2026 ECNP Congress

PS04-4213

From projection to precision: stress and distress variables in the Rorschach Performance Assessment System—a systematic review and meta-analysis

Judit Lippai — T.D. Fehér, B. Kertész, K. Karimi, K.K. Fazekas, P. Hegyi, G.Z. Rubovszky, L. Giromini, X. Gonda · Semmelweis University, Centre for Translational Medicine, Budapest, Hungary

2026 ECNP Congress

Introduction

Mental disorders represent a major and increasing global health burden, underscoring the need for accurate diagnostic tools [1]. In contemporary dimensional psychodiagnostic research, the limitations of single-domain instruments have led to increased emphasis on multimethod assessment (MMA), within which performance-based methods provide incremental validity over self-report measures by capturing implicit processes less accessible to conscious awareness [2,3]. The Rorschach test—requiring meaning-making from semi-structured stimuli—may capture complex intrapsychic processes if it meets evidence-based psychometric standards, as supported by the Rorschach Performance Assessment System (R-PAS), a refined approach with international norms and growing empirical support [4]. Neuropsychological and psychophysiological findings further support the interpretive validity of R-PAS variables [5], although it remains unclear whether Stress and Distress variables differentiate psychiatric patients from individuals without psychiatric diagnoses.

Aims

To assess whether R-PAS Stress and Distress variables in psychiatric samples deviate from the standardized normative value.

Methods

The present systematic review and meta-analysis was conducted in accordance with the PRISMA 2020 guidelines and prospectively registered in PROSPERO (CRD420251233059). Studies examining psychiatric populations using R-PAS were included. A search of PubMed, EMBASE, the Cochrane Library, and r-pas.org/library on 8 December 2025 yielded 3,672 records. After duplicate removal, two reviewers independently screened titles and abstracts and conducted full-text review. Given the standardized R-PAS metric, deviation-from-norm analyses provided clinically interpretable benchmarks.Asingle-arm meta-analysiscompared means with the standardized R-PAS normative mean (100). Random-effects models estimated pooled means with 95% confidence intervals, and heterogeneity was assessed using Higgins & Thompson’s I² statistics. An individual participant data (IPD) level meta-analysis is ongoing; therefore, current findings should be considered preliminary.

Results

The included studies encompassed diagnostically heterogeneous samples (ADHD, schizophrenia, mood and eating disorders, and traumatized patients). For Critical Content Percentage (CritCont%), 6 studies including 360 participants showed a pooled mean of 100.45 (95% CI: 95.42–105.48), with no significant deviation from the normative mean (p = 0.828) and substantial heterogeneity (I² = 77%, 95% CI: 49-90%). For Morbid Content (MOR), 5 studies including 318 participants showed a pooled mean of 102.88 (95% CI: 97.57–108.20), again with no significant deviation from the normative mean (p = 0.207), and substantial heterogeneity (I² = 80%, 95% CI: 53–92%). Similar non-significant patterns were observed for other available Stress and Distress variables. The high heterogeneity may reflect differences in diagnostic composition, clinical severity, and sample characteristics across studies.

Conclusions

Preliminary findings do not show consistent deviations of R-PAS Stress and Distress variables from normative values in heterogeneous psychiatric samples. These variables may not function as general transdiagnostic markers of psychopathology, although their utility in specific, well-characterized clinical subgroups remains possible. Within a multimethod assessment (MMA) framework, however, such variables may still contribute incremental information when interpreted alongside other data sources. These findings have implications for the identification of clinically relevant and valid markers of distress within contemporary psychiatric research. Future research should focus on more homogeneous and clearly characterized clinical populations with larger samples to clarify their potential diagnostic and interpretive value.

References

  1. Fan, Y., Fan, A., Yang, Z., & Fan, D. (2025). Global burden of mental disorders in 204 countries and territories, 1990–2021: results from the global burden of disease study 2021. BMC psychiatry, 25(1), 486.
  2. Bornstein, R. F. (2021). Multimethod assessment of personality and psychopathology. The Oxford handbook of personality and psychopathology assessment.
  3. Mihura, J.L., Meyer, G.J., Dumitrascu, N., Bombel, G., 2013. The validity of individual Rorschach variables: Systematic reviews and meta-analyses of the comprehensive system. Psychol. Bull. 139 (3), 548.
  4. Meyer, G.J., Viglione, D.J., Mihura, J.L., Erard, R.E., Erdberg, P., 2011. A manual for the Rorschach performance assessment system. R-PAS, Toledo, OH.
  5. Giromini, L., Viglione Jr., D.J., Pineda, J.A., Porcelli, P., Hubbard, D., Zennaro, A., Cauda, F., 2019. Human movement responses to the Rorschach and mirroring activity: An fMRI study. Assessment 26 (1), 56–69.