MCMI-III

Popularity

MCMI has become extremely popular.MMPI-2 more popularRorschach more popular

Author : Ted Millon

Ted Millon

MCMI-III: Part of a Suite of Millon Inventories

Millon Clinical Multiaxial Inventory – III Millon Adolescent Clinical Inventory Millon Index of Personality Styles – Revised Millon Behavioral Medicine Diagnostic Millon College Counseling Inventory Millon Pre-Adolescent Clinical Inventory

Overview of the MCMI-III

Administer To: 18 years + (18-55 sample) Reading Level

8th Grade Completion Time

25 minutes (175 items) Formats

Paper-and-pencil, audiocassette, computer Report Options

Interpretative and Profile Scoring Options:

Hand, Mail-in, Microtest Q

Normative Sample

998 males and females with a wide variety of diagnoses

Included individuals from:independent practicesclinicsmental health centersforensic settingsresidential settingshospitals

Key Features of the MCMI-III

Multiaxial InventoryAll 14 PDs from DSM-IV and DSM-III-R

95 test items directly reflect DSM-IV Axis II criteria

Use of “prototypal” items Base rates…not T scores Personality patterns based upon Millon’s

theoretical construct Utilized “threefold validation model”

Axis I Clinical Syndromes Anxiety

apprehensive to phobic, tense.restless, physical manifestations, worrisome

Somatoformpreoccupation with healthhypochondriacalcould be medical problem

Bipolar-Manicelation inflated self-esteemoveractivityIrritabilitydecreased need for sleep

Axis I Clinical Syndromes

Dysthymiachronic low-grade depressionbehavioral apathy, low self-esteem

Alcohol Dependencecurrent or historical alcohol abuse or

dependence

Drug Dependencecurrent or historical drug abuse or

dependence

Axis I Clinical Syndromes

Post-Traumatic Stress Disorder Experience of previous trauma Reacted with…

○ intense fear○ feelings of helplessness○ distressful recollections ○ nightmares of traumatic event.

Contrast with Other Contrast with Other InstrumentsInstruments

Some Issues in Using the MCMI

MCMI is extremely “theory heavy” Multiple difficult concepts

What is a personality disorder?What is a base rate score?What is a prototypal item?What is the multiaxial model?

A full day could be spent on any single PD.Each PD has its own body of clinical theory.

Importance of PDs to Importance of PDs to AssessmentAssessment

Axis II Personality Disorders

14 PDs from DSM-III, DSM-III-R, and DSM-IV, including those in the Appendix.

Schizoid Sadistic (DSM-III-R Appendix)

Avoidant Compulsive

Dependent Negativistic (DSM-IV Appendix)

Depressive (DSM-IV Appendix) Masochistic (DSM-III-R Appendix)

Histrionic Schizotypal

Narcissistic Borderline

Antisocial Paranoid

Prevalence Rates are High

Prevalence rates in community studies average about 13% (Mattia and Zimmerman, 2001)Compulsive: 4%Histrionic, Schizotypal, Dependent: 2%

If the prevalence rates of PDs in the community are high, then the prevalence of maladaptive personality traits must be higher.

PDs Exact a Huge Toll on Society

Some PDs repeatedly trample on the rights of others.

Some PDs repeatedly enter periods of crisis and are at risk for committing suicide.

Some PDs become disproportionally involved in litigation.

All PDs are believed to be at least somewhat resistant to psychotherapy.

Why do we Need a Theory?

Some obvious reasonsTo understand our clientsTo suggest effective psychotherapiesTo suggest avenues of advancing our science.

The real reasonsEvery taxonomy is really based on theory.Theory provides a way of organizing and

differentiating the subject matter of the field.

Every Science Has a Taxonomy

Every science has a taxonomy.A taxonomy is a system of constructs

that guides thinking about the subject domain.○ Chemistry : Periodic table of elements○ Physics : Standard model of fundamental

forces and particles.○ Biology : Branches of the tree of life.

Purpose of Taxonomy:Periodic Table of Elements

First published by Dmitri Mendeleev in 1869.

Knowing the element means automatically knowing the atomic weight and possible chemistry of the element.

Taxonomy brings structure to a field. Taxonomy inter-relates and differentiates

the phenomena of the field.

Taxonomy should “Carve Nature at its Joints”

If we know what group at atom belongs to…We its electron orbitalsWhat kinds of compounds might be created, and with

what other elements.

Classification is not merely descriptive, but explanatory.

To the extent that a classification “works for us,” we are entitled to believe that it has objective existence in nature.

Stages of Scientific Development

All sciences pass through a “natural history” stage. Observe the phenomena of the subject domain in

sufficient detail to establish primitive systems of classifications.

Natural History Phase

Discovery of Organizing Principles Core to the Science

Birth of Science: Reworking of

Taxonomy into Explanatory Categories

1 2 3

Linnaeus Darwin: Theory of Evolution

Modern Biological Classifications based on Genetics and Evolution

In the Natural History Phase, Domains of Clinical Science Grow Independently

Theory InstrumentationTherapy

Where the domains of clinical science are disconnected, each domain “flourishes” independently of the others.

Sometimes theory, therapy, and measurement intersect, and sometimes they don’t.

List of Psychotherapies (A through L) Acceptance and commitment therapy (ACT) Adlerian therapy Analytical psychology Art therapy Attack therapy Attachment-based therapy (children) Attachment therapy Attachment-based psychotherapy Autogenic training Behavior modification Behavior therapy Biodynamic psychotherapy Bioenergetic analysis Biofeedback Bionomic psychotherapy Body psychotherapy Brief therapy Classical Adlerian psychotherapy Characteranalytic vegetotherapy Child psychotherapy Client-centered psychotherapy Co-counselling Cognitive analytic psychotherapy Cognitive behavior therapy (CBT) Coherence therapy Collaborative therapy Concentrative movement therapy Contemplative psychotherapy Conversational model Core process psychotherapy Dance therapy Depth psychology Daseinsanalytic psychotherapy Developmental Needs Meeting Strategy (DNMS) Dialectical behavior therapy (DBT) Dreamwork Drama therapy

Dyadic Developmental Psychotherapy (DDP) Ecological Counseling Emotional Freedom Techniques (EFT) Encounter groups Eye Movement Desensitisation and Reprocessing (EMDR) Existential therapy Exposure and response prevention Expressive therapy Family Constellations Family therapy Feminist therapy Functional Analytic Psychotherapy (FAP) Focusing Freudian psychotherapy Gestalt therapy Gestalt Theoretical Psychotherapy Grinberg Method Group Analysis Group therapy Guided Imagery Therapy Hakomi Holistic psychotherapy Holotropic Breathwork Holding therapy Humanistic psychology Human givens psychotherapy Hypnotherapy Integrative body psychotherapy Integral psychotherapy Integrative psychotherapy Intensive short-term dynamic psychotherapy Internal Family Systems Model Internet based psychotherapy Interpersonal psychoanalysis Interpersonal psychotherapy Jungian psychotherapy Logotherapy

List of Psychotherapies (M through Z) Marriage counseling Milieu Therapy Mindfulness-based Cognitive Therapy Mindfulness-Based Stress Reduction (MBSR) Mentalization based treatment (MBT) Method of Levels (MOL) Morita Therapy Multimodal Therapy Multitheoretical Psychotherapy Music therapy Narrative Therapy Neuro-linguistic programming (NLP) Nonviolent Communication Object Relations Psychotherapy Orgonomy Parent-Child Interaction Therapy (PCIT) Pastoral counseling/therapy Person-centered (or Client-Centered or Rogerian) psychotherapy Personal construct psychology (PCP) Play therapy Positive psychology Positive psychotherapy Postural Integration Primal therapy Primal integration Process Oriented Psychology Provocative Therapy Psychedelic psychotherapy Psychoanalytic psychotherapy Psychoanalysis Psychodrama Psychodynamic psychotherapy Psychosynthesis Psychosystems Analysis

Pulsing (bodywork) Radix therapy Rational Emotive Behavior Therapy (REBT) Rational Living Therapy (RLT) Rebirthing-Breathwork Recovered Memory Therapy Re-evaluation Counseling Reiki Relationship counseling Relational-Cultural Therapy Relational Empowerment Therapy Reprogramming Reality therapy Rubenfeld Synergy Reichian psychotherapy Rolfing Self-relations Psychotherapy (or Sponsorship) Sensorimotor Psychotherapy SHEN Therapy Social Therapy Solution focused brief therapy Somatic Psychology Sophia analysis Status dynamic psychotherapy Systematic desensitization Systematic Treatment Selection (STS) Systemic Constellations Systemic Therapy T Groups Thought Field Therapy Transactional Analysis (TA) Transactional Psychotherapy (TP) Transference Focused Psychotherapy Transpersonal psychology Twelve-step programs Unitive Psychotherapy Vegetotherapy

Principles of ReinforcementPrinciples of Reinforcement

Millon’s 1969 TheoryMillon’s 1969 Theory

Based on Reinforcement Principles

Source of Reinforcement (Self versus Others) Independent types

○ Turn to their own values and desires for reinforcement. Dependent types

○ Derive reinforcement from the responses and attention of others.

Detached types○ Derive few rewards from self or others.

Ambivalent types○ Are deeply conflicted about whether to pursue their own values

and desires or those of others.○ Gets psychodynamic formulations into the model.

The Eight Basic Patterns, MCMI-I

Dependent Independent Detached Ambivalent

Active Histrionic Antisocial Avoidant Negativistic

Passive Dependent Narcissistic Schizoid Compulsive

Looks like a very clean model. Looks like a structural model of the PDs.

But is not structural in the sense that a circumplex is structural.

Taxonomic Problem Does not generate all the PDs. Paranoid, Borderline, Schizotypal PDs not developed by the

model.

Familiar and Unfamiliar Patterns

Dependent Independent Detached Ambivalent



FamiliarEasily

Accepted

LessFamiliar

RequiresComment

Passive-Detached Pattern

Passive-Detached(Schizoid)ShyEmotionally colorlessSeemingly insensitive to

emotions of others.Devoid of affectionate

needs.Lack strong ambitions or

motivation.

Active-Detached Pattern

Active-Detached(Avoidant)Highly alert to the

emotions of others.Overstimulated by social

engagement.Low self-esteem.Withdraws due to fears of

social humiliation.

Avoidant PD Movie

Active-Ambivalent Pattern

Active-Ambivalent (Negativistic)Filled with conflict between

the desires of self and the demands of others.

When turned to others, experiences inner resentment.

When turned to self, experiences guilt.

Negativistic PD Movie

Passive-Ambivalent Pattern

Passive-Ambivalent (Compulsive)Overcontrolled, repressed.Overly compliant to rules

and regulationsPerfectionistic to the point of

overwork.Indecisive

Severe Personality DisordersDependent Independent Detached Ambivalent



Severe Personality Pattern

Borderline Paranoid Schizotypal Borderline or Paranoid

The basic patterns exhibit stylistic preferences. The severe PDs are structurally compromised. Taxonomic Strength

Seems to establish a continuum of severity between the PDs and the Axis I disorders

Detached Patterns

Derive reinforcement neither from themselves or others.

Ultimately builds a bridge between forms of social withdraw and schizophrenia.Passive-detached = Schizoid = Negative SymptomsActive-detached = Avoidant = Positive Symptoms

SchizoidAvoidant

Schizotypal

From Histrionic and Dependent to the Borderline

Histrionic and Dependent Attention and focus are on others. Self-esteem is measured by the attitudes of others.

Borderline Emotional lability and Identity Diffusion

○ Deficits of identity development and self-definition lead to inadequate internal controls.

Pathologies of Attachment.○ Desperate needs for affection○ Fears of abandonment.

Histrionic,Dependent

Borderline

Creates an Interpretive Principle

The MCMI-I contained the eight basic personalities.

Plus the severe personalities. Borderline Paranoid Schizotypal

Creates an Interpretive Principle Severity of personality

pathology is judged by elevation of the Borderline, Paranoid, and Schizotypal scales.

So for example…

Same profile, but with highly elevated Borderline. Much more severe personality

pathology. Structural aspects of pathology

will take precedence over stylistic ones.

The MCMI-II’s The MCMI-II’s

Prototypal ModelPrototypal Model

The Structure of the DSM:

Characteristics of Prototypal Model

Prototypes are pure expressions, or “ideal types,” not intended to exist in nature.

Few patients will exhibit all of the characteristics of the prototype.

Many patients will have a minority of the characteristics of any particular diagnostic prototype.

Those who have enough will reach “diagnostic threshold,” and obtain a diagnosis.

Imagine Personality Pathology as a Space

Normal distribution in each of its two dimensions.

Normal Distribution Bivariate Normal Distribution

Item Weighting

Some items weighted more than others. MCMI-II

Prototypal items weighted 3 points.Other items weighted 2 or 1 points.Criticized for extensive item overlap.

MCMI-IIIRevised weighting scheme to reduce item overlap.Prototypal items weighted 2 points.Peripheral items weighted 1 point.

What are Prototypal Items?

Prototypal model used by DSM.

Some features more central to construct, while others lack specificity and are more peripheral.

Contrasts to monothetic model of DSM-II

C1

Clinical Prototype

C4

C3

C2

C5C6

C7

Near edge of prototype

Narcissistic Personality: Prototypal versus Peripheral Items

5. I know I’m a superior person, so I don’t care what people think.

26. Other people envy my abilities. 67. I have many ideas that are ahead of the

times.

21. I like to flirt with members of the opposite sex. (histrionic)

38. I do what I want without worrying about its effect on others. (antisocial)

80. It’s very easy for me to make many friends (histrionic).

Prototypal Items

(example)

Peripheral Items

(example)

Diagnostic Criteria and Prototypal Items

Diagnostic Criteria: Compulsive PD MCMI-III Prototypal Item

1. Preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.

82. I always make sure that my work is well-planned and organized.

2. Shows perfectionism that interferes with task completion (e.g., unable to complete a project because own strict standards are not met).

114. A good way to avoid mistakes is to have a routine for doing things.

3. Excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).

137. I always see to it that my work is finished before taking time out for leisure activities.

Not all diagnostic criteria have a prototypal item, but most do. Prototypal items can be inspected to determine if individual meets

criteria. Prototypal items can go into interpretive report.

Creates an Interpretive Principle

Use prototypal items to suggest diagnostic criteria to inquire.The DSM makes the diagnosis, not the

MCMI.Use the MCMI to suggest diagnoses.Examine prototypal items to see if they

support particular DSM criteria.

Base Rate Scores and Base Rate Scores and Diagnostic EfficiencyDiagnostic Efficiency

Base Rate Scores, not T Scores

T Scores implicitly assume that the base rate of all disorders is equal. All T-score beyond

a certain threshold are considered abnormal and interpretable.

Normal Distribution

Base Rate Scores, not T Scores

Adjust raw scores based on the actual prevalence rates.If 20% of patients are depressed, then

the test should reflect this.If 5% of patients are bipolar, then test

should reflect test.

Ideally, the BR = Consequence of Possessing the Amount of a Trait or Disorder

Gives not the “amount” of the trait as evidenced by some deviation score.

Instead, gives the pathological potential or consequences of the amount of the trait.

Thresholds should be Equated in terms of GAF

Schizoid

Avoidant

Dependent

Histrionic

Narcissistic

100 90 80 70 60 50 40 30 20 10

GAF

Diagnostic Threshold

Nevertheless, Can be useful in Detecting Asymptomatic PDs

Can be useful in detecting asymptomatic PDs.

Definition of Asymptomatic PDsOccurs when the individual possesses a PD in the

absence of anxiety or depression, or any other Axis I disorder.

Loose definition: Some antisocial PDs are notoriously low in anxiety.

Behavior is Product of Person and Situation

Normal Abnormal

Normal Little or no potential for an Axis I problem.

Personality Disorder: Problems perceiving self and others. Imposes self onto environment and makes a normal situation into an abnormal one.

Abnormal Crazy SituationAdjustment Disorder: Person in a crazy situation

Potential for Maximal PathologyPerson with personality pathology in a situation that would cause problems for a normal person.

The Person (Axis II)

The S

ituation (Axis IV

)

Individuals Seek Out Matching Environments

Case adapted from Millon, 1969. Roy was a successful sanitation engineer involved in planning

water resources for a large city. His job called for foresight and independent judgment, but little

supervision or affiliation with others. In general, he was appraised as a competent and reliable, but

undistinguished employee. Some coworkers saw him as shy, others as cold and aloof. Difficulties centered around his relationship with his wife, who

insisted they come for therapy, due to his unwillingness to join family activities, lack of affection for her, and disinterest in sex.

His wife tried to maneuver him into social situations, but to no avail.

Roy’s MCMI-III(constructed)

Roy is a schizoid personality who’s found an occupational match for his personality disorder.

Roy will okay as long as no one expects anymore from him.

Roy will manifest Axis I disorders due to his wife.

Diagnostic Efficiency: Positive Predictive Power

DiagnosisPositive

DiagnosisNegative

Test Positive True Positive(40)

False Positive (20)

Test Negative False Negative True Negative

Positive Predictive PowerTP / All Test PositivesWhen the test is positive, what are the chances

that the subject really has the diagnosis?40 / 60 = 67%

What’s the PPP here?

DiagnosisPositive

DiagnosisNegative


False Positive (900)

Test Negative False Negative True Negative

Positive Predictive PowerTP / All Test PositivesWhen the test is positive, what are the chances

that the subject really has the diagnosis?

Diagnostic Efficiency: Sensitivity

DiagnosisPositive

DiagnosisNegative


False Positive

Test Negative False Negative(40)

True Negative

SensitivityTP / All Real PositivesWhat percentages of people who have the

condition are picked up by the test?40 / 80 = 50%

What’s the Sensitivity here?

DiagnosisPositive

DiagnosisNegative


False Positive

Test Negative False Negative(200)

True Negative

SensitivityTP / All Real PositivesWhat percentages of people who have the

condition are picked up by the test?40 / 80 = 50%

Diagnostic Efficiency of PD Scales

Interpretive Principle

Don’t let the test rule your decision-making process.MCMI-III often fails to find disorder where

clinicians judge it present (sensitivity)MCMI-III often flags a subject as disordered,

when clinicians judge it absent (positive predictive power)

Other instruments don’t even report this information.

Integration Intrinsic to Definition of Personality

Think about what personality…Habitual patterns of thinking, feeling, and

relating…Personality is the patterning of variables across

the entire matrix of the person.

Current Perspectives on Personality

Biophysical Models Temperament Theories: Siever, Akiskal Neurobiological Theories: Cloninger, DePue

Intrapsychic Models Psychodynamic Theories: Freud, Abraham, Reich Structural Theories: Kernberg

Phenomenological Models Cognitive Theories: Beck, Ellis, Horowitz Lexical Theories: Goldberg, Costa, Widiger

Behavioral Models Social Learning: Bandura Interpersonal: Benjamin, Kiesler

We cannot look for organizing principles that issue from any particular perspective. Otherwise, we end up with just another perspective.

Parable of Blind Men and the Elephant

“It’s like a wall” “No, it’s like a long

rope” “No, it’s like a

column”

No, it’s interpersonal. No, it’s cognitive. No, it’s

psychodynamic. No, it’s biological.

This Sets our Theoretical Agenda

The history of personality is a history of part-functions.

Integrating principles outside the parts.

We can expect other taxonomies that embody principles that will be concealed by our “grand theory.”

Robert Trivers

Reciprocal Altruism (1971) Parental Investment (1972) Parent-Offspring Conflict (1974)

Sociobiology, E.O Wilson (1975)

Behavior is a by product of natural selection.Behaviors have evolved over time.Today’s behaviors are those that

have been evolutionarily successful.

Individual and social behavior are the products of successful evolution.

Evolutionary PolaritiesEvolutionary Polarities

Millon Found the Organizing Principles in Evolution

Pain versus Pleasure (life enhancement and life preservation) Basic survival aim. Help keep organisms from harm.

Active versus Passive Mode of adaptation. Once you exist, you exist within an environment. You can either modify your ecological niche to suit your own needs, or

passively accommodate to what the environment offers you. Self versus Other

Reproductive Male strategy, to reproduce the self over and over Female strategy, to invest greatly in others.

Pleasure vs Pain Polarity

Pleasure vs. PainSchizoid: Passive, low pleasure, low painDepressive: Passive, high pain, low

pleasureAvoidant: Active, high pain, low pleasure

Reversal of Pleasure and PainMasochistic: Passive ReversalSadistic: Active Reversal

Self vs Other Polarity

High OtherDependent Personality: Passive, high other.Histrionic: Active, high other.

High selfNarcissistic: Passive, low otherAntisocial: Active, low other

Self-Other AmbivalenceCompulsive: PassiveNegativistic: Active

From Toward a New Personology (1990)

Nothing new happened taxonomically No new personality constructs

Functional and Structural Domains

BehavioralBehavioralActsActs

Narcissistic PersonalityNarcissistic Personality

Self-Image

Object Representations

Mood-Temperament

DefenseDefenseMechanismsMechanisms

InterpersonalInterpersonalConductConduct

CognitiveCognitiveStyleStyle

HaughtyExpressive Behavior

ExploitiveInterpersonal Conduct

ExpansiveCognitive Style

AdmirableSelf-Image

InsouciantMood/Temperament

ContrivedObject Representations

RationalizationRegulatory Mechanism

SpuriousMorphologic Organization

Operationalize Personality Across its Major Domains

Narcissistic Personality

Narcissistic PD (See Packet for PD Descriptions)

Functional Domains Structural Domains

Expressively Haughty (e.g., acts in an arrogant, supercilious, pompous, and disdainful manner, flouting conventional rules of shared social living, viewing them as naive or inapplicable to self; reveals a careless disregard for personal integrity and a self-important indifference to the rights of others).

Admirable Self-Image (e.g., believes self to be meritorious, special, if not unique, deserving of great admiration, and acting in a grandiose or self-assured manner, often without commensurate achievements; has a sense of high self-worth, despite being seen by others as egotistic, inconsiderate, and arrogant).

Interpersonally Exploitive (e.g., feels entitled, is unempathic and expects special favors without assuming reciprocal responsibilities; shamelessly takes others for granted and uses them to enhance self and indulge desires).

Insouciant Mood-Temperament (e.g., manifests a general air of nonchalance, imperturbability, and feigned tranquility; appears coolly unimpressionable or buoyantly optimistic, except when narcissistic confidence is shaken, at which time either rage, shame, or emptiness is briefly displayed).

Expansive Cognitive Style (e.g., has an undisciplined imagination and exhibits a preoccupation with immature and self-glorifying fantasies of success, beauty or love; is minimally constrained by objective reality, takes liberties with facts and often lies to redeem self-illusions).

Contrived Object-Relations (e.g., internalized representations are composed far more than usual of illusory and changing memories of past relationships; unacceptable drives and conflicts are readily refashioned as the need arises, as are others often simulated and pretentious).

Rationalization Regulatory Mechanism (e.g., is self-deceptive and facile in devising plausible reasons to justify self-centered and socially inconsiderate behaviors; offers alibis to place oneself in the best possible light, despite evident shortcomings or failures).

Spurious Morphologic Organization (e.g., morphologic structures underlying coping and defensive strategies tend to be flimsy and transparent, appear more substantial and dynamically orchestrated than they are in fact, regulating impulses only marginally, channeling needs with minimal restraint, and creating an inner world in which conflicts are dismissed, failures are quickly redeemed, and self-pride is effortlessly reasserted).

Another Interpretive Principle

Since personality is about integration…The domain descriptions are provided to

operationalize the PDs.

When writing case reportsConsider borrowing text from these functional

and structural domains.


Multiaxial Model

Axis I: Classical Phenomenological Syndromes (e.g., Anxiety, Depression, Schizophrenia)

Axis II: Personality Disorders Axis III: Medical Disorders Axis IV: Psychosocial Environment Axis V: Global Assessment of Functioning


Multiaxial Model: Lines of Causality in Psychopathology

Axis I: Clinical

Syndromes

Anxiety, Depression =Fever, Cough, Boils

Axis II: Personality Disorders

Histrionic, Sadistic =Immune System

Axis IV: PsychosocialEnvironment

Marriage, Money =Infectious Agents

The shift to multiaxial conceptions resembles the shift that occurred in medicine a century ago.

Interaction of Axis IV and Axis II produces Axis I

Example: The Schizoid-Compulsive Accountant

Mark S. worked quietly and efficiently for many years “crunching numbers” for a financial services company.

His greatest pleasure seem to derive from performing his tasks to perfection.

He seldom displayed any emotion to others, and was always observed existing at the fringes of company parties. He was never observed with a girlfriend, and others at the company reported his reluctant to engage anyone socially, where he was known as “a man of few words.”

Because of his excellent work history, and nearly perfect attendance, he was assigned to manage a group of young accountants, newly recruited when the company expanded.

Interacting with the new employees made Mark feel anxious, to the point that he began missing work.

In therapy, Mark had little insight into the source of his anxiety. In part, it seemed to derive from the fear that his supervisees would not be able

to perform at his standards. In part, Mark felt that his cozy corner of the world had been intruded upon by

outsiders as a result of his new responsibilities. He longed to return to his previous position.

What is the interaction between

Axis IV and Axis I that produces Axis I?

Example: The Narcissistic Portfolio Manager

Mark S. managed several million in securities for a financial services company.

His greatest pleasure seem to derive from the admiration he received at performing his job perfectly.

His confidence was obvious, especially at company parties. He was never seen without a girlfriend, and others at the company noted his desire to move forward up the company ladder. Although he was sometimes noted for his insensitivity, his self confidence drew others to him.

Because of his excellent work history, and nearly perfect attendance, he was assigned to manage a group of young business school graduates, newly recruited when the company expanded.

Interacting with the new employees made Mark feel anxious, to the point that he began missing work and drinking.

In therapy, Mark had little insight into the source of his anxiety. In part, it seemed to derive from the fear that his supervisees would embarrass him

by tarnishing the admirable self-image he secretly nurtured. In part, Mark felt that the new recruits were inferior to his own skills and ability, and

resented “wasting his time with people so hopelessly ignorant.” He longed to return to his previous position.

What is the interaction between

Axis IV and Axis I that produces Axis I?

Creates An Interpretive Principle

Multiaxial model is an intrinsically integrative conception. Provides a model of

how psychopathology emerges and is perpetuated.

Specifically requires us to develop an integrative conception of the patient that transcends a list of diagnoses.

The Schizoid-CompulsiveAccountant

Multiaxial Model: Establishes Causal Pathways of Psychopathology

Axis I: Clinical

Syndromes

Axis II: Personality Disorders


1

23

5

4

1) What are the psychosocial (Axis IV) issues exerting stress through the current situation?

2) Are these issues being “metabolized” by the personality structure?

3) How is the individual reacting to awareness of their own clinical syndromes? (typically with increased rigidity, further reducing range of coping responses)

4) How is increased rigidity of personality feeding back on influencing the psychosocial situation?

5) How are clinical symptoms influencing the psychosocial situation?

Multiaxial Model: Allows us to Understand Asymptomatic Personality Disorders

Recall that Axis I = Interaction of Axis II and Axis IV.

Accordingly, some personalities will “inhabit” environments that allow them to capitalize on their particular traits. Like species that are adapted to a

narrow ecological niche. If the environment changes just a

little, the species is threatened. Only when these environments

change does the person exhibit symptoms. A schizoid-compulsive accountant

develops panic attacks when relocated from an isolated office to a more central location.

An intelligent narcissistic high school student, admired by his classmates, becomes depressed when he realizes he’s “just another student” at a very exclusive school.

Axis II: Personality


Without the Multiaxial Model…

Multiaxial model specifically requires that we create an integrated conception of the individual’s psychopathology.

Without a theory of the individual personality…You’re left treating Axis I disorders alone.You leave patients with an enduring

vulnerability.

With the Multiaxial Model and a Personality Theory…

You have a comprehensive basis for an integrated science of psychopathology.

Personality becomes central to the whole adventure of psychopathology.

Example: Vicious Circles in the Narcissistic PD

BLAMEViolates self-image of perfection. Must purge self of evidence of possible imperfection, particularly guilt. Hypersensitivity to possible slights and criticism from others. Reacts with hurt, anger, rage.

Rationalization of own shortcomings.

Projection of own faults onto others.

Escalation of hypersensitivity

DepressionDue to realistic feedback, grandiose self not so grand.

Acting outFailure to regulate anger leading to verbal or physical aggression, even battering.

Substance UseReduces self-monitoring and intrusive thoughts related to self-blame.

AnxietyDue to threats to validity of the grandiose self

Imagine having such diagrams for all the PDs

Axis II

Axis I

Axis IV

Validity Scale

Consists of three items.“I flew across the Atlantic 30 times last year”“I was on the front cover of several magazines

last year”“I have not seen a car in the last ten years”

Score of 2 is invalid. Score of 1 is questionable.

Modifying Indices

Disclosure Index (X)Variation from midrange

Desirability Index (Y)Appear socially attractive, morally virtuous,

emotionally well-composed Debasement Index (Z)

generally opposite of scale Y High Y, Low Z: Fake good? Low Y, High Z: Fake bad? Cry for help?

Scoring Adjustments

Disclosure Adjustment accounts for under and over reporting

Anxiety - Depression Adjustment accounts for acute or intense emotional

state Inpatient Adjustment

accounts for nuances of this population Denial - Complaint Adjustment

accounts for personality pattern defensiveness

Evaluate Possible Diagnoses

Personality ScalesBR > 75 suggests personality traitsBR > 85 suggests personality disorder

Clinical ScalesBR > 75 suggests presence of syndromeBR > 85 suggests prominence of syndrome

With the exception of scale X, low scores are not interpretable

Making Personality Disorder Diagnoses

BR 85 suggests a PD diagnosisHowever, PPP and SENS not perfect at BR 85

Always check MCMI-III profiles against diagnostic criteriaEndorsements of prototypal items may be relevant

to specific diagnostic criteria.

Keep the DSM General Criteria for a Personality Disorder in mind.

Keep in mind the Severe Personality Disorders

Example MCMI-III Profile

Dealing with the Problems of Axis IIDealing with the Problems of Axis II

Comorbidity and PD-NOSComorbidity and PD-NOS

PDNOS is most used Diagnosis

In other words, existing PD categories don’t provide adequate coverage.

“The majority of patients with personality pathology…are currently undiagnosable on Axis II.” Westen & Arkowitz-Weston (1998)

Can a taxonomy endure when it’s constructs fail to diagnose over half the patients?

Arbitrary Diagnostic Boundaries DSM-III (1980) adopted behaviorally specific

criteria sets in order to increase diagnostic reliability.

No justifications for any diagnostic thresholds.Dramatic changes in prevalence rates across DSMsSchizotypal prevalence dropped from 11% to 1%

from DSM-III to III-RThis is like publishing a test with no external validity

studies.

Massive Comorbidity of PDs

PD constructs are useless when patients receive four or five diagnoses.Structured interviews consistently find extensive co-

morbidity of PDs.This situation has existed in DSM-III, published in

1980 (nearly 30 years)

Because the MCMI is coordinated to the DSM, it inherits this problem.Recall that diagnostic efficiency statistics are

generally good.Some profiles show 4 or 5 elevated PDs.

Cross-Cultural Issues Amplify Problem

MCMI uses base rate scores, not T scores.Accurate diagnosis rests upon accurate estimates of

base rates.If base rates vary substantially…

○ Some disorders over-represented○ Others under-represented

What are the base rates of PDs in the Philippines? Base rates of the PDs are unknown. Not even certain whether these PDs exist… Or are there other PDs specific to this culture? Is it even ethical to assessment patients using American norms?

Remember, MCMI struggles with certain disorders

Subtypes of PersonalitySubtypes of Personality

Comorbidity is the Rule, not the Exception

Comorbidity exist because nature presents itself in few prototypes.Most human beings will be complex cases.

Functional and Structural DomainsFunctional and Structural Domains

Grossman Facet ScalesGrossman Facet Scales

Look at the Grossman Facet Scales

Elevations above BR 65 are interpretable.Find the interpretive text associated with that

PD from the personality domain descriptions.That interpretive text can be adapted for your

domain-focused clinical report.

Facet Score

Profiles

Narcissistic PD Personality Domains

Functional Domains Structural Domains

Expressively Haughty (e.g., acts in an arrogant, supercilious, pompous, and disdainful manner, flouting conventional rules of shared social living, viewing them as naive or inapplicable to self; reveals a careless disregard for personal integrity and a self-important indifference to the rights of others).

Admirable Self-Image (e.g., believes self to be meritorious, special, if not unique, deserving of great admiration, and acting in a grandiose or self-assured manner, often without commensurate achievements; has a sense of high self-worth, despite being seen by others as egotistic, inconsiderate, and arrogant).

Interpersonally Exploitive (e.g., feels entitled, is unempathic and expects special favors without assuming reciprocal responsibilities; shamelessly takes others for granted and uses them to enhance self and indulge desires).

Insouciant Mood-Temperament (e.g., manifests a general air of nonchalance, imperturbability, and feigned tranquility; appears coolly unimpressionable or buoyantly optimistic, except when narcissistic confidence is shaken, at which time either rage, shame, or emptiness is briefly displayed).

Expansive Cognitive Style (e.g., has an undisciplined imagination and exhibits a preoccupation with immature and self-glorifying fantasies of success, beauty or love; is minimally constrained by objective reality, takes liberties with facts and often lies to redeem self-illusions).

Contrived Object-Relations (e.g., internalized representations are composed far more than usual of illusory and changing memories of past relationships; unacceptable drives and conflicts are readily refashioned as the need arises, as are others often simulated and pretentious).

Rationalization Regulatory Mechanism (e.g., is self-deceptive and facile in devising plausible reasons to justify self-centered and socially inconsiderate behaviors; offers alibis to place oneself in the best possible light, despite evident shortcomings or failures).

Spurious Morphologic Organization (e.g., morphologic structures underlying coping and defensive strategies tend to be flimsy and transparent, appear more substantial and dynamically orchestrated than they are in fact, regulating impulses only marginally, channeling needs with minimal restraint, and creating an inner world in which conflicts are dismissed, failures are quickly redeemed, and self-pride is effortlessly reasserted).

Narcissistic Facet Scales

Admirable Self-Image Believes self to be meritorious, special, if not unique,

deserving of great admiration, and acting in a grandiose or self-assured manner, often without commensurate achievements; has a sense of high self-worth, despite being seen by others as egotistic, inconsiderate, and arrogant.

Expansive Cognitive Style Has an undisciplined imagination and exhibits a

preoccupation with immature and self-glorifying fantasies of success, beauty or love; is minimally constrained by objective reality, takes liberties with facts and often lies to redeem self-illusions.

Interpersonally Exploitive Feels entitled, is unempathic and expects special favors

without assuming reciprocal responsibilities; shamelessly takes others for granted and uses them to enhance self and indulge desires.

Adapt text from the personality domains to different sections of the case-focused clinical report.

MCMI-III

Documents

Transcript of MCMI-III