J. Christopher Fowler

An Examination of Interrater Reliability for Scoring the Rorschach Comprehensive System in Eight Data Sets

In this article, we describe interrater reliability for the Comprehensive System (CS; Exner, 1993) in 8 relatively large samples, including (a) students, (b) experienced researchers, (c) clinicians, (d) clinicians and then researchers, (e) a composite clinical sample (i.e., a to d), and 3 samples in which randomly generated erroneous scores were substituted for (f) 10%, (g) 20%, or (h) 30% of the original responses. Across samples, 133 to 143 statistically stable CS scores had excellent reliability, with median intraclass correlations of .85, .96, .97, .95, .93, .95, .89, and .82, respectively. We also demonstrate reliability findings from this study closely match the results derived from a synthesis of prior research, CS summary scores are more reliable than scores assigned to individual responses, small samples are more likely to generate unstable and lower reliability estimates, and Meyers (1997a) procedures for estimating response segment reliability were accurate. The CS can be scored reliably, but because scoring is the result of coder skills clinicians must conscientiously monitor their accuracy.

Construct validity and factor structure of the difficulties in Emotion Regulation Scale among adults with severe mental illness

BACKGROUND The Difficulties in Emotion Regulation Scale (DERS: Gratz and Roemer, 2004) is a measure of emotion-regulation capacities with good construct validity, test-retest reliability and internal consistency. Factor analytic studies have produced mixed results, with the majority of studies supporting the original 6-factor model while several studies advance alternative 5-factor models, each of which raises questions about the psychometric validity of the Lack of Emotional Awareness factor. A limitation of prior psychometric studies on the DERS is the reliance on healthy subjects with minimal impairment in emotion regulation. The current study assesses the construct validity and latent factor structure of the DERS in a large sample of adult psychiatric inpatients with serious mental illness (SMI). METHODS Inpatients with SMI (N = 592) completed the DERS, Acceptance and Action Questionnaire (AAQ-2), Patient Health Questionnaire (PHQ-SADS), and research diagnostic interviews (SCID I/II) at admission. RESULTS DERS total scores were correlated with AAQ-2 (r = .70), PHQ-Depression (r = .45), PHQ-Anxiety (r = .44) and moderately correlated with PHQ-Somatization (r = .28). Confirmatory factor analysis indicated that five and six-factor model produced equivalent fit indices. All factors demonstrated positive correlations with the exception of difficulty engaging in goal-directed behavior and lack of emotional awareness. CONCLUSIONS The DERS is a strong measure with excellent internal consistency and good construct validity. Caution is warranted in discarding the six-factor model given the equivalence with the five-factor model, particularly in light of the body of clinical research evidence utilizing the full scale.

Predicting DSM-IV Cluster B Personality Disorder Criteria From MMPI-2 and Rorschach Data: A Test of Incremental Validity

Despite their frequent conjoint clinical use, the incremental validity of Rorschach (Rorschach, 1921/1942) and MMPI (Hathaway & McKinley, 1943) data has not been adequately established, nor has any study to date explored the incremental validity of these tests for predicting Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) personality disorders (PDs). In a reanalysis of existing data, we used select Rorschach variables and the MMPI PD scales to predict DSM-IV antisocial, borderline, histrionic, and narcissistic PD criteria in a sample of treatment-seeking outpatients. The correlational findings revealed a limited relation between Rorschach and MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) variables, with only 5 of 30 correlations reaching significance (p < .05). Hierarchical regression analyses showed that both the MMPI and Rorschach data add incrementally in the prediction of DSM-IV borderline and narcissistic PD total criteria scores. The findings were less clear for the incremental value of Rorschach and MMPI-2 data in predicting the total number of DSM-IV histrionic PD criteria, which were best predicted by Rorschach data, and antisocial PD criteria, which were best predicted by MMPI-2 data. In addition to providing evidence of the incremental validity of Rorschach data, these findings also shed light on the psychological characteristics of the DSM-IV Cluster B PDs.

Personality and symptom change in treatment-refractory inpatients: evaluation of the phase model of change using Rorschach,TAT, and DSM-IV Axis V.

In this study, we examined global treatment outcomes during 16 months of intensive, psychodynamic treatment for 77 inpatients suffering from treatment-refractory disorders. Hypotheses based on the phase model of treatment change (Howard, Lueger, Maling, & Martinovich, 1993; Howard, Moras, Brill, Martinovich, & Lutz, 1996) were supported in the study results. Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) Axis V scales assessing behavioral functioning demonstrated large and medium effect size change, whereas stable, enduring personality functioning assessed by psychoanalytic Rorschach scales and the Social Cognition and Object Relations Scale (Westen, 1995) for the Thematic Apperception Test (Murray, 1943) demonstrated small and medium effect size change. We also report assessment of reliable change index and clinical significance. The ecological validity of Rorschach measures is supported by significant validity coefficients (in the hypothesized directions) between implicit measures of personality functioning and behavioral ratings.

Exposure to interpersonal trauma, attachment insecurity, and depression severity

BACKGROUND Exposure to traumatic events is a nonspecific risk factor for psychiatric symptoms including depression. The trauma-depression link finds support in numerous studies; however, explanatory mechanisms linking past trauma to current depressive symptoms are poorly understood. This study examines the role that attachment insecurity plays in mediating the relationship between prior exposure to trauma and current expression of depression severity. METHODS Past trauma and attachment anxiety and avoidance were assessed at baseline in a large cohort (N=705) of adults admitted to a specialized adult psychiatric hospital with typical lengths of stay ranging from 6 to 8 weeks. Depression severity was assessed at day 14 of treatment using the Beck Depression Inventory-II. RESULTS Interpersonal trauma (e.g., assaults, abuse) was correlated with depression severity, whereas exposure to impersonal trauma (e.g., natural disasters, accidents) was not. Adult attachment partially mediated the relationship between past interpersonal trauma and depression severity at day 14 among psychiatric inpatients. LIMITATIONS Measure of trauma exposure did not systematically differentiate the age of exposure or relationship to the perpetrator. Individuals scoring high on the self-report attachment measure may be prone to over-report interpersonal traumas. CONCLUSIONS Treatment of depression in traumatized patients should include an assessment of attachment insecurity and may be fruitful target for intervention.

Perceptions about e-cigarette safety may lead to e-smoking during pregnancy

Electronic cigarettes (e-cigarettes) are nicotine-delivery devices that are increasingly used, especially by young people. Because e-cigarettes lack many of the substances found in regular tobacco, they are often perceived as a safer smoking alternative, especially in high-risk situations such as pregnancy. However, studies suggest that it is exposure to nicotine that is most detrimental to prenatal development. The authors studied perceptions of tobacco and e-cigarette health risks using a multiple-choice survey. To study the perceived safety of e-cigarettes versus tobacco cigarettes, 184 modified Global Health Youth Surveys (WHO, http://www.who.int/tobacco/surveillance/gyts/en/ ) were completed electronically or on paper. Age range, smoking status, and perceptions about tobacco cigarettes and e-cigarettes were studied. The results verified that younger people use e-cigarettes more than older people. Tobacco cigarettes were perceived as more harmful than e-cigarettes to health in general, including lung cancer and pregnancy. Although more research is necessary, the authors postulate that the perception that e-cigarettes are safer during pregnancy may induce pregnant women to use these devices more freely. Given that nicotine is known to cause fetal harm, pregnant mothers who smoke e-cigarettes could cause even greater harm to the fetus because e-cigarettes are perceived as being safer than tobacco cigarettes. Until more data about the effects of nicotine during pregnancy are available, the authors advocate for labeling of e-cigarettes as potentially harmful, at least during pregnancy.

Narcissism in the Rorschach Revisited: Some Reflections on Empirical Data.

This study investigates the extent to which the Rorschach was able to identify accurately pathological expressions of narcissism according to the methodological recommendations offered by T. Nezworski and J. Wood (1995). Ninety-one patients who were found to meet DSM-IV criteria for an Axis II disorder (Cluster A personality disorders = 10; antisocial = 20, borderline = 25, histrionic = 5, narcissistic [NPD] =15; Cluster C personality disorders = 16) and 50 nonclinical participants were compared on 5 Rorschach variables: reflection, pair, personalization, idealization, and the egocentricity index. The results of this study indicate that selected Rorschach variables can be used effectively to differentiate NPD patients from a nonclinical sample and from Cluster A, Cluster C, and other Cluster B personality disorders. Also, the reflection and idealization variables were found to be empirically related to DSM-IV diagnostic criteria for NPD and a self-report measure of NPD. Finally, these two variables could be used for classification purposes in ways that were clinically meaningful in the diagnosis of NPD. Narcissistic personality disorder (NPD) was included as a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association, 1980) in large part because of widespread interest in the theoretical and clinical concept of narcissism by psychodynamic psychotherapists (Kernberg, 1970, 1975, 1984; Kohut, 1971, 1977; Pulver, 1970; Stolorow, 1975; Teicholz, 1978). However, the justification for regarding NPD as an independent diagnostic entity having distinguishable features from other personality disorders has been the matter of some controversy

Convergent validity of Rorschach and TAT scales of object relations.

The Rorschach Mutuality of Autonomy Scale (MOA; Urist, 1977) and the Social Cognition and Object Relations Scale (SCORS; Westen,1995) have been shown to be reliable and valid measures of interpersonal functioning. Utilizing a sample of 57 outpatients with a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) Axis II diagnosis, this study extends the findings of previous research demonstrating the reliability and convergent validity of each measure. Analyses focused on the convergent validity between the Rorschach MOA Scale and 8 SCORS variables (complexity, affect, emotional investment in relationships, emotional investment in values and morals, understanding of social causality, management of impulses/aggression, self-esteem, identity/coherence of self) ratings of Thematic Apperception Test (Murray, 1943) narratives. The conceptual nature and clinical utility of these findings are discussed in relation to psychological assessment.

A Rorschach Exploration of the DSM-IV Borderline Personality Disorder

Rorschach data has been useful in identifying the DSM Borderline Personality Disorder (BPD) and has potential for improving our understanding of this disorder. Recently, the DSM-IV BPD has been shown to be composed of 3 primary or core factors: Factor I-unstable self-other images. Factor II-deficits in affect and thought modulation, and Factor III-impulsive self-damaging actions. In a sample of outpatients with personality disorders. we explored the relationships among 6 psychoanalytically derived Rorschach scales (primitive aggression, oral dependency, self-other differentiation, splitting, devaluation, and projective identification), and the core BPD features. Significant correlations were found between 5 of the Rorschach variables and BPD total scores. Correlations between these 5 variables and the BPD core features showed that oral dependency needs were negatively associated with all 3 BPD core features, whereas the defenses of devaluation and splitting were positively associated with these core features. The clinical implications of these findings are reviewed.

An Empirical Study of Seriously Disturbed Suicidal Patients

Aspects of unconscious processes in a group of seriously disturbed psychiatric patients are examined in an effort to predict near-lethal suicide attempts and explore psychoanalytic formulations of suicide. The Rorschach Inkblot Test, the most widely used projective measure in suicide research (Bongar 1991), was chosen for its potential to shed light on specific unconscious processes. Psychic states commonly associated with suicide were measured by psychoanalytic Rorschach analog scales and then subjected to a progression of statistical analyses in order to predict future occurrence and lethality of suicide attempts. On the basis of a priori hypotheses, the authors developed a suicide index comprising four psychoanalytic Rorschach signs that predicted, with considerable accuracy, which patients would later make near-lethal suicide attempts. The best predictors were unconscious processes indicative of penetrating affective overstimulation, disturbance in the capacity to maintain adequate ego boundaries, and depressive affective states characterized by a morbid preoccupation with death and inner decay. These findings provide empirical support for several well-known formulations of the unconscious motivations for suicide.