SIS Journal of Projective Psychology & Mental Health

ISSN 0971-6610 SIS Journal of Projective Psychology & Mental Health Volume: 27 Number: 02 July 2020 Editorial Assessment of Depression: Which are the Prominent Mental Health Instruments in Research Studies? Chris Piotrowski 63-67 Presidential Address: Advances in Projective Psychology: Techniques and Applications Bankey Lal Dubey 68-70 Understanding Rorschach Research: Using the Mihura (2019) Commentary as a Reference Jason M. Smith, Carl B. Gacono, Patrick Fontan, Ted B. Cunliffe, & Anne Andronikof 71-82 Co-Morbidity of Sleep Disorders in Veterans with PTSD: An Integrated Synopsis of 109 Studies (1995-2020) Chris Piotrowski 83-97 Psychological Trauma and Resulting Physical Illness: A Review Rachana Kumari and Anjana Mukhopadhyay 98-104 Somatic Imagery Test (SIT) as a Measure of Trauma Resolution in a Case of Abortion Nicole Compagnoni & Bankey L. Dubey 105-111 Therapeutic Intervention through Somatic Imagery Test - A Case Study Shubhika Singh & Bankey L. Dubey 112-115 Sensitivity of SIS-II scoring system in detecting specific delusion in patients with Schizophrenia: Preliminary Observations Shivani Singh & Satyadhar Dwivedi 116-119 Analysis of Psychological Interventions for Insomnia Co-morbid with Depression Vikas Sharma and Padmakali Banerjee 120-123 Official Publication of the Somatic Inkblot Society www.somaticinkblots.com

SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH is a refereed journal and published twice a year (January, July) by the SOMATIC INKBLOT SOCIETY and is devoted to the advancement of research in the areas of projective psychology, personality assessment, psychotherapy and mental health. The journal is broadly concerned with the development of inkblot tests and personality assessment in clinical, counseling, cross cultural, organizational and health psychology settings. It aims to reach clinical psychologists, psychotherapists, psychiatrists, social workers, medical professionals and professional managers interested in the understanding and modification of human behavior. The journal includes (a) research articles (b) book reviews (c) brief reports (d) news about conferences and letters to the editor. MANUSCRIPTS PREPARATION: Manuscripts should be prepared in accordance with the format of APA. The manuscript should be prepared only in MS Word. No other formats are acceptable. An MS Word Template for preparing manuscript can be downloaded from the SIS Website. MANUSCRIPTS SUBMISSION: The print version of the manuscript is not considered. The typewritten manuscript in MS Word should be submitted only through email to any one on following Email IDs. (1) Dr. Bankey L. Dubey, Ph. D. Editor Emeritus, SIS Journal, Email: bldubey@gmail.com (2) Dr. Naveen Gupta, Ph.D. Editor-in-Chief, SIS Journal, Email: dr_naveengupta@yahoo.com (3) Dr. Rakesh Kumar, Ph.D. Executive Editor, SIS Journal, Email: jain.imhh@gmail.com Note: The Editorial Board of Journal of Projective Psychology and Mental Health have full rights to accept/reject or require a re-submission of submitted manuscripts. Minor additions/ deletions/ changes can also be made in the manuscript at the level of Editors. JOURNAL SUBSCRIPTION: The Journal of Projective Psychology and Mental Health is delivered to the members of the Somatic Inkblot Society as a membership privilege according to the nature of the membership and opted preference for Print Version or Soft Copy. We encourage the individuals and Institutions to become member of the Somatic Inkblot Society on the prescribed Membership Application Form available in this issue of the Journal to receive a copy of the journal. Non-members may purchase any single issue in print version or soft copy on the prevailing rates which are quoted in the latest issue of the journal. Current Rates: Foreign: $45 and Indian Rs. 600/- per issue. (1) All online payments through NEFT/cheque/direct cash deposit for the journal should be made to following bank account: Name of Account: SIS Journal of Projective Psychology and Mental Health Bank Name: State Bank of India Branch Address: Property No.4, Block-A, Sector-23, Dwarka, New Delhi-110077, Account No. 32297525238 IFS Code: SBIN0032182 Type of Account: Saving Bank (2) The intimation of online payment, cheque or cash payment should be intimated with proof of payment to the Editor-in-Chief on following address or email ID. Please request for mandatory acknowledgement of payments. Dr. Naveen Gupta, Ph.D., Director, Hindustan Institute of Management and Computer Studies, Farah, Mathura-281122 U.P. (INDIA) Email: dr_naveengupta@yahoo.com, Cell: 91-9627182913

CHANGE OF ADDRESS: Any changes in address should be communicated for updating our records and seamless receipt of the Journal to Prof. B.L. Dubey,Email: bldubey@gmail.com Copyright ©1994.Somatic Inkblot Society, India/USA SIS Website: http://www.somaticinkblots.com

EDITORIAL Assessment of Depression: Which are the Prominent Mental Health Instruments in Research Studies? Historically, the assessment of depression has garnered a central role in evaluation of mental health (Brantley et al., 2004; Cusin, et al., 2010; IsHak et al., 2002; Piotrowski, 1996). Indeed, a perusal of 2 popular texts on psychological assessment (i.e., Hunsley & Mash, 2008; Maruish, 2000) finds several chapters on the issue of depression in children, adolescents, adults, and the elderly. Noteworthy, several modern scales purporting to assess depression levels have gained the attention of clinicians and assessment faculty. For example, instruments like the Patient Health Questionnaire (PHQ-9), the Patient-Reported Outcomes Measurement Information System (PROMIS; Young et al., 2019), and the Hospital Anxiety and Depression Scale (HADS: see Turk et al., 2015) may offer alternative avenues for the efficient, brief assessment of mood states. A careful review of rankings of the most popular tests reported in „test usage‟ studies, over the past 50 years, indicates that symptom-focused scales in the area of depression have been quite prominent (see Archer et al., 1991), including usage at psychology internship sites (Piotrowski & Belter, 1999). Piotrowski and Lubin (1990) found the following instruments highly ranked by clinicalhealth psychologists in the assessment of depression: the MMPI, Beck Depression Inventory, Profile of Mood States, the Zung Self- Rating Scale for Depression, the CES-D; the Children‟s Depression Inventory and the Geriatric Depression Scale were used moderately. More recently, a national survey of professional psychologists found that symptom-specific measures, including the Beck Depression Inventory (BDI), were the most frequently used tests (Wright et al., 2017). It would be of interest to examine the level of clinical acceptance of various measures of depression over the past few decades. One approach would be to determine the magnitude of usage of depression assessment instruments most noted by researchers in the mental health field. To that end, the current exercise involved an online search in the database PsycINFO. The main keyword was „depression‟ which needed to appear as a term in the Title of published articles. In order to appreciate changes over time, this analysis was performed across 3 timeframes (1920-1989; 1990- 2004; 2005-2020). The issue was not in the total number of articles, but in the ranking of the top tests which were the most emphasized across research studies. Table 1 presents the aggregated results of these analyses, with a listing of the top assessment instruments cited across thousands of studies. Interestingly, the BDI (I & II) and the Hamilton Rating Scale for Depression were the top 2 tests across all time frames. Table 1. Top Assessment Instruments in Research on Depression indexed in PsycINFO 1920-1989 (Total n=6,688 articles) 1990-2004 (Total n=16,996 articles) 2005-2020 (Total n=41,468 articles) Beck Depression Inventory Hamilton Rating Scale for Depression Beck Depression Inventory (I & II) Hamilton Rating Scale for Depression Beck Depression Inventory (I & II) Hamilton Rating Scale for Depression SADS Geriatric Depression Scale CES-D Social Adjustment Scale Montgomery-Asberg Depression Rating scale DSM Structured Interview Children‟s Depression Inventory MMSE MMSE Dyadic Adjustment Scale Hospital Anxiety & Depression Scale Montgomery-Asberg Depression Rating Scale

Raskin Depression Scale DSM Structured Interview Patient Health Questionnaire (PHQ- 9) Symptom Checklist-90 (SCL-90) General Health Questionnaire Hospital Anxiety & Depression Scale Zung Self-Rating Depression Scale Zung Self-Rating Depression Scale Mini-International Neuropsychiatric Interview Bellevue Index of Depression Beck Anxiety Inventory A recent analysis found that the BDI was used at least moderately in 21 (60%) of the 35 surveybased studies of practice settings since 1989 (Piotrowski, 2018). Apparently, this high level of clinical acceptability has impacted professional training, in that 7 of the 10 surveys of academic settings, in the 2018 analysis, showed from moderate to high levels of training emphasis with the BDI. Thus, the BDI has been strongly embraced by mental health professionals. These findings, based on bibliometric data, can indeed inform assessment practices. The BDI is popular in mental health assessment, perhaps due to brevity, ease of scoring, specificity, and a substantial body of research literature. Moreover, the BDI furnishes the busy clinician with interpretable quantitative assessment data. This supports comprehensive mental health evaluation, in that brief, symptom-focused measures tend to facilitate treatment planning, monitoring of clinical progress, and evaluation of outcome assessment (Maruish, 2000, pp. 398-405). In fact, recent survey data indicate that professional acceptance of the Beck inventories is on the increase (see Piotrowski, 2018; Wright et al., 2017). Evidently, this popularity of the BDI has been reflected in survey studies on test usage, and in the clinical curriculum of both professional psychology training programs and internship settings in recent years (see Table 2). What factors may account for the popularity of these 2 scales? Indeed, the BDI and the Hamilton Rating Scale for Depression have had few selfreport competitors in the assessment of depression when first introduced in the mental health literature. As a result, even 30 years later, these instruments have outranked all other brief instruments used in assessing depression (see Piotrowski & Lubin, 1990). Moreover, following robust revisions, the BDI-II emerged as a muchimproved instrument both conceptually and clinically (confirmed by the positive reviews of the BDI-II in the Mental Measurements Yearbook). Table 2. Emphasis or Use of the BDI in Training/Practice Settings across Studies (2010-2017) Study Country Sample Findings Smith et al. (2010) USA 404 members of the International Neuropsychological Society or National Academy of Neuropsychology surveyed on personality assessment practices The Beck scales were used by 86% of the respondents to some degree; 30% use these inventories „sometimes‟. Donoso et al. (2010) USA 150 professionals who conduct vocational rehabilitation evaluations Amongst a variety of types of tests, the BDI ranked 5th, used by 58% of respondents. Ackermann & Pritzl (2011) USA 213 forensic psychologists surveyed on tests used with parents in child custody evaluations in 2008 The BDI was ranked 7th, and used by one-third of the sample in assessment of parents in custody evaluations. Evers et al. (2012) 17 European countries Testing practices reported by 12,606 professional psychologists in Europe Overall, the BDI was the 6th most popular test, used by 7% of respondents; in Turkey (20%), Spain (14%), Germany (12%), Austria (12%), U.K. (9%), Norway (8%), Sweden (7%), Netherlands (5%).

*Neukrug et al. (2013) USA Based on survey data from 210 counselor educators across the U.S., this study examined graduate-level coverage of assessment instruments by instructors Amongst a copious list of tests, the BDI ranked #1, covered by 99% of instructors. Peterson et al. (2014) USA 926 counselors (clinical mental health, school, occupational) rated tests of all types regarding usage Overall, amongst an extensive list of testing instruments, the BDI ranked #1 (most popular in mental health clinics). Neal & Grisso (2014) International sample: USA (45%), Canada (7%), Europe (3%), Australia- New Zealand (4%) 434 forensic examiners of professional organizations Across a variety of forensic/legal domains, the BDI was used occasionally only for „Disability‟ (17%) and „Civil tort‟ (8%) evaluations. *Ready & Veague (2014) USA Compared training in psychological assessment across 3 training models (Clinical-Science, Scientist- Practitioner, Practitioner-Scholar) in APA-Accredited programs The BDI-II was the 4th most popular test, covered between 53% and 88% of programs. *Bates (2016) USA Dissertation study, reporting views of 182 internship directors toward doctoral-level assessment training &usage of specific tests by interns BDI: 87% of these settings rely on the BDI in general; 65% of interns use the BDI frequently; 56% of directors prefer training with the BDI prior to internship. Rabin et al. (2016) USA & Canada Testing practices of 512 neuropsychologists; members of INS and NAN Among „Top‟ tests for „personality assessment‟, the BDI was ranked 2nd . *Ready et al. (2016) USA & Canada Views of Directors of internship settings on pre-internship preparation in assessment; Data based on 236 APPIC sites Among a myriad of mental health tests, the BDI-II ranked 3rd, used by 61% of the internship sites. Wright et al. (2017) USA 279 members of APA in practice, with an interest in Assessment; A cautionary note- Data based on low response rate (17%) Amongst all types of psychological assessment instruments, symptomspecific tests (e.g. BDI) were ranked #1 among the top 13 tests. *Mihura et al. (2017) USA Of 244 APA-accredited doctoral clinical psychology programs, 83 usable surveys were analyzed regarding assessment training The survey, in a general fashion, inquired about „coverage‟ in graduate-level assessment courses and practicum; The BDI was not among top tests in the domain of Personality or Psychopathology. Egeland et al. (2017) Norway, Denmark, Sweden, Finland Surveyed 702 neuropsychologists in Scandinavia on use of self-report tests and questionnaires in practice The BDI-II ranked #1, used by 63% of respondents. Note. Studies marked with asterisk (*) focused on graduate/internship training.

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. Presidential Address: Advances in Projective Psychology: Techniques and Applications Respected Chief Guest Dr. Subodh Kumar, Member secretary RCI, Prof. Waheeda Khan, Dean and Convener of 9th SIS International Conference, Prof. S. L. Vaya, Dr. Antino Cervigni, Dr. Antonio Cervigni, Foreign and Indian delegates, professional friends and students, Members of the Organizing Committee, Office bearers of Somatic Inkblot Society, ladies and gentlemen! On behalf of the members of the Organizing Committee of 9th SIS International Conference at SGT University, Gurugram Delhi and Somatic Inkblot Society, I welcome you to the 9th International conference of the Somatic Inkblot Society. The theme of the conference is “Advances in Projective Psychology: Techniques and Applications”. The journey of Projective Psychology & Techniques began with Sigmund Freud who defined „projection‟ as a defensive process in which impulses, wishes, and ideas of an aggressive and sexual nature are internalized since their conscious recognition would be too painful to acknowledge to the ego. In “projection”, they are placed on selected other to avoid internal conflicts temporarily. Along the way great minds like Prof. Chris Piotrowski, Prof. Murstein and Prof. Wilfred Cassell added to the popularity of projective techniques. According to Prof. Piotrowski projective techniques received their impetus as a revolution against self-report, paper and pencil tests of the first half of the twentieth century, which were notoriously susceptible to „social desirability‟ effects, or the tendency of test-takers to present themselves in the most favorable light. Per Prof. Murstein Projective techniques were envisioned by their creators as “depth” instruments, which could penetrate the individuals‟ defenses, and provide a royal road to the unconscious. Prof. Cassell has stated that the Projective methods use the language of dreams, visual imagery, and symbolic thought, the most basic forms of thinking and expression. In addition, projective tests speak the language of repression and bring whatever is buried in the mind closer to consciousness, so revealed subject matter is accessible for mental processing and dealing with reality. In my years of working with projective techniques I have found these techniques tend to more effectively penetrate a person‟s „Outer Shell‟ of defenses and surface behavior. Unlike personality questionnaires, projective tests do not require reading questions or manuals, do not offer the scope for motivational distortions in response pattern to guard one‟s social self-representation and have access to deeper internal dynamics of mental processes. As most of you are aware, Herman Rorschach introduced the first inkblot test “The Rorschach Inkblot test” in 1921 with 10 inkblots cards followed by “Holtzman Inkblot test” in 1956 with two series each with 45 cards. Then in 1980 Wilfred A. Cassell introduced the 20 card Somatic Inkblot test called SIS-I. He then introduced the 62 image SIS-II in CD and Booklet form. These tests have attracted immense interest from research scholars with twelve PhD‟s already awarded and many more in the pipeline. Five of these twelve PhD‟s have happened under the guidance of one superhuman. I will take a moment to recognize this superhuman, Dr. Rakesh Kumar. In 1994, the SIS Journal of Projective Psychology & Mental Health was launched by the SIS society. The journal has started its 27th year and is going strong under the leadership of Dr. Naveen Gupta, Editor in Chief and Director of Hindustan Institute of Management & Computer Studies, Farah, Mathura. The Somatic Imagery test measures certain important personality traits such as Productivity, Imaginative ability, Controlled emotionality, Good adjustment, Group conformity, Interpersonal relationship, Team building, Sharing common view of things, Self/Ego states, Erotic fantasy,

Pessimistic attitude, Aggressive expression and Suspicious attitude. The instrument measures these traits in high and low scores. It is an agile personality assessment tool that can be used by Clinical Psychologists, Counselors, School Psychologists, Mental Health Practitioners and HR Professionals. Application of Somatic images empowers the assessment processes by rapidly screening a person with desirable and undesirable personality traits. It also brings to surface the information that the individual fails to report in a standard interview process. Moreover, once a candidate is selected, having the opportunity in follow-up session to retest him/her with the relatively objective computerized instrument, can prevent economic losses, that occur when the person/incumbent becomes a full-time employee and found to be a mismatch for the job. In viewing semi-ambiguous stimuli, deep-seated material that was previously forgotten may be brought into awareness. For example, if the individual had traumatic experiences in the past, this unresolved memory could distort and emotionally color his/her perception of the situation at work. „TAT‟ and „Word Association Test‟ are included in the Armed Forces Selection Board in India. HIT and Somatic Inkblot Test have been used successfully as „group administered‟ test on general population and in industry. In its electronic form, the SIT procedure with accompanying software programs facilitates an easy and quick interpretation of the scores. The respondents are asked to write the responses on each image. At the end of the test, the responder is asked to select the „most liked‟ and the „least liked‟ images, including the reasons for the selection. The results are interpreted by a software and a report for the responder is generated. The report is used by practitioners in the management of conflict resolution for teams, productivity management for teams, team selection, cost reduction exercises, stress management and employee morale management. We have also noticed positive changes in the responses on Somatic imagery after 10 to 15 session of psychotherapy. The test works as psychological thermometer and indicates the effect of pharmacological or psychotherapeutic intervention. The process of relaxation technique which we normally induce in most of the cases and ask the client to practice it at home is illustrated in SIS Journal of Projective Psychology & Mental Health. Those practicing yoga and subjective introspection and hence is dwelling in the area of subjective well-being will appreciate and enjoy the reported publications. In 1996 SIS research scholar Anand Dubey began his journey of combining the SIS tests with computing technology with the goal of automating administration, scoring and case management. After two decades of research and application of the automated tests in both clinical and industrial settings, Mr. Dubey released the cloud based 30 images Somatic Imagery Test. He also created a mental health management system that helped clinicians and practitioners in automating the entire test life cycle. Today the SIT 30 is being used in clinical setting for Personality Assessment and Therapeutic Intervention, it is being used in business organization for team building and team selection, it being used for detecting Sex offenders in school systems and last but not the least as a social Match Making tool. What makes the SIT 30 unique is that people can take the test in the privacy of their own homes while feeling secure, uninterrupted and confident. The responses given on various images are analyzed via an analysis game and then shared with individual clients with possible solutions. The mental health management system allows a global team of experts to be utilized in providing analysis and intervention. Robust case management and artificial intelligence is built into the mental health management system and this allows quick and effective intervention. The online portal is available worldwide and is bringing consumers and providers together despite geographical barriers. Still more promising is the tele-therapy where expert can select and administer the psychotherapy suitable to the client remotely. Cognitive behavior therapy, cognitive drill, psychoanalytically oriented psychotherapy, coupled with meditation, yoganidra and hypnotic relaxation are much practiced techniques. Indian psychologists were

the first to recognize the centrality of the concept of self in the personality and developed technique of yogic meditation, the basis of many healing programs. Yogic meditation helps in controlling the mind body functions. A logical extension of this is the interest of many Indian mental health professionals in SIT, which attempts to establish the psychopathology of problems and effective psychotherapeutic intervention. I would like to share our plan in future. We have launched the Dubay Healing Center under the leadership of Anand Dubey with the mission of raising the level of mental health education and intervention worldwide. The Dubay Healing Center team is utilizing the latest techniques in artificial intelligence to categorize, score and interpret patient and client responses using established norms. A large data warehouse is bringing documented/published cases from research to real life practice and thus providing an invaluable aide to diagnostic practices and practitioners. A whole new generation of computer savvy psychologist can utilize the DHC system to learn projective techniques and raise the rates of therapeutic intervention worldwide. • Imagine being able to administer the SIT via any computing device. • Imagine having the test and its responses being available for many years. • Imagine having a game that allows you to analyze responses with hints and prompts. • Imagine being able to share your analysis with a global list of experts and garnish their knowledge. • Imagine being able to help 10 patients in the time it takes to help one. I invite you to administer the SIT 30 available at dubayhealingcenter.com. You can also download our Journal and published cases from the DHC portal of the journal website www.somaticinkblots.com. I would also like to thank SAGE publications and my co-authors Anand Dubey and Padmakali Banerjee for helping bring to reality my latest book titled “Inkblot Personality Test: Understanding Unconscious Mind”. This incredible journey of the Somatic Inkblots and SIS Journal of Projective Psychology and Mental Health would not have been possible without the incredible contributions of Maj. General K. R. Banerjee, Brigadier Daniel Saldanha, Col. Suprakash Chaudhury, Professors Nilanjana Sanyal, Prof. Jayanti Basu, Dr. Antonio Cervigni, Dr. George Savage, Prof. Amool R. Singh, Prof. Rakesh Pandey, Prof. Sam Manickam, Dr. Manisha Dasgupta, and Members of the Editorial Board of SIS Journal of Projective Psychology & Mental Health. Thank you for your support. Last but not the least, I need to recognize Shweta Sharma, General Secretary of the SIS society whose invaluable hard work has made this conference possible. Jai Hind! Bankey Lal Dubey, Ph.D., DM & SP, DPM. President Somatic Inkblot Society, Global Director Dubay Healing Center (USA) 7490 Coon Club Road, Medina, OH-44256 (USA) Email: bldubey@gmail.com

surrounding our internal validity criteria and our approach to validating Rorschach research. Mihura also conducted additional statistical analyses that failed to address important, critical issues. In this article, we further clarify the importance of refining internal validity criteria for Rorschach research and Rorschach metaanalytic studies (our 2018 article). We offer this information and analysis to guide the Rorschach consumer toward a better understanding of how to assess the validity of Rorschach data and empirical findings. Criticisms of our criteria for evaluating Rorschach research (inter-rater reliability, IQ/Education level, Rorschach Responses, Lambda/F%, sample size) and our recommendation to include descriptive data for critical variables in all published Rorschach studies contradict accepted standards for Rorschach research. Mihura stated that ―the associations between the Rorschach and self-report measures were not used to determine the validity of Rorschach variables‖ (p. 171) in her meta-analyses. Consequently, we applied our methodological criteria to only Mihura‘s externally assessed criteria studies (removing self-report studies; 67%) and found that 91% had three or more problems related to internal validity (13 had counter-intuitive findings). In addition, other central issues related to meta-analyses, application/validation studies, and counter-intuitive findings regarding the Rorschach were discussed. Introduction: The goals of the Smith et al. (2018) article, ―A Scientific Critique of Rorschach Research: Revisiting Exner‘s Issues and Methods in Rorschach Research (1995)‖ were to 1) better understand the quality of Rorschach research studies--using criteria presented in Exner‘s (1995a) edited Rorschach research book and more recent evaluation criteria (Cunliffe et al., 2012; Gacono, Loving, & Bodholdt, 2001); 2) to offer understandable criteria for the Rorschach practitioner, manuscript reviewer, and researcher to assess the validity of Rorschach research; 3) to challenge, support, or offer cautions on the use of meta-analytic articles that significantly impact the applied usage and acceptance of the Rorschach and other psychological measures (also see Andronikof, 2019; Fontan, 2019; Fontan & Smith, 2018; Gacono, 2019); and 4) ultimately to help reduce poorly designed studies that contribute to apparent controversies in the Rorschach literature—at a time when this body of Rorschach research mostly contribute to the devaluation of the instrument. Primarily using the meta-analyses of Mihura, Meyer, Dumitrascu, and Bombel (2013) as our ―subject‖, as it was a recent study, we sought to examine the methodology used in individual studies (application versus validation) and to determine if these studies accounted for inter-rater reliability, presented descriptive statistics for IQ/Education, Lambda/F%, number of Rorschach Responses, and had an appropriate sample size (these would be found in a method section, hence methodology). The importance of these descriptions has been discussed in depth previously, and in the case of Lambda more recently (see Gacono, 2019). Our article resulted in a critique from Mihura (2019) published in Rorschachiana. As we were not offered the opportunity to provide a comment to further clarify any unresolved issues, one is offered here1. It was suggested that we attempted to evaluate the impact of Exner (1995a) before and

after its publication, specifically stating an ―article [that] is framed as a formal evaluation of whether researchers have followed Exner‘s (1995a) recommendations in his Rorschach methodology book– but this research question is not tested‖ (Mihura, p. 170). However, our purpose was ―In this article, the studies from the Mihura et al. (2013) meta-analyses were analyzed examining their quality in light of Exner (1995a) and others (Cunliffe et al., 2012; Gacono et al., 2001)‖ (Smith et al., 2018, p. 188). Our objectives were neither to assess researchers‘ compliance to Exner‘s and his co-contributors (1995a) research criteria, nor to determine if researchers had been applying these criteria after 1995. Our point was and is that these well accepted criteria, should have been considered when selecting studies for inclusion in Rorschach meta-analyses, because retrospectively, these criteria, when not followed, are known to lower internal validity. Mihura et al. (2013) included these studies in their meta-analyses on the external validity of Rorschach scores without examining the quality of the studies nor determine if the studies had any internal validity issues. We have not been the only ones to offer concerns about the Mihura et al. (2013) meta-analyses. Tibon Czopp and Zeligman (2016) stated there were concerns with the descriptions and external criteria of some of the Rorschach variables used in the meta-analyses. As a significant support for the Rorschach Performance Assessment System (R- PAS; Meyer, Viglione, Mihura, Erard, & Erdberg, 2011) comes from these meta-analyses, it is imperative that the data from this different Rorschach system be open to scientific scrutiny. Considering scientific considerations and ethical guidelines, we provided our data for the Mihura (2019) commentary. In preparation of this current commentary, we asked for the Mihura et al. (2013) meta-analytic data in order to review meta-analytic decisions and judgments; unfortunately, this request was rejected. Background: Scientific collaboration: Mihura (2019) stated that ―[s]cience must be able to incorporate corrective feedback and to criticize itself. However, when proposing a scientific criticism, one must take great care to ensure that the critique itself is scientific and accurate. Perhaps the best way to address concerns about others‘ research is to talk directly with the researchers involved‖ (p. 182). Fontan did this when he organized a series of meetings during the 2017 International Society of the Rorschach and Projective Measures Conference in Paris between R-PAS authors (Meyer, Mihura, Erdberg) and CSIRA members (Andronikof, Fontan, Smith). The intention was to directly discuss the points raised in the Smith et al. (2018) paper and other concerns with the R-PAS method. Further objectives were to find ways to collaborate and to move toward a third system based on the Exner Comprehensive System (CS; Exner, 2003) and R-PAS. We were unable to receive continued support for these discussions. Consequently, the focus of this article was an evaluation of the first point, ―when proposing a scientific criticism, one must take great care to ensure that the critique itself is scientific and accurate‖ (p. 182). Meta-analytic research: A current trend in psychology, is accepting the findings of metaanalyses without scrutiny of the individual studies- -a pattern where statistical gloss is used to cover methodological flaws (Gacono 2019). A second pattern--conducting additional statistical analyses that do not address conceptual gaps raised in critiques--is not unique to Mihura. It contributes significantly to the ―armchair quality‖ of research, and the creation of ―pseudo-debates‖ and ―apparent controversies‖ (Gacono, 2019; Piotrowski, 2017). A better scientific practice would be increasing the quality of the articles used in a meta-analysis rather than expecting that the meta-analysis would correct for poor methodological quality (Ioannidis, 2016). Due to our commitment to the ethical and competent use of the Rorschach, our examination of the quality of research articles included in metaanalyses has been an ongoing project. In 2012, we examined the Wood et al. (2010) meta-analyses examining psychopathy and the Rorschach (Cunliffe et al.) and found multiple conceptual and methodological concerns related to the studies they used. This led us to evaluate further these issues

using the Mihura et al. (2013) meta-analytic studies as our primary subject matter. In the process of our reviews, we became aware of the degree to which meta-analyses influenced critical decisions such as acceptance or rejection of manuscripts submitted for publication and professionals‘ views of psychological tests. Though meta-analyses are widely used in science, there are many concerns with how it is applied (Ioannidis, 2016). One of the first critics of metaanalyses in the field of Psychology was Eysenck (1978). In his criticisms of the Smith and Glass (1977) meta-analysis about psychotherapy, he was perplexed by the low standards of inclusion studies reported by Smith and Glass. Specifically, he stated ―a mass of reports – good, bad, and indifferent- are fed into a computer in the hope that people will cease caring about the quality of the material on which the conclusions are based‖ and ―the notion that one can distill scientific knowledge from a compilation of studies mostly of poor design, relying on subjective, unvalidated, and certainly unreliable clinical judgments, and dissimilar with respect to nearly all the vital parameters, dies hard‖ (p. 517). Eysenck has not been the only one to criticize meta-analyses (also see Slavin, 1986). Greco, Zangrillo, Biondi-Zoccai, and Landoi (2013) also cautioned against meta-analyses especially related to the quality of research included. They wrote, ―the conclusions of a meta-analysis depend strongly on the quality of the studies identified to estimate the pooled effect. The internal validity may be affected by errors and incorrect evaluations‖ (p. 222). They also stated, ―it is strongly recommended that reviewers use a set of specific rules to assign a quality category, aiming for transparency and reproducibility‖ (p. 222). Schmidt and Hunter (2014) drew special attention to the importance of making sure that the data on which a meta-analysis is based were reliable and valid. Further, they stated that ―one requirement of an effective epistemology in empirical research is proper correction for the artifacts that distort the empirical data‖ (p. 554). Applying statistics without putting them into context is never justified (i.e., Simpson paradox). It may lead to large effect sizes and statistical significance, but the results can still be meaningless. This over-evaluation of statistical prowess at the expense of conceptual understanding has resulted in the tail (statistics) wagging the dog (sound conceptual driven methodology; Gacono 2019). As noted by Gacono (2019), ―one strategy for dealing with confusing findings on Rorschach research is to narrow the stimulus field; to focus on the Ds and Dds rather than getting lost in the Ws created by statistics‖ (p. 106). Perhaps, Sigmund Freud said it best, ―Those critics who limit their studies to methodological investigations remind me of people who are always polishing their glasses instead of putting them on and seeing with them‖ (in Reik, 1956, p. 54). Points of Clarification related to Mihura (2019) Methodological bias/internal validity: Mihura critiqued our use of the term ―methodological bias‖ and stated that internal validity issues were a better description of this notion, and that ―bias‖ refers to a person‘s judgment and we agree. Two of our authors (Fontan & Andronikof) are French, and they proposed the term ―methodological bias.‖ To the French ―bias‖ refers more directly to methods (biais méthodologique) than to a person‘s judgments. ‗Internal validity issues‘ is a better description of the concerns we raise in our paper, and it also helps to substantially explain our purpose. Mihura (2019) stated that ―[i]f a study does not have internal validity, then the study‘s results are not meaningful in the first place even to the sample and setting in which the study was conducted‖ (online supplemental). We concur, as this point was the very purpose of our paper, specifically, if the results are real or an artifact of the methodology. This means a Rorschach study with poor internal validity (e.g., poor inter-rater reliability, many Rorschach protocols with R < 14) would be considered unsound and meaningless and would not be appropriate for a meta-analysis. Although she did not agree with our terminology and suggested a different one, she dismissed our assertion that internal validity issues in her metaanalyses were present, despite our findings that

91% of the studies in the Mihura et al. (2013) meta-analyses had poor internal validity. The definition Mihura provided and what we noted in Smith et al. (2018) has the same meaning. Exner’s (1995b) internal validity criteria: Mihura (2019) suggested that we should have examined how the studies included in her metaanalyses (Mihura et al., 2013) have responded to Exner‘s (1995b) Rorschach research recommendations (studies before and after 1995; are they making the same methodological issues?). In her commentary (Mihura, 2019), she implied that studies prior to 1995 had significantly more internal validity issues than those published after 1995. Yet, these older studies with questionable internal validity were still included in Mihura et al.‘s (2013) meta-analyses, making it necessary to evaluate their internal validity. We stated in our paper that Exner (1995a/b) was not the only source in providing criteria for evaluating the quality of Rorschach research (Cunliffe et al., 2012; Gacono et al., 2001). Specifically, we used the following criteria2 where there is a large consensus in current Rorschach research (R, Lambda, & interrater reliability; Smith et al., 2018, p. 189): 1. IQ/Education level i. Did the article have statistics related to IQ/Educational level (M and range)? ii. If either mean or range was provided, did the article include both statistics? iii. If IQ range was reported, did all participants have an IQ ≥ 80? 2. Responses a. Did the article have statistics related to R (M and range)? b. If mean was provided, did the article include range? c. If range was provided, did the article include mean? d. If range was reported, did all protocols have R ≥ 14? 3. Lambda/F% a. Did the article have statistics related to Lambda/F% (M and range)? b. If mean was provided, were the means for Lambda/F% < 0.99/50%? c. If mean was provided, did the article report range? d. If the mean of Lambda/F% > .99/.50, did the article report IQ/Education Level? (L/F% > .99/.50 and IQ/Education level were examined in combination as this affects generalizability.) 4. Interrater reliability a. Did the article have interrater reliability statistics? b. If interrater reliability was reported, were there values for ICC/κ ≥ .60 or ≥ 80% agreement? 5. Sample size a. Did the article have comparison groups with ≥ 20 participants? Mihura (2019) stated that our criteria ―were not sound‖ (p. 169), and that Exner‘s and some of the Smith et al. authors‘ published studies did not use these criteria. However, in the Mihura table (2019, p. 172), the data were inaccurate. There were only seven articles from Exner as Primary Investigator. Exner, Colligian, Boll, Stischer, and Hillman (1996) had only one issue, while one had three issues, five had four issues, and none had five issues (M = 3.42). The same can be said for the Smith et al. authors. One had two issues, five had three issues, three had four issues, and none had five issues (M = 3.22). The mean issues for Exner, Smith et al., and R-PAS authors‘ studies were similar and not statistically significant (Exner = M = 3.42; Smith et al. = M = 3.22; R-PAS = M = 3.06; F[2,30] = 0.43, p = 0.65; see Table 13 ). Inter-rater reliability: Mihura (2019) stated that ―Weiner (1991) was the first to establish the need to report Rorschach interrater reliability‖ (p. 172- 173). However, only 78.4% of the studies reported inter-rater reliability after 1991 (12% before 1991; Mihura, 2019). All studies (pre/post 1991) were still included in the Mihura et al. (2013) metaanalyses. Without an inter-rater reliability statistic, 2See https://mfr.osf.io/render?url=https%3A%2F%2Fosf.io%2Fxqhy8%2Fdownload for how we classified all 210 studies 3See online supplement data: https://mfr.osf.io/render?url=https%3A%2F%2Fosf.io%2Fxqhy8%2Fdownload

Table 1. Methodological Issues in Mihura et al. (2013) meta-analyses studies by Exner, Smith et al. (2018), & R-PAS Authors as Primary Investigators Methodological Issues Exner (n = 7) Smith et al. (n = 9) Mihura, Meyer, Viglione, & Erdberg (R- PAS) (n = 17) 0 (0%) 0 (0%) 0 (0%) 1 (14%) 0 (0%) 1 (6%) 0 (0%) 1 (11%) 3 (18%) 1 (14%) 5 (56%) 7 (41%) 5 (71%) 3 (33%) 6 (35%) 0 (0%) 0 (0%) 0 (0%) M = 3.42 M = 3.22 M = 3.06 Note. M = mean; n = number of studies. For the exact study count see the online supplemental at https://mfr.osf.io/render?url=https%3A%2F%2Fosf.io%2Fw8ms9%2Fdownloa it is not possible to determine the reliability and validity of the study and makes the generalizability of the findings impossible when counter-intuitive findings are produced (Gacono, 2019). It should be noted that many of the research studies presented at the Society of Personality Assessment (SPA) conferences prior to Wiener‘s (1991) recommendation routinely presented some form of interrater agreement, although, perhaps not enough of them (CBG). Sample size: Mihura (2019) stated we should have used Exner‘s suggestion of 15 for sample size rather than the 20 we recommended. We utilized Dies‘ recommendation in Exner (1995a) where he examined studies with 20 or fewer participants (1995, p. 106). Mihura (2019) in her reply recommended using a ―combined‖ sample size of N = 105 for validation purposes (p. 182). While small sample size research is prone to raise statistical errors, Mihura (2019) mentioned, A key strength of meta-analytic procedures is that they combine small-N studies to produce a more powerful result. Imagine 10 studies with N = 15 and r = .40. In an individual study with such a small N, that correlation is not significant (p = 0.14). However, if you combine all 10 studies in a meta-analysis, you now have a sample size of 150, and r = .40 is significant at p = 0.00000040 (p. 173). We agree if studies can reasonably be combined (i.e., that they seem to assess the same construct). However, this determination was not always present in Mihura et al. (2013, p. 562) and is frequently difficult to achieve in Rorschach research where conceptual issues are often overlooked. For example, Mihura et al. (2013) stated that the ―Isolation Index was not significantly related to its criteria that indicate Social Isolation, Either the Behavior or the Psychological Experience (r = .12, S = 4; Asperger‘s, child maltreatment [including 80% neglect], and parent ratings of withdrawn/depressed children‖ (p. 571). In the four studies on the Isolation Index included in Mihura et al. (2013) meta-analyses, one focused on the effectiveness of the CS Depression Index (DEPI) between 30 depressed (ICD criteria) individuals and 30 participants from a normative sample in which the authors proposed a revision to the DEPI (George & Kumar, 2008). Another studied the psychological functioning of children and adolescents with severe burns using the Rorschach and the Child Behavior Checklist (Holaday & Blakeney, 1994). Holaday, Moak, and Shipley (2001) compared 24 boys (children and adolescents) with Asperger's to 24 boys with emotional and behavioral disorders (not on the autism spectrum). Finally, the last study examined Rorschach indices and MMPI-A scales of 157 children and adolescents to determine the severity of abuse inflicted on them (Perfect, Tharinger, Keith, & Lyle-Lahroud, 2011). Clearly, these studies provided no direct information on the CS Isolation Index (i.e., social isolation/sociometric status). The conceptual gaps in these studies were ignored when applying them to a meta-analytic study of the Isolation Index. Simply stated, the lack of evidence for the Isolation Index speaks more directly to the lack of relevant research rather than a lack of construct validity concluded in the Mihura et al. (2013) meta-analyses.

With sample size, idealism and realism need to be differentiated. Ideally, quality Rorschach research with a sample size of 15 or 20 could, and at times, should be published; however, this appears to be unrealistic with the current academic journal publishing criteria. For example, we recently submitted an article to a prominent journal (Journal of Personality Assessment) that publishes R-PAS/CS articles. The editor did not send out the Rorschach article for review, because the ―sample size is much too limited to draw confident conclusions about these data‖ (Personal Communication with Editor, January 30, 2019). This judgment was rendered despite the comparison groups having more than 30 in each group with a limited number of statistical comparisons which made the sample sizes adequate for the study. Therefore, our criterion was probably less stringent based on the current research climate and this would suggest metaanalyses in the future may include less appropriate studies and the meta-analyses may not be able to correct for methodological deficits (also see Piotrowski, 2017; Thomas, 2019). Additionally, when reviewing a manuscript for publication and considering an appropriate sample size for a given study, one must always consider the uniqueness of the sample and the number of variables (relative to the N) that are being statistically analyzed. For example, in a pilot study examining 10 subjects where only 25 subjects exist in the known universe, it would not be in the interest of science to discard the data because the sample was less than 20. Certainly, a small sample size limits the number of statistical comparisons that can be conducted. In one review years ago, CBG was told the sample size was too low for a sample of sexual homicide perpetrators (N = 38; despite a limited number of comparative analysis), an opinion totally out of context in the real world where this had been the largest sample of this type of subject in the literature at the time. A very difficult sample to obtain as, fortunately, sexual homicide perpetrators do not ‗grow on trees.‘ Gacono and colleagues (1994) have repeatedly provided descriptive data for samples studied, but have been more selective, based on sample size, in choosing small numbers of variables for statistical comparison (thereby not increasing the chance of a statically significant finding that occurs as an artifact of comparing a plethora of variables). Small sample sizes can be scientifically useful, when statistical analyses are limited, when the conclusions are offered as preliminary, and when the participants studied were difficult if not impossible to obtain (e.g., valid protocols of sexual homicide perpetrators). It seems we have reached a stage were many reviewers lack an awareness of the reason for assigning a specific number to sample size and fail to incorporate these principles into their decision making, rather they base their decisions on a set number isolated from any meaningful context. Number of Responses: Along with Lambda, the number of responses (R) is used to assess validity. A 20-subject sample with a mean R of 15 (which is below the expectation of normative data; Exner, 2003) would likely not be appropriate for a validation study related to specific variables, ratios, or indexes. It may be a valid indicator of the sample studied. The best use of the data would be to explain the constriction of R in the specific sample as related to the personality functioning of the sample (Gacono & Gacono, 2008). Is this a sample of low IQ or brain injured subjects? Why is the R well below the mean for most comparison samples? Hence, the findings may be valid for the individual study, but including it in meta-analyses to assess validity of individual Rorschach variables, however, would be inappropriate. Smith et al. (2018) mentioned that 22 studies included in the Mihura et al. (2013) meta-analyses had less than 14 responses. Mihura stated this was because those studies were conducted prior to Exner (1990) changing the Comprehensive System administration procedure and should not be considered an error. The goal of Smith et al. (2018) was to show the quality of the study relative to being able to accept the findings— particularly when those findings were atypical. The minimum number of responses was increased to R ≥ 14, to help increase the validity of an individual protocol. The need to consider R when evaluating a study‘s findings remains essential regardless of when the study was conducted. Interestingly, however, older studies with this methodological issue (R < 14) were still included in the Mihura et al. meta-analyses.

We have frequently stated that many lower R protocols are clinically valid (Gacono & Meloy, 1994). We distinguish between clinical usage which must be evaluated on an individual case by case basis, and the inclusion of an unspecified number of low R protocols for analyzing group data. Lambda or Form%: Providing descriptive statistics for Lambda or F% is essential for determining the appropriateness of a study for comparative analysis (i.e., generalizability; Gacono, 2019). Lambda is a straightforward computation, L = F\R-F. By definition, the more Pure F in the record relative to R, the higher the Lambda. Therefore, there are fewer other determinants (i.e., C, T, Y, V) in a record dominated by Pure F (Gacono, 2019). High Lambda (i.e., constricted protocols), most frequently lack a normative distribution of other determinants and variables. For example, a protocol with a Lambda of 1.50 and 15 responses means that of the 15 possible responses, 9 had pure form only and only 6 responses had an opportunity for other determinants. By contrast in a protocol with 15 responses and a Lambda of 0.50, there are 5 pure form and 10 other responses that may have determinants. Beyond the math, one must consider the reason for the protocol‘s constriction (high Lambda) which has an additional generalized effect of constricting the number of determinants produced on any response that were not pure form (Gacono, 2019; Gacono & Gacono, 2008). Equally important is the inclusion of basic descriptive data (M, SD, Frequency) for the Rorschach variables studied. The inclusion of descriptive data for Lambda and the variables studied, make it possible to determine if a finding of ―no relationship‖ is an artifact of these confounds or a true finding. For example, are the lack of findings the result of the protocol constriction (Lambda) or the fact that there were not enough of the variable studied. Validation studies that attempt to assess the relationships among variables and indices, where elevated Lambdas exist, are mostly inappropriate (Gacono, 2019). Additionally, presenting this basic demographic information is essential for determining the distribution of the variables. As Viglione (1995) noted many variables form J- shaped curves not amenable to analysis with parametric procedures. Like the need to include descriptive data for Lambda, including mean, standard deviation, and frequency for variables studied is essential related to determining validity as well the generalizability of a study. The additional statistical analyses that were conducted by Mihura (2019) did not address this conceptual problem with Lambda. She interpreted our findings as the need for controlling Lambda, a position we have never advocated for. A statistical analysis by Giromini, Viglione4, and McCullaugh actually found ―as compared to the [Rorschach] international norms5, the CS 600 norms provided an even better fit for our San Diego sample, when the Lambda variable was taken into consideration‖ (2014, p. 361)—highlighting the importance of Lambda when interpreting Rorschach results. IQ and Education: Other factors, such as IQ/Education level, may also impact Rorschach production. While factors that impact Rorschach production do not necessarily need to be controlled (e.g., in descriptive studies where the constriction is an accurate reflection of the personality functioning being examined; see Gacono & Gacono, 2008), these variables should always be considered and reported in validation studies. This allows the reader to determine the appropriateness of the study when it is compared to other studies with more normal distributions—and frequently explains the presence of counter-intuitive findings (Gacono, 2019). If IQ is not assessed/available, at least education should be provided as it is a basic demographic characteristic (our criterion was IQ and/or education level). Actually, Meyer, Giromini, Viglione, Reese, and Mihura (2015) stated with Rorschach variables ―the only demographic variable that produced several significant correlations is education‖ (p. 58)— highlighting its importance in Rorschach research. 4 A co-author of R-PAS 5 The international norms are used in R-PAS

Counterintuitive findings and negative results: Mihura (2019) contended that our counter-intuitive conceptualization was problematic. Recently, discussing counterintuitive findings, Gacono stated ―this body of poorly designed research frequently results in contradictory and/or counterintuitive findings that are best understood by their methodological errors rather than true findings‖ (2019, p. 104). Counterintuitive findings (those that occur counter to theory and other welldesigned studies) may be true findings or these may be an artifact of methodological errors (Gacono, 2019; Gacono et al., 2001). It is essential for the inclusion of descriptive data (M, SD, frequencies) for Lambda, R, and the variables studied in order to assess a study‘s internal validity. We did not imply that ―every [Rorschach] finding [was] to be supportive‖ (Mihura, 2019, p. 178) or it is counterintuitive. Instead, we discussed the value of negative findings within the studies with methodological issues. Specifically, we stated, ―[i]n all, 45 studies had counterintuitive findings (43.3%). Owing to the methodological issues it is unclear if these findings are due to Type II error, the findings are real, an artifact of the methodology, a quirk, or an atypical sample‖ (Smith et al., 2018, p. 194). From this, it should be clear that we consider that some negative findings might be real, it is just impossible to determine which ones represent true findings, considering the internal validity of the study (using our abovementioned criteria). In order to refine our operationalization of counterintuitive findings, it may be more apt to state these findings are simply negative results, to include non-significant results and those inconsistent with theory in poorly designed studies. Examining only the validation studies (N = 101), 32 of the self-report (introspective) studies and 13 of the externally assessed studies had counter-intuitive findings. Application and validation studies: Mihura (2019) stated that our distinction between validation and application studies is not significant and the reason ―why researchers are comparing groups does not matter‖ (p. 177). Further, she stated, If two studies‘ methodologies are the same, it does not matter why the researchers state they are comparing the groups. For instance, one researcher might test the validity of X-% by comparing patients with schizophrenia to those with schizotypal personality. Another researcher might use X-% to see if perceptual accuracy differs between these patient groups. The first is a validation study; the second is an application study. However, each study might use the same methodology and study design, and both speak equally to the validity of X-% (p. 178). That research objectives and hypotheses do not matter needs to be addressed (―it does not matter why the researchers state they are comparing the groups‖ p. 178). Concerning the above example between schizophrenics and schizotypals, such a study would not be very appropriate if a researcher was to assess the validity of X-%. Indeed, psychiatric groups here are a proxy, or an indirect measure of the construct which is assessed (some schizophrenics may be stable; some schizotypals may be in crisis; some might be misdiagnosed). Instead a researcher trying to assess the validity of X-%, should seek a direct measure of reality testing failures, such as form perception tests (e.g., Benton Face Recognition; Hooper Visual Organization Test). Therefore, research objectives matter, as there should be a close correspondence between research design and its objectives. This is an important issue. In an application study, a Rorschach score relies on the assumption that this score is valid. If this study is considered, without hesitation, as equivalent to a validation study, it leads to a tautological problem (i.e., proving something, which is assumed to be true, or more simply proving that truth is true). Therefore, logically, a Rorschach score is either valid or the Rorschach score is not valid. Indeed, in the application study, the score is assumed to be valid. In a validation study, the objective is to assess the validity of a score. These are scientifically quite different. However, and in contradiction with her reply to our paper, Mihura et al. (2013) stated elsewhere,

Table 2. Self-Report/Externally Assessed Classifications noted in the Mihura et al. (2013) Studies Type of Study Self-Report/External Application/Validation E E/SR SR Total Application Validation Total Note. E = externally assessed criteria study; SR = self-report study. Table 3. Methodological Issues with the Different Types of Studies cited in Mihura et al. (2013) External Total E Self-Report Total SR Total # issues A V A V Total Note. E = externally assessed criteria study; SR = self-report study; A = application; V = validation. Three studies were excluded that had both Self-Report/Externally assessed criteria to simplify results. there are two types of studies that contain potentially relevant validity coefficients. The first type is specifically designed to validate a psychological test variable, and in this type of study an external criterion measure is purposefully chosen to match the test variable‘s construct. The second type is designed to understand a condition and uses the psychological test variable as the external validity criterion. Often, the goal of this type of study is to describe psychological characteristics that differ between groups. For example, the research question might be ―How do patients with borderline personality differ from patients with schizotypal personality?‖ or ―How do sex offenders differ from other types of offenders?‖ In these cases, a multiscale test like the Rorschach is used as an assessment tool to understand the target conditions with the assumption that its scores provide valid measures of many different psychological constructs. This second type of study can contain a substantial number of coefficients that are not intended to be a probative evaluation of the test variable‘s construct validity, as well as some coefficients that may qualify as core validation criteria (p. 558). Results presented in Tables 2 and 3 show that most validity coefficients, based on externally assessed criterion in Mihura et al.‘s metaanalyses, were based on application studies (~65%), which is in contrast with the position related to their last sentence in the above quote. Assessing internal validity: Mihura (2019) stated: ―I applied Smith et al.‘s (2018) 0 to 5 study methodological ratings to the 770 metaanalytic findings in Mihura et al. (2013). A higher score indicates that Smith et al. thought the study had more methodological problems. The relationship between their ratings and the validity effect sizes was r = .099‖ (p. 179). Based on this result, Mihura concluded that the criteria we used ―were not sound‖ (p. 169) due to the low validity effect size. She suggested that the criteria we chose did not affect the meta-analyses and the studies should not have been removed because of them. However, these analyses did not address our contentions (Smith et al., 2018). Mihura (2019) also insisted on the point that the criteria we used referred to internal validity and that her meta-analyses assessed the Rorschach variables‘ external validity. Basically, Mihura managed to demonstrate that internal and external validity are not related, or more simply that methods and results are two different things. The very idea that internal validity can be assessed by external validity, or that the quality of the methods is related to the effect sizes of the results is very

perplexing and speaks to the conceptual gaps mentioned above. Reliability and validity are two different concepts. We never expected studies with better methodology to present higher effect sizes, but simply to have higher reliability coefficients and be conceptually sound. Externally assessed validity criterion: Mihura (2019) reported that not all the Mihura et al. (2013) meta-analyses articles/studies were used to test the validity of the Rorschach scores. Specifically, she stated ―associations between the Rorschach and self-report measures were not used to determine the validity of Rorschach variables‖ because ―Rorschach studies using self-report measures for validity criteria are typically published in less rigorous journals‖ (i.e., journal impact factor, p. 171). She disagreed with our inclusion of those studies reported in Smith et al.‘s (2018) analyses. This means that the Mihura et al. (2013) validity results were derived from a smaller set of the 210 articles. Consequently, we examined each of the articles included in our analyses to determine if these investigations were a self-report study and/or an externally assessed study (see Tables 2 & 3) using the criteria from Mihura et al. (2013) with most of the studies being externally assessed (67%). However, 91 (65%) of the articles that were considered externally assessed criteria articles were application studies while only 35% (50) were validation studies with externally assessed criteria. Concerning external criteria studies, 91% of the studies presented with three or more internal validity issues (86% for validation studies; 93% for application studies). Therefore, the internal validity issues were still present even when only examining the externally assessed studies. Conclusion: The Mihura et al. (2013) meta-analyses and subsequent commentary (Mihura, 2019) provided useful ―subjects‖ for studying current trends in Rorschach research. It is essential to understand the issues, in the context of our article (Smith et al., 2018), as these findings, discussions, and conclusions are utilized to accept or deny manuscripts for publication, and to promote the R- PAS. Reviewers and editors must understand that the R-PAS is still early in its development, has unaddressed problems and issues with its validity, the normative data, and variables used (Fontan & Smith, 2018). For manuscript reviewers, a more in-depth understanding of both conceptual and statistical issues is needed to ensure sound scholarship is not spuriously rejected and inferior research published. Understanding the conceptual basis of the Rorschach and its variables is essential for providing a fair review (Gacono, 2019). We encourage reviewers to not become enamored with the statistical gloss at the expense of verifiable conceptual foundations (Gacono 2019). The issues we raise are not a ‗controversy‘ but rather based on a scientific approach to the data. We strongly recommend that R-PAS not be used in any context, clinical or forensic, without further validation of its utility and validity, based on R- PAS administered protocols and validation studies with R-PAS variables. While the CS has an extensive history of clinical and forensic usage meeting the standards of admissibility and being accepted in the courtroom (Gacono & Evans, 2008; Gacono, Evans, & Viglione, 2008; McCann & Evans, 2008; Meloy, 2008), R-PAS does not (extensive applied usage, meeting various critical standards) and, in our view, the rush to use it will ultimately be to the detriment of the Rorschach. In research terms, it is premature to consider data generated by R-PAS as appropriate for application studies, but rather needs to be considered only in validation designs. We encourage and welcome scientific debate where the goal is to discover the truth and to improve the psychometric credibility of research findings. Mihura‘s responses in her commentary were like previous responses to the criticisms of her meta-analyses (see Tibon Czopp & Zeligman, 2016). A pattern in which issues raised are responded to by conducting additional statistical analyses that fail to address these concerns. However, the commentary was helpful to us in highlighting areas in need of further clarification. As Mihura noted in her commentary (2019, p. 179), in the spirit of ethical guidelines and scientific cooperation, we provided her with our data for review and analysis6 ; however, she refused (Personal communication, March 17, 2019) to provide her meta-analytic data to us

despite multiple requests, stating the data were no longer available in ―their original format‖, it was more than five years after publication, and that the data we requested would be explained in her reply (it was not). This last point is of significant concern--that data used in a significant way to support and promote R-PAS is no longer available in ―their original format‖. 6To continue our openness, we have released online all our decisions for Smith et al. (2018) and this article at https:// mfr.osf.io/render?url=https%3A%2F%2Fosf.io%2Fxqhy 8%2Fdownload References: Andronikof, A. (2019). What future for the Comprehensive System? Paper presented at the 3rd Congress of the Comprehensive System International Rorschach Association (CSIRA/ARISI). https://www.researchgate.net/ publication/3377414 39 Cunliffe, T.B., Gacono, C.B., Meloy, J.R., Smith, J.M., Taylor, E.E., & Landry, D. (2012). Psychopathy and the Rorschach: A response to Wood et al. (2010). Archives of Assessment Psychology, 2(1), 1-31. Dies, R. (1995). Conceptual issues in Rorschach research. In J. E. Exner (Ed.), Issues and methods in Rorschach research (pp. 25-51). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Exner, J. E. (1990). A Rorschach workbook for the Comprehensive System. (3rd ed.). Asheville, NC: Rorschach Workshops. Exner, J. E. (Ed.). (1995a). Issues and methods in Rorschach research. Mahwah, NJ: Erlbaum. Exner, J. E. (1995b). Introduction. In J. E. Exner (Ed.), Issues and methods in Rorschach research (pp. 1–24). Mahwah, NJ: Erlbaum. Exner, J. E. (2003). The Rorschach: A comprehensive system (4th ed.). Hoboken, NJ: Wiley. Exner, J. E., Colligan, S. C., Boll, T. J., Stischer, B., & Hillman, L. (1996). Rorschach findings concerning closed head injury patients. Assessment, 3, 317–326. Eysenck, H. J. (1978). An exercise in mega-silliness. American Psychologist, 33(5), 517. Fontan, P. (2019). The Future of the Rorschach test. Journal of Japan Rorschach Society for the Comprehensive System, 23(1), 2-8. Fontan, P., & Smith, J.M. (2018). A Critical Review of R-PAS, Symposium conducted at the Society for Personality Assessment at the 2018 Society of Personality Assessment Annual Convention, Washington DC, USA. https://www.research gate.net/publication/328743530 Gacono, C.B. (2019). The importance of Lambda to the generalizability of Rorschach findings reported in the literature. SIS Journal of Projective Psychology & Mental Health, 26, 104-106. Gacono, C. B., & Evans, F. B. (Eds.). (2008). The LEA series in personality and clinical psychology. The handbook of forensic Rorschach assessment (N. Kaser-Boyd & L. A. Gacono, Collaborators). Routledge/Taylor & Francis Group. Gacono, C. B., Evans, F. B., & Viglione, D. J. (2008). Essential issues in the forensic use of the Rorschach. In C. B. Gacono, F. B. Evans (Eds.) & N. Kaser-Boyd, L. A. Gacono (Collaborators), The LEA series in personality and clinical psychology. The handbook of forensic Rorschach assessment (p. 3–20). Routledge/Taylor & Francis Group. Gacono, L.A., & Gacono, C.B. (2008). Some considerations for the Rorschach assessment of forensic psychiatric outpatients. In C.B. Gacono, F.B. Evans, N. Kaser-Boyd, & L.A. Gacono (Eds.), The handbook of forensic Rorschach assessment (pp. 421-444). New York: Lawrence Erlbaum Associates. Gacono, C. B., Loving, J. L., & Bodholdt, R. H. (2001). The Rorschach and psychopathy: Toward a more accurate understanding of the research findings. Journal of Personality Assessment, 77, 16-38. Gacono, C.B., & Meloy, J.R. (1994). The Rorschach assessment of aggressive and psychopathic personalities. Hillsdale, NJ: Erlbaum. George, L., & Kumar, R. (2008). Diagnostic efficiency of new Rorschach Depression Index (DEPI). SIS Journal of Projective Psychology & Mental Health, 15, 118–127. Giromini, L., Viglione, D. J., & McCullaugh, J. (2015). Introducing a Bayesian approach to determining degree of fit with existing Rorschach norms. Journal of Personality Assessment, 97, 354–363. doi:10.1080/00223891.2014.959127. Greco, T., Zangrillo. A.,Biondi-Zoccai,G., & Landoni1, G., (2013)Meta-analysis: pitfalls and hints. Heart Lung Vessel.5(4): 219–225. Holaday, M., & Blakeney, P. (1994). A comparison of psychologic functioning in children and adolescents with severe burns on the Rorschach and the Child Behavior Checklist. Journal of Burn Care & Rehabilitation, 15, 412–415. Holaday, M., Moak, J., & Shipley, M. A. (2001). Rorschach protocols from children and adolescents with Asperger‘s disorder. Journal of Personality Assessment, 76, 482–495.

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Sleep disturbances are a prominent feature of PTSD, quite evident in the veteran population. The scope of published literature on the PTSD-Sleep nexus is rather voluminous; yet reviews on this body of scholarship, from a bibliometric perspective, are rather nonexistent. The current study aims to provide a synthesis of this select literature using a bibliometric content analysis approach. To that end, the dataset was targeted on primary research, i.e., peer-reviewed articles indexed in the database PsycINFO. The search was limited to studies where the main focus was on the combined topics of sleep disorders and PTSD (in veteran populations only), evident from the Abstract of individual articles. This procedure yielded 109 articles spanning 1995-2020. The author reviewed and summarized each study in order to garner the main findings of the investigation. The aggregate findings were then integrated into a summary report, based on the general consensus of the analysis. The main conclusions were: In terms of investigatory focus, the most prominent topics were nightmares, obstructive sleep apnea (OSA), and insomnia; several subject areas exhibited moderate levels of research attention, i.e., sleep quality, daytime sleepiness, TBI, combat or blast exposure, and sleep-related body movements. Furthermore, depression and pain represented 12% of the dataset of articles. Noteworthy, nearly all studies noted the efficacy of Cognitive-Behavioral and Imagery Rehearsal approaches in the treatment of Sleep-PTSD symptomatology. Overall, this body of scholarly literature confirms the poly-morbidity of conditions involving the PTSD-Sleep nexus in veteran populations. Introduction: There is a myriad of traumatic events that can prompt stress reactions, such as war zone experiences, accidents, physical assaults, and both natural and man-made disasters (Moore & Penk, 2019; Rodriguez et al. 2017; Sripada et al., 2020; Stoddard et al., 2018; Xenakis, 2014). Thus, military veterans can be subjected to multiple major stress events in their lifetime (Pugh, 2014). Whereas lifetime prevalence rates of posttraumatic stress conditions (hereon, PTSD) range from 6% to 8 % in the general population, veterans and active-duty military personnel report rather high rates (about 20%) of PTSD diagnoses (see Katz, 2016). Comprehensive clinical assessment has long confirmed that sleep problems are a key hallmark of PTSD conditions, as well as a common comorbid factor in a myriad of mental health disorders (Dikeos & Georgantopoulos, 2011; Fawcett, 2015). Moreover, copious research studies, with a focus on co-morbidity, have confirmed the link between PTSD and significant sleep dysfunction and diagnosed sleep disorders (Brim & Riggs, 2019; Caldwell & Redeker, 2005; Dagan et al., 1991; Harvey et al., 2003; Khazale et al., 2016; Pace-Schott & Bottary, 2018; Piotrowski, 2020). A review of the behavioral science literature indicates that scholarly work on the PTSD-Sleep nexus is an active area of research (Piotrowski, 2020). Indeed, sleep disturbances in the context of post-traumatic reactions (i.e., PTSD) are chief complaints of military veterans, supported by findings of copious research (Babson et al., 2013; Bramoweth & Germain, 2013; Cappuccio et al., 2018; El-Gabalawy et al., 2018; Hermes & Rosenheck, 2014; Jaramillo et al., 2015; Lommen et al., 2016; Moore et al., 2020; Shattuck et al., 2013; Soreca et al., 2019; van Liempt, 2012). In a study on major complaints of 812 veterans entering treatment for PTSD, Rosen et al. (2013) found that sleep disturbances and nightmares were identified as major concerns. Yet the extant literature on the (role) impact of sleep disturbances on veteran populations with PTSD symptomatology reflects a broad scope of research endeavors. Due to the fact that this is a

84 Piotrowski .. burgeoning area of scholarly investigation, it would be informative to provide a concise summary of research studies to date. To that end, the aim of the current project is to identify and synthesize key findings of the extant literature on the PTSD-Sleep disorders link, which may offer directions for future research efforts. Investigatory Approach: Bibliometric approaches, including content analysis, applied to the study of mental health issues have gained credence as an acceptable research methodology (Mogil, 2009; Piotrowski, 2014, 2018, 2019). The current study utilized a content analysis strategy of the extant literature. In order to obtain a pool of pertinent articles, the author conducted a Boolean search of the database PsycINFO. The terms PTSD, “sleep disorders” or sleep, and veterans comprised the online search strategy, where all these keywords needed to be noted in the Abstract of peer-reviewed articles. In addition, several additional studies were identified via a manual review of bibliographies of obtained articles. Based on this search strategy, 109 studies were retained as the dataset for the current analysis. Major Conclusions Based on Review: Based on the content analysis of 109 journal articles, the following were the most pertinent findings with regard to the literature on the nexus of sleep disorders in veterans with PTSD: • Nightmares/disturbing dreams and obstructive sleep apnea were the most researched topics • Sleep quality was a major area of scholarly investigation • Insomnia, TBI, body movements during sleep, and daytime sleepiness comprised about 30% of the dataset of articles in the analysis • Combat exposure and „blast exposure‟ was the focus of 10% of the investigations • The issues of depression or pain represented 12% of the studies • REM findings accounted for 5% of the dataset • With regard to treatment, 9 of 10 studies reported significant improvement with cognitive-behavioral interventions; 4 of 6 studies found positive outcomes using imagery rehearsal therapy (IRT); mind-body approaches proved equivocal Several observations are worthy of mention: First, several subject areas received scant attention from researchers, i.e., fatigue, exercise, heart rate variability (HRV), obesity, emotion regulation, and alcohol/drug abuse. Second, at least 10% of the studies in the review reported on negative findings; thus, supporting the position that this clinical area of investigation does not reflect publication bias. However, the issue of the „Filedrawer problem‟ could not be ascertained. As the issues of nightmares, insomnia, and obstructive sleep apnea were the predominant areas of research, Table 1 provides a synopsis of the 57 studies where these subject topics were the main focus of study. (For a full summary of the 109 studies, interested readers may contact the author: cpiotrowski@uwf.edu) Table 1. Studies (n=57; 1995-2020) on the topic of Nightmares, Insomnia, or OSA/CPAP in PsycINFO Study Reference Aim of Study Sample/Measures Major Findings Mellman et al. (1995) Study focused on physiological correlates of symptomatic sleep events in PTSD 131 Vietnam combat veterans; sleep diaries and polysomnography Subjects with diagnosed PTSD reported recurrent awakenings, disturbing dreams, thrashing body movements during sleep, and panic features upon awakening; these symptoms occurred post-REM stage sleep. Neylan et al. (1998) Examined the differential role of combat exposure, PTSD symptoms, co- Vietnam veterans (n=1,167); archival data from national veterans‟ Frequent nightmares were strongly associated with PTSD, accounted for by war zone exposure; however,

morbid psychiatric/medical disorders, and substance abuse to explain domains of sleep disturbances database combat exposure was moderately correlated with insomnia and disrupted sleep; frequency of nightmares was not related to alcohol abuse, medical or psychiatric conditions. Esposito et al. (1999) Studied dream content in combat-related PTSD 18 Vietnam combat veterans; developed dream report instrument 50% of the sample‟s target dreams contained threatening features; but the type of dream features varied widely. Engdahl et al. (2000) Studied the role of REM sleep in PTSD 30 elderly veterans, exposed to war trauma 3 to 5 decades earlier, diagnosed with PTSD; polysomnography Perceptions of sleep quality for the PTSD group were a) more negative compared to controls, and b) had higher percentage of REM sleep; This PTSD sample also experienced sleep apnea and sleep movement disorders. Raskind et al. (2003) Investigated the efficacy of the drug „Prazosin‟ for sleep disturbances in PTSD conditions 10 Vietnam combat veterans with both PTSD and trauma-related nightmares; Clinicianadministered PTSD Scale; 5-month double-blind protocol Prazosin was effective in reduction of distressing dreams, insomnia, and severity of PTSD symptoms; this drug was well tolerated by the sample. Harb et al. (2009) Studied the feasibility (CBT) Imagery Rehearsal for treating insomnia and PTSD nightmares Iraq War veterans (n=7) in treatment Imagery Rehearsal showed promising post-effects with regard to nightmares, sleep quality, and PTSD symptomatology. Lu et al. (2009) Studied imagery rehearsal therapy (IRT) for PTSD nightmares 15 veterans with PTSD who previously completed traumafocused PTSD treatment; attended 6 IRT group sessions No benefits reported immediately posttreatment; however, within 3-6 month follow-up, nightmare frequency and PTSD symptomatology decreased significantly; no effects on sleep quality and depression were found. Plumb (2010) Investigated types & severity of sleep disturbances in Iraqi/Afghanistan war personnel Former military personnel; PTSD Checklist, Pittsburgh Sleep Quality Index, Combat Exposure Scale, Anxiety Screen Majority of sample reported disturbed sleep (56% as “bad”); delayed sleep onset (41%); nighttime awakenings (59%); nightmares (trauma-related, 30%; not trauma-related, 27%); veterans with greater war exposure had more sleep issues; those with higher education levels and ranks reported fewer sleep concerns. Picchioni et al. (2010) Investigated the mediating role sleep dysfunctions between combat stress and PTSD Data, obtained in 2004, from 576 Army veterans of the Iraq War Insomnia and nightmare scores had large mediation effects between combat stressors and PTSD; authors claim that sleep disturbances contribute to the development & maintenance of a myriad of mental health symptoms. Wanner et al. (2010) Studied multi-component treatment for nightmares in PTSD 2 case studies involving Vietnam veterans Authors cite that 50%-88% of Vietnam veterans experience chronic Posttraumatic nightmares; both veterans in this study showed moderate reductions in sleep disturbances and well as PTSD

.. symptoms over the course of treatment. Nappi et al. (2010) Studied the efficacy of IRT therapy (relaxation, psychoeducation, cognitive restructuring) for PTSD nightmares Veterans diagnosed with PTSD; full-course IRT treatment protocol Those who completed the fulltreatment, had significant reduction in nightmare frequency and intensity, severity of insomnia, and PTSD symptoms. El-Solh et al. (2010) Studied adherence to various therapies for Positive Airway Pressure in PTSD cases 142 veterans with PTSD; CPAP nightly usage 58% of these patients, with PTSD, were non-compliant with CPAP protocol use, which increased nightmare frequency. Cook et al. (2010) Examined the efficacy of imagery rehearsal for PTSD nightmares 124 Vietnam War veterans with chronic PTSD vs. control group; 6 IR sessions delivered in group format Pre-post changes were noted for sleep quality and PTSD for both groups, but not for nightmares; Imagery rehearsal in group form proved rather ineffective. Hurwitz & Khawaja (2010) This paper extols the benefits of treating obstructive sleep apnea (OSA) in patients with PTSD „Commentary‟ on earlier research study of 142 veterans wi th OSA (see El-Solh et al., 2010) Author cautions that CPAP treatment for OSA may exacerbate PTSD symptoms or increase nightmare intensity; Thus OSA-PTSD comorbidity should be a focus of study. Van Liempt et al. (2011) Investigated whether Obstructive sleep apnea (OSA) was associated with higher levels of PTSD severity 20 Dutch veterans with combat-related PTSD diagnoses; Clinician- Administered PTSD Scale High apnea indices were found in 29% of PTSD cases; PTSD severity was linked to OSA; Nightmare severity was similar in PTSD-OSA patients as compared to PTSD patients without OSA. Capaldi et al. (2011) To specify sleep difficulties in returning combat veterans of Iraq War 69 combat veterans at the Walter Reed Army sleep clinic; polysomnography (PSG), sleepiness scales; medical diagnoses were obtained, retrospectively, from medical records Sleep apnea, excessive awakenings, daytime sleepiness were prominent in this cohort of patients; more frequent arousals from sleep were found for PTSD veterans; PSG data differentiated diagnostic categories. Gellis& Gehrman (2011) Examined the effects of cognitive therapy (CBT) for insomnia in longstanding PTSD 8 veterans with chronic insomnia & PTSD (Vietnam, 1st Gulf war); actigraphy, subjective evaluation of sleep patterns Perhaps due to the short duration of CBT, actigraphy-defined sleep, frequency of nightmares, and PTSD severity were unchanged at posttreatment. Ulmer et al. (2011) Studied a multicomponent CBT strategy in the treatment for insomnia and nightmares in PTSD conditions 22 veterans diagnosed with PTSD; CBT for insomnia, and Imagery Rehearsal for nightmares; sleep diary Short term effects were significant, with substantial reductions in PTSD symptoms and insomnia severity; Authors suggest implementing targetspecific interventions for distinct sleep disturbances. Long et al. (2011) Examined exposure group therapy for nightmares in treatment for PTSD 37 veterans diagnosed with both PTSD and nightmares; 6 group sessions of Imagery Rescripting and Exposure Findings indicated that this novel treatment approach reduced PTSD severity and nightmare frequency; Sleep duration was also increased.

Therapy Wright et al. (2011) Conducted an evaluation on whether insomnia is an antecedent vs. consequence of PTSD 659 Iraq War combat veterans; Longitudinal design (4 months vs. 1-yr. post-deployment) Insomnia and psychological symptoms were associated across both time frames; Findings support the role of insomnia in the development of additional co-morbidity. Wallace et al. (2011) Compared insomnia characteristics in Iraqi war veterans with PTSD & TBI versus those with PTSD alone 36 veterans in treatment at the Miami VA Post- Deployment clinic; assessed for sleep disorders, pain, depression and quality-oflife‟; underwent polysomnography & kept sleep diaries Significant co-morbidity for sleep disorders was found for insomnia patients; despite obtaining more sleep, PTSD-TBI veterans experienced more daytime sleepiness. Holowka et al. (2012) Examined comorbid diagnostic features of PTSD in veterans 798 Vietnam veterans meeting criteria for „current‟ PTSD and 189 for „lifetime‟ PTSD Flashbacks, nightmares, and interpersonal detachment had the greatest degree of diagnostic specificity; These findings were consistent with symptomatology of trauma-exposed veterans. Yesavage et al. (2012) Studied sleep-disordered breathing (SDB) in veterans with PTSD 105 Vietnam War veterans; polysomnography and cognitive testing data 69% of sample had high apnea index scores; Cognitive assessment profile was not associated to SDB. Schoenfeld et al. (2012) Presented a review of prior findings on efficacy of pharmacotherapy and CBT treatments for sleep disturbances in PTSD patients Review of the literature study CBT and Imagery rehearsal therapy are as effective as pharmacological treatments (e.g., Prazosin); CBT has targeted insomnia and nightmare complaints in PTSD veterans. Margolies et al. (2013) Studied the impact of combined CBT intervention for insomnia and nightmares in PTSD treatment 40 combat Iraq War veterans; 4 sessions of CBT with adjunctive IRT treatment Patients who participated in combined CBT/IRT reported improved sleep quality, and a reduction in PTSD symptom severity and distressed mood. Hasler et al. (2013) Examined psychological and neural correlates of chronotype in PTSD 36 combat-exposed veterans with varying degrees of PTSD; evaluated PET scans, REM sleep, diaries, and polysomnography Evening-type vets had greater PTSD symptoms, more disturbed sleep, and intense nightmares; Chronotype is linked to neural activity in arousal regulatory regions in vets with PTSD Pigeon et al. (2013) Studied the prevalence and severity of PTSD related to nightmares and insomnia over time 80 veterans recruited from VHA primary care facilities; Insomnia Severity Index and PTSD Checklist; 6-mo. post baseline assessment Insomnia and nightmares were strongly associated with severity for both PTSD and depression; insomnia persisted, over time, with PTSD scores. Authors suggest that addressing insomnia early in treatment may reduce PTSD severity. Baddeley & Gros (2013) Evaluated CBT as a pretreatment protocol to Case study; veteran with comorbid insomnia and Significant reductions in insomnia and PTSD were found after the CBTI-

.. exposure therapy in PTSD PTSD; 6 CBTI sessions, followed by 7 sessions of trauma-specific exposure therapy Exposure therapy protocol; and these results were noted after a 3 month follow-up. Plumb et al. (2014) Studied the impact of deployment in the Iraq war on a variety of sleep disturbances related to co-morbid conditions 375 active military and veterans; Pittsburgh Sleep Quality Index, PTSD Checklist-Military version, PHQ-9 45% of the sample reported difficulties in sleep onset, sleep duration, and insomnia; sleep problems were related to combat exposure, increased depression & anxiety scores, and PTSD symptomatology; sleep disturbances tend to have comorbid mental health factors. Tamanna et al. (2014) Investigated the effect of CPAP on nightmares in PTSD 69 veterans with both OSA and PTSD; polysomnographic data, Epworth scale Reduced nightmare frequency after CPAP treatment was best predicted by CPAP compliance; PTSD patients need to be screened clinically for symptoms of OSA. Germain et al. (2014) Examined insomnia, sleep quality, depression, and anxiety levels in veterans 40 OEF/OIF/OND combat-exposed veterans; 4-week treatment involving sleeppromoting behaviors; used insomnia and sleep quality indices, PTSD Checklist and Beck inventories Both interventions (suggestions vs. reading material) showed improvement in insomnia; Apparently, educational self-help strategies can be effective in the treatment of insomnia in veteran populations. Lang et al. (2014) Studied the role of insomnia in wounded veterans with PTSD/ pain symptomatology Retrospective medical records of 137 veterans at a VA Polytrauma clinic 52% of this sample had high prevalence for PTSD, insomnia, and pain; PTSD and pain severity were positively correlated; Authors argue that sleep disturbances affect pain tolerance and promote cognitive deficits; thus, compromising rehabilitation efforts in poly-trauma veterans. Forbus& Kelly (2015) Determination of obstructive sleep apnea (OSA) risk in veterans seeking PTSD treatment 264 veterans (26% female) The rate of OSA risk was nearly 73% for the entire sample; but OSA risk was not correlated with PTSD symptom severity; treatment for OSA could reduce complaints of insomnia. Ghadami et al. (2015) Studied both objective and subjective indices of disrupted sleep in veterans 32 veterans with PTSD experiencing insomnia; PSQI and CA-PTSD scale; Actigraphy data Results indicated that „self-report‟ data is unreliable in these patients; thus, „objective‟ assessment (e.g., actigraphy) is required for valid evaluation protocols. Gehrman et al. (2015) Utility of Sleep diaries in sleep disturbances In a 6-week prospective design, 105 veterans completed sleep diaries Daytime stressors were associated with increased nightmare frequency; PTSD severity were related with sleep disruption, duration of sleep, and nightmares. Straus et al. Sleep dysfunction 45 OEF/OIF/OND Sleep efficiency was worse for PTSD

(2015) variability in militaryrelated PTSD veterans with PTSD vs. 25 patients with primary insomnia vs. insomnia group; Results suggest that there is more „variability‟ in sleep problems with combat exposed veterans. Stocker et al. (2016) Examined exposure to blast on sleep in combat veterans with PTSD 71 Iraq war veterans with & without PTSD; sleep measures; REM/NREM sleep PTSD had a main effect on insomnia severity, sleep quality, and disruptive nocturnal behaviors; no significant blast x PTSD interaction on sleep measure was found; authors state that blast exposure is not linked directly to sleep quality, insomnia, and disruptive sleep beyond the effects of PTSD. Harb et al. (2016) Studied the role of lucid dreaming in the context of PTSD and recurrent nightmares 33 middle-east combat veterans; 6-sessions of CBT treatment for insomnia Pre-treatment, these veterans reported high dream awareness and low dream control; Post-treatment (Rehearsal therapy), dream content increased which was related to reduction in nightmare distress. Khazale et al. (2016) Examined sleep-related problems in combatinduced PTSD Veterans with war-zone experience There is a strong link between PTSD in veterans and sleep disturbances (i.e., insomnia, nightmares, sleep apnea, parasomnias, and movement of extremities during sleep. El-Solh et al. (2017) Investigated the therapeutic effects from CPAP duration and PTSD symptomatology 47 combat veterans with OSA and diagnosed PTSD; polysomnography, Epworth Sleepiness Scale, PTSD Checklist-Military version, nightmare scales; over 3-month period For patients with prolonged CPAP usage, improvement of PTSD symptoms with those with OSA was more pronounced; treatment adherence was linked to reduction of nightmare distress and frequency. Reist et al. (2017) Studied whether sleep disturbances impede therapeutic interventions (i.e., benefits) in PTSD treatment 18 combat veterans with diagnosed PTSD; PTSD Checklist PTSD patients with sleep-disordered breathing had low PTSD Checklist scores, compared to those without sleep disturbances; Findings suggest that the efficacy of exposure therapy for PTSD patients is affected by sleep quality. Beck et al. (2017) Efficacy of the Mantram Repetition Program for PTSD-related insomnia Veterans with PTSD; a mind-body spiritual intervention with CBT features Results indicated that this veterans sample showed a reduction in insomnia symptoms, as well as PTSD symptomatology. Mesa et al. (2017) Studied Cognitive Processing Therapy (CPT) in veterans with obstructive sleep apnea (OSA) 68 OSA veterans in treatment vs. 276 non- OSA veterans; selfreported PTSD symptoms OSA-positive patients reported greater PTSD severity post-treatment; OSApositive patients with CPAP therapy reported less PTSD severity vs. non- CPAP; authors conclude that OSA can reduce effectiveness of CPT in veterans with PTSD. Haynes et al. (2017) Examined the effect of sleep disorders on cognitive processing therapy (CPT) outcomes 32 veterans; engaged in CPT for combat-related PTSD; Patients with moderate sleepdisordered breathing responded best to CPT; authors conclude that sleep disorders can be salient factors in

.. discussions on who responds to CPT for PTSD conditions. King et al. (2017) Explored patterns of sleep complaints with and without PTSD-TBI context In this longitudinal design, 291 Iraq war veterans; self-report sleep data Over 18-month period, there was an average of 25% reduction in sleep disturbance; majority of change occurred within the first 6-month period; veterans with TBI-related PTSD reported changes in sleep quality, fatigue, and nightmare frequency. Scott et al. (2017) Examined if history of TBI was associated with response to CBT for PTSD-related sleep problems 94 veterans involved in Imagery Rehearsal as part of CBT in treatment for insomnia and recurrent nightmares Verbal memory functioning was associated with nightmare distress & frequency, and thus, less likely to benefit from CBT; veterans with TBI displayed greater levels of sleep disturbances. Phelps et al. (2018) Examined whether posttraumatic nightmares differed in content dependent on sleep-stage 35 veterans vs. current military members; using ambulatory polysomnography Of 24 reported nightmares, 10 arose during REM sleep and 14 from non- REM stages; the majority of nightmares were associated with respiratory or leg-movement events; author contend that PTSD-associated nightmares point to other concurrent sleep disturbances. DeViva et al. (2018) Studied the effects of cognitive-behavioral therapy sessions in treatment for PTSD on insomnia 47 veterans diagnosed with PTSD; Insomnia Severity Index Significant improvements in sleep onset and sleep efficiency, but no link to total sleep time. Lee & Gabriele (2018) Studied Racial differences on the relationship between PTSD and insomnia and BMI in trauma-exposed Black vs. White veterans PTSD & insomnia and BMI were related to BMI, but only for the Black sample; thus. PTSD and insomnia may be a central dynamism in weightrelated health problems in Black veterans. Rezaeitalab et al. (2018) Studied polysomnographic patterns in veterans with obstructive sleep apnea (OSA) in PTSD and non- PTSD conditions Iranian male veterans; 40 with PTSD vs. 32 without PTSD; BMI and Epworth Sleepiness Scale OSA in patients with PTSD was associated with insomnia, but not daytime sleepiness; these results were not confirmed for the non-PTSD group. Gutner et al. (2018) Focused on treatment preferences of veterans regarding insomnia, PTSD, and depression 622 young adult veterans; sample obtained via Facebook Key finding indicated that this sample of vets preferred treatment for insomnia compared to PTSD or depression; there was a preference for personal counseling and App-based self-help treatment. Colvonen et al. (2019) Studied the proposition of addressing insomnia prior to implementing 12 veterans with insomnia and PTSD in CBT and 2NITE protocols; sleep Findings showed decrease in PTSD scores, insomnia severity, and a significant increase in Quality-of-Life

PTSD treatment diaries, actigraphy data index scores; also, there was a significant increase in total sleep time; authors argue that CBT and Prolongedexposure would augment existing PTSD treatment protocols. Walters et al. (2019) Impact of „Prolonged Exposure‟ (PT) modality on sleep Veterans and postdeployment military members; 12 weeks of PT, PT & IRT/CBT combination; Clinician- Administered PTSD Scale PE did not improve sleep quality, but lessened PTSD symptomatology; IRT/CBT improved insomnia complaints and somewhat lessened nightmare frequency; thus, targeting sleep concerns in PTSD enhances the efficacy of Prolonged Exposure protocols. Rosen et al. (2019) Studied the temporal association between insomnia and PTSD severity 1,649 male and female Iraq veterans; over a 2.5 yr. period, interview data, self-report data, and medical records data were obtained About 75% of the participants with PTSD reported insomnia difficulties; Vets without PTSD experienced fewer sleep; over time, sleep disturbances predicted increased PTSD severity; Also, particularly among male vets with PTSD, high rates of sedativehypnotic use were noted. Leng et al. (2019) Studied the long-term risk (up to 14 yrs.) of sleep disorders after TBI Over 364,000 treated in the US VA Health Care Administration; data obtained from the National Patient Care Database TBI veterans had a significant increased risk of developing sleep disorders, particularly insomnia and hypersomnia; this association did not differ by PTSD status over time. Lopez et al. (2020) Investigated insomnia and nightmares in veterans, postintervention for treatment of PTSD & depression 232 veterans undergoing Behavioral Activation & Therapeutic Exposure Both insomnia and nightmare episodes were reduced. DeViva et al. (2020) Examined relationship between daytime PTSD and sleep duration over 2 days 42 post-2001 veterans; PTSD Checklist (3 times per/day) High levels of PTSD symptoms follow poor sleep the prior night; but, peak PTSD during the day does not impact next-day sleep quality. Conclusion: This review found that the scope of research emphasis on the nexus of sleep and PTSD has focused beyond the traditional pathophysiology of sleep disturbances, to include mental health aspects of these comorbid conditions. Moreover, nearly all of the studies in this analysis employed high-level methodologies and cited extensive, salient literature. The investigations on the topic of nightmares, insomnia, and obstructive sleep apnea (OSA) were the predominant research domains in studies on veterans with PTSD (see Sacre, 2012). In fact, the VA and DOD practice guidelines for management of PTSD emphasize the central role of nightmares in PTSD-related insomnia. Future bibliometric analyses could shed some light on any significant differences between younger versus elderly veterans in coping with PTSD-Sleep dysfunction (Gamaldo et al., 2016), as well as empirical studies on the efficacy of medications for various sleep disorders in veteran populations.

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range of serious and life-threatening illnesses including cardiovascular disease, neuroendocrinal functioning, reproductive system and gastrointestinal disorders. There are numerous studies showing that individuals who are exposed to a traumatic event have an increased likelihood of poor self-reported health, morbidity (as indicated by physical exam or laboratory tests), utilization of medical services, and mortality. The aim of this review is to examine the relationship between psychological trauma and physical health. A review of the current research findings show a link between exposures to traumatic events (such as war, disasters, motor accidents, domestic violence, crime and sexual assault) and subsequent physical health. Introduction: „Trauma‟ refers to events, rather than their potential consequences, and has been authentically defined as a discrete event or events with threat to life or bodily integrity that result in fear, helplessness, or horror (DSM-IV-TR; American Psychiatric Association, 2000).Traumatic events or trauma exposure refers to the actual events themselves such as car accidents, assaults, abuse and natural disasters. Traumatization refers to the process by which a traumatic event incurs posttraumatic stress. Posttraumatic stress denotes to the client-reported distress attributed to traumatic events (e.g., feeling upset in response to reminders, wanting to avoid places related to the trauma). Prevalence of experiencing at least one traumatic event in life has been reported among 60% of men and 51% of women in the general population (Kessler, et al, 1995). Exposure to early life adversity, such as physical abuse, sexual abuse, and neglect are common traumatic incidents. Approximately one third of children are estimated to experience physical abuse (Anda et al., 1999); approximately one in four girls and one in five boys experience sexual victimization during childhood (Finkelhor, et al, 1990). Other forms of non abuse trauma, such as exposure to community violence, are also common (Bell & Jenkins, 1993).Kessler et al. (1995) reported the three most experienced types of trauma of witnessing someone being badly injured or killed; being involved in a fire, flood, or natural disaster; and being involved in a life-threatening accident. Data from the Canadian Community Health Survey (N=36,984) indicated that participants with PTSD had significantly higher rates of cardiovascular disease, respiratory diseases, chronic pain syndromes, gastrointestinal illnesses, and cancer (Sareen, et al, 2007). PTSD following a human-made disaster showed similar health effects (N=896; Dirkzwager, van der Velden, Grievink, & Yzermans, 2007). PTSD was found to be associated with new vascular events while physician-reported vascular, musculoskeletal, and dermatological problems. These problems appeared even after controlling for previous health problem, smoking, and demographic characteristics. Research has documented specific impacts of trauma exposure and PTSD on numerous body systems: cardiovascular, immunological, neuroendocrine, reproductive, and gastrointestinal. Acute and long-term stress affects heart rate and impairments of cardiovascular functioning. Witnessing and experiencing a traumatic event leads to long-term changes in systolic blood pressure (Wilson et al., 1998), atrioventriciular defects (Boscarino & Chang, 1999), and increased risk for coronary events (Brydon, Magid, & Steptoe, 2006). Stress is linked to sustained high blood pressure levels, which in turn leads to atherosclerotic plaque (McEwen, 2005). In a longitudinal study by Uchino, et al, (2005),

trauma-exposed adults were found to have an increase in systolic blood pressure reactivity and parasympathetic withdrawal in response to acute stress. Trauma exposure and stress have a direct consequence on an individual‟s immune system functioning. McEwen (2005) has suggested that acute stress may immediately enhance the immune system, whereas chronic stress is linked with immune suppression. Initially, the immediate response to stress activates and elevates the immune system. However, with continued exposure to stress there is evidence of dramatically reduced functioning of the immune system, which leads to vulnerability to disease; similarly, autoimmune disturbance leads to the deterioration in the functioning of vital organs. Stress increases the peripheral lymphocytes (natural killer [NK] cells and cytotoxic T cells) during exposure to the stressor; subsequently immune cells decrease to below baseline levels following the stressor (Breznitz et al., 1998; Delahanty,et al, 2000; Dougall & Baum, 2004). In a study by Kawamura, Kim, and Asukai (2001), the immune system of individuals with PTSD was found to be compromised and linked to longterm health complications. The number of lymphocytes, T cells, NK cell activity, and IL-4 were reported to be significantly lower than in non-PTSD individuals. Acute stressful events and psychological stress have been found to be a precipitant to gastrointestinal disorders that affect the entire gastrointestinal tract, including IBS (Farthing, 1995; Fleisher, 1997). Both psychological and physical stressors are reported to be associated with altered contractile responses of the colon (Horwitz & Fisher, 2001). Murray et al. (2004) examined the effects of stress on the autonomic outflow to the gut in IBS (Irritable bowel syndrome). A study by Leserman et al. (1996) found that women with assault histories were more at risk for IBS and severe organic gastrointestinal disorders. Furthermore, psychological stress also influences the motor function in the small bowel in patients with and without IBS (Horwitz & Fisher, 2001; Snape, Carlson, Matarazzo, & Cohen,1977). PTSD diagnosis following trauma exposure is also a predictor for the development of gastrointestinal disorders, including ulcers and IBS (Grahn, et al, 1995; Stam, 2007; Weisberg et al., 2002). Further though less investigated thee vidence on the association between trauma and reproductive disorders is consistent. Trauma has been linked with chronic pelvic pain, sexual problems, infertility and miscarriage, preterm delivery, and low birth weight of neonate. Farley and Patsalides (2001) interviewed 600 adult women and found an increased incidence of reproductive symptoms in women with a history of trauma. Spinhoven et al. (2004) found that physical assaults were related to chronic pelvic pain. Matsubayashi, Hosaka, and Makino (2006) examined the role of distress in infertility. They found that women experiencing significant psychological distress had a higher level of a type of immune cells called “natural killer” (NK) cells. Elevated NK cell activity may expel an embryo from the uterus. Elevated NK cell counts are associated with both traumatisation and recurrent pregnancy loss. Trauma increases the risk for fibromyalgia (Haviland, et al, 2010) and musculoskeletal disease (McFarlane, et al, 1994). Dorn, et al, (2008) found that in a sample of accident survivors, musculoskeletal problems were elevated relative to community controls. Farley and Patsalides (2001) surveyed 600 women and found increased musculoskeletal symptoms in those with a trauma history. During a traumatic event, the nervous system goes into survival mode (the sympathetic nervous system) and sometimes has difficulty in reverting back into its normal relaxation mode (the parasympathetic nervous system). If the nervous system stays in survival mode, stress hormones such as cortisol are constantly released, causing an increase in blood pressure and blood sugar, which can in turn reduce the immune system‟s ability to heal. Physical symptoms start to manifest when the body is in constant distress. Trauma survivors often have significant physical health problems that can linger for many years after the traumatic event has ended and are often above and beyond the effects of direct physical injury (Kendall- Tackett, 2007). PTSD patients who experienced childhood abuse or partner

violence in adolescence or adulthood reported twice as many symptoms on a review of systems than their age-matched, nonabused counterparts. The likelihood to abuse substances and report of wide variety of chronic pain syndromes have also been reported more among trauma survivors (Kendall- Tackett, Marshall, & Ness, 2000, 2003). Substantial evidences have been shown strong links between the experience of trauma and physical health outcomes including more negative evaluations of overall health, increases in risky health behaviors, and increased risk for lifethreatening diseases with exposure to traumatic events (Ullman & Siegel, 1996; Felitti et al., 1998; Plichta & Falik, 2001; Lang et al., 2003; Ullman & Breklin, 2003; Nicolaidis et al., 2004; Rodgers et al., 2004). Also germane to physical health outcomes, trauma is associated with higher levels of risky health behaviors including smoking, substance use, excess body weight, use of seatbelts, and risky sexual behaviors (Rodgers et al., 2004). Data from the National Comorbidity Study found that patients with a history of childhood or partner abuse reported more pain when describing their current health symptoms. Van Houdenhove, Luyten, and Egle (2009) found that 64% of patients who had either fibromyalgia or chronic fatigue syndrome had experienced at least one type of either child or adult trauma. A wide range of traumatic exposures and experience scan lead to poor health. Some of this is attributable directly to injury suffered during the trauma. Psychoneuroimmunology (PNI) explores that many illnesses are because severe or overwhelming stress, and any resultant PTSD, alters and dysregulates the key systems that are part of the stress response. Researchers have discovered that traumatic events dysregulate the hypothalamic-pituitary-adrenal axis and sympathetic nervous system. Research from the field of psychoneuroimmunology (PNI) suggests that traumatic life events can lead to health problems through dysregulation of another key system: the inflammatory response. Human bodies have several interdependent mechanisms in place designed to preserve life in the face of danger: catecholamine, hypothalamicpituitary-adrenal (HPA) axis, and immune response. In response to threat, the sympathetic nervous system responds by releasing the catecholamines, norepinephrine, epinephrine, and dopamine which in turn shape fight-or-flight response. The HPA axis responds with a chemical cascade: the hypothalamus releases corticotrophinreleasing hormone (CRH), which causes the pituitary to release adrenocorticotropin hormone (ACTH), which causes the adrenal cortex to release cortisol, a glucocorticoid. There have been numerous studies over the past 15 years that have examined changes to the HPA axis and sympathetic nervous system that occur in the wake of traumatic events and/or PTSD (Bremner, 2005; Kendall-Tackett,2000). Wilson, Friedman, andLindy (2004) used McEwen‟s (1998) model ofallostasis to explain the effects of PTSD onthese systems and subsequent health problems. Allostasis refers to the body‟s attempt to maintain stability through stress and change. When the body is overwhelmed by stressors, allostaticload (or body “wear and tear”) occurs. Traumatic events can increase allostaticload by chronically activating the HPAaxis and sympathetic nervous system. This dysregulation can be manifested with elevated or abnormally low levels of cortisol, and low or elevated levels of norepinephrine (Kendall- Tackett, 2000). But the sympathetic nervoussystem and HPA axis are not the only systems involved. The immune system responds to threat by releasing proinflammatory cytokines. These cytokines increase inflammation and serve the adaptive purpose of helping the body heal wounds and fight infection. A key finding of PNI research is that both physical and psychological stress can trigger the inflammatoryresponse (Robles, Glaser, & Kiecolt-Glaser, 2005). Sleep disturbance is anothercommon aftereffect of trauma which can negatively influence health. Sleep disorders are also quite common among trauma survivors, especially for those who are diagnosed as suffering from PTSD. Several studies have documented disturbed sleep patterns in men and women whohave experienced violence and resultant acute stress disorder (ASD) or PTSD. Teegen (1999) observed in a European community

sample, 68% of sexual abuse survivors reported having sleep difficulties, with 45% having repetitive nightmares. Hulme (2000) found that sleep problems were common among women primary-care patients who were sexual abuse survivors. Fifty-two percent of sexual abuse survivors reported that they could not sleep at night (compared with 24% of the nonabused group), and 36%reported nightmares (compared with 13%). The most common symptom was intrusive thoughts, reported by 53% of sexual abuse survivors (compared with 18% of the nonabused group). In a study of sleep disorders in sexual assault survivors, 80% had either sleep-breathing or sleepmovement disorders. Both disorders were linked to higher levels of depression and suicidality. Women who had both types of sleep disorders had the most severe symptoms. For these women, fragmented sleep appeared to potentiate the symptoms they experienced after their assault, making coping with the after matheven more difficult (Krakow et al.,2000).In a sample of female rape survivors with PTSD, trauma-related sleep disorders had an independent impact on health, even after controlling for both depression and PTSD (Clum, Nishith, & Resick, 2001). Koss and colleagues (1991) studied a sample of women drawn from a health maintenance organization. Victims, compared to non victims, reported poorer physical health and more physical health symptoms. Victims also reported increase frequency in visiting physician after victimization, relative to before victimization. Specifically focusing on sexual assault, Golding (1994) found that assaulted women were more likely than non assaulted women to report a wide range of physical symptoms, both those that could be explained by drug use, illness, or injury, as well as those that could not. Assaulted and non assaulted women did not differ in the likelihood of reporting at least one chronic disease, although reports of several diseases were higher among assaulted women. Coping processes are a key mediator in connecting stress exposure to outcomes. Lawler and colleagues (2005) found that greater use of avoidance coping related to the traumatic event (e.g., tried to forget about it) was related to more negative outcomes in their mixed-gender sample of college students. Avoidance coping in relation to health concerns and in relation to traumatic events mediated the relationship between PTSD and physical health outcomes as assessed by functional health and self-reported medical diagnoses. Conclusions: The literature review on trauma and health related symptoms consistently shows that exposure to trauma is related to poor health outcomes. Given the prevalence of trauma in the general populationroughly 5% in men and 10% in women (Kessler et al., 1995). The existing data can be used to argue that exposure to trauma is a significant public health problem that has social and economic costs. Thus, in a concluding remark this review of literature supports that trauma exposure leads to negative physical health consequences. Most of the body‟s systems are adversely affected by trauma. Specifically, there is a significant disruption to gastrointestinal functioning, the cardiovascular system, immunological functioning, the reproductive system, the musculoskeletal system, neuroendocrine functioning, and finally brain structure and functioning. Not only are these systems broadly affected by symptoms, but the risk factors for development of future medical disease are exponentially greater following exposure to trauma. References: American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text revision). Washington, DC: Author. Anda, R. F., Croft, J. B., Felitti, V. J., Nordenberg, D., Giles, W. H., Williamson, D. F., & Giovino, G. A. (1999). Adverse childhood experiences and smoking during adolescence and adulthood. Journal of the American Medical Association, 282, 1652-1658. Arias, I. (2004). The legacy of child maltreatment: Long-term health consequences for women. Journal of Women‟s Health, 13, 468-473.

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Snape, W. J., Carlson, G.M., Matarazzo, S. A., & Cohen, S. (1977). Evidence that abnormal myoelectrical activity produces colonic motor dysfunction in the irritable bowel syndrome. Gastroenterology, 72, 383-387. Spinhoven, P., Roelofs, K., Moene, F., Kuyk, J., Nijenhuis, E., Hoogduin, K., & Van Dyck, R. (2004). Trauma and dissociation in conversion disorder and chronic pelvic pain. International Journal of Psychiatry in Medicine, 34, 305-318. Stam, R. (2007). PTSD and stress sensitization: A tale of brain and body. Part 1: Human studies. Neuroscience and Biobehavioral Reviews, 31, 530-557. Teegen, F. (1999). Childhood sexual abuse and long term sequelae. In A. Maercker, M. Schutzwohl, & Z. Solomon (Eds.), Posttraumatic stress disorder: A lifespan developmental perspective (pp. 97-112). Seattle: Hogrefe& Huber. Uchino, B. N., Holt-Lunstad, J., Bloor, L. E., & Campo, R. A. (2005). Aging and cardiovascular reactivity to stress: Longitudinal evidence for changes in stress reactivity. Psychology and Aging, 20, 134-143. Ullman, S., &Brecklin, L.R. (2003). Sexual assault history and health-related outcomes in a national sample of women. Psychology of Women Quarterly, 27, 46-57. Ullman, S., & Siegel, J.M. (1996). Traumatic events and physical health in a community sample. Journal of Traumatic Stress, 9, 703-720. Van Houdenhove, B., Luyten, P., &Egle, U. T. (2009). The role of childhood trauma in chronic pain and fatigue. In V. L. Banyard, V. J. Edwards, & K. A. Kendall-Tackett (Eds.) Trauma and physical health: Understanding the effects of extreme stress and of psychological harm. London: Routledge. Weisberg, R. B., Bruce, S. E., Machlan, J. T., Kessler, R. C., Culpepper, L., & Keller, M. B. (2002). Nonpsychiatric illness among primary care patients with trauma histories and posttraumatic stress disorder. Psychiatric Services, 53, 848- 854. Wilson, D. K., Kliewer, W., Plybon, L., Zacharias, J., Teasley, N., &Sica, D. A. (1998). Violence exposure and ambulatory blood pressure in African-American adolescents. International Journal of Rehabilitation and Health, 4, 223- 232. Wilson, J. P., Friedman, M. J., & Lindy, J. D. (2004). Treatment goals for PTSD. In J. P. Wilson, M. J. Friedman, & J. D. Lindy (Eds.), Treating psychological trauma and PTSD (pp. 3-27). New York: Guilford Press. SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH (An Official Publication of Somatic Inkblot Society) Published Regularly Twice a Year in January and July First Volume Published in 1994 All Volumes of the SIS Journal are also available in PDF Format Individuals/Institutions can become Member of Somatic Inkblot Society by Submitting Membership Application Form Given in the Journal and Receive Print Version/Soft Copy of the Journal Published After the Date of Membership Free of Cost Bankey L. Dubey, Ph.D., DPM, DM&SP, Editor Emeritus, SIS Journal of Projective Psychology and Mental Health, E-mail : bldubey@gmail.com

This case was selected to illustrate the use of Somatic Inkblot test (SIT) in a woman who had been traumatized by abortion almost 6 months before. She expressed how she was feeling happy after knowing she has conceived and wanted to become a mother. It was a kind of forced decision on her. The Somatic Images helped in understanding her craving for affection from her mother, deprivation of maternal pleasure after abortion, disturbed interpersonal relationship with her partner, sexual conflict and depressive thoughts. Her responses changed after psychotherapy and she showed improvement. Significant SIT responses on Pre- and Post-therapy are discussed to illustrate the healing power of SIT. Introduction: Abortion is the deliberate termination of a human pregnancy, most often performed during the first 28 weeks of pregnancy. Abortion is legal in many countries, and a woman can terminate a pregnancy on request during the first 90 days. However, the existing religious beliefs, and practices do not allow abortion in some countries. The abortion may have severe impact on women particularly when she is mentally not prepared to terminate the fetus. Often, women develop guilt feelings and feel she has done something wrong, for which God will not forgive her. It is also evident that abortion is associated with a decrease in emotional and physical health. For some women these negative emotions may be very strong and can appear within a few days and in some after many months. The psychological impact may be in a form of post-traumatic stress disorder with possible symptoms such as: eating disorders, relationship problems, guilt feelings, depression, suicidal thoughts, sexual dysfunction and abuse of alcohol and drugs. Being a student of clinical psychology, I have been very interested in understanding the unconscious mind and “why we do what we do”. The questionnaires have their limitations and the projective tests particularly inkblot images are the only procedure to peep through the inner depth of a person. I was lucky enough to meet Dr. Antonio Cervigni, who allowed me to attend the workshops held by Prof. Bankey L. Dubey, Global Director Dubay Healing Center (USA) who taught me to have a much more insightful view of personality using Somatic Imagery Test (Dubey and Dubey, 2018, Dubey, Banerjee and Dubey, 2019) The SIT is a semi structured, projective, diagnostic procedure and is an adjunct to psychotherapy. It is structured by a sequential presentation of intentionally designed and field-tested inkblot-like images. These stimuli demonstrate typical and atypical response potentials. The technique is based on spontaneous, individually generated responses to semi-ambiguous figures, which elicit intrapsychic associations specific to the person presented with them. These images evoke symbolism and meanings unique to the responding individual such as present in somatic delusions and affect-charged dreams. The test stimuli can be differentiated from typical and atypical peer norms and can be analyzed according to internationally recognized diagnostic criteria. The procedure is an adjunct to psychotherapy because responses can be further explored to create a more effective treatment plan, and can be re-addressed in later discussions, providing opportunities to elicit deeply defended material. During the administration of the SIT procedure, clients may abreact emotional conflict raised to consciousness by the images, which can be a therapeutic experience (Cassell and Dubey, 2003). The SIT is self-administered test. It can also be used as “group administered Test” under

supervised instruction. The test is available on website: www.2d-crowd.com. The test has helped me to develop skills that I will use in my future clinical practice. I believe that SIT is an X-ray procedure of personality which helps one to investigate the unconscious mind of a person and find the psychopathology of the case. It also helps one to measure the progress of psychotherapy like a “Thermometer” (Dubey, Banerjee and Dubey,2019).The test can be used for all types of patients, regardless of their ethnicity, race, and specificity of disorders. The SIT is not only an aid for the psychologist, but it is also very important for the patient himself, who can discover his latent contents through the test responses and become aware of his/her emotional state. The test is not very popular in Italy and I hope soon it will get place on the clinician’s desk. The case: Ms. Xis a 27-year-old female, working as an attorney in Italy. She is currently living with her boyfriend in a comfortable apartment. She never had any problems during childhood and grew up in a healthy family atmosphere. As she described she had a bad period in her life during late adolescence, in which the bond with her mother got deteriorated, due to continuous misunderstandings. During this period, she chose to contact a psychotherapist to resolve the problems. After advice, she noticed improvement in her relationship with her mother. Recently, she had to face another problem related to motherhood. She suffered an abortion. The abortion was consciously chosen by her and her partner, who scrupulously evaluated all the alternatives; however, for her, this was a very difficult choice to overcome. A few months later, she was administered Somatic Imagery Test (SIT), in which she projected disturbed physical and psychological discomfort. Overall, she managed to live a happy life. After a year, I decided to administer the Somatic Imagery test to understand the changes and personal growth that the client had claimed during her journey to overcome the abortion trauma and to monitor the progress of psychotherapy. In the second administration, the patient had overcome with most of the difficulties and showed improvement in her relationship with her mother, though the pain of the trauma which she had undergone after abortion was yet to be resolved. The clinically significant SIT responses on pre and post administration are shown in Table 1 and interpreted using content analysis and psychoanalytic interpretation. Table 1 shows clinically significant responses on Pre and Post administration SIT Images Pre-therapy Responses SIT Administered on May 4, 2018 Post-Therapy Responses SIT Re-administered on May 16, 2019 Happy child, clown, atomic bomb. Happy person, teddy bear, ball, clown. Woman, (bandaged face, dancing woman and flessible) and apple. Smiling woman (black hair, shapely woman, dancing, sincerity)and Apple. Two dancers Two people are dancing together, tow hearts, two kisses, holding hands, happiness, moving coordinated A fetus, a pregnant woman’s belly Ear One hand in bush Many hands, asking for help, suffering, flames, a big hand at the center, burn. Pods, rain, small plant that sprouts Two pigeons kissing, a heart, two tongues, love, the fruit hanging from above on a branch- an apple. Lungs internal organs- lungs Turtle, two children, a bird seen from above Turtle, two children, a bird seen flying from below. Fish bone, spiral, spine Spine, straight, erect, stable, point of support, totem, mask, eyes. Cell, vagina, mollusc Vagina, depth, cross, concentric, mussel, pendant,

Somatic Imagery Test 107 jewel A face, hourglass, an alien Fetus, curled up, wadding, ultrasound Animal lying with horns (suffering) Breast, fingers, torn dress, naked A sad man and a sad woman. Two faces, two brains, a sad and worried face or rather angry, whisper, reassure. A woman and a child (she is in the picture and the child with head only) Two people, two faces, one mask, remove the mask, eyes, black, heads Two seated people looking at each other and playing Dialogue, two people chatting, confrontation, elderly people sitting Paper planes, scribbles, triangles, geometric drawings. Knives, point blades, scribbles, grater, erasures, throwing. A heart, halo, an apple, a sun in the background. Heart inside a heart with round background, crystal, spotted heart. A fish, a jellyfish between two rocky walls Penis, fish, nemo and dori reef, stings upwards" A sun, two hearts, a broken ball with cracks. Heart cracked, tentacles, card of hearts behind, sun, rays, heart at the center, world shattered, brightness, luminosity A battle, an explosion, a clipping Bottle of sparkling wine bang, New Year’s Eve, burst, crop, gun, pistol, trigger. Un person supine down the road Person on the road, in the middle of the lanes, tracks, rest, waiting. A fetus, a baby, a chick A fetus, two children, a chick, look at each other. Lady with shawl, makeup, hair up Mom welcoming baby, hug, baby who wants to go up on his mom’s lap Fear, man running away Man running, leg down, fear, face anguished Family, children, trees Family, holding hands, mother, father, two children, going together, loving Image 4: She perceived “happy child, clown, atomic bomb" during first administration. Happy child and Clown are the normal response whereas atomic bomb indicates aggression. The happy child reflects her happy childhood and lots of fun and enjoyment like clown. She confirms that as a child she felt very happy, full of ideas, cheerful and funny like a clown. Atomic bomb may indicate her active involvement with full of energy and vitality during childhood. She further confirms the fact that as a child she was very active and full of vitality. The atomic bomb may also indicate aggression which can be explored during therapy session. In the second testing she perceived “Happy person, teddy bear, ball, clown”. Perception of Teddy bear is very normal response which may also indicate that the feeling of aggression is processed after and during therapy. Image 5: She viewed “Woman, (bandaged face, dancing woman and flessible) and apple” on first testing. Both are normal response. However “bandaged face” may indicate physical injury/trauma. Probably this might be the trauma of abortion which she felt lateron. She gave normal response “Smiling woman (black hair, shapely woman, dancing, sincerity), and Apple” after psychotherapy. The quality of responses also improved after therapeutic intervention. Image 6: She perceived “Two dancers” on this image though two persons (male and female) would have been a better response. Not perceiving “Male and Female or Couples” may indicate conflicting relations with her boyfriend. However her response “Two people are dancing together, two hearts, two kisses, holding hands, happiness, moving coordinated” on second administration improved significantly, indicating better loving relationship, togetherness and bond of love and happiness. Image 7: She saw “Fetus” on this image indicating her mental preoccupation with her pregnancy and trauma. After psychotherapy she perceived “Ear” - a normal response.

Image 8:She viewed“one hand in bush” on the first testing which may indicate known issues/problems which she is trying to resolve. On the second testing “Many hands, asking for help, suffering, flames, a big hand at the center, burnbandaged face” may indicate support and help and desire to run away from something that makes her suffer. This may also indicate her known problems for which she is trying to seek help and support.“The Big hand at the center” may indicate desire to get support from superpower/God. Often people having faith in God may give responses having spiritual symbols. This is also a sign of prognostic indicator. Image 9: She viewed “Pods, rain, small plant that sprouts" on this image may indicate her ongoing still immature love, which is slowly growing. It shows that the relationship with her partner is young, like a bud that needs rain to become a strong and stable plant. On second testing she perceived “Two pigeons kissing, a heart, two tongues, love, the fruit hanging from above on a branch - an apple” indicates togetherness, intimate relationship and love with her partner. No longer does she speak of a plant that is sprouting, but of fruit, that is something ripe and ready. Moreover, she identifies the figure with “love”, with the kiss and with “passion” (tongues). This further indicates that the relationship with her partner is becoming more mature, adult and happy. The client confirms improved relationship with her partner. Image 12: She viewed "Lungs” on both testing sessions – which is a normal response, and indicates her healthy body imagery. Image 13: She perceived “Turtle, two children, a birdseen from above” on first testing and “Turtle, two children, a bird seen flying from below” on second testing.As such responses on both testing looks normal, indicating good interpersonal relationship with her parents during childhood. What is interesting to note that she perceived the bird from above in first testing and bird from below in second testing. This makes me think of Freud's dream theory, which states that flight is an effect of sexual desire and orgasm, or even of life in the womb. Seeing a bird from above may indicate the desire to escape from something or from someone; while a bird seen from below can symbolize the desire to be free or to reach an important goal. Also, the word "protection" is added. Perhaps, the client is looking for support. Image 14: She projected “Fish bone, spiral, spine” on this image, which is a normal response. On the second testing, she vied this as “ Spine, straight, erect, stable, point of support, totem, mask, eyes”. Projection of eyes on this image may indicate her suspicious attitude towards her partner. Image 15: She perceived “Cell, vagina, mollusc” – which is a normal response. Even on the second testing she projected “Vagina, depth, cross, concentric, mussel, pendant, jewel” - which is a normal response. The perception of “CROSS” is a spiritual symbol indicating her faith and wish to get support / help from GOD. Image 16: She viewed it as "A face, hourglass, an alien”. Fetus is normal perception on this image. The hourglass may indicate, the time that passes, just like in the case of an adult woman who feels ready to become a mother, but for some reason renounces this condition. Perhaps it is precisely this renouncement that worries the client. In simpler words, the girl's unconscious desire seems to tell us "I am giving up pregnancy even though I am the right age and even though I am afraid that one day it will be too late". Moreover, the word "hourglass" could also refer to something that empties. In fact, the “alien” may be the feeling of situational rejection of FETUS and non-acceptance of pregnancy leading to abortion. Image 17: She projected “Animal lying with horns (suffering)" on this image. It is interesting to note that she did not perceive the most common response “breast” on this image. Avoiding perception of breast may serves as defense mechanism to protect her maternal instinct because of the kind of forced decision of abortion. It may also indicate emotional conflict with mother figure (herself as mother).The animal lying with horns indicates her aggression and hostility, towards her partner (destructors) and suffering as symbolic representation of her inner cry. Also, the words

"horns" and "suffers” may indicate a sense of danger, pain and insecurity. She wanted support from her mother during such stressful situation but due to difficult relationship she failed to get emotional support. After therapy sessions her responses “Breast, fingers, torn dress, naked” improved to some extent and she perceived breast which is a normal response. However, “torn dress, and naked” still indicates a kind of physical assault, hostility and aggression which must be addressed during therapy session. Image 18: She projected “A sad man and a sad woman” in the forst testing session. It may indicate pensive mood of her and her partner.However, her responses after therapy changed and she perceived “Two faces, two brains, a sad and worried face or rather angry, whisper, reassure”. The “reassurance” may indicate her desire to get reassurance from her partner towards life in future. It is a good prognostic indicator. Image 19: She projected “A woman and a child (she is in the picture and the child with head only) - undeveloped child may indicate her trauma of abortion in the form of immature pregnancy. Though her responses on second testing “Two people, two faces, one mask, remove the mask, eyes, black, heads” improved to some extent after therapy, yet she needs support and assurance towards happy motherhood. Image 20: She perceived “Two seated people looking at each other and playing.” In the first testing session which is a normal response.However,on the second testing she viewed “Dialogue, two people chatting, confrontation, elderly people sitting” may indicate unpleasant dialogue/conversation with her partner before abortion. Image 21: She projected “Paper planes, scribbles, triangles, geometric drawings” on the first testing session which is a normal response. However, the suppresed anger came out after therapy and she projected “Knives, pointed blades, scribbles, grater, erasures, throwing”. Knives and pointed blades may indicate flared up hostility. The psychotherapist must help the client to release her aggression during therapy session. Image23: “A fish, a jellyfish between two rocky walls" is projected on first testing. Normally people see male sex organ on this image. Fish is the symbolic representation of male sex organ. “A jelly fish between two rocky walls” may indicate her desire to see his partner having hard time in relationship. This may also indicate her hatred towards his partner. She further expressed that she has lost sexual interest and did not have satisfactory relationships with his partner. However, the responses on second testing “Penis, fish" look improved response and an indicator of maturity to deal with her partner. Image 24: She projected “A sun, two hearts, a broken ball with cracks” on first testing. Thebroken ball may indicate a kind of broken relationship with her partner because of forced abortion. The theme continued on the second testing as she perceived ““Heart cracked, tentacles, card of hearts behind, sun, rays”. The “heart cracked” and “world shattered” may indicate her pensive and aggressive mood with feelings of disturbed, shocked, devastated, traumatized sufferings as she expressed during therapy session that she has hadthe right age to become mother and she was never ready for abortion. Image 25: "A battle, an explosion, a clipping" - she perceived on first testing which may symbolize uncontrolled aggression. Similar theme is projected on image 21. However, the aggression reduced to some extent after psychotherapy and she projected “Bottle of sparkling wine bang, New Year’s Eve, burst, crop, gun, pistol, trigger” on second testing. This shows the effect of psychotherapy and the power of Somatic Inkblot test in pulling out the suppressed unconscious material. Image 26: In the first testing she viewed “A person supine down the road." This may indicate her injured ego and depressive mood. On the second testing she perceived “person on the road, in the middle of the lanes, tracks, rest, waiting." It may indicate that she is taking rest and waiting for her loved one to support her. This is positive response and looks as if psychotherapy has improved her mental condition. Somatic Imagery Test 109

Image 27: She projected “A fetus, a baby, a chick” on first testing and “A fetus, two children, a chick, look at each other” on second testing, which are normal perception. “Look at each other” may indicate care, expectation and hope towards life. Image 28: She viewed “Lady with shawl, makeup, hair up” but avoided to perceive “mother holding her child” which is most common response on this image. Avoiding to perceive “Baby/Child” may indicate her trauma of abortion. It may also indicate her “conflict with mother”. A person who has lost her child may often avoid baby on this image. However, on the second testing, she perceived “Mom welcoming baby, hug, baby who wants to go up on his mom’s lap”is normal response. Positive effect of psychotherapy is visible on various images of Somatic inkblot test. “Mom welcoming baby, hug, baby who wants to go up on his mom’s lap” may also indicate that she is eager to become mother again. Image 29: She perceived “Fear, man running away” on first testing and almost similar response “Man running, leg down, fear, face anguished” on second testing may indicate a kind of uncertainty, anxiety and fear towards life. This must be addressed during therapy session. Card 30:She projected “Family, children, trees” on first testing and "Family, holding hands, mother, father, two children, going together, loving" on second testing. After psychotherapy her response improved significantly and showed concern of family, togetherness, mutual support and love. Here she specified the concept of family and added love and mutual support that is desired within each family. Quantitative Analysis: On both administration of SIT she gave high number of responses which indicates that she has high productivity, high creative ability and high functional intelligence. She has given high percentage of human responses indicating stable relationships and good interpersonal skills. The "animal" responses are low indicating latent aggression that is often not listened to, but all in all, they are negatively related to "human" responses. The anatomical responses are low and indicate no pathology in the area of healthy body imagery, though there is partial anxiety towards one's body image. The protocol shows depressive content but is not alarming. A higher number of Most Typical responses (MT) are suggestive of coherent, logical thinking, and ability to keep up with the demands of society. It may also be interpreted as a measure of ego strength and team concept. It may also indicate negotiation skills and confidence in words to resolve issues. There is no denying the existence of an issue in sexual conflict which can be addressed during therapy session. It also indicates good prognosis. On second administration of SIT she gave almost more than the double of the answers than pre-test administration. The indices further indicate high creativity and functioning intelligence. Human responses are still very high, while animal responses have increased slightly, indicating her good socio-emotional competence and her propensity towards people. The anatomical score still shows a slight concern towards the body, but sexual responses have increased, indicating an improvement in intimate relationship with her partner. Finally, there are many movements, which make us think of the fact that she has regained her vitality and is active as before the onset of her symptoms. The client has projected responses such as "marrowbone", "baobab", "erect, totem", "vagina, depth, mussel", "trigger, bat" that clearly represent sexuality (Image 9,14,15,17). In the first administration, she perceived only one sexual response (female genitalia), while on second administration she perceived both male and female genitals. Her interpersonal relationship with her partner has improved and she feels happy with her boyfriend. Conclusion: It can be concluded that the client is a very strong and emotionally stable person and is able to face the obstacles of life. A year before, she had some depressive thoughts and some relationship issues, while at present, there is an improvement in the tone of expression and overall her mood. Her

relationship with her partner has improved and they communicate with each other comfortably. She has regained her vitality and desire to do, though the road to complete resolution of her trauma is yet to complete. However, the prognosis is that she will be able to overcome this obstacle without taking so many painful residues. It is also interesting to note how the phallic and pelvic symbols are reported so intensively in the second testing. The findings clearly indicate the rejuvenating power and healing effect of somatic images. References: Cassell, W. A. and Dubey, B. L. (1996) Efficacy of the Booklet and Monochromatic Version of the SIS in a Case of Repeated Miscarriages. SIS Journal of Projective Psychology & Mental Health, 3: 131-145. Cassell, W, A. and Dubey, B. L. (2003) Interpreting Inner World through Somatic Imagery: Manual of Somatic Inkblot Series. SIS Center, Anchorage, (USA) (www.somaticinkblots.com), Dubey B. L., Banerjee P. and Dubey Anand (2019) Inkblot Personality Test: Understanding the Unconscious Mind, SAGE Publication. Dubey B.L. and Dubey Anand (2018) Manual of Somatic Imagery test (2018) Dubay Healing Center, 7490 Coon Club Road, Medina, OH 44256 (USA) SIS Abstracts Download The soft copies of the abstracts of published papers of all issues in SIS Journal of Projective Psychology and Mental Health commencing from Volume 1 (Launching year 1994) to the current year can be downloaded free of cost from the website of Somatic Inkblot Society on following URL: SIS Abstracts: http://somaticinkblots.com/abstracts/ Copyright ©1994. SIS Center, India Somatic Imagery Test 111

The Somatic Imagery Test (SIT- online version) was administered to a 54 years old female to understand her personality and inner cry, if any. The inkblot images were helpful to bring out high dissatisfaction and poor interpersonal relationship with her partner, mild depression and suppressed hostility with lots of unprocessed unconscious material that aided the process of therapeutic intervention. The responses were analyzed using content analysis and psychoanalytical interpretation. Introduction: The Somatic Inkblot Series (SIS) is a semi - structured, projective, diagnostic procedure and is an adjunct to psychotherapy. It is structured by a sequential presentation of intentionally designed and field-tested inkblot-like images. These images demonstrate typical and atypical response potentials. The somatic inkblots procedure is projective because it is based on spontaneous, individually generated responses to semiambiguous figures, which elicit intra psychic associations specific to the person presented with them. Since its inception, the SIS test has undergone transformation that led to the development of different versions of the test and has now adapted modern technology which helps the clinician to administer and use the test in diverse situations effectively (Dubey and Dubey, 2018, Dubey et al, 2019, Dubey et al., 2005). The Somatic Imagery test (SIT) is a short version of 30 somatic images for quick assessment. It is designed for self-administration after supervised instruction. The test is also used as “Group administered test”. The subject is asked to go to http://dubeyhealingcenter.com and follow the instructions “Most people find this test fun and interesting. First, please relax, and prepare to enjoy. Please write each in terms of what they resemble or look like to you. Different people see different things in the inkblots. It is important to write whatever the inkblot looks like to you. Please include everything you see even if it reminds you of something remote, vague, highly personal or even potentially embarrassing. Please include everything you see with as much detail as possible. Also include any outstanding emotional reaction that you might feel in responding to these images”. The test may take about 30 minutes to complete. Please be assured that there are no right or wrong answers. Mental health professionals with training and experience in projective techniques will have little difficulty integrating the scoring and charting conventions used with the SIT. Inkblot Personality Test: Understanding the Unconscious Mind (Dubey, et al, 2019, Cassell and Dubey, 2003), can be a resource for increasing one‟s skill in the interpretation of responses on Somatic Imagery test. Since the procedure conceptually taps into the same stream of imagery as seen in dreams, daytime fantasies and visual hallucinations, a background in the interpretation of such content, either in a direct or latent symbolic way, is helpful. Clinicians experienced in the art of psychotherapy will readily adapt to this technique (Kwiatkowski,et al, 1978). They will find the SIT an useful aid, especially for people who cannot draw. In a sense, the SIT (employs) uses art as a diagnostic and therapeutic approach for those who cannot engage in traditional art procedures. Other clinicians with experience in dream interpretation, visualization techniques, guided imagery, active imagination therapies and

hypnotherapy will also readily adapt to this procedure (Dubey et al, 2019). The present case study analyses the responses of a female client who approached one of the authors (SS) for psychotherapy. She was administered the Somatic Imagery Test (SIT) - the online version (www.Dubayhealingcenter.com), to find out the unprocessed unconscious material having clinical significance. Case X: The Client X was a 54-year old married female, Hindi speaking, who approached for help. The main complaints of the client were frequent anger outbursts, irritation, hot flashes, general dissatisfaction in life, lack of peace/low mood, unpleasant past experiences, disturbed sleep, worry about future, low self-esteem and overall distress. She is an only daughter to her parents in a family of five brothers. She was very close to her father as a child and reported that she was his favorite child. She also reported that her father was a man of ideals and was extremely short tempered. As a child, she wasn‟t very close to her mother. She is educated till 11th standard and regrets not being allowed to continue her education. This makes her feel conscious, leading to low self-confidence at times. She got married at the age of 21 years. She feels that she was neglected and never received love, acceptance and attention that she expected from her husband and in-laws. The Somatic Imagery Test (SIT) was administered to her following the standard procedure ((Dubey and Dubey, 2018, Dubey et al, 2019) for understanding her overall personality and unprocessed unconscious material that needed to be addressed during psychotherapy. She was motivated and cooperative during testing. The clinically significant responses were interpreted using content analysis and psychoanalytic interpretation. Image 1: She perceived “looks like a child holding” indicating her need for support and a kind of insecurity. On interaction she accepted that she still needs support from her family. Image 2: “Roots of plant” is a normal response. Image 3: She perceived “Bat on top. Heart shape in the middle and bat-type figure below too” which are normal responses. Image 4: She projected “looks like dog on the side and Face of human - big round”. The dog on the side indicates good interpersonal relationship during childhood. However, the “big human face” may indicate strict discipline and authoritative attitude of parents during childhood. The findings are supported by her case history. Image 5: She viewed “Apple. Lips and snake-like shape below” on this image. Apple is the most common normal response on this image. She had avoided perceiving “dancing lady”, the second most common response on this image. If a female is unable to perceive dancing lady, it may indicate that the happiness from her life has gone away. It is a strong indicator of poor interpersonal relationship with her partner and mild depression, which is supported by her case history. Instead of perceiving dancing lady, she has perceived “a snake” which is symbolic of phallus. She also perceived lips along with the phallus which could be indicative of feelings that may correlate with intimate relationship. “Lips and snake” may further indicate oralerotic and passive-receptive tendency (Schafer Rorschach). Overall, her response is indicative of poor interpersonal relationship with her partner, which can be discussed during therapeutic session. Image 6: She did not perceive anything on this image. Projection of “male and female, or any two persons” is a healthy response, suggestive of good interpersonal relationship. Rejection of this image may indicate poor interpersonal relationship with her partner which is also supported by her responses on image 5. Image 7: She viewed “Ear” on this image - a most typical and normal response. Image 8: Seeing “Full palm” is also a most typical normal response on this image.

Image 9: She perceived the image as “Hen (left side) and “Lizard shape” (Right side). Inside both - small birds” Perceiving lizard is a sexual connotation. Hen may symbolize weak, helpless female. The normal response on this image is „two birds interacting or making love.‟ Avoidance of this is suggestive of frustrated love affair and conflict in love relationship. The Lizard may also indicate negative attitude towards her partner (Phillips and Smith). Image 10: She saw “Ribcage; lungs” which is a normal response. Image 11: Seeing “Animal in the center – may be a dog and heart shape on the outside” are normal responses. Dog may indicate “Passive - dependency” (Klopfer Davidson). Image 12: She projected “Kidney” which is a most typical and normal response. Image 13: She perceived on this image “human shadow and 2 children on the side” which is a normal response and is indicative of good interpersonal relationship with parents especially with father which corroborates with her case history too. Image 14: “Backbone” is normal response on this image which is indicative of heathy body imagery. Image 15: “Vagina” is a normal response on this image which is indicative of healthy erotic and body imagery. Image 16: She perceived “Sonography image of a fetus in the womb” which is a normal response. Image 17: She projected “Nipple” on this image. Breast is the most common perception and a normal response. Non-perception of breast may indicate deprivation/ conflict with mother during childhood. Those who lost their mother during childhood, lived away from their parents, often reject this image. A female having undeveloped breast, or sexual trauma may also find difficult to perceive this image. It further indicates client‟s craving for affectional need from her mother. She expressed that she was not very close to her mother during childhood and has conflicting relationship with her mother and mother-in-law. Image 18: She perceived “Face of a Women and man. Women, on the right looking in anger. Man, on the left just looking at her with attention”. The client expressed that this is how her husband looks at her and she reacts in this manner. This response clearly indicates expression of aggressive behavior towards her partner. Image 19: She projected “Two skulls - Left one is female and right is male”. Two faces are most common response on this image. Avoiding perceiving two faces may indicate poor interpersonal relationship between wife and husband. Image 20: She viewed “Two people sitting on a chair having conversation - male and female” is normal response. This suggests that the client has a mature approach to handle the situation and is attempting to have a smooth relationship with her husband. Image 21: She projected “Looks like lady's half body (in pink). Also, looks like horse's half body too”. Here, her response “half horse” is a sexual connotation. Generally, half horse is an atypical response and may indicate sexual interaction under pressure or painful situation. The “horse” also indicates ambivalence towards domineering father/authority (Phillips and Smith) which is supported by her case history. Image 22: Normally, people see a heart on this image but, the client has rejected this image, which may indicate conflicting love relationship. It may also indicate cardiac problems of self or of some significant family member(s). Image 23: She could not perceive anything on this image. Malesex organ is the most common response. Female having sexual conflict or sexual trauma may reject this image because it symbolizes male phallic region. Image 24: She perceived the image as “Disease, Cancer cell.” In this image, she avoided perceiving the hearts which is indicative of disturbed interpersonal relationship. And, cancer could be indicative of the painful situation which she is perceiving constantly.

Image 25: She did not perceive anything and rejected this image which may suggest suppressed hostility/ aggression. She has expressed aggression on Image also. The psychotherapist must address to manage such aggression during therapy session. Image 26: She viewed it as a “Child standing inside a circle” which is a rare response on this image. Most people perceive it as „body resting; soul leaving body; person doing yoga, and dead person‟. Avoidance of common percept on this image may indicate fear / death anxiety. Image 27: She said, “Small babies of hen when they come out - Chicken”. Here, in this image, the client avoided to perceive human baby, which may indicate aggressive attitude or feeling of separation from children. Image 28: “Mother holding the child in her arms and embracing the child really close to her chest”- This is a normal response indicating affection towards children. She has used the Hindi word “Chipkana” which may further indicate insecurity that her children should not go away and/or leave her. Image 29: “Running Man” is a normal response to this image. Image 30: “Parents and two kids.” is a most typical normal response. Conclusion: Overall, the client gave 11 Most Typical responses which indicate that she has contact with reality, has good ego strength and is free from psychotic ailments (no psychotic features). However, she rejected 4 images which indicate that she has high dissatisfaction in her personal intimate relationship, sexual conflict, mild depression and suppressed hostility. All in all, her responses revealed high degree of preoccupation with her strained interpersonal dynamics with her partner. The SIT analysis was shared with the client and she corroborated the results. She is currently undergoing psychotherapy and is being treated for relational and emotional issues. The outcome is encouraging, and the client is feeling better after three sessions. The SIT procedure can be considered an excellent tool to tap into one‟s unconscious mechanism and unprocessed painful materials. It gives the therapist a head start into the direction of exploration in therapy. The use of SIT and its findings greatly helped in establishing rapport with the client, eliciting psychopathology and in therapeutic planning. References: Cassell, W, A. and Dubey, B. L. (2003).Interpreting Inner World through Somatic Imagery: Manual of Somatic Inkblot Series. SIS Center, Anchorage, (USA) (www.somaticinkblots.com), Dubey B. L., Banerjee P. & Dubey Anand (2019).Inkblot Personality Test: Understanding the Unconscious Mind, SAGE Publication. Dubey B.L. & Dubey Anand (2018) . Manual of Somatic Imagery test. Dubay Healing Center, 7490 Coon Club Road Medina, OH 44256 (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. Kwiatkowski , J.S., D. Perahia, D. and B. Pullman, B. (1978). Aspects of oxo pyridine‐water interactions, Wiley online Library: https://doi.org/10.1002/qua.560140819

The present study was an attempt to differentiate SIS-II responses between delusion of infidelity and other delusions in patients with schizophrenia. The sample comprised of 5 patients having delusion of infidelity and 5 patients having other delusions drawn from inpatient department of Institute of Mental Health and Hospital, Agra. The Scale for the Assessment of Negative Symptoms (SANS), Scale for Assessment of Positive Symptoms (SAPS) and SIS-II (62 image Booklet Form) were administered for gathering relevant information. The findings revealed that there is no significant differences in statistical analysis but mean scores are showing difference between the scores which patients with delusion of infidelity and other delusion obtained on eleven categories. Introduction: Schizophrenia is a chronic psychiatric disorder with a heterogeneous genetic and neurobiological background that influences early brain development and is expressed as a combination of psychotic symptoms such as hallucinations, delusions, disorganization, motivational and cognitive dysfunctions. The disorder usually begins before age 25 years, persists throughout life, and affects individuals of all social classes. The lifetime prevalence of schizophrenia is about 1 percent, which means about one person in 100 will develop schizophrenia during their lifetime. Schizophrenia is equally prevalent in men and women. The peak age of onset are 10 to 25 years for men and 25 to 35 years in women (Kaplan & Sadock, 2015). Disorder of content of thought: According to DSM-5, delusions are fixed beliefs that are not amenable to change considering conflicting evidence. Their content may include a variety of themes include persecution, jealousy, love, grandiosity, ill health, guilt, nihilism and poverty. Jealousy is a common but complex emotion and within an intimate relationship and it has some advantage. It is the behaviour that ensures the complete and singular possession of one’s partner, which allows the dissemination of one’s own genes at the cost of those of a true rival (Daly, 1982). Cultural differences have been found and jealousy within an interpersonal relation is more common in cultures where sexual gratification is allowed within marriage and in cultures which values more on personal property (Harris, 2004). A morbidly jealous person suffers irrational thoughts and may show extremes of behaviour where the dominant theme will be preoccupation with partner’s infidelity based on unjustified evidences. The commonly recognised forms of psychopathology in morbid jealousy are obsessive jealousy, overvalued idea, and delusion of jealousy (Kingham, 2004). In delusional jealousy, the sufferer accuses their partner of infidelity and does not resist the thought; on the contrary, they continuously try to confirm their suspicions, like constantly enquiring their partner to extract a confession. Delusion is still difficult to treat. Haddad et al, (2014) had conducted a study on non-adherence with anti-psychotic medication in schizophrenia: challenges and management strategies and its result showed that the non-adherence rate increased to 50%. Higashi (2013) had conducted a study on medication adherence in schizophrenia to understand the factors influencing adherence and consequences of non-adherence. Results showed that 74% of patients had discontinued medication within 18 months due to insufficient efficacy, intolerable side-effects or for other reasons (Lieberman, 2005), yielding non-adherence rates in schizophrenia to range from 37% to 74%. Individuals with mental disorders tend to be less

adherent for several reasons. They may deny their illness; they may experience adverse effects that dissuade them from taking more medication; they may not perceive their need for medication; or they may have grandiose symptoms or paranoia. Kumar (2001) conducted a study to identify the prominent SIS-I indices among hospitalised male chronic schizophrenics. 32 male hospitalised chronic schizophrenics and 32 normal patients was drawn from Agra Mansik Agrogyashala. The analysis of results indicated that the schizophrenic group scored lower on total number of responses, animal responses, anatomical responses, sex responses, most typical responses and typical responses. Auslander et al, (2002) compared 27 medically stable outpatients with paranoid schizophrenia to 17 out-patients with non-paranoid schizophrenics and normal comparison participants. The paranoid patients showed significantly less impairment on Rorschach measure of perceptual inaccuracy and cognitive slippage. The present study was an attempt to gather preliminary observations to explore if SIS-II scoring system is sensitive enough in detecting specific delusion in patients with Schizophrenia. Methodology: The sample was collected from the Inpatient Department (IPD) of the Institute of Mental Health and Hospital, Agra. 10 patients with Schizophrenia were taken for the study. Five of them had a prominent delusion of infidelity and the other five had other delusions. Following tools were administered – (a) Scale for assessment of Positive symptoms (b) Scale for assessment of Negative symptoms (c) SIS-II (62 image Booklet Form). For result analysis Mann-Whitney U test was used. Results: Table 1. Comparison between Group ± SD and Mean rank Variables Group (Mean ± SD) Mean Rank Z U Delusion of infidelity Other delusion Delusion of infidelity Other delusion SANS 38.8 ±7.2 33.6 ± 16.4 6.60 4.40 -1.152 .675 SAPS 39.2± 13.8 34.2 ± 31.8 5.90 5.10 -.419 .249 Total response 59.6±2.4 62 ± 0 -1.00 .317 Human response 15± 15 12.2 ± 2.8 -.529 .597 Animal response 10.4 ± 4.6 9 ± 6 5.80 5.20 -.315 .753 Anatomical response 13.4 ± 5.6 19.8 ± 31.2 5.20 5.80 -.317 .751 Sex response 0.8 ± 3.2 0 ± 0 -1.00 .317 Movement response 1.4 ± 2.6 3.6 ± 5.4 4.20 6.80 -1.448 .147 Most Typical response 5.6 ± 3.4 4.6 ± 1.4 -.532 .595 Typical response 23.2 ± 18.8 9.2 ± 2.8 6.90 4.10 -1.471 .141 Atypical response 22.8 ± 20.2 32.8 ± 16.2 4.40 6.60 -1.149 .251 Rejection 2.4 ± 9.6 0 ± 0 -1.00 .317

118 Singh & Dwivedi Pathological Anatomy scale 0 ± 0 0.6 ± 0.4 -1.964 .050 Depression scale 0 ± 0 0 ± 0 5.50 5.50 0.00 1.000 Hostility and Aggression scale 0.4 ± 0.6 0.6 ± 1.4 5.30 5.70 .000 .811 Paranoia scale 0 ± 0 0 ± 0 5.50 5.50 -1.017 1.000 * Sig at 0.05 level Nonparametric statistics was used to see significant difference between Z scores of both the groups in 11 scoring categories of SIS II. None of the Z scores showed significant differences in 11 scoring variables among the two groups. Discussion: Somatic Ink blot Series (SIS) has been used with different clinical groups in India and found to be very effective tool in diagnostic evaluation and therapeutic intervention. It has also been used on various population. The preliminary observation was conducted to find out the potential of the SIS- II to tap differences, if any, between Delusion of Infidelity and other Delusions in patients with Schizophrenia in terms of their specific responses to the 11 scoring categories of the test. Results revealed that SIS II scoring system is not able to differentiate among the different anomalies of thought-content in terms of delusions. Similar study was conducted by Dwivedi (2015), who used Exner’s comprehensive system to tap different disorders of content of thought specifically delusion of infidelity. He also didn’t find any significant difference between both the groups in 93 scoring variables of Exner’s comprehensive system. This implies the presence of relative homogeneity among response nature when clients suffering from different delusions are considered. A study was conducted by Dubey et al (1992) on normal cohorts, neurotic and schizophrenic. They also found there were not many significant differences among the groups in terms of their 11 categories of responses. This might be inferred that SIS may be viewed as a mentor in more therapeutic domains rather than being a specific diagnostic instrument. In this direction another study was conducted in 1997 by Mishra and Dwivedi by using SIS-II on normal individuals, neurotic depressive, anxiety neurotic, paranoia and undifferentiated schizophrenia. He also found no significant difference in groups in terms of their scoring. In the current study, some of the scores of the variables were found to be higher in patients having delusion of infidelity. Human response was obtained to be high in patients having delusion of infidelity which means that this group has stronger interpersonal relationships with human beings. Among patients with other delusions, such responses are low which might be indicative of a desire to be away from others and may indicate schizoid or social isolation tendencies. Patients having delusion of infidelity had given large number of animal responses in comparison to patients having other delusions. This implies that they are more comfortable with animals than people and appear to be psychologically immature. Patients having other delusions scored more on anatomical responses than the mean scores of clients having delusion of infidelity. This indicates that patients having other delusions are preoccupied with internal body organs. Mean score of Sex response in patients having delusion of infidelity signify sexual anxiety and/ or dysfunction. Movement responses indicate movement in human beings or animals. Patients having delusion of infidelity had scored relatively higher on most typical responses, which is suggestive of coherent, logical thinking, and ability to keep up with the demands of the society. It may also be interpreted as a measure of ego strength and team concept. More typical responses are given by patients having delusion of infidelity which are commonly seen by healthy people on a particular image.

Patients having other delusions scored higher than the mean score of patients having other delusion. This indicates the degree of psychological or psychiatric disturbance in patients with other delusions. There is no rejection of images by patients having other delusions. Further, mean score of patients having delusion of infidelity shows thought blockage and an inability to think coherently. Hostility and aggression are seen more among patients having other delusions, which appear to involve physical assault or body injury. The quest for delineating SIS-II associated with specific delusions may not come to an end with this preliminary observation. The other option for such an attempt could be to do a qualitative analysis of the content of responses and enquiry which may give clues to the presence of specific delusions. The delusions may get reflected in the themes of the responses. In future, an attempt will be made to present qualitative data relevant to the delusions. The system of content-based analysis has already been standardized and well researched in the context of Somatic Inkblot Series. Other projective techniques like TAT, HIT may also be explored to see whether they permit the detection of specific delusions. Thus, the quantitative analysis through SIS-II does not seem to be sensitive enough to detect specific disorder of content of thinking, specifically in terms of delusion of infidelity. A quantitative or contentbased analysis may provide clues to the theme of delusions which need be explored empirically in future studies having a greater sample size. Reference: Auslander, L. A., Perry, W., &Jeste, D. V. (2002). Assessing disturbed thinking and cognition using the Ego Impairment Index in older schizophrenia patients: Paranoid vs. nonparanoid distinction. Schizophrenia research, 53(3), 199-207. Daly, M., Wilson, M., &Weghorst, S. J. (1982). Male Sexual Jealousy. Ethology and Sociobiology, 3, 11-27. Dubey, B. L., Mishra, M., Dwivedi, C. B., & Mishra, N. (1994). Diagnostic and therapeutic utility of Somatic Inkblot Series-II and Rorschach. SIS Journal of Projective Psychology & Mental Health, 1(1), 18. Dwivedi, M. M. C. (1997). Content Scale Based Diagostic Compatibility of the SIS-II with Rorschach Test in Normal, Neurotics and Schizophrenics. SIS Journal of Projective Psychology & Mental Health, 4(1), 119. Dwivedi, S. D. (2015). Sensitivity of Exner's comprehensive scoring system in detecting specific delusions in psychotic patients: Preliminary observations. SIS Journal of Projective Psychology & Mental Health, 22(1), 58. Haddad, P. M., Brain, C., & Scott, J. (2014). Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies. Patient related outcome measures, 5, 43. Harris, C. R. (2004). The evolution of jealousy: Did men and women, facing different selective pressures, evolve different" brands" of jealousy? Recent evidence suggests not. American scientist, 92(1), 62-71. Higashi, K., Medic, G., Littlewood, K. J., Diez, T., Granström, O., & De Hert, M. (2013). Medication adherence in schizophrenia: factors influencing adherence and consequences of nonadherence, a systematic literature review. Therapeutic advances in psychopharmacology, 3(4), 200-218. Kingham, M., & Gordon, H. (2004). Aspects of morbid jealousy. Advances in Psychiatric Treatment, 10(3), 207-215. Kumar, S., Singh, R., & Mohanty, S. (2001). A study of Somatic Inkblot Series-I in Hospitalised Male Chronic Schizophrenics. SIS Journal of Projective Psychology & Mental Health, 3(1), 31. Lieberman, J. A., Stroup, T. S., McEvoy, J. P., Swartz, M. S., Rosenheck, R. A., Perkins, D. O., ... & Severe, J. (2005). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New England journal of medicine, 353(12), 1209-1223. Sadock, B. J and V. A. Sadock. Kaplan and Sadock’s Synopsis of Psychiatry. 11th edition, 2015, Wolters Kluwer Health/Lippincott Williams and Wilkins, New Delhi.

considerable impact on the mental health of individuals. Insomnia is a frequent complaint in the cases of depression and adds to the distress associated with it. It is therefore important to understand the relationship between these two separate clinical conditions. The present article attempted to examine the two conditions from psychological management perspective based on available research literature. The research indicated that the two conditions are frequently interrelated. There is a robust research evidence for the management of insomnia by using the cognitive and behavioral therapy for insomnia and studies have examined the transfer of benefits to associated conditions like depression and anxiety. However, more research needs to be conducted to further explore the linkage and common causative factors underlying insomnia and associated psychiatric condition like depression. Introduction: Sleep is basic human need and is prerequisite for healthy functioning. The complex nature of sleep has made it subject to much scientific investigation. It is essential aspect of human survival. Sleep disturbances and insomnia therefore are major concerns for people in general. Insomnia is often reported by patients with chronic medical conditions and is widespread in patients experiencing psychiatric disorders like depression (Li et al., 2016). The insomnia co-morbid with depression is often overlooked and is assumed to be a part of depression. The insomnia remains hidden and is associated with poor management of primary condition. Moreover, the presence of insomnia in depression is related to increased suicidal risk and relapse (Nutt, Wilson & Paterson, 2008). There is a bi-directional relationship between insomnia and depression which influences the trajectory of psychopathology (Franzen & Buysse, 2008; Fang, et al, 2019). People with insomnia also commonly report symptoms of depression (Manber & Chambers, 2009). Similarly, depression also has insomnia as one of the major concerns (Jindal &Thase, 2004; Fava, 2004). Contrary to the belief and existing literature, weak association between depression and insomnia and strong relationship between insomnia and insomnia co-morbid with depression was reported in a longitudinal study (Buysee et al., 2008). Insomnia is generally the first to appear in a typical depressive syndrome and usually the last symptom to resolve indicating the role of common causal factor of heightened arousability (Staner, 2010). In few cases insomnia may never be resolved despite the successful management of depression. The insomnia is also conceptualized as a risk factor for the development of depression (Chang, et al, 1997). Studies have also indicated that insomnia is an important predictor of depression (e. g., Breslau, et al, 1996). Stressful life events can precipitate sleeplessness. However, perpetuating factors play a major role in maintaining insomnia over a long period of time. In depression presence of sleep in- compatible behaviors may contribute to conditioned arousal at bedtime leading to insomnia. Alternatively, the presence of sleep difficulties may also lead to depression because of inherent distress and ruminations in insomniacs. Behavioral/ Cognitive management in the context of Comorbidity: Insomnia and depression are interrelated conditions (Herrick &Sateia, 2016). However,

there is dearth of evidence which suggests that treating one disorder improves or prevents the other. Researchers have attempted to treat insomnia associated with psychiatric conditions like depression. In this context, Morin, Kowatch, & O'Shanick, (1990) found benefits of sleep restriction therapy in the management of insomnia associated with depression in a single case analysis. The research in behavior therapy for insomnia has led to the development of different management components in the context of insomnia. Education about sleep hygiene practices, relaxation therapies, sleeps restriction therapy and stimulus control intervention are behavioral techniques specifically utilized for the management of insomnia. These interventions were found to be successful in the management of insomnia associated with psychiatric conditions (Dashevsky& Kramer, 1998). Behavior therapy for insomnia led to improvements in sleep and depressive symptoms highlighting its effectiveness in the management of insomnia co-morbid with depression. Cognitive behavior therapy for insomnia is useful in the management of insomnia in patients suffering from psychiatric conditions (Perlis, et al, 2001, Sharma & Sinha, 2010). The intervention was associated with decrease in sleep onset latency time, total wake up time and number of nightly awakenings. Findings suggest there was increase in total sleep time of the treated participants. In a similar study Taylor, et al, (2007) studied cognitive behavior therapy of insomnia in the context of insomnia co-morbid with depression. The improvements were reported in all insomnia related outcome variables and corresponding decrease in levels of depression. Morawetz (2003) examined clients suffering from long standing sleep difficulties (n=86) with majority having associated depression. The self-help intervention for sleep resulted in lowering the levels of depression. In addition, among people who did not learn to sleep better, none experienced a significant reduction in depression. Insomnia may also be associated with medical condition along with the psychiatric problems (Taylor et al., 2007). Apart from medical conditions like HIV and cancer, cognitive behavior therapy for insomnia is applied in variety of depressive disorders, anxiety and stress related conditions. In many instances’ insomnia is a co-morbid condition. Along with depression and other psychiatric conditions, medical problems may be associated with insomnia. Moderate to large effect size have been recorded (Smith, Huang & Manber, 2005). Wagley, et al, (2013) investigated efficacy of cognitive behavioral intervention for insomnia in psychiatric outpatients using a randomized design (n=30). The results highlighted normalized sleep patterns in 18% of treated participants and none in the control group. The research evidence also indicates superiority of therapist administered cognitive behaviour therapy than the selfadministered intervention in the management of co-morbid insomnia and depression (Ashworth et al., 2015). Insomnia is also frequently reported by geriatric population (e. g., Morgan, et al, 1988). The research studies have focused on age related cognitive and behavioral factors for the management of insomnia in geriatric conditions. The assessment related aspects are important in making formulation pertaining to insomnia. In this context Petit, et al (2003) examined the aspects related to assessment and management of primary and secondary insomnia. The researchers also analyzed the published studies and found that psychological management of primary and secondary insomnia by using sleep hygiene techniques, sleep restriction therapy, stimulus control intervention, paradoxical intention and cognitive therapy individually and in multicomponent approach has adequate research support. The review supports the administration of cognitive behavior therapy for insomnia in depression and certain medical illnesses. Tan et al., (1987) used psychotherapeutic and behavioral interventions in 20 patients suffering from psychiatric disorders and found positive results in social interaction and quality of life. The analysis supports the specific intervention for insomnia in people with depression. This approach has positive impact on insomnia and symptoms of depression. The identification of common causal factors has facilitated common intervention components.

Conclusion: Insomnia is a persistent and pervasive problem for many patients suffering from depression. The studies have shown that insomnia persists even after depression is treated. It contributes to poor quality of life and complicates the co-morbid psychiatric condition. The findings of the present review emphasize treating insomnia along with depression. The CBT can also be used to augment the effects of anti- depressive medication in major depression (Manber et al., 2008). Insomnia predicts occurrence of depression which suggests that management of insomnia will be able to counter associated psychiatric conditions (Riemann &Voderholzer, 2003). Advances in behavior and cognitive behavior therapies have contributed in managing insomnia in patients with depression. Lemola, et al (2013) found relationship between optimism and sleep quality. The optimism attitude model (Banerjee & Puri, 2016) can be utilized with people having sleep difficulties. It is also important to address the specific issues concerning the nature of insomnia in depression. The management of insomnia is also associated with alleviation of symptoms associated with depression. The application of the approach to manage insomnia secondary to depression is not popular due to the belief of the clinicians that insomnia is a bi- product of depression and treatment of depression will automatically lead to alleviation of sleep difficulties. This belief is challenged by the fact that insomnia complaints are present even after treatment of depression and targeted intervention for insomnia is required for insomnia co-morbid with depression. The cognitive-behavioral management approaches are increasingly gaining prominence as a preferred treatment modality for insomnia co-morbid with depression. References: Ashworth, D. K., Sletten, T. L., Junge, M., Simpson, K., Clarke, D., Cunnington, D., & Rajaratnam, S. M. (2015). A randomized controlled trial of cognitive behavioral therapy for insomnia: an effective treatment for comorbid insomnia and depression. Journal of Counseling Psychology, 62(2), 115. Banerjee, P., & Puri, A. (2016). The Symphony of OAM (Optimism Attitude Model) Impacting Performance and Mental Health. EC Psychology and Psychiatry, 1, 149-157. Breslau, N., Roth, T., Rosenthal, L., &Andreski, P. (1996). Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biological psychiatry, 39(6), 411-418. Buysse, D. J., Angst, J., Gamma, A., Ajdacic, V., Eich, D., & Rössler, W. (2008). Prevalence, course, and comorbidity of insomnia and depression in young adults. Sleep, 31(4), 473-480. Chang, P. P., Ford, D. E., Mead, L. A., Cooper-Patrick, L., &Klag, M. J. (1997). Insomnia in young men and subsequent depression: The Johns Hopkins Precursors Study. American Journal of Epidemiology, 146(2), 105-114. Dashevsky, B. A., & Kramer, M. (1998). Behavioral treatment of chronic insomnia in psychiatrically ill patients. Journal of Clinical Psychiatry, 59(12), 693-699. Fang, H., Tu, S., Sheng, J., & Shao, A. (2019). Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms and treatment. Journal of Cellular and Molecular Medicine, 23(4), 2324-2332. Fava, M. (2004). Daytime sleepiness and insomnia as correlates of depression. The Journal of Clinical Psychiatry,65, 27-32. Franzen, P. L., & Buysse, D. J. (2008). Sleep disturbances and depression: risk relationships for subsequent depression and therapeutic implications. Dialogues in clinical neuroscience, 10(4), 473. Herrick, D. D., & Sateia, M. J. (2016). Insomnia and depression: a reciprocal relationship. Psychiatric Annals, 46(3), 164-172. Jindal, R. D., & Thase, M. E. (2004). Treatment of insomnia associated with clinical depression. Sleep medicine reviews, 8(1), 19-30. Lemola, S., Räikkönen, K., Gomez, V., & Allemand, M. (2013). Optimism and self-esteem are related to sleep. Results from a large community-based sample. International journal of behavioral medicine, 20(4), 567-571.

Li, L., Wu, C., Gan, Y., Qu, X., & Lu, Z. (2016). Insomnia and the risk of depression: a metaanalysis of prospective cohort studies. BMC psychiatry, 16(1), 375. Manber, R., & Chambers, A. S. (2009). Insomnia and depression: a multifaceted interplay. Current Psychiatry Reports, 11(6), 437-442. Manber, R., Edinger, J. D., Gress, J. L., …T. F., &Kalista, T. (2008). Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep, 31:4, 489-495. Morawetz, D. (2003). Insomnia and depression: which comes first?Sleep Research Online, 5(2), 77-81. Morgan, K., Dallosso, H., Ebrahim, S., Arie, T., & Fentem, P. H. (1988). Characteristics of subjective insomnia in the elderly living at home. Age and ageing, 17(1), 1-7. Morin, C. M., Kowatch, R. A., &O'Shanick, G. (1990). Sleep restriction for the inpatient treatment of insomnia. Sleep: Journal of Sleep Research & Sleep Medicine, 13(6), 183-186. Nutt, D., Wilson, S., & Paterson, L. (2008). Sleep disorders as core symptoms of depression. Dialogues in clinical neuroscience, 10(3), 329. Perlis, M. L., Sharpe, M., Smith, M. T., Greenblatt, D., & Giles, D. (2001). Behavioral treatment of insomnia: treatment outcome and the relevance of medical and psychiatric morbidity. Journal of behavioral medicine, 24(3), 281-296. Petit, L., Azad, N., Byszewski, A., Sarazan, F. F. A., & Power, B. (2003). Non‐pharmacological management of primary and secondary insomnia among older people: review of assessment tools and treatments. Age and ageing, 32(1), 19-25. Riemann, D., & Voderholzer, U. (2003). Primary insomnia: a risk factor to develop depression?. Journal of affective disorders, 76(1-3), 255-259. Sharma, V., & Sinha, U. K. (2010). Psychological Management of Insomnia in Patients with Depression. Indian Journal of Clinical Psychology, 37(2), 172-178. Smith, M. T., Huang, M. I., & Manber, R. (2005). Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders. Clinical Psychology Review, 25(5), 559-592. Staner, L. (2010). Comorbidity of insomnia and depression. Sleep medicine reviews, 14(1), 35- 46. Taylor, D. J., Lichstein, K. L., Weinstock, J., Sanford, S., & Temple, J. R. (2007). A pilot study of cognitive-behavioral therapy of insomnia in people with mild depression. Behavior Therapy, 38(1), 49-57. Taylor, D. J., Mallory, L. J., Lichstein, K. L., Durrence, H. H., Riedel, B. W., & Bush, A. J. (2007). Comorbidity of chronic insomnia with medical problems. Sleep, 30(2), 213-218. Wagley, J. N., Rybarczyk, B., Nay, W. T., Danish, S., & Lund, H. G. (2013). Effectiveness of abbreviated CBT for insomnia in psychiatric outpatients: sleep and depression outcomes. Journal of Clinical psychology, 69(10), 1043- 1055. Paperless Policy of SIS The Members of SIS are invited to Contribute to the Paperless Policy of Somatic Inkblot Society by opting for Soft Copies of SIS Journal of Projective Psychology and Mental Health instead of Print Version. The soft copies of every issue will be delivered directly on members Email. This will not only save our trees and be environment friendly but also would be time efficient. Write to me directly for opting out print version of SIS Journal on my Email ID: bldubey@gmail.com Bankey L. Dubey

Somatic Inkblot Society Office Bearers: President: Rakesh Kumar, Ph.D. Vice President, International: Anand Dubey, MBA. Vice President, India: Rakesh Pandey, Ph.D. Editor-In-Chief: Naveen Gupta, Ph.D. Gen. Secretary: Shweta Sharma, M.Phil. Joint Secretary: Abhilasha Singh, Ph.D. Treasurer: Padma Dwivedi, M.A. Executive Editor: Rakesh Kumar, Ph.D. Executive Members: Asheem Dubey, MBA. Satyadhar Dwivedi, M.Phil. Sandhya R. Mohanty, Ph.D. Mridula Mishra, Ph.D., Amita Puri, Ph.D. Swarnlata Kumari, M.Phil. M.P.Singh, Ph.D. Riju A. Singh, Ph,D,

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SIS JOURNAL OF PROJECTIVE PSYCHOLOGY &MENTALHEALTH: ACHIEVEMENTS Journal in WHO’sListing Members of Somatic Inkblot Society will be glad to know that SIS Journal of Projective Psychology and Mental Health has been listed by World Health Organization (Global Forum for Health Research) among 25 indexed journals that have published the highest number of articles on mental health from LMICs in Latin America, Africa and Asia (Medline and PsycINFO). Extract from table-6 of “Research Capacity for Mental Health in Low - and Middle - Income Countries: Results of a Mapping Project “(www.globalforumhealth.org) is given below:

Rank Journal Country Language Revista de Psicoanalisis Argentina Spanish Revista de Neurologia Spain Spanish Revista Brasileria de Psiquiatria Brazil Eng.,Spani.,Portuguese Arquivos de Neuro-psiquiatria Brazil Portuguese Acta Psiquiatricaypsicologica de Amercia Laina Argentina Spanish Journal of the Medical Association of Thailand Thailand English, Thai British Journal of Psychiatry UK English Acta Psychiatrica Scandinavica Denmark English Salud Mentale Mexico Spanish Vertex Argentina Spanish Journal of Personality and Clinical Studies India English Social Psychiatry and Psychiatric Epidemiology Germany English Revista Medica de Chile Chile Spanish South African Journal of Psychology South Africa Afrikaans, English Psychological Reports USA English South African Medical Journal South Africa Afrikaans, English The Australian & New Zealand Jr. of Psychiatry Australia English International Journal of Social Psychiatry U. K. English Psychiatry Research Ireland English Social Science & Medicine U. K. English Revista De Saude Publica Brazil Portuguese International Journal of Geriatric Psychiatry U. K. English Journal of Projective Psychology & Mental Health India English Journal Brasilerio de Psiquiatria Brazil Portuguese Psychiatry and Clinical Neurosciences Australia English

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Abstracted in “APA”Psyc INFO Regd. No. 71632/99, RNI Delhi SIS Journal of Projective Psychology & Mental Health Jul 2020 EDITOR EMERITUS: Bankey L. Dubey, Ph.D., Director Dubay Healing Centre, 7490 Coon Club Rd, Medina, OH 44256 (USA) E-mail: bldubey@gmail.com EDITOR-IN-CHIEF: Naveen Gupta, Ph.D., Director, Hindustan Inst. of Mgt.& Computer Studies, Farah, Mathura-281122(India) Email: dr_naveengupta@yahoo.com EXECUTIVE EDITOR: Rakesh Kumar, Ph.D. Head, Dept of Clinical Psychology, Institute of Mental Health & Hospital, Agra-282002 (India). Email: jain.imhh@gmail.com EDITORS: Anand Dubey, MBA, CEO, Dubay Healing Center, 7490 Coon Club Rd, Medina, OH 44256 (USA) Email: ad@dubay.bz Chavi Bhargava Sharma, Ph.D. Exe. Director & Dean Beh & Soc Sciences, Manav Rachna International University, Faridabad-121001 (India) Email: psychologistchavi@gmail.com Christopher Piotrowski, Ph.D. Research Consultant, University of West Florida, 504 Concordia Blvd. Pensacola, FL 32505 (USA) Email: cpiotrowski@uwf.edu Nilanjana Sanyal, Ph.D., Former Prof. University of Calcutta, Email: sanyal_nilanjana2004@rediffmai.com PUBLICATION MANAGER: Brijesh.K.Gupta, MBA Hindustan Inst. of Mgt.& Computer Studies, Farah, Mathura-281122(India) EDITORIAL CONSULTANTS: Abhilasha Singh, Ph.D. AiloUhinki, Ps.D. Amita Puri, Ph.D. Amool R. Singh, Ph.D. Anand P. Singh, Ph.D. Anjana Mukhopadhyay, Ph.D. Antonio Cervigni, Ph.D. Bhavana Arya, Ph.D. Brig. D. Saldanha, M.D. Carina Coulacoglou, Ph.D. Carl B. Gacono, Ph.D David J. Sperbeck, Ph.D. Dharmendra Jain, D.M. J.V. Weissenberg, M.Sc. Jashobanta Mahapatra,Ph.D. Jayanti Basu, Ph.D. Krishan K. Sony, Ph.D. LSS Sam Manickam, Ph.D. M.P.Singh, Ph.D. Manisha Dasgupta, Ph.D. Manoj K. Pandey, M.Phil. Nalini Mishra, Ph.D. Nilesh B. Wagh, Ph.D. Padma Dwivedi, M.A. Padmakali Banerjee, Ph.D. Prasant K. Roy. M.Phil. Radhe Shyam, Ph.D. Rakesh Pandey, Ph.D Robert B. Williams, Ph.D. S.L. Vaya, Ph.D. S.Chaudhury, M.D., Ph.D. Sandhya Verma, Ph.D. Sandhyarani Mohanty, Ph.D. Sanjukta Das, Ph.D. Shashi Sethi, Ph.D. Yogesh K. Arya, Ph.D.