MCMI-TI PERSONALITY DISORDERS IN RECENT-ONSET BIPOLAR DISORDERS

BRUCE TURLEY AND GLEN W . BATES

Swinburne Institute of Technology Melbourne, Australia

JANE EDWARDS AND HENRY J. JACKSON

Royal Park Hospital Melbourne, Australia

This study investigated the personality disorders of 21 recent-onset Bipolar Disorder patients using the revised Millon Clinical Multiaxial Inventory (MCMI-11; Millon, 1987). Personality disorder assessments, conducted after patients clinical symptoms had settled, indicated that 17 patients received at least one MCMI-I1 personality disorder diagnosis with a trend toward multiple diagnoses. Narcissistic, Antisocial, and Histrionic personality disorders were diagnosed most frequently and were the scales most elevated. Schizoid and Compulsive personality disorders were the scales least elevated. Diagnostic concordancebetween the MCMI-I1 and the Structured Interview for DSM-111 Personality (SIDP; Pfohl, Stangl, & Zimmerman, 1983) was poor; the MCMI-I1 made more multiple diagnoses. Implications of the discrepanicesbetween these instruments and suggestions for future research are discussed. Millon (198 1, 1986) has articulated a comprehensive theory of personality disorders and their refationship t o clinical syndromes. This theory has been operationalized in the revised Millon Clinical Multiaxial Inventory (MCMI-11; Millon, 1987). The present study investigated MCMI-II-diagnosed personality disorders in Bipolar Disorder inpatients. Research has shown that maladaptive personality influences the nature and course of depression and modifies treatment response (e.g., Andreoli, Gressot, Aapro, Tricot, & Gognalons, 1989; Frank, Kupfer, Jacob, & Jarrett, 1987; Joffe & Regan, 1989). A more specific focus on premorbid personality in bipolar patients has been invited by researchers who suggest that maladaptive traits may influence lithium compliance in these patients (Schou, 1988) and alienate social supports that buffer against relapse (Miklowitz, Goldstein, Nuechterlein, Snyder, & Mintz, 1988; OConnell, Mayo, Eng, Jones, & Gabel, 1985). However, research into maladaptive personality patterns associated with mania remains fragmentary. Psychoanalytic investigations based on clinical observations have implicated underlying obsessional and narcissistic character styles (Aleksandrowicz, 1980). Retrospective psychometric studies have noted obsessionality and extraversion as associated with affective disorders. Yet, the issue remains inconclusive in the absence of standardized constructs for clinical syndromes and personality disorders or compatible assessment measures (Akiskal, Hirshfield, & Yerevanian, 1983; Hirshfield, Klerman, Keller, Andreasen, & Clayton, 1986; Pica et al., 1990).
We express our gratitude to Simone Pica and Raymond Rudd for their assistance in the collection of data for this paper. We also thank Dr. Jim McLennan for his comments on an earlier draft of the manuscript. Requests for reprints should be addressed to Dr. Glen W. Bates, Department of Psychology, Swinburne Institute of Technology, P.O. Box 218, Hawthorn, Victoria, 3122 Australia.

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The advent of DSM-111 and its revision, DSM-III-R (American Psychiatric Association, 1980, 1987), and the publication of Millons (1981) theory have laid stronger foundations for research into personality disorders by providing standardized constructs. Structured assessment instruments such as the MCMI-I1 and the Structured Interview for DSM-I11 Personality (SIDP; Pfohl et al., 1983) have emerged to operationalize those constructs. Moreover, DSM-I11 introduced a multiaxial format designed to facilitate diagnosis of personality disorders (placed on Axis 11), concomitant with clinical syndromes (placed on Axis I). It also anticipated patterns of comorbidity between specific personality disorders and particular syndromes, although no such associations were predicted for Bipolar Disorder. Overall, Millons (1981, 1986) theory of personality disorders exhibits many parallels with DSM-III-R, and the compatability of the diagnostic categories of the MCMI-I1 has been emphasized (Millon, 1987). The main conceptual difference is that Millon offers a theory-driven model rather than the descriptive approach favored by DSM-III-R. Millon proposes that the various personality disorders are coping patterns that reflect combinations of three underlying dimensions: self-other orientation, active-passive presentation, and pleasure-pain motivation. While all personality disorders are related to these dimensions, Paranoid, Borderline, and Schizotypal disorders are referred to as more severe patterns. Millon (1986) adopts an interactionist approach to comorbidity. Clinical syndromes such as Bipolar Disorder are viewed as expressions of a complex of personality characteristics that are exhibited under stressful or otherwise vulnerable conditions. Evaluation of how validly the MCMI-I1 corresponds with specific DSM-III-R personality disorders awaits empirical investigation. Existing research with the SIDP and the MCMI-I1 suggests that there may be differences between the two systems. Pica et al. (1990) used the SIDP to identify personality disorders in 26 inpatients with bipolar diagnoses. Sixty-two percent of their sample was assessed to have one or more personality disorders, with Histrionic, Borderline, Passive-Aggressive, and Antisocial the most frequently diagnosed. Pica et al.s results contrast with Millons (1987) MCMI-I1 validity data, which presented a personality disorder profile for patients with Bipolar Disorder in which Histrionic and Passive-Aggressive personality patterns were most prominent, followed by Self-Defeating and Dependent patterns. These results were obtained from 49 patients given a Bipolar Disorder diagnosis according to criteria then under preparation for DSMIII-R and in line with Millons (1981, 1986) theoretical framework. A related methodological issue is the noted tendency for self-report instruments to suggest more pathology compared with clinical interviews (e.g., Hyler et al., 1989; Widiger & Frances, 1987). Nazikian, Rudd, Edwards, and Jackson (1990) observed this trend in a study that compared SIDP and MCMI-I personality disorder assessments. Their research was conducted on psychiatric inpatients with a range of Axis I diagnoses that excluded Bipolar Disorder and Schizophrenia. Poor diagnostic concordance between the SIDP and the MCMI-I was reported, an indication that the MCMI-I may incorporate different constructs of personality disorder than the SIDP. The present study was an exploratory investigation into MCMI-I1 diagnosed personality disorders in 21 inpatients given DSM-III-R diagnoses of Bipolar Disorder or Schizoaffective Disorder Bipolar Type. The patients were a subset of the sample of 26 used by Pica et al. (1990) for whom MCMI-I1 data were available. There were three aims: The first was to report the frequency and type of categorical MCMI-I1 personality disorder diagnoses. The second aim was to investigate the MCMI-I1 dimensional trait scores. This inquiry incorporated additional assessment information from patients personality disorder profiles unavailable through categorical diagnoses. Finally, a preliminary investigation was conducted into the level of diagnostic concordance in the frequency and type of personality disorders assessed by the MCMI-I1 and the SIDP. That analysis offered an index of the compatibility of the MCMI-I1 assessments with the DSM-I11 framework.

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Based on Millons (1987) validity data, it was anticipated that Histrionic and PassiveAggressive personality disorders might be the most prominent on the MCMI-11. Because patients in this study were drawn from the sample used by Pica et al. (1990), the pattern of SIDP responses already was known. METHOD

Subjects The sample comprised 12 male and 9 female inpatients at Royal Park Hospital with DSM-111-R diagnoses of Bipolar Disorder or SchizoaffectiveDisorder Bipolar Type. The two diagnostic groups were pooled because previous research has identified few substantive differences between patients with either disorder (Levinson & Levitt, 1987; Pica et al., 1990). Patients with organic or drug-induced mood disorders were excluded. To optimize accurate assessment of premorbid personality, the sample was limited further to patients with recent-onset (less than 5 years) bipolar symptoms. All subjects gave written consent for their participation and granted permission to involve an informant for SIDP assessments. The mean age of patients was 30.23 (SD = 9.53); the average age of onset of 26.81 (SO = 10.25) was consistent with epidemiological data on Bipolar Disorder, which places the modal age of onset as under 30 (Krauthammer & Klerman, 1979). One-quarter (23.8010) of the subjects had received their first bipolar diagnoses within the previous year, and for nearly half (47.6%) the period since first onset was 2.5 years or less. The average number of previous admissions was 3.05 (SD = 2.16). Personality disorder assessments were conducted after patients had been hospitalized for an average of 24.09 days (SD = 15.04). All patients were fluent in English with an average of 11.40 years of education (SD = 2.77). Measures Personality disorder The Millon ClinicalMultiaxial Inventory (MCMI-11, Millon, 1987) is a 175-item true/false self-report inventory designed for use among clinical populations. The present study focused on the dimensional and categorical assessments on the 13 personality disorder scales included in the inventory. Millon (1987) reports that eight of the personality disorder scales have attained stability coefficients in the .70s with a range of .49 (borderline scale) to .75 (histrionic scale). There are few published studies that have investigated the reliability and validity of the MCMI-11. However, Streiner and Miller (1989) found that the net effect of item weighting on the instruments validity was negligible. Piersma (1989a, 1989b) reported that the revisions incorporated into the MCMI-I1 improved its reliability compared with the MCMI-I. The Structured Interview f o r DSM-111Personality (SIDP; Pfohl et al., 1983) is a semi-structured interview explicitly designed to diagnose 11 DSM-I1 personality disorders. It comprises 160 standardized questions arranged according to 16 functional categories (e.g., self-esteem, egocentricity, interpersonal relations). All items are addressed t o patients, while selected items are addressed to informants (e.g., family member, close friend). Stangl, Pfohl, Zimmerman, Bowers, and Corenthal (1985) reported a reliability Kappa of .71 for the presence or absence of personality disorders for the SIDP. Interrater reliability for particular personality disorders was variable; Kappa ranged from .30 (Compulsive) to .90 (Dependent). State measures Three state measures were administered prior to the MCMI-I1 and SIDP assessments to ensure that personality assessments were made when patients mood states and clinical symptoms had stabilized.

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The Beck Depression Inventory (BDI; Beck, Rush, Shaw, & Emery, 1979) comprises 21 items rated on a 4-point scale (0 = absent to 3 = extreme). The total score reflects intensity of state depression, with scores that range from 0 to 63. Kendall, Hollon, Beck, Hammen, and Ingram (1987) recommended that designation of depression be reserved for patients with scores above 20. A review of the psychometric performance of the BDI reported a mean consistency alpha of .87 with test-retest reliability consistently above .60 (Beck, Steer, & Garbin, 1988). The Bech-Rafaelson Mania Scale (BRMS; 1978) takes approximately 15 minutes to administer and consists of 1 1 interview items that assess manifestations of mania such as flight of thought and motor activity. Bech, Bolwig, Kramp, and Rafaelson (1979) reported a Kendall concordance coefficient of .95 for interrater reliability. Ten items reflected significant item-total score homogeneity (range of r = .72 to .94, all ps < .001). The other item (sleep) yielded a correlation of .48 (p < .05). The Scalefor Positive Symptoms (SAPS; Andreasen, 1984) measures hallucinations, delusions, bizarre behavior, and positive formal thought disorder derived from 30 items (global items excluded). Items are scored on 5-point scales from 0 = absent to 5 = severe and are summed to provide a total score from 0 to 150. Walker, Harvey, and Pearlman (1988) reported a mean interrater kappa of .84 for positive symptoms in a sample that comprised patients with diagnoses of Schizophrenia and Bipolar Disorder. The Structured Clinical Interview for DSM-ZZI-R (SCID-P; Spitzer, Williams, & Gibbon, 1986) is a structured interview designed to diagnose Axis 1 DSM-III-R clinical syndromes among psychiatric populations. The SCID-P is designed for use by a trained interviewer and has a flexible modular format. Riskind, Beck, Berchick, Brown, and Steer (1987) reported an interrater reliability K coefficient of .74 07 < .01) in assessing Axis 1 disorders, an indication of satisfactory diagnostic reliability. Procedure Procedural descriptions are based on those outlined by Pica et al. (1990). SCID-P and SAPS diagnostic interviews were conducted by JE and HJJ. BDI and BMRS mood state measures were administered to patients by a third clinical psychologist and a clinical masters student. Personality assessments were conducted by the latter two individuals when clinical opinion, reinforced by the results of the state measures, determined that each patients mood and symptom state were settled.
RESULTS In all inferential analyses, two-tailed tests for significance were reported because no directional predictions were made.

Assessment of Mood State and Psychotic Symptoms Analyses of BDI, BMRS, and SAPS assessments indicated that patients mood and symptom states had stabilized prior to personality disorder assessments. The mean BDI score was 9.52 (SD = 6.12). Twenty patients scores were below the cut point of 21 recommended by Kendall et al. (1987) as an indication of depressed state. The mean BMRS score was 6.33 (SD = 3.44); a highest score of 14 (possible range 0-44) indicated acceptably low levels of manic symptoms. The mean SAPS score for total positive symptoms was 7.10 (SO = 9.41), acceptably below levels necessary to register the presence of severe symptomatology (Andreasen & Olsen, 1982). In terrater Reliability Two raters made seven SIDP diagnoses. For 5 of the 7 patients, there was perfect agreement between raters on the SIDP for personality disorder diagnoses. The overall kappa coefficient of .91 was acceptably high.

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Two raters made seven SAPS and SCID-P assessments and eight BMRS assessments. Interrater agreement was significant for the BMRS (r = .90, p < .01, two-tailed) and SAPS (r = .98, p < .001, two-tailed). There was perfect agreement on six out of seven of the SCID-P diagnoses; the only difference was on the subcategory of Bipolar Disorder assessed for one patient.

MCMI-II Personality Disorder Analyses Due to the small size of the sample and the exploratory nature of the study, the emphasis was on descriptive analyses of the personality disorder categories and dimensional scores for this bipolar sample. The MCMI-I1 validity index indicated that two MCMI-I1 profiles were of questionable validity. With these profiles excluded, all computations in the following section were based on a sample size of 19. Categorical MCMI-Ilpersonality disorder diagnoses. The MCMI-I1 assessed 89% of patients as having at least one personality disorder (M = 2.74 disorders, SD = 4.82). Fifty-eight percent were diagnosed with more than one disorder. Table 1 shows that the most frequently diagnosed personality disorders were Narcissistic, Antisocial, Histrionic, and Passive-Aggressive. Least-frequent diagnoses were Paranoid, Schizotypal, and Compulsive. The four most frequently diagnosed disorders showed more males than females in the Antisocial (8 male, 1 female), Narcissistic (7,2), and Passive-Agressive (5,2) disorders. For Histrionic personality disorder, there were 4 males and 3 females. Overall, 31 personality disorders were diagnosed in the 10 males within the sample (after the two invalid profiles were removed). Eight of these were in one patient. Collectively, the 9 females received 17 of the diagnoses.
Table 1 Frequency of MCMI-11 Diagnoses and Correspondence with SIDP Diagnoses
Diagnostic category Diagnostic frequency MCMI-I1 SIDP Concordance MCMI-I1 and SIDP Agree Disagree Present Absent Present Absent

Self-other cluster Dependent Histrionic Narcissistic Antisocial Compulsive Passive-Aggressive PIeasure-pain cluster Self-defeating Avoidant Schizoid Aggressive (Sadistic) Severe personality pathology Schizotypal Borderline Paranoid Mixed

0 10

16 6 9 10

2
4

1
A

17

16 16

0
1

0 2 0

17 1s
18

1 0
1

N = 19. Note.-The MCMI-I1 has no category for mixed diagnoses, and the SIDP has no category for SelfDefeating or Aggressive-Sadistic diagnoses.

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Frequencies for categorical diagnoses listed in Table 1 are based on MCMI-I1 dimensional scores above the base rate 84 cutting line. This adopts a conservative approach (compared with using the base rate 74 cut-point) and was used by Hogg, Jackson, Rudd, and Edwards (1990) as a basis for comparison with SIDP categorical diagnoses. MCMZ-ZZ dimensional profies. Table 2 summarizes means and standard deviations for each of the personality disorder scales and for the modifier indices. In line with frequency analyses, this general profile shows the greatest elevations on the Antisocial, Histrionic, and Narcissistic scales. The Passive-Aggressivemean trait score is relatively lower compared with frequency data for that disorder. This was due to a broad spread of scores in this category (SO = 33.69). The scores displayed in Table 2 also suggest a tendency for patients to endorse more items on the dependent and self-defeating scales than indicated by the categorical data.
Table 2

Means and Standard Deviations for MCMI-II Dimension Scales (N = 19)

Diagnostic category Modifier indices Disclosure Desirability Debasement Self-other cluster Dependent Histrionic Narcissistic Antisocial Compulsive Passive-Aggressive Pleasure-pain cluster Self-defeating Avoidant Schizoid Aggressive (sadistic) Severe personality pathology Schizotypal Borderline Paranoid Base rate scores M SD

65.37 63.63 50.05 67.10 76.16 74.74 78.47 53.80 69.42 69.05 64.84 56.26 69.00 62.31 63.68 59.26

19.64 19.62 18.69 23.49 19.81 28.32 26.34 17.87 33.69 21.70 22.20 25.20 21.24 11.41 26.29 17.07

Mean scores on 10 personality disorder scales were elevated above base rate 60, the indicator of median prevalence rates for each disorder among clinical populations. Millons severe personality pathology scales clustered around this median. Paranoid, Schizoid, and Compulsive mean scores were below a base rate of 60. Comparison of MCMZ-ZZ and SIDP categorical diagnoses. Categorical personality disorder diagnoses assessed by the MCMI-I1 and the SIDP were compared to examine correspondence between MCMI-I1 assessments and an instrument specifically designed to measure DMS-I11 personality disorders. Comparisons of MCMI-I1 and SIDP assessments for each personality disorder can be determined from Table 1. The rate

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of personality disorder diagnoses was almost one-third (3 1.12%) higher for the MCMI-I1 when compared with the SIDP. The only categories in which the SIDP diagnosed a higher frequency of personality disorders were Histrionic and Borderline. The level of agreement between the MCMI-I1 and the SIDP on overall presence or absence of personality disorders was poor. Table 1 shows that the MCMI-I1 and SIDP only agreed on 12 positive diagnoses. Comparisons for each personality disorder showed that the most dramatic diagnostic discrepanices between the two instruments were the high comparative frequencies of Narcissistic and Antisocial personality disorders reported by the MCMI-11. Kappa coefficients were calculated for the four personality disorders for which at least one instrument made five positive diagnoses. Diagnostic concordance was poor, and only one could be considered fair (ks = .07 Histrionic; .02 Narcissistic, - .09 Passive-Aggressive, .47Antisocial). The small sample precluded further investigation of diagnostic concordance with kappa. Kappa can only be used where at least one instrument has made a minimum of five positive diagnoses (Jackson et al., 1991). DISCUSSION The principal finding of the present study was that Narcissistic and Antisocial personality disorders were the most prevalent disorders in this sample of Bipolar disordered patients, followed by Histrionic and Passive-Aggressive disorders. Thus, from within Millons theoretical framework, the predominant area of personality disturbance was located in difficulties on the self-other dimension, specifically, in balancing selfpreoccupation and social responsibility. Interestingly, according to Millon (198 l), those personality disorders are among the less disabling patterns of disturbance. The association of less severe personality pathology with Bipolar Disorder is consistent with the proposal that Bipolar Disorder is a less severe clinical syndrome than schizophrenia (Crow, 1990). Moreover, a higher incidence of personality disorders judged by Millon as more severe (e.g., Paranoid, Schizotypal) has been demonstrated by the MCMI-I to be associated with schizophrenia (Hogg et al., 1990). The high prevalence rates for Narcissistic personality disorder support the association between the narcissistic character style and mania noted in psychoanalytic writings (Aleksandrowicz, 1980). In contrast, the low rate of Compulsive personality disorders in this sample conflicts with Akiskal et al. (1983), who reported that this trait was among the most consistently identified in research on the premorbid personality of bipolar patients. However, contrary to the present study, those studies did not utilize DSM-III-R diagnostic criteria, did not use standardized assessment instruments, and did not control for patients mental states at the time of testing (Pica et al., 1990). Therefore, that difference may be a product of methodological limitations. Information from the dimensional profiles offers modification of the clinical picture provided by categorical diagnoses. For example, trait scores on Dependent, SelfDefeating, and Aggressive (Sadistic) showed these patterns to be more common in the sample than the categorical analyses suggested. Therefore, these personality patterns warrant further examination in terms of their role in Bipolar Disorder. In contrast, the diverse spread of scores on the Passive-Aggressive scale indicates that while seven patients received this categorical diagnosis, this trend was not representative of the whole sampIe. Widiger and Frances (1988) have observed that Histrionic, Narcissistic, and PassiveAggressive personality disorders may not be fully reported in self-report measures because patients with these tendencies are prone to deny or be unaware of these egosyntonic traits in themselves. The capacity of the MCMI-I1 to register these patterns as prominent traits and to measure their associated response styles are strengths of the instrument. In addition, scores on the modifier indices showed relatively open attitudes to disclosure, with a strong inclination toward positive image projection rather than

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self-deprecation or symptom exaggeration. Thus, Millons (1987) observations about the tendency of Histrionic and Narcissistic character types to deny psychopathology were supported in the present study. The pattern of dimensional scores partially replicated Millons (1987) validity data for Bipolar Disorder. Consistent with Millon, Histrionic and Passive-Aggressive personality disorders were among the four most elevated scales, and Schizoid and Compulsive ranked lowest. However, whereas Millon located Self-Defeating and Dependent personality disorders as among the four most elevated, those disorders were replaced by Antisocial and Narcissistic in the present study. Overall, this represents a reasonable degree of correspondence. The overall ratio of personality disorders identified was virtually equivalent for the MCMI-I1 and the SIDP. However, the MCMI-I1 was far more likely to make multiple diagnoses than the SIDP. The MCMI-I1 identified a total of 52 personality disorders compared with 30 for the SIDP. This trend is consistent with previous studies (e.g., Hogg et al., 1990; Nazikian et al., 1990; Widiger & Frances, 1987). Widiger and Frances (1987) suggested that categorical models of personality pathology, such as the SIDP, are less suited to conceptualizing multiple maladaptive traits like those represented in MCMI-I1 profiles. Thus, self-report instruments like the MCMI-I1 provide a broad band of personality disorder data and are well suited to preliminary exploration of the clinical picture. Clinical interviews appear to be better suited to consideration of contextual and case history material at the point of diagnosis. The MCMI-I1 and SIDP concurred in identifying Antisocial, Histrionic, and PassiveAggressive personality disorders as the most prevalent. However, the SIDP identified Narcissistic personality disorder as much less prevalent than did the MCMI-I1 and made twice the number of Borderline diagnoses. Furthermore, for individual patients, diagnostic agreement was extremely poor. The instruments concurred on only 12 positive diagnoses; the MCMI-I1 provided 32 positive diagnoses that were not supported by the SIDP. The MCMI-I1 did not identify 15 personality disorders diagnosed by the SIDP. In sum, both instruments are locating disturbance in the same broad domain of personality pathology. Disagreement centers primarily on the boundaries between specific disorders within the domain. This may be due to the high level of overlap between Histrionic, Narcissistic, and Borderline personality constructs (Pope, Jonas, Hudson, Cohen, & Gunderson, 1983). It also may reflect the arbitrary and tentative nature of boundaries between different personality disorders at this early stage of research (Widiger, Frances, Spitzer, & Williams, 1988). The small sample size precludes any firm conclusions about the diagnostic concordance of the two instruments. Nevertheless, the correspondence between the present results and other studies (e.g., Nazikian et al., 1990) suggests that further research is needed to determine the sources of poor diagnostic concordance. Possible explanations include the general unreliability of personality disorder assessments (Frances & Widiger , 1986), overlapping criteria sets (Oldham, 1987), or structural problems with the instruments themselves. In conclusion, this study has shown that, when examined with the MCMI-11, recentonset Bipolar Disorder may be linked to personality disorders that involve disturbances in self-expression and social relationships, specifically: narcissistic, antisocial, histrionic, and passive-aggressive patterns. The general pattern of results was consonant with Pica et al.s (1990) SIDP data. However, this study suggests that the MCMI-I1 may have poor diagnostic concordance with the SIDP, which more directly operationalizes the diagnostic assumptions of DSM-111.
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