Emotional Intelligence, Exner’s Special Indices on Rorschach in Schizophrenia 

Pushpanjali Vishwakarma, Satyadhar Dwivedi and Rakesh Kumar 

The present study aimed to explore the associations among emotional intelligence and Rorschach’s special indices in patients with schizophrenia. A sample of 30 male patients with different types of schizophrenia (diagnosed using ICD 10) each within age range of 18-45 years was taken. Subjects were selected by purposive sampling on the basis of inclusion and exclusion criteria from the in-patient department of IMHH. MSREIS-R test and Rorschach inkblot test (Exner system) were administered on the patients to assess different components of emotional intelligence and the special indices respectively. The results revealed that two components of emotional intelligence (a) ability to utilize emotions and (b) to manage emotions in self were significantly reflected on following Exner’s indices (i) Suicide constellation (ii) Depression Index and (iii) Coping 

Deficits index. 

Emotional intelligence is a global capacity of regulation, management, control, and use of emotions in decision-making. Emotional intelligence promotes healthy and adaptive functioning. It is also related to understand and control own and recognize others’ emotional states. People with high level of emotional intelligence tend to experience a healthy balance of feelings such as: motivation, awareness, peace of mind, friendship, balance, self-control, autonomy, freedom, contentment and appreciation. In contrast people with lower level of emotional intelligence tend to feel more: loneliness, fear, guilt, frustration, depression, emptiness, bitterness, lethargy and disappointment, anger, dependence and failure (Darwin, 1965).Several researchers studied the importance and the application of emotional intelligence in schizophrenia. A lower level of emotional intelligence has a significant association with schizophrenia on all measures of El and demonstrates poorer neuro-cognition and social functioning (Dawsons et al., 2012). Lack of social cognition may also be a risk factor for psychosis such as poor performance on social cognition tasks was significantly correlated with psychosis in young people who were at ultra-high risk of psychosis (Kim et al., 2011). Other studies indicate that impaired social cognition is significantly associated with schizophrenia. Impairments have been documented in several domains including personal decision making, handling stress, lack of empathy, self-disclosure, selfacceptance, insight, affect recognition (Edwards et al., 2002; Fiszdon& Bell., 2009; Hoekert et al., 2007; Pinkham et al., 2007).However, little is known about other aspects of emotion processing that are critical for adaptive functioning. 

Rorschach is a known as a projective tool assessing different aspects of personality and the special scores given tend to assess the severity of psychopathology. Exner’s system also includes the different standardized indices to tap coping deficits (CDI), obsessive (OBS) and suicidal tendency (S-CON), hyper-vigilance style (HVI), depression (DEPI) and perceptual thought disorder (PTI) where PTI tends to measure the severity of psychopathology in perceptual and thinking processes. In the response pattern of Rorschach psychodiagnostic test on schizophrenic patients, the productivity of responses can be low or high, organization capacity can be low, whole responses are fewer than normal, there can be less or even absence of movement responses, color responses can be high and can be absent if it is not reactive schizophrenia. Besides these, form quality is poor, popular responses are less, position response may be present, pathognomonic signs are likely to be present, human responses can be low or absent. In the year 1884, 1986, Exner identified a five item index, involving eight variables related to mediation or ideation which was designated as ‘Schizophrenia Index’ (SCZI). The SCZI was revised in 1991 including 12 variables used in six criterions (Exner, 1991) such as : SCZI1= x+%<.61 and S-%<.41 or X+%<.50, 

SCZI2= X-%>.29,  SCZI3= FQ->=FQu or FQ>FQo+FQ+, SCZI4= Sum Level 2 Special Scores>1 or FAB2>0, SCZI5= Sum6> 6 or WSum6>17, SCZI6= M-> 1 or X-%>. 40). It proved useful for the diagnosis of the possible presence of a psychotic-like condition, especially schizophrenia and also in discriminating psychotic disorders from non-psychotic disorders. However, it was suggested that it might be better considered as a ‘Psychosis Index’ and later the term ‘Perceptual Thinking Index’ (PTI) was used (Exner, 2000). The resulting items that comprise the special indices and the criteria for their application are:- 

PTI (Perceptual- Thinking Index): XA% < .70 and WDA% < .75 (ii) X-% < .29 (iii) LVL2 > 2 and FAB2 > 0 (iv) R < 17 and WSUM6 > 12 or R > 16 and WSUM6 > 17 (v) M - > 1 or X-% > .40 The PTI replaces the schizophrenia index (SCZI). There is no critical cut-off value. If PTI score of four or five signify considerably patients have more meditational/ideational trouble than score of zero, one or two. S-Constellation (Suicide Potential): (i) FV + 

VF + V + FD>2 (ii) Color-Shading Blends > 0 (iii) 3r + (2) / R <. 31 or > .44  (iv) MOR > 3 (v) Zd> + 3.5 or Zd< - 3.5 (vi) Es> EA (vii) CF + C > FC (viii) X + % < .70 (ix) S > 3 (x) P < 3 or P > 8 (xi) Pure H < 2 (xii) R< 17 

The S-CON was developed in 1970 using the protocols of 59 individual that affected their own death (Exner& Wylie 1977) in which are included 12 heterogeneous variables. When the S-CON score is eight or greater it is likely that the person has suicidal tendency. SCON cutoff criteria, being less than 8, should not be interpreted to mean that no selfdestructive preoccupation exists. Some 

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interpreters are inclined to worry over protocols that have S-CON values of 7. 

DEPI (Depression Index): (i) FV+ VF+ V> 0 ) or (FD> 2) (ii) (Col – Shd Blends > 0) OR ( S> 2 ) (iii)(3r + (2) / R > .44 and Fr + rF = 0) OR( 3r + (2) / R <. 33) (vi) (Afr< .46 ) OR ( Blends < 4 ) (v) Sum Shading > FM = + m ) OR ( Sum C’ > 2 ) (vi) (MOR < 2) OR ( 2 x AB + Art + AY > 3 ) (vii) Cop < C2) OR (Bt + 2 x CI + Ge + Ls + 2 x Na / R > .24) The DPI values represent the affective problem rather than specifically equating positive value with diagnostic categories (Exner, 2001) in which are included 7 heterogeneous variables. When the positive DEPI score is five or more, likelihood of the person tends to be diagnosed as a being depressed, or having an affective disorder, such as being emotionally distraught, cognitively depressed and having sense of helplessness. 

CDI (Coping Deficit Index): (EA < 6) OR ( 

Adj< 0 ) (ii) (COP < 2 and (AG < 2 ) (iii) (Weighted Sum C < 2.5 ) OR *(Afr< . 46 ) (vi) (Passive > Active + 1) OR (Pure H < 2 ) (v) (Sum T > 1 ) OR (Isolate / .24 ) OR (Food > 0) 

The positive score of four or five on CDI suggests issues of interpersonal skill, adjustment and social deficits (Weiner &Exner, 1991; Exner&Sanglade, 1992). 

HVI (Hypervigilance Index): FT + TF + T = 0 

(ii) (2) Zf> 12 (iii) (3) Zd> + 3.5 (vi) (4) S > 3 (v) H + (H) + Hd + (Hd) > 6 (vi) (H) + (A) + (Hd) + (Ad) > 3 (vii) H + A:Hd + Ad < 4:1(viii) Cg > 3 

When the positive score is five on HVI, it is likely that the person is having paranoid-like features or is irrationally suspicious of others. This was supported by Exner (1986) who identified during a study of 150 paranoid schizophrenics of whom more than 70% were positive for all five variables, and more than 85% were positive for at least four of the five. 

OBS (Obsessive Style Index): (i) Dd> 3 (ii) 

Zf> 12 (iii) Zd> + .3 0 (vi) Populars> 7 (v) FQ + > 1 The OBS index is positive if 1 or more is true: 

Conditions 1 to 5 are all true, 2 or more of 1 to 4 are true AND FQ + > 3, 3 or more of 1 to 5 are true AND X + % > .89, FQ + > 3 AND X + % > .89 

68: Vishwakarma, Dwivedi & Kumar

The OBS is not found positive among schizophrenic and inpatients depressed cases (Exner, 1990). 

The perceptual cognitive processes that invoke subjects in formulating and articulating their responses provide clues to their characteristic ways of dealing with life experiences and their psychological state and traits. It also helps to understand how they process information and  how  they prefer  to  cope  with  problem  solving situation  (Weiner,  1997). However the Rorschach test is the most widely used method for assessing suicide risk in clinical settings and assess  broad  personality characteristics  and  their  behavior (Blatt, 1990; Exner,1988; Weiner, 1997) by evaluating cognitive processing via examination of  the  individual  has  assigned to their  perceptual experiences (Exner,1978; Weiner,1997). 

PTI and CDI have been found positively correlated with the ICD-10 diagnosis of schizophrenia (Kumar &Khess, 2004; Gomilla, 2011; Rosenbaum, 2012; Gooding, et al., 2012).Exner, (1986) conducted study on 150 patients with paranoid schizophrenia; they found that paranoid schizophrenics had more than 70% positive for all five variables on HVI (Hypervigilance index) and more than 85% positive  for at least four of the five. Study done by Hilsenroth et al., (1998) using Rorschach Inkblot Test on schizophrenic patients and normal population, indicated that the schizophrenic patients differed significantly on the Rorschach Schizophrenia Index SCZ11 =x+%<.61 and s-%<.41 or x+%<.50 and also Exner (2001) found that positive DPI values noted in 30% of inpatients schizophrenia who have Lambda value less than 1.0, and about 22% of inpatients schizophrenic that have Lambda value of 1.0 or greater. These finding lead to the conclusion that positive DEPI value are associated with affective problem.  

Rationale for the study: Persons with schizophrenia reflect impairments in social cognition either during the course, following the illness or even in prodromal phase (Dawsons et al., 2012). Social cognition encompasses the concept of emotional intelligence, and furthermore, deficits in emotion perception and processing have been extensively documented in schizophrenia and have also been associated with poor psychosocial functioning (Kee et al., 2009, Ellen et al., 2007). However, little is known about other aspects of emotion processing that are critical for adaptive functioning. These studies have also established the association of impairments in emotional intelligence with the severity of psychopathology in schizophrenia (Kee et al., 2009). Rorschach is a known projective tool assessing the different aspects of personality and the special scores given tend to assess the severity of psychopathology. Exner’s system also includes the different standardized indices to tap coping deficits (CDI), obsessive (OBS) and suicidal tendency (SCON), hyper-vigilance style (HVI), depression (DEPI) and perceptual thought disorder (PTI) where PTI tends to measure the severity of psychopathology in perceptual and thinking processes.Thus, it can be hypothesized that impaired psychosocial and adaptive functioning, as a reflection of impaired emotional intelligence, should also be present in Rorschach profile and must be reflected in different indices just like psychopathology is assumed to be reflected in the profile. PTI and CDI have been found positively correlated with the ICD-10 diagnosis of schizophrenia (Kumar &Khess, 2003; Gomilla, 2011; Rosenbaum, 2012; Gooding, et al., 2012), but none of the study has correlated directly Exner’s special indices with emotion intelligence so far. Therefore, the present study seeks to go one step ahead exploring the association among Emotional Intelligence, psychopathology and Exner’s special indices. The present study thus aimed to explore the extent to which emotional intelligence and Exner’s special indices were correlated with one another and in what manner. 

Method: 

The study was conducted at Institute of Mental Health & Hospital, Agra. Study Protocol was approved by ethical & scientific committee of the Institute of Mental Health & Hospital, Agra. Sample consisted of 30 male patients between 18 to 45 years of age with diagnosis of schizophrenia as per ICD-10 Diagnostic criteria. Following tools were administered: 

1. Multidimensional Self-Report Emotional Intelligence Scale-Revised(MSREIS-R) MSREIS-R test developed by Panday and Anand,(2008) for the purpose of assessing emotional intelligence in five different dimensions- ability to express and appraise emotion, ability to utilized emotion, ability to manage emotion in self, ability to manage emotion in others. This is a Likert scale score arranged on 1-6 point scale like strongly disagree, averagely disagree, somehow disagree, somehow agree, averagely agree, and strongly agree. Minimum score will be 51 and maximum will be 306. Full scale reliability Cronbach’s alpha coefficient is .95.

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2. Rorschach inkblot test (Exner system) developed by Herman Rorschach in 1921. Scoring was done using Exner’s Rorschach Comprehensive System according to the following areas: Location (L), Determinants (D), Content (C), Developmental Quality (DQ), Form Quality (FQ), Popular Responses (P), Organizational Activity (Z), Special Scoring and also integrated 6 section (Core section, Ideational section, Affect section, Meditational section, Processing section and Interpersonal section) and 7 special indices (S-Constellation, Perceptual-Thinking Index, Depression Index, coping Deficit Index, Hypervigilance Index, Obsessive Style Index). Inter scorer reliabilities of 0.85 or higher. Early Meta analyses indicated that validity ranged from 0.40 to 0.50. Results: 

The study was a cross sectional correlation study conducted on 30 patients with schizophrenia diagnosed as per ICD 10-

Diagnostic criteria. 

Table 1 elaborates different sociodemographic variables including marital status, religion, education, occupation, socioeconomic status and habitat. Sample included 18(60%) married and 12(40%) unmarried patients among whom 28 

(93.90%) of patients belong to Hindu religion while only 2(6.7%) are Muslims and 

16(53.3%) patients are living in rural areas. 2(6.7%) of patients are educated up to Primary level, 15(50%) up to Middle, 9 (30%) up to High school or Intermediate and only 4(13.3%) patients are educated up to Graduation. Most of the sample (N=23, 76.7%) is unemployed. 10(33.3%) patients belong to low socio-economic status, 14 (46.7%) to upper lower, 4(13.3%) to middle, and only 2 (6.7 %) belong to upper middle economics status. Mean and standard deviation of the continuous variable like, age, age of onset, and duration of illness were determined. The mean age of the sample is 34.60 with a standard deviation of 6.85. Minimum age of onset of the sample is 20.11, with maximum age of onset being 

33.29. Duration of illness varies from 2.23 to 

12.31. 

Table 2 explores the bivariate correlation between MSREIS-R test scores and special indices on Rorschach test. Ability to express and appraise emotions is not found correlated significantly with any of the special indices on Rorschach. But a significant negative correlation of the ability to utilize emotions was present with both, the suicidalconstellation index (p<0.05, r=-.369) and the depression index(p<0.05, r=-.387). The ability to manage emotions in self is found highly but negatively correlated with the coping deficit index only (p<0.01, r=.494).Significant negative correlation is also 

present between the total scores of MSREISR test with the coping deficit index (p<0.05, r= -.386).  

Discussion: 

The present study was conducted in the Institute of Mental Health and Hospital, Agra with the purpose of exploring the relationship among emotional intelligence, and Exner’s special indices on Rorschach test. It was a cross-sectional correlation study in which subjects were selected by using purposive sampling technique based on inclusion and exclusion criteria. Sample consisted of 30 patients with schizophrenia those who were already diagnosed by consultant psychiatrist using ICD-10 diagnostic criteria (WHO, 1993). Emotional intelligence was measured by using Multidimensional Self-Report Emotional intelligence Scale-Revised. Rorschach Inkblot test (scoring done by Exner’s system) was used to find the scores on special indices like Perceptual thinking index, s-constellation index, coping deficit index, depression index,Obsessive style index, and hypervigilance index. 

Emotional Intelligence and Rorschach Special Indices: 

The main objective of the investigation was to find the correlation between emotional intelligence and special indices on Rorschach. The Scores on MSREIS-R demonstrated significant correlations with several of the special indices on Rorschach in patients with schizophrenia. The result showed significant negative correlation of the ability to utilize emotions with both the suicide-constellation index (SCON) and depression index (DEPI). The three components, ability to express and appraise emotions, and the ability to manage emotions in self and in others, were not found significantly associated with any of the indices whether being DEPI, SCON, PTI or CDI. The patients of schizophrenia have always been labeled for their abnormal emotional reactions. Individual with low level of emotional intelligence tend to suffer from feelings of loneliness, fear, frustration, guilt, emptiness, depression, instability, lethargy, disappointment, anger, dependence and failure (Darwin, 1965). Usually they feel difficulty in expressing their self in society, at the same time; they feel that others do not understand their emotions that further leave them frustrated and sad. However, this is not the case in our finding as DEPI or SCON were not correlated with the ability to express or appraise emotions. Poor insight towards illness in schizophrenia may bring more problems in utilizing their emotions. Most of the suicides have been quoted in postschizophrenic depression or when they are gaining insight (Sharaf et al., 2012). Such problems make schizophrenic patients more vulnerable to depression, leading further to suicide. 

Kee et al. (2009) highlighted that complexity with emotional intelligence in patients with schizophrenia let them feel extreme level of difficulty to manage and adjust to the society, or follow norms of the society. In this study, significant negative correlation was found between the ability to manage emotions in self (but not in others) with the CDI. Total scores on MSREIS-R were significant but negatively correlated with the CDI. But the CDI showed no correlation with the ability to utilize emotions or with the ability to express and appraise emotions. Low emotional intelligence of patients with schizophrenia is an accumulative result of the underlying disease over time. It is the ability to perceive feelings and thoughts through proper and appropriate words, discriminating between real and unreal emotional expression and utilize emotions for personal growth (Mayer & Salovey, 1997). However problem in the 

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ability of management of emotions in self was the only component found associated with CDI in the present study.  

Thus, the present findings support the association between emotional intelligence and Exner’s special indices to some extent. The present study has further attempted to explore the possibility of associations between the deficits in emotional intelligence and special indices because the deficit in emotional perception and processing have been extensively documented in schizophrenia and have also been associated with poor psychosocial functioning. 

Conclusion: 

The aim of the study was to explore associations in emotional intelligence and Exner’s special indices on Rorschach in patients with schizophrenia. The results revealed that two components of emotional intelligence (a) ability to utilize emotions and 

(b) to manage emotions in self were significantly reflected on following Exner’s indices:  (i) Suicide constellation, (ii) Depression Index, and (iii) Coping Deficits index. These three indices are linked with underlying affective spectrum of sadness which could be represented as follows: coping deficits lead to depression which in turn leads to suicidal thinking. There is a need to further examine the role of above two components of emotional intelligence in depression not only in persons with schizophrenia but also in other population. Whether the problems in ability to utilize emotions and manage one’s own emotions serve as risk factors for severe emotional problems like depression, need to be established empirically. This may further help in identification of at-risk population and providing psychosocial support for primary prevention. The sample included all subtypes and only male participants limiting generalization. 

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