Disordered Thinking and the Rorschach

Theory, Research, and Differential Diagnosis

James H. Kleiger

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135828714
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

In Disordered Thinking and the Rorschach, James Kleiger provides a thoroughly up-to-date text that covers the entire range of clinical and diagnostic issues associated with the phenomenon of disordered thinking as revealed on the Rorschach. Kleiger guides the reader through the history of psychiatric and psychoanalytic conceptualizations of the nature and significance of different kinds of disordered thinking and their relevance to understanding personality structure and differential diagnosis. He then moves on to thorough reviews of the respective contributions of David Rapaport, Robert Holt, Philip Holzman, and John Exner in conceptualizing and scoring disordered thinking on the Rorschach. These synopses are followed by an equally fascinating examination of less well known research conceptualizations, which, taken together, help clarify the basic interpretive conundrums besetting the major systems. Finally, having brought the reader to a full understanding of systematic exploration to date, Kleiger enters into a detailed analysis of the phenomenological and psychodynamic aspects of disordered thinking per se. Even experienced clinicians will find themselves challenged to reconceptualize such familiar categories as confabulatory or combinative thinking in a manner that leads not only to new diagnostic precision, but also to a richer understanding of the varieties of thought disturbances with their equally variable therapeutic and prognostic implications. With Disordered Thinking and the Rorschach, Kleiger has succeeded in summarizing a wealth of experience pertaining to the rigorous empirical detection and classification of disordered thinking. Equally impressive, he has taken full advantage of the Rorschach as an assessment instrument able to capture the richness of personality and thus capable of providing a unique clinical window into those crucially important differences in the quality of thought that patients may evince.

PART
1

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INTRODUCTION TO THOUGHT DISORDER AND THE RORSCHACH

The subject of thought disorder and the Rorschach test create a natural harmony. Not only do they share a number of similar concepts, but they also have overlapping historical roots. Beginning with a conceptual review of past and current theories and controversial issues regarding the nature of thought disorder, I will then turn to the subject of measurement and describe how the Rorschach has always been regarded as an ideal method for measuring and studying thought disorder. In Chapter 2, I examine the role that the Rorschach has played over the last 75 years as a major method for assessing and studying disordered thinking.

CHAPTER
1

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CONCEPTUALIZING DISORDERED THOUGHT

Mrs. A eyed me suspiciously as I handed her Card III of the Rorschach. From the outset, she had expressed her reluctance to look at the inkblots, repeatedly asking about the purpose of the test and the nature of the blots. Gingerly accepting the card, she responded promptly: “Oh, this is two people with insectoid heads, ripping the scalp off some fat guy in the middle so they can drop a red wig into his brain. He has to be really fat because it would take two people to do something like that.” Without so much as a breath, she added, “This isn’t so bad. These blots are interesting.”

Although taken by surprise by the sudden emergence of this strikingly primitive and bizarre response, I had to agree with her sentiments: these blots are interesting. Moreover, I began to wonder about the meaning of this unusual, rather unforgettable response. Beyond the obvious indication that her thinking was disturbed and that this regressive shift in her thought processes and reality testing was associated with primitive aggressive fantasies, I was not quite satisfied that my inferences had gone far enough. I could play more with the thematic content of the response and infer a self-other paradigm characterized by sadomasochistic themes or a feeble and vulnerable sense of self. Likewise, I could concentrate on the formal aspects of the response and conclude that Mrs. A’s reasoning was severely strained, and that she had the capacity to become delusional. However, I felt that these inferences, while useful as possible starting points, were static and did not go far enough in helping me understand what her strained logic, idiosyncratic use of language, primitive content, and unrealistic combinations might actually mean about how she experienced the world. Put simply, I was left wondering more about the meaning of the psychological processes underlying this bizarre response.

Apart from the circular conclusion that thought disorder scores tell us that a person has a “thought disorder” or “impaired reasoning,” what do they actually mean in terms of how an individual perceives the world, interacts with others, or feels about him or herself? Is it possible to derive more than static, one-dimensional inferences from Rorschach thought disorder scores? This is the question that inspired this book—how to go about deepening our understanding of different manifestations of thought disorder using the Rorschach. In particular, I am interested in exploring the conceptual meaning of different types of thought disorder, not only in terms of their differential diagnostic implications (and associated treatment considerations) but, more interestingly, in terms of what different forms of thought disorder can tell us about the psychological/phenomenological experience of the respondent.

Although there are many ways to measure and understand thought disorder, the Rorschach Test seems particularly well suited to this endeavor. With its lengthy history in the field of psychodiagnostic assessment, the Rorschach has been widely used as a research and clinical instrument for assessing and studying varieties of disordered thinking. In the last century, researchers pioneered a variety of Rorschach-based systems for scoring and interpreting manifestations of thought disorder. This book is a tribute to the work of these individuals and an attempt to synthesize and extend their contributions.

However, before attempting to explore the meanings of traditional thought disorder scoring on the Rorschach, it is important to begin at a more basic starting point. What is “thought disorder” anyway? How might we define, conceptualize, and measure it?

WHAT IS THOUGHT DISORDER?

Accurate assessment of complex clinical phenomena rests on the clarity of the concepts that we seek to measure. Without agreement about the nature and scope of the clinical entity under question, assessment efforts can be confusing and contradictory as different approaches yield different findings about concepts that are inherently unrelated. Regardless of what kind of instrumentation is used, the clinical assessment of thought disorder must begin with a clarification of the meaning of the concept.

“Thought disorder” is a widely used and often misunderstood term with a history of controversy regarding scope of definition, underlying mechanisms, and diagnostic specificity. Following the presentation of a comprehensive working definition of disordered thinking, various controversies regarding the conceptual nature and the measurement of thought disorder can be addressed. A brief examination of these issues will set the stage for a review of pioneering efforts to use the Rorschach to evaluate and understand thought disorder.

THE NATURE OF THOUGHT DISORDER

Definition of Thought Disorder

More than 80 years ago, Emil Kraepelin (1896) and Eugen Bleuler (1911) identified disturbances in thinking as an important feature in dementia praecox (Kraepelin’s term) or schizophrenia (Bleuler’s term). Kraepelin described the deterioration in intellectual processes as an incoherent ordering of ideas which, instead of flowing in a linear manner, become “derailed” from their appropriate course. Kraepelin cared about thought disorder because it helped him isolate diagnostic groups with differing prognoses.

Bleuler made formal thought disorder the cornerstone of his theory for understanding the clinical phenomena of schizophrenia. He cared about thought disorder because it offered a path to understanding the central defect in a syndrome (the group of schizophrenias) otherwise marked by different, varied, and florid symptomatology. Bleuler thought that if he could identify and measure the central defect of the syndrome, he might be able to home in on the underlying cause and possibly discover a treatment. According to Bleuler’s theory, the key to understanding schizophrenia lay in the pathological nature of the patient’s thinking, specifically the disturbed associations among thoughts and feelings that are split from one another. He termed this splitting process “loosening of associations,” which he viewed as the primary symptom of schizophrenia and the basis for all the clinical phenomena that follow.

Although by today’s standards Bleuler’s associationist approach provides an outdated and restricted explanation of thought disorder, it held sway in psychiatric circles up until the mid-1970s. For example, The Comprehensive Textbook of Psychiatry/II (Freeman, Kaplan, and Saddock, 1976) defined formal thought process disorder in terms of “irrelevance and incoherence of the patient’s verbal productions. It ranges from simple blocking and mild circumstantiality to total loosening of associations, as in word salad” (p. 1333).

Even today, many psychiatric clinicians retain a one-dimensional view of thought disorder by equating it with the concept of “looseness of associations.” The following DSM IV (American Psychiatric Association, 1994), definition of schizophrenic thought disorder is characterized by this narrow associationist approach, which tends to ignore the complexity and varied nature of disordered thinking.

Disorganized thinking (“formal thought disorder,” “loosening of associations”) has been argued by some (Bleuler, in particular) to be the single most important feature of schizophrenia.… The person may “slip off track” from one topic to another (“derailment” or “loose associations”); answers to questions may be obliquely related or completely unrelated (“tangentiality”) [p. 276].

Other attempts to conceptualize thought disorder go beyond the singularity of associational psychology. Fish (1962), for example, defined thought disorder as a disturbance of conceptual thinking in the absence of serious brain disease and in the presence of adequate intelligence. Harrow and Quinlan (1985) provided another simple definition by stating that thought disorder describes a variety of diverse types of verbalization and thinking that are labeled by others as bizarre and idiosyncratic. One cannot argue with this defintion; however, it does not take us very far. Harrow and Quinlan’s definition amounts to stating that “crazy people say crazy things” without beginning to consider what it is about “crazy” thinking-and there are many things, not one thing-that makes it seem “crazy” to others. Used in this limited way, “thought disorder” is an empty concept. It may satisfy the professional’s need for a more dignified term than “crazy,” but offers no starting point for either a more precise taxonomy of different kinds of crazy presentations or a starting point for an analytic inquiry into what the various causes and implications of these presentations may be.

A more comprehensive definition of thought disorder would be one that encompasses a broader perspective that includes not only traditional concepts such as impaired pace and flow of associations, but also such factors as errors in syntax, word usage, syllogistic reasoning, inappropriate levels of abstracting, failure to maintain conceptual boundaries, and a breakdown in the discrimination of internal perceptions from external ones. Such a definition comes closer to capturing the multidimensional nature of disturbances in thought organization. Defined in this broad manner, disordered thinking has been conceptualized and elaborated in a variety of ways, some of which have led to confusion and sparked disagreement and controversy over the decades.

Unraveling the Conceptual Tangles of Thought Disorder

What are other ways in which disorders of thinking may be characterized, studied, and understood? The study of thought disorder covers broad conceptual territory, with clear historical roots, controversial issues and dialectical positions, and links to related fields of linguistics and the neurosciences. I believe that it is useful to understand something about the background of the concept, the arguments that have cropped up along the way, and the different perspectives from which thought disorder can be studied and applied. The following review is not intended to be exhaustive but highlights a number of important vantage points along the conceptual pathway.

THOUGHT DISORDER OR SPEECH DISORDER. Psychiatric researchers and psycholinguists have disagreed about the conceptual and terminogical nature of thought disorder. The term “thought disorder” has been widely accepted among psychiatric researchers who view language and speech as representative of thought (Harrow and Quinlan, 1985; Lanin-Kettering and Harrow, 1985; Holzman, Shenton, and Solovay, 1986). Holzman, probably the clearest spokesman for this group, has asserted that language is a transparent medium through which thought is expressed. According to Holzman, since deviant verbal productions of psychotic patients reveal disturbed thought processes, the peculiarities in psychotic communication should be labeled “thought disorders” and not speech or language disorders. Harrow and Quinlan (1985) acknowledged that speech and thought are not necessarily isomorphic with one another and that bizarre communication may, in some cases, be a product of impaired expression of reasonable ideas. However, like Holzman, they believed that their research supported the conclusion that faulty language or speech is generally a result of strange thinking and, hence they, too, favor the term “thought disorder.” Andreasen (Andreasen, Hoffman, and Grove, 1985) also retained the term “thought disorder” in her research; however, she was more troubled by the “conceptual entangling of thought and language” (p. 202). Despite her use of the traditional terminology, Andreasen favored scrapping the term “thought disorder” and substituting terms such as “communication disorders,” “dysphasia,” or “dyslogia” (Andreasen, 1982).

Linguists have typically challenged the assumptions of psychiatric researchers and disputed the empirical basis for equating speech with thought. Chaika (1990), who introduced the term “speech disorder,” accused psychiatric researchers of circular reasoning in claiming that disturbed thinking necessarily underlies disturbed speech. She said that there is no empirical evidence that demonstrates that disordered thinking always produces disordered speech. Although thought is expressed through language, it is a logical fallacy, according to Chaika, to conclude that language is a direct expression of thought. Chaika’s view, echoed by others (Harvey and Neale, 1983), is that language, speech, and thought cannot be equated, and that all that we can study are observable disturbances in speech. Making inferences about the nature of underlying thought processes, based on the quality of an individual’s verbal productions, is unwarranted.

Both Holzman and Chaika agreed that thought disorder and language or speech disturbances can occur independently. Holzman used this finding to argue that since language and speech disorders are separate entities (clinically distinct from psychotic thought disorders), it is reasonable to conclude that the verbal anomalies of psychotic patients result directly from disordered thinking. Conversely, Chaika viewed the independence of thought and language/speech as the basis for concluding that thought is not equivalent with and cannot always be inferred from speech. Chaika reminded us that psychotic thought disorder is not necessarily accompanied by any of the florid speech disorders, nor do any of these automatically indicate disordered thinking.

Regardless of whom one chooses to believe, it is clear that thought and speech are independent and can coexist in a variety of ways. People can either say things strangely, they can say strange things, or they can do both. In other words, people can express logical ideas in the form of bizarre speech, bizarre ideas in the form of coherent speech, or bizarre ideas through the medium of bizarre and deviant speech.

Harvey and Neale (1983) criticized the term “thought disorder,” which they felt was confounded with disturbances in speech and language, and recommended that traditional terminology be replaced with two new categories, one called “discourse failure” and the other, “deviant cognitive processes that relate to discourse failures.” Andreasen’s (1982) terms “dysphasia” and “dyslogia” seem to capture this same division between deviant speech and deviant ideas. This bifurcated view of thought disorder is also suggestive of the distinction traditionally made between thought disorders of form versus thought disorders of content.

Part of the difficulty may be that, by virtue of training and interests, psychiatric researchers and linguists place emphasis on different areas of functioning. Holzman, for example, is a psychologist and psychoanalyst interested primarily in studying underlying thought processes, while Chaika is a linguist chiefly interested in the pragmatic analysis of verbal discourse. Chaika is more concerned with the form of deviant speech, such as disturbances in syntax, semantics, and coherence, while Holzman is concerned as much with the content as with the form. Furthermore, Chaika looks at the formal qualities of deviant speech and entertains a range of possible causative explanations, whereas Holzman assumes that deviant verbalizations and strange ideas reflect disturbed thinking. In essence, Holzman’s approach is consistent with psychiatric and psychodiagnostic methodology, in which one assumes that inferences about underlying psychological structures and organization can be made on the basis of observable behavior. By contrast, Chaika challenges these assumptions and questions the validity of inferring the nature of that which is not available for direct observation.

Despite Chaika’s cogent arguments, there are a number of reasons that Rorschach clinicians will choose to retain the traditional term “thought disorder” to describe deviant verbal productions of psychotic patients. First, “thought disorder” is the traditional term used in clinical diagnostic and treatment settings to describe the deviant verbal productions and peculiar ideas of psychotic patients. Introducing new terminology, such as “speech disorder,” “dysphasia,” or “dyslogia,” may clear up confusion for some; but it would undoubtedly contribute to a further muddying of the water in a more general sense, as clinicians and researchers would now have multiple terms to argue about and use in contradictory ways. Relatedly, all of the major Rorschach thought disorder systems have retained the traditional terminology, making for a shared conceptual language. Even non-Rorschach thought disorder researchers such as Andreasen, who has been quite critical of the term “thought disorder,” has elected to continue using this term. Secondly, psychodiagnosticians spend as much, if not more time, evaluating the nature of patients’ fallacious reasoning and peculiar ideas (often expressed in the context of normal and coherent speech) as they do evaluating the formal qualities of their deviant or bizarre speech. It is unclear how the term “speech disorder” would apply to the kinds of problems in logical reasoning that psychologists encounter on testing. Further, using the term “dysphasia” to describe deviant speech and “dyslogia” to describe strained logic seems somewhat cumbersome. Although intended to increase clarity and precision in clinical thinking, these new terms may actually invite more confusion. To make the distinction between dysphasia and dyslogia, psychologists can instead employ the traditional concepts of disorders in the “form” versus “content” of thought. These more recognizable terms can then be subsumed under the broader heading of either “thought disorder” or “disordered thinking.”

Thus, for the purposes of this book the traditional terminology will be used. Although the terms “thought disorder” or “disordered thinking” are surely flawed and surrounded by a degree of conceptual unclarity, they are the best terms we have to communicate our understanding of commonly encountered clinical phenomena in psychotic patients.

SPECIFICITY: DISENTANGLING THOUGHT DISORDER FROM SCHIZOPHRENIA. From a historical perspective, the psychiatric and psychodiagnostic study of thought disorder has been inseparable from the evaluation and diagnosis of schizophrenia. Up to the mid-1970s, the centrality and specificity of thought disorder to schizophrenia was largely unquestioned (a fact that will be echoed repeatedly throughout this book). Until relatively recently, the work of the Andreasen group (Andreasen and Powers, 1974; Andreasen, 1979a, b) and the Harrow group (Harrow and Quinlan, 1977; Harrow et al., 1980, 1982; Rattenbury et al., 1983) demonstrated convincingly that disordered thinking is as prominent in manic psychosis as it is in schizophrenia. Harrow and Quinlan (1985) found that not only do high levels of thought disorder occur in both manic and schizophrenic patients but that there is no difference in the extent of thought disorder between the two groups. This is an issue that w...