. About that, we should mention pathological reactions to real mourning (suicide in death anniversaries). Wish for reunification more deeply concerns the loss or the refusal by an imaginary object, the reunification is with an almighty loved object; in such situations the key role would be played by a precarious narcissistic balance leading to the desire of coming back to primary narcissism (death as a feeling of oceanic omnipotence. Kohut, 1977). According to Asch (1980) the reunification would be achieved by acting fantasies in which two persons union is caught back through a regression to a sadomasochistic relationship where the suicidal subject sees him/herself as a passive victim of an external Super Ego (destiny, death). In borderline patients, who tend to make of suicide threats the mainstay of relationships, dynamics concerning narcissistic regression and a lack of a body identity seem to be very important and they are traceable, for instance, in well known self-harm acts, like cutting their own arms. Here are two clinical cases of patients with borderline personality disorder with an attempted suicide in their past: results of the psycho-diagnostic phase will be presented along with a report of the following psychotherapeutic treatment. Clinical intervention has implied a first diagnostic phase where, near to other diagnostic tools, the following projective graphic tests were used: Draw a person test by Machover, Baum test by Kock, Family drawing by Corman, Wartegg test, Rorschach Test. They were scored following their authors, Rorschach test was scored according to Klopfer’s method while for dynamic interpretations we referred to Chabert Tests results were discussed with patients before getting started with therapy. This was conducted according to psychodynamic method, on a weekly basis and open term. Patient A: Mrs. A is fifty years old, divorced, with a 33 years old son and a 28 years old daughter. She has a ministerial job and has being living by herself, except for the last year when her daughter came back home. She was sent to us by her psychiatrist (unable to continue the therapy) who took her in charge after she was dismissed from a psychiatric ward for an attempted suicide by overdose of medicines one year before. The patient is constantly focused on depressive issues, showing poor ability to analyze psychological aspects, she relates to us constantly trying to manipulate the setting. Her defenses about her suicide attempt look very high, she hardly remembers anything and avoids talking about it; as for the suicide attempt and the psychiatric admission, a real post traumatic disorder is traceable. Psychodiagnosis: The patient has great difficulties to deal with projective tests and she even struggles to get finished with each of them. Draw a Person test: In the Draw a person Test, the patient draws a woman face, a sketch, an impression, but surprisingly similar to her own face in a peaceful mood (despite her limited drawing skills). Lips and eyes are evidenced, emphasizing the importance of oral dimension, while the hair suggests a saucy look referring to a much younger age of the patient then the actual one. The head is drawn on the right side of the sheet (like later the male head) recalling an extratensive and communicative dimension, that, although present in the patient’s life, is never hinged upon a solid relational skill. To the repeated invitation to draw a whole human figure, the woman definitely refuses. She hardly manages to express a comment only at the end of the test: “She is twenty, nothing special, static, frightened, she is watching”. The patient expresses in this comment her experiential

Attempted Suicide and Projective Suggestions 133 background, the importance of imaginative and narcissistic dimensions to contrast with the limited experience of the world. The other comment, which seems to come from nowhere “But usually one has a body” expresses her difficulties both with the identity problem and with body experiences. Clinical history allows to point out, against the human figure drawing, the emotional importance of the patient’s corporeality: she makes depend on her own look the possibility to relate with others; the body she’s almost constantly and without any reason unhappy with, is object of persistent care and aesthetic worries (she even undergoes two aesthetic surgeries for abdominoplasty and blefaroplasty) but it’s object of self-harm too. The body experiences are consequently related to intense emotions, both positive and negative, that can’t come to a mental representation. The missing body also tells us about a splitting process from mind that doesn’t allow a psychosomatic agreement: the patient doesn’t show indeed any somatization tendencies, but splitting remains to characterize her psychic life and expresses her depressive tendencies. The male figure is drawn in profile and it’s described with emotional detachment: “a man forty years old, ugly, harsh, bad, I don’t know, I drew a fright”. Also in this case the body is missing and the male figure seems absorbed in the splitting field, so that projective processes are not allowed except for some shy comments. Family Drawing: Having to do the Family Drawing, the patient shows even more difficulties: she walks away from the table and says: “I’m not able to do it”. Then she drafts her own current family, herself and her two children, although they aren’t living at home, at the moment. The daughter is still not married and she lives by herself, the son, which is older, lives with his grandmother, while the patient lives alone. The physical distance seems to correspond to an emotional distance too, the figures indeed don’t touch each other and her own figure is not only isolated, but it doesn’t even have hands and legs. Also in this case, like in the human figure drawing test, the draft of her body is very incomplete and it’s marked by transparency. Here too, like in all the three drawings, the head has the utmost importance, the stroke, which is interrupted, sometimes repeated and insisted, like in the eyes, expresses both insecurity and the tendency to impulsivity. The draft of her children’s body (the only ones who have a body in these representations) expresses a not much distinct body experience. It’s marked with childish and aggressive tendencies (pointed hands in children are drawing). In the family representation the patient considers herself in a central role, she represents the children in a younger age than the current one without specify it; especially her daughter is represented as a child. Her comments express a feeling of extraneousness with tones of wonder about her children’s growth: “It’s me and my children, but then Emiliano has become huge”. Male identity seems however to be the one better clear-cut for the patient: her son’s body is more represented as a unit than female figures which are essentially unfinished. Her representation suggests intense difficulties about sexuality. In any case not even with her children we can find a more complex dimension of conflict on a psychic level; in the family representation the three figures remain essentially isolated and unable to have any relationship. Baum Test: As for “Baum Test”, the patient performed the reactive drawing following both Koch’s traditional instructions and a modified test version by Saraceni (a fantasy tree).

134 Rossetti and Daini She starts to draw the tree on the left side of the sheet, and then she stops, rubs it out and starts again on the right side top. The tree (a common tree), drafted with an impressionistic and broken stroke as well, has a sturdy trunk and a constricted crown. Roots and ground are missing at all, so that the tree seems suspended in the air. Two almost broken branches, open in opposite directions, floating inside the crown, seem to suggest the presence in the patient’s mental life of her two children, not like a self continuation or like a consequence of her own psychological investment though, but like two emotional important elements, confusedly conflicting with each other. So her conscious mental life looks constrained while her unconscious life looks simply forgotten. The fantasy tree is also located on the right side of the sheet and it confirms the extratensive but also expressive tendencies of the patient that on a more conscious level she keeps repressed. Branches and leaves are flames and they reach out toward the top of the sheet and almost get out of it. So the patient’s imaginative life seems to be run by unbridled drives and it reflects a grandeur self concept than the patient let us know during the talking. Also in this drawing a strong trunk indicates a residual strength of the Ego, but there is a large knot on it that can be related to her life traumatic events. The straight ground line of this second tree drawing more clearly suggests displacement processes. The patient’s comment “It fascinates me, it’s a tree with flames that doesn’t go up in flames” expresses a self concept more related to the narcissistic dimension than the first one, and the paradoxical meaning of the flame that doesn’t go in flames recall an archetypal omnipotent dimension. Wartegg: The Wartegg Test shows how in the group of suicide attempters the presence of more than one rejection of answers on part of the patient indicates an attempt to face psychic issues through rationalization, but a not successful attempt because of her high impulsiveness.

Protection’s need (VIII), also pointed out in answers order, causes a pathological answer through a reverse moon inconsistently described: “it stinks, but it calms me down, I like starry nights” “I like it more because I draw a moon in it, because the sign is rounded”. The response to the third square (a country house among cypresses) looks ambiguous too: on one hand it reminds places of her childhood and shows a drive to realize her own goals, on the other hand the reference to cypresses (in Italy mostly cemetery trees) leaves worrying questions to clinicians. Especially the projective test confirms that selfharm issue is built on an identity problem: in the first square the patient draws a question mark that reflects her own existential uncertainty; her comments are on shame feeling and selfcriticism. This is the drawing she likes the least because it’s too trivial. However no other hint of a personal identity comes out from the whole test Another clearly pathological answer emerges from the second square, where the patient draws a man with a mustache coming from another time: the male figure is source of anxiety that replaces the display of her own tendencies to sensitivity and to interpersonal intuition and prevents them. The seventh square is among the uncompleted ones, the stroke remains alone and unfinished in the square. At the end of the test the patient so comments on the mere stroke: “It looks like a flimsy little worm” (according to Wartegg, an expression of isolation) with relation to the issue of femininity that yet seems to fill so much of her life and her conscious behaviors: the patient indeed became a mother when she was very young and in her middle-age too she alternates several male partners.

Attempted Suicide and Projective Suggestions 135 The squares she refused, other than VII, are IV and V, where the patient couldn’t answer nor comment. Superego valences and aggressive instinct don’t even seem to be part of her mental activity: their unconscious direction looks impossible to understand, even though her many self-harm acts could have led patient’s reflections to a reality level. Rorschach test: The patient refuses to perform Rorschach test because she performed it some years ago. Treatment: The patient underwent a Day Hospital treatment after a period of hospitalization for attempted suicide (overdose of medicines). Despite she underwent psychotherapy some years before, at the beginning she had difficulties, being focused on depressive symptoms and pharmacological treatment, which yet she was following in a very erratic way. Her parents have a central role, even though she never felt part of the family. Her father, already death, has always been source of anguish, while with her mother an intense ambivalent relationship emerges, which has began since her very childhood. The patient has been looking at her mother with disconcert for a long time, astonished at the fact that an affair of hers was denied, against any evidence, by her mother and the whole family. This matter and her quest for truth do not seem to have undermined her trust in her mother, nor had an adequate attention from her mother ever contributed to modify her feelings. During the following months a deepening psychological exploration makes her depression worse, which leads to a Day Hospital pharmacological treatment. This crisis seems related to a more accurate reflection and communication of the patient about herself, which causes a narcissistic withdrawal, bringing back the idea of death. While tidying up at home, the patient finds an old diary of hers and clothes of her hospitalization time, and these things bring up bitter thoughts about the time when she had to face up maternity and work by herself and even more bitter thoughts about the hospitalization time, about the changes in her own body and efficiency: the high dosage of pharmacological treatment deformed her body and reduced the efficiency that had before marked her, despite her being alone.

After Day Hospital admission, along with resistances to go back to a rigorous psychotherapy setting, the patient looks calmer in exploring her own denials of psychological experiences. She can now recall the history of hospitalization for the suicide attempt. Her depressive feelings had come in long before, when she was pregnant with her second child. At that time she was about to divorce her husband who bears on himself her persecutory dynamics. But for a long time the patient couldn’t take on less passive attitudes.

The second pregnancy binds her to a man that she doesn’t love anymore. Only after the third month, when for a diagnostic error she thinks she lost her child, she has the courage to leave him, while the pregnancy goes on and she’s almost unaware of it: a twin non diagnosed pregnancy had caused an abortion, at the third month, while the other twin was born at term, being experienced by her mother like a subject fastened to life in a worrying arrogant way. During the pregnancy feelings of death and life interchange all the time; not even the delivery can calm down these feelings. This second pregnancy is experienced with a deep ambiguity which will affect the following relationship with her daughter, about her the patient will always have ambivalent feelings marked with very serious feelings of guilt and in a fusion relationship her daughter is sometimes experienced like an evil creature. The woman, which is present and preoccupied during her mother’s whole treatment, can’t have with her an affective relationship. The patient seems to forget about her and to refuse her concrete psychological support every time she withdraws in her own narcissism. More complex dynamics like the one about the comparison with her

136 Rossetti and Daini daughter femininity and the other about her rivalry towards her daughter don’t even come out in the whole first period of therapy. At the beginning one of the most expressed elements is the intense anger which male figures as her ex-husband, her son, her current partner can bring out of her, showing moreover her poor ability to distinguish among their identities; her son arouses in her the same anger feeling like her husband does, his image in his mother’s mind looks fragmentary and marked from time to time with different emotions. When she try to invest him with her own narcissistic needs (her son like a tool to realize her own ambitions), she never get satisfaction cause her son looks totally fastened to his own passivity and quest for immediate fulfillment. Only her father’s image remains idealized for the woman although he has been a source of anxiety since her childhood. The patient seemed to read a depressive element in his father and since her childhood she had been afraid that he might attempt suicide although this never happened. Anyway it’s interesting to point out how her father’s image, highly idealized, stays a protective image during the whole therapy, that doesn’t “call her” so much from an afterlife to an imaginary reunion, as he encourages her to stay alive and, according to patient, intervenes occasionally on her behalf like a real guardian angel. During the second part of therapy, dynamics related to female images become more relevant, especially the mother and the daughter of the patient begin to become the object of stronger and stronger projections, with all the characteristics of the good object the first one and of the bad object the latter one. As to her mother, she is currently suffering from Alzheimer’s, she needs ongoing cares, so she’s admitted to a nursing home; her health condition are also likely to encourage doctors to clarify from the very beginning that she will never recover; in fact they imply that she could die any minute now. In this situation the patient seems to find again an affective dimension she never experienced before with her mother. Indeed only now that her mother has lost all her femininity and self-sufficiency, the affective channel, no more undermined by competition, seems free to open up. On one hand the patient claims that her mother is dead three years before (that is when Alzheimer’s disease has started) because that isn’t her mother anymore. And such feelings go on with fantasy of putting an end to the sufferings of both of them: she goes as far as bringing into the hospital two kitchen knifes in order to kill her mother and then to commit suicide. On the other hand a new affective dimension with her mother, never experienced before or strongly denied although desperately wanted, is now happening and she has to deal with it: the moments when she nurses her mother restoring a primary fusion are very intense. Such situation however doesn’t go with a stable conscious integration of the maternal object; in fact it creates a condition of a dangerous impending loss of the omnipotent object just found again.

Psychotherapy can only encourage limited reflections in the patient, about the impending threat of her mother’s death. Same thing happens with other real situations that the patient perceives as additional threats. Her daughter in the meanwhile goes back home to her mother’s and undertakes many of the household expenses (the patient isn’t in a good financial condition and she has an eviction order, at the moment), which is source of a deep frustration for the patient. In such situation indeed the daughter takes on the psychological meaning of a persecutory object, she reproaches her all the time about her disorder, she doesn’t show any understanding about it, in fact she takes every opportunity to harass her for her doing nothing and her inability to react to the disease. The patient clearly experiences again all the persecutory aspects she once used to project on her mother, and she doesn’t seem to be able to contain her daughter’s disturbing aggressiveness.

Attempted Suicide and Projective Suggestions 137 So the patient ends up in an unstable balance and a new Day Hospital treatment is necessary; in this occasion she shows up in the hospital for the first time with her sister and brother, who are seriously preoccupied because of the situation and are unable to give her their support without colluding with her typical manipulative dynamics. In this occasion the patient shows great difficulties to accept a structured therapy setting, she keeps having extremely manipulative attitudes even toward pharmacologic therapy. The persisting stress generated by the impressive dissociation experienced about the two figures of her daughter and her mother, if on one hand opens to more authentic scenarios, allowing a balance even though precarious, on the other hand it determines a series of actingouts that make the patient create the basis for a greater and greater narcissistic withdrawal: she persuades other doctors to issue medical certificate for work, she manages to obtain drugs especially benzodiazepines, she keeps having manipulative attitudes with her family and colleagues. The therapeutic work which is very difficult because of her strong resistances, in this phase it is focused on mother-daughter dynamics. Although during the sessions the patient is able to maintain an acceptable Ego cohesion, so that she shows from time to time a good integration of the good and the bad object, this ability is however limited just to sessions and to the presence of an auxiliary Ego, and it doesn’t seem able to persist outside, where apparently the environment can’t in any way provide an adequate containment.

It’s now that the patient experiences a psychotic episode: she first sees herself jumping under a train she was really waiting for, vividly and intensely hallucinating her own death, then, once brought back home, she sees in the mirror not her own face but her mother’s face. It will take a long time for her to be able to elaborate this episode during the sessions. Meanwhile the ongoing and blazing fights with her daughter result in an intake of several medicines, a gesture with all the marks of a demonstration. The patient refers about it as if in an altered consciousness state she started ingesting the pills one by one until she finished them, not with a suicidal intention but just to be able to sleep and not have to listen to her daughter any longer. During the following period, medical aspects related to pharmacological therapies strengthen her psychological resistances also in terms of an irregular attendance to sessions. Afterwards the patient starts again to attend to sessions regularly, while her daughter, who moved out with a new partner, announces to be pregnant. It seems like the patient recovered an acceptable psychological cohesion; she is able to explore the ambivalence related to the new situation: the fusion relationship with her daughter on one hand and the envy toward her situation on the other (her daughter’s partner and his family are idealized). Inconsistent behaviors are anyway apparent, as a claimed death will and in the same time her undergoing minor aesthetic surgeries. Fantasies about her future grandchild emerge; her birth indeed is expected for the same month the patient was born and she wishes that her grandchild will be the spitting image of herself so that her daughter will have to take care of her. In such context the death of one dog of the patient’s makes emerge again the specter of a continuity interruption in her personal experience, her defenses seem to falter but they provide an acceptable control anyway, on the opposite the environment around her doesn’t seems able in any way to deal with the anxiety of a possible psychological breakdown of hers. Besides her daughter, struggling with her pregnancy becomes very understandably and naturally hostile to any attacks on pregnancy itself. The patient refuses a new day hospital therapy

138 Rossetti and Daini and, especially urged by her sister who meanwhile got in touch with other clinicians, decides for a nursing home. When the patient is released, she shows a very deep regression about her own personality, she starts a troubled relationship with a man of the same age of her son and who is a drugs abuser, she adopts behaviors like driving at a crazy speed and threatening more and more concretely self-harm acts. The therapeutic relationship starts again, in time a good alliance and trust were built but, from the very beginning it is clear the enormous difficulty that the patient’s regression now causes in psychological exploration. The grandmother role that soon the patient will play seems a well functioning area but it is completely dissociated from the general psychic picture. In the meantime the birth of her little granddaughter and especially the death oh her own mother later, shake her fragile balance and she shows up at a session with a noticeable cut on her arm which needs treatment. The patient describes the act in the perspective of a dissociation of consciousness, a way to generate an altered status of consciousness, preparing everything to inflict the cut to herself, having to clean the bathroom from blood and to avoid being suspected at all, etc. etc. All the same, a hint on thinking about her inner world seems to find its way out when she can talk about the immense sorrow which she can’t experience but which she perceives having to distance herself from. But there is no awareness of the self-harming meaning behind this “distancing herself from”, in fact the cut exhibition, the need for treatment and the vivid story she makes out of it, all these things confine it to the strictest pragmatism. Her family pressures for a new hospital admission, in an ambiguous situation due to the presence of several clinicians, bring her again to a nursing home. During the hospitalization, the clinical picture will have difficulties to become stable; the patient will cut her arms again in the bathtub in spite of both psychological and pharmacological support in a protected environment. She will start again the therapy after being released. Patient B: Patient B, a woman 26 years old, addresses to Psychiatric Day Hospital on her endocrinologist‘s recommendation, which took her in charge for a serious overweight treatment and for an insulin resistance. The psychological question that the patient asks herself in the beginning is about a possible eating disorder. Although she is conscious to have many other psychological problems, as a matter of fact she never asked for help. She never completed her university studies in spite of her intellectual skills, because of both financial reasons and her fickle nature. At psycho-diagnosis time, she is working as a laboratory analyst, even though she always had occasional jobs. Her suicide attempt dates back four years before: the patient, after some serious losses (the death of her grandparents and of a dear friend who was as old as her), get poisoned with benzodiazepines; she goes on sleeping in her bedroom for four days and paradoxically no one in the family calls a doctor or tries to wake her up. She wakes up spontaneously days after. She says that no explanation is asked out of her by her family, everything goes in silence, and no body looks for psychological help.

She recovers from this episode part by herself part with the help of a friend of hers, a psychologist, which she has an ambiguous relationship with. At diagnosis time this relationship is coming to an end. Psychodiagnosis: Draw a Person Test: She performs the graphic tests with a soft stroke and draws little figures on the left side

Attempted Suicide and Projective Suggestions 139 of sheet, at the top, suggesting a tendency to introversion and insecurity about body image. The figures are somehow geometrical and childish. About the male figure she says: “He says nothing to me, he came out this way”. So a possible ambivalence toward masculine, marked with the feeling of being attacked by it, is denied and disguised by the figure’s sketchiness. The pinpoint eyes indicate difficulties to establish relationships with the other sex, which fits into the patient’s history. The female figure, also sketchy, is inconsistently described at first as a woman ten years younger than male figure and then it is identified with the maternal figure: “I thought of my mom”. That leads her to go again through the denial process, since she comments on the first figure denying having thought of her father. The geometrical graphic feature identifies a female slim body composed by two triangles, where the breast is missing and the shoulders are strong: difficulties about the feeling to be fed and protected by her mother go with a competition with the male gender. Commenting on the drawing, the patient also denies being fond of her own mother and she doesn’t seem to represent in the woman an identification figure. This difficult issue seems to concern especially the body, whose representation goes totally away from the perception of herself that the patient could have. As a matter of fact she is clearly overweight, at the moment, so the drawing also looks like a compensatory representation. Family Drawing Test: In the Family Drawing Test we find again the same graphical features, a light pressure and the figures at the top left, which suggests a low self-confidence and emotional immaturity. The ideal family is composed of more characters than her real one, which indicates her need and quest for love and support. Also in this case, the male figure is the first one to be drawn and it looks stiff and with superegoic traits. The female figure, with whom the patient identifies, stretches out her arm to a male figure representing an unrealized love. This mode of representation allows us to glimpse the unfulfilled desire to establish a more serene relationship with the male figure. A baby is also drawn, who can allude to a maternity desire or who can show difficulties with adjustment and growth processes. The distance between her own representation and her mother’s suggests a detached emotional relationship between the patient and her mother figure; which would explain these growth and identification difficulties. Baum Test: The tree representation shows a more centered and less insecure self than in the human figures’. The tree occupies the central part of the sheet and it has bigger proportions. The roots are not represented even if the trunk looks straight and balanced; the crown is a little bit constricted and closed, indicating shyness and distrust. The branches are represented with geometrical parallel strokes, and they are open, suggesting an absence of independence and difficulties to take decisions; little fruits into the crown show a naïve personality, not mature yet and in need to assert itself and to prove its own skills and potentialities. Wartegg: In Wartegg Test the patient responds to all the stimuli and she shows, through the formal level, a higher average intellectual level. A vigorous and geometric trait confirms her tendencies to rationalization, except for the response to the first square where the drawing of a butterfly, identification symbol, looks more soft and elusive. Her judgment and her capacity to analyze reality look intact: the patient has good intellectual and critical skills. Psycho-affective dynamics instead, related to aggressiveness and activity levels, at the test time are not functional or aimed to a goal, in fact they go

140 Rossetti and Daini with ambivalence and conflict feelings. That can lead, in the patient’s overt behavior, to a waste of her interests and to starting in the same time several activities, without evaluating if it’s actually possible to conclude them. That is confirmed by the slight increase of the tension index, which points out anxiety and impulsivity which tend to be released outside in a messy way and which are not aimed at achieving a goal. Aggressive energies are experienced with ambivalent feelings and they are strongly controlled, although not always successfully. Even if at the moment it’s not easy at all to solve methodically problems and difficulties posed by the environment, it is possible to identify in this area some potential, a base to build a more high organization level in the personality structure. In her test, the patient shows a clear aspiration to a relationship with the maternal aspect, while she shows difficulties and ambivalence with the father figure and generally with authority. This can be source of extended tensions, of reactive conducts and of a discomfort that pervades much of the subject’s behavior. Greater potentials come out of the test about both the relationship with the other sex and generally libidinal energies; as for now, they are experienced with difficulties, but in time they will be able to develop. The most problematical areas seem to be the one related to authority and to the father figure (IV square) and the one related to aggressive tendencies (V square). In this last square the patient draws a church roof, so hiding an aggressiveness direction and selfaggressive tendencies (the drawing develops downwards). Rorschach test: Rorschach Test, which shows an average number of responses ad a neurotic reality index, is marked with a refusal at VI card and with a regular number of vulgar answers. The first impression that the patient gives of herself is characterized by detachment and fear feelings (she answers to the first card: “I see a cicada with outstretched wings, it’s a little disgusting”), but female identity, deep in her unconscious dimension, looks more solid than in Draw a Person test, (III card: two women talking). Male figure perception (IV card) is on the opposite consistent with The Human Figure Drawing: “at first I don’t see anything in it; it would seem a sort of animal turning its back on me, a gorilla or something like that. It could also be a man falling. While I see the animal’s back, the almost human figure is in front of me and it’s falling far away from me”. This answer expresses a deep lack of communication with the male figure and the feeling of abandon related with her own hostility too. In Rorschach Test, the patient swings between loving infantile images, like in the answer to the second card: “two circus elephant united” or to the seventh: “some little fawns, little rabbits”, to the tenth: “the same two little elephant, as before”, and a series of more worrying images. Inhibition and refusal of sexuality come out from the refusal to the sixth card and from the following answers, for example from the one to the eighth card: “bodices Moulin Rouge style, those stiff bodices, corsets. It also seems a medieval armor”. More structured but ambivalent and worrying looks the relationship with the maternal image. The answers to the seventh and to the ninth cards are an example. In the seventh little animals image is transformed into pieces of those same animals indicating a dispersion of the childish image. And another surfacing of unconscious tendencies is expressed in the second part of the answer and the inversion of figure/background which recalls her a satanic image, specifically just the devil head image: the maternal unconscious image seems to be linked to supernatural and hostile powers; equally structured is the answer to the ninth card which begins with a stiff and idealized image: “in the background there seems to be a door, an arched door, probably a glass door”; the emotional intensity of the relationship with the maternal figure is represented with flames but it doesn’t seem possible to integrate the maternal image. The patient says indeed: “The downside

Attempted Suicide and Projective Suggestions 141 doesn’t say anything to me”. A rationalization process follows the denial one, helped by the card colors: “Maybe flowers downside, flowers and flames protecting the door which I see behind”, “but I don’t feel it as an obstacle, I feel it as a protection, I have the feeling that it’s a biblical figure”. The inconsistence of the patient’s deep feelings changes her distance from the card; she adds: “I like it, can I have a copy?” which concludes with her peace of mind. Answering to this card, the patient expresses symbolically the issues related to her suicide attempt, first of all their relationship with female symbols and with an emotional intensity related to instinct, this pressing emerging seems to be rationally bridled due to the difficulties with maternal figure who imposes a need denial. In this case the suicide attempt seems to be for the patient the achievement of a state without any needs and where a maternal protection requires the disappearance of the self as a source of instinctual and relational aspirations. Treatment: After the psychological diagnosis, the patient begins a weekly psychotherapy which will last one year. During the first session she focuses directly on the root issues: her relationship with men and her need to control all her body functions. Food control, apparently the reason for the consultation, stays paradoxically in the background. She can’t rely on men and among her memories traumatic situations in the borderline between reality and fantasy show up. The current partner, much older than she is, is a man who, in turn, has difficult and indefinite relationships with women. Their relationship can’t become clear and this is one of the most important reasons of the present crisis, her feelings for him are ambivalent and confused. About control need, the patient would often like to deny even the existence of her body needs; It comes out at the beginning that she just can’t go to the toilet away from home, and this is a cause of limitations and discomforts. In a psychopathological sense this symptoms are distant from phobias because they concern all her body functions (sometimes the patient can’t even eat in public), and a conflict psychological structure is missing. At the beginning of the therapy, the patient also tells us about this difficulty in her relationship with her mother: when she was a child, her grandparents used to give her some money and her mother used to take it away from her saying: “You sleep and you eat in this home!”. So the mere fact to have needs opened the door to a maternal massive intrusiveness and greediness (Also at the time of therapy the patient was still giving her salary to her family to help them and wasn’t able to detach herself from them).

During the first therapy sessions the patient’s anger isn’t able to come out, while the clinical focus remains on the present situation, especially on her relationships with men. In the background it is possible to guess a grand reactive Self, meaning that while the patient could manage not to need anyone, even her own body, they’re other people to need her: it’s her that gives her partner psychological help, her that responds to her ageing parents’ needs.

Some hypoglycemic crisis which makes her live a more intense experience of body and hunger disconcerts her and also undermines the therapeutic relationship with the endocrinologist whom the patient invests with maternal values; indeed the overweight problems persist. A change in the sessions comes after about tree months with the first dream report: the patient sees from above a village built on the edge of a volcano ready to explode; she dreams about “a situation of a quiet life, about living together with that danger”. The patient realizes that the volcano ready to explode is a representation of herself; the whole dream seems to be a structural dream (Kernberg) in which the view from above represents a first splitting and a detachment from the rest of her personality, the

142 Rossetti and Daini village represents the usual defense strategies of rationalization and denial that the patient uses to preserve a loving and integrated image of her family and interpersonal reality, while the volcano represents the most genuine Self aspirations related to the aggressive urges not anymore adequately repressed. A deep resentment toward both her partner and her father begins to come out and to be expressed, due to the deep disappointment that they caused to her, not protecting her and not promoting her social realization. After many resistances, the patient begins to talk more about her childhood: in order to balance the negligent conducts of her parents, since she was a little girl, she used to stay with her grandparents and to spend very long periods of time with them and her uncles. She still cherishes in her mind an idealized image of her grandparents, while the uncles are felt as a negative and deeply disturbing model as well. She often has been involved in their fights and has seen violence between them. A feeling of exclusion comes out again about them. A confused anger begins to emerge, especially against his uncle, a violent man, but not even from him she can drive herself away and overcome the affective ambivalence. Emotional attachment and anger emerge at the same time also toward this figure.

The massive shift of emotions and anxieties related to family members on all the social relationships brings the patient to be deeply distrustful of others and in severe difficulties especially in front of positive affects. Now she claims she’s able to recognize hostile people and negative relationships, while she has difficulties with loving and romantic attitudes, she can’t believe them and responds aggressively, in a primitive and concrete way: she prevents any suitor, attacks them verbally so as to be even considered strange. This aggressiveness seems to come from deep divisions that the patient brings into sessions massively projecting her anguish over the therapist. The therapy time seems to be relevant, however, especially for a greater ability to relate without being overwhelmed by guilt. After a session where the patient is particularly defended, she seems able to overcome the rationalization of asthenia aspects against which she’s fighting (of a depressive nature); she keeps maintaining massive projective defenses where male figures prevent her to carry out important aspects of her life, but in the background we begin to glimpse the dependency and the consequent aggressiveness together with the reactive pattern toward both instinctual and relational aspects, two elements which we can work on. The patient reported two dreams: She is wrapped in a blanket, is huddled at home, she tells her parents and brother not to leave her alone and to shut the windows because she is afraid that someone will come. In the second dream, set in a medieval jousting tournament, the patient rides a black horse, powerful, who gives her security, she reins it in, she has to joust because of a lady who screwed it up, now she has to fight to repair this damage and has a bad feeling that her head could be blown off. Maybe there are also two men. About the first dream the patient can’t explore at all the central elements of not being alone, of asking her family non to go away, the very regressive situation of being wrapped in a blanket and huddled. In her conscious thinking, the denial of needs remains firm although she unconsciously expressed a deep desire for comprehension and support from her family. In the dream there is a hint of the suicide attempt episode when the patient takes refuge in her own bed, and the regression to a “maternal womb” situation seems justified by the fear of thieves. The projection on strangers of a hostile tendency of her own seems useful to preserve a positive parent’s image. The suicide attempt looks therefore related to a process of splitting the object; meaning that the patient keeps non being aware of her parents incompetence with consequences that she had to bear until then.

Attempted Suicide and Projective Suggestions 143 In the second dream, reported a little later, more articulated defenses and a more elaborated image of herself (horse and rider) come out. The patient associations bring her to realize the instinctual dimension symbolized by the horse, powerful and potentially dangerous but also tamable, and the fear to loss control and become insane suggested by the head loss image. Instead, the feelings toward the “lady” and two other male characters in the dream remain far from consciousness, perhaps again a picture of family members which is not consciously decoded. The patient seems to represent in the dream, through the image of the tournament where she must defend and remedy the faults of the “lady”, healing processes towards the maternal figure which dominated up to that point in her psychological structure. Not even in these circumstances she can express a critical awareness about her parents, however after this dream she starts to become more independent from family. The relation with the suicide attempt seems to be represented in the dream by the possible coming out of aggressive tendencies, symbolized by the black horse, against an Ego who can loss control. But this image looks less devastating than the volcano ready to explode present in the first dream. The therapy, in time, lightens up the devastating power of death desire that had led the patient to the desire to suppress herself. This can happen thanks to the fact that the patient dives deeper into her situation and reduces the psychological splitting processes that, however, are in part still present. Anyway a new love relationship, even if apparently a support one, allows her to begin processing the dynamics of the previous one and to acquire more mature attitudes toward her parents. Particularly she manages to look for what parents never gave her in childhood, and she reports this during sessions. That’s the reason why she always takes the trouble to help everybody: to obtain their approval; we begin to glimpse an awareness of the deprivation suffered in her childhood. Now she can deal with the suicide attempt, she can talk about it, showing all her disappointment due to the fact that nobody took care of her for days; however, a rational defense “It’s better to laugh it off than to cry” and a difficulty to let the anger for that episode come out persist. Deep down she keeps feeling guilty toward her parents and she can’t find an adequate mental representation. In later stages the patient will swing between the initial withdrawal of projections and the difficulties to be able to break free from parental figures, on a behavioral level a significant step forward compared to cope with the “predatory” aspects of the family is done, but there still is a sense of guilt toward them. In the following months, real economic difficulties lead the patient to discontinue the long-term therapy. The psychotherapy lasted one year and finished when the patient went back to work and the second love relationship was going on in a more realistic and planning dimension. And also a more realistic interest for her own physical health emerges from her independent initiatives to undergo medical checks. Discussion: The diagnosis can help to focus on more purely psychological issues than the apparent consultation reason. Patient B, who could complete diagnostic phase, has used that occasion to focus on really psychological problems, other than the mere eating disorder. This greater willingness to open up and to accept help seems to lead to the absence of further acting-outs both as a new suicide attempt and as a threat to it. About patient A, apart from important factors like age and a chronic personality disorder, the refusal to complete diagnosis is related to a greater difficulty to establish object relationship and so to accept the kind of help that psychotherapy can offer; a greater difficulty in entering the symbolic thinking leads to further acting-outs but also to the persistence of manipulative behaviors both with family and with clinicians. The blackmail pattern persists and tends to come out again as a base element in these relationships.

144 Rossetti and Daini Even if patient A has the same insight skill of patient B, she has more difficulties to integrate these intuitions in a personal and relational context; indeed after the incomplete diagnostic phase and at the beginning of therapy, a major depressive episode arises again without though any suicide attempt. A more deep focus on psychological dynamics seems on one hand to worry the patient, and concretely activate, on the other hand, suicidal tendencies. Indeed the new depressive episode seems also to represent her tendency to experience again the period of the dramatic suicide attempt and of the following hospital admission: the repetition compulsion is mitigated by the more open and less restrictive experience of Day Hospital treatment. To make a psychological diagnosis that also includes the projective tests is helpful for the therapist to highlight certain aspects of the disorder that seems absent from the initial report made by patients. A first diagnosis allows us to point out, especially through projective tests, personality dimensions that a post-critical reaction of the patients could hide in particular under depressive symptoms or obsessive reactions aiming to disguise under control suicidal tendencies. Especially both a particularly fragile ego and an incomplete process of identification can be pointed out, which distinguish the borderline personality from those with more precisely neurotic traits.

In our cases the most salient element resulted to be the difficulty concerning the body image and its relation with the suicidal act. In the reported cases, the body image looks extremely primitive or it’s even denied; and this inconsistently with the cognitive skills of the subjects. In suicidal dynamics, this self-body split provides the basis to accommodate the bad projections no longer tied to an object, as Maltzberger said. We could compare this body dynamics to another psychopathological situation where corporeality becomes central: eating disorders. In anorexic patients the body dimension seems similarly split and denied but the physical self seems anyway to be invested with libidinal energies: body representation in projective tests is much more advanced and detailed, and the symptoms classically described as “interceptive awareness” would recall as well a painful but active investment. On the opposite, the split of the body as present in these cases of attempted suicide seems to be related to a deep disinvestment of the body, which is not any more a place for pain while the mental representation of Self lets clearly come out the idea of death. The two patients show regressive tendencies both in Draw a Family and in Draw a Tree test, highlighting strong primary not satisfied needs concerning family context, which are an environmental correlate of patients’ lack of control on their own aggressive tendencies. This dynamics seem important in the two suicide attempt situations and at first look totally unconscious in both cases. Through psychotherapy, patient B slowly acquires awareness of this missing response to her needs. Anyway extremely primitive valences concerning family relationships seem to act in the course of case: regarding the possibility of a new suicide attempt, in patient B the total lack of an answer seems to have determined the patient’s decision to face her problems by herself and so it seems to have worked as a protective element against further suicide attempts.

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Role of Emotion Regulation Difficulties in Predicting Mental Health and Well-being Prachi Saxena, Akanksha Dubey and Rakesh Pandey The present study reports the relationship of emotion regulation difficulties and alexithymia with mental health and subjective wellbeing of an individual. Two hundred and eighty eight participants (218 males and 70 females) in the age range of 16 to 38 years (Mean age =20.78, SD= 2.95 years) were assessed on a measure of alexithymia, difficulties in emotion regulation, general mental health, and subjective well-being (assessed by Positive Negative Affect Schedule and Satisfaction with Life Scale). The results of the bi-variate correlation analysis revealed that difficulties in understanding and communicating as well as regulating emotions, in general, have a negative influence on health and wellbeing. However, the findings of step-wise multiple regression analysis indicated that some specific types of emotional deficits such as difficulties in identifying feelings, lack of emotional clarity and limited access to emotion regulation strategies were relatively more important in predicting the health status and well-being of an individual as compared to other emotional difficulties. Overall the findings imply that emotion regulation difficulties and alexithymia in general is associated with impaired mental health and lower level of happiness and life satisfaction, i.e., subjective well-being. The observed findings have been discussed in the light of the available empirical evidences. The role of emotions and emotional experiences in determining the health status of an individual, though, has been focus of psychological inquiry since long the last few decades have witnessed an invigorated interest in this area (see review by Pandey and Choubey, 2010). While emotions can be adaptive in many ways, emotions can also be maladaptive (Amstadter, 2008). For example, researchers have noted that while positive emotional experiences and emotional intelligence have a positive effect on mental health, suppression of emotions, inability or difficultly in understanding and communicating emotions (e.g. alexithymia), disposition to exaggerate emotional experiences may have health impairing effect (Pandey and Choubey, 2010). The functional role of emotions in mental health and subjective well being has been highlighted by several researchers (Quoidbach et al, 2010). The manner in which individuals are able to manage their emotional experiences to confirm adaptively to a given context appears to be important in mental health (Gross 1995)., Prachi Saxena and Akanksha Dubey, Research Scholar, and Rakesh Pandey, Ph.D., FSIS, Professor, Dept of Psychology, Banaras Hindu University,Varanasi-221005(India),(Correspondence to Rakesh Pandey, Email:rpan_in@yahoo.com) Key Words: Emotion regulation, alexithymia, positive/negative affect, life satisfaction, Mental Health and Well-being there are various affect related deficits, such as difficulties in understanding, communicating and regulating emotions that may adversely affect the mental health and subjective well being of an individual (Gross and Munoz, 1995; Taylor, 2004). The present paper deals with the role of emotion regulation difficulties and alexithymia in understanding the mental health status and well-being of an individual. Alexithymia is a cognitive-affective deficit in understanding and communicating emotions and has been conceptualized as a personality trait relating to inabilities or severe reductions in identifying, describing, and communicating feelings; difficulties in differentiating feelings from bodily sensations; and diminished affectrelated fantasy (Sher and Grekin, 2007). Initially alexithymia was, though, linked with only psychosomatic disorders; subsequent studies reported its association with a variety of other types of mental health problems (Taylor, 2004), such as depression (Bamonti et al., 2010),

148 Saxena, Dubey and Pandey anxiety disorders (Zeitlin and Mcnally, 1993), sleep disorders (Lundh and Broman, 2006), eating disorders (Speranza et al., 2005) and various interpersonal problems (Vanheule et al, 2007) and has been reported as significant risk factor for developing mental health problems (Taylor, 2004). Another emotion related deficit having some conceptual overlap but independent of alexithymia is difficulties in emotion regulation. Different researchers have defined emotion regulation in different ways. The present paper is based on the operational model proposed by Gratz and Roemer (2004) according to whom emotion regulation includes (a) awareness and understanding of emotions, (b) acceptance of emotions, (c) ability to control impulsive behaviours and behave in accordance with desired goals when experiencing negative emotions, (d) ability to use situational appropriate emotion regulation strategies flexibly to modulate emotional responses as desired in order to meet individual goals and situational demands. Difficulties in emotion regulation or emotional deregulation has been found to be associated with a number of mental health problems, such as depression(Gross and Munoz, 1995), anxiety disorders (Campbell-Sills et al, 2006), post traumatic stress disorder (McDermott et al, 2009), and social dysfunction (Gross and Munoz, 1995). Difficulties in emotion regulation have also been linked with high negative affect and lower level of positive affect and satisfaction with life (Quoidbach et al., 2010). As the preponderance of positive emotional experiences, relative absence of negative affect and satisfaction with life are indicator of subjective well-being, the aforesaid findings imply that emotion regulation difficulties would be associated with lower level of subjective well-being. From the preceding review it is evident that ability to understand and communicate emotions (i.e., lower level of alexithymia) and enhanced capacity to regulate emotions is likely to be associated with sound mental health and higher levels of subjective well being. Contrary to it, the alexithymic tendency (i.e., the difficulties in emotional understanding and communication emotion) and emotion regulation difficulties may result in a variety of mental health related problems and reduced happiness and satisfaction in one’s life. However, a closer review of the aforesaid empirical evidences bring to fore the fact that most of the aforementioned studies have examined only a few aspects of the multifaceted construct of alexithymia and emotional deregulation. Thus, it would be interesting and theoretically meaningful to examine the relative significance of different aspects of alexithymia and emotion regulation difficulties in predicting an individual’s level of mental health and subjective wellbeing. The present paper makes an attempt in this direction and examines not only the relationship of various dimensions of alexithymia and emotion regulation difficulties with various aspects of mental health and wellbeing but also explores the relative importance of these affective variables in predicting health and well-being. Materials and Methods: Sample: Two hundred and eighty-eight individuals (218 males and 70 females) in the age range of 16 to 38 years (Mean age =20.78, SD= 2.95 years) participated in the present study. The age range of female participants was 16 to 35 years (Mean age = 20.60 years, SD = 2.77 years) whereas that of male participants was 18 to 38 years (Mean age = 21.32 years, SD = 3.41 years). None of the participants reported any present or prior history of medical or psychiatric illness in a semi-structured interview conducted before the administration of the tools for the present study. Tools: The Hindi version of 20 item Toronto Alexithymia Scale (TAS-20-H)(Pandey, Mandal, Taylor, and Parker, 1996) was used to assess the level of

Emotion Regulation Difficulties and Mental Health 149 alexithymia of the participants. The TAS-20-H consists of 20 items rated on five-point scale of agreement and measures the three dimensions of alexithymia- difficulties in identifying feelings, difficulties in describing feelings, and externally oriented thinking. Emotion regulation difficulties were assessed using the Hindi adaptation of the Difficulties in Emotion Regulation Scale (DERS)(Pandey et al, 2010). The DERS is a 36 item measure that assesses an individual’s difficulties in regulating emotions across six domains. The Hindi version of the DERS was developed using the contemporary method of translations and backtranslation. The initial psychometric evaluation of the Hindi version of DERS (the DERS-H) revealed that the scale is psychometrically sound and reliable and the has a factor structure similar to the original DERS (Pandey et al., 2010). The 28 item version of the General Health Questionnaire (GHQ-28)(Goldberg and Hillier, 1979) was used to assess four dimensions of mental health, viz., somatic complains, anxiety & insomnia, depression and social dysfunction. The subjective well-being was gauged by two scales- one measuring positive/negative affect and the other life satisfaction. To assess the level of positive and negative the Hindi version of Positive Affect and Negative Affect Schedule (PANAS; (Pandey and Shrivastava, 2008) was used. It consists of 20 mood related adjectives (10 positive and 10 negative) that assesses two global dimensions of affect: positive and negative (Watson et al, 1988). Respondents are required to mark the level to which these moods were experienced by them during a specified period on a 5-point scale. The Satisfaction with Life Scale (SWLS; Diener, et al (1985) was used to assess the general life satisfaction. It is five item scale rated on 7-point scale. Procedure: The participants of the present study were contacted either individually or in small groups consisting of 3 to 4 persons. Before the administration of the questionnaires the participants were briefed about the purpose of the study and their task. After getting the consent of the participants the aforesaid questionnaires were administered as per the standard instructions of each questionnaire. All participants were requested to ensure that they have responded to each items of every questionnaire/scale. Results: To ascertain the relationship various affect related deficits (alexithymia and difficulties in regulating emotions) with various domains of mental health and subjective well-being (positive/negative affect and satisfaction with life) bi-variate correlation coefficients were computed. The obtained results have been displayed in Table 1. It is evident from the Table-1 that two dimensions of alexithymia (difficulties in identifying feelings and difficulties in describing feelings) are correlated significantly with all the dimensions of mental health and subjective well being. Further, the direction of correlation is positive will all the dimensions of mental health and well-being except positive affect and life satisfaction. However, the third dimension of alexithymia, externally oriented thinking (EOT), showed significant correlations with some dimensions but not with others. For example, it failed to correlate significantly with somatic complaints, anxiety, negative affect and life satisfaction. Here it is important to mention that higher score on various dimensions of GHQ indicate greater mental health complaints. Thus, the observed pattern of correlation suggests that the affective domain of alexithymia (difficulty in identifying and describing feelings) have significant and negative influence on all the dimensions of mental health and well-being whereas the cognitive component of alexithymia is associated with selected aspects of mental health such as social dysfunction, depression and reduced positive emotional experiences.

150 Saxena, Dubey and Pandey A similar pattern of correlations was also obtained between various dimensions of difficulties in regulating emotions one hand and mental health and subjective well being on the other (Table-2). All the dimensions of difficulties in emotion regulation except lack of emotional awareness correlated significantly with all dimensions of mental health and subjective well being. The lack of emotional awareness correlated significant with only one dimension of mental health and well being respectively, i.e., social dysfunction and positive affect. Table 2 Correlations of Dimensions of Difficulties in Emotion Regulation with Mental Health & Well Being Non acceptance of emotional resonses Difficulty engaging in goal directed behaviour Impulse control difficulties Lack of emotional awareness Limited access to emotion regulation strategies Lack of emotional clarity DERS total somatic Complains 0.270** 0.245** 0.251** 0.097 0.325** 0.344** 0.384** Anxiety & Insomnia 0.445** 0.278** 0.369** 0.082 0.457** 0.387** 0.514** Social Dysfunction 0.282** 0.211** 0.185** 0.135* 0.255** 0.314** 0.342** Depression 0.403** 0.202** 0.387** 0.027 0.413** 0.369** 0.468** GHQ Total 0.451** 0.299** 0.393** 0.096 0.480** 0.448** 0.550** Positive affect -0.251** -0.253** -0.294** -0.259** -0.272** -0.316** -0.407** Negative affect 0.435** 0.231** 0.338** 0.061 0.490** 0.334** 0.490** Satisfaction with life scale -0.161** -0.258** -0.232** -0.031 -0.255** -0.156** -0.280** This pattern of findings suggests that various types of difficulties in regulating one’s emotion negatively influence the mental health and subjective well-being of an individual. Although the findings of correlations are encouraging and show that alexithymia and difficulties in emotion regulation are related to mental health and subjective well being, it does not show Table1 Correlations of Various Dimensions of Alexithymia with Dimensions of Mental Health & Well Being Difficulties in identifying feelings Difficulties in describing feelings Externally oriented thinking Alexithymia total Somatic complains 0.386** 0.350** 0.087 0.373** Anxiety and Insomnia 0.456** 0.385** 0.082 0.423** Social Dysfunction 0.271** 0.276** 0.149* 0.311** Depression 0.430** 0.330** 0.139* 0.412** GHQ total 0.498** 0.427** 0.140* 0.485** Positive Affect -0.241** -0.220** -0.154** -0.272** Negative Affect 0.463** 0.311** 0.129 0.425** Life satisfaction -0.155** -0.155** -0.007 -0.147*

Emotion Regulation Difficulties and Mental Health 151 the relative significance of various domains of alexithymia and emotion regulation difficulties in predicting mental health problems and wellbeing. Thus, to address this objective, a series of step wise multiple regression analyses was conducted using various dimensions of alexithymia as predictor variables and various dimensions of mental health and subjective Table 3 Results of Step wise Multiple Regression Analysis using Dimensions of Alexithymia as Predictor Variables and Dimensions of Mental Health & Well Being as Criterion Predictors R R2 R2 change F change Sig of F change Beta t sig Dependent Variable : Somatic Complalns Difficulties in identifying feelings .386 .149 .149 49.336 .000 0.274 3.981 .000 Difficulties in identifying feelings .412 .169 .021 6.951 .009 0.182 2.637 .009 Dependent Variable: Anxiety & Insomnia Difficulties in identifying feelings .456 .208 .208 73.860 .000 0.351 5.282 .000 Difficulties in describing feelings .475 .225 .018 6.496 .011 0.170 2.549 .011 Dependent Variable: Social Dysfunction Difficulties in describing feelings .276 .076 .076 23.176 .000 0.175 2.432 .016 Difficulties in identifying feelings .304 .093 .017 5.159 .024 0.164 2.271 0.24 Dependent Variable: Depression Difficulties in identifying feelings .430 .185 .185 63.916 .000 0.430 7.995 .000 Dependent Variable: Positive Affect Difficulties in identifying feelings .241 .058 .058 17.284 .000 -0.241 -4.157 .000 Dependent Variable: Negative Affect Difficulties in identifying feelings .463 .215 .215 76.852 .000 0.463 8.767 .000 Dependent Variable: Satisfaction With Life Scale Difficulties in describing feeling .155 .024 .024 6.917 .009 -0.155 -2.630 .009 well being as criterion. The obtained results have been summarized in Table 3 and 4 The results of stepwise regression analysis using various dimensions of alexithymia as predictor and dimensions of health and wellbeing as criterion (Table-3) revealed that difficulties in identifying feelings emerged as the best predictor of all dimensions of mental health and subjective wellbeing except social dysfunction and satisfaction with life, explaining a total variance of approximately 5% to 22% of the various domains of health. Difficulties in describing feelings were the single best predictor of social dysfunction and negative affect and for some other dimensions of health the second best predictor (e.g., somatic complaints and anxiety). This pattern of findings suggests that the mental health status and well-being of an individual can be best predicted by the affective component of alexithymia, particularly

152 Saxena, Dubey and Pandey by difficulties in identifying feelings. Thus, it is evident that difficulty in identify feelings or being unable to understand feelings is the main deficit associated with various mental health symptoms and an inadequate level of subjective wellbeing. Table 4 Results of step wise Multiple Regression Analysis using Dimensions of Emotion Regulation as Predictor Variables and various Dimensions of Mental Health and well being as Criterion Predictors R R2 R2 change F change Sig of F change Beta t sig Dependent Variable: Somatic Complains Lack of Emotional Clarity .344 .118 .118 38.310 .000 0.261 4.294 .000 Difficulty in engaging in goal directed behaviour .396 .157 .039 13.021 .000 .136 2.166 .031 Limited access to emotion regulation strategies .410 .168 .012 3.954 .048 .139 1.988 .048 Dependent Variable: Anxiety & Insomnia Limited access to emotion regulation strategies .457 .209 .209 75.563 .000 .234 3.449 .001 Lack of Emotional Clarity .500 .250 .041 15.702 .000 .192 3.330 .001 Non acceptance of emotional responses .526 .277 .026 10.401 .001 .215 3.225 .001 Dependent Variable: Social Dysfunction Lack of Emotional Clarity .314 .099 .099 31.339 .000 .240 3.952 .000 Difficulty in engaging in goal directed behaviour .356 .127 .028 9.063 .003 .124 2.087 .038 Non acceptance of emotional responses .374 .140 .013 4.293 .039 .134 2.072 .039 Dependent Variable: Depression Limited access to emotion regulation strategies .413 .186 .186 65.368 .000 .235 3.385 .001 Difficulty in engaging in goal directed behaviour .474 .225 .039 14.170 .000 .191 3.239 .001 Non acceptance of emotional responses .492 .242 .017 6.447 .012 .174 2.539 .012 Dependent Variable: Positive Affect Lack of Emotional Clarity .316 .100 .100 31.665 .000 -.226 -4.019 .000 Difficulty in engaging in goal directed behaviour .379 .144 .044 14.519 .000 -.235 .4.306 .000 Lack of Emotional Awareness .432 .187 .043 15.04 .000 -.216 -3.880 .000 Dependent Variable: Negative Affect Limited access to emotion regulation strategies .490 .240 .240 90.155 .000 .320 4.720 .0004 Non acceptance of emotional responses .516 .266 .025 9.858 .002 .179 2.678 .008 Lack of Emotional Clarity .517 .278 .012 4.884 .028 .127 2.210 .028 Dependent Variable: Satisfaction With Life Scale Difficulty in engaging in goal directed behaviour feeling .258 .067 .067 20.471 .000 -0.174 -2.662 .008 Limited access to emotion regulation strategies .296 .088 .021 6.447 .011 -.167 -2.545 .011

Emotion Regulation Difficulties and Mental Health 153 A similar set of step wise multiple regression analysis was conducted using dimensions of difficulties in regulating emotions as predictors and various dimensions of mental health and well being as criterion. The findings are reported in Table 4. The findings revealed that lack of emotional clarity emerged as the best predictor of somatic complains, social dysfunction and positive affect whereas limited access to emotion regulation strategies emerged as the best predictor of anxiety and insomnia, depression and negative affect. Limited access to emotion regulation strategies also emerged as the second best predictor of satisfaction with life that was best predicted by difficulties engaging in goal directed behaviour. Other dimensions of emotion regulation difficulties that were found to be the significant predictors included difficulties engaging in goal directed behaviour and non acceptance of emotional responses. These findings suggest that, though, various dimensions of emotion regulation difficulties are associated with one’s mental health and well-being (as indicated by bi-variate correlation), only a few of them are relatively more important for understanding the health status of an individual. Overall, the findings suggest that individuals who are not clear about their emotional experiences and do not have adequate skills to regulate their emotions are more prone to have mental health problems and lower level of subjective well being. Taken together, the findings of the present study suggest that the affective component of alexithymia (particularly difficulty in identifying feelings) and certain specific types of emotion regulation difficulties such as lack of emotional clarity, limited access to emotion regulation strategies, difficulties engaging in goal directed behaviour and non acceptance of emotional responses are relatively more detrimental to one’s mental health and subjective well-being as compared to other domains of alexithymia and emotion regulation difficulties. Discussion: The findings of the present study empirically support the notion that difficulties in understanding, communicating and regulating emotions are related to the mental health and subjective well being of an individual. However, certain specific types of emotional deficits such as difficulties in identifying and describing feelings lack of emotional clarity, limited access to emotion regulation strategies, difficulties engaging in goal directed behaviour and non acceptance of emotional responses are relatively more detrimental to one’s mental health and subjective well-being as compared to other types of emotional difficulties. The finding that individuals with higher level of difficulties in identifying and describing feelings is related to various mental health problems such as depression, anxiety, insomnia, somatic complains, social dysfunction is supported by a number of earlier studies. For example, in a recent study the depressive symptom severity was found to be strongly associated with alexithymia particularly with the two dimensions –difficulty in identifying feelings and difficulty in describing feelings (Bamonti et al., 2010). Similarly, difficulties in identifying and describing feelings has been found to be related to high negative affect and lower level of positive affect and subjective well being (Yelsma, 2007). Lundh and Broman (2006) have argued that the difficultly in identifying feelings and difficulty in describing feelings index alexithymia via the person’s self assessment of his or her abilities, which is likely to be influenced by positive and negative affect. The externally oriented thinking, on the other hand, indexes alexithymia more indirectly, by asking for aspects of people’s experience (awareness of external facts vs. internal experiences) and therefore is less likely to emerge as a predictor of the positive/negative effect. The findings of the present study that lack of emotional clarity and limited access to emotion regulation strategies play a more significant role in predicting mental health problems and subjective well being of an individual is supported by some indirect empirical evidences. For example, studies report that patients with panic attack show reduced emotional clarity and difficultly to distinguish between bodily sensations and emotional states, resulting in internal states being

154 Saxena, Dubey and Pandey perceived as ambiguous and unpredictable. Similarly, in a recent Meta analytic review Aldao and associates (2010) have noted that various types of psychopathology and mental health problems can be viewed as a result of limited access to emotion regulation strategies. Depressive individuals have been found to use dysfunctional strategies such as rumination and catastrophising and less frequently use positive strategies in regulating their emotions (McMurrich and Johnson, 2008) and as a result experience heightened intensity and duration of negative emotions (Liverant et al, 2008). To sum up, the findings of the current study adds to the existing literature demonstrating the role of specific types of emotional deficits such as difficulties in understanding, communicating and regulating emotions in determining the mental health and subjective well being of an individual. References: Aldao, A., Nolen-Hoeksema, S., and Schweizer, S. (2010). 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Penetrative Interpretation of the Inner Self of a Case through Projective Imagery: A Comparative Exploration Nilanjana Sanyal, Manisha Dasgupta and Sarika Agarwal The paper highlights the clinical probing of a case, aged 8years, first born, and belonging to a Muslim family of middle socio-economic strata, living with maternal grandparents, and having adjustment problems. She was administered with the Children’s Apperception Test (CAT), Fairy Tale Test (FTT), and Somatic Inkblot Series – (SIS-II). The three different projective tests were administered for crossverification of the findings. Results revealed striking congruence of the signs of the searches in relation to the clinical delving of the interview and the projective probing of the case, reflecting the clinical efficacy of projective tests in general. Projective tests for children allow their imagination and playful expression to be captured and transformed into a standardized format, rather than remain within the utterly idiographic domain of the playground or the clinician-patient relationship (Tuber et al, 2008). Such tests have been proved to be particularly useful when viewed through a psychodynamic lens because they operationalize and provide a database for many theoretical concepts underlying different psychodynamic schools of thought, thereby serving as a connective bridge between the measurement of individual personality, psychodynamic theory and treatment process. Projective material is everywhere; our challenge is to capture this material in a way that allows for meaningful comparisons and generalized findings .The road is open for new projective measures that will help to operationalize core tenets of psychodynamic theory and aid in the assessment of personality and psychopathology. In case of children in India, the most common projective test is the Children’s Apperception Test (Chowdhury, 1960, 1967). In fact the Children’s Apperception Test (CAT)(Bellak and Bellak,1949) was originally developed to unveil psychosexual conflicts accompanying different stages of children’s development . Examples of these conflicts include relationship issues, sibling rivalry, and aggression. Today CAT is most often used as an assessment technique in clinical evaluation. The Fairy Tale Test (FTT) (Coulacoglou, 2003) is a projective test designed for children aged 6 to 12 years. Its rationale rests on the relation between fairy tales and unconscious processes (Bettleheim, 1976). It is a novel way of assessing the inner lives of children through structured fantasy and story- telling, by providing a rich palette for the child’s projection of feelings, conflicts and wishes, and appears to be yet another significant projective test applicable for Indian children (Dasgupta and Sanyal, 2006; Sanyal et al, 2006; Sanyal and Dasgupta, 2008, 2009).The theoretical background is psychodynamic, based principally on the theories of ego and object relations. It is believed that fairy tales are symbolic representations of crucial “other” on the child’s life, parts of child’s personality (good or bad), and internal processes (id, ego and superego) (Shapiro et al, 1990). The Somatic Inkblot Series Test (SIS) (Cassell, 1990, Cassell and Dubey, 2003) appears to be yet another projective test which is of much significance in the present context. It is a structured, projective, diagnostic test and serves as adjunct to psychotherapy Nilanjana Sanyal, Ph.D. Professor, Manisha Dasgupta, Ph.D. Asst Prof. and Sarika Agarwal,M.A.Research Scholar, Dept of Psych., University of Calcutta, 92 A.P.C. Road, Kolkata-70000 (Correspondance on Email: sanyal_nilanjana2004@rediffmail.com) Key words: Projective imagery, Fairy Tale Test, Somatic Inkblot Series

156 Sanyal, Das Gupta and Agarwal and counseling. The SIS is structured by a sequential presentation of intentionally designed and field-tested inkblot like images. These images demonstrate typical and atypical response potentials. The SIS procedure is based on spontaneous, individually generated responses to semi-ambiguous figures, which elicit intra-psychic associations specific to the person presented with them. The present paper is an attempt to investigate the efficacy of three different projective tests, namely, The Children’s Apperception Test, The Fairy Tale Test and The Somatic Inkblot Series-II in clinical assessment, especially in terms of the diagnosis and detailed analyses of the findings of a child with adjustment and emotional problems. The purpose of the second fold is to draw resemblances in three different test findings as well as to locate any differentiating features therein. Background of the Case: The Case named Praveen (Name changed) aged 8 years 6 months, with complaints of low academic performance, Generalized fear from others, Aggressiveness, Forgetfulness, Inattentiveness, Being stubborn, Self- talking and Poor adjustment at home and in the school since last 18 months, was referred from a government hospital for personality assessment.. Family history: Perveen belongs to a Muslim, middle-class, joint family of eight members. She is the only child of her parents. She has been staying with her maternal grandparents since birth. Her mother stayed with her father only for about 5 months after her marriage and came back to her parents for ever. Her mother left her husband because he was suffering from some mental illness. Perveen never met her father even once. She lost her father when she was 18 months and lost her mother when she was 30 months. Both her parents died at a very early age. She was raised by her maternal grandparents, and presently she is being looked after by her maternal uncle and aunty. She spends most of her time sleeping and playing solitary games. As such, her interaction with her cousins is not very smooth. She often ends up getting into fights with them. Her informants reported that at times she would dress-up like a lady by wearing a sari and facing the walls, engages herself in monologue; and at other times she will go outside and mostly play alone. She attends school in the morning, comes back home, engages in playful activities in the afternoon, and prepares her lessons with the help of her tutor. Tests administered: A detailed interview was conducted with the case at the beginning. After establishing rapport, she was administered the following projective tests in two sessions: • Children’s Apperception Test (CAT) (Bellak, 1975). • Fairy Tale Test (FTT) (Coulacoglou, 2003). • Somatic Inkblot Series -SIS-II (Cassell and Dubey, 2003). Procedure followed for administering the CAT: The CAT was administered with the following instructions: “We would now engage in a game in which you will have to tell a story about pictures, which I would present to you; i.e. you are to tell me what is going on, what the animals are doing now, what happened before in the story and what might happen later.” Much encouragement and prompting was necessary, on the part of the test administrator. After all the stories had been related, further elaboration on specific points was made for clarification. Procedure followed for administering the FTT: The stories of Little Red Riding Hood and Snow White and Seven Dwarfs were told to her seven days before the day of assessment. The

Interpretation of the Inner Self through Projective Imagery 157 investigator introduced the child to the FTT on the day of testing as follows: “We are going to play a game with the popular fairy tale heroes that you have been told. I am going to ask you some questions about them and I would like to hear your opinion.” The cards were presented to the child in sets of three at a time in a standard order as instructed in the manual. The child was asked to respond to specific structured questions that related to the set of cards presented to her. Further probing was done whenever that was felt necessary to delve into the unconscious personality dynamics of the child in relation to the different variables. In the recording of the interpretation of the FTT responses, the places where query was done were specifically indicated by query mark (?) to signify the implication of specific probing. Behavioral observances of the child were also noted down during the process of administration of FTT for qualitative analyses. Scoring for the each of the scoring variables revealed from the FTT was done by rating majority of them on a 1-3 point scale whereby 1 denoted low and 3 denoted high intensity. Raw scores of all variables were converted into T-scores (mean = 50, Standard deviation = 10) as depicted in table 3. Procedure followed for administering the SIS-II: The patient was provided with SIS-II booklet consisting of 62 images in two series A and B, each with 31 images and the instructions printed on the last page of the booklet was read aloud as, “Most people find this test fun and interesting. First, please relax, take a few deep breaths, and prepare to enjoy. Please turn this booklet over, and study the sample response. Write what it look like to you. Please include everything you see even if it reminds you something remote, vague or highly personal. Please include everything you see with as much details as possible. Also include any outstanding emotional reaction that might occur in responding these images. Please begin from the first page; study the sample, and continue until completed.” The subject was asked to complete the identification data and the brief health history given at the back page of the booklet.

The client was finally asked to select 3 images that she liked the most and 3 images she liked the least. Test behavior: Perveen was co-operative and interested in three testing sessions. It was relatively easy to establish rapport with her. The tests were administered in three different sessions as it was difficult for the child to sustain her attention for a long period of time. She appeared to be very prompt and elaborative while responding to CAT cards. She responded to each of the questions with respect to the FTT cards without much difficulty. However, she showed reluctance occasionally while responding to the stimuli provided in SIS-II. She also rejected the specific SIS images, namely, 19A, 24A, 25A, 28A, 31A, 2B, 4B, 9B, 17B, 18B, 20B and 23B. Results: Her case was chosen for the presentation because her responses and the symbolic themes reflected on CAT stories and SIS responses support traditional psychoanalytical interpretations (Beltelheim, 1976) along with qualitative tunes. Personality: A. Findings of the CAT: A few significant findings as revealed by CAT are discussed below: Card 1: “These are hens and they are going to have their breakfast. They all belonged to a family but the eldest hen here is not related to them. She is just informing the others that today chicken has been prepared for breakfast”. This suggests the presence of strong oral needs along with

158 Sanyal, Das Gupta and Agarwal loose interpersonal bondage. The client is thus not able to find herself related to the parental figures, specifically the mother. This might be explained because of her intense emotional deprivation and trauma from maternal love and affection because of her mother’s death at very early and dependent stage of life. Card 3: “An old lion is sitting and he is feeling very hungry. He is wondering what to eat in order to satiate his hunger. He would then go out with a stick to search for good food, as he has grown old and cannot go about independently without the stick. He would then kill everyone - he will kill the cows so that he will be able to eat them. Again when he will feel hungry he would kill deer and eat them up.” It indicates the presence of prominent oral needs, a strong sense of inadequacy along with oral aggression (of biting nature). She feels less powerful and inept and thereby lacks self-confidence, resulting in poor self-image, which might be perhaps because of a lack of significant caregivers to identify with. Perveen also tends to use rationalization and undoing as her primary defenses. Card 7: “There was a lion and a monkey who were once good friends but one day, the monkey ditches the lion and pushes him into a river. From then onwards the lion no longer trusted any of the monkeys. Later, he became friends with another lion and took revenge against that monkey.” It suggests the striking presence of a sense of mistrust in the client along with traces of aggression as retaliation. This might be explained by the formation of faulty objectrelations, resulting in an “emotional crisis.” Card 10: “This is a child and his father. The father asks the child to go to the bathroom and take a bath and urinate there. His father goes out to catch chickens to cook and eat, by locking all the doors and windows so that his son will not be able to come out of the washroom. But still the child manages to come out by breaking the doors. The child over-eats the cooked meal, hence spoils the entire washroom and refuses to clean it. His father scolds him vehemently. The son leaves the home but after a few days he returns again.” It hints at the presence of anal orientation in the client. Perveen perceives her father to be very powerful, authoritative and punishing. She appears to adopt a rebellious stance to cope against the authoritative dictums of the father-figure and also tends to adopt undoing and acting-out as major defenses. Latent guilt-orientation may also be inferred, which requires further verification. B. Findings revealed from the FTT: Interpretation of the findings on personality variables as revealed by FTT: The obtained magnitude of the T-scores for the different variables as revealed from the FTT significantly brings out pathological personality profile. In fact, Table-1 reveals that she has strikingly high degree of sexual preoccupation, with high degree of aggression as envy, aggression Type A, oral aggression along with depressive loadings. Some of the characteristic responses of the case are presented as follows: 1. Little Red Ridding Hood (LRRH): Card –III: “She is thinking of returning home quickly from her grandmother’s place after giving food (?), and of running away home quickly from there. She’ll not wait there (?) because she does not like her grandmother’s place (?) for her grandmother give her plenty of work to do.” (AFTC = 2, FA =1) {Dynamic reflections hint at the presence of anxiety and fear of aggression} 2. WOLF: Card I: “He’s very hungry and wants to eat something

Interpretation of the Inner Self through Projective Imagery 159 Table 1 T-Scores on Each of the Different Personality Variables in the FTT. Serial No. Personality Variables Interpretation of the Variables Obtained T-Scores 1. Ambivalence (AMB) It is an ego-function which appears in different forms, such as indecision, doubt alternative responses and emotional conflict. 2. Desire for material things (DMT) Is associated with the desire to acquire material things including money, toys, clothes, cars, jewelry as material Pleasures. 3. Desire for superiority (DSUP) Reveals feelings of omnipotence and thedesire for great achievement as for the attainment of positions or social status. 4. Aggression as dominance (AGRDOM) It means to master one’s environment in order to impose one’s self or one’s will ant to satisfy one’s ambition. 5. Aggression as retaliation (AGRET) Is a means of aggression which is motivated by a negative traumatic event that occurred in the past? 6. Aggression as defense (AGRDEF) Is a form of aggression which primarily focuses on defending or protecting oneself or someone else when threatened or attacked. 7. Aggression as envy (AGRENVY) It arises when compares unfavorably to others and is characterized by feelings of inferiority, hostility or resentment. 8. Aggression type A (AGRA) It is primarily interpersonal and hostile, the major motives being hatred and pleasure. 9. Fear of aggression (FA) It reflects a fear of eminent attack threat or danger. 10. Oral aggression (OA) Most primitive or infantile form of aggression (eg.-biting, chewing, etc.). 11. Oral needs (ON) Reflects actual deprivation of food or symbolic deprivation of love and affection. 12. Desire for help(DH) Corresponds to a desire to offer assistance to others in need. 13. Need for affiliation (NAFIL) Refers to one’s need to engage in friendly behavior, acquire friends, or be a part of the social milieu. 14. Anxiety (ANX) Reflected through thought about impending dangers of distressing (eg. Harm, death, self-image, insecurity etc.). 15. Depression Refers to expression of feelings of unhappiness, rejection or loneliness. 16. Need for affection (NAFCT) Expressed as a need to offer and receive love and affection. 17. Relationship with mother (REL/MO) Reflects the quality of perceived relationship with the mother. 18. Relationship with father (REL/FA) Reflects the quality of perceived relationship with the father. <25 19. Adaption to the fairy tale content (AFTC) Reflects the Childs ability to confine the responses to fairy tale content version to which she is familiar; also reflects the child’s level of reality testing. 20. Repetitions (R) Involves a response that is similar (meaning wise) to the previous one and may be due to lack of imagination, Boredom or preoccupation with a particular theme. 21. Self-esteem (SE) Connotes the value that one places for oneself. <25 22. Need for protection (NPRO) Need to seek security or assistance from others who are perceived as strong as more powerful 23. Morality (MOR) Reflects issues related to moral judgments, dilemmas between what is right and what is wrong. 24. Sense of property (SPRO) Involves the determination of boundaries between “what is mine” and “what is not mine”. 25. Sexual preoccupations (SPRO) Reflects interests in as concern about sexual matters either in a social disguised form (marriage, falling in love) or in a more impulsive way.

160 Sanyal, Das Gupta and Agarwal (?). He’ll be able to eat (?). He’s waiting for somebody to pounce upon if anybody comes along his way” (ON = 1, OA = 2, AFTC = 2) {Dynamic probing indicate the presence of oral aggression and oral needs} Card III: “He has seen Little Red Ridding Hood and wants to eat her up (?). He’s very angry at LRRH as she didn’t give him food to eat (?). He will go to her grandmother’s place and lock her up. (OA = 1, ARET = 1, AFTC = 3) {Dynamic responses support the evidences of oral aggression and aggression as retaliation}. 3. DWARF Card II: “He’s worrying about his daughter and thinking to go back home to search her (?) He’ll not find his daughter and then send the queen away from his house (?). He is feeling sad.” (ANX = 1, D = 1, AFTC = 1) {Dynamic reflections indicate the presence of anxiety and depressive features .It also indicates the presence of proactive coping on the part of the client to combat danger.} Card III: “He is thinking of telling the queen that “if you don’t find my daughter, I’ll kill you and take revenge on you” (?). He’s feeling very angry (?). He’ll not get his daughter (?). He’ll not allow the queen to enter his house.” (AGRET = 3, R = 1, AFTC = 1) {Dynamic probing indicate the presence of prominent aggression as retaliation} 3. WITCH: Card III: “She is wondering how to go in front of Snow White as an apple seller. I don’t know how to carry myself (?). She wants to transform herself as an apple-seller by her magical tricks and then come back home after the mission.” (AGG = 3, AMB = 2, AFTC = 2 ) {Dynamic probing reveals intense degree of aggression along with feelings of ambivalence as well} 4. GIANT: Card II: “He’s thinking to meet a girl who is very beautiful (?). He would marry that girl (?) But he won’t be successful (?) because nobody will like him (?). He’s is now thinking of marrying a simple girl (?) but still won’t be successful” (SP = 2, SE = -1, AFTC = 1) {Dynamic reflections indicate the presence of preoccupations with sexual matters and negative self esteem on the part of the client.} Card III: “He’s thinking to marry just a good girl who would wear a good dress, cook good food (?) He did see a girl but she slapped him (?). Finally he would marry a poor girl but she would also not cook food for him (?) for she doesn’t like him” (SP = 2, ON = 1, DMT = 1) {Dynamic responses hint at the presence of sexual preoccupation, oral needs, and an underlying desire for material things} Scenes from the story of LLRH: Card II: “She is sitting and crying and thinking to herself that my mother doesn’t love me (?) Her mother will pester her for eating food but she’ll deny repeatedly. Then her mother will say that she had told just like that (?) then she’ll eat the food and lie down. (REL/MO = -1, NAFCT = 1, AFCT = 2, ON = 1, D = 2) {Dynamic probing indicates the presence of a rejecting and punishing mother figure along with underlying depressive feelings and oral needs}

Interpretation of the Inner Self through Projective Imagery 161 Card III: “It’s morning and LRRH’s mother told her to go to her grandmother’s place with food. But she said that she’ll not have food. Her mother became angry to which LRRH also got angry. She’ll leave home (?). LRRH’s feeling very sad (?).She’ll not return home.” (D = 1, ON = 1, REL/MO = -1, AFTC = 2) {Dynamic responses support the presence of conflicts in the client with regard to compliance and autonomy with authority figures. Her responses also indicate the presence of depressive loadings, oral needs and the symbolic abandonment of the mother-figure on the part of the client.} Scenes from snow white and the seven dwarfs: Card 1: “The prince wants to marry to marry Snow White but Snow White does not trust him. She feels that he has been sent by the queen (?). She’ll ask the dwarfs whether to marry the prince (?). She’ll marry the prince finally.” (REL/FA = -1, AMB = 3, AFTC = 3 ) {Dynamic probing hint at the presence of general mistrust in relationship owing to poor relationship with her parental figures along with ambivalence in her relationships} Card 2: “Snow White is telling the prince that my Dwarfs have told if you don’t send her back to them within a week, I’ll not marry you (?). He’ll not agree initially but would agree a little later (?) they’ll marry at the end. The prince agreed to the Snow White at the end.” (AMB = 1, AFTC = 2) {Dynamic reflections indicate the presence of conditional relationships along with feelings of ambivalence on the part of the client.} Findings of the SIS- II: Rejection of images: 12 (19A, 24A, 25A, 28A, 31A, 2B, 4B, 9B, 17B, 18B, 20B and 23B). A few significant responses on the SIS-II along with their content analyses have been provided as follows: Image A7: She has responded on this image as, “A girl is going to take the apple but she won’t be able to get it as it is very high.” {This suggests the presence of oral needs along with a strong sense of inadequacy and a feeling of hopelessness on the part of the client. This projected symbolism corroborates with the findings of the client in the CAT. Her sense of inadequacy may be explained by the formation of faulty object-relations}. The symbolism projected can be incorporated into her psychotherapy. For example, her psychotherapist may ask her in the detailed enquiry such questions as “How do you think that she feels?”, “Do you ever feel in a hopeless situation?” etc.etc. Image A11: She has viewed it to be a, “A picture of a person who is falling down and has been injured” {this response sequence totally reflects the mental mechanism of projection, since there is little inkblot structure consistent with what she reported seeing. Here the physical “injury” symbolizes her incredibly painful emotional ones. Her inner world suffering goes far beyond the limits of formal diagnostic terminology and classification. Recognizing the limits of descriptive language and theory, it may be postulated that it reflects the presence of low self-esteem, intense sense of inadequacy, emotional void, castration-anxiety, somatization-tendency and inwardly-directed aggression in the client. It also hints at an underlying sense of guilt which requires further verification. She appears to be uprooted as far as social support is concerned. This hints at her severely “injured narcissistic self”}.

162 Sanyal, Das Gupta and Agarwal Image A13: She has responded to it as, “A person’s hand is on fire, as she has put her hand in fire by accident, but she would become better after sometimes.”{This probably reflects the intense “emotional pain” that the child went through in her life (losing both her parents at a very early age), self-blaming tendency, again supporting her depressive orientation, along with a wishful thought that everything would be fine some day. The latter wish introduces a hopeful element in her attitude to psychotherapy thereby improving her prognosis. Image A20: She perceived this image as, “Two candles - images of two people - can be seen on the candle.”{It suggests her pensive feelings and stance towards parental authority/figures in general, which is associated with a lot of uncertainty and insecurity. She is unable to get rid of her unpleasant memories, which she wants to control and remove forever. This perhaps explains her depressive ruminative and catastrophizing tendencies that cause her much internal distress. As she receives psychotherapeutic opportunities to express her inner cry, her outlook should improve dramatically}. Image A22: She viewed the card as, “A spider’s web - the spider will sit in the middle of its web to spread it.” {It suggests the desire for propensity and fame in life, and hence supports her materialistic orientation to have some “emotional anchor”, security and independence. In addition, the selection of a biting animal symbol may reflect a direct projection of her inner rage from parental abandonment and ongoing conflict with her grandmother. Image A23: She perceived it as, “A bone is lying around; someone has thrown it away.” {It reinforces her sense of inadequacy, owing to a sense of being no longer needed, of losing worth, having an underlying fear of being castrated. This might be explained by her traumatic experiences in her life that had perhaps shattered her sense of worth greatly. As such, she appears to be confused regarding her meaning in life}.In the detailed enquiry while exploring parental abandonment issues, her psychotherapist might ask her “Do you ever feel like someone who has been thrown away?” Image A27: She has responded the card to be, “A snake creeping up a person’s body - stomach - and it will then smear poison in it.” {This image is normally perceived to be a female breast. Avoiding female breast may indicate her deprivation from maternal affection due to the death of her mother during infancy. The poisonous animal creeping up to smear poison may indicate her adverse situation. It might particularly symbolize the presence of difficult relationship with her aunt, who is perceived to be poisonous whom she does not like. In the absence of psychotherapy, if stressed later in life, she might tend to decompensate with florid paranoid symptoms}. Images A31: It is remarkable that she rejected this images which is normally perceived as two persons a male and a female. Rejection of this image may indicate disturbed interpersonal relationships among parents which is further confirmed by her responses on CAT. Image B15: She perceived it as “A storm has come and everything will be destroyed.” {It probably hints at the “emotional storm” the client went through early in her life for which she tends to be apprehensive regarding probable misfortunes to a great extent. It also reflects her depressive mood towards life in general, as well as her underlying rage}.

Interpretation of the Inner Self through Projective Imagery 163 Image B16: She viewed it “A needle.” {People generally perceive the card to be a spine or vertebrae. The needle may symbolize her painful imagery from deprived parental affection and underlying hostility. Image B28: She perceived this image as “A girl’s photo.” {The image is generally perceived as ‘mother and her child’. However, the client has been unable to view the commonly perceived response perhaps because of the loss of mother and deprived maternal affection}. Image B31: She viewed it “Four children.” {Being the last image of the test, it has been created in such a way that people tend to carry back home the concept of a happy family. Since the client does not have a happy family life, she has failed to perceive the parental figures and instead projects her need for affiliation and support by perceiving the stimulus as four children}. The SIS-II responses were able to bring out the disturbed interpersonal relationship, conflicting family relations, maternal deprivation, craving for affection, feeling of aloofness, frustration and aggressive outlook. SIS images have been successful in identifying the inner conflicts, particularly in family area. The overall findings on three projective tests have brought out the following: • Presence of oral needs. • Need for affiliation. • Adjustment problems. • Craving for affection. • Castration anxiety. • Depressive features. • Emotional deprivation. • Self inadequacy. • Poor quality of relationship with parents/parental figure. • Loose interpersonal bondage. • Aggressive orientation. • Poor self-image • Prominent features of aggression as envy • Oral aggression • Aggression Type A • Emotional immaturity • Craving for materialistic gains, and • Sexual conflicts The personality profile of the present case may be schematically represented as follows Fig 1: Schematic representation of the personality profile of the case Cognition • → Presence of oral needs • → High loading of aggression Affection • → Depressive features • → Need for affection and social affiliation • → Emotional deprivation • → Loose interpersonal bondage • → Low self-esteem • → Castration-anxiety • → Prominent defenses : rationalization Cognition • → Sexual preoccupation • → Poor relationship with mother Cognition • → Adjustment problems • → Low academic performance • → Inattentiveness • → Forgetfulness • → Fearfulness with regards to others • → Self-talking Stubbornness

164 Sanyal, Das Gupta and Agarwal The common threads appear to hint at the fact that the three projective tests tend to probe into the analytic/dynamic folds of personality but differ in their respective sharpness in offering interpretative angles to the qualitative bents of personality. The FTT appears to offer a very detailed elaborative profile in terms of the assessed personality variables. The SIS measures the inner core and CAT measures the interpersonal relationships and findings of both the tests support the findings of the FTT in their own distinctive and unique flavors. Conclusion: The case study sheds light to the penetrative capacity of projective techniques in unveiling one’s personality from the qualitative angle, and also to the sufficiently high and dependable inter-projective test reliability that adds to the clinical significance of such assessment, in general (Kitron and Benziman, 1990, Barlow, et al, 2003). References: Barlow, C.M., Jolley, R.P., White, D.G., and Goldraith, D. (2003). Rigidity in children’s drawings and its relation with representational change. Journal of Experimental Child Psychology, 86(2): 124-152. Bellak, L. (1975). The T.A.T, C.A.T., and S.A.T. in clinical use (3rd ed.) New York: Grune and Stratton. Bellak, L., and Bellak, S. (1949). Children’s Apperception Test. Berkeley, California: C.P.S. Co. Bettelheim, B. (1976) The Uses of Enchantment. The Meaning and Importance of Fairy Tales, New York: Knopf. Cassell, W.A., and Dubey, B.L. (2003). Interpreting inner world through somatic imagery: Manual of the Somatic Inkblot Series (2nd revision). Somatic Inkblot Center, Anchorage, Alaska, USA. Cassell, W.A.(1900) Somatic Inkblot Series –II Booklet, SIS center, Anchorage,AK Chowdhury, U. (1960). An Indian modification of the Thematic Apperception Test. Journal of Social Psychology, 51, 245-265. Chowdhury, U. (1967). An Indian Modification to the Children’s Apperception test. New Delhi:Manasayan. Coulacoglou (2003). Fairy Tale Test, Manual, Toronto: Much Health Systems, Inc. Dasgupta, M. and Sanyal, N. (2006). A review of personality assessment techniques assessment of children in India. Journal of Psychometry, Vol. XX, No. 2, 2006, 22 – 36. Kitron, D.G. and Benziman, H.(1990). The children’s apperception test: possible applications for adults. The Israel Journal of Psychiatry and Related Sciences; 27(1): 29-47. Sanyal N., and Dasgupta, M, (2009). Diagnostic value of the Fairy Tale Test as compared to Children’s Apperception Test: A case study. SIS Journal of Projective Psychology and Mental Health, Vol. 16, No. 2, July, 2009, 160-165. Sanyal, N. and Dasgupta, M. (2008). The application of the Fairy Tale Test in India. In Coulacoglou, C. (Ed.) Exploring the child’s personality: Developmental, Clinical and Cross-Cultural Applications of the Fairy Tale Test. Chales C. Thomas, Springfield, Illinois, U.S.A., pp. 264- 302. Sanyal, N., Dasgupta, M., Marinakis, D., and Doukas, O. (2006). Personality assessment of a child with emotional problems: A case study. SIS Journal of Projective Psychology and Mental Health, Vol. 13, No. 2, 139-146. Shapiro, J.P., Leifer, M., Martone, M.W., and Kassem, L. (1990). Multi – method assessment of depression in sexually abused girls. Journal of Personality Assessment, 55, 234 – 248. Tuber, S., Goudsmit, N., Ferst, A., Shargin, S., and Wolitzky, R. (2008). A review of projective tests for children: Recent Developments. In Coulacoglou, C. (Ed.) Exploring the child’s personality: Developmental, Clinical and Cross-Cultural Applications of the Fairy Tale Test. (2008). Chales C. Thomas, Springfield, Illinois, U.S.A., pp. 264-302.

Diagnostic Indicators of SIS-I among Non Paranoid Schizophrenics Bhawna Singh, Rajni Kashyap and A. K. Srivastava Somatic Inkblot Series-I was administered to 50 non-paranoid Schizophrenic patients and 50 normal subjects to identify the diagnostic indicators of non paranoid schizophrenics. The results indicated that the patient group scored lower on total response, animal response, sex, human movement, most typical and typical response Psycho-diagnosis is a major role of psychologists working in clinics. The Inkblot techniques is the most frequently used psychological tests and the Somatic Inkblot Series is a new addition among inkblot tests. The SIS-I consists of 20 inkblot images in card form. The test has been employed to study coronary patients (Rathee et. al., 1994), Male transsexuals (Sahay and Srivastava, 1994), Drug addicts (Mitra and Mukhopadhyayl, 1996), Normal subjects (Rathee and Singh, 1996), Obese patients (Cinzaia and Roberto, 1998) and Chronic Schizophrenics (Kumar et. al, 2001, Dubey and Cassell, 1993, Mishra and Dwivedi, 1997). The findings of various studies indicate that the SIS indices were able to differentiate significantly between Schizophrenics and normal subjects. The present study is an extension of previous study on SIS-I to identify the diagnostic indicators of non paranoid schizophrenic patients. Materials and Method: The sample consisted of 100 subjects. (50 normal and 50 non-paranoid schizophrenic patients). The patient group diagnosed clinically on the basis of DSM-IV criteria, were taken from inpatient department of Institute of Mental Health and Hospital, Agra. The normal subjects, matched on age and education were drawn from general population. The normal subjects were screened through GHQ-60 to rule out any psychiatric and physical illness. The prospective subjects were administered Somatic Inkblot Series-I Cards (Cassell, 1980) under standard instructions. The data was analyzed using percent mean and standard deviation. Results and Discussion: Table 1 shows demographic characteristics of the normal and non-paranoid patients included in the study. Table 1 Demographic Characteristics of the Sample Variables Non Paranoid Schizophrenics (n=50) Normal (n=50) Mean age 38.58 Yrs. 35.7 Yrs. Education Up to 5th std. 22 (44%) 22 (44%) 5th + Std. 28 (56%) 28 (56%) Sex Male 41 (82%) 25 (50%) Female 9 (18%) 25 (50%) Domicile Rural 19 (38%) 27 (54%) Urban 31 (62) 23 (46%) Bhawna Singh (Research Sholar) 50 A, Gandhi Nagar, Agra, Rajni Kashyap, Reader,Dept. of Psychology, D. J. Degree College, Baraut and Ajai K. Srivastava, Ph.D. Institute of Mental Health & Hospital, Agra, Email: drajaik@gmail.com Key Words: SIS, SIS Images

166 Singh, Kashyap and Srivastava The percentage mean and SD of various SIS-I indices in both the groups indicate that non-paranoid schizophrenic patients scored low on total number of Response, Animal response, Sex response, Movement response, Most Typical response and Typical response and high on Human response, Anatomical response, Atypical response and Rejection of cards. The statistically significant difference between patient group and normal subjects was observed on total Response, Human response, Animal response, Most Typical response, Typical response, Atypical response and Rejection of images. The findings of present study support the findings of previous studies (Kumar et. al. 2001 and Srivastava, 2002). Table 2 Percentage of Mean and SD of SIS-I indices of Non-paranoid Schizophrenics and normal Subjects SIS-I Indices Non-paranoid Schizophrenic Normal Mean S.D. Mean S.D. t- Value Total Number of response 20.02 4.40 34.84 15.00 6.701*** Human response 21.43 17.441 14.71 6.857 2.536** Animal response 25.20 15.337 30.55 10.233 2.053** Anatomy 19.56 19.356 14.49 9.537 1.662 Sex response 1.15 2.696 1.23 1.965 0.15 Movement 4.13 6.082 4.83 5.446 0.60 Most typical response 7.40 6.923 13.29 6.037 4.537*** Typical response 48.47 17.90 62.06 10.85 4.591*** A Typical response 44.40 20.796 23.51 14.023 5.898*** Card rejection 17.35 22.093 0.50 1.260 5.385*** *** Significant at 1% level...................................** Significant at 5% level. Conclusion: Result of the present study indicate that as compared to normal subjects the non-paranoid schizophrenics scored low on total number of Response, Animal response, Sex response, Movement response, Most Typical response and Typical response and higher on Human responses, Anatomical response, Atypical response and Rejection of cards. The findings clearly indicate the discriminating power of SIS-I between non-paranoid schizophrenic patients and normal subjects. References: Cassell, W.A. (1980) Somatic Inkblot Series-I and Body Symbolism, SIS Center, Anchorage, Alaska(USA). Cinzia, S. and Ferro, R. (1998) The SIS-I and Body Image Evaluation in Subject Suffering from Serious Obesity. SIS Journal of Projective Psychology and Mental Health, 5, 105-113. Dubey,B.L. and Cassell,W.A.(1993) Some Experiences with Somatic Inkblot Series. British Journal of Proj. Psy. 38,1: 19-41 Kumar, S., Singh, R. and Mohanty, S. (2001) A Study of Somatic Inkblot Series-I in Hospitalized male chronic Schizophrenics. SIS Journal of Projective Psychology and Mental Health, 8: 91-94.

Diagnostic Indicators of SIS-I among Non Paranoid Schizophrenics 167 Mishra, M. and Dwivedi, C.B. (1997) Content Scale Based Diagnostic Compatibility of the SIS – II with Rorschach Test in Normals, Neurotics and Schizophrenics. SIS J. of Proj. Psy. & Ment. Health, 4:121-140. Mitra., G., and Mukhopadhyay, A. (1996): SIS and Social Anxiety : An Assessment of Personality Factors of Drug Addicts. SIS Journal of Projective Psychology and Mental Health, 3:2, 153-164. Rathee, S.P., Goel, D.S., Chawla, M.L., Saldanha, D. and Dubey, B.L. (1994): A Study of Somatic Inkblot Series-I in Coronary Cases. SIS Journal of Projective Psychology and Mental Health, 1, 51-64. Rathee, S.P., and Singh, A. (1996): A Comparative Study of Male and Female on Somatic Inkblot Series-I. SIS Journal of Projective Psychology and Mental Health, 3, 43-49. Sahay, M., and Srivastava, P.K. (1994) Somatic Inkblot Series-I in Male Transsexuals. SIS Journal of Projective Psychology and Mental Health, 1, 73-79. Srivastava, A.K. (2002) Somatic Inkblot Series-I: A Meta Analysis. SIS Journal of Projective Psychology and Mental Health, 9, 33-97.

Pathological Personality and Approval Motive in Smokers Archana Singh, S. K. Singh and R. K. Singh This study was carried out with the aim to study the psychopathological components in the personality of smokers and reaction to social approval motives. A group of 20 male smokers (mean age 25.23 yrs) were selected from Patna district and a demographically matched sample of 20 male non -smokers were also selected from the adult population. Tools used in the study were Personal and Socio demographic data sheet, Rorschach Inkblot Test, Beck Depression Inventory and Approval Motive Scale. Results showed that smokers have significantly higher level of anxiety and poor coping resources, higher on neuroticism and lower on agreeableness and conscientiousness in comparison to non smokers. Smokers have poor level of thinking and social isolation. Significant lower trend in normative behavior and social approval scores proved their social avoidance from social norms. The study concluded that chain- smoking may be an indicator of some inert psychopathology. The severity of nicotine dependence is illustrated by the fact that up to 50% of smokers who suffer a severe disease, such as myocardial infarction and lung cancer (pneumectomized patients), resume smoking (Pomerleau, 1997). Until recently, the dependence resulting from the consumption of tobacco was not classified as a drug addiction, partly because the hazards to health were not widely recognized, and also because this habit was not associated with intoxication or with a socially unacceptable behavior. But times changed, and the results of many studies lead unquestionably to the conclusion that tobacco consumption leads to dependence, that nicotine is the drug present in tobacco that is responsible for dependence, and that the pharmacological and behavioral processes determining tobacco dependence are similar to those causing addiction to other drugs, such as heroin and cocaine (Pomerleau, 1997). Under these circumstances, research works focused specifically on dependence represent a starting point for the progress in understanding what is known and what has still to be discovered about the dynamics of tobacco consumption (Shadel,2000). Researchers state that social, familiar and individual risk factors can predispose an individual to dependence. Among these factors, personality features Archana Singh, Research Scholar, S. K. Singh, Ph.D. Sr. Lecturer, Dept. of Psychology, M.B.S.P.G. College, Gangapur, Varanasi and R. K. Singh, Ph.D. Lecturer Cum Counselor, DISHA Centre, Beur Jail, Patna. Key Words: Personality, Rorschach in Smokers making the individual susceptible to the properties of nicotine can play a crucial role in the process. There is strong evidence that vulnerability to dependence is a function of high sensitivity to nicotine. Thus, psychological factors related to this sensitivity can play a central role in determining who starts, who continues and who quits smoking (Carton et al, 2000). Smoking is a serious health hazard. Very few smokers know or will acknowledge the fact that it affects physical and mental health and their life span is shortened by five and half minutes for each cigarettes smoked, approximately as long as the cigarettes lasts (Nath, 1986). Nicotine and carbon mono-oxide are most destructive components of smoking. Sahakian et.al. (1989) highlighted that nicotine may act on the cortical mechanism in visual perception and attention. Jamner et.al. (1999) established a link between the use of nicotine and reduction of anger in individuals with prominent hostility trait in their personality. Black et.al, (1999) found that cigarettes smokers develop increased rates of mood disturbances and anxiety. Wolf et.al, (1999) examined the relationship between cigarettes smoking and self reported physical and mental functioning. Cigarettes smokers

Pathological Personality and Approval Motive in Smokers 169 have reported of having poor functioning of physical and mental health. A negative correlation was identified between smoking and lower emotional and social well being. Geist and Herrmann (1990) examined exsmokers and non-smokers and found that exsmokers have significantly greater self-control as well as considerably higher needs for order and endurance than smokers. On the other hand, smokers were found to have markedly lower needs for affiliation than non smokers. Koval and Pederson (1999) highlighted that some smokers do have rebellious attitude whereas some tobacco smokers showed schizotypal and borderline personality traits (William et.al., 1996; Kolliakou and Joseph, 2000). Bray et.al. (1991) found that use of cigarette can have negative effects on the health, social life, family relationship and work performance. Trinder et.al. (2000) suggested that smoking, status and social class are independently associated with the severity of respiratory symptoms. The present study is thus, an attempt to explore the personality correlates of chain smokers to study the psychopathological components of personality of chain smokers and their reaction to social approval motives. Material and Methods: A group of 20 male smokers (mean age 25.23 yrs) were selected from Patna district. This group made up the experimental group for the study. The study fixed a criterion for smokers of 15-20 cigarettes consumption per day. A demographically-matched sample of 20 male non smokers was also selected from the adult population. This group made the control group for the study. In the non smoking group only those individuals were selected who had no history of smoking at all. Both samples were selected on the bases of purposive sampling method. Tools: The following tools were used in the study: 1. Rorschach Inkblot Test: It consist of 10 standard inkblots cards. Beck’s procedure was followed for scoring and interpretation. 2. Approval Motive Scale (Tripathi and Tripathi, 1980). This is an objective questionnaire, containing 72 items. The subject has to choose one answer by indicating “true” or “false”. The scale covered 7 areas of approval motive, namely normative behavior (NB), Social conformity (SC), Positive self presentation (PSP), Defensiveness (Def), Dependency (Dep), Social responsiveness (SR), and Social approval (SA). 3. Beck Depression Inventory (Beck et al, 1961): The BDI has become one of the most widely used instruments for assessing depression. A total of 21 items are present in the scale. Each statement is scored on a 4-point scale (0-3) and a total score is obtained by summing the ratings of each statement. Procedure: All the subjects were selected through inclusion and exclusion criteria set for the present study. Reliable information was taken through the administration of personal data sheet. Rorschach Inkblot Test, Beck Depression Inventory and Approval Motive Scale were administered individually following standard procedure. Results: Means, SD and t-values of Rorschach indices of both groups are shown in Table 1.

170 Singh, Singh and Singh Table 1 Means, SD and t-ratio Values of Rorschach Indices of Smokers and non Smokers Rorschach variables Chain smokers(n=20) Mean ± SD Non smokers(n=20) Mean ± SD t-values R 22.5±8.9 21.95±7.5 .21NS IRT 26.43±4.5 20.40±5.02 2.63** W 5.02±1.11 5.30 ±.98 .90NS D 14.63±2.42 13.90± 2.58 .90NS Dd 2.2±.95 2.0 ±.80 .40NS S .86±.40 .74± .24 .54NS M 1.01±.95 3.05 ±1.02 6.8NS F+% 40.02±10.03 36.05± 10.5 1.20NS C .45±.16 .56 ±.20 2.75** Y,YF,FY 4.09±1.80 2.1 ±.75 9.04** V,FV 1.90±.74 .56 ±.23 8.01** H 5.09±2.1 8.72± 1.5 6.40** An 5.70 ±1.19 14.93±2.50 15.80** A% 10.19 ±3.19 6.15 ±2.19 5.61** Sex 8.00 ±4.51 5.23± 3.46 2.34** Blood 7.18 ± 2.13 3.19± 3.15 4.75** ** significant at .01 level, NS – not significant The Table 1 shows that both groups differed significantly on the IRT (t=2.63), M (t=6.8), F+% (t=1.20), C (t=2.75), Y (t=9.04), V (t=8.01), H (t=6.40), An (t=15.80), A% (t=5.61), Sex (t=2.34) and Blood (t=4.75) indices of the Rorschach test. Table 2 shows that the smokers scored significantly less than their counterpart nonsmokers on two sub scales of approval motive i.e. normative behavior (t=4.05, p<.01) and social approval (t=5.75, p<.01). The rest of the subscales, however, did not show significant mean difference. Table 2 Means, SD and t-ratio Values of Subscale of Approval Motive of Smokers and non Smokers Approval motive subscales Chain smokers(n+20) M±SD Non smokers(n=20) M±SD t-values Normative behavior 4.57±1.23 5.75±1.38 3.90** Social conformity 5.05±1.65 4.70±1.55 .76 NS Positive self presentation 3.89±1,80 4.63±1.45 1.45 NS Defensiveness 4.76±1.35 5.75±1.57 .07 NS Dependency 3.97±1.19 4.30±1.30 .80 NS Social responsiveness 4.23±1.23 4.67±1.06 .67 NS Social approval 11.65±2.18 13.45±.89 5.89** ** significant at .01 level, NS: not significant

Pathological Personality and Approval Motive in Smokers 171 Discussion: This study is carried out with the aim to study the psychopathological components in the personality of chain smokers and their reaction to social approval motives. Smokers were compared to non smokers on Rorschach Inkblot Test and Approval Motive Scale. Results showed that smokers have significantly higher level of anxiety and poor coping resources in comparison to non-smokers. Findings of other studies also supported the present finding (Cassell and Dubey, 1998; Mitra and Mukhopadhyay, 2000). Terracciano, Costa (2004) also found that current smokers scored higher than never smokers on neuroticism and lower on agreeableness and conscientiousness; former smokers scored intermediate on these higher-order dimensions. Smokers have significantly high level of inferiority-feelings and poor reality contact in comparison to nonsmokers. Results also showed that smokers avoided anatomical figures. This finding is consistent with other findings of Mitra and Mukhopadhya, (1996, 2000). Avoidance of common anatomical structure on Rorschach Inkblot Test shows conflict of the smokers and denial of the effect of smoking on their body. Smokers have poor control over the emotional charged stimuli. They do not react with these stimuli in proper way. They show childish emotional behavior. Higher sex responses in smokers are likely to signify sexual anxiety. High percentage of animal responses in Smokers indicates immaturity, frustration and failure. Normal subjects have seen low animal and high human responses which indicate maturity and good interpersonal relationship. Cassell and Dubey, (2003) have also found significantly low human responses and high animal responses which indicates social isolation tendencies and psychological immaturity among drug dependents. Swendsen et. al., (2002) found that specifically, the subjects with substance use disorders differed in the dimensions of alienation, control, harm avoidance, and the higher-order traits of negative emotionality and constraint. Smokers significantly got lower scores in social approval and social conformity sub-scales in comparison to non-smokers. Mitra and Mukhopadhya, (2000) also found lower trends of normative behavior and social approval scores in smokers. It again proves smoker’s desperate attitude towards social norms. Thus a conclusion may be drawn that smoking is a symptom of some inert psychopathology. A carefree approach towards the social expectations and avoidance to social conformity along with anxiety for negative evaluation is some of the highlights of the personality correlates of smokers. References: Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (June 1961). “An inventory for measuring depression”. Arch. Gen. Psychiatry 4: 561–71. Black, D.W., Zimerman, M. & Coryell, W.H. (1999). Cigarette smoking and psychiatric disorder in community sample. Annals of Clinical Psychiatry, 11, 129-136. Bray, R.M., Marsden, M.E. & Peterson, M.R. (1991). Standardized comparisons of the use of alcohol, drugs and cigarettes among military personnel and civilians. American Journal of Public Health, 81, 865-874. Carton S., Le Houezec J., Lagrue G., Jouvent R. (2000). Relationships between sensation seeking and emotional symptomatology during smoking cessation with nicotine patch therapy. Addict Behav; 25:653-662. Cassell, W, A. and Dubey, B. L. (2003) Interpreting Inner World through Somatic Imagery: Manual of Somatic Table 3 indicates significantly higher level of depression among smokers (M=21.01) than non smokers (M=7.03)(t=3.01 p<.01). Table 3 Mean, SD and t-values of Beck Depression Inventory of Smokers and non Smokers Scale Chain smoker Non smoker t-values B.D.I. M SD 21.01 5.98 7.03 8.32 3.01**

172 Singh, Singh and Singh Inkblot Series. Anchorage (USA): SIS Center. Cassell, W.A. & Dubey, B.L. (1998). Application of Somatic Inkblot Series in personality assesment, diagnosis, screening and therapy. SIS Journal of Projective Psychology and Mental Health, 5, 3-32. Geist, C.R. & Herrmann, S.M. (1990). A comparison of the psychological characteristics of smokers, ex-smokers and non smokers. Journal of Clinical Psychology, 46, 102-105. Hughes J.R., Gust S.W., Skoog, K.,and Keenan R.M., Fenwik J.W. Symptoms of tobacco withdrawal: a replication and extension. Arch Gen Psychiatry; 48:52- 59. Jamner, L.D., Shapiro, D. and Jarvik, M.E. (1999). Nicotine reduces the frequency of anger reports in smokers and non-smokers with high but not low hostility : A ambulatory study. Experimental and Clinical Psychopharmacology, 7, 454-463. Swendsen,J.D.; Conway; K.P., Rounsaville, B.J. and Merikangas, K.R. (2002). Are Personality Traits Familial Risk Factors for Substance Use Disorders? Results of a Controlled Family Study , Am J Psychiatry 159:1760- 1766 Kolliakou, A. and Joseph, S. (2000). Further evidence that tobacco smoking correlates with schizotypal and borderline personality traits. Personality and Individual Differences, 29, 191-194. Koval, J.J. and Pederson, L.L. (1999). Stress coping and other psychosocial risk factors : A model for smoking in grade 6 students. Addictive Behaviour, 24, 207-218. Mitra, G. and Mukhopadhyay, A. (1996). SIS and social anxiety- An assessment of personality factors of drug addicts. SIS Journal of Projective Psychology and Mental Health, 3, 153-164. Mitra, G. and Mukhopadhyay, A. (2000) Psychological Factors in Drug Addicts and Normals: A Comparative study. SIS J. Proj, Psy. & Mental Health, 7:53-78. Nath, U.R. (1986). Smoking : Third world alert. Oxford University Press. Walton Street, Oxford. Pandey, R., Mishra, M. and Dwivedi, C.B. (2003). Diagnostic significance of sex responses on SIS-II on sex and non sex images. SIS Journal of Projective Psychology and Mental Heath, 10, 205-208. Pomerleau, O.F. (1997). Nicotine dependence. In : Bollinger C.T., Fagerström K.O., editors. The tobacco epidemic. Prog Respir Res [Basel]; 28 : 122-31. Sahakian, B., Jones, G., Levy, R., Gray, J. and Warburton, D. (1989). The effects of nicotine on attention, information processing and short-term memory in patients with dementia of the alzheimer type. British Journal of Psychiatry, 154,797-800. Shadel, W.G., Shiffman S., Niaura R., Nichter M.,and Abrams D.B. (2000). Current models of nicotine dependence: what is known and what is needed to advance understanding of tobacco etiology among youth. Drug and Alcohol Depend; 59:1, 9-22. Singh, A.R. and Dubey, B.L. (1997). SIS II profile of drug and alcohol dependent. SIS J.Proj. Psycho. & Mental Health, 4, 69-74. Terracciano, A. and Costa, Paul T(2004) Smoking and the Five-Factor Model of Personality, Addiction, Volume 99, Number 4, pp. 472-481 (10). Trinder, P.M., Croft, P.R. & Lewis, M. (2000). Social Class, smoking and the severity of respiratory symptoms in the general population. Journal of Epidemiology and Community Health, 54, 340-343. Tripathi, N.K.M. & Tripathi, L.B. (1980). Manual for approval motive scale. Agra Psychological Corporation, Agra. William, J.H., Wellman, N.A., Allan, L.M. & Taylor, E., Tonin, J., Feldon, J. and Rowlins, J.N.P. (1996). Tobacco smoking correlates with schizotypal and borderline personality traits. Personality and Individual Differences, 20, 267-270. Wolf, S.H., Rothemich, S.F., Johnson, R.E. & Marsland, D.W. (1999). Is cigarette smoking associated with impaired physical and mental functional status? An office based survey of primary care patients. American J.Preventive Medicine, 17, 134-137.

Dissociative Convulsion Disorder: A Case Study Preeti Pandey, Ajay Tiwari and Nalini Mishra The Somatic Inkblot Series (Cassell and Dubey,2003) was administered to a 16 years old girl, studying 10th grade with complaints of fits of unconsciousness, severe headache, low mood and nausea. She was diagnosed as a case of “Dissociative Convulsion Disorder” as per ICD-10. The SIS response projected her poor interpersonal relationship, pent up aggression, physical abuse and disturbed family functioning. The SIS imagery was used as therapeutic intervention tool with positive change in her condition. The patient was a sixteen years old girl, studying in 10th grade. All of her birth and developmental milestones were normal, with no past history of any behavioral, psychological and neurological problems. She had been a good, sincere student, praised by her teachers .She always secured fourth or fifth position in her class among 40 students. Her parents were not satisfied with her achievements and compelling her to get first position. None of the parents supported her on any issue except her younger brother, who used to solace her in times of distress. Her symptom started four months earlier when she took admission in class 10th. As reported by her parents, she had frequent fits of unconsciousness with severe headache and restlessness. During his pre-board examination, she became very anxious, and often used to cry. She had a love relationship with a 23 years old person who got married and left her. When she thinks about her lost love relationship, she becomes more anxious and suffers from severe headache with fits of unconsciousness. She further developed problems in her fingers and could not write the answers in the examination. She was referred for psychological evaluation and therapeutic intervention. On psychological assessment it was observed that when she failed to solve a problem she will develop muscular rigidity which will improve/disappear after someone helped her in solving it. During therapeutic session, she expressed severe concern about the punitive reaction of her parents of not securing the first position in the class. In addition, during therapy, she also indicated the abusive relationship between the parents. She further reported that her father frequently abused her mother verbally as well as physically. He is also an alcoholic and would not pay any attention to children. Current Symptoms: Her presenting symptoms at initial psychological evaluation included nervousness, shyness, severe headache, convulsive movements, clenching of teeth, low mood etc. She had poor self image and lack of self confidence. She was diagnosed a case of Dissociative Convulsion Disorder as per ICD-10. Her attacks were pseudo seizures. On EEG and CT scan no abnormality was found in cerebral activity. SIS Responses: Three Most Liked Images: A7: “structure of a girl in dancing position” is normal response suggesting his ego strength and positive attitude towards life. Preeti Pandey, M.A. Psychologist, Email: pretty.pandey@gmail.com and Ajay Tiwari, Ph.D., Director, Nai Subah Counseling Center, Jawahar Bhavan, Sankat Mochan, Lanka , Varanasi-221005 and Nalini Mishra, Ph.D. Principal, Dhirendra Mahila P.G.College, Sunderpur, Varanasi-221005 Key Words: Conversion Disorder, Beck Depression Inventory.

174 Pandey, Tiwari and Mishra A14: “A pretty girl sitting on a lonely beach with sad mood” indicates her pensive mood and feeling of loneliness. In the detailed enquiry her psychotherapist may ask her do you sometime feel this grief like this girl. B29: “A girl coming home from school and looking very happy” may indicate her wishful thinking to have a happy home during childhood which she never had. This may also indicate her regression and wish to be a school going girl to avoid problems. In the detailed enquiry it should be suggested that if she participate in the therapy, she will become like this happy girl. Three Least Liked Images: B 31: “People standing close, arguing with each other, a bad practice” this image brings out the imagery of “Happy family (Father, Mother and two children) but she has avoided seeing a happy family because of the broken / disturbed family relationship. This reminds you of how you feel when an argument in your family. B 5: “A girl pointing a pistol to other person” may indicate her aggressive and hostile attitude towards her boy friend that cheated her. Who this reminds you of in your real life? Have you ever wished to hurt or even to kill your boy friend? When did you experience having broken and painful heart? A 9: “A man and a woman in silent mood” may indicate her depressive mood and poor inter personal relationship either between parents or with her father. What it reminds you of in your real world? Analysis of a few significant responses: A 3: “A girl running and crying for help.” Her inner cry has come out on the surface that she needs help from others. This may also be indicative of her wishful thinking to get support and help from her family members/ therapist. Does this girl remind you of yourself and your inner cry? If you share your emotional feeling, your psychotherapist will be able to help you? A 5: “A broken and painful heart” may indicate her depressive feelings about her lost love relationship. A 10: She viewed this image as “the face of very sad woman and she is weeping marred by distressful life”. This may depict her projection towards her mother who often had physical assault from her husband and feels depressed. This may also bring out her sympathy towards her mother and her inability to help her. In addition here question may be asked whether she is able to weep herself or not and she needs to be encouraged to express her grief which will reduce her pain and symptoms A 13: “Helpless hand is approaching” may indicate her pensive feeling towards life. She also needs support and help. Here she may be asked directly when she feels helpless of herself (may be recall certain theories of depression based upon to learn helplessness). A 29: “Looks like an evil thing straight out of a horror film I saw earlier.” The image on A29 is more like TAT’s blank card which works as pure projection and the imagery of “Evil thing and horrifying thoughts” suggest her traumatic memories. Here question may be asked directly about any post-traumatic dream which she may be experiencing. It is always important, whenever possible to link her inkblot responses to her disturbing symbolic “nightmares”.

Dissociative Convulsion Disorder: A Case Study 175 A 31: “A man and woman talking with each other, something serious”. This may indicate disturbed relationship either with her boy friend or among parents. Question need to be asked in this regard what brings to her mind. B 3: “Hearts once broken never heal.” Once again the broken heart concept has come back suggesting her pessimistic and depressive feelings of broken love relationship. Her psychotherapist need to suggest that while she feels hopeless with her broken heart, that psychotherapy may help her. B 4: “I never fulfilled my desires in this atmosphere” may indicate her dissatisfaction particularly in the family. B 6: “A sad girl in mirror” indicates her own sufferings and grief ridden unconscious material. B 15: “Please stop this violence for GOD” suggests that she is fed up with violence in the family. Her repeated instances of being exposed to angry and violent family scene likely played a role in her muscular skeletal symptoms. Certain vulnerable women inhibit the expression of their own inner rage by psychomotor skeleton muscle inhibition. This mechanism has been referred to as “Character Armored”. B 19: “Burning sun and broken heart, how sad, no one gives protection”. This may suggest her broken love affair and broken home with feelings of hopeless and helplessness. Her therapist might well question her in regard to possible suicidal ideation which she has not reported given the intense feelings of hopelessness and helplessness. B 28: “Woman in distressful situation” may indicate her sympathetic feelings towards her mother as well as her own personal anguish.

Interpretation of SIS Responses on Re administration (After sessions of Psychotherapy): Response to three most liked Images: A 7: “A girl in dancing position, trying to catch the apple” is a good response suggesting her ego strength and positive attitude towards life. The dancing position is improvement of her earlier mood prior to psychotherapy. B 31: “Father Mother and two children, nice picture with whole family” also suggest improvement and positive change after therapy. B 29: “A girl wins in a race competition”. She has moved from an aggressive and hostile attitude to make success in life is a positive change. Following therapy a dramatic improvement was observed in the images previously labeled as least liked for example, see B31 and B5. Analysis of other significant responses: A 3: “A beautiful fairy with magic stick coming from sky to resolve human problems”. This response indicates her hope and optimistic thoughts for life. It indicates that the supportive psychotherapy has made positive change. A 5: “Eagle catching a heart” although she still retains some heaviness and sadness in her heart, it is being reduced symbolize by Eagle catching her heart and flying upwards out of her past pain. A 10: “A girl sees her face in mirror and smile on herself”. This response indicates her positive ego strength and changed mood in comparison to her perception on this image at initial testing. It

176 Pandey, Tiwari and Mishra also indicates that the therapy has helped her to solve her problems and develop positive attitude towards life. A 13: “A powerful hand capable for security” indicates her positive strength and self confidence. A 29: “A picture of a hill station” indicates her happy mood and feeling of enjoyment. A 31: “A girl is smiling and a boy in sad mood” projects her improved state of mind in smiling shape and wishful thinking to see her ex-boy friend in agony and sad mood. B 3: “A girl giving answer of some difficult questions” This is the direct projection of how certain of her psychotherapist’s questions have caused her to face the painful emotional issues involved in grieving the loss of her love relationship. B 4: “A mother and child” is an improved normal response in comparison of earlier projection of depressive response on this image. B 5: “A boy and girl playing with ball” is a good response indicating her happy mood. B15: “A picture of many grasshoppers and spade like knives” is again an improved response in comparison of earlier aggressive response on this image. B19: “A bug/ sun” is again a normal response though he gave depressive response on initial testing. B 28: “A mother hugging the child” indicates good interpersonal relationship particularly with mother. Treatment plan: The long term treatment plan involved improving coping strategies, family intervention and supportive psychotherapy supplemented by SIS symbolism in therapeutic process. The combination appeared to have marked therapeutic effects and the family members have also noticed considerable improvement after therapeutic intervention. Conclusion: The SIS Booklet form was administered to a 16 years old girl, studying in class 10th with presenting symptoms of nervousness, frequent headache and convulsive movements, initially and after 14 sessions of psychotherapy. She had low self esteem and lack of confidence. Her response on Somatic Inkblot Series-II reflected her disturbed family relationship and unexpressed “inner cry”. Her responses on readministration changed significantly. The SIS symbolic interpretation helped her in recovering from the stressful family situation. References: Cassell, W.A. and Dubey, B.L.(2003) Interpreting Inner World through Somatic Imagery, SIS Center, 4406, Forest Road, AK 99517(USA).

Depression, Personality Characteristics and Gain among Female Patients Suffering From Somatoform Disorder and Chronic Physical Pain in Comparison to Normal Controls Damayanti Datta, Jayanti Basu and Gautam Bandyopadhyay The study purports to compare the degree of depression, certain personality characteristics and perceived gain in persons suffering from somatoform disorder, orthopedic pain and normal controls. The sample consisted of 30 women suffering from somatoform disorder, 30 from orthopaedic pain and 30 normal controls. They were administered a detailed information schedule, the Beck Depression Inventory, the Neo Five Factor Inventory and a Gain schedule prepared for the purpose. MANOVA was conducted to determine the significance of differences among the groups, followed by individual ANOVAs and Scheffe’s tests. Results revealed that depression and gain from disease were highest and extraversion lowest in the somatoform group. The two patient groups differed from the control in terms of other personality variables. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (Loeser and Treede, 2008). Experience of pain may be chronic or acute depending on its duration, and somatic or psychogenic depending on its source. Somatic or nociceptive pain is caused by ongoing stimulation of nociceptor (unpleasant stimuli) due to a chemical, thermal or mechanical event that has the potential to damage body tissue (Besson, 1999; Loeser & Treede, 2008). Psychogenic pain, also called the somatoform pain, is physical pain caused, increased or prolonged by emotional or behavioral factors. In comparison to physical pain, its course and nature depends more on the psychosocial characteristics of the patient, and its management entails attention to the socio-cultural and personality characteristics of the person, as well as the deeper meaning of the pain. The symbolic meaning of psychogenic pain has been highlighted by psychoanalytically oriented researchers. Freud in his study of neurosis demonstrated how hysteria was associated with experience of pain that had deep symbolic significance and sustained Damayanti Datta, Counsellor, Army School, Barrackpur, Kolkata, Jayanti Basu, Professor, Dept. of Applied Psychology, University of Calcutta, 92 APC Road, Kolkata-700009 and Gautam Bandyopadhyay, Associate Professor, Dept. of Psychiatry, R. G. Kar Medical College, Kolkata.(Corresponding author: Dr. Jayanti Basu, Email: basumjt@gmail.com) Key words: Somatoform disorder, orthopedic pain, depression, personality, gain by apparent and subtle gains (Freud, 1923, 1926). The category of Somatoform disorder in DSM IV and ICD 10 enumerates the diagnostic criteria of a number of pain experiences presumably originating in psychosocial causes. The major criterion of diagnosis is absence of known physical cause by thorough investigation. While the classification may have simplified diagnosis for practitioners, there are indications that the category may be a misnomer so far as it draws a clear body-mind distinction and also stigmatizes the sufferers of somatoform disorder by suggesting that the pain is not real. The strict division between somatic and psychogenic pain, has been criticized by a number of researchers. Evidences are accumulating to indicate that even pain of clear physical origin has associated psychological and social factors. Szasz in the 50s denied the division between organic and psychogenic pain and claimed that such distinction confuses the interrelation between private and public views of pain experience (Szasz, 1957). The

178 Datta, Basu and Bandyopadhyay role of deeper understanding of the symbolic meaning of any kind of pain and the need for psychoanalytically informed treatment of pain irrespective of its believed origin has been highlighted by a number of recent works (Borghetti-Hiscock, 2007; Taylor, 2008). Apart from psychoanalytical criticisms, inputs from clinical practice as well as empirical researches have pointed out that pain is a complex phenomenon, sensitive to different dimensions of our physical and personal experiences (Gamsa, 1994; Innes, 2005). A group of Stanford University researchers have demonstrated through a longitudinal study followed up for 4 years that the psychological factors predict back pain better than actual experimental discography (Carragee et al., 2004). A number of studies have attempted to understand the relation between pain and personality characteristics in terms of origin of pain and its treatment. Somatoform patients have been observed to score high on neuroticism dimension and less in extraversion and agreeableness dimension (Kirmayar et al., 1994). According to a recent study, negative affectivity is associated with high levels of both somatic and emotional distress. Agreeableness and conscientiousness may influence interactions with health care providers that lead to the failure of medical reassurance to reduce distress. Absorption of social normativity may make individuals more liable to focus attention on symptoms and more vulnerable to suggestions that induce illness anxiety (Garcia-Campayo et al,2009). Jenseu (2007) investigated personality characteristics in 73 non-psychotic psychiatric inpatients who suffered from pain. Neuroticism, anxiety and hostility were the most common correlates. The author emphasized the role of anxiety induced muscle spasm as mediator of pain. A recent experimental study indicated that cold pressure sensation was mediated by anxiety sensitivity (Keogh et al., 2006). Personality characteristics and personality disorders have also been studied in relation to pain experience. Commonly associated personality traits are those characterized by avoidant, paranoid, self defeating and obsessive compulsive features. Crimlisk (1998) reviewed 73 consecutive patients with neurologically unexplained symptoms and found that 45% were diagnosed with a personality disorder. In another study, personality disorders in somatization disorder patients were 62.95% compared to 28.2% in controls (Weisberg, 2000). The prevalence of personality disorders is significantly greater in the pain population than in the general population (Peters and Vancleef, 2008). Certain personality styles such as hypochondriasis and hysteria are common in chronic pain sufferers (Peters and Vancleef, 2008). Studies further demonstrated that psychopathological factors like depression, fear, anxiety, avoidance beliefs, psychological distress etc., coupled with situational factors like negative workplace characteristics, mediate perpetuation of back pain and neck pain as well as transition from acute to chronic pain (Brox et al., 2005; Bruce et al., 2006; Campbell et al., 2003; Henningsen and Sattel, 2003; Linton, 2001; Magni et al., 1994). Depression and pain share biological pathways and neurotransmitter, and mutually reinforces the implications in perception of symptom severity, diagnostic complication and treatment (Blair et al., 2003). Patients with and without pain symptoms have been found to differ in terms of depression severity, anxiety with irritable mood, sympathetic nervous system arousal, and gastrointestinal problems as well as poorer quality of life (Hussein et al., 2009; Vlaeyen and Linton,2000). Correlational studies show that the relation between pain indices and depression is moderate (Edrington et al., 2010). The presence of impairing pain, especially when moderate to severe, negatively influences the recognition and treatment of depression. Similarly, depression as a comorbid condition in pain patients generates more pain complaints and greater impairment (Blair et al., 2003). It is also notable that cognitive behavioral treatment may not reduce all components of mood and

Depression & Personality Characteristics of Somatoform Disorder 179 pain simultaneously, but the effect is mediated by demographical factors and acceptance of pain, thus hinting once again toward personality characteristics (Samwel et al., 2009). A few studies have, contrarily, pointed out that psychological factors are weakly or selectively associated with pain experience. For example, one study showed that among a number of personality and social variables, all except fear avoidance belief were only weakly associated with pain perception (van der Wundt, 2007). Gain or advantages obtained by the patient out of illness has been another significant aspect often discussed in relation to pain. The origin of the concept is closely related to psychoanalytical formulation of hysteria by Freud (1923), but has been recognized by later researchers as an associated component of conversion disorder and other somatoform disorders (Ron, 2001; van Egmond, 2003, 2005). Gain may be primary or secondary (Fishbain et al., 1995). The primary gains of illness refer to the strictly internal and ordinarily hidden psychological advantages which form the basis of illness. The primary gain can be said to be motivated by avoidance of conflict. Clinically the end gain may include achievement, or the reinforcement of denial. of control, and of repression, the diversion and/or absorption of available psychic energy, resolution of conflict, substitutive and symbolic gratification, masochistic and sadistic wish fulfillment in response to a pathological superego formation, inhibition of possible unwanted overt action or compromise formations. The secondary gain, in turn, is the material advantage later secured from the symptom after its establishment. When this advantage is secured outside of conscious awareness, it is the epigain. Patients accrue tangible advantages and benefits as a result of being sick. Some such benefits include being excused from obligations, being excused from difficult life situations like examination, receiving company of the beloved ones like family members, getting sympathy, special attention and support, controlling other person’s behavior, controlling social situation, convert unfavorable life situations into favorable ones. In recent years, the role of defensive gains has been explored in different languages in clinical literature. For example, Kozlowska (2007) explained how physical reactions serve the purpose of defensive maneuvers in both animals and humans. Secondary gain seems to be used more in response to stressful life events (Craig et al., 1994). The concept of gain has been reinstated in the context of illness behavior as well (Ford, 1997). The present study has taken up its clue from the above works and purports to compare the degree of depression, certain personality characteristics and perceived gain in persons suffering from somatoform disorder, and from orthopedic pain and normal controls. Here, the five personality factors (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness) defined by Costa and McCrae (1992) have been investigated. The present study focuses on the women patients only, since sex differences have been implied in pain. While it is no more believed that hysteria occurs in women only, the processing of psychological factors in pain is understandably culture bound. Keogh et al. (2006) observed that there might be a sex-specific difference in the way in which the psychological factors might be related to pain. In this study, the fear of arousal-related symptoms and behavioral measures of pain were associated in men. Among women the fear of gastrointestinal symptoms and cognitive concerns were related to a greater sensitivity to self-reported pain. Method: Participants: The participants were 90 women with age ranging between 21 and 45 years. Among them 60 were taken from R. G. Kar Medical College of Kolkata based on diagnosis of either Somatoform or Orthopedic disorder, and 30 were normal controls. All participants

180 Datta, Basu and Bandyopadhyay were literate, below 12th grade with lower socioeconomic status (income between Rs. 2000 to Rs. 5000.per capita per month). None was gainfully employed. The two patients were taken through convenience sampling. The 30 matched normal women were taken from the relatives of the patients.

Among the patients, 30 had been diagnosed with somatoform disorders, specifically somatization disorder, conversion disorder and pain disorder, with some kind of pain being the major reported symptom. They attended the Outpatient Psychiatry Department of R.G.Kar Medical College and Hospital, Kolkata, and diagnosed independently by two psychiatrists. Detection of malingering or psychotic symptoms served as exclusion criteria. Another 30 women reported to the Outpatient Orthopedic Department of the same hospital with the complaint of orthopedic pain, and diagnosed by two attending physicians independently as rheumatoid arthritis. For all of them, some organic indicators of pathology have been obtained. The participants, however, were not under any systematic treatment for pain reduction at the time of data collection, except taking ad-hoc medicines available across the counter. Most of them were tested on the first day of visit. Permission of the ethical committee of the hospital had been taken prior to data collection, and informed consent from the patients had been taken. Measures Used: 1. Detailed information schedule: The patients were interviewed for personal and medical history by using an Information Schedule. 2. The Beck Depression Inventory: Second Edition (BDI-II): The BDI-II is an instrument to assess symptoms corresponding to criteria for diagnosing disorders listed in the DSM-IV (1994). This included items from 21 domains, namely: mood, pessimism, sense of failure, self-dissatisfaction, guilt, punishment, selfdislike, self-accusation, suicidal ideas, crying, irritability, social withdrawal, indecisiveness, body image change, work difficulty, insomnia, fatigability, loss of appetite, weight loss, somatic preoccupation, loss of libido. Each participant is asked to assess oneself for her condition in the past two weeks. While a Bengali adaptation of BDI-I is already available (Basu et al., 1995), BDI –II is not yet available in Bengali adaptation. Therefore, a working version of the scale in Bengali has been prepared taking items from BDI-I intact and translating and back translating the remaining items with the help of two experts in both languages and a clinical psychologist. The Chronbach’s alpha reliability of this version was found to be 0.89. 3. The Neo Five Factor Inventory (FORM-S): The five personality factors (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness), defined by Costa and McCrae (1992) have been used in this study. It consists of 60 questions. A brief description of the domains follows: Neuroticism (N): is an assessment of adjustment or emotional stability versus maladjustment or neuroticism. Persons high on N domain tends to experience negative affects such as fear, sadness, embarrassment, anger, guilt, disgust. They are also prone to have irrational ideas, are less able to control impulses, and to have poor coping ability stress. Extraversion (E): Extroverts like people, prefer large groups and gatherings, are assertive, talkative, and active. They like excitement and stimulation and tend to be of cheerful disposition. They are upbeat, energetic and optimistic. Introverts are reserved, independent and prefer to be alone

Depression & Personality Characteristics of Somatoform Disorder 181 Openness (O) : Open persons have active imagination, aesthetic sensitivity, attentiveness to inner feelings, preferences for variety, intellectual curiosity and independence of judgement – have often played a role in theories and measures of personality. High O scores are modestly associated with both education and intelligence, especially divergent thinking. Low O score is associated with conventional and conservative outlook. Agreeableness (A): The agreeable person is fundamentally altruistic. He or she is sympathetic to others and eager to help them, and believes that others will be equally helpful in return. By contrast, the disagreeable or antagonistic person is egocentric, skeptical of others’ intentions and competitive rather than co-operative. Low A scorer may have Narcissistic, Antisocial, Paranoid Personality Disorders, whereas high A scorer may have Dependent Personality Disorder. Conscientiousness (C): The conscientious individual is purposeful, strong-willed and determined, and may be an essential element of extraordinary success in any profession. They are scrupulous, punctual and reliable. Simultaneously, it may be associated with fastidiousness, compulsive traits or workaholic behaviour. Low C scorers are not necessarily lacking in moral principles, but may be less exacting in its application. They are relatively more hedonistic. The reliability of NEO-FFI is well established. The test retest reliabilities were found to be 0.79, 0.79, 0.80, 0.75, 0.83 for N, E, O, A and C, respectively. The applicability of NEO-FFI in India has been established. In the present research, a translated version of the scale has been prepared by consulting two experts in both languages and a clinical psychologist. A pilot survey with 100 college students yielded Split half reliability values of .81, .77, .76, .76, and .79 respectively for the five scales. 4. The gain questionnaire: A 40 item questionnaire was prepared for this specific research with the purpose of assessing the gain from the disorder. Items representing both primary and secondary gains were included. Initially a large number of items representing gain were collected from survey of literature and consultation with experts including clinical psychologists and psychoanalysts. After editing for language, duplication and clarity, a total of 50 items were retained. This was administered to 100 participants with age ranging between 20 and 40 years. Subjects responded on a five point scale to each item. Item analysis was done by calculating the item-total correlations and 40 items were finally retained. This was again administered to 50 male and 50 female normal subjects. Subsequently the data for the upper and lower 25% were compared for these 40 items and all the‘t’ values were found significant. Therefore, these 40 items were retained as the final scale. Reliability was calculated on 90 participants. The obtained alpha reliability was 0.82, and split-half reliability was 0.83. Scoring and analyses: All the data were hand scored. Multiple Analysis of Variance (MANOVA) was done to examine whether the Depression, Personality characteristics (neuroticism, extraversion, openness, agreeableness, conscientiousness) and Gain scores taken in combination differed among the 3 groups, namely patients with Somatoform disorder, patients with physical pain disorder and healthy controls. Subsequently, univariate analyses of variance (ANOVA) were conducted for each variable to determine whether the three groups differed significantly in terms of these variables. Scheffe’s multiple comparison tests were conducted to see which pairs of groups differed significantly in terms of the variables. Results and Discussion: The results of the analysis is presented in Table 1.

182 Datta, Basu and Bandyopadhyay Table 1 Mean and SD of Depression, Personality Characteristics (Neuroticism, Extraversion, Openness, Agreeableness, Conscientiousness) and gain scores for the 3 groups and the results of MANOVA PERSONALITY CHARACTERISTICS DEPRESSION N E O A C GAIN Somato Form Mean 37.1 35.33 11.47 13.93 19.73 22.2 156.4 SD 9.72 5.41 4.05 5.92 8.70 4.58 18.02 Physical Pain Mean 29.77 34.63 15.00 14.27 14.27 25.87 140.97 SD 8.12 8.31 5.72 6.03 6.67 4.46 15.41 Normal Mean 8.73 17.83 30.93 23.3 22.5 30.53 115.4 SD 7.63 9.93 9.90 10.01 8.22 7.01 10.56 Wilke’s Lambda value (MANOVA 0.196, (F 14.60**) Univariate F-values (ANOVA) 89.198** 44.85** 65.81** 14.81** 8.42** 17.45** 57.29** Mean difference and significance by Sheffe’s test between S & P 7.33** .70 -3.53* -.33 5.47* -3.67* 15.43** Mean difference and significance by Sheffe;s test between S &N 28.37** 17.50** -19.47** -9.37** -2.77 -8.33** 41.00** Mean difference and significance by Sheffe;s test between P &N 21.03** 16.80** -15.93** -9.03** -8.23** -4.67* 25.57** S denotes ‘patients with somatoform disorder’, P denotes ‘patients with orthopaedic pain’, N denotes ‘normal controls * p<0.05 ** p<0.01 The results reveal that when the variables are taken in combination, the three groups differed significantly from each other, as the Wilke’s lambda value is highly significant. Separate ANOVAs also yielded significant F values for each group, implying that the means of each variable differed significantly among the three groups. Multiple comparisons by Scheffe’s test further indicate that depression was greatest in the patients with Somatoform disorder, followed by those with orthopedic pain. Depression was lowest in the normal group. Each of these three groups differed significantly in terms of depression from each other. Neuroticism was almost equally high in the two patient groups, but significantly lower in the normal group. Extraversion was lowest among the patients with somatoform disorder, moderate in those with orthopedic pain and highest among the normal controls. Each group differed significantly from the other two. Openness was almost equally low in the two patient groups, but differed significantly from the more open normal participants. Agreeableness was lowest in the patients with orthopedic pain, moderate in the patients with somatoform disorder and highest in the normal group. The somatoform group did not differ from the normal group in terms of agreeableness, but differed significantly from the patients with orthopedic pain. The normal group differed from those with physical pain in terms of agreeableness. Conscientiousness was highest in the normal group, moderate in the orthopedic pain group

Depression & Personality Characteristics of Somatoform Disorder 183 and lowest in somatoform group. There was significant difference between each pair. Gain was highest among the somatoform group, followed by orthopedic pain group and then by the healthy controls. Each group differed significantly from other groups. Thus, the group with diagnosed somatoform disorder was characterized by high depression, high degree of neuroticism, low extraversion, low openness, moderate agreeableness, low conscientiousness and high gain from symptoms. The group suffering from orthopedic pain had moderate level of depression, high degree of neuroticism, moderate extraversion, low openness, low agreeableness, moderate conscientiousness and moderate gain from symptoms. The two groups shared high neuroticism and low openness but, in terms of all other variables, the group with orthopedic pain had somewhat better personality characteristics and lower gain motives in comparison to the patients with somatoform disorders. That depression is associated with somatoform disorders as well as physical pain has been reported by a large number of studies (Campbell et al., 2003; Hussein et al., 2009; Katon et al., 1982). However, the present study suggested that the degree of depression was higher in women suffering from somatoform disorder in comparison to those suffering from physical pain. While it is difficult to ascertain the explanation of the findings, or suggest any causal hypothesis, it may be stated tentatively that psychological complications are higher in somatoform disorder than in physical pain. It also needs to be remembered that depression, somatization tendencies and pain may be mutually connected in a complex way, as suggested by the bio-psychosocial approach to pain (Melzac and Wall, 1996). High neuroticism in the somatoform group corroborates the occurrence of high depression in them. Furthermore, scrutiny of the personality factors reveals that the somatoform group seems to be lacking in social qualities as they are low in extraversion and openness, but they are more agreeable than the patients with physical pain and also less conscientious. Together these last two traits may indicate a manipulative tendency, which may have been reflected in the perceived gain from disease. These findings and interpretations corroborate with the works of Kirmayar et al. (1994) and Garcia-Campayo et al. (2009). On the whole, the study suggests that the cognitive processing and meaning of pain differs between the two patient groups and these are associated with their personality characteristics. The findings support the claim that perceived pain is medicated by cognitive understanding of the pain and its social context (Melzac and Wall, 1996). Studies further reveal that perceived pain is a function of perceived controllability, especially through cognitive regulation via the prefrontal cortex (Amat et al., 2005; Solomons et al., 2007; Valet et al., 2004). Since the pattern of mediation through prefrontal cortex becomes a sustained tendency, the role of personality as enduring organization of perception and behavior becomes salient in the context of pain. Thus, the possibly exaggerated pain in somatoform disorder may be one way of coping with pain- physical, cognitive or both in an interactive fashion. It is expected that the present findings can be used for curative purpose of patients in clinical settings for cognitive reconstruction. The present study is limited by having women only as its participants. Also, the comparison among different somatoform disease groups was not done. Future research may be conducted with a larger sample and taking into account the variations in diagnosis, age and gender. This kind of research is particularly significant in the context of defining and refining the still obscure category of somatoform disorder. References: Amat, J., Baratta, M. V., Paul, E., Bland, S. T., Watkins, L. R., Maier, S. F. Medial prefrontal cortex determines how

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Coping Strategies and Psychological Defenses Used by Mentally ill Criminals Vidhata Dixit, D. K. Kenswar, Jai Prakash and Amool R. Singh Coping strategies and defense mechanisms are an individual’s important personality traits which strongly influence the ease with which people are able to form and maintain healthy relationships. Certain psychological traits including coping strategies and defenses are frequently detected in the personalities of criminals prone to aggression and maladjustment. Identification of these will be helpful in predicting risk of criminal acts in these patients as well as their better management. A total of 25 male mentally ill criminals and 25 normal controls were selected through purposive sampling technique. Defense Mechanism Inventory (DMI) and Brief Approach/Avoidance Coping Questionnaire (BACQ) were administered individually. Mann Whitney-U test was used to find out differences between two groups. Results showed that mentally ill criminals used more of maladaptive defenses like Turning against object (TAO), Projection (PRO), Turning against self (TAS) and Reversal (REV), but used less an adaptive defense mechanism of Principalization (PRN). As regard coping strategy, the criminal mentally ill patients lagged behind significantly to approach a problem situation and avoided them than the normal controls by keeping themselves away from social interaction, lacking planning and action related diversions showed negative attitude regarding tackling current problems. It is generally agreed that both coping strategies and defense mechanisms represent adaptive efforts to manage perceived threats whose demands exceed available resources and thus they produce beneficial psychological and social effects to the individual (Ihilevich and Gleser, 1986). Coping strategies are often conceptualized as personal resources of an individual in his or her psychological adaptation to stressful situations or events (Engel, 1977; Petrie and Moss-Morris, 1997). Whenever a person’s internal resources, skills, or motivation are insufficient to resolve inner conflicts or master external threats to well being, the psychological defenses come into play as relatively stable response dispositions that serve to distort the reality (Ihilevich and Gleser, 1986). However, some investigators use the concepts of coping strategies and defense mechanisms interchangeably. Reacting to frustrating, difficult and painful Vidhata Dixit, Res. Scholar, D. K. Kenswar, Asso. Professor, Jai Prakash, Asso. Professor and Amool R. Singh, Director, Ranchi Institute of Neuro-Psychiatry and Allied Sciences (RINPAS), Kanke, Ranchi-834006 (India) Key Words: Defense Mechanism, Coping Strategy, Criminal Mentally Ill situations and experiences, they function as an automatic and well synchronized firewall, helping to defend against hurting and abusive relationships and promote healthy and nurturing relationships (Khan et al., 2008). Crime is one of the greatest evils of our society and clinicians commonly identify criminality with emotional illness and look upon clinical therapy as a solution to crime (Jha, 1971). Mental patients are sometimes detained in the jail or sent to the mental hospitals for treatment after commission of the crime (Jha, 1971). The psychopathology of criminal behavior has long been a subject of interest for the behavioral scientists. Much attention has been paid to investigate the psychodynamics of these individuals (Blender, 1959; Berkowitz, 1962; Blackburn, 1969). Criminal behavior has been explained in terms of social disorganization, cultural conflicts and psychological determinants. Of the psychological variables, it

Coping Strategies and Psychological Defenses Used by Mentally ill Criminals 187 is a heterogeneous combination of personality traits which have been receiving wide attention. It has been observed that certain psychological traits such as emotional immaturity, impulsivity, lack of socialization, and a decreased capacity to tolerate frustration are frequently detected in the personalities of criminals prone to aggression (Duncan et al., 1958). If personality characteristics like coping strategies and defenses are associated with criminal behavior in mentally ill patients, identification of these will be helpful in predicting risk of criminal acts in these patients as well as their better management. Keeping these points in view, present study was conducted to find out coping strategies and defenses used by mentally ill criminals. Methodology: Sample: The study sample consisted of 25 mentally ill male patients with criminal records admitted at the prisoner-ward of Ranchi Institute of Neuro- Psychiatry and Allied Sciences (RINPAS), Ranchi; and 25 male controls matched with age, education and other socio-demographic variables. The participants in control group were selected from Kanke (Ranchi) and neighboring areas using purposive sampling technique. Tools: Both the groups were assessed with following tools: Socio-demographic and clinical data sheet (self prepared). Defense Mechanism Inventory (Mrinal and Mrinal, 1971): This inventory is a diagnostic clinical tool designed to provide indices of five defensive styles common to well functioning adults. The five groups of defense mechanisms, it measures, namely Turning against others (TAO) Turning against object (TAO), Projection (PRO), Principalization (PRN) and Turning against self (TAS) closely represent the defense mechanisms like reaction formation, denial, regression, repression, compensation, projection, intellectualization and displacement.

Brief Approach/Avoidance Coping Questionnaire (Finest et al., 2002): The 12 item BACQ helps to assess coping briefly as one variable among many others in order to provide a general measure of the individual’s approach to stressful situations. The scale conceptualizes the coping strategies into two broad rubrics namely- approach oriented coping style, in which the individual attempts to deal with life events by actively approaching the stressor; and avoidance oriented coping style, in which the individual moves away from the life stressors. Procedure: To find out differences between experimental group and control group in respect of sociodemographic details, independent sample t-test was used for continuous variable like age but Chi-square test was used for group variables. Mann Whitney-U test was used to find out differences in Mean (± SD) scores of Defense Mechanism Inventory (DMI) and Brief Approach/Avoidance Coping Questionnaire (BACQ). After completing the socio-demographic and clinical data sheet, Defense Mechanism Inventory (DMI) and Brief Approach/Avoidance Coping Questionnaire (BACQ) were administered. Mann Whitney-U test was used to find out differences in Mean (± SD) scores of Defense Mechanism Inventory (DMI) and Brief Approach/Avoidance Coping Questionnaire (BACQ). Results: Table 1 show that mentally ill criminals were comparable to normal controls in relation to age, religion, marital status, education,

188 Dixit, Kenswar, Prakash and Singh Table 1 Socio-Demographic Details of Criminal Mentally ill Patients and Normal Controls Socio-demographic Variables Mentally ill Criminals (N = 25) Normal Controls (N = 25) df t value Mean ± SD Mean ± SD Age (in years) 30.120 ± 5.732 30.60 ± 6.157 -.285 n (%) n (%) ÷2 Religion Hindu 18 (72) 18 (72) .000 Muslim 6 (24) 6 (24) Christian 1 (4) 1 (4) Marital status Married 17 (68) 13 (52) 1.333 Unmarried 8 (32) 12 (48) Education Primary-Middle 10 (40) 10 (40) .000 Above Middle 15(50) 15 (60) Occupation Employed 13 (52) 19 (76) 3.125* Unemployed 12 (48) 6 (24) Residence Urban 11 (44) 12 (48) .406 Semi-urban 8 (32) 6 (24) Rural 6 (24) 7 (28) Socioeconomic status Low 11 (44) 12 (48) .081 Middle 14 (56) 13 (52) *Significant at p<.05 (2-tailed) residence and socioeconomic status. However, a significantly greater number of mentally ill criminals were unemployed in comparison to the normal controls [12(48%) versus 6(24%); X2 = 3.125; p<050]. The patient and control groups were compared on various types of defense mechanisms and the findings have been summarized in Table 2. Table 2 Defense Mechanisms used by Criminal Mentally Ill Patients and Normal Controls Defense Mechanisms Mentally ill Criminals (N=25) Normal Controls (N=25) Z Value Mean ± SD Mean ± SD Turning Against Object (TAO) 39.85 ± 12.19 24.80 ± 9.44 -3.737*** Projection (PRO) 43.05 ± 10.99 33.80 ± 7.66 -2.744** Principalization (PRN) 40.80 ± 12.77 47.20 ± 6.47 -2.062* Turning Against Self (TAS) 48.70 ± 12.23 36.12 ± 14.12 -2.597** Reversal (REV) 48.90 ± 11.28 43.76 ± 12.78 -1.932 *Significant at p<.05 (2-tailed); **Significant at p<.01 (2-tailed); ***Significant at p<.001 (2-tailed)

Coping Strategies and Psychological Defenses Used by Mentally ill Criminals 189 Results of Table 2 revealed that mentally ill criminals scored high on turning against object (M=39.85 ± 12.19) in comparison to normal control subjects (M= 24.80 ± 9.44) and difference between experimental group and control group was significant at 0.001 level (Z= -3.737, p<0.001). They were more of aggressive, impulsive and rebellious in nature. They showed defying superiors especially father figure. They showed poor self control, tend to evade responsibility. They were unable to socialize and frequently displace their frustration on to more vulnerable others. Mentally ill criminals used defense mechanism of projection most frequently (M=43.05 ± 10.99) than that of normal control subjects (M=33.80 ± 7.66; Z=- 2.744, p<0.01). They have also demonstrated externalizing symptoms of argumentativeness, fighting and destructiveness, expressed more intolerance. It is also evident that mentally ill criminals used lesser principalization defense mechanism (M=40.80 ± 12.77) than that of normal subjects (M=47.20 ± 6.47, Z=-2.062; p<0.05). Low score on Principalization has been expressed in terms of dysphoric affects such as anxiety, anger, and hostility. They were found to be emotionally unstable with high score on turning against self (M=48.70 ± 12.23) than normal control subjects (M=36.12 ± 14.12, Z=2.957,p<0.01). They tend to be anxious and guilt ridden. Table 3 Coping Strategies used by Criminal Mentally Ill Patients and Normal Controls Coping Strategies Mentally ill Criminals (N=25) Normal (N=25) Z Value Mean ± SD Mean ± SD Approach Oriented Strategies 22.12 ± 2.93 24.00 ± 3.21 -2.162* Social-Emotional Approach 7.55 ± 1.98 7.52 ± 1.89 -.058 Action Related Approach 7.75 ± 1.61 8.20 ± 1.82 -1.225 Cognitive Approach 10.30 ± 2.57 12.28 ± 2.20 -2.654** Avoidance Oriented Strategies 21.48 ± 2.52 19.24 ± 4.70 -1.676 Social-Emotional Avoidance 7.00 ± 2.02 7.00 ± 1.97 .000 Action Related Avoidance 7.05 ± 1.70 6.20 ± 1.95 -1.433 Cognitive Avoidance 10.85 ± 1.78 8.84 ± 2.82 -2.360* *Significant at p<.05 (2-tailed); **Significant at p<.01 (2-tailed) It is clear from table 3 that the mentally ill criminals adopted more avoidance oriented strategy (M= 21.48 ± 2.52) than that of normal control subjects (M= 19.24 ± 4.70). The mentally ill criminals also showed poor emotional expression and they tend to keep themselves away from social interaction. They were unable to tackle their problems actively, lacking planning and action related diversions. They also showed low level of motivation for performing the activities. It is also clear from the table that mentally ill criminals showed negative attitude regarding tackling current problems and consider that these problems have no solutions. They also reflected denial as coping strategy while dealing their day to day practical problems. Discussion: One of the major findings of this study was that both the groups (i.e. criminal mentally ill patients and normal controls) were matched in almost all of the socio-demographic details except the type of occupation. They were engaged in and so its influence is negligible. Further, the study revealed that out of five types of defenses mentioned in Defense Mechanism Inventory (DMI), the criminal mentally ill patients used more of the defenses like Turning against

190 Dixit, Kenswar, Prakash and Singh object (TAO), Projection (PRO), Turning against self (TAS) and Reversal (REV). However the defense mechanism Principalization (PRN) was used significantly more by normal controls. To describe it further Turning against object (TAO) is the defense mechanism which involves the expression of direct or indirect aggression which serves to master perceived external threats or mask inner conflicts which are too painful to confront consciously (Ihilevich & Glesser, 1986). Aggression is regarded as a primitive defense, originating from the fightflight response and it is frequently employed when more complex and mature defenses fail (Ihilevich & Glesser, 1986). The defense mechanism of ‘Projection (PRO)’ deals with the expression of hostile thoughts, behaviour and feelings towards the other. It has been ranked by expert judges as the most maladjusted of all defenses in the Defense Mechanism Inventory (Dodd, 1972). Also, it has been found to be a relatively ineffective defense against anxiety (Ranseen, 1982). Turning against self (TAS) is a class of defense mechanism which falsifies reality for the purpose of reducing perceived one’s self esteem against the effects of negative experiences. It has been rated as the second most or most pathological defense on the Defense Mechanism Inventory (DMI) by the clinical judges (Dodd, 1972; Gleser and Ihilevich, 1979). The studies employing the Defense Mechanism Inventory (DMI) have found that TAS is associated with depression (Gleser and Ihilevich, 1969), guilt (Schill et al., 1976), anxiety (Ranseen, 1982), low self esteem (Berg, 1982), and Suicidal behaviour (Scholz, 1973). Reversal (REV) is the defense mechanism which deals with the responses to internal or external threats which minimize the severity of the perceived threats or conflicts and fail to acknowledge the existence of otherwise obvious dangers (Ihilevich & Glesser, 1986). It encompasses such classical defense mechanisms as denial, negation, repression, reaction formation (Breznitz, 1983, Dorpat, 1985, Jacobson, 1957, Juni, 1981 & Madison, 1961) and these classical defenses are usually expressed in Pollyanna-like attitudes, exaggeratedly cheerful emotions, and unduly positive behavioral responses to frustrating or threatening events. Further, it has been found that Reversal (REV) is associated with poor coping ability (Yu, 1981), increased blood pressure (Minsky, 1978), higher physiological activation (Assor et.al; 1986), and the presence of various psychosomatic symptoms (Gur & Gur, 1975). Thus, it is evident that extensive use of Reversal (REV) defense is highly maladaptive. In view of above explanations of different defense mechanisms, it becomes obvious that the kinds of defenses criminal mentally ill patients use excessively are primitive, immature, pathological and maladaptive. Further, a significantly less use of Principalization (PRN) by criminal mentally ill patients supports these findings and it shows the internal consistency of the Defense Mechanism Inventory (DMI). Principalization (PRN) has been mentioned as the most adaptive of the five DMI defenses by the clinical judges (Dodd, 1972; Gleser and Ihilevich, 1979) and it encompasses such classical defense mechanisms as intellectualization, rationalization, and isolation (Ihilevich and Gleser, 1986). The studies have found that ‘principalization’ is associated with more satisfactory adaptation as measured by level of assertiveness (Massong et al., 1982), degree of self-esteem (Berg, 1982), emotional stability (Glesser & Ihilevich, 1979), ego strength (Rohsenow et al., 1978), coping ability (Yu, 1981), adaptive functioning (Kaley & Hovey, 1983), and lower symptom distress (Frank et al., 1984). As regard coping strategy used by criminal mentally ill patients and normal controls, it was found that the criminal mentally ill patients lagged behind significantly to approach to a problem situation than the normal controls. On further analysis of the subtypes of coping strategies, it became evident that it was their attitude not to approach but to avoid the current as well as long term problems (see table 3) which made a difference overall. The finding

Coping Strategies and Psychological Defenses Used by Mentally ill Criminals 191 of Yu (1981) supports our study in the sense that faulty defenses are associated with poor coping ability in the individuals. The above findings in areas of psychological defenses as well as coping strategies are unique in context of lack of research works to discuss psychological characteristics of criminal mentally ill patients especially in Indian population. Conclusion: The findings of the study reveal that criminal mentally ill patients use unhealthy defense mechanisms in terms of excessive use of primitive, immature, pathological and maladaptive defenses as well as poor use of adaptive defense mechanism. Also these patients have the attitude not to approach but to avoid their current as well as long term problems. References: Berg, K. E. (1982). Self-esteem, ego defenses, and cognitive bias of white and nonwhite collar criminals. Unpublished doctoral dissertation, University of Kentucky. (University Microfilm N. 8311240). Berkowitz, L. (1962). Aggression: a social psychological analysis. New York: McGraw Hill. Blackburn, R. (1969). Sensation seeking, impulsivity and psychopathic personality. Journal of Consulting and Clinical Psychology, 33, 571-574 Blender (1959). Children and adolescents who have killed. American Journal of Psychiatry, 116, 510-513 Brenznitz, S. (1983). The seven kinds of denial. In: S. Brenznitz (Ed.), The denial of stress (pp. 257-280). New York: International University Press. Dodd, C. D. (1972). Individual differences in the generalityspecificity of ego defense mechanisms across threat content areas. Unpublished doctoral dissertation, University of Texas. (University Microfilm No. 723563). Dorpat, L. T. (1985). Denial and defense in the therapeutic situation. New York: Jason Aronson. Duncan, G. M., Frazier, H. S., Litin, E. M., Johnson, A. M. and Barren, A. J. (1958). Etiological factors in the first degree murder. Journal of American Medical Association, 1755-1758 Engel, G.L. (1977). The need for a new medical model: a challenging for biomedicine. Science, 196(4286), 129- 136. Finest, A., Steine, S., Haugli, L., Steen, E. and Laerum, E. (2002). The Brief Appoach/Avoidance Coping Questionnaire: development and validation. Psychology Health and Medicine, 7 (1), 75-85. Frank, S. J., McLaughlin, A. M., & Crusco, A. (1984). Sex role attributes, syptom distress, and defensive style among college men and women. Journal of Personality and Social Psychology, 47, 182-192. Gleser, G. C. & Ihilevich, D. (1969). An objective instrument for measuring defense mechanisms. Journal of Consulting and Clinical Psychology, 33, 51-60. Gleser, G. C. & Ihilevich, D. (1979). Personality factors and ego defenses. Academic Psychology Bulletin, 1, 171- 179. Ihilevich, D. and Gleser, G. C. (1986). Defense Mechanisms: Their classifications, correlates and measurement with the Defense Mechanism Inventory (DMI). Odessa (USA), Psychological Assessment Resources, Inc. 1993. Jacobson, E. (1957). Denial and repression. Journal of the American Psychoanalytic Association, 5, 61-92. Jha, B. K. (1971). A study of the nature of criminal offences of mental patients. Indian Journal of Psychiatry, 10, 166- 176. Juni, S. (1981). Theoretical foundations of reaction formation as a defense mechanism. Genetic Psychology Monographs, 104, 107-135. Kaley, M. & Hovey, J. (1983). Prevention: interfacing planned parenthood services and community mental health. Report submitted to Michigan department of Mental Health. Khan, N. A., Jahan, M., Singh, A. R. and Sengar, K. S. (2008). Psychological defenses used by the substance dependents. SIS Journal of Projective Psychology & Mental Health. 15, 152-156. Madison, P. (1961). Freud’s concept of repression and defense: Its theoretical and observational language. Minneapolis: University of Minnesota Press. Massong, S. R., Dickson, A. L., Ritzler, B.A., & Layne, C. C. (1982). Assertion and defense mechanism preference. Journal of Counseling Psychology, 29, 591-596. Mrinal, N. R. & Mrinal, U. (1971). Manual for Defense Mechanism Inventory. National Psychological Corporation, Agra (India). Petrie, K. & Moss- Morris, R. (1997). Coping with chronic illness. In: A. Baum, S. Newman, J. Weinman, R. West & C. Mc.Manus (Eds.), Cambridge Handbook of Psychology, health and medicine (pp. 84-87). Cambridge: Cambridge University Press. Ranseen, J. D. (1982). Coping styles in type A and type B male students in response to a threat to self esteem stressor. Unpublished doctoral dissertation, Ohio University. (University Microfilm No. 8300027). Rohsenow, D. J., Erickson, R. C. & O’Leary, M. R. (1978). Understanding Intellectual Development. Hinsdale, IL: Dryden.

192 Dixit, Kenswar, Prakash and Singh Schill, T., Rader, G., Evans, R. & Segall, S. (1976). Defense preference of high- and low- hostility guilt subjects. Journal of Consulting and Clinical Psychology, 44(5), 867. Scholz, J. A. (1973). Defense styles in suicide attempters. Journal of Consulting and Clinical Psychology, 41, 70- 73. Yu, M. T. (1981). Personal defensive disposition and coping ability among parents of deaf-blind multi-handicapped children. Unpublished doctoral dissertation, The University of Oklahoma. (University Microfilm no. 8122792) International Conference on Recent Advances in Cognition & Health (ICRACH-2012) Organized by Department of Psychology Banaras Hindu University, Varanasi, India January 23 - 24, 2012 Venue Department of Psychology Banaras Hindu University, Varanasi, India ICRACH Important Dates Registration Fee Early Registration (by 30 Nov. 2011) Late Registration (after 30 Nov. 2011) Abstract submission November 10, 2011 Delegate (outstation) Rs. 1500 Rs. 2000 Acceptance notification November 20, 2011 Delegate (outstation) Rs. 1000 Rs. 1500 Full paper submission December 10, 2011 Student (local) Rs. 500 Rs. 750 Contact Details

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Associational Contents of Rorschach and its Relationship with Verbal Intelligence in adults Shweta, R. C. Bajpai, A. R. Singh and K. S. Sengar Intellectual functioning of individuals has very close correlation with Rorschach responses. Being able to think logically, coherently, flexibly and constructively are personality strengths of individuals that promote good adjustment. People function best when they can use ideation effectively without allowing thoughts to dominate their psychological lives at the expense of feeling or their peace of mind. Being open to emotional as well as ideational experience contributes to good adjustment by providing people with a broad repertoire of coping skills and being in control of the contents of their minds which helps people to avoid becoming preoccupied with disturbing thoughts. The content of a work of art has no actual existence in the subject’s actual world but in Rorschach Inkblot Test, individuals perceive the same with their imaginative ability. The purpose of the present study is to see the relationship between verbal intelligence and various associational content responses on the Rorschach Inkblot Test by following Beck’s system. The sample includes 340 Indian adult non patients, ranging in age from 20 to 30 years, who were drawn through stratified systematic random sampling technique from the capital of India, Delhi. Result indicates both positive and negative correlation between verbal intelligence and Rorschach contents. Some Contents do not show any correlation. Further, total twenty seven contents have been obtained which have significant contribution in describing the Indian personality The associational content of Rorschach test has a very important contribution in interpreting the personality of an individual as a whole as projection gets structured with regard to the experiences of individuals that get reflected through the theme specifically (Beck, 1952). The content of responses gives some information about the degree of energy that the subject applies to his work and the amount of pleasure he gets from it, and also indicates how adaptable he is, to understand his working conditions (Kronenberg and Lemkau, 1998). Initially Rorschach (1921) used only six content responses, namely H (Human), Hd (Human detail), A (Animal), Ad (Animal detail), Ls (Landscape), and Obj (Inanimate objects). When the test was in its developmental age, it became obvious that these six categories do not provide adequate differentiation of many frequently reported classes of objects. Therefore, each of the systematisers expanded Shweta Clinical Psychologist, LGBRIMH, Tezpur, Assam, R. C. Bajpai, Asst. Professor, (Biostatistics) Army College of Medical Sciences (ACMS), New Delhi, K. S. Sengar, Asst.Professor and A. R. Singh, Prof of Clinical Psych. & Director, RINPAS, Ranchi, (Email for Correspondence:achyutsengar9@gmail.com). Key words: Rorschach, Verbal intelligence, Associational Content, Correlation, VAIS. Rorschach’s original listing considerably to provide for a greater discrimination. Beck (1949) used the longest (35) length, Klopher and Davidson (1962) the shortest of categories (23), and Exner (1974) comprised 26 categories in his comprehensive system. Later on Beck et al. (1961) had increased the formal symbols for associational content and gave separate abbreviations for every possible item such as Pr for Personal, Ru for Rural etc for more comprehensive analyses of the personality. Regarding the interpretation of content responses, Beck (1949) suggested that within the psychological sciences there are yet no systematically established laws as to the meanings of particular content themes. There is a large literature, principally contributed by psychoanalysts, in which content is being interpreted. He utilizes Murray’s principle that content communicates needs. The more

194 Shweta, Bajpai, Singh and Sengar individualized is the theme, the more certainly it discloses uniquely personal psychological needs in that individual. Certain themes appear with a sufficient frequency to be at a safe lead towards constancy in meaning. Analyses of Rorschach responses give more values to two significant aspects of content, namely range of content and type of content. A stretched range of content is especially characterized which reflects versatility of one’s mind and his enriched conceptualization-ability. Riding high on the confidence to convert his thought, knowledge, curiosity into real world gives an edge in achieving somewhat productive responses at large. For a more obvious reason, contractions of content showcase the person of having channelized vision and lowered horizon. It transcends to his daily routine and seriously affects his negotiations with life-affairs, that is, always remaining short of his capacities (Shweta and Bajpai; 2010). Interpretation of Rorschach content should be based on the variety of contents, the number of each content, and their overall configuration, as well as the implications that other Rorschach factors may have for the meaning of the content scoring (Aronow et al., 1995). Studies have also shown that, wide ranges of contents are associated with intellectual flexibility, whereas low range suggests intellectual constrictions and rigidity. Keeping this in view, the authors attempt to explore the various content categories given by Indian respondents on Rorschach plates and to study their relationship with verbal intellectual functioning. Materials and Methods: The sample for the present study consisted of one hundred seventy male (n = 170) and one hundred seventy female (n = 170) Indian adults (n = 340) from Delhi. The group was matched with respect to gender and different socio-demographic variables with the help of well designed, pre-tested and semi structured questionnaires and subsequently rated on General Health Questionnaire-12 (GHQ-12) to assess the normal well being. Those who scored above the cut off point (≥ 2) were excluded from the study. None of the subjects had a history of psychiatric treatment, and none were receiving any treatment. Subsequently Verbal Adult Intelligence Test (VAIS) and the Rorschach Inkblot Test were administered individually by following Beck’s method (Beck, 1961). Statistical Analyses: Data were coded, entered and analyzed by using SPSS (version 18.0) package and articulated in percentage. Various descriptive measures (Mean, Median, Mode, SD, Skewness & Kurtosis) were calculated to understand the nature of data. To see the association between gender and socio-demographic characteristics Chi-square test was used. The Mann-Whitney ‘U’ test was used to set up the relationship between the two genders and different variables of Rorschach Inkblot Test Spearman Rank correlation coefficients were used to establish the relationship between Verbal Quotient (VQ) and various Rorschach variables in both genders. ‘P’ value less than 0.05 was considered statistically significant. Results: Table 1 illustrates the various demographic details of subjects. Most of the respondents lied between the age range of 26 to 30 years (54.1%), followed by 20-25 yrs.(45.9%), were Hindu (55.3%) followed by Sikh (15.9%), Muslims (19.7%) and others (7.61%) respectively. Education-wise little less than half of the subjects were graduates (47.4%) followed by education till twelfth standard (22.97%) and 10th standard or below 13.5%. 51.8% subjects were married while 48.2% were unmarried, 72.6% of the subjects belonged to nuclear

Associational Contents of Rorschach & Verbal Intelligence 195 Table 1 Gender wise Comparison of Socio-demographic Characteristics Socio-demographic Variables Male (%) Female (%) Total (%) x2 (d.f.) P value (n=170) (n=170) (N=340) Age distribution (in years) 20-25 79 (46.5) 77 (45.3) 156 (45.9) 0.047(1) 0.828 26-30 91 (53.5) 93 (54.7) 184 (54.1) Religion Hindu 97 (57.1) 91 (53.5) 188 (55.3) 2.281 (3) 0.516 Muslim 29 (17.0) 38 (22.4) 67 (19.7) Sikh 26 (15.3) 28 (16.5) 54 (15.9) Others 18 (10.6) 13 (7.6) 31 (9.1) Marital Status Unmarried 102 (60.0) 82 (48.2) 184 (54.1) 4.438 (1) 0.030 Married 68 (40.0) 88 (51.8) 156 (45.9) Educational Status Up to 10th 14 (8.2) 23 (13.5) 37 (10.9) 4.495 (3) 0.213 Up to 12th 31 (18.2) 39 (22.9) 70 (20.6) Graduate 85 (50.0) 76 (44.7) 161 (47.4) Higher Education 40 (23.5) 32 (18.8) 71 (21.2) Employment Status Unemployed 68 (40.0) 120 (70.6) 188 (55.3) 32.172(1) 0.000 Employed 102 (60.0) 50 (29.4) 152 (44.7) Occupation Not working 13 (7.6) 50 (29.4) 63 (18.5) 36.665 (3) 0.000 student 52 (30.6) 60 (35.3) 112 (32.9) job 60 (35.3) 27 (15.9) 87 (25.6) Business 45 (26.5) 33 (19.4) 78 (22.9) Family Income (Rs/month) 15000-20000 38 (22.4) 44 (25.9) 82 (24.1) 4.538(2) 0.103 20000-30000 79 (57.1) 78 (45.9) 175 (51.5) 30000-50000 35 (20.6) 48 (28.2) 83 (24.4) Type of Family Nuclear 127 (74.7) 120 (70.6) 247 (72.6) 0.725(1) 0.394 Joint 43 (25.3) 50 (29.4) 93 (27.4) Family Size 2-5 persons 116 (68.2) 108 (63.5) 224 (65.9) 0.837(1) 0.360 6-10 persons 54 (31.8) 62 (36.5) 116 (34.1) family, while 27.3% belonged to joint family setup. Statistically no significant difference was found with respect to age, religion, education, family income, family type and family-size except marital status (P=0.030), employment status (P=0.000) and occupation (P=0.000) between male and female groups. It reflects the Indian socio-cultural fabric setup where the male dominance is generally prevalent in these three segments.

196 Shweta, Bajpai, Singh and Sengar Table 2 Descriptive statistics of Rorschach Content Variables and VAIS Scores Rorschach Variables Mean Median SD Skewness Kurtosis Minimum Maximum Human (H) 4.6 5.0 1.7 -0.1 -1.2 2.0 7.0 Human detail (Hd) 0.9 1.0 0.8 0.7 0.3 0.0 3.0 Animal (A) 6.7 6.0 1.8 0.3 -0.8 4.0 10.0 Animal detail (Ad) 0.9 1.0 0.8 0.2 -1.4 0.0 2.0 Botany (Bt) 1.0 1.0 0.7 0.0 -0.6 0.0 2.0 Anatomy (An) 1.2 1.0 0.9 0.4 -0.6 0.0 3.0 Household (Hh) 0.3 0.0 0.4 1.1 -0.7 0.0 1.0 Nature (Na) 0.4 0.0 0.5 0.3 -1.9 0.0 1.0 Sex (Sex) 0.6 0.0 0.7 0.9 -0.5 0.0 2.0 Cloud (Cl) 0.8 1.0 0.5 -0.1 0.0 0.0 2.0 Blood (Bl) 0.8 1.0 0.7 0.2 -0.8 0.0 2.0 Implement (Im) 0.3 0.0 0.5 0.9 -1.3 0.0 1.0 Music (Mu) 0.3 0.0 0.5 1.6 1.6 0.0 2.0 Anthropology (Ay) 0.2 0.0 0.4 1.2 -0.6 0.0 1.0 Abstraction (Ab) 0.7 1.0 0.6 0.3 -0.7 0.0 2.0 Geography (Ge) 0.5 0.0 0.6 0.7 -0.4 0.0 2.0 Personal (Pr) 0.6 1.0 0.7 0.6 -0.7 0.0 2.0 Art (Art) 0.5 0.0 0.5 0.1 -2.0 0.0 1.0 Landscape (Ls) 0.9 1.0 0.7 0.2 -1.0 0.0 2.0 Religion (Rl) 1.0 1.0 0.7 0.0 -1.0 0.0 2.0 Science (Sc) 0.5 0.0 .9 1.9 3.3 0.0 5.0 Cloth (Cg) 0.3 0.0 0.5 1.0 -1.1 0.0 1.0 Food (Fd) 0.3 0.0 0.5 1.8 3.6 0.0 3.0 Astronomy (As) 0.5 0.0 0.5 0.1 -2.0 0.0 1.0 Mythology (My) 0.6 0.5 0.7 0.9 0.6 0.0 4.0 Architecture (Ar) 0.5 0.0 0.5 0.1 -2.0 0.0 1.0 Fire (Fi) 0.5 0.0 0.5 0.1 -2.0 0.0 1.0 Verbal Quotient (VQ) 119.0 119.0 8.4 -0.1 -0.7 100.0 139.0 Table 2 shows the overall descriptive analyses which explain the nature of distribution of all chosen variables of Rorschach in the general population. Most of the Rorschach variables are not normally distributed. The average VQ of the Indian adult was 119. Table 3 shows that among all the content categories, only five content categories, namely, sex (P=0.000), impletion (P=0.001), geography (P=0.012), religion (P=0.040) and cloth (P=0.041) differed significantly between male and female groups. Both male and female respondents showed positive correlation between intellectual functioning and human content responses, abstraction, religion, science, and fire content whereas, animal content was negatively correlated with intellectual functioning. Similarly, “cloud”, and astronomy content responses were positively correlated while “personal” and food content were negatively correlated among males and botany “household” content was negatively correlated with females only.

Associational Contents of Rorschach & Verbal Intelligence 197 Discussion: The human (H) content is one of most important variables of the Rorschach protocol and reflects the subject’s ability to hold interpersonal relationship whereas Hd responses reflects the person’s attitude, mood, and self-conception (Rapaport et al, 1968). According to Beck (1961) these two content categories tend to increase with age. The average mean value for this content category was obtained by Indian adults to be 4.6±1.7 which was found to be consistent Table 3 Gender wise Comparison and Spearman Rank Correlations with VAIS Score of Rorschach Content Variables Gender wise comparison of Rorschach Content Variables Spearman Rank Correlation with VAIS Rorschach Content Variables Male (n=170) Femal (n=170) P value Male (n=170) Femal (n=170) Combined (N=340) Mean SD Mean SD r P value r P value r P value H 4.659 1.686 4.571 1.642 .601 .524 .000 .111 .151 .315 .000 Hd .953 .855 .924 .730 .957 -.123 .110 .028 .715 -.049 .365 A 6.594 1.799 6.841 1.755 .145 -.560 .000 -.535 .000 -.552 .000 Ad .888 .788 .918 .810 .754 -.048 .534 .021 .785 -.013 .806 Bt 1.047 .669 .994 .639 .451 -.037 .635 -.255 .001* -.146 .007* An 1.200 .854 1.159 .925 .570 .123 .109 .002 .982 .064 .242 Hd .235 .425 .276 .449 .385 -.112 .147 -.160 .037 -.141 .009* Na .400 .491 .435 .497 .510 .036 .642 .008 .920 .020 .716 Sx .718 .723 .388 .608 .000 .176 .022 -.055 .478 .080 .140 C .835 .562 .835 .530 .955 .162 .034* .060 .439 .109 .045 BI .841 .691 .782 .639 .476 .020 .795 -.029 .704 .002 .972 Im .382 .487 .224 .418 .001* -.083 .280 -.036 .637 -.044 .416 Mu .294 .529 .282 .501 .949 -.064 .409 .084 .277 .012 .830 Ay .259 .439 .229 .422 .528 -.010 .898 .091 .239 .041 .450 Ab .676 .649 .753 .633 .235 .163 .033* .450 .000 .303 .000 Ge .594 .630 .424 .552 .012* -.025 .745 -.017 .824 -.009 .864 Pr .547 .626 .694 .714 .072 -.198 .010* -.018 .817 -.108 .046 Ar .476 .501 .471 .501 .914 -.087 .260 .022 .777 -.033 .549 Ls .918 .692 .853 .719 .373 .066 .391 .175 .022 .124 .022 RI .924 .662 1.082 .757 .040* .189 .013* .219 .004* .200 .000 Sc .653 1.073 .418 .790 .069 .549 .000 .512 .000 .531 .000 Cg .235 .425 .335 .473 .041* -.083 .282 .017 .831 -.037 .498 Fd .276 .544 .335 .543 .177 -.177 .021* .085 .271 -.048 .376 As .465 .500 .488 .501 .665 .162 .035 .093 .227 .122 .025* My .582 .711 .700 .760 .156 .096 .214 .117 .130 .099 .068 Ar .459 .500 .506 .501 .386 .105 .171 .094 .224 .097 .073 Fi .447 .499 .500 .501 .329 .262 .001* .248 .001* .249 .000 Note: P value less than 0.05 taken as statistically significant and indicated by *

198 Shweta, Bajpai, Singh and Sengar with Beck’s original value (4.02) and shows no significant difference between males and females, indicating that both genders have an adequate empathetic capacity which perhaps constructs a significant contribution to good social and interpersonal adjustment. When the mean values of H were correlated with VAIS scores, it was found to be highly significant (P=0.00). This indicates that Indians have an extensive interest in people, are more likely to have elevated self-esteem, and have greater intelligence too. Similar findings have been reported by Beck and Molish (1967), Fisher (1967), Rawls and Slack (1968). Hd shows no correlation with intellectual functioning. It was observed that Animal responses take place more often than any other content category and comprise 38% to 48% of the normal adult record (Beck et al, 1950; Cass and McReynolds, 1951). The scores gained by Indian males (6.59±1.79) and females (6.84±1.74) on this particular content category show no significant difference and negative correlation with intellectual functioning. That indicates finer adaptiveness and adjusting ability and mature thought processes. These findings are consistent with higher intelligence, often having low number of A responses (Allen, 1954). Phillips and Smith (1953) recorded that optimal range of A% is 20 to 40% but decreases as intelligence and Movement (M) responses increase whereas Ad shows no correlation with VAIS scores. The overall mean score of botany content category was 1.0±0.7 and almost similar scores were obtained by both genders. The presence of botany responses indicates pleasant toned affect; it also portrays the youth’s association with birth, concern over advancing age or childbearing function (Schafer, 1954) that, in turn, describes the value of the Indian culture and its family system. However, male participants show no significant correlation with intellectual functioning whereas females show significant negative correlation (P=0.007) with VAIS scores. \ The average score of Indians on household content was found to be 3±.4 and shows no statistical difference between the two genders. It also exhibits significant negative correlation with intelligence (P=0.009) which indicates possible dependency needs, domestic interest (Beck, 1952) and acceptance of their role as females that reflects the impact of the Indian value system and strong relationship with family. The mean value of cloud content was found to be .8±.5 and shows no significant difference. As far as verbal intelligence is concerned only male respondents (P=0.034) show positive correlation with intelligence. Cloud responses are indicators of suspicious behaviour and anxiety regarding them to be countered by negative determinants (Schafer, 1954) but in the present study most of the cloud responses were shape-appropriate. Thus, this finding cannot be generalized. Scores for Abstraction content was obtained by Indian adults (0.7±0.8). It does not differ significantly among the two genders and shows positive correlation with intellectual functioning (P=0.00) indicating that Indian adults have good adjustment capacity and superior intelligence (Phillips and Smith, 1953) and that they have the ability to reflect their feelings directly, whether it is dysphoric or euphoric (Klopfer and Davidson, 1962). Personal content (0.6±0.7) again does not show any difference between the genders. However, only male participants exhibit (P=0.01) negative correlation with intellectual ability. It reflects their ability to think differently than groups and have sensitivity towards selfidentity. Both genders show positive correlation between VAIS scores and religion, science and fire content whereas, food content was negatively correlated and astronomy content was positively correlated with verbal intellectual functioning of only males. It is imperative to note here that among all the

Associational Contents of Rorschach & Verbal Intelligence 199 content categories, only five content categories, i.e. sex, implement, geography, religion and cloth differ significantly with gender. Less mean values on sex and implement content categories obtained by females gives the sight of the Indian’s fixed mindset and orthodox approach about least discussed topics of sex and sexuality and also indicates that male respondents have destructive and possible paranoid tendency than females. Whereas, slight higher differences on geography content shows that female respondents are more assertive and successfully adjusted (Phillips and Smith, 1953) than male respondents. Similarly female respondents scored high values on religion and cloth content that indicates innocence and denial of guilt as defences against superego conflicts, intellectual defence against passive-submissive needs, and concern regarding authority (Schafer, 1954) and feminine identification (Schafer, 1954). Conclusion: In conclusion, the present study provides a large range of contents which describes the wide Indian mind-set and hint at the surroundings that is broad enough to give them space to fly their imagination. Out of twenty seven content categories, twelve content categories were either positively or negatively correlated with verbal intellectual functioning indicating that they have significant impact on one’s personality. To get a broader picture and wider implication of this study, the full version of WAIS must be administered in future studies which may provide more wider visualization of content in perspective of intellectual functioning and cultural background. References: Aronow, E., Reznikoff, M.,and& Moreland, K. L. (1995). The Rorschach: Projective technique or psychometric test? Journal of Personality Assessment, 64, 213–”228. Allen, R., (1954), Recording the Rorschach Protocol: Journal. of Clinical Psychology. 10:2, 195-196. Banks, J. A. and Banks, C. A. (1997): Multicultural education: Issues and perspectives (3rd ed.). Boston, MA: Allyn & Bacon. Beck, S.J., (1949): Rorschach’s Test. I Basic processes. (2nd ed., rev.) New York: Grune & Stratton xiii,227 p. Beck, S.J., Rabin, A.I., Thieson, W.G., Molish, H., and Thetford, W.N., (1950): The normal personality as projected in Rorschach test. Journal of Psychology,30,241-298. Beck, S. J., (1952): Rorschach’s test. III. Advances in interpretation. New York: Grune &Stratton, viii, 301p. Beck, S. J., Beck, A.G., Levitt, E.E, and Molish, H.B., (1961): Rorschach’s test. I: Basic Processes. 3rd Ed. New York: Grune and Stratton. Beck, S. J., and Molish, H.B., (1967): Rorschach’s test: a variety of personality pictures. 2nd Ed. New York: Grune & Stratton. Cass, W.A.Jr, and McReynolds, P.A. (1951): A contribution to Rorschach norms. Journal of. of Consulting Psychology,. 15;178-184. Exner, J. E., Jr. (1974): The Rorschach: A comprehensive system (Vol. 1). New York Exner, J. E., Jr. (1986): Some Rorschach data comparing schizophrenics with borderline and schizotypal personality disorders. Journal off Personality Assessment.50; 455-471. Fisher S., (1967): Projective methodologies. Annual Review of Psychology,18,165-190. Klopher, B., and Davidson, H.G., (1962): The Rorschach technique. New York: Harcourt, Brace & World. Kronenberg, B., and Lemkau, P., (1998): Herman Rorschach: Psychodiagnostics , Verlag Hans Huber; translation and English edition . 3rd Ed. Pershad, D. and Verma, S.K., (1988): Translation and adaption of WAIS-R verbal scale in Hindi. In the concept and assessment of intelligence. National Psychological Corporation, Agra. Phillips, L. and Smith, J.G., (1953), Rorschach interpretation: advanced technique. New York, Grune. Rapaport, D, Gill, M. and Schafer, R., (1968): Diagnostic psychological testing, revised edition edited by R.R Holt. New York: International Universities Press. Rawls, J.R., Slack, G.K., (1968): Artists versus non-artists: Rorschach determinants and artistic creativity. Journal of Projective Techniques and Personality Assessment. 32: 3, 233-7. Schafer, R., (1954): Psychoanalytic interpretation in Rorschach testing. New York: Basic Books. Shweta, Bajpai R .C, Sengar K.S, Singh A. R, Desai N. G, (2010): Rorschach Profile of Indian Adults. SIS Journal of Proj Psychology & Mental Health, 17: 2, 180-186. Smith. S.R., Archer, R.P., (2008): Personality Assessment. New York: Routledge Press.

Cognitive Flexibility in Patients with Bipolar Affective Disorder: Current Episode Mania S. K. Yadav, S. Alreja, K. S. Sengar and A. R. Singh Bipolar Affective Disorder (BAD) is characterized by recurrent episodes of mania and depression interspersed with episodes of complete recovery. However, some residual cognitive deficits are reported. The present study aimed to see cognitive flexibility in patients suffering from Bipolar Affective Disorder with current episode of Mania on Comprehensive Trail-making Test in terms of deficits in Psychomotor speed, Visual search and Sequencing, Attention and Set shifting. Fifty patients suffering from Bipolar Affective Disorder with current episode of Mania diagnosed according to ICD-10 DCR criteria and fifty normal participants matched with respect to age and gender were taken for the study. Participants were individually assessed on Comprehensive Trail-Making Test to examine the status of these cognitive functions. In comparison to normal participants manic patients felt significant problems in almost all the areas under study. Cognitive flexibility is the human ability to adapt with the help of cognitive processing strategies to face new and unexpected conditions in the environment (Cañas et al, 2003). This definition involves three important characteristics. Firstly, Cognitive Flexibility is an ability which could imply a process of learning, that is, it could be acquired with experience. Secondly, Cognitive Flexibility involves the adaptation of cognitive processing strategies. A strategy, in the context of this definition, is a sequence of operations which searches through a problem space (Payne e al, 1993). Cognitive flexibility, therefore, refers to changes in complex behaviors, and not in discrete responses. Finally, the adaptation tends to occur to new and unexpected environmental changes after a person has been performing a task for some time. Bleulerian view demonstrates that cognition and thought disorders are the central and pathognomic symptoms of schizophrenia. Despite the prominence of Bleuler’s view, prior to the 1970s there was scattered clinical observation of cognitive disturbances in manic Sujit K. Yadav, M.Phil, Clinical Psychologist, DMHP, Gumla, Jharkhand, Sarika Alreja, Clinical Psychologist, Mahendru Psychiatric Hospital, Kanpur, K. S. Sengar, Ph. D., Asst Professor and Amool R. Singh, Ph. D., Professor & Head, Dept. of Clinical Psychology & Director, RINPAS, Kanke, Ranchi ( E Mail for Correspondence: achyutsengar9@gmail.com) Key Words: Bipolar Affective Disorder, Manic state, cognitive flexibility. Trail Making Test patients. A number of investigators have questioned the specificity of thought disorder in a systematic way. In the1970s, two large research programs, began to produce solid evidence backing the proposal that thought disorder is not merely unique to schizophrenia, but a prominent feature of hospitalized manic patients too (Andreasen et al,1974; Harrow et al 1990). Patient with mania have been studied using tasks that assess aspects of learning and memory, visuospatial ability and executive function. In a study conducted by Taylor & Abrams (1973), test of attention, visuospatial function and memory were administered to patients with mania, approximately half of whom exhibited moderate and severe global cognitive impairment. Another important factor in cognitive and, more specifically, executive efficacy is the speed with which operations are accomplished, that is, psychomotor performance. Deficiencies in psychomotor speed have been observed in a number of previous studies (Martinez-Aran et al., 2004) and have been associated with impairments in controlled attention (Wilder-

Cognitive Flexibility in Patients with Bipolar Affective Disorder 201 Willis et al., 2001) and memory (Kieseppa et al., 2004; Mojtabai et al 2000). Objective: The present study was conducted to assess cognitive flexibility of patients suffering from bipolar affective disorder with current episode of mania. Methodology: Sample: The present study was a cross-sectional study for which a sample consisting of fifty patients with bipolar affective disorder with current episode of mania and fifty normal individuals was selected by using purposive sampling technique. The mean age of manic patients was 28.54 + 6.14 years and of normal participants was 28.12 + 4.83 years. All participants were males and right handed. Most of the subjects were in the age range of 22-35 years, educated above matric level, married, Hindus and employed. The majority of participants was belonging to joint families and hailed from middle socio-economic status from semi urban and rural areas of Jharkhand and Bihar. Subjects with any other co-morbid conditions were excluded. All participants were co-operative. Informed consent was taken for the study. Tools: Socio-demographic and Clinical Data Sheet: It is a semi-structured Performa, containing the information about socio-demographic variables like age, sex, religion, education, marital status, domicile, and occupational and clinical details like age of onset and duration of illness. Hand Preference Battery: This scale was constructed by Annett (1970), to ascertain the hemispheric dominance of the individual. Young Mania Rating Scale (YMRS): The YMRS (Young et al., 1978) is an 11-item instrument used to assess the severity of mania. YMRS features operationally defined anchor points and the normal expected score is >=20. Rating is based on patient’s self-reporting of his or her condition over the previous 48 hours, and clinician’s observation of the behavior of the patient. General Health Questionnaire-12: Originally, the GHQ (Goldberg & Hiller, 1979) is a 60-items self- administered screening test, which is sensitive to the presence of psychiatric disorders in individuals presenting in primary care settings and non-psychiatric clinical settings. The GHQ is not designed to detect symptoms that occur with specific psychiatric diagnoses, rather, provide a measure of overall psychological health or wellness. The GHQ-12 is a shorter version of the GHQ 60, containing 12 items. Comprehensive Trail Making Test (CTMT): The CTMT is developed by Reynolds in 2002. The CTMT comprises a standardized set of five visual searches and sequencing tasks that are heavily influenced by attention, concentration, resistance to distraction and cognitive flexibility (or set shifting), in addition to more obvious visual search and sequencing demands of the task. The basic task of trail making, and thus of CTMT, is to connect a series of stimuli (numbers, expressed as numerals or in word form, and letters) in a specified order as rapidly as possible. The details of the trails are as under: Trail 1 - In Trail 1, the examinee draws a line to connect the numbers 1 through 25 in order, each contained in a plain black circle. Trail 2 - In Trail 2, the examinee draws a line to connect the numbers 1 through 25 in order, each contained in a plain black circle. Twentynine empty distracter circles also appear on the same page.

202 Yadav, Alreja, Sengar and Singh Trail 3 - In Trail 3, the examinee draws a line to connect the numbers 1 through 25 in order, each contained in a plain black circle. Thirteen empty distracter circles and 19 distracter circles containing irrelevant line drawings appear on the same page. Trail 4 - In Trail 4, the examinee draws a line to connect the numbers 1 through 20 in order, where 11 of the numbers are presented as Arabic numerals (e.g.,1,7) and the remaining numbers are spelled out in English language form (e.g., Nine). Trail 5 - In Trail 5, the examinee draws a line to connect in alternating sequence the numbers 1 through 13 and the letters A through L, beginning with 1 and drawing a line to A, then 2, then B, and so on until all numbers and letters are connected. Fifteen empty distracter circles appear on the same page. The primary score derived for each trail is the number of seconds required to complete the task. Procedure: Socio demographic information was collected by using the Socio Demographic Data Sheet. Information was gathered from reliable sources such as case record file and patients’ relatives. Participants with bipolar affective disorder currently in Mania were selected from the inpatient units of RINPAS. Participants who fulfilled the inclusion/exclusion criteria were screened on severity using the Young’s Mania Rating Scale. Normal participants were agematched individuals working at the institute. They were screened on the basis of General Health Questionnaire-12 to rule out probable psychiatric problems. Comprehensive Trail Making Test was administered to all the participants. Statistical analyses: Performance of participants on comprehensive trail making test was compared by using t- test. SPSS version 16 was used for the analyses. Results: The data have been analyzed and presented in table. The Table consists of the sub-variables in the five trails of Comprehensive Trail Making Test, i.e. trail 1, 2, 3, 4, 5 on which the two groups were compared. Findings of the study suggest that normal participants reported no or negligible problem in all five trails; whereas manic patients reported difficulties in performing these tasks. The difference between both groups was statistically significant in all areas. Table 1 Showing Results of the Study Trails Dimensions Normal (N=50)M+S.D Patients (N=50)M+S.D t- value Trail 1 Time 44.20±21.57 122.74±71.28 7.45** Error 0.06±0.31 0.42±0.88 2.71** Trail 2 Time 42.24±18.25 112.30±68.02 7.04** Error 0.12±0.38 0.50±0.73 3.23** Trail 3 Time 43.44±15.12 120.86±75.75 7.08** Error 0.02±0.14 0.34±0.79 2.79** Trail 4 Time 44.38±24.12 157.32±96.98 7.99** Error 0.20±0.49 0.68±1.36 2.34* Trail 5 Time 71.36±39.51 215.30±140.18 6.98** Error 0.48±0.70 1.86±2.39 3.91** ** p < .01 * p < .05

Cognitive Flexibility in Patients with Bipolar Affective Disorder 203 In the area of time taken in Trail 1, Trail 2, Trail 3 Trail 4 and Trail 5 both the groups differed significantly at 0.01 levels. Similarly, in the area of error on Trail 1, Trail 2, Trail 3 and Trail 5 the difference was found significant at 0.01 levels and on Trail 4 both the groups differed significantly at 0.05 levels. The findings of the study further suggested that poor performance in Comprehensive Trail Making Test is an indicator of impairment in maintaining / shifting mental set which is significantly higher in the inpatient group than control group. Discussion: The results of the present study showed significant five visual searches and sequencing tasks that are heavily influenced by attention, concentration, resistance to distraction, and cognitive flexibility (or set shifting) of manic patients in comparison to normal participants. Findings are consistent with other studies showing Bipolar affective disorder group to have impaired sustained attention and executive functioning on Trail making test (Kolur et al, 2006). Subjects with bipolar disorder (euphoric or in manic/depressed state) also have difficulties with shifting cognitive set, as can be observed in TMT scores of bipolar affective disorder and schizophrenic performance, which requires concept alternation. In this study, patients were found impaired in the psychomotor domain as has been previously observed (Zubieta et al., 2001). Findings of the present study further indicate that manic patients have deficits in occurrence of new and unexpected environmental changes in conditions where a person has been performing a task for some time. The findings of the present study are consistent with the findings of Henry et al. (1973). Patients suffering from mania were found to have impairments in serial word-list learning. The results presented in table 1 shows that the deficits are significant in attention span in manic group when compared to normal subjects. Findings further reveal that manic subjects are easily distractible as distractibility and over-activity are the main pathological characteristics of the manic illness. Findings in this area are significantly consistent with their pathological features. Their poor performance on tests of attention, on trail making test, and digit span test were also reported by the Asarnow and McCrimman, (1981) and Martinez-Aran et al., (2004). With one exception (Sapin et al., 1987) among all the studies reviewed in this area the patients involved were on psychotropic medication which may have influenced their cognitive function. Regarding lithium treatment some studies have reported impairments in memory, vigilance and attention (Shaw et al., 1987; Kocsis et al., 1993) whereas others have reported no changes (Engelsman et al., 1988) or even improvement (Zerbi et al., 1981). Consistent findings of the present study are similar to analytical findings of the 45 studies by Bora et al. (2009). Patients in a euthymic state, found large effect-size impairments (d= .83-.86) in speeded setshifting, verbal learning and sustained visual attention, moderate-to-large size effects (d =.59 - .77) in processing speed, working memory (digit backward), conceptual flexibility and perseveration, visual memory and verbal fluency, with processing speed deficits being linked to medication effects. Small effects were evident in visual copy and auditory attention (digit span; d =.23 - .37). There have been a number of studies conducted in this area, and sustained attention and working memory were found to be poor even in remitted BD patients (Ferrier et al., 1999; Mojtabai et al., 2000). Difficulties due to interference and poor set shifting ability have been reported in stable BD patients in comparison to normal (Ali et al., 2000) but findings of Krabbendam et al., (2000) are inconsistent. Furthermore, some studies do not support the findings of impaired sustained attention and selective attention in remitted patients (Addington et al., 1997) while the opposite is true for studies with TMT on BD patients (Ferrier et al., 1999). The subjects of the present study’s experimental group were

204 Yadav, Alreja, Sengar and Singh asymptomatic and were not completely remitted. This could have accounted for the differences with the other studies. Bipolar patients showed extensive cognitive abnormalities with a pattern of deficits that is not unique to this disease. Most of the work has centered on cognitive impairments in schizophrenia and very few reports discuss cognitive dysfunction in bipolar affective disorders and even lesser researches look at manic episode. Bipolar patients exhibit a lesser degree of deficits as compared to schizophrenics, particularly concerning pre-morbid and current Intelligence Quotient and perhaps attention, memory and executive functions (Daban et al., 2006). Our findings are consistent with a growing body of evidence that people with bipolar disorder experience a range of cognitive deficits particularly memory, attention and executive functions despite average intelligence. Future research on cognitive deficits in bipolar patients may be conducted on larger samples to allow the examination of specific cognitive deficits; using cognitive measures that are sufficiently specific and sensitive, and have ecological validity; longitudinal studies controlling for psychopathology; and investigation of heterogeneity of cognitive functions in patients in relation to neurobiological findings. Conclusion: The results of the present study showed significantly poorer performance by manic individuals on all five visual searches and sequencing tasks that are heavily influenced by attention, concentration, resistance to distraction, and cognitive flexibility (or set shifting) of the Comprehensive Trail Making Test in comparison to normal participants. It is apparent from the findings of the present study and previous researches in this area that manic illness cause significant impairments in cognitive domain of such individuals which may lead to many psychosocial impairments/ deficits. Though, these deficits are significantly less severe than schizophrenia, they cannot be ignored; rather they need to be remediated and such individuals must be considered for neuropsychological rehabilitation to attain their previous level of functioning to certain extent, which subsequently may reduce both psychosocial and financial burden and help them to reintegrate and reestablish themselves in the community at large. References: Addington, J. & Addington, D. (1997); Attentional vulnerability indicators in schizophrenia and bipolar disorder. Schizophrenia Research, 23, 197-204. Ali, S.O., Denicoff, K.D., Altshuler, L.L., Hauser, P., Li, X.M, Conrad, A.J., Mirsky, A.F., Smith-Jackson, E.E. and Post, R.M. (2000): A preliminary study of the relation of neuropsychological performance in neuroanatomic structures in Bipolar disorder. Neuropsychiatry, Neuropsychology & Behavioural Neurology, 13, 20-28. Andreasen N C, Powers P (1974): Over inclusive thinking in Mania and Schizophrenia. Schizophrenia, 125, 452- Annett, M. (1970): A classification of hand preference by association analysis. British Journal of Psychiatry, 61, 303-321. Asarnow, R. F., and McCrimman, D. J. (1981): Span of attention deficit during the post psychotic stages of Schizophrenia: A replication and extension. Archives of General Psychiatry, 38, 1006-1011. Bora, E., Yucel, M., & Pantelis, C. (2009): Cognitive endophenotypes of bipolar disorder: A meta-analysis of neuropsychological deficits in euthymic patients and their first-degree relatives. Journal of Affective Disorders, 113, 1-20. Cañas, J.J. Quesada, J. F., Antolí, A., and Fajardo, I. (2003): Cognitive flexibility and adaptability to environmental changes in dynamic complex problem-solving tasks, Ergonomics, 46, 482. Daban, C., Martinez-Aran, A., Torrent, C., Tabarez- Seisdedos, R., Balanza-Martinez, V., Salazar-Fraile, J., Selva-Vera, G., & Vieta, E. (2006): Specificity of cognitive deficits in bipolar disorder versus schizophrenia: A systematic review. Psychotherapy and Psychosomatics, 75 (2), 72-84. Engelsmann, F., Katz, J., Ghadirian, A.M., Schachter, D. (1988): Lithium and memory: a long-term follow-up study. Journal of Clinical Psychopharmacology, 8, 207–212. Ferrier, I.N., Stanton, B.R., Kelly, T.P. and Scott, J. (1999): Neuropsychological function in euthymic patients with disorder. British Journal of Psychiatry, 175, 246-251. Goldberg, D. P., & Hiller, V. F. (1979): A scaled version of the General Health Questionnaire. Psychological Medicine, 9, 139-145. Goldstein, K. (1943). Brain concussion: Evaluation of the

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