Can MMPI-2 Content Scales Predict CBT Outcomes for Anxiety Disorders? Ray Hawkins, Martha Spriggs, Hanjoo Lee, & Martita Lopez Fielding Graduate University The University of Texas at Austin X-Sieve: CMU Sieve 2.2 X-Sender: lopez@mail.psy.utexas.edu Date: Thu, 3 Nov 2005 17:55:07 -0600 To: Ray Hawkins <hawkins@psy.utexas.edu> From: Martita Lopez <lopez@psy.utexas.edu> Subject: Poster 1.  Unnecessary word "in" in Abstract, sixth line from bottom. 2.  Under the lit review I doubt that the word "collinearity has two Ls. 3.  Under Discussion on line 5 from the top the sentence reads like a word is missing ("only about 25% that accounted for...") 4.  Under References, the Michael et al. one is missing a word in the title (after "significant") Other than these very minor typos it looks great!  Many thanks for doing this, Ray- Martita -- Introduction Results Discussion Abstract. The integration of objective personality measures into cognitive behavioral interventions may be important for implementing practice research networks for treatment effectiveness studies. Hawkins, Spriggs, Lee, & Lopez (2005, November) recently found that the MMPI-2 clinical scales did not predict outcomes in cognitive-behavioral treatments (CBT) for anxiety disorders. In this follow-up paper we report preliminary data obtained from a practicum training clinic archival database to explore the predictive validity of the MMPI-2 content and supplementary scales for these CBT outcome measures. The anxiety disorder diagnoses consisted of panic disorder with or without agoraphobia (PD, n=69), generalized anxiety disorder (GAD, n=44), and social phobia (SP, n=91). DSM-IV diagnoses were verified using the Structured Clinical Interview (SCID), idiographic cognitive-behavioral case formulations were made, and treatment (a median of 11 sessions) was provided according to published CBT treatment manuals. The MMPI-2, general self-report measures (e.g., Beck Depression Inventory, Beck Anxiety Inventory), and domain-specific measures of core maintaining factors (e.g., Panic Appraisal Inventory, Anxiety Sensitivity Index, Penn State Worry Questionnaire) were administered as part of a baseline psychological evaluation. These self-report scales were also given every 2-3 weeks until the end of treatment to measure outcomes. The preliminary results show that several of the correlations of the MMPI-2 content and supplementary scales with the post-treatment domain-specific outcome measures, or with pre- to post-treatment change scores, attained statistical significance, but these effects were attenuated, or disappeared entirely, when the contributions of the baseline scores (e.g., BAI) were partialed out. We also examined whether MMPI-2 scales could discriminate those clients who showed clinically significant improvements in end-state functioning (Jacobson & Truax, 1991) from those who did not. Separate analyses conducted within the PD, GAD, and SP diagnostic groups did not reveal any difference in MMPI-2 content and supplementary mean scores between the "improved" vs. "not improved" clients. We tentatively conclude that the MMPI-2 content and supplementary scales, like the MMPI-2 clinical scales (Hawkins et al., 2005, November), may add very little value to the goal of predicting CBT outcomes in treatment effectiveness studies. At the University of Texas Clinical Psychology Training Clinic we have found the MMPI-2 to be more useful for an idiographic case conceptualization and "therapeutic assessment" that may strengthen the therapist-client relationship (i.e., Finn, 1996), but this application, and its causal mechanisms need further empirical validation. The preliminary results show that several of the correlations of the MMPI-2 content and supplementary scales with the post-treatment domain-specific outcome measures, or with pre- to post-treatment change scores, attained statistical significance, but most of these effects were attenuated, or disappeared entirely, when the contributions of baseline (e.g., BDI and/or BAI) scores were partialled out. We also examined whether MMPI-2 scales could discriminate those clients who showed clinically significant improvements in end-state functioning (based on Jacobson's 1984 criteria) from those who did not. Separate analyses conducted within the PD, GAD, and SP diagnostic groups revealed few differences in MMPI-2 content and supplementary scale mean scores between the clients that showed clinically significant improvement (“CSI”) and those who were not improved (“No CSI”) according to the criteria of Jacobson & Truax (1991). The MMPI-2 is a ubiquitous measure of personality that has shown limited value in predicting outcomes in psychotherapy in general and in CBT in particular. These results supported the Michael et al. (2004) finding that MMPI-2 composite measures (derived from content and supplementary scales) did significantly predict some outcome measures. But the amount of variance explained was modest (approximately 5%), amounting to only about 25% of the variance accounted for by the baseline scores on the CBT domain specific scales (e.g., BDI, BAI). Moreover, MMPI-2 content and supplementary scale elevations were generally unrelated to global outcome (i.e., CSI vs. No CSI). For the entire anxiety group (N=170) t-tests revealed no statistically significant differences between the CSI and No-CSI outcomes. For the PD, GAD, and SP subgroups only three of the 87 t-tests attained statistical significance. Discriminant function analyses on the MMPI-2 content and supplementary scales for the entire sample of anxious clients did not attain statistical significance for separating those clinically improved (CSI) from those not improved (No-CSI). There are several limitations of this study that should be mentioned. This clinical data base contained clients with clinically significant levels of anxiety disorder (as verified by SCID DSM-IV diagnoses and elevated scores on domain specific measures), who were treated by doctoral students being trained in the use of manualized ESTs, with outcomes that were comparable to published benchmark treatment effectiveness studies (e.g., Hawkins & Lopez, 2004). Nevertheless this database comprised a relatively small convenience sample lacking a comparison or control group. Does the MMPI-2 have utility in CBT? We have found the MMPI-2 to be more useful for an idiographic case conceptualization and treatment planning. Cluster analysis of MMPI-2 clinical and content scales may be useful to identify subgroups that overlay DSM-IV Axis I anxiety disorder categories. We are currently investigating this possibility. Table 1a & 1b. The Pearson bivariate correlations for the MMPI-2 content scales (1a) and supplementary scales (1b) with each of the outcome measures, showing several statistically significant relationships (122 out of 288 1a; 101 out of 234 1b). Table 2a & 2b. Partial correlation analyses for the MMPI-2 content scales (2a) revealed that 17 statistically significant relationships remained after the contribution of the baseline scores was removed, and 14 significant relationships were left for the supplementary scales (2b) * p < .05; ** p < .01; *** p < .001 2a 1a Conclusions We tentatively conclude that the MMPI-2 content and supplementary scales add very little value to the goal of predicting CBT outcomes in treatment effectiveness studies. Hawkins et al. (2005, November) drew the same conclusion for the MMPI-2 clinical scales. At the University of Texas Clinical Psychology Training Clinic we have found the MMPI-2 to be more useful for an idiographic case conceptualization and "therapeutic assessment" that may strengthen the therapist-client relationship (i.e., Finn, 1996), but this application, and its causal mechanism(s), should be also be empirically validated. 1b 2b Literature Review Evaluation of psychological assessment tools as predictors of therapeutic outcome could contribute to the existing body of knowledge regarding clinical effectiveness, but few conclusions about specific instruments have been reached to date. A review of the literature revealed little information regarding the MMPI-2 (Butcher, 1997) in predicting therapeutic outcome. Chisholm, Crowther and Ben-Porath (1997) examined selected MMPI-2 scales’ ability to predict premature termination and psychotherapeutic outcome. Findings revealed that elevations in content scales (DEP and ANX) were stronger predictors of therapeutic progress than were elevations on scales 2 and 7, and elevations on scale 4 predicted improvement in global psychopathology scores. The outcome measures used by Chisholm, et al. were based on individual therapist’s ratings, rather than on objective measures. Clearly, a gap in the literature exists regarding the predictive value of the MMPI-2 scales in therapeutic outcome, particularly with regard to specific types of psychotherapy and standardized measures of treatment outcome. Michael, Furr, Masters, Collett, & Spielmans (2004, July) have recently examined the utility of the MMPI-2 clinical scales to predict clinically significant change in psychotherapy. A multiple regression analysis using 8 MMPI-2 scales (excluding Mf and Si) was run against scores from the Outcome Questionnaire-45 (OQ-45) for a sample of 48 patients from a community clinical sample who were referred to a university-based clinic for outpatient therapy. The multiple regression model did not yield statistically significant results due to the relatively small sample size, along with a high degree of multicollinearity among the scales which occurred in that particular sample. Consequently, a composite scale score was computed and used in the model, and results indicated a negative correlation between elevated levels of psychopathology and symptom reduction as measured by the OQ-45. Results of a logistic regression analysis also revealed that elevations on the Pt, Sc, Pd and Hy scales predicted the poorest chance of clinically significant improvement as measured by the OQ-45. We decided to conceptually replicate the Michael et al. findings using archival clinical data gathered over the past 15 years from the University of Texas Clinical Psychology Training Clinic. Hawkins, Spriggs, Lee, & Lopez (2005, November) recently found that the MMPI-2 clinical scales did not predict outcomes in cognitive behavioral treatments (CBT) for anxiety disorders. The present study examined the predictive validity of the MMPI-2 Content and Supplementary Scales. References Butcher, J.N. (1997). Personality assessment in managed health care: Using the MMPI-2 in treatment planning. NY: Oxford University Press. Chisholm, S. M., Crowther, J. H., & Ben-Porath, Y. S. (1997). Selected MMPI-2 scales' ability to predict premature termination and outcome from psychotherapy. Journal of Personality Assessment, 69(1), 127-144. Finn, S.E. (1996). Manual for using the MMPI-2 as a therapeutic intervention. Minneapolis: University of Minnesota Press. Hawkins, R.C. II, & Lopez, M.A. (2004, July). Treatment effectiveness in the training clinic: A preliminary outcomes study. Paper presented at the American Psychological Association convention, Honolulu, HI. Hawkins, R.C. II, Spriggs, M., Lee, H., & Lopez, M. (2005, November). Can the MMPI-2 predict outcomes from cognitive-behavioral treatments for anxiety disorders? Presented at the Association for Behavioral and Cognitive Therapy convention, Washington, D.C. Jacobson, N.S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 29 (1), 12-19. Michael, K.D., Furr, R.M., Masters, K.S., Collett, B.R., & Spielmans, G.I. (2004, July). Predicting clinically significant change in psychotherapy: The utility of the MMPI-2. Poster presented at the American Psychological Association convention, Honolulu, HI. Shadel, W.G.(2004). Introduction to the special series: What can personality science offer cognitive-behavioral therapy and research? Behavior Therapy, 35(1), 101-111. Treatment Outcome CSI NO CSI T Score Figure 1. MMPI-2 Content scales, PD group (N=69), showing clients with “clinically significant improvement” (CSI, n=42) vs. clients without clinically significant Improvement (No CSI, n=27). T-tests revealed statistically significant differences between the CSI and No-CSI subgroups for only one content scale: ASP (No CSI > CSI, p =.01). Figure 3. MMPI-2 Content scales, GAD group (N=44), showing clients with “clinically significant improvement” (CSI, n=26) vs. clients without clinically significant Improvement (No CSI, n=18). T-tests revealed no statistically significant differences between the CSI and No-CSI subgroups for these MMPI-2 Content scales. Figure 5. MMPI-2 Content scales, SP Group (N=91), showing clients with “clinically significant improvement” (CSI, n=51) vs. clients without clinically significant improvement (No CSI, n=40). T-tests revealed no statistically significant differences between the CSI and No-CSI subgroups for these MMPI-2 Content scales. For Further Information Method Ray Hawkins, Ph.D., ABPP (Clinical Psychology) Core Faculty, Fielding Graduate University, School of Psychology Associate Faculty, Episcopal Theological Seminary of the Southwest Lecturer, Psychology Department The University of Texas at Austin 1 University Station A8000 Austin, TX 78712-0187 Phone: 512-232-3354 E-MAIL: rhawkins@fielding.edu The MMPI-2, general self-report measures (e.g., Beck Depression Inventory, Beck Anxiety Inventory), and domain-specific measures of core maintaining factors (e.g., Panic Appraisal Inventory, Anxiety Sensitivity Index, Penn State Worry Questionnaire) were administered as part of a baseline psychological evaluation. These self-report scales were also given every 2-3 weeks until the end of treatment to measure outcomes. “Clinically significant improvement” (CSI) was defined for each outcome measure according to the method of Jacobson & Truax (1991). For each client treated a global CSI outcome was determined by an algorithm (i.e., global CSI indicated when at least one outcome measure showed CSI and no other outcome measure showed a significant deterioration in outcome). Figure 2. MMPI-2 Supplementary scales, PD group (N=69), showing clients with “clinically significant improvement” (CSI, n=42) vs. clients without clinically significant Improvement (No CSI, n=27). T-tests revealed statistically significant differences between the CSI and No-CSI subgroups for only two supplementary scales: OH (CSI > No CSI, p =.003) and GF (CSI > No CSI, p =.022). Figure 4. MMPI-2 Supplementary scales, GAD group (N=44), showing clients with “clinically significant improvement” (CSI, n=26) vs. clients without clinically significant Improvement (No CSI, n=18). T-tests revealed no statistically significant differences between the CSI and No-CSI subgroups for these MMPI-2 Supplementary scales. Figure 6. MMPI-2 Supplementary scales, SP Group (N=91), showing clients with “clinically significant improvement” (CSI, n=51) vs. clients without clinically significant improvement (No CSI, n=40). T-tests revealed no statistically significant differences between the CSI and No-CSI subgroups for these MMPI-2 Supplementary scales.