Reassessing the validity and reliability of the MMPI Alexithymia Scale.

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Reassessing the Validity and Reliability of the MMPI Alexithymia Scale R. Michael Bagby , James D.A. Parker & Graeme J. Taylor Published online: 10 Jun 2010.

To cite this article: R. Michael Bagby , James D.A. Parker & Graeme J. Taylor (1991) Reassessing the Validity and Reliability of the MMPI Alexithymia Scale, Journal of Personality Assessment, 56:2, 238-253, DOI: 10.1207/s15327752jpa5602_5 To link to this article: http://dx.doi.org/10.1207/s15327752jpa5602_5

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JOURNAL OF PERSONALITY ASSESSMENT, 1991, 56(2), 238-253 Copyright @ 1991, Lawrence Erlbaum Associates, Inc.

Reassessing the Validity and Reliability of the MMPI Alexithymia Scale R. Michael Bagby Clarke Institute of Psychiat y and University of Toronto

Downloaded by [New York University] at 23:53 10 January 2015

James D. A. Parker York University

Graeme J. Taylor Mount Sinai Hospital and University of Toronto

In the past decade, alexithymia has emerged as a heuristically useful personality construct used to explain the pathogenesis of a variety of physical illnesses, including classical psychosomatic diseases, somatization disorders, hypochondriasis, and somatoform pain disorders. Unfortunately, research evaluating the alexithymia construct has been conducted with little attention to assessing the psychometric properties of various scales used to measure it. In two separate studies, we examined various scale and item properties as well as the factor structure and validity of the Minnesota Multiphasic Personality Inventory Alexithymia Scale (MMPI-A), one of the most commonly used scales to assess alexithymia. In Study 1, the 22 items that comprise the MMPI-A were extracted &om a computerized MMPI data bank which included separate samples of psychiatric inpatients and outpatients. Poor item-to-scale characteristics and only moderate levels of internal reliability were found for both samples. Factor analysis produced factors that were poorly related to the theoretical domains of the alexithymia construct. In Study 2, we found little support for validity of the scale as those patients identified as alexithymic and nonalexithymic by the MMPI-A did not differ on several theoretically relevant scales. These results question seriously the value of the MMPI-A in investigating the alexithymia construct.

O v e r t h e past few years, a n increasing number of researchers have begun t o reexamine t h e relationship between personality variables a n d physical illnesses


REASSESSING THE MMPI-A

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(Friedman & Booth-Kewley, 1987; Holroyd & Coyne, 1987). Individual differences on personality factors, such as explanatory style (Peterson & Seligman, 1987), hostility (Williams et al., 1980), and neuroticism (Costa & McRae, 1987), have all been postulated to be associated with the predisposition, onset, and maintenance of physical illness. One personality variable that has received considerable attention in the ~ s ~ c h i a t rand i c psychosomaticmedicine literature but is relatively unknown in the psychological and behavioral medicine literature is the personality construct of alexithymia. The term alexithyrnia was coined by Sifneos (1973; from Greek roots meaning no words for feelings) to refer to a cluster of cognitive and affective characteristics that had been reported repeatedly by clinicians treating patients with classical psychosomatic diseases (Marty & de M'Uzan, 1963; Nemiah & Sifneos, 1970; Ruesch, 1948; Shands, 1975). In the mid-1970s, these cognitive and affective characteristics, described in separate studies, were more re cis el^ defined and integrated into the multidimensional construct known as alexith~mia(Nemiah, Fre~berger,Gr Sifneos, 1916). The essential features of the alexithymia construcr are: (a) difficulty in identifying and describing feelings; (b) difficulty distinguishing between feelings and the bodily sensations of emotional arousal; (c) constricted imaginal process as evidenced, in part, by a paucity of fantasy; (d) and aL cognitive style that is externally oriented and stimulus bound (Taylor, 1984). It has been hypothesized that the limited emotional awareness and cognitive processing of affects leads to a focusing on and amplification of the somatic component of emotional arousal, a tendency thought to contribute to somatization and the vulnerability to hypochondriasis (Barsky & Klerman, 1983; Lane & Schwartz, 1987). Many clinicians and researchers are of the opinion that the alexithymia construct also provides an approach to understanding the role of emotions in the development of a wide variety of physical diseases, in particular those traditionally regarded as psychosomatic (Nemiah et al., 1976; Taylor, 1987). Several instruments have been developed to measure the alexithymia construct including two interviewer-rated schedules-the ,41exithymia Provoked Response Questionnaire (APRQ; Krystal, Giller, & Cicchetti, 1986) and the Beth Israel Hospital Psychosomatic Questionnaire (BIQ Sifneos, 1973)-and several self-report scales-the Analog Alexithymia Scale ~(Faryna, Rodenhauser, & Torem, 1986), the MMPI-A (Kleiger & Kinsman, 1980), the Schalling-Sifneos Personality Scale (SSPS; Apfel 16r Sifneos, 1979), the revised Schalling-Sifneos Personality Scale (SSPS-R; Sifneos, 1986), and the Toronto Alexith~miaScale (TAS; Taylor, Ryan, & Bagby, 1985; Taylor et al., 1988). In addition, various dimensions of the alexithymia construct have been assessed with projective measures. The Symbolic Archetypal Test 9 (SAT9; Cohen, Auld, Demers-Desrosiers, & Catchlove, 1985) is a projective drawing technique which assesses the capacity for fantasy formation. More recently, Asklin and Bernat (1987)and Acklin and Alexander (1988)derived and cross-validated a set


240

BAGBY, PARKER, TAYLOR

of Rorschach response characteristics hypothesized to be associated with alexithymia using a variety of conceptually relevant indices from the Rorschach Comprehensive System (Exner, 1986). Of these instruments, the MMPI-A has been one of the most widely used measures. There are several factors that have contributed to the popularity of this scale. It is a brief self-report measure and, as such, is conveniently administered and scored. In addition, because the questions are part of the standard MMPI item pool, which is used widely in both general medical and psychiatric settings, the scale can be incorporated in retrospective and prospective studies. Kleiger and Kinsman (1980) developed the MMPI-A utilizing the empirical criterion method of scale construction (Meehl, 1945), with scores from the BIQ as the external criterion. The scale was derived from a sample of 100 patients suffering from chronic respiratory diseases who were administered the MMPI within 3 weeks following their admission to hospital. Items were retained for the MMPI-A if they differentiated between alexithymics and nonalexithymics as classified by BIQ scores. One liability with the criterion group test construction strategy is that, although the scale may have empirical validity in that it differentiates the contrast groups, the items may not adequately represent the entire domain of the theoretical construct. As outlined by Briggs and Cheek (1986), the first step in the development of an empirically derived measure is to establish empirical validity (i.e., differentiate between the contrast groups); the second step is to uncover the inherent underlying dimensionality of the test. It is also important to cross-validate the scale on separate and independent samples, However, evidence emerging from studies investigating the validity of the MMPI-A are, at best, equivocal. Federman and Mohns (1984), for example, were unable to replicate the correlation between the BIQ and MMPI-A, reported in the original validation study (Kleiger & Kinsman, 1980), with a sample of migraine headache patients. Similar failures to replicate the significant correlation between the BIQ and MMPI-A have been reported with chronic pain patients (Demers-Desrosiers, Cohen, Catchlove, & Ramsey, 1983), general psychiatric and medical patients (Krystal et al., 1986), and patients diagnosed as hypertensive (Paulson, 1985). A similar pattern of nonsignificant correlations between the MWI-A and other measures of alexithymia have also been reported, including the APRQ (Krystal et al., 1986), the SSPS (Bagby, Taylor, & Atkinson, 1988; Krystal et al., 1986; Norton, 1989; Paulson, 1985), and the TAS (Bagby et al., 1988). Other studies have attempted to validate the MMPI-A by examining score differences between patients with somatization disorders or physical diseases and groups of patients without physical symptoms. Doody and Taylor (1983), for example, reported significant differences between psychoneurotic patients and patients with inflammatory bowel diseases (ulcerative colitis and Crohn's disease), with the latter group scoring significantly higher on the MMPI-A.



241

Similarly, Greenberg and O'Neill (1988) reported a significantly lower percentage of alexithymics (i.e., as classified by the MMP1-A cutoff scores) in a sample of psychiatric inpatients than in samples of patients with a variety of physical illnesses. Greenberg and Dattore (1983), however, failed to reveal differences between healthy normals, psychosomaticpatients and schizophrelnic patients. Still other studies with college student samples have been unable to find significant correlations between the MMPI-A and various measures of somatic complaints, including the Symptom Check List-90R (SCL-90R) Somatization scale, the Psychosomatic Symptom Checklist (Bagby et al., 1988), and the Somatic Complaints Scale of the Cornell Medical Index (Cooper & Holmstrom, 1984; Norton, 1989). Evidence from construct-type validity studies, although inconsistent, has been somewhat more positive. Congruent with the hypothesis that alexithymics reveal a different pattern of psychopathology than psychoneurotic patients, Mendelson (1982)found that nonalexithymic pain patients, as identified by the MMPP-A, scored higher on the Neuroticism subscale of the Eysenck Personality Inventory (EPI-N) than those categorized by the MMPI-A as nonalexithymic. Similarly, Norton (1989) reported a low magnitude correlation between the MMPK-A and the EPI-N with a sample of college females. However, although Doody and Taylor (1983) found that the MMPT-A was successful in differentiating between bowel disease and psychoneurotic groups, these groups were also differentiated by the MMPI scales P~~chasthenia, Paranoia, and Schizophrenia. More recently, Greenberg and O'Neill (1988) found that patients identified as alexithymic on the MMPI-A produced Rorschach responses consistent with the hypothesis that alexithymics are less verbally productive and have "less ability to fantasize" as measured by the number of Rorschach responses (R) and human movement (M), respectively, whereas those identified as nonalexithymic did not. Norton (1989) found a negative correlation between the MMPI-A and rhe Absorption scale of the Multidimensional Personality Questionnaire, which measures an individual's capacity to become involved in imaginative processes. But again, Doody and Taylor (1983) found that the MMPI-A did not correlate with Rorschach and Thematic Apperception Test (TAT) measures of affect expression and the capacity for fantasizing. Given the potential difficultieswith empirically derived measures and inconsistency of validational evidence for the MMPI-A, the objectives of our study were to: (a) evaluate the theoretical homogeneity of the scale through estimates of internal reliability and item-to-scale correlations, (b) examine the underlying dimensionality of the MMPI-A using factor analysis as the method of evaluation, and (c) assess the validity of the scale by examining the differences between alexith~micsand nonalexithymics with a set of theoretically relevant variables. To this end, two studies were conducted. In Study 1, the internal consistency and other item and scale properties were assessed for the MMPI-A using two separate psychiatric inpatient and outpatient samples. In addition, the

242


MMPI-A was factor analyzed using these two patient groups. In Study 2, a subsample of these psychiatric patients was utilized to explore the group differences between alexithymics and nonalexithymics on several different variables.

STUDY 3 Method


Subjects The 22 MMM-A items were extracted from completed MMPIs of 704 psychiatric patients. These MMMs comprised part of a computerized psychological data bank maintained by the Department of Psychology, Clarke Institute of Psychiatry. The Clarke Institute is a large psychiatric training and research facility providing a wide range of inpatient and outpatient services. To ensure patient anonymity, only the age, sex, presenting problem, and the service that assessed the patient were retrieved along with the 22 MMPI-A items. Data protocols with any missing variables were deleted. The final sample consisted of a total of 618 protocols-398 inpatients (257 males, 141 females) and 220 outpatients (126 males, 94 females). The mean age was 33.3 years (SD = 11.7)for the male inpatients and 35.4 years (SD = 12.2) for the female inpatients. The mean age was 33.6 years (SD = 11.2) for the male outpatients and 35.1 years (SD = 11.6) for the female outpatients.

Procedure Means, standard deviations, Kuder-Richardson (KR-20) reliability coefficients and mean interitem correlations for the MMM-A were computed separately for the inpatient and outpatient samples. Next, the 22 MMPI-A items were intercorrelated separately for the inpatient and outpatient samples and were factor analyzed. Given the concern that factor analysis of dichotomous variables has the potential to yield artifactual dimensions (see, e.g., Cattell, 1978), we followed Atkinson (1988) and examined each correlation matrix for psychometric adequacy using Bartlett's (1950) test of sphericity, the Kaiser-Meyer-Olkin measure of sample adequacy (KMO; Kaiser, 1970), and inspection of the off-diagonal elements of the anti-image covariants matrix (Kaiser, 1963) as recommended by Dziuban and Shirkey (1974) prior to factor analysis. Following evidence of the suitability of these two correlation matrices for factor analysis, each matrix was subjected to principal axis factoring and rotated to a varimax solution. Scree test and eigenvalues (>1.0) were used to select the number of factors to rotate (Cattell, 1978).

;!43


Results and Discussion


Scale Properties and Item Characteristics For the inpatient sample the mean MMPI-A score was 11.5 (SD = 3.2) for lthe males and 11.2 (SD = 3.3) for the females. One hundred eighteen (29.6%) of the inpatients had scores of 14 or more, which is the recommended cutoff score for alexithymia (Kleiger & Kinsman, 1980). Seventy-nine (19.8%) of the males and 39 (27.8%) of the females scored above this cutoff level. For the outpatient sample, the mean MMPI-A score was 10.8 (SD = 3.4) for males and 8.31 (SD = 3.4) for the females. Fifty-three (24.1%) of the outpatients scored 14 or above on the MMPI-A. Thirty-two (25.4%) of the males and 21 (22.3%) of the females scored 14 or more. A chi-square analysis comparing the proportion of patients scoring above and below the cutoff level in the inpatient and outpatient groups for both the males and females was nonsignificant. These mean scores and percentages are considerably higher than those reported in college students (Bagby et al., 1988; Norton, 1989) and marginally higher than those reported previously for psychiatric inpatients (Greenberg 6r O'Neill, 1988). The internal reliability coefficient (KR-20) and mean interitem correlation coefficient of the MMPI-A were 0.58 and 0.06, respectively, with the inpatient sample and 0.61 and 0.06 with the outpatient sample. For the inpatient sample, 7 of the 22 items had corrected item-total correlations < 0.20; for the outpatient sample, 11 items were below this level. These estimates of scale homogeneity are generally higher than those reported by both Bagby et al. (1988) and Norton (1989) with samples of college students. Nevertheless, these values suggest only a marginal level of internal consistency.

Factor Analysis Adequacy of correlation matrices. All three measures of psychometric adequacy indicated that the MMPI-A correlation matrices for both the inpatient and outpatient samples were suitable for factor analysis. For the inpatient sample, Bartlett's test of sphericity indicated that the MMPI-A items were interdependent, x2(376) = 795.96, p < .0001. The overall KMO (0.67) also revealed that the items belonged together psychometrically. Only 14.7% of the off-diagonal elements of the anti-image covariants matrix were greater than 0.09, indicating that the matrix of the covariances of the individual items approach a diagonal. Similarly, the MMPI-A items for the outpatient sample proved . psychometrically interdependent according to ~artl&'s test of sphericity, X2(198) = 616.02, p < .0001, the overall KMO (0.68), and the anti-image covariants matrix (18.6% of off-diagonal >O.O9), all indicating that the mat~ix was satisfactory for factor analysis. -


244


Factor structures. Factor analysis of the 22 items on the MMPI-A with the inpatient sample resulted in nine factors with eigenvalues greater than unity (i.e., greater than I), and the scree test indicated no clear break or plateau prior to the ninth factor. In order to determine the number of factors for extraction and rotation, we subsequently employed the "trivial factors method" outlined by Gorsuch (1983, p. 169). The nine factors were rotated to a varimax solution. This analysis produced four trivial factors (defined as all factors that do not have at least two item loadings greater than significance > 0.35). The remaining five factors were rotated; this solution produced two trivial factors, and subsequently three factors were rotated which produced no nontrivial factors. These three factors and their loadings are presented in Table 1. The three factors accounted for 16.6% of the total variance or 9.3%, 3.9%, and 3.4%, respectively. Nine of the 22 items did not load significantly (>0.35) on any of the three factors. Factor 1 contains seven items with significant loadings whose content lack coherency, and we were unable to detect a central theme. Factor 2 has three items with significant loadings whose content reflects restlessness, excitability, and mania. Factor 3 also has three items with significant loadings. The content of these items revolve around passive occupational styles and interests. Factor analysis of the 22 MMPI-A items with the outpatient sample also resulted in nine factors with eigenvalues greater than 1.0 with no clear break evident in the scree test prior to the ninth factor. Varimax rotation of these nine factors produced a solution with four trivial factors, and subsequently five factors were rotated which produced a solution with one trivial factor. Thus, four factors were rotated to a varimax solution which contained no trivial factors. These four factors and their loadings are also presented in Table 1. The four factors accounted for 22.5% of the total variance, or 11.8%, 5.4%, 3.0%, and 2.4%, respectively. Seven items failed to load significantly on any of the four factors. Factor 1 is comprised of five items with significant loadings; however, as with the inpatient sample, there is no apparent theme that would meaningfully describe these items as a group. Factor 2 contains three items with significant loadings whose content reflects need for excitement. Factor 3 contains two significant item loadings whose content belies any coherent relationship. Factor 4 contains three significantlyloaded items, whose content represents restlessness and mania. The results from these factor analyses indicate that a rather sizable proportion of the items do not appear to be related to the factors extracted from the entire scale. These results also corroborate the marginal internal reliability of the scale, suggesting that the MMM-A fails to measure a common theoretical core. The purpose of Study 2 was to extend the evaluation of the MMPI-A by examining its construct validity. The specific aims were to examine the overall relationship between the MMM-A and other related constructs and to determine if the MMPI-A could differentiate alexithymic from nonalexithymic

TABLE 1 Factor Structure of the MMPI Alexithymia Scale for Psychiatric Inpatient and Outpatient Samples - --

Inpatients Factors


MMPI Items During one period when I was a youngster, I engaged in petty thievery. A t times I feel like smashing things. I am troubled by discomfort in the pit of my stomach every few days or oftener. I would like to be a florist. I do not worry about catching diseases. I used to keep a diary. When I get bored I like to stir up some excitement. I daydream very little. I would like to be a journalist. I like science. I have periods of such great restlessness that I cannot sit long in a chair. I have been disappointed in love. Sometimes without any reason or even when things are going wrong I feel excitedly happy, "on top of the world." It does not bother me that I am not better looking. If I were a reporter I would very much like to report sporting news. A t times I have very much wanted to leave home. I worry over money and business. Sometimes I become so excited that I find it hard to sleep. If given a chance I could do something that would be of great benefit to the world. I am attracted by members of the opposite sex. There are certain people I dislike so much that I am inwardly pleased when they are catchirig it for something h e y have done. I have to urinate no more often than others. Note. Factor loadings greater than .35 are in italics.

1

2

3

Outpatients Factors

hZ

1

2

3

4

hZ

246


patients (as categorized by the MMPI-A cutoff scores specified by Kleiger & Kinsman, 1980) on several personality and psychopathological variables germane to the alexithymia construct. We included a statistical test of between group differences in addition to the correlational analysis, as many researchers and clinicians routinely employ cutoff scores when using the MMPI-A.

STUDY 2

Method


Subjects In this study, the MMPI-A and seven other MMPI scales were randomly extracted from completed MMMs of 200 psychiatric patients. The MMPIs are part of the same computerized psychological data bank described in Study 2. Data protocols with any missing variables were deleted. The final sample consisted of 178 subjects (120 males, 58 females). The mean age was 31.3 years (SD = 12.8) for the males and 33.8 years (SD = 13.6) for the females.

Measures Seven MMM scales were selected prior to data analysis based on their hypothesized relationship with the alexithymia construct. Four of these scalesPoor Health (Wiggins, 1969), Somatic Complaints (Harris & Lingoes, cited in Graham, 1987), Physical Symptoms (Serownek, cited in Graham, 1987), and Physical Malfunctioning (Harris & Lingoes, cited in Graham, 1987)-were included on the presumption that alexithymics are more prone to somatize or experience physical illnesses than nonalexithymics (Lesser, 1985; Nemiah et al., 1976; Taylor, 1984). Although there is considerable item overlap among the various scales, collectively they represent a wide and diversified domain of somatic and physical problems and are thought to represent a fair and liberal test of MMPI-A validity. The remaining two scales-Hypochondriasis (McKinley & Hathaway, 1940) and Ego Strength (Barron, 1953)-represent constructs that have been hy-pothesized to have some theoretical relationship to alexithymia. Greene (1978) suggested that the Hypochondriasis scale represents a crude index of psychological mindedness and is reflective of a lack of insight into emotional and physical problems. One consistent theme in the literature on alexithymia is that alexith~micsare not psychologically minded (Bagby, Taylor, & Ryan, 1986; Sifneos, 1975; Singer, 1977; Taylor, 1984). If the MMPI-A is a valid measure, then alexithymics, as identified by the MMPI-A cutoff level, should score significantly higher than nonalexithymics on the Hypochondriasis scale. We expected alexithymics to score lower than n~nalexith~mics on the Ego Strength


2,47


scale. Ego Strength, as a gross measure predictive of potential successful outcome to psychotherapeutic intervention (Barron, 1953),is theoretically relevant to the alexithymia construct in that clinicians and investigators alike have repeatedly indicated that alexithymics respond poorly to insight-oriented psychotherapy (Krystal, 1982/1983; McDougall, 1984; Sifneos, 1975; Taylor, 1984). We explicitly excluded MMM scales L, K, and F, used by Greenberg and O'Neill(1988), as measures of defensiveness and denial to evaluate the construct validity of the MMPI-A, because alexithymia is conceptualized as a deficit in the processing of emotions rather than as a denial of affects and impulses (see, e.g., Lane & Schwartz, 1987; McDougall, 1974; Nemiah, 1975, 1977; Parker, Bagby, & Taylor, 1989; Sifneos, 1974; Taylor, 1987). Thus, these scales do not reflect variables that bear any meaningful relationship with the alexithymia construct.

Procedure The MMM-A was scored for each of the 178 patient protocols. Following the procedure utilized in investigations that have used the MMI'I-A and consistent with the Kleiger and Kinsman (1980) criterion, a score of 14 or more was categorized as falling within the alexithymic range. Thirty-six (20.2%) of the patients scored within this range. The nonalexithymic group consisted of those patients whose MMM-A scores were in the lower 20% of the sample (N = 35). Although most studies have used the cutoff score of 13 or below to form nonalexithymic groups, we chose the lower 20% in order to equalize the number of subjects in each group and to eliminate any source of error variance associated with scores occurring in the medium range.

Results and Discussion The mean MMPI-A score was 15.53 (SD = 1.29) for the alexithymic group and 6.03 (SD = 1.29) for the nonalexithymic group. The difference was highly significant, t(69) = - 27.27, p < .001. The alexithymic group was significantly older (M = 38.11 years, SD = 15.59) than the nonalexith~micgroup (M = 30.51 years, SD = 10.89), t(69) = -2.37, p < .02. However, there was no difference in years of education between the alexithymic group (M = 10.72, SD = 3.53) and the nonalexithymic group (M = 10.42, SD = 4.8). A chi-square analysis comparing the proportion of males and females in the alexithymic and n~nalexith~mic range was nonsignificant. The correlations between the MMPI-A and the other MMPI scales used in this study were as follows: Physical Malfunctioning (.02, ns), Poor Health ( - .13, p < .05), Somatic Complaints (-.lo, ns), Physical Symptoms (.28, p < .01), Ego Strength (.21, P < .01), and Hypochondriasis ( - .lo, ns). In general, these correlation coefficients are of low magnitude and account for little of the variance. Table 2 presents the comparisons of the alexithymic and non-

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BAGBY, PARKER, TAYLOR TABLE 2 Means, Standard Deviations, and t-Test Comparisons for the Alexithymic and Nonalexithymic Groups on the MMPI Scales Nonalexithymic

MMPI Scale Physical Malfunctioning Poor Health Somatic Complaints Physical Symptoms Ego Strength Hypochondriasis


*p

Alexithymic

M

SD

M

SD

4.40 8.74 5.63 4.03 36.57 11.26

2.27 3.37 3.64 2.62 7.95 6.16

4.69 7.69 5.06 2.86 40.72 9.94

1.76 5.15 4.05 2.22 8.43 7.36

t

- .61 1.02 .63 2.02* -2.14** .82

< .05. **p < .01.

alexithymic patients (based on MMPI-A cutoff scores) on the various MMPI scales. Group means were statistically compared using t tests. As is evident from Table 2, none of the seven scales differentiated the nonalexithymic group from the alexithymic group in the expected direction. Three of the four scales assessing somatic complaints and/or physical problems were in the opposite direction, with the nonalexithymics having marginally higher scores on these three scales than the alexithymics. This result is consistent with a growing number of studies indicating no meaningful relationship between the MMPI-A and measures of somatic complaints (Bagby et al., 1988; Cooper & Holmstrom, 1984; Norton, 1989). The Ego Strength and Hypochondriasis scales had significant differences but opposite to the direction hypothesized.

GENERAL DISCUSSION The outcome of this investigation provides little convincing evidence that the MMM-A is either a reliable or valid measure of the alexithymia construct. The results neither indicate a common theoretical core among the MMPI-A items nor do they indicate that the underlying dimensions of the MMPI-A adequately represent the theoretical domains of the alexithymia construct. The relatively low estimates of internal consistency across both the inpatient and outpatient samples provide little evidence of overall item homogeneity. These results replicate previous findings of poor internal consistency of the MMPI-A (Bagby, Taylor, & Atkinson, 1988; Norton, 1989). Similarly, factor analysis of the 22 items for the inpatient and outpatient samples produced three and four factor solutions, respectively, whose content were, in general, both uninterpretable and not directly relevant to the hypothesized domains of the alexithymia construct. Noticeably absent from the scale, for example, are item domains related to the capacity to identify and communicate feelings and to distinguish



249

between feelings and the bodily sensations of emotional arousal, which are central components of the alexith~miaconstruct (see, e.g., Nemiah et al., 1976; Taylor, 1984). The most likely explanation for the failure of these factors to emerge is that their content domain is not represented by the item pool of rhe MMPP. This is not surprising inasmuch as the alexithymia construct encompasses personality characteristics that are decidedly different from the neurotic and psychotic psychopathologies (Nemiah et al., 1976; Taylor, 1987) that the MMPI: items were specifically intended to assess. The failure of the MMPI-A items to assess the alexithymia construct adequately brings into question the appropriateness of the external (empirical)scale construction strategy in the development of psychological measures, especially those examining hypothetical personality constructs (see, e.g., Burisch, 1984; Goldberg, 1972; Hogan & Nicholson, 1988; Meehl, 1972; Norman, 1972; Nunnally, 1978). This strategy is most suitable when there is a need to develop a psychological test that will reproduce an already established factor of personality (Wiggins, 1973). The strategy is unsuitable for a personality test that intends to be examined for construct validity (Nunnally, 1978). Typically, criterion test construction strategies produce complex factorial compositicins that belie meaningful interpretation and, as such, add little to the understanding of the construct that the items presumably represent (Briggs & Cheek, 1986). The results of our study, coupled with the theoretical basis of the alexithymia construct, support the inappropriateness of this strategy. Although many researchers have treated alexithymia as a firmly established criterion, it is a construct still in need of validation and exploration (Lesser & Lesser, 1983). In this vein, the use of the BIQ as the external criterion in the selection of the MMPI-A items is, perhaps, procedurally incorrect. Using one scale designed to measure a hypothetical personality construct to create another, especially when the scale used as the criterion has suspect psychometric qualities itself (Taylor & Bagby, 1988), does not appear to be a sound methodological approach, Perhaps a more judicious strategy in deriving an MMPI-A would be to follow the Wiggins's (1966) scale development procedure. In this scenario, raters familiar with the substantive domains of the alexithymia construct would be instructed to search for questions in the MMPI item pool that they think are representative of the domains. The selected items could then be refined empirically to filter items that do not demonstrate discriminative ability sequentially. The number of items on the current MMPI-A that are not related to the substantive domain the scale allegedly measures indicates that such an item selection procedure should have been undertaken initially. What we are arguing for, in essence, is a rational, rather than empirical, scale construction approach in the development of measures for hypothetical personality constructs, in general, and for the alexithymia construct, in particular. Unfortunately, the results of this study also cast doubt on the validity and generalizability of previous studies which have drawn inferences about the

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alexithymiaconstruct from results obtained with the MMPI-A. Researchers and clinicians are advised to consider other measures of the alexithymia construct, in particular the TAS and the Rorschach Alexithymia Indices. These measures were rationally developed, have an accumulating body of research (Acklin & Alexander, 1988; Taylor, Bagby, Ryan, &Parker, in press) on which to evaluate their psychometric adequacy, and, as we outlined elsewhere (Taylor & Bagby, 1988), appear to be more suitable measures for use in clinical settings and in future research.


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R. Michael Bagby Department of Psychology Clarke Institute of Psychiatry 250 College Street Toronto, Ontario M5T 1R8


Received January 16, 1990 Revised April 12, 1990

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