Therapeutic approach to referential thinking in a case of schizotypal disorder

- 79 - Departamento de Personalidad, Evaluación y Tratamiento Psicológicos Anuario de Psicología Clínica y de la Salud Annuary of Clinical and Health Psychology Year 2011 • Volume 07 • Pages 79 to 93 Abstract This article has two different aims: first, to test whether the Rorschach Psychodiagnostic Test can confirm the psychiatric diagnosis of 245 schizophrenic inpatients when the initial diagnosis was based on the criteria of the RDC and DSM-IV for the differentiation of schizophrenia; and second, to determine whether there are statistically significant differences between two refined samples of 191 “acutely aggravated” and 54 chronic schizophrenic patients. The following tests were used: the Rorschach Psychodiagnostic Test (Comprehensive System), the Research Diagnostic Criteria, the DSM-IV and the Katz Adjustment Scale. A cross-sectional study design was used to compare the groups with the Mann Whitney U, in order to test for differences between the two refined acute and chronic samples. Analysis of the data confirmed the precision and efficacy of the Rorschach test for the differential diagnosis of schizophrenia and distinguishes it from borderline personality and bipolar disorder. Application of the Mann-Whitney U to the two refined samples of acute and chronic patients (refined due to the presence in their protocols of L>5; R<14; X+%>70%; few M, no M- and no level 2 special codes), confirmed the existence of statistically significant differences at three confidence levels (<0.01; 0.02 and 0.05). In the two refined acutely aggravated and chronic groups, the presence of the mechanisms of splitting, loss of perceptual accuracy, dissociated and delusional thought, isolation and deficient interpersonal relationships was confirmed in 100% of cases and all of them complied with the six criteria of the Schizophrenia Index and the five criteria of the Perceptual Thinking Index. These features were also observed in the 245 patients from the overall sample, including those who did not fully comply with these indexes. Analysis of the values of the Rorschach structural summary in the samples of acute and chronic patients studied revealed additional information about the personalities and behavior of these people and aided in focusing their treatment. However, the most important aspect of the Rorschach test is that it does not require a three-month, six-month or two-year period to perform a differential diagnosis of people with schizophrenia, as is the case with the RDC and the DSM-IV. Key words: Schizophrenia, Rorschach test, differential diagnosis. Received: 10/4/2010 Accepted: 7/31/2011 Contact informaction: María Vives Gomila, Ph D. Senior Professor, University of Barcelona Provenza, 304, 3º-2ª 08008 – Barcelona Telf.: 630 912 445 Regular Article The Rorschach test in the differential diagnosis of 245 schizophrenic inpatients María Vives Gomila, Ph D. Senior Professor, University of Barcelona Introduction The concept of schizophrenia has evolved since Morel (1853, 1860) used the term “dementia praecox” and Bleuler (1911) replaced it with schizophrenia, or “group of schizophrenias,” mentioning the splitting (spaltung) of the different psychic functions as one of its most important characteristics. Many authors have described the causes and symptoms, as well as the classification and differential diagnosis criteria of schizophrenia (Kraepelin, 1896, 1918; Bleuler, 1911; APA; Arieti, 1955, 1959; Weiner, 1966; Ey, 1971, 1973; Portuondo, 1973; McReynols, 1974; Jenkins, 1974; Jackson, 1974; Spitzer, Endicott & Robins, 1975, 1977, 1978; Crow, 1980, 1982; Obiols & Obiols, 1988; Obiols, 2000; Meyer (2002); Exner, 1968-2005; and many others). Weiner (1966) departed from the premise of four criteria for diagnosing a schizophrenic patient: the presence of a thought disorder, evidence of inaccurate perception of reality, poor emotional control and ineffectiveness in interpersonal relationships. Exner (1978) included these criteria in the first schizophrenia index of what would become his Comprehensive System. Two variables in the Rorschach are fundamental for demonstrating the presence of a psychological disorder: X-% and Wsum6. X-% (percentage of all answers with form quality minus) is an indicator of a disorder in the perception of reality (when X-%>29%) and WSum6 (weighted sum of level 2 special scores) indicates the presence of serious thought disorders when > 17 (Weiner, 2002; Exner, 2000, 2003). These two variables form part of the Schizophrenia Index (SCZI) and the Perceptual Thinking Index (PTI). Before the implementation of the Perceptual Thinking Index (PTI), the Schizophrenia Index (SCZI) confirmed a diagnosis of schizophrenia if six, or in some cases only four or five, of its variables were fulfilled. The Perceptual Thinking Index was introduced as way to avoid the false positives of what was then considered to be the final Schizophrenia Index on the Rorschach (SCZI). - 80 - Anuario de Psicología Clínica y de la Salud Annuary of Clinical and Health Psychology Year 2011 Volume 7 The review of diagnoses of people with schizophrenia performed via Rorschach by three Rorschachists from the European School (Loosli-Usteri, Bohm and Alcock) and Portuondo, amongst the Americans, provided information on the scope and usefulness of the Rorschach test for the diagnosis of schizophrenia. On tests of these patients, Loosli-Usteri (1965) obtained a low number of responses, failure on cards I and VII and “disjointed” content. In protocols of schizophrenic patients, Bohm (1972) observed a medium to high number of responses, a lack of popular responses on card V, failures on cards VIII, IX and X, sequences of well or badly viewed forms, an increase in W (whole) and W- responses and an increase in Dd (unusual details) among paranoid schizophrenics who occasionally presented delusional ideas. Alcock (1965) proposed three characteristics to be identified in the test for the presence of schizophrenia: flight of ideas, ideas of reference and hallucinatory perception. Alcock borrowed Bleuler’s concept of ‘flight of ideas’, which corresponds to a thought form which is interrupted in the middle of a thought and is followed by other ideas which are not interrelated (the DR2 in this study and the DR of Portuondo). As regards ‘ideas of reference’, according to Alcock, the frequent association of perceived images can be indicative of this characteristic when linked to personal experience, although they are not always pathognomonic in her opinion. In the case of ‘hallucinatory perception’, the reality of the inkblot is replaced by the sensations and feelings projected onto them by the patients, giving rise to movement, form quality minus and morbid content responses (M-, FQx-, MOR). Portuondo (1973) attributes the following characteristics to these patients: loss of the sense of reality (F+%), few popular responses (P), deviant verbalizations (DV) with a predominance of autistic logic, disjointed responses (DR), few responses with normal detail (D¯), low emotional control (FC¯), few human interests, H and Hd <20%, predomination of destructive impulses (CF+C>FC), human movements (M) with low form quality, oppositionality (S) and animal and inanimate movement greater than human movement (FM+M>m). The point of reference in this study comprises normative North American groups (samples from Exner, 2000, 2002) and an initial document on people with acute schizophrenia (Vives, 1984, 1989) cited by Exner (1986, 1994), in which the four basic criteria set out by Wiener (1966) were found to be present. In this investigation, we are interested in confirming the hypothesis of our initial study (1984) in samples which are much broader –given the higher number of patients–, and refined –excluding very high or very low values of specific variables which could affect the overall interpretation— without ceasing to be considered schizophrenic. As a result, the aim of this investigation consists of performing the differential diagnosis of inpatient schizophrenics via the Rorschach test and testing to see whether there are significant differences between two refined “acute” and chronic samples. Two hypotheses are proposed: 1) Whether the Rorschach test can confirm the psychiatric diagnosis of 245 schizophrenic inpatients when the initial diagnosis was based on Research Diagnostic Criteria and the criteria of the DSMIV for the differentiation of schizophrenia, and 2) whether the values obtained in a refined sample of people with “acutely aggravated” schizophrenia differ significantly from those obtained in a refined sample of people with chronic schizophrenia, by applying the Rorschach test to both samples. Participants This study consisted of two groups of male participants, 191 acute and 54 chronic, between the ages of 19 and 45, with a mean age of 35. We believe that the interval between 19 and 45 years is sufficiently broad to cover a range of possibilities which, justified from the clinical perspective and that of the Rorschach, does not restrict the possibility of studying them. Their sociocultural level is medium to medium-low. The use of different approaches to perform this study (RDC, DSM-IV and Rorschach) ensures the differential diagnosis of schizophrenia and its differentiation from the diagnosis of other conditions. According to an argument by Weiner (1966, 1982) that is particularly important in clinical research, the use of the Rorschach requires that the subjects’ condition be confirmed before the test is applied, by taking into account which indexes best represent these characteristics. The first group was composed of 191 patients in an acute phase of the illness (admitted for initial onset) who meet the criteria of defined and present schizophrenia of the RDC (Spitzer, Endicot & Robins, 1977) and the criteria of the DSM-IV (APA, 1997, 2002) which are defined in sections A, B, C (Continuous signs of disturbance for at least six months, and during more than one month if different symptoms of criteria A are met), D and E. With the exception of 5 illiterate Box I. Variables of the Schizophrenia Indez (SCZI) and the Perceptual Thinking Index (PTI) Schizophrenia Index (SCZI) Perceptual Thinking Index (PTI) 1.- X+%<61% 1.- XA%<70% and WDA%<75% 2.- X-%>29% 2.- X-%>29% 3.- FQx->=FQxu or R.FQ->FQo or RFQ->FQo +FQ+ 3.- level2 de CE>2 and FABC2>0 4.-SUM CE. level2>SUM CE level1 and FABC2>0 4.- R<17 Y WSUM6>12 or R>16 Y WSUM6>17 5.- SUM6 >6 ó SUM or WSUM6>17 5.- M->1 or X-%>40 6.- M->1 ó X-%>40 - 81 - http://institucional.us.es/apcs Vives Gomila Regular Article The Rorschach test in the differential diagnosis of 245 schizophrenic inpatients subjects, 95 had completed primary education, 67 primary and incomplete secondary education and 24 had an associate degree. Only 15 were currently married. The second group was composed of 54 long-term inpatients with significant signs of schizophrenia, present more or less continuously during a minimum period of two years. They presented a set of symptoms which met the criteria described in the RDC and the DSM-IV for the definition of chronic schizophrenia. Their sociocultural level varied: 32 had completed primary education while 9 had not, 7 were illiterate and 6 had intermediate-level associate degrees. Regarding their marital status, 50 were single, 3 divorced and one widowed. 30 of them possessed a family history of the illness and 5 were unaware of this information. The two groups of participants came from a range of Spanish regions: Extremadura, Catalonia, Galicia, Andalusia, Castile and Zaragoza. The protocols of people with schizoaffective and mood disorders (criteria D* of the DSM-IV) were excluded, along with patients considered by the Rorschach to be depressive and “borderline”, due to a failure to fulfill the variables of the Schizophrenia Index (SCZI) and the Perceptual Thinking Index (PTI) on the test. Instruments The following tests were applied: the Rorschach Psychodiagnostic Test (Comprehensive System by J.E. Exner, 2000- 2004), the RDC (1975, 1977) and the criteria of the DSM-IV (2002) for the differentiation of schizophrenia. Complementarily, the respective caregivers applied the Katz Adjustment Scale (Katz & Liberty, 1963) to their patients. A cross-sectional study design was used to compare the groups via the Mann-Whitney U, after having performed a descriptive analysis of the variables of the structural summary of the Rorschach test on the 245 inpatients. The 191 “acute” patients had been given an initial diagnosis by the acute psychiatry service of three hospitals in the province of Barcelona. Two “judges” applied the criteria of the RDC (all met criterion no. 8) and the criteria specified in the DSM-IV for the diagnosis of schizophrenia to the interviews conducted. The chronic patients had been inpatients at the institution for a minimum of two years and were characterized by a gradual reduction in their cognitive ability as described by their respective psychiatrists and caregivers. In fact, it was not possible to include catatonic patients in the study, given the characteristics of rigidity and isolation which they presented. The Rorschach test was administered between 10 and 15 days after the acute patients had been admitted and two years following the admission of the chronic patients. The protocols obtained and reviewed by three “judges” (1998-2004) comprised the first results from people with schizophrenia obtained with the Rorschach in Catalonia and the first results with the Comprehensive System in all Spain. All of the patients arrived medicated with fluphenazine or thioridazine, sulpiride, eskazine or levomepromazine, and Risperdal (risperidone), Zyprexa (olanzapine), Clozapine, Seroquel (quetiapine) from their respective primary care centers and continued to receive medication on a daily basis once admitted. Results Five stages of analysis were performed: 1) Descriptive analysis of the means and standard deviations of the SS variable groups of the Rorschach test of 191 “acutely aggravated” schizophrenic patients. 2) Descriptive analysis of the means and standard deviations of the SS variable groups of the Rorschach test of 54 chronic schizophrenic patients. 3) Analysis of the typology of the current period of schizophrenia in the two refined acute and chronic samples. 4) Comparative analysis of the two refined acute and chronic samples via the Mann-Whitney U. 5) Descriptive analysis of the human movement determinant, M, and its relation to human content, Pure H. Qualitative analysis of the Katz Adjustment Scale confirmed the characteristics provided by other variables and indexes. 1) Descriptive analysis of the means and standard deviations of the SS variable groups of the Rorschach test of 191 “acutely aggravated” schizophrenic patients. According to observations, these groups consist of people without a defined response style (EB) who attempt to avoid any stimulus perceived as ambiguous or complex (Lambda) and have flattened mental activity (FM+m). They tend to be flexible in their ideation (a:p) and specify their experiences (pure form, F, and normal detail, D, responses). They also tend to isolate themselves and to dissociate and simplify reality (Lambda↑). They present severe thought disorders (DR2, INC2, FABC2, CONT), which together with the weighted sum of level 2 special codes (Wsum6) shows the presence of serious pathology. (Appendix: Tables XVI and XVII)1. Despite their limited initiative to observe and organize the stimulus field (Zf), the result of this organizational effort tends to fall within the parameters of non-patients (Zd), and their aspirations are slightly greater than their operational ca- Sample of acute schizophrenic patients Table I: Ideation variables EB= M: SumC = 2.25:1.92 a:p=3.3:1.4 MOR=1.14 Lev-2=6.49 DR2= 3.30 INCOM2=2.24 FABCOM2= 1.67 CONTAM = 0.92 WSum6= 59.9 M-=0.87 - 82 - Anuario de Psicología Clínica y de la Salud Annuary of Clinical and Health Psychology Year 2011 Volume 7 pacity (W:M). The low number of popular responses (P=3.6) on meaningful cards (I, III, V, VIII and X) may consist of a measure of their difficulty in partaking in common thought and a demonstration of their peculiarity (FQxu; Xu%). They possess poor perceptual adjustment (X+%; XA%, WDA%), with an increasing loss of perceptual accuracy (FQx->FQxu; FQf-> FQfu; X-%>29%) (Appendix: Tables X, XII, XIX). They present low receptivity to emotional stimuli (Afr) and are unable to easily interact with their environment (lack of M in pure H). They show ambivalence, dissociation and convey a painful affective state (analysis of the blends or DM). They have difficulty in controlling their emotions, displaying behaviors such as “acting out” which may interfere with their cognitive processes (CF+C>FC) (suicide attempts, only one successful). Their affective restriction (SumC’) predominates, as well as suffering, defenselessness (SumY), cautious pursuit (T) or resignation (T=0) of affective closeness, and negative introspection (V), associated with depression and suicide attempts – though globally these latter values were relatively low. The production of anatomical content (An) in response to an aggressive stimulus (S) which was not present may be related to the difficulty in expressing affect (SumC’), which they retain or somatize (Appendix: Tables X, XII, XXI). 1 Another group of tables have been included (in the APPENDIX) with a view to clarifying the interpretation of the Rorschach variables used in this study (Tables X to XXII). They possess low self-esteem (Egocentricity index), which together with the loss of perceptual accuracy (FQx-, X-%) and the complexity and mixture of the aforementioned painful feelings (DM, C’, Y, V), cause them difficulties in interpersonal relationships (M=2.25; M-=0.87). They comply with the majority of the variables of the Schizophrenia Index (SCZI= 4.37) and those of the Perceptual Thinking Index (PTI= 4.79), the latter being more reliable (Box I and Appendix: Tables XX, XXI, XXII). 2) Descriptive analysis of the means and standard deviations of the SS variable groups of the Rorschach test of 54 chronic schizophrenic patients. Likewise, according to observations, this group consists of people who attempt to avoid any stimulus perceived as ambiguous or complex (Lambda), whose psychological functioning leads them to control and restrict both affective and primitive needs, which are almost never satisfied (FM). They possess severe thought disorders, indicative of the severe cognitive disorganization from which they suffer (DR2, CONTAM), poor perceptual adjustment (X+%, F+%; X-%; XA%, WDA%) and loss of perceptual accuracy (X-%, FQ->FQu) (Appendix: Tables XVII, XIX, XX). They tend to withdraw psychically (Afr¯) for fear of feeling overwhelmed or invaded by emotions which they cannot control (CF+C>FC). In addition to low self-esteem, they also present few human interests and deficient or highly deficient interpersonal relationships [M- in Hd, (H), (Hd), A, Ad contents]. Only a single participant was able to achieve appropriate interaction with the environment (Appendix: Tables XXI, XXII). 3) Analysis of the typology of the current period of schizophrenia in the two refined samples of 39 acute and 24 chronic patients. The diagnoses made by applying the criteria of the RDC and the DSM-IV for the differentiation of schizophrenia were confirmed in each sample with the Rorschach test; a diagnostic coincidence of 98% was found in the acute patients and 97.8% in the chronic patients. The Schizophrenia Index (SCZI) and the Perceptual Thinking Index (PTI) were not met for only two acute patients and one chronic patient (Box I). Table II: Information processing and cognitive mediation variables Zf= 8.16 Zd= 0.32 W:M= 7.46: 2.25 PSV=0.53 DQ+=3.57 DQv=2.9 P= 3.6 X+%= 45% XA%<70% WDA%<75% FQx>FQxu = 5.59>2.95 FQf->FQfu= 3.24>1.80 X-%= 33% Table III: Affect variables Afr=.43 Blends:R= 1.72:17.01 CF+C>FC= 1.39>0.72 SumC’=1.46 SumY= 0.45 T= 0.14 V= 0.04 S=1.93 Table IV: Self-perception and interpersonal relationship variables Ego [x de 3r +(2)/R =.25] FD=0.15 MOR=1.14 (M= 2.25; M- =0.87) H=1.74 Hd=1.59 A=5.95 (A)=0.1 Ad=0.97 (Ad)=0.03 - 83 - http://institucional.us.es/apcs Vives Gomila Regular Article The Rorschach test in the differential diagnosis of 245 schizophrenic inpatients 4) Comparative analysis of the two refined acute and chronic samples via the Mann-Whitney U. The comparative analysis of the two samples (N=39 and N=24) conducted by means of the Mann-Whitney U revealed statistically significant differences at three confidence levels < 0.01, 0.02 and 0.05. The reduction and refinement of the protocols was based on the increase or decrease in the values of specific variables [high or very high Lambda (L>5); low number of responses (R<14); X+% greater than 70%; protocols without M and M-; few special codes (lack of DR and CONTAM), and one or two variables on the Schizophrenia Index (SCZI)] (Appendix: Table XVII). When the Mann-Whitney U was applied, it was possible to observe the lack of perceptual adjustment or perceptual peculiarity (Xu% =.007. N of C < 0.01 and FQxu%=.013. N of C <0.02), loss of objectivity (dispersion and splitting of mental associations, DR2=0.02. N of C=0.02), and experiences of stress and dissatisfaction (FM+m=0.02. N of C= 0.02) in “acute” schizophrenic patients. In the chronic patients, the tendency to defend themselves from emotional stimuli was seen to be increased (Afr↓=.009) (anxieties resulting from the fear of interpersonal relationships. N of C <0.01); loss of perceptual accuracy (FQf-↑=.045. N of C <0.05) and the tendency to perform erroneous synthesis processes (DQv/+=.035. N of C <0.05). Table VIII shows all of the values obtained and their significance (Appendix: Tables XVII, XIX, XXI). 5) Descriptive analysis of human movement determinants, M, and their relation with human content, pure H (interest in people and interpersonal relationships). The qualitative analysis of human movement determinants (M) in relation to human contents, H, provides information on the interest in people and the low quality of their interpersonal relationships [(M-, or Mo in Hd, A, (H, Hd)]. This table shows the proportion of the human movement determinant, M, the distribution of its form quality (+, o, u, -), the increase in M-, linked to deficient interpersonal relationships, as well as the increase in human detail, [Hd], and whole animal (A) contents, aspects linked to partial object relationships and stereotyped thoughts respectively. The values of the chromatic (FC:CF+C) and achromatic (SUMC’) color variables, and the relation between space responses, S, and An and AG contents (as escape routes from their aggressiveness) may reflect a lack of affective control (C) and difficulties in channeling their oppositionality or hostility (relationship between S, AG and An), which were more visible in “acute” patients (Appendix: Tables XII, XIV, XXI). Table VI: Affect, self-esteem and interpersonal relationship variables Afr=.50 CF+C>FC SumC’= 73 SumY=.73 T=.17 V=.03 S=1.63 Ego=.25 Blends:R=.90: 17.50 FD=.03 MOR=1.83 H=1.43 Hd=1.17 (H)=.87 (Hd)=.17 A=5.97 Ad=1.40 Sample of chronic schizophrenic patients Table V: Ideation, information processing and cognitive mediation variables EB= 2:2 a:p=2.57:1.23 es = 3.53 DR2= 2.04 CONT=.85 FABC2=1.67 INC2=1.63 MOR=1.83. X+%=43% X-%=44% XA%<70% WDA%<75% FQx->FQxu Wsum6= 47.30 M-=.70 Box II: Typology of current period of schizophrenia. Diagnoses of two refined samples of 39 acute patients and 24 chronic patients via rdc, dsm-iv and rorschach DIAGNOSES VIA RDC AND DSM-IV: DIAGNOSES VIA RORSCHACH: “Acute” sample “Acute” sample - 36 paranoid schizophrenics - 37 paranoid schizophrenics - 2 undifferentiated schizophrenics - 2 non-schizophrenic patients via Rorschach - 1 hebephrenic schizophrenic (Do not comply with the variables of the SCZI or PTI indexes) “Chronic” sample: “Chronic” sample’: - 22 paranoid schizophrenics - 22 paranoid schizophrenics - 2 residual schizophrenics - 1 residual schizophrenic - 1 non-schizophrenic patient via Rorschach (SCZI, PTI) - 84 - Anuario de Psicología Clínica y de la Salud Annuary of Clinical and Health Psychology Year 2011 Volume 7 Table VII: Statistically significant differences between “acute (n=39)” and “chronic (n=24)” patients via Mann-Whitney U “Acute” schizophrenics “Chronic”schizophrenics - Xu% = .007 ** - Afr↓ = ..009 ** - FQxu% = .013 * - FQf-↑= .045 . - FM+m = .015 * - DQv/+=..035 . - DR2 = .02. ** p< 0.01 * p< 0.02 . p< 0.05 Table VIII: Comparative analysis of the variables of the structural summary of the rorschach test for two refined samples of acute and chronic schizophrenic patients via Mann-Whitney U T-test: acute schizophrenic patients (mean 1: n = 39) Chronic schizophrenic patients (mean 2: n = 24). Variable Mean 1 Mean 2 Z Probability Z Sum 35.55 26.23 19.615 .0498 . Dd 35.69 26.00 20.791 .0376 . DQv/+ 29.06 36.77 21.018 .0356 . Fqxu 36.40 24.85 24.713 .0135 * FQf- 28.46 37.75 19.983 .0457 . Sum C’ 35.54 26.25 20.494 .0404 . Blends 35.55 26.23 20.396 .0414 . DR2 36.10 25.33 23.093 .0209 . FM+m 33.31 25.00 24.222 .0154 * Es 35.73 25.94 20.804 .0375 . S-% 35.64 26.08 20.641 .0390 . Xu% 35.81 24.19 26.588 .0078 ** Afr 27.33 39.58 25.902 .0096 ** ** p < 0.01 * p < 0.02 . p <0.05 Table IX: Descriptive analysis of the m determinant in the sample of acute patients (n=39) and its relationship with human content, h. Variable Mean Std. Dev. Minimum Maximum M2.25 1.98 0 7 MQ+ 0 0 0 0 Mqo 1.15 1.21 0 5 Mqu 0. 24 0.43 0 1 MQ-* 0.87 1.11 0 4 Ma 1.62 1.64 0 7 Mp 0.69 1.01 0 4 H1.74 1.63 0 6 (H)* 0.97 1.14 0 5 Hd* 0.127 0.33 010 (Hd) 0.127 0.33 0 1 A5.95 2.42 111 Ad 0.97 1.31 0 6 - 85 - http://institucional.us.es/apcs Vives Gomila Regular Article The Rorschach test in the differential diagnosis of 245 schizophrenic inpatients Discussion From the descriptive analysis of the acute and chronic samples, it is possible to infer that they are dissociated people who avoid complex situations (L↑), tend to simplify reality and specify their experiences. If the splitting of mental associations constitutes one of the characteristics of the thought of these patients, the Rorschach test would confirm their presence through an increase in serious or level 2 special codes (WSum6=56.9 in acute patients; 47.30 in chronic patients) and specifically, through the production of deviant responses (DR2 A=3.3; C=2.04) and contaminations (CONT A=0.93; C=0.80) which demonstrate the delusional processes present in all acute patients and a large proportion of chronic patients. Their perceptual and cognitive peculiarity, together with the presence of serious thought disorders, is another indication of the severe disorganization from which they suffer (X+%, XA% and WDA% much lower than 60%, 70% and 75% respectively). Their deficient affective control CF+C>FC, their affective restriction (C’) and their intense painful experience affect the fragility of their interpersonal relationships, which is exacerbated by their low self-esteem. This contrast of painful feelings may motivate their suicide attempts, which was successful in the case of only one patient. Their Rorschach tests showed the variables which could alert us to possible suicide attempts (S↑↑+m+Multiple color-shading determinants +Lambda↑). All of these data match the variables obtained by Exner (2002) in his research on schizophrenic inpatients (N=200). The aforementioned significant differences between acute and chronic patients underscore the increase in deviant responses (DR2), gradual loss of realistic perception and their influence on information storage processes present in both samples. Similarities with the study by Vives (1989) are observed in the predomination of FM+m responses amongst acute patients and FQxresponses amongst chronic patients. The descriptive analyses of negative human movement (M-) responses may confirm the presence of deficient interpersonal relationships, which were more pronounced amongst acute patients. Exner (1978, 1986) established that the presence of M- confirmed the existence of a thought disorder, given that it is uncommon to find M- amongst non-patients. Since then, it has formed one of the criteria of the SCZI and current PTI indexes. It was possible to confirm the presence of M- in schizophrenic patients in the study of the initial samples by Vives (1984, 1989). Of the 25 patients who presented M, 17 were M- while 20 of the 25 presented M together with Mu or Hd and (H), evidencing the precarious nature of their interpersonal relationships. Upon comparing the results of the 191 acute patients with those of North American schizophrenic inpatients (N=128), we observed that in our sample 4 to 6 of the variables of the Schizophrenia Index and 4 of the Perceptual Thinking Index (PTI) were met. The following special codes increase notably: DR2 and CONTAM; Lambda; S in location; the determinants M-, m, pure C, pure F and the contents of anatomy (An), clouds (Cl), sex (Sx) and X-ray (Xy). Meanwhile, the values of WSumC, EA, es, Adj D, Mov, active and passive decrease, reflecting that the characteristics which point to people with schizophrenia are much more marked in patients from our regions (Appendix: Table XVIII). Conclusions In terms of the question as to whether the application of the Rorschach test to schizophrenic inpatients can confirm the psychiatric diagnosis obtained via RDC and the DSM-IV for the differentiation of schizophrenia (1st hypothesis), we believe the answer is yes. The Rorschach adequately differentiates the illness and matches the diagnosis obtained via the application of both classificatory systems in 98% of “acute” patients and 97% of “chronic” patients from the refined samples. In the total sample of 191 acute and 54 chronic patients, the agreement between the diagnoses of both classificatory systems and the Rorschach is lower. However, in this case the precision and efficacy of the test in differentiating between patients with schizophrenia and people who are “borderline” or suffering from bipolar disorder is confirmed. This allowed the false positives to be eliminated from the SCZI index – due to the low number of responses, few or no M and M-, few special codes or with appropriate form quality. The 39 acute patients and the 24 chronic patients tested positive on all of the variables of the Schizophrenia Index and the Perceptual Thinking Index. Given the above, we believe that it would be advisable to avoid a differential diagnosis, in this case of schizophrenia, through the exclusive application of wellknown classification systems. One of the greatest achievements of this research was the continual discovery of level 2 special codes in acute samples, where it was possible to observe, in the same protocol, the presence of DR2 (splitting of verbal associations) and CONTAM (delusional thought) and more florid responses than those given by chronic patients, the presence of which in the test constitutes an indicator of schizophrenia. These results largely agree with those obtained by the pioneers of the European School (Alcock & Bohm) and those of more modern European (Rosell, Merceron and Hussein) and North American (Exner, Weiner, Meyer, Viglione and Portuondo) authors on the diagnosis of patients with schizophrenia. The significant differences identified between the two refined samples of acute and chronic patients, as well as the analysis of each group, made it possible to confirm that an increase in serious thought disorders (DR2, CONTAM, FABC2), together with M-, high WSum6 and an increasing - 86 - Anuario de Psicología Clínica y de la Salud Annuary of Clinical and Health Psychology Year 2011 Volume 7 loss of perceptual accuracy (PTI variables) on the Rorschach constitute an indicator of the thought and style of the schizophrenic patient and make the test the best instrument for its detection. References Alcock, T. (1965). La prueba de Rorschach en la práctica. México: Fondo de Cultura Económica (Original del inglés, 1963). American Psychiatric Association (1997). DSM-IV. Manual Diagnóstico y Estadístico de los Trastornos Mentales. Barcelona: Masson. American Psychiatric Association (2002). DSM-IV-TR. Manual Diagnóstico y Estadístico de los Trastornos Mentales. Barcelona: Masson. Arieti, S. 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