Psychological Resources and Stress Tolerance Capacity on Rorschach in Patients with Schizophrenia and Bipolar Affective Disorder

Kriti Jain, Deapti Mishra & Ranjeet Kumar

        It is evident that psychological recourses and stress tolerance capacity are found poor in various psychiatric conditions that have significant impact on their treatment outcome but are less studied. This study caters to the need to assess and compare the presence of psychological resources, stress tolerance abilities, and capacity to control, as well as coping ability in patients with BPAD and schizophrenia. A sample of 30 patients with Schizophrenia and 30 patients with BPAD, diagnosed clinically by a consultant psychiatrist based on ICD-10 were selected for the study from Gwalior Mansik Arogyashala. (Gwalior Mental Hospital) Patients of both genders, ranging from 18-50 years, having more than 16 responses on Rorschach were included in the study. The findings of the study reveal that patients with BPAD have significant differences in various Rorschach variables such as psychological resources, though poor in both groups, but were extremely limited in patients with schizophrenia compared to the patients with BPAD. Minimal stress tolerance was seen in patients with schizophrenia in comparison to BPAD. Situational stress is seen more in BPAD, with poor capacity of control in both groups.

Introduction:

        Clinical psychologists try to understand the personality of their clients to provide them with suitable and effective treatment. Personality is defined as a link between intellect and individual characteristics; the degree to which these affect one another in a person may be seen in their actions and reactions (Sarason, 1945; Vane & Guarnaccia, 1989). There is a diversity of approaches to personality assessment. The behavior and responses of individuals may be assessed and compared to groups of people of comparable ethnicity, socioeconomic position, educational attainment, and gender. Personality tests determine how similar or unlike a person is to the general population and provide measures of such characteristics as feelings and emotional states, preoccupations, motivations, attitudes, and approaches to interpersonal relations. The Rorschach and the TAT are the projective procedures, out of the 10 tests most often employed by clinical psychologists (Watkins et al. 995).

        Rorschach is an important tool to assess structure of personality. Its interpretation is based on the process by which persons organize their responses to the Rorschach, which is representative of how they confront other ambiguous situations requiring organization and judgment. In Exner’s Comprehensive System, to assess available resources and their use, four crucial variables are grouped together under the rubric "Four Square." It consists of Experience Balance (EB), which reflects the sum of the human movement (M) determinants as compared to the weighted sum of the chromatic color (C) determinants; EA stands for Experienced Actual, which is a simple sum of the two parts in the EB. On one side of the ratio, experience base (eb) represents the total of FM plus n, and on the other side, the sum of all shading and C' answers; the total of the two parts of the eb is called experience potential (ep). EB and EA are seen to represent purposeful, more controlled, and organized psychological activities employing available resources, whereas eb and ep measurements are thought to represent uncontrollable needs and emotions that operate on the individual. Exner emphasizes that a higher EA does not always imply more efficient behavior, but that an individual with a persistently greater ep is unlikely to demonstrate successful behavior over an extended period of time. The Controls and Situational Stress variables assess the coping style and mental ability, such as cognitive and emotional resources to cope with stress (e.g., planning, imagination), as well as the type of internal and external stresses that one needs to cope with (e.g., distracting, disruptive, or distressing internal experiences).

        Usually, schizophrenia is marked by basic and distinctive cognitive and perceptual abnormalities, as well as inappropriate or blunted affect. Although certain cognitive deficiencies may develop with time, clear consciousness and intellectual capacity are typically retained. On the other hand, Bipolar Affective Disorder is a mood disorder characterized by two or more episodes in which the patient's mood and activity levels are significantly disturbed. This disturbance consists of some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression). Repeated episodes of hypomania or mania are also classified as bipolar disorder. It is evident that psychological recourses and stress tolerance capacity are found poor in various psychiatric conditions, which has significant impact on their treatment outcome.

        The purpose of this study is to understand the psychological resources and stress tolerance capacity present in patients with schizophrenia and BPAD. There is a dearth of research regarding the use of the RIBT particularly in the Indian subcontinent, though various indices and variables have been proven effective in eliciting psychopathology and making diagnoses (Jorgensen, Anderson, and Dam, 2000; Perry et al., 2003, Dao and Prevatt, 2006), there are still many that need to be replicated, especially in India. Meyer and Archer (2001) identified the CDI as one of several Rorschach indices that remain under-researched. There is a need to study the psychological resources that are present in patients with BPAD and schizophrenia so that those resources can be used along with their stress tolerance capacity to help manage their symptomology and prevent relapses. Lastly, there is a need to compare the presence of psychological resources, stress tolerance abilities, and capacity to control, as well as coping abilities, between the patients with BPAD and schizophrenia, so that it will clarify and differentiating both disorders in a better way. This study will further help in the therapeutic intervention and psychological management of both conditions.

Methodology: Aim

The aim of this study was to assess and compare the psychological resources and stress tolerance on Rorschach Inkblot Test in patients with Schizophrenia and bipolar affective disorder. This is a cross-sectional descriptive study. The sample included patients of both sexes, in the age range of 18-50 years, having more than 16 responses on Rorschach Inkblot Test.

Materials

Brief Psychiatric Rating Scale (Overall et al., 1967): The BPRS assesses the level of 18 symptom constructs such as hostility, suspiciousness, hallucination, and grandiosity in patients having or suspected of having schizophrenia or other psychotic disorders.

Young Mania Rating Scale (Young et al., 1978): This scale is intended for use by clinically experienced raters to assess severity of Mania. The YMRS is an 11-item interviewer rated scale. The items have five defined grades of severity.

Hamilton Rating Scale for Depression (Hamilton, 1967): The HRSD is used to quantify the severity of symptoms of depression.

The Rorschach Inkblot Test (Rorschach, 1921): Rorschach Comprehensive System (CS) (Exner,1974) was used in this study.

Procedure

        The study was conducted at the inpatient and outpatient department of Gwalior Mansik Arogyashala, Gwalior (M.P.) The sample consisted of 60 patients (30 each of Schizophrenia and BPAD), diagnosed by a consultant psychiatrist following the ICD-10 diagnostic criteria. After taking the consent of the subjects, the primary information regarding demographic variables of all the subjects was collected on a semi-structured clinical data sheet. The severity of the patients with BPAD current episode mania was rated by using YMRS, for current episode depression HDRS was used, and patients with schizophrenia were rated on BPRS. The Rorschach Inkblot Test was administered to patients individually following Exner’s (1974) method of administration, scoring and interpretation.

        The Experience Actual (EA) variable provides a combined ideational / affective index of adaptive capacities. Low EA (below 6.5) identifies normatively insufficient coping resources. The adequacy of coping capacities in relation to the level of demand people are experiencing was measured by indices of the D score (D) and the Adjusted D score (Adj D). The D score provides an indication of current control and stress tolerance capabilities. The D score at minus level indicates that a person currently is in an overload state and, as a result, may be more prone to some form of impulsiveness than ordinarily is the case. The Adj D score, on the other hand, affords an index of the typical or customary capacity for control. It helps to distinguish between relatively persistent and relatively situational experienced stress. The Adj D at minus level indicates relatively chronic and longstanding difficulties in one’s capacity for control. D < Adj D, the Rorschach index of situational stress, indicates that some circumstance exists that has reduced the person’s capacity for control and has caused stress tolerance to be lower than usual.

Statistical Analysis

        The statistical analysis was done with the help of IBM SPSS- Statistical Package for Social Sciences for Windows, Version 25, released in 2017 (Armonk, NY: IBM Corp.) For the analysis of continuous variables t-test was applied, and for categorical variables Chi square test was applied. For clinical details and symptom assessment of the patients with schizophrenia, mean and standard deviation (SD) were applied.

Results:

The quantitative data was gathered on all the variables and the results were analyzed. Results are summarized in the following tables:

Table 1. Comparison of Four Square of Rorschach Test of Patients with BPAD and Schizophrenia Variables Groups t p

Note: N=30 in each group, M= mean, SD= standard deviation *p<.05, **p<.01, ***p<.001

Table 2. Comparison of Psychological Resources (Experience Actual) Scores of Rorschach Inkblot Test of Patients with BPAD and Schizophrenia

Note: N=30 in each group, n= frequency, %= percentage, χ2= Chi- square

Table 3. Comparison of Capacity for Control (Adjusted D) Scores of Rorschach Test of Patients with BPAD and Schizophrenia

Note: N=30 in each group, n= frequency, %= percentage, χ2= Chi- square

Table 4. Comparison of Stress Tolerance (D) Scores of Rorschach Test of Patients with BPAD and Schizophrenia

Note: N=30 in each group, n= frequency, %= percentage, χ2= Chi- square

Discussion:

The present study aimed to assess and compare the psychological resources and stress tolerance on the Rorschach (Inkblot) Test in patients with schizophrenia and Bipolar Affective Disorder.

Demography and Epidemiology

        When the groups were compared regarding personal details, no significant difference was found between the two groups in terms of age, sex, education, religion, domicile, family type, socio-economic status, and marital status. This indicates that there was no confounding effect of these socio-demographic variables. However, a significant difference was found in employment status on the variables of this study. Most patients with BPAD were employed (76.7%) contrary to patients with schizophrenia where only 30% were employed while 70% were unemployed. The difference in employment status can be substantiated by research findings which state that being unemployed has been related to lower cognitive and social functioning, higher levels of negative and depressive symptoms, as well as lower levels of education in individuals with schizophrenia (Holm et al., 2021). Unemployment found in most schizophrenia patients might be due to psychosocial impairment because of psychiatric illness as they were unable to cope on their occupational front which is also substantiated by the downward drift theory (Lapouse et al., 1956). In the present study, the mean age of the patients with BPAD was 32.07 years (SD= 7.01) and that of schizophrenia was 31.47 years (SD= 6.60) It is in congruence with the fact that both the groups were matched with respect to age. The number of men with BPAD was higher in the study, 76.7% sample of the group was male and 23.3% was female. Similarly, in the group with schizophrenia, 83.3% of patients were male compared to only 16.7% of females. It is seen that the incidence of schizophrenia is greater in men (1.4:1 male: female ratio; McGrath et al., 2004). The low percentage of female patients might also reflect the negligence of female mental health as female patients are admitted less often for the treatment of psychiatric conditions due to traditional conservative views. The males being the breadwinners of the family receive the attention of the family members and are brought to the medical facilities earlier and in preference to the females (Kumar, 2001). In our research, most patients among both groups were educated up to secondary level, i.e., 76.7% of patients with BPAD and 80% of schizophrenia patients.

Findings on Rorschach Inkblot Test:

Psychological Resources

        The experience balance (EB) ratio shows the extent to which a person is internally oriented as opposed to being more externally directed and behaviorally responsive to outside stimuli. EBratio here showed significant difference between patients with BPAD and Schizophrenia (Table 1). It indicates that patients with BPAD predominantly have extra tensive style to deal with problems in comparison to schizophrenic patients. They use their feelings in their decision-making process, on the other side schizophrenic patients are likely to prefer to keep emotions aside during decision making process (Exner, 1978).

        The Experience Actual (EA) is an indicator of psychological resources that a person can always use, and a low value means that available resources are limited. On comparing patients with BPAD and schizophrenia, significant differences were seen between the two groups. According to Exner’s Comprehensive System, the average range for EA in adults is between 7 and 11. The mean EA of the patients with BPAD was 5.12 (SD= 2.76), whereas for the schizophrenia group it was 3.84 (SD= 2.47). Significantly lower EA than average, i.e., below 6.5 for adults, suggests more limited available resources. The mean EA score of both the groups was found to be low suggesting poor psychological resources with the schizophrenia group having extremely poor psychological resources. In describing EA, as a "supply of inner energy" or "emotional essence", Beck seemed to imply that the EA index reflected an underlying instinctual energy force. In fact, Beck stated that the sum of human movement and color responses "communicate feeling tones derived from the id reservoir" (Beck, 1960). The forces reflected by EA lead to adjustment or maladjustment depending on the strength of the ego to master or direct this emotional energy or vitality. Thus, Beck originally seemed to understand EA as an emotional energy force that could be harnessed adaptively or unleashed in an explosive manner. The patients with good psychological resources in the BPAD group were 40% and, in the schizophrenia group only 26.67% (Table 2). However, 60% of the patients in the BPAD group and 73.33% of the patients in the schizophrenia group had limited psychological resources.

Capacity for Control

        The AdjD score, on the other hand, affords an index of the typical or customary capacity for control. It helps to distinguish between relatively persistent and relatively situational experienced stress. There is a significant difference seen between the two groups on Adj D scores with a higher mean score of the BPAD group (M=0.58, SD= 1.07) at 0.01 level of significance. Deviant Adj D indicates relatively chronic and longstanding difficulties in one’s capacity for control. Exner defined control as the “capacity to form decisions and implement deliberate behaviors that are designed to contend with the demands of a situation” (Exner, 2000). In other words, it is the ability of a person to organize and maintain control over one’s thoughts, behavior, and emotions, to at least some extent, and to remain on task. It is important to remember that the controls cluster assesses only the capacity to control. In other words, the capacity to control behavior does not mean that the person will always appropriately control their impulses, thoughts, emotions, and behaviors. (Table 3).

The es sum is an index of a person’s degree of disorganization and helplessness. Persons scoring high on es have a low frustration tolerance, and it is difficult for them to be persistent, even in meaningful tasks (Exner, 1978). In our research findings, the mean Experience Stimulation (es) obtained by the BPAD group is

4.42 (SD= 2.74) and that of the group with schizophrenia is 3.30 (1.81); no significant difference can be seen between the mean of both the groups. It reflects presence of disorganization & helplessness in both the groups. (Exner, 1974).

Stress Tolerance

        The D Score is a further measure of the client’s ability to tolerate stress. It is essentially a means of evaluating the degree of available resources the person has (EA) versus the number of disorganized events that are occurring beyond the person’s control (es). The mean score obtained for the group with BPAD is 0.38 (SD=1.40) and for schizophrenia is 0.11 (SD=1.24). However, no significant difference was seen between the patients with BPAD and schizophrenia on stress tolerance (Table 4). The results confirm the findings of earlier studies (Exner 1986, 1991) concerning the poor tolerance for stress in psychotic patients. They perceive a lot of stress and lack the resources to deal with it (low D, Adj D). Stress tolerance, in contrast, is the ability of the person to tolerate stress, which, like control, can fluctuate depending on the demands of the person. The demands on the person can be external (e.g., comprehensive examinations in graduate school) or internal (e.g., depression or anxiety). In times of high demand, psychological resources are depleted, thus the tolerance for stress is decreased. Research suggests that people with schizophrenia have reduced distress tolerance as compared to healthy control samples (Chiappelli et al., 2014; Nugent, Chiappelli, Rowland, Daughters, & Hong, 2014). Early work has linked lower distress tolerance to reduced social functioning (Nugent et al., 2014), negative mood states (Stanage-Becker, 2009), cognitive deficits (Nugent et al., 2014), and psychotic symptoms (Bonfils, Minor, Leonhardt, & Lysaker, 2018; Stanage-Becker, 2009). Recent research has also shown a robust effect wherein people with schizophrenia-spectrum disorders report experiencing greater personal distress (i.e., internal, self-oriented distress upon seeing the negative situations of others) (Bonfils, Lysaker, Minor, & Salyers, 2017).

        Adj D findings in the patients with BPAD is 0.58 (1.07) and, patients with schizophrenia are 0.07 (0.89). There is a significant difference between the groups on 0.01 level of significance. According to Exner’s Comprehensive System, a score of zero or greater shows that people with low EA, are chronically more vulnerable to becoming disorganized by many of the natural everyday stresses of living in a complex society, which seems to be true for both our patient group.

Situational Stress

        In our research (Table 4); the value of D is lower than the value of Adj D in the group of patients with Bipolar Affective Disorder. D< Adj D, is the Rorschach index of situational stress, indicates that some circumstance exists that has reduced the person’s capacity for control and has caused stress tolerance to be lower than usual. They appeared to be in a state of chronic stimulus overload that reduced their capacity for control and their tolerance of stress.

        Because they do not have enough resources readily available to contend with all the stimulus demands they experience. Their avoidance tendencies may be aggravated when confronted with emotional stimuli. As a result, they often become much more socially constrained. This might indicate that they function best in routine and predictable situations. Adapting to new situations presents difficulties in which they are prone to become distracted, disorganized, and impulsive. Most mania patients tend to have difficulty contending with the demands of the social model and often feel helpless or inept because of their coping limitations or deficiency. The results confirm the findings of earlier studies (Exner 1986, 1991) concerning the poor tolerance for stress in psychotic patients. They perceive a lot of stress and lack the resources to deal with it (low D, Adj D).

Conclusion:

        The findings of the present study reveal that patients with BPAD & schizophrenia have significant differences with respect to various Rorschach variables. Psychological resources were poor in both groups but were extremely limited in patients with schizophrenia compared to the patients with BPAD. Poor stress tolerance was found in both groups with minimal stress tolerance in patients with schizophrenia in comparison to patients to patients with bipolar affective disorder. Situational stress is seen more in patients with BPAD, current episode mania. Capacity for control is poor in both groups; however, patients with BPAD have poorer control.

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