Journal o f Clinical PsycholoD, in Medical Settings, Vol. 1, No. 2, 1994

Personality Disorder Correspondence Between the Millon Behavioral Health Inventory (MBHI) and the Minnesota Multiphasic Personality Inventory (MMPI) Edward A. Wise 1,2

The MBHI and MMPI personality disorder scales were analyzed for convergent and discriminant validity. Correlational data demonstrated that six of the eight scales were significantly related, while the remaining two scales approached significance. Further analyses of these data, however, demonstrated that none of the scales correlated significantly better with its convergent scale compared to nonconvergent scales. The MBHI classified significantly more of the sample as personality disordered (93%) compared to the MMPI personality disorder scales (17%). Furthermore, the MBHI tended to describe the sample as falling within the Anxious cluster of personality disorders, whereas the MMPI described them within the Dramatic cluster. Single scale codetype correspondence was found to be 15%, while two-point concordance was 12.5%, indicating very low congruence between personality style codetypes. These two measures do not appear to be measuring the same personality style constructs. KEY W O R D S : personality disorder; Millon Behavioral Health Inventory; Minnesota Multiphasic Personality Inventory; coping style; validity.

INTRODUCTION

Since the advent of the Diagnostic and Statistical Manual-Ill (1980), numerous instruments have been devised in an effort accurately to detect 1Mental Health Resources and University of Tennessee, Center for Health Sciences, Psychiatry Department, Memphis, Tennessee. 2To whom correspondence should be addressed c/o Mental Health Resources, 5575 Poplar Avenue, Suite 613, Memphis, Tennessee 38119. 167 I068-9583/94/0600~0167507,00/0© i994 Plenum PublishingCorporation

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and describe personality disorders (e.g., Coolidge, 1984; Hyler, 1983; MilIon, 1982, 1983; Morey, Waugh, & Blashfield, 1985; Widiger & Frances, 1987). Interestingly, however, no attempts to validate the personality coping styles as measured on the Millon Behavioral Health Inventory (MBHI) could be located in the literature. This is in contrast to the Minnesota Multiphasic Personality Inventory (MMPI), which has been compared to numerous other instruments (e.g., Dubro, Wetzler, & Kahn, 1988; Holliman & Guthrie, 1989; McCann, 1989; Morey, 1986; Widiger & Sanderson, 1987). More specifically, Morey et al. (1985) selected items from the original MMPI item pool that were judged to be consistent with the 11 DSM III (APA, 1980) personality disorder criteria. Items were then selected based on their ability to discriminate between high and low scores on a given personality disorder scale. The resulting MMPI personality disorder scales are comprised of 164 items, and all but 7 of these have been retained for future use on the MMPI-2 (Bagby, 1990). Morey et aL (1985) demonstrated that most of these personality disorder scales correlated well with the original MMPI clinical scales, given the DSM III descriptions of the disorders. For example, the Avoidant (AVD) personality disorder scale correlated with the MMPI Social Introversion (.89), Psychasthenia (.71), and Depression (.63) scales in a manner consistent with social anxieties and depression. This result also corresponds with the 2-7-0 codetype believed to characterize the Avoidant personality. Similarly, the Antisocial (ANT) personality disorder scale correlated with the Psychopathic Deviancy scale at .52 and the Mania scale at .57, a finding consistent with the 4-9 profile typically found with antisocial personalities. The Paranoid (PAR) personality disorder scale was correlated with the MMPI clinical scales tapping profound mistrust of others and psychotic thought processes (Paranoia, .68; Schizophrenia, .75). The Dependent (DEP) personality disorder scale was associated with anxiety (Psychasthenia, .60) interpersonal discomfort (Social Introversion, .54), and unhappiness (Depression, .47). Similarly, as one would expect, the Compulsive (COM) personality disorder scale correlated highly with Psychasthenia (.57). Interestingly, the Passive Aggressive (PAG) personality disorder scale correlated highly with the Schizophrenia (.75) and Paranoid (.68) scales, suggesting rather severe pathology accompanied by resentment, anger, and mistrust; also noteworthy was the correlation with Psychopathic Deviancy (.38), further suggesting unresolved anger and character problems. The Schizoid (SCZ) personality disorder scale was correlated with Social Introversion (.64), Schizophrenia (.36), and Psychasthenia (.30), a pattern describing a lack of interest in relating to others, impaired cognitive processes, rumination, and self-absorption. Morey found that the Histrionic

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(HST) personality disorder scale correlated negatively with MMPI Hysteria Scale (-.20), a finding consistent with Millon's (1983) work comparing the Millon Clinical Multiaxial Inventory (MCMI) and the MMPI. Both authors explained these negative results by stating that the DSM-III construct of Histrionic Personality is quite different from the traits measured by the MMPI Hysteria scale. Furthermore, the HST scale correlated -.73 with Social Introversion, -.47 with Depression, and .30 with Mania. Hence, it appears that HST is associated with gregariousness, denial of depression, and an energetic presentation. Similarly, the Narcissistic (NAR) personality disorder scale was associated with an expansive mood (Mania, .44), extraversion (Social I n t r o v e r s i o n , - . 6 2 ) , and an inverse relationship with Depression (-.58). A number of additional studies have further demonstrated the validity, reliability, and stability of the MMPI personality disorder scales (e.g., Hurt, Clarkin, & Morey, 1990; McCann, 1989; Morey, 1986; Morey, Blashfield, Webb, & Jewell, 1988; Morey & Le Vine, 1988; Smith, Cantrell, & Fuller, 1988; Streiner & Miller, 1988). The lack of validity studies on the Coping Style Scales of such a farreaching instrument is not without reason. More specifically, the lack of hand scoring materials for the MBHI, coupled with the commercial cost of processing the results, may partially be responsible for the lack of validation research on these scales. Furthermore, in their recent review of the ]iterature, Craig and Weinberg (1993) found 10 studies in which the Millon Clinical Multiaxial Inventory (MCMI) was used with a diversity of medical populations, despite the existence of the MBHI. From a clinical practice standpoint, it would appear that clinicians are more familiar with the MCMI and with its comparatively large research base, which may lead them to choose the MCMI over the MBHI. The lack of research on the Coping Style Scales may also be attributable to the fact that most readers of the MBHI manual (Millon, 1982) have concluded that the test was entirely developed for, normed on, and validated with medically ill patients. Millon (1982) states in the manual, however, that the MBHI eight Coping Style scales were "derived" from Millon's theory of personality" (p. 1). While the MBHI Coping Style scales were developed for medical patients, they are nonetheless constructs derived from Millon's personality theory, just as the MCMI personality disorder scales were, and are applied to medical populations. In contrast, the Psychogenic Attitudes, Psychosomatic, and Prognostic scales were, in fact, developed specifically for medical patients. Under the heading "Development of the Coping Style Scale Items," MiUon (1982) further states that "medical populations were n o t included in the evaluation phase" of the items that came to be known as the Coping Style scales (p. 24; italics added). Unlike the repetitive explicitness with which Millon indicates that the test development sample was

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derived from medical settings, there is no mention that the sample used for validation purposes, those who completed the MBHI, MMPI, Symptom Check List 90 (SCL), California Personality Inventory (CPI), etc., were actually medical patients. Furthermore, the only validation the Coping Style Scales have received to date were those cited in the manual and one subsequent study by Wise (1994). Wise (1994) reported that despite the fact that both the MBHI and the MCMI are measures of Millon's theory of personality, they demonstrated significant variability between paired mean scores on the personality disorder and Coping Style Scales, extremely poor codetype correspondence, unique factor structures, and relatively low convergent and discriminative validity. He concluded that the two instruments did not produce equivalent measures of personality style and demonstrated less than adequate psychometric validity. With respect to the validation of the MBHI Coping Style Scales, Millon (1982) stated that traditional psychological tests "do provide some index of convergent validity of the scale being measured" (p. 27) and proceeded to utilize a number of clinical scales to validate MBHI coping style constructs, including the MMPI, CPI, SCL, etc. It appears, however, that the MBHI Coping Style Scales should demonstrate their highest levels of validity in comparison to other personality disorder measures. None of the instruments originally utilized to establish the validity of the MBHI Coping Style Scales, however, contained personality disorder measures. Hence, it appears that other than Wise's previously mentioned study, the Coping Style scales have not been validated against other measures of personality style. Although Morey's scales were empirically derived to measure DSMIII personality disorders, eight of these scales (Schizoid, Avoidant, Dependent, Histrionic, Narcissistic, Compulsive, Antisocial, and Passive Aggressive) appear to correspond to the basic eight Coping Style Scales found on the MBHI (Introversive, Inhibited, Cooperative, Sociable, Confident, Respectful, Forceful, and Sensitive). Millon has stated that the "eight basic coping styles are derived from Millon's theory of personality" (MBHI, p. 1), just as the MCMI scales were "constructed as an operational measure of syndromes devised from a theory of personality and psychopathology" (Millon, 1969, 1981). Similarly, in addressing the question of interpreting the MBHI personality Coping Style Scales (MBHI, p. 12), MilIon refers the reader to his texts (1969, 1981), in which he describes prototypical personality styles. There can be little doubt that Millon int e n d e d both the MCMI and the MBHI to m e a s u r e the constructs associated with his theoretical prototypical personality styles. Speaking with reference to the MCMI, Millon (1986) has stated that the theory underlying his test "provide(s) reasonable approximations (to) the DSM-III" personality disorders in that the DSM-III measures "the

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manifest structure of psychopathologic taxa, (while) the theory underlying the MCMI (measures) the latent structure of Axis II taxa . . . . (Hence,) the MCMI demonstrates commensurate levels of correspondence to the extent that the DSM-III and (Millon's) theory overlap in their conceptual and clinical categories" (p. 205). He goes on to state that "the MCMI was never promulgated as a measure of the DSM-III, but there were sufficient parallels between their criteria to recommend certain diagnostic assignments" (p. 206). To the extent that the MBHI is also a measure of Millon's theory of personality, and hence the "latent structure of Axis II taxa," it seems that the MBHI would also provide a "reasonable approximation" to the DSM-III "manifest structure of psychopathologic taxa." Thus, the MBHI should lend itself to being appropriately evaluated in comparison to other inventories measuring the DSM-III personality disorders, as has been the case with the MCMI. No comparative studies of the MBHI personality disorder scales were found. Furthermore, there were no MBHI studies that included a personality codetype analysis, despite the fact that most authors agree that few individuals manifest personality disorders in "pure" forms [American Psychiatric Assocation (APA), 1980; Choca, Shanley, & Vandenburg, 1992; Gunderson, Links, & Reich, 1990; Livesley, 1991; Millon, 1981; Schwartz, Wiggins, & Norko, .1989; Widiger & Frances, 1985a, b; Widiger, 1991; Wiggins & Pincus, 1989] and that a single personality disorder is less common than multiple ones (Reich, 1987; Tryer, 1988; Widiger & Rogers, 1989). Clinicians examining test data on a case-by-case basis typically rely on a configural approach to elucidate an individual's personality structure, thereby integrating apparent contradictions and inconsistencies (e.g., Butcher, Dahlstrom, Graham, Tellegen, & Kemmer 1989; Choca et aL, 1992; Mitlon, 1981). In light of the lack of research on the validity of the MBHI Coping Style scales, the present study was undertaken. More specifically, the present research was conducted to further assess the construct, discriminative, and concurrent validities of the MBHI Coping Style scales. The study examines correlational and frequency data, as well as codetype correspondence, between the MBHI and the MMPI personality disorder scales in an inpatient setting.

METHOD

Subjects In large general hospitals it is quite common for patients admitted to a psychiatric unit to exhibit numerous physical symptoms and syndromes (e.g., chest pain, heart palpitations, hyperventilation, gastrointestinal dis-

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tress, lupus, diabetes, arthritis, mitral valve prolapse, headaches, etc.) (Mayou, 1991; Kiesler, 1991). Similarly, in the present setting patients are typically first seen by their physicians in the office, on a medical unit, or in the emergency room, where their presenting physical symptoms may coexist with psychological disorders that often exacerbate their physical maladies. If appropriate, they are transferred to the psychiatric unit when medically stable. It should be noted that although this hospital does not have a specific medical-psychiatric unit, there was an unsuccessful bid to designate such a unit in light of the large number of medical-psychiatric patients treated. As a compromise, the psychiatric unit was renamed the "Behavioral Health" unit, to reflect the philosophy that problems of both behavior and physical health were treated on the unit. Subsequently, medical-psychiatric patients continue to be admitted to the Behavioral Health unit, along with the more typical psychiatric patients found on an open adult unit. Hence, many of the patients present with comorbid physical and psychological disorders. These data were based on 100 selected admissions to an open adult psychiatric inpatient unit in a large, general hospital of approximately 1000 beds located in a metropolitan area of the southeastern United States. As indicated above, these patients typically first presented to their physicians and were then referred for psychiatric consultation that included an initial psychological screening evaluation. Patients who presented with medical complaints or who were transferred from medical floors were included in the study. Those patients whose primary diagnoses involved organic brain syndromes, psychoses, alcohol, or drugs were not included in the study.

Procedure

Each individual was given a screening battery of objective, paper-andpencil, psychological tests within 72 hrs. of admission that included the Shipley Institute of Living Scale (SILS), MBHI, and MMPI. Incomplete SILS, invalid MBHI (V > 2) and MMPI (F > 100) protocols were automatically omitted from the study, resulting in an N = 72. [While F > 100 may appear excessively high, it should be noted that 12 subjects were omitted based on this criteria, thereby indicating that this cutoff score effectively eliminated the more extreme protocols. Furthermore, including elevations on the F scale would appear to meet the DSM-III criteria of "subjective distress" necessary to make a personality disorder diagnosis (APA, 1980, p. 305).] On the MBHI, a scale was considered elevated if the Base Rate (BR) was > 74, the cutoff established that indicates a subject possesses, to some

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clinically significant degree, the trait or disorder assessed. Patients with a BR > 84 are believed to demonstrate the assessed characteristic as a prominent or dominant feature of the clinical presentation. Similarly, on the MMPI, a scale was considered elevated if T > 69 according to the Colligan, Osborne, Swenson, and Offord (1983) norms. The MMPI overlapping items were used, as Morey (1985) found them to be more reliable than the nonoverlapping items and also reported that the median correlation between the overlapping and the nonoverlapping scales was .95. McCann (1989) has also observed that the overlapping scales tended to optimize concordance rates. The well-known and widely accepted methodology for evaluating convergent and discriminative validity described by Campbell and Fiske (1959) was utilized. Essentially, this method states that the correlation between two measures of the same construct (convergent validity) should be greater than the association between measures of different constructs (discriminative validity). The correlations between convergent or complementary scales were further evaluated by means of Hotelling's t tests to determine whether the correlations between the convergent scales were significantly greater than the correlations with nonconvergent or noncomplementary scales. Both MBHI and MMPI personality disorder scales were also analyzed for codetypes. The codetype assigned was the single highest scale and the two highest scales. In cases where the third or subsequent scale was equal to the score of the second scale in the codetype, the case was coded as concordant when possible. If codetype concordance was not possible, the scale with the lowest number was coded first. Scales were defined as concordant or matching if each had the same single scale elevation or the same two most highly elevated scales in either order (i.e., 1-2 or 2-1). Data were coded, tabulated, and analyzed by use of Number Cruncher Statistical Software (NCSS), a commercial statistical software package (Hintze, 1991).

RESULTS The sample (N = 72) may be described as predominantly white (71%; N = 58) females (69%; N = 50). The average age was 47, ranging from 18 to 83, with 78% of the sample falling between 18 and 64 years of age. The average number of years of education in this sample was 12.76 (SD = 2.04). Approximately one-third (36%) attended 13 or more years of school. The average Shipley IQ (Zachary, 1986) was 97 (SD = 15.95), falling within the average range of intelligence. There were no significant differences among SIQ, years of education, and sex or race.

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Although psychiatric epidemiological studies are somewhat controversial, this sample is consistent with previous literature reviews that show a preponderance of whites, women, and those between 18-64 years of age in psychiatric private treatment settings (Goldman & Ravid, 1980; Hafner, 1986; Kessler, Brown, & Boroman, 1981; Myers et al., 1984; Weissman & Klerman, 1977). These findings are also comparable to national figures [National Institute of Mental Health (NIMH) 1990] reflecting the age (18-64 years, 70.53%) and racial (white, 76.3%) compositions of psychiatric inpatients in nonfederal general hospitals. The present sample may be slightly overly representative of females compared to the NIMH data (56.9%) but, nonetheless, is consistent with the epidemiological trends cited above for women to be disproportionately represented in private psychiatric treatment settings. Finally, a review of the medical record following discharge demonstrated that 93% (n = 67) of the sample had comorbid medical and psychiatric diagnoses. By far, the most frequent primary psychiatric diagnoses were related to depressive disorders (93%), with 3% of the sample having been diagnosed with anxiety disorders and 4% as other (e.g., conversion disorders, somatoform disorders, etc.). Among the medical diagnoses, 46% of the sample were classified as diseases of the circulatory system (e.g., coronary artery disease, ischemia, hypertension, mitral valve prolapse, etc.), 15% had diseases of the bones, muscles, and joints (e.g., arthritis, herniated disk, lumbar pain, etc.), 11% had respiratory ailments, 7% had endocrine disorders (e.g., diabetes, amenorrhea, etc.), and 8% had diseases of the digestive system. Table I demonstrates that six of the eight diagonal correlations comparing the complementary MBHI and MMPI personality disorder scales are significant (r = .18-.61; Mx =.37). Additionally, of the two scales that are not significantly related (Introversive × Schizoid and Forceful × Antisocial), both approach significance. These data tend to support the hypothesis of construct and convergent validation between these two instruments. The average correlation (.37) explains only 14% of the variance between the two instruments. In fact, the highest obtained correlation of .61 between the Inhibited and the AVD scales accounts for only 37% of the variance between the two scales, leaving 63% unexplained or attributable to factors other than the converging scales. The range of variances between the converging scale correlations indicates that 63% (.622 - 1) to 97% (.18 z -1) of the convergent scale correlations are explained by factors other than the complementary scales. The average correlation also results in an index of predictive efficiency (Peatman, 1947, p. 459; McNemar, 1969, p. 141) that demonstrates a reduction in the error of estimate by only 7%

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MBHI-MMPI Personality Disorder Correspondence Table I. Pearson Correlations Between M M P I and M B H I Personality Styles* MMPI MBHI

SCZ

AVD

DEP

HIS

NAR

ANT

COM

PAG

.18

.44

-.03

-.44

-.32

-.10

-.10

.26

Inhibited

-.28

.61

.25

-.60

-.62

-.27

-.09

.58

Cooperative

-,43

.53

.25

-.45

-.58

-.23

-.17

.59

Sociable

-.09

-.42

-.25

.48

.41

.34

-.01

-.28

.13

-.40

-.39

.35

.47

.40

.16

-.32

Forceful

-.36

.22

-.11

-.20

-.06

.19

-.21

.42

Respectful

-.51

.35

.18

-.40

-.31

-.07

.22

.49

.35

-.15

-.37

-,16

.21

.02

.58

Introversive

Confident

Sensitive

.58

*N = 7 2 ; r > .20 = p

< . 0 1 ; r > .27 = p

< .005.

(range, 1.6 to 20.8%). That is, when a score on one scale is used to predict the complementary scale score, the predictive efficiency is improved only by an average of 7% better than a sheer guess (zero correlation). Further analysis of these correlations reveals some discrepant findings regarding the convergent and discriminative correlations. For example, comparing the correlation between the MBHI Introversive scale and the complementary MMPI SCZ scale by means of Hotelling's t test (Guilford & Fruchter, 1973, p. 167) indicates that the MBHI Introversive scale correlates significantly better with the MMPI AVD scale [t(69) = 2.48;p < .05] despite the fact that its complement is the SCZ scale. Similarly, the MMPI SCZ scale is significantly more correlated with the MBHI Sensitive scale than it is with the convergent Introversive scale [t(69); = 13.50, p < .05]. Also, the converging correlation between the MMPI SCZ scale and the MBHI Introversive scale (.18) is not significantly greater than the discriminate correlation between the SCZ scale and the Confident scale (.13) [t(69) = 13.50; p < .05]. Similar findings exist for both instruments and can be demonstrated for all of the scales involved. These findings suggest that these personality disorder scales demonstrate poor convergent and discriminative validity. Furthermore, the instruments classified subjects significantly differently with respect to the presence or absence of pathology. That is, analysis of these data by T and BR scores indicates that the MMPI classified only 17%

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(n = 12) of the sample as personality disordered ( T > 69), while the M B H I (BR > 74) classified 93% (n = 67) as personality disordered (Fisher's exact probability < .01). This finding indicates that there are significant differences in the classification rates between these two instruments. Table II depicts the high-point frequencies by scale. There, it is evident that significant disparities exist between the instruments with respect to their descriptions of the sample. T h e most frequent high points on the M B H I are on the Inhibited (29%; p < .01) and Respectful (18%; p < .01) scales, whereas they are on the Histrionic (31%; p < .01), Narcissistic (18%; p < .01), and D e p e n d e n t (18%) scales for the MMPI. Table II also demonstrates ~hat the instruments are significantly different in that the M B H I tends to describe the sample as falling primarily within the Anxious cluster, whereas the M M P I classifies them as falling within the D r a m a t i c cluster (Z2 (2) = 25.40; p < .0001). These findings further support the notion that there are, in fact, significant differences in the classification rates between these two instruments.

Table 11. High-Point Frequencies and Percentages MMPI f

MBHI %

f

%

Scale 8

11.11

9.7*

21

29.17

13

18.06

10

13.89

4

22

30.56*

2

2.78

5

13

18.06'

2

2.78

6

3

4.17

6

8.33

7

3

4.17"

13

18.06

8

4

5.56

10

13.89

38 27 7

52.78 37.50 9.72

10 54 8

13.89 75.00 11.11

1

7

9.7

2

7

3

Cluster Dramatic Anxious Odd

:/2(2) = 25.40; p < .0001 *Fisher's exact p < .01.

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Codetype correspondence between the two instruments is also quite low. In fact, single-scale codetype correspondence between the MBHI and the MMPI personality disorder scales was approximately 21%, whereas twopoint correspondence was an even lower 12.50%. The frequencies of high-point and two-point correspondence were so low that any scale specific interpretations are precluded. It is evident, however, that 75% of the single scale high-point matches and 66% of the two-point codetype matches were within the Anxious and Dramatic clusters, respectively.

DISCUSSION The MBHI and MMPI personality disorder scales demonstrate significant positive relationships for six of the eight scales, while the remaining two scales approached significance. This result appears to provide some evidence in support of construct validation between these measures. However, further examination indicates that none of the correlations between converging scales significantly differentiated themselves from the other nonconverging scales, suggesting that the scales are not clearly defined and do not significantly discriminate one category from another. Additionally, the MBHI tended to classify individuals as personality disordered significantly more often than the MMPI. The MBHI also described the sample as falling primarily within the Anxious personality cluster, whereas the MMPI described them as significantly more Dramatic. As one might subsequently expect, codetype correspondence between the personality disorder scales was quite low, indicating a lack of dimensional agreement in addition to the poor categorical concordance noted above. Clearly, these scales do not appear to be measuring comparable categories or dimensions of personality based on these findings. Given the discrepancy between the correlational data and the subsequent findings, it appears that correlations may be necessary to establish convergent and discriminative validity, but they are not always sufficient. That is, categorical assignments, cluster classification rates, and c o d e t y p e analyses provide additional validity information that can also be readily used by the practicing clinician. As indicated earlier, both the MCMI and the MBHI personality disorder scales are hypothesized to measure personality constructs derived from Millon's theory (1981). When the MCMI and MBHI were analyzed together, however, Wise (1994) demonstrated poor codetype correspondence, significant variability between paired mean scores, inconsistent correlational data, and unique factor structures. He concluded that the two instruments did not produce equivalent measures of personality style and demonstrated less than adequate psychometric concurrent and discrimina-

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tive validity. Now the MBHI has demonstrated similar results when compared to the MMPI personality disorder scales, which were devised to reflect DSM-III personality constructs. While there is no "gold standard" by which to measure personality disorders, one must wonder, "What, exactly, are the MBHI Coping Style scales measuring?" Although this is ultimately an empirical question, it is clear that Millon's (1982) intention was for the MBHI to measure his theory of personality, which parallel the latent structure of the DSM-III criteria. This may be asking too much from eight scales comprised of 64 overlapping items. Despite the fact that only 8 of 20 MBHI scales were evaluated, it is believed that the discrepant findings reported herein have significant implications. Such low concurrent and discriminative validity argues against the possibility of relying solely upon the MBHI or MMPI personality profiles to formulate a clinical composite from which to base treatment recommendations. Utilizing either the MBHI or the MMPI personality disorder scales to formulate an understanding about an individual's unique personality structure from which to derive a treatment plan, one could only expect to replicate the single- or two-point codetype approximately 10-20% of the time! Hence, interpretations derived from these codetypes would also be expected to demonstrate low levels of validity. Subsequently, treatment based on these results alone, such as in the case of a psychological screening evaluation, would most likely be inapplicable to an individual's primary personality difficulties. Similarly, in evaluating medical patients such as coronary bypass or transplant candidates for suitability, predictions of postoperative adjustment based on personality style are of considerable importance in educating the treatment team about anticipated problems and potential solutions (e.g., Allender, Shisslak, Kaszniak, & Copeland, 1983; Hecker, Norvell, & Hills, 1989; Kilpatrick, et al., 1975; Henrichs & Waters, 1972). Relying on elevated MBHI codetypes, however, one would match the MMPI singleor two-point codetypes less than 20% of the time. Research designed to study the concordance of MBHI personality types with external criteria such as structured interview or self-report questionnaires, as has been carried out with the MMPI, could further elucidate the nature of the relationships between these two instruments. Research analyzing the congruence among the Millon Adolescent Personality Inventory (MAPI), MCMI, and MBHI codetypes would also prove helpful in clarifying the relationships among these instruments, which are all based on Millon's theory. Comparisons of MBHI and MMPI-2 codetypes, perhaps with independent criteria such as interviews or other objective tests, could further elucidate the comparative accuracy of these instruments with re-

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spect to their Axis II classification rates. The availability of hand scoring materials for the MBHI would facilitate research with these instruments. It should be noted that one limitation of the present study is the low number of blacks (N = 21), as well as males (N = 28), that comprised the sample. In this regard, further research observing the effects of race, sex, and age on codetype correspondence is also suggested. The development of African American and Hispanic norms for the MBHI, such as those available for use with the MCMI, is also worthy of further exploration. On the basis of these results, the MBHI and MMPI personality diso r d e r scales do not appear to be measuring the same constructs. Subsequently, caution is urged in using one of these instruments as a substitute for the other as far as measuring enduring personality characteristics, basic coping styles, or personality disorders is concerned. That is, even with the same population, the MBHI and MMPI high-point codetype concordance is only 12-20%. These instruments do not appear to produce equivalent measures of personality style and hence demonstrate less than adequate psychometric construct, convergent, and discriminative validity when personality style scales are analyzed by frequency, correlational, and codetype data.

REFERENCES Allender, J., Shisslak, C., Kaszniak, A., & Copeland, J. (1983). Stages of psychological adjustment associated with heart transplantation. Heart Transplantation, 2(3), 228-231. American Psychiatric Assocation (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington, DC: American Psychiatric Press. Bagby, R. M. (1990). Status of the MMPI personality disorder scales on the MMPI2. MMPI-2: News and Profiles, 1, 8. Butcher, J., Dahlstrom, W., Graham, J., Tellegen, A., & Kaemmer, B. (1989). MMPI-2 mantlal for administration and scoring. University of Minnesota Research: Minneapolis. Campbell, D,, & Fiske, D. (1959). Convergent and disc riminant validation by the multitrait-multimethod matrix. Psychological Bulletin, 56, 81-105. Choca, J,, Shanley, L., & Vandenburg, E. (1992). Interpretative guide to MUlon Clinical Muttiaxiat Inventory. Washington, DC: American Psychological Association. Colligan, R. C., Osborne, D., Swenson, W. M., & Offord, K. P. (1983). The MMPI: A contemporary normative study. New York: Praeger. Coolidge, F. L, (1984). Coolidge Axis H Inventory. U.S. Copyright TXU 182-026, Washington, DC. Craig, R. J., & Weinberg, D. (1993). MCMI: Overview of the literature. In R. J. Craig (Ed,), The Millon Clinical Multiaxial hzventory: A clinical research hlformation synthesis (pp. 23-70). Hillsdale, N J: Lawrence Erlbaum Associates. Dubro, A. F., Wetzler, S., & Kahn, M. W. (1988). A comparison of these self-report questionnaires for the diagnosis of DSM III personality disorders. Journal of Personality Disorders, 2(3), 256-266. Gatchel, R. J., Deckel, A., Weinberg, N., & Smith, J. E. (1985). The utility of the MBHI in the study of chronic headache. Headache, 25(1), 49-54.

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