Coping and MCMI-II symptom scales

COPING AND MCMI-I1 SYMPTOM SCALES MARGARETE VOLLRATH RANDOLF ALNAES

University of Zurich Oslo, Norway Zurich, Switzerland

SVENN TORGERSEN

University of Oslo, Norway

The associations of the MCMI-II symptom scales with dispositional coping strategies were studied among 239 psychiatric outpatients. A similar core- pattern of emotion-focused coping was associated with all symptom scales except the bipolar scale. High scores on the MCMI-I1 symptom scales were associated with low use of adaptive emotion-focused coping (e.g., seeking social support) and high use of maladaptive emotion-focused coping (e.g., disengagement). Thought disorder, drug dependence, and delusional disorder also were associated with reduced use of problem-focused coping. The findings support the theoretical distinction between adaptive and maladaptive emotion-focused coping. The potential negative impacts of this coping pattern in terms of mental health and life adaptation are discussed.

Coping is an important resource for the regulation of well-being and maintenance of mental health under conditions of stress. Individuals with a broad, flexible, and effective repertoire of coping strategies are expected to deal successfully with minor and major stressful events in their life and to avoid more distress (Lazarus & Folkman, 1984).

Two major functions of coping currently are distinguished: the regulation of distressing emotions (emotion-focused coping) and attempts to change the problem that is caus- ing the distress (problem-focused coping) (Lazarus & Folkman, 1984). Most situations require both kinds of coping. Problem-focused coping tends to predominate when something constructive can be done, whereas emotion-focused coping tends to predominate when the stressor has to be endured (Folkman & Lazarus, 1980).

Because coping is an important predictor of distress, studies on populations with mental disorders might indicate what kind of coping may be maladaptive. Many studies have investigated coping strategies among subjects with mental disorders, especially anxiety and depression, but the majority did so in student populations. Some research has focused on psychiatric outpatients. Billings, Cronkite, and Moos (1983) found less problem-solving, less information seeking, and more emotional discharge coping among patients with unipolar depression. Parker and Brown (1982) reported less problem- solving, more passive coping, and self-consolation for depressives. For patients with anxiety disorders, especially panic disorder, similar findings have been reported. There was evidence for less problem-focused coping, more wishful thinking, more avoidance, and more seeking for social support (Borden, Clum, Broyles, & Watkins, 1988; Vitaliano et al., 1987; Vollrath & Angst, 1993).

Only a few studies have compared coping across different clinical syndromes by means of the same instruments. Miller, Surtees, Kreitman, Ingham, and Sashidharan

The study was supported by grants from the Norwegian Research Council for Science and the Humanities and by legacies administered by the University of Oslo, the Lier Hospital Foundation, the Anders Jahres Foundation and the Solveig and Johan P. Sommers Legacy. The authors wish to thank Karola Vollrath for her assistance in preparing the manuscript.

Correspondence should be addressed to Margarete Vollrath, Ph.D., Department of Social Psychology, University of Zurich, Ramistr. 66, 8001 Zurich, Switzerland.

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728 Journal of Clinical Psychology, September 1994, Vol. 50, No. 5

(1985) found similar associations of maladaptive coping (anger-in, anger-out, rumina- tion, consumption of alcohol and tobacco) with both anxiety and depression. Vitaliano, RUSSO, Carr, Maiuro, and Becker (1985) found less problem-focused and more wishful thinking among both depressive and anxious patients. Patients with personality disorders used less problem-focused coping and less social support, but more wishful thinking and avoidance than patients with other health problems (Vitaliano et al., 1990).

A comparison across studies is difficult because quite different coping scales were applied. But even with the same questionnaire, contrasting results were reported. This is especially true for problem-focused coping and seeking social support. Some studies found decreased problem-focused coping in anxiety and depression (Billings et al., 1983; Kleinke, 1988; Olah, Torestad, & Magnusson, 1989; Parker & Brown, 1982; Vitaliano et al., 1985). However, other studies did not find such an association (Blankstein, Flett, & Watson, 1992; Bruder-Mattson & Hovanitz, 1990; Chan, 1992; Coyne, Aldwin, & Lazarus, 1981; Hoffart & Martinsen, 1991; Kleinke, 1992), or only for men, but not for women (Billings & Moos, 1984).

Similarly, findings on the use of social support as a coping strategy among subjects with symptoms of mental disorders are contradictory. Some studies found increased seeking of social support to be associated with anxiety, depression, or other symptoms (Borden et al., 1988; Coyne et al., 1981; Vitaliano et al., 1985; Vollrath &Angst, 1993). Other studies reported no association or negative associations among anxiety, depression, and other symptoms and seeking social support (Hovanitz, 1986; Kashani & Orvaschel, 1988; Kleinke, 1988, 1992; Parker & Brown, 1982; Vitaliano et al., 1987).

Difficulties in comparing studies arise from different sources: Many samples are from the normal population, and their symptoms might be less severe. Symptoms or disorders were assessed in part by questionnaires and in part by diagnostic interviews. Coping referred to different stressful situations, partly to specific life problems, partly to the mental problems themselves. Finally, the most important obstacle for comparison is related to the measurement of coping. There is a wide variety of coping questionnaires, but most do not contain more than eight scales. Among these, problem-focused strategies tend to be underrepresented (Leventhal, Suls, & Leventhal, 1992) and too little differentiated. Carver, Scheier, and Weintraub (1989) criticize that different problem- focused activities have not been assessed separately. Furthermore, they contend that too little attention has been given to a better distinction among different emotion-focused strategies, although they may be sharply diverging in character. Finally, they hold that scales should be developed by focusing on points of theoretical interest rather than on empirical methods such as factor analysis.

Based on these premises, Carver et al. (1989) introduced a new questionnaire (COPE) that scores coping on 15 a priori scales These scales can be divided into three groups. The first comprises different aspects of problem-focused coping, like active coping, planning, or rearranging priorities. The authors consider these strategies adaptive in situations in which active coping efforts are required. The second group consists of emotion- focused strategies, which are viewed as potentially maladaptive by impeding or interfering with active coping in situations in which active coping would yield good outcomes (e.g., denial, disengagement). The third group consists of other, rather adaptive emotion- focused strategies, such as seeking emotional social support, positive reinterpretation, and religion. An important point is also that the instrumental and social aspects of seeking social support are assessed separately by this questionnaire.

In the present study, the associations between different clinical syndromes and the 15 coping stategies of the COPE were examined. Four questions guided our analysis. First, in what way and direction are the problem-focused coping strategies related to different clinical syndromes? Second, in which direction are the emotion-focused strategies related to symptoms? What is the role of seeking social support in particular? Third, is the theoretical differentiation between adaptive and maladaptive coping empirically

Coping and MCMI-II Symptom Scales 729

supported? Fourth, how specific are the associations with different clinical scales? Is there a general pattern of “neurotic” or “psychopathological” coping, or are different syndromes linked to very specific coping patterns?

METHOD

Subjects The present study is based on a follow-up investigation of psychiatric outpatients.

In 1984-85, the sample was drawn from the Outpatient Section of the Department of Psychiatry, Vinderen, University of Oslo, which has a catchment area of 70,000 in- habitants in the western part of Oslo. Patients with acute psychosis, acute crisis, substance abuse as the main problem, organic mental disorder, social problems, and language difficulties were excluded. At the first interview the sample consisted of 298 patients, aged 18 to 59 years (Alms & Torgersen, 1988a, 1988b).

Six years later, in 1990-91, all former patients were contacted again. Of the 298 patients, 1 patient had died of cancer and 5 of suicide; 3 patients could not be traced. Of the 289 patients who were contacted, 284 (98.3%) patients agreed to participate and were interviewed by one of the authors (R.A.). Two hundred thirty-nine of these patients (82.6%) correctly filled out inventories on psychiatric symptoms and coping. This sample comprised 72 males and 168 females, who were between 25 and 64 years of age at follow-up.

Measures For the assessment of different psychiatric symptoms, the MCMI-I1 (Millon, 1987)

was used. The MCMI-I1 is a 175-item self-report questionnaire that includes nine scales designed to measure different clinical conditions (Alms & Torgersen, 1988a, 1988b).

Coping strategies were assessed with the COPE, a 60-item self-report inventory that measures the frequency of dispositional coping strategies (Carver et al., 1989). Subjects were asked to report what they usually do when under stress. Fifteen coping strategies were scored. As previously pointed out, they can be subdivided into three groups according to their function and potential adaptivity. The group of problem-focused coping comprised the strategies active coping, planning, suppression of competing activities, restraint, and seeking social support for instrumental reasons. The group of potentially adaptive emotion-focused coping was assessed with the strategies seeking social support for emotional reasons, positive reinterpretation, acceptance, religion, and humor. The group of potentially maladaptive emotion-focused coping comprised the strategies denial, mental disengagement, behavioral disengagement, focus on and venting of emotions, and use of alcohol or drugs

Procedure In a first step, Pearson correlations were computed between the coping scales and

the MCMI-I1 scales. Because the coping scales were partly interrelated, multiple regression analyses were carried out in the next step to predict the MCMI symptom scales. These analyses were used to determine those coping strategies that share variance with the MCMI-I1 symptom scales. Each regression analysis was carried out with one of the MCMI scales as dependent and the coping scales as independent variables. To control for sex and age, these two variables always were entered first into the regression equations. After that, the coping strategies were entered by a stepwise procedure because there was no specific theoretical or empirical reason for a specific order among them.

RESULTS

In Table 1, the bivariate correlations between the 9 MCMI-I1 symptom scales and the 15 coping scales are presented. In the first group of problem-focused coping


Table 1 Correlations of Coping with the MCMI-II Symptom Scales (N = 239)

MCMI-I1 scales

COPE Bipolar/ Alcohol Drug

Anxiety Somatoform Manic Dysthymia Dependence Dependence

Problem-focused coping Active coping Planning Suppression of competing

Restraint Seeking social support for

instrumental reasons

Emotion-focused coping Potentially adaptive

activities

Seeking social support for emotional reasons

Positive reinterpretation Acceptance Religion Humor

Potentially maladaptive Denial Mental disengagement Behavioral disengagement Venting emotions AlcohoVdrug use

- . I S * - .08

.04

.09

- .18**

- .21** - . I S * - .06

.07

.05

.3 1 **

.34**

.45**

.14*

.18**

- .15* .11 - .18** - .13 - .08 .03 - .I0 - .10

.03 .09 .03 .03

.08 .02 .I0 .07

- .13* .08 -.17** - . I 1

- .15* - .19** - .19** - .05 - .13* .16* -.15* - .06 - .08 -.OO -.08 - .06

.08 .07 .08 .I1

.04 .25** .02 .06

.30** .21** .30** .28**

.35** .21** .33** .30**

.44** .09 .47** .29**

.16* .39** .16* .18**'

.20** .17** .23** .40**

- .08 - .I3

.02

.05

- .12

- .01 - .01 - .03

.05

.15*

.29**

.26**

.22**

.29**

.25**

MCMI-I1 scales

COPE Thought Disorder Major Depression Delusional Disorder

Problem-focused coping Active coping - .21** - .20** - .01 Planning - .17** - .13* - .I0 Suppression of competing

activities - .01 .04 .07 Restraint .I2 .08 .16* Seeking social support for

instrumental reasons - .26** - .17** - .16*


Seeking social support for emotional reasons

Positive reinterpretation Acceptance Re I i g i o n Humor

Denial Mental disengagement Behavioral disengagement Venting emotions AlcohoVdrug use

Potentially maladaptive

- .23** - .19** - .08

.05 - .01

.32**

.30**

.39**

.I0

.23**

- .18** - .16* - .09

.08

.oo

.31**

.35**

.46**

.20**

.24**

- .08 - .04 - .oo

.11

.06

.29**

.26**

.22**

.19**

.07

*p < .05. **p < .01, two-tailed.

Coping and MCMI-II Symptom Scales 73 1

strategies, a number of negative correlations with the MCMI-I1 scales were found. Active coping was related negatively to anxiety, somatoform disorder, dysthymia, thought disorder, and major depression. Planning showed significant negative correlations with thought disorder and major depression. Suppression of competing activities was unrelated to all symptom scales. Restraint was related only weakly to delusional disorder. Seeking support for instrumental reasons (i.e., seeking for help or advice) followed the pattern of active coping and also was related negatively to delusional disorder.

In the second group of potentially adaptive emotion-focused coping strategies, seeking support for emotional reasons was related negatively to most of the symptom scales except for bipolar/manic, alcohol dependence, drug dependence, and delusional disorder. The relationship with bipolar/manic was positive. Positive reinterpretation again was related weakly (but significantly) and negatively to anxiety, somatoform disorder, dysthymia, thought disorder, and depression. Acceptance was unrelated to the symptom scales. The same was true for turning to religion. Humor was related to bipolar disorder only in a positive direction.

In the last group of potentially dyfunctional coping strategies, there are ample correlations with the symptom scales. Positive moderate to medium-size correlations were found with virtually all symptom scales. Therefore, only the few exceptions will be pointed out here. Behavioral disengagement was not related to bipolar disorder. Venting of emotions was not related to thought disorder, while its relationship with bipolar disorder was especially strong. Use of alcohol and drugs was not related to delusional disorder, but was related particularly strongly to alcohol dependence.

Table 2 shows the results of nine regression analyses. The figures in the table repre- sent standardized betas. Because the significant betas formed patterns that were very similar for some disorders and different for others, we ranged the MCMI-I1 scales in a new way, which should render the similarities visible.

Anxiety, somatoform disorder, dysthymia, and major depression formed a group with practically the same predictors in the regression equations. Also the explained variance (R2) ran to very similar amounts for these disorders, namely, between 34% and 39%. High scores on these scales were predicted by little use of emotional support, less acceptance, increased disengagement (mentally and behaviorally), and increased 'focusing on one's own feelings and ventilating them. Patients with dysthymia and major depression also tended to use alcohol or drugs as a coping strategy. All four disorders were linked to the female sex and slightly to higher age.

Patients with bipolar disorder showed a somewhat different pattern of coping strategies. They were the only ones who used humor and had no tendency to disengage from their goals, but they ventilated emotions and tended to use alcohol or drugs.

Patients with high scores on the drug dependence, the thought disorder, and the delusional disorder scales seemed to form a second group with similarities of coping. They tended not to use instrumental social support, but, rather, denial, disengagement, and alcohol or drugs. With respect to some coping strategies, they differed from one another. For instance, patients with high scores on thought disorder did not tend to ventilate emotions. Patients with high scores on drug dependence, thought disorder, and delusional disorder tended to use denial, but those with alcohol dependence did not. Behavioral disengagement was only predictive of alcohol dependence and thought disorder, not of drug dependence and delusional disorder. Delusional disorder was the only scale with two significant predictors among the problem-focused coping strategies.

DISCUSSION

The set of 15 coping strategies measured by the COPE was related significantly to clinical symptoms of mental disorders, with up to 39% of common variance, although these patients were no longer In the acute phase of their disorder. First of all, this result

732 Journal of Clinical Psychology, September 1994, Vol. SO, No. 5

Table 2 Multiple Regressions of Coping on MCMI-11 Symptom Scales (N = 236)

MCMI-I1 scales

Major Step Anxiety Somatoform Dysthymia Depression

1 Sex .14 .14 .15 .15 I Age .14 .ll .11 .08

2 Problem-focused coping Active coping Planning Suppression of competing



activities


Seeking social support for emotional reasons - .27

Positive reinterpretation Acceptance - .I3 Re I i g i o n Humor

Denial Mental disengagement .25 .26 Behavioral disengagement .33 .32 Venting emotions .21 .21 Alcohol/drug use

Potentially maladaptive

- .21

- .16

- .23

- .15

- .25

- .17

.19 .23

.36 .33

.20 .25

.13 .13

.36 .34 .38 .39 (18.62; .oooO) (16.81; .oooO) (17.44; .oooO) (18.33; .oooO)

MMCI-I1 scales

Step Bipolar/ Alcohol Drug Thought Delusional

Manic Dependence Dependence Disorder Disorder

1 Sex .03 .08 - .04 - .02 - .09 1 Age - .07 .03 - .10 .01 .01

2 Problem-focused coping Active coping Planning Suppression of competing




activities

Seeking social support for

Positive reinterpretation .15 Acceptance - .20

emotional reasons

Religion Humor .16

- .21 - .22

.16

- .29

Coping and MCMI-11 Symptom Scales 733

Table 2 (continued)

MCMI-I1 scales

Step Bipolar Alcohol Drug Thought Delusional Manic Dependence Dependence Disorder Disorder

Potentially maladaptive Denial . I S .13 .I3

Behavioral disengagement .I9 .25 Venting emotions .34 .I2 .29 .23

Mental disengagement .15 .I4 16 . I 3

AIcohol/drug use .I4 .35 . I9 .I5

.23 .26 .25 .28 .I9 (9.60; .oooO) (13.16; .oooO) (10.81; .oooO) (12.50; .oooO) (7.65; .oooO)

indicates that habitual coping strategies are relevant facets of mental disorders and should be taken into account in both research and clinical contexts. Second, we regard the COPE as an instrument that has proven to be very well suited for research purposes in mental disorders.

Which coping strategies were involved? When only the correlational analyses were considered, most of the symptom scales were related negatively to both the problem- focused and the “adaptive” emotion-focused coping strategies, but related positively to the “maladaptive” emotion-focused strategies. These results, however, were modified by multiple regression analyses. There, in spite of the differentiated range of strategies examined, problem-focused coping lost its predictive power for symptoms of mental disorders. At the same time, the role of the two groups of emotion-focused strategies remained unchanged.

These findings are only seemingly at odds with those of other studies that concerned psychiatric patients. Most studies that have reported negative associations among anxiety, depression, and problem-focused coping used a simple scale for scale comparison (An- drews, Pollock, & Stewart, 1989; Billings et al., 1983; Parker & Brown, 1982; Vitaliano et al., 1987). In those studies that used multiple regression or MANOVA, problem- focused coping was not or not consistently related to anxiety or depression (Billings & Moos, 1984; Hoffart & Martinsen, 1991). Exceptions are the studies of Kleinke (1988) and Vitaliano et al. (1985). Hence, we suspect that the role of problem-focused coping in mood and anxiety disorders has been overrated.

However, one of the problem-focused scales, seeking social support for instrumental reasons, was associated negatively with three clinical MCMI-11 scales, namely, drug dependence, thought disorder, and delusional disorder. The latter two reflect disorders of marked severity with disturbed relation to reality and schizophreniform or paranoic features (Millon, 1987). Therefore, it could be hypothesized that deficits in problem- focused coping are indicative of the severity of pathology in terms of reality relatedness and functioning in daily life.

With respect to the emotion-focused coping strategies, our findings support a distinction between two subgroups, one of which is negatively and the other positively related to symptoms. This could explain why patients with distressing mental symptoms do not seem to be successful in managing their distress. Instead of denying, disengaging, venting emotions; and consuming alcohol, drugs or medication, they should be helped to rein- terpret positively, try to accept, be humorous, and seek emotional support from others.

Two aspects of seeking social support were distinguished in this study, the instrumental and the emotional. Both strategies were only negatively, not positively, related to the symptom scales. The more symptoms these patients experienced, the less they turned


to others for help or comfort. Patients with mood and anxiety disorders reported that they refrained from seeking emotional support, those with more severe disorders (thought disorder, delusional disorder) from seeking instrumental support. This result is puzzl- ing because patients with mood and anxiety disorders need emotional support above ail, while those with problems of reality relatedness would benefit from instrumental assistance. A direct comparison with other studies is difficult because these two different aspects of seeking support usually were not distinguished. Some studies in psychiatric patients found negative associations between symptoms and seeking support (Kleinke, 1988; Parker & Brown, 1982), while others found positive ones (Borden et al., 1988; Vitaliano et al., 1985; Vollrath & Angst, 1993). The type and stage of symptoms, as well as the availability of support, may be important. Furthermore, patients’ responses might depend on the way support seeking is assessed.

If associated clinical symptoms are accepted as a criterion for the differentiation of coping strategies, our results support to some degree the three groups distinguished by Carver et al. (1989) and also follow their theoretical assumptions with regard to their functionality. Moreover, a fourth group could be formed, which would contain those strategies that were neutral with respect to mental health (e.g., suppression of competing activities, religion, and humor). The functionality or adaptivity of coping is, of course, a complex problem because the evaluation of adaptivity depends on criteria, time perspec- tive, type of situation, etc. and needs to be studied longitudinally. From a theoretical point of view, it has been held that disengagement and denial are only dyfunctional in stress situations in which activity is required (Carver, Scheier, & Pozo, 1992; Lazarus, 1983). Denial, venting emotions, disengagement, and taking alcohol or medication might be effective in situations of overwhelming emotional distress. But, applied habitually across all kind of situations, these strategies probably will be dysfunctional with respect to achievement and mental health. This assumption is supported by evidence from longitudinal studies that showed that coping strategies like escapist fantasy, avoidance, and wishful thinking, which are similar to disengagement and denial, sustained and increased anxiety and depression (Aldwin & Revenson, 1987; Bolger, 1990; Felton & Reven- son, 1984; Miller et al., 1985; Rippetoe & Rogers, 1987).

There did not seem to be a high specificity in the coping patterns that were related with the various scales of the MCMI-11. Rather, a core pattern of “psychopathological” coping emerged with supplemental coping deficits for the more severe clinical scales. Only those patients with bipolar/manic symptoms showed a clearly different way of coping. In part, this lack of distinctiveness probably reflects the relatively high overlap among the clinical scales of the MCMI-XI. But these results also correspond to those of other studies, where few differences in coping were found among anxious and depressed patients (Miller et al., 1985; Vitaliano et al., 1985).

Patients with clinical symptoms clearly need effective coping strategies to dampen and regulate their increased emotional distress. But, according to their own reports in this study, such patients seemed habitually to use less effective strategies. Whether their type of coping is really habitual or waxes and wanes with the symptoms has yet to be investigated longitudinally. We also should like to point out a particular coping pattern that seems relevant for the degree to which these patients manage to seek and receive support and help. The more symptoms they had, the more they vented feelings without explicitly seeking support. Such an indirect way of appealing is probably not very motivating for their social networks, and psychiatric help may not be sought early enough. Irritation among members of the network and professional caretakers could result. This inability to turn toward others for help, comfort, and assistance should be a focus of active therapeutic interventions in both the patient and his or her network. Furthermore, teaching of adequate emotion-focused coping skills could enhance the patient’s ability for emotional self-regulation.

Coping and MCMI-II Symptom Scales 735

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THE INFLUENCE OF ACCULTURATION AND RACIAL IDENTITY ATTITUDES ON MEXICAN-AMERICANS’ MMPI-2 PERFORMANCE

GERARD0 D . CANUL AND HERBERT J . CROSS

Washington State University

Examination of the relationships among acculturation, racial identity, and the newly revised MMPI is warranted. This study investigated the degree to which racial identity influences Mexican-Americans’ performance on the L, K, and MF scales of the MMPI-2. Also investigated were individual differences in performance on the L, K, and MF scales as a function of acculturation. Fifty-one Mexican-American undergraduates from Washington State University participated by completing an acculturation scale, a racial identity attitude scale, and the MMPI-2. Results indicated that performance on the L and K scales is influenced by racial identity attitudes and levels of acculturation, however, no evidence was found to suggest a relationship between cultural variables and performance on the MF scale.

Research has investigated the differences between ethnic minorities and Anglo- Americans on MMPI performance. Research on MMPI and MMPI-2 performance of ethnic minority groups, including Mexican-Americans, African-Americans, and Native- Americans, has been noticeably sparse. As recently as 1990, the literature showed no research that investigated the hypothesis that Mexican-Americans’ acculturation may be associated with scores on MMPI-2 clinical and validity scales (Butcher, 1990; Groth- Marnat, 1990). Researchers have found that within-group differences can explain Mexican-American differences with regard to preference of counselor ethnicity, stress, and emotional problems (Cervantes & Castro, 1985; Keefe & Padilla, 1987). The broader

This article is based on the first author’s doctoral dissertation, which was supervised by the second author. We thank G. Leonard Burns, Gary G. Galbraith, Kathleen Harris Canul, Mary Gallwey, and RC for their feedback on this research.

Correspondence should be addressed to Gerard0 D. Canul, Department of Psychology, Washington State University, Pullman, WA 99164-4820.

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Coping and MCMI-II symptom scales