INTEGRATING THE SHEDLER-WESTEN ASSESSMENT PROCEDURE AND RORSCHACH COMPOSITE MEASURES FOR EXPLORING PSYCHOPATHOLOGICAL PATTERNS OF MENTAL FUNCTIONING

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1 Psychoanalytic Psychology 2012 American Psychological Association 2012, Vol. 29, No. 2, /12/$12.00 DOI: /a INTEGRATING THE SHEDLER-WESTEN ASSESSMENT PROCEDURE AND RORSCHACH COMPOSITE MEASURES FOR EXPLORING PSYCHOPATHOLOGICAL PATTERNS OF MENTAL FUNCTIONING Piero Porcelli, PhD IRCCS De Bellis Hospital, Castellana Grotte, Italy Vittorio Lingiardi, MD and Francesco Gazzillo, PhD Sapienza University of Rome Liat Appel, MA Bar-Ilan University Shira Tibon, PhD Academic College of Tel-Aviv Yaffo and Bar-Ilan University This study addressed the exploration of a multimethod psychodynamic assessment and its relation to psychopathological patterns. The study applies the Shedler-Westen Assessment Procedure (SWAP; Shedler, J., & Westen, D., 2006, Personality diagnosis with Shedler-Westen Assessment Procedure (SWAP): Bridging the gulf between science and practice. In P. D. M. Task Force (Ed.), Psychodynamic Diagnostic Manual (pp ). Silver Spring, MD: Alliance of Psychoanalytic Organizations.) and three composite Rorschach measures to a sample of 72 outpatients with various Diagnostic and Statistical Manual of Mental Disorders Axis I diagnoses (American Psychiatric Association, 2000, Diagnostic and Statistical Manual of Mental Disorders (DSM IV TR). Washington, DC: Author.): The Ego Impairment Index (EII-2; Viglione, D. J., Perry, W., & Meyer, G. J., 2003, Refinements in the Rorschach Ego Piero Porcelli, PhD, Psychosomatic Unit, IRCCS De Bellis Hospital, Castellana Grotte, Italy; Liat Appel, MA, Department of Psychology, Bar-Ilan University, Ramat Gan, Israel; Vittorio Lingiardi, MD and Francesco Gazzillo, PhD, Department of Psychology, Sapienza University of Rome, Italy; Shira Tibon, PhD, School of Behavioral Sciences, Academic College of Tel-Aviv Yaffo, Jaffa, Israel, and Department of Psychology, Bar-Ilan University, Ramat Gan, Israel. Preliminary results were reported at the Annual Meeting of the Society for Personality Assessment, San Jose, CA, March 24 28, We thank Roni Tibon and Roni Suchowski for programming the Rorschach Reality-Fantasy Scale (RFS) that processed the data in this study. The software can be downloaded from Correspondence concerning this article should be addressed to Piero Porcelli, Unità di Psicologia Clinica, IRCCS Ospedale De Bellis, Via Turi, I Castellana Grotte, Bari, Italy. porcellip@media.it 166

2 SWAP AND RORSCHACH MEASURES 167 Impairment Index incorporating the Human Representational Variable. Journal of Personality Assessment, 81, doi: /s jpa8102_06), measuring maladaptive ego functions; and two derivations of the Reality- Fantasy Scale (RFS; Tibon, S., Handelzalts, J. E., & Weinberger, Y., Using the Rorschach for exploring the concept of transitional space within the political context of the Middle East. International Journal of Applied Psychoanalytic Studies, 2, doi: /aps.30): the RFS-P, measuring proneness to fantasy (lowered negative scores) as compared to concrete thinking (elevated positive scores); and the RFS-S, measuring dissociative proneness. Consistent with the literature, in this study, the multimethod assessment revealed modest unilinear associations, if any, between each of the Rorschach indices and the SWAP scales. However, regression analyses showed that the joint use of the EII-2 and the RFS-P explained a substantial portion of the variance in the SWAP scales that indicate inhibition and avoidance (obsessive personality disorder score and Avoidant Q factor, respectively). Furthermore, when used with the RFS-S, the EII-2 was able to significantly explain variance in the SWAP scales that indicate interpersonal detachment (schizotypal personality disorder score and Schizoid Q factor). The implications of these results for clinical practice will be discussed. Keywords: SWAP, Rorschach Comprehensive System, personality disorders, mentalization, schizoid, dissociation Contemporary psychoanalytic theorists suggest that symptom patterns as described by the Diagnostic and Statistical Manual (DSM; American Psychiatric Association [APA], 2000) are not simply disorders but rather overt manifestations of the style in which patients characteristically cope with experience. The study of many enduring psychopathological patterns of mental functioning, and their resultant personality disorders, reveals enduring patterns of thinking, feeling, and behaving within relationships (Gabbard, 2005). This idea hints at the general perspective of functionally defined personality structure as a context for understanding psychopathological manifestations (Westen, Gabbard, & Blagov, 2006). In turn, this context constitutes the basic foundation of the Psychodynamic Diagnostic Manual (PDM Task Force, 2006). The PDM is aimed at providing a complementary diagnostic framework to the atheoretical DSM, by characterizing the full range of the person s mental functioning and thus enabling a shift from description of symptoms to inferential exploration of the dynamic processes that underline psychopathological manifestations. Accordingly, assessment data in the PDM are not designed to quantify DSM symptoms per se, but instead tap into the patterns of various traits and psychological processes (Bornstein, 2011). The goal of the current study is to demonstrate the utility of multimethod personality assessment for exploring this conceptual framework. Specifically, the study is aimed at exploring whether the use of the SWAP (Shedler & Westen, 2006) jointly with empirically supported psychodynamic-based indices derived from the Rorschach Comprehensive System ([CS]; Exner, 2003) can enhance our understanding of the multiple psychological processes that underlie psychopathological mental functioning. The Shedler-Westen Assessment Procedure (SWAP) is one of the major assessment tools recommended by the PDM. It is an observation-

3 168 PORCELLI, APPEL, LINGIARDI, GAZZILLO, AND TIBON based complex assessment instrument, which provides a fine-tuned, comprehensive evaluation of several personality dimensions that are relevant for diagnosis and treatment planning in clinical practice. Similarly, yet from another perspective, the Rorschach task provides us with substantial clues to how people tend to cope with experience and what we can learn from this about their personality dispositions and mental functioning. Indeed, the Rorschach CS is widely used in both public and private settings. Thus, adding well-validated composite indices that are based on the test provides clinicians with the opportunity to assess substantial dynamic processes without extending the number of tools already implemented in the majority of practice settings. In the practice setting, moreover, the evaluation of enduring psychopathological patterns, as defined by DSM Axis II disorders, has direct influence on treatment planning and outcome. Thus, for example, it has been shown that patients who meet a DSM comorbid diagnosis that fits both Axis I and Axis II disorders have poorer responses to therapy as compared to those with the same Axis I diagnosis but without any Axis II personality disorder (Candrian, Farabaugh, Pizzagalli, Baer, & Fava, 2007; Fan & Hassell, 2008; Gómez-Beneyto, Salazar-Fraile, Martí-Sanjuan, & Gonzalez-Luján, 2006). In line with this approach, psychoanalytic psychologists agree that it would be very useful for clinicians and researchers to explore different sources of information about a person s style of coping with both external and internal stimuli. This exploration can suggest additional hypotheses, conjectures, and observations that might be complementary to those gained from the sources of data upon which empirically oriented clinicians usually rely. The characteristics of personality structure that define patients proneness to fit into a diagnosis of a specific personality disorder can be assessed by several methods, including behavioral observations, inferences based on the patient s own accounts of his or her life and relationships, the observer s emotional reactions to interaction with the patient, structured or unstructured interviews, historical records or significant persons who know the patient well, and the administration of a battery of standardized personality assessment instruments that consists of self-report, clinician-report and performancebased measures. Of these, self-report inventories are the more familiar and widely used instruments. It is, however, interesting to note that practice clinicians seem to rely more on asking direct questions or using self-report scales when they make inferences about Axis I diagnoses, but rely primarily on behavioral observations and subtext they draw from patients narrative descriptions when they make inferences about Axis II diagnoses (Westen, 1997). Furthermore, most problems arising from using the DSM criteria for diagnosing personality disorders are related to the different conceptual status of diagnosis and assessment. Both terms are usually used interchangeably, even though they have different meanings: diagnosis aims to classify a patient s symptoms and behaviors into categories (i.e., understanding the psychopathological manifestations), whereas assessment aims to evaluate the complex array of dispositional and situational factors that combine to form the patient s unique subjective experience, beliefs, emotional patterns, motives, traits, defenses, and coping strategies (Huprich & Bornstein, 2007). One of the problems in evaluating personality characteristics in clinical settings is the difficulty of translating clinical judgments and inferences generated by information gathered from multiple sources into a meaningful framework (Bornstein, 2010; Westen & Weinberger, 2004). Thus, psychometric scales with the same labels, aiming to measure the same construct, may not entirely meet the assumption of commensurability (Pace &

4 SWAP AND RORSCHACH MEASURES 169 Brannick, 2010). Furthermore, clinicians may be observing the same clinical manifestations while using different languages and labels to describe those manifestations, or the clinicians may be attending to different aspects of the clinical material. The three composite CS-based measures used in this study (the Ego Impairment Indices [EII-2], the protocol-based mean Reality-Fantasy Scale [RFS-P] and the RFS scatter [RFS-S]) are based on psychodynamic theory. Nonetheless, unlike the SWAP, which is extensively discussed and used in the PDM, the Rorschach CS and its derivations are not. This however is consistent with the relatively few psychoanalytic-oriented studies with the Rorschach CS, currently the most commonly used Rorschach method in the clinical practice. This study can therefore spotlight the Rorschach CS as an evidencesupported psychodynamic assessment, as the Rorschach has shown excellent psychometric properties across clinical and nonclinical samples around the world (Meyer et al., 2002; Meyer, Erdberg, & Shaffer, 2007; Musewicz, Marczyk, Knauss, & York, 2009; Viglione & Meyer, 2008; Viglione & Taylor, 2003; Weiner & Greene, 2008). The SWAP The SWAP (Shedler & Westen, 2006) is a broadband assessment instrument designed to provide clinicians with a standard vocabulary for case description that provides a common language for the same spectrum of clinical phenomena and is based on clinical interviews. Its vocabulary consists of 200 statements that are either close to the observed data (e.g., Tends to get into power struggles, or Is capable of sustaining meaningful relationships characterized by genuine intimacy and caring ) or that require minimal inference about internal processes (e.g., Tends to see own unacceptable feelings or impulses in other people instead of in him/herself ). Because the SWAP is jargon-free and clinically comprehensive, it has the potential to be used as a language for describing personality characteristics and mental functioning by skilled clinicians of all theoretical perspectives (Shedler & Westen, 2006, 2007). Its theoretical nature and empirical foundations have made the SWAP one of the most reliable methods for assessing mental functioning with the PDM. The SWAP yields scores for 11 prototypical descriptions of personality disorders based on the DSM (PD scores) and 11 personality dimensions based on clinical descriptions of personality characteristics through Q-factor analysis (Q factors). The EII-2 From the theoretical perspective of ego psychology, the EII-2 has been developed as a measure of psychological impairment and thought disorder. It is intended to provide data regarding deficits in ego functions (reality testing, reasoning processes, and the quality of object relations). In fact, the Rorschach offers an optimal opportunity to measure impairment because it induces the respondent to use available cognitive, affective, and human or representational resources to organize a response to an ambiguous and complex task. The subject is provided with little, if any, guidance and structure for organizing and making choices among contradictory and interconnected response alternatives. Thus, the task minimizes extraneous influences on the test responses so that the subject s problemsolving style and idiosyncrasies, including thinking disturbances, influence test responses greatly (Kleiger, 1999). According to this conceptualization, the EII-2 incorporated Rorschach CS variables that were theoretically selected to correspond with different ego

5 170 PORCELLI, APPEL, LINGIARDI, GAZZILLO, AND TIBON functions (poor reality testing assessed with poor form quality [FQ-], thought disturbances with cognitive special scores [WSum6], inhibition of needs and urges with Critical Contents [An, Bl, Ex, Fi, Fd, Sx, Xy, AG, and MOR], distorted object and self representations with the quality of responses of human movement [M-], and perceptions of others [PHR, GHR]). These variables were empirically derived from factor analysis of a Rorschach database of patients with depression (Haller & Exner, 1985). The EII-2 showed replicable factorial validity, excellent reliability, temporal stability, and predictive validity of long-term treatment outcomes (Perry, McDougall, & Viglione, 1995; Perry & Viglione, 1991; Stokes et al., 2003). The RFS The RFS (Tibon, Handelzalts, & Weinberger, 2005) is based on Smith s (1990) idea to apply Winnicott s (1971) construct of potential space, and Ogden s (1985) model of psychopathological manifestations as forms of collapse of the transitional space between reality and fantasy, to Rorschach work. Accordingly, the assessment of what constitutes a normal or a healthy personality is defined in terms of the dialectical resolution on the reality fantasy continuum. In line with this conceptualization, the Rorschach task of responding to the 10 inkblots might be conceived as inviting the person to enter the transitional space between reality and fantasy. The ambiguity of the blot and the nature of instructions (What might this be?) create a situation in which respondents are expected to both find and make something out of the blot, keeping an enriching tension between the given blot and their fantasy. Schafer (2002) states that from the point of view of thought organization, the fluctuating psychic levels in the Rorschach response process and the changes from the perceptual to the interpretive attitude or vice versa appear to involve shifts between reality and fantasy. Rorschach percepts, like transitional objects, are simultaneously created (in the sense that the blot is given its meaning by the inner world of the subject) and found (in the sense that the final response has to be within the limits of the existing blot features) and might therefore be assumed to reveal the patient s ability to preserve potential space. When reality collapses into fantasy, the clinician might observe the mental phenomena usually manifested in psychosis. In Rorschach terms, the blot is experienced as if it were real. The percepts may become terrifying or enjoyable in themselves, and respondents may feel as if they were part of the response. On the flip side, when fantasy collapses into reality, the capacity to imagine and to symbolize is impaired (e.g., Bucci, 1997), as seen in normotic patients, that is, subjects showing marked conventionality, conformism, and overadaptation to the social environment (Bollas, 1989). In Rorschach terms, subjects may feel difficulty in giving responses. They may begin some of their responses by insisting that it is just an ink blot. Some of these subjects are keen observers and will note what details are missing to make it look like a real bat. Given that the Rorschach cards bear relatively concrete resemblance to the real objects, with which they are assumed to fit, these subjects do not adapt themselves to the basic task of the test to misperceive the stimulus. They cannot pass the threshold where perception as recognition becomes perception as interpretation (Leichtman, 1996). When reality and fantasy are experienced as parallel and equal conditions without the ability to create and preserve potential space, dissociative states may occur. In line with this conceptualization, the RFS refers to each Rorschach response as being located on a continuum of fabulization between the two

6 SWAP AND RORSCHACH MEASURES 171 extreme poles of reality and fantasy. The RFS yields two scores. The first is related to the mean RFS score of a protocol (RFS-P) and is interpreted bidirectionally as a psychoticlike collapse of external reality into the inner fantasy world (negative score) or a normotic-like collapse of fantasy into reality-bound, factual representations (positive score). The other score is related to the standard deviation RFS score of a protocol (RFS-S) and is interpreted as a dissociation or lack of integration of external reality and inner world (higher score). Previous research shows that RFS-P scores, which approximate zero in normative healthy samples, were significantly lower in patients with psychotic symptoms and significantly higher in medical patients with psychosomatic symptoms (Tibon, 2005; Tibon, Porcelli, & Weinberger, 2005). In addition, RFS-S scores significantly distinguished between patients with restricting anorexia and patients engaged in binge eating, with the latter group showing an elevated score within the dissociative spectrum, confirming the hypothesized dissociative component in binge eating behaviors (Tibon & Rothschild, 2009). Furthermore, as compared to nonpatients, a significant elevation of the RFS-S has been observed in patients with dissociative identity disorder (Zeligman, 2010). Aim of the Study Both the EII-2 and the RFS provide clinical psychologists with a unique opportunity to assess dimensions of personality structure that might have a substantial effect on psychopathological mental functioning. In contrast to other psychodynamic-oriented Rorschach scales that have shown a long tradition of translating personality constructs into operational clinical terms (Bornstein & Masling, 2005), such as Holt s (1978) measure of primary process thinking, or the Lerner Defense Scale (Lerner, 1998), the EII-2 and the RFS are based on the well-validated Rorschach CS, which also provides international normative data (Meyer et al., 2007). Furthermore, the EII-2 and the RFS dimensions and some related psychopathological patterns are also evaluated by some of the SWAP scales, though under different labels and using different sources of data. From a multimethod perspective, however, we can thus hypothesize that integrating the EII-2 and the RFS with the SWAP may widen our understanding of multiple personality functions and dynamic processes that underline psychopathological manifestations. In particular, we expected that because of the low effect sizes generally found between hetero-method assessments (Bornstein, 2010; Ganellen, 2007; Meyer, 1997), the three Rorschach indices (EII-2; RFS-P; RFS-S) taken separately would show low-to-moderate association with the SWAP scores. It would be possible, however, that when the EII-2 is used jointly with one of the RFS derivations, the predicted associations with the SWAP scores would improve. Specifically, based on a large body of psychoanalytic literature (e.g., Huprich, 2009; Person, Cooper, & Gabbard, 2005), it was hypothesized that impairment in ego functions (elevated EII-2) together with the incapacity to process affect-laden representations because of concrete, externally bound thinking style (elevated RFS-P) would be associated with some of the SWAP scales assessing psychopathological patterns of functioning (mainly Cluster C like patterns), whereas elevated EII-2 together with proneness to dissociate external-bound from fantasy-derived representations (elevated RFS-S) would be associated with some other SWAP scales (mainly schizoid and schizotypal patterns).

7 172 PORCELLI, APPEL, LINGIARDI, GAZZILLO, AND TIBON Method Participants Subjects were adult outpatients who were referred to the clinical psychology service of a research-based hospital (IRCCS De Bellis, Castellana Grotte, Italy) from January to December Patients were referred for consultation for a variety of psychological or functional somatic problems and/or psychopathology from a variety of referral sources (general practitioners, medical specialists, psychiatrists, self-referrals) within the local area. In order to keep clinical validity, no stringent exclusion criteria were adopted. Patients were excluded only if they were aged 18 or 64 years, had cognitive impairment in addition to psychotic disorders, refused to cooperate, or did not provide enough information for personality assessment. All patients agreed to participate and gave their informed consent. The study protocol was approved by the local Ethics Committee. Description of the Sample A total of 72 outpatients entered the study: 42 (58.3%) women and 30 (41.7%) men. The subjects mean age was years (SD 9.22 years), and the mean of their number of years of education was (SD 2.99 years). Psychiatric diagnosis was assigned according to the Italian version of the Structured Interview for DSM IV Disorders (SCID; First, Spitzer, Gibbon, & Williams, 2000) that were administered early in the recruitment process. The most common psychiatric diagnoses were somatoform disorders (N 24, 33.3%), anxiety disorders (N 22, 30.6%), mood disorders (N 20, 27.8%), and adjustment disorders (N 6; 8.3%). Twenty-one patients (29.2%) had comorbid Axis II personality disorders, the most frequent of which were borderline (N 7, 9.7%) and narcissistic (N 4, 5.6%) personality disorders. Measures The SWAP is a Q-sort set of 200 personality-descriptive statements yielding a range of meaningful information about cognitive, emotional, motivational, and relational functioning (Shedler & Westen, 2006; Westen & Shedler, 1999a; 1999b). Based on clinical interviews, the rater is required to describe the patient by ranking the 200 items into eight scores, from the least descriptive (score 0) to the most descriptive (score 7). To maximize reliability and minimize error variance, the Q-sort method requires clinicians to arrange the items into a fixed distribution that approximates the right half of a normal distribution. The SWAP distribution is therefore asymmetric, with many items receiving scores of 0 (not descriptive) and progressively fewer items receiving higher scores. Following the transformation into standardized T scores, 22 scales are obtained: 11 scales of personality disorders consistent with the description on DSM personality disorders according to a panel of experts or prototypes (PD scores) and 11 scales for personality factors empirically derived from descriptions of patients according to their therapists through Q-factor analysis (Q factors). The psychometric properties of reliability and validity of the SWAP have been repeatedly demonstrated in several studies (Diener & Hilsenroth, 2004; Shedler & Westen, 2007). The Italian-language version of the SWAP was used in the present investigation (Westen, Shedler, & Lingiardi, 2003). The EII-2 is a composite index that incorporates five Rorschach CS subcomponent variables entered with different weights (or factor score coefficients) into an equation: distorted form quality of perceived objects (FQ-), indicating poor reality testing; the

8 SWAP AND RORSCHACH MEASURES 173 weighted sum of cognitive Special Scores (WSum6), indicating thought disturbances; Critical Contents (anatomy, blood, explosions, fire, food, sex, X-ray contents, and aggressive and morbid responses) pointing to images associated with needs and urges that are typically inhibited, minimized, or indirectly expressed in adaptive thinking; human movement responses with poor form quality (M-), indicating strange conceptions regarding human experience; and the ratio between accurate, benevolent, intact, and realistic human representations and those that are distorted, malevolent, damaged, and confused (GHR:PHR). The shared association between these five variables is thought to correspond to the estimation of the degree of psychological disturbance (Viglione, Perry, & Meyer, 2003). The EII-2 was developed for measuring deficits in ego functioning through the assessment of reality testing, thought disturbances, inhibition of needs and urges, distorted object and self representations. Unlike the traditional Rorschach CS constellation indices, which similarly point to impaired adaptation (Weiner, 2003; Weiner & Greene, 2008) but are primarily atheoretical, the EII-2 aims at integrating Rorschach CS variables with psychoanalytically oriented thinking and therefore fits into the PDM approach. High scores on the EII-2 are thought to indicate individuals with poor psychological resources and low ability to adjust psychologically. The EII-2 provided unique variance beyond variables of the Minnesota Multiphasic Personality Index (MMPI) in the prediction of psychological impairment as measured by the severity of psychiatric diagnosis (Dawes, 1999). It showed significant correlations with measures of psychotic processing in impaired groups of schizophrenic patients (Perry & Braff, 1994; Perry, Viglione, & Braff, 1992) and also with neurophysiological information processing measures in a small sample of patients with schizotypal personality disorder (Cadenhead, Perry, & Braff, 1996). Furthermore, the EII-2 successfully differentiated between small groups of schizophrenic patients, showing that undifferentiated and disorganized subtypes of nonparanoid schizophrenic patients had higher EII-2 scores (i.e., were more impaired) than organized paranoids (Perry et al., 1992). Additionally, the EII-2 significantly predicted treatment outcomes in patients with major depression (Perry & Viglione, 1991). In a child psychiatric population, the EII-2 was associated with severity of symptoms at baseline, and even though it was not associated with short-term response to an inpatient treatment program, it was a better predictor of long-term outcome than initial symptoms, clinician-rated global assessment of functioning, or immediate response to treatment. This result is thought to be due to the fact that the EII-2 relates to traits of psychological vulnerability to the presence of long-term problems (Stokes et al., 2003). The RFS is a composite Rorschach index (Tibon et al., 2005) that includes a combination of variables that are composed of a set of scores derived from the Rorschach CS, plus a new special score, Reality Collapse (RC), that is assigned to responses where the subject reacts to the blot as if it were a thing in itself and is completely losing distance from the blot (e.g., I can smell it, a party, I can even hear the music ). Each response is scored according to specific steps on an 11-point scale ranging from 5(extreme reliance on fantasy) to 5 (extreme reliance on reality). A score of 5 represents the most extreme case of reliance on fantasy with minimum contact with external reality (e.g., responses with Level 2 Cognitive Special Scores: two potatoes with eyes and mouth trying to climb up some kind of pipe or pole ), whereas a score of 5 represents a strong reliance on the real features of the blot with minimal input of fantasy (form-based responses without inclusion of either movement, color, or shading and/or attributing abstract meaning, e.g., a cloud because of its shape ). All the RFS scores are summed and divided by the number of responses, revealing the protocol-based mean RFS (RFS-P).

9 174 PORCELLI, APPEL, LINGIARDI, GAZZILLO, AND TIBON Because the RFS-P is bipolar, ranging from 5 to 5, the use of the mean score only, may cloud the real results, particularly in dissociative cases where reality and fantasy are experienced as parallel without the ability to create and preserve potential space. RFS scores at both extremes might thus be expected to cause a mean RFS score approximating zero, which would be interpreted as a balanced use of reality and fantasy features in creating the response. To avoid this misinterpretation, another derivation, defined as the RFS scatter (RFS-S), is calculated by computing the RFS standard deviation of the responses in the protocol. This score helps detect patients who are dissociating. Although less investigated than the EII-2, the RFS has shown very promising results. Lowered scores in the negative range of the RFS-P (indicating reality collapsing into fantasy) were shown in psychotic patients and elevated scores in the positive range (indicating fantasy collapsing into reality) in patients with a chronic medical disease and alexithymia than control nonpatients. Also, significant higher scores on the RFS-S (indicating failure to integrate the processing of inputs from the external reality with the processing of aspects of inner fantasy) have been observed in patients with dissociative identity disorder and eating disorders compared to healthy control subjects (Tibon, 2005; Tibon & Rothschild, 2009; Tibon, Weinberger, Handelzalts, & Porcelli, 2005; Zeligman, 2010). Procedure Patients were included if there was a sufficient number of clinical interviews for completing the SWAP. The Rorschach test was administered according to the CS standards (Exner, 2003), usually after the first preliminary interview (usually on the second or third session), but was not scored until after the whole assessment process, which typically lasted five to six sessions. The SWAP was compiled based on clinical interviews and applied blindly to the results of the Rorschach test, following at least three sessions of clinical interviews. All 72 outpatients gave valid Rorschach protocols according to the CS standards (Exner, 2003), with 14 or more responses per protocol. A pool of 25 protocols was randomly selected to evaluate interrater agreement as to the coding of responses according to the CS, in which the coders had extensive experience. The scoring of each of the 25 protocols was done independently by two coders. The overall level of agreement between coders was excellent, as shown by the mean intraclass correlation coefficient (ICC) of.96 (SD.11). In particular, the variables used in the RFS yielded ICC values ranging from.78 for Special Scores of Contamination (CONTAM) and Inappropriate Logic (ALOG), to 1.00 for pure form (F) and popular (P) responses, while those used in the EII-2 yielded ICC values ranging from.88 for Critical Contents, to.98 for GHR and PHR. Statistical Analyses Two major factors may affect data obtained with the Rorschach test and need to be controlled for response style and interrater agreement (Exner, 1995). First, Rorschach indices may vary because of a number of factors beyond interindividual differences of personality organizations. The two variables that index the overall richness or complexity of a protocol are the number of responses (R), and the Lambda (L) index, which indicates the proportion of responses prompted by relatively simple form features rather than other, more subtle or complex, qualities of the inkblots. The R and L variables are excellent markers of the primary source of variance in Rorschach scores, as revealed in the first dimension of factor analysis (Meyer, Riethmiller, Brooks, Benoit, & Handler, 2000;

10 SWAP AND RORSCHACH MEASURES 175 Meyer & Viglione, 2008). We compared R and L scores obtained by our patients with normative data to evaluate whether these two variables had to be included as confounders in the statistical analyses. Although the CS codes meet the criterion of at least 80% interrater agreement, allowing them to be included in the scoring model (Exner, 2003), variables included in any particular study need to be reliably coded by the actual researchers. We used the ICCS to assess the reliability of codes between expert examiners. ICC values greater than.60 are considered good, and those greater than.74 are considered excellent. Apart from controlling for possible sources of problems at the Rorschach protocol level, we examined whether sociodemographic variables (gender, age, and education) might moderate the relationship between the Rorschach indices and the SWAP scales and therefore are variables for which we need to control. Similarly, we examined whether psychiatric disorders in terms of the presence of Axis I or Axis II DSM syndromes might constitute moderating variables for which we should control. The unilinear association of the EII-2, the RFS derivations, and the SWAP scores was evaluated with Pearson s product-moment correlation. Two sets of multiple regression analyses were then applied. In the first set, we analyzed to which extent each of the three Rorschach indices (criteria) were independently predicted by the SWAP PD and Q-factor scores. In the second set of multiple regression analyses, the order of dependent and independent variables was reversed, and the SWAP factor scores served as criteria, with the three Rorschach indices as predicting variables. The second set of regression analyses was intended to evaluate whether the joint use of Rorschach indices might explain more variance of the SWAP scores than the use of any single Rorschach index alone. All the regression models were controlled for sociodemographic and psychiatric variables. Finally, a moderating model formed by partial correlation values (i.e., correlations resulting after controlling both the outcome and the predictor variables for control variables) was planned to illustrate graphically the significant associations among the Rorschach indices and the SWAP scales. Results Description of the Rorschach Indices Results of a t test comparing the sample as to the number of responses (R) per protocol (M 23.47; SD 8.37 responses) to the international normative combined sample (Meyer et al., 2007), with mean R of and SD of 5.68, did not show any significant difference (t 1.63; p.05). Also, the results of the t tests that compared these two samples as to the Lambda (L) did not show any significant difference (M 1.07; SD 0.91; M.86; SD.95), with t 1.86 and p.06. However, within our sample, 36% of the patients showed an avoidant, oversimplified coping style (L 1.00), resulting in a higher proportion of pure form responses (i.e., responses prompted by processing only the formal outline of the blot). This frequency is nonetheless consistent with the percentages of nonpatients showing L 1.00 (28%) in the international normative combined sample of Meyer et al. (2007) ( ; p.13). Although nonsignificant, the mean RFS-P of.19 (SD.75) in our sample was found to be higher than the mean of.07 (SD.58) found in nonpatients (t 1.11; p.27), pointing to a tendency toward reality-bound responses within the normotic spectrum. Nonetheless, the mean RFS-S score of 2.58 (SD.32) was significantly higher (t 4.15; p.001) than the expected values for nonpatients (M 2.37; SD.33), with Cohen s

11 176 PORCELLI, APPEL, LINGIARDI, GAZZILLO, AND TIBON (1988) associated effect size d of.65, which points to a tendency toward dissociation. The mean EII-2 score of.53 (SD 1.13) was in the expected range of values for outpatients (typically ranging from 0 to.60). However, 32% of the participants showed moderate to severe ego impairment (EII-2.80). Search for Possible Moderators: Sociodemographic Factors The relationships of age, gender, and education with the SWAP and the Rorschach measures were examined in order to control for possible moderating variables in the regression analyses. Age did not correlate significantly with any of the SWAP scales or the Rorschach indices. Table 1 shows the gender comparison of SWAP and Rorschach scores. The Rorschach scores were not significantly different in men and women. However, men had significantly higher scores on some of the SWAP measures, suggesting that men had more severe schizoid and avoidant conditions. Apart from the SWAP Paranoid Q factor and the Narcissistic PD scale that correlated significantly with level of education, with r.33; p.01; d.70 and r.25; p.05; d.52, respectively, no correlation Table 1 Comparison of SWAP Mean (SD) Scores Between Male and Female Patients Male patients (n 30) Female patients (n 42) t (df 70) p d (95% CI) SWAP PD scores Paranoid (8.10) (8.20) ( 2.66, 2.72) Schizoid (10.76) (8.28) ( 3.11, 3.23) Schizotypal (11.29) (7.69) ( 3.09, 3.28) Antisocial (7.41) (7.38) ( 2.63, 2.26) Borderline (8.32) (10.42) ( 2.64, 3.48) Hystrionic (9.14) (10.25) ( 2.94, 3.40) Narcissistic (9.40) (8.75) ( 3.20, 2.79) Avoidant (7.62) (10.19) ( 2.27, 3.53) Dependent (9.22) (8.97) ( 3.09, 2.89) Obsessive (8.68) (8.10) ( 2.78, 2.78) SWAP Q factors Dysphoric (8.24) (8.11) ( 2.86, 2.52) Antisocial (7.17) (7.23) ( 2.40, 2.36) Schizoid (11.07) (7.89) ( 3.05, 3.10) Paranoid (6.71) (7.07) ( 2.19, 2.36) Obsessive (10.19) (10.56) ( 3.32, 3.54) Hystrionic (10.01) (9.71) ( 3.12, 3.39) Narcissistic (10.28) (9.50) ( 3.69, 2.87) Avoidant (8.35) (7.43) ( 2.33, 2.88) Depressive high functioning (9.86) (10.27) ( 3.08, 3.58) Emotional dysregulation (8.14) (9.61) ( 2.90, 2.90) Dependent (9.57) (10.06) ( 3.09, 3.40) Hostile (8.29) (8.09) ( 3.12, 2.77) High functioning (10.42) (10.98) ( 3.43, 3.59) Rorschach RFS-P.18 (.89).19 (.64) (.31,.20) RFS-S 2.65 (.33) 2.53 (.30) (.28,.49) EII-2.79 (1.27).64 (.99) (.07,.70) Note. SWAP Shedler-Westen Assessment Procedure; PD personality disorder; RFS-P Reality-Fantasy Scale, protocol-based mean RFS; RFS-S Reality-Fantasy Scale scatter; EII-2 Ego Impairment Index.

12 SWAP AND RORSCHACH MEASURES 177 between level of education and the SWAP measures or Rorschach constellations was significant. Because of the significant results as to the association between SWAP and the two sociodemographic factors of level of education and gender, these two background characteristics were considered a potential moderating variable to control for in regression analyses. Search for Possible Moderators: Rorschach Variables R and L The subgroup of patients with avoidant style (L 1.00) did not score significantly different on the SWAP scales as compared to those with L 1.00, except for the SWAP Q factor of Emotional Dysregulation with high L patients (M 50.45; SD 9.28) scoring higher than low L patients (M 45.12; SD 8.28), with t 2.51; p.01; d.62 and 95% confidence interval (CI) between 2.96 and Furthermore, as a continuous variable, L weakly correlated only with Q-Schizoid (r.22; p.05; d.45; with 95% CI of 2.77, 3.81). Finally, the number of responses to the Rorschach did not correlate with any SWAP scales. To sum up, neither R nor L was found as a potential moderating variable to control for in regression analyses. Search for Possible Moderators: Psychopathology The relationships of DSM Axis I and II disorders with the SWAP and Rorschach measures were examined in order to explore the potential effects of different psychopathological manifestations as possible moderating variables that should be controlled for in the regression analyses. ANOVA showed that the SWAP and Rorschach measures were not significantly different across the different Axis I disorders. Accordingly, Axis I disorders were not taken into consideration in further analyses. Table 2 presents comparison of the SWAP and Rorschach measures between patients with and without personality disorders. Analyses of the t tests presented in Table 2 demonstrate that patients with personality disorders showed consistently less psychological health than those without personality disorders, on several SWAP scales. Specifically, patients diagnosed with personality disorders showed higher scores on Paranoid, Schizotypal, Antisocial, Narcissistic, Dysphoric, Obsessive, High Functioning Depressive SWAP PD, and/or Q dimensions and lower scores on High Functioning Q score. The Rorschach constellations, however, were not significantly different between patients with and without Axis II personality disorders. Because of the significant results with the SWAP scales, Axis II morbidity was considered a potential moderating variable to control for in regression analyses. Association Between SWAP and Rorschach Indices: Unilinear Regression Analyses Simple regressions showed that the EII-2 and the RFS derivations were significantly correlated. EII-2 was associated negatively with RFS-P (r.66; p.001) and positively with RFS-S (r.30; p.01), showing that individuals with healthier ego functioning are more reality-bound and have also higher ability to integrate external and internal representations. The EII-2, however, did not correlate significantly with any SWAP scales. RFS-P significantly correlated with PD-Schizoid (r.25; p.03) and PD-Obsessive (r.32; p.01), suggesting that individuals who tend to stick to reality might be socially and emotionally inhibited. RFS-S significantly correlated with PD- Schizoid (r.23; p.05), PD-Schizotypal (r.28; p.05), and Q-Schizoid (r.26; p.05), suggesting that individuals with difficulties in integrating external and inner experiences have basic relatedness problems, resulting in poor mentalization and inter-

13 178 PORCELLI, APPEL, LINGIARDI, GAZZILLO, AND TIBON Table 2 Comparison of SWAP, RFS, and EII-2 Mean (SD) Scores Between Patients With and Without Personality Disorders Without personality disorders (n 51) With personality disorders (n 21) t (df 70) p d (95% CI) SWAP PD scores Paranoid (7.52) (8.78) (2.68, 3.14) Schizoid (9.07) (11.48) ( 2.90, 4.52) Schizotypal (9.05) (10.43) ( 2.78, 4.14) Antisocial (6.26) (8.66) ( 2.15, 3.30) Borderline (8.89) (11.27) ( 4.11, 3.17) Hystrionic (8.78) (11.62) ( 3.53, 3.84) Narcissistic (7.46) (10.95) ( 3.69, 3.03) Avoidant (7.82) (12.22) ( 1.25, 6.11) Dependent (9.15) (8.30) ( 1.44, 4.61) Obsessive (7.86) (9.28) ( 1.20, 4.95) SWAP Q factors Dysphoric (6.78) (8.13) ( 3.58, 1.75) Antisocial (6.28) (8.29) ( 3.23, 2.05) Schizoid (9.05) (11.32) ( 3.95, 3.35) Paranoid (6.92) (6.83) ( 2.61, 2.19) Obsessive (9.96) (9.68) ( 4.57, 2.32) Hystrionic (9.48) (11.50) ( 2.54, 4.99) Narcissistic (8.74) (10.97) ( 3.85, 3.25) Avoidant (7.66) (9.37) ( 1.92, 4.21) Depressive high functioning (9.00) (9.73) (.03, 6.65) Emotional dysregulation (9.25) (8.17) ( 3.18, 2.85) Dependent (9.66) (10.82) ( 2.48, 4.80) Hostile (8.53) (7.59) ( 2.44, 3.14) High functioning (9.98) (9.41) (.47, 6.30) Rorschach RFS-P.23 (.81).16 (.59) (.01, 46) RFS-S 2.55 (.32) 2.64 (.30) (.73, 51) EII-2.60 (1.02).83 (1.33) (.74, 10) Note. SWAP Shedler-Westen Assessment Procedure; RFS-P Reality-Fantasy Scale, protocol-based mean RFS; RFS-S Reality-Fantasy Scale scatter; EII-2 Ego Impairment Index. personal detachment, which might provide a schizoid-like clinical picture. Overall, the results showed that, taken individually, every single Rorschach index has modest, if any, associations with any given single SWAP scale that fell within the range of.23 to.32, as is expected between hetero-method measures of personality assessment. Association Between SWAP Scales and Rorschach Indices: Multiple Regression Analyses The main hypothesis of the current study was that impairment in ego functions (elevated EII-2) together with the incapacity to process affective-laden representations because of concrete, externally bound thinking style (elevated RFS-P) would be associated with some of the SWAP scales assessing psychopathological patterns of functioning, whereas ele-

14 SWAP AND RORSCHACH MEASURES 179 vated EII-2 together with proneness to dissociate external-bound from fantasy-derived representations (elevated RFS-S) would be associated with some other SWAP scales. Applying multiple regression (see Table 3), in which Rorschach indices were inserted jointly into the equation, showed that, consistent with the findings being revealed from the unilinear regression analysis, the EII-2 was associated with RFS derivations but not with any of the SWAP scales. Nonetheless, the RFS-P was able to significantly and independently predict the personality dimensions of emotional and social inhibition (PD- Obsessionality and Q-Avoidance), suggesting that individuals with poor mentalization are Table 3 Predicting Each EII-2, RFS-P, and RFS-S From the Other Rorschach Indices and SWAP Scales, Controlling for Gender, Education, and Personality Disorders R 2 R 2 F F df Partial r p EII-2 Model 1-A a Model 1-B a RFS-P , RFS-S , Model 2-A b Model 2-B b RFS-P , RFS-S , RFS-P Model 3-A c PD-obsessive , Model 3-B c EII , PD-schizoid , Model 4-A d Q-avoidant , Model 4-B d EII , Q-avoidant , RFS-S Model 5-A e PD-schizotypal , Model 5-B e EII , PD-Schizotypal , Model 6-A f Q-schizoid , Model 6-B f EII , Q-schizoid , Note. In all models, gender, education, and Axis II morbidity were entered as independent variables. SWAP Shedler-Westen Assessment Procedure; RFS-P Reality-Fantasy Scale, protocol-based mean RFS; RFS-S Reality-Fantasy Scale scatter; EII-2 Ego Impairment Index. a Predicting EII-2 from PD scores solely (1-A) and jointly with the 2 RFS indices (1-B). In Model 1-A, no variable entered the final model. b Predicting EII-2 from Q factors solely (2-A) and jointly with the 2 RFS indices (2-B). In Model 1-A, no variable entered the final model. c Predicting RFS-P from PD scores solely (3-A) and jointly with the EII-2 (3-B). d Predicting RFS-P from Q factors solely (4-A) and jointly with the EII-2 (4-B) e Predicting RFS-S from PD scores solely (5-A) and jointly with the EII-2 (5-B). f Predicting RFS-S from Q factors solely (6-A) and jointly with the EII-2 (6-B).

15 180 PORCELLI, APPEL, LINGIARDI, GAZZILLO, AND TIBON emotionally and socially inhibited. Furthermore, the RFS-S showed significant association with the personality dimensions of schizoidism, namely poor mentalization and interpersonal detachment (PD-Schizotypal and Q-Schizoid), suggesting that difficulties in integrating external and internal experiences (dissociative proneness) are being revealed in schizoid-like interpersonal detachment. However, these results became much more apparent, over and above potential moderator variables (sociodemographic and DSM Axis I and Axis II comorbidity) when each of the RFS derivations was combined with the EII-2. As shown in Table 4, when used jointly with the RFS-P, the EII-2 significantly predicted SWAP PD-Obsessive and Q-Avoidance, and when used with the RFS-S, the EII-2 significantly predicted the PD-Schizotypal and the Q-Schizoid. Modeling Moderators Between the Rorschach Indices and the SWAP The overall relationships found within our sample among SWAP scales, the EII-2, and the RFS are summarized in Figure 1. Partial correlation coefficients, indicating to what extent the variables are associated with one other while both the outcome and the predictor variables are controlled for confounders, show that no SWAP scale was predicted uniquely by the EII-2. However, the EII-2 and the RFS-P were significantly associated with emotional (PD-Obsessive) and social inhibition (Q-Avoidant and PD-Schizoid) and the EII-2 and the RFS-S with poor mentalization and interpersonal detachment (Q-Schizoid and PD-Schizotypal). Discussion The assessment of personality functioning is a complex and challenging task (Widiger & Samuel, 2005). Multiple assessment instruments are usually administered, but their use is biased by the differing nature of the source data. Accordingly, behavioral observations are influenced by the particular type of relationship developed within the clinical setting; unstructured interviews are constrained by the limited range of topics that are considered and by the ambiguities inherent in the interactive process; structured interviews and self-report instruments are largely dependent on conscious self-representations, social desirability, motivation to communicate frankly, and individual defensiveness; and per- Table 4 Predicting SWAP Scales From the Rorschach Indices (EII-2, RFS-P, and RFS-S), Controlled for Gender, Education, and Personality Disorders R 2 F df p PD-obsessive RFS-P , Q-avoidant RFS-P , PD-schizotypal RFS-S , Q-schizoid RFS-S , Note. SWAP Shedler-Westen Assessment Procedure; RPS-P Reality-Fantasy Scale, protocol-based mean RFS; RFS-S Reality-Fantasy Scale scatter; EII-2 Ego Impairment Index.