METHODOLOGICAL VARIATIONS IN THE USE OF THE MMPI FOR DIAGNOSIS OF BORDERLINE PERSONALITY

DISORDER AMONG ALCOHOLICS PETER HORVATH THURIDUR JONSDOTTIR-BALDURSSON

Acadia University Dalhousie University

Methodological variations in the scoring and interpretation of the MMPI and their effects on discrimination between borderline and non-borderline personality disordered alcoholics were investigated. Subjects were 49 male and female inpatient alcoholics in an Icelandic psychiatric hospital. Gunder- son’s Diagnostic Interview for Borderlines and the Michigan Alcoholism Screening Test were used to diagnose borderline personality disorder and alcoholism, respectively. Scoring and interpretation of the MMPI were varied in terms of the use and non-use of high F-scale profiles, and their impact on the frequency of various code types among borderline and non-borderline personality disordered alcoholics was considered. It was found that such methodological variations do not affect the frequency of some profile types, and, consequently, the discrimination between the diagnostic groups. Studies and coding systems should consider methodological variations in the scor- ing and interpretation of MMPI profiles and their consequent effects on diagnosis.

Methodological issues that concern the use of the MMPI for diagnostic, selection, and research purposes have been relatively neglected in the literature. For example, one methodological issue concerns whether to use K-corrected or non-K-corrected norms to obtain the T scores on the clinical scales. Although the K-correction of five of the clinical scales is the usual procedure, there has been little research on it. More research has been suggested to investigate its clinical utility in various populations (Dahlstrom, Welsh, & Dahlstrom, 1972; Greene, 1980). The K-correction has been found to reduce efficiency in the detection of psychopathology in some clinical populations by increas- ing the number of false positives (Bloom, 1977; Wooten, 1984). Whether the use of the K-correction enhances or reduces the accuracy of diagnosis and interpretation in clinical populations remains unresolved.

Some of the most frequently used coding systems also have left out the MF (Masculinity-Femininity) and Sr (Social Introversion) clinical scales in the development of code types because of the absence of adequate research and information on these scales (Graham, 1977; Marks, Seeman, & Haller, 1974). Other systems have included these scales in their code types based on what little research was available (Duckworth, 1979; Greene, 1980). Inclusion of these scales in the coding of a profile may, of course, influence the kind of high-point profiles obtained. Inclusion of MF has increased predictive accuracy based on profile interpretation in some psychiatric samples (King & Kelley, 1977).

A third methodological issue concerns coding profiles with tied scores. For exam- ple, if one is using a two-point code system, and two of the three highest scales are tied, one may disqualify such a profile from a two-point code system, disregard one of the tied scores, or consider both two-point code types, based on each of the tied scores as

For their generous help with the project, we wish to thank Tomas Helgason, Head of the Department of Psychiatry, Johannes Bergsveinsson, Head of Alcoholic Programs, Department of Psychiatry, and Gylfi Asmundsson, Head of the Department of Psychology at the National University Hospital, Reykjavik, Iceland.

Correspondence that concerns this article should be sent to Peter Horvath, Department of Psychology, Acadia University, Wolfville, Nova Scotia, Canada BOP 1 XO.

238

Methodological Variations in the Use of the MMPI 239

the second scale. Difficulties with ties occur both at the stage of development of code types and at the point of their use. In developing some code types, one of the high points in ties was disregarded. For example, Marks et al. (1974) classified adolescent profiles into two-point code types using the scale with the lowest numerical value, when the sec- ond and third highest scales were tied.

No standard is available to code individual profiles when ties occur among high- point clinical scales. For example, if one is using a two-point code system and the sec- ond and third highest scales are tied, choosing the appropriate code becomes a prob- lem. Marks et al. (1974) suggest a number of solutions rather than a uniform procedure, including trying to match the profile to the code types most similar in terms of the overall configuration of the clinical scales, or discounting the high-point scale of the profile that is not represented among the code types and using the next highest scales to match a code type. Other authors recommend that such substitution and reclassification schemes not be used because of lack of confirming evidence (Archer, 1987; Graham, 1977). Other options include interpreting individual scales or going to a three-point code system, rather than the preferred two-point one, if there is one available with the appropriate code type. Most authors of code systems, however, ignore the problem and make no recom- mendation about what to do in case of tied scores or when a particular profile does not match any of the offered code types.

Another methodological issue concerns which MMPI coding system provides the most valid prediction of psychopathology. Some traditional approaches have used com- plex configurational rules that allow for several high-point clinical scales to be entered in the code types (Gilberstadt & Duker, 1965; Marks & Seeman, 1963; Marks et al., 1974). Research has suggested, however, that two-digit high-point code types are as reliable as the more complex systems (Fowler & Hodo, 1975; Gynther, Altman, & Sletten, 1973; Lewandowski & Graham, 1972). Consequently, a number of systems have been based on the use of the two-digit high-point code types (Graham, 1977; Greene, 1980; King & Kelley, 1977). It remains an empirical question as to which code system is best to predict certain types of psychopathology, such as borderline personality disorder.

High Sc (8) profiles and two-point code types, such as 8-4, 8-6, and 8-7, have characterized borderline personality disorders (Hurt, Clarkin, Frances, Abrams, & Hunt, 1985; Snyder, Pitts, Goodpastor, Sajadi, & Gustin, 1982). The 8-2-4 three-point code type has been associated most frequently with borderline personality disorder (Edell, 1987; Widiger, Sanderson, & Warner, 1986). Other studies have found a 2-4-7-8 four- point code type to characterize borderline disorders in some clinical populations (Gustin et al., 1983; Jonsdottir-Baldursson & Horvath, 1987; Patrick, 1984).

It is standard procedure to consider a profile with a high F scale (T score 2 100) as invalid (Duckworth, 1979; Graham, 1977; King-Ellison Good & Brantner, 1961; Lanyon, 1968). Nevertheless, it also has been suggested that high elevation of the F scale may be an index of the severity of psychopathology or distress rather than of the in- validity of the profile (Archer, 1987; Dahlstrom et al., 1972; Greene, 1980). Some studies of borderline disorders have included profiles with high F scales (Archer, Ball, & Hunter, 1985; Widiger et al., 1986), whereas others have not (Gustin et al., 1983; Jonsdottir- Baldursson & Horvath, 1987). In most studies, however, the methodology used is not reported. The present study examined whether including or excluding profiles based on high F scores changed the frequencies of high-point profiles or code types and their use for diagnosis among borderline and non-borderline personality disordered alcoholics.

METHOD Subjects

Patients in the alcoholic rehabilitation and detoxification units of the National University Hospital, Department of Psychiatry, Reykjavik, Iceland, consecutively ad-

240 Journal of Clinical Psychology, March 1990, Vol. 46, No. 2

mitted over a 2-month period, who fulfilled the requirement of 2 weeks of sobriety, participated in the study. Excluded from the study were patients who were overtly psychotic, mentally retarded, under 18 years of age, or who refused to participate or could not complete the study.

The range in age of the 49 subjects (33 male and 16 female) was 18 to 60 years (M = 38.7, SD = 12.4). All data were gathered during the patients’ hospitalization and with their consent. There was no reward for participation. Instruments

The Michigan Alcoholism Screening Test (MAST; Morey, Skinner, & Blashfield, 1984; Selzer, 1971) was used to confirm the diagnosis of alcoholism. The MAST con- sists of 25 yes/no questions given different weights in scoring. The range of the scores is 0-53 points; scores of 0-3 points indicate nonalcoholism, 4 points suggest alcoholism, and 5 points and above indicate varying degrees of alcoholism. All 49 subjects scored above 5 on the test with a range of 9 to 53 (M = 40.16, SD = 9.58).

Kolb and Gunderson’s (1980) Diagnostic Interview for Borderlines (DIB) was used to classify the subjects as having borderline personality disorder. The DIB scale con- sists of 29 scored statements that reflect the presence or absence of borderline characteristics. The focus is on five content sections: social adaptation; impulse-action patterns; affects; psychotic symptoms; and interpersonal relations. The scoring of the statements is based on 132 discrete units of information, obtained from structured ques- tions or tables that are filled out. The section scores are converted into a 0 to 2 scale (scaled section score) so that each of the five sections has equal weight in determining the overall diagnostic score, which has a range of 0 to 10. According to the test’s most stringent criterion, an individual with a total score of 7 to 10 is diagnosed as having borderline personality disorder.

Because the DIB score is determined in part by questions that pertain to alcohol use and because our sample was selected for alcohol use, the contribution made by alcohol use items was subtracted from the DIB score, as in the Nace, Saxon, and Shore (1983) study.

The relative discriminating power of the MMPI based on the inclusion vs. the ex- clusion of high F-scale (T score 2 100) profiles was tested in reference to the diagnosis of borderline personality disorder.

Procedure The measures and interviews were administered by the same experimenter. The time

spent on the individual interviews varied from 1 % hours to 3 hours. All data were col- lected and rated by the same experimenter with the exception of the MMPI answer sheets, which were scored by the secretary of the Department of Psychology in the hospital. The experimenter first rated the MAST scores and the DIB scores to form a group of 35 alcoholics without borderline personality disorder and a group of 14 alcoholics with borderline personality disorder. It was not until all other scores had been entered that the experimenter retrieved the scored MMPI answer sheets from the secretary.

RESULTS When high F-scale (T score 2 100) profiles were included, the K-corrected Sc scale

was most frequently the highest scale among both borderline (7 out of 14) and non- borderline patients (8 out of 35). The differential frequency of the high Sc scale among the two diagnostic groups was not significant on a chi square test.’

Among the non-borderline patients, there was a considerable drop in the frequency of K-corrected high Sc scales with the exclusion of 7 high F-scale profiles. The frequency

‘All the chi-square tests for independence were corrected for continuity.

Methodological Variations in the Use of the MMPI 24 1

of the high Sc scales dropped from 8 (22.9%) to 1 (2.9%). This decrease in frequency was significant, ~ ' ( 1 , n = 35) = 4.00, p < .05. There was also a 10-point drop in the mean T score on the Sc scale, from the condition that used all profiles (M = 72.66, SD = 24.90) to the condition in which all high F-scale profiles were removed (M = 62.36, SD = 13.60). The mean dropped to a level that is not considered clinically significant. The highest elevation now occurred on PD, which is typical of a common alcoholic sub- type. (See Table 1.) There were no other significant changes in the frequencies of any high-point or code types based on the exclusion of high F-scale profiles from considera- tion among the non-borderline or borderline patients.

Table 1 Means and Standard Deviations of MMPI Variables (T Scores) Among Nonborderline Personality Disordered Groups

High F-scale High F-scale profiles included profiles excluded

(n = 35) (n = 28) Scale M SD M SD

54.77 75.86 48.89 66.54 72.60 63.71 71.83 64.26 66.71 62.74 72.66

62.77 54.17

8.42 21.10

8.64 16.70 12.70 9.82

12.80 10.10 15.70 14.60 24.90

14.00 9.42

55.54 67.04 50.29 62.57 68.71 61.68 69.43 63.61

61.50 57.21 62.36

57.96 52.36

8.53 10.60 7.62

15.30 9.13 8.76

11.20 10.80

12.30 9.66

13.60 10.70 8.62

The exclusion of 7 high F-scale profiles made the discrimination between borderline and non-borderline patients based on the frequencies of high Sc scales significant. While the frequency of the K-corrected high Sc scales remained at 50.0% (7 out of 14) among the borderline patients, it decreased from 22.9% (8 out 35) to 2.9% (1 out of 28) among the non-borderlines, and, therefore, made the discrimination between the two diagnostic groups significant, ~ ' ( 1 , N = 42) = 10.21, p < .01. There were no other changes in the discrimination power of any other high-point scales or code types as a consequence of the exclusion of high F-scale profiles.

DISCUSSION The exclusion of high F-scale profiles affected only the non-borderline group; it

tended to decrease considerably the frequency of high Sc-scale profiles and produced a mean profile typical of a common alcoholic subtype (O'Leary, Donovan, Chaney, & O'Leary, 1980). The decrease in the frequency of the Sc scale is not totally unexpected because elevations on the F scale are correlated highly with those on the Sc scale (Graham, 1977). The results also suggest that elevations on Sc among non-borderline disordered

242 Journal of Clinical Psychology, March 1990, Vol. 46, No. 2

alcoholics are likely to be correlates of distress, plea for help, malingering, or unreliable responding, as the corresponding high elevations on F tend to indicate (Evans & Dinning, 1983; Greene, 1980; Wasyliw, Grossman, Haywood, & Cavanaugh, 1988). Elevations on Sc among the borderline disordered alcoholics, on the other hand, are more likely to be indications of personality disorder (Morey, Roberts, & Penk, 1987). The high Sc- scale profile type has been found to characterize borderline personality disorder (Hurt et al., 1985). It is not surprising, therefore, that the exclusion of high F-scale profiles also increased the power of the Sc scale to differentiate between borderline and non- borderline personality disordered alcoholics.

Methodological variations, therefore, in the scoring and interpretation of the MMPI can affect significantly the frequency of some high-scale configurations and, consequently, the power of the MMPI to discriminate among diagnostic groups. The exclusion of high F-scale profiles altered the frequency of the high Sc-scale profile type to a point at which it could be of practical use in discriminating between the two alcoholic diagnostic groups. Methodological approaches to the MMPI vary or are often unreported in the literature. There is no uniformity in the procedures to make the results of studies or coding systems comparable. Future studies and interpretive systems based on the MMPI should pay closer attention to these considerations and also spell out the methodological approach used. Our results were notable, but based on a small sample. Consequently, some of the described methodological variations should be tested on larger samples.

REFERENCES ARCHER, R. P. (1987). ARCHER, R. B., BALL, J. D., &HUNTER, J. A. (1985). MMPI characteristics of borderline psychopathology

BLOOM, W. (1977). Relevant MMPI norms for young adult Air Force trainees. Journal of Personality Assess-

DAHLSTROM, W. G., WELSH, G. S., & DAHLSTROM, L. E. (1972). An MMPZhandbook, Vol. 1. Clinicalinter-

DUCKWORTH, J. (1979). MMPZ interpretation manual for counselors and clinicians (2nd ed.). Muncie, IN:

EDELL, W. S. (1987). Relationship of borderline syndrome disorders to early schizophrenia on the MMPI.

EVANS, R. G., & DINNING, W. D. (1983). Response consistency among high F scale scorers on the MMPI.

FOWLER, R. D., & HODO, G. L. (1975). A comparison of classification rates of the original and revised Marks

GILBERSTADT, H., R DUKER, J . (1965). A handbook for clinical and actuarial MMPZ interpretations.

GRAHAM, J. R . (1977). GREENE, R. L. (1980). GUSTIN, Q, L., GOODPASTER, W. A,, SAJADI, C. PITTS, W. M., JR., LABASSE, D. L., R SNYDER, S.

(1983). MMPI characteristics of the DSM-111 borderline personality disorder. Journal of Personality Assessment, 47, 50-59.

GYNTHER, M. D., ALTMAN, H., & SLETTEN, 1. W. (1973). Replicated correlates of MMPI two-point code types: The Missouri actuarial system. Journal of Clinical Psychology, 29, 263-289.

HATHAWAY, S . R., & MCKINLEY, J. C. (1983). Minnesota Multiphasic Personality Inventory: Manual for administration and scoring. Minnesota: University of Minnesota Press.

HURT, S. W., CLARKIN, J. F., FRANCES, A., ABRAMS, R., & HUNT, H. (1985). Discriminant validity of the MMPI for borderline personality disorder. Journal of Personality Assessment, 49, 56-61.

JONSWTTIR-BALDURSSON, T . , & HORVATH, P. (1987). Borderline personality disordered alcoholics in Iceland: Descriptions on demographic, clinical, and MMPI variables. Journal of Consulting and Clinical

Using the MMPZ with adolescents. Hillsdale, NJ: Erlbaum.

in adolescent inpatients. Journal of Personality Assessment, 49, 47-55.

ment, 41, 505-510.

pretation (rev. ed.). Minneapolis: University of Minnesota Press.

Accelerated Development.

Journal of Clinical Psychology, 43, 163-176.

Journal of Clinical Psychology, 39, 246-248.

and Seeman rules. Journal of Clinical Psychology, 31, 665-667.

Philadelphia: Saunders. The MMPZ: A practical guide. New York: Oxford University Press. The MMPZ, an interpretive manual. New York: Grune & Stratton.

Psychology, 55, 138-741.

Methodological Variations in the Wse of the MMPI 243

KING, G. D., & KELLEY, C. K. (1977). MMPI behavioral correlates of spike-5 and two-point code types with scale 5 as one elevation. Journal of Clinical Psychology, 33, 180-185.

KINGELLISON GOOD, P., & BRANTNER, J. P. (1961). A practicalguide to theMMPI. Minneapolis: University of Minnesota Press.

KOLB, J. E., & GUNDERSON, J. G. (1980). Diagnosing borderlines with a semi-structural interview. Archives of General Psychiatry, 37, 37-41.

LANYON, R. F. (1968). A handbook of MMPI groupprofiles. Minneapolis: University of Minnesota Press. LEWANDOWSKI, D., & GRAHAM, J. R. (1972). Empirical correlates of frequently occurring 2-point code types:

A replicated study. Journal of Consulting and Clinical Psychology, 39, 467-472. MARKS, P. A., & SEEMAN, W. (1963).Theactuarialdescription ofpersonality: An atlas for use with theMMPI.

Baltimore: Williams & Wilkins. MARKS, P. A., SEEMAN, W., & HALLER, D. L. (1974). The actuarial use of the MMPI with adolescents and

adults. Baltimore: Williams & Wilkins. MOREY, L. C., ROBERTS, W. R., & PENK, W. (1987). MMPI alcoholic subtypes: Replicability and validity

of the 2-8-7-4 subtype. Journal of Abnormal Psychology, 96, 164-1 66. MOREY, L. C., SKINNER, H. A., & BLASHPIELD, R. K. (1984). A typology of alcohol abusers: Correlates

and implications. Journal of Abnormal Psychology, 93, 408-417. NACE, E. P., SAXON, J. J., c SHORE, N. (1983). A comparison of borderline and non-borderline alcoholic

patients. Archives of General Psychiatry, 40, 54-56. O’LEARY, M. R., DONOVAN, D. M., CHANEY, E. F., & O’LEARY, D. E. (1980). Relationship of alcoholic

personality subtypes to treatment follow-up measures. Journal of Nervous and Mental Disease, 168,

PATRICK, J. (1984). Characteristics of DSM-111 borderline MMPI profiles. Journal of Clinical Psychology,

SELZER, M. L. (1971). The Michigan Alcoholism Screening Test: The quest for a new diagnostic instru- ment. American Journal of Psychiatry, 127, 1653-1658.

SNYDER, S., PITTS, W. M., GOODPASTOR, W. A., SAJADI, C., & GUSTIN, Q. (1982). MMPI profile of DSM- 111 borderline personality disorder. American Journal of Psychiatry, 139, 1046-1048.

WASYLIW, 0. E., GROSSMAN, L. S., HAYWOOD, T. W., & CAVANAUOH, J. L., JR. (1988). The detection of malingering in criminal forensic groups: MMPI validity scales. Journal of Personality Assessment, 52, 32 1-333.

WIDIGER, T. A., SANDERSON, C., ~t WARNER, L. (1986). The MMPI, prototypal typology, and borderline personality disorder. Journal of Personality Assessment, 50, 540-553.

WOOTEN, A. J. (1984). Effectiveness of the K correction in the detection of psychopathology, and its impact on profde height and configuration among young adult men. Journal of Consulting and Clinical Psychology,

475-480.

40, 655-658.

52, 468-473.