Post on 19-Nov-2014
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
Active Histrionic Antisocial Avoidant Negativistic
Passive Dependent Narcissistic Schizoid Compulsive
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
Active Histrionic Antisocial Avoidant Negativistic
Passive Dependent Narcissistic Schizoid Compulsive
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
Test Positive True Positive(100)
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
Test Positive True Positive(40)
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
Test Positive True Positive(50)
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.
The Structure of the DSM:
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
The Structure of the DSM:
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
Axis IV: PsychosocialEnvironment
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
Axis IV: PsychosocialEnvironment
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.