The MMPI scales which correspond to major diagnostic categories are called the

The Millon Clinical Multiaxial Inventory–III

The Millon Clinical Multiaxial Inventory–III (MCMI-III) is a 175-item true/false, self-report questionnaire designed to identify both symptom disorders (Axis I conditions) and personality disorders (PDs).15 The MCMI was originally developed as a measure of Millon's comprehensive theory of psychopathology and personality.16 Revisions of the test have reflected changes in Millon's theory along with changes in the diagnostic nomenclature. The MCMI-III is composed of three Modifier Indices (validity scales), 10 Basic Personality Scales, three Severe Personality Scales, six Clinical Syndrome Scales, and three Severe Clinical Syndrome Scales. One of the unique features of the MCMI-III is that it attempts to assess both Axis I and Axis II psychopathology simultaneously. The Axis II scales resemble, but are not identical to, the DSM-5 Axis II Disorders. Given its relatively short length (175 items vs. 567 for the MMPI-2), the MCMI-III can have advantages in the assessment of patients who are agitated, whose stamina is significantly impaired, or who are otherwise suboptimally motivated. An innovation of the MCMI continued in the MCMI-III is the use of Base Rate (BR) Scores rather than traditional T-scores for interpreting scale elevations. BR scores for each scale are set to reflect the prevalence of the condition in the standardization sample. The critical BR values are 75 and 85. A BR score of 75 on the personality scales indicates problematic traits, whereas on the symptom scales it signals the likely presence of the disorder as a secondary condition. BR scores of 85 or greater on the personality scales indicate the presence of a personality disorder. A similar elevation on the symptoms scales signals that the disorder is prominent or primary.

4.14.3.1 Millon Clinical Multiaxial Inventory

The MCMI (Millon, 1977, 1987, 1994) was developed by Theodore Millon for making clinical diagnoses on patients. The MCMI was intended to improve upon the long-established MMPI. In contrast to the MMPI/MMPI-2, the MCMI was designed with fewer items; is based on an elaborate theory of personality and psychopathology; and explicitly focuses on diagnostic links to criteria from the Diagnostic and statistical manual of mental disorders (DSM).

The MCMI was developed rationally rather than empirically. Millon has stated in his three test manuals (1977, 1987, 1994) as well as elsewhere (Millon & Davis, 1995) that development of the MCMI is to be an ongoing process. To keep the MCMI maximally useful for clinical diagnosis and interpretation, it must be continually updated in view of theoretical refinements, empirical validation studies, and evolutions in the official DSM classification systems. Most updated test manuals leave the test user with the impression that the developer considered test revision a necessary evil. Very rarely do you see continuous improvement as a test developer's goal, in part because this ever-changing process makes the accumulation of a solid research base difficult.

All three MCMI versions comprise 175 true/false items. However, across versions, the exact test items have evolved through revision or replacement. The number of scales and validity indices that can be calculated from these items has also increased. The original version, the MCMI-I, had 20 clinical scales and two validity scales. The MCMI-II yielded 22 clinical scales and three validity scales. The current MCMI-III has 24 clinical scales, three modifying indices and a validity index. Many items appear on several scales making for great item overlap.

On the MCMI-III, 14 clinical scales assess personality patterns that relate to DSM-IV Axis II disorders. Another 10 scales measure clinical syndromes related to DSM-IV Axis I disorders. The modifying indices, Disclosure, Desirability, and Debasement, are correction factors applied to clinical scale scores to ameliorate respondents' tendencies to distort their responses. The validity index comprises four bizarre or highly improbable items meant to detect careless, random, or confused responding.

The relationship between scales and items is explicated in detail in the manual. Millon started with a theory-based approach to writing items, followed by an evaluation of the internal structure of the items, and finally engaged in an assessment of the diagnostic efficiency of each item for distinguishing among diagnostic groups before final placement of an item on a scale. Millon departed from usual psychometric practice in a way that results in some unfortunate complications. Item overlap across scales is permitted: on average, items appear on three different scales with differential weights. This makes scoring inordinately complex, which makes assessment of scale homogeneity complex, and in turn this makes evaluation of the empirical structure underlying the scales complex. There are technical solutions for these problems but the result is that the MCMI is not an easy instrument with which to work.

Despite its psychometric drawbacks, the theory underlying the MCMI is generally agreed to be elegant and a substantial asset (McCabe, 1987; Reynolds, 1992). Each dimension measured by the test has a clear conceptual link to Millon's theory of psychopathology. Such a theory allows for the generation of clinical inferences based on a small number of fundamental principles (Millon & Davis, 1995). Not only do these inferences guide measurement, but also they enhance understanding of the constructs, bear on practical treatment decision, and produce research hypotheses.

One of the stated goals of the MCMI is to place patients into target diagnostic groups. To this end, the MCMI scales are directly coordinated with the DSM diagnostic categories. How well does the MCMI live up to its aim? The manuals report good evidence of diagnostic efficiency. However, the recent literature (available on the MCMI-I and MCMI-II) suggests the following three generalizations. First, the MCMI has only modest accuracy for assigning patients to diagnostic groups across a variety of clinical criteria (e.g., Chick, Martin, Nevels, & Cotton, 1994; Chick, Sheaffer, Goggin, & Sison, 1993; Flynn, 1995; Hills, 1995; Inch & Crossley, 1993; Patrick, 1993; Soldz, Budman, Demby, & Merry, 1993). Second, the MCMI may be better at predicting the absence than the presence of a disorder (Chick et al., 1993; Hills, 1995; Soldz et al., 1993). Third, the MCMI may be better at predicting some types of disorders than others but there is little agreement on which ones (Inch & Crossley, 1993; Soldz et al., 1993).

One source of the difficulty may be the base rate scores. Raw scores on scales are weighted and converted to base rate scores. The base rate scores reflect the prevalence of a particular personality disorder or pathological characteristic in the overall population. Their use is intended to maximize the number of correct classifications relative to the number of incorrect classifications when using the MCMI to make diagnoses (Millon & Davis, 1995). If the estimated base rates for the various diagnostic categories are poor, then the predictive accuracy of the MCMI can be expected to be poor (Reynolds, 1992).

One negative consequence of the type of norms used in the development of the MCMI inventories is that they do not discriminate between patients and normals. Use of the MCMI assumes that the subject is a psychiatric patient. Consequently, the MCMI overpathologizes individuals who are not actually patients. The MCMI should not be used where issues of normality need to be addressed. For example, if the test were used in family custody evaluations or personnel screening, the test interpretation would appear very pathological—it cannot do otherwise.

How does the MCMI compare to the MMPI? The MCMI publisher appears to emphasize that the MCMI and MMPI-2 measure different characteristics and the MCMI is shorter to administer to patients. Whereas the MMPI measures a broad range of psychopathology, the MCMI has its premier focus on the assessment of personality disorders. Consonant with its rational construction, the elaborate theoretical underpinnings of the MCMI are impressive. In contrast, however, the test literature that supports the validity of the MMPI/MMPI-2 is not available for the MCMI. Validation research on it has not proceeded at a very high pace. Whether the MCMI will have either the clinical utility or the heuristic value that the MMPI enjoys remains unanswered until more clinical research, and perhaps more refinements, are undertaken with the MCMI.

Tests of Personality, Psychopathology, and Psychological Function

Objective psychological tests, also calledself-report tests, are designed to clarify and quantify a patient's personality function and psychopathology. Objective tests use a patient's response to a series of true/false or multiple-choice questions to broadly assess psychological function. These tests are calledobjective because their scoring involves standardized procedures and the application of normative data. Objective tests provide excellent insight into how patients see themselves and want others to see and treat them. Self-report tests allow the patient to communicate their psychological difficulties to their caregivers directly.

The Minnesota Multiphasic Personality Inventory–2 (MMPI-2) is a 567-item true/false, self-report test of psychological function.9 It was designed to provide an objective measure of abnormal behavior, basically to separate subjects into two groups (normal and abnormal) and to further categorize the abnormal group into specific classes. The MMPI-2 contains 10 clinical scales that assess major categories of psychopathology and three validity scales designed to assess test-taking attitudes. MMPI-2 validity scales are (L) lie, (F) infrequency, and (K) correction. The MMPI-2 clinical scales include (1) Hs, hypochondriasis; (2) D, depression; (3) Hy, conversion hysteria; (4) Pd, psychopathic deviate; (5) Mf, masculinity–femininity; (6) Pa, paranoia; (7) Pt, psychasthenia; (8) Sc, schizophrenia; (9) Ma, hypomania; and (10) Si, social introversion. More than 300 new or experiential scales have also been developed for the MMPI-2. The MMPI-2 is interpreted by determining the highest two or three scales, called acode type. For example, a 2–4–7 code type indicates the presence of depression (scale 2), impulsivity (scale 4), and anxiety (scale 7), along with the likelihood of a personality disorder.9

The Millon Clinical Multiaxial Inventory-III (MCMI-III) is a 175-item true/false, self-report questionnaire designed to identify both symptom disorders and personality disorders.10 The MCMI-III is composed of 3 modifier indices (validity scales); 10 basic personality scales; 3 severe personality scales; 6 clinical syndrome scales; and 3 severe clinical syndrome scales. One of the unique features of the MCMI-III is that it attempts to assess a wide variety of psychopathology simultaneously. Given its relatively short length (175 items vs 567 for the MMPI-2), the MCMI-III has an advantage in the assessment of patients who are agitated, whose stamina is significantly impaired, or who are suboptimally motivated.

The PAI4 is one of the newest objective psychological tests. The PAI includes 344 items and a 4-point response format (false, slightly true, mainly true, and very true) to make 22 non-overlapping scales. These 22 scales include: 4 validity scales, 11 clinical scales, 5 treatment scales, and 2 interpersonal scales. The PAI covers a wide range of psychopathology and other variables related to interpersonal function and treatment planning (including suicidal ideation, resistance to treatment, and aggression). The PAI possesses outstanding psychometric features and is an ideal test for broadly assessing multiple domains of relevant psychological function.

4.11.5.5 Multicultural Considerations

The MCMI-IV has been translated into Spanish and validated in a Spanish-speaking population by the test's developers (Millon et al., 2015). We know of no studies evaluating the cultural fairness of MCMI-IV scores. Historically, however, using the MCMI to assess individuals from racial minority groups has been controversial because of significant profile differences across racial groups. Specifically, it was found that individuals in inpatient treatment who were Black scored significantly higher on the MCMI at the item-level (Choca et al., 1990) and at the scale level (Munley et al., 1998) compared to individuals who were white. Similar findings exist for individuals who are Hispanic (Ghafoori and Hierholzer, 2010). Thus, significant further research should be conducted to evaluate the cultural fairness of MCMI-IV scores in a variety of cultural groups.

Risk Factors

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Current evidence supports a familial risk factor for HD.

Intolerance of uncertainty and rejection, difficulties identifying and regulating emotions, and anxious and fearful attachment patterns are HD predictors.

Patients with HD scored high on at least one of the MCMI-III Personality scales. The most frequently elevated scores were for the Avoidant, Dependent, Depressive, and Schizoid scales.

Attention Deficit and Hyperactivity Disorder has emerged as a predictor of hoarding behaviors, while individuals with Autism Spectrum Disorders show higher hoarding behavior frequencies.

Exposure to traumatic and stressful life events has correlated with the presence and increased severity of HD.

The incidence of hoarding behaviors in a community samples has been inversely associated with income level.

Millon Clinical Multiaxial Inventory—Third Edition

The Millon Clinical Multiaxial Inventory—Third Edition (MCMI-III) is another frequently used objective personality measure. The MCMI-III provides information about the presence of psychological disorders including personality disorders. The MCMI-III is a 175-question, true/false psychological instrument used in clinical settings with individuals 18 years and older. The reading level (average Flesch-Kincaid Grade Level 5.7) is higher than the MMPI-2.

The normative population is composed of patients seen in individual practice, clinics, mental health centers, forensic settings, residential facilities, and hospitals. The MCMI-III uses “Base Rate” scores for the purposes of reporting and interpretation. A Base Rate (BR) score of 60 [BR60] represents the median score, as opposed to T scores where 50T is the median, with BR0 being the lowest possible score and BR115 the highest. The presence of a specific personality trait is generally indicated at BR75, whereas scores of BR85 and above suggests the full presence of a personality characteristic. Base rate scores are criterion, not norm, referenced—indicating that BR scores do not indicate if a score is common or not, only whether the trait or characteristic is present.

The MCMI-III has 28 scales including 14 Personality Disorder Scales, 10 Clinical Syndrome Scales, 4 Correctional Scales. The Personality Disorder Scales include: Schizoid, Avoidant, Depressive, Dependent, Histrionic, Narcissistic, Antisocial, Sadistic (Aggressive), Compulsive, Negativistic (Passive-Aggressive), Masochistic (Self-Defeating), Schizotypal, Borderline, and Paranoid. The Clinical Syndrome Scales include: Anxiety, Somatoform, Bipolar, Manic, Dysthymia, Alcohol Dependence, Drug Dependence, Post-Traumatic Stress Disorder, Thought Disorder, Major Depression, and Delusional Disorder. The Correctional Scales include: Disclosure, Desirability, Debasement, and Validity. The Personality Disorder Scales were designed to correlate with DSM-IV Axis II disorders, whereas the Clinical Syndrome Scales correlate with the DSM-IV Axis I disorders.

Another study examined the ability of the MCMI-III to be reliably used to assess intervention in pain management at a pain management center in Paducah, Kentucky.18 One hundred consecutive patients were evaluated for major depression or generalized anxiety disorder using a DSM-IV-TR questionnaire and physician interview; all participants also completed the MCMI-III and P-3 inventories as part of a psychological evaluation. A positive diagnosis of major depression or generalized anxiety disorder, using the DSM-IV-TR criteria, was considered the criterion standard. The diagnosis of major depression on the MCMI-III showed 100% specificity but only 54% sensitivity; for generalized anxiety disorder, the MCMI-III specificity was 89%, whereas the sensitivity was 73%.

7.12.5.1.1 Millon Clinical Multiaxial Inventory-Ill

The original MCMI (Millon, 1983) has undergone two revisions, that is, MCMI-II (Millon, 1987) and MCMI-III (Millon, 1994). MCMI-III is a 175-item, true-false, self-report inventory specifically designed to assess PDs. This instrument is widely used in research and clinical activities, and its taxonomy is “aligned” with DSM-IV. The MCMI-III includes 14 personality pattern scales (Axis-II related) including: schizoid, avoidant, depressive, dependent, histrionic, narcissistic, antisocial, aggressive (sadistic), compulsive, passive–aggressive (negativistic), self-defeating, schizotypal, borderline, and paranoid. Additionally, 10 symptom scales (Axis-I related) are provided, covering moderate clinical presentations (e.g., anxiety, dysthymia, alcohol dependence) and severe symptoms (e.g., thought disorder, major depression). It has three validity scales designed to detect random or confused response patterns and defensiveness. The MCMIis designed to be given only to those suspected of having a PD, and thus, should not be used for differential diagnosis in nonclinical populations. The MCMI has been the focus of numerous publications since its development in 1967, and earlier versions have been shown to have good psychometric properties, although it is said to be more reliable in diagnosing among PDs than in differentiating between clinical syndromes (Millon, 1992). Psychometric properties of the MCMI-III are currently being evaluated.

4.01.5.2.1 Multi-scale Inventories

Several popular self-report inventories (e.g., MMPI-3 (Ben-Porath and Tellegen, 2020), the PAI (Morey, 2007), and the Millon Clinical Multiaxial Inventory—IV (Million et al., 2015)) have multiple scales that afford measurement across a wide range of psychopathology and personality characteristics. Although these can be quite lengthy (e.g., >300 items) and, therefore, take 30–60 min to complete, and require a baseline reading level, they do afford a large amount of information despite the time investment. The MMPI-3, for instance, covers every spectrum of psychopathology, such as internalizing, thought disorder, externalizing, and somatization (e.g., Sellbom et al., 2021), which would be impossible to cover in a 50-min clinical interview. Moreover, these multi-scale inventories, as mentioned earlier, have validity scales to assess for response bias that generalizes to the whole assessment, and can be particularly useful in contexts in which individuals have an external incentive to misrepresent themselves. Lee et al. (2022) provide a comprehensive review of the most common multi-scale inventories, including their strengths and limitations.

Publisher Summary

Therapists are asked to summarize a patient's status at the beginning of treatment and at the end of the time services were rendered. The forms, scales, templates, and guidelines provided in this chapter assist the therapist chart out the results of the therapy and the changes that have occurred. The education of patients regarding their testing results and their personal history is easier if therapists utilize the forms in this chapter and other similar tools. The Iceberg Model (IM) is discussed in detail for visually interpreting results of the Millon Clinical Multiaxial Inventory-III (MCMI-III). Not only is it easy to understand for clients but also supplies a structured protocol for psychologists. Global assessment of relational functioning (GARF) scale is given to rate the patient's relational unit and level of functioning at the present time in his/her life. The GAF score is derived for a patient based on the patient's social, psychological, and occupational functioning on a daily bases in all areas of his/her life. Social and occupational functioning assessment (sofa) scale is used to estimate a person's level of functioning with respect to his/her mental and physical problems. The scale is completed as to how the patient is able to actually function in occupational settings and in social settings. The time period on which the rating is based should be this past month, or some other designated time frame.

3.07.3.1 Personality, Mood States, and Mental Disorders

Personality traits typically are understood to be stable behavior patterns present since young adulthood (Wiggins & Pincus, 1992). However, few SRIs emphasize this fundamental feature. For example, the instructions for the MMPI-2 make no reference to age of onset or duration (Hathaway et al., 1989). Responding true to the MMPI-2 borderline item, “I cry easily” (Hathaway et al., p. 6) could be for the purpose of describing the recent development of a depressive mood disorder rather than a characteristic manner of functioning. Most MMPI-2 items are in fact used to assess both recently developed mental disorders as well as long-term personality traits (Graham, 1993).

SRIs that required a duration since young adulthood for the item to be endorsed would be relatively insensitive to changes in personality during adulthood (Costa & McCrae, 1994), but SSIs are generally preferred over SRIs within clinical settings for the assessment of personality traits due to the susceptibility of SRIs to mood-state confusion and distortion (Widiger & Sanderson, 1995; Zimmerman, 1994). Persons who are depressed, anxious, angry, manic, hypomanic, or even just agitated are unlikely to provide accurate self-descriptions. Low self-esteem, hopelessness, and negativism are central features of depression and will naturally affect self-description. Persons who are depressed will describe themselves as being dependent, introverted self-conscious, vulnerable, and pessimistic (Widiger, 1993). Distortions will even continue after the remission of the more obvious, florid symptoms of depression (Hirschfeld et al., 1989).

Piersma (1989) reported significant decreases on the MCMI-II schizoid, avoidant, dependent, passive-aggressive, self-defeating, schizotypal, borderline, and paranoid personality scales across a brief inpatient treatment, even with the MCMI-II mood state correction scales. Significant increases were also obtained for the histrionic and narcissistic scales, which at first appeared nonsensical (suggesting that treatment had increased the presence of histrionic and narcissistic personality traits), until it was recognized that these scales include many items that involve self-confidence, assertion, and gregariousness. Piersma concluded that “the MCMI-II is not able to measure long-term personality characteristics (‘trait’ characteristics) independent of symptomatology (‘state’ characteristics)” (p. 91). Mood state distortion, however, might not be problematic within outpatient and normal community samples (Trull & Goodwin, 1993).

SSIs appear to be more successful than SRIs in distinguishing recently developed mental disorders from personality traits, particularly if the interviewers are instructed explicitly to make this distinction when they assess each item. Loranger et al. (1991) compared the assessments provided by the Personality Disorder Examination (PDE; Loranger, in press) at admission and one week to six months later. Reduction in scores on the PDE were not associated with depression or anxiety. Loranger et al. concluded that the “study provides generally encouraging results regarding the apparent ability of a particular semistructured interview, the PDE, to circumvent trait-state artifacts in diagnosing personality disorders in symptomatic patients” (p. 727).

However, it should not be presumed that SSIs are resilient to mood state distortions. O'Boyle and Self (1990) reported that “PDE dimensional scores were consistently higher (more symptomatic) when subjects were depressed” (p. 90) and Loranger et al. (1991) acknowledged as well that all but two of the PDE scales decreased significantly across the hospitalization. These changes are unlikely to reflect actual, fundamental changes in personality secondary to the brief psychiatric hospitalization.

The methods by which SRIs and SSIs address mood state and mental disorder confusion should be considered in future research (Zimmerman, 1994). For example, the DSM-IV requires that the personality disorder criteria be evident since late adolescence or young adulthood (APA, 1994). However, the PDE (Loranger, in press) requires only that one item be present since the age of 25, with the others present for only five years. A 45-year old adult with a mood disorder might then receive a dependent, borderline, or comparable personality disorder diagnosis by the PDE, if just one of the diagnostic criteria was evident since the age of 25.