Rorschach markers in offspring of manic-depressive patients

Abstract

Background: Previously published data show large differences between euthymic Israeli adult bipolar patients and US normative data on several measures of psychological functioning as assessed with a sensitive projective measure (Rorschach Inkblot Test). The current study examines the Rorschach performance of healthy offspring of bipolar parents and compares them to matched normal controls. Methods: 14 asymptomatic offspring of Israeli manic-depressive parents were matched for age, gender, and other demographic variables with 14 children of normal parents. All subjects were individually administered the Rorschach Inkblot Test, and protocols were scored blindly according to the Exner Comprehensive System. Results: Offspring of bipolar parents, like bipolar patients themselves, show significantly increased incidence and severity of thought disorder (as defined by Exner), lower numbers of cognitively mediated affective responses, and fewer responses indicating conventional perceptions. Limitations and conclusions: Although the sample size is small, this study strengthens the possibility that these measures of psychological functioning may serve as markers for manic-depressive illness.

Introduction

The classic conception of manic-depressive or bipolar (BP) illness (Kraeplin, 1921) revolves around discrete episodes of acute illness (either mania or depression) interposed on a background of periods of ‘normalcy’, in which the remitted (euthymic) patient is presumed to be essentially no different from persons who were never ill. Although some psychoanalytically oriented writers have explored the possibility that bipolar patients share a particular personality structure (Arieti, 1957, Cohen et al., 1954), subsequent research has generally failed to find consistent personality differences between these patients and normal control groups (Goodwin and Jamison, 1990). One line of investigation suggests that an underlying temperament trait of low Persistence (Cloninger et al., 1993) may characterize BP patients even when euthymic (Osher et al., 1996, Osher et al., 1999), but it may be that this conception is simplistic in that it does not address important dimensions of psychological functioning such as cognition and affect. In addition, two preliminary reports (Scharfetter et al., 1997, Mirene et al., 1998) raise questions as to the robustness of the finding of low Persistence in euthymic BPs.

The Rorschach Inkblot Test (Rorschach, 1921) is one psychological assessment instrument which measures functioning across a wide range of indices — perceptual, cognitive, affective, interpersonal, and others. The Rorschach is a very popular instrument among clinicians (Lubin et al., 1984) as well as among researchers, with over 6000 research studies published by the early 1980s (Aiken, 1996). The Rorschach was not universally well regarded among researchers, however, partly because of the clinical and intuitive approach often associated with the interpretation of this test. The utility of the instrument in quantitative research was improved by the work of Exner, whose Comprehensive System (Exner, 1974, Exner, 1995) has distilled the several older, competing methods of scoring and interpretation into one uniform, systematic, and empirically validated system. The Exner system has been utilized in Rorschach studies of diverse disorders, including PTSD (Goldfinger et al., 1998), schizophrenia (Adair and Wagner, 1992), and childhood attention deficit and hyperactivity disorder (Bartell and Solanto, 1995).

Decina et al. (1983), comparing 31 children of BP parents to 18 normal controls, noted that children of BPs had significantly higher ratios of color to movement responses. Approximately half of the experimental group, however, received a clinical diagnosis, which makes it difficult to know the extent to which this finding reflects pathology rather than underlying predisposition. These Rorschachs were scored using the Klopfer system, and other indices do not appear to have been examined. An early version of Exner was used by Mandel et al. (1984) in comparing the Rorschach performance of 35 euthymic BP patients with existing US norms. Highly significant (P<0.0001) differences were found on nine variables, with BP patients showing lower levels of cognitively-modulated affective responses, poorer overall reality testing, and higher levels of formal thought disorder. It is not impossible that the observed differences were due to residual illness, to the effects of repeated episodes of acute illness, or to the effects of psychotropic medication (taken by almost all BP patients over the course of the illness). If, on the other hand, these Rorschach differences are part of the psychological expression of the genetic diathesis to manic-depressive illness (Belmaker and Biederman, 1994), they should be present before the actual onset of the illness itself. In order to test the hypothesis that the differences are psychological markers of the genetic diathesis for BP disorder, the current study compares the Rorschach protocols of the asymptomatic offspring of bipolar parents (OBP) to the protocols of children of normal parents (controls). Since the Rorschach is very sensitive to developmental processes, the children were matched for age and grade level as well as for sex, ethnic background, and parental socio-economic status. A preliminary analysis of the data (Last et al., 1989) discussed the similarities between the adult bipolar protocols and the protocols of the children of bipolar patients but, at that time, the childrens’ protocols were translated into English (from the original Hebrew) and scored in translation; in addition, an earlier version of the Exner Comprehensive System was employed. The present paper reports the results of final analyses conducted on the original protocols, scored from the original Hebrew transcripts, and in accordance with the 1995 version of the Exner scoring system (Exner, 1995).