Perceptualand Motor Skills, 1992, 7 5 , 147-158. O Perceptual and Motor Skills 1992
RORSCHACH INDICATORS O F MULTIPLE PERSONALITY DISORDER ' SUSAN M. LABOTT
FRANK LEAVITT
Henry Ford Horpital
Rush Medical College Rush Presbyterian-St. Luke's Medical Center
BENNETT G. BRAUN, ROBERTA G. SACHS
Dissociative Disorders Unit Rush Norfh Shore Medical Center Summary.-The increase in reported cases of Multiple Personalicy Disorder underscores a great need to differentiate clearly this from other psychiatric disorders and from simulation of Multiple Personality Disorder. Two sets of Rorschach signs have been advanced as clinical markers by their developers, namely, Barach and also Wagner, Allison, and Wagner. As the Wagner signs are prevalent in much of the research on Rorschach responses in Multiple Personality Disorder, the purpose of the present study was to evaluate these signs using Wagner's administration and the resulting Rorschach protocols of 16 Multiple Personality Disorder patients and 16 psychiatric controls. Analysis indicated that this system was deficient in correctly classifying these 32 protocols. A new marker, the Splitting Response, emerged, however, which was more useful. This response, in combination with at least one Dissociative response, produced an accuracy rate of 94%. These new criteria may be useful aids in the detection of Multiple Personality Disorder from Rorschach protocols. Replication is urged.
Multiple Personality Disorder is a controversial psychiatric diagnosis that has again captured the attention of clinicians. The first reported case of Multiple Personality Disorder was referred to as "Exchange Personalities" in a publication by Eberhardt Gmelin in 1791 (Larrnore, Ludwig, & Cain, 1977). The second was "Mary Reynolds" in 1816 (Salama, 1980). Since then, the history of the disorder has been discontinuous. After an initial spurt of popularity, it largely disappeared as a diagnostic entity. By 1944, only 76 cases were cited in an historical review of the disorder by Taylor and Martin (1944). Currently, however, it is not uncommon to find single studies reporting 100 or more cases (e.g., Braun & Grey, 1987; Putnam, Guroff, Silberman, Barban, & Post, 1986; Schultz, Braun, & Kluft, 1989). There are several different ways to account for the reemergence of the disorder. Some investigators suggest that the disorder has simply been underestimated (Bliss, 1980; Rosenbaum, 1980) because the peculiar pathology has been inappropriately labeled schizophrenia. Others argue that the fascination evoked by Multiple Personality Disorder among both clinicians and patients 'The authors thank Mark Wolwer and two anonymous referees for comments on an earlier draft. Address requests for reprints to Susan Labott, Ph.D., Consultation-Liaison Psychiatry, Henry Ford Hospital, 2799 W.Grand Blvd., Detroit, MI 48202.
148
S. M. LABOTT, ETAL.
and the demand-characteristics of the clinical situation promote the adoption of artificial roles (Spanos, Weekes, & Bertrand, ,1985; Thigpen & Cleckley, 1984), thereby increasing the frequency of diagnosis. Because there is controversy surrounding the correct diagnosis, attempts have been made to develop standardized ~roceduresfor identifying subtle markers, those of which patients are less cognizant and which would then be less susceptible to falsification. Several investigators have turned to sign approaches using the Rorschach test as the measuring instrument. To date, two approaches have emerged which appear to be strikingly different. Among these Wagner's signs are better known (Wagner, Allison, & Wagner, 1983). The Wagner signs were developed on the post hoc rationale that for the dissociation of secondary personalities to occur, the original personality must be cognitively complex and exhibit a large range of competing roles and affects. Five Rorschach patterns have evolved as signs, i.e., an active cognitive style, diverse human imagery, oppressive imagery, high levels of poorly modulated affect, and diverse emotional components. I n contrast to this descriptive approach to the patients' characteristics, Barach (1986) reasoned that, if alter personalities exist, they would produce detectable interference in the performance of the personality being tested. Given the hidden participation of alter personalities, patients with Multiple might r be expected t o deny Rorschach responses during Personality ~ i s o r d ~ inquiry that were elicited in the free-association part of the examination and also to produce more test content involving hidden figures. Results from both approaches are inconclusive. The Wagner approach has been more frequently publicized and studied, but the results are largely mixed. The confirmatory studies are based on very small samples (1 to 3 patients per study) and are probably best viewed as uncontrolled case studies (Wagner, et al., 1983; Wagner & Heise, 1974). Positive results for Barach's approach come from one small study conducted by the author (Barach, 1986). Neither set of signs received support in a study of the protocols of 18 known Multiple Personality Disorders (Gilbertson, Torem, & Kemp, 1989). Neither the Wagner nor the Barach system includes the most salient features that might be detectable in Rorschach protocols. Multiple Personality Disorder is a dissociative disorder. The experience of dissociation, even though it may exist outside of awareness, would be expected to leave Rorschach traces characterized by diffuse, hazy images of the environment. The disorder is also presumed to be generated by the splitting of the original personality into integrated parts. The self experience of splitting might well emerge in Rorschach content in the form of split or pulled-apart images. Our pilot work provided tentative support for these hypotheses. The purpose of the present study was to validate Wagner's proposed signs in a larger sample of cases authenticated by extended clinical evaluation
RORSCHACH/MULTIPLE PERSONALITY
149
in an inpatient sample. The study, with one change, replicated Wagner's procedure which was designed to identify clinical markers of Multiple Personality Disorder in the host personality using Piotrowski's Rorschach system. A matched sample of psychiatric patients was added as a control group. The study also assessed the utility of splitting and dissociative responses as clinical markers of Multiple Personality Disorder in the same sample and explored the manifestations of Barach's signs in the host personality using the Wagner study procedures. Subjects Participants, all female inpatients diagnosed with Multiple Personality Disorder, were seen on the Dissociative Disorders Unit at Rush Medical Center. Diagnoses were made by the attending psychiatrist (BB) on the basis of the DSM-111-R (American Psychiatric Association, 1987) criteria after a minimum of 30 days of intensive evaluation and treatment. Each diagnosis was confirmed independently by a psychologist (RS). The host personality, that personality who presented most often (Braun, 19861, was tested for the present study. This procedure was used because Wagner's signs are based on data obtained from the host and because the "presenting personality" has been tested in other studies of psychological and intellectual functioning of Multiple Personality Disordered patients (Coons, Bowman, & Milstein, 1988). Periodically during the administration of the Rorschach, the patient was asked if in fact the host was still present and participating. This procedure also served as a reminder to the patient. Psychiatric controls were female inpatients on a psychiatric unit at the same medical center and were referred for psychological testing during the period of this study. Discharge diagnoses (also based on DSM-111-R criteria) were used to categorize control patients. Additional requirements for selection of psychiatric controls consisted of the following: (1) no neurological disorder, (2) no psychotic disorder, (3) no dissociative disorder, (4) age 18 to 45 years old, and ( 5 ) at least a high school education. No significant differences were found between the two groups in mean age (patients with Multiple Personality Disorder = 34.4 yr.; Controls = 33.8) or years of education (for Multiple Personality Disorder 13.9 yr.; for Controls 14.2). Procedure A comprehensive psychological test battery was ordered by each patient's attending psychiatrist. The Rorschach (Piotrowski, 1957) was adminis'The specific diagnoses of the Control patients were as follows: 4 Major Depression, 1 D s thymia, 1 Intermittent Explosive Disorder, .2 Panic Disorder, 2 Obsessive Compulsive ~isordYei 1 Generalized Anxiety Disorder, 1 Agoraphobia, 1 Somatization Disorder, 1 Anorexia Nervosa, 2 Posttraumatic Stress Disorder.
150
S. M. LABOTT, E T A L .
tered as one component of the assessment procedure (which also included an interview, TAT, and MMPI). Administration of the Rorschach involved traditional Free Association and Inquiry phases. While the total testing time was greater, the amount of time spent with the patient on the Rorschach ranged from 1 to 3 hours. Scoring.-Protocols were scored using the Piotrowski (1957) system. This scoring system was chosen because it was used in the original and the validation studies of the Wagner signs (Wagner, et al., 1983; Wagner & Heise, 1974). Besides the standard Rorschach scoring, the following variables were also scored. Wagner signs.-The five Rorschach indicators of Multiple Personality Disorder developed by Wagner and his colleagues (Wagner, et al., 1983; Wagner, Wagner, & Torem, 1986) were scored as follows: 1. At least six movement responses (M + FM + m). 2. At least two human movement responses are qualitatively diverse, e.g., ". . . like he is orchestrating the elephants . . . hands up, just probably his job"; "Two men over a skull . . . it holds some kind of significance to men . . . they've been p f i n g it apart . . . parts of bone deteriorating . . .". 3. At least one movement response reflects a feeling of oppression, e.g., "like he's ready to pounce . . . like ready to attack these two small things." 4. At least three color responses, and C + CF>FC. 5. At least one color response is positive (e.g., red bow tie) and another is negative (e.g., blood). According to Wagner, et al. (1986), all five signs are necessary for a definitive diagnosis of Multiple Personality Disorder, and fewer than four of the signs contraindicates Multiple Personality Disorder. Barach indicators.-Given some concerns about the accuracy of the Wagner signs, Barach (1986) proposed another set of markers. Two types of responses are scored in this system. 1. Denial responses: During inquiry, the subject either (a) denies something reported in the Free Association, (b) has trouble locating something reported during the Free Association, or (c) confabulates to explain a percept reported in the Free-association phase. 2. Hiding responses: During either Free-association or Inquiry phases, (a) something in the blot is said to be hiding behind something else, appearing from behind something else, or appearing from within another part of the blot, (b) something seen in the blot is unaware of something else in the blot, or (c) a mask is seen in the blot. Barach indicates that Multiple Personality Disorder should be diagnosed when the number of Hiding + Denial responses is greater than 2. Splitting responses.-Expected to reflect the internal splitting of the self that occurs in Multiple Personality Disorder, split responses fall into the following three categories:
RORSCHACH/MULTIPLE PERSONALITY
151
1. Human division/splitting, such as people torn apart, being separated. 2. Abstract splitting (occurs with ill-defined objects, especially when internal pressure is suggested), such as abstract images being brokenltorn apart. 3. Divisions, involving other, nonhuman separation/split responses, e.g., animals cut down the center, cells dividing. Dissociative responses.-These responses occur when subjects present content with reference to viewing the world through a mist or fog so that people and objects look unclear, blurry, or far away. Examples include responses such as, like looking through a long blurry tube, people surrounded by clouds, walking in mist, ghost-like shadows of people, figures forming from smoke. (Smoke, clouds, and fog are not dissociative per se.) Previous research has characterized the experience of viewing the world through a fog as symptomatic of a dissociative disorder, and it is included as an item on the Dissociative Experiences Scale (Bernstein & Putnam, 1786). Reliability Analyses To assess reliability of the scoring of the major variables, 15 protocols (5 Multiple Personality Disorder and 10 psychiatric controls; 47% of the sample) were scored by two raters using the scoring criteria described above. Data for these analyses were gathered by the second author (FL) and scored blindly by the first (SL). Pearson product-moment correlations yielded the following relationships: (a) Piotrowski variables (i.e., total movement, total color, total forced color, oppressive movement, total R, F%, F + %) rs = .94 to .79 with only one exception (F + %. r = .81); (b) Total Wagner signs, r = .97; (c) Barach indicators: Total Hiding: r = .98, Total Denial: r = .97; (d) Splitting responses: r = .77; (e) Dissociative responses: r = .57; discrepancies in scoring (while only few in number) were resolved through discussion. Group Differences Values of Hotelling T 2 were calculated on the major variables of interest. A significant result was obtained ( T 2 = 121.64; F = 11.66, p
RORSCHACH INDICATORS O F MULTIPLE PERSONALITY DISORDER ' SUSAN M. LABOTT
FRANK LEAVITT
Henry Ford Horpital
Rush Medical College Rush Presbyterian-St. Luke's Medical Center
BENNETT G. BRAUN, ROBERTA G. SACHS
Dissociative Disorders Unit Rush Norfh Shore Medical Center Summary.-The increase in reported cases of Multiple Personalicy Disorder underscores a great need to differentiate clearly this from other psychiatric disorders and from simulation of Multiple Personality Disorder. Two sets of Rorschach signs have been advanced as clinical markers by their developers, namely, Barach and also Wagner, Allison, and Wagner. As the Wagner signs are prevalent in much of the research on Rorschach responses in Multiple Personality Disorder, the purpose of the present study was to evaluate these signs using Wagner's administration and the resulting Rorschach protocols of 16 Multiple Personality Disorder patients and 16 psychiatric controls. Analysis indicated that this system was deficient in correctly classifying these 32 protocols. A new marker, the Splitting Response, emerged, however, which was more useful. This response, in combination with at least one Dissociative response, produced an accuracy rate of 94%. These new criteria may be useful aids in the detection of Multiple Personality Disorder from Rorschach protocols. Replication is urged.
Multiple Personality Disorder is a controversial psychiatric diagnosis that has again captured the attention of clinicians. The first reported case of Multiple Personality Disorder was referred to as "Exchange Personalities" in a publication by Eberhardt Gmelin in 1791 (Larrnore, Ludwig, & Cain, 1977). The second was "Mary Reynolds" in 1816 (Salama, 1980). Since then, the history of the disorder has been discontinuous. After an initial spurt of popularity, it largely disappeared as a diagnostic entity. By 1944, only 76 cases were cited in an historical review of the disorder by Taylor and Martin (1944). Currently, however, it is not uncommon to find single studies reporting 100 or more cases (e.g., Braun & Grey, 1987; Putnam, Guroff, Silberman, Barban, & Post, 1986; Schultz, Braun, & Kluft, 1989). There are several different ways to account for the reemergence of the disorder. Some investigators suggest that the disorder has simply been underestimated (Bliss, 1980; Rosenbaum, 1980) because the peculiar pathology has been inappropriately labeled schizophrenia. Others argue that the fascination evoked by Multiple Personality Disorder among both clinicians and patients 'The authors thank Mark Wolwer and two anonymous referees for comments on an earlier draft. Address requests for reprints to Susan Labott, Ph.D., Consultation-Liaison Psychiatry, Henry Ford Hospital, 2799 W.Grand Blvd., Detroit, MI 48202.
148
S. M. LABOTT, ETAL.
and the demand-characteristics of the clinical situation promote the adoption of artificial roles (Spanos, Weekes, & Bertrand, ,1985; Thigpen & Cleckley, 1984), thereby increasing the frequency of diagnosis. Because there is controversy surrounding the correct diagnosis, attempts have been made to develop standardized ~roceduresfor identifying subtle markers, those of which patients are less cognizant and which would then be less susceptible to falsification. Several investigators have turned to sign approaches using the Rorschach test as the measuring instrument. To date, two approaches have emerged which appear to be strikingly different. Among these Wagner's signs are better known (Wagner, Allison, & Wagner, 1983). The Wagner signs were developed on the post hoc rationale that for the dissociation of secondary personalities to occur, the original personality must be cognitively complex and exhibit a large range of competing roles and affects. Five Rorschach patterns have evolved as signs, i.e., an active cognitive style, diverse human imagery, oppressive imagery, high levels of poorly modulated affect, and diverse emotional components. I n contrast to this descriptive approach to the patients' characteristics, Barach (1986) reasoned that, if alter personalities exist, they would produce detectable interference in the performance of the personality being tested. Given the hidden participation of alter personalities, patients with Multiple might r be expected t o deny Rorschach responses during Personality ~ i s o r d ~ inquiry that were elicited in the free-association part of the examination and also to produce more test content involving hidden figures. Results from both approaches are inconclusive. The Wagner approach has been more frequently publicized and studied, but the results are largely mixed. The confirmatory studies are based on very small samples (1 to 3 patients per study) and are probably best viewed as uncontrolled case studies (Wagner, et al., 1983; Wagner & Heise, 1974). Positive results for Barach's approach come from one small study conducted by the author (Barach, 1986). Neither set of signs received support in a study of the protocols of 18 known Multiple Personality Disorders (Gilbertson, Torem, & Kemp, 1989). Neither the Wagner nor the Barach system includes the most salient features that might be detectable in Rorschach protocols. Multiple Personality Disorder is a dissociative disorder. The experience of dissociation, even though it may exist outside of awareness, would be expected to leave Rorschach traces characterized by diffuse, hazy images of the environment. The disorder is also presumed to be generated by the splitting of the original personality into integrated parts. The self experience of splitting might well emerge in Rorschach content in the form of split or pulled-apart images. Our pilot work provided tentative support for these hypotheses. The purpose of the present study was to validate Wagner's proposed signs in a larger sample of cases authenticated by extended clinical evaluation
RORSCHACH/MULTIPLE PERSONALITY
149
in an inpatient sample. The study, with one change, replicated Wagner's procedure which was designed to identify clinical markers of Multiple Personality Disorder in the host personality using Piotrowski's Rorschach system. A matched sample of psychiatric patients was added as a control group. The study also assessed the utility of splitting and dissociative responses as clinical markers of Multiple Personality Disorder in the same sample and explored the manifestations of Barach's signs in the host personality using the Wagner study procedures. Subjects Participants, all female inpatients diagnosed with Multiple Personality Disorder, were seen on the Dissociative Disorders Unit at Rush Medical Center. Diagnoses were made by the attending psychiatrist (BB) on the basis of the DSM-111-R (American Psychiatric Association, 1987) criteria after a minimum of 30 days of intensive evaluation and treatment. Each diagnosis was confirmed independently by a psychologist (RS). The host personality, that personality who presented most often (Braun, 19861, was tested for the present study. This procedure was used because Wagner's signs are based on data obtained from the host and because the "presenting personality" has been tested in other studies of psychological and intellectual functioning of Multiple Personality Disordered patients (Coons, Bowman, & Milstein, 1988). Periodically during the administration of the Rorschach, the patient was asked if in fact the host was still present and participating. This procedure also served as a reminder to the patient. Psychiatric controls were female inpatients on a psychiatric unit at the same medical center and were referred for psychological testing during the period of this study. Discharge diagnoses (also based on DSM-111-R criteria) were used to categorize control patients. Additional requirements for selection of psychiatric controls consisted of the following: (1) no neurological disorder, (2) no psychotic disorder, (3) no dissociative disorder, (4) age 18 to 45 years old, and ( 5 ) at least a high school education. No significant differences were found between the two groups in mean age (patients with Multiple Personality Disorder = 34.4 yr.; Controls = 33.8) or years of education (for Multiple Personality Disorder 13.9 yr.; for Controls 14.2). Procedure A comprehensive psychological test battery was ordered by each patient's attending psychiatrist. The Rorschach (Piotrowski, 1957) was adminis'The specific diagnoses of the Control patients were as follows: 4 Major Depression, 1 D s thymia, 1 Intermittent Explosive Disorder, .2 Panic Disorder, 2 Obsessive Compulsive ~isordYei 1 Generalized Anxiety Disorder, 1 Agoraphobia, 1 Somatization Disorder, 1 Anorexia Nervosa, 2 Posttraumatic Stress Disorder.
150
S. M. LABOTT, E T A L .
tered as one component of the assessment procedure (which also included an interview, TAT, and MMPI). Administration of the Rorschach involved traditional Free Association and Inquiry phases. While the total testing time was greater, the amount of time spent with the patient on the Rorschach ranged from 1 to 3 hours. Scoring.-Protocols were scored using the Piotrowski (1957) system. This scoring system was chosen because it was used in the original and the validation studies of the Wagner signs (Wagner, et al., 1983; Wagner & Heise, 1974). Besides the standard Rorschach scoring, the following variables were also scored. Wagner signs.-The five Rorschach indicators of Multiple Personality Disorder developed by Wagner and his colleagues (Wagner, et al., 1983; Wagner, Wagner, & Torem, 1986) were scored as follows: 1. At least six movement responses (M + FM + m). 2. At least two human movement responses are qualitatively diverse, e.g., ". . . like he is orchestrating the elephants . . . hands up, just probably his job"; "Two men over a skull . . . it holds some kind of significance to men . . . they've been p f i n g it apart . . . parts of bone deteriorating . . .". 3. At least one movement response reflects a feeling of oppression, e.g., "like he's ready to pounce . . . like ready to attack these two small things." 4. At least three color responses, and C + CF>FC. 5. At least one color response is positive (e.g., red bow tie) and another is negative (e.g., blood). According to Wagner, et al. (1986), all five signs are necessary for a definitive diagnosis of Multiple Personality Disorder, and fewer than four of the signs contraindicates Multiple Personality Disorder. Barach indicators.-Given some concerns about the accuracy of the Wagner signs, Barach (1986) proposed another set of markers. Two types of responses are scored in this system. 1. Denial responses: During inquiry, the subject either (a) denies something reported in the Free Association, (b) has trouble locating something reported during the Free Association, or (c) confabulates to explain a percept reported in the Free-association phase. 2. Hiding responses: During either Free-association or Inquiry phases, (a) something in the blot is said to be hiding behind something else, appearing from behind something else, or appearing from within another part of the blot, (b) something seen in the blot is unaware of something else in the blot, or (c) a mask is seen in the blot. Barach indicates that Multiple Personality Disorder should be diagnosed when the number of Hiding + Denial responses is greater than 2. Splitting responses.-Expected to reflect the internal splitting of the self that occurs in Multiple Personality Disorder, split responses fall into the following three categories:
RORSCHACH/MULTIPLE PERSONALITY
151
1. Human division/splitting, such as people torn apart, being separated. 2. Abstract splitting (occurs with ill-defined objects, especially when internal pressure is suggested), such as abstract images being brokenltorn apart. 3. Divisions, involving other, nonhuman separation/split responses, e.g., animals cut down the center, cells dividing. Dissociative responses.-These responses occur when subjects present content with reference to viewing the world through a mist or fog so that people and objects look unclear, blurry, or far away. Examples include responses such as, like looking through a long blurry tube, people surrounded by clouds, walking in mist, ghost-like shadows of people, figures forming from smoke. (Smoke, clouds, and fog are not dissociative per se.) Previous research has characterized the experience of viewing the world through a fog as symptomatic of a dissociative disorder, and it is included as an item on the Dissociative Experiences Scale (Bernstein & Putnam, 1786). Reliability Analyses To assess reliability of the scoring of the major variables, 15 protocols (5 Multiple Personality Disorder and 10 psychiatric controls; 47% of the sample) were scored by two raters using the scoring criteria described above. Data for these analyses were gathered by the second author (FL) and scored blindly by the first (SL). Pearson product-moment correlations yielded the following relationships: (a) Piotrowski variables (i.e., total movement, total color, total forced color, oppressive movement, total R, F%, F + %) rs = .94 to .79 with only one exception (F + %. r = .81); (b) Total Wagner signs, r = .97; (c) Barach indicators: Total Hiding: r = .98, Total Denial: r = .97; (d) Splitting responses: r = .77; (e) Dissociative responses: r = .57; discrepancies in scoring (while only few in number) were resolved through discussion. Group Differences Values of Hotelling T 2 were calculated on the major variables of interest. A significant result was obtained ( T 2 = 121.64; F = 11.66, p
