An Overview of the Millon Clinical Multiaxial Inventory II-III

Testing and assessment have played a major role in defining human capabilities, skills and intelligence as well as to identify and categorize major mental disorders in order for practicing professionals employ proper diagnosis and treatment. Testing has also been used in the educational system more so as it is also deemed effective to use as a basis in choosing people for the right job to assisting individuals assess their capabilities in order to find a right career or aid them in choosing a respective course in the field of study of which they are more suitable. And also testing has been use to help people understand themselves better so that they become more efficient in coping with their everyday life.

There are a number of tests that have been widely used by clinicians as well as educators or practicing professionals. However, there are important factors for a test to be considered sufficient such as its validity and reliability and several important issues to consider such as; standardization, construction and judgments.

The following text will discuss one of the most widely accepted Assessment which is the Millon Clinical Multiaxial Inventory I-III (MCMI I-III) which was developed by Theodore Millon following the publication of his book Modern Psychopathology which had urged him to construct an instrument which was then called the Millon-Illonois Self Report Inventory (MI-SRI) which was used to measure the different dimensions of personality of which was then revised and was later incorporated to the personality disorders included and published in the Diagnostic and Statistical Manual of Mental Disorder (DSM).

An overview of the MCMI-III will be further discussed to be able to gain a better insight of the usefulness and the development of the test itself, its history and development, reliability and validity, assets and limitations, administrations as well as a comparison between the currently revised MCMI-III and the early version of the MCMI.

THE MILLON CLINICAL MULTIAXIAL INVENTORY

The Millon Clinical Multiaxial Inventory or MCMI (Craig, 1999) was developed to reinforced Millon’s model of psychopathology and it has been revised over the years to subsist with the advancement and modification of the different theories as well as to keep pace with the Diagnostic and Statistical Manual of Mental Disorder. It was introduced in 1997 and since then it has been considered one of the most accepted and widely researched and used instrument in clinical assessment and has been translated into several languages as well. The latest version (Growth-Marnat 2003) consist of 175 items that was scored which then produced 28 scales  known to be divided into six categories which was strongly associated with Millon’s Theory of Personally and the Diagnostic and Statistical Manual of Mental Health Disorder.

The five categories derived in the Millon Clinical Multiaxial Inventory (MCMI):

1. Modifying Indices
2. Clinical Personality Patterns
3. Severe Personality Pathology
4. Clinical Syndromes
5. Severe Syndromes

The MCMI I-III (Grohol, 2013) consists of 175 true-false test questions which would take duration of 30 minutes to complete by an average person. The test will then be scored produced from the 29 scales of which 24 are clinical and personality scales and 5 are to validate how the person took the test such as carelessness and choosing random answers. The MCMI is to the compared the MMPI which included a wider range of adult pathology that evaluates long standing clinical symptomatology and personality patterns. Also, (Growth-Marnat 2003) the MCM I-III is specifically used to assist in the diagnosis of mental disorders in Axix II. And it is often administers in clinical settings should there be a need of a diagnosis of personality dysfunction or mental health concern that is affecting the normal everyday and social function of an individual. However, it should be given into account that the instrument should not be the basis of the diagnosis but the information acquired is considered relevant in the diagnosis of mental issues. Moreover, the intent of the MCMI I-II Assessment is to diagnose problems in the psychiatric population and not for normal people and those who are considered to have a mild mental disturbance. (Grohol 2013) explained that base rate scores from the clinical and personality scale are calculated base on how the person responds to the administered test. Base scores between 75-85 considered to significantly determine a mental health concern. Whereas, base scores between 85 and higher determines a clinical concern or personality disorder.

RELIABILITY AND VALIDITY

Although a number of researchers argue that it would be better to use the MCMI I-II until more research and testing can be done for the MCMI I-III to be considered a sustainable instrument for assessment, studies on the validity and reliability of the MCMI as a tool can be considered that its consistency is predominantly strong and is a suitable psychometric instrument.

The alpha coefficient for the MCMI I-III exceeds .80 for the twenty (20) of the twenty six (26) scales of which depression has a high score of .90 and a low score for Compulsive of .66 (Growht-Marat 2003). On the test-retest reliability, it is reported that for a 5-14 day interval, it shows a median of .91 of which Somatoform got a highs score of .96 and debasement got a score of .82 which is the lowest. Further studies also concluded that personality scales shows higher stability than the clinical scales. However, some research also stated that there is a little difference when it comes to the difference between the mean of personality scales and clinical scales even after an extended re-test interval.

However, further studies indicate that MCMI shows a theoretical higher stability on the personality scales than the clinical scales in the MCMI I-III which shows a mean of .89 for personality scales and a higher score of .91 for clinical scales. Also, one of the issues when refers to evaluating MCMI and its validity is the fact that the previous validity studies of the old versions can be transferred and be combined to the current version.

In addition, Craig (1999) stated that psychometrist argue that the items are redundant and that the test is non-factorial which would result to factorial invariance. However, Millon strongly believes that covariation exist and is not particularly concern about the redundancy. It also be taken account that item overlap that resulted from the forced resemblance artificially increase correlations between the scales.

Also, in the study presented of the MCMI-I, it shows a four-factor structures which are:

-          General Adjustment

-          Paranoid behavior and thinking

-          Schizoid Behavior and Detachment

-          Social Restrain/Aggression

Millon however found 8 structures that Choca and Van Denburg labeled as:

-          General Maladjustment

-          Acting out/Self-Indulgent

-          Anxious and Depressed Somatization

-          Compulsive Defended/Delusional-Paranoid

-          Submissive/Aggressive-Sadistic

-          Addictive Disorder

-          Psychoticism

-          Self and other Conflictual/Erratic Emotionlaity.

The MCMI factor studies use a big sample size and different clinical population which consist of psychiatric patients/outpatients, criminal offenders and substance abusers of which used a varimax rotation to employ a principal component analysis.

In general, Craig (1999), stated that there is however an increase in stability in the reliabilities scale shown in every version of the test which suggest a more psychometrical good scale. Indeed, most of the scale in the MCMI-I and MCMI-III shows a sufficient reliability over test-retest intervals with reasonable exception of Dependent, Passive-Aggressive, Paranoid and Borderline scales. Overall, MCMI-III indicates good psychometrics and is therefore considered to be a valid and reliable test. Of which psychiatry patients are used as norms and a new weighted score was used.

However, Growth-Marat (2003) suggested that MCMI-III be used conservatively until further validity has been documented. Whereas, the MCMI-I demonstrates a good validity and reliability and has receive commendation as well as it is innovative. As a whole, the MCMI is a well developed test that provides a wide variety of information which focuses on the problematic personality disorder as well as the clinical symptomatology. The study also concluded that there is a good predictive power between .30-.80 which is also supported by further research.

DEVELOPMENT OF MCMI-II

Growth and Marat (2003), further discuss that the MCMI-II had mostly retained its original features from the MCMI. The need to further development the assessment is to be able to incorporate current research and finding on personality disorders while maintaining its alignment with the DSM III criteria. Apparently, the MCMI-II have reached a total of 175 items and 22 different scales and a rating of 1,2 and 3 were weighted on each individual items.

THE DEVELOPMENT OF MCMI-III

Currently, Growth-Marat (2003), state that there is an ongoing research on the development of the MCMI-III. Using the same procedures used with the MCMI and MCMI-II a 325 item test was developed where PTSD and Depressive Scale was added. There were 90 items from the MCMI-II which were changed but 85 of the items were retained.

MCMI-III Scale Categories and Reliability

Scale/Category Name	Abbreviation	No. of Items	Alpha
Modifying Indices Disclosure Desirability Debasement Validity	X Y Z V	NA 21 33 4	NA .85 .95 NA
Clinical Personality Patterns Schizoid Avoidant Depressive Dependent Histrionic Narcissistic Antisocial Aggressive (Sadistic) Compulsive Passive-Aggressive Self Defeating	l 2A 2B 3 4 5 6A 6B 7 8a 8b	16 16 15 16 17 24 17 20 17 16 15	.81 .89 .89 .85 .81 .67 .77 .79 .66 .83 .87
Severe Personality Pathology Schizotypal Borderline Paranoid	S C P	16 16 17	.85 .85 .84
Clinical Syndromes Anxiety Somatoform Bipolar: Manic Dysthymia Alcohol Dependence Drug Dependence Posttraumatic Stress Disorder	A H N D B T PT	14 12 13 14 15 14 16	.86 .86 .71 .88 .82 .83 .89
Severe Syndromes Though Disorder Major Depression Delusional Disorder	SS CC PP	17 17 13	.87 .90 .79

Source: Handbook of Psychological Assessment (4^th ed.), by Growth- Marnat, 2003, John Wiley and Sons, Inc

The table above shows the 28 scales which are divided into categories; of which the base rate scores are taken from the result of standardization sample done to 1,079 patients from different backgrounds and treatment settings.  In addition, some of the items were also retained where not taken out such as Sadistic Personality and Self defeating disorder even if they were already remove from the DSM IV.  Moreover, most items in the MCMI-III actually maintain its primary content and the changes are to present the increase in the severity of the symptoms. The reason for the changes is too also reduce and prevent people from endorsing items of which they expect that MCMI-III would be efficient and selective when it comes to the cause and effect of the disorder. Also, MCMI-III follows the following changes of which the weighing system was change to a 2 point system rather than the 3 point system which was originally included in the MCMI-II. The contents of the new publish version of the MCMI-II includes:

-          Three item validity index

-          Three modifier indices which is to assess bias in the response.

-          Fourteen Personality Scales

-          Ten Clinical Syndrome Scales.

Using the Cronbach’s alpha the consistency of the scale was predicted to be between .67 and .90 with a re-test stability of .84 ane .96 over five to fourteen days.

SUMMARY OF SCALE RELIABILITY MCMI-I to MCMI-III

MCMI-I	-          Personality Disorder Scales Passive Aggressive .19 t0 .91 Histrionic with a .71 median for all scales -          Clinical Syndrome Somatoform .45 to Bipolar Manic .67 with a .60 median value for all scales.	-          Avoidant and Dependent Scales (13 data sets) -          12 data sets for the remaining scales. -          5 days to 3 years Test-restest interval (with 3 months interval for most studies)
MCMI-II	-          Personality Disorder Borderline .62 to Compulsinve .78 with .74 median for all scales -          Clinical Syndrome Scales Somatoform .43 to Drug Dependent .72 with .66 median value for all scales.	-          Dependent Scale (8 data sets) -          7 data sets for the remaining scales. -          21 days to 4 months test-retest interval (with 2-3 months interval for most studies.
MCMI-III	-          Personality Disorder (base on three data sets) Depressive .58 to .93 Depressive with .78 median -          Clinical Syndrome Scale PTSD .44 to Major Depression .95 with .80 median value.	-          Two to three data sets depending on the scale -          5 days to 6 months test-retest interval -          Median correlation for clinical samples - reported later.

Source: Overview and Current Status of the Millon Multiaxial Inventory Journal by Robert J. Craig, 1999, Journal of Personality Assessment

INTERPRETATION PROCEDURE (Growth-Marat, 2003)

1. Determine Profile Validity

-          Random Responding – scores one or more from the three items on the MCMI-III Validity Scale.

-          Underreporting of difficulty – low score (less than 34) on Debasement and Disclosure. And high score on Desirability (over 75 base rate)

-          Faking good – It is advised to refer to the client’s history to be able to make a distinction.

-          Fake bad – high score (above 178) on Disclosure; high score (above 75) on Debasement.

-          Cry for help – moderate elevation

-          Increase Invalid Profile – progressive high score (base rate beyond 85)

2. Interpret the personality disorder scale

-          Elevation on the Severe Personality Disorder scale should be checked.

-          Elevated scale suggests one or more Clinical Pattern scale is elevated as well.

3. Interpret Clinical Syndrome Scale – The same with number two procedure.
4. Review Note Worthy Response

-          The MCMI-III included a series of Noteworthy responses that would guide practitioners to selectively note appropriate psychological report that would reflect the client’s behavior, affect and attitude.

5. Implications on Treatment and Recommendation should be elaborated

-          Target high problematic symptoms which have high elevation in the Clinical Syndrome scale as high priority. Such as, Substance abuse, Anxiety, depression. However, it is important for practitioners to understand the client’s pathology of personality patterns.

-          Treatment recommendation and suggestions are also provided in each of the personality disorder scale.

In conclusion, Craig (1999) stated that the MCMI is one of the extensively used assessment tool which provide a comprehensive theory and is coordinated closely with the DSM’s multiaxial format. Besides that it is easy to interpret, it also requires lesser time to administer the test. However, it is very important that one has to learn and familiarize the terminology used in the DSM to be able to conclude a more precise diagnosis.

Nevertheless, Craig (2006) advised that the MCMI should not be use as a single instrument for measurement although it has been widely accepted by practitioners.  In as much as it has its own strength, it is also important to recognize its limitations. He also added that the MCMI-III should only be use appropriately with adults being treated or evaluated in the mental health condition. The measurement also was design to identify clients with personality disorders and selected clinical syndromes. Moreover, he strongly advised that the assessment should not be employ with persons who are normal.

References

Gary, G.M. (2003). Handbook of Psychological Assessment 4^th Edition. John Wiley & Sons,     Inc. 311-353

John, M.G. (2013). Million Clinical Multiaxial Inventory (MMCI-III). Psychcentral.com. Retrived from http://psychcentral.co m/lib/millo n-clinical-multiaxial-invento ry-mcmi-iii/0006106

Robert, J.C. (1999). Overview and the Current Status of the Millon Clinical Multiaxial Inventory. Journal of Personality Assessment. 72(3). 390-406

Rober, J.C. (2006). Millon Clinical Multiaxial Inventory II/III. Psychological Assessment Resource. 1-7

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