Psychogenic Diplopia in an adolescent -Blind Analysis through Somatic Inkblot Test
L. S. S. Manickam & B.L. Dubey

(SIS Journal of Projective Psychology & Mental Health, (2024):31: 2, 113-118).

There are not many reports on psychogenic diplopia in children and adolescents which is diagnosed as ‘Dissociate neurological symptom disorder, with visual disturbance’ (DNSD) as per ICD-11 guidelines. Here we present a 12-year-old adolescent’s case report along with his responses on Somatic Inkblot Series (SIS-II) projective test along with the interpretation of the responses. The blind analysis of the report validates the known history and indicated the need for further exploration to aid the therapeutic process. The images revealed the client’s poor interpersonal relationships with his mother, father and peers, with a low self and aggressive attitude with desire to have power and authority. Such clients need personal counselling to address their negative attitude and aggressive behavior. More research of SIS-II with children and adolescents may help the clinicians to unravel the ‘inner cry’ and help them to process the unresolved issues during psychotherapy.

Introduction:

Diplopia is the disorder of vision in which two images of a single object are seen and also called double vision (Gräf & Lorenz, 2012).  Though diplopia is a frequent symptom in neurology and ophthalmology, non-organic (psychogenic) ‘diplopia is relatively rare’ (Gräf & Lorenz, 2012). In ICD 11 (WHO, 2018), psychogenic diplopia is classified as ‘Dissociate neurological symptom disorder’ (DNSD). Psychogenic diplopia is classified under ‘DNSD with visual disturbance’ (6B60.0) and is characterized by, “…visual symptoms such as blindness, tunnel vision, diplopia, visual distortions or hallucinations that are not consistent with a recognized disease of the nervous system, other mental or behavioral disorder, or other health condition and do not occur exclusively during another dissociative disorder” (p.51)  (WHO, 2018). Among adults, if the psychological causes of the functional visual disturbances are unexplored and the disorders misdiagnosed as factious disorder may lead to detrimental effects (Pozuelo, et al. 2023). Despite the growing literature describing clinical features and natural history of adult patients with DNSD, the clinical characteristics in children have received relatively little attention. Porteous and Clarke (2009) reported a child with diplopia and there were significant adverse psychosocial factors as well as physical abuse.

Patients with Medically Unexplained Symptoms (MUS) like psychogenic diplopia and other symptoms poses a challenge to the health service providers.  They are frequently referred to different departments in the medical setting and often subjected to inappropriate investigations and treatments. In Low- and Middle-Income Countries (LAMIC) like ours, patients with MSU’s consume significant health care resources as well as cause burden to the patients and their care givers. Therefore, identifying the causes of MSU at the early stage and providing them with the appropriate treatment, which requires an integrative approach (O’Neal & Baslet, 2018) assumes importance.

Cassell (1980, 1990) observed that the ‘the inner cry’ of the individuals may get better projected on to ‘not so ambiguous stimuli’ and in 1960 he developed the Somatic Ink Blot Series (SIS) test. Since then, the test has evolved through research (Dubey et al., 2005), and its revised version, the Somatic Inkblot Test (SIT) has adapted modern technology for online administration, scoring and interpretation (Aneja et al, 2023, Dubey 2020, Dubey & Dubey, 2020, 2021, Dubey, et al, 2019, Singh & Dubey, 2020, 2022). Studies have established the reliability and validity of SIS (Dubey, Pershad & Cassell, 1992; Verma, 1995), its effectiveness in diagnosis (Rathee, et. al., 1998), and therapy in different clinical conditions (Dubey et al., 2005; Manickam & Dubey, 2021). Clinicians reported the usefulness of SIS in therapy, in identifying the unconscious conflicts as well as the core of ‘the inner cry’ of persons with physical symptoms which are of psychogenic origin in adults (Manickam et al., 2004; Manickam et al 2013). Sanyal et al (2006) and Sanyal (2013) administered SIS to children and adolescents and found that the test offers a ‘lens’ or ‘window’ in a non-threatening way and it provides dynamic meaning in terms of their unconscious process. 

In this article we present the case report of an adolescent who was diagnosed as having psychogenic diplopia or ‘Dissociative neurological symptom disorder, with visual disturbance’ along with the SIS responses and its blind interpretation, which validates the psychodynamics of the client. 

Brief history of the adolescent and assessment:

A twelve-year-old adolescent boy from low socio-economic background was referred by the Pediatric department to the clinic for psychological evaluation of his symptom of ‘seeing everything in double’ for three months. When he first experienced the symptoms, he was evaluated by the ophthalmologist in his local area, who referred him for further evaluation and treatment to the private super specialty hospital. After the evaluation at the Ophthalmology department, he was referred to the neurologist and the neurologist confirmed a functional diplopia, and he was referred to the Pediatrician. 

Developmentally, since his mother had hypoglycemia while she was pregnant, she was admitted prior to the delivery in the hospital, and he was born out of full-term normal delivery. At the age of 2 he developed epilepsy and was on medication and subsequently the medication was stopped as per the advice of the neurologist. There was no delay in the miles stones of development reported and he was studying in a school near his grandmother’s place and his academic performance was reported to be average. Since he started his schooling, he stayed away from his parents. His father was working away from home in a private firm and mother was working and living in another place, away from his grandmother. He was informed that his living arrangements must change from the new academic year and must be shifted from the school where he was studying, since his father was transferred to a nearby place where his grandmother was living. Since then, he complained of seeing everything in double. However, while enquiring about the details for their reasons for living separately, the mother became defensive and did not give any further information. The boy also did not reveal much information and he was preoccupied in describing his symptoms. Since they did not visit the hospital again, the family dynamics nor what all could have contributed to the manifestation and maintenance of the symptom could not be elicited.

On routine psychological evaluation using Bender Gestalt Test (Bender, 1938), which is a well-known and established neuro psychological test that detects signs of perceptual distortions and Draw a Person Test (Machover, 1948) there were no ‘double perception’ and therefore SIS-II was administered, to explore the dynamic process.

A few clinically significant responses projected on the Somatic Inkblot Test are interpreted following Content analysis, symbolism, and psychoanalytic interpretation:

Image 1A: “Butterfly” is a beautiful response indicates his wishful thinking to enjoy like butterfly.

Image 2A: “Doll” indicates his craving for affection during childhood which is supported by the poor health of his mother during early childhood and his brought up by the grandmother.  

Image 6A (Image 4 of SIT): “inkblots “and rejected the common response teddy bear playing/enjoying on this image. Rejection of this may indicate parental deprivation (due to the death of either parent, living away from parents, staying with grandparents or other relatives etc.) during childhood, particularly before the age 6 years. The findings is supported by the case history also.

Image A7 (Image 5 of SIT): “A Girl” is a good response, though “Apple” and “Dancing Lady” is most typical response in this image. Avoiding perceiving “dancing lady” may project the poor health of his mother whom he observed, since beginning, having poor health and unable to take care of the client. Further he was raised by her grandmother. The response further indicates a poor relationship with his mother.

Image A9 (Image 6 of SIT): “A lady” is a good response, though avoided two ladies or two persons which further indicates poor interpersonal relationship with his mother.

Image A12 (Image 7 of SIT): “Fire”. Hand is the most typical response (MT) in this image which he has avoided and perceived it as “fire” which may indicates a severe adverse situation with lots of problems and the client is feeling helpless. Such people share their problems during therapy sessions.

Image A21 (Image 13 of SIT): “Tortoise”: He did not perceive two children in this image which may indicate poor interpersonal relationships with parents/father particularly during childhood. Often the image of two children is rejected when the father/ father figure is very authoritarian/strict.

Image A27 (Image 17 of SIT): “Stone” He did not perceived the most common response “breast” in this image which may indicate deprivation/ conflict with mother during childhood. Those who lost their mother during childhood, lived away from their parents, or reared by grandparents, often avoid “Torso” or “Breast” in this image.  

Image A31 (Image 18 of SIT): “White and Blue color”.  Couple, a man and woman are the most Typical normal response in this image, which may indicate smooth interpersonal relations between man and woman/ couples. The client did not perceive the common response may indicate his poor interpersonal relationships with his parents.

Image B4 (Image 19 of SIT): “Blue”. Two people, particularly father and son is the common response in this image which may indicate good interpersonal relations between father and son. Since the client has a negative attitude towards his father, he has avoided perceiving “Father and Son”, and perceived it as “Blue Color” which indicates a poor interpersonal relationship between father and son.

Image B5 (Image 20 of SIT): “Stick”. Two persons, “particularly colleagues, siblings, and friends, interacting, doing something are the most common responses which he has avoided may indicate his poor interpersonal relationship with significant others, particularly with his parents in this case. Perception of Stick may again indicate his negative attitude towards his father and desire to have authority and power. 

Image B19 (Image 24 of SIT): “Sun”. One many legged insects like spiders, sun and two hearts are the normal response in this image. A person having poor interpersonal relationship may avoid perceiving two hearts two on either side. The two hearts might symbolize the affection of his father and mother, which he feels deprived of.

Image B22 (Image 26 of SIT): “Stick” Body resting; soul leaving body; person doing yoga; or a dead person are the common response in this image. He perceived “Stick” and avoided common response may indicate his negative attitude towards his father and desire to have authority and power. This attitude may develop aggressive behavior later on which must be addressed during therapy sessions. 

Image B27 (Image 27 of SIT): “Rat”. Instead of perceiving a “Child” the most typical normal response in this image, he perceived it a “Rat” which indicates his negative attitude towards parents (Phillips & Smith,1953) 

Image B28 (Image 28 of SIT): “Light ink”. Mother hugging the child, mother holding the Child is a most common normal response in this image which may indicates his relationship with mother. Rejection of this image may indicate conflict with mother which is already discussed in the earlier image A27.

Image B29 (Image 29 of SIT): “Wooden stick”: Running person / boy / human figure is the most common response in this image which may indicate good ego strength, positive attitude, and healthy body imagery. Rejection of common response projects his low self and inferiority.

Image B31 (Image 30 of SIT): “Wooden stick” and avoided the most common response “Father-Mother and two children”. Rejection of the common percept in this image may indicate poor interpersonal relationships with parents, among parents or among close family members. The repeated perception of “stick” may indicate the authoritarian attitude of father. It may also indicate his wishful thinking to have power, authority and social prestige which he is lacking being a child. The issue must be addressed during therapy sessions with parents. 

The content analysis of the Somatic Inkblot Images indicates his average productivity and functional intelligence, contact with reality and awareness with his surroundings. He has shown poor interpersonal relationships with his mother, father and peers. He has also shown a low self and aggressive attitude with desire to have power and authority, which may lead to aggressive behavior and maladjustment with others in future. Personal counseling with parents might be of much help to manage his aggressive attitude.  

Findings and Discussions:

On the Somatic Inkblot test Set -A images, he gave responses to all 31 images and in the second Set- B images also he gave responses to all. However, in the second set, in the later images, he gave stereo typed responses of 9 Inkblot responses (like ‘light ink’, ‘white ink’ and so on). Though the ink responses do not have any symbolic meaning, it may indicate that he was trying to avoid further exploration of the dynamic process by not responding to what was obvious in the images. 

The interpretations of the Somatic Inkblot responses were done by the second author (BLD) who was aware of the age and gender but was blind to the symptoms and history of the client. BLD’s interpretation was the following: “The responses indicated that, the client is from a single parent, left in boarding school or parents living away from the client.  Children from orphanages or the children left in boarding school may give such responses. The children who feel unattended or unwanted or left behind on the mercy of God may also project such responses. The sibling relationship was not revealed”. 

Interestingly, the interpretation matched with the adverse circumstances of the adolescent. And it would be helpful to inform the mother who accompanied the adolescent to the clinic about the psychological causation of the neurological symptom with visual disturbance.  This may help their participation in a treatment process that can change “the way the brain processes information” and how the distress is expressed through physical symptoms and create new behaviors that break the established, unconscious pattern that leads to those new symptoms. A positive approach incorporating explanation and clinical assessment of visual ability and addressing adverse conditions appears to be beneficial. 

Manickam and Dubey (2021) found that the administration of SIT itself can be therapeutic, Sanyal (2013) observed that responses to the SIS-II in children served as a ‘therapeutic template’ because of which psychotherapy may be planned. The symptom was reported to us in the month of March, when it is time for the final examinations in school and therefore, whether the stress of studies had also contributed to maintaining the symptom has also to be explored. The obvious suppression of sexual responses suggests the need to explore the sexual history for which the patient did not get back for further sessions. Porteous and Clarke, (2009) observed that the three children and adolescents’ cases with medically unexplained visual symptoms they evaluated refused to have psychiatric evaluation.

Henningsen (2018) found patient-involving therapies being more effective than passive ones in children with medically unexplainable symptoms. O’Neal and Basket (2018) observed that most persons with functional neurological disorders will require an integrated multidisciplinary approach to treatment. Though transparency in explaining how the symptoms work appears to help patients with functional disorders, it may be a difficult task to educate the parent who does not live with the patient or who does not engage in the process of understanding the causes of the disorders.  

Conclusions:

Psychogenic diplopia or dissociative neurological symptom disorder, with visual disturbance which is a rare disorder appearing in male adolescent is reported. The administration of the projective technique, SIS helps in validating the adverse conditions of the patient along with the areas to be further probed in the therapy. The images revealed the client’s poor interpersonal relationships with his mother, father and peers, with a low self and aggressive attitude with desire to have power and authority. Such clients need personal counselling to address their negative attitude and aggressive behavior. The pattern with which the brain processes the information of those with dissociate neurological symptoms may require a different approach in treatment distinct from the conventional dissociative disorders.

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