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4 authors, including:
SEE PROFILE
Robert F. Bornstein
Department of Psychology
Gettysburg College
Mark J. Hilsenroth
Department of Psychology
University of Arkansas
Justin R. Padawer
Department of Psychology
University of Tennessee
J. Christopher Fowler
Erik H. Erikson Institute for Training and Research
Austen Riggs Center
Stockbridge, Massachusetts
Masling et al.s (1967) Rorschach Oral Dependency (ROD) scale has been
the most widely used projective measure of interpersonal dependency during
the last 30 years (Bornstein, 1996, 1999). ROD scores predict conformity,
compliance, help seeking, and interpersonal yielding in a variety of situations
and settings (Bornstein, Riggs, Hill, & Calabrese, 1996; Masling, Weiss, &
Rothschild, 1968; Shilkret & Masling, 1981). High scores on the ROD scale
are also associated with increased sensitivity to interpersonal cues (Masling,
Johnson, & Saturansky, 1974), an insecure attachment style (Duberstein &
Talbot, 1993), and difficulty terminating psychotherapy (Greenberg & Born-
stein, 1989).
These results support the convergent validity of the ROD scale as a measure of
interpersonal dependency (see also Viglione, 1999, for a review of research on this
issue). Other findings confirm that the ROD scale meets established psychometric
criteria for discriminant validity (Gordon & Tegtemeyer, 1983; Kertzman, 1980),
retest reliability (Bornstein, Rossner, & Hill, 1994), and interrater reliability (Juni
& Semel, 1982; Weiss & Masling, 1970). As expected, ROD scores show strong
positive correlations with scores on other projective measures of dependency
(Fowler, Hilsenroth, & Handler, 1996; Masling et al., 1967) and more modest cor-
relations with scores on self-report dependency measures (Bornstein, Rossner,
Hill, & Stepanian, 1994).
Given the widespread use of the ROD scale in clinical and research settings, there
has been surprisingly little exploration of the relationship between ROD score and
psychiatric diagnosis. In two early studies of this issue, Bertrand and Masling (1969)
and Weiss and Masling (1970) found that alcoholic psychiatric outpatients produced
higher ROD scores than nonalcoholic outpatients matched on salient demographic
and diagnostic variables. More recently, ROD scores have been found to distin-
guish eating-disordered from non-eating-disordered female psychiatric inpatients
(Bornstein & Greenberg, 1991), with eating-disordered patients showing higher
rates of both oral (i.e., food and mouth-related) and dependent imagery. High ROD
scores are also associated with elevated levels of depression in psychiatric inpa-
tients, outpatients, and nonclinical participants (ONeill & Bornstein, 1990, 1991);
in each of these samples, depressed participants had significantly higher ROD
scores than nondepressed participants matched on salient demographic and (in the
case of clinical participants) diagnostic variables.
Although the aforementioned studies assessed links between ROD scores and
several Axis I disorders, there has been only one investigation of the relationship
between ROD scores and Axis II personality disorder (PD) diagnoses. Blais,
Hilsenroth, Fowler, and Conboy (1999) assessed the correlations between ROD
scores and dimensional symptom ratings for each of the Diagnostic and Statisti-
cal Manual of Mental Disorders (4th ed. [DSMIV]; American Psychiatric As-
sociation, 1994) Cluster B PDs (i.e., antisocial, borderline, histrionic, and
narcissistic) in a mixed-sex outpatient sample. They found a significant negative
480 BORNSTEIN, HILSENROTH, PADAWER, FOWLER
METHOD
Participants
1Although reliable information in this area was not always available, previous studies have found
that medication history and status are unrelated to dependency levels in clinical samples (Fava et al.,
1994; Peselow, Robins, Sanfilipo, Block, & Fieve, 1992).
482 BORNSTEIN, HILSENROTH, PADAWER, FOWLER
TABLE 1
Demographic Characteristics of the Clinical Groups
Education
N Age (Years) Marital Status
did not influence the diagnostic process (the use of intake rather than discharge di-
agnoses also helped ensure independence of diagnoses and projective test data).
& Luty, 1999; Grilo et al., 1998). Interrater agreement in PD diagnosis was estab-
lished by independent ratings of a randomly selected pool of 31 PD outpatients. A
kappa coefficient of .90 regarding the presence or absence of a DSMIV PD diag-
nosis was obtained.
In the third phase, the records of these 91 patients were independently rated on
all DSMIV Cluster B PD symptom criteria using the same case material and meth-
odology described earlier. Interrater reliability was established by independent rat-
ings of a randomly selected pool of 25 patients. Kappa estimates of interrater
agreement regarding the presence or absence of individual DSMIV symptoms
were as follows: APD = .86, BPD = .80, and NPD = .90.
Demographic characteristics of the APDO, BPDO, NPDO, and D/APDO
groups are summarized in the bottom portion of Table 1. Axis I diagnoses in these pa-
tient groups were as follows: APDO (substance abuse disorder n = 10), mood disor-
der n = 5, adjustment disorder n = 1, impulse control disorder n = 1), BPDO (mood
disorder n = 9, substance abuse disorder n = 6, anxiety disorder n = 3, eating disorder
n = 3, adjustment disorder n = 2), NPDO (mood disorder n = 4, substance abuse dis-
order n = 3, anxiety disorder n = 1, adjustment disorder n = 1, impulse control disor-
der n = 1), and D/APDO (mood disorder n = 8, anxiety disorder n = 4).
Procedure
The administration and scoring of all Rorschach protocols followed the procedures
articulated by Exner (1993). Rorschach protocols were scrutinized for validity, and
2A sample size of 50 was used for the CSC group because this sample size enhanced the statistical
power of the analyses without being so large as to introduce heteroscedasticity problems that might
confound the results. Although the CSC participants were somewhat younger than the clinical partici-
pants, studies have shown that from late adolescence through middle adulthood, age is unrelated to
ROD score (Bornstein, 1993; Kertzman, 1980; Masling, 1986). CSC participants did not differ from
the combined clinical participant group with respect to number of years of education.
484 BORNSTEIN, HILSENROTH, PADAWER, FOWLER
any protocols with fewer than 14 responses and lambdas above 1.0 were omitted
from the study, as is standard in studies involving the Comprehensive System (see
Exner, 1993). For all participants, scoring of projective test data was done by Mark
J. Hilsenroth, who was unaware of group (diagnostic) assignment.
ROD scores were derived from the combined free-association and inquiry por-
tions of each participants Rorschach protocol, using the ROD scoring system of
Masling et al. (1967). In this system, a response is defined as oral dependent if it
falls into any of the following categories: (a) foods and drinks, (b) food sources, (c)
food objects, (d) food providers, (e) passive food receivers, (f) food organs, (g)
supplicants, (h) nurturers, (i) gifts and gift givers, (j) good luck symbols, (k) oral
activity, (l) passivity and helplessness, (m) pregnancy and reproductive anatomy,
and (n) negations of oral percepts (e.g., not pregnant, man with no mouth).
One point is assigned for each oral-dependent Rorschach response. Detailed re-
views of the construct validity of the ROD scale were provided by Bornstein
(1996) and Masling (1986).
To establish interrater reliability in ROD scoring, 20 Rorschach protocols were
chosen at random and rescored independently by J. Christopher Fowler, who was
unaware of the first coders scores and the participants group assignments. The
two sets of scored protocols were compared, and percentages of agreement were
calculated for the ROD. In addition, an intraclass correlation coefficient (ICC) was
computed between the two sets of scores. The resulting interrater agreement and
ICC statistics were 98% and .91, respectively.
RESULTS
TABLE 2
Rorschach Oral Dependency (ROD) Scores in Different Criterion Groups
ROD Score
Group M SD Range
The frequency of the 16 individual criteria that make up the ROD scale was ex-
amined for each of the clinical groups included in this study. These data are pre-
sented in Table 3. The most frequently occurring ROD subcategories were Food
Organs and Oral Activity. The least frequently occurring subcategories were Ne-
gations of Oral Percepts, Baby-Talk Responses, Gifts and Gift Givers, and Passiv-
ity and Helplessness. There were no discernable patterns of ROD subcategory
differences across the clinical groups. The last two columns in Table 3 summarize
the overall frequencies of each ROD subcategory, collapsed across diagnosis.
DISCUSSION
These results provide partial support for our a priori hypotheses. As expected,
BPDI participants produced higher ROD scores than the APDO, BPDO, and
CSC groups. However, contrary to expectations, the ROD scores of the D/APDO
group did not differ from those of other PD groups.3
The lower-than-expected ROD scores of the D/APDO group might be due in
part to the methods used to derive PD diagnoses in this investigation. PD diagno-
ses were derived from a review of patients chart records, and much of the infor-
mation contained in these records was based on patients reports of PD-related
3Although ROD scores were not significantly elevated in the D/APDO group, it is worth noting
that patients in this group had the second highest mean ROD score (.204) and the highest mean ROD
score of all outpatient groups. Only the BPDI participants had a higher overall ROD score (.265) than
the D/APDO group.
486
TABLE 3
Frequencies of Rorschach Oral Dependency (ROD) Scale Subcategories in Different Clinical Groups
Group
Note. PSDI = psychotic disorder inpatient; BPDI = borderline personality disorder (PD) inpatient; BPDO = borderline PD outpatient; D/APDO =
dependentavoidant PD outpatient; NPDO = narcissistic PD outpatient; APDO = antisocial PD outpatient; BR = overall base rate of a given ROD subcategory
(i.e., subcategory percept frequency divided by R); ROD % = frequency of a given subcategory relative to other ROD subcategories (i.e., subcategory percept
frequency divided by the total number of oral dependent responses). All figures are percentages, rounded to the nearest whole number. Overall means were
calculated collapsing across clinical groups.
an = 33. bn = 27. cn = 22. dn = 11. en = 14.
DEPENDENCY AND PERSONALITY PATHOLOGY 487
behaviors, cognitions, and affective responses. In other words, these chart records
contained a great deal of information regarding self-attributed traits and character-
istics, that is, traits and characteristics that are explicitly acknowledged (albeit re-
luctantly at times) by the patient (McClelland, Koestner, & Weinberger, 1989).
In contrast, the ROD scale assesses implicit (i.e., underlying, often uncon-
scious) dependency strivings, which may or may not be reported by a participant.
Previous studies have shown that in both clinical and nonclinical samples, correla-
tions between measures of implicit and self-attributed dependency needs are mod-
est at best, and typically in the .20 to .30 range (Bornstein, 1998b; Bornstein,
Rossner, & Hill, 1994; Bornstein, Rossner, Hill, & Stepanian, 1994). In this con-
text, the absence of a significant relation between avoidantdependent PD symp-
toms and ROD scores is less surprising. It may simply represent another example
of the discontinuity between individuals implicit and self-attributed dependency
needs (see Bornstein, 1998a, for a detailed discussion of this issue).
The substantial (and statistically significant) difference between the ROD
scores of the BPDI and BPDO groups might reflect one (or more) of several un-
derlying processes. It may be that the BPDO groups concerns regarding inti-
macy, and the potential loss of identity associated with merging with a valued
other, caused these patients to invoke various defenses and coping strategies aimed
at denying their underlying dependency needs (see Blais et al., 1999; Duberstein &
Talbot, 1993; Fowler et al., 1996). To the extent that ROD scores do in fact tap im-
plicit dependency strivings, these results would suggest that such defensive and
coping strategies can influence participants indirect expression of these needs on
projective tests such as the ROD scale.
Alternatively, the significant inpatientoutpatient BPD differences obtained in
this study might reflect changes in participants mood states during inpatient treat-
ment. Studies have shown that the onset of negative mood states is associated with a
significant increase in ROD scores (Bornstein, Bowers, & Bonner, 1996). To the ex-
tent that borderline patients show increases in depression following psychiatric hos-
pitalization, increases in their ROD scores would be expected. Such an explanation
is supported by the fact that the vast majority of BPD inpatients in our sample were
hospitalized following a suicide attempt or gesture related to interpersonal conflict
or loss. Concerns regarding rejection and abandonment might well have caused
these BPD inpatients to become preoccupied, at least temporarily, with dependency-
related issues, thereby inflating their ROD scores.
A third possibility concerns the BPD diagnostic criteria themselves. As numer-
ous clinicians and researchers have noted, BPD is a particularly heterogenous di-
agnostic category, and considerable controversy remains regarding the most
appropriate and useful criteria for classifying borderline patients (see Carr, 1987;
Costello, 1996; Lerner, Albert, & Walsh, 1987; Millon, 1996). It may be that in-
patient and outpatient diagnosticians use somewhat different strategies and be-
havioral anchor points in diagnosing BPD, leading to subtle, albeit important,
488 BORNSTEIN, HILSENROTH, PADAWER, FOWLER
4It is worth noting that ADPOs had the second lowest mean ROD score of all the groups assessed
in this study (.117), only slightly higher than that of BPD outpatients (.109). This result is consistent
with recent theoretical analyses of dependency strivings in antisocial PD, which predict low levels of
both implicit and self-attributed dependency needs in antisocial individuals (e.g., Bornstein, 1997;
Millon, 1996).
DEPENDENCY AND PERSONALITY PATHOLOGY 489
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Robert F. Bornstein
Department of Psychology
Gettysburg College
Gettysburg, PA 17325
E-mail: bbornste@gettysburg.edu