Popularity

 MCMI has become extremely

popular.
MMPI-2 more popular
Rorschach more popular
 Author : Ted Millon

Ted Millon
MCMI-III: Part of a Suite of Millon Inventories

 Millon Clinical Multiaxial Inventory – III

 Millon Adolescent Clinical Inventory
 Millon Index of Personality Styles – Revised
 Millon Behavioral Medicine Diagnostic
 Millon College Counseling Inventory
 Millon Pre-Adolescent Clinical Inventory
 Overview of the MCMI-III
 Administer To: 18 years + (18-55 sample)
 Reading Level
8th Grade
 Completion Time
25 minutes (175 items)
 Formats
Paper-and-pencil, audiocassette, computer
 Report Options
Interpretative and Profile
 Scoring Options:
Hand, Mail-in, Microtest Q
 Normative Sample
 998 males and females with a wide variety of
diagnoses
 Included individuals from:
independent practices
clinics
mental health centers
forensic settings
residential settings
hospitals
Key Features of the MCMI-III
 Multiaxial Inventory
All 14 PDs from DSM-IV and DSM-III-R
 95 test items directly reflect DSM-IV Axis II
criteria
 Use of “prototypal” items
 Base rates…not T scores
 Personality patterns based upon Millon’s
theoretical construct
 Utilized “threefold validation model”
 Axis I Clinical Syndromes
 Anxiety
 apprehensive to phobic, tense.
 restless, physical manifestations, worrisome
 Somatoform
 preoccupation with health
 hypochondriacal
 could be medical problem
 Bipolar-Manic
 elation
 inflated self-esteem
 overactivity
 Irritability
 decreased need for sleep
 Axis I Clinical Syndromes
 Dysthymia
chronic low-grade depression
behavioral apathy, low self-esteem
 Alcohol Dependence
current or historical alcohol abuse or dependence
 Drug Dependence
current or historical drug abuse or dependence
 Axis I Clinical Syndromes
 Post-Traumatic Stress Disorder
Experience of previous trauma
Reacted with…
○ intense fear
○ feelings of helplessness
○ distressful recollections
○ nightmares of traumatic event.
Contrast with Other
Instruments
 Some Issues in Using the MCMI
 MCMI is extremely “theory heavy”
 Multiple difficult concepts
What is a personality disorder?
What is a base rate score?
What is a prototypal item?
What is the multiaxial model?
 A full day could be spent on any single PD.
Each PD has its own body of clinical theory.
Importance of PDs to
Assessment
 Axis II Personality Disorders

Schizoid Sadistic (DSM-III-R Appendix)

Avoidant Compulsive
Dependent Negativistic (DSM-IV Appendix)
Depressive (DSM-IV Appendix) Masochistic (DSM-III-R Appendix)
Histrionic Schizotypal
Narcissistic Borderline
Antisocial Paranoid
 Prevalence Rates are High
 Prevalence rates in community studies
average about 13% (Mattia and
Zimmerman, 2001)
Compulsive: 4%
Histrionic, Schizotypal, Dependent: 2%
 Ifthe prevalence rates of PDs in the
community are high, then the prevalence of
maladaptive personality traits must be
higher.
 PDs Exact a Huge Toll on Society
 Some PDs repeatedly trample on the rights
of others.
 Some PDs repeatedly enter periods of crisis
and are at risk for committing suicide.
 Some PDs become disproportionally
involved in litigation.
 All PDs are believed to be at least
somewhat resistant to psychotherapy.
 Why do we Need a Theory?
 Some obvious reasons
To understand our clients
To suggest effective psychotherapies
To suggest avenues of advancing our science.
 The real reasons
Every taxonomy is really based on theory.
Theory provides a way of organizing and
differentiating the subject matter of the field.
 Every Science Has a Taxonomy

 Every science has a taxonomy.

A taxonomy is a system of constructs that
guides thinking about the subject domain.
○ Chemistry : Periodic table of elements
○ Physics : Standard model of fundamental forces
and particles.
○ Biology : Branches of the tree of life.
 Purpose of Taxonomy:
Periodic Table of Elements

 First published
by Dmitri
Mendeleev in
1869.
 Knowing the
element means
automatically
knowing the
atomic weight
and possible
 Taxonomy brings structure to a field.
chemistry of the  Taxonomy inter-relates and differentiates
element. the phenomena of the field.
 Taxonomy should
“Carve Nature at its Joints”
 If we know what group at atom belongs to…
We its electron orbitals
What kinds of compounds might be created, and with what
other elements.
 Classification is not merely descriptive, but explanatory.
 To the extent that a classification “works for us,” we are
entitled to believe that it has objective existence in
nature.
 Stages of Scientific Development

 All sciences pass through a “natural history” stage.

 Observe the phenomena of the subject domain in
sufficient detail to establish primitive systems of
classifications.

1 2 3
Birth of Science:
Discovery of
Natural History Reworking of
Organizing Principles
Phase Taxonomy into
Core to the Science
Explanatory Categories

Linnaeus Darwin: Modern Biological

Theory of Evolution Classifications based on
Genetics and Evolution
 In the Natural History Phase, Domains of
Clinical Science Grow Independently

Theory Therapy Instrumentation

 List of Psychotherapies (A through L)
 Acceptance and commitment therapy (ACT)  Dyadic Developmental Psychotherapy (DDP)
 Adlerian therapy  Ecological Counseling
 Analytical psychology  Emotional Freedom Techniques (EFT)
 Art therapy
 Encounter groups
 Attack therapy
 Eye Movement Desensitisation and Reprocessing (EMDR)
 Attachment-based therapy (children)
 Existential therapy
 Attachment therapy
 Exposure and response prevention
 Attachment-based psychotherapy
  Expressive therapy
Autogenic training
  Family Constellations
Behavior modification
  Family therapy
Behavior therapy
 Biodynamic psychotherapy  Feminist therapy
 Bioenergetic analysis  Functional Analytic Psychotherapy (FAP)
 Biofeedback  Focusing
 Bionomic psychotherapy  Freudian psychotherapy
 Body psychotherapy  Gestalt therapy
 Brief therapy  Gestalt Theoretical Psychotherapy
 Classical Adlerian psychotherapy  Grinberg Method
 Characteranalytic vegetotherapy  Group Analysis
 Child psychotherapy  Group therapy
 Client-centered psychotherapy  Guided Imagery Therapy
 Co-counselling  Hakomi
 Cognitive analytic psychotherapy  Holistic psychotherapy
 Cognitive behavior therapy (CBT)  Holotropic Breathwork
 Coherence therapy  Holding therapy
 Collaborative therapy  Humanistic psychology
 Concentrative movement therapy  Human givens psychotherapy
 Contemplative psychotherapy  Hypnotherapy
 Conversational model  Integrative body psychotherapy
 Core process psychotherapy  Integral psychotherapy
 Dance therapy  Integrative psychotherapy
 Depth psychology  Intensive short-term dynamic psychotherapy
 Daseinsanalytic psychotherapy
 Internal Family Systems Model
 Developmental Needs Meeting Strategy (DNMS)
 Internet based psychotherapy
 Dialectical behavior therapy (DBT)
 Interpersonal psychoanalysis
 Dreamwork
 Interpersonal psychotherapy
 Drama therapy
 Jungian psychotherapy
 Logotherapy
List of Psychotherapies (M through Z)
 Marriage counseling  Pulsing (bodywork)
 Milieu Therapy  Radix therapy
 Mindfulness-based Cognitive Therapy  Rational Emotive Behavior Therapy (REBT)
 Mindfulness-Based Stress Reduction (MBSR)  Rational Living Therapy (RLT)
 Mentalization based treatment (MBT)  Rebirthing-Breathwork
 Method of Levels (MOL)  Recovered Memory Therapy
 Morita Therapy  Re-evaluation Counseling
 Multimodal Therapy  Reiki
 Multitheoretical Psychotherapy  Relationship counseling
 Music therapy  Relational-Cultural Therapy
 Narrative Therapy  Relational Empowerment Therapy
 Neuro-linguistic programming (NLP)  Reprogramming
 Nonviolent Communication  Reality therapy
 Object Relations Psychotherapy  Rubenfeld Synergy
 Orgonomy  Reichian psychotherapy
 Parent-Child Interaction Therapy (PCIT)  Rolfing
 Pastoral counseling/therapy  Self-relations Psychotherapy (or Sponsorship)
 Person-centered (or Client-Centered or Rogerian) psychotherapy  Sensorimotor Psychotherapy
 Personal construct psychology (PCP)  SHEN Therapy
 Play therapy  Social Therapy
 Positive psychology  Solution focused brief therapy
 Positive psychotherapy  Somatic Psychology
 Postural Integration  Sophia analysis
 Primal therapy  Status dynamic psychotherapy
 Primal integration  Systematic desensitization
 Process Oriented Psychology  Systematic Treatment Selection (STS)
 Provocative Therapy  Systemic Constellations
 Psychedelic psychotherapy  Systemic Therapy
 Psychoanalytic psychotherapy  T Groups
 Psychoanalysis  Thought Field Therapy
 Psychodrama  Transactional Analysis (TA)
 Psychodynamic psychotherapy  Transactional Psychotherapy (TP)
 Psychosynthesis  Transference Focused Psychotherapy
 Psychosystems Analysis  Transpersonal psychology
 Twelve-step programs
 Unitive Psychotherapy
 Vegetotherapy
Principles of Reinforcement
Millon’s 1969 Theory
 Based on Reinforcement Principles
 Source of Reinforcement (Self versus Others)
 Independent types
○ Turn to their own values and desires for reinforcement.
 Dependent types
○ Derive reinforcement from the responses and attention of
others.
 Detached types
○ Derive few rewards from self or others.
 Ambivalent types
○ Are deeply conflicted about whether to pursue their own values
and desires or those of others.
○ Gets psychodynamic formulations into the model.
 The Eight Basic Patterns, MCMI-I
Dependent Independent Detached Ambivalent
Active Histrionic Antisocial Avoidant Negativistic
Passive Dependent Narcissistic Schizoid Compulsive

 Looks like a very clean model.

 Looks like a structural model of the PDs.
 But is not structural in the sense that a circumplex is structural.
 Taxonomic Problem
 Does not generate all the PDs.
 Paranoid, Borderline, Schizotypal PDs not developed by the
model.
 Familiar and Unfamiliar Patterns
Dependent Independent Detached Ambivalent
Active Histrionic Antisocial Avoidant Negativistic
Passive Dependent Narcissistic Schizoid Compulsive

Familiar Less Requires

Easily Familiar Comment
Accepted
 Passive-Detached Pattern
 Passive-
Detached(Schizoid)
Shy
Emotionally colorless
Seemingly insensitive to
emotions of others.
Devoid of affectionate needs.
Lack strong ambitions or
motivation.
 Active-Detached Pattern
 Active-Detached(Avoidant)
Highly alert to the emotions
of others.
Overstimulated by social
engagement.
Low self-esteem.
Withdraws due to fears of
social humiliation.
Avoidant PD Movie
 Active-Ambivalent Pattern
 Active-Ambivalent
(Negativistic)
Filled with conflict between
the desires of self and the
demands of others.
When turned to others,
experiences inner
resentment.
When turned to self,
experiences guilt.
Negativistic PD Movie
 Passive-Ambivalent Pattern
 Passive-Ambivalent
(Compulsive)
Overcontrolled, repressed.
Overly compliant to rules
and regulations
Perfectionistic to the point of
overwork.
Indecisive
 Severe Personality Disorders
Dependent Independent Detached Ambivalent
Active Histrionic Antisocial Avoidant Negativistic
Passive Dependent Narcissistic Schizoid Compulsive

Severe Borderline Paranoid Schizotypal Borderline or

Personality Paranoid
Pattern

 The basic patterns exhibit stylistic preferences.

 The severe PDs are structurally compromised.
 Taxonomic Strength
 Seems to establish a continuum of severity between the PDs
and the Axis I disorders
 Detached Patterns
 Derive reinforcement neither from themselves or
others.
 Ultimately builds a bridge between forms of
social withdraw and schizophrenia.
Passive-detached = Schizoid = Negative Symptoms
Active-detached = Avoidant = Positive Symptoms

Schizoid Schizotypal
Avoidant
 From Histrionic and Dependent to the Borderline
 Histrionic and Dependent
 Attention and focus are on others.
 Self-esteem is measured by the attitudes of others.
 Borderline
 Emotional lability and Identity Diffusion
○ Deficits of identity development and self-definition lead to inadequate internal controls.
 Pathologies of Attachment.
○ Desperate needs for affection
○ Fears of abandonment.

Histrionic, Borderline
Dependent
 Creates an
Interpretive Principle

 The MCMI-I contained the

eight basic personalities.
 Plus the severe
personalities.
 Borderline
 Paranoid
 Schizotypal
 Creates an Interpretive
Principle
 Severity of personality
pathology is judged by
elevation of the Borderline,
Paranoid, and Schizotypal
scales.
 So for example…
 Same profile, but with highly
elevated Borderline.
 Much more severe personality
pathology.
 Structural aspects of pathology
will take precedence over
stylistic ones.
 The MCMI-II’s
Prototypal Model
 The Structure of the DSM:
Characteristics of Prototypal Model
 Prototypes are pure expressions, or “ideal types,” not intended to exist in
nature.
 Few patients will exhibit all of the characteristics of the prototype.
 Many patients will have a minority of the characteristics of any particular
diagnostic prototype.
 Those who have enough will reach “diagnostic threshold,” and obtain a
diagnosis.
 Imagine Personality Pathology as a Space
 Normal distribution in each of its two dimensions.

Normal Distribution Bivariate Normal Distribution

 Item Weighting
 Some items weighted more than others.
 MCMI-II
Prototypal items weighted 3 points.
Other items weighted 2 or 1 points.
Criticized for extensive item overlap.
 MCMI-III
Revised weighting scheme to reduce item overlap.
Prototypal items weighted 2 points.
Peripheral items weighted 1 point.
 What are Prototypal Items?
 Prototypal model used by
DSM.
 Some features more C4
central to construct, while C7
others lack specificity and C3
are more peripheral. C1
Near edge of C2
 Contrasts to monothetic prototype
model of DSM-II
C6
C5

Clinical Prototype
 Narcissistic Personality:
Prototypal versus Peripheral Items
 5. I know I’m a superior person, so I don’t care
what people think.
Prototypal
Items  26. Other people envy my abilities.
(example)  67. I have many ideas that are ahead of the times.

 21. I like to flirt with members of the opposite sex.

(histrionic)
Peripheral  38. I do what I want without worrying about its
Items
effect on others. (antisocial)
(example)
 80. It’s very easy for me to make many friends
(histrionic).
 Diagnostic Criteria and Prototypal Items
Diagnostic Criteria: Compulsive PD MCMI-III Prototypal Item

1. Preoccupied with details, rules, lists, order, 82. I always make sure that my
organization, or schedules to the extent that the work is well-planned and
major point of the activity is lost. organized.
2. Shows perfectionism that interferes with task 114. A good way to avoid
completion (e.g., unable to complete a project mistakes is to have a routine for
because own strict standards are not met). doing things.
3. Excessively devoted to work and productivity to 137. I always see to it that my
the exclusion of leisure activities and friendships (not work is finished before taking
accounted for by obvious economic necessity). time out for leisure activities.

 Not all diagnostic criteria have a prototypal item, but most do.
 Prototypal items can be inspected to determine if individual meets criteria.
 Prototypal items can go into interpretive report.
Creates an Interpretive Principle
 Useprototypal items to suggest
diagnostic criteria to inquire.
The DSM makes the diagnosis, not the
MCMI.
Use the MCMI to suggest diagnoses.
Examine prototypal items to see if they
support particular DSM criteria.
Base Rate Scores and
Diagnostic Efficiency
Base Rate Scores, not T Scores
 T Scores implicitly
assume that the
base rate of all
disorders is equal.
 All T-score beyond
a certain threshold
are considered
abnormal and
interpretable.

Normal Distribution
Base Rate Scores, not T Scores
 Adjust raw scores based on the
actual prevalence rates.
If 20% of patients are depressed, then
the test should reflect this.
If 5% of patients are bipolar, then test
should reflect test.
 Ideally, the BR = Consequence of Possessing the
Amount of a Trait or Disorder

 Gives not the “amount” of the trait as

evidenced by some deviation score.
 Instead, gives the pathological potential or
consequences of the amount of the trait.
Thresholds should be Equated in terms of GAF

Schizoid

Avoidant

Dependent

Histrionic

Narcissistic

GAF
100 90 80 70 60 50 40 30 20 10

Diagnostic
Threshold
 Nevertheless, Can be useful in
Detecting Asymptomatic PDs

 Can be useful in detecting asymptomatic

PDs.
 Definition of Asymptomatic PDs
Occurs when the individual possesses a PD in the
absence of anxiety or depression, or any other
Axis I disorder.
Loose definition: Some antisocial PDs are
notoriously low in anxiety.
 Behavior is Product of Person and Situation

The Person (Axis II)

Normal Abnormal
The Situation (Axis IV)

Normal Little or no potential for an Personality Disorder:

Axis I problem. Problems perceiving self and
others. Imposes self onto
environment and makes a
normal situation into an
abnormal one.

Abnormal Crazy Situation Potential for Maximal

Adjustment Disorder: Pathology
Person in a crazy situation Person with personality
pathology in a situation that
would cause problems for a
normal person.
 Individuals Seek Out Matching Environments

 Case adapted from Millon, 1969.

 Roy was a successful sanitation engineer involved in planning
water resources for a large city.
 His job called for foresight and independent judgment, but little
supervision or affiliation with others.
 In general, he was appraised as a competent and reliable, but
undistinguished employee.
 Some coworkers saw him as shy, others as cold and aloof.
 Difficulties centered around his relationship with his wife, who
insisted they come for therapy, due to his unwillingness to join
family activities, lack of affection for her, and disinterest in sex.
 His wife tried to maneuver him into social situations, but to no
avail.
 Roy’s MCMI-III
(constructed)
 Roy is a schizoid
personality who’s
found an
occupational match
for his personality
disorder.
 Roy will okay as
long as no one
expects anymore
from him.
 Roy will manifest
Axis I disorders due
to his wife.
 Diagnostic Efficiency: Positive Predictive Power

Diagnosis Diagnosis
Positive Negative
Test Positive True Positive False Positive (20)
(40)
Test Negative False Negative True Negative

 Positive Predictive Power

TP / All Test Positives
When the test is positive, what are the chances
that the subject really has the diagnosis?
40 / 60 = 67%
 What’s the PPP here?

Diagnosis Diagnosis
Positive Negative
Test Positive True Positive False Positive (900)
(100)
Test Negative False Negative True Negative

 Positive Predictive Power

TP / All Test Positives
When the test is positive, what are the chances
that the subject really has the diagnosis?
 Diagnostic Efficiency: Sensitivity

Diagnosis Diagnosis
Positive Negative
Test Positive True Positive False Positive
(40)
Test Negative False Negative True Negative
(40)

 Sensitivity
TP / All Real Positives
What percentages of people who have the
condition are picked up by the test?
40 / 80 = 50%
 What’s the Sensitivity here?

Diagnosis Diagnosis
Positive Negative
Test Positive True Positive False Positive
(50)
Test Negative False Negative True Negative
(200)

 Sensitivity
TP / All Real Positives
What percentages of people who have the
condition are picked up by the test?
40 / 80 = 50%
Diagnostic Efficiency of PD Scales
 Interpretive Principle
 Don’t let the test rule your decision-making
process.
MCMI-III often fails to find disorder where clinicians
judge it present (sensitivity)
MCMI-III often flags a subject as disordered, when
clinicians judge it absent (positive predictive power)
 Other instruments don’t even report this
information.
 Integration Intrinsic to Definition of Personality

 Think about what personality…

Habitual patterns of thinking, feeling, and
relating…
Personality is the patterning of variables across
the entire matrix of the person.
Current Perspectives on Personality
 Biophysical Models
 Temperament Theories: Siever, Akiskal
 Neurobiological Theories: Cloninger, DePue We cannot look
 Intrapsychic Models for organizing
 Psychodynamic Theories: Freud, Abraham, Reich principles that
issue from any
 Structural Theories: Kernberg
particular
 Phenomenological Models perspective.
 Cognitive Theories: Beck, Ellis, Horowitz Otherwise, we
 Lexical Theories: Goldberg, Costa, Widiger end up with just
another
 Behavioral Models perspective.
 Social Learning: Bandura
 Interpersonal: Benjamin, Kiesler
Parable of Blind Men and the Elephant
 “It’s like a wall”
 “No, it’s like a long
rope”
 “No, it’s like a
column”

 No, it’s interpersonal.

 No, it’s cognitive.
 No, it’s
psychodynamic.
 No, it’s biological.
 This Sets our Theoretical Agenda

 The history of personality is a history of

part-functions.
 Integrating principles outside the parts.

 We can expect other taxonomies that

embody principles that will be concealed
by our “grand theory.”
 Robert Trivers
 Reciprocal Altruism(1971)
 Parental Investment (1972)
 Parent-Offspring Conflict (1974)
 Sociobiology, E.O Wilson (1975)

 Behavior is a by product of
natural selection.
Behaviors have evolved over time.
Today’s behaviors are those that
have been evolutionarily
successful.
Individual and social behavior are
the products of successful
evolution.
Evolutionary Polarities
Millon Found the Organizing Principles
in Evolution
 Pain versus Pleasure (life enhancement and life preservation)
 Basic survival aim.
 Help keep organisms from harm.
 Active versus Passive
 Mode of adaptation.
 Once you exist, you exist within an environment.
 You can either modify your ecological niche to suit your own needs, or
passively accommodate to what the environment offers you.
 Self versus Other
 Reproductive
 Male strategy, to reproduce the self over and over
 Female strategy, to invest greatly in others.
 Pleasure vs Pain Polarity
 Pleasure vs. Pain
Schizoid: Passive, low pleasure, low pain
Depressive: Passive, high pain, low
pleasure
Avoidant: Active, high pain, low pleasure
 Reversal of Pleasure and Pain
Masochistic: Passive Reversal
Sadistic: Active Reversal
 Self vs Other Polarity
 High Other
Dependent Personality: Passive, high other.
Histrionic: Active, high other.
 High self
Narcissistic: Passive, low other
Antisocial: Active, low other
 Self-Other Ambivalence
Compulsive: Passive
Negativistic: Active
From Toward a New Personology (1990)

 Nothing new happened taxonomically

 No new personality constructs
 Functional and Structural Domains

Defense
Mechanisms

Narcissistic Personality
Self-Image
Behavioral Interpersonal
Acts Object Representations Conduct

Mood-Temperament

Cognitive
Style
 Operationalize Personality
Across its Major Domains
Narcissistic
Personality
Haughty Rationalization
Expressive Behavior Regulatory Mechanism Insouciant
Mood/Temperament

Exploitive Admirable
Interpersonal Conduct Self-Image

Contrived Spurious
Expansive Object Representations Morphologic Organization
Cognitive Style
 Narcissistic PD (See Packet for PD Descriptions)

Functional Domains Structural Domains

Expressively Haughty (e.g., acts in an arrogant,
supercilious, pompous, and disdainful manner, flouting
conventional rules of shared social living, viewing them as
naive or inapplicable to self; reveals a careless disregard for
personal integrity and a self-important indifference to the
rights of others).
Admirable Self-Image (e.g., believes self to be meritorious,
special, if not unique, deserving of great admiration, and acting
in a grandiose or self-assured manner, often without
commensurate achievements; has a sense of high self-worth,
despite being seen by others as egotistic, inconsiderate, and
arrogant).

Interpersonally Exploitive (e.g., feels entitled, is Insouciant Mood-Temperament (e.g., manifests a general air
unempathic and expects special favors without assuming of nonchalance, imperturbability, and feigned tranquility;
reciprocal responsibilities; shamelessly takes others for appears coolly unimpressionable or buoyantly optimistic,
granted and uses them to enhance self and indulge desires). except when narcissistic confidence is shaken, at which time
either rage, shame, or emptiness is briefly displayed).

Expansive Cognitive Style (e.g., has an undisciplined Contrived Object-Relations (e.g., internalized
imagination and exhibits a preoccupation with immature and representations are composed far more than usual of illusory
self-glorifying fantasies of success, beauty or love; is and changing memories of past relationships; unacceptable
minimally constrained by objective reality, takes liberties with drives and conflicts are readily refashioned as the need arises,
facts and often lies to redeem self-illusions). as are others often simulated and pretentious).

Rationalization Regulatory Mechanism (e.g., is self-
deceptive and facile in devising plausible reasons to justify
self-centered and socially inconsiderate behaviors; offers
alibis to place oneself in the best possible light, despite
evident shortcomings or failures).
Spurious Morphologic Organization (e.g., morphologic
structures underlying coping and defensive strategies tend to
be flimsy and transparent, appear more substantial and
dynamically orchestrated than they are in fact, regulating
impulses only marginally, channeling needs with minimal
restraint, and creating an inner world in which conflicts are
dismissed, failures are quickly redeemed, and self-pride is
effortlessly reasserted).
 Another Interpretive Principle
 Since personality is about integration…
The domain descriptions are provided to
operationalize the PDs.
 When writing case reports
Consider borrowing text from these functional
and structural domains.
 The Structure of the DSM:
Multiaxial Model

 Axis I: Classical Phenomenological Syndromes (e.g., Anxiety,

Depression, Schizophrenia)
 Axis II: Personality Disorders
 Axis III: Medical Disorders
 Axis IV: Psychosocial Environment
 Axis V: Global Assessment of Functioning
 The Structure of the DSM:
Multiaxial Model: Lines of Causality in Psychopathology

Interaction
of Axis IV Axis IV: Psychosocial  The shift to
and Axis II Environment
produces
multiaxial
Axis I Axis II: Personality conceptions
Disorders
resembles the
Axis I: shift that occurred
Clinical
Syndromes in medicine a
century ago.
Anxiety, Depression =
Fever, Cough, Boils

Histrionic, Sadistic =
Immune System

Marriage, Money =
Infectious Agents
 Example: The Schizoid-Compulsive Accountant
 Mark S. worked quietly and efficiently for many years “crunching numbers”
for a financial services company.
 His greatest pleasure seem to derive from performing his tasks to
perfection.
 He seldom displayed any emotion to others, and was always observed
existing at the fringes of company parties. He was never observed with a What is the
girlfriend, and others at the company reported his reluctant to engage interaction
anyone socially, where he was known as “a man of few words.” between
 Because of his excellent work history, and nearly perfect attendance, he Axis IV and
was assigned to manage a group of young accountants, newly recruited Axis I that
when the company expanded. produces
 Interacting with the new employees made Mark feel anxious, to the point Axis I?
that he began missing work.
 In therapy, Mark had little insight into the source of his anxiety.
 In part, it seemed to derive from the fear that his supervisees would not be able to perform
at his standards.
 In part, Mark felt that his cozy corner of the world had been intruded upon by outsiders as a
result of his new responsibilities. He longed to return to his previous position.
 Example: The Narcissistic Portfolio Manager
 Mark S. managed several million in securities for a financial services company.
 His greatest pleasure seem to derive from the admiration he received at What is the
performing his job perfectly.
interaction
 His confidence was obvious, especially at company parties. He was never seen
without a girlfriend, and others at the company noted his desire to move forward
between
up the company ladder. Although he was sometimes noted for his insensitivity, his Axis IV and
self confidence drew others to him. Axis I that
 Because of his excellent work history, and nearly perfect attendance, he was produces
assigned to manage a group of young business school graduates, newly recruited Axis I?
when the company expanded.
 Interacting with the new employees made Mark feel anxious, to the point that he
began missing work and drinking.
 In therapy, Mark had little insight into the source of his anxiety.
 In part, it seemed to derive from the fear that his supervisees would embarrass him by tarnishing the
admirable self-image he secretly nurtured.
 In part, Mark felt that the new recruits were inferior to his own skills and ability, and resented “wasting
his time with people so hopelessly ignorant.” He longed to return to his previous position.
 Creates An
Interpretive Principle The Schizoid-Compulsive
Accountant
 Multiaxial model is an
intrinsically integrative
conception.
 Provides a model of
how psychopathology
emerges and is
perpetuated.
 Specifically requires us
to develop an
integrative conception
of the patient that
transcends a list of
diagnoses.
 Multiaxial Model:
Establishes Causal Pathways of Psychopathology
1) What are the psychosocial (Axis IV)
Axis IV: Psychosocial issues exerting stress through the
Environment current situation?
2) Are these issues being “metabolized” by
Axis II: Personality the personality structure?
Disorders 3) How is the individual reacting to
1 awareness of their own clinical
syndromes? (typically with increased
Axis I: rigidity, further reducing range of coping
Clinical responses)
Syndromes 2 4) How is increased rigidity of personality
feeding back on influencing the
3 psychosocial situation?
4 5) How are clinical symptoms influencing
the psychosocial situation?

5
 Multiaxial Model:
Allows us to Understand Asymptomatic Personality Disorders

 Recall that Axis I = Interaction of Axis II

and Axis IV.
Axis IV: Psychosocial  Accordingly, some personalities will
Environment “inhabit” environments that allow them to
capitalize on their particular traits.
 Like species that are adapted to a narrow
Axis II: Personality ecological niche.
 If the environment changes just a little, the
species is threatened.
 Only when these environments change
does the person exhibit symptoms.
 A schizoid-compulsive accountant develops
panic attacks when relocated from an isolated
office to a more central location.
 An intelligent narcissistic high school student,
admired by his classmates, becomes depressed
when he realizes he’s “just another student” at a
very exclusive school.
 Without the Multiaxial Model…
 Multiaxial model specifically requires that
we create an integrated conception of the
individual’s psychopathology.
 Without a theory of the individual
personality…
You’re left treating Axis I disorders alone.
You leave patients with an enduring
vulnerability.
 With the Multiaxial Model and a
Personality Theory…
 You have a comprehensive basis for an
integrated science of psychopathology.
 Personality becomes central to the whole
adventure of psychopathology.
 Example: Vicious Circles in the Narcissistic PD

Anxiety
Violates self-image of perfection. Due to threats to validity
BLAME Must purge self of evidence of of the grandiose self
possible imperfection,
particularly guilt. Hypersensitivity
to possible slights and criticism Depression
from others. Reacts with hurt, Due to realistic feedback,
anger, rage. grandiose self not so
grand.
Rationalization of Projection of own
own shortcomings. faults onto others. Acting out
Failure to regulate anger
leading to verbal or
physical aggression,
even battering.
Escalation of hypersensitivity
Substance Use
Reduces self-monitoring
Axis IV Axis II and intrusive thoughts
related to self-blame.

Imagine having such diagrams for all the PDs Axis I

 Validity Scale
 Consists of three items.
“I flew across the Atlantic 30 times last year”
“I was on the front cover of several magazines
last year”
“I have not seen a car in the last ten years”
 Score of 2 is invalid.
 Score of 1 is questionable.
 Modifying Indices
 Disclosure Index (X)
Variation from midrange
 Desirability Index (Y)
Appear socially attractive, morally virtuous,
emotionally well-composed
 Debasement Index (Z)
generally opposite of scale Y
 HighY, Low Z: Fake good?
 Low Y, High Z: Fake bad? Cry for help?
 Scoring Adjustments
 Disclosure Adjustment
accounts for under and over reporting
 Anxiety - Depression Adjustment
accounts for acute or intense emotional state
 Inpatient Adjustment
accounts for nuances of this population
 Denial - Complaint Adjustment
accounts for personality pattern defensiveness
 Evaluate Possible Diagnoses
 Personality Scales
BR > 75 suggests personality traits
BR > 85 suggests personality disorder
 Clinical Scales
BR > 75 suggests presence of syndrome
BR > 85 suggests prominence of syndrome
 With the exception of scale X, low scores
are not interpretable
 Making Personality Disorder Diagnoses

 BR 85 suggests a PD diagnosis
However, PPP and SENS not perfect at BR 85
 Always check MCMI-III profiles against diagnostic
criteria
Endorsements of prototypal items may be relevant to
specific diagnostic criteria.
 Keep the DSM General Criteria for a Personality
Disorder in mind.
 Keep in mind the Severe Personality Disorders
 Example
MCMI-III Profile
Dealing with the Problems of Axis II
Comorbidity and PD-NOS
PDNOS is most used Diagnosis
 In other words, existing PD categories don’t
provide adequate coverage.
 “The majority of patients with personality
pathology…are currently undiagnosable on
Axis II.” Westen & Arkowitz-Weston (1998)
 Can a taxonomy endure when it’s constructs
fail to diagnose over half the patients?
Arbitrary Diagnostic Boundaries
 DSM-III (1980) adopted behaviorally specific
criteria sets in order to increase diagnostic
reliability.
 No justifications for any diagnostic thresholds.
Dramatic changes in prevalence rates across DSMs
Schizotypal prevalence dropped from 11% to 1%
from DSM-III to III-R
This is like publishing a test with no external validity
studies.
 Massive Comorbidity of PDs
 PD constructs are useless when patients
receive four or five diagnoses.
Structured interviews consistently find extensive co-
morbidity of PDs.
This situation has existed in DSM-III, published in
1980 (nearly 30 years)
 Because the MCMI is coordinated to the DSM,
it inherits this problem.
Recall that diagnostic efficiency statistics are
generally good.
Some profiles show 4 or 5 elevated PDs.
Cross-Cultural Issues Amplify Problem
 MCMI uses base rate scores, not T scores.
 Accurate diagnosis rests upon accurate estimates of
base rates.
 If base rates vary substantially…
○ Some disorders over-represented
○ Others under-represented

 What are the base rates of PDs in the

Philippines?
 Base rates of the PDs are unknown.
 Not even certain whether these PDs exist…
 Or are there other PDs specific to this culture?
 Is it even ethical to assessment patients using American norms?
Remember, MCMI struggles with certain disorders
Subtypes of Personality
 Comorbidity is the Rule, not the Exception

 Comorbidity exist because nature presents

itself in few prototypes.
Most human beings will be complex cases.
Functional and Structural Domains
Grossman Facet Scales
 Look at the Grossman Facet Scales

 Elevations above BR 65 are interpretable.

Find the interpretive text associated with that
PD from the personality domain descriptions.
That interpretive text can be adapted for your
domain-focused clinical report.
 Facet
Score
Profiles
 Narcissistic PD Personality Domains
Functional Domains
Expressively Haughty (e.g., acts in an arrogant,
supercilious, pompous, and disdainful manner, flouting
conventional rules of shared social living, viewing them as
naive or inapplicable to self; reveals a careless disregard for
personal integrity and a self-important indifference to the
rights of others).
Structural Domains
Admirable Self-Image (e.g., believes self to be meritorious,
special, if not unique, deserving of great admiration, and acting
in a grandiose or self-assured manner, often without
commensurate achievements; has a sense of high self-worth,
despite being seen by others as egotistic, inconsiderate, and
arrogant).

Interpersonally Exploitive (e.g., feels entitled, is Insouciant Mood-Temperament (e.g., manifests a general air
unempathic and expects special favors without assuming of nonchalance, imperturbability, and feigned tranquility;
reciprocal responsibilities; shamelessly takes others for appears coolly unimpressionable or buoyantly optimistic,
granted and uses them to enhance self and indulge desires). except when narcissistic confidence is shaken, at which time
either rage, shame, or emptiness is briefly displayed).

Expansive Cognitive Style (e.g., has an undisciplined Contrived Object-Relations (e.g., internalized
imagination and exhibits a preoccupation with immature and representations are composed far more than usual of illusory
self-glorifying fantasies of success, beauty or love; is and changing memories of past relationships; unacceptable
minimally constrained by objective reality, takes liberties with drives and conflicts are readily refashioned as the need arises,
facts and often lies to redeem self-illusions). as are others often simulated and pretentious).

Rationalization Regulatory Mechanism (e.g., is self-
deceptive and facile in devising plausible reasons to justify
self-centered and socially inconsiderate behaviors; offers
alibis to place oneself in the best possible light, despite
evident shortcomings or failures).
Spurious Morphologic Organization (e.g., morphologic
structures underlying coping and defensive strategies tend to
be flimsy and transparent, appear more substantial and
dynamically orchestrated than they are in fact, regulating
impulses only marginally, channeling needs with minimal
restraint, and creating an inner world in which conflicts are
dismissed, failures are quickly redeemed, and self-pride is
effortlessly reasserted).
 Narcissistic Facet Scales
 Admirable Self-Image
 Believes self to be meritorious, special, if not unique, Adapt text
deserving of great admiration, and acting in a grandiose or from the
self-assured manner, often without commensurate personality
achievements; has a sense of high self-worth, despite domains to
being seen by others as egotistic, inconsiderate, and
arrogant.
different
sections of
 Expansive Cognitive Style the case-
 Has an undisciplined imagination and exhibits a
focused
preoccupation with immature and self-glorifying fantasies of
clinical report.
success, beauty or love; is minimally constrained by
objective reality, takes liberties with facts and often lies to
redeem self-illusions.
 Interpersonally Exploitive
 Feels entitled, is unempathic and expects special favors
without assuming reciprocal responsibilities; shamelessly
takes others for granted and uses them to enhance self and
indulge desires.