Correlation between psychological diagnosis (Rorschach Psycho-diagnostics) and clinical diagnosis

Background: A wide acceptance of the Rorschach test is shown in clinical practice and clinicians choose the test not only as a diagnostic instrument but as a therapeutic practice also, sometimes variety of opinion comes from health professionals and the validity of the test result become more challenging. It creates a cognitive dilemma and the clinician has two options: either choice to accept or reject the diagnosis.
Material & Methods: A total 80 cases were selected from the psychiatry ward and written informed consent was taken. Socio-demographical data sheet was applied. Without knowing the history and other diagnostic variables, the Rorschach test was administered to make a psychological diagnosis by a qualified clinical psychologist and the clinical diagnosis was made through ICD-10 DCR criteria by the competent psychiatrist.
Results: Among the participants, 37.5% belonged to 29-39 years age group; 58.75% were male. Most of the study samples were married (71.25%), 32.5% were educated up to 6-10th standard. The majority (38.75%) of the participants were unemployed and 51.25% belonged to rural areas. A majority, ie: 47.5% were in the middle-income group (50-74K) and living in a nuclear family (83.75%). Schizophrenia was the most frequent diagnosis in both categories, 38.75% belonging to the Rorschach diagnosis and 33.75% in the clinical category followed by Depression, mania, anxiety, obsession, psychosis, organic, and conversion disorder. Overall, a high correlation was found between both diagnostic categories (X2 =4.1, P=0.75). 
Conclusion: The findings of the study suggest that a high level of correlation was found between clinical diagnosis and Rorschach psycho-diagnosis.


INTRODUCTION
A wide acceptance of the Rorschach test is shown in clinical practice and clinician choose the test not only as a diagnostic instrument but as a therapeutic practice also, sometime variety of opinion comes from health professionals and the validity of the test result become more challenging.4,9It creates a cognitive dilemma and the clinician has two option, either choice to accept or reject the diagnosis10,11.Diagnostic instrument Rorschach test has been established as a major diagnostic tool in projective tests.The test itself assesses the structure of personality where it largely occupies the unconscious mind [1] .The test is language and culture-free; so this specialty enhances their area of acceptance and gains popularity among mental health professionals [11,12,13,14,15] who work with different demographic populations [2] .Clinical psychologists, who enthusiastically work in clinical settings, frequently utilize the test for diagnostic clarity [9,10] .Differences of opinion always happen between clinicians and it is obviously because of the subject matter (behavioral science), that time clinicians refer to the client for the Rorschach test to justify the validity [3] .So the test not only makes the diagnosis, moreover, it also establishes the validity.
Rorschach test has many scoring system like-Beck, Rappaport, Klofer and Exner.Every system has its approach and explanation without the major differences; they largely focus on validity so clinicians are not bound to use any particular scoring system for qualitative assessment.Regarding the administration part, clinicians take the response from the client by showing him/her to unstructured card where the clinicians write every response on a response sheet.In the inquiry phase, they eager to under-Rajesh Kumar

Study design
Descriptive, cross-sectional, hospital-based study

Study Settings
Tertiary care hospital, BPKIHS, Dharan, Nepal Subjects: 18 years and above referred for psychological assessment during the study period.A total 80 patients were selected on the basis of inclusion and exclusion criteria.

Sample Size:
All consecutive cases enrolled who meet the study criteria over a period of one year (expected at least 80 cases).

Study period:
One year (After the approval from the research committee)

Ethical clearance:
Ethical clearance has been taken from the Institutional Review Committee (IRC) under the Dean, Academics of BPKIHS, Dharan.

Data Collection Techniques/Methods:
1. Total 80 potentially eligible patients who fulfilled the inclusion and exclusion criteria, 18 years and above admitted to the ward, and referred for psychological assessment were enrolled in the study.(Appendix-1)2. Written informed consent was taken before enroll ment of the subject, (Appendix-2) 3. Socio-demographical profiles (Age, sex, ethnicity, occupation, education, geographical areas, etc.) were noted down using a semi-structured proforma developed for the study.(Appendix-3)4. For psychological diagnosis 'The Rorschach Psycho-di

Table 1:-Showing the socio-demographic variables of selected probands
stand the response to what the client has said in their words, according to the basis on the response, clinicians justify the location.In the context of determinant and content categories, they rationally obtained through the help of a manual [16] .ICD-10 diagnosis is made by a competent psychiatrist and the Rorschach test is administered by a qualified clinical psychologist.When orphan, abandoned, and custodial patients come; they are referred for a Rorschach test for diagnosis, after the test, real picture of their personality comes [6,7] , and they send for further management.The present study tries to find out the correlation between the clinical diagnosis as well as the psychological diagnosis, which was drawn from the Rorschach test.

DISCUSSION
The present study highlighted the correlation between both diagnostic categories; some diagnostic entities have a better correlation where some have marginal differences like-psychosis, mania, organic, and conversion.The psychosis category has many clinically diagnosed cases where wider differences have been seen [18] .This can appear due to the symptoms profile of the patient who was admitted to the ward and referred for diagnostic clarity.The Rorschach test segregated those potentially eligible for other diagnostic categories and the rest of the genuine cases were kept in the same place because the Rorschach test diagnosed the case through structure abnormality [17] .
The study also highlighted that married (71.25%) and the person who living in nuclear families (83.75%) are more prone to develop mental illness, although the limitations are quite justifiable because the selected cases were only sent for the Rorschach test and mostly were married and living in nuclear family.
High correlations were found in the other diagnostic categories like schizophrenia [20] , depression, anxiety, and obsession where the diagnostic variables were identified by the clinician as well as the Rorschach test, so diagnostic sensitivity has increased and reliability become more strengthened [19] .
This study has proven that the Rorschach test is the better option in clinical settings when diagnostic dilemmas occur and clinicians may choose this test for better outcomes.The major strength of this test is that we can find a reliable diagnosis who matches with the clinical diagnosis, which will be more impactful [17,18] .It is also useful in those patients who do not explain their symptoms well 'sometimes it may be a cause of negative symptoms' and the family member or an informant also does not know about him.
A study done in Nepal at Bharatpur (College of Medical Science, teaching hospital) has also found an almost similar correlation where the major category of diagnosis was schizophrenia and psychotic depression, on the other hand, psychosis has a low correlation [19] .

LIMITATION
The result drawn from a small sample size cannot be generalized.The second limitation is that this particular research is based on the Beck system and all cues and determinant keys are used from that manual only.Sometimes, professionals do not convince to support the old method because numerous new methods were available and they were more inclined to choose them.
Thirdly, the test itself has some limitation; there were limited diagnostic category where we cannot choose diverse diagnostic entity therefore only some major diagnosis has been mentioned in this study.
The fourth limitation is that when the patient visits psychiatric OPD, the consultant psychiatrist write the prescription and send it to the psychiatry ward, where some needy patient refers for a Rorschach test meanwhile they take the medication, therefore some of the symptoms might disappear and eventually diagnostic sensitivity of the test might be reduced.So it's ultimately affecting the diagnosis accuracy.

RECOMMENDATION
A good sample size can predict valuable as well as valid outcomes and timely assessment may be projecting better correlation for diagnosis and newer methods of the test can accentuate better and more acceptable findings.
Some possible biases always come when we work on human behaviour and their weird software, It keeps changing the dynamics which may affect any steps during research or it can be influenced through both side which impede repercussion [10] .
The present study highlighted the diagnostic accuracy between both diagnostic categories; it is quite obvious in clinical settings to discuss these issues very frequently between professionals.A variety of challenges always occur to make a valid and accurate diagnosis skilled professionals who have that kind of aptitude as well as potential clinicians are mandatory for this test [9,10] . 1

Table no .
1 shows that 37.5% of cases belonged to the 29-39 years age group; in addition, 15% of patients similarly referred to both age groups 18-28 and 51-61 years.Males outnumbered females and their percentage was 58.75%.
test, it was almost half.The 2.5% clinically diagnosed sample falls under Obsession whereas 3.75% of the subject belongs to the Rorschach category.In another category 2.5% Organic sample refers to clinical diagnosis and 1.25% of the subjects are related to Rorschach diagnosis.Finally,