smith ashley m-assessing pd with mmpi-2

8/11/2019 Smith Ashley M-Assessing PD With MMPI-2

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ASSESSING PERSONALITY DISORDERS USING THE MMPI-2-RF

A thesis submittedto Kent State University in partial

fulfillment of the requirements for

the degree of Master of Arts

by

Ashley M. Smith

August, 2010


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Thesis written byAshley M. Smith

B.A., Kent State University, 2006

M.A., Kent State University, 2010

Approved by

_________________________________, Advisor

Yossef Ben-Porath

_________________________________, Chair, Department of Psychology

Maria S. Zaragoza

_________________________________, Dean, College of Arts and Sciences

John R. D. Stalvey


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TABLE OF CONTENTS

LIST OF TABLES ............................................................................................................. iv

CHAPTER Page

I INTRODUCION ......................................................................................................1

Criterion Overlap and Disorder Co-morbidity .........................................................5

Assessing Personality Disorders .............................................................................6

The MMPI-2-RF ....................................................................................................11The Current Investigation .....................................................................................14

II METHOD ..............................................................................................................16

Participants .............................................................................................................16

Measures ................................................................................................................17

Procedure ...............................................................................................................21

III RESULTS ..............................................................................................................22

IV DISCUSSION ........................................................................................................32

Limitations .............................................................................................................42

Future Directions ...................................................................................................43

REFERENCES ..................................................................................................................45

APPENDIX A THE MMPI-2-RF SCALES ....................................................................51


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iv

LIST OF TABLES

Table Page

1 Hypotheses .............................................................................................................15

2 Correlations Between Higher-Order (H-O) Scales and Restructured

Clinical (RC) Scales and NEO-PI-R and SCID-II .................................................23

3 Correlations Between Somatic/Cognitive and Internalizing Scales and

NEO-PI-R and SCID..............................................................................................24

4 Correlations Between Externalizing, Interpersonal, and Interest Scalesand NEO-PI-R and SCID-II ...................................................................................25

5 Correlations Between the Personality Psychopathology Five (PSY-5)Scales and NEO-PI-R and SCID-II........................................................................26

6 Hypotheses and Results ........................................................................................34


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CHAPTER I

INTRODUCTION

A Personality Disorder is an enduring pattern of inner experiences and behavior

that deviates markedly from the expectations of the individuals culture, is pervasive and

inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to

distress or impairment (APA, 2000). Consistent with an organizational framework

introduced with DSM-III, the current classification system, DSM-IV-TR (APA, 2000)

categorizes personality disorders into three clusters, A, B, and C, with each including

several personality disorders. The 10 personality disorders are categorized into the

clusters based on descriptive similarities so that the disorders grouped into a particular

Cluster share similarities in their presentations, symptomatology, personality traits, and

behavioral observations (APA, 2000). Although not without its problems and limitations

(c. f. Kraus, 1991; Klonsky, 2000; Mahrer, 2000; Livesley, 1991), this clustering system

is currently the gold standard for diagnostic purposes. The first set of personality

disorders, Cluster A, includes: Paranoid Personality Disorder, Schizoid Personality

Disorder, and Schizotypal Personality Disorder. This cluster includes individuals who

appear to be odd or eccentric when compared with others (APA, 2000). Specifically,

Paranoid Personality Disorder involves a pattern of distrust and suspiciousness, such that

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the motives of others are interpreted as malevolent (APA, 2000). The prevalence rate for

this disorder is 0.5-2.5% in the general population. In addition, both Alcohol and other

Substance Use Disorders commonly co-occur with this diagnosis (APA, 2000). For

example, Chiao-Chicy and colleagues (1999) found that 15.9% of their heroin-addicted

sample obtained a diagnosis of Paranoid Personality Disorder

Schizoid Personality Disorder involves a pattern of detachment from social relationships

and a restricted range of emotional expression by the individual (APA, 2000). Prevalence

rates for this particular disorder are not stated specifically in the DSM; however, it is

uncommon in clinical settings (APA, 2000). Individuals with Schizoid Personality

Disorder often appear to have flattened affect.

Lastly, Schizotypal Personality Disorder is defined by a pattern of discomfort in

close relationships with others, cognitive or perceptual distortions, and eccentricities of

behavior (APA, 2000). The prevalence rate for this disorder is about 3% in the general

population (APA, 2000). Individuals diagnosed with Schizotypal Personality Disorder

may come across to others as socially phobic or as having bizarre experiences. Overall,

individuals with Cluster A disorders are typically disconnected from reality and may

appear paranoid, suspicious, or emotionally detached from others (APA, 2000).

The Cluster B Personality Disorders include Antisocial Personality Disorder,

Borderline Personality Disorder, Histrionic Personality Disorder, and Narcissistic

Personality Disorder (APA, 2000). Overall, individuals with Cluster B Personality

Disorders appear to be dramatic, overly emotional, erratic/reckless, or cold and uncaring

(APA, 2000). More specifically, Antisocial Personality Disorder is defined by a pattern


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of disregard for others and the violation of their rights (APA, 2000). These are

individuals who have typically had much interaction with the law and judicial systems as

both adolescents and adults. This is one of the more frequently occurring personality

disorders at 3% of community samples for men and 1% for women; however, in forensic,

substance abuse treatment and outpatient settings, the prevalence rates for this disorder

increase dramatically (APA, 2000). Further, high rates of comorbidity have been noted

between Antisocial Personality Disorder and Substance Use Disorders (APA, 2000).

More specifically, a study by Craig (2000) found prevalence rates of Antisocial

Personality Disorder ranging from 3 to 62% in an inpatient drug-abusing (i.e.- heroin and

cocaine) population.

Borderline Personality Disorder is classified as a pattern of instability and

problem behaviors in interpersonal relationships, disruptions or fluctuations of the

individuals self-image, and general impulsivity (APA, 2000). In the general population,

individuals are diagnosed with Borderline Personality Disorder at a 2% rate and up to

10% in outpatient treatment settings (APA, 2000). Individuals with a diagnosis of

Borderline Personality Disorder are also likely to have a co-occurring Substance Use

Disorder (APA, 2000). Research has demonstrated that individuals in treatment for a

Substance-related disorder have comorbid diagnoses of Borderline Personality Disorder

with prevalence rates ranging from 22.4% to 28.5% (Morgenstern, et. al., 1997; Skodol,

et. al., 1999).

Histrionic Personality Disorder involves a pattern of excessive emotionality and

attention seeking thoughts, behaviors, and motivations (APA, 2000). Individuals with this


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disorder may threaten to commit suicide, with no true intentions of doing so, to prevent

their partner from ending a relationship with them. They frequently aim to be the center

of attention in social situations as well. The prevalence rate for this disorder ranges from

2-3% in the general population and up to 15% in outpatient settings (APA, 2000).

Narcissistic Personality Disorder is characterized by a pattern of grandiosity, a

specific need for admiration, and a lack of empathy for others. The prevalence of this

disorder is fairly low at less than 1% of the population, but higher in clinical settings at 2-

16% (APA, 2000). In addition, individuals with Narcissistic Personality Disorder are at

an increased risk for a comorbid Substance Use Disorder, especially related to cocaine

abuse or dependence (APA, 2000). Individual with Narcissistic Personality Disorder may

often appear very self-centered and/or selfish. In addition, they may appear very

unempathic and require excessive admiration and praise from others (APA, 2000).

Cluster C Personality Disorders include: Avoidant Personality Disorder,

Dependent Personality Disorder, and Obsessive-Compulsive Personality Disorder.

Individuals with a Cluster C Personality Disorder typically appear to be very anxious or

fearful in a variety of situations (APA, 2000). Avoidant Personality Disorder is

characterized by a pattern of social inhibition, feelings of inadequacy, and

hypersensitivity to negative evaluation by others (APA, 2000). The prevalence rates for

this disorder are 0.5-1% in the general population and about 10% in clinical settings

(APA, 2000). People diagnosed with this disorder frequently over-react to criticism of

any kind and may seem very down on themselves, believing that they will never be good

enough.


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Dependent Personality Disorder is defined as a pattern of submissive and clinging

behavior that is related to an excessive need to be taken care of by others (APA, 2000).

Despite the fact that there is no specific rate listed, this disorder is one of the most

frequently reported personality disorders in mental health settings (APA, 2000).

Individuals with Dependent Personality Disorder may tolerate excessive negativity in

interpersonal relationships in order to maintain their dependency on others (APA, 2000).

Obsessive- Compulsive Personality Disorder is characterized by a pattern of

preoccupation with orderliness, perfectionism, and control (APA, 2000). This Personality

Disorder occurs in about 1% of the general population and in 3-10% of clinical

populations (APA, 2000). Individuals with Obsessive- Compulsive Personality Disorder

may not be able to keep a steady job because they take several hours to complete a simple

task.

Several flaws and limitations of the DSM-IV personality disorder classification

system have been identified. They include issues of comorbidity between the personality

disorders, related overlap of symptoms or diagnostic criteria, and consequent difficulty in

differential diagnosis of these disorders (Kraus, 1991; Klonsky, 2000).

Criterion Overlap and Disorder Co-morbidity

One of the difficulties with the current Axis II clusters is that some of the

symptoms or criteria within the clusters overlap. Although they may not be described

with identical language, several symptoms from each of the personality disorders are

similar within that same Cluster. In Cluster A, for example, suspiciousness, difficulties

maintaining interpersonal relationships, and inappropriate or constricted affect are


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characteristics of more than one disorder (APA, 2000). Similarly, in Cluster B,

impulsivity, anger, aggressiveness, intense interpersonal relationships, and affective

intensity are present in some form across the four personality disorders (APA, 2000). A

fear of rejection and/or criticism, inhibited interpersonal relationships, cognitive

preoccupation and difficulties in decision-making characterize more than one of the

Cluster C disorders (APA, 2000).

As a result of the overlap both within and between the three clusters of personality

disorders, it is not surprising that there is a significant amount of comorbidity between

the various disorders. In fact, research has demonstrated that an individual diagnosed

with one Personality Disorder is at an increased risk to have a second Personality

Disorder diagnosis (Kraus, 1991). More specifically, individuals diagnosed with any of

the Cluster A Personality Disorders are at an increased risk to develop comorbid Axis II

conditions, including the other Cluster A Personality Disorders, Avoidant, and Borderline

Personality Disorders (APA, 2000). Further, as stated in the DSM-IV-TR (APA, 2000),

an individual with any Cluster B Personality Disorder is at an increased risk to have

another comorbid Cluster B diagnosis. In terms of comorbidity and Cluster C Personality

Disorders, individuals diagnosed with any Cluster C Personality Disorder are also

frequently diagnosed with a comorbid Cluster A Personality Disorder or Borderline

Personality Disorder (APA, 2000).

Assessing Personality Disorders

A variety of methods have been developed to assess Axis II conditions. One

assessment technique that can be used is a structured interview, such as the Structured


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Clinical Interview for the DSM- Axis II (SCID II; First, Gibbon, Spitzer, Williams, &

Benjamin, 1997). This instrument asks standardized questions related to Personality

Disorder symptomatology. Further, the format of the interview corresponds with the

DSM-IV-TR (APA, 2000) criteria for each of the personality disorders (First, Gibbon,

Spitzer, Williams, & Benjamin, 1997).

Two additional assessment methods used to examine Personality Disorder

symptomatology are semi-structured and unstructured (e.g.social history) interviews.

These interviews include both open and closed-ended questions aimed at gathering

information about symptomatology, emotions, and so on. However, these two types of

interviews were not developed specifically for the assessment of personality disorders;

rather, they are also used to assess a wide variety of mental disorders.

Various attempts have been made to assess personality disorders with self-report

inventories. The MMPI (Hathaway & McKinley, 1943) has played a major role in this

area. The Pd (Psychopathic Deviate) scale was one of the early attempts to measure

personality disorder symptomatology. One of the eight original Clinical Scales, Pd was

designed to identify individuals with what would today be labeled Antisocial Personality

Disorder. Scores on this scale are associated with substance use/abuse, familial discord,

and antisocial behaviors (Graham, 2006), which are, as described earlier, associated

features of this disorder.

Building on the work of Hathaway & McKinley (1943), Morey, Waugh, and

Blashfield (1985) developed the first comprehensive set of scales used to measure

personality disorders with the MMPI. These researchers based their conceptualization on


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the Personality Disorder criteria, as defined by the DSM-III (APA, 1980), and used items

from the original MMPI (Hathaway & McKinley, 1943). According to Morey, Waugh,

and Blashfield (1985), two methods were employed during the construction of the scales.

First, the researchers selected four experienced clinical psychologists and asked them to

identify MMPI items that they believed to represent the specific diagnostic criteria of the

DSM-III (APA, 1980). They allowed some of the items to appear on more than one scale

because the diagnostic criteria listed in the DSM-III overlapped as well. These items were

then organized into 11 scales, based on the 11 personality disorders (Morey, Waugh, &

Blashfield, 1985). Secondly, the researchers conducted a series of internal consistency

analyses with the aim of making the items on their scales more homogeneous and

removing items to increase discriminant validity. This scale set contained 251 items with

varying numbers on each scale.

Because item overlap among the scales could be problematic, Morey, Waugh, and

Blashfield (1985) decided to create a second set of scales without overlapping items.

Items were assigned a single scale with which they were most correlated (Morey, Waugh,

& Blashfield, 1985). The non-overlapping scale set also contained 251 items (Morey,

Waugh, & Blashfield, 1985).

Hurt, Clarkin, and Morey (1990) demonstrated that the overlapping Morey et al.

(1985) scale set had adequate stability over a three to four week period in a sample of

individuals in treatment for substance abuse. The correlations between the first and

second time periods ranged from .82 to .93, demonstrating good test-retest reliability.

Overall, the empirical literature on these scales, reviewed by Widiger and Frances (1987)


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indicates that they possess good to excellent convergent validity (Hurt, Clarkin & Morey,

1990; Jones, 2005), but have some limitations in their discriminant validity (Wise, 1996).

Somwaru and Ben-Porath (1994) developed a set of Personality Disorder scales

from the MMPI-2 item pool based on the DSM-IV criteria. . The construction of this

scale set was similar to the development of the Morey et al. scales (1985). However,

Somwaru and Ben-Porath (1994) placed more emphasis on decreasing the amount of item

overlap between the scales (Ben-Porath, 1994), but did not develop a set of non-

overlapping scales. The final results included 266 items assigned to 10 different scales.

Reliability of the Somwaru and Ben-Porath (1994) scales was examined by the

authors. The scales obtained alpha values in the range of .68-.93, indicating that scores on

the scale sets had adequate to very good internal consistency (Somwaru, 1994). The

scale authors also examined test-retest reliability and reported test-retest values ranging

from .76-.92 (Somwaru, 1994).

Hicklin and Widiger (2000) examined the convergent validity of the Somwaru

and Ben-Porath scales using various criterion measures. They also compared them with

the Morey, et, al. (1985) scales. These authors concluded that the MMPI-2 Somwaru and

Ben-Porath scales are generally as valid as the Morey et al. scales (1985) in terms of

convergent validity, but they possessed increased convergent validity for the assessment

of Schizoid, Antisocial, and Borderline Personality Disorders. In examining discriminant

validity, there were no significant differences in the performance of the Somwaru and

Ben-Porath (1994), with discriminant validity coefficients ranging from .15-.52, and the


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Morey (1985) scales demonstrating values from .14-.52. Thus, both scale sets

demonstrated low to adequate discriminant validity (Hicklin & Widiger, 2000).

The MMPI-2 Psychopathology 5 (PSY-5) Scales are also designed to assess

personality disorder features. The five scales are: Aggressiveness (AGGR), Psychoticism

(PSYC), Disconstraint (DISC), Negative Emotionality/Neuroticism (NEGE), and

Introversion/ Low Positive Emotionality (INTR), (Harkness, McNulty, & Ben-Porath,

1995). These scales represent a dimensional approach to assessing personality disorder

symptoms, predicated on the notion that these phenomena are continuous, rather than

taxonic (Graham, 2006).

Using a method they called replicated rational selection, the first step in

developing the PSY-5 Scales was to identify MMPI-2 items that were representative of

those constructs identified by Harkness and McNulty (1994). This was accomplished by

first training a group of college students to understand what the constructs represent.

Then, the students selected MMPI-2 items that they judged to be related to or facets of

those constructs. The items chosen by a majority of the students were then combined to

form the preliminary set of scales.

A second step in scale construction involved the use of expert raters, where the

experts reviewed the items for each of the preliminary scales to ensure that the items

contained within that scale were clearly related to and measures of that particular

construct. Experts could delete, but not add items to the provisional scales.

The third step of scale development involved a series of statistical analyses. More

specifically, items from each scale were correlated with the other scales and if any item


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was too highly correlated with another scale, it was deleted. In addition, the scale authors

also made sure that there was no item overlap between the scales, so that each item was

only scored on one scale.

The PSY-5 scale authors recommend that they be used to aid in the diagnosis of

personality disorders (Harkness, McNulty, & Ben-Porath, 1995). The dimensional nature

of the constructs assessed by these scales is particularly useful as the field of psychology

begins to move towards a more dimensional conceptualization of personality disorders,

such as the Five Factor Model of Personality (Lynam & Widiger, 2001). Recent research

by Bagby, Sellbom, Costa, and Widiger (2008) suggests that the PSY-5 Scales better

predict symptoms of several personality disorders compared to the Five Factor Model. In

particular, the PSY-5 Scales outperformed the NEO-PI-R Scales in the prediction of

personality disorder symptom counts for Paranoid, Schizotypal, Narcissistic and

Antisocial Personality Disorders (Bagby, Sellbom, Costa, & Widiger, 2008). Another

study by Wygant, Sellbom, Graham, & Schenk (2006) also demonstrated the utility of the

PSY-5 Scales in the assessment of personality disorders. These authors illustrated the

incremental validity of the PSY-5 Scales to assess personality pathology above and

beyond the MMPI-2 Clinical and Content Scales. Thus, these scales provide additional

useful information relevant to the assessment of personality disorders not readily

available from other MMPI-2 Scale sets.

The MMPI-2-RF

The Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-

RF; Ben-Porath and Tellegen, 2008) is a 338-item revised version of the MMPI-2


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(Butcher, et al., 2001), designed to represent the clinically significant substance of the

MMPI-2 item pool with a comprehensive set of psychometrically adequate measures

(Tellegen & Ben-Porath, 2008, p.1).

The tests consists of a total of 50 scales including: eight Validity scales, three

Higher-Order scales, nine Restructured Clinical (RC) scales, twenty-three Specific

Problems (SP) scales, two Interest scales, and five revised Psychopathology Five (PSY-5)

scales. Appendix A lists and provides a brief description of the 50 scales of the MMPI-2-

RF.

A significant change to the MMPI-2 was the construction of the Restructured

Clinical (RC) Scales (Tellegen, Ben-Porath, McNulty, Arbisi, & Graham, 2003). The RC

Scales were derived from factor analyses of the original Clinical Scales to identify the

major distinctive component of each scale. A large common factor among the clinical

scales was placed into a new scale, Demoralization (RCd). Each of the remaining RC

scales represents a major distinctive component of one of the eight original Clinical

Scales. The authors of the RC Scales indicated that they were not intended to constitute a

comprehensive MMPI-2 assessment of psychopathology and personality characteristics

and that some of the facets of these scales warrant independent assessment. Thus, the

MMPI-2-RF was developed to add substantive scales that assess constructs either not

targeted by the RC scales or warranting more specific assessment (Ben-Porath &

Tellegen, 2008). The methodology used to construct the various substantive scales of the

MMPI-2-RF paralleled the development of the RC Scales to a large extent (Tellegen &

Ben-Porath, 2008).


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The substantive scales of the MMPI-2-RF are organized into a three-tiered

hierarchical structure. The Higher-Order Scales provide a broadband framework with

which to organize information obtained from the test. The three dimensions measured by

these scales, emotional, thought, and behavioral dysfunction, tap psychological factors

relevant to the assessment of personality disorders. Several of the RC Scales can also be

linked to personality disorder criteria as can the more narrowly-focused SP Scales. The

revised PSY-5 scales were designed specifically to assess variables related to personality

disorders.

Several studies provide information on the link between MMPI-2-RF scales and

personality disorder symptoms. Sellbom, Ben-Porath, and Stafford (2007) demonstrated

that RC 4 (compared with the original Clinical Scale 4) was the best MMPI-2 based

measure of Psychopathy, which is closely linked to Antisocial Personality Disorder.

Kamphuis, Arbisi, Ben-Porath, & McNulty (2008) found that the RC scales outperformed

the Clinical Scales in differential prediction of Axis II conditions. The MMPI-2-RF

Manual for Administration, Scoring, and Interpretation (Ben-Porath & Tellegen, 2008)

identifies certain personality disorders as diagnostic considerations (meaning that the

interpreter should consider whether the test-taker meets the actual diagnostic criteria) for

some personality disorder. More specifically, RC3 (Cynicism) may be linked to

personality disorders involving both mistrust of and hostility towards others (e.g.

Paranoid and Antisocial Personality Disorders; Ben-Porath & Tellegen, 2008). RC8

(Aberrant Experiences) may identify individuals with personality disorders associated

with unusual thoughts, perceptions, or experiences, such as Schizotypal Personality


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Disorder (Ben-Porath & Tellegen, 2008). Diagnostic considerations related to personality

disorders are also identified for some Specific Problems (SP) scales. For example,

Juvenile Conduct Problems (JCP) is linked to Antisocial Personality Disorder (Ben-

Porath & Tellegen, 2008), Interpersonal Passivity (IPP) to Dependent Personality

Disorder (elevated scores > 65) and Narcissistic Personality Disorder (low scores < 38)

(Ben-Porath & Tellegen, 2008). Lastly, because they assess the same constructs, the

revised PSY-5 scales similarly provide a dimensional model of personality disorder

symptoms. Ben-Porath & Tellegen (2008) link each of the PSY-5 scales with diagnostic

considerations related to one of the personality disorder clusters. AGGR-r and DISC-r

indicate possible Cluster B disorders, PSYC-r is linked with Cluster A disorders and both

NEGE-r and INTR-r indicate possible Cluster C disorders.

The Current Investigation

Personality disorder-related diagnostic considerations listed by Ben-Porath &

Tellegen (2008) are, for the most part, inferential. The purpose of the current study is to

examine the hypothesized link, empirically. Several hypotheses were developed prior to

conducting statistical analyses. Individual scales from each of the MMPI-2-RF scale sets

were hypothesized to be associated with the various personality disorders based on the

DSM-IV criteria and the diagnostic considerations listed in the MMPI-2-RF manual. One

Higher-Order scale and one PSY-5 scale, along with some RC or SP scales were

hypothesized to be associated with each of the personality disorders. The two Interest

Scales were not included in any hypotheses because they are not measures of

psychopathology. A complete list of the hypotheses is available in Table 1.


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Table 1. Hypotheses

Cluster AParanoid PD Schizoid PD Schizotypal PD

THD EID THD

RC3 RC2 RC2

RC6 SAV RC6

AGG DSF RC8

PSYC-r FML SAV

PSYC-r PSYC-r

Cluster B

Antisocial PD Borderline PD Histrionic PD Narcissistic PD

BXD EID EID BXD

RC4 BXD BXD RC4

RC9 THD RC7 RC9

ANP RC2 RC9 IPP (-)

JCP RC6 ACT AGGR-r

AGG RC7 SHY (-)

AGGR-r RC9 DISC-r

DISC-r SUI

SFD

ANP

AGG

FML

IPP (-)

SHY (-)

DISC-r

NEGE-r

Cluster C

Avoidant PD Dependent PD OCPD

EID EID EID

RC2 RC7 RC7

RC7 HLP RC9

SFD SFD STW

BRF NFC BRF

SAV STW NEGE-r

SHY IPP

INTR-r NEGE-r


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CHAPTER II

METHOD

Participants

Potential participants for this study included 1432 men enrolled in an addictions

treatment program at a Midwestern Veterans Hospital. To be included in this study, the

participants were required to complete all of the criterion measures in the study,

including: the Minnesota Multiphasic Personality Inventory 2, Borderline Syndrome

Index, NEO Personality Inventory Revised, and Structured Clinical Interview for the

DSM, Axis II. If one or more of these measures was missing or incomplete, that

individual was excluded from the final sample. After excluding individuals for missing

data, the sample size decreased to 996 men.

Individuals were also excluded from this study if they produced invalid MMPI-2-

RF protocols, based on the criteria in the MMPI-2-RF Technical Manual: Cannot Say

[CNS] raw score 18, Variable Response Inconsistency [VRIN-r] and/or True Response

Inconsistency [TRIN-r] T 80, Infrequent Responses [F-r] T = 120, or Infrequent

Psychopathology Responses [Fp-r] T 100. A total of 244 individuals (24% of the

sample) were excluded due to invalid protocols.

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After removing invalid protocols and missing criterion measures, the final sample

was made up of 752 men, with ages ranging from 23-75 (M = 44.4; SD = 8.7). The

sample was 57% African American, 37% Caucasian, and 6% had other ethnicities,

including American Indian, and Hispanic. The primary diagnoses in this sample, other

than substance abuse, included: Post-Traumatic Stress Disorder (6% of the sample),

Major Depressive Disorder (5% of the sample), and Pathological Gambling (4.5% of the

sample).

Measures

Minnesota Multiphasic Personality Inventory- 2- Restructured Form (MMPI-2-RF)

The MMPI-2-RF is a 338-item self-report inventory. The scales on the MMPI-2-

RF include: eight validity scales, three higher order scales, nine Restructured Clinical

(RC) scales, and five revised Psychopathology Five (PSY-5) scales. The validity scales

include 7 scales from the MMPI-2 that were revised and the addition of one new scale

(Ben-Porath & Tellegen, 2008). The three higher order scales were developed to measure

personality and psychopathology at their broadest levels. The next level of the hierarchy

includes the Restructured Clinical (RC) scales, which are identical to the RC scales of the

MMPI-2 (Ben-Porath & Tellegen, 2008). The PSY-5 scales are similar to those that

appear on the MMPI-2, but were revised for the MMPI-2-RF. Harkness and McNulty

(2007) used an iterative process consisting of both internal and external analyses. They

removed 22 of the 96 items that transferred from the MMPI-2 to the MMPI-2-RF and

added 30 new items. This resulted in five non-overlapping scales consisting of 104 items.


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According to Harkness and McNulty (2007), the revised PSY-5 scales demonstrated

lower intercorrelations and analogous external validity, compared to the original scales.

However, they still assess the same dimensional models of personality pathology (Ben-

Porath & Tellegen, 2008). The lowest level of the hierarchy includes the 23 Specific

Problems (SP) Scales and two Interest Scales. These scales aim to measure certain

somatic, internalizing facets, externalizing facets, interpersonal problems, and interests of

individuals. Extensive empirical data regarding the psychometric characteristics of the

MMPI-2-RF are provided in the Technical Manual (Tellegen & Ben-Porath, 2008).

NEO Personality Inventory- Revised (NEO-PI-R)

The NEO-PI-R is a 240-item self-report questionnaire designed to assess five

broad domains of personality, including: extraversion, agreeableness, neuroticism,

conscientiousness, and openness. The measure also assesses six specific facets of each of

these five broad domains, where each broad domain contains six facets or subscales. The

facets for Extraversion are Warmth, Gregariousness, Assertiveness, Activity, Excitement

Seeking, and Positive Emotion (Costa & McCrae 1992b). The facets for Agreeableness

include: Trust, Straightforwardness, Altruism, Compliance, Modesty, and

Tendermindedness. Further, the Neuroticism factor contains the facets of Anxiety,

Hostility, Depression, Self-Consciousness, Impulsiveness, and Vulnerability to Stress. In

addition, the Conscientiousness factor includes Competence, Order, Dutifulness,

Achievement Striving, Self-Discipline, and Deliberation facets. Finally, the factor of

Openness contains the facets of Fantasy, Aesthetics, Feelings, Actions, Ideas, and Values.

Costa and McCrae (1992b) report internal consistency estimates for the broad domains


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with alphas ranging from .86 to .92 for the broad domains and .56 to .81 for the thirty

facet subscales. The authors also attribute the lower internal consistency values of the

facets to the fact that each facet only contains eight items. Therefore, it is not

unreasonable to expect lower estimates (Costa & McCrae 1992b). Examination of test-

retest correlations of six years demonstrates that the NEO-PI-R possess adequate to very

good temporal stability estimates, with alphas ranging from .63 to .83.

Lynam and Widiger (2001) developed a method for assessing the DSM-IV

personality disorders using the NEO-PI-R. The authors asked DSM experts to rate

prototype cases using all 30 facets of the Five Factor Model (FFM). Then, they combined

the ratings to identify a pattern of NEO-PI-R prototype scores for each of the DSM-IV

(APA, 2000) personality disorders. Lynam and Widiger (2001) reported good agreement

(i.e., r= .48-.66) among the raters for those prototypes and stated that the prototypes map

onto the DSM-IV personality disorder criteria well. In the present study, we compared

the prototypes generated by Lynam and Widiger (2001) to each participants individual

NEO-PI-R profile. This comparison yields a set of similarity scores. The similarity scores

are generated into the same metric as the prototypes, allowing for the direct comparison

of the individuals NEO-PI-R scores and the Lynam and Widiger (2001) prototypes. An

individual is more likely to have a particular personality disorder as their similarity scores

becomes closer to the prototype for that disorder. Thus, our participants received a NEO-

PI-R prototype similarities score for each of the ten DSM-IV personality disorders.


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20

The Structured Interview for the DSM, Axis II (SCID-II)

The SCID-II (First, Gibbon, Spitzer, Williams, & Benjamin, 1997) is a highly

structured clinical interview designed specifically to aid in diagnosis of Axis II disorders.

Responses to the interview questions are rated as either present, absent, or sub-threshold.

A study by Smith and colleagues (2003) examined the criterion validity the DSM-IV

SCID-II, and demonstrated poor agreement between the DSM-IV SCID-II and the

Wisconsin Personality Disorders Inventory-IV (WISPI-IV; Klein & Benjamin, 1996)

with kappas at or below .40. While there are no studies examining the reliability of DSM-

IV SCID-II, previous studies have examined the reliability of the instrument with the

DSM-III. For example, the authors of the instrument report interrater reliability with

kappas ranging from .24 to .74 when the instrument was administered to patients (First,

Gibbon, Spitzer, Williams, & Benjamin, 1997).

The Borderline Syndrome Index

The Borderline Syndrome Index (BSI; Conte, Plutchik, Karasu, & Jerrett, 1980) is a

52- item self-report inventory intended to assess features and characteristics of Borderline

Personality Disorder utilizing a true/false response format. More specifically, the measure

focuses on borderline functioning in the areas of poor impulse control, absence of a

consistent self-identity, depression, anhedonia, impaired object relations,

depersonalization, and a number of neurotic symptoms (Sansone, Fine, Seuferer, &

Bovenzi, 1989). The test authors examined reliability by calculating internal consistency

and they demonstrated high internal consistency, with a Chronbachs alpha of .92 (Conte,

Plutchik, Karasu, & Jerrett, 1980). Convergent validity was examined between the BSI


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21

and the Diagnostic Interview for Borderlines (DIS; Gunderson, Kolb, & Austin, 1981).

The results indicated that convergent validity between the two measures is high, with

correlations between the instruments of .88 (DAngelo, 1991).

Procedure

The archival data set was collected at a Midwestern VA medical center in an

addiction treatment unit. The data collection took place over a three-day period upon

admission to the hospitals inpatient addiction treatment program. The addictions that

individuals were being treated for included alcohol, drug, illicit substances, and

gambling. The measures administered during this time include: a computerized version of

the MMPI-2, a demographic questionnaire, and a set of extra-test measures. MMPI-2-RF

scales were scored from individual responses to the MMPI-2 items. Tellegen and Ben-

Porath (2008) demonstrated that individuals completing the two versions of the test

produce interchangeable scores on the MMPI-2-RF scales. Included in this set of extra

test measures were the NEO-PI-R, the SCID-II, and the BSI. Lastly, in accordance with

ethical considerations and patient confidentiality, all identifying personal information was

removed from the data.


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CHAPTER III

RESULTS

Zero-order correlations were calculated between the substantive MMPI-2-RF

scales and NEO-PI-R prototype similarities, the SCID-II personality disorder symptom

counts, and the Borderline Syndrome Index total scores. Tables 2-5 provide results for all

of the correlational analyses that were conducted. The zero-order correlations had to meet

two requirements for interpretation. First, the correlation had to reach statistical

significance, at p .05. In addition, correlations between MMPI-2-RF Scales and the

NEO-PI-R prototype similarities and Borderline Syndrome Index scores had to reach a

magnitude of at least .4, or a medium effect size as defined by Cohen (1981), for

interpretation. Correlations between MMPI-2-RF Scales and the SCID-II symptom

counts had to reach a magnitude of at least .2, or a small effect size (Cohen, 1981). The

magnitude of .4 was selected for the NEO-PI-R because the strength of the correlations

between the MMPI-2-RF scales and the NEO-PI-R were consistently higher than those

with the SCID-II, likely as a result of shared method (self-report) variance. These effect

size requirements were set based on procedures followed in previous empirical research

(e.g., McNulty, Ben-Porath, & Graham, 1999) to narrow the focus of interpretation of the

analyses, as almost every correlation reached statistical significance.


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Table 2. Correlations Between Higher-Order (H-O) Scales and Restructured Clinical (RC) Scales and NEO-PI-R and SCID-II

Higher Order (H-O)

Scales Restructured Clinical (RC) Scales

Criterion Measure EID THD BXD RCd RC1 RC2 RC3 RC4 RC6 RC7 RC8 RC9

NEO-PI-R Paranoid PD .53* .22 .30 .46* .28 .46* .31 .32 .29 .48* .21 .24

SCID Paranoid PD .21* .24 .18 .21* .19 .10 .18 .19 .19 .27* .24* .24*

NEO-PI-R Schizoid PD .46 .00 -.12 .37 .20 .61* .05 .00 .06 .26 .00 -.23

SCID Schizoid PD .10 .15 .00 .10 .14 .08 .08 -.02 .12 .13 .13 .05

NEO-PI-R Schizotypal PD .72* .19 .19 .67* .34 .68 .20 .31 .24 .56* .22 .11

SCID Schizotypal PD .16 .27 .04 .18 .13 .10 .08 .06 .24 .22* .26 .11

NEO-PI-R Antisocial PD .19 .11 .50 .23 .08 .08 .21 .43 .16 .22 .13 .41

SCID Antisocial PD .05 .05 .15 .07 .04 .04 -.01 .12 .09 .09 .05 .09

NEO-PI-R Borderline PD .66 .26 .45 .68* .32 .47 .26 .49* .30 .58 .31 .40

SCID Borderline PD .27 .20 .15 .29* .15 .16 .10 .16 .19 .29 .23 .20

BSI Borderline PD .75 .41 .34 .77* .42* .52 .34 .42* .40 .68 .46 .38

NEO-PI-R Histrionic PD .09 .12 .39 .19 .03 -.07 .06 .34 .11 .15 .16 .38

SCID Histrionic PD .09 .09 .09 .11 .04 -.01 .06 .05 .12 .15 .09 .17

NEO-PI-R Narcissistic PD -.03 .14 .44 .01 .02 -.14 .20 .32 .17 .10 .13 .42

SCID Narcissistic PD .14 .19 .17 .18 .07 .02 .14 .16 .19 .23* .21* .26

NEO-PI-R Avoidant PD .66 .14 -.02 .59* .31 .67 .13 .13 .17 .48 .16 -.07

SCID Avoidant PD .29 .13 .01 .27* .12 .24 .04 .05 .13 .25 .15 .03

NEO-PI-R Dependent PD .40 .00 -.23 .39 .16 .45* -.07 -.07 -.01 .24 .03 -.23

SCID Dependent PD .17 .14 .06 .20* .08 .10 .08 .06 .15 .18 .15 .12

NEO-PI-R Obsessive-Compulsive PD -.17 -.07 -.30 -.25 -.04 -.06 -.04 -.29 -.07 -.15 -.12 -.27

SCID Obsessive-Compulsive PD .13 .22* .07 .13 .12 .01 .14 .07 .17 .20 .23* .19

Note: N= 752; Bold & underlining = Supported hypothesis; * = Unanticipated, but significant result; NEO-PI-R= The NEO-PI-R Personality

Inventory Revised; SCID= Structured Clinical Interview for the DSM- Axis II; BSI= Borderline Syndrome Index.23


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Table 3. Correlations Between Somatic/Cognitive and Internalizing Scales and NEO-PI-R and SCID

Somatic/Cognitive Scales Internalizing Scales

Criterion Measures MLS GIC HPC NUC COG SUI HLP SFD NFC STW AXY ANP BRF MSF

NEO-PI-R Paranoid PD .32 .17 .22 .23 .34 .27 .33 .37 .35 .36 .34 .51* .18 .02

SCID Paranoid PD .16 .15 .13 .18 .21* .17 .10 .15 .19 .20 .20 .23* .11 .02

NEO-PI-R Schizoid PD .35 .13 .13 .16 .25 .18 .32 .31 .33 .19 .15 .14 .09 -.02

SCID Schizoid PD .10 .06 .15 .12 .09 .05 .13 .06 .15 .12 .11 .11 .06 -.04

NEO-PI-R Schizotypal PD .48* .21 .28 .24 .48* .38 .40* .59* .57* .50* .38 .40* .26 .06

SCID Schizotypal PD .11 .05 .11 .13 .20* .12 .11 .14 .14 .15 .21* .14 .16 .02

NEO-PI-R Antisocial PD .09 .06 .09 .04 .18 .10 .09 .18 .14 .18 .14 .38 .06 -.04

SCID Antisocial PD .02 .04 .01 .03 .07 .03 .04 .03 .05 .06 .08 .11 -.02 -.05

NEO-PI-R Borderline PD .39 .20 .29 .22 .47 .37 .33 .60 .52* .54* .42* .55 .27 .06

SCID Borderline PD .18 .11 .11 .13 .24 .25 .19 .24 .20* .24* .24* .24 .16 .01

BSI Borderline PD .47* .25 .34 .31 .61 .54 .48* .68 .57* .59* .51* .51 .37 .07

NEO-PI-R Histrionic PD .01 .03 .06 .00 .16 .11 -.01 .17 .14 .19 .13 .20 .11 .02

SCID Histrionic PD .00 .04 .01 .01 .09 .06 .06 .07 .08 .12 .11 .15 .11 .02

NEO-PI-R Narcissistic PD -.06 .01 .04 .02 .05 .02 -.02 .05 -.05 .04 .09 .31 .03 -.04

SCID Narcissistic PD .06 .06 .02 .07 .18 .16 .12 .15 .13 .18 .19 .15 .14 .07

NEO-PI-R Avoidant PD .44* .19 .24 .24 .41* .32 .39 .54 .53* .42* .33 .27 .24 .09

SCID Avoidant PD .16 .06 .09 .11 .22* .24* .15 .25 .25* .21* .17 .13 .12 .02

NEO-PI-R Dependent PD .29 .09 .12 .12 .25 .18 .24 .40 .41 .26 .15 -.04 .16 .12

SCID Dependent PD .09 .02 .08 .09 .17 .12 .13 .16 .17 .19 .14 .12 .13 .03

NEO-PI-R Obsessive-Compulsive PD -.10 .05 -.06 .01 -.17 -.13 -.01 -.24 -.19 -.19 -.10 -.12 -.09 .02

SCID Obsessive-Compulsive PD .07 .06 .10 .08 .16 .13 .13 .09 .12 .16 .12 .15 .15 .02


Inventory Revised; SCID= Structured Clinical Interview for the DSM- Axis II; BSI= Borderline Syndrome Index. 24


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Table 4. Correlations Between Externalizing, Interpersonal, and Interest Scales and NEO-PI-R and SCID-II

Externalizing Scales Interpersonal Scales Interest Scales

Criterion Measures JCP SUB AGG ACT FML IPP SAV SHY DSF AES MEC

NEO-PI-R Paranoid PD .24 .16 .46 .06 .33 .01 .50* .38 .47* -.21* -.10

SCID Paranoid PD .14 .17 .14 .18 .20* .07 .03 .09 .10 .00 .07

NEO-PI-R Schizoid PD -.02 .00 -.05 .22 .09 .42 .68 .46* .49 -.23* -.22*SCID Schizoid PD .04 .04 .08 .03 .03 .06 .09 .10 .16 -.03 .01

NEO-PI-R Schizotypal PD .19 .18 .31 .01 .36 .34 .56 .55* .44* -.13 -.18

SCID Schizotypal PD .02 .05 .13 .13 .16 .03 .11 .11 .12 .01 .01

NEO-PI-R Antisocial PD .34 .20 .43 .16 .23 -.20 -.04 -.01 .09 -.06 .08

SCID Antisocial PD .13 .06 .19 .04 .10 .01 .06 .03 .05 -.08 .03

NEO-PI-R Borderline PD .34 .27 .50 .19 .45 .08 .24 .36 .25 -.09 -.06

SCID Borderline PD .07 .13 .24 .15 .24 .01 .10 .13 .09 -.10 .00

BSI Borderline PD .23 .29 .46 .25 .49 .12 .25 .46* .38 -.04 -.07

NEO-PI-R Histrionic PD .26 .16 .25 .24 .20 -.15 -.32 -.11 -.18 .14 .10

SCID Histrionic PD .03 .00 .15 .13 .14 .08 -.03 .01 .03 .02 .05

NEO-PI-R Narcissistic PD .28 .12 .39 .20 .16 -.38 -.14 -.16 .03 .03 .15

SCID Narcissistic PD .10 .12 .21* .22* .21* .06 -.02 .03 .05 .02 .06

NEO-PI-R Avoidant PD .06 .09 .14 -.08 .26 .43* .59 .57 .42* -.17 -.24

SCID Avoidant PD .01 .06 .11 .04 .15 .17.23 .27

.14 .00 -.05

NEO-PI-R Dependent PD -.09 -.01 -.17 -.12 .08 .50 .26 .39 .11 -.10 -.23

SCID Dependent PD .02 .10 .12 .09 .13 .04 .00 .10 .02 .01 .01

NEO-PI-R Obsessive-Compulsive PD -.19 -.17 -.18 -.17 -.18 -.01 .21 .00 .12 -.17 - .06

SCID Obsessive-Compulsive PD .01 .10 .15 .20 .16 .07 .00 .09 .02 .03 .06

Note: N= 752; Bold & underlining = Supported hypothesis; * = Unanticipated, but significant result; NEO-PI-R= The NEO-PI-R

Personality Inventory Revised; SCID= Structured Clinical Interview for the DSM- Axis II; BSI= Borderline Syndrome Index.

25


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Table 5. Correlations Between the Personality Psychopathology Five (PSY-5) Scales and NEO-PI-R and SCID-II

Personality Psychopathology Five (PSY-5) Scales

Criterion Measure AGGR-r PSYC-r DISC-r NEGE-r INTR-r

NEO-PI-R Paranoid PD .14 .19 .16 .45* .46*

SCID Paranoid PD .13 .22 .15 .24* .00

NEO-PI-R Schizoid PD -.35 .00 -.17 .20 .70*SCID Schizoid PD -.01 .12 -.04 .12 .11

NEO-PI-R Schizotypal PD -.23 .20 .11 .55* .59*

SCID Schizotypal PD .01 .29 .01 .17 .09

NEO-PI-R Antisocial PD .33 .09 .42 .24 -.02

SCID Antisocial PD .09 .05 .11 .09 .06

NEO-PI-R Borderline PD .06 .26 .35 .63 .28

SCID Borderline PD .07 .20* .09 .29 .09

BSI Borderline PD -.01 .42* .25 .66 .30

NEO-PI-R Histrionic PD .19 .13 .38 .21 -.27

SCID Histrionic PD .12 .11 .05 .15 -.03

NEO-PI-R Narcissistic PD .48 .11 .37 .08 -.19

SCID Narcissistic PD .13 .22* .14 .19 -.06

NEO-PI-R Avoidant PD -.37 .15 -.08 .46* .63

SCID Avoidant PD -.12 .13 -.02 .22* .21

NEO-PI-R Dependent PD -.55* .05 -.20 .25 .36

SCID Dependent PD .00 .14 .03 .20 .03

NEO-PI-R Obsessive-Compulsive PD -.02 -.09 -.32 -.21 .14

SCID Obsessive-Compulsive PD .08 .25 .05 .18 -.04


Inventory Revised; SCID= Structured Clinical Interview for the DSM- Axis II; BSI= Borderline Syndrome Index. 26


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ForParanoid Personality Disorder, an association was hypothesized with the

Higher-Order Thought Dysfunction (THD) scale. The SCID-II measure of Paranoid

Personality Disorder was significantly associated with THD; however, the NEO-PI-R

measure of this disorder was not significantly associated with this scale, as the correlation

did not reach a medium effect size.

Moving down the hierarchy to the Restructured Clinical (RC) Scales, there were

no interpretable associations between either the NEO-PI-R or SCID-II measures of

Paranoid Personality Disorder and RC3 or RC6, as the correlations did not meet the

required effect size. For the Specific Problems (SP) Scales, Aggression (AGG) was more

strongly associated with the NEO-PI-R measure of this disorder; whereas, the SCID-II

correlation did not meet the effect size requirement. Examination of the PSY-5 Scales

revealed that the SCID-II Paranoid Personality Disorder was significantly associated with

the MMPI-2-RF Psychoticism (PSYC-r) Scale; whereas the correlation with the NEO-PI-

R did not reach the magnitude required for interpretation. There were several unexpected,

significant associations between EID, RCd, RC7, ANP, and NEGE-r and both the NEO-

PI-R and SCID-II measures of Paranoid Personality Disorder.

In examining the results for Schizoid Personality Disorder, a significant

association was found between the NEO-PI-R measure of this disorder and the Higher-

Order EID Scale. In addition, there was a significant association between RC2 and NEO-

PI-R measure. The Interpersonal scales Social Avoidance (SAV) and Disaffiliativeness

(DSF) were also significantly associated with the NEO-PI-R measure of Schizoid

Personality Disorder; however, the Family Problems (FML) scale was not significantly


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associated with this measure as hypothesized. The PSYC-r Scale was not significantly

associated with the NEO-PI-R as anticipated. Finally, there were no interpretable

associations between any selected MMPI-2-RF scales and SCID-II symptom counts, as

the correlations were statistically significant, but failed to meet the effect size

requirement.

For Schizotypal Personality Disordersymptomatology, THD, RC2, RC6, RC8,

SAV, and PSYC-r, were significantly associated with the SCID-II symptom counts and

the NEO-PI-R similarities. Finally, there was also a significant association between RC8

and both the NEO-PI-R similarities and the SCID-II; however, this association was not

initially hypothesized.

ForAntisocial Personality Disordersymptoms, the associations between

hypothesized MMPI-2-RF Scales and NEO-PI-R prototype similarities were much

stronger than the correlations with the SCID-II measure of this disorder. None of the

correlations between select MMPI-2-RF Scales and the SCID-II were interpretable, as

they did not meet the effect size requirement. However, the NEO-PI-R measure of

Antisocial Personality Disorder was significantly associated with BXD, RC4, RC9, AGG,

and DISC-r. Whereas the findings just described were in line with our hypotheses, there

were no interpretable associations between the NEO-PI-R or SCID-II measures of this

disorder and the Specific Problems Scales of Anger Proneness (ANP) and Juvenile

Conduct Problems (JCP), or the PSY-5 Aggressiveness Scale (AGGR-r) as hypothesized.

The results for assessingBorderline Personality Disordersymptomatology

indicate that associations were present across all levels of the MMPI-2-RF measurement


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hierarchy. Beginning with the Higher-Order Scales, EID was significantly associated

with the NEO-PI-R, SCID-II, and BSI measures of this disorder. However, unexpectedly

THD and BXD were also significantly associated with these measures. The Higher-Order

BXD scale was only significantly associated with the NEO-PI-R. In terms of the RC

Scales, the strongest relations were between RC7 and the NEO-PI-R, SCID-II, and BSI.

Significant associations were also demonstrated between RC2 and the NEO-PI-R and

BSI, and RC8 and the SCID-II and BSI. RC9 was also significantly associated with both

the NEO-PI-R and SCID-II. Further, the Specific Problems Scale SFD was most strongly

associated with Borderline symptomatology, as measured by the three criterion measures.

Strong associations were also present for the ANP, AGG, and FML. In addition, a

significant association was demonstrated between the SHY and the BSI. Inconsistent with

the hypotheses, significant relations were not observed between Interpersonal Passivity

(IPP) and any of the three criterion measures. Finally, the Negative

Emotionality/Neuroticism PSY-5 Scale was strongly associated with the NEO-PI-R,

SCID-II, and BSI; however, no significant associations were present for DISC-r, as

hypothesized. There were also unanticipated associations found between RCd, COG,

NFC, STW, and AXY and the NEO-PI-R, SCID-II, and BSI.

In examiningHistrionic Personality Disorder symptomatology, the results

demonstrate that there were statistically significant associations between several of the

predicted MMPI-2-RF scales and the NEO-PI-R and SCID-II measures of this disorder.

However, none of those associations reached the effect size requirement for

interpretation.


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ForNarcissistic Personality Disorder, an association was found between the

NEO-PI-R measure and BXD; whereas the SCID-II results did not have a large enough

effect size for interpretation. RC9 was significantly associated with both the NEO-PI-R

and SCID-II measures of this disorder. The PSY-5 AGGR-r scale was significantly

associated with the NEO-PI-R, but not the SCID-II. Hypotheses were not supported for

RC4 and IPP, which were not significantly associated to either criterion measure as

expected.

ForAvoidant Personality Disordersymptomatology, significant associations were

present between all hypothesized MMPI-2-RF Scales (EID, RC2, RC7, SFD, SAV, SHY,

and INTR-r) and the NEO-PI-R and SCID-II measures of this disorder. However, one

Specific Problems Scale, Behavior-Restricting Fears (BRF) was not meaningfully

associated with either criterion measure as hypothesized. There were also several

associations present that were not initially hypothesized. RCd, COG, NFC, STW, and

NEGE-r were all significantly associated with both the NEO-PI-R and SCID-II. The

magnitude of the correlations was greater between the expected MMPI-2-RF Scales and

the NEO-PI-R measure, compared with the SCID-II.

The results forDependent Personality Disorderdemonstrated significant

associations between EID, SFD, NFC, and IPP and the NEO-PI-R Dependent Personality

Disorder similarity scores. Only one scale, NEGE-r, was meaningfully associated with

the SCID-II, but not the NEO-PI-R. Inconsistent with the hypotheses, RC7 and some of

its facets, such as Helplessness/Hopelessness (HLP) and Stress/Worry (STW) were not


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significantly associated with Dependent Personality Disorder symptomatology, as

assessed by the NEO-PI-R or SCID-II.

Finally, examination of Obsessive-Compulsive Personality Disorder

symptomatology demonstrated a lack of meaningful relations between hypothesized

MMPI-2-RF Scales and the NEO-PI-R and SCID-II measures of this disorder. Only one

association reached the effect size requirement for interpretation, and a significant

association was observed between RC7 and the SCID-II measure. In general, the

magnitude of the correlations was much weaker for OCPD than for any other personality

disorder symptomatology.


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CHAPTER IV

DISCUSSION

The primary objective of this study was to examine associations between MMPI-

2-RF scales and measures of personality disorder symptomatology. The MMPI-2-RF has

several new scales that may be particularly useful in the assessment of personality

disorders. This study examined the link between scores on select MMPI-2-RF scales and

personality disorder symptoms to determine whether the personality disorder-related

diagnostic considerations listed by Ben-Porath & Tellegen (2008) are supported

empirically. In addition, anticipated associations were also derived from the DSM-IV

diagnostic criteria for each personality disorder. Thus, both the DSM-IV and the

personality disorder-related diagnostic considerations (Ben-Porath & Tellegen, 2008)

served as guidelines for which MMPI-2-RF scales would be expected to be related to

each of the criterion measures. A correlational design was utilized and all participants

completed several criterion measures under standardized instructions.

Across the personality disorder clusters the magnitude of the correlation patterns

was much stronger for the NEO-PI-R personality disorder (PD) measures and the

Borderline Syndrome Index scores, in comparison with the SCID-II symptom counts.

The strongest pattern of correlations for the Cluster A personality disorders was found for

Schizotypal Personality Disorder, with all specific hypothesis supported by the results.

32


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For Cluster B, the strongest pattern of correlations was demonstrated for Borderline

Personality Disorder, where all but two hypotheses were supported. The two hypotheses

that were not supported included a predicted negative association between the

Interpersonal Passivity (IPP) Specific Problems Scale and criterion measures of

Borderline symptomatology, and a predicted association between the PSY-5

Disconstraint Scale and Borderline symptomatology, as measured by the NEO-PI-R,

SCID-II, and BSI. Finally, Avoidant Personality Disorder exhibited the strongest

correlational pattern among the Cluster C personality disorders, with all hypotheses

supported, except for the Behavior-Restricting Fears (BRF) scale. Across the three

personality disorder clusters, Borderline Personality Disorder measures had the strongest

associations with the MMPI-2-RF. Table 6 provides a detailed summary of the support

for the individual hypotheses for each personality disorder.

As mentioned, the associations between select MMPI-2-RF scales and the NEO-

PI-R prototype similarities were generally stronger than those with the SCID-II. One

potential explanation from the stronger findings with the NEO-PI-R has to do with the

dimensionality of the constructs being assessed. The NEO-PI-R is designed to measure

the Five Factor Model (Costa & McCrae, 1992); a dimensional model of personality. The

scales of the MMPI-2-RF are dimensional in nature, as higher scores or elevations are

indicative of greater psychopathology. In addition, the PSY-5 Scales of the MMPI-2-RF

are closely linked to Five Factor Model (Bagby, Sellbom, Costa, & Widiger, 2008);

therefore, there is a strong connection between several of the constructs being measured

by both the MMPI-2-RF and the NEO-PI-R. Thus, one may expect that the MMPI-2-RF


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Table 6.Hypotheses and Results

Cluster A

Paranoid PD Schizoid PD Schizotypal PD

EID EID * THD **

RCd RC2 * RC2 *

THD ** SAV * RC6 **

RC3 DSF * RC7

RC6 FML RC8 **

RC7 PSYC-r COG

ANP INTR-r* SAV *

AGG * PSYC-r **

PSYC-r **

NEGE-r

Cluster B

Antisocial PD Borderline PD Histrionic PD Narcissistic PD

BXD * EID *** EID BXD *

RC4 * THD* BXD RC4

RC9 * BXD ** RC7 RC9 ***

ANP RCd RC9 IPP (-)

JCP RC2 * ACT AGGR-r *

AGG* RC6 SHY (-)

AGGR-r RC7 *** DISC-r

DISC-r * RC9 ***COG

SUI **

SFD ***

NFC

STW

AXY

ANP ***

AGG ***

FML***

IPP (-)

SHY (-)

DISC-r

NEGE-r ***

Note: *= Hypothesis supported for NEO-PI-R only; **= Hypothesis supported for SCID-II only;

***= Hypothesis supported for both NEO-PI-R and SCID-II; = Hypothesis supported for BSIonly; *= Hypothesis supported for NEO-PI-R and BSI only; **= Hypothesis supported forSCID-II and BSI only; = Significant result that was not hypothesized.


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Table 6, continued

Cluster C

Avoidant PD Dependent PD OCPD

EID *** EID * EID

RCd RC7 RC7 **

RC2 *** HLP RC9

RC7 *** SFD * STW

COG NFC * BRF

SFD *** STW NEGE-r

NFC IPP *

STW NEGE-r **

BRFSAV ***

SHY ***

NEGE-r

INTR-r ***

Note: *= Hypothesis supported by NEO-PI-R only; **= Hypothesis supported by SCID-

II only; ***= Hypothesis supported by both NEO-PI-R and SCID-II; = Hypothesissupported by BSI only; *= Hypothesis supported by NEO-PI-R and BSI only; **=Hypothesis supported by SCID-II and BSI only; = Significant result that was nothypothesized.


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36

and NEO-PI-R would be more strongly linked as both measures assess personality from a

dimensional perspective.

In contrast, the SCID-II is a more taxonic-type of assessment tool. The SCID-II

interview questions are closely aligned with the DSM-IV criteria for each personality

disorder, which are also taxonic. Despite the fact that SCID-II symptom counts were

utilized in this study, the symptom counts themselves are taxonic in nature. The rater is

asked to indicate the presence or absence of a given symptom, and they do not rate how

much or how little (i.e. - severity) of that symptom is present. Since the SCID-II and

MMPI-2-RF scales take different perspectives (i.e. - taxonic vs. dimensional) to

assessment of symptomatology, it is, perhaps, not surprising that the associations between

these two measures are generally of smaller magnitude.

Another potential explanation for stronger associations between the MMPI-2-RF

and NEO-PI-R prototype similarities has to do with common method variance. Both the

MMPI-2-RF and NEO-PI-R are self-report instruments. Therefore, the correlations

between the two measures may be somewhat artificially inflated. It is possible that some

of the co-variance between the MMPI-2-RF and NEO-PI-R may be attributed to the

measurement method, rather than the constructs of interest. Thus, the common method

variance shared between the two measures may have increased the systematic

measurement error in this study. To address the common method variance concern,

findings were only interpreted if they reached the magnitude of .4 or greater, which is a

medium effect size, as defined by Cohen (1988).


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Two sets of personality disorder symptoms do not appear to be adequately

assessed by the criterion measures utilized in this study. First, there were no significant

associations between select MMPI-2-RF scales and the NEO-PI-R prototypes or SCID-II

symptom counts for Histrionic Personality Disorder. In fact, none of the hypotheses

associated with Histrionic Personality Disorder were supported in this study. One

potential explanation for the lack of support may relate to the substantial symptom

overlap shared between Histrionic and Borderline Personality Disorders. Blagov and

Westen (2008) examined the relationships between Histrionic and Borderline

symptomatology, as they were skeptical of the validity of diagnosing Histrionic

Personality Disorder. They demonstrated that a large majority of the patients in their

study shared symptoms that overlapped between Histrionic and Borderline Personality

Disorder, as defined by the DSM-IV. For example, both disorders share symptoms

associated with internalizing and externalizing symptoms, such as anxiety, stress, worry,

and acting out behaviorally. In this study, the strongest pattern of correlations, across all

clusters, was demonstrated for Borderline Personality Disorder. However, Histrionic

Personality Disorder demonstrated the weakest pattern of associations, as none of the

hypotheses were supported. Therefore, a potential explanation for the discrepancy in

patterns may have to do with the overlap in shared symptomatology between the

disorders. Since the patterns are so discrepant, it appears that some of the Histrionic

symptomatology may have been misclassified. Furthermore, the pattern of results in this

study is consistent with the findings of Blagov and Westen (2008). The second set of

personality disorder symptomatology that was largely unsupported in this study was for


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Obsessive-Compulsive Personality Disorder. With this disorder, only one significant

association was demonstrated between RC7 and the SCID-II. There were no significant

associations between any MMPI-2-RF scale and the NEO-PI-R. A potential explanation

for the unsupported hypotheses relates to the DSM-IV diagnostic criteria. The

unanticipated associations found between the SCID-II and particular MMPI-2-RF scales,

such as THD, RC8, and PSYC-r, suggest that there is a much larger thought distortion

factor associated with OCPD. Thus, the initial hypotheses conceptualized OCPD as more

of an internalizing disorder; whereas, the results of this study suggest that OCPD may be

more appropriately labeled as a thought disorder. A related potential explanation for

the unsupported hypotheses may also be low base-rates. Most of the participants in this

study did not report significant symptoms associated with OCPD.

As noted in Table 6, the results of this study also demonstrated some unexpected

associations between the MMPI-2-RF scales and the criterion measures for several of the

personality disorders, including: Paranoid, Schizotypal, Borderline, and Avoidant

Personality Disorder. Thus, these unexpected associations occur across all three clusters

of personality disorders. The unanticipated associations (e.g., EID, RCd, RC7, ANP, &

NEGE-r) exhibited for the Cluster A personality disorders all involve scales that assess

symptoms associated with general distress or demoralization and negative emotionality.

For both Clusters B and C, the unexpected associations (e.g., - RCd, COG, NFC, STW,

AXY, and NEGE-r) are related to symptoms of distress, cognitive difficulties, such as

confusion memory problems, and internalizing symptomatology, including anxiety and

worry for example.


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The results of this study suggest that Cluster A and Cluster C personality

disorders are both related to internalizing symptomatology. Further, The Cluster A and

Cluster C personality disorders demonstrate strong associations with measures of

negative emotionality in this study. Thus, it appears that individuals with Cluster A or

Cluster C personality disorders experience significant amounts of negative emotionality,

such as anxiety, worry, and stress.

In addition, Cluster B personality disorder symptoms were found to be linked

more to externalizing symptomatology, which is consistent with the criteria listed in the

DSM-IV-TR (APA, 2000). However, Borderline Personality Disorder appears to

represent a mixture of both internalizing and externalizing symptoms, which is also

consistent with the DSM criteria. Research by Krueger and colleagues (2001)

demonstrated an association between externalizing symptomatology and the construct of

Disconstraint. The results of this study suggest that individuals with Cluster B personality

disorders have a tendency to be more impulsive, act out behaviorally, and are likely to

have difficulty controlling their own behavior. Evidence in support of this notion is

demonstrated by the strong associations noted between the MMPI-2-RF scales of BXD,

RC4, RC9, and DISC-r and the NEO-PI-R, SCID-II, and BSI measures of Cluster B

symptoms.

Evaluation of the personality disorder-related diagnostic considerations

recommended by Ben-Porath & Tellegen (2008) indicated that almost every

consideration was supported in this study. Specifically, support was found for the

consideration of Antisocial Personality Disorder if an elevation on RC 4 is present. In


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addition, the recommendation to consider a personality disorder manifesting unusual

thoughts or perceptions when RC8 is elevated was demonstrated to be accurate as well.

Support was also demonstrated for the consideration that elevations on RC9 are

indicative of Narcissistic Personality Disorder. Furthermore, Ben-Porath and Tellegens

(2008) recommendation to evaluate for Dependent Personality Disorder when

Interpersonal Passivity is elevated was also supported. Elevations on the Social

Avoidance Specific Problems Scales were also associated with Avoidant Personality

Disorder, as Ben-Porath and Tellegen (2008) suggested. Also, according to Ben-Porath

and Tellegen (2008), elevations on the Disaffiliativeness Specific Problems Scales

warrant a consideration of Schizoid Personality Disorder. This recommendation was

upheld by the results of this study as well. Ben-Porath and Tellegen (2008) also provide

personality disorder-related diagnostic considerations for each of the PSY-5 scales and

each consideration was supported by the findings in this study. Thus, the results provided

support for consideration of a Cluster B personality disorder when elevations were

present on both AGGR-r and DISC-r. In addition, elevations on PSYC-r warrant a

consideration of a Cluster A personality disorder. Finally, the results also suggest that

Cluster C personality disorders should be considered when an elevation was present on

NEGE-r or INTR-r.

There were two personality disorder-related diagnostic considerations that this

study failed to support. No significant associations were found between RC3, Cynicism,

and personality disorders characterized by mistrust or hostility (i.e.Paranoid

Personality Disorder). In addition, there was no support for the association between JCP,


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the Juvenile Conduct Problems Scale, and Antisocial Personality Disorder. Perhaps the

association between JCP and Antisocial Personality Disorder may not be present due to

the fact that the NEO-PI-R does not assess criminal behaviors.

If replicated, the results of this study indicate that the personality disorder-related

diagnostic considerations by Ben-Porath and Tellegen (2008) are clinically useful and

empirically supported. While a majority of the considerations suggested are supported by

the results of this study, there are several associations between the criterion measures that

were not initially anticipated. More specifically, the Cluster A personality disorders

appear to be characterized by more internalizing-type symptomatology than initially

hypothesized, as significant associations were demonstrated between RC7 and Paranoid

and Schizotypal Personality Disorders, for example. In general, it appears that individuals

with personality disorder symptomatology are reporting more distress than is reflected in

the DSM-IV and the diagnostic considerations stated by Ben-Porath and Tellegen (2008).

Thus, it is likely that the unanticipated correlations found in this study reflect associated

features, rather than the core components of a given personality disorder Therefore, a

combination of the personality disorder-related diagnostic considerations (Ben-Porath &

Tellegen, 2008) plus elevations on scales assessing distress and internalizing

psychopathology is more likely to indicate the presence of a given personality disorder.

By using this combination of scale elevations, the potential exists to make test

interpretation more accurate and clinically useful.


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Limitations

The current study has several limitations. First, the DSM-IV-TR (APA, 2000)

diagnostic criteria for each personality disorder were used to develop the set of

hypotheses utilized in this study. Currently, the DSM-IV-TR (APA, 2000) is the gold

standard used by psychologists to diagnose personality disorders. Thus, the hypotheses

utilized in this study were developed based on the most prominent set of criteria

available. However, the criteria provided by the DSM are not without their own

limitations and flaws. More specifically, empirical research has suggested that there are

alternative methods of defining personality disorder symptomatology (Lynam & Widiger,

2001), such as examining symptoms on a continuum of severity, rather than a dichotomy.

Thus, there are alternative methods and criteria that may have been used to develop the

hypotheses for this study.

Another potential limitation of this study relates to the sample. This study utilized

an all- male sample and women were not included due to their small number. Previous

research has demonstrated differences between men and women with a variety of

disorders diagnoses (e.g., depression) and on a variety of different psychological

constructs (e.g., aggression). Personality disorders also appear to be consistent with this

pattern of differences between men and women as well. For example, differences

between men and women have also been noted in the DSM-IV-TR (APA, 2000)

prevalence rates of personality disorders. Men are more likely than women to be

diagnosed with Antisocial Personality Disorder (APA, 2000). It appears that the opposite

effect also exists, where women may be diagnosed with a particular personality more


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often than men. For example, research by Bornstein (1996) demonstrated that Dependent

Personality Disorder was diagnosed more often for women than men. Thus, it is unclear

as to whether the results of this study would generalize to women in the same setting.

The final potential limitation of this study also relates to the sample and

generalizability of findings. The sample utilized in this study was enrolled in treatment in

an addictions unit at a VA medical center. Individuals participating in the addictions

treatment had a variety of addictions, including alcohol, drug, and gambling addictions.

All of the participants also had Axis I conditions as well. Thus, there were tremendous

rates of comorbidity between psychological diagnoses and substance abuse and/or

dependence diagnoses, which could impact the ability of these results to generalize across

outpatient treatment settings where not all individuals receiving mental health treatment

have primary co-morbid substance abuse difficulties. In addition, the participants were

veterans of various military branches. The generalizability of the results may also be

influenced by the nature of the veteran sample as well.

Future Directions

Future research should be conducted to evaluate the link between elevated MMPI-

2-RF scales and personality disorder symptomatology using samples of women, other

outpatient samples, and samples from inpatient settings. Thus, it would be important to

replicate the findings of this study with women, as the sample in this study is all men. In

addition, it is unclear whether the results of this study would generalize to other

outpatient samples where individuals are not enrolled in addictions treatment; therefore,

future research should examine this link in outpatient settings that do not include


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addictions treatment. Replicating the results of this study in inpatient settings would also

be important for future research, as individuals in inpatient settings are likely to

experience different symptoms of psychopathology. In addition, these associations should

also be explored in forensic and medical settings, as personality pathology may impact

diagnosis and treatment planning in those particular settings.

Finally, future research should also examine the use of other criterion measures to

assess personality disorder symptomatology. The criterion measures utilized in this study

are not the only self-report or interview measures of personality disorder

symptomatology available. Research in this area could be strengthened by implementing

the use other criterion measures to examine the link between elevations on MMPI-2-RF

and personality disorder symptomatology. For example, the Dimensional Assessment of

Personality Pathology- Brief Questionnaire (DAPP-BQ; Livesley & Jackson, in press)

and the Schedule for Nonadaptive and Adaptive Personality (SNAP; Clark, 1992) are two

self-report measures that may be particularly useful in assessing personality disorder

symptomatology, as both measures were developed with a focus on Axis II symptoms. In

addition, therapist ratings of personality disorder symptomatology may also offer another

alternative method of assessment as well.


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REFERENCES

American Psychiatric Association (2000).Diagnostic and Statistical Manual of Mental

Disorders- Fourth Edition- Text Revision. Arlington, VA: American Psychiatric

Association.

American Psychiatric Association (1980).Diagnostic and Statistical Manual of Mental

Disorders- Third Edition.Arlington, VA: American Psychiatric Association.

Bagby, R. M., Sellbom, M., Costa, P. T., & Widiger, T. A. (2008). Predicting diagnostic

and statistical manual of mental disorders-IV personality disorders with the Five-

Factor Model of personality and the Personality Psychopathology Five.

Personality and Mental Health,2(2), 55-69.

Ben-Porath, Y. S. & Tellegen, A. (2008).Minnesota Multiphasic Personality Inventory-

2- Restructured Form: Technical Manual. Minneapolis: University of Minnesota

Press.

Blagov, P. S., & Westen, D. (2008). Questioning the coherence of Histrionic Personality

Disorder: Borderline and hysterical personality subtypes in adults and

adolescents. Journal of Nervous and Mental Disease,196(11), 785-797.

Bornstein, R. F. (1996). Sex differences in Dependent

Personality

Disorder prevalence

rates. Clinical Psychology: Science and Practice,3(1), 1-12.

45


50/57

46

Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989).

Minnesota Multiphasic Personality Inventory-2: Manual for administration and

scoring.Minneapolis: University of Minnesota Press.

Chiao-Chicy, C., Shang-Ying, T., Lien-Wen, S., Tien-Wei, Y., Chang-Jer, T., & Hai-

Gwo, H. (1999). Psychiatric co-morbidity among male heroin addicts: Differences

between hospital and incarcerated subjects in Taiwan.Addiction, 94(6), 825-832.

Clark, L. A. (1993).Manual for the Schedule for Nonadaptive and Adaptive Personality

(SNAP). Minneapolis: University of Minnesota Press.

Conte, H. R., Plutchik, R., Karasu, T. B., & Jerrett, I. (1980). A self-report Borderline

Scale: Discriminative validity and preliminary norms. The Journal of Nervous

and MentalDiseases, 168(1), 428-435.

Costa P. T., & McCrae, R. R. (1992).NEO-PI-R Professional Manual. Odessa, FL:

Psychological Assessment Resources.

Craig, R. J. (2000). Prevalence of personality disorders among cocaine and heroin

addicts. Substance Abuse, 21(2), 87-94.

DAngelo, E. J. (1991). Convergent and discriminant validity of the Borderline

Syndrome Index.Psychological Reports, 69, 631-635.

First, M. B., Spitzer, R. L., Williams, J. B. W., & Gibbon, M. (1997). Structured Clinical

Interview for DSM-IV Axis II Personality Disorders (SCID-II) user's guide and

interview.Washington, DC: American Psychiatric Press.

Graham, J. R., Ben-Porath, Y. S., & McNulty, J. L. (1999).MMPI-2 Correlates for

outpatient mental health settings. Minneapolis: University of Minnesota Press.


51/57

47

Graham, J. R. (2006).MMPI-2: Assessing personality and psychopathology. New York:

Oxford University Press.

Gunderson, J. D., Kolb, J. E., & Austin, V. (1981). The Diagnostic Interview for

Borderline patients.American Journal of Psychiatry, 138, 896-903.

Harkness, A. R., & McNulty, J. L. (1994), The Personality Psychopathology Five (PSY-

5): Issues from the pages of a diagnostic manual instead of a dictionary. In S.

Strack & M. Lorr (Eds.),Differentiating Normal and Abnormal Personality (pp.

291-315). New York: Springer.

Harkness, A. R., McNulty, J. L., & Ben-Porath, Y. S. (1995). The Personality

Psychopathology Five (PSY-5): Constructs and MMPI-2 scales.Psychological

Assessment, 7,104-114.

Harkness, A. R. & McNulty, J. L. (August, 2007).Restructured Versions of the MMPI-2

Personality Psychopathology Five (PSY-5) Scales. Paper presented at the meeting

of the American Psychological Association, San Francisco, CA.

Hathaway S. R., & McKinley, J. C. (1942). The Minnesota Multiphasic Personality

Schedule. Minneapolis: University of Minnesota Press.

Hicklin J. & Widiger, T. A. (2000). Convergent validity of alternative MMPI-2

Personality Disorder Scales. Journal of Personality Assessment, 75, 502-518.

Hurt, S. W., Clarkin, J. F., & Morey, L. C. (1990). An examination of the stability of the

MMPI personality disorder scales.Journal of Personality Assessment, 54(1&2),

16-23.


52/57

48

Jones, A. (2005). An examination of three sets of MMPI-2 Personality disorder scales.

Journal of Personality Disorders, 19(4), 370-385.

Kamphuis, J. H., Arbisi, P. A., Ben-Porath, Y. S., & McNulty, J. L. (2008). Detecting

comorbid Axis-II status among inpatients using the MMPI-2 Restructured

Clinical Scales.European Journal of Psychological Assessment, 24(3), 157-164.

Klonsky, D. E. (2000). The DSM classification of personality disorder: Clinical wisdom

or empirical truth? A response to Alvin R. Mahrers problem 11.Journal of

Clinical Psychology, 56(12), 1615-1621.

Kraus, A. (1991). Methodological problems with the classification of personality

disorders: The significance of existential types.Journal of Personality Disorders,

5(1), 82-92.

Krueger, R. F., McGue, M., & Iacono, W. G. (2001). The higher-order structure of

common DSM mental disorders: Internalization, externalization, and their

connections to personality.Personality and Individual Differences, 30, 1245-

1259.

Livesley, J. W. (1991). Classifying personality disorders: Ideal types, prototypes, or

dimensions?Journal of Personality

smith ashley m-assessing pd with mmpi-2

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