Relationship of Pretreatment Rorschach Factors to Symptoms, Quality of Life, and Real-Life Functioning in a 3-Year Follow-Up of Traumatized Refugee Patients

Figures & data

Table 1. Real-life functioning, symptoms, and quality of life, at Time 1 (T1), Time 2 (T2), and Time 3 (T3).

	T1 (treatment start)			T2 (1-year follow-up)			T3 (3-year follow-up)
Variable	N	%/M	n/SD	N	%/M	n/SD	N	%/M	n/SD
Indications of real-life functioning
Communicated in Norwegian	51	50.9%	26				50	70.0%	35
Presently Employed	51	21.6%	11				50	34.0%	14
Indications of psychological disorder
Anxiety > 1.75, indicating clinically significant anxiety	50	96.0%	48	46	89.1%	41	45	86.7%	39
Depression > 1.75, T1, indicating major depression	50	98.0%	49	46	91.3%	42	45	91.1%	41
PTSD-Total ≥ 2.5, indicating PTSD	49	81.6%	40	20	75.0%	15	41	65.9%	27
Symptom scores
Anxiety	50	2.87	0.59	46	2.68	0.67	45	2.65	0.63
Depression	50	2.94	0.52	46	2.81	0.61	45	2.74	0.64
PTSD-Total	49	2.82	0.47	20	2.88	0.53	41	2.64	0.69
PTSD-Reexperiencing	49	2.91	0.68	20	2.84	0.67	49	2.75	0.78
PTSD-Arousal	49	3.10	0.49	20	3.13	0.47	41	2.86	0.78
PTSD-Avoidance	49	2.57	0.58	20	2.72	0.67	41	2.43	0.68
Quality of life (QOL)
QOL-Physical Health	49	28.2	13.8	17	36.1	20.0	42	38.3	17.7
QOL-Psychological Health	49	25.3	15.7	17	30.0	15.1	42	33.5	16.6
QOL-Social Relationships	49	35.0	21.7	17	44.4	25.8	42	42.4	21.4
QOL-Environmental Conditions	49	45.0	18.5	17	44.6	14.9	42	48.5	14.1

Note. Anxiety = Questions 1–10, Depression = Questions 11–25, Hopkins Symptom Checklist–25 (HSCL–25), scaled 1–4. PTSD-Total = Questions 1–16; PTSD-Reexperiencing = Questions 1, 2, 3, and 16; PTSD-Arousal = Questions 6, 7, 8, 9, and 10; PTSD-Avoidance = Questions 4, 5, 11, 12, 13, 14, and 15, Harvard Trauma Questionnaire (HTQ), Part IV, scaled 1–4. QOL-Physical Health, QOL-Psychological Health, QOL-Social Relationships, and QOL-Environmental Conditions = Domains 1, 2, 3, and 4 of the World Health Organization Quality of Life–BREF (WHOQOL–BREF), scaled 1–100. For comparison, the international means on WHOQOL–BREF (Skevington et al., 2004) were 64.8, 60.0, 57.2, and 54.0 on Domains 1 to 4, respectively. T1 measures of HTQ, HSCL–25, and WHOQOL–BREF were presented in Opaas and Hartmann (2013).

^a Two of the remaining participants communicated in English and did not need an interpreter.

^b Four individuals started to work and one gave up working during follow-up.

Table 2. RIM variable means in subgroups with low, medium, and high component scores.

	Trauma Response subgroups
	Constricted (n = 12)		Middle (n = 29)		Flooded (n = 10)		International norms
Variable	M	SD	M	SD	M	SD	Mint	SDint
Trauma Response score	–1.20	.30	–.01	.45	1.47	.68
Blends	0.33	.49	3.62	2.06	7.30	2.87	4.01	2.97
CF+C	0.50	.67	2.45	1.48	4.90	1.60	1.99	1.88
m	0.33	.89	1.86	1.90	6.00	2.91	1.50	1.54
F%	.68	.20	.41	.18	.16	.12	.39	.17
TCI	.14	.17	.42	.25	.84	.40	.17	.13
M	0.42	.52	2.90	1.76	6.40	3.81	3.73	2.66
SevCog	.25	.45	1.72	1.51	4.40	2.50	0.5	0.9
	Reality Testing subgroups
	Impaired (n = 11)		Middle (n = 28)		Adequate (n = 12)		International norms
	M	SD	M	SD	M	SD	Mint	SDint
Reality Testing score	−1.53	.51	.10	.42	1.16	.23
FQ-%	.37	.11	.17	.07	.13	.07	.10	.07
FQo%	.33	.12	.46	.10	.62	.08	.60	.15
D	1.82	2.23	6.32	3.40	11.0	3.79	9.89	5.81
R	13.45	5.41	17.57	5.99	22.50	7.73	22.31	7.90

Note. RIM = Rorschach Inkblot Method. Means are shown in bold. M_int= means of the international norm data; SD_int = standard deviations of the norm data. Trauma Response and Reality Testing: RIM principal components (Opaas & Hartmann, 2013). Blends, CF, C, m, M, F%, D, R (Comprehensive System; Exner, 2003); TCI (Trauma Content Index; Armstrong & Loewenstein, 1990); and R–PAS (Meyer et al., 2011) variables SevCog (Severe Cognitive Codes: unweighted sum of Level 2 Cognitive Codes + CONTAM and ALOG), FQo% (Ordinary Form Quality%), and FQ-% (Form Quality Minus%). International norms from Meyer, Erdberg, and Shaffer (2007), Meyer et al. (2011; SevCog, FQo%, FQ-%), and Meyer (for Opaas & Hartmann, 2013; CF+C, TCI).

^a The subgroups: RIM component scores < –0.75 (Low), –0.75 to 0.75 (Middle), and > 0.75 (High).

^b Stated as proportions.

Table 3. Relationships of RIM components with symptoms and QOL, adjusted for time.

	Estimate [95% CI]	PP	t(df)	p	R^2	r
Anxiety
Trauma Response, negative values	−0.15 [–0.49, 0.19]	−5.0	−0.88 [1, 48]	.38	.06	.25
Trauma Response, positive values	0.22 [–0.05, 0.49]	7.3	1.64 [1, 48]	.11
Reality Testing	−0.16 [–0.31, –0.01]	−5.3	−2.17 [1, 49]	.035	.09	.29
Depression
Trauma Response, negative values	−0.04 [–0.37, 0.29]	−1.3	−0.23 [1, 48]	.82	.03	.18
Trauma Response, positive values	0.11 [–0.15, 0.37]	3.7	0.89 [1, 48]	.38
Reality Testing	−0.06 [–0.21, 0.08]	−2.0	−0.88 [2, 49]	.38	.03	.18
PTSD-Total
Trauma Response, negative values	0.09 [–0.22, 0.41]	3.0	0.58 [1, 48]	.56	.04	.21
Trauma Response, positive values	0.07 [–0.17, 0.31]	2.3	0.58 [1, 48]	.57
Reality Testing	−0.13 (-0.27, 0.01)	−4.3	−1.86[1, 49]	.069	.08	.28
PTSD-Reexperiencing
Trauma Response, negative values	0.24 [–0.16, 0.63]	8.0	1.22 [1, 48]	.23	.05	.23
Trauma Response, positive values	0.07 [–0.23, 0.38]	2.3	0.48 [1, 48]	.63
Reality Testing	−0.10 [–0.28, 0.09]	−3.3	−1.06 [1, 49]	.29	.03	.17
PTSD-Arousal
Trauma Response, negative values	0.01 [–0.33, 0.35]	0.3	0.07 [1, 48]	.95	.04	.20
Trauma Response, positive values	0.07 [–0.19, 0.34]	2.3	0.57 [1, 48]	.57
Reality Testing	−0.15 [–0.30, –0.01]	−5.0	−2.08 [2, 49]	.043	.09	.31
PTSD-Avoidance
Trauma Response, negative values	0.11 [–0.23, 0.45]	3.7	0.45 [1, 48]	.66	.03	.18
Trauma Response, positive values	0.06 [–0.21, 0.32]	2.0	0.44 [1, 48]	.66
Reality Testing	−0.11 [–0.27, 0.04]	−3.7	−1.68 [1, 49]	.099	.06	.25
QOL-Physical Health
Trauma Response, negative values	6.85 [–2.33, 16.04]	6.9	1.50 [1, 48]	.14	.12	.34
Trauma Response, positive values	−5.40 [–12.70, 1.90]	−5.4	−1.49 [1, 48]	.14
Reality Testing	3.92 [–0.16, 7.99]	3.9	1.93 [1, 49]	.059	.13	.36
QOL-Psychological Health
Trauma Response, negative values	−0.85 [–9.85, 8.15]	−0.9	−0.19 [1, 48]	.85	.07	.26
Trauma Response, positive values	−1.74 [–8.90, 5.42]	−1.7	−0.49 [1, 48]	.63
Reality Testing	4.21 [0.37, 8.06]	4.2	2.20 [1, 49]	.032	.13	.35
QOL-Social Relationships
Trauma Response, negative values	−1.60 [–13.50, 10.30]	−1.6	−0.27 [1, 48]	.79	.06	.25
Trauma Response, positive values	−5.46 [–14.93, 4.00]	−5.5	−1.16 [1, 48]	.25
Reality Testing	4.69 [–0.61, 9.99]	4.7	1.78 [1, 49]	.081	.08	.28
QOL-Environmental Conditions
Trauma Response, negative values	6.51 [–2.36, 15.37]	6.5	1.48 [1, 48]	.15	.04	.21
Trauma Response, positive values	−1.92 [–8.97, 5.12]	−1.9	−0.55 [1, 48]	.59
Reality Testing	3.49[–0.46, 7.43]	3.5	1.78 [1, 49]	.082	.05	.23

Note. RIM = Rorschach Inkblot Method; QOL = quality of life. Linear mixed effects analysis. Trauma Response and Reality Testing = RIM principal components (Opaas & Hartmann, 2013). Estimate (fixed effects coefficient) = difference in outcome for a one-unit increase in a RIM component. PP = Estimate transformed to percentage points = 100 × estimate/range of the outcome scale. R² was computed by Nakagawa and Schielzeth's (2013) method for obtaining marginal R² from generalized linear mixed effects models. r = square root of the marginal R². Negative and positive values of Trauma Response were included in the same model.

* p < .05.

^† p < .10.

Table 4. Overall interaction effects of RIM components and time on symptoms and QOL.

	Overall interaction
	F value (df)	p	R^2	r
Anxiety
Time × Trauma Response, negative values	0.21 (2, 84)	.81	.06	.25
Time × Trauma Response, positive values	0.14 (2, 84)	.87
Time × Reality Testing	0.75 (2, 86)	.48	.09	.30
Depression
Time × Trauma Response, negative values	0.06 (2, 84)	.94	.04	.20
Time × Trauma Response, positive values	0.88 (2, 84)	.42
Time × Reality Testing	0.07 (2, 86)	.93	.03	.18
PTSD-Total
Time × Trauma Response, negative values	0.85 (2, 53)	.43	.06	.24
Time × Trauma Response, positive values	0.12 (2, 53)	.89
Time × Reality Testing	2.67^† (2, 55)	.078	.11	.33
PTSD-Reexperiencing
Time × Trauma Response, negative values	0.38 (2, 53)	.69	.06	.24
Time × Trauma Response, positive values	0.20 (2, 53)	.82
Time × Reality Testing	2.29 (2, 55)	.11	.05	.23
PTSD-Arousal
Time × Trauma Response, negative values	0.55 (2, 53)	.58	.06	.25
Time × Trauma Response, positive values	0.93 (2, 53)	.40
Time × Reality Testing	0.90 (2, 55)	.41	.10	.32
PTSD-Avoidance
Time × Trauma Response, negative values	1.28 (2, 53)	.29	.05	.23
Time × Trauma Response, positive values	0.06 (2, 53)	.94
Time × Reality Testing	4.48* (2, 55)	.016	.12	.34
QOL-Physical Health
Time × Trauma Response, negative values	0.14 (2, 51)	.87	.12	.35
Time × Trauma Response, positive values	0.10 (2, 51)	.91
Time × Reality Testing	0.50 (2, 53)	.61	.13	.36
QOL-Psychological Health
Time × Trauma Response, negative values	0.44 (2, 51)	.65	.07	.27
Time × Trauma Response, positive values	0.05 (2, 51)	.95
Time × Reality Testing	0.29 (2, 53)	.75	.12	.35
QOL-Social Relationships
Time × Trauma Response, negative values	2.55^† (2, 51)	.088	.10	.31
Time × Trauma Response, positive values	0.29 (2, 51)	.75
Time × Reality Testing	1.58 (2, 53)	.22	.09	.30
QOL-Environmental Conditions
Time × Trauma Response, negative values	0.87 (2, 51)	.42	.05	.23
Time × Trauma Response, positive values	0.70 (2, 51)	.50
Time × Reality Testing	0.91 (2, 53)	.41	.06	.25

Note. RIM = Rorschach Inkblot Method; QOL = quality of life. Mixed effects analyses of RIM components interacting with time. R² was computed by Nakagawa and Schielzeth's (2013) method for obtaining marginal R² from generalized linear mixed effects models. r = square root of the marginal R². Negative and positive values of the Trauma Response component are included in the same model for each outcome variable, resulting in one R²value for each. Negative and positive values of Trauma Response were included in the same model. Models with significant overall values or significant time contrasts, detailed in Table 5 and visualized in Figure 1, are shown in italics.

* p < .05.

^† p < .10.

Table 5. Changes in symptoms and QOL related to interaction effects of RIM components and time, details.

	Difference between T1 and T2			Difference between T2 and T3			Difference between T1 and T3
	Estimate [95% CI], t	PP	p	Estimate [95% CI], t	PP	p	Estimate [95% CI], t	PP	p
PTSD-Total
Time × Reality Testing	−0.26 [–0.50, –0.02], –2.15	−8.7	.041	0.12 [–0.13, 0.37], 0.95	4.0	.34	−0.14 [–0.32, 0.05], –1.50	−4.7	.14
PTSD-Reexperiencing
Time × Reality Testing	−0.31 [–0.60, –0.01], –2.10	−10.3	.041	0.28 [–0.03, 0.58], 1.80	9.3	.077	−0.03 [–0.26, 0.20], –0.27	−1.0	.79
PTSD-Avoidance
Time × Reality Testing	−0.39**[–0.67, –0.11], –2.83	−13.0	.006	0.20 [–0.09, 0.49], 1.36	6.7	.18	−0.20^†[–0.41, 0.02], –1.83	−6.7	.073

Note. QOL = quality of life; RIM = Rorschach Inkblot Method. Mixed effects analyses of RIM components interacting with time. Interaction models with significant values overall (PTSD-Avoidance) or with significant time contrasts (T1–T2). See Figure 1 for visualization. Degrees of freedom = 2, 55. Estimate = interaction coefficient in the mixed effects model. PP = Estimate transformed to percentage points = 100 × estimate/range of the outcome scale.

* p < .05. **p < .01. ^†p < .10.

Figure 1. A model illustrating interaction effects over time of the Reality Testing component on outcome variables PTSD-Total, PTSD-Reexperiencing, and PTSD-Avoidance when component values are set to –1 (impaired Reality Testing), 0 (sample mean/somewhat lowered Reality Testing), and +1 (adequate Reality Testing).

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