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The Relationship Between the MCMI Personality Scales and DSM-III, Axis II Svenn Torgersen & Randolf Alnaes Published online: 22 Jun 2011.

To cite this article: Svenn Torgersen & Randolf Alnaes (1990) The Relationship Between the MCMI Personality Scales and DSM-III, Axis II, Journal of Personality Assessment, 55:3-4, 698-707, DOI: 10.1080/00223891.1990.9674105 To link to this article: http://dx.doi.org/10.1080/00223891.1990.9674105

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JOURNAL OF PERSONALTY ASSESSMENT, 1990, 55(3&4), 698-707 Copyright o 1990, Lawrence Erlbaum Associates. Inc.

The Relationship Between the MCMI Personality scales and DSM-III, Axis I1 Svenn Torgersen University of Oslo

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Randolf Alnm Department of Psychiatry University of Oslo

Compared were the personality scales of the Millon Clinical Multiaxial Inventory (MCMI) to the diagnosis of personality disorder, according to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed. [DSM-Ill]; American Psychiatric Association, 1980), obtained by means of the Structured Interview for the DSM-111 Personality Disorders (SIDP). The results from 272 psychiatric outpatients show a good correspondencefor the Avoidant and the Dependent scales, a fairly good correspondencefor the Schizotypal, the Histrionic, the Borderline, the Narcissistic, and the Paranoid scales, and no correspondencefor the Schizoid, the Passive-Aggressive, and the Compulsive scales. The Passive-Aggressive scale seems to be positively correlated to personality disorders in general, whereas the Compulsive scale seems to be negatively correlated to a number of personality disorders.

T h e possibility of assessing personality disorders by means of questionnaires seems a n attractive one. Parallel to the increasing interest in personality disorders following the DSM-lll's emphasis o n such disorders, clinicians and researchers have been eagerly seeking a n inventory for diagnosing personality disorders. T h e Millon Clinical Multiaxial Inventory (MCMI; Millon, 1983) presented itself as a tempting possibility for this purpose. However, critics have claimed that the correspondence between MCMI and DSM-111 personality disorders is more of a postulation than a reality (Widiger, Williams, Spitzer, & Frances, 1985, 1986). Some of the DSM-I11 criteria are not covered in the MCMI, and the MCMI scales comprise items that are irrelevant to the DSM-111 personality disorders. Furthermore, there is some overlap among

MCMI AND DSM-111

695)

the items in the different MCMI scales, which may make a precise diagnosis blr means of MCMI difficult (Retzlaff & Gibertini, 1987). Efforts to relate the lvICMI personality scales to various DSM-111, Axis I1 categories have given divergent results (Cantrell & Dana, 1987; Piersma, 1987; Widiger & Sanderson, 1987). We investigated the validity of the MCMI personality scales by comparing them to the DSM-111, Axis I1 diagnosis obtained by means of a clinical interview.

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SUBJECTS This study is part of an investigation of patients attending the Outpatient Section of the Department of Psychiatryat the University of Oslo, between May 1984 and December 1985. The criteria for inclusion in the study were that the patients had to be between 18 and 60 years old, were not psychotic, and did not come to the clinic because of a social crisis or drug or alcohol abuse as their main problems. Three hundred twenty-four patients were asked to participate, of which 298 (92%)agreed.

METHOD Upon admission, subjects were first interviewed by the Structured Clinical Interview for DSM-111 (SCJD; Spitzer & Williams, 1983) in order to receive a diagnosis according to DSM-111, Axis I, and Axis II. (The reliability check of the diagnoses are described by Alnaes & Torgersen, 1988.) The overall Kappa for Axis 11diagnoses were .88. Two months later (plus or minus 1 week), subjects were asked to fill out the MCMI (Millon, 1983). We decided to delay the filling out of the questionnaire for 2 months because the replies might have been influenced by the acute symptomatology crisis. In evaluating personality disorders by interview, it is possible to correct for the current state of psychopathology. Twenty six (8.796) did not show up, which left a final sample consisting of 272 subjects: 191 (70%) females and 81 (30%)males. The subjects were from high-income areas of Oslo; 26% had a college education, and 35% had a high school diploma. About half of the Axis I diagnoses consisted of different subgroups of depression, with anxiety as the second most common disorder. Eighty-onepercent of the subjects met the criteria for a personality disorder diagnosis (see Alnaes & Torgersen, 1988, for a more detailed description of the sample). Raw scores on all MCMI scales are converted to base-rate scores, in order 1:o reflect the prevalence of particular personality traits in a psychiatric population. A base-rate score of 60 represents the 50 percentile of all patients, whereas scores

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of 75 to 84 suggest that patients exhibit a trait or symptom. Base-rate scores of 85 and above indicate that patients have a particular personality style or clinical personality syndrome as their most prominent disorder.

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RESULTS Table 1 shows the mean base-rate scores and the standard deviations for the sample according to the personality scales. Means vary between 47 and 65, with a standard deviation around 23. If we compare these figures to Cantrell and Dana's (1987) outpatient study, we find that the scores in our sample are predominantly lower. The only exception is the Compulsive scale on which the base-rate score in our study was more than 10 points higher. The score on the Dependent scale was more than 12 points lower in our study, the base-rate score on the Passive-Aggressive scale was more than 11 points lower, the score on the Paranoid scale was 9 points lower, and the score on the Avoidant and Borderline scales were 8 points lower. It is unknown whether these differences reflect differences between Norway and the U.S. or whether our sample or Cantrell and Dana's sample is atypical for the outpatient samples in the two countries. The high socioeconomic level of our patients may have influenced the results. However, the mean base-rate scores were within 5 points above or below 60 (corresponding to 50th percentile) for seven of the scales. Table 2 shows the correlations among the base-rate scores for the different personality scales. The correlations are uniformly high. The results are similar to Millon's (1983). Of the eight correlations above .70 in our study, four are also above .70 in Millon's study, and the other four are between .59 and .68. These TABLE 1 Means and Standard Deviations for the Base-Rate Scores of the MCMI Personality Scales

Schizoid Avoidant Dependent Histrionic Narcissistic Antisocial Compulsive Passive- Aggressive Schizotypal Borderline Paranoid

M

SD

51.49 58.45 60.49 56.10 47.87 47.01 58.40 60.75 56.14 64.66 47.31

23.80 23.68 28.71 26.88 21.61 2 1.94 17.15 27.62 16.55 23.36 22.72

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TABLE 2 Correlations Between the Base-Rate Scores of the DifferentMCMI Personality Scales 2

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1. Schizoid 2. Avoidant 3. Dependent 4. Histrionic 5. Narcissistic 6. Antisocial 7. Compulsive 8. Passive-Aggressive 9. Schizotypal 10. Borderline 11. Paranoid

.73

3

4 .37 ,64

5

-.70 -.47 -.27

6

7

8

9

-.56 -.21 -.05 -.55 -.28 -.41 -.53 -.58 -.I8 .65 .28 -.36 .71 -.07 -.I7

1

.41 .69 .42 -.04 -.24 -.01 -.67

0 .75 39 .67 -.49 -.60 -.34 -.35 .63

1

-

1

-

.52 .78 .62 -.I7 -.36 -.19 -.52 37 .74

.;!9 .41 .;!3 -.05 .28 .46 -.38

.48 .36 .49

results are even more similar to Cantrell and Dana's (1987) study, in which all eight correlations were also above .70. The patients were given a score of 3 if they had a certain personality disorder according to the interview and a score of 2 if they almost fulfilled the criterion by lacking one characteristic. Nobody fulfilled the criterion for antisocial personality disorder. Table 3 shows the correlations among MCMI personality scales and the S D P data. We observed that except for the Compulsive (nonsignificant) and the Passive-Aggressive scales ( p < .01), the correlations between personality scale and the corresponding personality disorder according to the SIDP are highly statistically significant at p < .001. Discluding the two scales just mentioned, tlhe TABLE 3 Correlations Between MCMI Personality Scales and SIPD DSM-111, Axis II Personality Disorders SIDP MCMI

1

1. Schizoid 2. Avoidant 3. Dependent 4. Histrionic 5. Narcissistic 6. Antisocial 7. Compulsive 8. Passive-Aggressive 9. Schizotypai 10. Borderline 11. Paranoid Note.

r 2 .lo, p

.39 .33 .03 -.29 -.20 -.08 -.04 .ll .30 .11 .06

< .05. r

2 .36 .42 .21 -.29 -.39 -.I8 -.22 .26 .43 .31 .05

3

4 .31 .43 .38 -.22 -.41 -.30 -.I9 .31 .44 .34 -.03

5 -.09 .08 .06 .20 .07 .13 -.32 .31 .10 .20 .17

7

8

-.09 .19 -.03 .17 -.05 .09 .22 -.I5 .18 -.I3 .15 -.I5 -.21 -.05 .07 .13 -.04 .18 .O1 .10 .08 .08

.14, p < .01. r t .18, p

< .001.

9

1

0

j

1

1

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correlations vary between .42 and .18, with the highest for avoidant, schizoid, dependent, and schizotypal personality disorders, and the lowest for narcissistic, paranoid, and histrionic personality disorders. The scales often have higher or similar correlations to other personality disorders. The Paranoid scale has similar correlations to borderline and schizotypal personality disorders as to the paranoid personality disorder, the Schizotypal scale has higher correlations to avoidant and dependent personality disorders than to the schizotypal personality disorder, the Histrionic scale has similar correlations to the narcissistic personality disorder as to the histrionic personality disorder, the Borderline scale has similar correlations to the dependent disorder as to the borderline personality disorders, and the Avoidant scale has similar correlations to the dependent and schizotypal disorders as to the avoidant personality disorders. The Histrionic and the Narcissistic scales also have high negative correlations to the schizoid, avoidant, dependent and schizotypal personality disorders. The Compulsive scale has a particularly high negative and the Passive-Aggressive scale a particularly high positive correlation to the borderline personality disorder. These two scales have a negative and positive relationship to a number of other personality disorders as well. A high score on the Passive-Aggressive scale seems to be an indication of personality disorders generally, whereas a high score on the Compulsive scale means that a personality disorder is unlikely. Table 4 presents the prevalence of the disorders according to the SIDP, the base rates based on the MCMI (accordingto a cutoff point below 65,75, and 85), sensitivity (true positive rate), specificity (true negative rate), positive predictive power, negative predictive power, and the probability level applying the chisquare test. Sensitivity is the probability of the questionnaire identifying the case, given the fact that the person really has the disorder. Specificity is the probability that the questionnaire rejects the diagnosis, given the fact that the person does not have the disorder. The sensitivity and specificity are strongly related to the cutoff point of the questionnaire. The higher the cutoff point, the lower the sensitivity and the higher the specificity. The reason is simply that if a few of the total population get the score, a few with the disorder will also get the score. Consequently, a few of those without the disorder will also get the score. Positive predictive power (PPP) is the probability that a person who has the disorder, according to the questionnaire, actually has it. Negative predictive power (NPP) means the probability that a person who does not have the disorder, according to the questionnaire, is free of the disorder. PPP increases with the increasing sensitivity of the test and the prevalence of the disorder in the population and decreases with the base rate for the test according to the chosen cutoff point as shown in the following formulation: PREV D,

PPP = SENS PREV Q

.

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where SENS is sensitivity, PREV D is the prevalence of disorder, and PREV Q is the prevalence of the cases above the chosen cutoff point for the questionnaire. This formula is easily calculated, based on the definitions of the concept. It is also possible to calculate a corresponding formula for NPP:

1 - PREVD, NPP = SPECl - PREV

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a

where SPEC is the specificity at each cutoff point. When we view Table 4, it is important to understand that the SENS will decrease with an increasing cutoff point, and SPEC will increase. If the test is to be of any importance, the SENS must be above the base rate according to the cutoff point and the SPEC higher than the complementary to the base rate (1base rate). We observe that this is true for the Paranoid and Schizoid scales at a cutoff point of 65 for SENS, for the Schizotypal, Histrionic, Narcissistic, Borderline, and Passive-Aggressive scales at all cutoff points for SENS, but not for SPEC, and for the Avoidant and Dependent scales at all cutoff points for both SENS and SPEC. The Compulsive scale showed neither higher SPEC nor higher SENS than would be expected from the base rate. When we look at PPP and NPP, we must have our formula in mind. The scales related to the disorders with the highest prevalence must be expected to have the highest PPP. Furthermore, the PPP would be expected to increase with increasing cutoff. The opposite is true for NPP. PPP is positively related to SENS, and NPP is positively related to SPEC. The important issue concerns whether PPP is above the prevalence for the disorder (PREV D) and whether NPP is above the complementary to the prevalence (1-PREV D). The Paranoid scale is fairly good for the highest cutoff point, as are the Histrionic, Narcissistic, and Borderline scales, whereas the Schizotypal scale is very good at the highest cutoff point. The Avoidant and Dependent scales are good at all cutoff points. The Schizoid, Compulsive, and Passive-Aggressive scales do not seem to have any PPP or NPP above the expected based on the prevalence.

DISCUSSION The intercorrelations between the different MCMI scales are very high and remarkably similar to those of previous studies. One reason may be the overlap among the various scales (i.e., the application of the same items in the different scales), as was shown by Retzlaff and Gibertini (1987). Most scales, except the Compulsive and the Passive-Aggressive scales, corre-

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MCMI AND DSM-111

70,5

late fairly well with the corresponding disorder, measured by means of the SIDE'. As is reasonable, due to the correlations between the scales, however, many scales are correlated to the same disorder and many disorders to the same scale. The interesting feature of the Passive-Aggressive scale is the fact that even if it has a very low correlation to the passive-aggressive personality disorder, it has a high correlation to other disorders. Correspondingly, the Compulsive scale has a high negative correlation to many other disorders. One reason might be due to the inclusion of the many negative items. These two scales, however, seem to measure something substantial about the personality even if it does not measure the corresponding DSM-111 personality disorder. It is important to keep in mind, as Millon (1983, 1985) often stated, that the MCMI ~ e r s o n a l i scales t~ are not intended to measure ~ersonalitydisorders that are completely identical to those of the DSM-111, Axis 11disorders. An analysis of the hit rates show that the Avoidant and the Dependent scales were the best, whereas the Schizotypal, Histrionic, Borderline, Narcissistic, and Paranoid scales were useful at the highest 84/85 cutoff point. However, the high correlations between the scales and the similar correlations between one scale and a number of personality disorders may limit the influences of the MCMI far differential diagnoses. Our results are in accordance with Piersma's (1987) findings for dependent personality disorder, reporting good agreement between the MCMI and the clinical diagnosis, bur our findings are not in agreement with his negative findings for the Borderline and Histrionic scales. Regarding Widiger and Sanderson's (1987)findings about the correspondence of interviews and MCMI for avoidant and dependent but not for passive-aggressive personality disorders, our results are in complete agreement. On the other hand, our results may be considered in disagreement with Millon (1983)and Gibertini, Brandenburg, and Retzlaff (1986), who showed that all MCMI personality scales have a close correspondence to clinical diagnoses. The Millon study was not directly baseid on DSM-111 criteria, however, but on the MCMI scale definitions, and thus does not say anything about the relationship between DSM-111 personality diagnosis and the MCMI. Widiger et al. (1985) commented on how different Millon's concept of the passive-aggressive and the compulsive personality disorders was from the DSM-111 criteria. The negativistic personality measured by means of Millonj's Passive-Aggressive scale is more of a general emotionally unstable, masochistic type; thus it is not strange that the correlation is fairly high to borderline, histrionic, and dependent personality disorders. Millon's conforming and submissive-compulsive concept seems to be an antithesis to the flamboyant features of the DSM-111 borderline and histrionic personality disorders, whereas the Passive-Aggressive scale seems to measure these traits.

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CONCLUSIONS The MCMI has a limited discriminant validity, because the scales often correlate equally high to a number of personality disorders. The MCMI Avoidant, Dependent, Schizotypal, Histrionic, Narcissistic, Borderline, and Paranoid scales show acceptable Lit rates as to convergent validity, but this is not the case for the Schizoid, Compulsive, and Passive-Aggressive scales. When comparing the value of these scales according to our study, it is important to take into consideration the prevalence of the corresponding disorders in our population. The prevalence strongly effects the positive predictive power. When choosing the appropriate cutoff point, one should use a low cutoff point to increase sensitivity if it is important to detect a rare disorder and a high cutoff point to increase positive predictive power if it is important not to waste resources on false positives. Irrespective of the cutoff points, it is evident that the MCMI identifies a number of false positives and false negatives. Thus, a perfect fit does not exist. This was not, however, Millon's intention. Furthermore, two measures with a moderate correspondence may have a higher relation to a third hypothetical concept and thus a higher validity than this study has disclosed. For instance, it has been demonstrated that patients with a mixed major depression-anxiety disorder have a remarkably high frequency of borderline, avoidant, dependent, and passive-aggressive personality disorders, compared to other patients, irrespective of whether the MCMI or the SIDP have been applied (Alnaes & Torgersen, in press-a, in press-b). Perhaps the "real" disorder may partly be detected by questionnaires and partly by interviews. It is reasonable to suggest that predictive validation research, in addition to studying convergent and discriminant validation as has been done in this study, should take place.

ACKNOWLEDGMENT This study was supported by grants from the Norwegian Research Council for Science and the Humanities, Solveig and Johan P. Sommer's legacy, Haldis and Josef Andresen's legacy, and funds administered by the University of Oslo. We thank D. E. Eilertsen for technical and statistical assistance.

REFERENCES Alnaes, R., & Torgersen, S. (1988). DSM-111 symptom disorders (Axis I) and personality disorders (Axis II) in an outpatient population. Acta Psychiatrica Scandimwica, 78, 348-355. Alnzes, R., & Torgersen, S. (in press-a). DSM-I11 personality disorders among patients with major depression, anxiety disorders and mixed conditions. Journal of Mental and Nervous Diseuse.

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Alnzs, R., & Torgersen, S. (in press-b). MCMI personality disorders among patients with major depression with and without anxiety disorders. Journal of Personality Disorders, in press. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. Cantrell, J. D., &Dana, R. H. (1987). Use of the Millon Clinical Multiaxial Inventory (MCMI) as a screening instrument at a community mental health center. Journal of Clinical Psychology, 43, 366-375. Gibertini, M., Brandenburg, N., & Retzlaff, P. D. (1986).The operating characteristicsof the Millon Clinical Multiaxial Inventory. Journal of Personality Assessment, 50, 554-567. Millon, T. (1983). Millon Clinical Multiaxial Inventory manual (3rd ed.). Minneapolis: National Computer Systems. Millon, T. (1985). The MCMI provides a good assessment of DSM-UI disorders: The MCMI-U will prove even better. l o u d of Personality Assessment, 49,379-391. Piersma, H. L. (1987). The MCMI as a measure of DSM-111, Axis U diagnoses: An empirical comparison. Journal of Clinical Psychology, 43, 478-483. Retzlaff, P. D., & Gibertini, h4. (1987). Factor structure of the MCMI basic personality scales and common-item artifact. Journal of Personality Assessment, 51, 588-594. Spitzer, R., & Williams, J. (1983). Structured Clinical Interview for DSM-I11 Disorders (SCID). New York: New York State Psychiatric Institute, Biometric Research Department. Widiger, T., & Sanderson, C. (1987). The convergent and discriminant validity of the MCMI as a measure of the DSM-IU personality disorders. Journal of Personality Assessment, 51, 228-242. Widiger, T., Williams, J., Spitzer, R., & Frances, A. (1985). The MCMI as a measure of DSM-111.. Journal of Personality Assessment, 49, 366-378. Widiger, T., Williams, I., Spitzer, R., &Frances, A. (1986). The MCMI as a measure of DSM-111: A brief rejoinder to Millon (1985). Journal of Personality Assessment, 50, 198-204.

Svenn Torgersen Department of Psychology University of Oslo Postbox 1039, Blindern 03 15 Oslo 3 Norway Received February 3, 1989 Revised March 9, 1990

The relationship between the MCMI personality scales and DSM-III, axis II.

Compared were the personality scales of the Millon Clinical Multiaxial Inventory (MCMI) to the diagnosis of personality disorder, according to the Dia...
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