2011. Vol.2, No.4, 335-341
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.24053
A Comparative Analysis of MMPI and Rorschach Findings
Assessing Combat-Related PTSD in Vietnam Veterans
—Analysis of MMPI and Rorschach Findings Assessing PTSD
Ioanna Katsounari1, Jordan Jacobowitz2
1 Social Work Department, Frederick University, Nicosia, Cyprus;
2The Chicago School of Professional Psychology, Chicago, USA.
Email: firstname.lastname@example.org, email@example.com, firstname.lastname@example.org
Received March 17th, 2011; revised April 20th, 2011; accepted May 22nd, 2011.
There has been a proliferation of assessment research on Post-traumatic Stress Disorder (PTSD) over the past
twenty years. In spite of recent advances in the PTSD assessment research, there continues to be a controversy
as to whether the MMPI or Rorschach is more useful in determining the presence of PTSD. The present com-
parative analysis of the research literature will carefully evaluate controlled empirical studies, which utilized
psychometric measur es such as the MMPI/2 and Rorschach to identify PTSD in Vietnam Veterans. This analysis
is guided by the paucity of comparative data for standardized objective and projective instruments to assess
combat-related PTSD. The analysis indicated that the MMPI as an assessment instrument focuses on symptom
recognition of PTSD while the Rorschach seems to be more likely to identify chronic adaptations to trauma. The
significance of pre-combat factors, such as preexisting personalit y, and their impact on the way individuals make
meaning and express traumatic experiences needs to be further addressed in future research. The need for reli-
able and valid measures to assess combat-related PTSD is urgent as an increasing number of soldiers re t urn from
Keywords: PTSD, Combat Trauma, PTSD Assessment, Rorschach, MMPI
The heterogeneity and complexity of symptoms that can be
indicated in PTSD is often difficult to distinguish from other
psychiatric diagnoses, many of which are characterized by the
same symptoms. Indeed, some researchers have seriously ques-
tioned the legitimacy of PTSD as a psychiatric diagnosis except
for “pure” cases when only disorder-specific symptoms are
found and no Axis II diagnoses are observed (Hyer et al.,
The need for psychological measures that fully capture the
dynamics and vicissitudes of traumatic stress responses to
combat is urgent. An increasing number of returning soldiers
from war torn areas need to be evaluated for the diagnosis of
PTSD. Very relevant to the current article is the fact that there
is frequently a “delayed reaction” between initial and later
screenings of returning soldiers in the proportions of those re-
porting mental health problems. For soldiers in the reserves,
for instance, the percentage of soldiers reporting mental health
problems nearly doubled (from 12.7% to 24.5%) between the
time of returning from Iraq to three to six months later (DeAn-
gelis, 2008). Psychological instruments that can reliably iden-
tify psychiatric problems as soon as possible would contribute
to earlier and possibly more efficac io us intervent ions.
In the early and late 70’s, procedures for the assessment of
PTSD consisted mainly of clinical interviews that evaluated the
presence of or absence of a DSM (Diagnostic and Statistical
Manual of Mental Disorders) diagnosis. In addition, question-
naire and structured interviews were employed to assess pre-
military, military, and post-military history (Keane & Fairbank,
1983). It was not until the early 80’s that some studies began to
investigate the use of objective psychological tests, such as the
Minnesota Multiphasic Personality Inventory (MMPI/MMPI-2)
to aid in the diagnosis of PTSD. Less work has been done using
projective testing, and specifically the Rorschach, to help diag-
nose PTSD patients. The Rorschach is a promising tool in that
it can detect varying levels of war-related stress in soldiers and
address the complex symptomatology inherent in traumatic
states often not readily accessible on self-report measures
(Sloan, Arsenault, & Hilsenroth, 2002).
This comparative analysis of assessment measures is espe-
cially valuable since it scrutinizes whether the most popular
psychometric techniques assess the interactive effects of pre-
morbid personality variables, personal resource variables, and
the nature of the stressor dimensions in a particular traumatic
event. The particular population (Vietnam Veterans) was se-
lected because of the plethora of studies conducted using these
two instruments to assess both acute but also chronic trauma.
Psychlit searches were conducted using terms such as Vietnam
Veterans and PTSD, MMPI/2 a nd PT SD, Rorschach and PTSD.
The content and methodology of the studies relevant to the
analysis were then reviewed.
MMPI and PTSD
Several studies have attempted to identify a combat-related
PTSD profile on the MMPI. Most studies show a high-point
code of 8-2 with a moderately elevated F-scale score to be sug-
I. KATSOUNARI ET AL.
gestive of combat-related PTSD diagnosis (Fairbank, Keane, &
Malloy, 1983; Wilson & Walker, 1990; Albrecht et al., 1994).
The F, 2-8/8-2 code is representative of a combat-related PTSD
sample for the MMPI-2 as it has been for the MMPI. However,
Albrecht et al., (1994) pointed out that it is possible for some
differences to be seen on the Harris-Lingoes subscale scores
due to their increased variability, and this increased variability
must be noted by clinicians who are comparing scores from the
MMPI-2 with the MMPI.
In addition, the MMPI validity scales (L, F, and K) are
higher for PTSD patients as opposed to control groups. Re-
searchers have cautioned against generalizing this mean profile
configuration at the individual patient level. They suggested
that individual profile configurations show considerable vari-
ability for highpoint and two point codetype (Albrecht et al.,
1994; Baldrachi et al., 1999; Fairbank, Keane, & Malloy, 1983;
Munley, Bains, Bloem, & Busby, 1995; Wilson & Walker,
Scale 8 elevations among male Vietnam veterans diagnosed
with PTSD reflect to a large extent difficulties with depression
and dissociation. However, a significant proportion of variance
in scale 8 scores is also accounted by both non-overt and overt
psychotic symptoms. Clinicians should be cautious not to mis-
construe MMPI-2 scale 8 scores as strong signs of psychosis
among PTSD sufferers. However, psychotic symptoms should
be carefully assessed in PTSD veterans as well. It has also been
suggested that when the symptoms of a severe stress disorder
like PTSD are present, depressive symptomatology may occur
as a direct function of the inability of individuals to engage in
reinforcing activities (Burke & Mayer, 1984; Elhai et al., 2003).
The psychasthenia scale (7) has also been found to be ele-
vated among Vietnam Veterans, indicating the tendency to
ruminate about the trauma and experience episodes of traumatic
imagery. The elevated three-point code (2-8-7) suggests obses-
sive rumination about trauma-related imagery and affect in
persons suffering from PTSD. In addition, MMPI clinical
scales (2, 8, 7, 6) appear to be assessing the DSM-III-R symp-
tom clusters of intrusion, avoidance, and physiological hy-
perarousal (Wilson & Walker, 1990).
In terms of the content scales, PTSD sufferers score signifi-
cantly higher on the Anger (ANG) scale and on the Social Dis-
comfort Scale (SOD). The high scores found on the SOD and
ANG scales appear consistent with the social alienation and
anger control problems often seen clinically in combat veterans
with PTSD (Glenn et al., 2002).
The elevations studies have found on the validity, clinical,
and subscales of the MMPI seem to identify a global PTSD
profile that overlaps with other affective and anxiety disorders.
Research has raised important questions in terms of what PTSD
comorbidity means given the current classification system. It is
highly likely that most PTSD combat veterans present with a
complex diagnostic picture. A very important consideration
would be whether different diagnostic groups are distinct
groups or overlapping manifestations of the same group (e.g.
PTSD + Anxiety vs PTSD + Depression). Most commonly,
these groups receive treatment based on the assumption that
they share more behavioral similarities than differences. Re-
searchers argued that this inadequacy resides in the categorical
nature of the DSM-III-R, which assumes that human behavior
patterns can be divided into clearly delineated groups with dis-
crete and non-overlapping types of behavior. However, most of
PTSD symptoms overlap with at least one another diagnostic
category within the DSM-III-R. MMPI research can prove very
useful in distinguishing between the various comorbid groups
and develop distinct therapeutic interventions based on their
unique presentations (Weyermann, Norris, & Hyer, 1996).
The PTSD (Pk) scale was found to be significantly higher on
the MMPI-2 than on the MMPI. The PTSD scale (PK) has been
found to be high in both face validity and content validity for
the PTSD symptom complex, and its use improves on the di-
agnostic hit rates obtained from the validity and clinical scales
alone. At present, this scale is considered to represent the best
effort at PTSD measurement among Vietnam veterans (Keane,
Malloy, & Fairbank, 1984). However, research has at times
shown conflicting findings when different studies attempted to
cross-validate this scale. The best conclusion is one of caution
where the use of MMPI-PTSD scale is concerned. In psychiat-
ric populations, the PTSD MMPI measures may be useful in
ruling out the diagnosis of PTSD, but high scores may suggest
only further attempts to be made to establish the diagnosis
(Hyer et al., 1987; Munley et al., 1995). In addition, PTSD
optimal cutting scores might vary with the co-existence of sub-
stance abuse, the presence of specific referral for PTSD treat-
ment and race (Watson, Kucala, & Manifold, 1986).
In addition, the PTSD (Ps) scale has been found to be more
robust in the differentiation of PTS symptomatology in a group
of outpatient Vietnam combat veterans (Baldrachi et al., 1999).
Overall, utilizing the MMPI-2, and specifically the PS and PK
scales, could aid in the initial assessment of such individuals,
thereby contributing to a multimodal evaluation to assess for
the presence or severity of PTSD symptom (Watson et al., 1986;
Gayton et al., 1986; Cannon et al., 1987).
Findings also suggested that symptom overreporting is often
part of veterans suffering from PTSD. However, although stud-
ies showed that these veterans respond to both the obvious and
neutral items at a rate higher than did the other groups, they do
not respond differentially between obvious and neutral items.
One can therefore argue that PTSD veterans are not differen-
tially endorsing or overreporting symptoms and that regardless
of compensation, one need not imply negative features with
symptom overreporting (Tolin et al., 2004).
The data also suggested that the Fp scale is less sensitive to
psychopathology than are alternate overreporting indices such
as the F, Fb, F-K, Ds, and O-S, and therefore, may be of greater
utility in the assessment of PTSD in veterans. Therefore, Fp
may be a more val id measure of overrepoting as it is less likely
to be artificially elevated for individuals in extreme distress
because of frank psychopathology (Tolin et al., 2004).
To conclude, it appears that current research practices may
not yield definitive estimates of symptom overreporting among
veterans evaluated for PTSD. This is because severely impaired
patients are more likely to seek compensation. In addition, CS
veterans not diagnosed with PTSD may suffer from psychiatric
disorders other than PTSD, therefore it would be inappropriate
to conclude that these individuals are faking PTSD. The impor-
tant issue is how this symptom feature is part of PTSD for
Vietnam Veterans. Researchers suggested that once acceptance
of the disorder is legitimized in inpatient settings, PTSD veter-
ans feel free to express their problems. By doing so, veterans
can reaffirm their identity, band with other veterans, and make
I. KATSOUNARI ET AL. 337
sense out of confusing symptoms (Hyer, Fallon, Harrison, &
Boudewyns, 1987). Therefore, a multi-team, multi-modal,
multi-assessment approach to the diagnosis of PTSD in combat
veterans is necessary to ensure that correct identification of
malingering veterans is made (Tolin et al., 2004).
Rorschach and PTSD
Projective methods, such as the Rorschach, offer some dis-
tinct contributions for assessing combat-related PTSD. They are
often less direct and intrusive than objective tests, which helps
circumvent the guardedness of trauma survivors. Re-experi-
encing the traumatic events through recollections, nightmares,
or flashbacks can severely interfere with the cognitive proc-
esses set in motion by the Rorschach, and particularly with the
capacity to perceive events objectively and to think logically
(Ephraim, 2002). Studies using the Exner scoring system have
found the Rorschach useful in the assessment of civilians with
PTSD and in identifying PTSD in nonveteran groups of adults
(Sloan, Arsenault, & Hilsenroth, 2002). However, to this date
only a limited number of published studies used the Rorschach
in the assessment of PTSD focusing on U.S. combat veterans of
the Vietnam War. Findings in regards to the assessment of
PTSD in Vietnam Veterans using the Rorschach have shown
Earlier research supported that guilt over combat atrocities
appears to be the basic trauma as indicated in the content analy-
sis of the Rorschach (Salley & Teiling, 1984). Later research
indicated that Rorschach protocols show an abreactive repeti-
tion of the trauma, with the inkblots serving only as the stimuli
in the process. These findings have suggested that PTSD suf-
ferers when presented with ambiguous or affectively charged
stimuli they react to current situations as a recurrence of the
traumatic stress. Specifically, chromatic cards (II, III, VIII, IX,
X) seem to provoke uncontrolled and apparently trauma- re-
lated experiences (Van der Kolk & Ducey, 1989).
In terms of the veteran’s experience type, the research has
shown inconsistent findings. Part of the research has indicated
that Vietnam veterans are classified as extratensive (Van der
Kolk & Ducey, 1989; Souffront, 1987; Swanson et al., 1990).
Extratensive protocols of Vietnam veterans have been found to
be characterized by extensive and gory blood and anatomy
content, uncensored and uncontrolled references to traumatic
Vietnam experiences, high number of inanimate movement (m)
responses, and an absence of integrated whole (Q++ and W+)
location and developmental quality responses (Van der Kolk &
Coartative protocols of Vietnam veterans show very few re-
sponses, no use of color, and few or no M responses. These
were interpreted as evidence of the veterans’ inability to inte-
grate immediately affective experience and to structure experi-
ence through higher cognitive processes. The extratensive and
coartated Rorschach records suggest the failure of active ego
adaptation, one in the direction of overwhelmed undercontrol,
the other in the direction of rigid overcontrol. These trauma-
tized men lacked the internal processing mechanisms that might
lead to the integration of trauma (Van der Kolk & Ducey,
Other studies have shown that a large group of Vietnam vet-
erans falls into the introversive and ambitensive category of
experience type (Goldfinger et al., 1998; Hartman et al., 1990).
These findings suggested that Vietnam veterans suffering from
PTSD use a less efficient problem solving and coping style
(ambitent EB) than controls, are less likely to use a more effi-
cient coping style (introversive EB), and have more mental
access to combat-related imagery than non-PTSD Vietnam
veterans, although few appear preoccupied with gory, traumatic
scenes. These researchers argued that this could suggest that in
the course of chronic PTSD, preoccupation with traumatic im-
agery may attenuate over time, with periodic reemergences
during episodes of exacerbated symptomatology.
Overall, it has been found that PTSD sufferers show a higher
proportion of color to movement scores. It has been suggested
that the PTSD sufferers experience affective stimulation in
excess of their capacity to process, control, and delay the im-
pact of trauma through the “higher” symbolic capacities for
thinking, reflection, planning, and perspective-taking (Souffront,
1987; Van der Kolk & Ducey, 1989).
One further finding is that PTSD subjects show an extraor-
dinarily high number of inanimate movement responses (Van
der Kolk & Ducey, 1989). The results indicated that the inani-
mate movement response was the best discriminator between
veterans with PTSD and veterans without PTSD (Souffront,
1987). This again indicated that PTSD patients experience a
significant amount of tension, discomfort, and situational stress.
Another notable finding in this research was the veterans’ very
low tolerance for stress (Hartman et al., 1990; Swanson et al.,
In terms of the accuracy and specificity of form quality, the
PTSD sufferers showed an interesting combination of (1) heavy
emphasis on conventional (“ordinary”) form at the expense of
sharp and accurate perception, and (2) a very high proportion of
the amorphous (formless) categories. This combination appears
to be a counterpart of the duality of response to trauma, repre-
senting the biphasic cognitive processing of traumatic experi-
ence. Rorschach’s of the Vietnam Veterans confirmed the
clinical impression that people with severe PTSD are incapable
of modulated affective experience; they either respond to affec-
tive stimuli with intensity, which is appropriate only to the
traumatic situation, or they barely react at all (Van der Kolk &
Another finding was the tendency of these patients to view
reality in an unconventional manner and often distort reality in
their perception of situations. Notable was also their inclination
toward an oversimplified view of situations. Under stress, these
patients were likely to distort reality, however, this distortion
was not psychotic. They were able to perceive reality in a con-
ventional manner (Swanson et al., 1990).
Vietnam veterans were also likely to display affect in an un-
modulated manner, which amplified their impulsivity. As a
result, they tended to avoid emotionally laden situations. Al-
though they seemed uninterested in people, and often were
perceived by others as cold and distant, they were not particu-
larly lonely. Isolating themselves from others may help them
minimize their exposure to emotionally laden situations,
thereby decreasing the possibility of finding themselves in
situations where they may behave impulsively (Swanson et al.,
Overall, studies to this date researching the association of
PTSD to specific Rorschach scores have shown discrepancies,
I. KATSOUNARI ET AL.
which will only be resolved through further control studies
larger in scale and more diverse in demographics and traumatic
history. These methodological improvements will allow a con-
stellation of Rorschach variables to emerge consistently across
studies as indicators of cognitive and emotional sequelae of
traumatic reactions to combat exposure. The variables that have
been found consistently on these studies include intense and
poorly modulated affect, impulsivity, unconventional reality
testing, and inconsistent problem solving.
Conclusions and Future Research Suggestions
Research indicates that the Rorschach does not consistently
or globally measures self-reported characteristics as does the
MMPI (Meyer, 1996). Subsequently, it appears that we should
not be comparing these two measures. PTSD on the MMPI is
really PTSD as it is consciously reported by the patient. On the
other hand, PTSD on the Rorschach is PTSD as it is manifest in
implicit perceptual propensities and qualities of verbal articula-
tion (Meyer, 1997).
Rorschach scores do not typically measure constructs that re-
side within conscious awareness. It has been suggested that to
the extent that Rorschach constructs are not viewed as consis-
tently tapping conscious and deliberately reported phenomena,
clinical interpretations will be more accurate (Meyer, 1996).
Individuals who have experienced prolonged and repeated
trauma display massive efforts to protect their psyche, which
involve defense mechanisms such as denial, dissociation,
avoidance, and repression (Herman, 1997). The Rorschach
seems to be more likely to identify such chronic adaptations to
Brende (1983) suggested that the pronounced identity
changes observed in Vietnam veterans bear a notable similarity
to the disorders of self typically found in borderline and narcis-
sistic patients. Hartman et al., (1990) has indicated in his re-
search that for his group of Vietnam veterans, the mean Ror-
schach Schizophrenic Index was in the range reported for bor-
derline and schizotypal populations. Again, the Rorschach
seems to provide ac cess to c overt personality traits that may not
surface on the MMPI. Additional research is needed to explore
the relationship between combat-related PTSD and borderline
Shatan (1973) identified guilt feelings and self-punishment
as the first theme of most concern to Vietnam veterans. In the
research reviewed, guilt arising from participating in or wit-
nessing inhumane actions in combat was only noted in one
Rorschach study. Objective tests, such as the MMPI, seem to
leave out the personal subjective quality of the veteran’s ex-
perience. The second theme of feeling of being scapegoated is
not noted in any of the tests, but it might be related to scale 6
(paranoia) elev ations in the MMPI.
This analysis has suggested that considering the possibility
of coexistence of PTSD and other, more traditional, forms of
psychopathology exacerbated or triggered by combat experi-
ence is important. Both MMPI and Rorschach have indicated
that there is a high degree of comorbidity with PTSD, particu-
larly with depression and anxiety. The presence of comorbid
disorders often complicates the diagnostic picture of PTSD on
the assessment tool. Evaluators of combat related PTSD need to
consider the possibility of co-existing symptomatology that
may not fit the diagnostic criteria for PTSD.
When the results of the Rorschach and the MMPI are some-
what inconsistent or contradictory, the clinician must make the
decision to emphasize certain aspects of the test findings, while
suppressing results from other sources of test data. In deter-
mining which results to emphasize, we must consider the rela-
tive reliability and validity of the specific data sources. Finn’s
(1996) suggestions for combining MMPI and Rorschach results
are highly recommended when such discrepancies are found.
Contradictory findings between the two tests underscores the
importance of reviewing other data sources, such as interview
data and psychosocial history data in reaching clinical conclu-
sions. Using a multi-method approach in the multidimensional
assessment of PTSD symptomatology should be the ideal ap-
The findings of the assessment literature suggest the possi-
bility of unique PTSD subtypes within Vietnam veterans.
Therefore, each veteran may display a different symptom pic-
ture. Subsequently, it is important to emphasize the individual
as the unit of analysis.
The development of PTSD is integrally related to how the
individual experienced specific combat events. The significance
of pre-combat factors in determining how individuals make
meaning of combat experience is not mentioned in the literature.
Preexisting personality needs to be assessed as an integral part
of the meaning the veteran will give to his combat experience,
and directly affect the form and expression of his posttraumatic
stress disorder. This does not imply that a personality disorder
was present in the veteran or would have developed it without
exposure to combat. It is more indicative of the importance of
close examination of pre-combat, combat, and post-combat
factors in attempting to understand the meaning of war experi-
ence to the individual.
War trauma has been directly conceptualized in the literature
as combat exposure. Most studies define war trauma and com-
bat exposure as comprising a single dimension. The definition
of combat and war trauma has been based on a traditional un-
derstanding of conflict in which certain territorial areas are held
by hostile troops and the proximity to those areas reflects the
level of combat exposure of the veteran. Some veterans had
been asked to place themselves in categories such as “moder-
ate,” “heavy,” “low” combat experience without attempting to
establish the objective comparability of these evaluations across
individuals (Laufer et al., 1984). This traditional definition of
war trauma needs to be re-conceptualized to include other
forms of combat situations that can potentially be traumatizing.
Locus of control (external and internal) is another variable
addressed in some of the studies reviewed. This is different
from helplessness in that it relates to the confidence in one’s
ability to affect their problems (Hyer et al., 1987). It appears
that investigating this variable may yield important data as to
the veteran’s coping style and vulnerability to depression and is
a critical issue to be addressed in therapy.
The use of psychometric inventories presupposes a working
knowledge of the psychological and social issues pertinent to
the veteran from a specific war zone. A working relationship
with the evaluator is critical for the open discussion of trau-
matic events, atrocities, and guilt-inducing memories. The use
of a structured interview that encompasses pre-combat military
personality factors, a military history, and post-combat adjust-
I. KATSOUNARI ET AL. 339
ment is critical when assessing PTSD.
In addition, knowing what combat has meant to the veteran is
critical both in understanding the way in which the disorder is
manifested and in working with the veteran psychotherapeuti-
cally to resolve the impact that traumatic combat experiences
have on his post-combat life.
The current managed care environment demands empirical
data to develop evidence-based outcomes. Rorschach and
MMPI data can greatly facilitate the clinicians’ ability to better
understand the individual’s cognitive, emotional, and interper-
sonal resources. Although, projective measures, like the Ror-
schach, have been at times deemed inappropriate for providing
that type of data, this review of the studies has shown otherwise.
The Rorschach’s ability to assess an individual’s psychological
resources indicates that it can provide a unique window through
which to observe subtle psychological variations. The com-
bined outcome data from both instruments can help contribute
to imperatives for good clinical standards of care and fiscally
responsible services for veterans with combat-related PTSD.
The studies reviewed presented with several methodological
and theoretical limitations. First and foremost, most of the
studies have used small sample sizes. Administering, scoring,
and interpreting the Rorschach could be an arduous task for
researchers aspiring to conduct large scale studies. However,
until more studies with larger sample sizes are conducted, it is
inappropriate to gen er alize the findings of smaller studies.
It is important for the evaluator to take into consideration
whether the veterans are assessed in an inpatient as opposed to
an outpatient setting. This may play a significant role because it
may provide essential information as to the severity of the
PTSD, the presence of other psychological disorders, the ser-
vices the veteran is currently receiving, and the willingness of
the veteran to admit his emotional struggles. It becomes in-
creasingly challenging for the researcher to discern whether the
Rorschach findings are a reflection of the PTSD syndrome or a
reflection of a comorbid condition instead. Although it is likely
that outpatient veterans may also suffer from a comorbid condi-
tion, the decreased severity of this condition may affect the
Rorschach findings to a lesser degree.
In addition, the profiles of veterans assessed by the Keane et
al. (1984) scale will differ depending on whether the assess-
ment was conducted in an inpatient vs. an outpatient setting.
This is because the Keane et al scale was normed on an outpa-
tient population and the cut off score represents those standards.
Participants in several of the studies were taking some type
of psychotropic medication (antidepressants, anxiolytics, neu-
roleptics). In addition, many had secondary diagnoses. Often,
the symptomatology they presented with was part of a comor-
bid condition rather than a clear cut PTSD disorder. The find-
ings do not help us discern whether the assessment findings are
rooted in PTSD, simply reflect these veterans being chronic
PTSD patients, or whether these patients have charactereologi-
cal problems, which flavor their PTSD.
Most of the studies reviewed in this analysis did not specify
the type of combat that the veteran was exposed to. Combat
status as defined in most of the studies did not necessarily re-
flect frequency and intensity of combat experience. There are
different degrees of combat exposure and they need to be as-
sessed carefully as they may determine the degree of PTSD. In
addition, studies have not looked into the differences in the
diagnostic picture of Vietnam veterans suffering from delayed
versus chronic versus acute trauma. It is highly likely that the
different diagnostic groups may reveal distinct MMPI profiles.
MMPI profile configurations do not take into account indi-
vidual variations. Some individual variations addressed in the
research are race and socioeconomic status. Other variations to
be taken into account include gender, ethnicity, education, re-
ligion, and age.
All the studies reviewed have failed to take into considera-
tion precombat personality influences. Crucial premorbid per-
sonality influences include the veteran’s personality structure
before exposure to combat, preexisting psychopathology, per-
sonal worldview, locus of control, life experiences, and per-
Researchers need to conduct more studies assessing Ror-
schach variables with acute symptoms of PTSD. Psychological
assessment soon after a war allows for potentially greater recall
of events, and the more extreme emotions associated with these
experiences. In addition, research has shown that data collected
within six months of exposure to trauma reduced the likelihood
that the individual may minimize, distort, or exaggerate ex-
periences or symptoms (Sloan et al., 2002). The Rorschach is
currently widely used in VA hospitals with newly returning
soldiers from war zones.
Differences in combat exposure need to be carefully assessed
as they may have an impact on the severity of PTSD symptoms
shown on the Rorschach. The amount of graphic details (mor-
bid, anatomy, violence, aggression, explosion, blood etc) on the
Rorschach is likely to increase with more direct and intensive
The studies showed discrepancies in terms of the coping
style (extratensive, introversive, ambitent) reported. These dif-
ferences likely stem from participant selection as well as meth-
odological differences between the various studies. These vari-
ables need to be closely monitored in future studies.
Among the Rorschach studies reviewed, the researchers
failed to consider precombat personality differences that may
have impacted the findings. Although, some researchers noted
the possible interference of demographic variables with the
Rorschach results, the influence of precombat personality is not
mentioned. As with the MMPI studies reviewed, this is a com-
mon gap in the literature that has not been addressed to this
It is important to interpret Rorschach findings in the context
of current PTSD theory, especially pertaining to combat-related
situations. The traumatized veterans’ anxiety, depression, and
somatic symptoms are not the same as ordinary anxiety, de-
pression, and somatic disorders. In addition, the cognitive im-
pairment indicated on the Rorschach is not ordinary impairment.
It is crucial that the Rorschach is scored and interpreted as
trauma-related. The criticisms of the studies also seem to un-
derscore the need for changes in some current Rorschach scor-
ing and interpretation guidelines when it comes to cases of
severe combat related PTSD. For example, the veteran’s cogni-
tive disturbances associated to intrusive symptoms and the
trauma-related nature of their symptoms should be directly
acknowledged by the scoring system and interpreted accord-
ingly. Current interpretive strategies fail to adequately assess the
veteran’s struggle by reducing symptomatology to a personality
style or an ego-syntonic character trait (Ephraim, 2002).
I. KATSOUNARI ET AL.
A major issue is the difficulty of differentiating between
manifestations of severe PTSD as opposed to psychosis, and
schizophrenia in particular. Future studies can be conducted
using these two instruments where individuals with severe
PTSD are compared to a schizophrenia-diagnosed patient com-
Somatic concerns can be part of the PTSD syndrome and
veterans may endorse more health complaints. There is a need
for further research on the effectiveness of projective measures
in assessing the complex relationship among physical and psy-
chological symptoms in individuals with war-related stress.
Future research that uses stricter diagnostic coding of groups
may prove valuable in illuminating the complexities of PTSD
and in enhancing our knowledge regarding its treatment.
The development of PTSD is integrally related as to how the
individual experienced the specific combat events. The signifi-
cance of precombat factors in determining how individuals
make meaning of combat experience is not mentioned in the
literature. Preexisting personality needs to be assessed as an
integral part of the meaning the veteran will give to his combat
experience and directly affect the form and expression of his
posttraumatic stress disorder.
A working relationship with the evaluator is crucial for the
open discussion of traumatic events, atrocities, and guilt-in-
ducing memories. The use of a structured interview that en-
compasses precombat military personality factors, a military
history, and postcombat adjustment is critical when assessing
PTSD. In addition, the traditional definition of war trauma
needs to be reconceptualized to include other forms of combat
situations that can poten t ially be traumatizing.
Rorschach and MMPI data can greatly facilitate the clini-
cians’ ability to better understand the individual’s cognitive,
emotional, and interpersonal resources. Although, projective
measures, like the Rorschach, have been at times deemed inap-
propriate for providing that type of data, this analysis of the
studies has shown otherwise. The Rorschach’s ability to assess
an individual’s psychological resources indicates that it can
provide a unique window through which to observe subtle psy-
chological variations. The combined outcome data from both
instruments can help contribute to imperatives for good clinical
standards of care and fiscally responsible services for veterans
with combat-related PTSD.
The question yet remains as to whether it is appropriate to be
comparing the two measures. PTSD on the MMPI is PTSD as it
is consciously reported by the individual. On the other hand,
PTSD on the Rorschach is PTSD as it manifests through im-
plicit and unconscious propensities of verbal articulation. Can
one argue then that they constitute measures of the same con-
struct, but simply represent conscious vs. unconscious articula-
tions of it? Or do they measure a completely different construct
better defined as a spectrum of disorders, which is yet to be
clearly captured by traditional diagnostic systems? The con-
tinuing understanding of the basic processes which underlie the
development of PTSD will likely resolve the uncertainties that
punctuate the study of trauma.
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