Change in Seasonal Beliefs Mediates the Durability Advantage of Cognitive-Behavioral Therapy Over Light Therapy for Winter Depression

In treating an acute episode of winter depression, cognitive-behavioral therapy for seasonal affective disorder (CBT-SAD) and light therapy are comparably efficacious, with improvement in depression symptoms during CBT-SAD mediated by reduced seasonal beliefs (i.e., maladaptive thoughts about the seasons, light availability, and weather). Here, we tested whether the enduring benefit of CBT-SAD over light therapy following treatment is associated with offsetting seasonal beliefs during CBT-SAD. Currently depressed adults with Major Depression, Recurrent with Seasonal Pattern (N = 177) were randomized to 6 weeks of light therapy or group CBT-SAD and followedup one and two winters after treatment. Outcomes measured during treatment and at each follow-up included depression symptoms on the Structured Clinical Interview for the Hamilton Rating Scale for Depression—SAD Version and Beck Depression Inventory—Second Edition. Candidate mediators measured at pre-, mid-, and posttreatment were SAD-specific negative cognitions (Seasonal Beliefs Questionnaire; SBQ); general depressogenic cognitions (Dysfunctional Attitudes Scale; DAS); brooding rumination (Ruminative Response Scale-Brooding subscale; RRS-B); and chronotype (Morningness-Eveningness Questionnaire; MEQ). Latent growth curve mediation models found a significant positive path from treatment group to the slope of SBQ during treatment, with CBT-SAD showing larger improvements in seasonal beliefs with overall change in seasonal beliefs in the medium-effect range, and significant positive paths from SBQ slope to depression scores at the first and second winter follow-ups, indicating greater change towards more flexible seasonal beliefs during active treatment was associated with less severe depression symptoms following treatment. Estimated indirect effects (treatment group → SBQ change * SBQ change → outcome) were also significant at each follow-up for each outcome with β_indirect ranging from .091 to .162. Models also found significant positive paths from treatment group to the slope of MEQ and RRS-B during treatment, with light therapy showing a greater increase in “morningness” and CBT-SAD showing a greater decrease in brooding during active treatment; however, neither construct emerged as a mediator of follow-up depression scores. Change in seasonal beliefs during treatment mediates both the acute antidepressant and long-term effects of CBT-SAD and explains lower depression severity following CBT-SAD relative to light therapy.     

An Empirical Evaluation of Millon's Dimensional Polarities

LASTPAGE study investigated the theoretical consistency for Millon's dimensional polarities (T. Millon &; R. D. Davis, 1996; T. A. Widiger, 1999) by administering the Millon Index of Personality Styles (MIPS; T. Millon, 1994) and Millon Clinical Multiaxial Inventory-III (MCMI-III; T. Millon, 1997) to 50 university counseling center students. Data were analyzed by correlating the MIPS polarity dimension scales with the personality disorder scales of the MCMI-III. Findings suggested more inconsistencies than consistencies with the underlying theoretical model. The greatest discrepancies were found for the expected relationships between the polarity dimensions and the narcissistic and compulsive scales, and to a lesser degree, the schizoid, avoidant, schizotypal, and negativistic scales. Discussion concerned how these divergencies might best be understood in light of Millon's conceptualization of Axis II disorders.     

Convergent validity of the MCMI-III personality disorder scales and the MMPI-2 scales

The MCMI-III personality disorder scales (Millon, 1994) were empirically validated in a sample of prisoners, psychiatric inpatients, and outpatients (N = 477). The scale intercorrelations were congruent with those obtained by Millon, Davis, and Millon (1997). We conclude that our Flemish/Dutch version shows no significant differences with the original version of the MCMI-III as far as intercorrelations are concerned. Convergent validity of the MCMI-III personality disorder scales was evaluated by the correlational data between the MCMI-III personality disorder scales and the MMPI-2 clinical (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and personality disorder (Somwaru & Ben-Porath, 1995) scales. Improved convergence was obtained compared with previous versions of the MCMI-I. Only the compulsive MCMI-III personality disorder scale remains problematic. The scale even showed negative correlations with some of the related clinical scales and with the corresponding personality disorder scales of the MMPI-2.     

A comparison of the MCMI-III personality disorder and modifier indices with the MMPI-2 clinical and validity scales

In this study, we examined the relationship of the MCMI-III (Millon, Davis, & Millon, 1997; Millon, Millon, & Davis, 1994) modifier indices and personality disorder scales to the validity and basic clinical scales of the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). The MCMI-III modifier indices highly correlated with all of the MMPI-2 validity scales except for the F(p) scale. Similarly, the MCMI-III personality disorder scales strongly covaried with the MMPI-2 validity and clinical scales except for the F(p) and 5 (Mf) scales. A factor analysis with Promax rotation revealed substantial relationships between the MMPI-2 and MCMI-III. However, the MMPI-2 F(p) scale did not tend to correlate with MMPI-2 or MCMI-III scales, indicating that F(p) scale variance was largely independent of other scales. The results suggest that clinicians should consider the interrelationship between personality characteristics and dissimulation.     

Depression, anxiety, and the MCMI-III: construct validity and diagnostic efficiency

This study aimed to enhance knowledge of the construct validity and diagnostic efficiency of the depression- and anxiety-related scales of the MCMI-III (Millon, 1994). The MCMI-III, various concurrent depression and anxiety measures, and an Axis I structured diagnostic interview were administered in a total sample of 696 outpatients with depressive disorders, anxiety disorders, or both. Sound construct validity was found for the Dysthymia and Major Depression clinical syndrome scales and the Avoidant and Depressive personality disorder scales. The validity of the Anxiety scale was poor, showing moderate convergence with panic and worry-related anxiety measures, but problems discriminating from depression. Operating characteristics for discriminating depressed patients from anxious patients were fair for the Major Depression scale, but poor for the Anxiety and Dysthymia scales.     

MCMI-II profiles of women with eating disorders: a cluster analytic investigation

A three-factor model of personality pathology was investigated in a clinical sample of 183 female patients in an outpatient eating disorders treatment program. Cluster analysis of MCMI-II personality scales (Millon, 1987) yielded three distinct personality profiles, which were consistent with previous studies. First, 16.9% of the sample comprised a High Functioning cluster, which manifested no clinical elevations on the MCMI-II and had significantly lower scores on the Eating Disorder Inventory (EDI; Garner; 1991) scales than the other two clusters. Second, 49.1% of the sample comprised an Undercontrolled/Dysregulated cluster. Finally, the remaining 34% of the sample comprised an Overcontrolled/Avoidant cluster. This final cluster had significantly higher EDI Ineffectiveness scale scores than the Undercontrolled/Dysregulated cluster group. Cluster membership was not associated with eating disorder subtype, suggesting that there is considerable variance in personality pathology within eating disorder diagnostic categories.     

Exploring the psychometric properties and construct validity of the MCMI-III anxiety and avoidant personality scales

The Millon Clinical Multiaxial Inventory (MCMI; Millon, 1983) is a commonly used self-report instrument designed to aid in the assessment of Axis I and Axis II disorders. Concerns have been expressed regarding the procedures used in the normative research for the current version of the MCMI (MCMI-III; Millon, 1994) leading to a call for additional validity research on the MCMI-III (Retzlaff, 1996). In this study, we investigated the psychometric properties of the MCMI-III's Anxiety and Avoidant personality scales in a sample of patients diagnosed with Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) anxiety disorders. Our results suggest that the MCMI-III Avoidant scale is reliable (r =.89) and it was found to demonstrate appropriate convergent and divergent validity with other self-report measures. The MCMI-III Anxiety scale also showed adequate reliability (r =.78); however, our findings raise some concerns about the discriminant validity of this scale. A scale composed of the MCMI-III core anxiety items was found to have better discriminant validity. These findings are consistent with those reported by other researchers regarding the relationship between self-report measures of anxiety, avoidance, and depression. We conclude that the MCMI-III measures of anxiety and avoidance are consistent with other measures of these constructs and may provide valuable clinical information in this regard.     

How useful are indices of personality pathology when assessing domestic violence perpetrators?

There has been considerable debate about profiling personality pathology when assessing and treating male perpetrators of domestic violence (DV). This study used the Millon Clinical Multiaxial Inventory (MCMI-III) to explore the severity and diversity of male perpetrator personality pathology and response bias in a group of DV perpetrators being assessed for a treatment program (N = 177). We analyzed the sample using the interpretive guidelines of White and Gondolf (2000); 54% of profiles in our sample fell into categories indicative of a personality disorder, and 37% of the total sample provided profiles indicative of severe personality pathology. These percentages were higher than White and Gondolf's findings but lower than some others. There was considerable diversity of personality pathology as well, supporting the contention that there is no one male DV perpetrator profile. Because of debate concerning the manner of responding on self-report instruments, we paid special attention to response biases in our sample. Twenty-six percent of our sample exaggerated (12%) or minimized (14%) their responses. We also found that response biases on the MCMI-III Modifying Indices were related to self-reported severity of psychopathology. This suggests that assessing severity of psychopathology is inadequate without reference to such biases.     

Empirical evaluation of the MCMI-III personality disorder scales

The MCMI-III personality disorder scales were empirically validated with a sample of 870 clinical patients and inmates. Prevalence rates of personality disorders were in general lower on the MCMI-III than clinical ratings, but trait prevalence was generally higher; thus a base rate of 75 on the MCMI-III could be a guideline in the screening of trait prevalence. However, the sensitivity of some MCMI-III scales was very low. Moreover, the correlations of most personality disorder scales of the MCMI-III were significant and positive with corresponding measures on clinical ratings and MMPI-2 personality disorder scales, but these were, in general, not significantly higher than some other correlations. As a consequence the discriminant validity seems to be questionable. The MCMI-III alone cannot be used as a diagnostic inventory, but the test could be useful as a screening device as a part of a multimethod approach that allows aggregation over measures in making diagnostic decisions.     

Dynamic of Change in Pathological Personality Trait Dimensions: A Latent Change Analysis Among at-Risk Women

This study explores longitudinally a four-factor structure of pathological personality trait dimensions (PPTDs) to examine both its structural stability and intra-individual changes among PPTDs over time. Personality Disorder (PD) scales of the Millon Clinical Multiaxial Inventory-III were administered to 361 low-income women with various psychiatric conditions (drug dependence, depression), who were followed in a two-wave study over 5-years. Cross-sectional and longitudinal factor analyses outlined a robust factorial structure of PPTDs, extrinsically invariant over time, representing Negative Emotionality, Introversion, Antagonism and Impulsivity. Despite moderate rank-order stability in the PPTDs, results also indicated substantial intra-individual variability in the degree and direction of change, consistent with trajectories of change in participants’ clinical diagnoses. Results are discussed in light of current debates on the structure and dynamic of pathological personality.     

Integrating psychopathology and personality disorders conceptualized by the MMPI-2-RF and the MCMI-III: a structural validity study

The Minnesota Multiphasic Personality Inventory-2-Restructured Form (Ben-Porath & Tellegen, 2008 ) Restructured Clinical scales and Higher Order scales were linked to the Millon Clinical Multiaxial Inventory-III (Millon, Millon, Davis, & Grossman, 2009 ) personality disorder scales and clinical syndrome scales in a Flemish/Dutch sample of psychiatric inpatients and outpatients, substance abuse patients, correctional inmates, and forensic psychiatric patients (N = 968). Structural validity of psychopathology and personality disorders as conceptualized by both instruments was investigated by means of principal component analysis. Results reveal a higher order structure with 4 dimensions (internalizing disorders, externalizing disorders, paranoid ideation/thought disturbance, and pathological introversion) that parallels earlier research on pathological personality dimensions as well as research linking pathological personality traits with mental disorders. Theoretical and clinical implications are considered.     

Self-esteem in patients with borderline and avoidant personality disorders

This study compared self-esteem in patients with avoidant personality disorder (APD) and borderline personality disorder (BPD). Patients diagnosed with one or more personality disorders answered the questionnaire Index of Self Esteem as part of a comprehensive evaluation within the setting of a treatment trial. Our hypotheses were that (1) both patients with APD and patients with BPD would report low levels of self-esteem, (2) patients with APD would report lower self-esteem than patients with BPD. We further expected that (3) patients with higher levels of depression would report lower levels of self-esteem, but that (4) both borderline and avoidant personality pathology would contribute to explained variance in self-esteem beyond what would be accounted for by depression. All of our hypotheses were supported. The results from our study showed a significant difference in self-esteem level between the two personality disorders, patients with APD reporting lower self-esteem than patients with BPD. Subjects with both disorders were measured to have self-esteem levels within the range that presumes clinical problems. Self-esteem represents an important quality of subjective experience of the self, and the study of self-esteem in PDs can offer new and important knowledge of PDs as self-pathology.     

The utility of the MAPI in the assessment of depression

The relationships between the Millon Adolescent Personality Inventory (MAPI; Millon, Green, & Meagher, 1982) and depression, as assessed by the Multiscore Depression Inventory (MDI; Berndt, 1968) were examined. Elevations on the MDI subscales were positively related to elevations on MAPI personality style Scale 2 (Inhibited) and Scale 8 (Sensitive) and on six of the eight MAPI expressed concerns scales. MAPI personality style Scale 4 (Sociable) and Scale 5 (Confident) were negatively correlated with the MDI. MAPI code types containing either Scale 2 or 8 were associated with a high MDI full-scale score. The subjects who received a MAPI computer-generated diagnosis of borderline personality disorder also had elevated MDI full-scale scores. The findings of this study appear consistent with the existing body of MAPI research, and the data suggest that the MAPI personality style scales may have both state and trait qualities.     

The Utility of the MAPI in the Assessment of Depression

The relationships between the Millon Adolescent Personality inventory (MAPI; Millon, Green, & Meagher, 1982) and depression, as assessed by the Multiscore Depression Inventory (MDI; Berndt, 1968) were examined. Elevations on the MDI subscales were positively related to elevations on MAPI personality style Scale 2 (Inhibited) and Scale 8 (Sensitive) and on six of the eight MAPI expressed concerns scales. MAPI personality style Scale 4 (Sociable) and Scale 5 (Confident) were negatively correlated with the MDI. MAPI code types containing either Scale 2 or 8 were associated with a high MDI full-scale score. The subjects who received a MAPI computer-generated diagnosis of borderline personality disorder also had elevated MDI full-scale scores. The findings of this study appear consistent with the existing body of MAPI research, and the data suggest that the MAPI personality style scales may have both state and trait qualities.     

Circular structure of the MCMI-III personality disorder scales.

Millon's (1987) circular model of personality disorders was examined in a large sample of psychiatric patients (N = 2,366) who completed the Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon, 1997) as part of routine assessment after presentation for treatment. Principal components analyses were conducted to identify the first two dimensions in MCMI-III base rate scores, weighted and unweighted raw scores, and nonoverlapping scale scores. Similar analyses were made on these scores when acquiescence was partialled out. Circular plots of the scales were examined against Millon's hypothesized arrangement and the model was tested using confirmatory factor analysis. Results replicated those of Strack, Lorr, and Campbell (1990) with the MCMI-II. Millon's horizontal Impassive-Expressive dimension was recovered in both regular and residual scores but the vertical axis appeared to represent an Impulsivity-Compulsivity dimension rather than the Autonomous-Enmeshed continuum envisioned by Millon. Although scale order followed Millon's predictions for the most part, a number of departures from theoretical expectations were noted and none of the score sets yielded a good fit to the hypothetical structure. Millon's model appears to have promise as a circumplex that can encompass all of the personality disorders but changes are needed to rectify discrepancies between the theory and empirical findings.     

Linking personality disorders and clinical syndromes on the MCMI-III

We examined the relationship between personality disorders (PDs) and clinical syndromes (CSs) as measured by the Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon, 1997) in a large, heterogeneous sample of psychiatric patients (N = 2,366) who completed the instrument as part of routine assessment following presentation for treatment. Using separate sets of base rate (BR) and nonoverlapping scale scores, we factor analyzed the PD and CS scales together and then separately. We correlated results from the latter analyses to determine how trait dimensions were associated with syndrome dimensions. We also studied co-occurrence at the scale level by examining CS score profiles of patients who were grouped according to their highest PD scale elevation > or = BR75. Results for the two score sets were very similar and were consistent with previous research on the MCMI-III and its predecessors that identified 3 underlying dimensions loading both PD and CS scales. Three fourths (76.2%) of the sample had a highest PD scale > or = BR75, and among these, 90% had at least 1 CS scale > or = BR75, whereas 62.4% had 3 or more CS scales above this elevation. Findings underscore the substantial overlap between PDs and CSs along 3 dimensions that resemble Horney's (1945) tripartite interpersonal distinction of moving toward, away, and against, as well as Eysenck's (1994) higher order factors of neuroticism, extraversion, and psychoticism.     

Assessing Old Order Amish outpatients with the MCMI-III

In this study, we examined Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon, 2009) characteristics in an Old Order Amish outpatient sample (n = 166), with a comparison group of Old Order Amish who were not receiving mental health treatment at the time of testing (n = 80). We also graphically compared the 2 Amish groups to a non-Amish psychiatric sample in the literature. Consistent with our hypotheses, the Old Order Amish outpatients scored significantly higher than the Old Order Amish comparison group on the majority of MCMI-III scales, with mostly medium effect sizes, suggesting that the MCMI-III is a useful personality instrument in discriminating between Old Order Amish clinical and nonclinical groups. In addition, the Amish outpatients scored similar to a non-Amish psychiatric sample in the literature on most personality scales. Future MCMI-III studies with the Amish are needed to replicate and generalize our findings.     

Winter Depression Recurrence One Year After Cognitive-Behavioral Therapy, Light Therapy, or Combination Treatment

The central public health challenge in the management of seasonal affective disorder (SAD) is prevention of depression recurrence each fall/winter season. The need for time-limited treatments with enduring effects is underscored by questionable long-term compliance with clinical practice guidelines recommending daily light therapy during the symptomatic months each year. We previously developed a SAD-tailored group cognitive-behavioral therapy (CBT) and tested its acute efficacy in 2 pilot studies. Here, we report an intent-to-treat (ITT) analysis of outcomes during the subsequent winter season (i.e., approximately 1 year after acute treatment) using participants randomized to CBT, light therapy, and combination treatment across our pilot studies (N = 69). We used multiple imputation to estimate next winter outcomes for the 17 individuals who dropped out during treatment, were withdrawn from protocol, or were lost to follow-up. The CBT (7.0%) and combination treatment (5.5%) groups had significantly smaller proportions of winter depression recurrences than the light therapy group (36.7%). CBT alone, but not combination treatment, was also associated with significantly lower interviewer- and patient-rated depression severity at 1 year as compared to light therapy alone. Among completers who provided 1-year data, all statistically significant differences between the CBT and light therapy groups persisted after adjustment for ongoing treatment with light therapy, antidepressants, and psychotherapy. If these findings are replicated, CBT could represent a more effective, practical, and palatable approach to long-term SAD management than light therapy.     

Trauma-Related Negative Cognitions Mediate the Relationship Between Avoidant Personality Beliefs and Impeded Response to Psychotherapy for PTSD

There is strong research evidence for the association of personality pathology and posttraumatic stress disorder (PTSD), as well as trauma-related negative cognitions (TRNC) and PTSD symptoms. However, the relationship between personality pathology and TRNC in the context of PTSD is mostly unknown. In the present study, we aimed to examine whether avoidant and borderline personality beliefs (PB, indicator of personality pathology) could predict therapy outcome in PTSD, and whether the relationship between PB and therapy outcome could be mediated by TRNC. Sixty patients with PTSD were assessed for PB, TRNC and PTSD symptoms at baseline, and for PTSD symptoms at the termination of Prolonged Exposure Therapy. Baseline avoidant PB predicted significant variance in PTSD symptoms at termination over and above baseline PTSD symptoms (16% reduction in treatment effect per SD on avoidant PB). Moreover, TRNC at baseline fully mediated the relationships between baseline avoidant PB and PTSD symptoms at termination. This is the first study to show that avoidant PB predicts treatment response in PTSD, and that patients with avoidant beliefs are more vulnerable to have TRNC, which are associated with impeded therapy response. Our results highlight the importance of targeting both dysfunctional PB and TRNC in PTSD interventions.