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Differentiation of Psychotic From Nonpsychotic

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Differentiation of Psychotic From Nonpsychotic

Psychiatric Inpatients: The Rorschach Perceptual
Thinking Index
a

Emil Benedik , Sana oderl

a b

, Jure Bon

a c

& Bruce L. Smith

d e

Psychiatric Hospital Begunje, Slovenia

Department of Psychology, University of Ljubljana, Slovenia

Department of Neurology, University Medical Centre, Ljubljana, Slovenia

Department of Psychology, University of California, Berkeley

Department of Psychology, Tsinghua University, Beijing, China

Version of record first published: 14 Feb 2013.
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Nonpsychotic Psychiatric Inpatients: The Rorschach Perceptual Thinking Index, Journal of Personality Assessment, 95:2,
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Journal of Personality Assessment, 95(2), 141148, 2013

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ISSN: 0022-3891 print / 1532-7752 online
DOI: 10.1080/00223891.2012.753898

ARTICLES

Differentiation of Psychotic From Nonpsychotic Psychiatric

Inpatients: The Rorschach Perceptual Thinking Index
EMIL BENEDIK,1 SANA C ODERL,1,2 JURE BON,1,3 AND BRUCE L. SMITH4,5
1
Psychiatric Hospital Begunje, Slovenia
Department of Psychology, University of Ljubljana, Slovenia
3
Department of Neurology, University Medical Centre, Ljubljana, Slovenia
4
Department of Psychology, University of California, Berkeley
5
Department of Psychology, Tsinghua University, Beijing, China

Downloaded by [46.164.3.187] at 07:29 25 February 2013

The aim of the study was to investigate the validity of the Rorschach Perceptual Thinking Index (PTI) to detect psychotic perceptual and thought
disturbance in a sample of Slovene psychiatric inpatients. Using a sample of 275 adult psychiatric inpatients of both sexes, we examined the
differences between patients with psychosis (PP) and patients with no psychotic features (NP) from various diagnostic groups on the global PTI
and its subcomponent variables. PPs obtained significantly higher PTI scores, indicating more disturbed perception and more thinking disturbance,
than NPs. No differences were found for diagnostic differences within the PP and NP groups. Results are in accordance with previous studies of the
PTI as a valid cross-cultural index of perceptual and thinking disturbance.

The issue of identifying psychosis accurately has proven to be

a complex and controversial endeavor for a long time (Cullberg, 2006). There are many disorders recognized today in
which psychotic phenomena occur, but the evidence needed
to conclude that they are separate entities is still lacking. Disorders such as schizophrenia, schizoaffective disorder, bipolar
disorder, major depressive disorder with psychotic features, and
substance-induced psychosis are clearly delineated and identified in psychiatric patients using criteria from modern diagnostic and classification systems such as the International Statistical Classification of Diseases and Related Health Problems
(10th ed. [ICD10]; World Health Organization, 2004) or the
Diagnostic and Statistical Manual of Mental Disorders (4th
ed., text rev. [DSMIVTR]; American Psychiatric Association,
2000; Regier, 2007). Diagnostic criteria for schizophrenia in
DSMIVTR consider it as a discrete entity and separate it especially from the affective psychoses (Dutta et al., 2007). As scientific evidence mounts, however, it is doubtful whether these
discrete diagnostic groups have discriminant validity (Jansson
& Parnas, 2007). Polydiagnostic studies actually do show considerable variation concerning their frequency, concordance, reliability, and outcome when using different sets of diagnostic
criteria (Jansson & Parnas, 2007). There is a considerable overlap in the therapeutic effects of antipsychotics and mood stabilizers in schizophrenia, schizoaffective disorder, and bipolar
disorder, which also share common risk genes (Dutta et al.,
2007). Structural imaging studies have identified similar whiteReceived January 25, 2012; Revised July 4, 2012.
Address correspondence to Bruce L. Smith, Department of Psychology, University of California, Berkeley, 2041 Bancroft Way, Suite 310, Berkeley, CA
94707; Email: blsmith@berkeley.edu

matter abnormalities of major longitudinal and interhemispheric

tracts in schizophrenia and bipolar disorder, but differing grades
of gray-matter deficits. Diagnostic boundaries of schizophrenia
are not clear, even in relation to normal mental functioning. Positive symptoms of psychosis like delusions and hallucinations
are present in the general population to a surprisingly large extent, at rates ranging from 4% to 17.5% (Allardyce, Gaebel,
Zielasek, & van Os, 2007; Dutta et al., 2007).
Symptoms defined by diagnostic criteria for schizophrenia
are commonly found in other kinds of psychoses as well. Factor
analytic studies usually demonstrate four or five major symptom domains of psychosis with manic, depressive, disorganized,
positive, and negative symptoms. Schizophrenic patients score
higher in the positive, negative, and disorganization factors,
whereas patients with affective diagnoses score higher in the
manic and depressive dimensions and lower in the negative and
positive dimensions. This implies a quantitative variation rather
than qualitative differences in symptom dimension scores across
current diagnostic categories (Allardyce et al., 2007).
The ICD10 and DSMIVTR contain diagnostic criteria for
evaluating psychosis in various psychotic and nonpsychotic disorders. The evaluation of psychosis can involve a wide range of
psychological tests (Kaplan & Sadock, 2007). Among them, the
Rorschach is one of the most widely used instruments among
clinical psychologists (Hilsenroth & Handler, 1995) and appears
uniquely suited as a measure of thought disorder (Kleiger, 1999).
Clinicians have used the Rorschach to aid in differential diagnosis of psychosis ever since Hermann Rorschach first reported
his findings on perceptual differences between schizophrenic
and nonschizophrenic patients in his monograph Psychodiagnostics (Rorschach, 1921/1964). One value of psychological
tests is in their potential abilty to detect early signs of psychosis

141

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142
before they are manifested as overt psychotic symptoms. That
would enable clinicians to plan and implement early treatment
interventions for psychotic disorders. Early interventions for individuals with psychotic disorders have been increasingly seen
as possessing the potential to produce better clinical outcomes
(McGorry, 1998). Both the costs associated with a psychotic
illness and the consequences of receiving late interventions underscore the importance of accurately and reliably diagnosing
psychoses as they occur among adults (Dao & Prevatt, 2006).
According to Exner (1991), Rorschach history is marked by
many attempts to identify variables that would provide a valid
differentiation of psychotic and nonpsychotic patients. Early in
the development of the Comprehensive System (Exner, 1974),
several investigations focused on the accurate identification of
psychosis and schizophrenia. Research showed (Exner, 1974,
1986, 1991, 1993) that some composite variables are related to
ideation (disordered thought) and others to mediation (perceptual inaccuracy). A number of previous researchers have demonstrated substantial validity for Rorschach variables and indexes, especially the Thought Disorder Index (TDI; Johnston &
Holzman, 1979), the Schizophrenia Index (SCZI; Exner, 1986,
1993), and the Ego Impairment Index (EII; Perry, Viglione, &
Braff, 1992), with specific clinical application to the assessment of the psychotic thought process (Hilsenroth, Fowler, &
Padawer, 1998; Jorgensen, Anderson, & Dam, 2000; Kleiger,
1999; Viglione & Hilsenroth, 2001). In a review of research
addressing the utility of the TDI, SCZI and EII, Viglione (1999)
concluded that indicators of form quality distortion and thought
disturbance demonstrate considerable utility across and within
diagnostic categories. In addition, the Rorschach appears to
demonstrate a sensitivity to underlying psychotic processes prior
to their clinical expression (Frank, 1990; Kleiger, 1999).
The Perceptual Thinking Index (PTI; Exner, 2000) is a variable to assess psychotic process in the Rorschach Comprehensive System that replaced the SCZI and brought both psychometric and conceptual improvements. The index includes five
empirical criteria. It measures the following constructs: reality testing, strained and illogical reasoning, distorted thought,
and social ineptness. According to Exner and Erdberg (2005),
the change in name emphasizes that the function of the PTI is
not a diagnostic one; rather, it is designed to indicate potential
difficulties in reality testing and ideational clarity. The authors
of the index concluded that rather than being conceptualized
as a diagnostic index that categorizes patients, it is a dimensional variable based on a construct of psychotic thinking as a
continuum.
Current research with the PTI has shown that it is an effective
index in differentiating psychotic from nonpsychotic patients.
Smith, Baity, Knowles, and Hilsenroth (2001) investigated the
PTI with children and adolescents in a psychiatric setting and
found that patients with higher PTI scores had significantly
higher scores on measures of atypicality, reality distortion, hallucinations and delusions, feelings of alienation, and social
withdrawal derived from self-report measures and parent rating
scales. The authors concluded that the PTI has the advantage of
accurately identifying persons with thought disorders. Ritsher
(2004) researched the relationship between Rorschach and Minnesota Multiphasic Personality Inventory2 (MMPI2; Butcher,
Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) indicators of
psychosis in adult psychiatric patients and found modest support
for the PTI but not the MMPI2 indicators in discriminating patients diagnosed with schizophrenia from those diagnosed with

BENEDIK, CODERL,
BON, SMITH
depression. Similar results were obtained by Dao, Prevatt, and
Horne (2008) in a study that confirmed better discriminative
validity of the the PTI as compared to the MMPI2 scales. Dao
and Prevatt (2006) also investigated evidence for reliability and
validity of the PTI among an adult inpatient population. Results
provided support for the PTI as an effective index in differentiating schizophrenic spectrum disorder patients from patients
with a mood disorder with no psychotic features. These results
are similar to those obtained by Kumar and Khess (2005) where
the PTI differentiated schizophrenic patients from manic patients. Other authors (Hilsenroth, Eudell-Simmons, DeFife, &
Charnas, 2007) who studied the validity and diagnostic efficiency of the PTI in relation to the accurate identification of the
psychotic disorder patients concluded that the PTI can be used
to effectively differentiate psychotic patients from a nonpatient
group as well as from personality disorder patients characterized by moderate to severe perceptual thought disorder. Recent
studies showed that the PTI also distinguished patients at high
risk for psychosis from those diagnosed as having nonpsychotic
disorders, but not from those diagnosed as psychotic (Iloenen,
Heinimaa, Korkeila, Svirskis, & Salokangas, 2010). DzamonjaIgnjatovic, Smith, Djuric Jocic, and Milanovic (2012) found that
the PTI, its successor the Thought and Perception-Composite
(TP-Comp: Meyer, Viglione, Mihura, Erard, & Erdberg, 2011),
and the EII all differentiated schizophrenic inpatients from
nonpsychotic inpatients in a Serbian sample.
Overall, a consistent finding across Rorschach studies is that
certain Rorschach variables and indexes, especially the PTI,
have demonstrated some association with psychosis and substantial ability to discriminate between psychotic patients and
other individuals. Further research is indicated to better establish the capacity of the PTI in differentiating schizophrenia from
other severe disorders and to investigate the cross-cultural applicability of the index.
The first aim of this study was to investigate the diagnostic
efficiency of the PTI in discriminating patients with psychosis
from patients with various nonpsychotic disorders in a Slovenian
sample. To date most of the empirical literature evaluating the
efficacy of the PTI has been conducted in the United States.
Data from other countries are needed to assess the cross-cultural
validity of measures derived from the Comprehensive System.
The second aim of the study was to find out whether the PTI
can discriminate among different psychotic disorders. Our main
hypothesis was that the PTI is a valid measure of perceptual and
thinking disorders in psychotic patients.

METHOD
Participants
The study involved 275 adult inpatients of both sexes (153
women and 122 men) drawn from an archival search of files
at a public psychiatric hospital in Slovenia, admitted between
2007 and 2010. Patients were assigned to the psychotic patients
(PP) or nonpsychotic patients (NP) group based on primary
admission diagnosis. Diagnoses of the PP group consisted of
patients with schizophrenia (n = 41), delusional disorder (n
= 11), brief psychotic disorder (n = 50), and mood disorders
with psychotic features (n = 31). Diagnoses of the NP group
consisted of patients with depressive disorders without psychotic features (n = 46), anxiety disorders (n = 17), alcohol
dependence disorder (n = 32), and personality disorders (n =
47). Every patient in the PP group was prescribed at least one

Downloaded by [46.164.3.187] at 07:29 25 February 2013

RORSCHACH PERCEPTUAL THINKING INDEX

antipsychotic medication, whereas most of those in the NP group
were prescribed at least one antidepressant or anxiolytic medication (except patients with alcohol dependence, who did not
receive any medication).
Only Slovenians were included in our sample. The PP group
(n = 133, 54.2% female) ranged in age from 18 to 85 (M =
36.88). The average educational level of this group was
11.68 years (SD = 2.23). The NP group (n = 142, 57.1% female) ranged in age from 17 to 79 (M = 43.65). The average
educational level of the NP group was 11.22 years (SD = 2.46).
To assess for potential confounding group demographic variables between the PP and the NP groups, we performed a chisquare test on gender and t tests on age and education. For
gender, the chi-square test indicated no significant differences
2(1, N = 275) = 3.74, p > .05 (two-tailed). The t-test statistics indicated no significant difference between two groups in
age (t = 1.83, p > .05) and education (t = 1.38, p > .05). In
terms of the Rorschach Erlebnistypus (EB) variable reflecting
problem-solving style, the PP group consisted of 24.8% introversive, 30.1% extratensive, 35.3% ambitent, and 9.8% avoidant
patients, and the NP group consisted of 30.3% introversive,
21.1% extratensive, 33.1% ambitent, and 15.5% avoidant patients. Results of a chi-square test for introversive (p = .25),
extratensive (p = .23), ambitent (p = .99), and avoidant (p =
.13) style showed no significant differences between groups,
and thus problem-solving style was not considered to be a confounding variable.

Procedure
We obtained institutional review board approval for all procedures from the hospital facility as well as from the University
of Ljubljana Ethics Committee. We performed a search of medical records of male and female adult inpatients admitted to the
hospital within the previous 4 years (20072010). The initial
sample consisted of 330 adult psychiatric inpatients assessed by
two psychiatrists to determine diagnosis using the Structured
Clinical Interview for DSMIV (SCID; First, Spitzer, Gibbon,
& Williams, 1997). Results revealed moderate to excellent interrater agreement of the Axis I and Axis II disorders based
on the SCID ( = .701.00). In addition, a random selection
of 30 diagnoses was selected and interrater reliability for those
cases was excellent ( = .92). In cases of discrepancies, final
diagnoses were made by consensus. We excluded 29 participants with delirium, dementia, amnestic, and other cognitive
disorders (e.g., mental disorders due to a general medical condition). We also excluded participants with invalid Rorschach
protocols, that is fewer than the minimum of 14 responses according to Exners (1993) criterion, and Rorschach protocols
that had both a Lambda value greater than 1 and 16 or fewer
responses. The latter criterion was based on Weiner (1996), who
suggested this pattern reflected defensiveness on the part of the
patient. Based on these last two criteria, we excluded a total of
26 patients, leaving a final sample size of 275 patients.
In all cases, the intake diagnosis was established before
the Rorschach was administered. Two clinical psychologists
trained in the Rorschach Comprehensive System and with at
least 5 years of experience in Rorschach diagnostic assessment
administered the Rorschach within the first 14 days following
the patients admission to the hospital. Administration and scoring of the Rorschach protocols followed Exners (1993) Comprehensive System guidelines with the structural summary produced through the Rorschach Interpretation Assistance Program

143
(RIAP 5; Exner, Weiner, & PAR Staff, 2001). The Rorschach
was routinely administered as part of an assessment battery
with patients who exhibited cognitive disturbances or depressive
symptoms. The Rorschach data did not influence the assignment
of diagnoses nor did the diagnosis influence the Rorschach data.

Instrument
The Comprehensive Systems (Exner, 2003) PTI index consists of the following variables:
1. XA%: Proportion of responses in which there is an appropriate use of form features.
2. WDA%: Proportion of responses given to whole (W) and
common detail (D) areas in which there is an appropriate use
of form features.
3. X%: Proportion of answers in which form use is not commensurate with the blot features.
4. WSum6: Weighted sum of problematic ideation scored according to six criteria: deviant verbalizations (DV), deviant
responses (DR), incongruous combinations (INC), fabulized
combinations (FAB), contaminations (CONTAM), and inappropriate logic (ALOG).
5. Level2: Sum of answers that reflect seriously dissociated,
illogical, fluid, or circumstantial thinking, according to preceding WSum6 criteria.
6. M: Sum of inaccurate human movement responses.
The score for PTI is determined according to five empirical
criteria (Exner & Erdberg, 2005) in which the total PTI score
represents the sum of positive criteria. Possible scores on the
PTI range from 0 to 5:
PTI1 = XA% .70 and WDA% .75.
PTI2 = X% .29.
PTI3 = Level2 2 and Level2 FAB 0.
PTI4 = R 17 and WSum6 12 or R 16 and WSum6 > 17.
PTI5 = M 1 or X% .40.
When examining individual components of the PTI, the
WSum6 values higher than 20 were reduced to 20 to minimize
the negative skew in the distribution. A similar procedure was
used to transform raw scores for Level2 (values greater than 5
were reduced to 5) and M (values greater than 3 were reduced
to 3). To estimate interrater reliability, 30 Rorschach protocols
were chosen at random and rescored independently by a clinical
psychologist who was blind to the original Rorschach scores as
well as to patients diagnoses. Level of interrater agreement was
calculated using Cohens kappa formula and intraclass correlation coefficient (ICC; Cohen, 1988). The kappa coefficients for
PTI indicated excellent interrater reliability ( = .85; ICC =
.80). The ICC and Kappa coefficients for coding criteria (PTI1,
PTI2, PTI3, PTI4, PTI5) and the variables that constitute the
PTI score (XA%, WDA%, X%, Level2, M, and WSum6)
were good to excellent (ICCs = .60.90; = .68.90). This
indicates adequate interrater reliability according to Cicchettis
(1994) interpretation guidelines. These results were consistent
with interrater reliability of Rorschach CS variables reported by
others (Dao & Prevatt, 2006; Exner, 2003; Smith et al., 2001).

RESULTS
Table 1 contains the descriptive statistic for the global PTI
score, statistics for PTI criteria (PTI1, PTI2, PTI3, PTI4, and


BENEDIK, CODERL,
BON, SMITH

144

TABLE 1.Descriptive statistics for the global PTI, PTI criteria, and PTI variables for the total sample and the psychotic patient and nonpsychotic patient groups.
Descriptive Statistics
Variable

PTI
.96
XA%
.74
WDA% .77
X%
.23
Level2
.81
WSum6 7.66
M
.46
PTI1
.24
PTI2
.24
PTI3
.08
PTI4
.22
PTI5
.18

SD
1.36
2.44
.13
.12
1.43
7.47
.83
.43
.43
.27
.42
.39

Total Samplea
Min Max Med Skew
.00 5.00 .00
.21 1.00 .76
.23 1.00 .78
.00
.58 .22
.00 5.00 .00
.00 20.00 5.00
.00 3.00 .00
.00 1.00 .00
.00 1.00 .00
.00 1.00 .00
.00 1.00 .00
.00 1.00 .00

1.35
.90
.94
.12
1.86
.57
1.83
1.22
1.22
3.21
1.35
1.66

Kurt

SD

.83 1.56 1.58

1.46
.70 .14
1.72
.73 .14
.21
.27 .13
2.53 1.40 1.77
1.17 10.73 7.96
2.42
.55 .90
.50
.41 .49
.50
.42 .48
8.35
.16 .49
.19
.38 .49
.76
.26 .44

Min

PP Groupb
Max Med Skew

.00 5.00 1.00 .63

.21 1.00
.71 .66
.23 1.00
.75 .66
.00
.58
.25 .25
.00 5.00 1.00 1.03
.00 20.00 11.24 .09
.00 3.00 0.00 1.59
.00 1.00
.00 .39
.00 1.00
.00 .59
.00 1.00
.00 1.90
.00 1.00
.00 .52
.00 1.00
.00 1.09

Kurt

SD

Min

.78 .39 .78

.74 .79 .10
.77 .81 .09
.36 .20 .10
.30 .27 .64
1.59 4.78 5.66
1.50 .37 .76
1.88 .24 .43
1.68 .24 .43
1.66 .08 .27
1.76 .22 .42
.83 .18 .39

NP Groupc
Max Med Skew

.00 3.00 .00

.04 1.00 .79
.42 1.00 .81
.00
.56 .20
.00 4.00 .26
.00 20.00 3.00
.00 3.00 .00
.00 1.00 .00
.00 1.00 .00
.00 1.00 .00
.00 1.00 .00
.00 1.00 .00

.95
.59
.50
.44
2.82
1.28
2.12
1.22
1.22
3.21
1.35
1.66

Kurt
.90
1.26
1.45
.91
9.27
.76
3.77
.50
.50
8.35
.19
.76

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Note. PTI = Perceptual Thinking Index; PP = psychotic disorders; NP = nonpsychotic disorders; Min = minimum; Max = maximum; Med = median; Skew = skewness; Kurt =
kurtosis. Artificial caps were placed on WSum6 (20), Level2 (5), and M (3).
a
N = 275. bn = 133. cn = 142.

PTI5) and PTI variables (XA%, WDA%, X%, Level2, M,

and WSum6) for the total sample as well as the group-specific
samples.
We found no significant gender differences on the selected
variables. Next we examined the differences between means of
PP and NP groups regarding the PTI variables and PTI criteria
with Bonferroni adjustment to protect against inflated Type I
error (Table 2). To assess for practical importance, we computed
Cohens d effect sizes with adjustment for unequal sample sizes
(Cohen, 1988). The results (Table 2) indicated medium (d = .50)
to large (d = .80) effect sizes for all variables except M and
PTI5 in the NP versus PP differentiation. The most significant
difference and largest effect was found on the total PTI score.
The PP group evidenced significantly higher raw scores on PTI
than the NP group. Examination of the PTI variables revealed
that the PP group evidenced significantly higher scores than
the NP group on the variables that describe low form quality
responses (X%) and the presence of disturbed thinking (Level2,
WSum6). The NP group had a significantly higher proportion of
good form quality answers (XA%, WDA%) than the PP group.

TABLE 2.t-test statistics and effect sizes comparing the psychotic patient and
nonpsychotic patient groups.
Variable

M PP

M NP

t Test (df = 273)

p Value

Cohens d

PTI
XA%
WDA%
X%
Level2
WSum6
M
PTI1
PTI2
PTI3
PTI4
PTI5

1.56
.70
.73
.27
1.40
17.78
.61
.41
.36
.16
.38
.26

.39
.79
.81
.20
.27
4.85
.55
.08
.13
.00
.08
.11

7.69
6.24
5.78
5.22
6.95
7.10
1.74
6.60
4.65
4.98
6.24
3.41

.001
.001
.001
.001
.001
.001
.082
.001
.001
.001
.001
.001

.94
.76
.70
.63
.84
.86
.22
.83
.56
.61
.76
.39

Note. The Bonferroni adjusted p value is .0042. Cohens (1988) d statistics were calculated using pooled variance and adjusted for unequal sample sizes. PP = psychotic disorders
(n = 133); NP = nonpsychotic disorders (n = 142); M PP = average mean for PP group;
M NP = average mean for NP group; PTI = Perceptual Thinking Index. WSum6, Level2,
and M- were trimmed to have maximum values of 20, 5, and 3, respectively.

Of the PTI criteria, PTI1 (XA% .70 and WDA% .75) best
differentiates the two groups (d = .83) and PTI5 (M > 1 or
X% > .40) is least able to differentiate the groups (d = .39).
Because the global PTI score represents a count variable with
values more or less indicative of cognitive disturbances (Exner,
2003), we also computed a Spearmans rho correlation coefficient to examine the relationship between the global PTI score
and the dichotomously coded PP and NP groups. Consistent
with the results in Table 2, the correlation was significant: =
.42, p < .001, two-tailed. Results also indicated significant correlations between the global PTI and all its component variables
(r = .26.90, all p < .001).
Table 3 contains the cumulative frequency distribution for PTI
scores at different cutting points, examined for each of the two
groups. Only 26.1% of the NP patient sample had a PTI equal
to or greater than 1, and less than 10% of the NP patients had
PTI scores equal to or greater than 2. None of the NP group had
a PTI score of 5 and almost none had a PTI score of 4 (0.8%).
On the other side, as expected, the PP group had a frequency of
61.7% at the PTI score of 1 or greater, and approximately half
of them had the PTI score of 2 or greater.
Next, we examined the differences in results on the global
PTI and the most significant PTI variables between the patients
from different diagnostic subgroups. The analyses of variance
(ANOVAs) and Bonferroni test revealed significant differences
between all subgroups on the global PTI, F(7, 274) = 8.20, p <

TABLE 3.Frequency distribution for different total PTI scores in the psychotic
patient and nonpsychotic patient groups.
PTI
PTI = 0
PTI 1
PTI 2
PTI 3
PTI 4
PTI = 5

PP Groupa

NP Groupb

38.3%
61.7%
46.7%
27.9%
15.1%
5.3%

73.9%
26.1%
9.2%
3.6%
0.8%
0.0%

Note. PTI = Perceptual Thinking Index; PP = psychotic disorders; NP = nonpsychotic

disorders.
a
n = 133. bn = 142.

RORSCHACH PERCEPTUAL THINKING INDEX

145

TABLE 4.Descriptive statistics for the PTI, WSum6, Level2, and XA% for different diagnostic subgroups.
PTI

WSum6

Level2

XA%

Subgroup

SD

SD

SD

SD

Schizophrenia
Delusional disorders
Mood disorders with psychosis
Brief psychosis
Depressive disorders
Anxiety disorders
Alcohol dependence
Personality disorders

41
11
31
50
46
17
32
47

1.76
1.73
1.51
1.40
.33
.59
.22
.51

1.62
1.61
1.65
1.52
.67
1.06
.55
.88

11.44
11.91
10.23
10.20
4.28
3.76
3.31
6.64

8.72
8.26
7.32
7.78
5.51
4.40
3.71
6.84

1.46
1.64
1.29
1.36
.24
.06
.21
.47

1.83
2.25
1.62
1.75
.52
.24
.42
.88

.66
.69
.72
.71
.80
.77
.79
.78

.17
.02
.13
.03
.10
.11
.09
.10

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Note. PTI = Perceptual Thinking Index.

.001; WSum6, F(7, 274) = 7.38, p < .001; Level2, F(7, 274) =
7.07, p < .001; and XA%, F(7, 274) = 5.86, p < .001. Table 4
contains the descriptive statistics for each of the subgroups.
There were no significant differences in results of the global
PTI, WSum6, Level2, and XA% among the patients with different psychotic disorders (schizophrenia, delusional disorder,
brief psychotic disorder, and mood disorders with psychotic features) who constituted the PP group: PTI, F(4, 132) = .45, p =
.77; WSum6, F(4, 132) = .34, p = .36; Level2, F(4, 132) =
.54, p = .70; XA%, F(4, 132) = 1.09, p = .36. We found
no significant differences in results on the PTI and XA% between nonpsychotic patients with depressive disorders, anxiety
disorders, alcohol dependence disorder, and personality disorders from the NP group as well: PTI, F(3, 141) = 1.36, p =
.26; XA%, F(3, 141) = 0.50, p = .68. There were some differences in results of WSum6 and Level2 between the patients
with nonpsychotic disorders: for WSum6, F(3, 141) = 2.80,
p < .05; Level2, F(3, 141) = 2.81, p < .05).
Patients with personality disorders reached significantly
higher scores on WSum6 and Level2 than other patients from
the NP group. These differences are confirmed by ANOVAs
with criteria PTI4, which consists of the WSum6 variable, F(3,
141) = 4.80, p < .01. It seems that patients with personality disorders give significantly more pathological answers than
other NP patients. We found the most significant difference on
WSum6 and Level2 scores between patients with personality
disorders and patients with alcohol dependence (for WSum6,
t = 2.87, p < .01; for Level2, t = 2.31, p < .01).
Finally we calculated diagnostic efficiency statistics to examine how well the PTI could differentiate between the PP and the
NP samples (Kessel & Zimmerman, 1993). We examined the
diagnostic efficiency statistics for the PTI at all possible criteria
points. To assess the clinical utility of the PTI in identifying
persons who have a psychotic disorder, diagnostic efficiency
statistics were calculated. The five different statistics calculated
were sensitivity (SN; the ability of the test to correctly identify
psychotic individuals as having a psychosis), specificity (SP;
the ability of the test to correctly identify nonpsychotic persons as not having a psychosis), positive predictive power (PPP;
the probability that an individual has a psychosis when the test
identifies him or her as having one), negative predictive power
(NPP; the probability that an individual does not have psychosis
when the test identifies him or her as not having psychosis), and
overall correct classification rate (OCC; the overall hit rate of
the proportion of PP and NP correctly classified by the test). The

diagnostic efficiency statistics for each of the PTI cutoff points

are presented in Table 5.
As expected, the PTI did well in the differentiation of the
PP group from the NP group. An examination of diagnostic efficiency statistics concerning the nonpatient sample revealed two major findings: First, only the PP group had PTI
scores of 5; therefore, the positive predictive power for the PP
group in comparison to the NP group was good. Second, it was
highly unlikely for the nonpsychotic patients to produce a PTI
greater than 2 and thus the possibility for the PTI to misclassify a nonpsychotic patient into the PP group was low. Between
PTI = 2 and PTI = 5, the optimal cutoff point depends on the
relative importance of sensitivity versus specificity in a given
clinical circumstance.

DISCUSSION
These findings reaffirm the utility of the PTI and extend this
to a culture different from that within which it was initially developed. This finding adds to the growing literature suggestive
of the cross-cultural applicability of the Comprehensive System.
This is an important finding as the use of the Rorschach expands
to more countries. In Slovenia, for example, the Comprehensive
System has only been widely used in the past few years, but
has become increasingly popular among clinical psychologists.
These findings are consistent with those found in a Finnish
sample (Iloenen et al., 1999), a Serbian sample (DzamonjaIgnjatovic et al., 2012), and a Russian sample (Ritsher, 2004).
Interestingly, in the latter study, the results demonstrated poorer
sensitivity than in other studies, a finding that was attributed to
different diagnostic criteria. Two tentative conclusions can be
TABLE 5.Diagnostic efficiency statistics for the PTI in the psychotic patient
and nonpsychotic patient comparisons.
PP vs. NP

SN

SP

PPP

NPP

OCC

PTI 1
PTI 2
PTI 3
PTI 4
PTI 5

.62
.47
.28
.15
.06

.74
.91
.96
.99
1.0

.69
.83
.88
.95
1.0

.67
.64
.59
.56
.53

.68
.69
.63
.58
.54

Note. For PP group, n = 133. For NP group, n = 142. PTI = Perceptual Thinking Index;
PP = psychotic patients; NP = nonpsychotic patients; SN = sensitivity; SP = specificity;
PPP = positive predictive power; NPP = negative predictive power; OCC = overall correct
classification.

Downloaded by [46.164.3.187] at 07:29 25 February 2013

146
drawn from these findings: cognitive symptoms of psychosis
appear to be consistent across cultures, or at least across Western cultures, and Rorschach measures of thought disturbance
appear to differentiate psychotic pathology from nonpsychotic
pathology. It is imperative that these studies be replicated in
non-Western societies, especially East Asian, as it has been
shown that there are significant differences in cognitive style
between Asian and Western individuals (Ji, Peng, & Nisbett,
2000; Masuda & Nisbett, 2001; Nisbett, 2003).
The diagnosis of psychosis requires comprehensive data from
a number of different sources and psychological assessment is
one of them. The Rorschach, in particular, can contribute important information in the diagnostic decision-making process,
although Rorschach data primarily identify aspects of personality functioning and only secondarily have a diagnostic purpose
(Weiner, 1994). However, the Rorschach technique has a long
history of use in assessment of psychotic thought disturbances
(Kleiger, 1999; Weiner, 1966). Previous research has demonstrated that the PTI is a reliable and internally consistent index
(Dao & Prevatt, 2006; Dao et al., 2008; Hilsenroth et al., 2007)
that has been shown to differentiate psychotic patients from depressed patients (Dao & Prevatt, 2006; Dao et al., 2008) and
from those with personality disorders (Hilsenroth et al., 2007).
This study demonstrated the ability of the PTI to differentiate
psychotic patients from a diagnostically heterogeneous group
of nonpsychotic psychiatric inpatients.
Our analysis demonstrated that the global PTI differentiates
adult psychotic inpatients from inpatients without psychotic disorders. That is to say, patients with psychosis have significantly
higher scores on the PTI compared to patients without psychosis. These results indicate that the PTI measures disorders of
perception and thinking that are most evident in psychotic mental disorders and are less characteristic for the nonpsychotic
group of mental disorders. This result is in accordance with
Exners dimensional conception of the PTI (Exner, 2003). Furthermore, based on our results, Exners cutoff point of 3 seems
like an adequate score for differentiation between patients with
psychosis and patients with nonpsychotic disorders. Fewer than
3% of our patients without psychotic disorders had PTI scores
equal to or greater than 3, and the same values of the PTI were
characteristic for almost one third of patients with psychosis.
According to our results, the probability of correct classification using these PTI criteria was fairly large and effective in
making a diagnostic decision about psychotic disorders. However, it is not suggested that the PTI could be the sole indicator
of a psychotic disorder. The PTI score of 3 or more should not
lead to the immediate diagnosis of psychosis. The PTI should
be evaluated in the context of the entire clinical record, which
includes other Rorschach data, results from other psychological
tests, and detailed exploration of personal history.
Because the PTI is a composite variable, we wanted to determine which partial variables were most valid in discriminating
between the psychotic and nonpsychotic group of psychiatric
inpatients. The results showed that the variables WSum6 and
Level2 that are represented in PTI3 and PTI4 and include deviant verbalizations, incongruous and fabulized combinations
of percept, contaminations of percept, and inappropriate logic,
have moderate to large discriminating power in our sample of inpatients. This result indicates that patients with psychosis, when
compared to different nonpsychotic groups of patients, have
more cognitive slippage and more formal and content thought

BENEDIK, CODERL,
BON, SMITH
disorders. They are more likely to use strange logic, unusual verbalizations, dissociative speech, bizarre interpretation of events,
unusual combination of percepts, and peculiar conclusions that
are not based on grounds of sound logic. In other words, it
would appear that aspects of formal thought disturbance are
more pronounced in psychosis.
Other important PTI variables for discrimination between PP
and NP groups are XA%, WDA%, and X%, which constitute
PTI1 and PTI2. These variables relate to the extent to which
the responses given by the individual are commensurate with
the stimulus features of the blots. The results show that patients
with psychotic disorders compared to nonpsychotic patients see
percepts in ways that are less form appropriate and more often
as unreal. The psychological process included in correct identification of form features is a process of apperception, which is
a complex process that includes other psychological functions
beyond perception. Apperception requires some reconciliation
(mediation) between the image that has been stored and items
available from the memory of the individual so as to accomplish the task of responding to the question What might this
be? (Exner, 2003). Disturbances in perception that occur in
our psychotic group of patients reflect detachment from or interference with adaptive reality testing. The extent to which
Rorschach responses are more or less congruent with their reality denotationthat is, the extent to which the form quality of
the response is adequateis one possible measure of veridical
interpretation of reality. In that way, reality testing refers to the
process by which a person distinguishes stimuli originating in
the outside world from those emanating from internal sources
(Johnston & Holzman, 1979). In psychotic impairment there is
a confusion between stimuli that arise internally and externally.
This is a difference between perception and apperception, a process that also includes the individuals mental representations
of self and others (Blatt, 1995; Kernberg, 1986).
The comparison of subgroups of patients confirms our main
hypothesis that disturbances in perception and thinking are more
characteristic of patients with psychotic disorders than nonpsychotic patients. There were, however, no differences among the
different psychotic subgroups. This is consistent with Exners
(2003) conceptualization of the PTI; namely, that it is an index of thought and perceptual disturbance and not specific to
the diagnosis of schizophrenia, per se. It is also consistent with
our earlier observation that there is considerable overlap and
diagnostic confusion among the different subtypes of psychotic
disorders. Additional analysis of nonpsychotic subgroups of patients shows that patients with personality disorders have more
disturbed thinking (WSum6, Level2) when compared to patients
with depression, anxiety disorder, or alcohol dependence. At the
same time, disturbed thinking in personality-disordered patients
is less severe than in patients with different psychotic disorders.
This finding is in accordance with a dimensional conceptualization of the PTI (Exner, 2003; Hilsenroth et al., 2007).
There are some limitations of our study that should be addressed in future work. First, the patients were assessed in
different phases of treatment. Their current mental state and
medication were not well controlled at the time of the assessment with the Rorschach. Future research should also address
that issue because presence of different symptoms and medication could affect Rorschach performance. Second, it would be
valuable for future studies to examine the psychometric characteristics of the PTI among various groups of patients in different

Downloaded by [46.164.3.187] at 07:29 25 February 2013

RORSCHACH PERCEPTUAL THINKING INDEX

treatment settings (e.g., inpatient vs. outpatient facility, patients
at the beginning vs. patients at the end of treatment) and in comparison with nonpatient controls as well. Third, the study also
has some methodological limitations. Despite the evidence that
the composite Comprehensive System variables do offer improved psychometric characteristics over their subcomponents
(Viglione, Perry, Jansak, Meyer, & Exner, 2003), psychometric
characteristics of the single subcomponent measures have not
been completely established.
The differentiation between psychotic and nonpsychotic patients is of somebut relatively limitedvalue clinically. Of
greater utility to the practicing clinician is the ability to make
valid prognostic predictions or specific treatment recommendations. Toward this end, future research should aim not simply
at replicating the findings regarding psychotic versus nonpsychotic patients, but rather using the PTI to assess degrees of
psychosis, likely prognosis, or response to specific treatments
(psychotherapy, pharmacotherapy, inpatient treatment, etc.). To
accomplish this task, dimensional outcome criteria need to be
developed.

CONCLUSION
The findings of this study extend previous research on the use
of the PTI in the assessment of the psychotic process. Despite
some methodological limitations, our results support the PTI
as a valid and promising measure of psychotic perceptual and
thinking disturbances in patients with different mental disorders.
According to our findings the PTI is an effective measure in
discriminating between psychotic and nonpsychotic groups of
patients. The fact that this measure was found to be valid in
Slovenia adds to the growing evidence for the cross-cultural
relevance of the Rorschach. This finding is consistent across
the literature and deserves further research, especially in nonEuropean societies.
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