SIS Journal of Projective Psychology & Mental Health

ISSN 0971-6610 SIS Journal of Projective Psychology & Mental Health Official Publication of the Somatic Inkblot Society Editorial: A Somatic Inkblot Series "bucket list" Exercise 75 -77 Wilfred A. Cassell SIS Illumination of Unreported Violent Impulses 78-80 Wilfred A. Cassell Somatic Inkblot Series-II (SIS-II): The Therapeutic Window of Emotionally-Withdrawn Children 81-90 Nilanjana Sanyal Therapeutic Effectiveness of SIS- II in a Case of Psychogenic Cough 91-97 L.S.S. Manickam, Mahbobeh Ghanbary and M. Kruthi

Personality Characteristic of Juvenile Delinquents as Compared to Non-Delinquents on Rorschach Test 98-105 Shweta Sharma, Deapti Mishra and Ranjeet Kumar Does Psychotherapy Benefit Pre and Post-operative Anxiety in Eye Diseases? 106-109 Daniel Saldanha,Vivek Goel, Anuja Kelkar, Arpita Karmakar, Preethi Menon, Kavita Bhatnagar, S.L. Jadav and , L.abanya Bhattacharya The Efficacy of Dance/ Movement Therapy as Revealed through the Qualitative Lens of Somatic Inkblot Series (SIS-II) 110-121 Manisha Dasgupta

Therapeutic Intervention through SIS Imagery: Two Case Studies 122-127 Antonio Cervigni

Mental Health Problems in Alexithymia: Role of Positive and Negative Emotional Experiences 128-136 Akanksha Dubey and Rakesh Pandey Behavioral Assessment of Mentally Challenged Children 137-140 L. N. Bunker, Subhash Meena and Laxmi Prajapat

Neonatal Outcomes in Women with Depression during Pregnancy 141-145 Shilpa Kumari and Shobhna Joshi

Volume 20 Number 2 July, 2013

Somatic Inkblot Society OFFICE BEARERS President:Bankey L. Dubey, Ph.D. Editor-in-Chief: Rakesh Pandey,Ph.D Vice President : Brig. D.Saldanha Gen. Secretary :Nalini Mishra, Ph.D. Joint Secretary :Akansha Dubey,M.A. Treasurer :Padma Dwivedi, M.A. Executive Members : Mike Baker, MBA. Wilfred A Cassell, M.D. Mary Cassell, M.A. Anand Dubey, MBA. Satchit P. Mandal, M.A. Tilottama Mukherjee, Ph.D. Preety Pandey, M.A. Ajay Tiwari, Ph.D. Pragya Tiwari, MBA. Sambhu Upadhyay, Ph.D. SIS

Editorial A Somatic Inkblot Series "bucket list" Exercise In less than a year, (if "God" wishes) my body will become eighty years old. Thankfully I do not feel its age! Yet, my energy for both personal and professional activities gives out much earlier at his senior stage in the life cycle. I now have to prioritize my personal life and SOMATIC INKBLOT SERIES (SIS) activities. It often reflect about what is essential in the time I have remaining until I die, or what is commonly called "kick the bucket". Based upon a popular American movie involving two aging men planning fun activities to complete before their dying, I now am envisioning a "Bucket List". This can be enriched by soon to be outlined SIS-II aided projective exercise which was originally created to dissolve death denial defenses. When the somatic structure in which I temporarily reside was younger, I confess that sometimes I participated in dangerous death defying outdoor activities. During such adventures, my brain's "Mental Mechanisms" employed the psychological defense of Denial. This is consistent with theory outlined by Ernest Becker, my now long deceased anthological professor, in his 1973 Pulitzer Prize winning book entitled "Denial of Death". Years later Becker's views originally shaped my planning the design of the suggestive structure intentionally embedded into the last card of first Somatic Inkblot Series (SIS-I) illustrated below in Figure 1. It may be recalled that in the SIS-I manual "BODY SYMBOLISM", Chapter 9 was devoted to the phenomenon of "Death Anxiety". Earlier normative data for Card XX of SIS-I was published for a healthy group of adolescents. This configuration was purposely designed to stimulate "Inner World" imagery with potential threat to the body. The expected life span of these responders far removed them in time from their body's death by natural disease conditions of late life aging. Without the peering power of projective assessment (or dream analysis), it might seem that they would only be experiencing low Death Anxiety in their "Inner World". Their symbolic responses to Card XX along with their associations in the detailed enquiry in brackets follow: "A face. There's a mask over the eyes (It's the Devil). Another person with blood running down. An ancient mask. The face of a baboon (someone gave it a sinister or threatening appearance). A face again. Another face. It looks mean. Another monster face (Its scary. Doesn't look nice. It's going to attack). Monster's face. Face. Face of a vampire bat. Mouth of a dog with two eyes. (It's a type of wild dog or wolf. Its mouth is open and ready to attack). A head skeleton. An animal opening its mouth. Death." These responses are consistent with the notion that structure in Card XX partially accomplished its preconceived goal. It stimulated the release from memory storage of imagery symbolically linked to "DEATH ANXIETY". Clinical experience suggested that this original Card can frequently provide a projective method for clinical assessment in various Mental Disorders. Moreover, its use enables an examiner to challenge psychological denial defenses of so-called normal death denying individuals. (e.g. Male adolescents) who impulsively place their bodies at risk by participating in "thrilling" life threatening activities. In Alaska where male Native adolescents have one of the highest rates of body directed violence frequently producing death, the projective use of this visual stimulus can assist in preventing death by suicide. Fig.1

Years later when SIS-II was contemplated, because of the importance in addressing issues related to violence certain additional "inkblots" were designed. Several were created to evoke imagery calculated to throw more specific projective light for illuminating otherwise unreported aggressive impulses. In my article in this month's journal, an illustrative example of SIS-II (Booklet version) projective findings are reviewed portraying the "Inner World" of both marital partners after the husband developed a severe paranoid psychosis. His wife felt terrorized after in bouts of psychotic rage, he erroneously accused her of marital infidelity. Although diagnostically useful as an interview aide in illuminating otherwise denied dangerous impulses in such potentially violent situations, SIS-I has definite limitations. None of the stimulus arrays replicate the temporal final existential state of "a body dying" with its resident's spiritual departing. Assisting one in mentally processing subjective experiences stemming from anticipating one's death historically was the task of a primitive group's "Medicine Man" . In more advanced cultures it gave rise to the impetus for the Death Anxiety dissolving dogma of the world's organized religions. In the modern world when dogma bound religious fanatics clash in ideology, it can provides rationalization fuel for irrational terrorists. Throughout my work I have hoped that SIS scientific studies could throw more rational light on what constitutes optimal cognitive/affect processing of existential issues. Consequently when SIS-II was contemplated, a decision was made to create more symbolic specific electronic color-form-movement stimulus releasing patterns. I envisioned designing a system of artificial intelligence that might act as a robotic consultant to enable the examiner to more specifically focus on a viewer's inner world of projective consciousness during the final stages of dying. Thus B22 illustrated below in Figure 2 was created depicting a human body with electronic movement patterns suggestive of the "living spirit" departing a dying body. A static version of this is illustrated below in Figure 2: Fig. 2 As might be expected, the viewer's religious training and cultural background strongly color the symbolism projected in relation to this ambiguous array. For example, an atheist or agnostic responder might simply see "A person dying with the breath departing "or simply "A death scene". Even for such cognitively focused responders, if the viewer suffers from a Mental Disorder with unresolved grief, such projected material may be utilized to release the "inner cry" in psychotherapy. For those who benefit from a positive inner spiritual world a more symbolically enriched approach may be planned in treatment. In such cases the therapist may verbally expand upon the visual scene. A suggestion may be given that the scene symbolizes a dying person's spirit moving to a higher spiritual plane of existence. Dogma consistent with the responder's religious belief system may be utilized and then an appropriate referral made to the professional religious authorities. A typical vision of a devout responder portrays the soul as leaving the body… to bond again with those of departed loved ones … ultimately radiating positive feelings of a viewer's higher power…or loving "God". Now as a senior citizen, it is more difficult to deny the ultimate somatic reality of one's mortality. Elderly people for additional reality testing, frequently experience the loss of friends 76 Cassell

who have made "one way out of the body trips". As one matures, I now advocate subjective spiritual image training for one's ultimate spiritual travel. This is quite analogous to an athlete preparing for a competitive event by conjuring up in body-mind-spirit consciousness patterns of the anticipated competition. Similar subjective visualization exercises visualization may be utilized in other than clinical situations. For example, such futuristic inner world travel may be conjured up in projective awareness as a modality for rethinking professional goals for all viewers, including members of our SIS society. For this type of existential application, before ending the trance like state, each professional member when introspecting while viewing B22 might ask the following question: "What legacy do I hope to leave for the SIS Society at the moment of my body's death?" The conceptual projective basis for dissolving death denial defenses facilitates bridging symbolic SIS work related to a death anxiety with what some clinicians collectively call "Mindful exercise" such as Yoga, Qi Gong and Tai Chi. At this time in the 21st century scientific literature there is substantial statistical evidence supporting the physiological and health benefits of such exercises. SIS workers are challenged to conceptually and clinically build future bridges with these growing disciplines. Moreover, it is suggested that future SIS research should be directed to developing A Somatic Inkblot “bucket list” Exercise 77 symbolic specific sensory input applications for 21st century communication technologies. Examples are "touch screen" tablets, smart phone and all related potential SIS theory empowering applications. Wilfred A Cassell, M.D., FAPA, APC. Editor Emeritus, SIS J. of Proj. Psy.& Mental Health, Director, SIS Center, 4501E, 104th Avenue, Anchorage, AK - 99507 (USA) E-Mail: siscassell2@yahoo.com

existence of suicidal and/or homicidal impulses. While many so tormented sufferers will readily report impulsivity of this nature, some highly dangerous individuals fail to do so. The Somatic Inkblot Series (SIS) can throw projective light to illuminate otherwise unreported deniers of violent impulses. This case report provides a clinical example involving a married couple in which the husband developed a Schizoaffective Type paranoid psychosis. Tormented by delusions, he falsely believed that his wife was having an affair. When he repeatedly confronted her in a face to face tense raging, she became terrorized. Although he denied impulses to hurt her physically, his threatening body language caused her to fear for her life and bring him for psychiatric/ psychological assessment. Both were individually administered the SIS-II Booklet version of the projective procedure. For the husband, the immediate goal was to clarify diagnostic issues. In the initial interview, he had reported a significant period of childhood physical and sexual abuse. His wife had indicated that he was an "A stay at home husband" who had a few minor paranoid tendencies. In spite of difficulties related to these, she said that he had been able to provide effective care for their children. The goals for the woman with SIS-II evaluation were to assess her reality testing in regard to her potentially dangerous marital situation. Both separately wrote their responses to the SIS-II Booklet. Since the man had a history of childhood abuse, his responses were first examined in regard to identifying adult residual from such early life trauma. Relative to this, his response to the "inkblot" which he rated as his "least favorite" inkblot was said to be "A penis…I don't like it…I have been touched before". He then spontaneously briefly elaborated upon about past childhood sexual abuse. However, because of his highly fragile mental state, no further associations were obtained. In regard to diagnosis, it was recognized that his wife's observations documenting a minor degree of suspicion, distrust and so-called "paranoia" might relate to such stressors. However, it seemed highly unlikely that his recent psychotic paranoid delusions could be entirely accounted for by his unresolved early life issues. It seemed more probable that a more serious mental condition such as "Schizoaffective Disorder" should be considered as a diagnostic possibility. Review of his Booklet answers supported this consideration. Next those responses that he gave that reflected a more allencompassing psychotic withdrawal of attention from the outer world of social events and its resultant perceptually related heightened "Body Awareness", He gave anatomical responses as follows: A1 "Looks like lungs", A2 "Looks like heart", for A5 he failed to recognize a human body gestalt and projected a psychologically regressive oral image as follows: "Looks like a mouth open eating a strawberry". He projected the response "Brain" in relation to A18 reflecting the type of insight often presents in psychotic individuals reflecting their introspective insight

into their cognitive distortions when attempting rational thinking. For B24 reflecting his psychotic accentuated Body Awareness, he gave the anatomical responses "lungs". His paranoid delusional concerns about being watched were reflected in projecting the abnormal response "Eye on top" in A8 and "Creepy eyes" in A10. Next his responses were examined in regard to the assessing the manner in which he mentally processed SIS-II structure related to aggression/ violence. In regard to viewing embedded SIS content depicting weapons and scenes related to body injury, B10 was imagined to depict "A cut on stomach of a woman…I don't like". For the knife like configurations in B15, he visualized "Knives and sharp objects". (His wife imagined B15 to symbolize "A mountain with Nature destroyed". This image of destruction symbolized her fear of being murdered. For B21 depicting an outline of a handgun, he failed to identify the embedded weapon and replaced the correct image with a much more powerful instrument of destruction in substituting the response Bomb". (His wife viewed it as a "Gun explosion". The "Explosive" connotation symbolized the intensity and lack of emotional control of her husband's rages. As indicated reflecting his somatic preoccupation for B24 he gave the anatomical responses "lungs" as well as his psychophysiology heightened awareness of "SENSORY FEEDBACK OF ACCENTUATED BREATHITH WHEN HYPERAROUSED. (This visual input stimulated recent traumatic memories from short term memory storage for his wife as follows: "A nose with large nostrils distorted…not normal". Thus it triggered memories of her husband's face, close up in a highly threatening body posture.) Consistent with this flood of stressful memories, his wife's "least favorite" or most threatening inkblot was B12. This was imagined to be "A man in pain with a boil", reflecting a direct symbolic projection of her empathetic painful awareness of her husband's intense "Inner World" agony. The "inkblot" that she rated as second most threatening stimulus scenes was B10. This was imagined to be the body of "A Mutilated woman". This pathological anatomical response replicated her anxiety laden dreams of being murdered. The third "Disliked" inkblot scene was evoked by B18. It depicted "A penis in the vagina, she visualized the threatening symbolism as follows: "A claw through a small tunnel". She disturbed her because "It looks intrusive". This symbolism suggested the need at some future time when his psychosis had been resolved that issues related to sexuality might need to be explored. Several other responses reflected the wife's current marital stressors. Thus A10 was said to be "A woman in pain", A13 was seen as "A hand reaching through fire…it looks distorted".B4 was seen as "An old man looking through hollowed eyes…scary!" B6 was seen as "A severed body"…It looks scary" In viewing B28 she avoided the structure depicting a mother nurturing an infant. Instead she visualized "A man alone". Lastly symbolizing the threat from such superimposed images of her raging sexually delusional husband, she envisioned B29 to remind her of "A threatening man!" Discussion: The authors recognize that each readers training, professional orientation as well as clinical experience in working with potentially dangerous individuals suffering some form of Mental Disorder will affect his/her response to this couple's case history. For example, it you are an experienced mental health professional, you will be able to identify readily with the terror experienced by this man's wife. In my psychiatric experience working with psychotics, I have had my life threatened many times and been physically assaulted more than once. As contrasted with other members of the mental health profession, Psychiatrists are much more likely to be attacked physically and/ or murdered. In the United States the risk is greater for those practicing alone privately in an isolated office, without a hospital staff security net. In such a vulnerable setting, it is possible to SIS Illumination of Unreported Violent Impulses 79

legally obtain a court order to restrain the threatening individual from geographical proximity. Yet the police refuse to intervene until the potential delusional perpetrator assaults or as the police indicated "shoots a weapon at you". The last man suffering from Schizophrenic Disorder, Paranoid Type that I committed to a psychiatric hospital for suicidal/homicidal impulses was in Anchorage, Alaska twenty years ago. He was placed upon oral antipsychotic medication and discharged in three days. He refused to comply with hospital staff instructions for follow-up medication management. Shortly after discharge he came uninvited to my office in a paranoid state threatening to kill me if I ever committed him again. This clinical case report examines the marital stressors activated when a husband develops 80 Cassell paranoid delusions falsely portraying that his wife is sexually unfaithful. Although there is an extensive literature concerning the propensity of an individual suffering from a Mental Disorder to commit violent acts, it is problematic determining such risk in a specific clinical case. References: Huber C.G. , Schottle D., Lambert M., Hottenrott. B., Agorastos, A., Naber, D. and Schroeder, K. (2012) Schizphr Res. Feb 134(2-3):273-8 Brief Psychiatric Rating Scale. Mossman, D. J. (1994) Assessing predictions of violence: being accurate about accuracy. Consult Clin Psychol, Aug. 62(4):783-92 Rydin , E., Asberg, M., Edman, G.and Schalling , D. (1990) Violent and nonviolent suicide attempts - a controlled Rorschach study Acta Psychiatr Scand , Jul 82(1) 30-9. De Pauw, K.W. and Szulecka, T.K. (1988) Dangerous delusions, Violence and the misidentification syndromes, Br J Psychiatry, Jan. 152, 91-6.

Somatic Inkblot Series-II (SIS-II): The Therapeutic Window of Emotionally-Withdrawn Children Nilanjana Sanyal Projections of varied kinds are part and parcel of daily emotional exchanges with the environment. They give vent to the unconscious realm of the mind that tends to threat the ego-system. Resistance and consequently repression are resultant effects. Projective techniques come at the aid at this juncture to penetrate deeper into the unconscious folds in a non-threatening way, thereby offering space for clients to open up their inner veils on a face-to face basis. The Somatic Inkblot Series-II (SIS-II) is one such projective assessment tool that is apt enough to provide therapeutic elements to unravel the unknown contents of one's personality. The present theoretical discourse plunges into the attempt to verify the therapeutic bearing of SIS-II as a "lens" or "window" in offering light to the unconscious in a non-threatening way with the help of some selected case studies in the form of child cases, whose responses to the same test provided dynamic meaning, in terms of their emotionality. The responses to the SIS-II seemed to verify the assumption that it serves as a "therapeutic template" on the basis of which the next line of treatment in terms of psychotherapy may be designed in future. The mechanism of projection is an uncontrolled spontaneous reflection of unknown unconscious contents of one's self-system. Such elements of unconscious are majorly repressed materials of life contents. Their open reflection in conscious interactional behaviors bears a threat to our ego system. Hence is the question of resistance and repression. The sole function of resistance is the attempt of the self-system to protect our conscious ego from experiencing of social embarrassment. The net result is tightened repressive behavioral mode. The study of psychodynamics of a self-system, especially where indications of pathologies are prominent seems to be a tough job. The free-association method of psychoanalysis is an available avenue to open up our unconscious where selfmotivation and cognitive stability is assessed. Otherwise, the only way left out seems to adopt projective techniques. The stimulants of such techniques are interventions into deep unknown possible pathologies. Projective techniques, in experienced investigators' hand, seem to have its total reign in the context (Mathur and Kumar, 1967; Mathur, 1967; Joshi and Srivastava, 1967). Hence, the need is to take into account of the nature of stimulants in projective technique with their possible implied interpretations to do a good job in the treatment parlance. In psychodynamic context, treatment concept includes assessment and psychodynamics and Nilanjana Sanyal,Ph.D., Professor and Former Head, Department of Psychology, University of Calcutta, 92 A.P.C. Road, Kolkata-700009, Email: sanyal_nilanjana2004@rediffmail.com Key words: SIS, emotional disorder, therapeutic window adoption of appropriate situation specific therapy modality. To judge the appropriateness of therapy, the notes on psycho-diagnostic elements are essential to obtain. The avenues of obtaining them are therapists' quality of insight into the process and available data on projective techniques. Along with other significant projective techniques, currently developed Somatic Inkblot Series-II (SIS) (Cassell and Dubey, 2003) seems to be a befitting and alternative choice for many therapists. In fact, projective tests provide a standardized arena in which to capture children's play and imagination, and hence serve as perhaps the primary reason to be very useful in work with children. Play and imagination for children are valid equivalents to dreams for an adult in that they are where a child's conscious and unconscious mental phenomena come together, so that a child can be found most mentally alive and present and creates structure… (Slade, 1994). Children use play and imagination to rehearse and repeat aspects of their experience they are coming to terms with, exploring or working towards mastery in their development. Projective tests allow the imagination and playful expression of children 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, Goudsmit, Ferst, Shargin and Wolitzky, 2008; Chowdhury, 1960, 1967; Bellak and Bellak, 1949; Dasgupta

and Sanyal, 2006; Sanyal and Dasgupta, Marinakis, and Doukas, 2006; Sanyal and Dasgupta, 2008; 2009). A child can be most mentally alive and present in play. "By putting experiences and feelings into play rather than words, the child is creating structure… Adults figure out how they feel by talking it through; very young children figure it out by playing about it." (Slade, 1994). Projective tests are designed to present the subject with a lesser degree of external structure "in order to allow maximal expression of the structuring principles of the individual personality." (Rapaport, 1950). The attempt of the present venture is to probe into the therapeutic elements available in SIS responses of a specific set of children and to establish SIS's efficacy in serving as a therapeutic window in the situation. Certain child case excerpts would be presented at this juncture to establish the point that the basic response to several SIS stimuli seem to be potent enough to bring out unconscious psychodynamic contents that need to be dealt with in therapy. All of the selected cases were found to be generally shy, emotionally constricted and hence less communicative in nature. Before the administration of SIS on them, it was a bit difficult to develop rapport with them but ultimately owing to experienced therapeutic skill, they were initiated in the testing session and certain amount of responses could be deduced from them. Only those responses had been selected for presentation that seemed to carry unconscious emotional loadings to signify the point that SIS stimulation are able to serve as therapeutic windows to give hints regarding the specific nature of pathologies embedded in the child. The general ambience of the testing session was very carefully made comfortable for the children to open up; sort of therapeutic holding was provided to them, with empathic words of the therapist, children ultimately took part in the testing session. The point here is that it is been felt that SIS administration itself needs this therapeutic orientation to bring out the unknown contents of one's personality, certain images were found to be rejected by the selected children specifically signifying the following features in them: • Constricted emotionality • Difficult relationship with mother figure • Emotional immaturity • Sense of inadequacy • Presence of anxiety loadings in personality • Identity confusion The rejection of these images also pinpoints the fact that the SIS stimuli of specific kinds are being able to touch the core pathologies in children and hence is the resistance to continue with their repression. Case 1: The case Ambrin, aged 8 years 6 months, came with the complaints of Low academic performance, generalized fearfulness with regard to others, aggressiveness, forgetfulness, inattentiveness, being stubborn, self- talking and poor adjustment at home and in the school. She had these symptoms since last 18 months. She was referred from a government hospital for personality assessment to the Department of Psychology, Calcutta University because of her presenting problems. Ambrin belonged to a Muslim, middle-class, joint family of eight members. She was the only child of her parents. She had been staying with her maternal grandparents since birth. Her mother stayed with her father only for around 4-5 months after her marriage, after which she came back to her mother's place. Her mother left her father as he was suffering from some mental illness where he was reported to suffer from seizures, the details of which could not be elicited. Ambrin did not meet her father even once. She lost both her parents at a very early age. She was 18 months of age when her father expired due to his mental illness followed by the death of her mother due to a heart attack one year later. Her maternal grandparents and her maternal uncle and aunty take care of Ambrin at present. She spent most of her time sleeping and playing (mostly engages in solitary games). As such, her 82 Sanyal

interaction with her cousins was not very smooth. She often ended 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, she engaged herself in monologue; at other times she would even go outside, sit in a stationed auto and play all by herself. Some of the significant responses to the SIS-II (Booklet version) are as follows: Image A7: She had responded to it as, "A girl is going to take the apple but she won't be able to take it as it is very high." {This suggests the presence of oral need along with a strong sense of inadequacy on the part of the client. The client's deprived emotional state owing to lack of parental support and a feeling of helplessness seems obvious that needs therapeutic language for explanations to her for their rectification.} Image A11: She had viewed it to be a, "A picture of a person who is falling down and has been injured" {This suggests 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 appeared to be uprooted as far as social support is concerned. This hints at her severely "injured narcissistic self" Only supportive therapeutic communication can put a balm to her bruises}. Image A13: She had 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), selfblaming tendency, again supporting her depressive orientation, along with a wishful thought that everything would be fine someday (which resembles regressive and magical thinking to some extent) The responses seem to be free association on her part}. Image A20: She responded to the 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 ruminative and catastrophizing tendencies that cause her much distress, owing to her depressogenic orientation. The contents need further associations to be explained to her in therapy that can ultimately result in her insight development and emotional improvement.}. 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" The response here is symbolic with loads of underlying emotions to be unraveled through therapy}. 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. The response seems to be the expression of "inner cry" that needs to be consoled through therapy}. Image A27: She had 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 body part, specifically a breast. Interestingly, the client perceived it to be a SIS II: The therapeutic window of emotionally-withdrawn children 83

poisonous animal creeping up to smear poison. This reflects the presence of difficult relationship with the mother figure, which is perceived to be poisonous and rejecting on the part of the client. The therapeutic implication of the response is obvious here}. Image B16: She had perceived it to be, "A needle." {People generally perceive the card to be a spine or vertebrae which connotes the imagery of the male sex organ. Her response indicates her idea of pain regarding sexual encounters. The clarification of the response awaits therapeutic intervention}. Image B28: She had viewed it to be, "A girl's photo." {Generally people tend to perceive this image as the picture of a 'mother and her child'. However, the client has been unable to view the commonly perceived response perhaps because of a lack of healthy objectrelations with the mother-figure. The ultimate meaning of her responses tended to bear therapeutic implications mostly}. Image B31: She had perceived the image to be, "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 same and instead projects her need for affiliation and support by perceiving the stimulus as four children}. Case 2: Meghaan, an 8 yrs. old, adopted Bengali girl of upper class family, having a single parent (resides with divorced mother), is excessively pampered, is shy, very emotionally immature, and had complaints of difficulty in socialization, difficultly in concentration. She is good in painting and dancing. She missed her father much and fantasized his presence and her cravings for a complete family were very prominent. Some of the significant responses to the SIS-II (video version) are as follows: Image A16: "Two birds building a nest"; Image B31: "A complete family all together." Both the above responses reflect her inner cry of having a congenial and complete family. Image A23: "Looks like a cactus." This indicates her emotional pains which tend to prick herself like "thorns". They need to be addressed in therapeutic interventions. Image B2: "flesh being roasted." It reflects helplessness on the part of the child borne out of intense emotional deprivation. The specified response frames certainly indicate the therapeutic intervention line to be adopted to help her. Case 3: The case Aditi, aged 9 years 6 months, came with the complaints of: Extreme difficulty in concentration, too much of restlessness, Constant fidgeting, Poor regard of her own self, Poor academic performance - poor grades in Mathematics specially, Intense sibling rivalry, Quarrelsome with regard to younger sibling, Complaint of both the parents (specially the mother) to love the younger sibling greater, than herself, Overt aggression toward mother, Poor adjustment at home and in the school. All the symptoms were present since the birth of the younger sibling (about 5 years ago) Aditi belonged to a Hindu, upper middle-class, nuclear family of four members. She was the first born and had a younger brother who is about 5 years old. Her parents' marriage had been a love affair involving two different Indian communities. However, marital discord had been reported to be present right from the beginning as reported by her mother, owing to a very authoritative, overpowering and aggressive husband, which was and is still difficult to be accepted on her part. The couple had been repeatedly reported to exchange verbal and physical abuses in front of the children. Besides, Aditi's mother reported that her husband became violent many a times and verbally abused the child that she was not worth of doing anything good and constructive to which the mother could not say anything to refute 84 Sanyal

for fear of aggravating the situation. Both the parents had yielded to physically hitting the child many times when she did not meet up to their expectations. The father was presently engaged in the corporate sector while the mother was pursuing her higher studies in the Social Science discipline. Aditi reported that both her parents did not have much time to spend time with her. Her mother was too busy with her outdoor academic work for her doctoral dissertation while the father seemed to be a tyrannical one to be with. She spent most of her time playing (mostly engaged in solitary games) and studying. She often ended up getting into fights with her younger brother. A few significant responses on the Somatic Inkblot Series - II (video version) along with their content analyses have been provided as follows. Images A1 and A29: She had responded to them as, "Two shoes; a person; hairs of two girls - pulling each other; cowboy" and "Ink paints being smeared on a mattress by my brother" respectively {They suggest the presence of sibling rivalry in the present child, which needs to be addressed in therapy}. Images A6 and A12: She had perceived them as, "Teddy bear playing with ball; a person playing with teddy bear," and "Baby in mother's womb, who is yawning" respectively. {This is indicative of the presence of regressive features and emotional immaturity in the child}. Images A8, A13 and A15: She had viewed them as, "Tree trunk - having hands; tap present; hair, mouth, eyes," "A tree whom nobody used to see has hands in future; so everybody can see it; is talking" and "A fetus who is joined with the umbilical cord of the mother" respectively {This response is suggestive of the fact that the child has prominent need for succorance, need for attention and security from 'significant others'}. Image A10: She responded to the image as, "Footprints of a person; desert - grasses, fungus." {It suggests the presence of constricted emotions in the child owing to the pangs of a disturbing family ambience. It is also an important ground to look into during therapeutic interventions}. Images A18, A19 and A27: She has viewed them as, "I gave a gift to mother - a heart with a bunny bear inside - coming towards my mother," "A pot - smoke coming out and inside it is food" and "Sea horse is being presented to someone" respectively. {This response set is suggestive of the fact that the child has ambivalence toward the mother figure who at times appears to be a positive caring figure for the child, while at other times appears to be clouded, mystical and difficult to understand on the part of the child. The inability to perceive the mother's breast in Image A27 also hints at the presence of strained relationship with the mother. These issues need to be taken care of during the therapeutic interventions, whose lead has been offered by the SIS-II}. Image B3: She responded to the image as, "A queen, with others bent before the queen in the courtyard." {It indicates the presence of hankering for graceful approval and acceptance of her by others}. Images B12 and B13: She had viewed them as, "A robot giving head to sacrifice because the owner told him to do so," and "A design of a candy; No, an octopus stringed the candy." {It is suggestive of the fact that the child perceives the significant others to be dictating in nature and overly authoritative and she feels herself "strained" by the emotional constraints owing to the dictatorial family ambience." Image B15: She responded to it as "A person - a wife throwing away knives to the husband." {It suggests that the child perceives the parental figures to be quarrelsome, which tend to disturb her mental peace and sense of security as a result of which she feels uprooted. Therapeutic holding is essential at this juncture to offer the child coziness and comfort to unwind herself into the maternal healing envelopes of the therapist}. SIS II: The therapeutic window of emotionally-withdrawn children 85

Images B21 and B24: She perceived the images to be, "An upturned mixer to throw babies from there," and "An octopus - eating a goat and a bus which is shattering down." {It suggests the presence of strong sibling jealousy and intense oral aggression}. Image B27: She had viewed it to be "Twins quarreling - both want to be boys, but both of them will be girls." {This hints at the presence of sibling rivalry as well as her dissatisfaction with her own gender identity probably because she feels utterly differentiated in the context}. Image B31: She has perceived the image to be, "Mamma, Papa, Baby, Baby." {This indicates that the child has deep cravings for a congenial family atmosphere}. The responses of Aditi to the images of the SIS-II (video version) have been successful in identifying the inner conflicts of the client. In this case study, it was the obvious perceptions of the client to the unstructured stimuli offered by the images of the specific projective test which helped the subject to project her inner conflicts relatively conveniently. Case 4: The case, Sukanta, was an 8 year old male child, residing at a shelter home at age 7 years, since his father died. He hailed from a low socioeconomic Bengali family. The child's relationship with his mother was reported be to supportive, congenial and comfortable though he admitted, to seek more consistent availability of the mother figure. According to him the interpersonal relationship with his peers was comfortable. He loved painting and crafts. As observed, he was a timid and well-behaved boy. In the first few years of his life, he had resided in the Sunderban areas and had witnessed the "Aaila" tragedy (fear of thunder and lightning). A few significant responses on the SIS-II (booklet version) along with their content analysis were as follows: Image A6: He had responded to it as "Paper doll". {This suggests the child's sense of inferiority, poor self-esteem and regressive tendencies, with a tone of uncertainty in life.} Images A9 and A22: He had viewed them to be "Breast or Chest," and "Chest" respectively. {This suggests the child's deep cravings for affection, warmth and belongingness respectively. The meaning-loaded symbolic expressions need therapeutic guidance to reach to a comfortable zone in life}. Image A27: He had responded to it as, "Light is falling on the tree." {This suggests the child's inability to perceive the human breast which indicates his difficult relationship with his mother figure. Having the perception of "Light falling on the tree," reflects his relationship with the mother in a latent way. The response is also indicative of his craving for emotional anchorage and shelter from significant others.} Image B6: He had viewed it as, "The leg has been cut." {This probably reflects castration anxiety, somatization tendency and his fragile self-due to the presence of narcissistic injury, owing to his unsettled frame of socialemotional life. Images B15 and B18: He had responded to the images as "Mountain," and "Water is falling." {The responses denote that the child is resistant to acknowledge his primitive impulses and has associated sexual guilt. Therapy needs to help him acknowledge them and enjoy in sociable ways.} Image B28: He had viewed it as, "Two persons holding a small child." {This response denotes the child's craving for delicate emotions in the form of affection and acceptance from parental figure(s) and a deep rooted desire for a healthy familial relationship. The suffocated emotional contents found indicative expression in specific response, the splurge of which can be found in therapy. 86 Sanyal

Case 5: Prasanta was an 8 yrs. old male destitute. His mother is alive while his father had deceased when he was about 6 years old. He presently resided in a shelter home. The relationship with his mother was supportive, congenial and comfortable as reported by the child. His mother came to meet him once in every month. He has one sibling, a younger sister who stayed with his mother. Thus, his present family consisted of his grandmother, grandfather, mother and one sibling. He and his family were victims of Aaila in 2008 (traumatic suffering from thunder and lightning). Interpersonal relationship of the client with his peers was reported to be comfortable. He preferred watching T.V. when he felt lonely. Some of his significant responses to the SIS (booklet version) were as follows: Image A3: The child responded to the image as, "Cloud". {The response is indicative of the child's identity crisis and emotional confusion.} Image A4: This image had been viewed as, "Thunder." {This response suggests that the child perceives reality to be full of danger and threatening. This requires attention in therapeutic sessions such that the client feels assured and emotionally cozy owing to the presence of psychological space offered by the therapist.} Image A6: he viewed the image to be ,"One teddy bear." {This response indicates the inability of the child to perceive the human figure which reflects poor self-esteem and feelings of inadequacy, regression and inferiority.} Image A14: This image has been viewed as "Boat." {It reflects the craving of the child to be with the mother in the familial context, owing to his emotional deprived condition. This issue requires to be addressed in the therapeutic sessions} Image A27: This image had been rejected. Rejection of this image perhaps reflects the presence of unhealthy object-relations of the child. Image B11: This image was viewed as, "Bear cuddled up." {This response reflects the child's need for warmth, succorance and affection as well as emotional coziness, of which the child had been much deprived. These need to be provided in the therapeutic sessions to offer "psychological space and emotional holding" to the child to enable him to open up gradually.} Image B18: This image was rejected. It perhaps reflects the child's sexual anxiety. Image B22: This image was seen as, "An upturned human." {This response reflects that the child perceives himself to be presently hung and is in an emotionally distressing condition.} Image 31B: The image was responded by the child as, "Human standing." This response denotes that the child lacks strong family bonds as he could not perceive any family in the respective image which is the typical response. His emotional void needs to be worked with in the therapeutic sessions such that he attains an emotional anchor and basic trust point in life context.} Case 6: Prabal, aged 9 years, male, belonged to a middle class Hindu joint family of 7 members. He had a younger sister of 5 yrs. and studied in class 4. The child was born of a full term caesarian delivery. There were no significant prenatal or perinatal complications. The client achieved his developmental milestones at the appropriate ages. He started schooling at the age of 3 years. The client did not suffer from any major illnesses since birth. However, in May 2009, he lost consciousness for a very brief period of time. At that time, he needed to be sprinkled with water for him to regain consciousness. In October 2009, the same series of events occurred again. For this reason, he was taken to the hospital followed by MRI and EEG tests. The MRI findings SIS II: The therapeutic window of emotionally-withdrawn children 87

are suggestive of a small CSF signal intensity lesion in right medial temporal region adjoining right peri-mesencephalic cistern. Features were also found to favor neuro-epithelial cyst. Awake EEG tracing showed a background rhythm of 9- 10 Hz; 50-70 v alpha waves were found to attenuate on eye opening. Other than movement artifacts, no epileptiform discharge could be noted. Since the episodes of losing consciousness, the client was reported by his father to become unmindful regarding his studies and also having headaches quite often. He was referred from a government hospital for personality assessment to the Department of Psychology, Calcutta University because of his presenting problems. He spent most of his time at school playing with his friends. His daily schedule included attending school in the morning, coming back home, engaging in playful activities in the afternoons, and then preparing his lessons for the next day. His hobbies included reading story books and playing outdoor games with his friends. A few significant responses on the Somatic Inkblot Series - II along with their content analyses have been provided as follows: Image A5: He has viewed it as, "Somebody has won a game, so he is lifting his hands in joy." {This suggests the presence of strong strivings of achievement in the child}. Image A6: He has responded to the image as, "It is night time; the man forgot to take the doll and left it near the tree." {His response hints at the presence of negligent father figure, with whom he appears to be emotionally-distant. His emotions seem not to be taken care of by the parental figure(s) appropriately, giving rise to his "inner cry" and depressive stance toward life in general}. Image A7: His response to the image is as, "A 10 yrs. old boy standing under the tree, and an apple fell on him." {It probably indicates the presence of too much stressor (s) for the client to cope up, thereby appearing to be overwhelming and making it difficult for him to adjust to them adequately}. Image A8: He perceived it as, "Blue makes it seem like a dark place; a ghost has taken the form of a tree." {It sheds light to his deepseated anxiety, sense of insecurity and fearfulness}. Image A13: He had responded to this image as, "A hand stuck in some bushes", may indicate his anxiety, insecurity and painful situations around him. Image B14: as, "Apple fallen on the ground." {This probably reflects the present distress of the child, with prominent feelings of "emotional confinement" that probably account for his depressive orientation. His feelings of worthlessness, hopelessness and helplessness may also be inferred}. Images A15, A21 and B28:The child perceived Image A15 to be, "The beak of a crane. Being surrounded by water, the crane is going to catch fish" while he perceived Image A21 to be, "A tortoise swimming in the sea - a Mother Tortoise." His response to image B28 was, "A mother putting her baby to sleep."{All the responses indicate the presence of oral needs, and thereby strong cravings for maternal love and affection on the part of the child}. Image A24: He responded to the image as, "An old mask, so it is torn." {This response also supports his difficult relationship with his parents, who are perceived by the child not to cater his emotional needs}. Image A27: He perceived it as, "A cave." {This indicates that the child is aware of his primitive impulses. It is interesting to note that the child did not respond to the image by telling the most typical response (ie, a breast), hinting at the rejection of the maternal figure by the child, owing to difficult object relations}. Images A28 and B15: The child viewed the image (A28) to be, "A hand reaching out for a 88 Sanyal

flag that is hanging," while image 15B was perceived to be "pieces of glass." {It suggests the presence of desire for superiority and thereby become 'striking' amongst others. The child's aggressive features in the form of retaliatory mechanism might be an avenue to attain the desired superiority as well. It is to be noted that the child's possible organic conditions may be responsible for his occasional aggressive outbursts}. Image A31: He perceived it as, "Feroz Gandhi, Indira Gandhi, Rahul Gandhi and Sanjay Gandhi." {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 perceive a congenial family life, he has failed to perceive the same and instead projects his need for affiliation and support by perceiving the stimulus as members of a particular renowned Indian family including children and grand-children. His lack of generalization of the same indicates his constricted emotional tone as far as family ambience and consequent affectivity are concerned}. The responses of Prabal to the images of the SIS-II have been successful in identifying the inner conflicts of the client. In this case study, it was the obvious perceptions of the client to the unstructured stimuli offered by the images of the specific projective test which helped the subject to project his inner conflicts relatively conveniently. Case 7: Smita, a seven-and-a-half year old female child of a sex-worker, was the youngest of three siblings, and studied in Class I. She hailed from a low socio-economic Bengali family having a single parent. She appeared to be a shy child and was not much open in her responses. Some of the key responses to the SIS-II (booklet version) are as follows: Image A24: She viewed it to be "One leg". {It is an image which assesses the nature of interpersonal relationship. Her response perhaps reflects her stringent interpersonal relationship with significant others perhaps because of the presence of a single parent and the emotionally deprived condition. It also reflects her associated sense of inadequacy and accompanied inferiority.} Image 31B: She perceived it as, "A tree." {Instead of the typical response of a family, the child perceived the image to be a tree, which is noteworthy in the context. It reflects the lack of a congenial family atmosphere in her life which accounts for her emotional crisis. This needs to be specially addressed in the therapeutic sessions to offer a "psychological analgesic" to her wounds.} Image 8A: She responded to the image as, "A shrub under a tree." {It reflects her strong need for identification with the mother figure which is difficult on her part because of the presence of an emotionally unavailable figure as reported by the child in the initial interview.} Image 4B: She perceived it to be "Two mummies." It reflects her constricted emotionality and possible aggression against her parental figures, with whom identification is difficult on her part. This needs to be taken up in therapeutic sessions to have emotional clarity and consequent smoothness in her personality frame.} Case 8: Pritam, a 10 year old male child, studying in Class IV, having a younger brother, was a child of a sex worker. His response to Image 31B of the SIS-II is strikingly different from the rest of the children as, "Blood inside stomach." It perhaps reflects his deep aggression and hostility against his family members. Internalized aggression appears to be present in the child in much amount. It also denotes pathological anatomy response which hints at his psychopathology. Thus the SIS-II is able to touch upon his inner conflicts and turmoil as a therapeutic "filter". It offers space for such issues to be addressed in therapeutic context later on. SIS II: The therapeutic window of emotionally-withdrawn children 89

Children are inexperienced being having the flairs of variety of primitivities within their sphere. Their immaturity, together with natural hints of conscience, tends to prevent them to express their hidden treasure of unconscious. The task seems difficult to have access to their possible roots of behavior pathologies. Projective windows, either in expressive arts or creative demonstrations or in response modes to projective stimulants are extremely important medium to follow unraveling their unconscious. The case citations with their excerpts of responses on SIS strongly indicates the idea that therapeutic windows are embedded in projective technique design-layouts. Should we peep into these windows to ultimately help the individuals to come out of the shells of their pathology? The answer awaits your nod in the context. References: Bellak, L., and Bellak, S. (1949). Children's Apperception Test. Berkeley, California: C.P.S. Co. 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. 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. 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. 90 Sanyal Joshi, M.C. and Srivastava, S. (1967). A study of hierarchy in defense mechanisms of children through a new CAT (Personal Communication). Mathur, P. (1967). Study of personality differences between the children of working and non-working mothers. (Personal Communication) Mathur, S. and Kumar, B. (1967). A study of delinquents and non-delinquents through C.A.T., Indian Journal of Applied Psychology, 4, 272-275. Rapaport, D. (1950). Theoretical implications of diagnostic testing procedures. In M. Gill, (Ed.), The Collected Papers of David Rapaport. New York: Basic Books, 334-356. 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. Slade, A. (1994). Making meaning and making believe: Their role in the clinical process. In Slade, A., and Wolf, D.P. (Eds.), Children at Play (pp. 81-107). New York: Oxford University Press. 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.

Therapeutic Effectiveness of SIS- II in a Case of Psychogenic Cough LSS Manickam, Mahbobeh Ghanbary and M. Kruthi Psychogenic cough in adults is not commonly reported and the treatment of the medically unexplainable symptom is a challenge to the health professionals. A case of 26 year old married male from Afghanistan, who was having cough for one year duration, diagnosed as psychogenic headache was administered Somatic Inkblot Series (SIS- II). He avoided perceiving sexual responses on images generally depicting sexual imagery, may indicate deep rooted sexual conflict. The SIS responses further helped in planning and providing integrative psychotherapy to him. Follow up of the client after one year showed that he is free of symptoms, has legally migrated to one of the European countries and is effectively engaged in work. There were two responses, which may be typical for Afghans, which needs further exploration. There is a need for revamping the therapeutic supervision of the trainees while dealing with clients who have sexual misconceptions and those who hail from multi-cultural settings. Medically unexplained symptoms are a challenge to the health professionals. One such symptom is the habit cough and has been denoted in the literature by various terms such as psychogenic cough, cough tic, honking cough, and barking cough (Irwin, Globe and Chang, 2006). There are three anatomical sources through which cough can originate: central nervous system, major airways, and pulmonary parenchyma. As reported by Ramanuja and Kelkar (2009) adult cough is divided into acute self-limiting cough (lasting less than 3 weeks), sub-acute cough (lasting 3 to 8 weeks), and chronic cough (lasting longer than 8 weeks). However, in children, the duration of the cough for diagnosing chronic cough is more than 4 weeks, the sub-acute lasts from 2 to 4 weeks and the acute lasts less than 2 weeks. Pavord and Chung, (2008) observed that around 46% of patients with chronic cough seen in secondary care settings have an unexplained symptoms. Psychogenic habit cough is reported mainly in children and adolescents. However, Gay et al (1987) reported four adult cases and Mastrovich and Greenberger (2002) reported two adult cases. Bhatia, et.al. (2002) reported 32 cases from India, both young and adults. Anbar (2007) had used hypnosis as an adjunct for the treatment of habit cough in a child and Anbar and Hall (2004) found self-hypnosis as an effective treatment strategy. Gay et al (1987) opined that L. S. S. Manickam, Ph.D., DMSP, Professor in Clinical Psychology, Dept. of Psychiatry, Mahbobeh Ghanbary, Formerly Psy. Intern, Dept. of Psychiatry, JSS Medical College, JSS University, M G Road, Mysore- 570004 IIndia) Email: lssmanickam@gmail.com and M. Kruthi, Guest Lecturer in Psychology, JSS College of Physiotherapy, M G Road, Mysore- 570004 Keywords: Psychogenic cough, SIS-II, Integrative Psychotherapy, Afghanistan in adults it can be treated with a combination of psychotherapy, relaxation therapy, and speech therapy. Blager, et. al. (1988) successfully used a combination of voice therapy, which had the component of breathing and relaxation techniques with psychotherapy for habit cough. Bhatia, et. al. (2002) found that their patients responded to medication, but only 50% of them showed improvement and 12.5 continued with symptoms at the time they reported the study. However, none of the studies reported the psychodynamics of the adult patients having psychogenic cough. Somatic Inkblot Series (SIS) developed by Wilfred Cassell in 1960 (Cassell, 1980) has been found to be therapeutically effective in medically unexplained symptoms, wherein the dynamics of somatic complaints has been explored (Manickam and Suhany, 2003). Since its inception, SIS test has undergone transformation that led to the development of different series and also adapted modern technology which helps the clinician to administer and use the test in diverse situations effectively (Dubey et al., 2005). An adult person, who presented with psychogenic cough of one year duration and was treated effectively with psychotherapy following administration of SIS-II, is presented in this case study. Case History: Mr. X, 26 year old married man, from Afghanistan came with the complaint of incessant cough of

intermittent nature, which increased in intensity in the night since one year of duration. Prior to his contact with us, he had consulted several physicians in Afghanistan and different hospitals in India. Since his brother was studying at Mysore he consulted the pulmonologist at JSS Medical College Hospital, Mysore . He was investigated thoroughly and the results including that of MRI did not show any 'abnormality' and therefore was referred for psychiatrist's opinion. The psychiatrist diagnosed him as having Somatoform Disorder and referred for psychological management. Mr.X is the fourth among 15 siblings, had studied upto 5th grade and hailed from low socio economic family. At the age of 12, he started to work in the construction sector and later assisted his elder siblings who made their living through their own business. Mr. X reported that his elder brothers were very demanding and therefore he did not like working with them because of their commanding nature. As he grew up, he had has frequently visited Iran, UAE and Turkey in search of employment and was imprisoned several times on the grounds of illegal immigration. Though he reported himself being submissive to his family, he had good relationship with his parents. However, he expressed anger towards his family since they restricted him from moving to Canada for employment. He also expressed feelings of low self-esteem, inferiority and at times ideas of worthlessness. Mr. X had two children who were living with his wife. Administration of SIS-II: One of the authors (LSSM) had previously treated a case with unexplainable medical symptoms using SIS (Manickam and Suhany, 2003) and found that SIS helps in exploring the psychodynamics of difficult to diagnose cases (Manickam et al., 2004). Therefore, the SIS-II Booklet Form was administered by another author (MG) who could speak the language of the patient. The patient has rejected altogether 16 images (A4, A10, A11, A24, A26, B1, B2, B7, B8, B10, B12. B13, B16, B18, B21, B24) which suggest neurotic constriction. He has responded on all images depicting Most Typical responses and perceived 13 MT which indicates his contact with reality, awareness with his problems, marginal ego strength, disturbed interpersonal relationship particularly with females, aggressive and hostile attitude, with free floating anxiety and insecurity. Other significant responses are interpreted below: 92 Manickam et al Table 1 Scoring of SIS Responses Area Images H A2-2, A3, A16-1, A21-1,2, A29, B4-1, B19B-1, 22,B7, B27, B31-1,2 A A2-1, A6-2,A8,A9,A25 At A1,A14,A17,A21-3,A28-2,B3,B4-2,B9,B19,B25 Sex M A5-1,2,A7 MT A12, A20, A30, B5-1,2, B22 T A6-1,A7-2,A15,A16-2,A18,A19,A22,A23,A28-1,A31,B6,B11,B17, B19-2,B20,B23,B29,B30 AT A5-3,A13-2,B6-2, B14, B28 Rejection A4, A10, A11, A24, A26, B1, B2, B7, B8, B10, B12. B13, B16, B18, B21, B24 Images likely to A7, A8,A18,A24,A25,A26,A27,B6,B18,B25,B26 depict Sexual responses

A1: Heart full of blood, something is hitting the heart, may indicate aggressive attitude with depressive contents which needs further probing. A2: (turning the booklet) he gave two normal responses. 1. On the right side is a bear. 2. On the left side is a human figure. A3: "Human body" who were running their own business. "I am not very keen on working with elder brothers in Afganistan because of their commanding nature". This may indicate disturbed interpersonal relationship with his cousins. A5: 1. There is a bird (down) which is trying to fly. Normal response, indicating good mood and ego strength. 2. "On top there is a bird flying" Normal response 3. "Between them, there is a heart" Normal response A6: 1. On the right side "there is a small bear" Normal response 2. On the left side "there is a duck" Normal response A7: "A bird is flying and playing with an apple" He has avoided perceiving dancing woman/ woman in action may indicate conflicting relationship with a woman. His interpersonal relationship with his wife and mother should be explored. A8: "Some bird is inside the water" on this card may indicate sexual connotation to satisfy erotic desire. A9: "Eyes and ears of a cat". Once again the theme of Image A7 is brought back which may further indicate his disturbed interpersonal relationship with opposite sex. A12: "Human ear". Normal response. A13: 1. Picture of tree. Normal response. 2. Behind that, there is a hand which wants to throw something. Normal response. A14: "Scan of the stomach, showing some problem". This may indicate his preoccupation with bodily symptoms generally seen in psychosomatic cases. A15: "Scan of the stomach, the stomach does not have any problem". May suggest his wishful thinking that he has no physical ailments and this may be a sign to good prognosis. A16: 1. Arm of a human being, Normal response. 2. In between there is a heart and inside there is a flute, Normal response. A17: "Scan of the human body and bones". May indicate preoccupation with bodily symptoms. A18: "Around the heart", Normal response. A19: "Intestine", Normal response. A20: "Two kidneys", Normal response. A21: 1. "Two arms of the human body", Normal response. 2. "Two hands", Normal response. 3. "And one heart", Normal response. A22: "Spinal cord" Normal response. A23: "Spinal cord" Normal response. A25: "Tortoise" He has avoided perceiving the female genitalia, a common response on this image may indicate severe conflict with a female. His relationship with his wife must be explored though he has avoided discussing more about his relationship with his wife. Therapeutic Effectiveness of SIS- II 93

A26: "Rejected" Fetus is a common response on this image and rejection may indicate traumatic experience due to aborted fetus which must be explored during therapy session. Afghans are known to have many children but the patient has only two children. A27: "Stone is falling down from the mountain" He has avoided seeing "breast" which is most common response on this image. This may further indicate deep rooted conflict and deprivation of mother's affection and the conflicting relationship with wife. A28: "Thigh and the bone may be broken" Body anxiety and depressive content is brought on the surface through this image. A29: "Lady is sitting and praying" this may indicate the kind of spiritual help people seek when they feel nothing is helping to control their sufferings. Such symbols are found to be very effective in healing process. The lady may symbolize his wife and praying might be spiritual healing. A30: "Skull" Normal response. A31: "Two human beings, but I cannot determine whether it is male or female" may indicate poor relationship with his wife. B3: "Part of the stomach in scan", may suggest preoccupation with bodily symptoms. B4: 1. "Two human beings". Normal response. 2. "The humans on the right has a problem in right ear", may indicate preoccupation with bodily symptoms. B5: 1. "Two seated human beings talking to each other". Normal response 2. "The human on the left has a radio". Normal response B6: "Hip of the human, wearing underwear", may be sexual connotation and imagery of erotic area. B9: "Lungs which has some problem", may indicate preoccupation with body problems. B11: Shepherd's jacket' Clinically not significant. B14: "Heart" Normal response B15: "There is a nail, saw and one tree from which something could be made", is a Normal response B17: "Heart" is a Normal response B18: "Rejected" Normally the image is perceived as male phallic organ and avoiding seeing it may indicate sexual deprivation or severe conflict in sexual area. B19: "A chest and two hearts on either side". Normal response B20: "Brain" Normal response. B21: "Rejected" Not significant B22: "Water is falling on the sleeping body". Seems like a normal response, though water falling on body may connote to erotic pleasure. B25: "A hole in the heart". Is a depressive response, may also indicate deprived love relationship. B26: "Axe" may indicate his aggressive attitude. B27: "The person looks like a cartoon figure". Avoidance of perceiving a child may indicate traumatic suffering during childhood. B28: "Lady with hands tied" may suggest the sufferings of his mother during childhood, which he has witnessed, should be explored during therapy session. The 94 Manickam et al

childhood trauma might also lead to aggressive behavior towards his wife which may deteriorate their healthy relationship. B29: "A person is running because he has urgent work or he is doing exercise" is normal response. B30: "A tray which looks like heart and on that there are dry fruits". Clinically not significant B31: "Four humans, two adults and two children", is a Normal response. Since there was suppression of sexual responses, both in the typical responses as well as the sexually related images, it was fed back to him- that there could be sexual disturbances in him. Following the breaking of the resistance barrier, he narrated his sexual history and sexual conflicts. Mr. X reported having nocturnal emission since 12 years and premature ejaculation since 7 years. He recalled having nocturnal emission for the first time at the age of 14 while he was in prison in UAE and its frequency increased when he was away from home. He reported occasionally having 2-3 'wet dreams' on a single night during cold weather and on the same night that he indulges in sexual intercourse. At the age of 15, Mr. X had sex with a man, and following that he indulged in masturbation. At the age of 19, Mr. X married a girl of 15 years. In the initial stage of their marriage, his wife often complained about his premature ejaculation and expressed sexual dissatisfaction. Response to Integrative Psychotherapy: The client was provided with integrative psychotherapy. Following the administration of SIS-II and his narration of sexual experiences, there was dramatic reduction in his symptom. He was discharged after 4 days of admission and but he regularly attended psychotherapy sessions at the hospital, though there was complete remission of his symptoms. After the evaluation and providing opportunity for the ventilation of the sexual problems, he was taught Jacobson's muscular relaxation in order to bring down the level of his anxiety. Following that sexual reeducation was provided. During therapy session, he narrated several misconceptions about loss of semen, which will lead to weakness, fatigue, back ache and poor eye sight. Similar findings were observed by patients with "semen loss" (dhat syndrome) in India (Dubey, 1977, Omprakash, 2007) and Pakistan (Khan, 2008). A cognitive approach was later taken to focus on his interpersonal problem with his spouse as well as family members including his elder brothers, with who he had severe conflicts. Another issue that was taken up was his repeated illegal migrating behavior to neighboring countries and subsequent imprisonment. The need to respect the law of each land during migration, the advantages of legal migration, its impact on improving his self-esteem and the freedom that he could enjoy was also taken up. Though he had physical symptoms, based on the integrative change model, an exploration of spiritual dimension, including guilt associated with sex and illegal migration was done so that appropriate therapy for affected dimension could be planned ( Manickam, 2013). Discussion: The suppression of sex responses on sex images of SIS-II appears to be 'definitive psychopathological indicator' of sexual conflicts. Pandey et.al, (2003) observed that due to the taboo related to the sex images, normal subjects volitionally reject non-sex images as a means of defense. The clinical popualation may employ the strategy of repression and in such an event they will fully compensate sex response with some other response. However, due to the inner disturbances related to sexual conflicts one might suppress the sex responses and go to the extent of rejecting more images in order to keep the ego boundaries intact. Therapeutic Effectiveness of SIS- II 95

Two of the responses of the client, 'Shepherd's jacket' (Image B11) and 'A tray which looks like heart and on that there are dry fruits' (Image B30), was evaluated by an expert in SIS, who was blind to the nationality and the problems of the client and he opined that these responses are clinically non-significant (B.L.Dubey, personal communication, November 12, 2012). However, one of the authors who hailed from the same region as that of the client observed that the two responses could be 'typical responses' for Afghans. The response 'shepherd jacket' looked similar to the one commonly used by the shepherds in Afghanistan and the response, 'A tray which looks like heart and on that there are dry fruits' corresponded to a common custom, that is observed in Afghanistan. Therefore, the responses may turn out to be 'Typical' responses for the people of 'Persian culture', if the test is administered to a larger sample of Afghans. The present case had a sudden relief of his symptoms following the ventilation of his problems. Probably the opportunity provided to let out his 'inner cry' through SIS could be one of the reasons. In countries where people tend to somatize their psychological distress, SIS may prove to be a better tool in understanding the psychopathology and act as a 'therapeutic window'. The patient was seen in 8 sessions and during the sessions the sexual reeducation was provided by one of the authors. The trainee who was providing the information initially showed resistance and said, "Sir, what is there to correct in what he is saying? If he has to be corrected, all my friends will have to be reeducated regarding sexual functions". Since the trainee was initially sharing the same concepts held by the client, the supervisor asked the trainee to literally translate the information provided by the supervisor. The fact that the trainees themselves are not possessing accurate scientific information related to sexual functions, is an eye opening one. The trainees cannot be taken for granted about the information they possess irrespective of their education and marital status. It also sheds light on the need for direct supervision of observing the trainees while they are conducting the therapy sessions or to make it mandatory for the trainees to provide video recorded session for supervision. The issue gets more complicated as in the present case, where the supervisor does not know the language of the client and finds it difficult to communicate effectively. Conclusions: Medically unexplained symptoms that pose challenge to health professionals may be well understood using SIS- II and its help in unraveling the psychopathology. As reported earlier, SIS- II may turn out to be providing a 'therapeutic window' to persons with psychogenic somatic symptoms. Providing integrative psychotherapy that addresses the different dimensions of the clients may help hasten the healing process. There is a need for relooking the supervisory process since the trainee therapists may not be possess adequate level of knowledge and competence in helping those clients with sexual mis-concepts and problems. This case study also points to the need for developing the normal response for the Afghan population. Acknowledgement: The authors wish to acknowledge their gratitude to Dr.T.S.S.Rao, Professor and Head, and Dr. Bindu Annigere, Tutor, Depat. of psychiatry for their support and to Dr. B.L.Dubey for his valuable assistance in interpreting SIS responses. Reference: Anbar, R.D. and Hall, H.R. (2004). Childhood habit cough treated with self-hypnosis. Journal of Pediatrics, 144, 213-217. Anbar, R.D. (2007). User friendly hypnosis as an adjunct for treatment of habit cough: a case report, The American Journal of Clinical Hypnosis, 50, 171-5. Bhatia, M.S., Chandra, R. and Vaid.L., (2002). Psychogenic cough: a profile of 32 cases. International Journal of Psychiatry Medicine, 32,353-360. 96 Manickam et al

Therapeutic Effectiveness of SIS- II 97 Blager, F.B., Gay, M.L. and Wood, R.P. (1988).Voice therapy techniques adapted to treatment of habit cough: a pilot study. Journal of Communication Disorders, 21: 393- 400. Cassel, W.A. (1980). Body Symbolism and the Somatic Inkblot Series. Alaska. Aurora Publishing co. Anchorage, USA. Dubey, B.L., Cassell, W. A., Manickam, L.S.S. and Singh., A. R. (2005). Efficacy of Somatic Inkblot Test in personality assessment, diagnostic evaluation and therapeutic intervention. Indian Journal of Clinical Psychology, 31, 10 -23. Dubey, B. L. (1977) Rorschach analysis of impotence cases and their response to psychotherapy. Indian Journal of Clinical Psychology, 4: 145-149. Gay, M., Blager, F., Bartsch, K., Emery, C. F., Rosenstiel- Gross, A.K., and Spears, J. (1987). Psychogenic habit cough: review and case reports. Journal of Clinical Psychiatry, 48, 483- 486. Ghanizadeh, A. and Firoozabadi,A. (2012). A review of somatoform disorders in DSM-IV and somatic symptom disorders in proposed DSM-V.PsychiatriaDanubina, 24, 353-358. Irwin, R.S., Glomb, W.B. and Chang, A.B. (2006). Habit cough, tic cough, and psycho- genic cough in adult and pediatric populations: ACCP evidence-based clinical practice guidelines. Chest, 129, 174S-179S. Khan, N. (2008) Dhat Syndrome: Physical and Psychological Implications. Unpublished Doctoral Thesis Submitted to University of Health Sciences, Lahore, Pakistan. Lorcan, P.A., McGarvey, C. C., Lucy, A. G., Liam, G. H., Richard, S., Madeline, E and Joseph, M. Prevalence of psychomorbidity among patients with chronic cough. Cough. 2: 4.doi:10.1186/1745-9974-2-4 Manickam L.S.S. (2013). Integrative change model in psychotherapy: Perspectives from Indian thought. Indian Journal of Psychiatry,55:322-328. http://www. indianjpsychiatry.org/text.asp?2013/55/6/322/105558 Manickam, L.S.S. and Suhany B.T. (2003). Psychotherapeutic Usefulness of SIS-II in a Male Client with Somatoform Disorder: Case Illustration. SIS Journal of Projective Psychology and Mental Health, 10,2,209-218. Manickam, L.S.S. Suhany B.T. and Jasseer, J. (2004). Psychotherapy of a Male Patient with Dissociative Convulsive Disorder: SIS Breaks the Resistance. SIS Journal of Projective Psychology and Mental Health, 11,36-44. Mastrovich, J.D. and Greenberger, P.A. (2002). Psychogenic cough in adults: a report of two cases and review of the literature. Allergy and Asthma Proceedings, 23, 27-33. 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 Health,10, 205-208. Pavord, I.D. and Chung, K.F. ( 2008). Management of chronic cough.Lancet, 371,1375-1384. Prakash O. (2007) Lessons for postgraduate trainees about Dhat syndrome. Indian journal of psychiatry, 2007, 49:208-10 Ramanuja, S. and Kelkar, P. (2009).Habit cough. Annals of Allergy, Asthma & Immunology,102, 2 , 91-95.

Personality Characteristic of Juvenile Delinquents as Compared to Non-Delinquents on Rorschach Test Shweta Sharma, Deapti Mishra and Ranjeet Kumar The incidence of Juvenile delinquency is increasing internationally. Various psychological, social and environmental factors are playing vital role in its development. The present study aims to find out the personality characteristics of juvenile delinquents as compared to non-delinquents on Rorschach Inkblot test. The sample consisted of 30 male delinquents from "Bal-Sampreshan Grah" and 30 non-delinquents from general Higher Secondary Schools, Raipur (Chhattisgarh).The findings revealed that both the groups differed significantly on W, Dd, FQ-, DQ+, DQV, M, Passive Movement p, Human Movement Passive, H, Hd, Ad, Hh, Experience Stimulation (es), Adjusted es, X-%, X+%, Zf, Interpersonal interest- Human content, and Total number of blends on Rorschach test. Reports of various researches and surveys show an increase in delinquent behavior of the children/ adolescents aged 14-20 years. On the basis of data compiled by National Crime Records Bureau, Government of India (1998) it was found that the delinquency rates are almost double for boys than girls (13% : 7 %). It is highest during early adolescence (12-16 years age group), though in an earlier report it was it was found highest (71%) in the age group of 18-21 years (late adolescence). It was further noted that Juvenile delinquency is more an urban than a rural phenomenon. The metropolitan cities like Delhi, Mumbai, Chennai, Calcutta, Ahmadabad, Hyderabad and Bangalore reported more juvenile delinquents than small cities and towns. Children living with parents and guardians are found to be more involved in the juvenile crimes. Only 5% juveniles were found to be homeless. This shows the role of faulty family environment in the development of juvenile delinquency. Low educational background (38% illiterate) was found to be the prime attribute of delinquency. Poor economic background is another important factor leading to juvenile delinquency. Almost all studies conducted in India on juvenile delinquency and its relation to the socioeconomic order show that majority of Juvenile delinquents belong to the bottom socioeconomic strata (NCRB, 1998). Various psychological, social and environmental factors may play vital role in the development and Shweta Sharma, M. Phil (M & SP), Deapti Mishra, Ph.D., M .Phil (M & SP), Associate Professor of Clinical Psychology, Post Graduate Institute of Behavioural and Medical Sciences, Raipur, Email: medsam11@yahoo.in(Corresponding Author) and Ranjeet Kumar, Ph.D., M. Phil (M & SP), Asst. Professor of Clinical Psychology, Gwalior Mansik Arogyashala, Gwalior (India) Key words: Juvenile delinquency, personality characteristics, Rorschach Inkblot test maintenance of juvenile delinquency. Among these, personality plays an important role. In many ways, the assumptions of general personality approach to delinquency are similar to those of psychoanalysis. The personality trait approach assumes that delinquency is a manifestation of underlying conflicts within the individual's psychological framework. It is regarded as symptomatic of underlying character problems and defects in ego structures, which manifest themselves in low frustration and anxiety tolerance, incapacity to regulate affective fluctuations, impaired impulse control, and disturbances in reality perception (Blos, 1963; Kaufman and Helms, 1958; Redl and Wineman, 1951; Eissler, 1949; Friedlander, 1945). Adolescents' antisocial behaviours reflect a defence against a regressive wish for passivity, against feelings of helplessness, and against the threat of object loss which has been proposed by Blos (1963). Other theorists (Chwast, 1967; Burke and Harrison, 1962; Rubin, 1957) also consider delinquency as an attempt to evade underlying feelings of depression and passivity. In a similar approach, it is assumed that the genesis of one's personality is in childhood (Masterson, 1972), although some of the proponents of this approach recognize the influence of ongoing life experiences in the development of personality characteristics. Another assumption is that a specific trait, or

coherent set of traits, characterizes a person's general outlook on life and consequently his or her overall behavior. Finally, it is assumed that a "negative" consequence, such as delinquency, must be preceded by a "negative" cause. It is assumed that negative or abnormal personality traits act in a general way to produce delinquency (Shoemaker, 2000). Many projective and non-projective psychological tests have been systematically administered on delinquents to find out crucial personality factors facilitating towards the development of a delinquent-orientation. Contrary to the expectations, the personality patterns of delinquents have not differed markedly from nondelinquents on a variety of psychometric instruments (Deri, 1954; Monachesi, 1950; Young, 1956). Recent studies have demonstrated the effectiveness of the Rorschach test in assessing psychopathology in adult samples, but very few studies are available on younger samples (Janson and Stattin, 2003). The present study is planned to find out Rorschach variables discriminating Juvenile delinquents from Non- Juvenile delinquents. Methodology: Sample: The sample consisted of 30 male delinquents from "Bal-SampreshanGrah", Mana camp, Raipur and 30 non-delinquents from "Govt. Higher Secondary School", Manabasti, and "Shivom Vidhyapith", Raipur, (India) in the age range of 12 to 18 years. Procedure: After taking consent for the study from concerned authorities, personal information was collected from the delinquent subjects on a socio-demographic data sheet, followed by individual administration of Rorschach Inkblot test. Non-delinquent adolescents were initially screened to rule out psychiatric problems with the help of PGI Health Questionnaire (Verma et.al., 1985). The socio-demographic details were noted and Rorschach test was administered individually following Exner's (2003) method of administration, scoring and interpretation. Results thus obtained were analysed using statistical package for social sciences [SPSS, 11.5 version].Descriptive statistics and student's t test were used wherever necessary to analyse the findings. Results and Discussion: The number of juvenile delinquents is increasing rapidly and there is a need to look into the factors leading to it. The present study was conducted in order to find out the personality characteristics of juvenile delinquents with the help of Rorschach Inkblot test. The findings indicate that the mean age of the delinquents was 16.20 yrs. and nondelinquents was 16.5 yrs. Most of the crimes were committed at age 14.84 yrs. Maximum numbers of juvenile delinquents were involved in murder and attempt to murder (56%), rape and stealing (15% each) and illegal keeping/ supplying of arms (10%). Most of them were literate. No significant differences were found in the type of family [nuclear and joint] between the two groups. Majority in both groups were on the lower side of socio-economic status. There were no significant differences in the total number of responses of both groups. In location categories of the Rorschach Inkblot Series, W and Dd were able to discriminate the groups significantly. W is related to the degree to which a person can interact in an efficient and active manner with his environment. It suggests that non-delinquents have better ability to organize and integrate their environment. Low W responses in delinquents reflected maladjustment (Exner, 1974). Delinquents scored significantly higher on unusual detail (Dd) responses, which reflected a need to pull back from the ambiguities that may be contained in a whole response. It represents a retreat from a person's environment by focusing on details rather than either perceiving the whole situation or noticing the more obvious elements of the environment. Personality Characteristic of Juvenile Delinquents 99

Developmental quality relates to a person's relative ability to analyse and synthesize information. Juvenile delinquents gave higher DQ+ as compared to non-delinquents. A high DQ+ is consistent with more intelligent, complex, and sophisticated persons. However, this greater complexity does not necessarily mean that the person is well adjusted or even that his or her cognitions are accurate (Exner,1993; 2003). Moreover, most of the DQ+ responses had poor form quality. It frequently appears in records of seriously disturbed subjects (Exner, 1986). Though juvenile delinquents scored significantly higher than nondelinquents on DQ-V, the mean (1.80) was within the normal range for adolescents. Higher number of blends in delinquents as compared to nondelinquents also suggested an unusual amount of complexity, to the extent that the person may be overly burdened [Exner, 1993; 2003] 100 Sharma et al A relatively high number of M responses among delinquents in this study suggested that they are overly interested in their fantasy life. In the present study, movement responses were distinctly weighted in M direction when compared to colour indicating that juvenile delinquents were more prone to use their inner life for basic gratifications. Such persons may be Table 2 Comparison of FQ & DQ Responses in Juvenile Delinquents & Non-Delinquents Variables Groups t-test JD [N-30] ND [N-30] Mean SD Mean SD FQ + 0.00 0.00 0.00 0.00 t can't be computed FQ O 6.25 4.74 7.60 3.18 1.05 FQ u 9.55 6.59 8.45 7.15 0.50 FQ - 15.20 12.27 8.40 6.54 2.18* DQ + 4.10 4.17 1.30 1.68 2.77** DQ O 25.05 12.18 21.30 15.65 0.84 DQ V/+ 0.00 0.00 0.00 0.00 t can't be computed DQ V 1.80 2.28 0.65 1.13 2.01* Table 1 Comparison of Total Number of Response & Locations in Juvenile Delinquents & Non Delinquents Variables Groups t-test JD [N-30] ND [N-30] Mean SD Mean SD Total no. of responses [R] 31.00 14.92 24.35 14.76 1.417 Whole [W] 2.55 2.78 5.45 4.40 2.48* Detailed [D] 9.80 6.32 9.40 5.72 0.21 Minor detail [Dd] 17.30 13.67 9.25 11.95 1.98* Space [S] 0.55 1.05 0.35 0.74 0.69 *p=<0.01 *p<0.01, **p<0.05, DQ=Developmental quality, FQ= Form quality

outgoing in social relations but internally, are prone to use their inner life for the satisfaction of their important needs (Exner, 1986). As compared to non-delinquents, quality of M was poor in juvenile delinquents. Weiner (1982) has suggested that more M responses may be related to deficient social skills and poor interpersonal relationships. Active-passive ratio relates to the features of cognitive flexibility versus narrowness or constriction. Findings of this study showed that as compared to nondelinquents, delinquents gave more active as well as passive responses, the latter being significantly more (p<0.05) as juvenile delinquents have comparatively more movement responses on the whole. Within group juvenile delinquents gave more active responses than passive responses. Exner (1974) also found more active movement responses in the records of acute schizophrenics, subjects with a history of assaultiveness and a group of character disorders Personality Characteristic of Juvenile Delinquents 101 *p<0.01 Table 3 Comparison of Determinants in Juvenile Delinquents & Non Delinquents Variables Groups t-test JD [N-30] ND [N-30] Mean SD Mean SD Form - F 24.80 12.92 20.60 13.15 1.01 Human movement - M 4.35 7.61 0.65 0.98 2.15* Animal movement - FM 2.10 2.31 1.50 1.96 0.88 Inanimate movement - m 0.25 0.55 0.05 0.22 1.50 Pure color - C 0.75 1.06 0.40 0.82 1.16 Color form - CF 0.60 0.75 0.60 1.04 0.00 Form color - FC 0.80 0.83 0.65 0.87 0.55 Pure achromatic - C' 0.40 0.99 0.10 0.30 1.28 Color achromatic - C'F 0.05 0.22 0.00 0.00 1.00 Form achromatic - FC' 0.10 0.30 0.15 0.48 0.38 Pure texture - T 0.30 0.47 0.10 0.30 1.59 Texture form - TF 0.00 0.00 0.05 0.22 1.00 Form texture - FT 1.85 2.88 0.80 1.43 1.45 Pure vista - V 0.05 0.22 0.00 0.00 1.00 Vista form - VF 0.00 0.00 0.05 0.22 1.00 Form vista - FV 0.10 0.30 0.05 0.22 0.58 Pure shading - Y 0.15 0.36 0.10 0.30 0.46 Shading form - YF 0.10 0.30 0.05 0.22 0.58 Form shading - FY 0.45 0.68 0.20 0.69 1.14

A variety of content categories are generally considered to contain information relating to a person's needs, preoccupations, and social interactions, but in the present study, the focus of both groups was on 3-4 content categories only. Presence of significantly more Human content responses in this study is in contrast with earlier studies on criminals (Walters, 1953), adjudicated delinquents (Ray, 1963; Richardson, 1963) and in adolescents awaiting sentence for serious assaults crimes (Exner et al, 1975).The reason might be that many juvenile delinquents in this study were institutionalised for long and 102 Sharma et al were about to be discharged. Although human responses were found more in juvenile delinquents most of them had poor form quality (fq-) and poor human responses signifying that they have interpersonal difficulties, are socially inept and they are interpersonally ineffective (Exner,2003). Ratio of H+(H):Hd+(Hd) should be 1:3 but in the present study it is 1:1 which indicates "paranoid style" (Exner and Hillman, 1984). More Hd responses are common among people who are more guarded and suspicious in their views of social environment and there is possibility that the social environment is often misinterpreted (H+A:Hd+Ad=>3). Table 4 Comparison of Content in Juvenile Delinquents & Non Delinquents Variables Groups t-test JD [N-30] ND [N-30] Mean SD Mean SD Whole human-H 5.40 3.08 2.30 2.43 3.53** Fictional human-[H] 0.20 0.69 0.05 0.22 0.91 Human detail-Hd 5.60 5.18 1.25 1.91 3.15* Fictional human detail-[Hd] 0.05 0.22 0.10 0.30 0.58 Human experience-Hx 0.20 0.52 0.00 0.00 1.71 Whole animal-A 9.50 6.67 10.05 4.90 0.29 Fictional animal-[A] 0.00 0.00 0.05 0.22 1.00 Animal detail-Ad 0.55 1.43 2.60 5.08 1.73* Fictional animal detail-[Ad] 0.05 0.22 0.00 0.00 1.00 Anatomy-An 1.15 1.38 2.05 1.79 1.77 Art 0.05 0.22 0.20 0.52 1.17 Anthropology-Ay 0.15 0.48 0.50 1.10 1.30 Blood-Bl 0.25 0.71 0.05 0.22 1.19 Botany-Bt 0.70 1.03 0.90 1.29 0.54 Clothing-Cg 0.70 1.38 0.20 0.41 1.55 Clouds-Cl 0.25 0.63 0.30 0.57 0.26 Explosion-Ex 0.10 0.30 0.05 0.22 0.58 Fire-Fi 0.10 0.30 0.20 0.41 0.87 Food-Fd 0.00 0.00 0.10 0.30 1.45 Geography-Ge 0.20 0.69 0.15 0.48 0.26 Household-Hh 0.05 0.22 0.40 0.59 2.45* Landscape-Ls 1.30 2.12 0.70 0.86 1.16 Nature-Na 0.95 1.60 0.30 0.65 1.67 Science-Sc 4.40 13.72 1.20 1.19 1.03 Sex-Sx 0.70 2.27 0.00 0.00 t not computed X-Ray-Xy 0.00 0.00 0.05 0.22 1.00 Idiography- Id 0.10 0.30 0.75 2.89 0.99 *p<0.01, **p<0.05

Personality Characteristic of Juvenile Delinquents 103 Juvenile delinquents have scored high on X-% and low on X+%, indicating that they were having some difficulty in translating perceptual inputs appropriately or accurately. Comparatively less number of X+% also supports that juvenile delinquent persons tend to perceive things in a less conventional and realistic manner. Thus it is evident that in juvenile delinquents, the magnitude of impairment was considerable, leading to greater probability of inappropriate behaviour. Experienced stimulation [es] and adjusted [es] were higher in delinquents as compared to non-delinquents which also reflected their disorganized functioning as well as their helplessness. They have a low frustration tolerance and it is difficult for them to be persistent, even in meaningful tasks (Exner, 1978; 1986). Table 6 Comparison of Core Section in Juvenile Delinquents & Non Delinquents Variables Groups t-test JD [N-30] ND [N-30] Mean SD Mean SD Lambda- L 1.95 1.10 1.50 1.96 1.90 Experience actual- EA 6.75 7.71 5.45 4.40 1.66 Experience stimulation- es 5.70 4.71 3.00 3.29 2.10* D Score 0.15 1.92 0.15 0.48 0.67 Adjusted es 4.90 4.07 2.65 2.94 2.00* Adjusted D Score 0.30 1.86 0.05 0.60 0.79 *p<0.01 **p<0.05 Table 7 Comparison of Mediation Section in Juvenile Delinquents & Non Delinquents Variables Groups t-test JD [N-30] ND [N-30] Mean SD Mean SD XA % 0.88 1.69 0.65 0.10 0.59 WDA % 0.68 0.39 0.72 0.13 0.43 X- % 0.49 0.23 0.33 0.10 2.17* X+ % 0.20 0.13 0.33 0.13 3.14** Xu % 0.30 0.13 0.32 0.12 0.53 *p<0.01, **p<0.05 Table 5 Comparison of Ideation Section in Juvenile Delinquents & Non-Delinquents Variables Groups t-test JD [N-30] ND [N-30] Mean SD Mean SD Active movement- a 3.80 5.95 1.60 1.90 1.57 Passive movement-p 2.90 2.91 0.55 1.09 3.37** Human movement active 2.35 5.80 0.40 0.75 1.48 Human movement passive 2.00 2.65 0.25 0.55 2.88** Intellectualization index 0.20 0.52 0.70 1.49 1.41

Table 8 Comparison of other Sections in Juvenile Delinquents & Non Delinquents Variables Groups t-test JD [N-30] ND [N-30] Mean SD Mean SD Frequency of Z-score- Zf 2.45 2.87 6.40 4.32 3.40** Processing efficiency- Zd -0.72 2.75 2.72 4.54 1.68 Interpersonal interest- Human cont. 11.50 5.45 3.35 2.66 6.00*** Isolation index- Isolate/R 0.16 0.14 0.11 0.12 0.97 Ego Centricity index- 3r+(2)/R 0.16 0.13 0.28 0.44 1.15 Affective ratio- Afr 0.46 0.25 0.42 0.15 0.55 Total number of blends 3.60 2.94 1.25 2.26 2.82** **p<0.05 level, ***p< 0.001 level 104 Sharma et al It is evident from this discussion that juvenile delinquents have some specific personality correlates. The findings further revealed that both the groups can be significantly differentiated on W, Dd, FQ-, DQ+, DQV, M, Passive Movement p, Human Movement Passive, H, Hd, Ad, Hh, Experience Stimulation (es), Adjusted es, X-%, X+%, Zf, Interpersonal interest- Human content and total number of blends on Rorschach inkblots test. Thus, the study pinpoints the penetrative and diagnostic capacity of the Rorschach Inkblot Test in differentiating delinquents from their normal counterparts. It also highlights the uniqueness of this special group of children, namely, delinquents as far as their personality make-up is concerned, which makes them apart from their matched normal partners. This necessarily segregates them from the mass, such that rehabilitative strategies may be implemented in future to enable overall personality development of this special group of individuals from humanitarian and societal points of view. Acknowledgement: We sincerely thank the authorities and inmates of "Bal-SampreshanGrah", Mana camp, Govt. Higher Secondary School", Manabasti, and "ShivomVidhyapith", Raipur, for their kind cooperation. References: Blos, P. (1963). The concept of acting-out in relation to the adolescent process. Journal of American Academy of Child Psychiatry.2: 18-136. Burke, H. L., and Harrison, S. L. (1962). Aggressive behavior as a means of avoiding depression. American Journal of Orthopsychiatry, 32: 416-422. Chwast, J. (1967). Depressive reaction as manifested among adolescent delinquents. American Journal of Psychotherapy, 21: 575-584. Deri, S. K. (1954). Differential diagnosis of delinquents with the Szondi test. Journal of Projective Techniques, 18: 33-41. Eissler, K. R. (ed.) (1949). Searchlights on Delinquency, New York: International Universities Press Exner, J. E. (1974). The Rorschach: A Comprehensive System.Vol.1.New York: Wiley. Exner, J. E. (1978). The Rorschach: A Comprehensive System. Current research and advanced interpretations. Vol. 2. New York: Wiley. Exner, J. E. (1986). The Rorschach: A Comprehensive System. Basic Foundations (2nded.).New York: Wiley. Exner, J. E. (1993). The Rorschach: A Comprehensive System. Basic Foundations (3rded.). New York: Wiley. Exner, J. E. (2003). The Rorschach: A Comprehensive System. Basic Foundations (4th ed.). New York: Wiley. Exner, J. E., and Hillman, L. (1984). A Comparison of content distributions for the records of paranoid schizophrenics and nonparanoid

Personality Characteristic of Juvenile Delinquents 105 schizophrenics.(Unpublished), Rorschach Workshops (293). In: Basic Foundations (2nd ed.) .New York: Wiley. Exner, J.E., Bryant, E.L., and Miller, A.S. (1975). Rorschach responses of some juvenile offenders. (Unpublished), Rorschach Workshops (214) In: Basic Foundations (2nded.). New York: Wiley. Friedlander, K. (1945). The formation of the anti-social character. Psychoanalytic Study of the Child 1: 189- 203. Janson H. and Stattin, H. (2003). Prediction of adolescent and adult delinquency from childhood Rorschach ratings. Journal of Personality Assessment, 81 (1): 51- 63. Kaufman, I., and Helms, L. (1958). The body image of the juvenile delinquent. American Journal of Orthopsychiatry. 28: 146-159. Masterson, J. F. (1972). Treatment of the Borderline Adolescent: A Developmental Approach, Wiley, New York. Monachesi, E. D. (1950). Personality characteristics of institutionalized and non-institutionalized male delinquents. Journal of Criminal Law & Criminology.41: 167-179. National Crime Records Bureau (NCRB) Government of India (1998). Survey on Juvenile Delinquency. Ray, A.B. (1963). Juvenile delinquency by Rorschach inkblots. Psychologia,6,190-192. Redl, F. and Wineman, D. (1951) Children Who Hate, Free Press-Macmillan, New York. Richardson, H. (1963). Rorschach of adolescent approved school girls, compared with Ames normal adolescents. Rorschach Newsletter, 8, 3-8. Rubin, M. (1957) Delinquency, a defense against loss of objects and reality. Psychoanalytic Study of the Child, 12: 335-355. Shoemaker, D.J. (2000). Theories of delinquency: an examination of explanations of delinquent behaviour (4thed.). New York: Oxford University. Verma,S.K., Wig, N.N., and Pershad, D. (1985). PGI Health Questionnaire N-1. National Psychological Corporation: Agra Walters, R.H. (1953). A Preliminary analysis of the Rorschach records of fifty prison inmates. Journal of Projective Techniques,17, 436-446. Weiner, I.B. (1982). Conceptual and empirical perspectives on the Rorschach assessment of psychopathology. Journal of Personality Assessment, 62,498-504. Young, F. (1956). Responses of juvenile delinquents to the TAT. Journal of Genetic Psychology, 88: 251.

Does Psychotherapy Benefit Pre and Post-operative Anxiety in Eye Diseases? Daniel Saldanha,Vivek Goel, Anuja Kelkar, Arpita Karmakar,Preethi Menon, Kavita Bhatnagar, S.L. Jadav and Labanya Bhattacharya Patients about to undergo surgery are often anxious. The fear of impending surgery on an important organ such as eye involves considerable anxiety as complications often result in infection and blindness. Long term psychological problems may follow surgical interventions. Does early psychotherapy and psychoactive drugs do benefit these cases? The study attempts to answer some of these questions. It is a matter of everyday observation that patients about to undergo surgical procedures for any disorder are often anxious and it is the duty of the attending physician to decrease their fears of having the surgical operation. Many investigators have looked for relationships between psychological state before surgery and postoperative psychological state or during recovery (Liu et al 1994, Padmanabhan, et al 2005, Rosen, et al 2008, Haugen et al, 2009). Anxiety as such is not new as it is commonly experienced by all of us in various situations. Anxiety is an alerting signal; it warns us of impending threat, external or internal, and is sometimes life-saving. Pathological anxiety, on the other hand, is an inappropriate response to a given stimulus by virtue of either its intensity or duration. (Benjamin and Virginia, 2007).The incidence of pre-operative anxiety in surgical cases have been noted as high as 51.8% and successful operative procedure reduces this anxiety considerably (Saldanha, 2002).It was also observed in this study that psychotherapy along with psychoactive drugs together reduces anxiety by 23.92% of the cases. Other investigators too, have reported managing anxiety in elective and emergency surgical patients (Karanci and Dirik, 2003, Carr et al., 2006, Pritchard 2009).This being the case, the fear of impending surgery on a sensitive and important organ such as the eye tends to evolve considerable anxiety in the patient population (Thomas et al, 1989, Biswas, et al, 1999, Mokashi et al, 2004, Heather et al, 2010). Surgery on the eye has inherent multiple problems. Complications may result in blindness. Long-term Brig. Daniel Saldanha, B.Sc., M.D. (Psychiatry),Professor, Preethi Menon, MSc (Psychol), MD (Psy)Asst.Professor, Vivek Goyal, MBBS, Anuja Kelkar, MD and Arpita Karmakar, MBBS Residents in Psychiatry, Kavita Bhatnagar, MD, Professor ophthalmology, Jadav, S.L,MD,Professor Community Medicine, Bhattacharya, L.,M.D., D.P.M., Professor and HOD Psych, at Padmashree Dr D.Y. Patil Medical College and Research Centre, Deemed University, Pimpri, Pune-411018 (Correspondence: Brig. Daniel Saldanha, Email: saldanhavalsa@gmail.com) Key words: Pre and Post-operative Anxiety, Psychotherapy, Psychoactive drugs psychological complications may follow eye surgery. It is in this respect that a study was planned to understand and document the anxiety status prevalent among the population and whether psychotherapy would benefit such cases. Material and Method: The study included 100 cases in the age group of 18-80 years with eye problems requiring surgery, who were admitted to a semi-urban tertiary care hospital from Jul 2011 to April 2012. Those who were already under psychotropic medication were excluded. They were evaluated on Hamilton's Anxiety Scale within 72 hours of admission (before the surgical intervention), after the eye surgery and before discharge from the hospital. The Hamilton's Anxiety Scale quantifies the severity of anxiety symptomatology that is often used in psychotropic drug evaluation. When the scale is used repeatedly for the same person at intervals, the individual assessment should be independent of the other. As far as possible one should avoid asking about changes since the last interview; rather the patient should be asked to describe the condition during the interval that has just passed. It consists of 14 items, each defined by a series of symptoms. Each item is rated on 4 point scale, ranging from 0 (not present) to 4 (severe) (Hamilton 1959, Chaudhury et al, 2004).The patients were grouped into those with Cataract and Non-Cataract problems. Results: One hundred cases with eye problems who were taken for study were grouped into Cataract and

Non cataract groups. Non-cataract group included Dacrocystitis, Pterygium, Glaucoma and Astigmatism. A majority of them (86%) were for cataract surgery. Though cataract surgery is an out-patient procedure, the authors admitted them particularly for the study to understand the real nature of the anxiety prevailing in these types of patients. Table 1 shows that the majority in the cataract group 63% had mild anxiety and 22% of them had moderate to severe anxiety. The anxiety levels had reduced following surgery as evident from the following table. Psychotherapy benefit in pre and post-operative anxiety 107 In the non-cataract group, out of 14 patients, only 3 patients had moderate to severe anxiety levels which resolved following surgery and other treatment as shown in table 2. Table 2 Number of individuals belonging to different ranges of anxiety in the Non-Cataract Group Anxiety Range Preoperative Post-operative At Discharge Normal Mild Moderate Severe Total Summary of the patients who underwent surgery and other modes of treatment (discussed separately) to reduce pre- and post-operative anxiety are shown in table 3.The table clearly shows the change that has taken place form pre-operative status to post-operative one. The change in the anxiety status is one hundred percent in both moderate and severe anxiety range. Age Range 40-80, Mean 61.87, SD 9.71 Pre-operative Anxiety range Score: 0-45 Post-operativeAnxiety Score: 0-25 df=6, x2=36.965, p < 0.000 Age Range: 20-70, Mean 45.86,SD 16.01 Pre-op Anxiety Range Score: 02-37 Post-op Anxiety Score: 0-23 df=6 x2 =7.05 p < 0.133 Age Range: 18-81, Mean 59.63, SD 12.07, df =6, x2= 39.09, p<0.0000 Table 1 Number of individuals belonging to different ranges of anxiety in the Cataract Group Anxiety Range Preoperative Post-operative At Discharge Normal Mild Moderate Severe Total Table 3 Summary of findings Anxiety Range Pre-operative Post-operative At Discharge Change in percent Normal 7% Mild 22% from moderate to severe changed to Mild Moderate 100% change Severe 100% change Total

108 Saldanha et al Therapeutic Intervention: Patients who were found to manifest anxiety symptoms were divided into mild, moderate and severe.74% of the cases were manifesting mild anxiety symptoms; hence the treating Ophthalmologists were made aware of these symptoms. They only needed insight-oriented psychotherapeutic inputs to resolve their preanxiety state. Moderate and severe anxiety (22%) cases however required a detailed and thorough assessment of their anxiety state. Besides psychotherapy they also required psychoactive drugs in the form of anxiolytics to bring down their pre- as well as post-operative anxiety states. The change could be seen before the discharge of the patients. Out of 100 cases, 89 patients had mild anxiety before discharge compared to 96 cases that had manifested anxiety from mild to severe degree. Discussion: Owing to the fact that cataract surgery involves an outpatient procedure, one tends to take patients for granted. If the patient is not explained the procedure of surgery and the complications at times such as infections and blindness (which occur rarely these days with strict antisepsis and advanced high-tech procedures), he is bound to have pre-operative anxiety.This is seen in nearly 96% of the cases in this study. Mokashi et al(2004)found hand holding by a nurse and a clear patient communication regarding the surgical procedure were found useful in 150 cataract surgical patients in UK.Since cataract surgeries are done under local anesthesia and patients are aware what they are undergoing, pre-operative and peri-operative anxiety makes it all the more important to address this issue. Thomas et al (1989) found that lack of patient's technical knowledge of the procedure itself in many cases was found to be anxiety-provoking and hence knowledge regarding the operative procedure is a must for every individual undergoing ocular surgery. This observation, however, has to be critically evaluated in the light of new techniques and advancement in the treatment of eye disorders over the years. Anxiety symptoms have been documented in several of surgical procedures as reported by Saldanha (2002) in low intensity conflict-ridden areas in Northern India and how it can be managed by simple psychotherapy and anxiolytic drugs. Karanci and Dirk (2003) found significant drop in anxiety from pre-to postoperative period in 146 emergency abdominal surgical patients due to the coping skills following effective surgical interventions. Pritchard (2009) stressed the importance of finding pre-operative anxiety in day-care surgical patients which, if not managed, can have adverse outcomes in a patient's life. Anxiety due to dental extractions is well-known particularly due to post-operative pain (Liu et al, 1994).To reduce post-operative pain many advocate the use of medazolam for anxiolytic effects prior to surgical procedure. The predominant action of benzodiazepines is hypnotic, anxiolytic, anticonvulsant, myorelaxant and amnesic which is useful in a wide range of conditions that reduces anxiety. Since use of diazepam interferes in evaluation of post-operative anxiety, as the halflife of diazepam is over 100 hours, none of the patients were given this drug pre-operatively. As some studies have found that majority of the patients experience no change or decrease in anxiety symptoms routine, use of small doses of oral pre-medication one hour prior to surgery is not advocated (Jacobson et al, 1995).Our findings suggest that routinely small doses of pre-medication is not required. There is a need to assess the cases for anxiety symptoms in every individual prior to surgical procedure. Hamilton's Anxiety Scale is a 14 item scale each defined by a series of symptoms. Each item is rated on a five-point scale scored from 0-5 .This scale is often used to measure anxiety levels before considering the options of using anxiolytic drugs. The evidence of anxiety levels in the cataract group is highly significant because of the nature of surgery involved whereas in noncataract group the individual doesn't show the same level of anxiety. However, individual insightoriented psychotherapy is essential to combat even moderate anxiety. All cases of mild anxiety (74%) were only given insight-oriented

psychotherapy. Those who had moderate to severe anxiety (22%) were given anxiolytic drugs like Clonazepam in the doses of 0.25 to 0.5 mg at night. In severe cases, higher doses were given which were closely monitored to prevent habituation. Conclusion: Psychotropic drugs and psychotherapy has a role in reducing the anxiety in pre- and postoperative eye cases. Use of the anxiolytic drugs have to be monitored carefully in view of their potential addictive effects. References: Benjamin, J. S. and Virginia, A. S. (2007).In Kaplan and Sadock's Synopsis of Psychiatry 10th edit. Lippincott Williams & Wilkins, 530 Walnut Street, Philadelphia, A 19106-3621 USA Chapter 16; Anxiety disorders: pp. 579-582. Biswas,S., Bhatnagar,M., Rhatigan, M., Kincey, J., Slater,R. and Leatherbarrow, B.(1999). Low dose midazolam infusion for oculoplastic surgery under local anaesthesia.Eye,13:537-540 Carr,E.,Brockbank,K.,Alien,S.and Strike,P.(2006). Patterns and frequency of anxiety in women undergoing gynecological surgery. Clinical Nursing,15 (3): 341-352. Chaudhury,S.,Sudarsanan, S., Saldanha,D.,Pawar, A.A., Ryali,V.S.S.R., Srivastava,K. and Kundeyawala, S.M.(2004) Assessment of Anxiety. In Handbook of Psychiatric Rating Scales.Navjeevan, Chapter 8. Printing Press, 2158, New Modikhana, Pune 411001. pp 101-114. Hamilton. (1959). The assessment of anxiety states by rating.Br J Med Psychol.32:50-55. Haugen, A.S.,Eide, G.E., Olsen, M.V., Haukeland, B., Remme, A.R, and Wahl, A.K. (2009). Anxiety in the operating theatre: A study of frequency and environmental impact in patients having local, plexus or regional anaesthesia. Clinical Nursing, 18(16):2301- 2310.doi:10.1111/j.1365-2702.2009.02792.x. Heather, D.H., Bonnie, S.S., and Thomas, H. (2010) .Anxiety in older patients waiting for cataract surgery: Investigating the contributing factors. Canadian Journal on aging. 2001:20(01):97-112.Published on line 29 November 2010.doi:10.1017/S0714980800012150 Jacobson, J., Rane, K and Ruberg. (1995) Oral premedication one hour before Minor Gynecological Surgery. Does it have any effect? A comparison between Ketobemidone,Lorazepam,Propranolol and Placebo. Acta Anaesthesiol Scand (Denmark) 39(3):359-63 Karanci, A.N. and Dirik, G. (2003) Predictors of pre- and postoperative anxiety in emergency surgery patients' Psychosom Res.55 (4):363-369. Liu, R., Barry, J. E. and Weinman, J. (1994) Effects of Background Stress and Anxiety on Post-operative Recovery. Anaesthesia (England), 49 (5) 382-6. Mokashi,A., Leatherbarrow,R., Kincey,J., Slater,R., Hillier,V. and Mayer,S.(2004). Patient communication during cataract surgery.Eye.18:147-151. Padmanabhan,R.,Hildreth,A.J. and Laws,D.(2005) A prospective, randomized, controlled study examining binaural beat audio and preoperative anxiety in patients undergoing general anesthesia for day care surgery. Anaesthesia, 60:9,874-877. Pritchard,M.J.(2009) Managing anxiety in the elective surgical patient.Br J Nurs 18(7):416-419. Rosen,S.,Svenson,M.and Nilsson,U (2008). Calm or not Calm: the question of anxiety in peri-anaesthesia patient. J Perianesth Nurs 23:4,237-246.doi:10.1016/ j.opan.2008.05.002 Saldanha.D. (2002) How common is Anxiety in Surgical Cases? SIS Journal of Projective Psychology & Mental Health, 9:2,114-120. Thomas,P., O'Malley., Newmark, T.S, Rothman, M.I. and Strassman, D.H. (1989). Emotional aspects of Cataract Surgery. International Journal of Psychiatry in Medicine, Volume 19(1):85-89 Psychotherapy benefit in pre and post-operative anxiety 109

The Efficacy of Dance/ Movement Therapy as Revealed through the Qualitative Lens of Somatic Inkblot Series (SIS-II) Manisha Dasgupta Synergies of meaningful movements form the basic elements of individuals' unique way of relating with others in the environment. Mind-body-connectivity serves as one of the chief pillars of dance/ movement therapy, which relies on the search for one's "authentic movements", to bring about gradual somatic transformations and consequent psychic modifications. The study involved the use of dance/ movement as a therapeutic tool on a clinical case having emotional problems to verify its efficacy. The Somatic Inkblot Series-II (SIS-II) was used as a measure to determine any significant change(s) through the projective mode following a pretest and posttest design paradigm, where eight sessions of dance movement therapy (DMT) were carried about with distinct focus on different body movements following the Limon technique. Both quantitative as well as qualitative analyses were done to unfurl the efficacy of the therapeutic intervention, if any, on the client's personality profile and profile of mood states. DMT was found to have a substantial qualitative effect in molding the personality profile along with mood state as revealed through qualitative improvement in the nature of responses on the SIS-II. The case manifested specific trend of "inner growth" in personality make-up in the post-test sessions. This effect was also found to persist even after the therapeutic sessions had been withdrawn (for at least a period of two weeks). Implications of dance/ movement therapy in the clinical arena have also been discussed. Manisha Dasgupta, Ph.D., Assistant Professor, Department of Psychology, University of Calcutta, 92 A.P.C. Road, Kolkata-700009, Email address: manisha_peu@rediffmail.com Key words: Dance/ movement therapy, emotional disorder, qualitative perspective Movement is the pre-eminent sign of life. Synergies of meaningful movement are part and parcel of the repertoire of all animate forms through which one individual effectively communicates with the other, being affectively linked. As such, emotion and movement go hand in hand, being dynamically congruent. Thus, individuals are always engaged in a projective mode through movements of varied kinds. Penfield (2004) opines that movement, like a dream, is another "royal road", which offers access to the unconscious. This has its bearing in the therapeutic mode by using movements as the bases for delving deep into the "symbolic experience" of individuals by reflecting on personal experiences, using the radar of "authentic movements", being fostered by dance/movement therapy. Dance/ Movement Therapy (DMT): A Conceptual Overview: Dance/ movement therapy (DMT) is defined as "the psychotherapeutic use of movement and dance through which a person can engage creatively in a process to further their emotional, cognitive, physical and social integration" (ADMTUK 2002). DMT, also termed movement psychotherapy or dance therapy, is a form of psychotherapy in which the creative use of movement and dance plays a fundamental role within the therapeutic alliance. DMT interventions engage somatic, emotional and perceptual processes simultaneously. In a session, the dance/ movement therapist seeks an attuned, embodied awareness of the client's physical and emotional presence (Bernstein, 1986; Bloom, 2006; Pallaro, 2007). This awareness comes from observing subtle shifts in posture, eye contact, breath patterns, and voice changes. The therapist seeks to create and work with the client's sense of "feeling felt" (Siegel 1999), and being responded to by another. Dance can provide adaptation and change realities, including physical limits, loss, and illness, by emphasizing bodily awareness, the principle that the body moves like a unit, and that mind and body are inseparable (Berrol et al, 1997; Cotter, 1999; Diefenbach, 2003; Krantz, 2007). Dance/ movement therapy uses movement in order to improve the physical and emotional integration of the individual (Castro, 1992; Goodill, 2005a, 2005b; Parslow et al, 2008). Berroll et al (1997) pointed out some fundamental principles of dance/ movement therapies are:

•Powerful vehicle for psychological change; •Unique catalyst for emotional and physical expression; •Powerful facilitator and enhancer of communication and interaction; •Booster to the mechanical and qualitative aspects of physical function. Movements of the body, being products of projection of the self, represent subtle forms of behaviour. The need is felt at this juncture to penetrate deep into the unconscious layer through projective techniques to help assess the efficacy of therapeutic techniques like the DMT. The Somatic Inkblot Series (SIS-II) appears to be an effective tool to envisage this journey. Hence, the present research involves adopting an idiographic approach of a clinical case to examine whether: a) Dance/ movement therapy (DMT) has any effect in molding the personality profile along with mood states of the selected case, by adopting pre-and-posttest research design paradigm. b) Whether the effect of dance/ movement therapy (DMT), if any, is therapeutic and persists even after the sessions have been withdrawn (for at least a period of two weeks). Method: The case was a 36 yr. old married female, having two children, on whom DMT was applied. She hailed from an upper class Bengali family, was a research student of the social science discipline in a reputed Indian University. She was the youngest child of three siblings, was a mediocre student all throughout her academic career, but was very good at painting, piano and other creative endeavors. However, she received strong discriminatory treatment, self-deprecatory remarks and negligence from her parents. The father was dominating and authoritarian in the family. She tended to prefer being alone. She got engaged to a boy of a different community and married him even at the non-acceptance of the boy's family in spite of understanding the fact that her fiancé was both verbally and physically abusive even before marriage. Nevertheless, she still remained firm in her decision of having him as her life-partner. Her world started to revolve around only her husband and she started to fare poorly at studies as she forcefully had to stop her research for the sake of her family. They also had to shift their place of residence because of her husband's job. She became a mother of two and reported that her children were the most precious. The extensity of emotional and physical abuse continued to such an extent that she decided to resume her studies to her earlier locality followed by the shifting of the whole family to their earlier locality. She remained fearful of her husband. She commented that she did not want to be a parent like her own parents for her children. Ambivalence toward her husband was observed. The chief complaints were as follows: • Low self-confidence; • Low self-esteem and self-image • Extreme anxiety over performance • Emotional clouding • Poor standards in performance • Anxiety regarding husband's mood variations and consequent abusive behaviors. Temperamentally she appeared to have a euthymic mood though sometimes she used to be tearful and depressed. The home atmosphere was not congenial because of the continuous presence of repeated deprecatory comments and physical abuses by her husband (sometimes even in front of her children). Therapeutic intervention: Therapeutic intervention was accomplished over a period of two months, twice weekly, for 40 minutes each (totaling sessions and approximately 5 and half hours). During every session, music was used to encourage and help movement. The main goal was to provide her with a safe and comfortable environment where she could feel free to move without fear of falling, while improving her own body movement control. The pre-testing and post-testing conditions SIS-II & Efficacy of Dance Therapy 111

involved an assessment of her mood states (measured with the help of Profile of Mood States) and personality (measured with the help of Somatic Inkblot Series- II). A second post-test measure of the dependent variables was carried out after a fortnight of post-test assessment without any intervention of dance/ movement therapy. The specific goals were: •Improving her self-image •Facilitating emotional expression to loosen the rigidity in her body and body movements •Re-enunciating trust to her own self •Understanding her potentials and nurturing them adequately. Tests administered: 1. Profile of Mood States (POMS) (McNair et al, 1971): It consists of 37 items measuring mood disturbance. Items on the scale are rated using a 5-point Likert scale from 0 (not at all) to 4 (extremely). Participants are asked to rate how they have been feeling during the past one week. The scale consists of 6 mood factors: tensionanxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia and confusionbewilderment. Internal consistency of the scale has been found to be high and test-retest reliability has been found to be adequate. 2. Somatic Inkblot Series (SIS-II) (Cassell and Dubey, 2003): It is a projective test of personality which consists of an (A) Series and a (B) Series, each with 31 images, for a combined series of 62 images. There is also a sample image in the beginning. The stimulus images are printed in rectangles measuring about 5 X 6 cm, each with a space provided below the image for writing the response. All the images are contained in an eight-page booklet. The first seven pages consist of the stimulus images and the space for responses. The last page is printed with instructions for self-administration, and a place for a brief health history and personal data. It consists of images printed with blue ink on grey paper. There is no time limit for which test anxiety is reduced. Here, the subject is also asked to rate the three-inkblot images that he "most liked" and the three images that he "least liked". This inquiry invites positive or negative affective discharge. The subject's emotional investment provides valuable diagnostic clues to his/her psychological functions. This standardized test has also been reported to have high reliability and validity (Cassell and Dubey, 2003). The protocol of the case was chosen for presentation because her responses and the symbolic themes reflected in the responses to the SIS-II along with data obtained in the DMT sessions reflected support to traditional psychoanalytic interpretations (Bettelheim, 1976). Session Technique of movement Observations I • Minimal movements involving The client's shoulders became stiff while moving head rotation (both clock and them upwards during Tai chi. She also exhibited anti-clock-wise with four counts difficulty in release movement. each), toe-movement followed by She frowned her eye-brows and immediately folding hands (left and right hand opened her eyes, breaking her session, and individually and then both hands reported that she did not like the sight of "butterflies" together with four counts of (which was given to her as a cue in the guided inhalation and release). imagery session). When the imagery was changed • Tai chi with both hands to that of a "fluttering bird", the client again opened 112 Dasgupta Table 1 Treatment Program / Intervention based on Dance/ Movement Therapy (DMT) and Related Observations

• Exercise involving guided her eyes, was very restless and reported with imagery/ improvisation. much disgust that she did not like the sound of anything fluttering. The client who was unwilling to participate in the imagery task any further that day. II • Repetition of earlier exercises She said that she liked to observe water from a • Exercise distance and did not feel like being in the same." involving I have a phobia of water," she said. "I feel confined…, guided I feel like I might get drowned as I do not know imagery/ swimming. The other day, I had said I did not like improvisation butterflies because it gives me a distressful image (where imagery of somebody crushing it to death by its feet. I also of a water do not like the fluttering sound of wings as it conveys body a message of being in danger - which it is in a was situation prior to death - it has been confined to provided). a small place for which the organism is fluttering its wings to gain freedom." Thereafter, the case confined that she had repeated histories of child abuse (three times), which she did not disclose to anybody for a very long time. She felt mis-understood by her parents and perceived great emotional distance from her siblings as well. III • Repetition of earlier exercises She appeared to have stiffened her back muscles • Massage technique which could be felt during the massage technique. • Exercise When she was asked to depict her current involving emotional state by her body movements, she guided expressed the same by crouching low on a chair imagery/ with both hands holding her forehead, and then improvisation reported that she felt thoroughly distressed. (where When asked about the reason, she reported that she she felt very low especially because she received was a severe scolding by her doctoral supervisor because instructed of her unsatisfactory progress in her research work. to imagine Resistance in the therapeutic sessions was noted anything which could be understood by her missing the time that of prior appointments, and telling at the outset came into to shorten the session. her mind She reported that she would open her hairs and let at the the strong breeze blow into her face and her hairs. thought of a "The sea is beautiful, is vast but is also dangerous. sea shore) It can do anything. I'll wet my feet at the beginning and perhaps take a few steps forward, let water to rise to the level of my knees and probably to my waist. But I'll get scared of getting drowned and getting carried away. I'll step backwards. The sea is vast. We are simply minute beings - with the vastness SIS-II & Efficacy of Dance Therapy 113

of the sea around…It probably questions the existence of God. It feels so small to be in front of the sea - with its vastness and with our 'big' problems seeming to be very small in comparison to the sea." IV • Repetition of earlier exercises The client could soften her muscles substantially • Exercise involving guided for which she reported feeling much more imagery/ improvisation. relaxed than the other days. Here the subject was instructed to She reported imagining playing the violin. She imagine anything that came into exhibited repeated movements of the right hand her mind at the thought of a violin over the violin and holding the violin by the left in front of her. hand. Then she made consequent movements to place the instrument on the table, and stood still for a while. After the session, the client reported, "I took my time to play the violin. I felt good inside - felt relaxed - I was playing the violin in my own way. Sometimes I was listening to the music outside, and was playing accordingly, but mostly I was playing the instrument all by myself, in my own rhythm. It was a dimly lit room which I imagined in which I was playing the violin. I was having a comfortable feeling inside me." V • Repetition of earlier exercises She moved herself as if to wet the fingers of the • Exercise involving guided hands and then her face. This was followed by imagery/ improvisation. wetting both the left and right foot. She stood up Here the subject was instructed from her chair with her eyes closed, bent forward, to imagine anything that came appeared to collect water within the folds of her into her mind at the thought of palms and started splashing water on her face. a waterfall in front of her. Then she wet her whole body, sat down, wet her feet and body, sprinkled water to her fingers and appeared relaxed. She sat as she was for a few minutes in a very relaxed posture. At the end of the session, she reported that the imagery brought to her mind about two imageries - one when she was 6yrs. of age when she had gone to visit a waterfall with her parents and her siblings. There was the sound of water gushing nearby with nature and greenery all around. It reminded her of the coolness of water, its strength and vitality as well as its purity. She also reported another imagery where she recalled herself visiting another waterfall with her husband and her children sometimes back. VI • Repetition of earlier exercises She moved herself as if to wet the fingers of the hands • Exercise involving guided and then her face. This was followed by wetting both imagery/ improvisation. the left and right foot. She stood up from her chair • Here the subject was instructed with her eyes closed, bent forward, appeared to to imagine anything that came collect water within the folds of her palms and 114 Dasgupta

into her mind at the thought of started splashing water on her face. Then she wet herself in a life boat in the midst her whole body, sat down, wet her feet and body, of a stormy weather in the sea. sprinkled water to her fingers and appeared relaxed. She sat as she was for a few minutes in a very relaxed posture. At the end of the session, she reported that the imagery brought to her mind about two imageries - one when she was 6yrs. of age when she had gone to visit a waterfall with her parents and her siblings. There was the sound of water gushing nearby with nature and greenery all around. It reminded her of the coolness of water, its strength and vitality as well as its purity. She also reported another imagery where she recalled herself visiting another waterfall with her husband and her children sometimes back. The client could soften her muscles substantially for which she reported feeling much more relaxed than the other days. She reported to have experienced a very distressful imagery in comparison to the last session. The client retorted, "There were very big waves - dark greenish, bluish green waves - enveloping me. I felt I am all alone, I did not know how to swim, and so was cling ing on to the life-boat for safety and security. It was a very stormy weather and I had nothing to do, but was about to get drowned. I was thinking that I would get drowned in the vast ocean. I was feeling confined in the huge body of water around, and was also feeling very trivial in the vast ocean around." As such, the per ception of reality was harsh on the part of the client who had a pessimistic outlook, and consequent poor self-esteem and lack of adequacy. The case recounted her abuse at 6yrs. of age when she was all alone with the domestic helpers. She also was in tears when she said that her father forgot to pick her up from school repeatedly on a number of days and suddenly remembered about 3-4 hours later after the school had got closed. Besides, her mother had confessed to her that she was truly inter ested in her son and not in her daughter. She further reported that she did not have any playmates in child hood, for which she used to play with her reflection in the mirror. She hated herself and many a times, gave punches and/ or blows on her reflection in the mirror. VII • Repetition of earlier exercises She stood up, clenched both the hands together and • Exercise involving guided seemed to hold an axe. After a while she started SIS-II & Efficacy of Dance Therapy 115

116 Dasgupta imagery/ improvisation. chopping down imaginary trees in a clearing first Here the subject was instructed by striking with her axe three times in one direction. to imagine anything that came It was followed by the same series of activities in into her mind at the thought of the other direction. During the process, she appeared herself chopping down trees in to be devoted to her task and felt tired at times a forest. because of the sudden expenditure of much physical energy. At times, she also clenched her teeth, tightened her facial muscles and was frowning while giving her last blows. Towards the end, at the fall of the trees, both her hands trembled slightly. J.D. reported that the session was quite tiring; she involved herself in chopping down the trees quite seriously, however, after the felling of them, she felt guilty because of her act as she had killed innocent lives. She felt bad inside, let down and guilty as reported by the client. Her responses indicated her deep-rooted guilt feelings at the venting out of aggression because of the very rearing-up pattern as well as her very low self-image and associated inferiority feelings. VIII • Repetition of earlier exercises The client could soften her muscles substantially • Exercise involving guided for which she reported feeling much more imagery/ improvisation. relaxed than the other days. Here the subject was asked to She reported that she imagined that she had gone imagine whatever comes to mind. out with her entire family for a ride in their private car - with her holding the hands of her husband in the front, and the other hand holding the hands of her children at the back. She conceived of a wellknit family with enough cohesiveness, love, affection and belongingness. Results: Table 2 Profile of Mood States of the Case in Pre-, Post- and 3rd Administration after two Weeks of Dance Movement Therapy Dimensions of Mood States Pre-test condition Post-test condition 3rd administration after two weeks of DMT Tension-anxiety Depression-dejection Anger-hostility Vigor-activity Fatigue-inertia Confusion-bewilderment Total mood disturbance

Discussion: A. Quantitative analysis of results: The changes in the overall mood states of the subject may be attributable to the effects of dance/ movement therapy (DMT). The trend of the present findings is also supported by studies of Salgado (2010) who found that DMT has an effect on ameliorating the emotional states of individuals. B. Qualitative analysis of results: A qualitative improvement was also noted in the overall personality make-up in the post-test sessions as revealed from the SIS in the client (Cassell and Dubey, 2003): Images that have been rejected by the client in pre-test condition: B24, B26. Images that have been rejected by the client in post-test condition (after 8 sessions of DMT): A11, B26. Images that rejected by the client in post-test condition (after 2 weeks of termination of DMT): None Interpretation of SIS responses in Pre-Test Session: Image B15: "Daggers are thrown flying towards a woman" and Image B1: "Hell - figures on a boat travelling through a river of fire."{The perception of reality appears to be very harsh, 'aggressive' and dangerous for the present client, as reflected from the dynamic point of view. This may be understood in line with the many physical abuses that have been up hurled at her since childhood, that have crippled her self-confidence gravely}. Image B17: "A heart enveloped in a haze." {It is suggestive of her cravings for love and affection, though at the same time being confused, owing to her sense of intense emotional crisis}. Image A25: "A bird's head. A closed flower." {Her response reflects her apathy toward any form of sexual intimacy, which supports her acknowledgement of the same in one of the later sessions of DMT. She is aware of her primitive impulses, however, she ceases to enjoy them any further, probably because she has developed a 'shield' around herself to protect against any further abuses on the part of her partner, as a compensatory behavior}. Image B28: "A bald woman in melancholy." {It pinpoints her depressive stance that the client has developed toward life in general, being unable to combat the different stressors efficiently}. Image B31: "Four children." {The client has been unable to perceive the image as the typical response, namely, "A family" probably because she does not have a congenial family-life. Instead, she perceived it to be "four children" indicating her regressive tendencies once again and her need for peer support through siblings}. Interpretation of SIS responses in Post-Test Session (after 8 sessions of dance/ movement therapy): Image A10: "Eyes and nose of a girl wearing 'burkha' (Face mask in Muslims). Eyes appear puffed" and Image A17, "Rib cage of a man with lungs in middle. Enveloped by a black cloak-like object."{It is suggestive of her negative emotions and identity-crisis of which she appears to become aware of to a certain extent by dint of the therapeutic sessions}. SIS-II & Efficacy of Dance Therapy 117 Table 2 indicates subtle changes in the mood profile of the case in the post-test condition and a remarkable decline in the same in the 3rd administration (post-test) after two weeks of DMT without any therapeutic intervention. It indicates that the case reported a decline in depressiondejection, fatigue-inertia and confusionbewilderment in the post-test condition.

Image A24: "A big fat woman holding onto three children. Sense of warmth and coziness is there." {This shows a remarkable improvement in her mental status where she fantasizes a cozy family atmosphere, with a warm mother-image. It probably reflects her craving for maternal love and affection and sibling support where she fantasizes her mother to love all the children genuinely without any apparent discrimination. It is interesting to note that her response to the specific image has undergone a substantial transition qualitatively from her response in pre-testing session where she responded as "A picture of children huddled together inside a confined space. A human baby"}. Image B31: "A happy family - Mother, father, two children." {This response hints at the fact that the client craves and fantasizes for a happy and congenial family in spite of all the oddities in her life. She looks forward to the cohesion in the family as a pillar of support for her emotional upheavals}. Interpretation of SIS responses on 3rd administration (after 2 weeks of termination of DMT): Image A5: "Hibiscus above. A heart. A fat man conducting an orchestra." {This symbolically represents the strong cravings of the client for love and affection. It also reflects her dynamicity and spontaneity in performance that had earlier been difficult for her}. Image B15: "Daggers and thorns aimed at enemy." {This response involves a dramatic shift from "Daggers and thorns flying towards a woman" in the pre-testing session, where personalization was evident. The DMT sessions have perhaps helped the client to develop a better insight into her problems, making her to project the altered version of her psyche in the 3rd administration of the SIS}. The DMT sessions have perhaps helped the client to develop a better insight into her problems, making her to project the altered version of her psyche in the 3rd administration of the SIS}. 118 Dasgupta Table 3 Comparison of SIS responses on 1st, 2nd and 3rd testing for quick view 1st testing: Pre-testing session, 2nd testing: Post testing session (after 8 sessions of DMT), 3rd testing: Post-testing session ( two weeks after termination of DMT) Image 1st,2nd,3rd Testing Response to SIS image A5 1st testing A heart, a flower, one legged fat man with a sickle. 2nd testing Heart-shape, a hibiscus flower, a fat man with raised hand. 3rd testing Hibiscus above, a heart, a fat man conducting an orchestra. B15 1st testing Daggers and thorns flying towards a woman. 2nd testing Daggers, nettles being hurled at a barely visible figure. 3rd testing Daggers and thorns aimed at enemy. B22 1st testing A man lying down inside a hole, his spirit leaving his body. 2nd testing A man snoring in his sleep. 3rd testing Sleeping man B28 1st testing A bald woman in melancholy 2nd testing A person putting her hand on the shoulders of a girl. 3rd testing A bald mother holding on to her daughter. B31 1st testing Four children. 2nd testing A happy family - mother, father, two children. 3rd testing A happy family.

SIS-II & Efficacy of Dance Therapy 119 Overall comments: Specifically, the change in the qualitative nature of the SIS-II responses in the different testing sessions may be attributable to DMT. Integrative in form and function, it appeared to address the case's needs through physical and emotional self-expression, enhancing her well-being in the progressing sessions (Berrol et al, 1997, Cotter, 1999; Diefenbach, 2003, Krantz, 2007). Some of the highlights of the dance/movement therapy approach used in the present study for the case were creating and maintaining a consistent "holding environment" (Winnicott, 1965; 1971) that established a basic trusting relationship - a zone of comfort consequently; channeling aggressive impulses into appropriate and interesting motor avenues; and strengthening the client's movement resources so that she was better able to cope with challenges in the environment. The feeling of safety and trust was fostered through the "holding environment" that was created by providing a space for the case to explore her surroundings fully (Lundy and McGuffin, 2005). Trust was enunciated by dint of the therapeutic movement relationship whereby her essential constellation of movement(s) characterizing her expression was recreated by the therapist herself in her own body. This enabled the subject to know that her bodily expressions were clearly understood, which further stimulated motor learning, kinesthetic memory and active imagination (Chaiklin, 1975). It called for interactional synchrony/ mirroring in the therapeutic set-up, which essentiated the use of body coordination. The safe environment increased her sense of comfort, responsiveness, and involvement. The structure of the session was very consistent and stable. Predictability in relationships provided safety for trust to flourish and for creativity, spontaneity, and feelings to be contained (McCarthy, 2008). It enabled in providing bigger and agile movements to broaden her respective kinesphere and movement vocabulary. This consequently uplifted the client's self-image to at least an extent to have better insight regarding her potentials. It is through dance/ movement action that the case developed bodily insight gradually and became aware of effort-shape analysis (Payne, 2004). For the case, breath-flow, alignment of the body, centrality, tension, rhythm and use of space were considered to keep a track of the health-dysfunction continuum (Schoop, 1974). Movements were rigid, inflexible, with breath-flow being irregular and lacking spontaneity in the initial few sessions of both the clients. Gradually, she showed improvement in the qualitative spectrum of body-movements toward the latter sessions and also appeared more relaxed and comfortable with her body. She was psycho-educated as regard her body attitudes and was made aware of whether her body shape was appropriately connected to the task(s) at hand. She was also made aware of the internal kinesthetic experience of movement (Barteinieff, 1980). Her body attitude was notified and the client was made aware whether her body shape was appropriately connected to the task in hand or not. This made the client to utilize her sense of body awareness to have her respective internal kinesthetic experience of movement. The DMT therapeutic sessions enabled the subject to be aware of movements which she used to perform mechanically earlier and instead focussed and increased her attention on particular tasks, thereby bringing about improvement in different phases of their general life. As such, she exhibited improvement in body coordination in the later session of dance/ movement therapy, which was reflected in her body reflexes as well as effort. Her flow of movement was observed to change from bound to free in the later sessions. The later movements were also found to have a Gestalt effect along with interactional synchrony. The client was also observed to utilize her kinespheres in a better fashion. The aim of the therapist was to help her have bigger and agile movements. In addition, the therapeutic sessions helped the client to utilize her kinesthetic memories to remember the position of various body parts in movement or in

stillness to have a better grip over her respective kinesthetic adjustment (Barteinieff, 1980). It, in turn, increased her movement vocabulary and consequently the phrasing of movement. Spatial awareness improved in the client qualitatively, which also had its reflections in the overall expressional aspects. Hence, individual DMT appears to be a powerful tool in re-integrating a fragmented self-suffering from emotional problems, by particularly focusing upon the quality of therapeutic relationship as revealed by distinctly different changes in the qualitative domain of the SIS-II responses (van der Kolk, 1994; Cotter, 1999; Cohen and Walco, 1999). Conclusion: Dance/ movement therapy (DMT) has an effect in molding the personality profile along with mood states of the selected case in the present study, by adopting pretest and posttest research design paradigm. The case exhibited reduction in her negative emotions and overall mood disturbance as well as manifested specific trend of "inner growth" in her personality make-up in the posttest sessions. The effect of dance movement therapy (DMT) is therapeutic and persists even after the sessions have been withdrawn (for at least a period of two weeks). References: ADMTUK (2002). Arts Therapy: Benchmark Statement. Gloucester. Quality Assurance Agency for Higher Education. Online Available <http:// www.qaa.ac.uk/ academicinfrastructure/ benchmark/ health/ Art Therapy.pdf> (accessed 23 September, 2005). Bartenieff, I. (1980). Body movement: Coping with the environment. New York: Gordon and Breach Publishers. Bernstein, P. (1986). Theoretical approaches in dance/ movement therapy. Dubuque, IA: Kendall/ Hunt. Berroll, C.F., Ooi, W.L., and Katz, S.S. (1997). Dance/ movement therapy with older adults who have sustained neurological insult: A demonstration project. American Journal of Dance Therapy, 19(2), 135-160. Bettelheim, B. (1976). The Uses of Enchantment. The Meaning and Importance of Fairy Tales, New York: Knopf. Bloom, K. (2006). The embodied self: Movement and psychoanalysis. London: Karnac. 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. Castro, E.D. (1992). A danca, o traalho corporal e a apropriacao de si mesmo.

Revista Terapia Ocupacional, 3, 24-32. Chaiklin, H. (Ed.) (1975) Marian Chace: Her Papers. Columbia, MD: American Dance Therapy Association. Cohen S.O, and Walco, G.A. (1999). Dance/Movement therapy for children and adolescents with cancer. Cancer Pract. Jan-Feb;7(1):34-42. Cotter, A.C. (1999). Western movement therapies. Physical medicine and rehabilitation clinics of North America, 10(3), 603-616. Diefenbach, N. (2003). O "EU CORPORAL" em terapia morfoanalitica. Fisioterapia am Movimento, 16(2), 73- 82. Goodill S.W. (2005 a). Dance/movement therapy for adults with cystic fibrosis: pilot data on mood and adherence. Altern Ther Health Med. Jan-Feb;11(1):76-7. Goodill, S.W. (2005 b). An introduction to medical dance/ movement therapy. London and Philadelphia: Jessica Kingley Publishers. Krantz, A. (2007). When walls become doorways: Creativity and the transforming illness (Book Review) American Journal of Dance Therapy, 29(2), 149-150. Lundy, H. and McGuffin, P. (2005). Using dance/movement therapy to augment the effectiveness of therapeutic holding with children. J Child Adolesc Psychiatr Nurs. Jul-Sep;18(3):135-45. McCarthy, D. (Ed.) (2008). Speaking About the Unspeakable : Non-Verbal Methods and Experiences in Therapy with Children. London, , GBR: Jessica Kingsley Publishers, p 45. McNair, D., Lorr, M., & Droppleman, L. (1971). POMS Manual for the Profile of Mood States. San Diego: Educational and Industrial Testing Service. Pallaro, P. (2007). Somatic counter-transference: The therapist in relationship. In P. Pallaro (Ed.), Authentic movement: Moving the body, moving the self, being moved. A collection of essays. (Vol II). London: Jessica Kingsley. Parslow, R., Morgan, A.J., Allen, N.B., Jorn, A.F., O'Donnell, C.P., & Purcell, R. (2008). Effectiveness of complementary and self-help treatments for anxiety in 120 Dasgupta

SIS-II & Efficacy of Dance Therapy 121 children and adolescents. The Medical Journal of Australia, 188(6), 355-359. Payne, H. (2004). Introduction: Embodiment in action. In Dance Movement Therapy: Theory, Research and Practice, 2nd edition, Routledge, Taylor and Francis Group, London and New York, pp. 1-16. Penfield, K. (2004). Another royal road: Freudian thought applied to authentic movement. In Dance Movement Therapy: Theory, Research and Practice, 2nd edition, Routledge, Taylor and Francis Group, London and New York, pp. 132-148. Salgado, R. (2010). The use of dance in the rehabilitation of a patient with multiple sclerosis. American Journal of Dance Therapy, 32: 53-63. Schoop, T. (1974). Won't you join the dance? A dancer's essay into the treatment of psychosis. Palo Alto, CA: Mayfield Publishing Co. Siegel, D.J. (1999). The developing mind. New York: Guilford Press. van der Kolk, B.A. (1994). The body keeps the score: Memory and the evolving psychobiology of post traumatic stress. Harvard Review of Psychiatry, 1, 253-265. Winnicott, D.W. (1965) The Maturation Process and the Facilitating Environment. London: Hogarth Press. Winnicott, D.W. (1971). Playing and reality. London: Karnac. Acknowledgement: I am thankful to Prof. Nilanjana Sanyal, Ph.D., Dept. of Psychology, University of Calcutta, Kolkata 700 009, for her valuable guidance and assistance in the study.

Therapeutic Intervention through SIS Imagery: Two Case Studies Antonio Cervigni The Somatic Inkblot Series Card form was administered to two cases for diagnostic formulation and therapeutic intervention. The test was used first time by the clinician though he has heard about the test in Italy. The test was found valid in assessing personality and diagnostic evaluation. It helped in therapeutic planning and trapping unprocessed unconscious material. The test must be included in every clinic as a therapeutic procedure. I am a developmental psychologist with psychoanalytic training, and in my professional life I have been using many projective tests to investigate the personality of my patients, but the timing and the length of performing and marking had always discouraged me until I lost the desire and the habit of using this convenient and effective tool for psychological investigation. I had heard about SIS, but in Italy it is very difficult to find someone who can teach you the theory and technique of this test. The curiosity on the subject was mainly due to the desire to find out if SIS could really explore and assess the depth and significance of somatic symptoms, conversion reactions, somatic hallucinations and sexual dysfunctions: all psychopathological problems which, in hindsight, are difficult to study and evaluate with a classical projective test like the TAT, CAT (Pattenoir etc.). There are meetings in life that modify your horizons by showing possibilities and new ways hitherto hypothetical and remote. For me and for my profession as a developmental psychologist, this has been the case when I had internet discussion with Prof. Bankey L. Dubey, President of "Somatic Inkblot Society". With great kindness, he sent me the SIS Test with Manual and suggested me to administer the test on my selected patients (Cassell and Dubey, 2000, 2002, 2003). He also helped me with Scoring and Interpretation of SIS responses of two patients. This is how my very personal AntonioCervigni, M.A. Casa di Cura DR. Marchetti Via Ariani,9 Macerata Italy. Email: antonio.cervigni@gmail.com www.psicologiaesviluppo.it Key Words: SIS Test, Therapeutic Intervention, Projective Therapy clinical trial has started with Somatic Inkblot Test. After a careful reading and subsequent study of the manual, I administered SIS-I card form to two selected patients. The cases are discussed below: Case 1: Mr.X, male 16 years old, visited my clinic the first time for getting relief of his symptoms of obsessions and rituals. The SIS-I test (1980, 1984, 1996) was administered which he completed in 30 minutes. He chose images on Card 16 and 2 as "Most liked" and images 18 and 13 "Least liked". The significant SIS responses are interpreted here: Most Liked Responses: Card 16: "A carnival mask and two big eyes". Heightened eye response may indicate paranoid tendency. Card 2: A red heart and a person. "The drawing makes me to feel very happy." This may indicate that he has good ego strength and contact with reality. Least Liked Responses: Card 18:"Mountains". Looks OK. Card 13:"A heart upside down. It causes sadness and anguish". This response is in continuation of the broken heart symbol on card 8.The theme of depressive content and aggression continues and the therapist

should explore this through case history and therapy session. Other Significant Responses: Card 1: "A person lying on a stool" is a depressive content. Card 3: "A woman with long hair and two persons dancing", is a good response with popular percept, which suggests his healthy interpersonal relationship. Card 4: "An apple, a person with black hair". It is a Most Typical response; which suggests good ego strength and happy mood. Card 5: "A squirrel, a red heart and in the center and two arms". It may indicate separation from parents or some traumatic experiences during child hood which can be explored during therapy session. Card 6: "Two curtains and an arrow". The arrow might be an aggressive response, which should be explored during therapy session. Card 7: A person upside down, which may again indicate healthy interpersonal relationship. Card 8: "A thorax of the human body and a broken heart." The broken heart may indicate underlying depressive component or some broken love affairs, though less common at this age. Card 9: "Two potatoes". A heart/Kidney is generally perceived in this image. Avoiding perceiving the common percept may indicate body/organ anxiety often seen in the family of a closed relative. Card 10:"Two red lips and a red wire". Though the response is normal but Red at two places might be a significant diagnostic indicator in favor of early psychotic condition. Card 14:"A pine cone". Avoidance of sexual imagery on this card may indicate sexual repression, though less common at this age. Card 17:"A jar containing anger and suffering", may indicate his aggressive and sad mood. He has lots of anguish inside, which is alarming. The therapist should take care of this during therapy sessions. Card 20:"An angry face and a bracelet". Here like in card 17, projection of an angry face symbolizes his inner anger. Angry face on this card and Red lips on Card 10 might be an indicator of paranoid features. The therapist should also ensure during therapy session if others are looking towards him. Finally it might be noted that in terms of diagnostic consideration, it is likely that this adolescent boy is suffering from Obsessive Compulsive Disorder in early stages. He has also shown depressive contents for which an antidepressant drug such as Prozac might be of great help. He is advised Cognitive Behavior Therapy, to take care of early mixed symptoms of OCD with underlying depressive affect and irritability. While he may currently deny suicidal and homicidal impulses, it is of concern clinically that the intensity of his depression and hostility requires close monitoring. He perceived a total of four responses suggesting that he may be experiencing color shock. Here is a youth, clinically suffering from OCD and showing such color shock which may be in the early stages of Schizophrenic disorder. This needs to be ruled out. Discussion and Interpretation: It was the first visit of the patient to my clinic when he says he is suffering from a series of uncontrollable obsessions that make it difficult to Therapeutic Intervention through SIS Imagery 123

manage his normal teenager life. I decided to administer the test to find out the severity of the problems. He was relaxed and attentive and expressed his curiosity about the test we were going to do. This was an ideal condition for the administration of any procedure. He had completed the test in 30 minutes and indicated the two images he liked the most (16 and 2) and the two which he liked the least (18 and 13). I started analysing the first response which he indicated "Most Liked" "A carnival mask with two large eyes." The "two large eyes" are very strong indicator of paranoia, fully compatible with the clinical picture he had presented at the beginning of our meeting. This diagnosis was reinforced by his next response on Card 20 "An angry face and a bracelet", which may indicate his unexpressed anger and his fear of other people's judgement towards him. The following therapeutic interviews confirm the accuracy of my initial conclusion. It should be noted how much the clinical suggestions of Dr. B. L. Dubey has been valuable since, as a result of the interpretation of SIS responses , he suggested me to investigate, during the therapeutic interview, the possibility that the young had some paranoid ideas in symmetry with the judgment of others towards him. Going forward with the marking and the clinical interpretation, the picture of the young man has increasingly defined the presence of a strong obsessive-compulsive disorder that SIS could unravel and make clinically analyzable. By Lacanian language I am going to explain that I have identified in the clinical case of Mr. X, examined by SIS, an obsession characterized by an inability to accept the "big other." The obsessive, in fact, cannot accept a lack in the big others because he accused himself to lack it. He was convinced to be responsible for the lack in the "other" and thus his obsessional neurosis was structured in a marked manner: in the clinical theory this attitude means that the child feels responsible for the "mother's wound." There is, therefore, an obsessional neurosis, a reaction of defense against this lack in the other, theorized by Lacan as foreclosure of castration. On Card 5 in fact, he sees "A squirrel, a red heart and two arms in the middle" that can be interpreted as trauma from separation. Once again the test is enlightening about the therapeutic path to follow during the therapeutic sessions. Ultimately SIS, together with a proper analytical interpretation, has proved an invaluable tool in framing the patient and, in consideration of the responses, we have assumed an obsessivecompulsive disorder diagnosed in the early stages of development. It should also be noted that the boy in some responses markedly stressed the "red" color, thus highlighting a shock related to color; the clinic and the interpretation of SIS teaches us that this could be a sign of the beginning of a schizophrenic syndrome to be taken into consideration and analyzed in the following therapeutic meetings, probably with neuropsychiatric support. Case 2: Mr. A., 20 years old, male, was accidentally shot on his face by a hunter while he was riding his motorbike one year ago. He had developed panic attacks and felt always angry. He had a little lead-marble near his heart and it was innocuous but he thought it was the cause of all his physical problems. He took the SIS 20 Card testing 35 minutes and responded to all 20 images. He was nervous during testing. He was taking psychotherapy from September 2012, once a 124 Cervigni

week. The significant SIS responses are interpreted here: Card 1: "A mask" This response may project his wishful thinking to protect himself in hiding position to avoid unconscious fear and painful traumatic memory which he encountered by the hunter's gun shot. Card 2: "A smiling man and a heart" is Most Typical (MT) response. It indicates his normal ego strength and a sign of good prognosis. Card 3: "Two aliens who fall in love and a twisted snake" (MT). Two aliens may symbolize the hunter and the difficult situation, he is trying to adjust and twisted snake may indicate anxiety in erotic /sexual area. The therapist should enquire during therapy session if the patient has developed problems in the area of interpersonal/sexual relationship. Card 4: "A dancing woman and an apple". Both responses are normal and most frequently seen by others which may indicate good mental health, good ego strength and sign of good prognosis. His dancing part is still intact and he will improve after psychotherapeutic intervention. This also might be the outcome of therapeutic help to him. Card 5: "Two kids, a coat of arms and two red balls". Normally a big man/(Parental/authority figure) is perceived along with two children. Avoiding the big man may indicate his fearful encounters with the "hunter" or some traumatic childhood experience. Card 6: "Two hanged fish and a red arrow facing down", may be his aggression which should be addressed during psychotherapy. Card 7: "A big read heart and a big donkey" is a normal response which indicates his healthy body imagery. Card 8: "A thorax with a heart", is again a normal response which indicates his healthy body imagery. Card 9: "Two lungs hung on a pedestal and an inverted cross". (MT) Two lungs is good response indicating healthy awareness of body and the "Cross" may indicate spirituality which is going to work as "Spiritual healing" in his case. His therapist should take note of it during the psychotherapy sessions. Card 10: "A flower with a strange mask". The theme of Card 1 where he saw Mask is back again on this image, which may indicate his anxiety. Card 11: "A stomach with a heart in the lower part of the drawing". It is normal response though many internal body responses may indicate anxiety and hypochondriacal symptoms. Card 12: "An alien's tracksuit". The theme of the alien is back indicating earlier stressful situation and related anxiety. Card 13: "A big gluteus with a big hole in the center". The big hole may indicate his suffering and anxiety, due to the injury inflicted by the hunter. Card 14 "A strange eye". This might be his suspicious attitude, though only one eye response may not be enough to interpret as abnormal sign. Normally people perceive the female genitalia on this card and the "Eye" might be the symbolic connotation of female genitalia and a healthy response. Another explanation could be that "avoiding perceiving phallic symbol" might indicate anxiety or sexual conflict which can be explored during therapy session. Card 15 " A spinal column" (MT) It is a good response needs which needs no explanation. Therapeutic Intervention through SIS Imagery 125

Card 16: "Two cats and near the eyes two black blots and a thin neck". The second eye response may indicate suspicious attitude of the patient which should be addressed during therapy session. Card 17: "A pelvis" is most commonly perceived as a good normal response, and may indicate healthy body imagery. Card 18: "A crown" is again a most commonly perceived good normal response. Card 19: "A bat" is a normal response. Card 20: "An open mouth mask with two horns above". Open mouth may indicate anxiety and two horns represent aggressive expression. As a whole, the SIS procedure indicates healthy body imagery, contact with reality, heightened anxiety, suspicious attitude and aggressive expression. He has also shown sexual conflict which might be due to later development of gunshot accident. However, the SIS protocol does not suggest any major psychiatric diagnosis. Anxiety and tension with suspicion are obvious in the case because of traumatic situation he has experienced. It seems that he is getting benefit from psychotherapy. Discussion and Interpretation: The patient has been following a weekly therapy for the last 5 months, complaining disorders of anxiety and fear related to his personal history: while riding a bicycle he has been accidentally hit on his face by a hunter who was firing a Rabbit. He was nervous and completed the test in about 35 minutes. I am familiar with his medical and personal history and I'm curious to interpret his responses on the SIS test. His responses are normal and do not merit therapeutic attention, but only few responses struck me and made me understand the clinical path to be followed and the efficacy of the word treatment. On Card 4 he perceived this image as "a woman dancing with an apple". The response may indicate a good conscience of his ego combined with an equally valid inner strength and good analytical path detectable in the information of dance and in the woman's movement that suggest a positive evolution in the dynamics of healing. Mr. A has great difficulties with the authority figures and also with his father, an absentminded man in contrast with a hyper-protective mother, which caused suffering and anger. The fact of having remained defenseless before a man who shot him had deeply marked his ego and his personality structure. The Card 5 was normally viewed as a male figure, a big man, but he had perceived it as "Two children, a coat of arms, and two red balls". The response may be analysed as his father's denial by the boy who, rather than seeing a big man (the hunter/the father), described two small children (his childhood).Once again, the psychoanalytic interpretation comes into play in the margin of SIS and suggests to me an extract by Jacques Lacan about the father evaporation: "The father represents the opposite and complementary pole to the female: he is the one who separates the child from the mother, bringing him to leave his initial state of dependence to take a more active and autonomous attitude towards himself and his life"."The maternal model is a "fusion", the paternal one represents the detachment. The fundamental paternal function is to allow children to watch his mother from outside, ensuring the remodelling of their physical and mental identity" This expression can be detected by his interpretation of Card 14 which is normally perceived as a vagina but Mr. A has seen it as "a strange eye". Dr. B. L. Dubey while discussing on tele-therapy group session, suggested me to understand that I should depend on the clinical 126 Cervigni

Therapeutic Intervention through SIS Imagery 127 history of the young man: "avoiding perceiving phallic symbol might indicate anxiety in phallic area which can be explored during therapy session". I close my report with a statement by Freud dating back to 1927. "The conscious ego is first and foremost" Conclusion: In conclusion, the use of SIS procedure can be considered an excellent tool to trap unconscious mechanism and unprocessed painful materials. Both the cases discussed have helped in therapeutic planning and the patients have shown improvement. I personally believe that the SIS test should be the part of my analytic investigation tools. Acknowledgement: I express my deep gratitude to Dr.Dubey for the help in interpreting both cases. I hope to meet him who opened new frontiers to me. References: Cassell, W. A. (1980) Body Symbolism and the Somatic Inkblot Series. Anchorage, Alaska. Aurora Publishing. Cassell, W. A. (1984) Computerized Projective Testing as an Aid in Medical Diagnosis. Alaska Medicine, 26:1, 1-9. Cassell, W. A. and Dubey, B. L. (1996) The Use of the Rorschach and SIS in Releasing Somatised Grief. SIS Journal of Projective Psychology & Mental Health, 3: 3 - 32. Cassell, W. A. and Dubey, B. L. (2000) Inkblot Responses as an Aid to Therapy.SIS Journal of Proj. Psych. & Mental. Health, 7:3-10. Cassell, W. A. and Dubey, B. L. (2002) Application of Somatic Inkblot Series-I: New Scoring System. SIS Journal of Projective Psychology & Mental Health, 9: 5- 22. Cassell, W, A. and Dubey, B. L. (2003) Interpreting Inner World through Somatic Imagery: Manual of Somatic Inkblot Series. Anchorage (USA): SIS Center. Freud, S. (1917)Introduction to Psychoanalysis (Vorlesungen zur Einführung in die Psychoanalyse). W.W. Norton & Co Lucan, Jacques. (1977) The Seminar, Book XI, The Four Fundamental Concepts of Psychoanalysis, ed. by Jacques-Alain Miller, translated by Alan Sheridan, W.W. Norton & Co., New York.

Mental Health Problems in Alexithymia: Role of Positive and Negative Emotional Experiences Akanksha Dubey and Rakesh Pandey Previous empirical evidences show that though, alexithymia is associated with a variety of somatic and mental health problems, the exact mechanism that makes alexithymic individual prone to mental or somatic illness has not yet been uncovered. Based on earlier observations that alexithymic individuals are characterized by anhedonia and a proneness to negative emotional experiences, the present study examines the mediational role of positive negative emotional experiences in alexithymia - health relationship. Hundred fifty adults were assessed on the measures of alexithymia, mental health, and positive/negative affectivity. The correlation analysis revealed alexithymia and its various dimensions correlated significantly positively with mental health problems and negative affect correlated significantly and negatively with positive affect which suggest that alexithymic individuals are prone to mental health problems and negative emotional experiences and lack hedonic capacity. Further, it was also noted that negative emotional experiences and reduced capacity for positive emotions were related with greater number of mental health problems. This pattern of relationship among the measures of alexithymia, mental health and positive-negative affect suggests the possibility that anhedonia and proneness to negative emotions may explain the link between alexithymia and mental illness. To test this possibility a structural relationship model linking alexithymia an mental health directly as well as indirectly through positive and negative affect was tested using AMOS 20. The findings revealed a significant direct effect of alexithymia on mental health as well as indirect effect through positive/negative emotions. The findings suggest that alexithymia is associated with mental health problems and these problems may be partly due to the alixithymics' anhedonic tendency and their propensity to experience negative emotions. The findings have been discussed in the light of the existing literature and a future direction for research has also been proposed. Rakesh Pandey, Ph.D., FSIS, Professor,(Corresponding author, Email:rpan_in@yahoo.com) and Akanksha Dubey, Research Scholar, Dept of Psychology, Banaras Hindu University,Varanasi-221005(India) Key Words: alexithymia, anhedonia, mental health, mediation. Alexithymia is a cognitive-affective deficit characterized by: (i) difficulty in identifying and describing feelings, (ii) difficulty in distinguishing between feelings and bodily sensations, (iii) impaired symbolic activity as evidenced by paucity of fantasy and other imaginative activity, and (iv) externally oriented thinking i.e., a preference for focusing on external events rather than inner experiences (Nemiah, Freyberger, and Sifneos, 1976; Taylor, 1984). Alexithymia is associated with a reduced emotional functioning and difficulties in understanding and communicating emotion and feelings are at its core (Sifneos, 1973). Apart from the said affective deficits, it has also been linked with numerous other affective difficulties which includes anhedonia ( reduced capacity for positive emotional experiences, prevalence of and proneness towards negative emotions (Simonsson-Sarnecki, Lundh, et al., 2000), poor emotional regulation and stress management abilities (Luminet, Rimé, Bagby, and Taylor, 2004). Alexithymic individuals have been found to report a variety of somatic and mental health problems. Such a wide range of emotional difficulties present in alexithymic individuals make them prone to a variety of mental and physical health problems (Lumley, Stettner, and Wehmer, 1996; Taylor and Bagby, 2004). Numerous researches have demonstrated that alexithymia is linked with a variety of symptomatic complaints including depression and anxiety(Berthoz, Consoli, Perez-Diaz and Jouvent, 1999; see Taylor, 1984, 1994 for a review), somatic complaints (Parker, Bagby, and Taylor, 1989; Taylor, Parker, Bagby, and Acklin, 1992, Vassend, 1987), hypertension (Todarello, Taylor, Parker and Fanalli, 1995), inflammatory bowel disease (Porcelli, Zaka, Leoci, Centonze, Taylor and Parker 1995), somatoform disorders (Cox, Kuch, Parker, Shulman and Evans 1994), panic disorder (Zeitlin and McNally, 1993) and eating disorders (De Groot, Rodin and Olmstead, 1995). A bulk of studies relates alexithymia to a number of physical health problems such as various heart related problems (Mattila et al., 2009; Temoshok et al., 2008), sensitivity to anxiety (Devine, Stewart and Watt, 1999), severity of depression (Honkalampi, Hintikka,

Laukkanen, Lehtonen and Viinamäki, 2001) as well as recovery from depression (Salminen, Saarijarvi, Äarela, Toikka, and Kauhanen, 1999). Despite the convincing empirical evidences that alexithymia makes an individual at risk to develop a variety of physical and mental health problems, the mechanism through which it leads to health related problems is not yet clear. Some explanatory mechanisms linking alexithymia with mental/physical health problems have been extended. For instance, some researchers argue that the alexithymic individuals' poor capacity for identifying and understanding emotions coupled with a deficit to express emotions sum to emotion suppression and emotional suppression may lead to health diminishing effect (Pandey & Chaubey, 2010). For instance, Pennebaker (1993) advocates that spontaneous and habitual disclosure of emotion in general has positive effect and suppression of emotion has a negative effect on health. He stated that the nonverbal expression of emotions is related with an abrupt reduction in autonomic nervous system (ANS) activity. Another hypothesis linking alexithymia with physical and mental problems argues that these physical and mental illness are the consequence of alexithymic's inability to appreciate, distinguish and express affect, which in turns, increases the physiological arousal and those negative subjective state, that are not governed by psychological strategies. For example, Friedlander, Lumley, Farchione and Doyal (1997) support the speculation from their study that increased physiological arousal and subjective negative emotional experiences in alexithymic's may be a cause that leads to poor health. The aforesaid hypotheses though provide some explanatory link between alexithymia and health related problems, other possibilities also exist. For instance, the proneness of alexithymic individuals to negative emotional experiences and a reduced capacity for positive negative emotional experiences may be a potential factor contributing to the health related problems among alexithymics. This trait-like disposition to positive/negative affects has been a focus for researches in the area of health psychology for a long period of time. During the last three decades numerous studies investigated the trait like characteristics of self-reported affects and arrived at two conclusions: first, there are temporally stable and transsituationally consistent individual differences in affective experiences. Second, these individual differences can be described by a two-dimensional structure, which is composed of two broad factors that were termed positive affect and negative affect (Russell and Barrett, 1999; Watson and Clark, 1992). Positive affects is the pleasurable and subjective experiences of happiness whereas negative affect is the subjective distress and unpleasurable engagement. Individuals having high positive affect tend to experience a range of positive emotions for example, enthusiasm, alertness and joy etc, whereas low PA is considered by sadness and lethargy. It is characterized by the tendency to experience a wide range of distressing negative emotions such as anxiety, anger, contempt, disgust, guilt, fear, nervousness and depression. Positive affective component plays a vital role in the mental health. In fact it is an essential component of mental health area (e.g., Jahoda, 1958; Taylor and Brown, 1988). Happy individuals are prone towards good mental health than their less happy counterparts. Deiner and Seligman (2002) found that people belonging to the happiest groups were seen with lesser symptoms of psychopathology, such as depression, hypochondriasis, or schizophrenia (see also Chang and Farrehi, 2001; Lu and Shih, 1997). Clark, Watson, and Mineka, (1994) argued that the absence of hedonic and positive affect `is a distinguishing characteristics of depressive people. Individuals experiencing greater positive affect are less likely to undergo from distressing situation (Lyubomirsky, king and Deiner., 2005), and social phobia or anxiety (Kashdan and Roberts, 2004). Contrary to it, individuals with elevated negative affect are prone to experience higher levels of negative emotions, they react extremely negative to stressful situations and show more physiological and Mental Health Problems in Alexithymia 129

psychological symptoms than those who are having low negative affect (Watson and Clark, 1984). From the preceding review it is evident that alexithymia is associated with a variety of mental/physical health problems as well as anhedonia and a tendency to experience negative emotions. Further, such health problems are also linked with positive/negative affect. Thus, it is likely that alexithymia - health relationship may be mediated by the positive/ negative affect. Recently, some empirical evidences provide some support to such speculation. For example, in a study Phoebe and associates (Bailey and Henry, 2007) assessed alexithymia, somatization and negative affect in a general adult sample and observed that specific facets of alexithymia (enhanced fantasy life and difficulty identifying emotions) were significantly associated with somatization, and these pathways were perfectly mediated by negative affectivity. Such mediational role of negative affect in alexithymia - health relationship has been reported in other clinical samples such as in individuals suffering from pain (Hosoi et al., 2010) and patients with medically unexplained symptoms (Gucht, 2002). The mediating role of negative and positive affect in the relationship of alexithymia with medically unexplained symptoms (MUS) has been reported by others also (De Gucht, Fischler, and Heiser, 2004). For example, De Gucht and associates (2004) observed that after controlling the dimensions of negative and positive affect, neuroticism and alexithymia no longer exerted a significant direct effect on MUS. Instead, their effect became indirect; mediated through negative affect (neuroticism), and positive affect. In the light of the aforesaid preliminary empirical evidences, the present study makes an attempt to re-examine the relationship among the constructs of alexithymia, positive/negative affect, and mental health and to test how and to what extent the alexithymia - mental health relationship is mediated by positive negative emotional experiences. The mediation hypothesis was tested following the structural equation modeling approach using AMOS 20. Materials and Methods: Sample: The present study was carried on relatively heterogeneous sample of 150 middle class male and female adults in the age range of 21 to 40 years. Participants beyond this age range were not included in the study because the dynamics of stress and health in the teen age and older age is quite different from the early and middle adulthood. Those subjects were also excluded from the present study who reported any history of chronic medical illness, psychiatric illness, and/ or neurological damage or disease. The participants belonged to varied educational level ranging from under matriculation to PhD level. Attempt was made to sample the participants from different occupational background such as marketing, teaching, defence, law, private firms, house-wife, students etc. Tools: The following self-report measures were used in the present research to assess alexithymia, psychosocial stress and various dimensions of health. 1. Hindi version of twenty-item Toronto Alexithymia Scale (TAS-20-H: Pandey, Mandal, Taylor, and Parker, 1996; Pandey, 1993) was used to assess the prevalence of alexithymic characteristic among the participants. The TAS- 20-H has 20 items with 5-point rating scale. This scale is comprised of three dimensions of alexithymia namely Difficulty identifying feelings, Difficulty describing feelings and Externallyoriented thinking. The TAS-20 - H has been found to be extremely comparable with the original TAS-20, and has demonstrated satisfactory internal consistency, test-retest reliability and validity (Pandey, 1993, 1995; Pandey & Mandal, 1993). Higher score indicates higher level of alexithymia. 130 Dubey & Pandey

2. The Hindi version of Positive and Negative Affect Schedule (PANAS - H; Pandey and Srivastava, 2008 ) was used to assess the trait of positive-negative affectivity. This scale consists of 20 mood adjectives (10 positive and 10 negative) and the respondents are asked to indicate how often they experience the mood states reflected in various mood adjectives on a 5- point scale ranging from 1( a little bit or never ) to 5 (nearly always). Higher score indicates higher level of the assessed affect. 3. General Health Questionnaire (GHQ, Goldberg, 1978). The 28-item version of GHQ was used to gauge four dimensions of mental health viz., anxiety, somatic complaints, social dysfunction and depression. This questionnaire consists of 28 items with four response alternatives ranging from always (0) to never (3).Higher scores on this questionnaire indicate poor mental health. Procedure: The aforesaid tests/scales were administered to participants either individually or in small groups consisting of to persons. Before administering the said questionnaires, the instructions were to complete each questionnaire was clearly explained to all the participants their queries (if any) were also attended properly. Before returning the booklet each participant was requested to ensure that he/she has responded to each and every item of the test booklet. If any item was found to be unresponded, then the participants were requested to complete it again. The correlation among the constructs of alexithymia, positive/negative affect and mental health was computed in addition to examining the mediating role of positive/negative affect in alexithymia and health relationship. The mediation analysis was done using AMOS 20. Results: Before, examining the mediating role of positive negative affect in the relationship of alexithymia and mental health, it was essential to examine the correlation of alexithymia and its various dimensions with health. The obtained correlations have been presented in Table1. Table 1 Correlation between Alexithymia (and Its Dimensions) and Mental Health And Its Various Domains Variables Somatic Anxiety and Social Severe total GHQ complaints Insomnia Dysfunction Depression Difficulty in identifying feelings .350** .474** .151 .309** .423** Difficulty in describing feelings .264** .308** .155 .254** .319** Externally oriented thinking .112 .098 .010 .140 .123 Total Alexithymia .326** .406** .150 .324** .398** Mental Health Problems in Alexithymia 131 ** p < .01 It is apparent from Table-1 that difficulty in identifying feelings, difficulty in describing feelings and overall alexithymia score correlated positively and significantly with all the dimensions as well as total score on GHQ except social dysfunction. The externally oriented thinking (one of the dimension of alexithymia), however, failed to correlate significantly with any subscale or the total score of the GHQ. The observed pattern of correlation between alexithymia and mental health suggest that higher level alexithymia is associated with more symptoms of mental health problems. However, the deterioration in the mental health of alexithymic individuals is largely because of their affective deficits (difficulty in identifying and describing feelings) and not because of the deficit in the cognitive component (externally oriented thinking) of alexithymia as it failed to correlate significantly with various subscales of the GHQ. Another important observation is the

non-significant correlation of the social dysfunction either with alexithymia (total score) or any of its dimensions. To explore the relationship of alexithymia with positive and negative affect another correlational analysis was done. It is evident from Table 2 that alexithymia and its dimensions correlated significantly negatively with positive affect and positively with negative affect. The obtained pattern of association suggests that greater alexithymic tendency is associated with greater negative emotional experiences and decreased positive emotions. 132 Dubey & Pandey The relationship of positive/ negative affect with mental health was also examined and the findings (Table 3) revealed that all domains of mental health correlated significantly and negatively with positive affect. Contrary to it, the negative affect correlated positively with various domains of mental health except social dysfunction. This pattern of correlation suggests that prevalence of negative emotional experiences and reduced positive emotions are associated with symptoms of mental health problems. Overall the findings suggests that predominance of positive emotional experiences in one's life decreases the probability of mental health related problems whereas predominance of negative emotional experiences may result in poor mental health. Further, the findings also revealed that higher the level of alexithymia greater the chance of having mental health problems as well as greater negative emotional experiences and fewer positive emotional experiences. This pattern of correlation among the measures of alexithymia, mental health and positive-negative affect also suggests the possibility that anhedonia and proneness to negative emotions associated with alexithymia may be a factor responsible for the poor mental health of alexithymic individuals. In other words, the negative impact of alexithymia on mental health may be indirect (mediated) through positive and negative affect. To test the aforesaid mediation hypothesis, a mediation path model was constructed taking positive and negative affect as mediator of the relationship of alexithymia and health. The model assumes that alexithymia may lead to high negative affect and/or reduced positive feelings which in turn may lead to poor mental health (indirect or mediated effect of alexithymia on health) as well as the alexithymia may have a Table 2 Correlation of Positive and Negative Affect with Alexithymia and its Dimensions Variables Positive Affect Negative Affect Difficulty in identifying feelings -.311** .341** Difficulty in describing feelings -.234** .218** Externally oriented thinking -.255** .219** Total score of Alexithymia -.346** .340** ** p < .01 Table 3 Correlation of Positive and Negative Affect with Mental Health and its Various Domains Variables Positive Affect Negative Affect Somatic complaints -.258** .390** Anxiety and insomnia -.205** .458** Social dysfunction -.363** .093 Severe Depression -.307** .406** Total score of GHQ -.354** .448** ** p < .01

direct effect on mental health also. These direct and indirect (mediated) effects of alexithymia on mental health was tested using the structural The coefficients shown over the respective paths in Figure 1 represent the standardized direct effects and the indirect effects of alexithymia on health through positive and negative affect is shown in the box. It is evident from the figure that alexithymia has a significant indirect effect on mental health through both positive affect (0.071) and negative affect (0.115) as well as a significant direct effect on mental health (0.23). The total standardized effect of alexithymia on mental health was found to be .441 of which it exerts a direct effect of .23 and indirect effect of .186 (through positive and negative affect).The regression weights associated with direct and indirect effects suggest that with one unit increase in the standard score of alexithymia the standard score of mental health increases by .23 units directly and .186 units indirectly (.115 and .071 through negative and positive affect respectively). The aforesaid model representing the direct and indirect effect of alexithymia on mental health was found to be a good fit as evident from a nonsignificant Chi square associated with this model (X2= 2.304, P>.129) and the acceptable values other fit indices (X2/df=2.304, GFI=.992, AGFI=.923, TLI=.911, CFI=.985) as per the contemporary criteria of evaluating goodness of fit of a structural relationship model. The standardized residuals was found to be .037, which was well below the prescribed upper limit of .08. However, the RMSEA was slightly higher (.094) than the prescribed upper limit of .08. Taken together, the various fit indices suggest that the hypothesized model (Figure 1) represents a good fit. Overall, this causal model suggests that alexithymia directly impairs the mental health of an individual as well as it impairs the mental health indirectly by increasing the negative emotional experiences and reducing the positive ones. However, the significant direct and indirect effects of alexithymia on mental health suggest that the alexithymia- mental health relationship is not fully mediated by positive and negative affect. Mental Health Problems in Alexithymia 133 Negative affect Positive affect Mental health problems (Total score on GHQ) Alexithymia (total score on TAS-20-H) e1 e2 e3 .35** a b c d .33** -.21** -.34** .23** Indirect effect of alexithymia on mental health through: Negative affe ct: 0 .11 5** Positive affect: 0.071 ** Total indirect effect: 0.186* * modeling approach with the help of AMOS 20 and the obtained standardized path (regression) coefficients have been shown in Figure 1. Figure 1: The causal model linking Alexithymia and Mental Health through Positive and Negative Affect

Discussion: The findings support the earlier observations that alexithymia is associated with poor mental health inasmuch as a significant direct effect of alexithymia on mental health was observed over and above the indirect effect of positive/negative affect. Since alexithymia is characterized by a difficulty in understanding and communicating emotions and feelings, such deficits are likely to impair the mental health of an individual directly. For instance, researchers noted that the symptom of frequent anxiety and fear was observed in the individuals with greater difficulties in identifying and describing emotional states (e.g., Devine, Stewart, and Watt, 1999). The prevalence of alexithymia has also been reported to be high in a variety of mental disorders (e.g., Parker, Taylor, Bagby, and Acklin, 1993; see Taylor, 1994). The present study contributes to and expands upon the existing literature on alexithymiamental health relationship by demonstrating that the poor mental health of alexithymic individuals is partially the result of the alexithymic tendency (the direct effect) and partially because of their anhedonic tendency and preponderance of negative emotional experiences (the indirect effect of alexithymia). The findings provide support to the hypothesis that the alexithymia mental health relationship is mediated by positive and negative affect. Overall, this finding imply that the reduced positive and enhanced negative emotional experiences in alexithymic individuals play a significant role in the development of various mental health related problems. The alexithymic's greater propensity towards negative emotions (e.g., Connelly & Denney, 2007) and reduced capacity to experience positive emotions has been well documented in the literature (see Taylor, 1984, 1994 for review). Further, it also well documented that elevated level of negative emotions and/or reduced positive emotions are linked with a variety of health related problems including mental health (Deiner and Seligman, 2002; Chang and Farrehi, 2001; Lu and Shih, 1997; Watson and Clark, 1984). Thus, these empirical evidences provide indirect support to the present observation that mental health problems in alexithymia may be an indirect effect of the alexitymics' anhedonia and tendency to experience negative emotions. The observed significant mediational role of positive/negative affect in alexithymia - mental health relationship is also corroborated by some direct empirical evidences (e.g., Bailey and Henry, 2007; Hosoi et al., 2001). However, unlike the earlier studies, the findings of the present study suggest that alexithymia - mental health relationship cannot be explained completely through the indirect effect of positive/ negative emotional experiences inasmuch as a significant direct effect of alexithymia on mental health was also noted. This observation suggests the possibility that some cognitiveaffective deficits other than anhedonia and enhanced negative affect may also be responsible for mental health problems of alexithymic individuals. For instance, researchers have noted that alexithymia is also associated with a deficit in cognitive processing and regulation of emotions (e.g., Kessler, Kammerer, Hoffmann, and Traue, 2009; Taylor, 1994). Thus, the emotion regulation difficulties found in alexithymia may be an additional factor responsible its detrimental effect on mental health inasmuch as emotion regulation difficulties have been found to impair health (Gross and Munoz, 1995; Liverant et al., 2008; Lundh and Broman, 2006; Stein et al., 2008). In fact, recently a study by Pandey and associates (Pandey, Saxena, and Dubey, 2011) demonstrated that alexithymia is characterized by emotion regulation difficulties and such difficulties may be a factor responsible for the poor mental health of alexithymic individuals. Conclusions: Overall, the findings of the present study suggest that alexithymia is associated with impaired mental health and the poor mental health of alexithymic individuals is partly the result of their an hedonic tendency and propensity to experience negative emotions. However, 134 Dubey & Pandey

alexithymia has also a direct effect on mental health beyond its indirect effect through positive/ negative affect. The observed significant direct effect, however, may be because of some other cognitive - affective deficits (present in alexithymia) potentially linked with mental health problems. The existing literature suggests the possibility that emotion regulation difficulties may emerge as a potential mediator variable in the relationship of alexithymia and mental health through positive/negative affect.

Future research, thus, may focus on exploring the mediating role of other cognitive-affective deficits (associated with alexithymia) in relation to positive/negative affect in the alexithymia - mental health relationship. References: Bailey, P. E., & Henry, J. D. (2007). Alexithymia, somatization and negative affect in a community sample. Psychiatry research, 150(1), 13. Barrett, L. F., & Russell, J. A. (1999). The Structure of Current Affect Controversies and Emerging Consensus. Current Directions in Psychological Science, 8(1), 10-14. Berthoz, S., Consoli, S., Perez-Diaz, F., & Jouvent, R. (1999). Alexithymia and anxiety: compounded relationships? A psychometric study. European Psychiatry, 14(7), 372-378. Chang, E. C., & Farrehi, A. S. (2001). Optimism/pessimism and information-processing styles: can their influences be distinguished in predicting psychological adjustment?. Personality and individual differences, 31(4), 555-562. Clark, L. A., Watson, D., & Mineka, S. (1994). Temperament, personality, and the mood and anxiety disorders. Journal of abnormal psychology, 103, 103-103. Cox, B. J., Kuch, K., Parker, J. D., Shulman, I. D., & Evans, R. J. (1994). Alexithymia in somatoform disorder patients with chronic pain. Journal of Psychosomatic Research, 38(6), 523-527. De Gucht, V., & Fischler, B. (2002). Somatization: a critical review of conceptual and methodological issues. Psychosomatics, 43(1), 1-9. De Gucht, V., Fischler, B., & Heiser, W. (2004). Neuroticism, alexithymia, negative affect, and positive affect as determinants of medically unexplained symptoms. Personality and Individual Differences, 36(7), 1655- 1667. Dedroot, J., Rodin, G., & Olmsted, M. (1995). Alexithymia, depression, and treatment outcome in bulimia-nervosa. Comprehensive Psychiatry, 36(1), 53-60.Fisch, R. Z. (1989). Alexithymia, masked depression and loss in a Mental Health Problems in Alexithymia 135 Holocaust survivor. The British Journal of Psychiatry: The Journal of Mental Science, 154, 708. Devine, H., Stewart, S. H., & Watt, M. C. (1999). Relations between anxiety sensitivity and dimensions of alexithymia in a young adult sample. Journal of Psychosomatic Research, 47(2), 145-158. Diener, E., & Lucas, R. (1999). Personality and subjective well-being. In D. Kahneman, E. Diener, & N. Schwarz (Eds.), Well-being: Foundations of hedonic psychology (pp. 213-229). New York: Russell Sage Foundation. Diener, E., & Seligman, M. E. (2002). Very happy people. Psychological science, 13(1), 81-84. Friedlander, L., Lumley, M. A., Farchione, T., & Doyal, G. (1997). Testing the alexithymia hypothesis: Physiological and subjective responses during relaxation and stress. The Journal of nervous and mental disease, 185(4), 233-239. Goldberg, D. P. (1978). Manual of the general health questionnaire. Nfer. Gross, J. J., & Muñoz, R. F. (1995). Emotion regulation and mental health. Clinical Psychology: Science and Practice, 2(2), 151-164. Honkalampi, K., Hintikka, J., Tanskanen, A., Lehtonen, J., & Viinamäki, H. (2000). Depression is strongly associated with alexithymia in the general population. Journal of psychosomatic research. Hosoi, M., Molton, I. R., Jensen, M. P., Ehde, D. M., Amtmann, S., O'Brien, S., Arimura T., & Kubo, C. (2010). Relationships among alexithymia and pain intensity, pain interference, and vitality in persons with neuromuscular disease: Considering the effect of negative affectivity. Pain, 149(2), 273-277. Hu, L., & Bentler, P. M. (1995). Evaluating model fit. In R. H. Hoyle (Ed.), Structural equation modeling: Issues, concepts, and applications (pp. 76-99). Newbury Park, CA: Sage. Jahoda, M. (1958). Current concepts of positive mental health. New York: Basic Books. Jöreskog, K. G., & Sörbom, D. (1993). LISREL 8: Structural equation modeling with the SIMPLIS command language. Scientific Software. Kashdan, T. B., & Roberts, J. E. (2004). Social anxiety's impact on affect, curiosity, and social self-efficacy during a high self-focus social threat situation. Cognitive Therapy and Research, 28(1), 119-141. Kessler, H., Kammerer, M., Hoffmann, H., & Traue, H. C. (2009). Regulation von Emotionen und Alexithymie: Eine korrelative Studie. PPmP-Psychotherapie· Psychosomatik· Medizinische Psychologie, 60(05), 169-174. Liverant, G. I., Brown, T. A., Barlow, D. H., & Roemer, L. (2008). Emotion regulation in unipolar depression: The effects of acceptance and suppression of subjective emotional experience on the intensity and duration of sadness and negative affect. Behaviour Research and Therapy, 46(11), 1201-1209.

136 Dubey & Pandey Lu, L., & Shih, J. B. (1997). Sources of happiness: A qualitative approach. The Journal of Social Psychology, 137(2), 181-187. Luminet, O., Rime, B., Bagby, R. M., & Taylor, G. J. (2004). A multimodal investigation of emotional responding in alexithymia. Cognition & Emotion, 18(6), 741-766. Lumley, M., Stettner, L., & Wehmer, F. (1996). How are alexithymia and physical illness linked? A review and critique of pathways. Journal Of Psychosomatic Research, 41(6), 505-518. Lundh, L. G., & Broman, J. E. (2006). Alexithymia and insomnia. Personality and individual differences, 40(8), 1615-1624. Lyubomirsky, S., King, L., & Diener, E. (2005). The benefits of frequent positive affect: does happiness lead to success?. Psychological bulletin, 131(6), 803. Mattila, A., Saarni, S., Salminen, J., Huhtala, H., Sintonen, H., & Joukamaa, M. (2009). Alexithymia and Health- Related Quality of Life in a General Population. Psychosomatics, 50(1), 59-68. Nemiah, J. C., Freyberger, H., & Sifneos, P. E. (1976). Alexithymia: A view of the psychosomatic process. In O. W. Hill (Ed.). Modern trends in psychosomatic medicine (Vol. 3, pp. 430-439). London: Butterworths. Pandey, R. (1993). Emotional processing deficit and personality correlates of Alexithymia. Unpublished Doctoral dissertation, Banaras Hindu University, India. Pandey, R., & Choubey, A. K. (2010). Emotion and Health: An overview. SIS Journal of Projective Psychology and Mental Health, 17, 135-152. Pandey, R., & Srivastava, N. (2008). Psychometric evaluation of a hindi version of positive-negative affect schedule. Industrial Psychiatry Journal, 17(1), 49. Pandey, R., Mandal, M. K., Taylor, G. J., & Parker, J. D. (1996). Cross?cultural alexithymia: Development and validation of a Hindi translation of the 20?item Toronto alexithymia scale. Journal of clinical psychology, 52(2), 173-176. Pandey, R., Saxena, P., & Dubey, A. (2011). Emotion regulation difficulties in alexithymia and mental health. Europe's Journal of Psychology, 7(4), 604-623. Parker, J. D. A., Bagby, R. M., & Taylor, G. J. (1989). Toronto alexithymia scale, EPQ, and measures of somatic complaints. Personality and Individual Differences, 10, 599-604. Pennebaker, J. W. (1993). Putting stress into words: Health, linguistic, and therapeutic implications. Behaviour research and therapy, 31(6), 539-548. Porcelli, P., Zaka, S., Leoci, C., Centonze, S., & Taylor, G. J. (1995). Alexithymia in inflammatory bowel disease. Psychotherapy and Psychosomatics, 64(1), 49-53. Salminen JK, Saarijärvi S, Aärelä E, Toikka T, Kauhanen J (1999). "Prevalence of alexithymia and its association with sociodemographic variables in the general population of Finland". Journal of psychosomatic research (1): 75-82. doi:10.1016/S0022- 3999(98)00053-1 Sifneos, P. E. (1973). The prevalence of 'alexithymic' characteristics in psychosomatic patients. Psychotherapy and Psychosomatics, 22(2), 255-262. Simonsson-Sarnecki, M., Lundh, L., Torestad, B., Bagby, R., Taylor, G., & Parker, J. (2000). A Swedish translation of the 20-item Toronto Alexithymia Scale: Crossvalidation of the factor structure. Scandinavian Journal of Psychology, 41(1), 25-30. Stein, D., Ives-Deliperi, V., & Thomas, K. (2008). Psychobiology of mindfulness. CNS Spectrums, 13(9), 752-756. Taylor, G. J. (1984). Alexithymia: concept, measurement, and implications for treatment. The American Journal of Psychiatry, 141(6), 725-732. Taylor, G. J. (1994). The alexithymia construct: Conceptualization, validation, and relationship with basic dimensions of personality. New Trends in Experimental and Clinical Psychiatry, 10, 61-61. Taylor, G., & Bagby, R. (2004). New trends in alexithymia research. Psychotherapy and Psychosomatics, 73(2), 68-77. doi:10.1159/000075537. Taylor, G.J., Parker, J.D.A., Bagby, R.M. & Acklin, M.W. (1992). Alexithymia and somatic complaints in psychiatric out-patients. Journal of Psychosomatic Research, 36, 417-24. Taylor, S. E., & Brown, J. D. (1988). Illusion and well-being: a social psychological perspective on mental health. Psychological bulletin, 103(2), 193. Temoshok, L., Waldstein, S., Wald, R., Garzino-Demo, A., Synowski, S., Sun, L., & Wiley, J. (2008). Type C coping, alexithymia, and heart rate reactivity are associated independently and differentially with specific immune mechanisms linked to HIV progression. Brain Behavior and Immunity, 22(5), 781-792. doi:10.1016/ j.bbi.2008.02.003. Todarello, O., Taylor, G. J., Parker, J. D., & Fanelli, M. (1995). Alexithymia in essential hypertensive and psychiatric outpatients: a comparative study. Journal of Psychosomatic Research, 39(8), 987-994. Vassend, O. (1987). Personality, imaginative involvement, and self-reported somatic complaints: relevance to the concept of alexithymia. Psychotherapy and psychosomatics, 47, 2, 74-81. DOI:10.1159/ 000288001. Watson, D., & Clark, L. A. (1984). Negative affectivity: the disposition to experience aversive emotional states. Psychological bulletin, 96(3), 465. Watson, D., & Clark, L. A. (1992). Affects separable and inseparable: on the hierarchical arrangement of the negative affects. Journal of Personality and Social Psychology, 62(3), 489. Zeitlin, S., and Mcnally, R. (1993). Alexithymia and Anxiety Sensitivity in Panic Disorder and Obsessive- Compulsive Dosorder. American Journal of Psychiatry, 150(4), 658- 660.

Behavioral Assessment of Mentally Challenged Children L. N. Bunker, Subhash Meena and Laxmi Prajapat The present study assessed 10 mentally challenged children on Madras Development Programming System (MDPS) Behavioural Scale before and after a training programme. The comparison of the behavioural assessment data on six domains of using 't' revealed a significant difference between pre and post activities. The findings indicated that training brought a significant improvement in gross motor activities, fine motor activities, meal time activities, dressing behaviour, toileting activities, and receptive language among the mentally challenged children as indicated by higher post test score as compared to the pre-test score. The findings have been discussed in the light of available empirical evidences. Mental retardation (MR) is a generalized disorder appearing before adulthood, characterized by significantly impaired cognitive functioning and deficits in two and more adaptive behaviours. Generally MR has an IQ below 70. Once focused almost entirely on cognition, the definition now includes both a component relating to mental functioning and one relating to individuals' functional skills in their environment. As a result, a person with below-average intelligence (IQ 70- 84) may not be considered mentally retarded, unless the intellectual deficits are associated with other medical and behavioural signs and symptoms. Non-syndromic mental retardation refers to intellectual deficits that appear without other abnormalities. In the 17th century, the intellectual disabilities were considered as a disease, and believed that it was caused by structural problems in the brain. It could be due to genetically created problems or acquired later in life (Porter and Wright,2003). According to DSM-IV, three criteria must be met for a diagnosis of mental retardation: an IQ below 70, significant limitations in two or more areas of adaptive behaviour (as measured by an adaptive behaviour rating scale, i.e. communication, selfhelp skills, interpersonal skills, and more), and evidence that the limitations became apparent before the age of 18 (Sebastian, 2007). Jayanti (1989) has provided educational classification of the levels of Mental Retardation. Children with mental retardation may learn to sit up, to crawl, or to walk slightly later than other children. Both adults and children with mental L.N.Bunker, Ph.D, Asso. Professor, Subhash Meena, Research Scholar, Email: sbhshmeena@yahoo.com (corresponding author) and Laxmi Prajapat, M.A. (Psy), Dept. of Psychology, Jai Narain Vyas University, Jodhpur-342001 Keywords: behavioral assessment, mental retardation retardation may also exhibit some of the following characteristics: delays in oral language development, deficits in memory skills, difficulty learning social rules, difficulty with problem solving skills, delays in the development of adaptive behavior such as self-help or self-care skills, lack of social inhibitors. They generally take longer to learn language, develop social skills, and take care of their personal needs, such as dressing or eating. Nevertheless, virtually every child is able to learn, develop and become a participating member of the community. Individuals with developmental disabilities often experience challenges in acquiring toileting skills, which highlights a need for effective toilet training strategies that can be readily disseminated to caregivers (Rinald and Mirenda, 2012). Treatment of Mental Deficiency: As such there is no particular treatment to cure the mental deficiency, yet such children needs proper care and attention to keep them physically well. They need continuous training and support to be well kept, clean, well dressed and timely check for proper hygiene. It has been observed that many such children do not grow properly yet, they can learn to adjust to their environment and may lead a normal life. Educating their parents and significant others in their surrounding helps in big way. They should be informed about the limitations of these children. As such they can add in improving the happiness of these children by providing healthy home environment, regular health check-up,

positive attitude of family members, particularly the parents and mixing with normal children of the family and surroundings. Occupational therapy has proved to be very effective in treating MC children and preventing the development of further defects. There are thousands of agencies worldwide, that providing assistance to help such people. Right from day care centres to residential homes, special schools, rehabilitation centers, non-profit centers providing training to learn some skill what they can, and petty jobs to make them occupied gainfully. There are many agencies who are organizing programs for parents of such children to understand how to help and grow these children. Behavior Assessment: A functional behavioral assessment looks beyond the ordinary behavior. The focus when conducting a functional behavioral assessment is on identifying significant, person-specific social, affective, cognitive, and environmental factors associated with the occurrence (and nonoccurrence) of specific behavior. This broad perspective offers a better understanding of the purpose behind behavior. Behavioral intervention plans is based on an understanding of "why" the child's behavior is extremely useful in addressing a wide range of problems. A behavioral assessment should provide descriptive information about the functional abilities of child by assessing his/her adaptive behavior by using a standard assessment tool. Heber (1961) described adaptive behaviour as, "the effectiveness with which the individual copes with the nature and social demands of his environment". Prior to the development of adaptive behaviour scales and intelligence tests, "social incompetence" was the main characteristic used to determine whether a person was mentally retarded (Nihira, 1969).This systematic observation and analysis of Child's skills and deficits forms the basis of the educational programming. It identifies the individual's present developmental level and planning for developing different skills in future. With this background, the present study makes an attempt to perform behavioural assessment of mentally challenged children before and after a training programme using a standardized behavioural assessment tool. Method: Sample: The study was conducted on a purposive sample of 10 mentally retarded (MR) children who met the DSM-IV criteria of MR. The participants were recruited from TEPSE and HEPSEN institute, Jodhpur. Tools and Procedure: Madras Development Programming System (MDPS) Behavioural Scale developed by Jeyachandran, et. al., (1975) was administered for behavioural assessment. The Scale has six domains: •Post GMA / Pre GMA: Domains of improvement in the Gross Motor Activities. •Post FMA / Pre FMA: Domains of improvement in the Fine Motor Activities. •Post MTA / Pre MTA: Domains of improvement in the Meal Time Activities. •Post D / Pre D: Domains of improvement in the Dressing. •Post TA / Pre T: Domains of improvement in the Toileting Activities. •Post RL / Pre RL: Domains of improvement in the Receptive Language. The aforesaid measure was administered on the MR children individually before the start of the training and after completion of the training. To detect transfer effects, the training and pre/posttraining sessions employed different tasks hypothesized to rely on similar interference resolution mechanisms. Pre and post-trial behavioral adjustments were also analysed to assess potential mechanisms of traininginduced improvements. Relative to pre-training, participants showed reduced reaction time (RT) in post trials, suggesting improved interference resolution. 138 Bunker et al

Behavioral Assessment of Mentally Challenged Children 139 It is evident from the table that as compared to pre-training session the participants showed significant improvement on all the six domains after completion of the training as evident from higher post-trial score. This pattern of findings suggest that training can bring significant improvement in the activity level of MR children and imply that MR children are amenable to behavioural training. The present study was conducted to find out the level of behavioural improvement among mentally challenged children using the behavioral assessment approach. To fulfil the objectives, 10 mentally challenged children were administered MDPS Scale before and after a training programme. The finding that MR children showed significant improvement in all 6 domains of pre and post activities suggest that training brought overall improvement. The credit of this improvement can be given to training activities and positive family environment. Parents/family involvement in the teaching or training of these children increases the personal worth and sense of participation. The parents become more active to fulfil the requirements of their children. It also helped in learning the cleaning and bathing activities of children. Beyond that there are specific programs where they can learn basic life skills, though they take comparatively longer time to accomplish. Such skills as tooth brushing, bathing, clean toilet habits; dressings etc. help them to lead an independent life with little support. Once they become independent, they learn newer skills even late in their life with the help of their families, caregivers and clinicians. However, changes to normal behavior depend on the severity of the condition of retardation. The mild retardation may be associated with a lack of curiosity and quiet behavior, while severe mental retardation is associated with infant-like behavior throughout life (Shapiro, 2007). It is easier to train children with mild sub normality but tough to change children with severe sub normality. Continuous efforts and regular intervention do bring some noticeable change. Table 1 Mean Scores on Pre and Post trials on MDPS Behavioural Scale DOMAINS N MEAN SD t Pre GMA/Post GMA Before=8.5 4.28 **5.08 After=17.2 2.86 Pre FMA/Post FMA Before=8.2 5.08 *2.74 After=13.9 3.62 Pre MTA/Post MTA Before=8.4 4.4 **4.34 After=16.0 2.90 Pre D/Post D Before=7.8 4.8 *2.31 After=12.6 3.98 Pre TA/Post TA Before=6.6 5.31 **3.91 After=14.4 2.72 Pre RL/Post RL Before=9.4 5.6 **3.16 After=16.9 4.40 Results and Discussion: The mean score (along with SD) on the six domains of the MDPS behavioural scale was computed for pre and post- training period and the significance of difference was examined using t test. The obtained findings have been presented in Table1. *p<0.05, ** p<0.05 & 0.01

Behavioural training and psycho-educational programmes bring positive behavioural changes in MR children is supported by numerous studies. For instance, Uma (1989) studied 90 children with mental retardation of mild, moderate and severe degree from four special schools in Bangalore. 45 children had undergone yogic training for one academic year (5 hours weekly) with an integrated set of yogic practices (such as breathing exercises, pranayama, loosening exercises, surya namaskar, yogasanas and meditation. They were compared before and after yogic training with a control group of 45 mentally retarded children matched for age, sex, IQ and socio-economic status, who were not exposed to yoga training but continued their usual school routine. The experimental group improved significantly in social adaptation as compared to the control group. The present study supported the findings of Uma (1989). Conclusion: The findings of the present study emphasised the needs of continuous training program to improve the activities level of mentally challenged children. They need regular monitoring to develop skills required at different age level. The findings further indicated that a well-specified training program aimed at improving child's development and peer competencies may be of great significance particularly in case of mentally challenged children. References: Heber R. F. (1961). A Manual on Terminology and Classification in Mental Retardation. (Rev. Ed.) Monograph supplement, American Journal of Mental Deficiency. Jeyachandran P. et. al., (1975) Madras Developmental Programming System, Vijay Human Services, Madras, India. Nihira K. (1969). Factorial Dimensions of Adaptive Behaviour in Adult Retardates. American Journal of Mental Deficiency. Porter, R and Wright, D. (2003). The Confinement of the Insane: International Perspectives, 1800-1965. Cambridge University Press. Rinald, K. and Mirenda,P. (2012). Effectiveness of a modified rapid toilet training workshop for parents of children with developmental disabilities. Research in Developmental Disabilities, Volume 33, Issue 3, Pages 933- 943. Shapiro, B.K, and Batshaw, M.L. (2007). Mental retardation (intellectual disability). In: Kliegman RM, Behrman RE, Jenson, H.B., Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 38. Sebastian Simon(2007). Mental Retardation, eMedicine,08- 23. Uma, K., Nagendra, H. R., Nagarathna, R., Vaidehi, S. and Seethalakshmi, R. (1989). The integrated approach of yoga: a therapeutic tool for mentally retarded children: a one-year controlled study. Journal of Intellectual Disability Research, 33: 415-421. 140 Bunker et al

addition to some important psychological changes some of which may have adverse birth outcomes. The focus of the present study is on the effect of depression associated with pregnancy on the birth outcomes. It has been well documented that women often suffer from depression during the pregnancy (Cox, Connor, &Kendell, 1982; Spinelli, 1997; Kitamura, Shima, Sugawara, & Toda, 1996) and this antepartum mood dysregulation may have significant impact on maternal and fetal wellbeing. Several studies have demonstrated that depression during pregnancy is associated with adverse birth outcomes (Orr & Miller, 1995; Steer, Scholl, Hediger, &Acher, 1992). One of the adverse birth outcomes of depression during pregnancy that has been widely documented is the low birth weight (Zimmer-Gembeck&Helfand, 1996; Paalberg, Vingerhoets, Passchier, Heiner, &Vangeijn, 1999). For instance, it has been noted in a study that women with depressive symptoms late in pregnancy had a 3.97 risk of delivering a low birth weight, a 3.3 risk of delivering before gestation, and 3.02 risks for Sukautrive growth rate (Steer et. al., 1992). Higher levels of depression during pregnancy has been found to be associated with more pregnancy complication, perinatal deaths,premature births, and poorer infant states scores (McDonald etal, 1963; Pilowsky& Sharp, 1971; Zax, Sameroff, &Farnum, 1975). Many studies have indicated that depression and anxiety during pregnancy affect neonatal outcome including the increased risks of spontaneous preterm delivery, low birth weight, operative delivery (cesarean section and instrumental vaginal delivery), and admission to a neonatal intrusive care unit among offspring of women with antenatal depression (Chung, Lee, Yip et al., 2001; Hoffman & Hatch, 2000; Orr, James, Blackmore, & Prince, 2002). Preceding evidences though suggest that depression during pregnancy is associated with adverse birth outcomes, some researchers failed to support this finding (Perkin, Bland, & Peacock, 1993; Peacock, Bland, & Anderson, 1995). Such observations not only contradict the notion that depression during pregnancy may lead to adverse birth outcomes but also put a need to further examine this issue. Given the substantial prevalence and adverse effects of depression during pregnancy and inconsistency in findings regarding its impact on perinatal outcomes, the present study reexamined the relationship of depression during pregnancy with poor perinatal or birth outcomes. More specifically, the present study examined the relationship of depression during pregnancy with gestational age, birth weights of infants, and apgar scores of 1 and 5 minutes of infants. It was

hypothesized that depression during pregnancy would have significant adverse effect on neonatal outcomes in terms of lesser gestational age, lower birth weight, and apgar scores of 1 and 5 minutes of infants. Method: Sample: The study was conducted on the sample of two hundred pregnant women in second trimester and third trimester of their pregnancy and aged between 20-30 years. The participants were recruited from Obstetrics Department of Institute of Medical Sciences, Banaras Hindu University of Varanasi. Only those participants were included in the present study who were able to read and write Hindi and reported no psychological or psychiatric disease necessitating hospitalization. Those pregnant women were excluded from the present study who were HIV positive or were having chronic infectious diseases, cardiopathy, mental diseases, hypertension/preeclampsia/eclampsia. Those who reported vaginal bleeding or multiple deliveries were also not included in the study. Tools: Depression was measured using the Centre for Epidemiological Studies Depression Scale (CES- D; Radloff, 1977). It consists of 20 items and includes content such as depressed mood, feelings of guilt, worthlessness, helplessness and hopelessness, loss of energy, and sleep and appetite disturbances (Radloff & Teri, 1986). Respondents rate the frequency of 20 symptoms ranging from 0 "rarely or none of the time" to 3 "most or all of the time". A total score that ranges from 0 to 60 is calculated by summing all items. 142 Kumari & Joshi The scale has demonstrated satisfactory reliability and validity (Radloff& Teri, 1986). Neonatal outcomes measures were obtained from hospital records and it included three neonatal outcomes i.e., gestational age, infant weight and apgar score of 1 and 5 minutes. All the three outcomes were treated as continuous variable. Gestational age was measured in weeks at delivery using "37 weeks" clinical criterion. Infant weight was measured in grams using "2500 grams" clinical criterion. Apgar score was determined by evaluating the newborn baby on five simple criteria on a scale from zero to 10. The five criteria included Appearance, Pulse, Grimace, Activity, and Respiration. Scores <3 are generally regarded as critically low, 4 to 6 fairly low and 7 to 10 generally normal. Procedure: Before collecting the data participants were informed about the objectives of the study and their informed consent was obtained. The data was collected in two sessions and the sessions were arranged in such a way that it coincided with the subject's antenatal clinic appointment. The self-report measure of depression was administered individually and the information regarding birth outcomes was obtained from hospital record after delivery. Results: Table 1 presents the correlation between demographic variables and pregnancy outcomes. It is evident from the table that all of the demographic variables are significantly related to pregnancy outcomes. Table 1 Correlation between Demographic Variables and Neonatal Outcomes Gestation age Infant weight Apgar score 1 minute Apgar score 5 minute Age -.360** -.374** -.394** -.393** Education .319** .372** .346** .345** Income .328** .362** .409** .435** Parity .153* .148* .181* .185** BMI 2nd trimester .406** .442** .501** .522** BMI 3rd trimester .468** .488** .556** .566** * p<0.05, ** p<0.01

Neonatal Outcomes in Women with Depression 143 The age of the mother was significantly negatively correlated with the gestational age (r= -.36, p<0.01), birth weight (r= -.37, p<0.01) one minute apgar score (r= -.39, p<0.01) and five minutes apgar score (r=-.39, p<0.01) of the infants, indicating that mothers with higher age were more likely for having a infant with less gestational age, birth weight, and lower apgar score of infant. But, education was significantly positively correlated with gestational age (r= .31, p<0.01), infant weight (r= .37, p<0.01), apgar score 1 minute (r= .34, p<0.01) and apgar score 5 minute (r= .34, p<0.01). Similarly, income and parity was significantly positively related to gestational age (r= .32, p<0.01 & r= .15, p<0.05), infant birth weight (r= .36, p<0.01 & r= .14, p<0.05), and apgar score of 1 minute (r= .40, p<0.01 & r= .18, p<0.05) &apgar score of 5 minutes (r= .43, p<0.01, r= .18, p<0.01). Body mass index (BMI) of 2nd and 3rd trimester were also significantly positively correlated to gestational age (r= .40 & r=.46, both p<0.01), infant birth weight (r= .44 & r=. 48, both p<0.01), and apgar score of 1 min.(r= 50, r= .55, both p<0.01) and apgar score of 5 minute (r= .52 & r= .56, both p<0.01), revealing that BMI (body mass index) is an important factor in determining gestational age, infant weight, and apgar score of newborn baby. Table 2 shows the correlation between depression during 2nd and 3rd trimester of pregnancy with infant weight, gestational age, apgar score of 1 minute and apgar score of 5 minutes. As we can from the table that depression during 2nd and 3rd trimester is negatively correlated with gestational age (p<0.01), infant weight (p<0.01), apgar score of 1 minute (p<0.01), and apgar score of 5 minutes (p<0.01) showing that women who reported higher depression during pregnancy were more likely to deliver an infant of shorter gestational age and more likely to deliver a low birth weight infant along with lower apgar scores of 1 and 5 minutes. The preceding analyses revealed that the neonatal outcomes were significantly influenced by both the level of depression as well as various demographic characteristics. Thus, there is a need to examine the relationship between depression and neonatal outcomes after controlling the effects of demographic variables. For this purpose a hierarchical multiple regression analyses was conducted using depression during 2nd trimester as predictor variables and neonatal outcomes as criterion variables while controlling the effect of demographic variables. The demographic variables were entered at first step and depression was entered at second step. The findings of the analysis revealed that depression during 2nd trimester was significantly negatively correlated with gestational age (?= - .44, p<0.001), infant weight (?= -.46, p<0.001), apgar score 1 min. (?= -69, p<0.001), and apgar score 5 minutes (?= -.70, p<0.001) even after controlling the effects of demographic variables. After controlling the effect of demographic variables, the depression explained 7.7% of the variance in gestational age, 8.3% of the variance in infant weight, 18.7% of the variance in apgar score 1 minute and 19.3% of the variance in apgar score 5 minutes. The result suggests that higher depression during second trimester is predictive of lesser gestational age, infant weight, apgar score of 1 min. and apgar score of 5 min. Table 2 Correlations between Depression of 2nd and 3rd Trimester and Neonatal Outcomes Gestation age Infant weight Apgar score of Apgar score 1 minute of 5 minute Depression 2nd trimester -.593** -.632** -.764** -.782** Depression 3rd trimester -.604** -.636** -.771** -.781** ** p<0.01

144 Kumari & Joshi A similar hierarchical regression analysis was conducted using depression of 3rd trimester as predictor variable and pregnancy outcomes as criterion variables. The findings revealed that depression was significantly negatively related to gestational age (?= -.53, p<0.001), infant weight (?= -.50, p<0.001), apgar score of 1 minute (?= - .61, p<0.001) and apgar score of 5 minutes (?= - .58, p<0.001) even after controlling the effect of demographic variables. Further, it was also observed that depression accounted for 11.6% of the total variance on gestational age, 10.3% of total variance on infant weight, and 15.2% of total variance on apgar score of 1 minute and 14.1% of total variance on apgar score of 5 minutes. Thus, the result indicates that higher depression in 3rd trimester may adversely affects the pregnancy outcomes in terms of gestational age, infant weight, and apgar score of 1 & 5 minutes. Discussion & Conclusion: The aim of the present study was to examine the relationship between depression and neonatal outcomes. Results from the present data indicate that depression during pregnancy may have deleterious effects on neonatal outcomes. The present finding is consistent with earlier observations that depression during pregnancy is linked with low birth weight (Zimmer- Hembeck&Helfand, 1996; Paalberg, et al., 1999). Several other studies which showed that women with depressive symptoms had more chances of delivering a low birth weight and preterm baby (Dayan et al., 2008; Steer, School, Hediger, &Acher, (1992). These studies provide further support to the findings of the present study. Based on the findings of present study this paper confirms that women experiencing more depression during pregnancy had more chances of delivering an infant of low birth weight and preterm gestation along with lower apgar scores. The existing literature examining the relationship between depression and birth outcomes provides controversial results, as some studies didn't find any association between these variables. The present piece of work provides some information for clarification of the nature of the relationship between depression (during pregnancy( and neonatal outcomes and significantly adds to the existing literature. Future research should be conducted with methodologically sound proceduret to clarify the nature of relationship between these variables. However, there are several limitations to the study. This study was conducted on healthy group patients by leaving the high-risk patients and the present study had focused on ante partum depression of pregnancy not on the postpartum mental states. Therefore, future research could focus on the sample of high-risk pregnant women and on postpartum mental states. We hope our findings will stimulate further research that would yield empirical evidence to support better detection and screening of antepartum mood states. References: Chung, T. K., Lau, T. K., Yip, T. K., et al., (2001). Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes. Psychosomatic Medicine, 63, 830-834. Cox, J. L., Connor, Y. M., &Kendell R. E. (1982).Prospective study of the psychiatric disorders of childbirth.British Journal of Psychiatry, 140,111-17. Dayan,P.&Huys,Q.J.M(2008).Serotonin,inhibition,and negative mood.PloSComput Biol,4(2)e4. Hoffman, S. & Hatch, m. C. (2000). Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women. Health Psychology, 2000, 19, 535-543. Kitamura, T., Shima, S., Sugawara, M., & Toda, M.A. (1996). Clinical and psychosocial correlates of antenatal depression: a review.Psychotherapy Psychosomatics, 65, 117-23. Mc Donald, R. L. &Christiakos, A. C. (1963).Relationship of emotional adjustment during pregnancy to obstetric complications in unmarried primigravidas.American Journal of Obstetric Gynecology, 90, 195-201. Orr, S. T., James, S. A., & Blackmore Prince, C. (2002).Maternal prenatal depressive symptoms and spontaneous preterm Birth among Afirican-American women in Baltimore, Maryland.American Journal of Epidemiology, 156, 797-802. Steer, R. A., Scholl, T. O., &Hediger, M. L. etal. (1992). Selfreported depression and negative pregnancy

Neonatal Outcomes in Women with Depression 145 outcomes. Journal of Clinical Epidemiology, 45, 1093- 1099. Paalberg, K. M., Vingerhoets, A. J., Passchier, J., Dekker, G. A., Heinen, A. G., & Van Geijn, H. P. (1999). Psychosocial predictors of low birth weight: a prospective study. British Journal of Obstetrics and Gynecology, 106, 834-841. Peacock, J. L., Bland, J. M., Anderson, H. R. (1995). Preterm delivery: effects of socioeconomic factors, psychological stress, smoking, alcohol, and caffeine. British Medical Journal, 311, 531-535. Perkin, M. R., Bland, J. M., & Peacock, J. L. etal (1993).The effects of anxiety and depression during pregnancy on obstetric complications.British Journal of Obstetric and Gynecology, 100, 629-634. Pilowsky, I. & Sharp, J., (1971). Psychological aspects of pre-eclamptictoxaemia: a prospective study. Journal of Psychosomatics Research, 15, 193-197. Spinelli M. G. (1997). Interpersonal psychotherapy for depressed antepartum women: a pilot study. Ame J. Psychiatry, 154, 1028-30. Zax, M., Sameroff, A., &Farnum, J. E. (1975).Childbirth education, maternal attitudes and delivery. American Journal of Obstetrics Gynecology, 123, 185-190. Zimmer-Gembeck, M. J. and Helfand, M. (1996). Low birthweight in a public prenatal care program: behavioral and psychosocial risk factors and psychosocial intervention. Social Science Medicine, 43,187-97.

Dear SIS Members and friends, You will be pleased to learn that both SIS-I instrument are available on Website for online assessment. If you want to use these techniques for personality assessment, clinical diagnosis/treatment or research, you are welcome to contact us regarding any help we might be able to provide. You are invited to view these on the following websites: http://psyche.dubay.bz We will welcome comments, suggestions and any constructive criticism about the SIS applications. We also invite your contributions to our SIS Journal, related to projective psychology and mental health. Looking forward to hearing from you! Sincerely Wilfred A. Cassell, Email: siscassell2@yahoo.com Bankey L. Dubey, Email: bldubey@gmail.com RakeshPandey, E-Mail: rpan_in@yahoo.com SOMATIC INKBLOT SOCIETY IS PUBLISHING ITS JOURNAL SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH a half yearly publication in January and July. It started in 1994 and has published 39 issues in 20 years. The Journal is available on Society's Web Site at http: //www.somaticinkblots.com The Journal from Volume 1-18 is available in (Acrobat ) Members of Somatic Inkblot Society can get it on a nominal payment of US $50 (for Overseas Members) and Rs.1500/- (for Indian Members). The Individual and Institutional Members of Somatic Inkblot Society/SIS Journal Can get the current issue and future issues of the Journal through Electronic mail free of charge Please indicate if you wish to get the Journal inHard Copy or through Electronic mail To: Bankey L. Dubey, Ph.D., DPM, DM&SP, Editor Emeritus, SIS J. of Proj. Psy. & Mental Health, E-mail : bldubey@gmail.com OR RakeshPandey, Ph.D., FSIS, Editor in Chief, Professor, Dept. of Psychology,Banaras Hindu University,Varanasi-221005 Cell:91-9415812329, E-Mail: rpan_in@yahoo.com

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Abstracted in "APA's Psyc INFO" Regd. No. 71632/99, RNI Delhi SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH EDITORS EMERITUS : Wilfred A. Cassell, MD, Director, SIS Center, 4501E,104th Ave, 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 Amool R. Singh, Ph.D., Director, RINPAS Kanke, Ranchi-834006 (India). Cel.:91-9431592734, E-mail:sisamool@yahoo.com EDITOR-IN-CHIEF : Rakesh Pandey, Ph.D. Professor, Dept. of Psychology, Banaras Hindu University,Varanasi-221005 Cell:91-9415812329, E-Mail: rpan_in@yahoo.com EDITORS : Silvia Daini, M.D., Instituto di Psichiatria e Psicologia, UniversitàCattolica del SacroCuore, Roma, Largo Francesco Vito 1, 00168, Rome ( Italy) Email: daini@katamail.com Anand Dubey, MBA, 4406 Forrest Road, Anchorage, AK 99517 E-Mail: anand.dubey@gmail.com L. Sam S. Manickam, Ph.D., Professor Dept of Psychiatry, JSS University, Mysore, 570004,Email: lssmanickam@gmail.com Nilanjana Sanyal, Ph.D., Prof. Dept. of Psy, University of Calcutta, 92 A. P. C Road, Kolkata-700009 Email: sanyal_nilanjana2004@rediffmai.com, M. P. Singh, Ph.D. 1329, Sec.70,G.T.B. Complex, SAS Nagar (Punjab) Email: mpsingh1329@gmail.com EDITORIAL CONSULTANTS : Yogesh K. Arya, Ph.D., India Jayanti Basu, Ph.D. India Antonio Cervigni, M.A.., Italy Suprakash Chaudhury, M.D., Ph.D.India Carina Coulacoglou, Ph.D., Greece Manisha Dasgupta, Ph.D. India Akanksha Dubey, M.A., India Padma Dwivedi, M.A., USA R.P. Gupta, M.A., India M. Jahan, Ph.D., India Anatoly B. Khromov. Ph.D., Russia H. Kumar, Ph.D., USA Rakesh Kumar, Ph.D., India Ranjeet Kumar, Ph.D., India S.P. Mandal, M.Sc., India Lisa Milne, Ph.D., Australia Nalini Mishra, Ph.D., India Tilottama Mukharjee, Ph.D., India Paola Nicolini, M.A., Italy Edward M. Petrosky, Ph.D., U.S.A. Stefano Reschini, M.A, Italy Barry A. Ritzier, Ph.D., U.S.A. Brig. D. Saldanha, M.D. India Radhe Shyam, Ph.D.India R.N. Singh, Ph.D., India Umed Singh, Ph.D. India Ajay Tiwari, Ph.D., India Ailo Uhinki, Ps.D., Finland Yasho V. Verma, Ph.D., India Robert B. Williams, Ph.D., Canada Volume 20 Number 2 July, 2013 Registered Journal, The Office of the Registrar of Newspapers for India (Regd. No. 71632/99, RNI Delhi)