Popularity MCMI has become extremely popular. MMPI-2 more popular
Rorschach more popular
Author : Ted Ted Millon M illon Ted Millon
MCMI-III: Part of a Suite of Millon Inventories Millon Clinical Multiaxial Inventory – III
Millon Adolescent 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 practices
clinics
mental health centers
forensic settings
residential settings
hospitals
Key Features of the MCMI-III Multiaxial Inventory All 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
Somatoform preoccupation with health hypochondriacal could be medical problem
Bipolar-Manic elation inflated self-esteem overactivity Irritability decreased need for sleep
Axis I Clinical Syndromes
Dysthymia chronic low-grade depression
behavioral apathy, low self-esteem
Alcohol Dependence current or historical alcohol abuse or dependence
Drug Dependence current 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 Instruments
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. theory.
Importance of PDs to Assessment
Axis II Personality Disorders
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 t he 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 reasons To understand our clients
To suggest effective psychotherapies
To suggest avenues of advancing our science.
The real reasons Every taxonomy is really based on theory. theory.
Theory provides a way of organizing and differentiating differentiat ing 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 Taxono Purpose Taxonomy: my: Periodic Table of Elements 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 orbitals
What kinds of compounds might be created, and with what other elements.
Classification is not merely descriptive, but explanatory. To the extent that a classification classific ation “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 sufficie nt detail to establish primitive systems of classifications.
1 Natural History Phase
Linnaeus
2 Discovery of Organizing Principles Core to the Science
Darwin: Theory of Evolution
3 Birth of Science: Reworking of Taxonomy into Explanatory Categories
Modern Biological Classifications based on Genetics and Evolution
In the Natural History Phase, Domains of Clinical Science Grow Independently
Theory
Therapy
Instrumentation
List of Psychotherapies Psychotherap ies (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 Communicatio Communication n Object Relations Psy chotherapy Orgonomy Parent-Child Interaction Therapy (PCIT) Pastoral counseling/thera counseling/therapy py 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 Relational-Cu ltural 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 Transpersonall psychology Transpersona Twelve-step programs Unitive Psychotherapy Vegetotherapy
Principles of Reinforcemen Reinforcement Reinforcementt Millon’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
Familiar Easily Accepted
Less Familiar
Requires Comment
Passive-Detached Pattern PassiveDetached(Schizoid) Detached (Schizoid) Shy
Emotionally colorless
Seemingly insensitive to Seemingly emotions of others.
Devoid of affectionate needs.
Lack strong ambitions or motivation.
Active-Detached Pattern
Active-Detached(Avoidant) Active-Detached (Avoidant) Highly alert to the emotions of others.
Overstimulated by social Overstimulated engagement.
Low self-esteem.
Withdraws due to fears of social humiliation.
Avoidant PD Movie Mo vie
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 Passive-Amb ivalent Pattern Passive-Ambivalent (Compulsive) Overcontrolled, repressed.
Overly compliant to rules and regulations
Perfectionistic to the point of overwork.
Indecisive
Severe Personality Disorders Dependent
Independent
Detached
Ambivalent
Active
Histrionic
Antisocial
Avoidant
Negativistic
Passive
Dependent
Narcissistic
Schizoid
Compulsive
Severe Personality Pattern
Borderline
Paranoid
Schizotypal
Borderline or 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 Passive-detach ed = Schizoid = Negative Symptoms
Active-detached = Avoidant = Positive Symptoms
Schizoid Avoidant
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 personalitie personalities. s. 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 Prototypal 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-III Revised 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
C4 C7 C1
Near edge of prototype
C3
C2 C6 C5
Clinical Prototype
Narcissistic Personality: Prototypal versus Peripheral Items Prototypal Items (example)
5. I know know I’m I’m a supe superi rior or pers person, on, so I don don’t ’t car care e what people think.
26. Other people envy envy my abilities. abilities.
67. I have many ideas ideas that are ahead ahead of the times. times.
Peripheral Items (example)
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).
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 t he 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 to 137. I always see to it that my the exclusion of leisure activities and friendships (not work is finished before taking accounted for by obvious economic necessity). 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 Diagnostic Efficiency
Base Rate Scores, Sco res, 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, Sco res, 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, 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
GAF 100
90
80
Diagnostic Threshold
70
60
50
40
30
20
10
Nevertheless, Can be useful in Detecting Asymptomatic PDs
Can be useful in detecting asymptomatic PDs. Definition of Asymptomatic PDs Occurs 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 The Person (Axis II) Normal T h e S it
Normal
u a ti
o n
(A x is IV )
Abnormal
Abnormal
Little or no potential for an Personality Disorder: Axis I problem. Problems perceiving self and others. Imposes self onto environment and makes a normal situation into an abnormal one. Crazy Situation Potential for Maximal Adjustment Disorder: Pathology Person in a crazy situation Person with personality pathology in a situation that would cause problems for a normal person.
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 her,, and disinterest in sex. s ex. 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 Diagnosis Positive
Diagnosis Negative
Test Positive
True Positive (40)
False Positive (20)
Test Negative
False Negative
True Negative
Positive Predictive Power TP / All Test Positiv Positives es When the test is positive, what are the chances that the subject really has the diagnosis? 40 / 60 = 67%
What’s the PPP here?
Diagnosis Positive
Diagnosis Negative
Test Positive
True Positive (100)
False Positive (900)
Test Negative
False Negative
True Negative
Positive Predictive Power TP / All Test Positiv Positives es When the test is positive, what are the chances that the subject really has the diagnosis?
Diagnostic Efficiency: Sensitivity
Diagnosis Positive
Diagnosis Negative
Test Positive
True Positive (40)
False Positive
Test Negative
False Negative (40)
True Negative
Sensitivity TP / All Real Positives What percentages of people who have the condition are picked up by the test? 40 / 80 = 50%
What’s the Sensitivity here?
Diagnosis Positive
Diagnosis Negative
Test Positive
True Positive (50)
False Positive
Test Negative
False Negative (200)
True Negative
Sensitivity TP / All Real Positives What 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 Per sonality
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 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 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 Altruism (1971)
Parental Investment (1972)
Parent-Offspring Parent-Of fspring 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 Polarities Evolutionary
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, strategy, to reproduce the self over and over
Female strategy, strategy, to invest greatly in others.
Pleasure vs Pain Polarity
Pleasure vs. Pain Schizoid: Passive, low pleasure, low pain
Depressive: Passive, high pain, low pleasure
Avoidant: Active, high pain, low pleasure
Reversal of Pleasure and Pain Masochistic: Passive Reversal
Sadistic: Active Active Reversal
Self vs Other Polarity
High Other Dependent Personality: Passive, high other.
Histrionic: Active, high other.
High self Narcissistic: Passive, low other
Antisocial: Active, Active, low other
Self-Other Ambivale Ambivalence nce Compulsive:: Passive Compulsive
Negativistic: Active
From Toward a New Personology (1990)
Nothing new happened taxonomically No new personality constructs
Functional and Structural Domains Defense Mechanisms
Narcissistic Personality Self-Image Behavioral Acts
Object Representations Mood-Temperament
Cognitive Style
Interpersonal Conduct
Operationalize Personality Across its Major Domains Narcissistic Personality Haughty Expressive Behavior
Rationalization Insouciant
Regulatory Mechanism
Mood/Temperament
Exploitive
Admirable
Interpersonal Conduct
Self-Image
Contrived Expansive Cognitive Style
Object Representations
Spurious
Morphologic Organization
Narcissistic PD (See Packet for PD Descriptions) Functional Domains
Structural Domains
Expressively Haughty (e.g., acts in an arrogant, Admirable Self-Image (e.g., believes self to be meritorious, supercilious, pompous, and disdainful manner, flouting special, if not unique, deserving of great admiration, and acting conventional rules of shared social living, viewing them as in a grandiose or self-assured manner, often without naive or inapplicable to self; reveals a careless disregard for commensurate achievements; has a sense of high self-worth, personal integrity and a self-important indifference to the despite being seen by others as egotistic, inconsiderate, and rights of others). arrogant). Interpersonally Exploitive (e.g., feels entitled, is Insouciant Mood-Temperament (e.g., manifests a general air unempathic and expects special favors without assuming of nonchalance, imperturbability, and feigned tranquility; reciprocal responsibilities; shamelessly takes others for appears coolly unimpressionable or buoyantly optimistic, granted and uses them to enhan ce self and indulge desires). 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 Contrived Object-Relations (e.g., internalized imagination and exhibits a preoccupation with immature and representations are composed far more than usual of illusory self-glorifying fantasies of success, beauty or love; is and changing memories of past relationships; unacceptable minimally constrained by objective reality, takes liberties with drives and conflicts are readily refashioned as the need arises, facts and often lies to redeem self-illusions). as are others often simulated and pretentious). Rationalization Regulatory Mechanism (e.g., is selfdeceptive 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 reports Consider borrowing text from these functional and structural domains.
The Structure of the DSM:
Multiaxial Model Axis I: Classical Phenomenological Syndromes (e.g., Anxiety, 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 Psychopatholo Psychopathology gy Interaction of Axis IV and Axis II produces Axis I
Axis IV: Psychosocial Environment Axis II: Personality Disorders Axis I: Clinical Syndromes Anxiety, Depression = Fever, Cough, Boils
Histrionic, Sadistic = Immune System Marriage, Money = Infectious Agents
The shift to multiaxial conceptions resembles the shift that occurred in medicine a century ago.
Example: The Schizoid-Compulsive Accountant Mark S. worked quietly and efficiently for many years “crunching numbers” for a financial services company 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 c ompany 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, therapy, Mark had little l ittle 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 sev eral million in securities for a financial services serv ices 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 c ompany ladder. Although he was sometimes noted for his insensitivity, 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 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 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.. perpetuated
Specifically requires us to develop an integrative conception of the patient that transcends a list of diagnoses.
The Schizoid-Compulsive Accountant
Multiaxial Model: Establishes Causal Pathways of Psychopathology 1)
Axis IV: Psychosocial Environment
2)
Axis II: Personality Disorders Axis I: Clinical Syndromes 2
3)
1
4)
3 4
5)
5
What are the psychosocial (Axis IV) issues exerting stress through the current situation? Are these issues being “metabolized” by the personality structure? How is the individual reacting to awareness of their own clinical syndromes? (typically with increased rigidity,, further reducing range of coping rigidity responses) How is increased rigidity of personality feeding back on influencing the psychosocial situation? How are clinical symptoms influencing the psychosocial situation?
Multiaxial Model: Allows us to Understand Asymptomatic Asymptomatic Personality Disorders Recall that Axis I = Interaction of Axis II and Axis IV IV..
Axis IV: Psychosocial Environment
Axis II: Personality
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.
Without the Multiaxial Model… Multiaxial model specifically requires that we create an integrated conception of the individual’s psychopathology 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
BLAME
Violates 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
Axis IV
Axis II
Imagine having such diagrams for all the PDs
Anxiety Due to threats to validity of the grandiose self Depression Due to realistic feedback, grandiose self not so grand. Acting out Failure to regulate anger leading to verbal or physical aggression, even battering. Substance Use Reduces self-monitoring and intrusive thoughts related to self-blame.
Axis I
Valid alidity ity Scal Scale e
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 fr om midrange
Desirability Index (Y) Appear socially attractive, morally virtuous, emotionally well-composed
Debasement Index (Z) generally opposite of scale Y
High Y, Y, Low Z: Fake Fa ke good? goo d? 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 Personal ity Scales
BR > 75 suggests personality traits
BR > 85 suggests personality disorder
Clinical Scales
BR > 75 suggests presence of syndrome
BR > 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 diagnosis However,, PPP and SENS not perfect at BR 85 However
Always check MCMI-III profiles against diagnostic criteria Endorsements 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 II Comorbidity 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 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 DSMs
Schizotypal prevalence dropped from 11% to 1% from DSM-III to III-R
This 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 comorbidity 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 the se PDs exist…
Or are there other PDs specific to this culture?
Is it even ethical to assessment patients using American American norms?
Remember,, MCMI struggles with certain Remember c ertain disorders
Subtypes of Personality
Comorbidity is the Rule, not the Exception Exc eption Comorbidity exist because nature presents itself in few prototypes. Most human beings will be complex cases.
Functional and Structural Domains Grossman 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, Admirable Self-Image (e.g., believes self to be meritorious, supercilious, pompous, and disdainful manner, flouting special, if not unique, deserving of great admiration, and acting conventional rules of shared social living, viewing them as in a grandiose or self-assured manner, often without naive or inapplicable to self; reveals a careless disregard for commensurate achievements; has a sense of high self-worth, personal integrity and a self-important indifference to the despite being seen by others as egotistic, inconsiderate, and rights of others). arrogant). Interpersonally Exploitive (e.g., feels entitled, is Insouciant Mood-Temperament (e.g., manifests a general air unempathic and expects special favors without assuming of nonchalance, imperturbability, and feigned tranquility; reciprocal responsibilities; shamelessly takes others for appears coolly unimpressionable or buoyantly optimistic, granted and uses them to enhan ce self and indulge desires). 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 Contrived Object-Relations (e.g., internalized imagination and exhibits a preoccupation with immature and representations are composed far more than usual of illusory self-glorifying fantasies of success, beauty or love; is and changing memories of past relationships; unacceptable minimally constrained by objective reality, takes liberties with drives and conflicts are readily refashioned as the need arises, facts and often lies to redeem self-illusions). as are others often simulated and pretentious). Rationalization Regulatory Mechanism (e.g., is selfdeceptive 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
Expansive Cognitive Style
Believes self to be meritorious, special, if not unique, deserving of great admiration, and acting in a grandiose or self-assured manner, manner, often without commensurate achievements; has a sense of high self-worth, despite being seen by others as egotistic, inconsiderate, and arrogant. 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, 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 casefocused clinical report.
