Case 101: The Rorschach in the Assessment of Neurocognitive Functions: Applications in the Clinical Neurosciences

The Rorschach in the Assessment of Neurocognitive Functions: Applications in the Clinical Neurosciences

Carmela Mento, Maria Catena Silvestri, Michele La Versa, Clara Lombardo & Chris Piotrowski

        Based on copious research findings, the Rorschach test can be considered an instrument that has the potential to assess critical cognitive functions. A systematic review of the scientific literature has indicated that when individuals observe an action, in absence of any visible motor activity, the cortical motor system is activated. In fact, previous studies have shown that viewing sentences that suggest movement activates the motor cortex. Recent studies have applied brain stimulation such as Repetitive Transacranial Magnetic Stimulation (rTMS) to investigate cortical activation for human movement on the Rorschach test and have suggested that attributing human movement to Rorschach stimuli (M responses) is associated with corticospinal excitability. In order to identify published research in this area, a systematic review of the literature indexed in the databases Pubmed and Google Scholar was conducted. Search terms were “Neuroscience” AND “Rorschach Test”. Initial search output identified 51 publications, and a total of 11 studies were reported with inclusion criteria. Based on aggregated data, the results supported the utility of the Rorschach Test in studying neuropsychological and cognitive functions. In the light of this contention, the current study presents research evidence supporting the use of the Rorschach in the neuroscience field.

 

Introduction:

        The Rorschach test (1942) consists of a series of 10 plates with ambiguous inkblots, in which the candidate must answer the question “what could it be?” In neuroscience field, the Rorschach task can be considered a valuable tool to assess cognitive functions, such as, perceptual and visuospatial abilities, associative memory, verbal skills, problem solving, emotions, and impulses (Jimura et al., 2021; Mento et al., 2019; Mento et al., 2020; Meyer, 2016; Piotrowski, 2017). Recently, Giromini and colleagues (2019a) introduced the concept of the neurobiological foundation of Rorschach interpretations. The authors proposed a parallelism between mental, verbal and perceptual behaviors that occur during Rorschach administration and those that occur in the external environment. Therefore, the same regions of the brain engaged by the candidate in the production of a given code should be identical to the ones engaged in reproducing, in the external environment, during the processing of the stimuli through perception. Viglione et al. (2003) provided a behavioral analysis of Rorschach response process that considered the nature of the behaviors occurring during the task and the generalization of these behaviors to similar everyday situational and natural contexts. Ales and colleagues (2020) found that measures of the Engagement and Cognitive Processing domain of the Rorschach Performance Rating System (R-PAS) were associated with eye tracking variables reflecting cognitive engagement and effort. Zigmunt Piotrowski (1937) introduced 10 signs in diagnosis of organic impairment, and other evidence of neuropsychological functions revealed by Rorschach assessment was noted in an historical review of the clinical literature (see C. Piotrowski, 2018).

        The Human Movement (M responses), by Rorschach (1921), has been considered one of the best indicators regarding information about semantic representations. In fact, previous authors have suggested the utility of the Rorschach task in the diagnosis of brain lesions (Ebitz & Hayden, 2016). This is in line with Embodied Cognition theories which are focused on the role of motor cortex in semantic representations. According to these theories, words gain at least a part of their connotative meaning through specific perceptive, emotional, and motor representations, and memory recovery requires neural re-enactment of these sensory-motor traces (Desai et al., 2013).

        Giromini and colleagues (2019b) suggested that the Rorschach human movement (M) response could be associated with an embodied simulation mechanism mediated by the mirror neuron system (MNS). Since the Rorschach percepts are a static stimulus, any apparent movement would reflect an imaginative process and specifically, during the movement response, the activation of motor system regions during both recognition and action productions would be expected. Several studies have demonstrated the involvement of the sensory motor system in language and cognition (Gagnon et al., 2018; Gallese et al., 2018). The motor system, including the primary motor and premotor cortex, is thought to partially support action verb comprehension and production (Pulvermüller, 2005).Previous studies have indicated that semantic processing of action related to language is accompanied by an involvement of motor cortical areas, as shown by functional Magnetic Resonance Imaging (fMRI), electroencephalography (EEG), and motor evoked potentials induced by transcranial magnetic stimulation (TMS; Aziz-Zadeh, 2008).

        Neuroimaging studies have highlighted activation of the primary motor cortex and the pre-motor cortex for sentences describing actions (Aziz-Zadeh et al., 2008). This finding was also confirmed by the fMRI study of Desai and colleagues (2013) which showed that secondary motor cortex becomes activated when subjects deal on tasks with metaphors concerning actions. Functional imaging has shown that the primary motor and premotor cortex are activated when action verbs are presented as single words and, that generation of action words activates the premotor and supplementary motor area. The premotor cortex has been found to be involved in the processing of action semantics. In this regard, Balser and colleagues (2014) attribute this to the role of the premotor motor cortex in action planning, and some studies have identified the brain areas involved in planning and performing body movements. Based on the premise that the Rorschach M response may depend on an identification or embodied simulation mechanism, research has suggested that attributing human movement to ambiguous visual stimuli would associate with a mirroring activity (Giromini et al., 2019). Moreover, recent advances in neuroimaging could offer a unique opportunity on the interpretation of Rorschach test responses. For example, some research findings suggest that individuals with anorexia nervosa and body dysmorphic disorder tend to show abnormalities in visual processing on testing and in the front striatal systems (Feusner et al., 2010; Giromini et al., 2017). As another example, an interesting pattern of brain activations in the middle temporal (MT) area and inferior convexity of the prefrontal cortex has been observed when schizophrenia patients were exposed to a series of visual motion processing tasks at Rorschach. However, despite the extensive body of literature on Rorschach research, there are few Rorschach studies involving neuroimaging data. In the light of this, the aim of the current study is to explore the utility of the Rorschach task and its potential application in the clinical neurosciences.

 

Method:

        Data for this systematic review were collected in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) (Page et al., 2021). The PRISMA consists of a checklist intended to facilitate preparation and reporting review/meta-analysis studies by identifying, selecting, and critically appraising relevant research, and collecting and analyzing data from the studies that are included in the review (see Table 1).

 

Table 1. PRISMA 2021 flow diagram for new systematic reviews which included searches of databases.

Identification of studies via databases and registers	Screening	Included
Records identified n = 51	Records removed before screening: Duplicate records removed (n =10) Records removed for other reasons (n =25)	Studies included in review: n = 11
	Reports excluded: 35 Reason 1: for the irrelevance to the topic in question. Reason 2: review articles, editorial comments, and case reports/series.

 

 

• Eligibility criteria:

 

        Articles were included in the review according to the following criteria: English language, publication in peer reviewed journals, quantitative information (research data results) on the Rorschach in neuroscience field, and year of publication since the 2015. Articles were excluded by title, abstract, or full text for the processes connected to this topic, and for irrelevance to the topic in question. Further exclusion criteria were review articles, editorial comments, and case reports/series. In order to depict a contemporary perspective, this review focused on research since 2015 regarding the Rorschach task and its application in the neuroscience field.

 

 

• Search strategy and study selection:

 

        A comprehensive literature search was conducted in the PubMed and Google Scholar databases, and the initial search conducted used the keywords: “Neuroscience” AND “Rorschach Task”. The research output listed 51 citations; no additional studies, meeting the inclusion criteria, were identified by checking the reference list of the selected articles. Of these, 40 studies were excluded according to inclusion and exclusion criteria. After the screening, a total of 11 studies reported on the neurocognitive aspects of the Rorschach. Articles were selected based on the title and abstract; then the entire article was read to determine whether the title/abstract was related to the specific issue of the Rorschach task in neurosciences and if the article potentially met the inclusion criteria. The cited reference lists of the selected articles were also examined in order to identify additional studies meeting the inclusion criteria. Details of this analysis are reported on Table 2 and Table 3.

Table 2: List of search terms entered into the PubMed, and Google Scholar search engines for identification the studies for this systematic review.

Number	Search term
1	Neuroscience [all fields]
2	Rorschach Task [all fields]
3	1 AND 2
4	English [Language]
5	2015/01/01 to 2021/07/01 [publication date]

Table 3: Characteristic of the studies included in the review

Author(s)	Study Aim	Sample	Clinical Tools	Key Findings
Ales et al.	This study investigated	A nonclinical	Rorschach task	This research
(2020)	whether complexity	sample of 71	Eye Link 1000 Plus	studied whether the
	and the other related	adult	Desktop Mount	complexity and
	Rorschach Performance	volunteers.	tracker	other related, R-
	Assessment System (R-			PAS variables
	PAS) variables in the			would associate
	engagement and			with increased
	cognitive processing.			engagement and
				cognitive effort
				while visually
				scanning the
				Rorschach
				inkblots, as
				measured by a
				number of eye-
				tracking variables.
Andò et al.	This study tested this	36 participants	Repetitive	These findings may
(2015)	hypothesis that the		transcranial	be interpreted as
	exposure to certain		magnetic	being consistent
	visual stimuli would		stimulation (rTMS)	with the hypothesis
	automatically trigger		The Rorschach task	that there is a link
	action simulation in the mind of the observer.			between the MNS and the “feeling of movement” people
				may experience,
				when observing
				ambiguous stimuli
				such as the
				Rorschach cards
Andò et al.	The authors studied the		Repetitive	This study showed
(2018)	effects of repetitive		transcranial	the association
	transcranical magnetic		magnetic	between M and
	stimulation (rTMS) on		stimulation (rTMS)	higher-level
	attribution of		Rorschach inkblots	cognitive
	movement to			functioning.
	ambiguous stimuli and
	EEG mu suppression.
Cristofanelli	The aim of this study		Functional Magnetic	This study showed
et al. (2016)	was to analyses to explore the brain‟s		Resonance Imaging (fMRI)	that is possible studied with
	functional architecture		Rorschach task	Rorschach protocol
	in relation to			personality traits and
	psychological			cognitive functions.
	constructs of Rorschach
	variables related to
	perceptual styles and
	personality traits.

Doležal et al. (2015)	Studied the eye movements and neurological problems.	384 participants	Rorschach test	The eye tracking can be used for screening in preschool age even with children who cannot yet read by easier tasks.
Giromini et	In this study the authors	26 healthy	Rorschach Test	These findings are
al. (2017)	studied the Neural	volunteers	Functional Magnetic	in line with the
	activity during		Resonance Imaging	traditional
	production of		(fMRI)	conceptualization
	Rorschach responses.			of the test, as they
				suggest that taking
				the Rorschach
				involves (a) high
				level visual
				processing, (b) top-
				down as well as
				bottom-up
				attentional
				processes, and (c)
				perception and
				processing of
				emotions and
				emotional
				memories.
Giromini et	The aim of this study	26 healthy adult	The Rorschach was	The Rorschach test
al. (2019)	was to study the human	volunteers.	administered during	is most important
	Movement Responses		fMRI	in clinical practice
	to the Rorschach and			for to improve the
	Mirroring Activity.			knowledge of patient‟s
				personality, and
				mirror neurons.
Giromini et	The authors studied the	26 healthy adult	The Rorschach test	The Rorschach
al. (2021)	Human Movement	volunteers	Electroencephalogra	human movement
	Responses to the		m (EEG)	(M) response could
	Rorschach and		Repetitive	be associated with
	Mirroring Activity.		transcranial	an embodied
			magnetic	simulation
			stimulation (rTMS)	mechanism
			Functional Magnetic	mediated by the
			Resonance Imaging	mirror neuron
			(fMRI)	system.
Palmieri et	The authors studied	21 participants	Rorschach test	Clinical settings
al. (2019)	suicidal ideation with		Beck Depression	should consider
	Rorschach assessment.		Inventory	Rorschach as one
				of eligible tools of
				investigation on

				this field.
Porcelli et al. (2013)	Studied the Movement in the Rorschach Human Movement Responses.	21 participants	Rorschach inkblots	The Rorschach human movement (M) response could be associated with an embodied simulation mechanism.
Vitolo et al.	The goal of the current	26 healthy	Rorschach inkblots	The authors
(2021)	study was to test the	participants	Functional Magnetic	hypothesized that
	robustness and validity		Resonance Imaging	the greater the level
	of those eye-tracking		(fMRI)	of engagement and
	findings by inspecting			cognitive effort put
	fMRI data.			in place by a
				Rorschach test-
				taker, the greater
				the engagement of
				his/her cortical
				areas reflecting
				ongoing top-down
				attentional
				processes should
				be.

 

Results:

        The results highlighted research findings confirming that sentences that referred to action and movement activated the region of the motor cortex controlling movement. This is in line with the Embodied Simulation Theory which illustrates the crucial role of the motor system in the semantic representation of action. Ales et al. (2020) investigated complexity and the other related Rorschach Performance Assessment System (R-PAS) variables in engagement and cognitive processing and showed that these variables would associate with increased engagement and cognitive effort while visually scanning the Rorschach inkblots. Andò et al. (2015) studied the exposure to certain visual stimuli that would automatically trigger action simulation in the mind of the observer, and this revealed a link between the MNS and feeling of movement in a person when observing ambiguous stimuli, such as the Rorschach task. In another study, Andò et al. (2018) revealed the effects of repetitive transcranial magnetic stimulation (rTMS) on attribution of movement to ambiguous stimuli. Cristofanelli and colleagues (2016) analyzed the brain‟s functional architecture in relation to psychological variables related to perceptual styles and personality traits. Doležal et al. (2015) studied the eye movements and neurological problems on the Rorschach task. Giromini et al. (2017) studied neural activity during production of Rorschach responses and suggested that on the Rorschach task, high level visual processing is implicated, such as top-down and bottom-up attentional processes, and perceptual and emotional memories. Giromini et al. (2019b) studied the Human Movement responses on mirroring activity. The Human Movement responses are central in other studies: Giromini et al. (2021) showed that the Rorschach human movement (M) could be associated with embodied simulation mechanism mediated by the MNS; Porcelli et al. (2013) studied the „Feeling‟ of movement in the Rorschach Human Movement responses; Vitolo et al. (2020) tested the validity of eye-tracking findings using fMRI data, and hypothesized the greater the level of engagement and cognitive effort put in place by a person in a Rorschach task; finally, Palmieri et al. (2019) analyzed the M responses on the level of suicidal ideation in survivors.

 

Discussion:

        The scientific literature on brain mechanisms evoked by responses to the Rorschach task is rather limited. However, some research shows that Rorschach stimuli is associated to sensorimotor cortex processes (e.g., Giromini et al., 2019). Giromini and colleagues (2019a), in an attempt to fill this gap in the literature, administered 10 Rorschach inkblot stimuli to 26 healthy volunteers during fMRI. The results revealed that watching the inkblots activated temporo-occipital and frontoparietal areas, with greater activity in some small sub cortical regions in the limbic system. These results are in line with the traditional conceptualization of the test, as the results suggest that responding to Rorschach stimuli involves high-level perceptual processing and processing of emotions and emotional memories.

        This is in line with the Theories of Embodied Cognition, pointing to the crucial role of the motor system in the semantic representation of action, where it is possible to postulate a deficit in information processing in cognitive impairments, such as patients with dementia. These theories propose that motor experience is integral to the representation of semantic actions. In other studies, the suppression of the 8 Hz to 13 Hz, over the somatosensory cortex, reflect mirroring activity in the brain associated with the MNS (Fox & Blatt, 1969).The Rorschach M response has been associated with an embodied simulation mechanism, i.e., in a setting when people were exposed to ambiguous stimuli, the observer would also need to experience a feeling of movement within his/her body (Andò et al., 2015). Giromini and colleagues (2010) studied 15 participants with the Rorschach test, as an index of mirroring activity in the brain, and hypothesized that identification of human movement would associate an increased EEG. Andò et al. (2015) in a rTMS study, supported the link between M responses, embodied simulation and mirroring activity, and in 36 nonclinical adults, half of the participants were stimulated over the left inferior frontal gyrus (a putative MNS area), while the other half, were stimulated over the vertex (a control site). Recently, Giromini and colleagues (2022) investigated whether Rorschach test tables that elicit Movement responses could influence the excitability of the motor cortex and therefore increase motor evoked potentials (MEPs). These authors studied a sample of 15 women (control group), and a sample of 22 participants (patients) aged between 21 and 41 years; however, contrary to the authors' initial hypothesis, the results did not have a corresponding neurophysiological counterpart.

 

Conclusions:

        Based on the scientific literature, cognitive process involved in producing an M response is presumed to involve identification or embodied simulation. This finding has important implications for cognitive neuroscience. The ambiguous Rorschach stimuli might reflect an embodied simulation mechanism. Capacity to understand emotions and sensations depends on embodied simulation, a functional mechanism through which actions, emotions, or sensations activate our internal representations of the body states that are associated with these social stimuli, as if we were engaged in a similar action or experiencing a similar emotion or sensation.

Lastly, the current review highlights the importance of the Rorschach task for the neuroscience field regarding cognitive impairment and cognitive markers in relation to patterns in organic disease. Moreover, this diagnostic viewpoint has clinical implications for psychological treatment and cognitive rehabilitation. Additionally, in order to trace impairment evolution during the disease process, the Rorschach method may provide an interdisciplinary assessment for patients and contribute to best practice for improvement of quality of life.

Limitations: Only articles in the English language were included in this review. Future research should include relevant studies published in other languages.

 

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