Depression, Cognition, and Anosognosia in Alzheimer's Disease: A Rorschach Analysis

Research investigating the relationship between depression and anosognosia, or lack of insight, in Alzheimer's disease has reported positive, negative, and no correlation. One possible reason for the discrepant findings may be due to depression not being accurately assessed or cleanly defined. Overlap between the symptoms of depression and dementia make discerning the presence of depression in dementia difficult, especially when diagnosed by interview or self-report methods. Further, the role cognitive dysfunction associated with Alzheimer's disease and premorbid psychological functioning play in depression and anosognosia also remain poorly understood, as does the effect on the phenomenological perspective of the individual with Alzheimer's disease. The present study sought to clarify these issues by utilizing the Rorschach Inkblot test in conjunction with the Comprehensive Scoring system to assess depression and other variables possibly contributing to this construct.

Projective assessment of depression with the Rorschach sidesteps the behavioral symptoms and conscious filters that cloud accurate diagnosis while allowing consideration of additional factors such as ease and ability with which affect is processed and perceived social inadequacy in the individual. As a neuropsychological instrument, the Rorschach variables associated with the Cognitive Triad - information processing, cognitive mediation, and ideation - allow inclusion of information on the cognitive functioning of the individual as well.

Forty-two individuals diagnosed with Alzheimer's disease were assessed with a self-report instrument, the Geriatric Depression Scale (GDS), the Mini-Mental State Exam, and the Rorschach. Variables taken or derived from the Rorschach consisted of an indicator of depression, the DEPI; an assessment of ability to moderate and process affective, AFFECT; a gauge of perceived social inadequacy, the CDI; and, the three variables of the Cognitive Triad. A brief indicator of past psychological functioning was also obtained, and each participant was also asked to share his/her personal perspective on having been diagnosed with memory problems.

As expected, correlations between self-report measures of depression and projective measures were non-significant. Contrary to predictions, neither measure demonstrated a significant correlation with anosognosia, and ANCOVA's showed no significant difference between the means of DEPI or CDI based on past-psychological history or anosognosia status. A stepwise linear regression indicated that AFFECT, CDI, and Cognitive Mediation accounted for a significant amount of variation of depression, but past psychological history or anosognosia did not account for any additional variation. Phenomenological interviews were reviewed for predominate themes across all protocols, while individual responses yielded new insight into how anosognosia affects the individual's perception of the world and may contribute to depression. Integration of all analyses suggests that depression and anosognosia are multidimensional constructs, as is cognitive dysfunction in Alzheimer's disease, making a single unidimensional relationship unlikely. Instead, the variability reported in studies should be considered a reflection of the complexity of the constructs involved.