2011. Vol.2, No.7, 687-693
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.27105
Formal Characteristics of Thematic Apperception Test Narratives
of Adult Patients with an Autism Spectrum Disorder. A
Preliminary Study
Elisabeth Eurelings-Bontekoe1, Kirsten Zwinkels1, Hanneke Schaap-Jonker2,3,
Moshen Edrisi4
1Institute for Psychological Research, Clinical Psychology Unit, University of Leiden, Leiden, The Netherlands;
2Faculty of Theology and Religious Studies, University of Groningen, Groningen, The Netherlands;
3Dimence Institute of Mental Health, Zwolle, The Netherlands;
4GGZ Divers, Leiden, The Netherlands.
Received July 19th, 2011; revised August 23rd, 2011; accepted September 26th, 2011.
This study explored the usefulness of a Thematic Apperception Test (TAT, Murray, 1943) narrative scoring
system to detect signs of autistic information processing. A total of 27 patients with an Autism Spectrum Disor-
der were compared to a control group (N = 67) of patients with other psychiatric disorders. As an external indi-
rect measure of social functioning two dimensions of the Social Cognition and Object Relation Scale (SCORS;
Westen,1985) were used: Capacity for Emotional and Moral Investment in Relationships and Understanding of
Social Causality. TAT narratives were rated on the prevalence of eight phenomena, as proposed by Edrisi and
Eurelings-Bontekoe (2009). Autistic patients showed a lower level of social insight and were particularly char-
acterized by high scores on Weak Central Coherence, Jumping to Conclusions and Difficulty with describing/
interpreting movements. Results provide preliminary support for the usefulness of the TAT scoring system, but
need to be replicated using larger samples and blind scoring.
Keywords: Autism, Thematic Apperception Test, Social Cognition, Adults
Autism Spectrum Disorders (ASDs) are neurodevelopmental
disorders, characterized by a triad of symptoms: limited recip-
rocal social interactions, disordered verbal and nonverbal
communication, and restricted, repetitive behaviors or circum-
scribed interests (Tager-Flusberg & Caronna, 2007). The DSM-
IV Pervasive Developmental Disorders section includes five
different disorders: Autistic Disorder (AD), Rett’s disorder
(RD), Childhood Disintegrative Disorder (CDD), Asperger’s
Syndrome (AS), and Pervasive Developmental Disorder Not
Otherwise Specified (PDD-NOS) (American Psychiatric Asso-
ciation, 2000). Patients with Autism, AS and PDD-NOS share
the feature of limited reciprocal social interactions. In addition
to this feature, patients with Autism show disordered verbal and
nonverbal communication and restricted, repetitive behaviors
or circumscribed interests. Patients with AS suffer from lim-
ited reciprocal social interactions, and show restricted, repeti-
tive behaviors or circumscribed interests, but no deficits in
verbal or nonverbal communication. Finally, patients are di-
agnosed with PDD-NOS if they suffer from limited reciprocal
social interactions combined with either disordered verbal or
non verbal communication or restricted repetitive behaviors. In
addition to the DSM-IV-TR (APA, 2000) criteria, three func-
tional criteria may be described: impaired executive functioning
(Ozonoff, South, & Provencal, 2005), weak central coherence
(Happé & Frith, 2006), and impaired theory of mind (Baron-
Cohen, 2000; Tager-Flusberg, 2007). According to Minshew,
Sweeney, and Luna (2002), information processing is disor-
dered in patients with ASDs. Problems occur especially in
complex information processing, involving the processes that
pose the highest information processing demands (Beaumont &
Newcombe, 2006).
Assessment Using the Thematic
Apperception Test
The Thematic Apperception Test (TAT; Murray, 1943) was
originally designed to measure normal dimensions of personal-
ity in the general population (Langan-Fox & Grant, 2006).
Westen (1985, 1991a, 1991b) developed the Social Cognition
and Object Relations Scale (SCORS) to score TAT narratives.
Social cognition is defined by the thought processes involved
in understanding of behavior and motives of other people,
whereas object relations pertain to the individual’s thoughts and
feelings about people (Westen, 1991b). From this social cogni-
tion perspective, the TAT is an excellent instrument, because it
asks subjects to draw on their internal object representations to
construct characters and interaction in response to an ambigu-
ous interpersonal situation (Cramer, 1999). Originally, Westen
(1985) distinguished four dimensions within the SCORS: 1)
Complexity of representations of people, (COM) assesses the
extent to which the subject clearly differentiates the perspec-
tives of self and others; 2) Affect tone of relationship para-
digms (ATT), assesses affective quality of representations of
people and relationships; 3) Capacity for emotional investment
in relationships and moral standards (EI), assesses the extent to
which inner representations of relationships reflect an egocen-
tric attitude; and 4) Understanding of social causality (SOC),
assesses a patients’ capacity to understand causal relationships
in social interactions. In diagnosing Autism the dimensions EI
and SOC seem to be most informative.
The TAT has mainly been used in studies among children
with ASD as opposed to adults and quantitative data concerning
the coherence of narratives of adult ASD patients are virtually
lacking (Beaumont & Newcombe, 2006). The idea of using the
TAT in the assessment of Autism among adults is quite novel
and unconventional. Indeed, to the best of our knowledge, there
is only one study that addressed the coherence of narratives of
adult ASD patients (Beaumont & Newcombe, 2006). These
authors compared the TAT narratives of 20 patients with High
Functioning Autism (HFA)-AS with those of 20 controls re-
garding the mean proportion of mental state words, of mental
state causal statements and of action causal statements. The two
groups differed only with respect to the proportion of mental
state causal statements, in such a way, that control narratives
included a significant greater proportion of mental state causal
statements than the narratives of ASD patients, implying that,
although HFA-AS patients tend to use mental state words to a
similar extent as controls, they are less inclined to provide ex-
planations for characters mental state than controls (Beaumont
& Newcombe, 2006).
Recently, Edrisi and Eurelings-Bontekoe (2009, 2011) sug-
gested the usefulness of the TAT in detecting signs of ASD. On
the basis of several years of clinical experience, they have de-
scribed eight phenomena that are considered typical for patients
with ASD.
Aims of the Study and Hypotheses
The aim of this study was to explore the validity of the TAT
ASD scoring system as described by Edrisi and Eurelings-
Bontekoe (2009). This was done in two ways. First, we studied
the association between the percentage of ASD phenomena in
TAT stories and the SCORS dimensions EI and SOC. Next, we
compared patients with ASDs and psychiatric controls regard-
ing mean scores on EI and SOC and the percentage of ASD
phenomena in TAT narratives. We hypothesized that the corre-
lations between the percentage of ASD phenomena in TAT
narratives and the scores on the SCORS dimensions EI and
SOC would all be negative. Furthermore, we hypothesized that
patients with ASD would score lower on EI and SOC and
would show a higher percentage of ASD phenomena in TAT
narratives than the psychiatric controls.
Material and Methods
Twenty seven patients with a diagnosis in the autistic spec-
trum and in treatment (either ambulatory or in some living ar-
rangement) in a specialized mental health care setting partici-
pated in the study. The group consisted of six females (22.2%)
and 19 males (70.4%). Gender was unknown for two patients
(7.4%). Age ranged between 19 and 54 years, with a mean age
of 30.6 years, (SD = 9.71). Four patients (14.8%) were diag-
nosed with Autism, six patients (22.2%) were diagnosed with
AS and 17 (62.9%) with PDD-NOS.
The control group was matched on gender. Control TAT data
were selected from data collected by Eurelings-Bontekoe am-
ong a large and heterogeneous sample of psychiatric patients
(Eurelings-Bontekoe, Luyten, & Snellen, 2009). The control
group (N = 67) consisted of 19 females (28.4%) and 48 males
(71.6%). The average age of this group was 39.4 years (SD =
10.51). Age ranged between 22 and 60 years. The exclusion
criterion for this group was an ASD diagnosis.
The Social Cognition and Object Relation Scale (SCORS;
Westen, 1985, 1991a, 1991b) was used as an external indirect
measure of social functioning. In this study the following two
dimensions as originally described by Westen (1985) were
rated: Capacity for Emotional and Moral Investment in Rela-
tionships (EI), as a measure of affective social functioning and
Understanding of Social Causality (SOC), as a measure of cog-
nitive social functioning. Low scores on EI reflect an egocen-
tric and selfish attitude, high scores reflect the capacity to es-
tablish and maintain reciprocal social interactions. SOC as-
sesses a patient’s capacity to understand causal relationships in
social interactions. Low scores reflect illogical causal relation-
ships, high scores reflect understanding of causal relationships
in terms of both inner motives and external circumstances. Each
dimension is scored on a five-point rating scale, with higher
scores on EI and SOC representing higher levels of social func-
tioning. Studies have provided considerable evidence for the
convergent and discriminant validity of the SCORS (Ackerman,
Hilsenroth, Clemence, Weatherill, & Fowler, 2001, Cramer,
1999; Peters, Hilsenroth, Eudell-Simmons, Blagys, & Handler,
2006; Porcerelli, Shahar, Blatt, Ford, & Greenlee, 2006; for a
review, see Huprich & Greenberg, 2003). Interrater reliability
of the scoring of the TAT protocols of the ASD patients (ICC
(2,2)) was .88 for EI and .96 for SOC (both excellent). ICC (2,1)
were respectively .79 and .92 (excellent; see Table 1). The TAT
protocols of the control group had already been scored on the
SCORS variables EI and SOC with good to excellent interrater
reliability (Eurelings-Bontekoe et al., 2009).
The second measure used in this study was the rating of ASD
phenomena in TAT narratives. Based on clinical experience,
Edrisi and Eurelings-Bontekoe (2009) defined and described
eight phenomena that they consider typical formal characteris-
tics of TAT protocols of patients with ASD:
1) Weak Central Coherence, i.e. trying to understand the
meaning of the picture by concentrating on details, including
irrelevant ones, instead of utilizing the whole context. Example:
Table 1.
ICC two way random effect model, single (2,1) and average measures
(2.2) for SCORS dimensions EI and SOC and for ASD phenomena.
Variables Single measures Average measures
SCORS Emotional Investment.79 .88
SCORS Social Causality .92 .96
Weak Central Coherence .93 .96
Ruminating .85 .92
Weak Theory of Mind .91 .95
Jumping to Conclusions .61 .76
Multiple Scenario’s .98 .99
No Social Connectedness .85 .92
No Parallel Processes .47 .64
Problems with describing/
interpreting movements .75 .86
“I see a boy, looking at a violin with a bow. The violin lies on
the table on top of a piece of paper or a piece of cloth. I can not
see whether there is music on it”.
2) Ruminating. The patient does not know what an object or
person in the picture stands for and starts ruminating about it.
Patients can not turn their attention away from certain associa-
tions. Example: “The room is a little bit dark, I think the light
comes from outside. However, the light may also come from
the lamp, because on the left side of the room there is no light
from the hallway and the right side of the room is a little lighter.
And at some places you can see the shadows the lamp casts”.
3) Underdeveloped Theory of Mind, i.e. the patient is unable
to theorize about what the persons in the picture could feel and
think. Emotions are derived from external cues like eyes, mouth,
and posture. Examples: “He is depressed, because of his mouth”;
“he is thinking, because his left eyebrow is raised higher than
his right”. If the patient cannot see a person’s face, he is unable
to tell what this person could be feeling or thinking: “I cannot
tell what the man is feeling, because I only see his back”.
4) Jumping to Conclusions, i.e. the patient makes illogical
inferences and “jumps to conclusions”. For example: “This
woman has her eyes closed, so she is practising yoga”. Or:
“This is a single bed, so they cannot be a couple”. Or: “Their
hands look similar, so they are brother and sister”.
5) Describing multiple scenario’s. The patient describes sev-
eral potential scenarios to explain what could be going on.
Example: “He is sad, because something happened to the violin,
or he is angry because it is broken, or he is anxious because he
is unable to play the violin”.
6) Lack of social connectedness. Persons on the picture do
not interact or are not related to each other. Sometimes they are
described as being “pasted” into the picture. Example: “Well,
there are three figures, three people. Let’s see. This lady in
front is staring in the distance. They are not looking at the pub-
lic, neither is the horse. This is strange … what happens is … it
is very incoherent. Those people are not related to each other,
they are not connected. It is all individual. Yes, there is no in-
teraction, … At the end, he goes on working, she is going home
to eat and she will go on studying”.
7) Inability to describe parallel processes, i.e. the patient is
unable to describe events simultaneously, but instead tends to
describe the events consecutively. Example: “After they have
stopped hugging they will eat”.
8) Problems with describing and interpreting movements
spontaneously. The patient has trouble describing and inter-
preting movements in frozen images. Movements are described
on the basis of posture or direction in which the person looks.
Example: “Her shoulder is bent towards the room, therefore she
is entering the room”. Or “The woman looks to the right side of
the picture, therefore she is walking into that direction”. Diffi-
culties with the interpretation of movement may very well be
clarified by the story of a patient with PDD-NOS who de-
scribed this inability as follows: “In many pictures it seems as if
the picture has been taken while people on the picture are mov-
ing. Since you do not see anything else you cannot tell whether
a person is for instance leaving or entering a room. Closed eyes
are also difficult. It is possible that at the moment the picture
was taken the man accidentally blinked his eyes, but it is
equally possible that his eyes were already closed for a longer
time, yes, than he may be unconscious, that is more dramatic”.
Concerning the ASS phenomena, ICC (2,1) was excellent for
all phenomena except for the phenomena Jumping to Conclu-
sions and of No Parallel Processes, for which ICC’s (2,1) were
respectively good and fair. However ICC’s average measures
(2,2) were good for No Parallel Processes and excellent for the
rest of the ASD phenomena (see Table 1).
The participants in the ASD group (N = 27) who had agreed
to participate in the study were paid a house visit by one of
several (eight) investigators. Investigators were psychologists,
test assistants, or nurses, who were qualified or instructed to
take TAT-interviews. Interviews took about one hour. The TAT
was administered using standard guidelines (Conklin & Westen,
2001), asking the patient to describe what happens, what led up
to the situation, what the outcome would be, and what the
characters would be thinking and feeling. The following six
TAT cards were administered in the same order to all ASD
patients: 1, 2, 5, 6 BM, 13 MF, and 18 BM. All narratives were
recorded on audiotape and transcribed verbatim. Sixty seven
control cases were selected. TAT pictures used in this group
were 1, 2, 13 MF, 4, 3 BM, 7 GF.
The TAT protocols of the control group had already been
scored on the SCORS variables EI and SOC. The second author
scored the protocols of the ASD patients for EI and SOC and
scored all protocols, including those of the psychiatric controls
for the occurrence of each of the eight ASD phenomena, after
having been trained by the first author. The ratings for the two
SCORS dimensions were averaged across the six TAT cards
yielding a single mean score on each dimension for each pa-
For each patient and each protocol, the frequency of occur-
rence of the above-mentioned ASD phenomena was counted.
Since the amount of recognizable phenomena in each story is
dependent upon the length of the protocol, protocol length was
corrected for by dividing the frequency of each ASD pheno-
menon per protocol by the number of words in each protocol
and by multiplying this number by 100 yielding a percentage
score for each ASD phenomenon per protocol. These percent-
age scores of ASD phenomena were used in the MANCOVA
and Discriminant Analysis. To be able to establish interrater
reliability for the present study, the third author independently
scored a random selection of 20 ASD protocols for the SCORS
variables SOC and EI and for the ASD phenomena. The Intra-
class Correlation Coefficient, two way random effect model
(ICC; Shrout & Fleiss, 1979) was used to calculate interrater
reliability. ICCs are considered to be excellent if greater
than .74, good if ranging from .60 to .74, fair, if ranging from.
40 to .59 and poor if under .40 (Cicchetti, 1994).
Groups were compared regarding gender and age using Chi-
square statistics and t-test for independent samples respect-
tively. In order to investigate whether the TAT ASD phenom-
ena were associated with social functioning as operationalized
by the two SCORS variables SOC and EI, we calculated Pear-
son product-moment correlations between these SCORS vari-
ables and the ASD phenomena.
MANCOVA was used in order to study the differences be-
tween ASD patients and psychiatric controls regarding mean
scores on EI and SOC, mean percentages of ASD phenomena
and the number of words per protocol with age as a covariate.
Effect sizes were calculated in terms of partial eta squared
(ηp2). According to conventional criteria (Cohen, 1988) a ηp2
of .01 is small; .06 moderate; .14 large. Cohen’s d’s were cal-
culated as an Effect Size (ES) measure of differences between
groups (Cohen, 1977). According to conventional criteria, d
.20 is considered a small ES; d = .50 a medium ES; an d .80
a large ES.
Finally, a canonical Discriminant Analysis (method stepwise)
was used to investigate the power of the ASD TAT phenomena,
to discriminate between the ASD group and the psychiatric
Influence of Background Variables
Gender was evenly distributed across the two groups (χ2
= .18; df = 1, p = .68). The groups did however differ from each
other regarding age (t (92) = –3.75, p < .05). As a consequence,
age was taken into account as a covariate.
Correlations between SCORS Variables and ASD
Table 2 shows that all but two ASD phenomena, Multiple
Scenario’s and Inability to describe parallel processes, were
negatively associated with the two SCORS variables. Difficul-
ties with describing/interpreting movements was negatively
correlated with EI only.
Differences between the Groups on ASD Phenomena
MANCOVA was used to compare groups regarding mean
scores on the SCORS variables EI and SOC, the ASD phe-
nomena, and the mean number of words per protocol. Age was
used as covariate.
There was a significant main effect for group (F(11, 93) =
18.46, p < .001 with a huge ES (ηp2 = .72); ASD patients
scored significantly lower than psychiatric controls with large
ESs (with the exception of SOC, where a medium ES was
found) on the following variables: EI (F(1, 93) = 23.35, p
< .001, d = .1.16; M = 1.34, SD = .26 and M = 1.68, SD = .31
respectively), SOC (F(1,93) = 7.28, p < .01, d = .53; M = 1.59,
SD = .30 and M = 1.79, SD = .41 respectively), Weak Central
Coherence (F(1, 93) = 46.20, p < .001; d= 1.68; M = .24, SD
= .19 and M = .03, SD = .09 respectively), Ruminating (F(1, 93)
= 12.74, p < .01; d = .79; M = .25, SD = .18 and M = .12,
SD= .16 respectively), Underdeveloped Theory of Mind (F(1,
93) = 23.41, p < .001; d= 1.08; M = .59, SD = .42 and M = .18,
SD = .37 respectively), Jumping to Conclusions (F(1, 93) =
17.67, p < .001; d= 1.03; M = .83, SD = .78 and M = .35, SD
= .26 respectively), No social connectedness(F(1, 93) = 17.35,
p < .001, d = 1.07; M = .33, SD = .28 and M = .11, SD = .17
respectively), and Problems with describing/interpreting move-
ments, (F(1, 93) = 27.20, p < .001; d = 1.40, M = .10, SD = .12
and M = .005, SD = .03 respectively). In addition, the mean
number of words in protocols of ASD patients was significantly
higher than that in protocols of psychiatric controls (F(1, 93) =
22.51, p < .001; d = 1.08), M = 1123.44, SD = 674.51 and M =
649, 14, SD = 305.90 respectively).
No significant differences were found for Multiple Sce-
nario’s (F(1, 93) = 2.44, ns), and Inability to see parallel proc-
esses, (F(1, 93) = .45, ns).
Which TAT Phenomena Discriminate Best between
the Two Groups?
Finally, a Discriminant Analysis, method stepwise, was used
to discriminate the ASD group from the control group on the
basis of the ASD phenomena.
The analysis yielded one discriminant function with an Ei-
genvalue of 1.33 (Wilks λ= .43; χ2 = 75.77; df = 5; p < .001).
Canonical correlation was .76. For results see Table 3. This
function is dominated by Lack of Central Coherence (.67; Table
3(a)). Table 3(b) shows the correlations of the variables with
the discriminant function. Table 3(c) displays the function at
group centroid, showing that this discriminant function sepa-
rates the ASD group from the control group. Therefore, cases in
the ASD group were particularly characterized by high scores
on Lack of Central Coherence, Problems with describing/in-
terpreting movements and Jumping to Conclusions as opposed
to cases in the control group, which scored low on these vari-
ables. On the basis of this discriminant function 91.5% of cases
could be classified correctly (see Table 3(d)). Sensitivity was
81% and specificity was 96%. These figures imply that nine-
teen out of hundred persons with ASD receive a false negative
diagnosis, whereas four out of hundred persons without ASD
receive a false positive diagnosis. Positive Predictive Power
(PPP), or the probability that a person with scores typical for
the ASD group actually has an ASD, was .88. Negative Predic-
tive Power (NPP), or the probability that a person without
scores typical for the group with ASD actually has no ASD,
was .93. It should be kept in mind that, unlike Sensitivity and
Table 2.
Pearsons correlations betwee n th e SC ORS variables and the ASD TAT phenomena (N = 93).
ASD Phenomena SCORS Emotional Investment SCORS Unde rstanding Soc ial Causality
Weak central coherence –.40** –.32**
Ruminating –.29** –.25*
Weak theory of mind –.52** –.48**
Jumping to conclusions –.34** –.24*
Multiple scenario’s –.08 –.11
No social connectedness –.44** –.34**
No parallel processes –.04 –.01
Problems with describing/interpreting movements –.27** –.18
Total ASD phenomena –.58** –.49**
Note: **Correlation is significant at the .01 level (2-tailed). *Correlation is significant at the .05 level (2-tailed).
Table 3.
(a) Standardized canonical discriminant function coefficients; (b) Pooled within-groups correlations between discriminating variables and standardized
canonical discriminan t function; (c) Function at group centroids; (d) Classification of results f o r predicted group membership .
Variables Function 1
Weak central coherence .67
Multiple scenario’s .41
Problems with describing movement .41
Jumping to conclusions .38
Ruminating .37
Variables Function 1
Weak central coherence .66
Problems with describing movements .54
Jumping to conclusions .41
Ruminating .30
Multiple scenario’s .16
Group Function 1
ASD group 1.80
Control group .73
Predicted Group Membership
ASD group Control Group Total
Count Percentage Count Percentage Count Percentage
Original Group ASD 22 81.5 5 18.5 27 100.0
Control group 3 4.5 64 95.5 67 100.0
Note: 91.5% of original grouped cases correctly classified.
Specificity, PPP and NPP are dependent upon the base rate of
the condition in the population being tested. PPP decreases with
decreasing prevalence. Likelihood ratio plus (LR+), expressed
as sensitivity/1-specificity, was 20.25, meaning that a positive
result is 20 times as likely for those who have ASD as for those
who do not suffer from ASD. Likelihood ratio minus (LR),
expressed as specificity/1-sensitivity, was 5.05, indicating that
low scores on the ASD phenomena are five times more likely to
have come from a person who does not suffer from ASD than
from a person who suffers from ASD. These figures imply that
the odds for a false negative diagnosis are relatively greater
than the odds for a false positive diagnosis.
This study was aimed at exploring the usefulness of a TAT
ASD scoring system, using ASD phenomena, as described by
Edrisi and Eurelings-Bontekoe (2009). As expected, ASD pa-
tients differed significantly from psychiatric controls concern-
ing all ASD phenomena, except for the phenomena Multiple
Scenario’s and Inability to Describe Parallel Processes. In addi-
tion, as compared to psychiatric controls ASD patients scored
significantly lower on the SCORS dimensions EI and SOC,
which is in line with a lower level of social-emotional insight
among ASD patients as compared to psychiatric controls. As
expected, mean scores on these two dimensions were nega-
tively associated with the mean percentage of ASD phenomena
in TAT narratives.
Also, the two groups differed significantly regarding the
mean number of words of the TAT protocols, with patients with
ASD using approximately twice as many words as psychiatric
controls. The large number of words used by ASD patients may
reflect their great effort to construct a story.
Discriminant analysis showed that cases in the ASD group
were particularly characterized by high scores on Weak Central
Coherence, Problems with describing/interpreting movements
and Jumping to Conclusions as opposed to cases in the control
group, which scored relatively low on these variables Weak
central coherence of TAT narratives and jumping to conclu-
sions reflect the inability of ASD patients to see “the Gestalt”
of a picture and their limited insight into the fact that social
interactions may be determined by a multiplicity of inner and
outer causes. ASD patients tend to focus on one particular de-
tail and compose the story around this detail. If this detail is
irrelevant, this may result in an incomplete of completely in-
correct interpretation of the social situation. Interestingly, the
inability to describe and see movements spontaneously may
parallel the results of Holaday, Moak and Shipley (2001), who
compared Rorschach responses of 24 boys with AS, with that
of 24 boys with behavioural or emotional disorders, and who
found that the mean number of M (Movement) responses in the
protocols of boys with AS was signifycantly lower as compared
to that of the contrast group. A relatively low number of M
responses refers to impaired reasoning and impaired imagina-
tion (Holaday et al., 2001).
Specificity (96%) was somewhat higher than sensitivity
(81%). A relatively lower sensitivity than specificity increases
the probability of a false negative diagnosis, as was also shown
by the Likelihood ratio minus (LR). On the other hand, a high
specificity has the advantage of decreasing the probability of a
false positive diagnosis. In other words, the TAT scoring sys-
tem has the risk of missing patients with ASS, but has a lower
risk of falsely diagnosing patients with ASS, who in fact do not
suffer from the condition. Therefore, although further assess-
ment is always needed, this is especially so in case a patient is
clinically suspected for ASD, even if the TAT narratives do not
show the typical ASD phenomena.
The results of this study need to be viewed in de context of
several limitations.
First, the researcher scoring the narratives was aware of
which group the stories belonged to. However, with the excep-
tion of Multiple Scenario’s and No Parallel Processes, each of
the ASD phenomena and the total mean percentage of ASD
phenomena were negatively correlated with affective and cog-
nitive aspects of social functioning as measured with the
SCORS. Moreover, the TAT protocols from the ASS patients
showed a significant lower level of emotional investment and
understanding of social causality than those of the psychiatric
controls. The TAT protocols of the 67 controls had already
been scored on SCORS variables outside the context of this
study. Furthermore the two groups did not differ from each
other regarding the two ASD phenomena Multiple Scenario’s
and No Parallel Processes, precisely the phenomena that were
not associated with social functioning as measured with the
SCORS. Finally, interrater reliability was good to excellent.
Taken together, the association of the ASD phenomena and the
SCORS social cognition variables in the expected direction
tentatively suggest that the ASD phenomena as they have been
scored in the present study did tap low social cognition.
Second, although the patients with ASD were assessed by
specialized clinicians, we did not confirm the diagnoses. Third,
only a small number of ASD patients participated in the study,
which might have affected the results. Fourth, the study sample
is not fully representative of the actual population of people
with ASDs. Another limitation of the study could be that a
somewhat different set of cards was used for the control group
and the ASD group. Whereas the control group described sto-
ries for the cards 1, 2, 13 MF, 4, 3 BM and 7 GF, the ASD
group saw the cards 1, 2, 5, 6 BM, 13 MF and 18BM. Although
the content of the narrative is not relevant in scoring for ASD
phenomena, the cards may have differed in the amount of de-
tails, emotional impact and the sort of relationship depicted. It
cannot be entirely excluded that at least part of the differences
between the two groups might be attributed to the differences in
cards presented.
Therefore, even though results of this study are promising,
more research is definitively needed to verify and confirm the
present results. Such studies should include a larger sample of
patients with ASD. In addition scoring of the TAT narratives
should be done blind to the group the patient belongs to and
further studies should use the same set of cards for all groups
under study.
Although the use of the TAT in the assessment of patients
who are suspected for an Autism Spectrum Disorder is rather
unconventional and novel in clinical practice, the results of this
preliminary study suggest the usefulness of a formal analysis of
TAT narratives in the assessment process among adult patients
who are suspected for Autism.
TAT narratives of patients with Autism are particularly
characterized by weak central coherence, difficulties in de-
scribing and interpreting movements, and jumping to conclu-
sions. These information processing problems may underlie the
difficulties these patients may encounter in social interactions.
APA (2000). Diagnostic and statistical manual of psychiatric disorders
IV-TR. Washington DC: American Psychiatric Association.
Ackerman, S. J., Hilsenroth, M. J., Clemence, A. J., Weatherill, R., &
Fowler, J. C. (2001). Convergent validity of Rorschach and TAT
scales of object relations. Journal of Personality Assesment, 77,
295-306. doi:10.1207/S15327752JPA7702_11
Baron-Cohen, S. (2000) Theory of mind and autism: A fifteen year
review. In S. Baron-Cohen, H. Tager-Flusberg, & D. J. Cohen (Eds.),
Understanding other minds. Perspectives from developmental cogni-
tive neuroscience (pp. 3-21). Oxford: University Press.
Beaumont, R., & Newcombe, P. (2006). Theory of mind and central
coherence in adults with High-Functioning Autism or Asperger Syn-
drome. Autism, 10, 365-382. doi:10.1177/1362361306064416
Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for
evaluating normed and standardized assessment instruments in psy-
chology. Psychologica l Assessment, 6, 284-290.
Cohen, J. (1977). Statistical power analysis for the behavioural sci-
ences. New York: Academic Press.
Conklin, A., & Westen, D. (2001). Thematic apperception test. In W.
Dorfman, & M. Hersen (Eds.), Understanding psychological as-
sessment: Perspectives on individual differences (pp. 107-133). New
York: Kluwer Academic/Plenum.
Cramer, P. (1999). Future directions for the Thematic Apperception
Test. Journal of Personality As sessment, 72, 74-92.
Edrisi, M., & Eurelings-Bontekoe, E. H. M. (2009). Gifted, but ham-
pered; early detection of Autism Spectrum Disorders among adults
by means of clinical interview, personality questionnaires and the
Thematic Apperception Test. Wetenschappelijk Tijdschrift Autisme,
2, 44-53.
Edrisi, M., & Eurelings-Bontekoe, E. H. M. (2011). Doubts about the
diagnosis. In R. Borra, R. van Dijk and R. Verboom (Eds.), Cultuur
en psychodiagnostiek (pp. 185-197). Houten: Bohn Stafleu van
Loghum. doi:10.1007/978-90-313-8580-5_13
Eurelings-Bontekoe, E. H. M., Luyten, P., & Snellen, W. M. (2009).
Validation of the theory driven profile interpretation of the Dutch
Short form of the MMPI using the TAT Social Cognition and Object
Relations Scale (SCORS). Journal of Personality Assessment, 91,
155-165. doi:10.1080/00223890802634274
Happé, F., & Frith, U. (2006). The weak coherence account: De-
tail-focused cognitive style in autism spectrum disorders. Journal of
Autism and Developmental Disord ers, 36, 5-25.
Holaday, M., Moak, J., & Shipley, M. A. (2001). Rorschach protocols
from children and adolescents with Asperger’s Disorder. Journal of
Personality Assessment, 76, 482-495.
Huprich, S. K., & Greenberg, R. P. (2003). Advances in the assessment
of object relations in the 1990s. Clinical Psychology Review, 23,
665-698. doi:10.1016/S0272-7358(03)00072-2
Langan-Fox, J., & Grant, S. (2006). The Thematic Apperception Test:
Toward a standard measure of the big three motives. Journal of Per-
sonality Assessment, 87, 277-291.
Minshew, N., Sweeney, J., & Luna, B. (2002). Autism as a selective
disorder of complex information processing and underdevelopment
of neocortical systems. Molecular Psychiatr y, 7, 14-15.
Murray, H. (1943). Manual for the Thematic Apperception Test. Cam-
bridge, MA: Harvard University Press.
Ozonoff, S., South, M., & Provencal, S. (2005). Executive functions. In.
F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of
autism and pervasive developmental disorders (pp. 606-627). New
Jersey: John Wiley and Sons.
Peters, E. J., Hilsenroth, M. J., Eudell-Simmons, E. M., Blagys, M. D.,
& Handler, L. (2006). Reliability and validity of the Social Cognition
and Object Relations Scale in clinical use. Psychotherapy Research,
16, 617-626. doi:10.1080/10503300600591288
Porcerelli, J. H., Shahar, G., Blatt, S. J., Ford, R. Q., Mezza, J. A., &
Greenlee, L. M. (2006). Social cognition and object relations scale:
Convergent validity and changes following inpatient treatment. Per-
sonality and Individual Differences, 41, 407-417.
Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations—uses in
assessing rater reliability. Psychologica l Bulletin, 86, 420-428.
Tager-Flusberg, H. (2007). Evaluating the Theory-of-Mind Hypothesis
of Autism. Current Directions in Psychological Science, 16, 311-315.
Tager-Flusberg, H., & Caronna, E. (2007) Language disorders: au- tism
and other pervasive developmental disorders. Pediatric Clinics of
North America, 54, 469-481. doi:10.1016/j.pcl.2007.02.011
Westen, D. (1991a). Clinical assessment of object relations using the
TAT. Journal of Personality Assessment, 56, 56-74.
Westen, D. (1991b). Social cognition and object relations. Psycho-
logical Bulletin, 109, 429-455. doi:10.1037/0033-2909.109.3.429
Westen, D. (1985). Social Cognition and Object Relations Scale.
Original manual to use for training. Ann Arbor: Department of Psy-
chology, University of Michigan.