SIS-I Profile of PTSD Patients

Rachana Kumari and Anjana Mukhopadhyay

        Somatic Inkblot Series (SIS) has emerged as a powerful procedure in projective psychology. It is based on the principles of projection and uses inkblots to interpret the responses given by an individual. The interpretation is further used to map the personality and psychodynamics. The SIS has become an effective diagnostic projective tool for the assessment of patients suffering from various psychiatric problems. The present investigation s elected 25 high and 25 low trauma affected adult (18 to 45 years) patients, both male and female cases, from various trauma centers of Varanasi. The level of trauma symptoms was assessed with the PTSD checklist civilian version (PCL-C). The present study aims at delineating the diagnostic power of the SIS in PTSD patients. The results indicated that several indices and pathological contents of SIS-I were able to discriminate the groups.

        SIS-I is a semi-structured projective diagnostic instrument and an adjunct to psychotherapy. It is based on the spontaneous, individualized responses to semi-ambiguous inkblot figures which elicit intra-psychic associations. SIS provides images in three forms- on cards, in a booklet and on videotapes. Altogether five forms have been evolved: SIS-I (20 cards), SIS-II Booklet 62 images, SIS-II Video, SIS-I Video, and SIS living images. The test has been administered on a variety of population: adults and children (Kumar &Singh, 2007); militants (Saldanha, 2002); managers and students (Singh & Dwivedi, 1998); normal, neurotics and psychotic patients (Pershad et. al., 1997) and clients with ADHD (Jain, Singh &Kumar, 2002). SIS-I has also been used on Schizophrenics, to measure their ego strength (Mahapatra et. al., 2009); for detection of invisible imagery in bipolar depression (Shyam et. al., 2009). It has also been used to study gender differences (Singh, et al. 1999), marital discord (Manickam & Suhani, 2014) PTSD (Cassell, 2006; Cassell, et. al., 1999, 2000; Cassell & Dubey, 2014) and somatic grief (Cassell & Dubey, 1996).

Traumatic experiences are terrible, very oppressive, startling and difficult to confront for anyone. It is an unexpected situation for which no human being seems to be prepared. These events cause strange, unusual, disturbing and generally incomprehensive reactions, even for the victim. The Post-

        Traumatic Stress Disorder (PTSD) is a psychiatric classification which integrates in a diagnosis of the symptoms that appear after a traumatic event. Traumatic symptoms that stay once the intensity of the acute symptoms diminishes are not enough to classify as PTSD though the real psychological state of the victim suggests the impact of trauma as unmanageable. PTSD is strongly associated with a wide array of physical health problems, (Boscarino, 2004; Hoge et al, 2007) and infantry soldiers‟ have reported lasting symptoms of fatigue and dizziness which could be attributed to PTSD and depression (Hoge et al., 2008).

        Evidence suggests that PTSD symptom severity is related to seeking psychological help (Zlotnick et al., 2002; Boscarino et al., 2004). Of special importance to emergency mental health programs are the extreme stressor critical incidents, such as natural and man-made disasters and human perpetrated violence in the form of physical or sexual assaults. Frequently, these events result in psychological trauma (American Psychiatric Association, 1994; Flannery, 1994; Everly & Lating, 1995; van der Kolk, McFarlane, & Weisaeth, 1996) with its major and painful disruptions in psychological functioning.

Rachana Kumari, Res.Scholar, Dept of Psychology, Banaras Hindu University, and Anjana Mukhopadhyay, Ph.D.

Professor, Mahila Mahavidyalaya, Banaras Hindu University, Varanasi-221005 (Correspond to Email: anjana.mukhopadhyay11@gmail.com).

Key Words: Somatic Inkblots, SIS, PTSD death, if it is not treated. Untreated trauma and PTSD may result in permanent disability, medical and legal expense, increased sick leave, increased industrial accidents, social and community disorganization, lost productivity, and intense psychological distress. The toll in human suffering is enormous and unacceptable.

Hypotheses:

1. The high trauma affected patients‟ group would score higher on different SIS indices i.e., A, AT, Sex, M, At, and Rejection as compared to their low trauma counterparts.
2. The high trauma affected patients‟ group would score lower on different SIS indices i.e., H, MT and T as compared to their low trauma counterparts.
3. The high trauma affected patients‟ group would score high on different SIS pathological contents i.e. pathological anatomy score, depression, hostility and aggression and paranoia compared to their low trauma counterparts

Methodology:

Sample: The initial sample of the present study was comprised of 84 subjects (both male and female) age ranging from 18 to 45 years. Patients admitted in hospitals/trauma centers (Apex Hospital, DLW, Varanasi, Trauma center, BHU, Varanasi and Apollo Hospital, Mehmoorganj, Varanasi) after facing some automobile accidents, explosions, fires, earthquakes, sexual assaults or other terrifying experiences and undergoing treatment for at least 6 weeks were considered for screening the cases. PTSD Checklist-civilian version (PCL-C) was administered on the total sample (N=84). Based on PTSD checklist, 50 trauma affected subjects were screened out in terms of intensity of symptoms i.e. high trauma affected and low trauma affected groups. Final distribution of group stands with the following sample size viz. high trauma (N=25) and low trauma (N=25).

Measures

PTSD Checklist-Civilian Version (PCL-C) (Weathers et al., 1993): The PCL is a standardized self-report rating scale for PTSD comprising 17 items that correspond to the key symptoms of PTSD. Respondents indicate how much they were bothered by a symptom over the past month on a 5-point scale, encircling their responses ranging from “1”not at all to “5” extremely. Internal consistency (Cronbach's alpha) for the entire scale was .94 (Blanchard et al., 1996).

SIS Projective Test (Dubey & Cassell, 1980):The test consists of 20 ink blot images, printed on white cards. Images provide enough obvious anatomical structures. Responses are evaluated both qualitatively and quantitatively. Four pathological contents of quantitative measures are pathologic anatomy score (PAS), depression (D), hostility and aggression (HAS) and Paranoia (P). On the other hand, SIS indices namely, typical (T), atypical (AT), sex response (SEX), movement response (M), anatomy response (At), and rejection (Rej) are assessed qualitatively. The correlations computed for content categories for human, animal, anatomy and most typical responses ranged between 0.71 to 0.92.

Procedure:PTSD Checklist-Civilian Version (PCL-C) was administered on the total sample of eighty-four subjects. Fifty trauma affected subjects were screened out based on standardized cut off scores. In the 17 items of the PTSD Checklist, response categories 3-5 (Moderately or above) were rated as symptomatic and responses 1-2 (below Moderately) as non-symptomatic. PTSD checklist used the DSM criteria for a diagnosis

i.e. Symptomatic response to at least 1 “B” item (Questions 1-5), Symptomatic response to at least 3 “C” items (Questions 6-12), and Symptomatic response to at least 2 “D” items (Questions 13-17). Trauma affected subjects who fulfilled the criteria for the BCD categories of items only formed the clinical sample for the study. SIS projective technique was administered on both the group namely high trauma and low trauma affected patients.

Statistical Analysis:

Scores on each variable of SIS-I were converted into percent scores by taking total Results:

number of responses as denominator. Mean,

SD and„t‟ tests were used to analyze the data.

Table 1: Percentage Means, SDs and t-values of SIS indices obtained for high and low trauma affected subjects

*p<.05, **p<.01, NS=Not significant

Table 1 shows percentage means, SDs and t- values of high trauma affected subjects and low trauma affected subjects for the SIS indices. Percentage means are noticed to be significantly high for atypical response, animal response and movement response (p<0.01). Results also indicate high mean score for rejection of images (p<0.05) than low trauma affected groups. Anatomical response percentage mean reported significantly low

score than their low trauma counterparts leading to rejection of hypothesis 1. A subsequent significantly low mean score may also be observed for typical response and sex response. Human response, most typical response and total number of responses means however could not differentiate between high trauma and low trauma affected group.

Fig. 1: Comparative bar diagram of percentage means of SIS indices for the high and low trauma affected Groups

Bar diagram (fig.1) has drawn the actual status of all the SIS indices in its comparative framework. Thus, the hypothesis 1 and 2 is mostly accepted.

Table 2: Means, SDs and t-values of SIS Pathological Contents of High and Low Trauma Affected Subjects

Table 2 contains the means, SDs and t-value of the four pathological contents assessed in rating scales, obtained for the high trauma and low trauma affected group. High trauma group has been independently compared with low trauma group and the t-values have been reported. The responses obtained for the SIS

scale were rated in terms of the factors from 0 to 3. The t-value confirms that high trauma affected group are significantly high (p<0.01) in pathological anatomy score, depression contents, paranoid ideation and hostility and aggression contents than their low trauma counterparts.

Fig. 2: Comparative bar diagram of means of SIS pathological contents for the high and low traumaaffected groups

The bar charts (fig.2) drawn for high trauma and low trauma affected group scores project that the pathological components viz. PAS, D, HAS and P are present in the high trauma affected group. Hypothesis 3 for SIS pathological contents thus stands in full support.

Discussion:

T        he result of the present study revealed that high trauma affected subjects are significantly high on animal response (p<.05) in comparison to the low trauma affected subjects. More animal responses are indicative of frustration, hostility, immaturity

and primitive behavior. It shows the respondent is more comfortable with animals than human beings or psychologically immature and poorly adjusted with his environment. It is also indicative of low socialization (Dubey, 1982). Confirmation of hypothesis of higher animal response has outweighed high trauma affected subjects in comparison to their low trauma affected counterparts.

        Rest of the indices narrates that in terms of atypical response, movement response and rejection of images, high trauma affected subjects have scored significantly higher among  all  these  subscales.  A typical responses are those of poor quality and with vague percept either in structure or verbalization. It is because perceived sensations are not processed and organized by secondary elaboration mechanism which involves ego functioning. Higher involvement of ego-functioning is linked with higher functioning of secondary elaboration that makes up poor, vague percept a more logical, coherent and meaningful percept. Therefore, a decline of atypical (AT) responses is an indication of sound ego functioning in low trauma affected subjects. However, according to Cassell and Dubey (2003)“the number of AT responses is found proportionate to the degree of psychological or psychiatric disturbance”. Khromov et al. (2004) observed that the persons with increased emotionality recorded more responses of atypical category. Thus, high trauma affected subjects seem to be anxious with their emotional life. Significantly high rejection of images (Rej) by high trauma affected group indicates their blockage of thought and an inability to think properly. It has been noticed that people reject images, which depict certain percept related to their traumatized experience or underlying painful memory. Cassell (1990) stated that rejection of images shows thought blockage and an inability to think properly. Rejection is the result of an inhibition or blocking of thought, more often a shock phenomenon in most cases (Bohm, 1958). Images of inkblots linked to negative psychological experiences develop a negative valence in some individuals and these activate conflicts which become overwhelming and consequently the images are rejected (Verma & Singh, 2014).

        The mean scores of movement responses were 9.15 in high trauma affected subjects as against 4.60 in low trauma affected subjects (t=2.82, p<0.01). The perceptions of actions in these blots are a psychological experience and thus indicate the creative energy of the individual. The projection of movement generally demonstrates active operation of dynamic forces in the individual. It indicates distribution of variant degree of unconscious psychic energy in different type of M responses as governed by ego-mechanism operational in the person.

        Typical responses are commonly perceived responses by normal or healthy people on animage which have reported significantly low percentage for the high trauma affected subjects compared to their low counterparts. It shows the tendency of social withdrawal. The typical responses indicated common perception of the world. The gestalt projections of images are signs of positive health. A higher number of typical responses therefore, are linked with the state of healthy physical, psychological and social functioning of an individual. It is an index of good ego- strength that evaluates reality in its own perspective. It utilizes individual‟s physical as well as psychological resources with optimal functioning in a dynamic and coherent mode to adopt with reality, because the ego-strength is correlated with solving problems realistically instead of adopting/ escape/ withdrawal or aggressive mode of behavior. Failure to score substantial responses on these SIS indices provides an indication that high trauma subjects decrease their ego strength for which realistic coping is interrupted. Typical responses (T) are indicative of reality testing and healthy perception (Cassell & Dubey, 2003).

        Anatomical responses reported significantly low mean score for the high trauma affected subjects than their low trauma counterparts leading to the rejection of hypothesis. High anatomical response of low trauma group indicates that they are preoccupied with their somatic symptoms and internal body organs. They have anxiety, poor self-image and concern about their health. In general anatomy responses indicate excessive preoccupation with bodily concerns without any critical physiological interpretation. Significantly low anatomical response of the high trauma group indicates that such patients are more affected psychologically than somatically.

Sex responses are scored for reproductive systems (both internal and external) and the sensuous points of the body. Heightened anxiety and pathology are reported to be associated with heightened projection. No significant difference has been reported by high trauma affected group which indicates that they are not suffering from sexual anxiety or any psychic pathology as such.

        Mean difference has not been reported statistically significant in most typical response, human response and total number of responses between high and low trauma affected subjects‟ projection measures. Most typical responses are indicator 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. Insufficient human response by high trauma affected group indicates their deficient interpersonal relationships and a tendency of social isolation as well as failure to identify with others. The present study registers low mean score for human response which may be a transient phase for the affected patients and can be recovered from this social repercussion if exposed to a rejuvenating course of intervention. Total number of responses suggests imaginative capacity and functioning intelligence of the subject. A high number of responses indicates masked depression. Since the total numbers of responses are quite balanced among high and low trauma subjects it is hinting at no global pathology.

        High trauma affected group reported highly significant value when measured in terms of SIS pathological contents. Pathological anatomy contents were found to be significantly high in high trauma affected group showing their excessive concern about physical health. Depression contents are also found to be highly significant substantiating dysphoric emotions in high trauma affected subjects which could be due to their poor health. Hostility and aggression contents are also registered significantly high in high trauma group. Paranoid ideation content was also reported to be significantly high in terms of mean difference. It indicates that high trauma group experienced an exaggerated sense of self- consciousness in social situation.

Conclusion:

        The psychological distress associated with PTSD patients in different trauma centers was assessed in the study. Twenty-five (n=25) patients with high trauma and 25 low trauma subjects were screened using PTSD checklist Civilian Version (PCL-C). After that SIS-I was administered to measure the in-depth personality pathology through projective measure to resolve the stagnant life. The findings of the present study clearly demonstrated thathigh trauma affected subjectscan be differentiated from low trauma affected subjects in the terms of different SIS-I indices.

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