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To cite this article: Edwin E. Wagner & Marion R. Heise (1981) Rorschach and Hand Test Data Comparing
Bipolar Patients in Manic and Depressive Phases, Journal of Personality Assessment, 45:3, 240-249, DOI:
10.1207/s15327752jpa4503_3
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Journal of Personality Assessment, 1981, 45, 3
etiology, dynamics and even diagnosis of the mood swing. Third, follow-up
of the disease (Beck, 1972). Further- and correct timing are necessary in or-
more, and interestingly enough, there der to obtain test data on the same pa-
are surprisingly few studies comparing tient in both phases of the psychosis and
the two phases of the illness by way of the researcher is usually frustrated by
projective techniques. For example, practical considerations such as termi-
Rorschach himself reports only one nation of hospitalization before the al-
such case (1921) and subsequent re- ternate phase occurs and uncertainly
search with this technique has been as to whether, by the time arrangements
limited and circumscribed. Levy and have been made to test the patient, the
Beck (1932) studied manics where the supposed manic or depressed phase has
diagnosis was "reasonably certain" but already shifted.
the depressed phase was not investigat- The present study attempts to deal
ed because of the nonresponsiveness of with and surmount the above mentioned
the subjects. Again, Schmidt and Fonda difficulties in order to obtain some re-
(1956) concentrated on only one phase liable comparisons between manic and
of the disorder comparing manics with depressed phases with projective tests.
normals and schizophrenics. Converse- These data in and of themselves should
ly, Donnelly, Murphy, and Scott (1975) prove to be of practical and theoretical
compared bipolar and unipolar patients value, at least providing a base for future
but concentrated on the depressed speculation and research. However, an
phase, ignoring the manic stage. Clear- additional purpose of this study is to
ly, it would be advantageous to com- check out a theoretical description of
pare the responses of a reasonably large the manic depressive psychosis as for-
number of manic depressives in both mulated by Structural Analysis (SA),
phases, preferably using the same sub- a theory of personality based on projec-
jects as their own controls. tive testing (Wagner, 1971; Wagner,
Why has this not been done? Several 1976). Briefly, SA postulates that per-
explanations suggest themselves. First, sonality is mediated through two hypo-
despite the fact that investigators such thetical constructs, the Facade Self (FS)
as Lewis and Piotrowski (1954) have and the Introspective Self (IS) which,
noted that "the diagnosis of the manic in turn, are surrounded by the trimodal
depressive psychosis is frequently diffi- functions of Emotion, Intellect and Be-
cult" (p. 25) and often confused with havior (see Figure 1). The FS represents
schizophrenia, the overt behavior of the basic, automatic attitudes and action
manic depressive at the time of hospit- tendencies directly interfacing with re-
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IS but, for the purposes of this study, for a pre-existing psychiatric or physical
the SA treatment of multiple personal- illness other than manic depressive psy-
ity is especially germane. It was held chosis. This qualification served to satis-
that multiple personalities emerge be- fy the criteria for a "primary affective
cause of conflicts within the IS which disorder" as specified by Winokur and
cause separate "personalities" to con- Clayton (1967). Second, each patient
stellate and then alternatively break was independently diagnosed as bipolar
through a weak FS. The effects of this type I on the basis of clinical observa-
process on Rorschach patterning were tion of specific symptoms listed by
specified and then observed in three Feighner et al. (1972). Observations
cases of multiple personality (Wagner were made regarding the phase a patient
& Heise, 1974). Essentially the same was experiencing, by the hospital staff
Rorschach patterning was subsequently as well as by the test administrator. Third,
verified by Danesino, Daniels, and Mc- a case history was taken for each patient
Laughin (1979). SA postulates that in which included the following informa-
the manic-depressive condition a similar tion: Type of medication administered,
phenomenon occurs except that, instead previous number of hospitalizations,
of various components of the IS break- and family history of affective disorder.
ing through intermittently, the IS thrusts All patients were tested while in local
itself through the FS more or less as a hospitals with the cooperation of the
unit in the manic phase and then recedes patient's attending physician as well as
in the depressed phase. Therefore, in the the patient's voluntary consent to par-
manic phqse, the FS merely acts as a ticipate in the research study. A total of
"mouthpiece" for the energized and un- 40 psychiatric inpatients met the criteria
trammeled IS; conversely, in the de- for inclusion in the study. Five patients
pressed phase, the IS withdraws, leaving in the manic phase of the disorder re-
a depressed, anergic FS. fused to take part in the study, and three
The Rorschach and the Hand Test other patients were too depressed to re-
are often used in tandem to portray SA spond to the stimuli on the projective
configurations since the former, al- instruments. Fifteen of the 32 remaining
though a "broad band" instrument, is subjects were tested in both the manic
a little weak in mirroring FS tendencies, and depressive phases of the disorder.
a deficiency which can be compensated A checklist of symptomatology pres-
for by the Hand Test which directly re- ent at the time of testing was maintained
flects overt action tendencies (or the for each patient. This insured accurate
lack of them). Operationally, it would identification of a moodswing as speci-
be predicted that, on the Rorschach, a fied by Feighner et al. (1972), as well as
E. E. WAGNER and M. R. HEISE
an additional check on the elimination vanced stage of depression but the ef-
of the schizophrenic subjects from the forts also resulted in failure due to the
population. Of the 15 patients, 9 were nonresponsiveness of the patients.
female, 6 xnale. All were caucasian. Seven All patients in this study were on med-
were married, 2 single, 4 divorced and ication at tirne of test administration.
2 widowed. The average age of onset Although this is considered to be a lim-
ranged fro~m28 to 40 with a mean age of itation of this research, it was not eth-
33.7. Nu~nberof previous hospitaliza- ically possible to withdraw or withhold
tions ranged from 2 to 17 with a mean medication from patients participating
of 9.7. in a research study of this type. How-
A careful attempt was made to clearly ever, an effort was made to test all sub-
differentiate the manic and depressive jects before medication was deemed to
phase in all subjects tested. Several be "effective" in the judgment of the at-
patients were rejected for retest because tending physician. Lithium medication
the examiner questioned the state of had been administered to all patients
mania or depression the subject was in this study, but, with three exceptions,
purported to be experiencing. Patients lithium chemotherapy had been initiated
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were, with three exceptions, tested two less than five days prior to testing. Ac-
to three days after hospital admission cording to Cade (1949) and Gershon
(or immediately upon release from se- (1976), lithium does not produce behav-
clusion) for mania, and one day follow- ioral changes in less than five days. The
ing notificartion that the patient had ex- three subjects who had been on lithium
perienced a moodswing. The system for more than five days were chronic pa-
proved successful for patients in the tients who, in the judgement of their
manic phase. Stage of mania was deter- attending physician, were not respond-
mined by an informal analysis of each ing to the drug anyway.
patient according to Young et al.'s rat- In order to1 calm patients who were
ing scale: for mania (Young, Biggs, Zieg- experiencing a manic attack, Haldol
ler, & Meyer, 1978). The manic stage (Haloperidol) was administered upon
was rated as "acute" for all research sub- hospital admi!;sion to reduce the frenetic
jects in this study, according to this activity evidenced by the manic patients.
scale. Manic patients are often placed in re-
It was not possible to follow a specific straints and/or seclusion for their own
format in terms of when patients would protection during the first day or two
be tested while depressed since all but of hospitalization. Haldol has been
one patient were tested initially while found to be effective in slowing down
in a manic mood. The single patient test- motoric behavior, but it does not affect
ed first in the depressive phase had thought processes for 21 to 42 days
cycled into this stage following a manic (Goodman & Gilman, 1975). On two
episode. However, an informal analysis occasions, depressed patients had been
of stage of depression was performed administered Elavil (arrnitriptyline hy-
for each patient tested by assessing the drochloride) several days to one week
subject on Hamilton's (1960) rating before they were tested. According to
scale for depression. The depressive Goodman and Gillnan (1975), Elvail
mood, as measured by this scale, ranged should produce improvement in de-
from simple to acute for all patients. pressed patients no sooner than two to
Two attempts were made to retest three weeks.
subjects while they were experiencing All patients were tested by one of the
the delirious phase of mania, but both authors (MRH) and scored indepen-
ended in failure. The subjects were too dently by the other (EEW). Since this
hyperactive and/or distractable to re- study was largely exploratory, two-tailed
spond to the test stimuli. Attempts were tests of significance were used with sig-
made to test several patients in an ad- nificance set at the usual .05 level.
244 Rorschach and Hand Test Data
Table 1
Medians, Ranges, Wilcoxon Matched-Pairs Signed Ranks Values, andpercentage of Hits
Using a Median Cutoff Point, Comparing Both Phases of a
Bipolar Manic Depressive Group (n = 15) on Rorschach and Hand Test Variables
Groups
Combined W~lcoxonTest
Vanable Manic Depressive Median Hit %
Cutoff
Medlan Range Median Range N T P
Rorschach
W 9 6-14 4 2-6 6 15 0 .008 89
D 7 1-18 6 2-10 6 13 26.5 .203 -
M 2.5 1-6 0 0-2 1 14 0 .008 89
FM 0 0-7 0 0-2 0 14 3.5 .008 89
m 0 0-4 0 0 0 7 0 0.16 -
F+ 6 2-14 8 5-12 8 13 32 NS -
ZC 1 0-3s 0 0-1 0 8 3.5 .047 72
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Table 1 (cont'd)
Groups
Comb~ned Wllcoxon Test
Variable Man~c Depressive Med~an Hit %
Cutoff
Median Range Med~an Range N T P
Dept. of Psychology
Wagner, E. E. Personallty correlates of Rorschach Akron, Ohlo 44325
scorlng determinants: Hypotheses derlved from
structural analysis. Journal of Personalrtl, As- Recelved February 22, 1980
sessment, 1978, 42, 466-473. Rev~sed: May 1, 1980