THE DIAGNOSIS OF SOMATIC DISORDERS USING MODERN MEANS OF PSYCHOLOGICAL TESTING

Абакарова Э.Г.

ORCID: 0000-0002-9798-1735, кандидат психологических наук,

Ставропольский государственный медицинский университет, г. Ставрополь

ДИАГНОСТИКА СОМАТИЧЕСКИХ РАССТРОЙСТВ СОВРЕМЕННЫМИ СРЕДСТВАМИ ПСИХОЛОГИЧЕСКОГО ТЕСТИРОВАНИЯ

Аннотация

Быстрый рост современного развития и социального взаимодействия является причиной эмоциональной нестабильности, которая приводит к психосоматическим расстройствам как у взрослых, так и у детей. Установить соотношение между соматическим заболеванием и психологической причиной или внутренним конфликтом относительно сложно. Не смотря на то, что психологи имеют в своем распоряжении целый арсенал методик, современные психологические тесты не могут быть использованы для постановки диагноза. Тест «Птица» (E.G. Abakarova, 2014) был разработан с целью определения вытесненной боли, которая может отражать причину психологической травмы. Диагностика состоит из двух этапов. Первый включает в себя рисование и описание птицы, а второй - описание пациентом своей истории болезни с рождения до настоящего времени. С помощью теста «Птица» было исследовано наличие психосоматических заболеваний у 54 студентов-медиков и 20 клиентов психолога, проходящих психотерапию. Результаты, полученные с помощью теста «Птица», выявили несколько групп психосоматических расстройств: травмы конечностей, заболевания опорно-двигательного аппарата, черепно-мозговые травмы, болезни глаз. Анализ данных продемонстрировал высокий уровень надежности при сравнении психосоматических расстройств и мест локализованных областей травмы на рисунках птицы. Согласно анализу изображений, описаний и медицинских историй, некоторые из травм и болезней, которые испытывали опрошенные, произошли после семейного конфликта или негативных психоэмоциональных событий. Именно эти повреждения были отражены в соответствующих местах на изображениях птиц. Новый проективный тест «Птица» Абакаровой Э.Г. имеет широкие прикладные возможности. Данная методика полезна в психологическом консультировании, психотерапевтической работе, а также диагностике психосоматических расстройств хронического генеза.

Ключевые слова: психосоматические расстройства, тест «Птица» (Абакарова Э.Г.), травмы конечностей, заболевания опорно-двигательного аппарата, черепно-мозговые травмы, болезни глаз.

Abakarova E.G.

ORCID: 0000-0002-9798-1735, PhD in Psychology,

Stavropol State Medical University, Stavropol, Russian Federation

THE DIAGNOSIS OF SOMATIC DISORDERS USING MODERN MEANS OF PSYCHOLOGICAL TESTING

Abstract

The rapid rise of modernity and public interaction is a cause of emotional instability, which can lead to psychosomatic disorders in both adults and children. Establishing the relationship between somatic illness and a psychological cause or internal conflict is relatively difficult. Although psychologists have an entire arsenal of test methods at their disposal, modern psychological methods prevent them being used to make a definitive diagnosis. The Bird Test (E.G. Abakarova, 2014) was developed to displace pain from the body and any pre-existing psychological trauma. The method comprises two stages. The first involves drawing and describing a bird, and the second a description by the patient of his or her medical history from birth to date. At the time of writing the Bird Test had been used to investigate psychosomatic illnesses in 54 medical students and 20 walk-in adult psychological patients. The data obtained via the Bird Test to date has shown several groups of psychosomatic disorder: limb injuries, locomotor conditions, head injuries and eye illnesses. Analysis of the Bird Test demonstrated a high level of reliability in the comparison of psychosomatic disorders and the illustration of localised areas of injury or illness on drawings of a bird.  According to the analysis of the pictures, descriptions and medical histories, several of the injuries and illnesses that the test subjects had suffered occurred after family conflict or negative psycho-emotional events. It is specifically these injuries that were reflected in the corresponding locations in the pictures of birds. E.G. Abakarova's new method of projective testing, the Bird Test, has a wide range of potential applications. The test is also useful during psychological consultations and psychotherapy with patients, and in the diagnosis of psychosomatic disorders caused by chronic conditions.

Keywords: psychosomatic disorders, the Bird Test (E.G. Abakarova), limb injuries, locomotor conditions, head injuries, eye illnesses.

Introduction

The rapid rise of modernity and public interaction is a cause of emotional instability, which can lead to psychosomatic disorders in both adults and children. Recent research has led to Somatic Symptom Disorder, formerly known as Somatoform disorder, to be classified as a category of disorder in a number of diagnostic schemes of mental illness, including the Diagnostic and Statistical Manual of Mental Disorders (latest version DSM-5), which is used by most mental health professionals in the United States [1]. An illness is classified as psychosomatic if it results from emotional states such as anger, anxiety, sadness, depression, interest, fear, joy and guilt. Other sources of psychosomatic illness can be any psychological trauma, conflict or tragedy, or indeed any happy event that results in a sharp change in the overall emotional background. These and similar events can lead to an onset of illness that results directly from the stress which has been endured [2].

The history of psychosomatic illness has seen numerous well-known conditions, among them bronchial asthma, allergies, false pregnancy and migraine, classified as “hysterical”, only to be removed from the list. However, it remains true that the work of a psychotherapist can help the patient to overcome his or her illness, which implies that, in cases where the patient has experienced psychological trauma, the illness is psychosomatic in nature.

Establishing the relationship between somatic illness and a psychological cause or internal conflict is relatively difficult. Although psychologists have an entire arsenal of test methods at their disposal, modern psychological methods prevent them being used to make a definitive diagnosis. Psychological tests do help doctors to better understand certain aspects of the patient's personality, improving treatment, and the information they provide is of assistance in determining the most effective form of treatment and therapeutic action. The evaluation and comparative analysis of psychological markers during treatment offer ways to adjust treatment when the patient has not made the progress hoped for.

A large number of psychological tests are used in the diagnosis of psychosomatic disorders. Some are based on self-evaluation on the part of patients, while others are projective tests. Reference to projection is a principle at the heart of the methodology behind all projective tests. Freedom in answering, with no judgement of results as “Good” or “Bad”, is also a necessary condition.

According to I.G. Malkina-Pykh [3], the Rorschach Test [4], Szondi Test [5] and Thematic Apperception Test (TAT) [6] are widely used in work with psychosomatic disorders in Russia. In these tests the patient either freely creates a drawing using the information he or she is given or finds meaning in selected pictures. The unforced answers are thought to enable the observer to evaluate the mechanisms and quality of the patient's thought processes, feelings and sensations, as well as how the patient perceives the real world.

In the Rorschach Test the patient examines ten symmetrical figures presented as “ink blots” and describes what he or she sees in them. However, the value of its use in psychoanalysis has become doubtful since it became widely available online [7, 8], restricting its application among active internet users and the well-educated in many countries.

The Szondi Test consists of 48 standardised cards featuring images of the psychologically ill (homosexuals, sadists, epileptics and those suffering from hysteria, catatonic schizophrenia, depression and mania), the majority of which were taken from German psychopathology textbooks. The cards are divided into six series of eight, with each series having one representation of each of the disorders. The patient chooses the two he or she likes most and the two he or she likes least from each series, and repeats the exercise six times in order to ensure reliable results. The Thematic Appreciation Test, meanwhile, has a series of cards with different subjects. The patient makes up and recounts a story to accompany them, expressing the thoughts and feelings of all the characters illustrated.

It is worth noting that interpreting the results of these tests is not easy, given the wide range of possible variations. The results must be used with rigour and care even in routine psychotherapeutic work, and even more professionalism is required of a psychodiagnostician using the tests to establish the nature of a psychosomatic disorder. In addition, the keys to the tests are widely available, which serves to further reduce the reliability of the results.

Among the projective tests which do not make use of prepared cards, but ask the patient to draw freely, the most popular in common use in the diagnosis of psychosomatic illnesses are the Draw-A-Man Test (F.L. Goodenough, 1926) and its later adaptations. Goodenough developed a scale which enables the observer to assess 51 elements of the drawing. In 1963 her test was modified by Dale Harris, in whose Goodenough-Harris Drawing Test men are asked to draw a woman after finishing their own drawing. Harris greatly simplified the way that the results were interpreted: the patient's drawing is compared as a whole to a master scale of 12 versions of a drawing. The test was created by Harris as a projective method of investigating personality [9].

The methods outlined above create a “psychophysical” portrait of individualism based on the recipient's impressions of his or her own body. Comparing the structure of the traits of character that the therapist provides with the patient's self-image creates a wider, objective perception of the respondent as a whole. Analysing the different areas of the patient's drawing, its shape, the development of its muscular and structural accents brings us closer to an understanding of essence of a personality and the relationships between its psychological and physical manifestations.

A range of important and universal criteria used to describe a person and create a psychological portrait have been found by analysing samples of test drawings “of yourself”:

1. The level of adherence to stereotypes in the drawing. In the overwhelming majority of cases the accent is placed on parts of the face (the eyes), ignoring the extremities (fingers); figures are static and heavy, in identical positions (facing the viewer), with shortened torsos and extremities; and emotional expressions and feelings are either entirely absent or present only as a perfunctory smile.
2. Aesthetic character. Bodies are roughly drawn, without due attention. Women tend to concentrate their efforts on the face (eyes and lips) and clothes, while the entire body is more important for men, and boys demonstrate strength. Portrayals of plasticity and a dynamic, “flying” person are rare; more common are “soldiers” – arms straight down, legs together – and “policemen”, with arms hidden and legs apart.
3. Awareness of body congruence. The head and limbs are not, as a rule, balanced, and proportion and size are not adhered to. Only artistically gifted respondents with well-developed fine motor skills pay attention to detail. The majority produce short, cut-off fingers, or no fingers, cut-off feet and a straight, hard back.
4. Level of reflection. As a rule, the drawing are not personal. Test recipients generally concentrate on existing norms when drawing themselves rather than on conveying their inner world. Personal motifs are present in the desire to look good in the eyes of future viewers, and thus test subjects use their imaginations more to hone the detail of their clothes than to attempt to portray the fine grain of their personalities.

The aim of this study was to determine the spectrum of detection of psychosomatic disorders using a projective the Bird Test.

Material and methods

The projective drawing is considerably more convincing in identifying disfunction in people who have undergone psychophysical treatment. Not all patients are able to express themselves verbally, which has resulted not only in opposition certain tests, but also in a degree of scepticism to the results of such tests. Projective tests are evaluated by comparing areas of tension on the body and in the drawing, and by any real pain or discomfort the patient experiences in different areas of the body.

“Tension” zones can be identified in the person drawn. The test respondent unconsciously captures and draws parts of the body in such a way that both mental and somatic disfunctions are visible in the overall style of the drawing. Of course, it is not possible to make a direct comparison in every case. The quality of the diagnosis depends  on the respondent's ability to draw, his or her comprehension of the task being set, and the psychotherapist's experience in observing and sensing individuality. For this reason  drawing tests are really just one facet of a wholistic approach to evaluating a person's functional state. They cannot be used to make an objective and trustworthy diagnosis.

Their limitations notwithstanding, the projective tests outlined above do partially reflect psychosomatic conditions. The Bird Test (E.G. Abakarova, 2014) was developed to displace pain from the body and any pre-existing psychological trauma. The method comprises two stages. The first involves drawing and describing a bird, and the second a description by the patient of his or her medical history from birth to date. The instructions to the patient are as follows: “Draw a bird, either one you have seen at some stage or an imaginary one, on the sheet of paper. Once you have done that, write a few sentences about the bird.” During the second stage the person taking the test either writes his or her medical history on the reverse of the test sheet or chooses from a list of illnesses – chronic respiratory illnesses (rhinitis, sinusitis, bronchial asthma, allergies etc.), endocrine disorders (obesity, goitre, diabetes etc.), disorders of the locomotor system (rheumatoid arthritis, osteoporosis, osteomyelitis, osteoarthritis etc.), blood, cardio-vascular, skin and oncological illnesses, joint injuries (bruises, fractures, dislocations etc.), problems in the digestive tract (poisoning, gastritis, duodenal ulcers etc.), skull and brain injuries and others. The psychosomatic aspect of the disorder is revealed by comparing the three parts of  the test.

Results

Abakarova's method has been used to support the psychological well-being of medical students for more than two years. In addition to identifying psychological tension, the Bird Test has reliably identified psychosomatic disorders in all its subjects (p=.05).

At the time of writing the Bird Test had been used to investigate psychosomatic illnesses in 54 medical students and 20 walk-in adult psychological patients.

During analysis, the main parts of the test respondent's body were compared with those of the bird he or she had drawn. The bird's head and neck were compared with those of the patient, the wings matched the patient's arms, the body and feet were compared with the patient's, and the bird's tail stood for the sexual organs (the state of the libido). The features of the head were compared as follows: the bird's eyes to the patient's eyes, the bird's beak to the patient's mouth, the bird's nostrils to the patient's nose. Other elements were examined separately; they include claws, feathers, tuft, spurs, webbed feet, comb and ears, as well as the bird's colouring.

The unity of the drawing and the bird's name (if present) was looked at in the written part of the test. Whether the bird is real or imaginary (a firebird) was noted. In some cases the patient was unable to name to the bird, but the observer was able to identify it because the patient had included its habitat, size and habits in the description. The analysis of the description then moved to the character, mood and health of the bird. The patients described their birds' characters using words such as “proud”, “loyal”, “unusual”, “diabolical”, “vengeful”, “friendly” and “strong”, among others. The test subjects were given traits, including timidity, food preferences, happiness, fatigue, intolerance, freedom and dependence.

Once the drawing and the description had been analysed, the results were compared with the patient's medical history. If necessary, the patient was asked to add details such as dates of illnesses and injuries. This helped to identify the psychosomatic aspects of the illnesses and injuries that were illustrated in the drawing and listed in the lifetime medical history. Occasionally the injuries identified were so old that patients had difficulty remembering the dates.

The data obtained via the Bird Test to date has shown several groups of psychosomatic disorder: limb injuries, locomotor conditions, head injuries and eye illnesses.

The psychosomatic nature of limb injuries was drawn as dashed lines, firm corrections or unevenly rendered parts of the birds' feet and wings. In some cases the limbs were entirely absent, as if the patient had forgotten to draw them. Later conversations with the test subjects provided a accurate view of the psychosomatic nature of the injuries in relation to the patient's history of psychological stress and resultant injuries.

One of the most vivid examples is illustrated in Figure 1. The patient, a 45-year-old woman drew a firebird that, though lacking wings, had a clearly-defined head, with eyes and a beak, on a long neck. It had a large tail with the plumage typical of a firebird, and large feet. Yet neither left nor right wing was there. It is worth noting that the patient had not been rushed; she had had enough time to draw all the parts and make corrections. The description read: “Beautiful. Intelligent. Slightly frightened.” According to her medical history, she had endured chronic and serious tonsillitis from childhood until the birth of her own child, and had also broken both left and right arms.

In the subsequent conversation the patient revealed that she had broken her arms in the year 2000. At that time she had been in an extramarital relationship. Her lover had become insistent and given her an ultimatum: to choose either him or her husband. She had not been ready for that intensity of courtship, nor was she prepared to sever ties with her husband. It was against this background that she broke her right arm.

Her left arm was broken in 2015. The injury was preceded by a difficult, year-long period of psychoemotional stress in her life. Her husband had begun an affair with another woman, at first clandestinely but then openly, and he had left the family for several months before returning to Patient 1 professing his love. She eventually accepted his apologies and they began to live together again, only for her to trip on the threshold of her front door and fall awkwardly on her left arm in the presence of her husband.

Fig. 1 – Patient, broken left and right arms. Left and right wings are missing

Our overall conclusion is that the injuries described were connected with emotionally-charged and psychologically traumatic events that the patient, even after the fact, spoke of with anxiety. At the time of the interview the patient's health did not worry her, but the emotional pressure and dissatisfaction in her marital relations remained.

Locomotor illnesses with a psychosomatic aspect were illustrated with the problem area either outlined or firmly corrected. Figure 2 shows a woodpecker drawn by a 75-year-old female patient with a history of deformative left-side coxarthrosis on her left side. The bird was drawn with a pen, making all the details very clear. The patient drew the feet, tail (twice) and eyes with great care.

Fig. 2 – Patient with deformative left-side coxarthrosis. Left foot corrected several times and forcefully drawn

 

She made a careful attempt to correct inaccuracies in the left foot, which as a result stands out and is noticeable even to an inexperienced observer. She was diagnosed with left-side coxarthrosis at the age of 50, after the death of her father. Significantly, she had not managed to marry or have children herself.

The description read: “Woodpecker – bright plumage”. This is worth analysing separately, given that it reflects a certain inaccuracy in the patient's idea of a woodpecker, which is in reality a relatively modest black and white bird with a bright red (or, in some sub-species, pink) area under the tail. The top of the head, the back and the upper tail are black, with a bluish gloss. The forehead, cheeks, shoulders and belly are brownish-white.

Patients with head injuries drew birds with deformed heads or heads that did not sit well with the rest of the picture. Picture 3 shows a bird drawn by a 34-year-old male patient with head injuries, foot injuries and a broken collarbone. The bird has a deformed head and eyes looking outwards. Also clearly visible is the disproportional shape of the right wing.

Fig. 3 – Patient with head injuries. Bird's head is deformed

 

The description read: “Bird after a long transit, very tired, resting”. The patient had clearly-visible aesthenia. In discussion it emerged that his head injuries had occurred in the workplace (an iron beam had fallen on his head). He had divorced his wife earlier that same year, losing almost all contact with their child.

Eye conditions with psychosomatic aspects were illustrated when patients drew empty eye sockets. A 28-year-old female patient with a cataract and glaucoma drew a dove. The empty eye sockets are clearly visible in the drawing. Although the eyeballs themselves are missing, eyelashes, a minor detail in the drawing, have been included. The patient was diagnosed with glaucoma at the age of 11. The patient's medical history revealed that at that same age she had been the victim of an attempted rape. She was seriously assaulted and underwent a long period of convalescence, after which she received her primary diagnosis.

Fig. 4 – Patient with cataract and broken hip. Empty eye sockets, misshapen feet

 

She also made several attempts to draw the bird's feet, but in the picture they are stylised and their shape cannot be clearly made out. She has experienced a broken hip. In the description the patient wrote, “Dove. Known as the bird of freedom, peace and family. Symbol of love and cleanliness” [10].

Discussion

Analysis of the Bird Test demonstrated a high level of reliability in the comparison of psychosomatic disorders and the illustration of localised areas of injury or illness on drawings of a bird.  According to the analysis of the pictures, descriptions and medical histories, several of the injuries and illnesses that the test subjects had suffered occurred after family conflict or negative psycho-emotional events. It is specifically these injuries that were reflected in the corresponding locations in the pictures of birds. In some cases the description of the bird added a generally unstable psycho-emotional state.

Conclusion

E.G. Abakarova's new method of projective testing, the Bird Test, has a wide range of potential applications. Used during psychological work with medical students, it identifies psychosomatic problems and helps psychologists and diagnosticians isolate problems stemming from adaptation to a new learning environment from earlier psychological trauma and psychosomatic disorders. The test is also useful during psychological consultations and psychotherapy with patients, and in the diagnosis of psychosomatic disorders caused by chronic conditions.

Список литературы / References

1. Somatic Symptom and Related Disorders [Электронный ресурс] ‒ URL: https://en.wikipedia.org/wiki/Somatic_symptom_disorder#cite_ref-2. (дата обращения: 23.11.2017).
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing, 2013. – P. 5–25. ISBN 978-0-89042-555-8.
3. Малкина-Пых И.Г. «Психосоматика: справочник практического психолога». – Москва; Изд-во «Эксмо». – 2005. – С. 992.
4. Роршах тест [Электронный ресурс] ‒ URL: https://en.wikipedia.org/wiki/Rorschach_test (дата обращения: 23.11.2017).
5. Mélon J. Notes on the History of the Szondi Movement, (French original [1]) // Text for the Szondi Congress of Cracow, August 1996. – Cracow. – 1996.
6. Schacter, D. S., Gilbert, D. T., & Wegner, D. M. Psychology: 2nd Edition / New York: Worth Publishers. ‒ 2011. ‒ 624 p. ISBN-10: 1-4292-1821-5
7. Heilman J.M., Kemmann E., Bonert M., et al. "Wikipedia: a key tool for global public health promotion". // Journal of Medical Internet Research. 13 (1):e14, 2011. doi:10.2196/jmir.1589. PMC 3221335 . PMID 21282098.
8. Noam Cohen «A Rorschach Cheat Sheet on Wikipedia?» [Электронный ресурс] // New York Times. ‒ JULY 28, 2009. ‒ URL: http://www.nytimes.com/2009/07/29/technology/internet/29inkblot.html (дата обращения: 23.11.2017).
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Список литературы на английском языке / References in English

1. Somatic Symptom and Related Disorders [Electronic resource] ‒ URL: https://en.wikipedia.org/wiki/Somatic_symptom_disorder#cite_ref-2. (accessed: 23.11.2017.).
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing, 2013. – P. 5–25. ISBN 978-0-89042-555-8.
3. Malkina-Pykh I. G. Psikhosomatika: Spravochnik prakticheskogo psikhologa [Psychosomatics: A handbook of a practical psychologist.] – M .: Izd-vo Eksmo – 2005. – P. 992. [in Russian]
4. Rorshakh test [Rorschach test] [Electronic resource] ‒ URL: https://en.wikipedia.org/wiki/Rorschach_test (accessed: 23.11.2017).
5. Mélon J. Notes on the History of the Szondi Movement, (French original [1]) // Text for the Szondi Congress of Cracow, August 1996. – Cracow. – 1996.
6. Schacter, D. S., Gilbert, D. T., & Wegner, D. M. Psychology: 2nd Edition / New York: Worth Publishers. ‒ 2011. ‒ 624 p. ISBN-10: 1-4292-1821-5
7. Heilman J.M., Kemmann E., Bonert M., et al. "Wikipedia: a key tool for global public health promotion". // Journal of Medical Internet Research. 13 (1):e14, 2011. doi:10.2196/jmir.1589. PMC 3221335 . PMID 21282098.
8. Noam Cohen «A Rorschach Cheat Sheet on Wikipedia?» [Electronic resource] // New York Times ‒ JULY 28, 2009 ‒ URL: http://www.nytimes.com/2009/07/29/technology/internet/29inkblot.html. (accessed: 23.11.2017).
9. Risunochnyye metodiki. Metodicheskoye posobiye dlya prepodavateley i uchashchikhsya sistemy psikhofizicheskogo razvitiya [Drawing techniques. The methodical manual for teachers and pupils of system of psychophysical development] / pod redaktsiyey S.V. Baranovoy [edited by S.V. Baranova] // Korporatziya “Razvitie i Sovershenstvovanie” [Corporation "Development and Perfection"], Moscow ‒ 2013 ‒ 15 р. [in Russian]
10. Abakarova E.G. Simvolicheskaya kontseptualizatsiya semeynykh otnosheniy v ornitomorfnykh simvolakh proyektivnogo testa «Ptitsa» [Symbolic conceptualization of family relations in ornithomorphic symbols of the projective test "Bird"]. // Vestnik Permskogo universiteta. Filosofiya. Psikhologiya. Sotsiologiya. [Perm University Herald. Series «Philosophy. Psychology. Sociology».] ‒ 2017. ‒ Iss. 2 ‒ P. 250-257. DOI: 10.17072/2078-7898/2017-2-250-257 [in Russian]