Disordered Thinking and The Rorschach: Theory Research And Differential Diagnosis (Book Review)

Author:  Kleiger, James H.
Publisher:  Analytic Press, 1999
Reviewed By:  Leonard Handler, Spring 2003, pp. 42-45

I would not say that Kleiger’s volume is a book you cannot put down. Indeed, I had to put it down frequently to ponder its complexities, so richly provided by Kleiger. It is a textbook, a reference book, a history book, and a clinical treatise, all combined in one well-executed volume.

Kleiger prepares the reader quite well for the difficult task ahead to comprehend the very complex but immensely interesting material to be presented. The study of thought disorder and thought disordered thinking on the Rorschach has been made rather difficult, he states, because of the wide range of terms used by various theoreticians and researchers to describe somewhat similar processes of disordered thinking, and because of the lack of clarity of the definitions of the terms used to describe disordered thinking, the use of a variety of conceptual systems, and the presentation of each category as unitary and discrete. These problems, and several others in the study of thought disorder on the Rorschach, make the topic quite complex.

Nevertheless, Kleiger has been very successful in his efforts to explain and clarify much of the material in this area. His book is a very impressive, clearly written volume, filled with many clinical examples. Almost anything and everything you might want to know about this topic is discussed somewhere in Kleiger’s well-organized and executed volume. I believe it will be a sourcebook on the topic of disordered thinking and the Rorschach for many years to come because it brings together a discussion of theory, clinical data, and research from a wide variety of sources.

What is even more impressive is Kleiger’s excellent ability to integrate all this diverse material. After a well-organized exploration of the concept or issue presented in each chapter, Kleiger provides a detailed interpretation and summary of the material in the chapter. While many authors provide chapter summaries, Kleiger’s summaries are even more impressive because of the way he considers a number of factors in the integration of findings in the summary. He does not merely summarize research findings, but rather, the studies are examined in the light of methodological difficulties, variations in method, differing criteria for inclusion of subjects, as well as variations in test technique, before any research summary is provided. Kleiger provides an integration of the research after he considers possible similarities and differences in findings, making diverse findings more understandable. Here Kleiger is especially helpful; he highlights differences in findings so that the reader can understand why they are obtained across studies and why research findings in some cases might differ from clinical findings on the Rorschach.

Kleiger provides a detailed review of the literature; indeed, his scholarship is impressive. His bibliography, for example, spans 30 pages; it is quite varied and yet very inclusive. He even includes references on aphasia and neurological issues in thought disorder, material on creativity, adaptive regression and intense religious experience, art history, post-traumatic stress disorder, diagnostic issues in borderline thought disorder, the mind and memory, the history of psychiatry, the MMPI, the TAT, as well as the prerequisite Rorschach literature and literature on psychoanalytic theory. In the latter area he includes material, for example, from Freud, Hartmann, Kernberg, Kohut, Kris, Schafer, Mahler, Pine, Rapaport, Schafer, Sullivan, Werner, and Winnicott. As an example of how inclusive Kleiger is in the consideration of his topic, he samples information from the following: A book by Eiduson, Scientists: Their Psychological World (1962); Ellman’s James Joyce (1959); Fuster’s, The Prefrontal Cortex (1980); a volume by Goertzel and Goertzel (1980), Linus Pauling: The Scientist as Crusader; Koestler’s (1964) The Act of Creation; Ernst Kris’s (1952) classic, Psychoanalytic Explorations in Art; and Werner’s (1952) classic, Comparative Psychology of Mental Development, to name just a few sources.

One reading of this volume does not do it justice because it is not possible to digest all the necessary subtleties and nuances of the data presented. Each thought disorder concept requires detailed exploration and examination, and Kleiger provides such discussion in the text. Indeed, he deconstructs each thought disorder concept he presents, demonstrating that each one is not a unitary concept, as there is considerable overlap with other related concepts and because the definition of each concept, as it has been described and used, varies considerably.

Kleiger explores the similarities and differences among concepts that appear, on the surface, to be discrete, yet are not, as well as concepts that appear to be different, but are not. He reviews the work of numerous theorists, each of whom proposed their own system of classification of Rorschach thought disorders, and he examines the similarities and differences among their systems. Kleiger examines the strengths and weaknesses of each system in reference to the others. He presents these systems in a fair and even-handed manner, without undue criticism.

In my opinion, the very last chapter of the book should be read first because I believe it would help the reader wade through the various systems of conceptualization and measurement of thought disorder presented in the book. In this chapter Kleiger categorizes approaches to the use of thought disorder in the Rorschach. He differentiates three levels of approach, the Global Sign approach, the Differential Diagnostic Sign approach and the Conceptual approach. Each approach is said to represent “a more complex, comprehensive, and differentiated approach than the previous one, and each subsumes the strategies of the former” (p. 347). Kleiger describes the Global Sign approach as binary and descriptive, focusing primarily on presence or absence in which thought disorder is represented as a “static unity that exists in an ‘all or nothing’ form” (pp. 347-348). The Differential Diagnostic Sign approach resembles the Global Sign approach but it goes a bit further in its emphasis on “the qualitative differences in ‘thought disorder profiles’ between different types of diagnostic entities” (p. 346).

The Conceptual approach is characterized by “efforts to flesh out the meaning of thought disorder signs for an individual’s adaptation” (p. 347). The emphasis of this approach is not on differential diagnosis, but “Instead, conceptual approaches seek to broaden the understanding of intrapsychic and interpersonal implications of different types of thought disordered responses. The search for a deeper meaning and a broader understanding of what these responses suggest to us about how a person might think about herself, relate to others, or perceive his therapist is what interests clinicians the most. This is…the approach I found most lacking in the literature and the approach I wanted to emphasize in this book” (p.347).

In addition to the above conceptual model, Kleiger-the-clinician rather than Kleiger-the-academician is heard more loudly here than anywhere else in the book. He decries the present-day situation in which the expenditure of more time to think through and conceptualize material is a luxury:

In our current professional climate with its zeitgeist of fast and furious clinical work, where all of us are pressured to do less with each patient we see, an approach that emphasizes careful and in-depth understanding of an individual’s thought processes might seem anachronistic. Yet it is precisely for this reason that an approach that values careful diagnostic assessment of psychological functioning and seeks to understand subtlety of meaning is critically important. Broadly speaking, the erosion of meaning and appreciation of complexity in the field of psychodiagnostic assessment is a grave threat not only to the profession but to the dignity and worth of the people we serve. The conceptual approach is important because it reflects the inherent value of thorough diagnostic understanding” (p. 348; italics mine).

Volume Content

The book is divided into four sections. Part 1, Conceptualizing Thought Disorder, examines the conceptual definitions of the phenomenon of thought disorder and the history of Rorschach approaches to the measurement of disordered thinking. To give the reader a glimpse of how Kleiger necessarily casts a wide net in his conceptualization of thought disorder, note the following quote:

A more comprehensive definition of thought disorder would be one that encompasses a broader perspective [compared with traditional definitions] 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 discrimination of internal perceptions from external ones. Such a definition comes closer to capturing the multidimensional nature of disturbances in thought organization (p. 6).

In Part 2, Kleiger focuses on an extensive list and description of thought disorder systems in the literature, including the seminal work of Rapaport, Robert Holt’s Primary Process Scoring System, the Thought Disorder Index (TDI) by Johnson and Holzman, Exner’s Special Scores and Schizophrenia Index, with an entire chapter devoted to lesser-known scoring systems. Each system is described in detail, including modifications made by later contributors. For each system, Kleiger includes a critique, emphasizing both its strong and weak points, often including valuable suggestions for improvement. The chapters in this section are a goldmine for researchers and practitioners alike because of their completeness, thoroughness and because of Kleiger’s informed and unbiased perspective.

Part 3, Conceptual and Theoretical Underpinnings, consists of Kleiger’s efforts to organize thought disorder scores into conceptual frameworks, including Pine’s “pluralistic psychoanalytic model” and progressing to a detailed study of the meaning of the major scoring categories. In this five chapter section Kleiger examines the ways in which researchers have attempted to link Rorschach thought disorder systems to underlying theories of mental functioning. However, Kleiger does much more in this section. He reviews the wide range of disordered thinking categories, devoting separate chapters to confabulatory thinking, combinative thinking, contaminated thinking, and paleologic thinking. In these chapters, which I consider to be the heart of the volume, Kleiger discusses the often confusing Rorschach thought disorder categories, problems in semantics and the various subtle dimensions of each category. For example, in the chapter on confabulation Kleiger states:

Confabulatory thinking is generally taken as an indication of cognitive impairment or thought disorder…Verbal confabulation implies a filling in of gaps or erroneous overgeneralization from part to whole, leading subjects to form sometimes far-reaching conclusions based on inadequate data. However, a number of conceptual and semantic issues have made the term more complex and difficult to understand and have contributed to confusion, controversy, and a lack of clarity when attempting to discover the meaning and clinical implications of the term ( p. 170).

Kleiger presents confabulation as a continuum and then indicates the possible diagnostic implications of the different confabulation levels. In this regard he states:

Rorschach confabulations can be excessively broad or excessively narrow in scope. They might involve the unfolding of a dramatic elaboration or a lengthy tangential or circumstantial commentary, on the one hand; or they may be crisply overspecific, on the other. Subjects may tell stories, with a beginning, middle, and end, or they may leap to one-or two-word conclusions that are absurd in their degree of specificity.

The overly specific confabulation is characterized by the inappropriately precise identity assigned to the image. [It] may be a brief response, quite different from the typically longer and more verbose ideationally embellished responses. For example, the Card VII response of “A Schnauzer, looks to be a female about three years old” doesn’t reflect excessive thematic, affective, or fantasy embellishment. The content is unremarkable and rather prosaic in nature, but it is inappropriate because the subject has provided specificity far beyond what the blot could justify. Overspecific confabulations with ordinary form level may reflect a situation in which an obsessional subject’s internal press for exactitude leads him or her to read inappropriate meaning into an event, revealing a need to be right and overly precise…Overly specific confabulations with poor form level become absurd responses, as exemplified by the following psychotic-level Card III response, “This here looks a lot like my grandfather, like parts of his stomach” (p. 182).

In addition, Kleiger points out, there are a number of content variables in the consideration of confabulation, classified in terms of whether the elaboration involves primarily thematic, affective, fantasy material, or some combination of these, or in terms of the tone or theme of the content (e.g., morbid, fusion, malevolent, magical, playful). Kleiger gives several examples here:

The response to Card III, “Two women who have just finished doing the wash together; they’re tired but will probably plan to rest awhile before going out to get something to eat” tells a story. There is little explicit affect and the story is grounded in realistic events…On the other hand, the Card II response “It looks like two fighters, really pissed off at each other, fighting to the death, bloody, pummeling each other into the ground until the loser cries out in agony. God what a mess!” exudes highly charged aggression. Although interpretively inappropriate given the stimulus, the response content itself is anchored in realistic concepts. In contrast, although the following…example…is excessively thematic and carries an explicit affective charge, it is characterized primarily by its departure from reality and immersion in fantasy. “It looks like a meeting of two, um…dragons who are comparing swords…or who are each so self-absorbed in themselves they’re ignoring each other and doing a hell-like, hellish…demonic…dance of the under-world… or they’re just staring at each other on rollers or standing on clouds, kind of pink clouds”. The specific content of the confabulation can reflect a theme or tone of malevolence, symbiosis, magic, or playful humor. Obviously, each of these, together with the degree of confabulation (mild, moderate, or severe) and the form level (-, u, o/+) may provide further interpretive or diagnostic clues…A severe confabulation with poor form and malevolent thematic content might suggest a psychotic process associated with both misperception and misinterpretation of a paranoid nature. One might also infer that this individual will exhibit marked perceptual impairment along with overly inferential thinking in the context of situations in which some external threat is identified. Hallucinations and paranoid delusions might be suggested by this type of confabulation. Similarly, a moderate level of confabulation anchored in adequate form and associated with merger fantasies might indicate heightened oversubjectivity in the context of symbiotic wishes (p. 184).

What follows in this chapter is a discussion of schizophrenic confabulations, manic confabulations, borderline confabulations, and PTSD confabulations.

The next chapter, Combinative Thinking, begins with a discussion of the psychological underpinnings of non-pathological combinative thinking, which is necessary, Kleiger indicates, in order to understand deviant combinative thinking. Here, too, Kleiger identifies a continuum of pathological combinations, mild (improbable or unlikely); moderate (impossible in reality, but without violation of body boundaries or boundaries between animate and inanimate objects); and severe (absurd or bizarre; impossible combinations in which there is a violation of either body boundaries or the boundary between animate and inanimate objects). The richness of Kleiger’s work is here no better illustrated than when he links concepts of parataxic and preoperational thinking to pathological combinations, and indicates that they have in common superstitious, egocentric, and correlational thinking.

Kleiger informs us that combinative thinking occurs in a wide range of clinical and normal subjects. He cautions:

Because of the ubiquity of combinative thinking across the diagnostic spectrum, it is important to avoid a rigid sign approach when considering diagnostic implications of fabulized and incongruous combinations. With the possible exception of manic conditions, the diagnostic specificity of both combinative scores is suspect. Several additional factors must be weighed before making premature links from combinative scores to diagnostic conclusions. Form level, intactness versus impairment of boundaries between adjacent objects, absurdity/ bizarreness of the combination, thematic content of the combination…and distance taken from one’s response are all critical factors that need to be considered when evaluating the diagnostic significance of a pathological combination (p. 204).

In the chapter on contaminated thinking, Kleiger also discusses a range of severity. He indicates that Contaminations can be classified as verbal (e.g., “bug-ox”; “pig-people”, where a person sees a bug and an ox, or a pig and people, in the very same area, and fuses the percept); perceptual, such as the simultaneous presence of two incompatible views of the same object; conceptual, based on “the merging or simultaneity of conceptual categories (without perceptual fusion or verbal condensation” (p. 214).

Kleiger indicates that contaminations have typically been viewed as a pathognomonic sign of schizophrenia, but that in the examination of the literature contaminations occurred in only about 16 percent of the schizophrenics. Although contaminations are extremely rare, and have low diagnostic sensitivity, they have high specificity. Contamination responses typically yield a false positive rate for diagnosis of schizophrenia of less than one percent, but a false negative rate for the diagnosis of schizophrenia of about 85 percent.

The final chapter of this section, Paleologic Thinking, concerns autistic thinking, in which inappropriate generalizations are made from contiguity. While paleologic thinking, at its worst, may be the source of psychotic delusions, there are certainly milder and more normal forms of such thinking, such as stereotyped thinking, and coincidental thinking (basing conclusions on circumstantial factors; e.g., where there’s smoke there’s fire).

In Part 4 Kleiger discusses differential diagnosis of Rorschach thought disorder, including pathognomonic signs of schizophrenia, schizotypal personality, schizoaffective disorders, affective disorders, depression, borderline syndromes, as well as issues involved in differential diagnosis, and discusses Rorschach thought disorder associated with a wide range of other conditions, such as PTSD, dissociative, delusional, obsessive-compulsive, and brain disorders.

A very important chapter in this section is titled, Creativity or Disordered Thinking? in which Kleiger examines the issue of whether creativity might be confused with disordered thinking. He concludes that creative people have greater access to primary process material, which is reflected in their Rorschach protocols. He states:

We would not be surprised to find primary process content, formal signs of thought disorder, and lower form level in the records of creative individuals. However, we would also not expect to find evidence of more severe indices of disordered thinking. Thought disordered responses, when they were given, would be milder and occur in the context [of] containment and control, benign or creative thematic material, and possibly some good Ms. Creative individuals are distinguished by their abilities to play with primitive ideas and unconventional forms of logic while simultaneously demonstrating a number of critical ego strengths (pp. 339-340).

Kleiger concludes this chapter with a description and discussion of the Rorschach of Linus Pauling, the scientist who won two Nobel Prizes, in an effort to separate creativity from psychopathology.

I will close this already too long review with a final quotation from Kleiger, which illustrates the complexity of his chosen subject, thought disorders in the Rorschach:

Although there are broad guidelines for associating certain types of scores with certain diagnoses or meaningful interpretations, there is clearly no isomorphic relationship that exists between scoring type and implication. Consider, for example, that different people can produce confabulations or combinatory responses for different reasons. Diagnostically, they may be bipolar, borderline, traumatized, or suffer from some combination of the above. Likewise, the meaning of these processes may differ from one person to the next. On the other hand, one individual may produce a variety of thought disorder signs/scores for essentially the same reason (pp. 352-353).

I would like to personally thank Dr. Kleiger for his valiant and quite successful attempt to deconstruct the topic of thought disorder on the Rorschach; he has helped to clarify a very complex area for me. His book is an excellent example of a W+.

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