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The status of the Rorschach and its role in neurophysiological assessment has had a rather erratic and not so cherished historical journey. Seminal research in this area largely focused on the Rorschach „sign‟ approach in the study of organic brain disorders, while later research investigated mediating factors such as IQ and affective states. At times, research efforts in this area lay dormant or encountered tepid scholarly reviews. Interestingly, there has been a flurry of recent enthusiasm and research activity on the potential of Rorschach analysis in the study of neurocognitive dysfunction. The current investigation provides a historical review of key research findings in this area, based on 58 studies identified via a bibliometric analysis of the extant mental health literature. The presentation traces the key milestones and findings reported in scholarly research over the past 80 years. The author offers tentative conclusions, based on this provocative body of literature.
Psychologists have had a long-standing clinical and research interest regarding the usefulness of the Rorschach in the study of diseases of the central nervous system, neuropsychological deficits, perceptual processes, conceptual complexity, and neurocognitive functioning (Malone et al., 2013; Martin & Estevez, 2005; Meyer, 2016;
Muzio, 2016; Piotrowski, 2015; Senkarik, 1989). Historically, however, the role of projective techniques with regard to ecological validity in both research and clinical applications has been questioned (e.g., Jonckheere, 1970; Lilienfeld et al., 2000). Although research attention in this assessment area has waned periodically over the years, there seems to have been a renewed interest, as exemplified by the recent special issue on Neuroscience and the Rorschach appearing in the journal Rorschachiana in 2016. This nexus has been systematically viewed from a) the neurophysiological bases of Rorschach responses (e.g., Porcelli & Kleiger, 2016) and
Seminal discussions on the potential applications of the Rorschach to organic brain diseases were noted by Hermann Rorschach‟s colleague Dr. Oberholzer during the initial introduction of the inkblots (see Kisker 1944, p. 43 for a discussion). Baker (1956), in a review of over 50 published studies, from 1936-1952 on the Rorschach, concluded that the presence of organic brain involvement was mostly evident in the qualitative aspects of the Rorschach protocol rather than in quantitative signs. Years later, the prominent neuropsychologist Muriel Lezak (1994) touted the potential of the Rorschach in the assessment of perceptual abilities in brain-injured patients such as accuracy in perception, integration of multiple stimuli segments, and response time. Although, over the years, neuropsychological tests have been part of the assessment armamentarium of practicing psychologists (Frauenhoffer et al., 1998; Harwood et al., 2011; Wright et al., 2016), projective tests have been largely neglected in neuropsychological practice (see Piotrowski, 2017; Rabin, 2005; 2016; Smith et
al., 2010).
The aim of the current study is to gain a perspective, historically, on the status of the Rorschach in research on neurocognitive dysfunction and the potential of this unique assessment method in neuropsychology practice. This review presents scholarly research findings reported in 58 studies on these issues published from 1936-2016.
Chris Piotrowski, Ph.D., University of West Florida (USA), Email: cpiotrowski@uwf.edu
Key Words: Rorschach, Neurocognitive dysfunction, Historical review, Neuropsychology
A bibliometric review entails obtaining a comprehensive search of the literature in order to identify the body of archival research on a select investigatory topic (Piotrowski, 2013, 2017). Since the focus of current study was on the use of the Rorschach in neuro- psychological research, the author performed on online keyword search of the database PsycINFO with terms such as Neuropsychological, Organic, Brain impairment, Head Injury. This repository of extant literature is the most comprehensive scholarly file in the field of psychology and behavioral sciences (Perdue & Piotrowski, 1991), including the sub-field of assessment. Second, a cross-reference procedure identified pertinent adjutant literature listed as cited references in key research articles. This systematic retrieval process identified 58 scholarly studies (mostly articles) which served as the data-pool for this historical review (1936-2016) of archival research on the Rorschach-Neuropsychology nexus. Table 1 presents the brief summary review of 58 key research studies.
„sign‟ approach have been critiqued for not examining moderator variables that could influence outcome, i.e., several researchers suggested that IQ was a significant confounding variable in these studies.
significant number of „false positives‟, providing evidence for a lack of discriminatory power.
for increasing incremental validity of neuropsychological testing data by inclusion of the Rorschach in multimethod assessment.
Rorschach analysis enhances detection of psychological disturbance, but not neuropsychological impairment or dysfunction.
benefits of Rorschach analysis in investigations examining cognitive deficits and dysfunction with comorbid emotional liabilities and disturbed affect.
integrated theoretical framework on incorporating the Rorschach in neuropsychological evaluations.
seems to be lacking in research direction; however, in recent years, there has been a resurgence of investigatory interest regarding neurophysiological substrates associated with Rorschach analysis.
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Table 1: Historical Summary Overview of 58 Research Studies |
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Study |
Method |
Findings |
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Z. Piotrowski (1936) |
Seminal research; Rorschach records of 18 cases of organic cerebral involvement |
6.2 „organic‟ Rorschach signs were found in this group compared to 1.5 in other patient groups; This study prompted a series of subsequent research efforts to corroborate these Piotrowski „signs‟ confirming organic brain involvement. |
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Z. Piotrowski (1937) |
33 records of 18 patients with organic brain disturbance |
10 Rorschach „signs‟ differentiated the organic group from the non-cerebral group; differences were found to be quantitative as opposed to qualitative; presence of 5 or more signs was indicative of brain damage. |
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Z. Piotrowski (1940) |
56 patients producing 5 or more organic „signs‟ |
Results showed that the number of signs was a function of personality change and increasing age; |
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Findings were tentative. |
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Harrower-Erickson (1940) |
Studied personality changes in brain tumor patients; Rorschach |
Main finding was „constriction‟ of personality; authors condone the use of the Rorschach in evaluation of patients with brain tumors. |
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Ross (1941) |
A replication of the Piotrowski (1940) study |
Findings showed that the Piotrowski „signs‟ lacked discriminatory power; i.e., identified false positives. Although 55% of the brain-damaged patients had 5 or more signs, so too did 20% of psychotics and 14% of neurotics. |
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Kisker (1944) |
20 psychotic patients who underwent prefrontal lobotomy |
Qualitatively, Rorschach signs pre-post-surgery were not significantly different; evidence for Piotrowski‟s signs were attributed to psychotic processes. |
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Klebanoff (1945) |
Presents a review of the extant literature, pre-1945, on studies of psychological disturbances associated with brain disorders |
This review concluded that the Rorschach was not an ideal assessment technique in the evaluation of organic brain disorders. |
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Aita et al. (1947) |
Tested for Piotrowski‟s organic signs |
Findings showed that most Rorschach „signs‟ did not differentiate moderate brain injury groups. |
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Hughes (1948) |
50 of 218 subjects with brain damage; tested for „signs‟ based on prior studies |
82% of the organic patients were classified by these new signs; however, based on Piotrowski‟s signs, only 20% of the organic group was correctly identified. |
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Diers & Brown (1951) |
Tested Hughes‟ organic signs in MS patients; Rorschach |
Found that low IQ MS patients exhibited a high number of organic signs, but the authors questioned the validity of the Hughes‟ sign criteria. |
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Dorken & Kral (1952) |
Examined Rorschach „signs‟ not produced by organic patients |
7 signs were identified; using this method, 93% of the organic patients were identified (as opposed to only 50% using Piotrowski‟s signs). |
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Yates (1954) |
Reviewed the available literature to determine the validity of psychological tests in assessment of brain damage |
This review found tepid support on the efficacy of the Rorschach on the reliability of organic „signs‟ in organic brain damage; most studies ignored predictive variables such as age and IQ. |
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Hertz & Loehrke (1954) |
50 veterans who suffered head trauma; Rorschach records |
While 5 or more Piotrowski signs could be indicative of post-traumatic encephalopathy, absence of these signs is not contra-indicative of organic pathology; the study found scant support for the Hughes‟ signs in this brain injured sample. |
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Reitan (1955) |
65 patients with verified brain damage; validation of Rorschach ratios |
Formally scored Rorschach variables, with the exception of the Human Movement response, differentiated the brain damaged group from normal; Speed of organizing ratio also differentiated these groups. |
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Hertz & Loehrke (1955) |
50 veterans who suffered head injury |
Based on Rorschach „configurations‟, which reflect qualitative features of the Rorschach, differentiated brain damaged patients; deficits in IQ, memory, and analytical ability were noted; emotional constriction and fatigability were observed. |
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Birch & Diller (1959) |
Discussed the central importance of „Perceptual‟ indicators of brain damage; Rorschach |
These authors claim that while the Rorschach does not appear to be sensitive to overall brain damage per se, specific Rorschach „signs‟ do confirm „organicity‟, i.e., an impairment in organization of perceptions. |
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Eckhardt (1961) |
700 psychiatric patients from |
Results showed that although Piotrowski‟s organic |
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mental hospitals in North Carolina |
signs were evident in Rorschach protocols of brain disorders patients, these signs were also present in other psychiatric disorders; thus, 5 or more „signs‟ seem to be indicative of intellectual impairment, whether organic or functional. |
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Birch & Belmont (1961) |
Patients with brain damage to right cerebral hemisphere |
These patients produced fewer responses than controls with a lessened ability to re-organize the Whole blot into parts; there was no evidence of impaired ability to alter perception on suggestion from examiner. |
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Belmont & Birch (1962) |
18 subjects with left cerebral hemiplegia; productivity (# of Rorschach responses) |
Low Rorschach productivity was associated with clear and specific perceptions; greater response output was related to reduced quality and analytic ability. |
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Neiger et al. (1962) |
Compared 20 epileptics, 40 schizophrenic, and 80 normal subjects on Piotrowski‟s organic signs |
Findings identified many „false positives‟ using the Piotrowski criteria, which should be used with caution in predicting brain damage; however, authors concluded that these „signs‟ provide an estimate of the regressive process in chronic psychotic disorders. |
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Haynes & Sells (1963) |
Reviews prior studies on the use of psychological tests in the assessment of organic brain damage |
Authors conclude that most studies did not use a multi-method approach (i.e., diagnostic signs, test scatter, qualitative data); authors propose a sequential multivariate measurement approach. |
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Evans & Marmorston (1963) |
Compared cerebral thrombosis patients (n=108) to heart patients (n=96) across several projective tests |
All tests, in aggregate, differentiated these 2 patient groups; the Rorschach performed the best; however, other tests were less successful. |
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Evans & Marmorston (1964) |
Investigated Rorschach „signs‟ in brain-damaged subjects |
Brain-damaged patients had higher scores on 46 „signs‟ associated with deficits in cerebral functioning; however, the transient cerebral symptom group could not be differentiated from the cerebral thrombosis group; Findings show that the „sign‟ approach has its limitations. |
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Kohen-Raz & Assael (1966) |
19 juvenile delinquents suspected of organic brain disorder; Rorschach & EEG |
Results indicated 4 patients showed maturational developmental lag; 7 Rorschach organic signs were noted. |
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Nedelcu & Zellingher (1971) |
30 male patients discharges after suffering cranial trauma; Rorschach |
On the Rorschach, fewer Form than Color responses were noted; about 50% of the group showed 5+ Piotrowski‟s organic signs; Findings suggest the importance of clinical attention to neuropsychological sequelae post-acute head trauma. |
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Vagrecha & Mazumdar (1974) |
20 epileptic patients & functional intellectual impairment; Rorschach |
Results indicated that although these patients exhibited serious IQ deficits, Piotrowski‟s signs were not evident; Findings confirm the position that IQ and „organic‟ signs on the Rorschach are not related. |
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Vitorovic et al. (1975) |
124 psychotic females; studies relationship between EEG & Rorschach |
Findings showed a high degree of conformity with signs of organic syndrome elicited by Rorschach test; abnormal EEGs were associated with organic psychosis. |
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Wagner et al. (1980) |
Studied efficacy of 3 projective techniques on differentiating brain damage |
Several Rorschach signs (i.e., Populars, F+%, m) were predictive of brain damage, but the authors caution that this relationship may be a function of IQ. |
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Ellis & Zahn (1985) |
35 adult patients with severe closed head injury; stepwise discriminant function analyses |
The CHI group differed from controls on #R, mean X+% and F+%, lower affective ratio (Afr), less color responses, and relation of W to D responses; Rorschach variables (DQV, FC, FQ Dif, T, D) correctly classified these patients the best; low Populars, poor reality testing, and predominance of poor perceptions indicated distortion of the apperceptive process; cognitive deficits included illogical perceptions, poor verbal expression. |
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Shukla et al. (1987) |
Studied Rorschach „signs‟ with Bender-Gestalt as the criterion; 35 female brain lesion patients vs. 35 schizophrenics vs. controls |
Results indicated that 3 of Piotrowski‟s signs (low Responses; high Form) identified the organic group. |
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Gold (1987) |
Critical review of emergent literature on the Rorschach response process |
Author concludes that Rorschach research neglects study on the linguistic representation of perceptual processes; suggests that adjutant research in neuropsychology and information processing could facilitate the link between perception and verbalization (i.e., language). |
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Frank (1991) |
Examined the use of the Rorschach in the assessment of cerebral dysfunction |
These patients manifest a unique cognitive style, i.e., responses tend to be concrete, perseverative, and stereotypical. |
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Acklin & Wu-Holt (1995) |
Offered a conceptual framework, based on neuropsychology and cognitive science, in understanding the functional operations during the Rorschach response process |
Authors frame their argument based on clinical research supporting the Rorschach in tapping visual attention, object recognition, associative memory, verbalization, and executive functions. |
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Zillmer & Perry (1996) |
Provided a conceptual basis on the nexus between neuropsychological abilities and mental health factors |
Based on factor analytic procedures, the authors proposed that personality and neuropsychological factors are not orthogonal constructs. |
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Exner et al. (1996) |
60 adult closed head injury (CHI) patients, within 1.5 months post-injury |
Rorschach data indicated no evidence of perceptual distortions or thinking disturbance; however, several mental health liabilities were found (simplistic mode of functioning (high L); deficits in decision-making; affective-interpersonal disengagement). |
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Perry et al. (1996) |
Patients with dementia of the Alzheimer‟s type |
Based on a „process‟ neuropsychological approach, the findings showed significant differences on linguistic errors and perseveration; Authors conclude that the Rorschach can be used as a tool in neuropsychological problem-solving evaluation. |
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Chaudhury et al. (1998) |
60 male inpatients with epilepsy; evaluation of Piotrowski‟s signs |
These Rorschach „signs‟ identified 65% of these patients, but also, 10% of control subjects. |
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Cattelani et al. (1998) |
22 patients with traumatic brain injury (TBI); several neuropsychological measures and Rorschach |
Findings showed that the Rorschach was sensitive to changes in cognitive style and personality, but more efficacious in severe head trauma patients; authors contend that the Rorschach does not provide incremental clinical data beyond that obtained by |
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standardized neuropsychology assessment evaluations. |
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Muzio & Luperto (1999) |
10 hospitalized elderly women with dementia; Rorschach |
Compared to control group, significant differences were reported on capacity of mentalization (EA<3), reality testing (X-%>.29), illogical reasoning, and impairment of thinking processes for the dementia patients. |
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Chaudhury et al. (1999) |
75 adult patients with head injury; evaluation of organic signs |
Based on Piotrowski‟s criteria, the authors identified 49 of the 75 patients; Piotrowski‟s signs had a specificity of 92.7%. |
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O‟Leary (2000) |
A literature review on neuropsychological aspects of borderline personality disorder (BPD) |
Studies using the Rorschach indicated deficits in visual memory and visual perception; Findings have implications for how BPD patients process emotional- laden material. |
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Sinacori (2000) |
A dissertation study on 67 neuropsychological evaluations of brain-injured subjects; Rorschach |
On the Rorschach, 60% of the sample showed positive Coping Deficit indices, an indicator of emotional disturbance; 25% had positive depression indices. |
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de Felipe-Oroquieta (2003) |
37 temporal lobe patients; emotional control ability; Rorschach & Stroop Color- Word Test |
Findings indicated a relationship between ability to inhibit automatic affective impulses and emotions. |
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Muzio (2004) |
Literature review; historical issues |
Enthusiasm on the efficacy of the Rorschach in the study of neurological populations was tempered in the 1960s; however, with advances with the Exner CS, there has been a resurgence of research interest in neuropsychology due largely to the amenability of the Rorschach in the assessment of cognitive functioning and affect. |
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Smith et al. (2007) |
27 children; Rorschach & Rey- Osterreith Complex Figure Test (ROCF) |
In this study on the utility of the Rorschach response process in neuropsychological assessment, the findings showed a link between accuracy of ROCF renditions and measures of developmental quality and perceptual accuracy on the Rorschach. |
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Asari et al. (2008) |
Studied neural substrates that underlie „unique‟ responses on the Rorschach |
Findings showed that unique responses were associated significantly with activation of the right temporal pole, known to be related to both social and emotive processing, storage of perceptual-emotional linkages, and semantic memory. |
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Castelli et al. (2008) |
14 Parkinson‟s disease patients undergoing bilateral deep brain stimulation; pre-post evaluation |
Rorschach indices indicated no major modifications of personality structure. |
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Asari et al. (2010a) |
Investigated the link between amygdala volume and production of unique Rorschach responses |
Results indicated that emotion-related neural circuits in the limbic system seem to be associated to unique perception and FQ-responses on the Rorschach. |
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Asari et al. (2010b) |
Studied the modulatory effect of the amygdala during the Rorschach response process |
Findings indicated a link between the Rorschach unique response ratio and WSumC; Results confirmed the interference of emotion on perception when taking the Rorschach. |
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Ozura & Stukovnik (2011) |
Case study with multiple |
Although the authors contend that the Rorschach has |
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sclerosis patients |
potential in patients in neurology as a problem-solving instrument, this study concluded that the test lacks a theoretical basis framed on brain-behavior relationships needed in neuropsychological assessment. |
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Hiraishi et al. (2012) |
Used neuroimaging (near- infrared spectroscopy) to study prefrontal cortex of adolescents; several projective tests |
Neuro-assessment of the Brodmann Area 10 showed that the Rorschach was right-hemisphere dominant; authors contend that these findings reflect emotion and sociality. |
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Ilonen et al. (2012) |
8 sclerosing leukoencephalopathy (PLOSL) patients; Rorschach analysis |
On the Rorschach, these patients showed low Productivity, few Blends, problems in organization, and disturbed concept formation; In line with neuro- radiological data, Rorschach protocols were concordant with signs of frontal type of dementia. |
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Muzio (2016) |
Editorial comment on „Special issue‟ |
Author confers the nexus of Rorschach performance in neuropsychological assessment; psychologists need to be aware of neuro-cognitive correlates of Rorschach variables and indices. |
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Meyer (2016) |
Children; Rorschach-PAS |
Rorschach scores most linked to neuropsychological perceptual synthesis skills were those related to perceptual accuracy and complex perceptual representations; noteworthy, these scores were more strongly associated with verbal abilities than with perceptual organizational skills. |
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Ilonen & Salokangas (2016) |
267 adolescent psychiatric inpatients; 117 adults with psychotic disorders; Rorschach Coping Deficit Index (CDI) |
This study identified a link between coping deficit and cognitive capacity; impaired comprehension predicted elevated CDI in adolescents, perseveration tendency in adult patients; thus, the CDI seems to tap neuro- cognitive dysfunction and deterioration. |
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Ishibashi et al. (2016) |
40 normal adults; Rorschach & neuroimaging (fMRI); impact of color stimuli |
For Cards with chromatic color, significant increase in brain hemodynamics was observed in left visual area V4 and left orbitofrontal cortex; Findings support the neuro-cognitive features of the Rorschach response process. |
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Porcelli & Kleiger (2016) |
Commentary on brain mechanisms and cognitive functioning involving the Rorschach „human movement‟ M response |
Based on meta-analytic evidence and neuroscience research, the authors claim that M a) activates the mirror neuron system, b) is associated with higher- level cognitive ability, and c) provides an avenue in understanding of neuropsychological mechanisms underlying Rorschach response processes. |
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Cristofanelli et al. (2016) |
Reviews potential nexus regarding neuro-imaging (fMRI) techniques and personality assessment; Rorschach |
Authors propose framework to explore resting-state neural functional connectivity related to perceptual styles and personality traits on Rorschach variables. |
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