Mmpi 2 code types ppt

Personality Assessment Inventory (PAI)

Administration and Interpretation

Eileen Paniagua, Psy.D.

September 2018

History and Development

— Developed (1987-1991) due to limited availability of instruments with psychometrically solid construct validity and clinical utility

— Development focused both on rational and quantitative (empirical) methods for construct validation — PRIMARY GOAL: Improved DISCRIMINANT VALIDITY

— Modern psychometric science allowed for indexes, multi- faceted scales, interpretative variables not available at the time the MMPI and MCMI were developed

— Constructs for the test selected base on stability of importance in conceptualization of psychiatric disorders as well as significance in contemporary clinical practice

Development

§ Result of review of literature was 18 construct scales plus 4 validity scales

§ Scale items were written to assess for most central components of each psychiatric construct

§ Scales on PAI are designed to measure particular constructs represented by the scale names (vs. MMPI, 16PF)

§ PAI test items were developed and validated based on both conceptual nature and empirical adequacy, using multiple psychometric parameters or criterion

PAI and Scales

— Self-administered, objective inventory of adult personality

— Provides information on critical clinical variables

— 344 items

— Comprising 22 nonoverlapping full scales

— 4 Validity scales

— 11 Clinical scales

— 5 Treatment Consideration scales

— 2 Interpersonal scales

PAI Critical Items

— 27 Critical Items on the PAI

— Critical Items are identified as indicators of potential crisis situations and have very low endorsement in normal sample

— Critical Items facilitate follow-up questioning

Administration

— The PAI is a self-administered, objective inventory of adult personality

— Developed and standardized on a sample of adults ages 18 years and older

— Written at a 4th grade reading level

— 344 items take approximately 50 minutes to complete

— Scoring can be completed with computerized software or manually

PAI Scales & Abbreviations

— Validity Scales: — Inconsistency (ICN) — Infrequency (INF) — Negative Impression (NIM) — Positive Impression (PIM)

— Clinical Scales: — Somatic Complaints (SOM) — Anxiety (ANX) — Anxiety-Related Dis. (ARD) — Depression (DEP) — Mania (MAN) — Paranoia (PAR) — Schizophrenia (SCZ)

— Borderline Features (BOR) — Antisocial Features (ANT) — Alcohol Problems (ALC) — Drug Problems (DRG)

— Treatment Scales: — Aggression (AGG) — Suicidal Ideation (SUI) — Stress (STR) — Non-support (NON) — Treatment Rejection (RXR)

— Interpersonal Scales: — Dominance (DOM) — Warmth (WRM)

Reliability

— Variety of internal consistency alphas across three samples (1,000 normative; 1,051 college student; 1,246 clinical)

— Median alphas for full scales are .81, .82, and .86 for the normative, college, and clinical samples, respectively

— Median test-retest reliability across all three samples was .83

— Mean absolute T-score change tended to be 2 to 3 T-score points for most full scales

Validity

— Four Validity scales built into PAI

— Inconsistency and Infrequency assess deviation from conscientious responding

— Negative Impression and Positive Impression assess impression management

— 1,000 computer-generated random response protocols were compared against profiles from the three subsamples and there was marked separation

— Fake-good and fake-bad studies also conducted on a sample of 90 adults

Interpretation Steps

— Step 1: Assessment of Profile Validity

— Step 2: Determination of appropriate reference (norm) comparison

— Step 3: Interpretation of Individual Scales & Subscales

(Configuration Analysis (Two Point Code Types) can also be interpreted with PAI data- for more information on configuration analysis refer to PAI manual and other resources:

1. PAI Professional Manual 2nd Edition- Leslie C. Morey

2. Essentials of PAI Assessment- Leslie C. Morey

Step One: Profile Validity

— Be aware of, and address, factors which could influence test response (setting, referral, potential use of results, secondary gains)

— Specific validity “threats”: — Careless or Idiosyncratic Responding:

— ICN: Inconsistency, IFN: Infrequency — Negative Profile Distortion:

— NIM: Negative Impression Management — Malingering Index — Rogers Discriminant Function

— Positive Profile Distortion: — PIM: Positive Impression Management — Defensiveness Index — Cashel Discriminant Function

Detecting Carelessness or Random Responding

— ICN: Inconsistency:

— 10 pairs of items (5 similar, 5 opposite)

— Detects carelessness, indifference, or confusion (vs. specific response set)

— May also be influenced by reading comprehension problems (missing negative wording, etc.)

— <64T=valid, generally consistent and attentive; 64- 72T=some inconsistency, carelessness, or confusion- interpret cautiously; ≥73T=invalid

— INF: Infrequency:

— Measures subjects who complete the PAI in an atypical manner due to carelessness, random responding, confusion, reading problems, or very idiosyncratic thinking or behavior

— <60T=valid, non-random; 60-74T=indicates unusual responding-more serious toward 74 (interpret cautiously/inquire)

— ≥75=subject did not attend to item content=random, reading problems, confusion = invalid-do not interpret

Detecting Negative Profile Distortion

§ Detecting/measuring the attempt to appear more pathological than is objectively observable

§ For secondary gain = Malingering

§ For attention/patient role = Factitious Disorder

§ In either case PAI clinical profile is likely to be markedly discrepant from clinical findings

§ Thus, profile reflects what the subject wants the clinician to see, vs. their subjective experience

§ Negatively exaggerated self-perception can also be a feature of some disorders (e.g. depression, BPD)

Negative Impression Management (NIM)

— NIM includes many items that sound like stereotypical pathological symptoms, but in fact are extremely rare or non-existent in clinical populations, many are also dissociative in nature

— Low scores (<73T) = little or no negative distortion

— Moderate scores (73-83) = some exaggeration of problems - interpret clinical elevations cautiously

— Higher scores (84-91) = Increased likelihood of distortion - cry for help, extreme negative self-evaluation, also beginning cut-off (>84) for malingering when context is high

— Very high scores (≥92) = strong suspicion of extremely negative self- presentation, careless response, or malingering. Regardless of cause, profile is not valid

— Fairly effective for detecting malingered psychosis

The Malingering Index

— Designed to be a more specific and discriminating indicator of malingering

— Comprised of 8 configural features of the PAI observed much more frequently with persons simulating psychiatric disorders, often related to mistake assumptions re: people with mental disorders

— Possible score of 0 to 8; (average 4.41 for malingerers, 0.8 for normal sample); ≥3 = 2 SD’s above mean for clinical sample; ≥5 =Extreme suspicion

— Strong sensitivity/specificity for severe pathology, moderate for milder disorders

Rogers Discriminant Function

§ A discriminant function (statistical formula) developed to distinguish bona fide patients from malingerers

§ Weighted combinations for 20 different PAI scores

§ Results in decimal score with a cut-off of 0 (> 0 = suggesting malingering); community and patient samples have means of - 1.0 (with SD of 1.0)

§ Suggested cut-off score for best sensitivity (95%) and specificity (95%) is +0.53

Positive Impression Management

— Low scores (<44) indicate honest responding; (44-57) suggest subject did not try to present unrealistic impression-but higher in range is uncommon for clinical subjects

— Moderate elevation (58-67) suggests an attempt to present self as free of common shortcomings (could be overt or covert)-interpret scales with caution

— High scores (≥68) suggest presentation of self as exceptionally free of shortcomings - validity of profile is seriously jeopardized

— Defensiveness Index: 8 factors used to further identify “fake good” (cut-off=6)

Step 2: Determining Appropriate Reference Comparison

— Community Versus Clinical Norms:

— PAI T-scores are referenced to a representative sample of adults living in the community (“normals”)

— Significant deviation from the norm (60 T=1 SD >mean = 84th percentile; 70 T=2 SD > mean = 96th percentile), (≥70T) indicates degree of problems or symptoms (e.g. depression) very unusual for general population, and, therefore, clinically significant.

PAI Profile (Skyline) Sample

PAI Individual Scale Interpretation

— SOM: Somatic Complaints

— Complaints & concerns about physical functioning & health matters in general

— Physical condition a central concern, may be in reaction to illness or tendency overreact or overemphasize

— Low scores = optimistic, alert, effective

— Moderate (60-70) scores = some concern re: health, typical for older adults or those with specific health issues

— High scores (>70) suggest problems or impairment related to somatic symptoms = unhappy, complaining, & pessimistic; >87 = ruminative, weak, disabled and handicapped by somatic issues

— SOM-C: Conversion

— Dramatic physiological symptoms associated with classic conversion disorder, usually sensory (blind, deaf, or numb) & motor (paralysis)

— Symptoms very rare in normal population, however MS & other neurological patients (and chronic, severe alcoholics) could get false positives

— SOM:S: Somatization

— Routine physical complaints (headaches, backaches, GI) notable for their frequency and variety vs. their presence

— More vague and diffuse complaints (physical symptoms + complaining style) constitute this disorder/scale

— General unhappiness and bitterness about health, dissatisfaction which can become generalized

— SOM-H: Health Concerns

— Preoccupation with health and physical functioning - self- perceived complexity of medical issues and intensity of efforts to ameliorate these problems

— Measure of level of focus vs. severity

— Actual medical patients range widely on this scale, reflecting variety of styles in facing health issues

— High scorers may be seen by others as hypochondriacal

— ANX: Anxiety

— Non-specific indicator of degree of tension and negative affect experienced by the subject

— Contains cognitive, somatic, & affective components of anxiety, but not the behavioral aspects (on ARD scale)

— Gives a broad measure of involvement of anxiety in overall clinical picture

— Average scores (<60)=few complaints of anxiety or tension- calm, optimistic, effective in coping with stress; Very low (<40)=freedom from fear, possible lack of prudence; Moderate elevation (60-70)=some stress & worry, sensitivity, emotionality; Scores >70=significant tension/anxiety, rumination, high-strung, nervous, timid, & dependant; >90=overwhelmed, generalized impairment, in crisis, look to ARD for diagnostic clarification

— ANX-C: Cognitive

— Items tap expectation of harm, ruminative worry, anxiety-based beliefs

— Dwell on events, internalizing approach to anxiety, vigilant to experience of anxiety, strong “trait”(vs. state) aspects

— Elevated scores indicate worry and concern about issues or events beyond control interfering with concentration, intrusive obsessions are possible

— ANX-A: Affective

— Items measure feelings of tension, apprehension, & nervousness

— Tends to be free-floating anxiety and tends to be persistent and trait-like

— Reflects low threshold for experience of threat or danger

— May have difficulty relaxing & be easily fatigued

— ANX: Physiological

— Items assess somatic expression of anxiety, including racing heart, sweaty palms, rapid breathing, & dizziness

— People with this scale elevated may not experience themselves as anxious, but show signs others see as anxiety

— Suggests a repressive style of dealing with stress and a resulting lack of insight

— ARD: Anxiety-Related Disorders

— Assesses phenomena central to 3 important anxiety disorders to help in diagnostic clarification of anxiety

— Full ARD scale is very difficult to interpret due to composite of 3 fairly diverse conditions

— Average scores=individual with little distress, calm, secure, adaptable; 60-70=occasional experiences maladaptive behaviors related to controlling anxiety, some fears, confidence issues; >70=impairment associated with distress/fear re: some situation (subscales), insecure, uncomfortable socially; >90=likely multiple anxiety disorders, severe turmoil, maladaptive behaviors present/ineffective

— ARD Subscales

— ARD-O: Obsessive-Compulsive: Intrusive thoughts/behaviors, rigidity, indecision, perfectionism, affective constriction

— ARD-P: Phobias: Common phobic fears (social, public transportation, heights, enclosed spaces, etc.)

— ARD-T: Traumatic Stress: Experience of traumatic events that cause continuing distress, having left person changed or “damaged” in some fundamental way

— DEP: Depression

— Intended to cover across major elements of depression & range of severity of symptoms

— Cognitive (negative filter/expectancies), Affective (unhappy/apathetic mood), & Physiological (sleep, appetite, energy) components

— Average scores=few complaints, stable, active, confident; 60- 70=unhappy at times, sensitive, pessimistic; 70-80=prominent dysphoria, withdrawing, anhedonic, moody, guilt-ridden; 80- 95=possible Major Depression; >95=MDE probable, hopeless, helpless, no energy, S/I common

— Depression Subscales

— DEP-C: Cognitive: thoughts of worthlessness, hopelessness, failure, indecisiveness, inability to concentrate

— DEP-A: Affective: Feelings of sadness, anhedonia, loss of interest

— DEP-P: Physiological: Level of functioning, activity, & energy, including disturbance of sleep, appetite, and weight loss

— MAN: Mania

— Designed to assess prototypical signs of a manic episode, the scale is focused on disruptions in mood, cognition, & behavior - elevations are rare & threshold for significance is low

— <55=few if any manic features (low MAN≠depression); 55- 65=active, outgoing, ambitious, confident; 65- 75=restlessness, impulsivity, high energy and/or moody, hot- headed; >75=likely mania, hypomania, overactive, irritable, impulsive, poor judgment, flight of ideas, grandiosity, poor interpersonal relations due to hostility & narcissism

— Mania Subscales

— MAN-A: Activity Level: Over-involvement in variety of activities, disorganized, accelerated thought processes & behavior

— MAN-G: Grandiosity: Inflated self-esteem, expansiveness, belief in special talents & abilities

— MAN-I: Irritability: Strained relationships due to frustration with inability of others to keep up with plans, demands, and ideas

— PAR: Paranoia

— Focused on symptoms and enduring characteristics of paranoia-ranging from suspiciousness (delusional disorder) to frank persecutory delusions (paranoid schizophrenia)

— Composition of the items focused on phenomenology of paranoia vs. overt symptoms to reduce impact of defensiveness

— Content addresses a vigilance in monitoring the environment for potential harm, tendency to resent/hold grudges, and sensitivity to perceived slights - a general measure of interpersonal mistrust & hostility

— <60=open & forgiving; 60-70=sensitive, skeptical, wary; 70- 83=overtly suspicious/hostile; >84=delusional, bitter, resentful

— Paranoia Subscales

— PAR-H: Hypervigilance: Suspiciousness, tendency to monitor environment for real/imagined slights

— PAR-P: Persecution: Beliefs that one has been treated unfairly & others are trying to undermine one’s interests

— PAR-R: Resentment: Bitterness & cynicism in relationships, tendency to hold grudges & externalize blame for misfortune

— SCZ: Schizophrenia

— Aims to measure unusual beliefs/perceptions; poor social competence/social anhedonia; and inefficiency/disturbance in attention, concentration, and associational processes

— Discriminant validity for SCZ is not super strong

— <60=effective socially, no cognitive disturbance; 60- 70=withdrawn/aloof, unconventional; 70-90=isolated, alienated, some thinking disturbance (concentration, perceptions); >90=active schizophrenia, confused, withdrawn, poor reality testing

— Schizophrenia Subscales

— SCZ-P: Psychotic Experiences: Focused on the experience of unusual perceptions, magical thinking, & unusual or delusional beliefs

— SCZ-S: Social Detachment: Focused on social isolation, discomfort, & awkwardness

— SCZ-T: Thought Disorder: Focused on confusion, concentration problems, and disorganization of thought processes

— BOR: Borderline Features

— BOR is aimed to be in line with Kernberg’s concept of Borderline as a level of personality organization, with greater instability and primitive defenses as the score rises

— <60=emotional stable with stable relationships; 60-70=moody, sensitive, dissatisfied, uncertain; 70-90=impulsive, labile, angry, suspicious, anxious, needy, ambivalent; >90=in crisis, major relationship problems, hostile, depressed, anxious, self-destructive, substance abusing

— Borderline Subscales

— BOR-A: Affective Instability: labile, moody, poor emotional control

— BOR-I: Identity Problems: Uncertain re: major life issues, lack of fulfillment, absence of purpose or direction

— BOR-N: Negative Relationships: History of ambivalent, intense relationships, issue of betrayal & abandonment

— BOR-S: Self-Harm: Impulsivity in areas with high potential for negative consequences

— ANT: Antisocial Features

— Designed to assess more in line with the concept of psychopathy (criminal exploitive personality) than the DSM ASPD diagnostic criteria (behavior focus)

— <60=considerate, warm, impulse control; 60-70=somewhat impulsive, risk-taking-may be self-centered and unsentimental; 70-82=impulsive, hostile, reckless, antisocial acts, callous in relationship; >82=prominent antisocial traits, unreliable, parasitic lifestyle, anti-authority, irresponsible, unremorseful

— Antisocial Subscales

— ANT-A: Antisocial Behaviors: history of antisocial acts/illegal behaviors - correlated with DSM ASPD diagnosis

— ANT-E: Egocentricity: Lack of empathy or remorse, exploitive approach to relationships - more related to Psychopathy

— ANT-S: Stimulus-Seeking: Craving for excitement & sensation, low tolerance for boredom, reckless & risk-taking (also relevant for psychopathy/acting-out)

— ALC: Alcohol Problems

— DRG: Drug Problems

— ALC: Direct inquiry re: alcohol problems (denial suppresses) and related consequences- scores >70 suggest alcohol abuse, >84=likely alcohol dependence

— DRG: Direct assessment of behaviors and consequences of drug use, abuse (>70), and dependence (>80)

— Aggression Subscales:

— AGG-A: Aggressive Attitude: Hostility, poor control over anger expression, belief in utility of aggression

— AGG-V: Verbal Aggression: Verbal expressions of anger ranging from assertiveness to abusiveness, readiness to express anger

— AGG-P: Physical Aggression: Tendency to have physical display of anger, including fights, property damage, threats of violence

Additional PAI Treatment Scales

— SUI: Suicidal Ideation — Item content ranges from thinking about death, to non-

specific suicidal contemplation, to current serious suicidal consideration

— Item content is obvious & direct, allowing for communication of cry for help, exaggeration/feigning, or denial

— Ideation vs. prediction: identifies need for further risk assessment, S/I is fairly common in clinical populations (<45T rare)

— 70-84T suggest recurrent thoughts = warning sign-assess other risk factors; 85-99T S/I is more intense-take precautions; ≥100T-morbid preoccupation = very high risk

Additional Treatment Scales- Perception of the Environment

— STR: Stress — Assesses life stressors in current or recent experience -

content includes family relationships, financial, job, major life changes - Relates to stability and predictability of environment

— NON: Nonsupport — Assesses perceived lack of social support, both in

availability and quality-higher scores = less perceived support, few close relationships, dissatisfaction

— STR & NON are often positively correlated & common in clinical pop. (64 & 60T ave.)

— Both have implications for treatment planning

— RXR: Treatment Rejection — Intended to assess for attitudes which are negative

indicators for treatment response — High-scorers are a risk for non-compliance — Content includes refusal to acknowledge problems, lack of

introspection, unwillingness to accept responsibility — Mean for clinical pop. Is 40T, and scores rising above 55T

may indicate poor prognosis.

— Interpersonal Style Scales

— DOM: Dominance — Captures degree to which person desires control in

interpersonal relationships — Low (<40) scorers relinquish control & are passive, self-

effacing, lack confidence — High (>60) scorers self-assured, confident, & dominant,

ambitious, prefer social situations where they have control — >70 suggest domineering and over-controlling, need to

control & expect admiration, don’t tolerate disagreement well

— WRM: Warmth

— Indicates degree person is interested in and comfortable with attachment relationships - positively related to indicators of adjustment

— <40T= distant in relationships, low value on close, lasting relationships, may be viewed as aloof; <30 = cold & unfeeling

— >60T= warm, friendly, sympathetic, high value on relationships & harmony; >70T=strong need to be accepted, may be too caring, trusting, & supportive for their own good