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* Complete coverage of administration, scoring, interpretation, and reporting
* Expert advice on avoiding common pitfalls
* Conveniently formatted for rapid reference
Quickly acquire the knowledge and skills you need to confidently administer, score, and interpret the Millon personality assessment tests
Essentials of Millon(TM) Inventories Assessment, Second Edition provides state-of-the-art, practical guidelines for using the Millon personality tests. In one easy-to-use new edition, you can access comprehensive information on five tests: the Millon Clinical Multiaxial Inventory (MCMI-III(TM)); the Millon Adolescent Clinical Inventory (MACI(TM)); the Personality Adjective Check List (PACL); the Millon Index of Personality Styles (MIPS); and, new to this Second Edition, the Millon Behavioral Medicine Diagnostic (MBMD(TM)).
Like all the volumes in the Essentials of Psychological Assessment series, this book is designed to help busy mental health professionals quickly acquire the knowledge and skills they need to make optimal use of major psychological assessment instruments. Each concise chapter features numerous callout boxes highlighting key concepts, bulleted points, and extensive illustrative material, as well as test questions that help you gauge and reinforce your grasp of the information covered.
Essentials of Millon(TM) Inventories Assessment, Second Edition provides comprehensive instruction in test administration, scoring, and interpretation. As well, this informative text provides expert assessment of the methods' relative strengths and weaknesses, valuable advice on their clinical applications, and illuminating casestudies. Complete with a foreword by Theodore Millon, who developed most of the tests covered in this book, you'll learn how to most effectively employ these popular measures of personality.
The book contains black-and-white illustrations.
|1||Essentials of MCMI-III Assessment||1|
|2||Essentials of MBMD Assessment||52|
|3||Essentials of MACI Assessment||106|
|4||Essentials of PACL Assessment||175|
|5||Essentials of MIPS Assessment||224|
Note The Figures and/or Tables mentioned in this sample chapter do not appear on the Web
Chapter OneESSENTIALS OF MCMI-III ASSESSMENT
The Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon, 1997a) is a 175-item true-false self-report measure of 14 personality patterns and 10 clinical syndromes for use with adults 18 years of age and older who are being evaluated and/ or treated in mental health settings. Since the introduction of this test in 1977, it has become one of the most frequently used assessment instruments for the examination of personality disorders and major clinical syndromes. Only the Rorschach ( Exner, 1993) and the Minnesota Multiphasic Personality Inventory- 2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) have produced more research within the past 5 years. There are now over 400 empirical studies (Craig , 1993a, 1997) and six books (Craig , 1993a, 1993b; Choca & Van Denburg, 1996; McCann & Dyer, 1996; Millon, 1997b; Retzlaff, 1995) based on this measure.
HISTORY AND DEVELOPMENT
The original version of this instrument, the MCMI-I (Millon, 1983a), was developed to operationalize the theory of psychopathology introduced by Millon (1969/ 1983b) in Modern Psychopathology. In that text he proposed three axes-active-passive, pleasure-pain, and self-other-as the basic building blocks of normal and abnormal personality. Conceived in terms of instrumental coping patterns designed to maximize positive reinforcements and avoid punishment, the model crossed the active-passive axis with four reinforcement strategies-detached, dependent, independent, and ambivalent-to derive eight basic personality patterns (asocial, avoidant, submissive, gregarious, narcissistic, aggressive, conforming, negativistic) and three severe variants (schizoid, cycloid, paranoid). Although Millon did not propose a for-mal model of clinical syndromes along with his personality taxonomy, he asserted that most or all psychiatric conditions (e. g., major depression, anxiety disorders, psychosis) could be best explained as extensions of personality.
Millon's strong theoretical interests led him to a test development strategy that was also grounded in theory. Jane Loevinger (1957 ) had previously pro-posed that assessment instruments be built in a three-step process with theory guiding development and validation in every step. Millon used her strategy to create the MCMI-I as well as subsequent editions of the instrument. The three steps of test development and validation described by Loevinger (1957 ) were called theoretical-substantive, internal-structural, and external. In the theoretical-substantial phase, items are generated for scales in terms of how well they conform to theory. Here Millon created an initial pool of face-valid items and then split the 1,100-item list into two equivalent forms.
For the internal-structural phase of development, scales are created to match a set of criteria defined by the theory. For example, Millon's (1997a; Millon & Davis, 1996 ) model posits that personality scales should have high internal consistency, test-retest reliability, and a theoretically consistent pattern of correlations with other scales. During this phase, the two test forms were administered to a variety of clinical samples, and Millon retained items with the highest item-total scale correlations. He then calculated item-scale inter-correlations and item endorsement frequencies and eliminated items with extreme endorsement frequencies (e. g., those below 15% and above 85%). This left 440 items, which were later reduced to 289. Millon gave the experimental form of the MCMI-I to a variety of clinical patients and had 167 clinicians complete a diagnostic form for each patient they had seen for assessment or therapy. The items were then reduced to 150. Three experimental scales were eliminated and three scales were added, and the validation process described above was then repeated until the final version contained 175 items.
For the third stage of external criterion validation, which is analogous to convergent-discriminant validity, Millon had psychiatric patients complete the final form of the MCMI-I along with several self-report measures of personality and clinical syndromes. Based on these data he judged that the scales were faithful to his theory, and the test was then published with norms based on over 1,500 psychiatric patients.
The second edition of the measure, the MCMI-II (Millon, 1987 ), was created to keep pace with changes in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders-III-R (DSM-III-R; American Psychiatric Association, 1987 ). An experimental form was developed according to the model previously described totaling 368 items. Scales measuring Self-Defeating and Aggressive (Sadistic) personality disorders were developed. A total of 45 items in the MCMI-I were changed, and Millon introduced an item-weighting system whereby prototype items (e. g., those items essentially related to the disorder) were given higher scores. He also derived three validity scales and increased the number of personality disorder scales from 11 to 13. Validation studies were then conducted as described earlier.
The MCMI-III was developed to bring the test in line with DSM-IV (American Psychiatric Association, 1994). Here 45 of the 175 items in the MCMI-II were changed, two new personality disorder scales- Depressive and Post-Traumatic Stress Disorder-were added to the test, the item-weighting system was changed from a 3-point to a 2-point system, scales were reduced in length, and noteworthy items pertaining to child abuse and eating disorders were added but not scored on any of the scales. Significantly, Millon made sure that most test items directly reflected diagnostic criteria in the DSM-IV. The published version of MCMI-III (see Rapid Reference 1.1 for publication information) contains a three-item Validity Index, three Modifying Indices to assess response bias, 14 personality scales, and 10 clinical syndrome scales. The personality and clinical scales contain 12 to 24 items each. Internal consistency of the scales was estimated to be .67 to .90 using Cronbach's (1951) alpha, and test-retest stability was estimated to be .84 to .96 over a period of 5 to 14 days (Millon, 1997a, pp. 57-59). Rapid Reference 1.2 summarizes the MCMI-III scales.
Item Overlap and Item Weighting
A notable feature of Millon's (1997a; Millon & Davis, 1996 ) model of psychopathology is that various personality types and clinical syndromes are presumed to be related to one another in a predictable manner. For example, schizoid and avoidant personality styles are believed to share a trait of social detachment. This trait makes both types of individuals appear distant, with-drawn, and uneasy in social situations. In decompensated form, these personalities are thought to be prone to Schizotypal and psychotic disorders.
In accordance with his model, theoretically related personality and clinical scales share certain items. The number of shared items varies across the test, but Millon (1997a) identified the most defining characteristics of a scale by assigning a weight of 2 to these primary, or prototypical items, and giving a smaller weight of 1 to items that are less definitive, or non-prototypical. Thus the central features of a personality style or clinical syndrome are weighted 2, whereas characteristics that are less central and defining are weighted 1. Careful readers will note in the test manual (Millon, 1997a) that items are given a weight of 2 only once, but may be scored 1 for one or more additional scales. This indicates that various traits and symptoms can be central to only one personality or clinical syndrome, but they may overlap with other, related personalities and syndromes.
The result of item overlap on MCMI-III scales is that there are moderately high scale intercorrelations. The test manual gives a matrix of scale intercorrelations that ranges from -. 80 to +. 85, although most values are more modest (in the range of -. 50 to +. 50; Millon, 1997a, Table 3.6 ).
The MCMI-III normative sample consisted of 998 psychiatric patients from the United States and Canada, whom Millon divided into two groups for test development purposes. The first group of 600 patients was used to create scales, and the second group of 398 patients was used for cross validation to verify accuracy of the standardized scores. Although modest in size, the normative sample represents a broad range of demographic characteristics. Patients were men (54%) and women (46%) from outpatient (52%) and inpatient (26%) settings, as well as correctional facilities (8%). Age range was 18 to 88, although 80% were between the ages of 18 and 45. Most of the patients had completed high school (82%), and among these 18% also had a college degree (18%). A notable limitation of the sample is that most subjects were White (86%), with only a small number of Blacks (8%), Hispanics (2%), and all others (4%) represented.
Base Rate Scores
MCMI-III personality and clinical syndrome scores were standardized as base rate (BR) scores rather than T scores. T scores were considered inappropriate by Millon (1997a; 1997b) because they assume an underlying nor-mal population distribution, and the MCMI-III normative sample consists of psychiatric patients. BR scores reflect the diagnoses of the individuals who make up the normative sample. For the MCMI-III, Millon had experienced clinicians provide DSM-III-R multiaxial diagnoses for all of the patients in the normative group. By knowing the scores of these patients on the MCMI-III, and their clinical diagnoses, Millon was able to create anchor points for his scales that would reflect the prevalence, or BR, of each psychiatric condition. BR scores of 60 were set at the median raw score obtained by all patients. BR scores of 75 were assigned to the minimum raw score obtained by patients who met criteria for the particular disorder or condition. BR scores of 85 were given to the minimum raw score of patients who were judged to have a particular disorder or condition as their primary problem.
For the personality scales, BR scores of 75 to 84 signify the presence of clinically significant personality traits, while BR scores of 85 or above suggest the presence of a disorder. For the clinical syndrome scales, BR scores of 75 to 84 indicate the presence of a syndrome, and BR scores of 85 or above denote the prominence of a particular syndrome. (See Rapid Reference 1.3.)
Since the publication of Modern Psychopathology (Millon, 1969/ 1983), Millon's model of psychopathology evolved and expanded. In its current form, Millon (1997b; Millon & Davis, 1996 ) asserts that the structure of a clinical science consists of four main elements: (a) a theory that explains the phenomena under observation, (b) a taxonomy that categorizes these phenomena into meaningful dimensions, (c) instrumentation that measures these phenomena, and (d) intervention that remediates problematic cases. Thus the MCMI-III is an instrument that measures Millon's taxonomy of classifying personality pathology, which was derived from Millon's bioevolutionary theory of personality development and pathology (Millon, 1990). Originally, the MCMI was not designed to be in agreement with official psychiatric nosology and nomenclature. However, subsequent revisions of the test have brought it closer to DSM categories.
Millon's theory posits three "survival aims" or polarities in the laws of nature (Figure 1.1). The first is to maintain existence. At the psychological level this polarity translates into activities organized to give pleasure or enhance one's life or to experience pain by merely preserving life. After existence has been ensured, the next organismic task is to adapt to one's environment. At the psychological level the adaptational polarity translates into actively changing one's environment or passively accepting and accommodating to one's circumstances of life. Finally, there is a need to replicate to ensure survival of the species. At the psychological level replication strategies pertain to whether one is focused primarily on one's self or on others through nurturing behaviors. Millon has recently introduced a fourth polarity, abstraction, but has not, as yet, developed this part of his theory.
This theory of personology development translates into a theory-based framework for both personality styles and personality pathology. Millon identified five main sources of reinforcement (independent, dependent, ambivalent, discordant, and detached) and two coping styles (active and passive). This translates into a five-by-two matrix of theory-derived personality disorders that closely corresponds with DSM-IV personality disorder categories but is not identical to it. For example, Millon's Self-Defeating and Aggressive (Sadistic) personality disorders are not found in DSM-IV but comprise styles and disorders emanating from Millon's theory.
Having developed a theory that posited the existence of certain personality disorders, Millon then developed instrumentation to assess these disorders. Although he primarily used a true-false methodology in scale development for the MCMI, he has also experimented with other assessment methodologies (e. g., diagnostic statements used for clinician ratings) as part of his instrument development, and Strack (1987, 1991) has used adjective checklist methodology to assess Millon's personality styles in nonclinical populations. The theory is not tied to an assessment methodology, and there may be multiple paths leading to the same assessment conclusion.
The MCMI-III was developed for use with men and women (18 years of age and older) seeking mental health evaluation and/ or treatment who read at minimally the eighth grade level. It was not meant to be used with nonclinical populations, and doing so will yield distorted test results. The inventory can be administered individually or in groups using a paper-and-pencil form, or via personal computer using a software program available from the test publisher. Administration time is typically 20 to 30 minutes.
The test does not require special instructions for administration. The directions printed on the answer sheet or presented via computer are sufficient for most people to accurately complete the questionnaire. However, it is good practice for examiners to develop rapport with testing clients prior to introducing an assessment instrument. In this regard the examiner can explain how the test will be helpful to their issues and how it will be used on their behalf. Clients should be advised that they will be given feedback on their test results, so it is important for them to answer as honestly as possible.
Testing Individuals With Special Needs
MCMI-III administration versions are available in Spanish, on audiotape for the visually impaired, and via computer. Hearing-impaired patients should be able to take this test by reading the instructions on the test answer sheet or those provided via computer administration of the items. For patients who otherwise are unable to take this test, the examiner may read the statements aloud and have the person respond "true" or "false" or perhaps nod his or her head to indicate the same.
Examiners who administer the test verbally to a patient must understand that they are giving the test in a manner that deviates from the way the test was standardized. Also, there are interpersonal processes existing between examiner and client that are not immediately present when the client is tested without the presence of an examiner. For example, the client may be considering what the examiner will think if he or she answers the verbally presented question in a certain way. These processes may alter the way a client responds to the items and therefore alter their scores. If there is no way to give this test other than to read the questions to the examinee, then the examiner is obligated to report this deviation in the report and to make some evaluative statement as to how the validity of the test may or may not have been affected by this kind of testing procedure.
SCORING THE MCMI-III
The test may be hand scored or computer scored using telescoring, mail-in answer sheets, or software for personal computers. Scoring stencils are available for hand scoring, which takes about 45 minutes. Because hand scoring can lead to errors owing to the many adjustments that are required for this test, Millon (1997a) recommends hand scoring each test twice to minimize errors.
If the test is administered with an answer sheet instead of via computer, upon the completion of the test the examiner should check the answer sheet for any double-marked items and make sure that no more than 12 items have been left unanswered. If any of these conditions exist, the answer sheet should be returned to the patient so that he or she can make the necessary corrections. The MCMI-III cannot be scored if (a) the sex of the client is unknown or unspecified, (b) the client is under age 18, or (c) there are 12 or more missing or double-marked items.
From Raw Scores to BR Scores
Raw scores for all scales except Disclosure (Scale X) are calculated by adding up the number of items endorsed for the scale, with care taken to assign the proper weight of 1 or 2 for each item. Disclosure is a composite score calculated from the raw scores of the basic 11 personality scales, as follows:
Disclosure = Schizoid + Avoidant + Depressive + Dependent + Histrionic + (Narcissistic 3 .67 ) + Antisocial + Aggressive + Compulsive + Passive-Aggressive + Self-Defeating
The raw scores for all scales except Validity are then transformed into initial BR scores, using the tables provided in Appendix C of the test manual. Millon provides separate tables for men and women because men and women differ in how they answer a personality inventory. Initial BR scores are then subjected to four possible corrections designed to compensate for distortions in test scores attributable to certain biases (see Rapid Reference 1.4).
The disclosure adjustment was designed to counterbalance the tendency of some clients to broadly underreport or overreport personal attributes and symptoms. When the raw Disclosure scale score is below 61, points are added to the initial BR scores of all personality and clinical syndrome scales. Points are subtracted from these scales if BR is above 123. The number of points added or subtracted is a function of how low or high the raw Disclosure scale is, and ranges from 0 to 20.
An anxiety-depression adjustment was developed to correct for the inclination of patients to overreport problematic features when feeling acutely anxious and/ or depressed. A correction is made whenever Anxiety and/ or Dysthymic Disorder are BR 75 or above, such that BR points are subtracted from scales Avoidant, Depressive, Self-Defeating, Schizotypal, and Borderline in proportion to (a) how elevated the scales are, (b) whether both scales are 75 or above or just one, (c) whether the client was an inpatient at the time of testing , and (d) how recently the client developed his or her presenting problem.
The inpatient adjustment was created to offset the tendency of some recently hospitalized clients to underreport the severity of their emotional problems. When a client is identified as an inpatient who developed a psychiatric condition (Axis I) within the past 4 weeks, 2 to 10 BR points are added to the Thought Disorder, Major Depression, and Delusional Disorder scales.
A denial-complaint adjustment is made to correct for the bias of some individuals to underreport the severity of their personality attributes. When the Histrionic, Narcissistic, or Compulsive scale is the most highly elevated among the 10 clinical personality patterns, the BR for that scale only is increased by 8 points.
Although the correction formulas are applied, in the order given, to all test protocols, it should be clear that some clients will not meet criteria for any of the corrections, whereas others will meet criteria for all of them. Because of this, the initial BR scores of some patients will not be altered, but the scores of others will be adjusted by a considerable amount.
There are two major computerized scoring programs available to interpret the MCMI-III. The test publisher has scoring and interpretive services and will provide a narrative report written by Millon. Psychological Assessment Resources, Inc., publishes an interpretive report developed by Robert J. Craig , Ph. D., ABPP, which requires that BR scores be available, either by hand scoring or by computer scoring, through the test publisher. The BR scores are then entered into the program and a narrative report is generated. Figure 1.3 (see page 43) illustrates a sample score profile.
HOW TO INTERPRET THE MCMI-III
Before interpreting the personality disorder and clinical syndrome scales, the examiner must (a) establish that the profile of scores is valid, and, if so, (b) interpret the client's response style. The MCMI-III contains four scales for assessing response characteristics: Validity, Disclosure, Desirability, and Debasement. Only the Validity and Disclosure scales are used to determine whether a test is interpretable or not. All four give clues about the way the client approached the test.
Validity and Response-Style Scales
The Validity Index (Scale V) consists of three improbable statements. If two or more of these statements are answered in the endorsed direction (e. g., true), the test is not valid. Because the Validity Index does not appear on the profile sheet, the psychologist must inspect the answer sheet to score this index in the hand-scored form or refer to the printout in the mail-in scoring form. However, even if one of the items in Scale V is answered "true," caution should be exercised in interpreting the remainder of the test.
The Disclosure Index (Scale X) identifies patients who are unnecessarily secretive and defensive (low scores) or openly frank and self-revealing (high scores). There are no items in this scale, which is calculated from the degree of positive or negative deviation from the midrange of an adjusted composite raw score from Scales 1 through 8B. Scores below BR 34 and above 178 invalidate the profile.
The Desirability scale (Scale Y) assesses the extent to which a respondent attempts to present himself or herself in an overly favorable, morally virtuous, or emotionally stable light. Clinical interpretation begins with BR scores above 74. The higher the BR score, the more the patient is denying psychological or personal problems. Scoring adjustments are made on scales known to be affected by high scores on Scale Y. Hence elevated scores on Scale Y do not invalidate the profile. Low scores on Scale Y are not interpreted. (See Rapid Reference 1.5.)
The Debasement scale (Scale Z) detects exaggeration of psychological problems and symptoms and the tendency to report more problems than may be objectively present. Clinically elevated scores on Scale Z may suggest a cry for help, acute emotional turmoil, or symptom exaggeration for personal gain. As with scores on Scale Y, elevated scores on Scale Z do not invalidate the pro-file. The MCMI-III makes scoring adjustments on scales affected by high scores on Scale Z. (See Rapid Reference 1.6.)
Although it is common to interpret the Modifying Indices individually, one can also interpret their configuration or their elevations in relation to one another. For example, a low score on Scale X and a high score on Scale Y might reflect a "fake-good" response set. High scores on Scales X and Z might reflect a "fake-bad" response set. Low scores on Scale X and high scores on Scales Y and Z suggest defensive responding (Scale X) and also the endorsement of antithetical symptoms and traits. The examiner would need to look at the personality and clinical symptom scales to make sense of such a Validity scale configuration (e. g., it might reflect manic and depressive traits and symptoms).
Clinical Personality Patterns Scales
The Schizoid scale (Scale 1) is a 16-item scale that represents the passive-detached component of Millon's typology. Nine items are given a weight of 1 and seven are weighted 2. Item content pertains to detachment, lack of sexual interest, behavioral withdrawal, avoidance of relationships, emotional suppression, introverted behaviors, and feelings of emptiness, irresponsibility, and a preference for being alone. (See Rapid Reference 1.7.)
Interpretation of High Scores High-scoring patients have severe relationship deficits. They appear aloof, introverted, emotionally bland and detached, with flat affect and an apparent low need for social contact. They have difficulties in forming and maintaining relationships and seem to prefer a solitary life. They also seem to require little affection and lack warmth and emotional expression. These patients are likely to drift through society in marginal social roles and are prone to develop anxiety reactions, Somatoform disorder, and brief reactive psychoses, particularly when social demands become inescapable. If married or in a committed relationship, their spouse or partner is likely to complain about a lack of emotional involvement or intimacy. Clinical Notes Some patients in psychiatric programs achieve BR scores on Scale 1 in clinically elevated ranges, suggesting the presence of schizoid traits but not necessarily a diagnosis of Schizoid personality disorder. Al-though the presence of schizoid traits appears in some alcoholic sub-types and in some Post-Traumatic Stress Disorder patients, it is usually associated with elevations in Scale 8A (Passive-Aggressive). Also, African American drug addicts often score in elevated ranges on MCMI-III Scale 1, reflecting a loner type of existence in which they do not want others to know their business. Although this reflects a lack of social outlets, it is probably not indicative of a Schizoid disorder.
The Avoidant scale (Scale 2A) is a 16-item scale that represents the active-detached component of Millon's typology. Eight items are weighted 1 and eight items are weighted 2. Item content pertains to feelings of rejection, avoidance of social situations, insecurities, sensitivities, and anxiety in social situations, feelings of worthlessness, anhedonia, self-blame, and expectations of criticism.
Interpretation of High Scores Patients with significant elevation of Scale 2A are hypersensitive to rejection, both fearing and anticipating negative evaluations. Thus they manifest a wary detachment (avoidance). Because they are quite sensitive to signs of disapproval, they tend to withdraw from or reduce social contacts. Others are able to maintain a good social appearance despite their underlying fears. Their essential conflict is a strong desire to relate socially and an equally strong expectation of disapproval, depreciation, and rejection. They may use fantasy as their main defense. They are at risk for developing social phobias.
Clinical Notes Studies have repeatedly found that many patients with major psychiatric disorders have elevated scores on Scale 2A along with Scale 8A (Passive-Aggressive). If you see this pattern of test scores, a psychiatric evaluation may be warranted. The 2A8A/ 8A2A code type appears to be a very reliable marker for psychological maladjustment. (See Rapid Reference 1.8.)
The Depressive scale (Scale 2B) is a 15-item scale that represents the passive-detached component of Millon's typology. Eight items are weighted 1 and seven are weighted 2. Item content pertains to self-blame, guilt, feelings of emptiness and worthlessness, pessimism, anhedonia, excessive worry over trivial matters, recurrent sadness, moodiness, feelings of failure, and admission of a previous suicide attempt.
Interpretation of High Scores The high-scoring patient is generally gloomy, pessimistic, overly serious, quiet, passive, and preoccupied with negative events. These patients often feel quite inadequate and have low self-esteem. They tend to unnecessarily brood and worry and, though they are usually responsible and conscientious, they also are self-reproaching and self-critical regardless of their level of accomplishment. They seem to be "down" all the time and are quite hard to please. They tend to find fault in even the most joyous experience. They feel it is futile to try to make improvements in them-selves, their relationships, or any other significant aspect of their life because their incessant pessimism leads them toward a defeatist outlook. Their depressive demeanor often makes others around them feel guilty, since these patients are overly dependent on others for support and acceptance. They have difficulty expressing anger and aggression and perhaps displace it onto themselves. Interestingly, while their mood is often one of dejection and their cognitions dominated by negative thoughts, they often do not consider them-selves depressed.
Clinical Notes This scale was designed to tap a depressive personality style, which is said to exist independent of a clinical depression. It is important to review elevations of Dysthymic Disorder (Scale D) and Major Depression (Scale CC) to ensure that elevations on Scale 2B are not associated with a clinical depression that might abate when the clinical disorder abates. In fact, there are no items in this scale that stipulate that these personality traits occur outside an episode of major depression, though that was the intent.
The Dependent scale (Scale 3) is a 16-item scale that assesses the passive-dependent variant in Millon's typology. Eight items are weighted 1 and eight are weighted 2. Item content deals with traits of acquiescence; submissiveness; concerns about being abandoned; fears of being rejected; self-blame; and feelings of inadequacy, worthlessness, and insecurity.
Interpretation of High Scores These patients tend to lean on others for security, guidance, support, and direction, and they seek out relation-ships that provide them with such emotional protection. They are passive, sub-missive, conforming, dependent, self-conscious, obliging, and placating, and they lack initiative, confidence, and autonomy. Their temperament is pacifying and they try to avoid conflict. They have a strong need to be nurtured and they seek out relationships or institutions to take care of them. They fear abandon-, so they act in an overly compliant manner in order to ensure protection. When their security is threatened, they are prone to develop Anxiety and Depressive disorders or substance abuse disorders.
Clinical Notes Scale 3 is often elevated in patients with major psychiatric disorders. Also, patients with clinical depression may obtain elevated scores on Scale 3. These scores often abate when the depression abates. The clinician is advised to ensure that scores on Scale 3 are not a symptomatic expression of a current affective disorder. Scale 3 shows good congruence with other self-report measures of dependence but shows low correspondence to structured psychiatric interview schedules assessing dependence.
The Histrionic scale (Scale 4 ) is a 17-item scale that represents the active-dependent variant in Millon's typology. Ten items are weighted 1 and seven are weighted 2. Item content addresses gregarious behavior, ease of social engagement and social facility, easy display of feelings, extroverted traits, flirtatious behavior, and need of excitement.
Interpretation of High Scores Clinical elevations describe individuals who are overly dramatic with strong needs to be the center of attention. They tend to be seductive in thought, speech, style, dress, or manner, and they seek constant stimulation, excitement, praise, and attention. They are emotion-ally labile, easily excited, and show frequent emotional outbursts. Out-wardly they are very gregarious and outgoing, but they tend to manipulate people to receive attention and approval. They can be quite socially facile and seductively engaging. However, their relationships are often shallow and strained due to their repeated dramatic and emotional outbursts and their self-centeredness. When stressed they are at risk for developing Somatoform disorder and marital problems.
Clinical Notes The character portrait just given fits well with descriptions of a Histrionic personality disorder. However caution is indicated when interpreting Scale 4 as a disorder as there is ample research to suggest that elevated scores may indicate a healthy histrionic style but not a disorder. The evidence is as follows: First, factor studies show that Scale 4 correlates positively with extroverted traits and behaviors and negatively with items pertaining to maladjustment. In addition, convergent validity studies indicate that Scale 4 correlates positively with measures of mental health and correlates negatively with measures of emotional maladjustment. A few studies also report that elevations on Scale 4 are associated with less distress, more positive life events, and fewer social problems. Third, manifestly normal people who have been given the MCMI have often attained their highest scores on Scale 4, including air force pilots in basic training and graduate students in psychology. Finally, except for substance abusers, Scale 4 elevations in psychiatric samples are infrequent (Craig , 1993a; 1997 ). Thus the major clinical decision is to determine whether an elevation on Scale 4 (a BR score above 84) represents a histrionic style or a Histrionic personality disorder.
In general Scale 4 is one of the strongest scales on the MCMI with excellent reliability, but prior versions of this scale have shown low correspondence with structured psychiatric interview schedules of the histrionic.
The Narcissistic scale (Scale 5) is a 24-item scale, which measures the passive-independent component of Millon's typology. Sixteen items are weighted 1 and eight are weighted 2. Item content pertains to egocentricity, independence, grandiosity, and feelings of superiority and comfort in social situations.
Interpretations of High Scores These patients are extremely self-centered, expect others to recognize them for their special qualities, and re-quire constant praise and admiration. They feel excessively entitled and demand social favors simply on the basis of who they are. They appear arrogant, haughty, conceited, boastful, snobbish, pretentious, and supercilious. They can be momentarily charming but show social imperturbability and exploit social relationships for self-gain. When they experience a narcissistic injury, they are prone to develop an affective disorder or even paranoia. Many substance-abusing patients demonstrate a Narcissistic personality disorder.
Clinical Notes As with Scale 4, Scale 5 has a research base that suggests that elevated scores indicate either a clinical personality disorder or a healthy adaptational personality style associated with nonclinical people. In factor analysis studies, Scale 5 loads positively on items dealing with extroverted traits and behaviors and negatively on items pertaining to maladjustment. Scale 5 correlates moderately with indices of mental health and negatively with all MCMI-III clinical syndrome scales, and with the exception of a sub-stance abuse disorder, elevations on Scale 5 are rare in psychiatric samples. Many nonclinical populations attain elevated scores on Scale 5 including air force pilots in basic training. On the other hand, research has also established that Scale 5 correlates positively with similar measures of pathological narcissism, especially with the Narcissistic scale of the MMPI and with the Narcissistic Personality Inventory (Craig , 1993a; 1997 ). Thus the clinical task is to determine whether clinically elevated scores represent a Narcissistic personality disorder or a narcissistic personality style. Prior versions of this scale have not correlated well with structured psychiatric interview schedules.
The Antisocial scale (Scale 6A) is a 17-item scale that measures the active-independent component of Millon's typology. Ten items are weighted 1 and seven items are weighted 2. His theory posits that the antisocial personality style is motivated to avoid control and domination; hence a substantial number of items in the scale pertain to the issue of independence. Other item content applies to traditional antisocial indicators, such as history of truancy and delinquency, and antisocial traits and attitudes.
Interpretation of High Scores These patients are intimidating , dominating, narcissistic, aggressive, fearless, pugnacious, daring, blunt, competitive, argumentative, self-reliant, vengeful, and harbor resentments to perceived slights. They often have an angry and hostile demeanor. Warmth, gentleness, and intimacy are viewed as a sign of weakness. They try to provoke fear in others as a way of controlling them. They use acting out as their main defense. They are prone to substance abuse, relationship difficulties, and vocational and legal problems.
Clinical Notes It is important to realize that a person can have an antisocial personality style in the absence of criminal behavior, though at the higher BR levels the absence of involvement with the criminal justice system is less likely (see Rapid Reference 1.9). Prior versions of this scale correlated moderately with similar measures of psychopathy, including both paper-and-pencil tests and structured psychiatric interview schedules.
The Aggressive (Sadistic) scale (Scale 6B) is a 20-item scale measuring the active-discordant component of Millon's typology. Thirteen items are weighted 1 and seven are weighted 2. Item content includes aggressive and controlling traits.
Interpretation of High Scores These patients tend to behave abusively toward others. They may exhibit traits that are dominating, hostile, intimidating , fearless, aggressive, hardheaded, antagonistic, arrogant, touchy, excitable, irritable, disagreeable, and angry. They use acting out as their main defense. They may react with brutal force when angered or provoked. Explosive outbursts are common. Some are able to sublimate these traits into socially approved occupations. Others may not engage in antisocial behavior but have an aggressive personality style. Patients with this personality style are prone to experience legal and marital problems.
Clinical Notes Look for evidence of spouse or child abuse among high-scoring patients. Also, high scores may suggest verbal rather than actual physical abuse. Prior versions of this scale showed modest correspondence with similar measures.
The Compulsive scale (Scale 7 ) is a 17-item scale that assesses the passive-ambivalent component of Millon's typology. Nine items are weighted 1 and eight items are weighted 2. Item content pertains to organized and perfectionistic behavior, impatience, good morals, obedient behavior, suppression of emotions, and rigidity.
Interpretation of High Scores These patients are behaviorally rigid, constricted, meticulous, respectful, polite, conscientious, overly conforming, organized, and respectful. They are often perfectionistic, formal, cooperative, moralistic, efficient, and flexible. They are known to suppress their strong resentment and anger toward those (usually authority figures) whose approval they seek. They generally have a repetitive lifestyle with patterned behaviors. Fear of social disapproval results in their being a model of propriety, though they may treat subordinates autocratically. They have a strong sense of duty and strive to avoid criticism. They rely on achievement and accomplishment of personal goals to feel worthwhile. Obsessional thinking may or may not be present.
Clinical Notes Although this scale was designed to measure a Compulsive personality disorder, there is substantial evidence to suggest that it may mea-sure a compulsive personality style. First, Scale 7 is rarely elevated in samples of psychiatric patients. In fact, it correlates positively with items pertaining to control of behavior and emotions, which is often an indicator of emotional adjustment. Second, the scale shows persistent negative correlations with measures of psychiatric disturbance. Third, nonclinical populations, including 1st-year seminary students; air force pilots in training; family practice residents; and college students, particularly males, often score highest on Scale 7. Fourth, the scale consistently correlates with measures of mental health and negatively with measures of emotional maladjustment. Fifth, higher Scale 7 scores often had better treatment outcomes related to improved mental health and improved self-esteem. Sixth, in the only published study featuring patients with a primary Obsessive-Compulsive disorder, the mean BR score on Scale 7 was 56 (e. g., normal). Finally, prior versions of this scale showed poor convergent validity with similar measures (Craig , 1993a; 1997 ). The evidence summates to suggest that elevated scores may be associated with a compulsive personality style but not a Compulsive disorder.
The Passive-Aggressive (Negativistic) scale (Scale 8A) is a 16-item scale that assesses the active-ambivalent component of Millon's typology. Seven items are weighted 1 and nine are weighted 2. Item content deals with irritability, impulsivity, hostility, verbal attacks, loss of control over anger, and cruel behaviors.
Interpretation of High Scores Traits that describe this character style include moody, irritable, negativistic, hostile, grumbling, pessimistic, querulous, anxious, complaining, and disgruntled. They seem to be constantly disillusioned. They often feel unappreciated and sulk over feelings that they have been treated unfairly. Their continued petulance results in problems with authority, coworkers, friends, and family. High-scoring patients can be passively compliant and obedient at one moment and negativistic and oppositional at the next.
Clinical Notes Scale 8A elevation is an excellent predictor of loss of control over emotions. High scores usually suggest the presence of a serious psychiatric disorder. Prior versions of this scale showed poor correspondence with structured psychiatric interview schedules that also purportedly measured passive-aggressive behavior. One reason for this difference is the psychiatric definition of this disorder, which suggests that anger is expressed indirectly. Millon's concept of the term leans more toward a negativistic character style rather than acting in passive-aggressive ways.
The Self-Defeating scale (Scale 8B) is a 15-item scale designed to assess the passive-discordant component of Millon's typology. Eight items are weighted 1 and seven are weighted 2. The disorder is akin to the psychoanalytic concept of masochism. Item content pertains to patients' acting in a self-sacrificing manner, feeling they deserve to suffer, demonstrating submissive behavior, placing themselves in inferior relation-ships, exhibiting mild depression, allowing themselves to be taken advantage of, and displaying disparaging attitudes.
Interpreting High Scores These patients often allow others to take advantage of them. They behave in a self-sacrificing and martyrlike manner and seem to seek out relationships in which they can acquire security and affection in re-turn for allowing themselves to be dominated and even abused. Look for evidence of victimization among high-scoring patients.
Clinical Notes Scale 8B seems to be moderately elevated in the profiles of many psychiatric patients. Instead of connoting the characteristics associated with a self-defeating personality, I believe that high scores in such cases reflect problematic behavior patterns, which are not in the best interest of the patient. Also, look for patterns of abuse and victimization among high-scoring patients. Finally, be mindful that there are very little research data with this scale on which to base definitive conclusions. (See Rapid Reference 1.10.)
Severe Personality Pathology Scales
The personality disorders in this section measure severe forms of the basic personality patterns. Millon believes that individuals with these characteristics are prone to develop psychotic disorders, including schizophrenia.
The Schizotypal scale (Scale S) is a 16-item scale that assesses more severe structural pathology. Seven items are weighted 1 and nine are weighted 2. Item content pertains to cognitive impairments, ideas of influence, interpersonal detachment and preference for social isolation, dependent behaviors, and feeling self-conscious.
Interpretation of High Scores High-scoring patients present as emotionally bland with flat affect or with an anxious wariness. Generally, they are socially detached and have a pervasive discomfort in social relationships. Accordingly, they remain on the periphery of society with few or no personal attachments. Thought processes may be tangential, irrelevant, or confused. They appear self-absorbed in their own thoughts. It is believed that they are prone to developed schizophrenia if sufficiently stressed.
Clinical Notes Scale S should be one of the scales inspected when evaluating for psychosis and major psychiatric disorders such as schizophrenia. Unfortunately Scale S has not demonstrated consistent clinical utility and some pathology is missed by this scale. Prior versions of this scale have shown low to moderate convergence with other measures of Schizotypal personality disorder.
The Borderline scale (Scale C) is a 16-item scale with seven items weighted 1 and nine items weighted 2. Item content pertains to unstable mood, anger, guilt, obstreperous behavior and reactions, dependency-seeking behavior, erratic moods, and unstable relationships.
Interpretation of High Scores These patients show attachment disorders with patterns of intense but unstable relationships, labile emotions, a history of impulsive behaviors, and strong dependency needs with fears of abandonment. They are preoccupied with seeking emotional support and are particularly vulnerable to separation anxiety. They seem to lack a clear sense of their own identity, so they constantly seek approval, attention, and reaffirmation. They use splitting and devaluation as their main defenses. They are prone to-ward brief psychotic reactions and suicidal gestures. More severe cases may also self-mutilate.
Clinical Notes Scale C has been shown to be elevated in patients with many other psychiatric disorders and probably reflects erratic emotionality associated with those disorders (Rapid Reference 1.11). There has been much research (N = 22 studies) on earlier versions of this scale. The volume of studies on this scale is sufficiently large to provide us with some tentative conclusions. In general, Scale C shows moderate to strong relationships with similar measures of the Borderline personality disorder.
The Paranoid scale (Scale P) is a 17-item scale with eight items weighted 1 and nine items weighted 2. Item content deals with ideas of control or influence, hypervigilant sensitivity, annoyance with others, delusional beliefs, grandiosity, and an edgy defensiveness.
Interpretation of High Scores The patients are vigilantly mistrustful and often perceive that people are trying to control or influence them in malevolent ways. They are characteristically abrasive, irritable, hostile, and irascible and may also become belligerent if provoked. Their thinking is rigid and they can be argumentative. They may present with delusions of grandeur or persecution and/ or ideas of reference. They use projection as their main defense.
Clinical Notes Drug addicts often obtain mildly elevated scores on Scale P. They have issues related to concerns about law breaking and getting caught, and not wanting people to know their business, so they are usually secretive. They endorse items on the MCMI pertaining to these traits, which results in some elevations on Scale P, but they are usually not paranoid in the clinical sense. If the patient has elevations on Scale T (Drug Dependence) along with elevations on Scale P, then a clinical interview needs to determine whether there is or is not a clinical paranoia.
Prior versions of this scale suggested that Scale P bore little relationship and had low correspondence to other measures of paranoia. This was true for both self-report inventories and structured psychiatric interview schedules.
Clinical Syndromes Scales
The Anxiety Disorder scale (Scale A) is a 14-item scale with eight items weighted 1 and six items weighted 2. It measures symptoms of generalized anxiety with item content pertaining to nervous tension, crying, indecisive-ness, apprehension, and somatic complaints. Interpretation of High Scores
The high-scoring patient has symptoms associated with physiological arousal. They would be described as anxious, apprehensive, restless, unable to relax, edgy, jittery, and indecisive. Symptoms can include complaints of insomnia, muscular tightness, headaches, nausea, cold sweats, undue perspiration, clammy hands, and palpitations. Phobias may or may not be present. High scores may meet the DSM criteria for Generalized Anxiety Disorder or other anxiety-related disorders.
Clinical Notes Because of the variability of symptom expression, it is not possible to determine exactly which of the many symptoms of anxiety an individual patient has based on elevations of Scale A. However, Scale A is a strong scale and correlates well with other measures of anxiety. It is usually elevated in a number of clinical disorders, reflecting psychic distress and maladjustment. In conditions where anxiety would be expected, re-search has established that Scale A elevations are present. Thus one can have a great deal of confidence when interpreting this scale. One problem, however, is that Scale A is also highly correlated with Scale D (Dysthymic Disorder). Thus the scale may not be able to distinguish between anxiety and depression. If Scale D is also elevated, emphasize the depressive component of symptom expression. If absent, emphasize the anxiety component if Scale A is elevated. (See Rapid Reference 1.12.)
The Somatoform Disorder scale (Scale H) is a 12-item scale with seven items weighted 1 and five items weighted 2. It measures elements of anxiety that may be displaced into associated physical symptoms. Item content pertains to vague bodily complaints, apprehension, crying, indecisiveness, and fatigue.
Interpretation of High Scores High-scoring patients show the persistent pursuit of medical care, even in the face of evidence that there is little, if any, physical cause to their symptoms. Their physical complaints can be related to any organ system. A review of the MCMI-III Noteworthy Responses is necessary to determine which symptoms the patient has endorsed as present. They tend to be whiny, complaining, restless, and worried, and they antagonize those closest to them with their chronic complaints of pain. Yet they tend not to respond to interventions. Their symptoms and reactions to symptoms may be developed unconsciously to gain sympathy, attention, and reassurance.
Clinical Notes High scores are usually seen among two kinds of patients: (a) those who displace their psychological problems and/ or stress into somatic channels and (b) those with legitimate medical problems who are coping so poorly with their illness that their psychological reactions are compounding the manifestation of their symptoms. In either case, these patients show persistent preoccupation with feeling in poor health and overutilization of the health care system.
This is not a well-researched scale, and few, if any, studies have been directed at the kinds of patients for which this scale would be most useful (e. g., patients in medical settings). What is known about this scale comes from re-search using psychiatric patients.
Bipolar: Manic Disorder
The Bipolar: Manic Disorder scale (Scale N) is a 13-item scale with eight items weighted 1 and five items weighted 2. It measures hypomania and some more severe manic symptoms. The scale contains items dealing with flight of ideas, excessive energy, impulsivity, inflated self-esteem, grandiosity, and overactivity.
Interpretation of High Scores Clinically elevated scores suggest a patient with labile emotions and frequent mood swings. During the manic phase, symptoms can include flight of ideas, pressured speech, overactivity, unrealistic and expansive goals, impulsive behavior, and a demanding quality in their interpersonal relationships. Extremely high scores may also suggest psychotic processes with delusions and hallucinations.
Clinical Notes To determine if the bipolar mania is of psychotic proportions, the examiner should look for elevations in Scales SS (Thought Disorder), PP (Delusional Disorder), or CC (Major Depression). Also, the examiner should ensure that elevations from this scale are not drug induced (see Scale T). Prior versions of this scale had good correspondence to other measures of mania, including the MMPI Hypomania (Ma) scale.
The Dysthymic Disorder scale (Scale D) is a 14-item scale with eight items weighted 1 and six items weighted 2. It measures depression of 2 or more years' duration. Dysthymic patients are able to carry on day-to-day functions despite their depressed mood. Item content addresses apathy, feeling discouraged, and lack of energy, crying spells, self-deprecatory cognitions, and guilt feelings.
Interpretation of High Scores Patients scoring high on this scale are behaviorally apathetic, socially withdrawn, feel guilty, pessimistic, discouraged, and are pre-occupied with feelings of personal inadequacy. They have low self-esteem and utter self-deprecatory statements, feel worthless, and are persistently sad. They have many self-doubts and show introverted behavior. If physical symptoms appear, they can include problems in concentration, poor appetite, and suicide ideation. Most do not meet the criteria for Major Depression.
Clinical Notes There are many ways to feel depressed. Not all of the above characterization will fit every patient who scores high on Scale D. The above represents the prototypal Dysthymic Disorder patient. However, the individual clinician will have to do a more thorough assessment of the patient's individual symptoms of Dysthymic Disorder, which is not possible from the MCMI-III alone.
Research has indicated that Scale D was actually a better predictor of Major Depression than Scale CC (Major Depression). Scale CC had difficulty in diagnosing the disorder of Major Depression in versions MCMI-I and MCMI-II because it contained no vegetative/ somatic symptoms, which are critical in distinguishing Major Depression from Dysthymic Disorder. This problem seems to have been corrected with the MCMI-III.
Previous versions of this scale showed generally moderate convergent validity with tests measuring similar constructs. Also, Scale D is highly correlated with Scale A. Thus, there is a strong element of anxiety inherent in both the construct and the scale. (See Rapid Reference 1.13.)
The Alcohol Dependence scale (Scale B) is a 15-item scale with nine items weighted 1 and six items weighted 2. Item content pertains to six items dealing directly with alcohol abuse and nine items dealing with traits often associated with problematic drinking. These include impulsivity, rationalizations, and lack of adherence to societal standards, selfishness, and aggressiveness toward family members.
Interpretation of High Scores Clinically elevated scores on Scale B indicate that the patient is reporting a history of current problematic drinking or personality traits frequently seen in alcoholics.
Clinical Notes Studies show that Scale B correlates in the .70s with Scale T (Drug Dependence). This is no accident since people who abuse alcohol commonly also abuse illicit drugs. Hence the scale has a built in associated to reflect this reality.
This scale assesses alcohol dependence both directly, through items pertaining to alcohol abuse, and indirectly, through items reflecting behavior associated with problematic drinking. Thus it is theoretically possible that a patient can endorse the latter items and obtain a high score on Scale B yet not be alcoholic. For example, if a patient endorsed all nonprototypical items, the BR score would be 79.
A clinical interview is required to determine if the patient has been abusing alcohol and, if so, the specific areas (e. g., medical, psychological/ psychiatric, social, legal, vocational, recreational, spiritual) that have been affected by alcohol abuse/ dependence. Earlier versions of this scale suggested it correlated with behaviors and traits associated with alcohol abuse, such as depression, dependence, anxiety, and extroversion.
The Drug Dependence scale (Scale T) is a 14-item scale with eight items weighted 1 and six weighted 2. Item content pertains to a history of and re-current pattern of drug abuse, disruptions in interpersonal relationships, and impulse control problems. Six items (the prototype items) assess drug abuse directly and eight assess it by evaluating for legal problems, adherence to societal standards, antisocial practices, independence, nonempathic behavior, irresponsibility, and rationalizations. These items are also associated with Anti-social personality disorder traits.
Interpretation of High Scores High scores suggest a person who has or had a problem with drug dependence and has personality and behavior traits associated with these problems. These include hedonism, self-indulgence, impulsivity, exploitiveness, and narcissistic personality traits. These patients are likely to be in considerable distress in social, occupational, familial, and legal areas. It is theoretically possible to endorse all nonprototype items on this scale and not abuse drugs. However, this is very unlikely.
Clinical Notes Scale T correlates from .50 to .79 with Alcohol Dependence (B). This is no accident, since conceptually and clinically there is a strong relationship between people who abuse drugs and those who abuse alcohol. Hence the scale has a built in correlation to reflect this reality.
Research has found low concurrent validity in diagnosing drug dependence with prior versions of this scale. MCMI-I Scale T identified about one third to one half of known drug abusers. No research was available on the predictive accuracy of MCMI-II Scale T. Perhaps patients are able to deny their drug abuse and can conceal it from detection on the MCMI. One study did report that about 50% of drug-dependent patients, if motivated to do so, are able to obtain normal values on Scale T (Craig , 1997 ). All research has shown that Scale T's ability to rule out drug abuse is excellent.
Earlier versions of this scale showed moderate correspondence with MMPI MacAndrew Alcoholism Scale and other measures often associated with drug-abusing behaviors, such as extroversion, hostility, and dominance. It show little or no relationship to measures of behavior and traits that bear no conceptual relationship to drug abuse.
Post-Traumatic Stress Disorder
The Post-Traumatic Stress Disorder scale (Scale R) is a new scale and was not in previous MCMI versions. It is a 16-item scale with eleven items weighted 1 and five items weighted 2. Item content deals with painful memories, nightmares, reports of a trauma, and flashbacks.
Interpretation of High Scores High-scoring patients report symptoms that might include distressing and intrusive thoughts; flashbacks; startle responses; emotional numbing; problems in anger management; difficulties with sleep or with concentration; and psychological distress upon exposure to people, places, or events that resemble some aspect of the traumatic event. A clinical evaluation is needed to determine which symptoms are present and the degree of functional impairment.
Clinical Notes If there is no trauma in the patient's history, the high scores could suggest emotional turmoil of a nontraumatic nature.
Most Post-Traumatic Stress Disorder scales were more specific to combat stress and may lack generalization to noncombat trauma. Scale R was constructed in such a way that it should pertain to both civilian and military trauma (Rapid Reference 1.14).
The Thought Disorder scale (Scale SS) is a 17-item scale with 11 items weighted 1 and 6 items weighted 2. It measures thought disorder of a psychotic nature. Item content pertains to ideas of influence, hallucinations, delusions, slights, and intrusive thoughts.
Interpretation of High Scores Patients with elevated scores on Scale SS are admitting to thinking that is disorganized, confused, fragmented, or bizarre. Hallucinations, and/ or delusions may also be present. Their behavior is often withdrawn or seclusive. They often show inappropriate affect and appear confused and regressed.
Clinical Notes Research has indicated problems with Scale SS in detecting major psychoses and schizophrenia. Prior versions of this scale indicated moderate correlations with similar measures such as the MMPI Paranoia and Schizophrenia scales.
Major Depression (Scale CC) is a 17-item scale with ten items weighted 1 and seven items weighted 2. Item content deals with suicidal ideation, cognitive and vegetative signs of depression, depressed affect, crying spells, and with-drawn behavior.
Interpretation of High Scores High-scoring patients may be unable to man-age their day-to-day activities. They are severely depressed, with feelings of worthlessness and vegetative symptoms of depression (e. g., loss of energy, appetite and weight, sleep disturbances, fatigue, and loss of sexual drive or desire). Suicidal ideation may be present. Their underlying personality style is likely to be of the emotionally detached type, especially dependent or depressed.
Clinical Notes Research has clearly established that the MCMI-I and MCMI-II Scale CC was unreliable in diagnosing Major Depression. This was because the earlier versions of the scale did not contain vegetative symptoms that are the hallmark of the disorder. Often elevated scores on CC indicated Dysthymic Disorder or some other depression diagnosis. MCMI-III Scale CC has added a number of vegetative items to the scale, which should in-crease its diagnostic efficiency. Earlier versions of the scale did correlate well with similar measures, such as MMPI Scale D (Depression) and the Beck Depression Inventory.
The item content of Delusional Disorder (Scale PP) -a 13-item scale with nine items weighted 1 and four items weighted 2- deals with delusions, grandiosity, and hypervigilance. The scale measures delusional thinking usually associated with a Paranoid disorder.
Interpretation of High Scores Patients scoring in the clinically significant ranges on Scale PP are likely to be diagnosed with some type of Paranoid disorder. They have persecutory or grandiose delusions, and maintain a hostile, hypervigilant and suspicious wariness for anticipated or perceived threat. They may also become belligerent and have irrational ideas of reference, thought influence, or thought control. The scale is thought to be a symptomatic expression of an underlying paranoid personality addressed in Scale P.
Clinical Notes Earlier versions of this scale indicated that Scale PP was weakly related to similar measures. As with Scale SS, the scale detects Delusional Disorder in patients willing to admit their symptoms on the test. Some patients are able to avoid detection of Thought Disorder on the MCMI.
Most data concerning gender, race, and age come from MCMI-I studies. No information on these variables has been published for the MCMI-III. When a pattern of differences does emerge, this does not necessarily imply test bias, since an alternative explanation is that the test is tapping true differences in the populations.
Also, the diagnosis of patients in these samples may not have changed, even when the group obtained statistically higher scores on a given scale. These facts should be taken into account when digesting the data presented below, which came from six studies (Craig , 1993a).
Males score higher on Scale 6A; females score higher on Scales H and CC. No gender effects consistently appear on Scales 2 and 8A. No other conclusions are warranted from the data.
Blacks consistently score higher on Scales 5, 6A, P, T, and PP. Whites consistently score higher on Scale D. Studies show no racial differences between Blacks and Whites on Scales 3, 7, 8A, and A. No data are available on differences between Whites and other ethnic groups on MCMI scales.
No consistent patterns have been found for patient age.
Step-by-Step Procedures for Test Interpretation
Step 1: Examine the Validity Index
1. The test is valid if Validity (Scale V) = 0. Results are of questionable validity if V = 1 and are invalid if V = 2 or 3.
2. The examiner must make sure Disclosure (Scale X) is in the valid range of 34 to 178.
3. The examiner must check Desirability (Scale Y) to see if the patient is understating psychopathology.
4. The examiner must check Debasement (Scale Z) to see if the patient is overstating psychopathology.
Then the examiner should write a paragraph describing the patient's response style using the interpretive notes presented earlier.
Step 2: Examine the Severe Personality Pathology Scales
When there are multiple scales elevated in both the clinical personality pat-terns and severe personality pathology scales, a general rule of thumb is to interpret scales suggesting more severe personality pathology first. Thus if Schizotypal (Scale S), Borderline (Scale C), and/ or Paranoid (Scale P) are clinically elevated, place the interpretive emphasis on these scales. Use the other elevated scales to provide associated features of the personality.
Step 3: Examine the Clinical Personality Patterns
Look for elevations in Scales 1 through 8B and interpret those scales that are clinically elevated. If more than three scales are scored at BR 75 or above, examiners should frame their interpretations using the highest two or three scales. Also, if there are multiple elevations, the examiner should think about what factor or factors are driving the elevations in those scales. For example, if Antisocial (Scale 6A), Aggressive (Sadistic) (Scale 6B), and Passive-Aggressive (Negativistic) (Scale 8A) are all elevated, anger is the emotion that permeates all these scales. If Schizoid (Scale 1), Avoidant (Scale 2A), and De-pendent (Scale 3) are all elevated, emotional detachment and passivity ac-count for these combined elevations.
Step 4: Examine the Clinical Syndrome Scales
The examiner should first interpret the severe clinical syndrome scales- Thought Disorder (Scale SS), Major Depression (Scale CC), and Delusional Disorder (Scale PP)- if the BR scores are 75 or above. Then the remaining clinical syndrome scales should be interpreted, from highest to lowest: When BR scores are 75 or above, the examiner can diagnose the syndrome as present; when BR scores are 85 or above, the syndrome may be the primary diagnosis (i. e., the main reason the client came for help). When there is more than one scale with a BR score of 85, the highest score is the primary Axis I diagnosis.
Step 5: Interpret the Meaning of Symptoms Within the Context of the Client's Personality Style or Disorder
If a patient has a mixed Narcissistic (Scale 5) and Antisocial (Scale 6A) personality, and elevated scores on Drug Dependence (Scale T), perhaps drug abuse is part of narcissistic indulgence. Or perhaps the patient has experienced a narcissistic injury and uses drugs to quell the hurt from this perceived injury. Or perhaps the patient is generally deviant and drug abuse is part of that overall deviance, characterized by acting out. Or perhaps there is a deep resentment of perceived attempts to control the patient and episodes of drug abuse function as a continuing sign of "independence" and a statement that the patient will not be controlled. Whatever the reason, the examiner must try to understand the meaning of the symptom in the person's life.
Step 6: Integrate Test Findings With Other Sources of Data
The examiner must never base clinical decisions on a single source of data, but instead use multiple sources of data and integrate test findings with ancillary information (e. g., history, clinical interview, collateral information, and medical records).
STRENGTHS AND WEAKNESSES OF THE MCMI-III
A clinician should know or suspect in advance of administering the test whether the client may have a personality disorder. Other inventories often can be used with normal and nonclinical populations, whereas the MCMI-III can only be used with clinical patients. Several characteristics of the MCMI-III, which highlight its major strengths and weaknesses relative to similar self-report inventories, follow.
1. Developed from a Comprehensive Clinical Theory. The test is an instrument derived from Millon's (1997a) comprehensive clinical theory of psychopathology.
2. Reflects Diagnostic Criteria Used in DSM-IV. The test is coordinated with the multiaxial format provided in DSM-IV and is linked to its conceptual terminology and diagnostic criteria.
3. Provides Diagnostic Accuracy. The MCMI-III takes into account the base rates, or prevalence, of personality disorders and clinical syndromes, thereby affording the opportunity for increased diagnostic accuracy.
4. Utilizes Validation Process. It was developed according to Loevinger's (1957) three-step validation process that allowed for refinement of the test from item selection to scale development to external validation using Millon's theory as the criterion.
5. Easy to Administer. It is relatively quick to administer (20 to 30 minutes) and measures a wide range of personality traits and symptoms.
6. Compact Design. There is no need for a separate test booklet since items and space for the respondent's answers are on the same form.
1. Imbalance Between True and False Items. With the vast majority of items keyed in the "true" direction, the test is susceptible to patients with an acquiescent response set (e. g., the tendency to report "true" when faced with an item that is equally true and equally false for the respondent).
2. Pathology and Disorder Assessments. The test is relatively weak in assessing patients with minor personality pathology and those with psychotic disorders.
3. Assessment of Styles Versus Disorders. The Histrionic, Narcissistic, and Compulsive scales appear to have difficulty in assessing those pathologies and seems more able to detect a histrionic, narcissistic, or compulsive personality style rather than a personality disorder.
4. Validity Problems. The test shows poor convergent validity with standard psychiatric rating schedules across most of its scales.
5. Personality Subtypes Not Accounted For. There may be subtypes of a given personality disorder that the MCMI-III does not tap. Millon has theorized about some of these subtypes, but they are not incorporated into the test construction.
6. Sample Population. The normative sample is modest in size and underrepresents minority groups.
7. Few Validation Studies. Although Millon's theory provides a rich con-text for interpreting test results and making predictions about patient behavior, few validation studies have been conducted to verify the accuracy of the theoretical deductions.
CLINICAL APPLICATIONS OF THE MCMI-III
Assessment of Personality Disorders
The MCMI-III provides a very good means for rapidly assessing the presence or absence of personality disorders. It is well known that Axis II disorders can affect the course and direction of Axis I disorders (e. g., clinical syndromes). Knowledge of a personality disorder within an individual patient can therefore influence treatment decisions and has relevance for predicting the patient's response to treatment. Also, personality disorders can be the focus of treatment in their own right and this diagnostic information is there-fore useful in treatment planning. Of course, it is also of value to learn that the patient does not have a personality disorder.
In forensic settings the MCMI-III can be useful in cases where personality disorders may be instrumentally related to a crime and also relevant at the penalty phase where personality disorders may be a mitigating factor in as-signing the sentence.
Assessing Personality Style
In addition to assessing for personality manifestations at the diagnostic level, the MCMI-III can provide us with value information concerning the presence of personality traits, which are important in understanding and treating all patients. Having this information can help us understand a patient's reaction to interventions and help to explain daily behavior patterns that may be dysfunctional.
Assessing Clinical Syndromes
The MCMI-III is able to assess most of the major (e. g., more severe) clinical syndromes in DSM-IV. Although it cannot provide specificity of those syndromes (e. g., Generalized Anxiety Disorder vs. Social Phobias), it does give us their categorical diagnosis (e. g., Anxiety). Research has also shown that objective diagnostic tests usually suggest the presence of clinical disorders that are occasionally missed in a clinical interview.
Assessing Severity of Disorders
Not only does the MCMI-III assess personality disorders and clinical syndromes, it is also able to reflect their severity. This knowledge is useful in a number of settings including mental health clinics, marital therapy, criminal evaluations, and routine screening.
Assessing Treatment Outcomes
By giving the MCMI-III prior to interventions and again after treatment the effectiveness of both pharmacological and psychosocial interventions can be assessed. The clinician can come to some conclusion as to which syndromes have improved by looking at pretest and posttest scores. When doing so, keep in mind that personality disorders are relatively ingrained and should not respond to short-term intervention approaches. Note too that some change in scale scores will occur by chance and as a function of the psychometrics of the test (e. g., internal consistency and test-retest reliability of the scales).
INTEGRATING MCMI-III AND MMPI-2 DATA: ILLUSTRATIVE CASE REPORT
The patient is a 37-year-old divorced, non-Hispanic White woman, who was self-referred for outpatient psychotherapy. She holds a B. A. in business management and is currently employed full-time in a management capacity. She presented with complaints of unresolved anger toward her father, whom she reported as having physically abused her during her childhood and adolescence. She was unable to recall incidents of sexual abuse, but she offered that on one occasion her father entered her bedroom while she was undressing and would sometimes enter the bathroom unannounced while she was using it. Since becoming an adult and leaving home, she reported that her father would ridicule her in front of family members. Because of this she broke off all contact with him and has not seen him or spoken to him in 7 years.
In spite of having no contact with her father, the patient finds that she "cannot get him out of my head." She often dwells on memories of abusive experiences and can become obsessed with reliving painful memories. On a few occasions while thinking about past abuse, she scratched her arms with a pair of scissors. She reported being very grouchy at work and has, on occasion, "thrown things around the house." Her roommate is now threatening to leave because of her volatile emotions. She attempted suicide twice in the past by taking overdoses of household medications, but apparently she never received psychiatric treatment following these episodes. She admitted that she is "an alcoholic" but has stated that she does not want to address this problem since "it will get better on its own," once she gets control of her anger. She reported being "depressed a lot" but works daily and receives excellent performance reviews. The MCMI-III and MMPI-2 (Butcher et al., 1989) were given to rule out a Borderline personality disorder and a Post-Traumatic Stress Disorder. Figures 1.3 and 1.4 present the test findings.
As can be seen in Figure 1.3, the Modifying Indices show no unusual response patterns, indicating that she cooperated with the testing. With regard to the personality scales, clinically significant elevations are noted on Depressive (Scale 2B), Compulsive (Scale 7 ), and Borderline (Scale C). With 2B the highest personality scale, and a BR score of 76 on Scale C, she probably does not have a Borderline personality disorder. The Scale C elevation is best understood as reflecting turbulent emotionality. She is more likely to exhibit a mixed depressive/ compulsive personality style with borderline and schizoid features. A diagnosis of Personality Disorder NOS on Axis II would be appropriate if evidence from the clinical interview verified that she met diagnostic criteria. Her personality pattern is replete with anxious apprehensiveness (Scales A, R) and depressive thoughts (Scales 2B, CC) that probably dominate her life. She is quite troubled and becomes easily dejected, perhaps in the belief that others will reject her. She is prone to erupt in temper tantrums against those whom she feels are uncaring, unsupportive, overly critical, and disapproving. Her Scale C elevation suggests that she is unpredictable and will vacillate between depression, explosive anger, and perhaps self-destructive activities. She may have learned to expect ridicule and hence sees the slightest bit of disapproval from others as yet another example that people cannot be trusted. Her compulsive (Scale 7 ) traits probably help her contain her emotions when she needs to (e. g., at work) and to keep focused on tasks when significantly distressed. Nevertheless, it appears that these features of her personality have been overwhelmed by the more disorganizing depressive and borderline forces. She has reported distressing recollections of traumatic experiences (Scale R), which were identified in her "true" responses to the statements: "I'm ashamed of some of the abuses I suffered as a child" and "I hate to think about some of the ways I was abused as a child." The Axis I diagnoses suggested by the MCMI-III include Generalized Anxiety Disorder, Major Depression, and Post-Traumatic Stress Disorder. The test did not detect alcohol abuse, which was reported during the initial interview. It is likely that she answered "false" to most of the items asking whether alcohol is a problem in her life.
Figure 1.4 gives summary scores for the MMPI-2 (Butcher et al., 1989). The patient endorsed a number of psychological problems, suggesting that she is in much emotional distress (F). Her defensive structure has been weakened (K, Es), and she is unable to cope effectively with the stresses in her life. Elevations on 7 of 10 basic clinical scales indicate T greater than 70, suggesting that she is chronically maladjusted. She is moody, angry, distrustful, resentful, and in much distress. Her depression contains both physical and cognitive symptoms (DEP and Depression subscales). She reports many family problems (FAM, Pd1) and feelings of alienation (2, Pd5). She is also quite angry (F, 4, 8, ANG) and has a high potential for ex-plosive behavior. Her interpersonal relationships are likely to be filled with disturbances. She is somewhat inhibited in social situations (SOD, Si1, Si2) and sees her social relationships as problematic. She also admits to problems with substance abuse (AAS) and her MacAndrew Alcoholism Scale- Revised (MAC-R) score confirms this. She may have suffered traumatic experiences (PS) such that substances may be used to cope with the symptoms. Her need for affection is quite strong (Hy2), but her feelings of alienation (Pd5, Sc1, Sc2) prevent her from satisfying these needs. Her tendency to withdraw, her extensive distress and maladjustment, poor coping skills, and significant depression suggest that she is a suicidal risk. Diagnoses associated with the MMPI-2 results are an affective disorder and/ or personality disorder.
Integration of Test Findings
The patient cooperated with the entire interview and testing process. Both self-report measures noted significant anxiety and depression and viewed her as psychologically maladjusted. She appears to have difficulty managing her emotions, especially anger, as noted on both tests. Traumatic experiences and symptoms figured prominently on both measures. Her alcoholism was more accurately identified by the MMPI-2. Both tests suggested a preoccupation with negative, particularly depressive, thoughts, that may dominate her life, and both suggested that she may be a suicide risk. A Borderline personality disorder was not identified by either test, but results of both instruments point to a prominent affective disorder and Post-Traumatic Stress Disorder on Axis I, and possibly a mixed personality disorder on Axis II.
Treatment goals suggested by the testing include (a) alleviating the patient's intense anxiety and depression, (b) carefully monitoring and eliminating her suicidal thoughts and self-mutilating behavior, (c) helping her cope more effectively with the symptoms of her traumatic past, (d) discontinuing the use of alcohol, (e) improving her relationship skills, and (f ) teaching her ways to modulate and control her feelings, especially anger.