L’intérêt du test de Rorschach dans l’évaluation diagnostique des troubles du spectre autistique

Abstract

ObjectifsIn France, since the government announced its new National Autism Strategy (2018–2022), health authorities have developed guidelines proposing standardized approaches and recommending diagnostic tools in order to improve the assessment of autism spectrum disorders. However, this protocol may be limited—especially with specific populations or in complex cases. More specifically, the issue of differential diagnosis is complex since the notion of an autism spectrum leads us to consider a greater diversity of autistic phenotypes with frequent comorbidities and with symptomatic overlaps with other psychiatric pathologies at any age. This leads clinicians to turn to other tools, including the Rorschach inkblot test. This article aims to present the Rorschach test as a tool able to support a different and supplementary clinical diagnostic approach for children and adults, especially in these complex diagnostic situations. MethodsThis article will present the current situation of this tool, already used by some clinicians, but which has not yet found its place in the recommended diagnostic procedures. Then, we will focus on the interests and limits of the Rorschach test in diagnosing autism spectrum disorders. Finally, we will conclude by expanding upon the major problem of differentiating autism spectrum disorders from other psychiatric disorders, supported by an integrative review of the literature on the original and current studies around this issue. ResultsThe Rorschach test is not integrated into autism spectrum disorders diagnostic procedures for technical reasons and because of a lack of research to support its use in this diagnostic framework, but also for more unjustified reasons and epistemological disagreements. However, the use of this test is possible and can add complementary data to those sought in the psychological assessment that takes into account the holistic dimensions of the individual. We argue that this complementarity is also expressed through the specificities of the test in terms of the test material, of spatial configuration, of the conditions of administration, of type of data collected, and of the intersubjective relationship that is engaged. This projective situation appears to be non-invasive and particularly adapted to the peculiarities of autism. A literature review of current French works thus shows the authors’ interest for this “test of limits” that can reveal specific modes of apprehension related to the autistic issues of building a bodily ego and differentiated psychic spaces. The princeps works on the Rorschach test already underlined the interest of the test in establishing a dynamic and singular psychological profile—to which can be added its ability to provide useful information for a differential diagnosis. These new works also highlight a number of qualitative differences between psychotic and autistic intrapsychic mechanisms and dynamic processes. Moreover, the test enable clinicians to take into account traces of “failures” and defensive mechanisms hindering the constitution of a contained psychic space and their possible evolutions towards “post-autistic” states—that is, to the possibilities of building and accessing different psychic spaces through a dynamic, life-long perspective from childhood to adulthood. International studies—mostly based on the Exner's Comprehensive System for Interpreting Rorschach—identify quantitative differences in several variables and group of variables between the protocols of autistic children or adults and those of other psychiatric populations, in particular those with schizophrenia. DiscussionThe literature review shows that research on the Rorschach test is emerging in France and around the world: this test seems to provide particularly interesting indicators related to the semiological characteristics of autism, but also to the singular cognitive and affective psychological functioning of autistic individuals. These quantitative and qualitative elements also appear to be able to help clinicians in making a differential diagnosis. This test's strong diagnostic potential remains to be confirmed by comparing results from different studies with different epistemologies and which will then have to be statistically verified by studies of larger cohorts. ConclusionsThe Rorschach test appears to be a promising tool that opens up a different approach to the diagnosis of autistic spectrum disorders and that can bring an original and complementary perspective to current diagnostic practices. Moreover, these innovative studies on the Rorschach test are likely to feed both basic research and actual practice. Further research is to be expected.