Rorschach Revised DEPI and CDI with Inpatient Major Depressives and Borderline Personality Disorder with Major

Depression: Validity Issues

Carole F. Carlson
University of Wisconsin, Oshkosh

Michael L. Kula
Milwaukee Psychiatric Hospital

Carole M. St. Laurent

Riverside Psychiatric

This study focused on the clinical field validity of the Rorschach comprehensive system revised DEPI and CDI indices. Forty admission protocols from two inpatient adult DSM-III-R diagnosed samples, one with Major Depressive Disorder, uncomplicated, and one with Major Depressive Disorder and concurrent Borderline Personality Disorder, were compared. Hypotheses were (a) both groups would be identified by the revised DEPI and (b) if the Depressed Borderline group was not identified by the DEPI, it would be identified by the CDI. Both hypotheses were negated, raising questions regarding the validity of the indices for use in clinical diagnosis, treatment, and clinical research. 1997 John Wiley & Sons, Inc.

In 1974 John Exner published the first volume of The Rorschach: A Comprehensive System (TRACS). His goal was to take what was empirically verifiable from the five existing prominent clinical Rorschach systems (Beck, 1950, 1952; Hertz, 1951; Klopfer & Kelley, 1942; Piotrowski, 1957; Rapaport, Gill, & Schaefer, 1946), and develop and disseminate a standardized Rorschach method which was easily taught, had high interscorer reliability, and interpre-

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 53(1), 5158 (1997) 1997 John Wiley & Sons, Inc.

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tive premises that would withstand validation demands. After having analyzed most of the scoring variables in the above mentioned five systems, the research work expanded to special scores and gradations of form quality as well as levels of developmental (cognitive) sophistication. The first Exner system index to be developed was the Egocentricity Index (EGOI) (Exner, 1974). This was followed by the Suicide Constellation (S-Con) (Exner & Wylie, 1977). By the early 80s interest focused on the development of indices for schizophrenia and depression. Initially these efforts examined variables thought to comprise these clinical entities. Success on early versions of the Schizophrenia Index (SCZI) and the Depression Index (DEPI) was limited and revisions followed; each revision moving not back in the direction of interpreter (Rorschacher) intuition, gut feeling, interpreter projection, or clinical artistry, but to more pure science, i.e., statistical analyses. This approach also abandoned the technique (used for the first SCZI) of attempting to look at the characteristic symptomatology of a disorder and develop an index composed of Rorschach variables previously shown to reflect these symptoms or characteristics. Instead, the techniques adopted by TRACS were those of identifying certain target populations, depressed individuals in the case of DEPI, and statistically isolating derived clusters of variables (profiles) characterizing a high percentage of the target group, but not of either normal populations or other target populations (e.g., schizophrenics, outpatients, character disorders). The efforts focused on statistical sensitivity, the ability to detect the diagnostic entity being evaluated (depression) with low false positives and high true positives, and specificity, the DEPI must not target (detect) the disorder (depression) in someone who does not have it (true negatives). Finally, the predictive value, the proportion of true positives and true negatives, must be good (75%) (Exner, 1991). While these actuarial methods are useful in developing an index from a target population, it is essential that additional research be done to test the scales on actual clinical populations (Wood, Nezworski, & Stejskal, 1996). This is requisite if TRACS is to serve the dual purposes for which it was designed, clinical diagnostic and treatment work and applied clinical research. The purpose of the current study is to contribute information to the understanding, validity, and utility of the new depression indices, the revised DEPI and the CDI (Coping Deficit Index). In 1982, Exner and Weiner published the first DEPI, which consisted of five criteria, with a value of four or five considered positive for depression. Values of less than four were considered negative. While the false positive rate was extremely low, the false negative rate was exceedingly high, often greater than 60% for some groups of clearly depressed subjects (Exner, 1990b). Thus, a positive DEPI signaled the presence of a significant depression while a negative DEPI was virtually meaningless. In 1986 (Exner, 1990b), work began on a DEPI revision (DEPI-R). This time, from a target group of 1350 cases, three groups of over 200 patients were selected on the basis of different kinds of depression: emotionally depressed, cognitively depressed, and helpless (in contending with a complex society). Factor analyses yielded unclear results necessitating the use of other approaches. A series of multifactor analyses of variance, intergroup correlational analyses, and discriminant function analyses revealed substantial overlap between the first two groups with the third much more discrete. The emotional and cognitive groups were collapsed into a single group of 471 individuals and used as a target search group for a DEPI-R. This yielded 15 variables arranged in seven tests as the new DEPI-R: 1. (FV VF V) 0 or FD 2 2. Color-Shading Blends 0 or S 2 3. 3r (2)/R .44 and Fr rF 0 or 3r (2)/R .33 4. Afr .46 or Blends 4 5. Sum of Shading FM m or Sum C 2

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6. MOR 2 or (2AB Art Ay) 3 7. COP 2 or Isolation Index .24 The cutoff point became 5 or greater with 5 not considered definitive but reflecting features common to depression. According to Exner (1990b, 1991) values of 6 or 7 more definitively reflect a significant affective problem. The target sample yielded an 85% true positive rate for values of 5, 6, or 7. When the DEPI-R was applied to the helpless group, only 17 were identified. Application of the new DEPI-R to other target populations yielded the following results: non-patient adults 3%; schizophrenics 17%; character disorders 13%; and outpatients 31%. The majority of these false positives had a value of 5. When applied to the 663 individuals from the original pool who could not be classified according to one of Exners three types of depression (emotional, cognitive, or helpless) 81% had DEPI values of 5, 6, or 7 (72% with values of 6 or 7). This left the majority of the helpless group to be accounted for. In a search for a second DEPI the helpless protocols not identified by the new DEPI were combined with the 69 false negatives from the original target group (emotional and cognitive) and subjected to a series of discriminant functions analyses and contingency matrices. This yielded a composite of 11 variables arranged in five tests: 1. 2. 3. 4. 5. EA 6 or Adj D 0 COP 2 and AG 2 Weighted Sum C 2.5 or Afr .46 Passive movement active movement 1 or Pure H 2 Sum T 1 or Isolation Index .24 or Food 0

If a critical value of 4 was applied, 81% of this group were identified. When applied to other target populations, this second index yielded the following results: non-patient adults 3%; schizophrenics 2025%; non-adjudicated character disorders 50%; inadequate personality disorders 88%; alcohol and substance abusers 74%; adjudicated character disorders 69%. This second depression index became known as the Coping Deficit Index (CDI) (Exner 1990b, 1991) because the variables contained in it appeared to be related to social/interpersonal activity, impoverished or unrewarding social relationships, and histories of social chaos and/or ineptness. The group with the highest number positive of CDIs (88%) was the inadequate personalities, a term which Exner has in previous work equated with the diagnosis of borderline personality disorder (Exner, 1986). This is higher than the hit rate for the target population (81%). Of greater interest to the current study is the fact that dating back to his 1986 Rorschach study comparing schizophrenics, borderlines, and schizotypals, Exner characterizes his borderline sample as having chronic problems in affect modulation stating that a composite of control and modulation failure creates a form of helplessness (our italics) in which affects become the dominant forces in commanding and/or directing functions and behavior with little regard for the circumstances or consequences. In effect, it is the product of an organizational structure that might best be described as immature and/or inadequate (our italics) (p. 469). Later in the same article he states: Similarly, the current label borderline seems overly general and potentially misleading. Quite possibly, by reverting to the older category of inadequate personality, the label would be more appropriately descriptive (our italics) (p. 470). As early as his 1978 Volume II Exner says of borderlines that, they do not have ready access to many of their resources that would be important for coping (p. 252). By the third edition of Volume I in 1993, the high incidence of significant CDIs in inadequate personalities, substance abusers and adjudicated character disorders led Exner to conclude that the CDI appears to afford a measure that tends to identify those who have coping limitations or deficiencies (p. 364). Exner (1993) also states that the depressive features characteristic of individuals with

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a positive CDI (i.e., the helpless third group of depressives in the original sample) usually are a by-product of the overall social coping problem (p. 363). To date, two published studies and one doctoral dissertation have addressed the validity of the new DEPI-R. A validity study investigating the DEPI-R in children and adolescents (Ball, Archer, Gordon, & French, 1991) found no significant relationships between the original or revised DEPI and clinical elevations on the Depression scale of the Personality Inventory for Children in an outpatient sample or treatment team diagnostic judgments in an inpatient sample. Meyer (1993), looking at an adult sample of 70 inpatients and 20 outpatients with a mixture of diagnoses, failed to find a significant relationship between the DEPI-R and self-report measures. Sells (1991), using the MMPI Depression scale and the DEPI-R, found only 50% correct classification across a group of 109 inpatients, including depressed and non-depressed individuals. The purpose of this study is to investigate the validity of the DEPI-R and CDI by comparing two groups of adults hospitalized in an affective disorders program, one group diagnosed with Major Depressive Disorder (MDD) alone, and the other group with concurrent diagnoses of Major Depressive Disorder and Borderline Personality Disorder (MDD/BPD). The hypotheses of this investigation were that the DEPI-R would significantly identify both groups as depressed and if the DEPI-R failed to identify members of the MDD/BPD, they would be identified by the CDI. METHOD Subjects The 40 patients in this study were drawn from an inpatient affective disorders program at a midwestern psychiatric hospital. All patients selected for the research had been independently diagnosed with major depressive disorder, uncomplicated type, or with both borderline personality disorder and major depressive disorder by the program psychiatrist and the psychologist providing diagnostic assessment. All testing was done by the same clinical psychologist, trained and experienced in the Exner Comprehensive Rorschach System. All diagnoses used DSMIII-R criteria (1987). Disagreement over diagnosis resulted in exclusion of the patient from the study. All APA ethical guidelines for research (American Psychological Association, 1992) and University of Wisconsin Oshkosh research guidelines were followed. The group diagnosed with Major Depression (MDD) group consisted of 20 individuals, 10 females and 10 males ranging in age from 17 to 57 years with a mean age of 37.8 years (SD 10.73). The Borderline group consisted of 20 individuals who met criteria for both the diagnosis of Borderline Personality Disorder as well as Major Depression (BPD/MDD). This group contained 18 females and 2 males, ranging in age from 19 to 49 years with a mean of 34.9 years (SD 9.06). Instruments The Rorschach Inkblot Test was administered and scored according to the Exner Comprehensive System-Revised (1990a, 1991). The revised Depression Index (DEPI-R) involves 15 variables arranged in seven tests each of which are determined as either true or false. A cutoff point of 5 or greater was used, with 5 not considered definitive but reflecting features common to depression. Values of 6 or 7 are more definitive, reflecting a significant affective problem. The Coping Deficit Index (CDI) is comprised of 11 variables arranged in five tests which must be scored positive or negative. The critical value is 4 or greater.

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Two additional measures were used to validate the presence of depression, the Minnesota Multiphasic Personality Inventory Depression scale T-scores (MMPID) and the Beck Depression Inventory (BDI) scores. Procedure Each individual was administered the Rorschach according to the Exner Comprehensive System by the same experienced examiner as part of a full diagnostic assessment battery (which also included the MMPI and the BDI) at the time of intake. This examiner also scored the Rorschachs, which were then coded and scored blind by two additional experienced clinicians, using the 1990a/1991 scoring revisions. Disagreements on scores were discussed and resolved. Once each of the protocols were scored, the sequence of scores was entered in the Exner (1990a, 1991) Rorschach Interpretation Assistance Program which calculated the Structural Summary and Constellations Worksheet. These results were then used as raw data. RESULTS Frequencies of positive index scores of the DEPI-R and CDI scores for each group of 20 protocols were calculated and subjected to chi-square analysis between the two groups. Means were also subjected to t-tests. An alpha level of .05 was used for all statistical tests. The findings shown in Table 1 indicate that the new DEPI identified 35% of the individuals in the MDD group, nearly half (43%) of whom had a DEPI-R of 5 which is definitive only for depressive features, not for the presence of a depressive disorder. Another 15% of the sample were positive for the second depression index, the CDI. Because 4 of the protocols were positive for both DEPI-R and CDI, 55% were identified by either one or both indices. In the MDD/BPD group, 20% were identified by the DEPI, half of whom had values of 5. The CDI identified another 10%, with none overlapping with the DEPI-R, bringing the total to 30%. Thus, using both indices the total number of false negatives was 45% for the MDD group and 70% for MDD/BPD group. Using the DEPI-R alone, the false negative rate for the MDD group was 65% and 80% for the MDD/BPD group. Chi square comparisons between groups showed no significant differences in the frequency of positive DEPI-R, 2 (1, N 20) 1.13, p .29, nor positive CDI, 2 (1, N 20)

Table 1. Frequencies and Percentages (in parentheses) of Positive and Negative Index Scores by Group
Group a Index Both DEPI and CDI Positive DEPI Positive and CDI negative Total Positive DEPI CDI Positive and DEPI Negative Total Positive CDI Total Positive DEPI or CDI Negative DEPI and CDI Positive DEPI of 6 or 7
a b

MDD 3 (15%) 4 (20%) 7 (35%) 4 (20%) 7 (35%) 11 (55%) 9 (45%) 3 (15%)

MDD/BPD 0 (0%) 4 (20%) 4 (20%) 2 (10%) 2 (10%) 6 (30%) 14 (70%) 2 (10%)

TRACS b Prediction 25% 50% 75% 18% 43% 93% 7%

n = 20 per group. Positive DEPI and CDI rates predicted by Exner (1991, p. 303).

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3.58, p .06 indicating that neither index is more likely to be preferentially useful for one diagnostic group or the other. One-tailed t-tests comparing mean number of positive DEPI-R tests between the MDD ( M 4.0) and MDD/BPD ( M 3.75) showed no significant difference, t (40) .67, p .28 signifying that neither group was more likely to score higher on the DEPI-R. One-tailed t-tests comparing mean number of positive CDI tests between MDD ( M 3.25) and MDD/BPD ( M 2.05) showed a significant difference, t (40) 3.29, p .001, indicating that the MDD group was more likely to score higher on the CDI. Descriptive statistics for the MMPID for the total group and the MDD and MDD/BPD groups separately are as follows: total group M 87, SD 10.2, range 70106; MDD group M 87.45, SD 9.7, range 70106; MDD/BPD group M 86.55, SD 10.92, range 67106. The BDI total group M 32.22, SD 10.46, range 1352; MDD M 29.65, SD 10.07, range 1352; MDD/BPD M 34.8, SD 10.45, range 1351. Pearson correlations indicated no significant relationship between the DEPI-R and either the MMPID, r (40) .27, p .05 or the BDI, r (40) .19, p .05. A significant correlation was found between MMPID and the BDI, r (40) .41, p .002. DISCUSSION The results of this study are congruent with the clinical field studies of Ball et al. (1993), Meyer (1992), and Sells (1991). Little agreement is demonstrated between the positive values on the new DEPI-R and the DSM-III-R diagnoses of Major Depressive Disorder whether it occurs alone or concurrently with a diagnosis of Borderline Personality Disorder. Two other independent measures of depression, the MMPID and the BDI, further validate the presence of depression and correlate highly with each other, but not with the DEPI-R. The current study suggests that the DEPI-R has low sensitivity (i.e., its true positive rate is very low for the MDD and the MDD/BPD group). These results negate the first hypothesis of this study. The CDI, as a second depression index developed from Exners grouping of helpless depressives and said to reflect interpersonal difficulties and social ineptness occurred significantly more frequently among the MDDs than the MDD/BPDs. However, in absolute numbers (7 of 20 MDDs and 2 of 20 MDD/BPDs) it is valueless in targeting either group. These results negate the hypothesis related to the CDIs purported ability to target BPD DSM criteria of major difficulties in interpersonal relationships. In a recent broad critique of TRACS, Wood et al. (1996) addresses several issues, one of which is especially relevant to the results of this study: the validity of certain indices. As also noted by Woods et al., neither the 1991 nor 1993 Exner TRACS volumes give the specific diagnostic criteria used to identify the patients in the depressed target sample used for the construction of the DEPI-R. This is in contrast to the discussion regarding the revised Schizophrenic Index which, at least in reference to the Monte Carlo procedure used to test the new SCZI, specifies that the schizophrenic subjects were drawn from a pool of DSM-III diagnosed first-admission schizophrenics. In this same procedure five groups of 100 individuals were drawn from a group of DSM-III-SADS diagnosed first admission major affective disorders (Exner, 1991, p. 23). Yet two pages later in the discussion of the DEPI-R, no diagnostic criteria are specified. In the first publication of the DEPI-R (Exner, 1990b), the initial target sample was given as 1350. In 1991, Exner described the target sample as over 1400, and in relation to the SCZI trials the DSM-III-SADS number is stated as 1421 (Exner, 1991). We were unable to find any reference to a sub-categorization (into types of affective disorders) of this pool, i.e., one does not know if it includes only individuals with major depressive disorders or whether it also includes

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bipolar disorders. While the SADS pool (used to test the SCZI) is said to contain first admission major affective disorders (Exner, 1991, p. 23) the DEPI-R depressed target sample is without inpatient or outpatient qualifiers. The best that one can infer is that the target sample criteria are DSM-III-SADS. It should also be noted that SADS (Schedule for Affective Disorders and Schizophrenia) is actually an interview guide designed to provide information that can be analyzed according to the RDC (Research Diagnostic Criteria) which provides the actual diagnosis. In conclusion, the scant research track record to date for the application of the TRACS DEPI-R in clinical field populations is not fulfilling the publication promise. Also, it is not at all apparent exactly what relationship the CDI has to interpersonal coping skills. On the basis of the few studies to date, it would appear that with regard to these two new TRACS indices, something happened on the way from the research lab to the clinical field. Clearly more research needs to be done on these as well as other TRACS indices if clinicians are to have confidence in their validity for psychological diagnosis and treatment as well as for clinical research. REFERENCES
American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd ed. revised). Washington, DC: Author. American Psychological Association (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 15971611. Ball, J.D., Archer, R.P., Gordon, R.A., & French, J. (1991). Rorschach depression indices with children and adolescents: Concurrent validity findings. Journal of Personality Assessment, 57, 465 476. Beck, S.J. (1950). Rorschachs test. I: Basic processes (2nd ed.) New York: Grune and Stratton. Beck, S.J. (1952). Rorschachs test. III: Advances in interpretation. New York: Grune and Stratton. Exner, J.E. (1974). The Rorschach: A comprehensive system. Volume 1. New York: Wiley. Exner, J.E. (1978). The Rorschach: A comprehensive system. Volume 2: Current research and advanced interpretation. New York: Wiley. Exner, J.E. (1986). Some Rorschach data comparing schizophrenics with borderline and schizotypal personality disorders. Journal of Personality Assessment, 50, 455471. Exner, J.E. (1990a). A Rorschach workbook for the comprehensive system (3rd ed.). Rorschach Workshops: Asheville, NC. Exner, J.E. (1990b). 1990 Alumni newsletter. Rorschach Workshops: Asheville, NC. Exner, J.E. (1991). The Rorschach: A comprehensive system. Volume 2: Interpretation (2nd ed.). New York: Wiley. Exner, J.E. (1993). The Rorschach: A comprehensive system. Volume 1: Basic foundations (3rd ed.). New York: Wiley. Exner, J.E., & Weiner, I.B. (1982). The Rorschach: A comprehensive system. Volume 3: Assessment of children and adolescents. New York: Wiley. Exner, J.E., & Wylie, J. (1977). Some Rorschach data concerning suicide. Journal of Personality Assessment, 41, 339348. Hertz, M.R. (1951). Frequency tables for scoring Rorschach responses (3rd ed.). Cleveland: Western Reserve University Press. Klopfer, B., & Kelley, D.M. (1942). The Rorschach technique. Yonkers-on-Hudson, NY: World Book. Meyer, G.J. (1993). The impact of response frequency on the Rorschach constellation indices and on their validity with diagnostic and MMPI-2 criteria. Journal of Personality Assessment, 60, 153180. Piotrowski, Z. (1957). Perceptanalysis. New York: MacMillan.

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Rapaport, D., Gill, M., & Schafer, R. (1946). Diagnostic psychological testing. Chicago: Yearbook Publishers. Sells, J.E. (1991). A validity study of the DEPI index: The Rorschach comprehensive system (Doctoral dissertation. University of Utah, 1990). Dissertation Abstracts International, 51, 5590B. Wood, J.M., Nezworski, M.T., & Stejskal, W.J. (1996). The comprehensive system for the Rorschach: A critical examination. Psychological Science, 7 (1), 310.