Extended Abstract
Introduction
In the last few decades, a type of mental disorders called Somatic Symptom Disorder (SSD) has emerged that is affected by emotional and psychological factors [2]. Patients with SSD usually have multiple physical symptoms that are unpleasant or lead to significant disruption in daily living and may not be medically justified [2]. Physical complaints that do not have specific causes are a process commonly seen in patients with SSD. People with this disorder have no view of the psychological symptoms of their illness and refuse to undergo psychiatric clinical therapies [7]. Due to the complexity of experiences in SSD, projective personality tests can be used to provide multidimensional psychological aspects of patients with this disorder [12]. The main purpose of this study was to investigate the differences between the projective responses of patients with and without SSD using Rorschach test in order to suggest useful psychological approaches to help patients with SSD and be used to treat and diagnose these patients.
Materials and Methods
This is a analytical study with cross-sectional design. The statistical population included all men and women aged 20-60 years with gastrointestinal disease and physical pain referred to the health centers of in Semnan, Iran in 2018. Of these, 70 were selected as study samples by using a convenience sampling technique and based on inclusion and exclusion criteria and divided into two groups of patients (n=35) and controls (n=35). The data collection tools were 15-item Patient Health Questionnaire Physical Symptoms (PHQ-15) and Rorschach test (Exner’s Comprehensive System). After receiving the initial diagnosis report from the physician, the patients completed the PHQ-15 and after a semi-structured interview, Rorschach test was performed by each patient. 
The psychometric properties of PHQ-15 have already been evaluated by Abdolmohammadi et al. Concurrent validity of this questionnaire with somatization subscale of the Symptom Checklist 90-item version (SCL-90) was 74%, and its internal consistency using Cronbach's alpha was 0.76 [20]. Rorschach test was designed by Hermann Rorschach, a Swiss psychiatrist [21]. It is a performance-based personality test that is interpreted based on individual responses to 10 symmetrical inkblots [22]. In order to analyze the collected data, multiple linear regression analysis, logistic regression analysis, and multivariate ANOVA were performed in SPSS v. 22 software.
Results
Affected and non-affected groups were compared in terms of educational level, gender, employment, education and other factors. Out of 70 samples, 67.1% were female. Their mean age was 34±3.51 years (ranged 21-57 years). Out of 35 people in the affected group, the PHQ-15 score of 18 was ranged 35-45 and for 12 samples, it was 30-35. The PHQ-15 score was less than 30 in control group. The logistic regression model included five location variables based on Rorschach test (W, D, Dd, Ds and Dds ). The results of the Hosmer-Lemeshow test as the most reliable goodness-of-fit test in the logistic regression, showed a chi-square value of 3.98 (Df= 8, P= 0.85). According to the results shown in Table 2, perceived location codes including D and Dd scores were able to significantly differentiate the SSD patients from controls (P<0.05).

Discussion
Statistical results showed that there was a significant difference between participants' projective responses (affected and non-affected) to Rorschach test cards in terms of location variables, and perceived location scores played a predictive role in separating the SSD patients from non-affected groups. Among the location variables, the D and Dd scores were more important in showing the response difference. In the interpretation of Exner's Comprehensive System, D scores are compared with W scores. 
The W score reflects an overall view of the individual and having a more comprehensive view. In this regard, it can be justified that individuals with SSD may be less comprehensive and the high frequency of Dd scores in them may indicate symptoms such as anxiety and obsessive-compulsive behaviors that were reduced due to their response details. The results of Yamamoto et al.'s study also showed that the perceived location scores of two groups of schizophrenia and autism were significantly different and those with schizophrenia had higher D scores [17]. Contrary to our results, Pasha Sharifi and Kheradpey in a study with the purpose of comparing the responses of depressed and anxious individuals with healthy people using Rorschach test, showed no significant difference between the scores of anxiety and depressed individuals in terms of Rorschach test variables [19].
SSD can be effective in choosing the location of perception and response to Rorschach test cards. In fact, if people are stressed and anxious, it will affect how they respond and pay attention to details. The results of this study, while confirming the importance of Rorschach test in the diagnosis of disorders that are affected by psychological factors, can be effective in designing treatment plans for people with disorders such as SSD. Since the results indicated high levels of anxiety in these patients, psychotherapy should also be considered in these patients' treatment plans.
Ethical Considerations
Compliance with ethical guidelines
The present study was approved by the Research Ethics Committee of Semnan University of Medical Sciences (code: IR.SEMUMS.REC.1397.029).
Funding
This article is taken from the bachelor's thesis of the first author in the field of clinical psychology, Faculty of Psychology and Educational Sciences, Semnan University.
Authors' contributions
All authors met the writing standards based on the recommendations of the International Committee of Medical Journal Editors (ICMJE), and they had equal attribution in preparing the paper.
Conflicts of interest
The authors declared no conflict of interest.