Rorschach and Dementia - Case Example

Summary:

Mr. X is a pleasant 9odd-year-old man originally from Y. He was referred for neuropsychological evaluation in order to evaluate his cognitive and emotional functioning.

During current evaluation Mr. X demonstrated mostly intact orientation, intact receptive language, and largely intact attention. He also demonstrated significant concentration, memory and executive functioning problems and mild problems with expressive language, sensory and motor functioning, and constructional skills. His Romberg was positive indicating difficulties with balance. The results of all seven CERAD battery tests, specifically designed to diagnose dementia, fell in the range consistent with mild-to-moderate dementia. These results fulfill the diagnostic criteria for dementia.

During testing Mr. X demonstrated significant problems with learning new words and remembering visual stimuli. His autobiographical memory was, however, largely intact. He also reported that he keeps up with the news by daily reading of newspapers and watching news programs. This was confirmed by his daughter. Thus, he is still capable of learning things which are emotionally salient and which he has a habit of keeping up with. This pattern of results is typical of patients for whom executive functioning disturbances precede memory loss. Their difficulties with learning are due to a combination of low cognitive energy and concentration problems, which have less effect on emotionally salient and habitual tasks then on novel and artificial tasks used during testing. In conjunction with motor disturbances and constructional deficits being more prominent than language deficits, this pattern of results indicates that subcortical dementia is most likely. Mr. X’s relative reported that he was diagnosed with Parkinson’s disease provisionally when he had several falls over ten years ago. His motor symptoms did not increase appreciably since that time. Given significant history of cardiovascular problems, a vascular etiology of his dementia is the most probable one. An MRI or a CT scan would further clarify the diagnosis.

Mr. X demonstrated no delusions or hallucinations during his current evaluation. His thought process was logical and goal-directed. He demonstrated no significant anxiety or mood disturbance during the interview and no evidence of it was revealed in test results. His insomnia and appetite disturbance are most likely due to his physical illnesses. His presentation does not currently fulfill the diagnostic criteria for anxiety or mood disorder. Given a clear history of significant loss preceding his depressive episode and full remission lasting for over two years, there appears to be no need for retaining this diagnosis.

The results of emotional testing indicate that Mr. X appears less capable of dealing with complex situations due to decreased cognitive capacity, leading to misinterpreting others’ actions and impulsive behavior, especially in emotionally salient situations. He is having difficulties with finding new ways to cope with situations, leading to resorting to inappropriate stock responses or becoming confused and angry. Thus, his increased irritability is largely due to cognitive difficulties associated with dementia. His cognitive difficulties are further exacerbated by misunderstandings caused by language barrier and significant hearing loss. Finally, due to decreased cognitive flexibility, Mr. X tends to perseverate on certain ideas. This may lead to becoming demanding, since it is more difficult for him both to let go of an idea and to understand the explanation why this idea is not a good one.

Diagnostic Impressions:

Axis I Vascular Dementia, Mild, Uncomplicated, with Behavioral Disturbance (290.40)

Axis II None (V71.9)

Axis III from records: hypertensive coronary artery disease with congestive heart failure, aortic sclerosis, mitral calcification, left bundle branch block, left arm phlebitis, Parkinson’s disease, arthritis, osteoporosis, anemia, vertigo, hearing loss, macular degeneration, carcinoma of prostate, dysphagia, gastroesophageal reflux disease, gastrointestinal bleeding, renal insufficiency, history of villous adenoma with collectomy, rectal polyp with polypectomy, glaucoma, neuropathy secondary to spinal stenosis, and insomnia

Axis IV Other

Axis V 45

Significant Features of the Structural Summary

Blends:R = 1 : 17 (7)

R = 17(1) L = 1.43(2)

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EB = 3 : 3.5 (3) EA = 6.5 EBPer = N/A

eb = 0 : 0 es = 0 D = +2 (4)

a:p = 0 : 3 (5) Sum6 = 0

Ma:Mp = 0 : 3 (6) Lvl-2 = 0

P = 3 (8)

X+%=0.53 (9)

F+% = 0.60

X-%=0.29(10)

S-%=0.40(11)

Xu% = 0.18

Zf = 9

Zd = -4.5 (12)

W : D : Dd = 6 : 8 : 3

W : M = 6 : 3

DQ+ = 3 (13)

DQv = 0

3r+(2)/R=0.24(15)

Fr+rF = 0

FD = 0 (16)

An+Xy = 0

MOR = 0

Ratios, Percentages, and Derivations

(1) Slightly lower number of responses is typical for people with decreased cognitive

capacity.

(2) VERY high Lambda - tendency to simplify responses, consistent with low cognitive capacity.

(3) The difference between cognitive and emotional coping resources is less then two - indicates absence of consistent coping style.

(4) Adjustment appears very good (+2), but, if you look at eb, you will see that it is because of a very structured, stressor-free environment, not because of good adaptation.

(5) Rigidly passive coping style (0 active : 3 passive).

(6) Expects others to solve his problems (for human movement responses 0 active : 3 passive).

(7) Low cognitive energy (very few blends).

(8) Low number of conventional responses (this is due to cultural differences in this case).

(9) Low X+% indicates low conventional form (due to distortions - see X-%).

(10) High X-% indicates high percent of cognitive distortions – see below for detailed analysis.

(11) High S-% - distorts reality when angry.

(12) Low Zd - underincorporator - low processing efficiency, ignores details.

(13) Low developmental quality of + - simplistic processing, consistent with low cognitive capacity.

(14) High isolation index - isolated.

(15) Very low egocentricity index - low self-esteem.

(16) No FD responses - no introspection, psychologically naive.

Sequence of Scores

Summary of Approach

Tendency to provide global and somewhat simplistic responses on black and white cards - cognitive style involving simplification; tendency to fragment on color cards - emotional involvement interferes with integration of information.