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

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

MINNESOTA MULTIPHASIC 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 about norms, language, and item content.
Desire to maintain as much research as possible Clinical Scales were kept with very limited changes

MINNESOTA MULTIPHASIC PERSONALITY INVENTORY 2 (MMPI-2)

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)

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).

DISTRESS AND THE MMPI-2

Watson (2005) proposed a three factor model to explain internalizing disorders: distress (negative emotionality), positive affect, and physiological hyperarousal.

He acknowledges the limitations to our understanding of where PTSD fits, but several large studies suggest PTSD loads highest on distress.

Several studies have identified emotional distress as the first-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 that distress may affect the interpretability of some MMPI-2 scales.

DISTRESS AND THE MMPI-2

The Infrequency (F) scale is a validity scale for overreporting, built with items infrequently endorsed by normal 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 group methods, selecting items that distinguished those with pathology 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.

RELATIVELY NEW 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.

INFREQUENCY PSYCHOPATHOLOGY SCALE (FP)

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 normative sample.

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 confirmed PTSD 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).

INFREQUENCY PSYCHOPATHOLOGY SCALE (FP)

Better Faker Groups

Incremental contribution over other validity scales in identifying trained fakers from individuals with PTSD related to 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 and in making decisions about access to compensation and pension (Arbisi, Murdoch, Fortier, & McNulty, 2004)

RESTRUCTURED CLINICAL SCALES (RC SCALES)

Criticisms were raised regarding the Clinical Scales

RESTRUCTURED CLINICAL SCALES (RC 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)

Watson & Tellegen, 1985, p. 221

RESTRUCTURED CLINICAL SCALES (RC SCALES)

RC1 Somatic complaints

Excessive preoccupation with physical health Withdrawn, passive, experience anhedonia Regard people as uncaring and untrustworthy Legal difficulties, angry, antagonistic Feeling targeted and mistreated Preoccupation with negative perceptions

RC2 Low positive emotions

RC3 Cynicism

RC4 Antisocial behavior

RC6 Ideas of Persecution

RC7 Dysfunctional negative emotions RC8 Aberrant experiences

Impaired reality testing, psychotic symptoms Poor impulse control, grandiose, euphoric

RC9 Hypomanic activation

RESTRUCTURED CLINICAL SCALES (RC SCALES)

In two VAMC samples (one male, one female), RC scales relationship to PTSD symptoms and diagnosis were examined (Wolf, Miller, Orazem, Weierich, Castillo, Milford, et al., 2008).
Allowed for replication and examination of gender differences In males, RCd (Demoralization) and RC7 (Dysfunctional Negative 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.

WOLF ET AL. (2008) RC SCALE ELEVATIONS IN INDIVIDUALS WITH PTSD

RC Scale 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 VA Men VA Women

RESTRUCTURED CLINICAL SCALES (RC SCALES)

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)

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

PERSONALITY PSYCHOPATHOLOGY-FIVE SCALES (PSY-5)

PERSONALITY PSYCHOPATHOLOGYFIVE 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)

PERSONALITY PSYCHOPATHOLOGYFIVE SCALES (PSY-5)

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 PSYCHOPATHOLOGYFIVE SCALES (PSY-5)

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 PATTERNS OF INTERNALIZING AND EXTERNALIZING PTSD

Internalizing Subtype PSY-5 Scales AGGR PSYC DISC NEGE INTR High High Veterans Work Low Externalizing Subtype Veterans High High High High Work

PERSONALITY PSYCHOPATHOLOGYFIVE SCALES (PSY-5)

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

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 information about response strategies. Currently, the research supports the continued evaluation of the RC and PSY-5 scales for PTSD assessment, but more 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 TO: JACOB-FINN@UTULSA.EDU