jacob finn
TRANSCRIPT
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THE MMPI-2 AND PTSD ASSESSMENT:
MORE THAN JUST THE PK SCALE
Jacob A. Finn, M.A. & Elana Newman, Ph.D
The University of Tulsa
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PRESENTATION
OBJECTIVES
Describe more recent MMPI-2 developments,
including the Infrequency Psychopathology (Fp)
Scale, the Restructured Clinical (RC) Scales, and
the Personality Psychopathology-Five (PSY-5)
Scales.
Explain research regarding the utility of these
scales for the assessment of PTSD
Discuss limitations to the research already
conducted and identify areas for future research
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PERSONALITY INVENTORY 2(MMPI-2)
The MMPI-2 is one of the most widely used and
researched assessment instruments.
567 True or False items
The original MMPI was published by Hathaway and
McKinley in 1943.
Clinical Scales developed by contrast group empirical keying
method
The MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, &
Kaemmer,1989) was published to address concerns aboutnorms, language, and item content.
Desire to maintain as much research as possible
Clinical Scales were kept with very limited changes
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Scale 1
Hypochondriasis
(Hs)
Scale 2 Depression (D)
Scale 3
Hysteria (Hy)
Scale 4
Psychopathic Deviate (Pd)
Scale 5
Masculinity-Femininity (Mf)
Scale 6
Paranoia (Pa)
Scale 7 Psychasthenia (Pt)
Scale 8
Schizophrenia (Sc)
Scale 9
Hypomania (Ma)
Scale 0 Social Introversion (Si)
PERSONALITY INVENTORY 2(MMPI-2)
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MMPI-2 AND THE PK SCALE
PTSD was not one of the clinical syndromes the MMPI
Clinical Scales were developed to measure.
The PK Scale (Keane, Malloy, & Fairbank, 1984) was
developed for the purpose of assessing PTSD by
contrasting veterans groups with and without a diagnosis.
The large portion of research on the PK scale has focused
on veterans.
The PK scale has been evaluated by several groups, with
many concluding the construct being measured by PK is
distress (Arbisi, McNulty, & Ben-Porath, 2004; Miller,Goldberg, & Streiner, 1995; Wetzel, Murphy, Simons,
Lustman, North, & Yutzy, 2003).
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DISTRESS AND THE MMPI-2
Watson (2005) proposed a three factor model to explaininternalizing disorders: distress (negative emotionality),
positive affect, and physiological hyperarousal.
He acknowledges the limitations to our understanding ofwhere PTSD fits, but several large studies suggest PTSD
loads highest on distress.
Several studies have identified emotional distress as thefirst-factor of the MMPI-2 item pool (Graham, 2006).
Not the only factor, but it is well-represented in item pool
Some researchers have found evidence to suggest thatdistress may affect the interpretability of some MMPI-2
scales.
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DISTRESS AND THE MMPI-2
The Infrequency (F) scale is a validity scale for over- reporting, built with items infrequently endorsed bynormal
individuals
Among first validity scales and based on Minnesota Normals
Some F item content reflects sex life, substance use, level of
functioning, sleep problems, and social support.
The Clinical Scales were developed through contrast groupmethods, selecting items that distinguished those withpathology from those without.
Issue with multiple elevations (lack of discriminant validity)
Some argue this is due to distress/demoralization (Tellegen,
Ben-Porath, McNulty, Arbisi, Graham, & Kaemmer, 2003)
How accurate are these and similar MMPI-2 scales if
the client is experiencing a high level of distress.
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DEVELOPMENTS IN THE
MMPI-2
New MMPI-2 scales have been developed with these
concerns in mind.
The Infrequency Psychopathology (Fp) Scale
The Restructured Clinical (RC) Scales
DSM-V Workgroups acknowledge that personality traits
add to the description of a diagnosis (Skodol, 2008, 2009)
The Personality Psychopathology-Five (PSY-5) Scales
The Fp, RC, and PSY-5 scales are all found on the new
MMPI-2-RF (Ben-Porath & Tellegen, 2008) in either their
original (RC) or a modified (Fp and PSY-5) form.
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INFREQUENCYPSYCHOPATHOLOGY SCALE
(FP )
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INFREQUENCY PSYCHOPATHOLOGY
SCALE (FP )
PTSD is thought to be an easier disorder to fake (Resnick,
West, & Payne, 2008).
Media coverage including PTSD
Emphasis of symptoms over signs
One of the benefits to using the MMPI-2 for PTSD
assessment is the presence of validity scales.
Arbisi & Ben-Porath (1995) constructed the Fp scale by
identifying items endorsed by 20% or less of individuals in
two inpatient samples and the MMPI-2 normativesample.
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INFREQUENCY PSYCHOPATHOLOGY
SCALE (FP )
Basic validation (Arbisi & Ben-Porath, 1995, 1997, 1998)
Less correlated with measures of distress and psychopathology
Less elevated in clinical samples and in individuals with confirmedPTSD than F and Fb
Greater PPP and classification accuracy in an inpatient faking
paradigm
Compensation-seeking populations
Produced proportion of invalid protocols comparable to the rates
found in other compensation seeking research, 20-30% (Tolin,Maltby, Weathers, Litz, Knight, & Keane, 2004)
Better discriminated undergraduates faking PTSD for
compensation from non-fakers and workplace accident victims with
confirmed PTSD, even when fakers were coached on PTSD
symptoms and/or validity scales (Bury & Bagby, 2002).
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Better Faker
Groups
Incremental contribution over other validity scales in
identifying trained fakers from individuals with PTSD relatedto childhood sexual assault (Elhai, Naifeh, Zucker, Gold,
Deitsch, & Frueh, 2004).
Largest effect in differentiating individuals with PTSD from
individuals with remitted PTSD coached and uncoached for
faking (Efendov, Sellbom, & Bagby, 2008).
It is important for clinicians to use actuarial data, such as
validity scales, in evaluating self-reported symptoms andin making decisions about access to compensation and
pension (Arbisi, Murdoch, Fortier, & McNulty, 2004)
INFREQUENCY PSYCHOPATHOLOGY
SCALE (FP )
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RESTRUCTURED CLINICAL
SCALES (RC SCALES)
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Criticisms were raised regarding the Clinical Scales
Long scales with item overlap, high intercorrelations, and
questionable subtle items
The RC Scales were developed in a 4-step process
(Tellegen et al., 2003)
Step 1: Develop a Demoralization Scale
Step 2: Identify the unique core factors to the Clinical Scales
Step 3: Build seed scales
Step 4: Analyze item pool for convergent and discriminant
qualities
RCd
Demoralization
Developed from items in Clinical Scale 2 and 7
Emotional discomfort, helpless, pessimistic
RESTRUCTURED CLINICAL
SCALES (RC SCALES)
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RESTRUCTURED CLINICAL
SCALES (RC SCALES)
Watson & Tellegen, 1985, p. 221
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RC1
Somatic complaints
Excessive preoccupation with physical health
RC2
Low positive emotions
Withdrawn, passive, experience anhedonia
RC3
Cynicism
Regard people as uncaring and untrustworthy
RC4 Antisocial behavior
Legal difficulties, angry, antagonistic
RC6
Ideas of Persecution
Feeling targeted and mistreated
RC7
Dysfunctional negative emotions
Preoccupation with negative perceptions
RC8
Aberrant experiences
Impaired reality testing, psychotic symptoms
RC9
Hypomanic activation
Poor impulse control, grandiose, euphoric
RESTRUCTURED CLINICAL
SCALES (RC SCALES)
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RESTRUCTURED CLINICAL
SCALES (RC SCALES)
In two VAMC samples (one male, one female), RC scales
relationship to PTSD symptoms and diagnosis wereexamined (Wolf, Miller, Orazem, Weierich, Castillo,Milford, et al., 2008).
Allowed for replication and examination of gender differences
In males, RCd (Demoralization) and RC7 (DysfunctionalNegative Emotions) were the strongest correlations with total
PTSD symptoms and a PTSD diagnosis, respectively.
In females, RC1 (Somatic Complaints) and RCd
(Demoralization) were the strongest correlations with total
PTSD symptoms, respectively.
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RC Scale VA Men VA Women
RCd
Demoralization
RC1
Somatic Complaints
RC2
Low Positive Emotions
RC3
Cynicism
RC4
Antisocial Behaviors
RC6
Ideas of Persecution
RC7
Dysfunctional Negative Emotions
RC8 Aberrant Experiences RC9 Hypomanic Activation
WOLF ET AL. (2008) RC SCALE ELEVATIONSIN INDIVIDUALS WITH PTSD
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Discriminate PTSD from other diagnoses in a college
sample (McDevitt-Murphy, Weathers, Flood, Eakin, &
Benson, 2007)
No RC scale distinguished PTSD and MDD, though RC2 and
RC4 were close to moderate effect sizes
RCd, RC1, RC2, and RC4
PTSD from Social Phobia
All RC scales
PTSD from well-adjusted individuals
Discriminate between internalizing and externalizing
subtypes of PTSD in a work-related trauma group
(Sellbom & Bagby, 2009)
Both externalizers and internalizers had high scores on RCd
and RC7.
RC3, RC4, and RC9 were higher in externalizers
RC1 and RC2 were higher in internalizers
RESTRUCTURED CLINICAL
SCALES (RC SCALES)
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Used to test the theoretical assumptions of Watsons
model of internalizing disorders (Sellbom, Ben-Porath, &
Bagby, 2008)
Large undergraduate sample and a large outpatient sample
RCd (Demoralization) loaded strongly on a distress factor
comprised of Depression, GAD, and PTSD measures
RC7 (Dysfunctional Negative Emotions) loaded strongly on a
fear factor comprised of Social Phobia, Specific Phobias, and
Agoraphobia measures
RC2 (Low Positive Emotions) loaded on Depression and on
Social Phobia
RESTRUCTURED CLINICAL
SCALES (RC SCALES)
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PERSONALITYPSYCHOPATHOLOGY-FIVE
SCALES (PSY-5)
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PERSONALITY PSYCHOPATHOLOGY-
FIVE SCALES (PSY-5)
Replicated Rational Selection (RRS) was used to identify
MMPI-2 items for the PSY-5 scales (Harkness, McNulty, &
Ben-Porath, 1995).
RRS involves educating a layperson regarding a construct of
interest and having them select relevant items.
No item overlap and highly face valid
Scales represent communication between client and clinician
Scales
Aggressiveness (AGGR)
Psychoticism (PSYC)
Disconstraint (DISC)
Negative Emotionality/Neuroticism (NEGE)
Introversion/Low Positive Emotionality (INTR)
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Aggressiveness (AGGR)
Instrumental aggression
Low scores: Interpersonally passive and submissive (Weisenburger,Harkness, McNulty, Graham, & Ben-Porath, 2008)
Psychoticism (PSYC)
Disconnection from reality
Disconstraint (DISC)
Impulsivity, rule-breaking
Low scores: Prone to structure and planning, controlled
Negative Emotionality/Neuroticism (NEGE)
Thinks negatively about self, others, world, and future
Introversion/Low Positive Emotionality (INTR)
Little interest in social activities and positive experiences
Low scores: Sociable and energetic
PERSONALITY PSYCHOPATHOLOGY- FIVE SCALES (PSY-5)
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PSY-5 scores are related to trauma-related internalizing
and externalizing symptom clusters
In a veteran sample (Miller, Kaloupek, Dillon, & Keane, 2004)
In a work-related trauma sample (Sellbom & Bagby, 2009)
PERSONALITY PSYCHOPATHOLOGY-
FIVE SCALES (PSY-5)
PERSONALITY PATTERNS OF
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PERSONALITY PATTERNS OF
INTERNALIZING AND EXTERNALIZING
PTSD
PSY-5 Scales
Internalizing Subtype Externalizing Subtype
Veterans Work Veterans Work
AGGR Low High
PSYC High
DISC High High
NEGE
INTR High High
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PSY-5 constructs contribute to the relationship between
PTSD and substance use (Miller, Vogt, Mozley, Kaloupek,
& Keane, 2006).
Alcohol = DISC and NEGE
Illicit substances = DISC
PSY-5 scales may be used to understand how someone
copes with a future stressor (Ferrier-Auerbach, Kehle,
Erbes, Arbisi, Thuras, & Polusny, 2009)
Sample of pre-deployment National Guard soldiers
Predictors of drinking frequency = DISC and NEGE
Predictors of quantity of drinking = DISC and NEGE
Predictors of frequency of binge drinking = NEGE and DISC
PERSONALITY PSYCHOPATHOLOGY-
FIVE SCALES (PSY-5)
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CONCLUSIONS
While the Clinical Scales may represent the core of the
MMPI-2, other scales may offer additional information.
The research suggests Fp provides important informationabout response strategies.
Currently, the research supports the continued evaluation
of the RC and PSY-5 scales for PTSD assessment, butmore research is needed to firmly establish their utility.
The scales of the MMPI-2 provide symptom-related
information, but they should not be used alone for
diagnosis.
A multi-method battery including a structured interview
and trauma-specific measures should be used with the
MMPI-2 (Penk, Rierdan, Losardo, & Robinowitz, 2006)
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QUESTIONS OR COMMENTS? FUTURE QUESTIONS CAN BE DIRECTED