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Do changes on MCMI-II personality disorder
scales in short-term psychotherapy reflect trait
or state changes?
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Do changes on MCMI-II personality disorder scales in
short-term psychotherapy reflect trait or state changes?
Hans Henrik Jensena; Erik Lykke Mortensena; Martin LotzbaDepartment of Health Psychology, Institute of Public Health, University of Copenhagen, Denmark
bPsychiatric Department, Bispebjerg Hospital, Copenhagen, Denmark
First Published on: 12 March 2008
To cite this Article: Jensen, Hans Henrik, Mortensen, Erik Lykke and Lotz, Martin (2008) 'Do changes on MCMI-II personality disorder scales in short-term
psychotherapy reflect trait or state changes?', Nordic Journal of Psychiatry, 62:1, 46 - 54
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Do changes on MCMI-II personality
disorder scales in short-term psychotherapy
reflect trait or state changes?
HANS HENRIK JENSEN, ERIK LYKKE MORTENSEN, MARTIN LOTZ
Jensen HH, Mortensen EL, Lotz M. Do changes on MCMI-II personality disorder scales in short-term psychotherapy reflect trait or state changes? Nord J Psychiatry 2008;62:4654. Oslo. ISSN 0803-9488.
The Millon Clinical Multiaxial Inventory (MCMI) has become an important and commonly used instrument to assess personality functioning. Several studies report significant changes on MCMI personality disorder scales after psychological treatment. The aim of the study was to investigate whether prepost-treatment changes in 39-session psychodynamic group psy-chotherapy as measured with the MCMI reflect real personality change or primarily reflect symptomatic state changes. Prepost-treatment design included 236 psychotherapy outpatients. Personality changes were measured on the MCMI-II and symptomatic state changes on the Symptom Check List 90-R (SCL-90-R). The MCMI Schizoid, Avoidant, Self-defeating, and severe personality disorder scales revealed substantial changes, which could be predicted from changes on SCL-90-R global symptomatology (GSI) and on the SCL-90-R Depression scale. The MCMI Dependent personality score was the only MCMI personality scale showing significant change when the SCL-90-R Depression change score was included as a covariate. Splitting patients into those with and without personality disorders did not change the results. Observed changes on MCMI-II personality disorder scales in short-term psychotherapy reflect change in symptomatic state. The MCMI-II Base Rate cut-off points probably include too many patients, justifying the introduction of new scoring procedures in the MCMI-III.
MCMI-II, Outcome evaluation, Psychological treatment, SCL-90-R, Statetrait changes.
Hans Henrik Jensen, Department of Health Psychology, Institute of Public Health, Faculty of Health Sciences, University of Copenhagen, Øster Farimagsgade 5A, PO Box 2099, DK-1014, Copenhagen K, Denmark, E-mail: [email protected]; Accepted 19 December 2006.
S
ince the Millon Clinical Multiaxial Inventory(MCMI) was developed more than 25 years ago, it has become an important and in clinical settings commonly used personality assessment instrument. In fact, only the Rorschach and Minnesota Multiphasic Personality Inventory (MMPI) have generated more published research (1). Thus, the MCMI has been widely used as a screening instrument for Axis II personality pathology in the prediction of Axis I disorder treatment response (2). It has, however, also been used as an outcome measure in studies of the effects of short-term therapy (37).
The assumption of longitudinal consistency is inher-ent in the definition of personality traits and personality disorders (8), but even though maladaptive traits may be stable in structure, the expression of severity may change over time (9). Thus, as evidenced by the low reliability of clinical assessment of personality disorders, it may be difficult to separate stable personality traits and
struc-tures from state fluctuations in symptomatology (10), which may be important in outcome research.
In the revisions of the MCMI (versions II and III), Millon attempted to separate more clearly state phe-nomena from scores on the personality disorder scales (11, 12). However, even though corrections for the influence of acute affective states have been incorporated into the scoring procedures, it appears that the MCMI measurement of personality traits may be influenced by changes in symptomatic state. Thus, Piersma and Piersma & Boes have documented that even with short prepost-treatment test intervals, the MCMI-II and MCMI-III personality profiles were significantly ‘‘ba-lanced’’ after acute treatment for depression (13, 14). The mean scores on the Schizoid, Avoidant and Self-defeating scales significantly decreased, and scores on the Histrionic and Narcissistic scales significantly in-creased. This effect was evident less than 20 days after admission to the hospital.
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Stankovic et al. (15) also observed changes in the Hamilton Rating Scale for Depression (HSRD) to be significantly associated with reduced scores on the Schizoid and Self-defeating personality disorder scales and with increased score on the Narcissistic scale (MCMI-II). This suggests that neither the MCMI-II nor the MCMI-III measure personality characteristics independent of clinical symptomatology in samples of depressed patients. On the other hand, Svartberg et al. (7) presented evidence of changes as measured on a composite MCMI-I Avoidant, Obsessivecompulsive, Dependent and Passiveaggressive scale in the post-treatment phase of a 2-year follow-up and indicated that the MCMI-I captured different domains of psycho-pathological changes than the Symptom Check List 90-R (SCL-90-R) Global Severity Index (GSI).
According to the data reported above, prepost-treatment improvement is likely to occur in MCMI scales indicating inhibited, detached and self-defeating personality features. Interestingly the MCMI-II Schi-zoid, Schizotypal, Avoidant, Passiveaggressive, Self-defeating, and to a lesser extent the Borderline personality disorder scale, have all been found to have high loadings on a ‘‘general maladjustment’’ factor (11). Improvements in general maladjustment during psy-chotherapy may share common features with reduction of acute and chronic distress, but also with improve-ments with respect to ‘‘demoralization’’ and ‘‘subjective incompetence’’ (16, 17).
In the present study, we will address the issue of treatment changes on the MCMI-II personality disorder scales in short-term group psychotherapy. We will explore associations between MCMI prepost-treatment changes and the SCL-90-R (18), which is the most commonly used measure of symptomatic state in psychotherapeutic research (19). Of the nine SCL-90-R subscales, some must be assumed to primarily reflect symptomatic state (e.g. Depression and Anxiety) while others to some extent reflect stable traits (e.g. Inter-personal Sensitivity). The GSI is based on all subscales and thus may be assumed to primarily reflect sympto-matic state, but also to some extent stable traits.
From the results described above, we predict that even though the present 3-month psychotherapy programme has no particular focus on treatment of personality disorders and deviant traits, prepost-treatment changes on the MCMI-II Schizoid, Borderline, Avoidant, Passiveaggressive, and Self-defeating personality disor-der scales will be substantial. If the expected prepost-treatment changes on MCMI personality disorder scales primarily reflect change in symptomatic state, they should be substantially related to changes in sympto-matic state as measured by SCL-90-R Depression and Anxiety scales. On the other hand, if the changes on the MCMI personality scales primarily reflect real changes
in stable personality traits, they should be less strongly related to symptomatic SCL-90-R scales, but perhaps stronger associations may be observed between some of the MCMI personality disorder scales and the SCL-90-R Interpersonal Sensitivity scale.
Material and Methods
Participants
The study is part of a long-term outpatient psychother-apy evaluation at Bispebjerg Hospital, Copenhagen. In 199095, 378 patients were treated and 348 (92%) accepted to participate in the evaluation project. Of these patients, 86 (25%) dropped out of treatment and 26 (7%) did not return post-treatment data. Thus, the present analysis is based on data from 236 patients with complete prepost-treatment data (Table 1). The patients were mostly referred to the department from general practitioners or psychiatrists (48%) or were inpatients or from psychiatric casualty departments at the hospital (38%).
At referral, the patients mostly had a tentative diagnosis. They were invited to a first interview with one of the psychiatrists or clinical psychologists. This interview was discussed at a conference leading to a diagnostic revision. During participation in a 4-day introduction group to the department and to psy-chotherapy, the diagnosis was further established after more than 1 week of observation and psychodynamic interviews.
Demographic information and ICD-8 classifications of the major diagnostic groupings are shown in Table 1. The majority of the patients in ‘‘other states’’ (13%) include cases of symptom neurotic states and remission of psychotic conditions. The neurotic states in Table 1 may roughly correspond with ICD-10 panic and generalized
Table 1. Demographic and ICD-8 diagnostic characteristics of 236 treatment completers included in the analysis.
Completers in project 236 (100%)
Mean (s) years of age 37.1 (10.9)
Mean (s) years at school 10.2 (1.7)
Vocational status:
Employed/under education 67%
Receiving social security 20%
Pension 14%
Formally educated 71%
Females 72%
Living with partner 36%
Having children 64%
ICD-8 diagnoses
Anxiety neurosis 29%
Depressive neurosis 11%
Unspecified neurosis 10%
Personality disorder other type 37%
Other states 13%
s, standard deviation.
PERSONALITY CHANGES IN PSYCHOTHERAPY
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anxiety disorders and other anxiety states, mixed anxiety and depressive disorders, mild depressive episodes and dysthymia, and unspecified neurotic disorders. ICD-8 personality disorders correspond roughly with ICD-10 anxious (avoidant) personality disorder (22%), and emo-tional unstable personality disorder with borderline type (15%).
Treatment
All participants completed a 39-session psychodynamic group psychotherapy programme (three times a week in 13 consecutive weeks). Almost half of the patients (48%) received medical treatment (mostly anxiolytics and antidepressants) at the beginning of therapy.
Non-academic staff (80%) in conjunction with a psychiatrist, physician or a psychologist conducted the majority of the therapies. All therapists had some or full
psychotherapeutic training, and all therapies were
con-ducted under supervision.
Tests
MCMI
-II
The MCMI-II (11) is validated for use in clinical populations only (ideally outpatients as in the present study) and measures 10 mild (18b) and three severe (S, C, P) personality disorders (see Table 3 for an overview of scales). Because of item overlap with the personality disorder scales, data from the nine scales of symptomatology were not analysed in the present study. Even though clinically validated Base Rate (BR) scores are most commonly used to present test profiles (20), raw scores are analysed in the present study. This is recommended by Millon, who suggested that raw scores may be more appropriate than BR scores in the statistical analysis of the MCMI-II, since BR scores are a non-linear transformation of raw scores (11). Moreover, several studies have questioned the proposed criterion validity of the BR transformation (21).
SCL
-R
The SCL-90-R (18) measures nine dimensions of symp-toms and distress, but only data from the Depression, Anxiety, Interpersonal Sensitivity and the GSI will be
presented in tables, even though all SCL-90-R scales
were included in the analyses (see results section below). The GSI is the most widely used global index of distress in psychotherapeutic research and is recommended as a single summary measure of scores on the nine scales (18, 19). The Depression and Anxiety scales were selected as indicators of symptomatic state (22) and the Interperso-nal Sensitivity scale selected because of an assumed relationship with several personality traits, including the MCMI-II Avoidant personality disorder scale (23).
Statistical analysis
Difference scores (post-treatment minus pre-treatment) were used as measure of change and calculated for MCMI personality disorder scales and the selected SCL-90-R scales, including GSI. Pearson correlations were calculated to test associations between difference scores,
and one sample t-tests were used to test whether mean
difference or change scores differed significantly from zero (Table 2). Linear regression was used to adjust MCMI personality disorder change scores for SCL-90-R change scores (this model included the relevant SCL-90-R change score as covariate and a constant to test whether the adjusted MCMI personality change score differed significantly from zero). Chi-square and the McNemar test for the significance of change are used in the analysis of categorical data (SPSS for Windows Inc., version 11.5, Chicago, IL). Because of the explorative nature of the study, alpha was set at 0.05.
Results
Pre
post-treatment changes
Pre-treatment, post-treatment and difference score
means (standard deviation, s) of the SCL-90-R and
MCMI scales are shown in Table 2. One-sample t-tests
revealed a significant prepost-treatment decline on all
scales (PB0.01), except for the MCMI Histrionic,
Narcissistic, Antisocial and Aggressivesadistic person-ality disorder scales.
Table 3 presents Pearson correlations between MCMI and SCL-90-R difference scores. As can be seen from the table, all SCL-90-R scale difference scores correlated significantly with MCMI Schizoid, Avoidant, Depen-dent, Passiveaggressive, Self-defeating, Schizotypal, Borderline and Paranoid difference scores. When adjust-ing MCMI difference scores (Table 2) for change on the
selected SCL-90-R scales, the t-values associated with
most MCMI changes became non-significant. When GSI change was included as a covariate none of the
MCMI scales showed significant change (t1.6; P
0.10). When change on Depression was included, change on the Dependent personality scale was still significant (t2.3, P0.02). When change on Anxiety or Inter-personal Sensitivity was included, the Schizoid, Depen-dent, Aggressivesadistic, Schizotypal, Borderline and Paranoid personality score changes were still significant
(t2.0, PB0.05). In the case of Interpersonal
Sensitiv-ity, change on the Avoidant personality disorder scale
also remained significant (t2.2, P0.03). The effects
of adjusting for symptomatic change were most pro-nounced for GSI and Depression and weakest for Interpersonal Sensitivity.
We subsequently made the reverse analyses, i.e. adjusted SCL-90-R scales difference scores for changes on the MCMI scales. In these analyses, all SCL-90-R HH JENSEN ET AL.
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difference scores remained significant (t5.28, PB
0.001).
Significant prepost-treatment changes (t7.04,PB
0.001) on a composite Avoidant, Dependent, Compul-sive and PasCompul-siveaggresCompul-sive MCMI-II scale as employed by Svartberg et al. (7) turned into non-significance after
covariation with GSI (t0.36, P0.7) and Depression
(t1.45, P0.2), but not with Anxiety (t2.25, P
0.03) or Interpersonal Sensitivity (t2.70, P0.008).
However, in the reverse analyses, changes on each of the SCL-90-R scales remained significant after covariance
with the composite MCMI scale (t5.43,PB0.001).
All the above results were replicated when depressive patients were excluded from the analysis. This was also the case for SCL-90-R GSI and Depression scales in subsamples comprising patients with or without person-ality disorders according to ICD-8, but for the Anxiety and Interpersonal Sensitivity scales the pattern of
Table 2. Mean (s) pre-treatment, post-treatment, and difference scores of Symptom Check List 90-R (SCL-90-R) subscales and Millon Clinical Multiaxial Inventory, version II (MCMI-II) personality disorder scales.
Pre- Post- Diff.
Raw score Raw score Raw score t-value
SCL-90-R
Global Severity Index (GSI) 1.62 (0.54) 1.23 (0.62) 0.39 (0.49) 12.1***
Depression 2.21 (0.73) 1.69 (0.83) 0.52 (0.74) 10.8***
Anxiety 1.93 (0.78) 1.44 (0.78) 0.49 (0.68) 11.0***
Interpersonal Sensitivity 1.79 (0.77) 1.39 (0.74) 0.40 (0.67) 9.1***
MCMI
1. Schizoid 22.3 (8.7) 18.8 (8.2) 3.5 (7.3) 7.4***
2. Avoidant 26.5 (12.4) 22.0 (12.4) 4.5 (10.0) 6.9***
3. Dependent 28.9 (9.2) 26.7 (9.1) 2.2 (6.7) 5.0***
4. Histrionic 28.6 (11.2) 28.2 (11.1) 0.4 (8.4) .7
5. Narcissistic 29.2 (11.3) 28.9 (11.0) 0.3 (8.9) .5
6a. Antisocial 26.5 (10.9) 25.6 (11.4) 0.9 (8.0) 1.7
6b. Aggressivesadistic 26.3 (11.6) 25.4 (11.4) 0.9 (7.9) 1.7
7. Compulsive 31.8 (8.2) 30.6 (8.2) 1.1 (5.6) 3.2**
8a. Passiveaggressive 30.1 (13.0) 27.3 (12.3) 2.8 (10.3) 4.2***
8b. Self-defeating 26.8 (12.1) 21.9 (12.6) 4.8 (10.6) 7.0***
S. Schizotypal 23.1 (11.3) 18.7 (11.8) 4.3 (9.2) 7.2***
C. Borderline 39.9 (16.9) 32.3 (17.7) 7.5 (14.4) 8.0***
P. Paranoid 22.9 (10.2) 20.4 (10.5) 2.4 (8.2) 4.6***
One-samplet-test (difference score deviating from zero).s, standard deviation. ***PB0.001; **PB0.01; *PB0.05.
Table 3. Pearson correlations between Millon Clinical Multiaxial Inventory, version II (MCMI-II) and Symptom Check List 90-R (SCL-90-90-R) difference scores.
SCL-90-R
GSI Depression Anxiety Interp. Sens.
MCMI
1. Schizoid 0.51*** 0.52*** 0.39*** 0.41***
2. Avoidant 0.59*** 0.57*** 0.43*** 0.52***
3. Dependent 0.25** 0.21** 0.24** 0.25**
4. Histrionic 0.01 0.02 0.03 0.02
5. Narcissistic 0.06 0.06 0.01 0.02
6a. Antisocial 0.17* 0.18* 0.11 0.09
6b. Aggressivesadistic 0.19** 0.23** 0.06 0.16*
7. Compulsive 0.06 0.08 0.05 0.11
8a. Passiveaggressive 0.47*** 0.42*** 0.32*** 0.32***
8b. Self-defeating 0.58*** 0.56*** 0.45*** 0.48***
S. Schizotypal 0.62*** 0.60*** 0.46*** 0.49***
C. Borderline 0.64*** 0.63*** 0.46*** 0.49***
P. Paranoid 0.28** 0.25** 0.18** 0.21**
GSI, Global Severity Index. ***PB0.001; **PB0.01; *PB0.05.
PERSONALITY CHANGES IN PSYCHOTHERAPY
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significant adjusted t-values were only replicated in
patients without personality disorders. When change in Depression was included as a covariate, change in Dependent personality disorder scores was significant
both in the subsample with personality disorder (n88;
t2.33, P0.02) and in the subsample comprising
neurotic patients (n148; t2.09,P0.03).
A post hoc analysis was conducted of the remaining SCL-90-R scales (Somatization, Compulsion, Hostility, Phobic Anxiety, Paranoia and Psychoticism). This analysis showed that including change on these scales as covariate had much less pronounced effects on MCMI-II changes, compared with change on the SCL-90-R scales presented in the tables.
Effect-sizes
Table 4 presents two widely used measures of effect size (19). ‘‘Delta’’ is used to express the mean difference scores as a fraction of the pre-treatment standard deviation (Table 4, left column). Delta-values
corre-spond to Cohen’s d (24), and according to general
conventions (25), the table reveals that several of the MCMI scales showed low to medium change (0.20 0.50), while the SCL-90-R scales to show medium to high change or effect sizes (0.500.80).
While delta is used to describe the size of mean changes, the Reliable Change Index (RCI) (26) may be used to evaluate change in individual patients. In the present study, the standard error of measurement of difference scores was calculated from the standard deviations and testretest reliability coefficients of each SCL-90-R and MCMI scale. In calculating RCI, test retest reliability data were based on the normal samples described in test manuals (11, 18) and the standard deviations were obtained from two samples of normal Danish men and women (27, 28). The raw score criteria for reliable change and the percentages of reliable improvers and deterioraters are shown in Table 4. The proportion of patients displaying reliable prepost-treatment changes was substantial for both the MCMI personality disorder scales and the selected SCL-90-R scales. Corresponding to the larger delta values for the SCL-90-R scales, only a small percentage of patients showed reliable deterioration on these scales while a much larger percentage of patients deteriorated on the MCMI personality scales. The GSI RCI employed in American psychotherapy evaluations have been some-what lower (0.34) than the GSI RCI (0.47) in the present analysis (29). Our RCI calculation is, however, in agreement with German norm populations and psy-chotherapy samples reporting a reliable change cut-off of 0.43 (30).
The MCMI BR score transformation and cut-off points have not been validated in a Danish population. However, the prepost-treatment raw-score changes described in Table 2 correspond to substantial changes in American BR scores. Table 5 shows the proportions of patients obtaining BR scores above 74 (clinically sig-nificant) at pre- and post-treatment. In this analysis, only patients without ICD-8 personality disorder, and ICD-8 personality disorder patients assumed to corre-spond with cluster C personality disorders, are included (i.e. Avoidant personality disorder). This parallels the patient population in Svartberg et al. (7). As can be seen from Table 5, MCMI Avoidant personality was the most prevalent in the personality disorder group (64%). However, a substantial part of the neurotic patients were classified as having Self-defeating (53%) and Avoidant personality disorder (49%) traits. The decline in these proportions is significant for several of the MCMI personality scales, and indeed if the American BR scores are taken at face value, they suggest that pre post-treatment changes in short-term psychotherapy is associated with change from deviant to normal person-ality in a significant number of patients.
Discussion
In the present sample of outpatients, not only high pre-treatment SCL-90 GSI levels (mean 1.62) were observed, but also end-state scores within the symptomatic range
Table 4. Effect-size measures.
Reliable change
Delta RCI % Improved % Deteriorated
SCL-90
Global Severity Index .72 .47 42.0 2.5
Depression .71 .74 36.1 2.9
Anxiety .62 .63 39.9 3.4
Interpersonal Sensitivity
.51 .62 34.0 6.3
MCMI
1. Schizoid .40 3.7 46.2 15.1
2. Avoidant .36 4.1 43.7 15.1
3. Dependent .23 4.6 33.2 13.9
4. Histrionic .02 5.3 25.6 24.8
5. Narcissistic .02 4.0 24.8 23.1
6a. Antisocial .07 4.8 35.3 25.2
6b. Aggressivesadistic .06 3.6 26.9 22.3
7. Compulsive .01 3.7 29.0 18.1
8a. Passiveaggressive .21 3.6 46.2 25.2
8b. Self-defeating .40 3.5 53.8 20.2
S. Schizotypal .39 3.7 54.2 18.1
C. Borderline .44 6.5 49.6 14.7
P. Paranoid .24 5.3 40.8 18.9
MCMI-II, Millon Clinical Multiaxial Inventory, version II, SCL-90-R, Symptom Check List 90-R.
Delta (difference score expressed as a fraction of pre-treatments), and percentage of patients with Reliable Change Index (RCI) improvement and deterioration. RCI indicates the raw score change (/) needed to obtain significance.
HH JENSEN ET AL.
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psychother-apeutic studies (31, 32), indicating that after 39 sessions of psychodynamic group psychotherapy, the average pa-tient*however much improved*is still in need of treat-ment. This conclusion is in agreement with our finding that only 42% of the patients reliably improved according to GSI RCI (Table 4), leaving 58% of the patients without symptomatic improvement exceeding the RCI.
MCMI pre
post-treatment changes
We found no significant prepost-treatment changes on the Histrionic, Narcissistic, Antisocial, and Aggressive sadistic scales, and on these scales similar percentages of patients showed reliable decrease and increase in post-treatment scores (about 25%, cf. Table 4). In contrast, almost half of the patients showed reliable change on the MCMI Schizoid, Avoidant, Passiveaggressive, Self-defeating, Schizotypal and Borderline scales (4454%). The mean changes on these scales corresponded to low to medium Delta effect sizes (0.360.44), whereas SCL-90-R Anxiety, Depression and the GSI effect sizes were medium to large (0.620.72).
As might be expected, larger changes were observed in scales primarily reflecting symptomatic state than in scales presumably measuring stable personality traits. However, we found MCMI-II personality score changes to be strongly related to changes in symptomatic state, in particular SCL-90-R GSI and Depression. These results
are in agreement with the observed ‘‘balancing’’ of
MCMI-II and MCMI-III profiles after treatment for depression (1315), although the majority (89%) of the patients in the present study had no depression diagnosis. Exclusion of the depressed patients from our sample did not substantially change the results (data not shown).
Changes on the SCL-90-R Anxiety and Interpersonal Sensitivity scales showed more moderate associations with MCMI personality disorder changes, compared with those of GSI and Depression. For the Anxiety scale, this may partly reflect the fact that several items measure somatic anxiety and panic symptoms. The Interpersonal Sensitivity scale, however, describes inter-personal relationships (e.g. ‘‘people are unfriendly, dis-like me or do not understand me’’). In agreement with Derecho et al. (23), we observed a significant pre-treatment correlation between the Interpersonal Sensi-tivity scale and the Avoidant personality disorder scale (r0.70), but when Interpersonal Sensitivity was in-cluded as a covariate in the analysis of prepost-treatment changes, most changes on the MCMI scales*including Avoidance*remained significant.
We conclude that in the present sample short-term dynamic psychotherapy was primarily associated with change in symptomatic state and that scores on MCMI personality disorder scale were biased in the sense that they were sensitive to changes in symptomatic state. We believe that at least two factors should be considered when trying to understand the sensitivity of the MCMI personality disorder scales to change in symptomatic state:
Firstly, it is likely that this sensitivity is not unique to the MCMI, but rather is a general characteristic of self-report personality inventories. For example, a number of significant correlations between SCL-90-R and NEO-PI-R scores (the Five-Factor Model) were observed in the Danish NEO standardization sample*in particular between SCL-90-R scores and the broad dimension of NEO Neuroticism (33). Thus, it is unlikely that inde-pendent measures of symptomatic state and personality traits (in particular traits related to psychopathology) can be obtained by self-report*extreme symptomatic
Table 5. Prevalence of Millon Clinical Multiaxial Inventory, version II (MCMI-II) personality disorder Base Rate (BR)74 in patients without (No PD) and with (PD) ICD-8 personality disorder (roughly corresponding with DSM-III Avoidant personality disorder).
Pre-treatment Post-treatment
MCMI BR74 PD No PD Chi-square PD No PD Chi-square
2. Avoidant 64% (34) 49% (73) 3.61 47% (25)$ 38% (56)$ 1.49
8b. Self-defeating 55% (29) 53% (79) 0.05 43% (23) 42% (62)$ 0.05
8a. Passive-Aggress. 49% (26) 33% (49) 4.38* 32% (17)$ 30% (45) 0.07
1. Schizoid 42% (22) 24% (36) 5.75* 21% (11)$ 15% (23)$ 0.79
C. Borderline 38% (20) 28% (42) 1.68 19% (10)$ 18% (27)$ 0.02
S. Schizotypal 19% (10) 10% (15) 2.79 13% (7) 6% (9) 2.75
3. Dependent 25% (13) 42% (63) 5.25* 23% (12) 30% (44)$ 0.93
7. Compulsive 15% (8) 17% (25) 0.08 17% (9) 15% (23) 0.07
P. Paranoia 6% (3) 5% (7) 0.08 8% (4) 5% (7) 0.62
Total no. of patients 53 149 53 149
Scales are arranged according to the pre-treatment prevalence in the personality disorder group. *Significant difference between groups (chi-square,PB0.05).
$Significant prepost-treatment change within groups (McNemar test,PB0.05).
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states will affect measures of traits and deviant person-ality traits will often be associated with high scores on scales of symptomatic states. This is in agreement with the high pre-treatment mean GSI level in the present sample, indicating that a large proportion of the patients initially were in an acute symptomatic state with many symptoms and a high level of distress.
Secondly, the association between state and trait found in self-report measurements may reflect the nature of personality disorders. During the last few decades, increasing evidence has questioned the distinction be-tween DSM clinical syndromes (Axis I) and personality disorders (Axis II), as well as the assumed chronicity of personality pathology. Thus, recent large scale prospec-tive studies on the outcome of personality disorders according to DSM-IV classification reveals that a substantial portion of the patients no longer meet the diagnostic criteria even over as short an interval as 1 or 2 years (34). These findings suggest one of two conclu-sions: 1) personality disorders are more benign and episodic than previously believed, or 2) personality disorder categories are invalid, and their apparent remission is an artifact of the classification system and the diagnostic criteria (35).
The most important conclusion of the recent findings is that personality disorders may be more meaningfully
conceptualized as ‘‘hybrids’’ of acute, temporary, ‘‘Axis
I-like’’ symptoms and long-lasting maladaptive traits relating to affective, cognitive and behavioural person-ality dysfunction (36). Thus, an integrative approach would involve describing personality at the broad level, as well as in terms of specific and transient behaviours of particular clinical importance (37).
Implications for psychotherapy research
The recent findings in personality pathology research are a challenge for both the diagnostic classification systems, and*in the present context*psychotherapeutic out-come evaluations. Costa et al. recommended the inclu-sion of dimeninclu-sional personality descriptions (i.e. the Five-Factor Model), and suggested a four-step strategy assessing temperament, acute problems in living (or symptoms), clinical severity of problems, and optionally, identifying a personality pattern (38). This strategy would help the clinician to focus on the most relevant problems that need to be addressed in therapy, and consequently the domains that should be measured in outcome research. Interestingly more than two decades ago, the DSM-III Task Force recommended that both Axis I and II should be routinely evaluated and encouraged formal description of all relevant personality characteristics even when there was no evidence of a distinctive personality disorder (39).
In the MCMI, however, the domains of change may be blurred solely because of the construction of the
scales. Corresponding with Millon’s personality theory (40) there is a considerable item overlap among the MCMI scales, and in this context, it is particularly important that several personality disorder scales (i.e. Schizoid, Avoidant, Self-defeating, Borderline) share items with scales of symptomatic states like Dysthymia and Anxiety (11). Because of the scoring procedures, symptomatic change during treatment may therefore change the MCMI personality disorder scores simply because of changes in states of depression or anxiety.
Pre-treatment levels of distress may influence responses to personality disorder questionnaires in several ways. The endorsement of retrospective evaluations in items
such as ‘‘I have alwayswanted to stay in the background
during social activities’’ (MCMI Avoidance scale, our italics) should not change within 3 months of psychother-apy. If they do, changes are likely to be related to recall bias influenced by the pre-treatment state. Subsequently, when the pre-treatment state of distress, depression, or ‘‘demoralization’’ is improved, the interpretation of the
past (‘‘I have always . . .’’) will probably lead to a less
pathological post-treatment answer.
Moreover, (group) psychotherapy may encourage the patients to confront conflicts and may stimulate changes
in interpersonal attitudes, leading to endorsement of
items relating to autonomy, aggression, egocentricity and risk-taking behaviours. This may explain why almost 25% of the patients had a reliable increase in Histrionic, Narcissistic, Antisocial and Aggressive per-sonality disorder score at treatment termination, and may also explain post-treatment disagreement with items such as ‘‘I am always willing to give in to others to avoid disagreements’’ which has a 3 points score on the Dependent personality scale.
Outcome may be viewed as a process, rather than a stable state. Gude & Havik identified unique groups of early and late improvers after short-term psychotherapy (32), and Sandell et al. found outcome reversals after long-term therapy, good end-states deteriorating, and moderate end-states improving at follow-up (41). This is in agreement with Svartberg et al. presenting evidence of post-treatment improvements on the MCMI-I cluster C personality disorder scales (7), indicating a significant contribution of personality disorder changes to sympto-matological improvements at a 2-year follow-up. How-ever, in the present study, prepost-treatment changes on a composite MCMI cluster C personality disorder scale, as employed by Svartberg et al. (7), could be explained by changes in symptomatic state as measured by the SCL-90-R Depression scale.
The MCMI Base Rate cut-off
The higher prevalence of Dependent personality
disor-ders according to BR74 in ICD-8 neurotic patients may
reflect dependent interpersonal behaviour associated with HH JENSEN ET AL.
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anxiety and depressive neurosis (6). Nevertheless, our results may also indicate that there may be too high a proportion of patients without real ICD-8 personality disorders, but with MCMI-II personality disorder score
above BR74. We cannot exclude the possibility of
‘‘under diagnostics’’ of personality disorders in a psy-chotherapeutic setting, but*as previously described (21)*the MCMI-II BR cut-off may also diagnose too many personality disorders (Table 5).
In agreement with the former versions of the test, the MCMI-III has personality disorder and clinical syn-drome item overlap. However, the introduction of new modifying indices, validation criteria, weighting systems and reformulations of items may increase the diagnostic power of the MCMI-III, and also make it more suitable for treatment research.
Conclusion
The MCMI is increasingly used in routine diagnostic testing and screening procedures (42) and an increase in the use of the MCMI as a therapy outcome measure may be predicted. The state/trait item overlap in the MCMI may be the most valid approach to personality disorder description. However, in treatment research the MCMI item overlap may confuse the interpretation of the domains of change as associated with the particular interventions.
The challenge for future research is to explore both pathological traits and state phenomena essential to clinical descriptions of personality disorders. The pre-sent study suggests that the MCMI reflects changes in short-term psychotherapy related to interpersonal de-pendency and submissive behaviour (Dependent person-ality disorder changes) independent of changes in
depressive state. Many questionnaires*like the
MCMI*are constructed for diagnostic purposes, and do not focus on descriptions of change with respect to normal and adaptive resources. This highly stresses the need for inclusion of specific scales designed to measure normal personality characteristics and changes in interpersonal relations. Other questionnaires*such as the Inventory of Interpersonal Problems (IIP)*may be more appropriate for describing short-term therapeutic change with respect to interpersonal behaviour (43, 44).
Acknowledgements*This research was supported in part by grants from the Danish Research Council for the Humanities (No. 9600938), Director Jacob Madsen and Wife Olga Madsens Foundation, and The Grant of 22nd June 1959. Thanks are owed to Vibeke Munk, M.A., for critical comments and help with the manuscript.
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Hans Henrik Jensen, mag.art., Associate professor, Department of Health Psychology, Institute of Public Health, University of Copenhagen, Denmark.
Erik Lykke Mortensen, cand.psych., Associate professor, Department of Health Psychology, Institute of Public Health, University of Copenhagen, Denmark.
Martin Lotz, Chief Physician, Psychiatric Department, Bispebjerg Hospital, Copenhagen, Denmark.
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