JOURNAL OF ?SRSOKAi?TY ASSESSMENT, 1992, 56(1), 35-50 CopymgM c 1.392,Lawrence Eribaurn Associates Inc.
Empirically Derived Personality Subtypes of Public Psychiatric Patients: Symptoms, Evalu atian Q Emotion in Caregivers
Personaiirv scaies 02 the Miiim Ciin~caiFduitiaxiai Inventcry-11 (MCM1-11) for 195 peych:stric inpa~ients(93 men and i 02 women) ir: 2 public faciliq were dsster analyzeci ti> dei&p ar; empirical slibtynjng according :c persc;r,zii:y traits. Subjects aim canple~edthe B r i e f y ~ p t o minven:urg (RSI), Methods of Coping Scale (h/lL?Cj, arid the Levri of Expressed Emotion Scale ilEEi. The h e personality subtypes :hat emerged were consistenr across t w o ciustering ~ e r h o d s( K - m t a x and conplere hicage). Suhrypes members differed on subscales of :he BSI. MOC, and LEE. Results ssppor: the reievance o i personaiitv r a x s a n 3 disorders ir, assessing psyc:?opatho!ogy iri psvck:ia:ric patienrs. Resdts aiso scpport :hc rekvence of subtvplng these pa:ients accordins tc! MCMI-!I results.
The develop:nel-.t of t h e Diagnosiic and Statisticd Mama! fir ?dental Disordcn (3rd ed.: rev. [DSM-K-Rj; ,Arnericar. Psychiatric .4ssoiiarinr,, 1987) is considered by many r e represept n d e z r improvement over past nt:empts tc. provide useful diagnostic guidelines to cl,ir,icizns ( E r l e r &L i - r a x e s , 1985). A mzjor strength of the DSM-111-3 has beer: :he separztiora o i the current symptarr, picture, recorded o n Axis I, from t h e reiaciidy enduring ps::erns s f thozghts: feeiings. a n d b e t ~ a v i s rthat characterize aR inciiviciual's personatitg fcrnctioning, recorded o n Axis I1 (Millon, 1981; WiPiiams, !985).T h e separation hetween Axis I a n d Axis I1 was intended ro ensnre chat consderntior: is giver; r:c the possible
presence of lmportant charactenstm (personality or tralt patho1og-d that are irequentlv over'looked \.;hie attention 1s dlrected to the usualii- more flori3 Axis I disorder :Hyier & Frances. 1955: Sptzer, Sheehv, & Endicot:, 1977: 3 1 s d~st:ncaon 1s Important because maladaptwe personaIxv trs:cs rizv coexst w t h , predrspose co, or result from Axrs I c ~ n d ~ t ~ and o n s ma\ s!gilli~cantiv influence their presentation, coarse, managenear, and response t c rrearrnent (Wil!iams, 1989.Even ir: major psychiatric disorders, such as bipoia: disorder LAkiskal, 1984; Gaviria, Flaherty, 5: Val, 1982): schizophrenia (Gunderssn Sr Siever, 1985;Hoizman et ai., 1488;Kendier, Masterson?L'ngaro, &. Davis, 19843, and depression (McGlashsan, iS155:Pilkonis & Frank, i953, personaii:~differences influence the vuinerabi1i:v and resilience oiindiiduais at risk for development of che illness as well as Its specific expression, time of onset, long-term course, and qua!ity of Imermorbid acfjusrment (?io!man e: a:., I998; W:lhams, 1985). Despie the innovation of a mukiaxial approach, the pesence of persnnaliry pathoiogy is irequendy ignored in contemporarv psychiarric practice. partlcuIarly ifi inpatient settings (Waiton, 1966). '4s a resulrt potentiaI1~vital inforxariol: is often ignored that mav aid in the assessment and :rearmenr piarming process (Andreoli, Gressor, Aapro, Tricot, G; Gugnalons, 1439.In the piblic ps&atric system: for exampie, the failure ro adequately assess :he presence of personalicv dysfmction or rbe interaction between personality and Axis 1 conditions has been identified as a source of x m e r o u s complications and frusrracinns in the development and implenen:arion oi intervention strategies (Pepper & Rypiewicz, 1.384). This failure is partly due t o ccnfusion attributable t o the categsricai model of ciassikaticn empioyed for personaiity disorders :n thc DSM-III-R (Cioninger, 1981).Several srudies have found rhz: the majority o€psychia:ric pacients can be diagnosed with several personaiiry disorders (Dabro, K"etzier, & Kahri, 1985: Widige:, Frances, Warner, & Biuhm, !9C;S), leading m a y authors t c propose dimensional models of personalicy disorders wl:ich ~ o u i daccount for the substantial co\wiation aznong the disorders [Cloninger, 1987; Miion. !9El). T h s srudy represenrs an attempt to identi5 personality subc~pesempirically in a p b l i c inpatient psvchiarr::: population and to obrair: externa! daca ro assess the inplicarions of &type membership for variables related rc clinical assessment and treatment. T o identify subtypes ernpiricaih ir: a set of data, :he statistical procedure of cluster a n a h i s has become a widely accepted method {GroveSr Andreasen, 1986).This procedure can be emploced tc: idenc~S\.subset. of a larger data set ir. which members are more like each other than ltke r n e d x r s of another subset. Cluster analysis has bee:> empioved to estsSilsh usefuI subsets of \WIOUE psychiatric conditions such as depressior? and psychosis (Lox, !?ti@. Lorr and Strack (19931,in e cluster analvtic study of personality variabies r : psychiatric outpatients, found evidence for four ptentiailv usefzl persznaiitv subtypes. These included a group with prominenr antisocia!, sadistic, and
passive-aggressive rraits; a group with prominent avoidanr, schizoid, and seifdefeating traits; 2 grslrp with prominent dependenr and compulsiz~etraits; and a gro~ipwithout strmg discriminative clxracrer:s:ics. These differences were nor assodared ~vitk.,Axis I diagnosis and may hsve important inpiications for the presexaion of psvchiatric probiems and response to various treatrnem inrerventions. We chose to employ the h?C?d!-Ii as z measure of prrscnaliry because it is derwed from a dirnenjionai model of personality w:th promtypes that parallel rhe DSM-!I!-R categories. As extern.! correiates? we selected several variabies that should be of ciinicai import in pianriing and implementing treatmenr s~rategies,perciculariy those of an interpersonal nature, One variable was the patient pertep:ion of expresseii erno:mn emitted by s~gnificar:t others. Expressed e n o ~ i o nby significant other$ has been demcnsrrated tc. be associated with su:corr?es for. a variety of psych;I. Current p ~ ~ c h o p a t h o i o gisyreflected il-.terms of nine Frmarv syxptnm dimensions and a giobal index of pscct..iarric distress. i he BSI is an abbre\.iated i.ersii?s of the S p p r o m Check List-W-Revised (Derogatis, Rickels, Ei Rock, 19761. The SSI was chosen as a face-\did seif-repnrr inventor,i. of psvchiatric s y m p t o m a t o i o ~t o assess variation ir, self-reported symptoms according r c subrvpe membership. The BSI was chosen in p~eferenseip the accite s l q x c r n scales of the MCh&Il d;ce to intercorrelation betweeri pecsona'iiq and s y ~ q x ~ r ~ scales o n the h4Ch.ll-II. MOC Sale. The MQC Scale (Edwards, 19%) is a
Empirically Derived Personality Subtypes of Public Psychiatric Patients: Symptoms, Evalu atian Q Emotion in Caregivers
Personaiirv scaies 02 the Miiim Ciin~caiFduitiaxiai Inventcry-11 (MCM1-11) for 195 peych:stric inpa~ients(93 men and i 02 women) ir: 2 public faciliq were dsster analyzeci ti> dei&p ar; empirical slibtynjng according :c persc;r,zii:y traits. Subjects aim canple~edthe B r i e f y ~ p t o minven:urg (RSI), Methods of Coping Scale (h/lL?Cj, arid the Levri of Expressed Emotion Scale ilEEi. The h e personality subtypes :hat emerged were consistenr across t w o ciustering ~ e r h o d s( K - m t a x and conplere hicage). Suhrypes members differed on subscales of :he BSI. MOC, and LEE. Results ssppor: the reievance o i personaiitv r a x s a n 3 disorders ir, assessing psyc:?opatho!ogy iri psvck:ia:ric patienrs. Resdts aiso scpport :hc rekvence of subtvplng these pa:ients accordins tc! MCMI-!I results.
The develop:nel-.t of t h e Diagnosiic and Statisticd Mama! fir ?dental Disordcn (3rd ed.: rev. [DSM-K-Rj; ,Arnericar. Psychiatric .4ssoiiarinr,, 1987) is considered by many r e represept n d e z r improvement over past nt:empts tc. provide useful diagnostic guidelines to cl,ir,icizns ( E r l e r &L i - r a x e s , 1985). A mzjor strength of the DSM-111-3 has beer: :he separztiora o i the current symptarr, picture, recorded o n Axis I, from t h e reiaciidy enduring ps::erns s f thozghts: feeiings. a n d b e t ~ a v i s rthat characterize aR inciiviciual's personatitg fcrnctioning, recorded o n Axis I1 (Millon, 1981; WiPiiams, !985).T h e separation hetween Axis I a n d Axis I1 was intended ro ensnre chat consderntior: is giver; r:c the possible
presence of lmportant charactenstm (personality or tralt patho1og-d that are irequentlv over'looked \.;hie attention 1s dlrected to the usualii- more flori3 Axis I disorder :Hyier & Frances. 1955: Sptzer, Sheehv, & Endicot:, 1977: 3 1 s d~st:ncaon 1s Important because maladaptwe personaIxv trs:cs rizv coexst w t h , predrspose co, or result from Axrs I c ~ n d ~ t ~ and o n s ma\ s!gilli~cantiv influence their presentation, coarse, managenear, and response t c rrearrnent (Wil!iams, 1989.Even ir: major psychiatric disorders, such as bipoia: disorder LAkiskal, 1984; Gaviria, Flaherty, 5: Val, 1982): schizophrenia (Gunderssn Sr Siever, 1985;Hoizman et ai., 1488;Kendier, Masterson?L'ngaro, &. Davis, 19843, and depression (McGlashsan, iS155:Pilkonis & Frank, i953, personaii:~differences influence the vuinerabi1i:v and resilience oiindiiduais at risk for development of che illness as well as Its specific expression, time of onset, long-term course, and qua!ity of Imermorbid acfjusrment (?io!man e: a:., I998; W:lhams, 1985). Despie the innovation of a mukiaxial approach, the pesence of persnnaliry pathoiogy is irequendy ignored in contemporarv psychiarric practice. partlcuIarly ifi inpatient settings (Waiton, 1966). '4s a resulrt potentiaI1~vital inforxariol: is often ignored that mav aid in the assessment and :rearmenr piarming process (Andreoli, Gressor, Aapro, Tricot, G; Gugnalons, 1439.In the piblic ps&atric system: for exampie, the failure ro adequately assess :he presence of personalicv dysfmction or rbe interaction between personality and Axis 1 conditions has been identified as a source of x m e r o u s complications and frusrracinns in the development and implenen:arion oi intervention strategies (Pepper & Rypiewicz, 1.384). This failure is partly due t o ccnfusion attributable t o the categsricai model of ciassikaticn empioyed for personaiity disorders :n thc DSM-III-R (Cioninger, 1981).Several srudies have found rhz: the majority o€psychia:ric pacients can be diagnosed with several personaiiry disorders (Dabro, K"etzier, & Kahri, 1985: Widige:, Frances, Warner, & Biuhm, !9C;S), leading m a y authors t c propose dimensional models of personalicy disorders wl:ich ~ o u i daccount for the substantial co\wiation aznong the disorders [Cloninger, 1987; Miion. !9El). T h s srudy represenrs an attempt to identi5 personality subc~pesempirically in a p b l i c inpatient psvchiarr::: population and to obrair: externa! daca ro assess the inplicarions of &type membership for variables related rc clinical assessment and treatment. T o identify subtypes ernpiricaih ir: a set of data, :he statistical procedure of cluster a n a h i s has become a widely accepted method {GroveSr Andreasen, 1986).This procedure can be emploced tc: idenc~S\.subset. of a larger data set ir. which members are more like each other than ltke r n e d x r s of another subset. Cluster analysis has bee:> empioved to estsSilsh usefuI subsets of \WIOUE psychiatric conditions such as depressior? and psychosis (Lox, !?ti@. Lorr and Strack (19931,in e cluster analvtic study of personality variabies r : psychiatric outpatients, found evidence for four ptentiailv usefzl persznaiitv subtypes. These included a group with prominenr antisocia!, sadistic, and
passive-aggressive rraits; a group with prominent avoidanr, schizoid, and seifdefeating traits; 2 grslrp with prominent dependenr and compulsiz~etraits; and a gro~ipwithout strmg discriminative clxracrer:s:ics. These differences were nor assodared ~vitk.,Axis I diagnosis and may hsve important inpiications for the presexaion of psvchiatric probiems and response to various treatrnem inrerventions. We chose to employ the h?C?d!-Ii as z measure of prrscnaliry because it is derwed from a dirnenjionai model of personality w:th promtypes that parallel rhe DSM-!I!-R categories. As extern.! correiates? we selected several variabies that should be of ciinicai import in pianriing and implementing treatmenr s~rategies,perciculariy those of an interpersonal nature, One variable was the patient pertep:ion of expresseii erno:mn emitted by s~gnificar:t others. Expressed e n o ~ i o nby significant other$ has been demcnsrrated tc. be associated with su:corr?es for. a variety of psych;I. Current p ~ ~ c h o p a t h o i o gisyreflected il-.terms of nine Frmarv syxptnm dimensions and a giobal index of pscct..iarric distress. i he BSI is an abbre\.iated i.ersii?s of the S p p r o m Check List-W-Revised (Derogatis, Rickels, Ei Rock, 19761. The SSI was chosen as a face-\did seif-repnrr inventor,i. of psvchiatric s y m p t o m a t o i o ~t o assess variation ir, self-reported symptoms according r c subrvpe membership. The BSI was chosen in p~eferenseip the accite s l q x c r n scales of the MCh&Il d;ce to intercorrelation betweeri pecsona'iiq and s y ~ q x ~ r ~ scales o n the h4Ch.ll-II. MOC Sale. The MQC Scale (Edwards, 19%) is a
