Examination of the MMPI-2 Restructured Clinical (RC) Scales in a Sample of Bariatric Surgery Candidates

Personality dimensions, depression, and eating behavior in individuals seeking bariatric surgery: a cluster analysis

Introduction

Psychiatric comorbidity is frequent in bariatric surgery candidates. This study aimed to classify bariatric surgery patients according to patterns of preoperative measures of the severity of the eating disorder (ED), depression, and personality traits.

Methods

In the present cross-sectional study, 115 adult candidates for bariatric surgery (75 females, 65.22% of sample; mean age 37) were considered for analysis. Patients' sociodemographic and psychopathological variables were collected. K-Means clustering analysis was adopted to classify bariatric surgery candidates according to their preoperative Eating Disorder Inventory-2 (EDI-2) scores. In addition, we assessed depression and personality traits using the Beck Depression Inventory-2 (BDI-2) and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2).

Results

Cluster analysis based on EDI-2 revealed two preoperative patterns: higher severity (n = 39), and low severity (n = 76). The more severe EDI-2 group had higher scores on the BDI-2 and presented higher scores on several MMPI-2 dimensions, particularly those related to anxiety (Psychasthenia, Anxiety, Fears, Obsessiveness), depression (Depression, including both content and clinical MMPI-2 subscales), externalizing symptoms (Anger, Cynicism, Type A Behavior), and social functioning (Social Introversion, Family Problems, Work Interference).

Discussion

Eating disorders symptoms in candidates for bariatric surgery are closely related to depression and different psychological conditions assessed with MMPI-2. These psychological variables should be evaluated preoperatively and targeted with more specific psychological interventions.

Professional Practice Guidelines for Personality Assessment

The current paper conveys guidelines for personality assessment developed by a work group formed by the Society for Personality Assessment (SPA), which are intended to serve as an aid for best practices specific to personality assessment for professionals, and a source of information for consumers and policy makers. The guidelines were developed after a careful and systematic review of the literature on personality assessment and examination of practice patterns, and were refined through multiple rounds of input from stakeholders including members of SPA and other professionals routinely conducting personality assessment. The guidelines address the scope of personality assessment and current practice trends, minimum education and training qualifications, ethical practices, diversity considerations, assessment procedures, and appropriate applications. By following these guidelines and other established professional standards, psychologists can help ensure that they practice ethically, competently, with appropriate attention to diversity, and to the highest standards of the profession. These guidelines can function as a resource for educators and supervisors of personality assessment. Additionally, the guidelines will serve as a benchmark for best practices in personality assessment and, as such, represent a first step in what is hoped to be an evolution of ever improving personality assessment standards of practice.

The MMPI-2-Restructured Form (MMPI-2-RF): Assessment of Personality and Psychopathology in the Twenty-First Century

This article describes the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and situates the instrument in contemporary psychopathology and personality literature. The historical evolution of the MMPI instruments is highlighted, including how failure to update the test for several decades resulted in increasing disinterest by basic researchers and how the restructuring efforts beginning in the 2000s promised to realign the instrument with basic research. In this regard, the construct validity associated with MMPI-2-RF scores in the context of contemporary dimensional models of psychopathology is considered. Research supporting the applied utility of the MMPI-2-RF scales in a variety of contexts-including mental health screenings, presurgical evaluations, forensic assessment, and public safety screening-is also reviewed. Critiques of the MMPI-2-RF are described and addressed. Finally, a series of recommendations for future updates of the MMPI-2-RF are described along with a path toward the MMPI-3.

A Comparison of the Descriptive Information from the MMPI-2 and MMPI-2-RF

Do MMPI-2 or MMPI-2-RF profiles differ in how accurately they depict examinees? To explore this question, we examined differences in clinical descriptions of equivalent profiles from the two instruments. Fourteen valid MMPI-2 protocols from an archival private practice sample were scored as both the MMPI-2 and the MMPI-2-RF. The resulting 28 profiles were coded separately by four raters using the Midwestern Q-Sort. Examinee descriptions from the two instruments were compared in terms of their (a) similarity, operationalized by q-correlations between corresponding MMPI-2 and MMPI-2-RF ratings; (b) descriptive validity, operationalized by correlations with q-sorts provided by the examinees' therapists; and (c) incremental descriptive validity, operationalized by incremental prediction of the therapist q-sorts by the MMPI-2 and MMPI-2-RF, one over the other. Descriptions from corresponding MMPI-2 and MMPI-2-RF score reports were highly intercorrelated. Ratings from both were valid predictors of therapist descriptions, and neither clearly outperformed the other in terms of incremental validity.

Assessment of Sex Offenders With the Minnesota Multiphasic Personality /Inventory-2-Restructured Form

This study examined the association between scores on the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) with static and dynamic risk assessment instruments, including the STATIC-99 and Level of Service Inventory-Revised (LSI-R). The sample included 304 male adults who were convicted of sexual offenses against children and were referred to a sex offender treatment program. On average, the sample had a Low-Moderate risk of re-offending according to the STATIC-99 and LSI-R. The results indicated that MMPI-2-RF scale scores in this setting are characterized by relatively high levels of under-reporting and externalizing psychopathology compared with the normative sample. We also found that scale scores in this sample produced reliability estimates that were similar to the normative sample. Finally, external correlations between the MMPI-2-RF scales and the risk assessment instruments indicated that the test was associated in expected ways with constructs measured by these instruments. Correlations were most robust among scales in the externalizing/behavioral dysfunction domain of the MMPI-2-RF. Overall, the results of the study support and guide use of the test in this population.

An Introduction to the Minnesota Multiphasic Personality Inventory-Adolescent-Restructured Form (MMPI-A-RF)

The Minnesota Multiphasic Personality Inventory-Adolescent-Restructured Form (MMPI-A-RF; Archer, Handel, Ben-Porath, & Tellegen, 2016) is a new broadband measure of adolescent psychopathology and personality. The MMPI-A-RF is the adolescent counterpart of the MMPI-2-RF (Ben-Porath & Tellegen, 2008/2011). The goal of the MMPI-2-RF development project was to capture the clinically significant substance of the MMPI-2 item pool with a psychometrically sound measure linked to contemporary models of personality and psychopathology (Ben-Porath & Tellegen, 2008/2011). Using the MMPI-2-RF scales and development methods as models, Archer et al. (2016) developed a 241-item adolescent self-report inventory-in contrast to the 478-items of the MMPI-A-that includes 48 new and revised scales. In this manuscript, I provide an overview of the rationale for the development of the MMPI-A-RF, an abbreviated review of its development process, brief descriptions of its 48 scales, and a subset of analyses bearing on reliability and validity. As with the MMPI-2-RF, one of our primary goals was to develop scales with improved discriminant validity relative to the heterogeneous Clinical Scales of the MMPI-2 and MMPI-A. The MMPI-A-RF development process employed a large sample of 15,128 adolescents (9,286 boys and 5,842 girls) drawn from a variety of settings. In addition to the development sample, subsequent validation analyses were conducted in multiple independent samples including numerous external criterion measures. The MMPI-A-RF is designed to provide a comprehensive assessment of adolescent psychopathology and personality in a wide array of clinical and forensic settings.

Understanding the role of psychopathology in bariatric surgery outcomes

Bariatric surgery is the most effective treatment for morbid obesity; however, a subset of patients who undergo this procedure regain weight or achieve suboptimal weight loss results. A large number of studies have examined whether psychological variables play a role in weight loss surgery outcome. Although presurgical psychopathology has been found to be associated with suboptimal results in some studies, this literature is equivocal. These inconsistent findings are reviewed and considered in the context of contemporary models of psychopathology. More specifically, the review focuses on the limitations of atheoretical, descriptive diagnostic systems and examines whether comorbidity within the mood/anxiety disorders, impulse control/substance use disorders and thought disorders can account for the inconsistent findings reported to date. Contemporary models of psychopathology are highlighted and linked to the Research Domain Criteria, which have been advanced by the National Institute of Health. Means for assessing psychological constructs congruent with these models are reviewed. Recommendations are made for standardizing approaches to investigating how psychopathology contributes to suboptimal bariatric surgery outcomes.

Psychological predictors of body image concerns 3 months after bariatric surgery

BACKGROUND

Although studies have associated postoperative weight loss with improvement in body image dissatisfaction, some individuals continue to report body image concerns after bariatric surgery. These concerns are linked to increased depressive symptoms and decreased self-esteem in bariatric populations.

OBJECTIVE

This study sought to explore preoperative factors that may predict early body image concerns 3 months after bariatric surgery.

SETTING

Academic medical center.

METHOD

Data were analyzed from 229 patients evaluated for bariatric surgery who completed a 3-month postoperative psychology appointment and the Minnesota Multiphasic Personality Inventory, Second Edition, Restructured Form (MMPI-2-RF). Scales measuring depression, persecution, self-doubt, and inadequacy were examined. Medical records were reviewed for demographic characteristics, psychotropic medication usage, history of psychological treatment, and current or lifetime depression diagnosis.

RESULTS

Patients who preoperatively scored higher on demoralization (F [1, 227] = 35.40, P< .001), low positive emotions (F [1, 227] = 4.18, P< .05), ideas of persecution (F [1, 227] = 15.24, P< .001), self-doubt (F [1, 227] = 27.47, P< .001), and inefficacy (F [1, 227] = 21.34, P< .001) were significantly more likely to report body image concerns 3 months after bariatric surgery. Similarly, body image concerns were more common in patients with a preoperative depression diagnosis (χ(2) = 8.76, P<.01), current psychotropic medication usage (χ(2) = 7.13, P<.01), and history of outpatient therapy (χ(2) = 8.34, P<.01) and psychotropic medication (χ(2) = 9.66, P< .001).

CONCLUSION

Bariatric surgery candidates with psychopathology and other psychological risk factors are more likely to report body image concerns early after bariatric surgery. Future research is warranted to determine whether this association remains further out from surgery.

Validity of Minnesota Multiphasic Personality Inventory – 2 – Restructured Form (MMPI-2-RF) scores as a function of gender, ethnicity, and age of bariatric surgery candidates

BACKGROUND

Presurgical psychological screening is used to identify factors that may impact postoperative adherence and surgical outcomes in bariatric surgery candidates. Minnesota Multiphasic Personality Inventory - 2 Restructured Form (MMPI-2-RF) findings have demonstrated utility for this task.

OBJECTIVES

To explore whether there are clinically meaningful gender, ethnicity, or age differences in presurgical MMPI-2-RF scores and the validity of these scores in bariatric surgery candidates.

METHODS

The sample was composed of 872 men and 2337 women. Ethnicity/race groups included 2,204 Caucasian, 744 African American, and 96 Hispanic individuals. A sample of 165 were not included in the ethnicity/race analyses because they were of another descent. Ages groups included 18-35 year olds (n = 454), 36-49 year olds (n = 1154), 50-64 year olds, (n = 1246), and 65 years old or older (n = 355). Validity data, obtained via a retrospective chart review, were available for a subset patients (n = 1,268) who were similarly distributed. Step-down hierarchical regression analyses were conducted to assess for differential validity.

RESULTS

Bariatric surgery candidates produced comparable MMPI-2-RF scores in all subsamples, indicating that the test norms generalize across demographic groups. Validity findings were also generally comparable, indicating that MMPI-2-RF scores have the same interpretive implications in demographically diverse subgroups of bariatric surgery candidates.

CONCLUSIONS

The MMPI-2-RF can assist in presurgical psychological screening of demographically diverse bariatric surgery candidates.

Use of Prehire Minnesota Multiphasic Personality Inventory-2–Restructured Form (MMPI-2-RF) Police Candidate Scores to Predict Supervisor Ratings of Posthire Performance

We examined associations between prehire Minnesota Multiphasic Personality Inventory-2–Restructured Form (MMPI-2-RF) scores and posthire performance ratings for a sample of 131 male police officers. Substantive scale scores in this sample were meaningfully lower than those obtained by the test’s normative sample and substantially range restricted, but scores were consistent with those produced by members of the police candidate comparison group (Corey & Ben-Porath). After applying a statistical correction for range restriction, we found several associations between MMPI-2-RF substantive scale scores and supervisor ratings of job-related performance. Findings for scales from the emotional dysfunction and interpersonal functioning domains of the test were particularly strong. For example, scales assessing low positive emotions and social avoidance were associated with several criteria that may be affected by lack of engagement with one’s environment and other people, including problems with routine task performance, decision making, assertiveness, conscientiousness, and social competence. Implications of these findings for assessment science and practice are discussed.

Minnesota Multiphasic Personality Inventory–2–Restructured Form (MMPI-2-RF) Predictors of Police Officer Problem Behavior

The purpose of this study was to investigate the predictive validity of the Minnesota Multiphasic Personality Inventory–2–Restructured Form (MMPI-2-RF) in a sample of law enforcement officers. MMPI-2-RF scores were collected from preemployment psychological evaluations of 136 male police officers, and supervisor ratings of performance and problem behavior were subsequently obtained during the initial probationary period. The sample produced meaningfully lower and less variant substantive scale scores than the general population and the MMPI-2-RF Police Candidate comparison group, which significantly affected effect sizes for the zero-order correlations. After applying a correction for range restriction, MMPI-2-RF substantive scales demonstrated moderate to strong associations with criteria, particularly in the Emotional Dysfunction and Interpersonal Functioning domains. Relative risk ratio analyses showed that cutoffs of 45 T and 50 T maintained reasonable selection ratios because of the exceptionally low scores in this sample and were associated with significantly increased risk for problematic behavior. These results provide support for the predictive validity of the MMPI-2-RF substantive scales in this setting. Implications of these findings and limitations of these results are discussed.

Minnesota multiphasic personality inventory-2 restructured form (MMPI-2-RF) scale score differences in bariatric surgery candidates diagnosed with binge eating disorder versus BMI-matched controls

OBJECTIVE

Binge Eating Disorder (BED) is among the most common psychiatric disorders in bariatric surgery candidates. The Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF) is a broadband, psychological test that includes measures of emotional and behavioral dysfunction, which have been associated with BED behaviors in bariatric surgery candidates; however these studies have lacked appropriate controls. In the current study, we compared MMPI-2-RF scale scores of bariatric surgery patients diagnosed with BED (BED+) with BMI-matched controls without BED (BED-).

METHOD

Three-hundred and seven BED+ participants (72.64% female and 67.87% Caucasian; mean BMI of 51.36 kg/m(2) [SD = 11.94]) were drawn from a large, database (N = 1304). Three-hundred and seven BED- participants were matched on BMI and demographics (72.64% female, 68.63% Caucasian, and mean BMI of 51.30 kg/m(2) [SD = 11.70]).

RESULTS

The BED+ group scored significantly higher on measures of Demoralization, Low Positive Emotions, and Dysfunctional Negative Emotions and scored lower on measures of Antisocial Behaviors, reflecting behavioral constraint. Optimal T-Score cutoffs were below the traditional 65 T score for several MMPI-2-RF scales. MMPI-2-RF externalizing measures also added incrementally to differentiating between the groups beyond the Binge Eating Scale (BES).

DISCUSSION

BED+ individuals produced greater elevations on a number of MMPI-2-RF internalizing scales and externalizing scales. Use of the test in conjunction with a clinical interview and other self-report data can further aid the clinician in guiding patients to appropriate treatment to optimize outcome.

Psychosocial correlates of pelvic floor disorders in women seeking bariatric surgery

BACKGROUND

Women who struggle with obesity are at a significant risk for pelvic floor disorders (PFDs), defined as urinary incontinence, pelvic organ prolapse, and/or fecal incontinence. The association between PFDs and reduced quality of life has been demonstrated; however, the psychosocial correlates of PFDs in women undergoing bariatric surgery have yet to be examined. The present study explored the potential psychosocial correlates of PFD. The setting was an academic medical center.

METHODS

Data were analyzed from 421 female patients evaluated for bariatric surgery. Based upon a screening questionnaire, participants were dichotomized as women with PFDs (n = 121) and women without PFDs (n = 300). Patients completed the "Minnesota Multiphasic Personality Inventory, 2nd ed., Restructured Form (MMPI-2-RF)," and medical records were reviewed for demographic data, body mass index, substance abuse/dependence history, history of physical and/or sexual abuse, psychiatric medication usage, and psychiatric diagnoses. MMPI-2-RF scales measuring depression, anxiety, somatic symptoms, and social support were examined.

RESULTS

Women with PFDs were significantly older (F(1,420) = 3.87, P < .05) and more likely to evidence a history of substance abuse/dependence (chi-square = 4.53, P < .05) and depression (chi-square = 4.31, P < .05) than women without PFDs. There also was a trend for previous inpatient hospitalization (chi-square = 2.93, P < .09), outpatient behavioral health treatment (chi-square = 2.89, P < .09), and psychotropic medication usage (chi-square = 3.32, P < .07). No differences were found in the objective psychological testing.

CONCLUSION

Women with PFDs may be more psychiatrically vulnerable than other bariatric surgery candidates. Additional research on the association among PFDs, substance abuse, and depression is warranted. Future research should consider whether this potential relationship changes postoperative bariatric surgery.

Diagnostic Construct Validity of MMPI-2 Restructured Form (MMPI-2-RF) Scale Scores

In the current investigation, the authors examined the diagnostic construct validity of the Minnesota Multiphasic Personality Inventory–2–Restructured Form (MMPI-2-RF) in a patient sample. All participants were diagnosed via the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P). The data set used in this study was composed of 544 patients—67 with bipolar disorder, 407 with major depressive disorder, and 70 with schizophrenia. Multivariate analyses revealed a pattern of mean scale differences among patient groups that was mostly consistent with the prominent features of each diagnostic group; logistic regression analyses identified a number of scales that were strong, unique predictors in the differentiation between pairs of diagnostic groups. The higher order scales (H-O)—the Emotional/Internalizing Dysfunction (EID) and Thought Dysfunction (THD) scales were most useful in differentiating between patient groups. For differentiating bipolar disorder patients from the other diagnostic groups, the Activation (ACT) Specific Problem scale was most useful. Although not all hypothesized scale differences emerged; overall, the pattern of results provides support for the diagnostic construct validity of the MMPI-2-RF scales.

Older bariatric surgery candidates: is there greater psychological risk than for young and midlife candidates?

BACKGROUND

Although severe obesity is dramatically increasing in older adults, many bariatric programs use age cutoffs due to concerns about greater perioperative morbidity and mortality risks. More recently, surgical outcomes have been reported in older adults. However, a paucity of data is available on the psychological risks of older bariatric candidates. Our objective is to examine psychiatric risk factors and weight loss outcomes in older (≥65 yr) versus midlife (40-55 yr) versus young adult (18-29 yr) patients.

METHODS

Older, midlife, and young adults (n = 608) who underwent weight loss surgery (74.6% women, 75.6% white, mean body mass index 48.07 ± 9.61 kg/m2) at the Cleveland Clinic Bariatric and Metabolic Institute completed a psychiatric diagnostic interview, and the Minnesota multiphasic personality inventory-2-restructured form, binge eating scale, and Cleveland Clinic behavioral rating scale before surgery. The data gathered from follow-up visits and weight loss outcomes at 1, 3, 6, 9, 12, and 18 months after surgery were measured.

RESULTS

Young adults had a greater reduction in excess body mass index than those at midlife in the first 6 months but no age differences were noted in the following year. Older patients were less likely to have a suicide history but the groups were equivalent on other psychiatric variables and self-report measures. Psychologist evaluators rated older adults less favorably on the capacity to consent and realistic nature of expectations.

CONCLUSION

Although medical risks may cause concern, older adults do not demonstrate any increased psychological risk factors compared with midlife or young adult surgical candidates and evidenced equivalent weight loss. However, concerns with lower ratings on consent and expectations warrant additional research.

Socially desirable responding by bariatric surgery candidates during psychological assessment

BACKGROUND

Most bariatric surgery programs in the United States require preoperative psychological evaluations for candidates for surgery. Among those who perform these evaluations is concern that many patients engage in "impression management" or minimizing the symptoms of distress to receive a recommendation to proceed with surgery from the mental health professional. We sought to assess the prevalence of socially desirable responding and its associations with measures of psychological functioning among bariatric surgery candidates at 2 academic medical centers in the United States.

METHODS

The participants were male (n = 66) and female (n = 293) bariatric surgery candidates who presented for psychological evaluation. The participants completed 2 measures of socially desirable response styles (Marlowe-Crowne Social Desirability Scale and Personality Assessment Inventory Positive Impression Management scale) and standardized measures of anxiety, depression, and alcohol-related problems.

RESULTS

The participants exhibited elevated scores on the social desirability indicators, with 33.3-39.8% scoring above the recommended cut-score on the Personality Assessment Inventory Positive Impression Management scale and 62.3-67% scoring 1 standard deviation above the standardization mean on the Marlowe-Crowne Social Desirability Scale. Scores on the Marlowe-Crowne Social Desirability Scale and Personality Assessment Inventory Positive Impression Management scale correlated inversely with the clinical measures of anxiety and depression, and the high/low scorers on the social desirability indices exhibited significant differences in anxiety and depression. Thus, elevated scores on the social desirability indices were associated with underreporting of certain clinical symptoms.

CONCLUSION

A substantial proportion of bariatric surgery candidates appear to present themselves in an overly favorable light during the psychological evaluation. This response style is associated with less reporting of psychological problems and might interfere with the accurate assessment of patient functioning.

The MMPI-2 Symptom Validity Scale (FBS) Not Influenced by Medical Impairment: A Large Sleep Center Investigation

The Symptom Validity Scale (Minnesota Multiphasic Personality Inventory—2—FBS [MMPI-2-FBS]) is a standard MMPI-2 validity scale measuring overstatement of somatic distress and subjective disability. Some critics assert the MMPI-2-FBS misclassifies too many medically impaired persons as malingering symptoms. This study tests the assertion of malingering misclassification with a large sample of 345 medical inpatients undergoing sleep studies that standardly included MMPI-2 testing. The variables included standard MMPI-2 validity scales (Lie Scale [L], Infrequency Scale [F], K-Correction [K]; FBS), objective medical data (e.g., body mass index, pulse oximetry), and polysomnographic scores (e.g., apnea/hypopnea index). The results showed the FBS had no substantial or unique association with medical/sleep variables, produced false positive rates <20% (median = 9, range = 4-11), and male inpatients showed marginally higher failure rates than females. The MMPI-2-FBS appears to have acceptable specificity, because it did not misclassify as biased responders those medical patients with sleep problems, male or female, with primary gain only (reducing sickness). Medical impairment does not appear to be a major influence on deviant MMPI-2-FBS scores.