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White paper: Instruction manual for the Dynamic Theory-driven
Profile Interpretation (DTP) of the MMPI-2
Subtitle: New interpretations, the MMPI-2 viewed from a developmental
perspective
by William M. Snellen, clinical psychologist, Bergen NH, the Netherlands, 2017
(translated into English 2021)
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Table of contents Page
1 Introduction 3
2 Principles of the DTP approach to the MMPI 5
2.1 Basic traits 6
2.2 Dynamic entities 7
2.3 Schema traits-structure 7
3 Clusters of the clinical scales 8
3.1 Control scales 8
3.1.1 Subclusters: scales 1, 2, and 3 9
3.1.1.1 Scale 2 high, scales 1 and 3 relatively low 9
3.1.1.2 Elevations in scales 1 and 3 9
3.1.1.3 Relative and absolute low scores in scales 1 and 3 10
3.1.1.4 Scales 1 and 3 high, scale 2 low 11
3.1.1.5 Scales 1, 2, and 3 high 11
3.1.1.6 Scales 1, 2, and 3 low 11
3.1.2 Scale 7 and its combinations 12
3.1.3 Scoring on scale 0 12
3.2 Impulsivity scales 16
3.2.1 Scale 9 high 16
3.2.2 Scale 4 high 16
3.2.3 Scale 9 low 17
3.3 Emotional instability, or vulnerability, scales 17
3.3.1 Scale 6 17
3.3.2 Scale 8 17
3.3.3 The combination of the EI scales 6 and 8 18
3.3.3.1 Combination 8 and 7 19
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With great thanks to Shaakya Vembar for correcting the first half and Sharon Galor for revising the
second half of my translation into English
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3.3.3.2 Combination 8 and 1 19
3.3.3.3 Combination 8 and 2 20
3.3.3.4 Combination 8 and 4 20
3.3.3.5 Combination 8 and 9 21
3.4 Mutual relationships between the clusters 21
3.4.1 Principles of the DTP interpretation of the MMPI 22
3.4.2 Mutual relationships between the MMPI score clusters 22
3.4.2.1 Control, impulsivity and EI high 23
3.4.2.2 Control high, impulsivity and EI low 23
3.4.2.3 Control low, impulsivity high and EI low 23
3.4.2.4 Control and impulsivity low and EI high 23
3.4.2.5 Control high, impulsivity high and EI low 24
3.4.2.6 Control low, impulsivity and EI high 24
3.4.2.7 Control high, impulsivity low and EI high 24
3.4.2.8 Control, impulsivity and EI low 24
3.5 Scale MF 24
4 State characteristics 25
4.1 Scales 1 and 3 25
4.2 Scales 2, 7 and 0 26
4.3 Scales 4 and 9 26
4.3.1 Scale 4 26
4.3.2 Scale 9 26
4.4 Scales 6 and 8 27
4.4.1 Scale 6 27
4.4.2 Scale 8 27
4.5 Deducing the state characteristics from the clinical scales 27
4.5.1 Clinical subscales 27
4.5.1.1 Subscales scale 3 28
4.5.1.2 Subscales scale 4 28
4.5.1.3 Subscales scale 6 30
4.5.1.4 Subscales scale 8 30
4.5.1.5 Subscales scale 9 31
4.5.2 Theory-driven expectations and hypotheses 33
4.5.3 Joint application of the MMPI-NVM (a short version of the MMPI in Dutch) 33
5 Validity, content and supplementary scales 33
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5.1 Validity scales L, F and K 34
5.1.1 L and K scales low and F high 34
5.1.2 L, F and K scales high 35
5.1.3 Scales L and K very low in combination with an average F score 35
5.1.4 Relatively high scores on the L and K scales with a fairly low F score 36
5.1.5 L, F and K scales low 36
5.1.6 Scale L high with scales F and K low(er)
or scale K high with scales L and F low(er) 36
5.1.7 Scales Fb and Fp 37
5.2 Content scales 37
5.2.1 The content scales each in their own right 38
5.2.2 Relevant combinations of the content scales 40
5.2.2.1 Cluster of Internalizing scales 40
5.2.2.1.1 Subcluster of scales ANX, FRS, OBS, and DEP 40
5.2.2.1.2 Subcluster of scales LSE and SOD 40
5.2.2.2 Cluster of the aggression scales 41
5.3 The supplementary Es scale 43
6 Special score profiles of the MMPI 43
6.1 Complexities 43
6.2 Inconsistencies 44
7 In conclusion 46
Reference list 46
1. Introduction
A clinical application of the Multiphasic Minnesota Personality Inventory’s (MMPI)
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theory-driven
profile interpretation (DTP) in patients characterized by psychopathology offers a wider scope
than that which psychodiagnostically-trained clinicians currently work with
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(Snellen et al, 2020).
In particular, the DTP considerably increases the number of possible interpretations and
clinically-relevant conclusions one can reach when connecting personality models to MMPI score
profiles (Caldwell, 2001). The DTP integrates both the trait- and psychodynamic models of
personality (Barlow, 2011). This integration allows psychodiagnosticians to illustrate client’s
(underlying) psychic strengths and weaknesses
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by inferring the nature of their basic traits via the
MMPI score profiles. This measure of covert psychic characteristics and structures is important
for clinicians to determine how demanding a treatment plan will be for each client. The coupling
of MMPI scoring positions of these basic traits to various psychodynamic entities enables the
measurement of underlying characteristics, as a client’s psychic capacities comprise of both
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Where MMPI is mentioned always the MMPI-2-TR is applied
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The DTP method is developed by W.M. Snellen and E.H.M. Eurelings-Bontekoe
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The terms client and patient as well as his or her are used interchangeably
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stable personality characteristics and the client’s unique developmental history (Eisenberg, 1977;
Westen & Arkowitz-Westen, 1998; Fonagy & Target, 2006; Luyten & Blatt, 2007; van Os, 2015).
Moreover, this interpretation method lets the clinician recognize the resilience and the
vulnerability (ability to regulate affect) of a client as well as the stress induced by circumstances
and the environment early and later on in life (Snellen, 1993). Psychic complaints, symptoms and
behavioral disturbances are assigned specific meanings in individuals based on how they are
embedded in their personalities (Westen et al, 1999; Westen & Arkowitz-Westen, 1998). The
MMPI is well suited for indirect, implicit measurement in clinical practice because of the bottom-
up statistical procedures by which the questionnaire has been constructed as a kind of general
psychopathology screener (Graham, 2011; ter Laak, 1995). Through its indirect, implicit
measurement of personality characteristics, the MMPI bypasses common flaws of self-reports. In
fact, the items of the MMPI are not very transparent in their measurement aims. Therefore, to
gain insight in the client’s underlying psychic dynamics, the clinician must construct an
interpretation of the MMPI score profiles based on given algorithms.
This white paper is meant to help the MMPI user interpret MMPI scoring positions and score
combinations in a theory-driven manner and is an addition to the various existing MMPI manuals
(amongst others, Hathaway & McKinley, 1943; Dahlstrom & Welsh, 1960; Butcher et al, 1989;
Lachar, 1990; Greene, 2000; Friedman et al, 2001; Graham, 2011). It also adds to the Dynamic
Personality Assessment handbook (Eurelings-Bontekoe & Snellen, 2003, 2017). One can primarily
consider it an appendix
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to the book Personality Diagnostics in Clinical Practice (Snellen, 2018)
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which covers all aspects and principles of the dynamic theory-driven profile (DTP) interpretation
method as the clinician may encounter in everyday practice (Snellen & Eurelings-Bontekoe, 2003;
Eurelings-Bontekoe et al, 2005; Eurelings-Bontekoe & Snellen, 2006; Eurelings-Bontekoe et al,
2008; Eurelings-Bontekoe et al, 2009; Eurelings-Bontekoe et al, 2010; Eurelings-Bontekoe et al,
2012; Eurelings-Bontekoe et al, 2014). The clinician must make sense of the available results in
order for a common thread to run through all the data on the various diagnostic methods and
techniques, and to achieve an individual descriptive diagnosis that does sufficient justice to the
nuanced clinical world (Groth-Marnat, 2009). For the clinical professional undertaking diagnostic
activities, the greatest added value of personality assessment is determining the mutual
relationship between stable personality factors (trait dimensions) and early as well as
subsequent psychic development (Lowijck et al, 2007). Through this he can also deduce the
degree of state-dimension loading in the clinical picture and understand the client’s underlying
psychic structure. The underlying structure can vary between being very weak to being strong
and fully developed, and can show deficits in both the basis of early developmental deficiencies
and structural impairments (for instance in the context of developmental disorders and limited
social abilities). In the case of limited social abilities, the client’s coping mechanisms only
developed to a small extent or were not developed sufficiently at all. In the case of clients with a
structural anxiety intolerance and initial psychic emotional and affective instability higher
copingmechanisms are badly needed to protect the client for stressinducing influences. Clients
are increased at risk for developing psychopathology of all kinds under stressful conditions when
they lack enough regulatory factors, and when they show impairments in the affective
maturation of psychic functioning (Frissen & Snellen, 1987; Luyten, 2013; Westen, 1997;
Abraham, 1997; Fonagy et al, 2002).
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The author and editor give permission for use and spread of this white paper
and free downloading from the website http://www.bsl.nl/mmpi
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My book is written in Dutch and not translated into English. Titel in Dutch: Persoonlijkheidsdiagnostiek in
de klinische praktijk
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Although it is possible to approach every diagnostic instrument in a theory driven and contextual,
model-based manner, this white paper is limited to the clinical application of DTP to the MMPI-2
(see for the Dutch version Derksen et al, 1993). An in-depth way to interpret the MMPI-2 in
particular is of great importance because of its frequent and international use on clients with
psychic complaints and symptoms. The DTP approach to MMPI clinical score profiles provides
additional insight into the client’s inner psychic world, that is, the nature of the underlying,
covert psychic structure that is neither visible nor retrievable in a direct manner. Furthermore,
the individualized approach outlined here adds idiographic insights to nomothetic data on the
interface between clinical-craftmanship and a statistical perspective (Molenaar, 2004). The DTP
perspective helps the diagnostician predict how individual clients will react to an increase in
stress and a decrease in external structure, particularly in the context of treatment. It provides
guidance to the clinician to set up a treatment policy that prevents over- and undercharging,
thereby saving unnecessary grief and costs for the client, practitioner, and for society.
This paper details the various MMPI score profile combinations coupled with their DTP-
perspective interpretations. In particular this paper intends to clearly guide psychodiagnosticians
who want to further their proficiency in and knowledge of a multi model-based, contextual
approach of the ten MMPI clinical scales. Attention is also given to a number of important
innovations and supplements that have been added to the MMPI-2, such as the validity scales,
additional clinical subscales, content scales, and a few supplementary scales. It offers clinicians a
handy overview of many possible relevant score combinations. For further explanation of the
DTP’s theoretical-clinical background information, it is necessary to consult the relevant books
cited above, as this paper only offers a brief description of the most important (partial) aspects of
the MMPI score profiles.
2. Principles of the DTP approach to the MMPI-2
- Detecting the four underlying basic traits: control, emotional instability, impulsiveness,
and social competence (Millon and Davis, 2000; Torgerson et al, 1993), see paragraph
2.1.
- Connecting the appropriate clinical scales (basic traits profile) with developmental-
theoretical and clinical-dynamic concepts in order to determine the nature and
seriousness of each of these underlying traits. Through this, the current meaning of the
scales is expanded and deepened.
- Interpretating various separate parts of the score profiles in conjunction with each other
- Explaining low scores on several clinical scales.
- Differentiating state- and trait characteristics within each clinical scale by, among other
things, simultaneously applying the MMPI and the Dutch Short Version of the MMPI
(NVM)/Dutch Clinical Personality Questionnaire (NKPV)
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(Snellen, 1990; Barelds &
Luteijn, 2015).
- Identifying specific patterns in the score profiles that refer to developmental disorders.
The DTP interpretation method of the MMPI is especially intended to determine the existing
nature and seriousness of negative affects (i.e. feelings of aggression) and the way they are
regulated. For instance, more or less fiercely aggressive feelings -with overlap and association
with negative emotions like anxiety and gloom - could be:
- Internalized and or somatisized
- Sublimated in regressive dependence
- Acted out impulsively
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The NKPV is an update, actually a modernization of the NVM
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- Rationalized, denied or disavowed
- Disconnected from the subjective experience through depersonalization and sometimes
the more severe phenomena of dissociation
- Converted into suspicion
- Warded off by worrying and avoidance behavior
- Result in disinhibition
- Manifest in behavioral disorders
- Covered up and fended off by pride, as a result feeling emptiness and ending up with
social withdrawal behavior associated with overall inner turmoil.
2.1 Basic traits
One can distill the following basic traits from the MMPI score profiles (Verheul, 2005):
- Anxiousness: an important genetic tendency (Frijda, 1988), also named emotional
lability. Highly fearful people demonstrate the inclination to suppress conditioned
responses. Anxiousness furthers inhibition in order to prevent undesirable consequences
by strengthening and stimulating the development of the behavioral inhibition system in
the makeup of the personality structure (Gray, 1971). The increased tendency and
vulnerability to develop negative emotions, (like tension, nervousness, irritability, worry,
feelings of alienation, self-pity, fits of anger, dreariness, uncertainty, and self-
punishment) does not mean that these psychopathological phenomena will definitely
occur, nor does it say anything about the degree of emotional differentiation, that is, the
quality of these negative emotions. It does give insight into the extent to which clients
with heightened anxiousness tend to react in an exaggerated way to external (negative)
and internal stimuli. Although the disposition for the development of these negative
emotions is to a large extent considered to be genetically determined, the degree,
nature, and actual presence of these negative feelings seems more a matter of the
nurture process.
- Impulsivity: this trait is understood to be a separate, specific biological entity
(Zuckerman, 1991). Zuckerman makes distinctions between impulsive behavior, unsocial
and antisocial attitude, and sensation seeking. People with these characteristics
undertake risky uncontrolled activities associated with uninhibited desires, aggression
and irritability. Although extraverts are more predisposed to impulsive and antisocial
behavior (because of an enhanced tendency to pursue especially positive emotions,) one
should understand the term ‘impulsivity’ as a heterogeneous concept (Livesley et al,
1998) that can apply to people falling anywhere on the extraversion spectrum; it is
composed of various components and is determined by multiple causal influences.
- Shyness: an extremely development-oriented personality quality (Gabbard 1994; Sperry
2003). 10-15% of young children show heightened, sometimes extreme, and in a number
of cases even pathological levels of this basic trait. Introversion (certainly in combination
with anxiousness) strongly predisposes a person to the development of shyness, but it is
not a prerequisite. Shyness is developed within intimate attachment relationships and
leads to inhibition and control (Tyrer & Stein, 1993). This trait can be regarded, when
present to a reasonable extent, above all as a sign of maturity and integration. This
personality trait promotes emphatic capacity and the competence to feel emotions
(inhibition is a necessary condition for being able to develop the ability to feel
altogether). An adequate inhibition system will additionally protect against loss of
control when confronted with frustration and offence. It stimulates safe attachment
relations and the capacity to mentalize. People scoring high on shyness can exhibit
characteristics such as the tendency to avoid social encounters and conflicts, over-
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adjustment to external demands, wishes, and obligations, inhibition in new situations,
and compulsiveness (Muller et al, 2007).
- Social (in-)competence (Siever & Davis, 1991), also referred to as the cognitive-
perceptual factor. 6-8% of the general population has such elevated structural
impairments in their social abilities, that they are more likely to malfunction in work and
relationships in the case of stress, due to cognitive and emotional disorganization under
stressful conditions (Siever & Davis, 1991; Vollema & Ormel, 2000; Livesley, 2001).
Dimensional schizotypal traits are recognizable in nearly half of the cases of clients who
seek help for psychic complaints in general.
The traits/dimensions discussed above can exist independently from each other and vary and
interact between themselves in all kinds of ways.
2.2 Dynamic entities
In the DTP interpretation method the diagnostician connects the following entities to the basic
traits from the previous section, in order to gain insight into internal psychic dynamisms:
- Antisocial features (ASP) and early, basic narcissism (Millon & Davis, 2000; Cleckley,
1988; Meloy, 1988, Gabbard, 1994; Kernberg, 1984; Kohut, 1978)
- Borderline personalities (Masterson, 1976; Adler, 1985, Kernberg, 1980)
It is important to differentiate between borderline personalities with more internal
dynamics (often diagnosed as dependent personality disorders) and subtypes with more
impulsive traits, the so-called low-level subtypes (Grinker et al, 1986; Krueger & Kaplan,
2001)
- The immature personality (IP)
The “infantile personality” (Kernberg, 1976), or, in other words, the immature
personality, can be located in the border region between the borderline and neurotic
organized clients
- The psychotic (personality-)organization (Kernberg, 1980; Frosch, 1988; Acklin, 1992)
The capacity for reality testing marks the transition region from the psychotic personality
organization (PPO) to the borderline personality organization (BPO)
- The neurotic (personality-)organization (NPO)
Neurotic symptoms result from intrapsychic conflicts. The person’s conscience formation
is often too strongly developed and has a great impact on total personality functioning.
The curtailment of undesirable and even forbidden negative feelings is so serious that it
interferes with flexible social and societal functioning because of a (too) high degree of
uncertainty, irresolution, feelings of guilt and shame, and tendencies for conformism and
rigidity. This is usually accompanied by the inclination to ruminate, self-devaluation and
self-criticism, difficulties in expressing and discharging tensions, compulsion for self-
control, wanting to be and do good in relationships, and a susceptibility to harbor
inferiority feelings and social anxiety.
2.3 Schema traits-structure
The diagram below (figure 1) represents the distinguishable traits as they are related to the
dynamic psychic entities mentioned in section 2.2 (Emotional instability, that is EI, corresponds
to the concept of anxiousness. Inhibition/defense and covers the notion of control and
maturation (Clarkin & Levy, 2006; Morey & Zanarini, 2000)); the level of the schizotypal
dimension runs on a scale from absent, through moderately serious, to strongly present, and is
perpendicular to the other dimensions and entities:
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Figure 1: Diagram of traits and dynamic entities combinations
+ PPO
Reality testing
High level Object constancy
Utopian
EI normality
Borderline
NPO
Low level IP
Low level
ASP Narcissism
-
-
Inhibition/defence +
+
Schizotypy
-
3. Clusters of the clinical scales
The clinical scales of the MMPI may be subdivided into three clusters that are related to the basic
traits, namely: control, impulsivity, and emotional instability.
3.1 Control scales
The control scales Hs, D, Hy, Pt and Si (respectively 1, 2, 3, 7, and 0) represent the functions of
psychic control on behavior, emotion, and thinking. These scales are, however, seldom all equally
raised at the same time. This combination of clinical scales fits a neurotic organization with
compulsive traits and with the necessary defense and inhibition (figure 1) traits, because in these
cases by definition, the level of control that is present is sufficient when combined with relatively
low positions on the impulsivity (Pd and Ma, respectively scale 4 and 9) and the emotional
instability dimensions (Pa and Sc, respectively scale 6 and 8). Within this personality structure
one processes stress, aggression, and other negative emotions in an internal way and therefore
pays an unavoidable price, such as: heavy-handedness, rumination, indecisiveness, uncertainty,
tiredness, feeling responsible for others, perfectionism, procrastination, social anxiety, and
physical discomfort. Additionally, this internalizing way of dealing with stress is accompanied by
strict functions of conscience like feelings of guilt and shame, compulsive and dependent traits
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and suppression of unwanted and forbidden feelings such as protest, as well as a tendency
towards self-devaluation and a very self-critical attitude. Expectations are quickly seen as
requirements and obligations. The DTP method thus provides not only a description of
observable phenomena, but also a record of internal psychic dynamics and ego-structural
characteristics.
Figure 2 shows what the MMPI profile for these cases looks like in general:
Figure 2: Internalizing MMPI profile
3.1.1 Subclusters: scales 1, 2, and 3
The first three scales 1, 2 and 3 display the representation of the inner negative feeling dynamics.
3.1.1.1 Scale 2 high and scales 1 and 3 relatively low
Figure 3 shows how this pattern frequently looks in mental healthcare:
Figure 3: High 2 and in proportion lower 1 and 3
Scale 2 reflects the subjective feeling of unwellness and psychic burden, and points, in particular,
to dissatisfaction with oneself and one’s existence. The main coping mechanism to deal with
negative emotions is to direct those emotions inward.
3.1.1.2 Elevations on scales 1 and 3
The elevations on scales 1 and 3 refer to somatization as an affect regulation mechanism, that is,
the development of physical complaints and symptoms under stress conditions. In the DTP
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 0
0
20
40
60
80
100
1 2 3
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interpretation method the following reasoning is applied: in clinical practice there appears to
exist a negative relation between the height of scale 2 and the normative scores on the
somatization scales 1 and 3. Mechanisms of somatization function to keep the dynamics that lie
behind scale 2, at least as low as possible. Tensions manifest more in the body and not so much
in the state of mind. The somatic mechanism is seen as an attempt to attenuate negative affects
by, importantly, making an appeal to the person’s social environment (regressive dependency in
interpersonal relationships; Eurelings-Bontekoe & Koelen, 2007). In the case of heightened
scores on scale 3 (Gordon, 2006) its (subtle) relational aspect is prominent. The reason for
wanting or needing to keep one’s negative emotional dynamics low can vary widely.
3.1.1.3 Relative and absolute low scores on scales 1 and 3
In psychopathology in general, and within specific dynamic entities in particular, high scores on
scales 1 and (especially) 3 are foreseeable. From a DTP point of view scale 1 and 3 scores are
soon weighted as relatively to low in order to be able to keep the psychic equilibrium, in
particular of importance under stress conditions as one uses somatization mechanisms as an
effort to reduce negative affects by means of bodily experiences and taking a passive-dependent-
regressive stance in relationships. For every dynamic entity the diagnostician can give an
indication for the assumed and expected specific score position and scoring range on the
NVM/NKPV, on the basis of an operationalized scoring schedule (see Snellen & Eurelings-
Bontekoe, 2017). On clinical and theoretical grounds, high scores on the somatization scales are
most likely as well as most desirable in: all the cases of the dependent-avoidant NPOs, all of the
borderline personalities, PPOs, IPs, and the hypervigilant-narcissistic subtypes. Depending on the
underlying level of ego-organization, a high score on the clinical scales of somatization can thus
have divergent meanings, ranging from the reflection of symbiotic needs though attempts to
keep control unto theatrical emotional hostage of social surroundings as sickness benefit in order
to avoid confrontation with inter- and intrapsychic conflicts.
There are three possible explanations for these scores being relatively and absolutely lower than
predicted:
- Mild to severe deficiencies in social coping skills (Gerritsen et al, 2009)
- Only slightly (or barely) utilizing somatization mechanisms due to a lack of learning
history combined with little exercise and identification, resulting in introjective coping
mechanisms (Blatt et al, 1997). In people with high-level functioning, these coping
actions are usually accompanied by robust self-devaluation and even intense self-
undermining.
- According to the DTP method, low scores on somatization emerge in clients with firm
narcissistic features. The prevailing DTP theory is that one detaches oneself from their
body and interpersonal contact by using dismissive attachment styles. Feeling and
internal dynamics have become supercooled, one can scarcely tolerate criticism, and the
self-presentation is pseudo-normal and quasi-autonomous. Blows to one’s sense of self
and the incitement of undifferentiated fury and jealousy - with the likelihood of
gloominess (the anaclytic depression; Descheemaeker et al, 2013) - only come about in
situations of frustration like abandonment, or when a person psychologically important
to them does not share in their wishes and desires. They then imagine themselves as
invulnerable, and are under the illusion of not needing the other person. They ignore
their own softer feelings, especially in intimate relationships. Specific follow-up
investigation can give a definite answer to early personality problems or how they
function to cover (other) deficits (Westen, 1991).
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Combinations of the possibilities and explanations mentioned above are common in all kinds of
mild and severe forms, and give the clinician a layered and multifaceted impression of the
patient.
3.1.1.4 Scales 1 and 3 high, scale 2 low
See figure 4 for a somatization profile
Figure 4: Somatization profile
This configuration can adopt all kinds of heights and the V-form can take a number of angles. It
can also go alongside all other possible combinations of scores within the MMPI score profile. All
these possible cases lead to the conclusion that one suppresses negative affects and also passes
them onto the environment in order to keep the person’s own suffering as low as possible.
3.1.1.5 Scales 1, 2, and 3 high
In this case the scores mostly lie more or less in a row; see figure 5:
Figure 5: High intrapsychic cluster
Here we see a higher score on scale 2 notwithstanding somatization. The person tries to
moderate negative affects but does so quite unsuccessfully. Mostly the cause of these additional
negative affects is about additional stress created by situational factors - for instance, on account
of recent and possibly still present PTSS and of feeling emotionally stuck.
3.1.1.6 Scales 1, 2, and 3 low
The occurrence of a profile with low scores on all scales of the intrapsychic cluster is noteworthy
in the case of the appearance of complaints and symptoms; see figure 6:
0
20
40
60
80
123
70
75
80
85
90
123
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Figure 6: Low intrapsychic cluster
Despite not using the somatization mechanism, no intrapsychic dynamics are reported. This
points to a defect in feeling.
3.1.2 Scale 7 and its combinations
Scale 7 (Pt) covers the domain of rational control with a tendency to ruminate, doubt, fear of
failure, uncertainty, and inhibition of the expression of aggression. Very high scores on scale 7
point to anticipation anxieties.
Low scale 7 scores are more unfavorable and complicate the picture in the presence of
psychopathology and presentation of psychic complaints. A mask of sanity then disguises a lack
of conscience with a tendency for acting-out behavior when frustrated.
A combination of scale scores that both rarely occur and are also hard to understand is made up
by elevations of the scales 2 and 0 with scale 7 (relatively) lagging behind; see figure 7:
Figure 7: Higher scales 2 and 0 with lower scale 7
Feeling unhappy due to social avoidance manifests itself without the accompanying cognitive
correlates. The DTP perspective hypothesizes that this has to do with the combination of
avoidant and (in particular) schizoid traits characterized by deficits in social coping skills
dominating the person.
3.1.3 Scoring on scale 0
35
40
45
50
55
1 2 3
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 0
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From a DTP point of view, giving meaning to the scores on scale 0 (heretofore scale 10) is
essential - that is, interpreting the scores from a developmental perspective. Scale 0 would then
represent inhibitions that have developed in the personality structure. Scale 0 makes the
theoretical-clinical connection between basic traits and dynamic entities (Snellen & Eurelings-
Bontekoe, 2003). According to the DTP interpretation method, Scale 0 is not only about the
presence or absence of social avoidance or skills per se but also and, more importantly, about the
degree of inner differentiation of one’s emotional life. Scale 0 correlates highly with the shyness
synonym dimension of the NVM/NKPV. As a personality trait shyness develops early in the
individual lifecycle, continuing up to and including the first half of the adolescence. It is regarded
as a developmental task, namely, the formation of a structural and internal emotional inhibition
system as a regulation mechanism for feeling and behavior. This system is indispensable for
meeting relational and social requirements later on in life and for dealing with frustrations and
daily hassles. It serves to keep and foster control, to be able to limit oneself from others, and to
restrain severe negative affects. When frustration grows the first natural reaction of people who
are mature in their personality development is the visible increase of feelings of self-doubt,
uncertainty, fatigue, anxiety, and feelings of guilt due to the stimulation of inhibition mechanisms
and in order to moderate feelings of undifferentiated negative affects and anger.
The literature shows a strong connection between scores on the NVM shyness dimension and
the maturity of defense mechanisms, the degree to which an inhibition system has developed,
and the presence of a differentiated internalized object relation formation (Eurelings-Bontekoe
et al, 2005). These interesting clinical findings can without doubt be transferred to scale 0. The
concept of shyness and thus also with the position on scale 0 gains importance because of a
much more extensive, deeper, and more layered meaning assigned to it. This shyness dimension
(social introversion) should not be confused with the temperamental dimension (extraversion-
introversion). Admittedly the MMPI contains this temperamental dimension implicitly, but it
cannot be extracted on face value (in contrast to the NVM and NKPV, which are distilled from the
MMPI). The comparison of scale 0 with the shyness dimension on the one hand, and the
locations of the scores on the temperamental introversion dimension on the other, is fascinating
in a diagnostic sense, especially when the tendencies diverge (in particular low scores on scale 0
combined with introversion as temperament; see below (Snellen & Eurelings-Bontekoe, 2017;
Snellen, 2018).
- High scores on scale 0
High scores on scale 0 indicate excessive inhibition, with the majority of the variance originating
in repressive influences and parentification processes in early childhood development
(somewhere between three and nine years of age). Very high scores on scale 0 are detected in
cases of people who are excessively inhibited and are affected by a lot of social anxiety, often
marked by the following covert characteristics: feeling so obliged to adjust accordingly and
adapt to others’ (supposedly) implicitly and explicitly formulated wishes and requirements that
one is no longer in touch with their own desires, motives and incentives. This rigid and defensive
attitude in avoiding confrontation enhances complaints like feelings of depression and anxiety,
avoidant behavior, self-devaluation, self-sacrifice, and can result in feelings of guilt and inferiority
of an almost self-undermining nature.
- Average scores on scale 0
When applicating the DTP interpretation method to the MMPI, making a distinction between the
immature personality and the PPO on the basis of the configuration of the clinical scales can
sometimes pose a problem. This very (clinically) relevant differentiation easily disappears in
the noise of the outcomes. On the basis of clinical findings and theoretical considerations
14
(Eurelings-Bontekoe et al, 2008) the hypothesis is set up such that in both entities the scores on
the shyness dimension and also on scale 0 will be situated around the average. In such cases,
aggressive feelings are warded off (but due to the lack of sufficient ego-strength, less strongly
than with NPOs), either by making use of splitting mechanisms related to a shortage of
individualization (IP) or by entering into symbiotic relationships, due to the absence of
separation (PPO). See figure 8 for possible MMPI profiles accompanying these entities:
Figure 8: MMPI profile of IP and PPO(-latent)
Generally in the application of self-report inventories, diagnosticians often tend to miss entities
like the IP or PPO (-latent; the concept “latent” refers here to the vulnerability only
becoming visible under stress conditions) because they do not ascribe enough meaning to the
relatively lagging score 0. And besides, with help of the NVM one can certainly distinguish the
hypothesized separation between the IP and PPO (Snellen & Eurelings-Bontekoe, 2003). In
that case the ratio between the scores on the shyness dimension and the psychopathology (EI)
dimension will turn out less favorable for the PPO. The clinical principal (DTP) reads as
follows: the more the EI is raised (this also counts for impulsivity), the stronger the
development of inhibition/defense is desired in order to be able to keep the psychic
balance in stress conditions and for continuation of regulating negative affects.
- Low scores on scale 0
Research confirms that low scores on the NVM/NKPV shyness dimension reflect a lack of
development of inner inhibition abilities (Eurelings-Bontekoe et al, 2009 and 2010), at least
when interpretated in a theoretically-driven way and in the context of the necessity of
conducting psychological assessment such as when psychic complaints, symptoms and behavior
disorders are present (otherwise low scores on these dimensions are not understood in this
manner because of the absence of psychopathology; superficial description then suffices. For
instance: one is not bothered by avoidance behavior, too much inhibition and social
anxiety). Low scores on the shyness dimension of the NVM/NKPV, and thus also on scale 0 of
the MMPI of clients with psychopathology, are compatible with only slight or little
emotional differentiation and with lack of conscience formation, increased impulsivity,
hedonism, low frustration tolerance, and opportunism (Snellen & Eurelings-Bontekoe, 2003). It
is then not so much about the presence of positive signs of psychopathology but rather about the
lack of a more mature development with deficiencies and deficits in the capacity to feel and
empathize in a sensitive way. Literally, a lack of shyness (low score on the NVM shyness
dimension) means not differentiating between people in a psychological sense. One does not
see the other as a separate individual with his own psychic make up. There is no real
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boundary between oneself and the other. That means that no real adjustment or tuning in can
take place either due to not being able to perceive important psychological differences and
nuances between others. The other person is not seen as a unique individual with his
own dynamics. The other fulfills a function in the regulation of the self. The other adds on to the
deficits in the possibility of experiencing oneself as an own individual by oneself. That is why
persons with a lack of individuality cannot see the other in their own right. They are perceived
through the desires and anxieties and are considered as an extension to one’s own personality.
It is therefore typical to look and think in superficial unidimensional black and white notions
about others because of a lack of perceiving depth in and boundaries between others. One
conducts oneself mainly as required in the actual moment, without having a sophisticated eye for
context and history. The other person functions as an instrument to complement the “self”.
Various roles are filled in, in an “as-if” (pretend-)mode (Bateman & Fonagy, 2006) and appear
convincing because of the adoption of absolute points of view, precisely due to a lack of core
identity. Shortcomings in the person’s self-reflection capacity reveal themselves only when
confronted with comment and criticism.
It is worthwhile when interpreting low scores on the MMPI scale 0 to further zoom into three
relevant and substantive clinical topics:
- Layered problematics
All MMPI profiles can accompany a low score on scale 0, including in cases of elevations in the
other control scales. When scales 2 and 7 are high, the pathology on the forefront is the same,
regardless of whether the score on scale 0 is high or low, for instance in the case of an eating
disorder (AN) with an increase in controlling nature and perfectionism. In these cases the
combination with a low score on scale 0 points to - see figure 9 - layered problematics, namely
inhibition in the psychic superstructure superimposed on as-if pathology in the foundation of the
personality structure. This then represents a paucity in the core identity of the personality build-
up.
Figure 9: Elevations on the control scales together with scale 0 low
- Ratio scores on scale 0 and 9
In clinical populations the ratio between the scores on scales 9 and 0 provides interesting
information about the presence of externalizing and internalizing characteristics in the nucleus of
the personality. The pleasure principle dominates when the score on scale 9 is high and the score
on scale 0 is low. It goes together with lack of ego-boundaries, as-if characteristics and
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exploitation of the social environment, while internalizing patients show the opposite score
positions, that is a high score on scale 0 and scale 9 low.
- Low scores on scale 0 in relation to the extroversion-introversion dimension
On the introversion pole of this dimension, low sores on scale 0 are less likely. A low score on
scale 0 will often occur in the case of early, pre-verbal attachment problems (Snellen &
Eurelings-Bontekoe, 2003). The young infant schema is found in survival mode together
with detachment and flight in the avoidant (dismissive) attachment strategy (Young &
Flanagan, 1998).
3.2 Impulsivity scales
The second cluster within the MMPI score profile of the clinical scales consists of the
combination of the two impulsivity scales Pd and Ma (respectively scale 4 and 9). The higher one
scores on these two scales the greater the chance of behavioral disturbances like acting-out and
addiction behavior.
3.2.1 Scale 9 high
Structural elevations on scale 9 point to the enhanced tendency for transgressive
behavior and primary short-term gratification of own needs. Heightened positions on scale 9
reflect the magnification of all negative tendencies that are visible in the MMPI
score profile; one’s own illusionary and uncorrected reality is always valid and comprehensive.
For a typical score profile, see figure 10:
Figure 10: Elevated scores on scales 4 and 9
The internal containment and processing of negative emotions hardly takes place, or not at all.
Life is a party until one needs to confront reality. Suddenly, very different sides of emotional life
then become visible: fury, suspicion, viciousness, externalization of negative emotions and not
taking responsibility for one’s own behavior and feelings. One sponges off of others in a
remorseless and persistent way, and when the victim gets worn out the process repeats itself
upon other person, who will always be available.
3.2.2 Scale 4 high
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Elevations on scale 4 have to do with impulsive traits. Scale 4 is, however, heterogeneously
composed and also extremely sensitive to state influences. Clients who seek professional help in
general very often show high scores on scale 4. Therefore it is important to check to what extent
the elevation on this scale can be attributed to state influences (affect impetus) and what to
structurally determined impulsive traits. The concept of impulsivity here takes a very broad view;
it refers to the indulging and abreacting of negative affects in a general sense.
3.2.3 Scale 9 low
The MMPI literature has very few, if any, descriptions of low scores on scale 9. Nevertheless,
clients with internalizing coping styles show frequently low or sometimes even very low scores
on scale 9. Low scores on scale 9 suggest, especially from a DTP perspective, the avoidance of
experiencing aggressive feelings that are not permitted and thus even self-condemned. Indeed,
low scores on scale 9 are always to be expected when scores on scale 0 are high. Very low scores
are related to the defense mechanism of “isolation of the affect”. They mostly refer to blocked
and split off traumatic experiences and unresolved feelings and experiences (see figure 11):
Figure 11: Low scores on scale 9
Most commonly seen is the blue line, which points, namely, to defense of aggressive feelings in
the case of higher forms of differentiation of emotional life. The red line refers to the isolation of
unresolved feelings to such extents that the defense and isolation of traumatic experiences and
perceptions are very likely.
3.3 Emotional instability, or vulnerability, scales
The third cluster consists of the combination of two scales, namely scales Pa and Sc (respectively
scale 6 and 8). These two scales differ in their meaning. Only in a small minority of the patients
who score high on these scales do we encounter blooming psychotic phenomena. Rather, both
scale 6 and 8 reflect more the underlying trait of emotional instability (EI or neuroticism) as they
are anchored in the personality make-up.
3.3.1 Scale 6
Those who structurally have high scores on scale 6 will, when under external pressure, more
quickly develop symptoms like acute fears, feelings of panic, distrust, irritability, annoyances, and
doubts about apparent certainties. The psychic skin is thin and too easy permeable for both
internal and external negative factors. Tensions as well as external threats give rise to excessive
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pessimism, fatigue, and not being able to detach and dismiss oneself from possible disaster
scenarios that one could keep worrying about in an obsessive manner.
3.3.2 Scale 8
The interpretation of scale 8 is more complex. Structural high scores on scale 8 point to laborious
social adjustment in terms of lack of relational suppleness, feeling inconvenienced by emotional
proximity and mutuality, and inflexible functioning in groups. Having to change roles and
contexts causes problems, one only functions on one gear, as it were. Emotional and cognitive
alienation phenomena develop under pressure such as depersonalization, or the feeling of little
contact with the self and others (respectively emotional and social alienation). Tensions are
reported as located “in the head” rather than in the body, and one complains about inner turmoil
and runaway thinking. A low level of ambition serves self-protection. The consequences of
tiptoeing around too long in often desperate attempts to meet external wishes and imposed
demands are feelings of hopelessness and despair, sometimes leading to abandoning the fight,
lack of volition, and in the end even resulting in total demoralization; there is also a heightened
possibility of the emergence of suicidal ideations. Structural elevations on scale 8 give cause to
assume persistence and tenacity of psychopathology.
3.3.3 The combination of the EI scales 6 and 8
In cases of structural elevations on the EI scales, scale 6 will almost always be a bit higher than
scale 8. At the same time, there is also hope for sufficient control; see figure 12:
Figure 12: Elevations of the EI scales 6 and 8 with simultaneous presence of control
High distress (high 2), relatively little somatization (moderate 1 and 3) and limited impulsivity
(somewhat raised 4 in combination with low 9) are encountered here. That points to high
control, avoidance, and compulsive traits (high 2, 7, 0) but also to high anxiety and mildly present
schizotypal traits (6, 7, 8). One tries to maintain integration and shield anxiety as much as
possible.
Figure 13 shows a much more complex profile with the same level of anxiety (EI):
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Figure 13: EI with deficient control:
Very little internal regulation is to be expected in clients with this profile, resulting in them
feeling internally swamped with fierce anxieties and the development of feelings of anger under
stress and frustration. There is then a serious possibility of all sorts of unpredictable and
capricious symptom formation and behavior disturbances.
Significant combinations of scale 8 with some other clinical scales follow below:
3.3.3.1 Combination 8 and 7
The combination of scales 8 and 7 reflects schizotypal traits (see also figure 13). Scales 1 and 3
are therefore low in an absolute sense (just as the score on the somatization dimension of the
NVM) and scale 7 mostly is a bit higher than scale 8. This concerns the continuously difficult
functioning of the client’s social coping mechanisms. Stress is, above all, cognitively processed,
and thinking is extra taxing and is making extra efforts for compensation with finally exhaustion
as a result. There are too many shortcomings in skills to channel tensions somatically and
relationally.
3.3.3.2 Combination 8 and 1
The combination of scales 8 and 1 causes concern for the development of an impending
psychotic process. Clients lacks self- and disease-insight. They attempt to create a ‘last
stronghold’, as it were, through a forced effort toward somatic externalization in order to
prevent an overall decompensation and disintegration; however, this is often in vain. See figure
14:
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Figure 14: High scores on scale 8 and 1
A typical 1-8 or 8-1 profile. One should bear in mind the chance of a lifelong risk for
decompensation, marginal functioning, shortage of motivation for seeking and accepting help
and thus for necessary outreach and guidance to reduce miseries like social failure. The
emotional life often is impoverished and scantly held together, with much negative symptom
formation.
3.3.3.3 Combination 8 and 2
In 8-2 combinations the introjective mechanisms are so structural in nature that one can hardly
get therapeutic motion in the inter- and intrapsychic dynamics, despite the suggestion of good
therapeutic possibilities to treat complaints and symptoms, and due to (often apparent)self-
insight and disease awareness; see figure 15:
Figure 15: High scores on scale 8 and 2
3.3.3.4 Combination 8 and 4
A combination of negative tendencies in the personality make-up that reinforce each other. One
does not feel reactions to offences intensely and adequately. One can prolong brooding and then
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abruptly, both for the surroundings and for oneself, show acting-out, (self-)destructive behavior
in a cold, severe, and unpredictable way without any advance warnings or signals; see figure 16:
Figure 16: High scores on scale 8 and 4
The red line reflects some control. The blue line refers to a combination of schizotypal and
impulsive traits.
3.3.3.5 Combination 8 and 9
When elevations on scale 8 go hand in hand with those on scale 9, then unpredictable
occurrences of psychotic phenomena are nearly always to be expected; see figure 17:
Figure 17: High scores on scale 8 and 9
The conclusion on the basis of the profiles presented in figure 17 is that the chance of
decompensation, emotional and cognitive disorganization, disintegration, and disinhibition is
anchored in the personality structure and is constantly present. Presumably there is also the
presence of odd and sometimes entirely bizarre-seeming phenomena as part of psychic
disinhibition, above all when scale 6 is elevated at the same time.
3.4 Mutual relationships between the clusters
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All three MMPI score clusters are hitherto separately described, but it is the intention to
diagnostically signify their relation to each other, which deepens interpretation for clinical goals.
3.4.1 Principles of the DTP interpretation of the MMPI
A number of principles will be discussed below to come up to the DTP approach to the MMPI
score profiles:
- If there is any degree of frustration tolerance, namely to be able to cope with and to
internally digest negative affects, then that will reflect in higher scores on the control
scales pertaining to both the impulsivity and the EI scales.
- The diagnostician compares the MMPI results with the expectancies of the hypothesized
prototypical score profiles that match a theory-driven basis with the dynamic entities.
They interpret identified deviations (state and/or deficits) between the two types of
profiles.
- All scores with a T-value ≥ 75 (2,5 sd) are at least partly determined by state influences.
- In essence clients will, whenever possible, try to safeguard their vulnerability and
impulsive propensity through maximizing their capacity for control. The possibilities for
control in the client’s profile reflect their maximum possible endeavors to that end.
- In the presence of psychopathology, it is extra noteworthy when clients do not report
negative affects. Average scores in these cases do not represent normality nor absence
of clinical signs and symptoms.
- From a clinical and statistical perspective, it is astonishing to find the majority of a
client’s scores hovering around the “normal” average, since after all, the averages for
every scale are the result of cross-sectional investigations in the general population.
- By applying the DTP method, the diagnostician presumes a referral of the mutual ratio of
the MMPI score clusters to the underlying structural characteristics with an
understanding of the individual resilience and vulnerability.
- The prototypical score profiles barely appear in pure form. Small variations,
abnormalities and subtleties are indeed clinical meaningful.
- Specific score profiles correspond with developmental tasks in critical and specific stages
of development. The development of these tasks often fall short in cases of
psychopathology with limited capacity to adapt and as a consequence, under pressure, a
rapid increase of negative affects will be experienced. It is important to note that from
the DTP point of view, average and low scores point to deficiencies in the adaptive
capacity on a more mature level.
- In the analysis of the entire MMPI profile, it is important not only to pay attention to the
form, but also to the total absolute elevation. The same scoring pattern can vary in
height, when associated with manifest or more latent (subclinical) clinical phenomena.
- The diagnostician ought to conclude the clinical subscales, as well as, the validation
scales, the content scales and a few supplementary scales when he considers the
meaning of the score profile of the indispensable clinical scales.
- Scale 0 plays a key role when interpretating the DTP according to the DTP method. This
procedure connects the developmental perspective with the basic traits.
- The greatest additional value of diagnosing the client using, among other things, the
MMPI lies in detecting inconsistencies between the clinical impression and the
underlying psychic structure and the basic traits.
- The MF scale (scale 5) is not contained in one of the three score clusters.
- The MMPI is to a great degree not suitable for treatment evaluation purposes.
3.4.2 Mutual relationship between the MMPI score clusters
23
The three clusters - control, impulsivity and EI - can be related to each other in in various ways:
3.4.2.1 Control, impulsivity and EI high
Figure 18: All clusters high
In this double-peaked 2-7 profile code we see also elevations of the scales 4, 6 and 8. The
impulsivity scales and the EI scales are so high that further incite of the control is hardly possible
anymore, despite the initial impetus in this direction. The control functions supposedly as a
‘’rooftop’’ over continuous threat of loss of control. This high-level problemic is commonly
observed among high-level borderline structures and is mainly clinically visible only in its
internalizing consequences causing, thereby a serious probability of underestimating the severe
inner turmoil and suffering.
3.4.2.2 Control high, impulsivity and EI low
See figure 2 (page 9). This profile should mirror a neurotic structure.
3.4.2.3 Control low, impulsivity high and EI low
See figure 10 (page 16) with additional description of antisocial traits.
3.4.2.4 Control and impulsivity low and EI high
Figure 19: EI high, control and impulsivity relatively low
24
Figure 19 represents a typical PPO profile: feelings of anxiety and panic easily occur in tasks-
induced stress and one gets rapidly confused.
3.4.2.5 Control high, impulsivity high and EI low
Control suggests the integration of thinking, feeling and acting. The split off, covered, primitive,
undifferentiated and injured underlying emotional level (often due to a problematic attachment
stemming from the early development) is not associated with this upper-level control layer
(horizontal dissociation; Kohut, 1966). This layer only becomes apparent when the client gets
offended, frustrated and/or abandoned, see for example figure 9 (page 16).
3.4.2.6 Control low, impulsivity and EI high
Refer to figure 13 (page 19) for an example. These combination of scores would mainly involve
low-level borderline personalities with both a chance of decompensation and acting-out
behavior.
3.4.2.7 Control high, impulsivity low and EI high
The emotional life and the acting behavior is so permeated by the anxieties and pessimism that
the personality pathology can be located on the dividing line between NPO and high-level
borderline personality characteristics. One is afraid of and tries whenever possible to evade
confrontation and risks. A passive dependent life style enables the maintenance of the lowest
possible stress levels.
3.4.2.8 Control, impulsivity and EI low
Figure 20: All clusters low
Profiles, as depicted in figure 20, with all the scores equal to or below average (submerged
profiles) are mostly encountered in forensic settings. The dynamics involved here are of as-if
personality characteristics and they are massively hidden behind a socially desirable façade. The
social adjusted attitude can suddenly turn into a tyrannical and even a ravaging, compelling
attitude.
3.5 Scale MF
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Low T values reflect the tendency to conform oneself to sex-role stereotypical behavior and
taking on stereotype gender roles. The other side of the gender coin remains consequently
underdeveloped, as far as men are concerned, the passive strivings and for women the active
strivings in the personality make up. Mutatis mutandis the reverse reasoning applies for clients
with high scores. Men, in these cases, are stagnated in their autonomy development. One avoids
rivalry by resigning themselves in advance to their fate as losers, often coupled with concealed
(closet) fantasies of grandeur. Women are scared to portray themselves in their passive traits
and desires, which is often a result of unresolved painful experiences due to these traits. When
the scores on the MF scale are raised or reduced considerably, it is also useful to also examine
the pair of GM-GF scores of the supplementary scales. Excessive raised scores indicate one sided
identification processes (e.g. men with high GM and women with high GF scores) and low scores
refer to fear and/or inability to adapt to the evaded gender-linked traits and attitudes.
Substantial clinical observations indicate that women with both low scores on the GM as well as
the GF scales nearly always have endured early (complex) trauma experiences.
4. State characteristics
Descriptions of code types in the classic manuals are often quite spurious when a clinical scale is
temporarily pushed up on the basis of state influences. The greatest source of error, when
interpretating the MMPI, consists of the confusing of the state and trait values of each clinical
scale.
One can distinguish three kinds of state influences that also can appear together:
- Affect impulse based on accumulated intense unresolved negative emotions
- Psychopathology in the narrower sense, for example, psychotic symptoms, severe
depressive phenomena, developmental disorders, bipolar disorders
- Neuropsychological dysfunctions, such as acquired brain injury (ABI) and congenital and
constitutional abnormalities.
The following are some reflections on the state characteristics of various clinical scales:
4.1 Scales 1 and 3
High scores on scale 1 and 3 can be expected when one tries to use somatization as coping
mechanisms in order to regulate and moderate negative emotions, provided this capacity must
be at one’s disposal. The need to apply it may originate from different reasons:
- Escaping from and putting up a barrier against impending psychic and psychotic
decompensation.
- The prevention of aggressive acting-out behavior and impulse breakthroughs.
- Borderline personalities, who try to counteract of being swamped by (putative) fear of
loss of control and (imminent) abandonment.
- Avoidance of being confronted with unresolved traumatic life-events, experiences and
feelings in the case of severe PTSS (CPTSS).
- Overdependency and the outsourcing of negative affects, in order to prevent the
experiencing of undesirable, unwelcome and disliked negative emotions. High level
personality structures protect themselves of feeling their own psychological suffering
and emotional pain. Low level personality structures attempt to parasite on their social
environment, see figure 21:
26
Figure 21: Low level structures with high scores on scale 1 and 3
4.2 Scales 2, 7, 0
Depending on the potencies and capacities for managing aggression, the control scales
4.2 Scales 2, 7, 0
Depending on the potencies and capacities for managing aggression, the control scales 2, 7 but
also scale 0, can show substantial increases in case of negative affect impetus. The so called
“silent sufferers”.
4.3 Scales 4 and 9
Initially scale 4 displays an elevation because of the affect impetus and only at a later stage, scale
9 will then also rise.
4.3.1 Scale 4
Scale 4 will rise when nearly all MMPI score profiles are under influence by state factors. High
scores on scale 4 in the score profiles are visible in both, externalizing and internalizing
personality problematic. This can be attributed to the heterogeneous construction of the scale
itself (see paragraph 4.5.1.2 about the subscales). Additionally, In cases of a more situationally
conditioned problematic, and when clients feel that they are not being taken seriously, do not
belong, are not being heard and feel worthlessness, will result in an elevation of these scores.
Sometimes an extreme elevation occurs Sometimes regardless of the psychic structure.
4.3.2 Scale 9
Low scores on scale 9 are also meaningful and stand for inhibition of aggression in the emotional
life. In the cases of high-level structures (high scores on scale 0) therefore scores ≥ 50 are thus
already considered as risen from a DTP point of view, because they are entirely attributable to
state influences. Mostly this arises from the mobilization of unresolved perceptions and
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(traumatic) experiences provoked by external triggers and exhaustion of the defense, see figure
22.
Figure 22: Scale increase due to negative affect impetus in combination with internalizing
mechanisms
Even though the score on scale 9 is low, one can, based on a DTP standpoint, even so consider it
as raised in this total score configuration.
4.4 Scales 6 and 8
4.4.1 Scale 6
Relatively speaking, scale 6 is very sensitive to state influences. The diagnostician can, when high
scores on scale 6 occur, easily and wrongly assume a high degree of emotional
instability and thus of vulnerability in the personality structure.
4.4.2 Scale 8
In the long run and after a long time of demoralization, even scale 8 can gradually show
elevations. A high score demonstrates despondency, feelings of desperation, hopelessness,
diminished ambition and reduced battle together with fear of losing the grasp on thinking and
feeling. Feelings of alienation are also prominently present.
4.5 Deducing the state characteristics from the clinical scales
In addition to the moderately successful attempts to correct scales of state influences with the
construction of the RC (restructured scales; van der Heijden et al, 2007), three separate and yet
converging methods for this purpose will be discussed here.
- The appraisal of the clinical subscales
- Theory driven expectations and predictions
- The joint use of the NVM/NKPV and the MMPI as a the “golden” couple.
4.5.1 Clinical subscales
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As compensation for the heterogeneous nature of most of the clinical scales, for a number of
these clinical scales item pools are identified within these scales that can contribute to the height
(high and low) of the total score on the scale. In the text here below follows a list of the subscales
that differentiate most:
4.5.1.1 Subscales scale 3
1. Hy1 Denial of social anxiety
2. Hy2 Neediness for affection
3. Hy3 Malaise
4. Hy4 Somatic complaints
5. Hy5 Inhibition of aggression
Re1: Denial of social anxiety
When the scores are elevated in this subscale, one experiences oneself as emphatically sociable,
flexible, easy going and pliable in social situations. As part of scale 3, it is mainly about covering
of social anxiety, fear of being rejected and being disapproved, jealousy and difficulty with
autonomy (their own and others). Feelings of irritation, anger and resistance are repelled.
Re2: Neediness in affection
High scores reflect regressive and often insatiable needs for dependency. There are three main
reasons why clients would have low scores:
- They have lost hope to receive affection and therefore shield (narcissistically) their
passive desires.
- They have had such bad experiences with receiving affection in the past, that they tend
to choose solitude and unhappiness above entering a full affective relationship with the
risk of being abused and exploited once again.
- They are so inept in relationships that withdrawal protects against another chance of
experiencing failure and disappointment.
Re3: Malaise
A diffuse and archaic feeling of exhaustion and despair.
Re4: Somatic complaints
Somatic complaints predominate, in some clients, as a correlate to diffuse anxiety, suppression
of anger and problems with autonomy.
Re5: Inhibition of aggression
What does a lower score on this subscale mean when the overall score on scale 3 is high? The
subjective evaluation of the prevailing anger is negative because this does not match well with
the self-image. Hence, one experiences subjectively a little bit of anger as hefty. This feeling
occurs despite massive repression and defense. That is why one quickly scores high on this
subscale, while aggressive and other unwanted negative emotions have only increased a little.
4.5.1.2 Subscales scale 4
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1. Pd1 Domestic discord
2. Pd2 Authority issues
3. Pd3 Social imperturbability
4. Pd4 Social alienation
5. Pd5 Self-alienation
Re1: Domestic discord
Elevations reflect present and past situational discontent about relations with relatives and
immediate family members.
Low scores indicate strong feelings of loyalty and saving important individuals from criticism and
blame.
Re2: Authority issues
Raised scores usually indicate having a proud position and of being easily hurt and offended
when receiving criticism. “I will not tolerate others telling me what to do; nobody needs to
interfere with my life”. In a limited number of cases, especially in more mature structures, the
function of taking this stance is more to keep distance form others, either due to feelings of
insecurity or to inability to handle emotional and relational proximity (in these cases Pd3 is ˂ 50).
Low and even very low scores are specific to internalizing clients, who tend to comply easily and
take on a docile attitude.
Extreme low scores occur very often in cases of internalizing clients, who have experienced bad
events, mostly of traumatic nature. They can even show raw scores of zero.
Re3: Social aloofness
From the DTP method perspective, this is the utmost important subscale of scale 4. All norm
scores with T-values ≥ 50 can be considered as significant based on clinical evidence. Social
aloofness implies not getting out of the way for anyone; not paying attention to the needs of
others nor accommodating anybody. “The world is mine” as primitive characteristics. The ability
to perceive others is hardly to nonexistent due to lack of one’s own psychic differentiation.
Especially in combination with a high score on the Pd2 subscale this is an indication of the
presence of antisocial traits, which is not subject to state influences. These scores are to be taken
seriously, also when the total score on scale 4 is relatively low. In rare social situation, the
aloofness covers up feeling offended, while shielding the intrinsic vulnerability, by taking on an
as-if indifferent, independent, composed and casual stance. In principle, one is certainly upset
but covers up the vulnerability by this attitude (also see page 32). In these cases the score on the
Ma3 is low, when they usually have the same heights (both low or both high).
Extreme low scores often occur in cases of internalizing clients, who have experienced disturbing
events, mostly of a traumatic nature.
Re4 and 5: Social and self-alienation
Scale 4 always has to do with characteristics of an interpersonal dyadic nature. The term
alienation denotes feeling disrespected, not being heard nor understood by significant others.
Both scores are nearly always elevated simultaneously. One does not belong; feels not being
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taken seriously; one is unworthy of being included nor of receiving attention. In case of
personality problems and psychopathology, it is even more remarkable if the scores on these two
subscales are not raised. Conversely, the whole scale 4 can be temporarily elevated, sometimes
very often and strongly so, without the impulsive antisocial markers Pd2 and Pd3.
4.5.1.3 Subscales scale 6
1. Pa1 Pursuit ideas
2. Pa2 Sensitivity
3. Pa3 Naivity
Re1: Pursuit ideas
Massive distrust, but also self-reported paranoid psychotic phenomena, provided they are
recognized as such, push up the score.
Low scores refer to childlike levels of trust and belief in the benevolence of mankind.
Re2: Sensitivity
This subscale, contrary to the suggested meaning due to the improper designation of this
subscale, relates to inner turmoil (irritability) and tension, that can increase substantially as a
result of state influences. This also allows scale 6 as a whole to (significantly) rise. This is
important because without sufficient awareness of this, the diagnostician might wrongly assume
excessive vulnerability, while it rather concerns inner negative affect impetus, due to unresolved
emotions (van Gael, 1996).
Low scores point to entire denial/negation of unwanted internal dynamics out of the illusion of
having these emotions under control.
Re3: Naivety
“Bien étonnés de se trouver ensemble”. One can be surprised by the fact that this subscale is
placed in scale 6. Nevertheless, the statistical relationship has valuable clinical significance.
Narcissistic and suspicious traits are often present together. Clients have the megalomaniac idea,
simply on the basis of magical denial of reality, that they will not be affected by accidents nor by
ill treatment. This subscale is hardly sensitive to state influences.
Low scores on Pa3 suggest that one is prepared to face one’s own psychic dynamics.
4.5.1.4 Subscales scale 8
1 Sc1: Social alienation
2 Sc2: Emotional alienation
3 Sc3: Deficient coping-cognitive
4 Sc4: Deficient coping- perception and behavior
5 Sc5: Deficient coping-disinhibition
6 Sc6: Odd sensory experiences
Re1 and 2: Social alienation and Emotional alienation
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Sc1 is about the difficulty to feel real connection with others. One is an outsider and a distant
spectator.
When Sc2 is high, one reports difficulties in getting in touch with the own emotional life. Clients
feel depersonalized. Sc1 and Sc2 are nearly always elevated in case of sever personality problems
and pathology.
It is remarkable to encounter average to low scores on these subscales, especially when
psychopathology is present. This occurs frequently in cases characterized by feeling defects, such
as early narcissistic disorders and autism spectrum disturbances.
Re3: Deficient coping-cognitive
The score on subscale Sc3 is often high and even extremely heightened in cases of
psychopathology. This score reflects frantic attempts to get a grip on one’s own negative
emotions through reasoning, which is sometimes the most important coping mechanism.
Also here average and lower scores count as notable.
Re4: Deficient coping-perception and behavior
The former designation, namely “conative or functions of will” was superior with respect to the
connotation of this subscale. This subscale is extremely sensitive to state influences. One
declares in an indirect manner feeling despondent; giving up ambition and the battle; having no
energy left to change something in the situation; feeling weary and in despair. Demoralization is
extremely present. This inner attitude is not always directed outwards straight away. The often
concealed severe feeling of demoralization, is therefore not so easily visible. One tends to please
the therapist by taking on an apparent cooperative stance, but has no real hope for a satisfactory
treatment result.
Re5: Deficient coping-disinhibition
Sc5 represents mainly the subjective experiencing of disinhibition, in the sense of control loss of
thinking and feeling. The score on Sc5 raises, specifically and mostly, in cases of more severe
psychopathology such as psychic and psychotic decompensation.
Re6: Odd sensory experiences
Scores on the Sc6 subscale concern unreal experiences and sensory sensations just as with
psychotic phenomena. For the same reason, this subscale in some cases can also be elevated
when serious dissociative symptoms appear. Also, with the presence of hefty not well
understood and unexplained somatic complaints and sensations that are often associated with
the context of somatoform disorders.
4.5.1.5 Subscales scale 9
1. Ma1: Immorality
2. Ma2: Psychomotor acceleration
3. Ma3: Imperturbability
4. Ma4: Ego-inflation
Re1: Immorality
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The subscale Immorality refers to a lack of conscience function. Opportunism tends to reign and
moreover, one does not conceive this characteristic as negative, often on the contrary.
Occasionally a client will score on this scale due to feelings of regret and remorse. One
embarrassedly admits and punishes one’s self for the amplified way of pursuing one's own needs
and interests.
Low scores emphasize excessively developed conscience function together with repressive
tendencies and (too) high ideals and goals.
Re2: Psychomotor acceleration
Psychomotoric agitation and disinhibition are related to antisocial traits, but also to
developmental disorders, such as attention deficit and hyperactivity disorders (ADHD).
Temporary overactivity can also cause elevations.
Low scores represent clients, who lack contact with their inner psychic dynamics, mostly caused
by the defense mechanism of “isolation of affect”, but sometimes also due to an inability to
connect rationality and emotions.
Re3: Imperturbability
Social (Pd3) and general imperturbability (Ma3) are commonly similar to reasonably. For clinical
interpretation ends of purposes, the values of the norm scores are also in line with each other.
When Pd3 and Ma3 differ, a high score on Pd3 is more favorable while scoring low at the same
time on Ma3 than the opposite. The hypothesis is in that case that egocentrism conceals and
covers vulnerability and sensitivity. When Ma3 is high relative to Pd3, it is the other way around.
A seemingly and opportunistic social attitude masks an underlying overall imperturbability. One
is not easily nor truly deeply emotionally touched by others and has little compassion and barely
any emotions when exploiting the social environment despite the appearance of the contrary. It
becomes especially evident in a deepening relationship (Matthijs, 1985).
Low scores correspond to low values on subscale Pd3.
Re4: Ego-inflation
High scores on the subscale ego-inflation indicate feelings of greatness. One reports feeling more
important than others, having more rights and permitting oneself without any question to take
up more space (oblivious narcissism). To interpretate these scores correctly, it is important,
similar to all other results, to consider the scores in the context of other outcomes. Within the
MMPI, as well as, other personality assessment methods. So why would clients, who are not
characterized earlier with having narcissistic traits, score somewhat high on the Ma4? The
interpretation of high scores on this subscale in these cases become extra important and have
additional value (layered psychopathology). Indeed, one tends to take on a detached and
withdrawn (in the self) attitude and is excessively focused on experiences and perceptions of
one’s own inner idealizations. But this attitude and focus have an alternative function compared
to clients with substantial narcissistic traits. Two possible hypotheses can be made to account for
these results:
- Inability due to structurally inadequate social coping and attunement mechanisms. The
confrontation with these deficits is avoided.
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- Anxiety of behaving passively and devotedly in intimate relationships. One safeguards
one’s self through fencing off one’s own emotional life from the outside world. There are
two possible reasons that may explain it. An internal and an external one. The internal
reason consists of counteracting impending fragmentation, decompensation and
disorganization, because of the mounting up of negative emotions in ego-weak,
vulnerable clients. The external reason consists of the disconnection of emotional
involvement with the social environment, due to numerous bad experiences, such as
traumatizing and exploitative relationships.
Those, who score low on this subscale, indicate the opposite. Namely hardly being allowed to
feel, belong and function in an authentic fashion.
4.5.2 Theory-driven expectations and hypotheses
Each dynamic entity matches with a prototypical score profile on the MMPI (Snellen, 2018;
Westen et al, 2010). Deviations, either in high or in low directions, can then be attributed to state
influences.
A few exempels:
- Elevated scores on the scales 4 and 9, as a rule, do not fit clients, who have a structural
inability for reality testing. Nevertheless, if these scores are higher than expected than
state influences account for these outcomes.
- High scores on the clinical scales 2, 7 and 0 but also high scores on scale 1 and 3 belong
to high-level borderline personalities. When the 9 score also rises, it almost always stems
from a breakthrough of trauma-related emotions.
- No high scores on the scales 4 and 8 can be expected in the context of a neurotic
personality structure with very high scores on the 2, 7 and 0 scales. When these scores
increase anyway, it should then be considered as temporarily pushed up, unless there
are alternative indications of other complications that interfere with the clinical
syndrome, such as severe schizotypal traits and neurocognitive disorders.
The so called attribution errors, namely interpretating assessment data from one biased
perspective and psychic domain, can blur, blind and distort the critical clinical view. Therefore,
only a multimethod, multi-conceptual approach of the clinical reality can help to distinguish the
various psychic domains and clarify the state-trait ratio.
4.5.3 Joint application of the MMPI and the NVM (a short version of the MMPI in Dutch)
The factor analyzed purification procedure of the MMPI in 1980 has resulted in the Dutch short
version of the MMPI, the NVM (DSM, Nederlandse Verkorte MMPI; Luteijn & Kok, 1985). With
the publishing of the NKPV in 2015 (Nederlandse Klinische Persoonlijkheids Vragenlijst, the Dutch
Clinical Personality Questionnaire; Barelds & Luteijn, 2015) an update was edited and
republished. Besides the three dimensions of somatization, shyness and (severe-)
psychopathology that are similar to the combination of specific clinical scales of the MMPI, there
are two dimensions that cannot be distilled from the MMPI on face value but are indeed
enclosed in the score profiles, namely negativism and extraversion. Because of these statistical
procedures, the NVM and NKPV are considerably less sensitive to state influences. The
diagnostician projects the outcomes of the NVM to clinical score profiles of the MMPI that are
based on the assumed NVM-MMPI relations. Found deviations of these expectations can then be
attributed to state characteristics. For example, heightened scores on the scales 6 and 8 with at
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the same time an average score on the NVM/NKPV dimension psychopathology. It is therefore
very beneficial to apply the NVM/NKPV and the MMPI concurrently in clinical individualized
practiced psychodiagnostic assessment procedures (Eurelings-Bontekoe & Snellen, 2013).
5. Validity, content and supplementary scales
Attention should be given to three very different types of scales: the validity scales, the content
scales and the supplementary scales. Although these scale groups have their own status, they
correspond in the sense that they each, in their own right are helpful with interpretating the
MMPI clinical scales.
5.1 Validity scales L, F and K
The purpose of the construction and the appraisal of the validity scales is to estimate the
reliability of the outcomes. Actual unreliability (at random response tendencies) rarely occur in
clinical setting. It is usually the question whether the client has filled in the questionnaire with an
open or defensive attitude. In this instance open means admitting signs of psychopathology and
defensive refers to the covering up of unacceptable aberrant feelings, thoughts and symptoms
(denial and social desirability). Defensiveness, seen in an elevation of the L scale, implies inability
of introspection nor being empathic to others. Clients with high scores are in different degrees of
severity conservative, fundamentalist and naive. The K scale indicates a more nuanced form of
social desirability, in which one tries to obscure weak and poorly appreciated qualities in one's
own and other people's eyes. The F scale represents both, the degree of felt distress and the
reported awareness of differentiation from the general population. In the second and adult
version of the MMPI (MMPI-2) two validity scales were added, the Fb and the Fp. Scale Fb relates
to the content scales and scale Fp, as part of scale F, to (confirmation of) rare items with a more
serious pathological signification.
Certain relevant score configurations:
5.1.1 L and K scales low and F high
Low scores on the scales L and K indicate an open attitude while completing the MMPI and the
acknowledgement of complaints and symptoms. Extreme scores on scale F reflect great suffering
(T-values ≥75) and the awareness of diverging from the norm, see figure 25:
Figure 23 Low L and K scales and extremely high F
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Three possible explanations can account for these results:
- Ego weakness and generally experienced vulnerability
- Aggravation of reported complaints and symptoms with the purpose receiving attention
for them in an amplified way (cry for help)
- Reflection of grave manifest psycho- and personality psychopathology.
5.1.2 L, F and K scales high
With elevations of the scores on all three validity scales at the same time, the peculiar case arises
that clients score high on the F scale together with completing the rest of the questionnaire in a
defensive way. This points to a high state influence in covering self-denounced and shamefully
perceived characteristics that one hides from the outside world by keeping up a façade. See for a
configuration of this kind figure 24:
Figure 24: Scales F, L and K high
5.1.3 Scales L and K very low in combination with an average F score
When scores on the scales L and K are low, one can appropriately expect a higher score on the F
scale. What might be the significance when the score on the F scale is relatively heightened, but
nevertheless it is not higher than average? See figure 25:
Figure 25: Low scores on the scales L and K in combination with an average score on scale F
Notwithstanding the open attitude, one does not declare much psychic dynamics, as can be seen
in the height of the F scale. It may imply inability or the use of defenses, one of the two
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L F K
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possibilities. In such instances a follow-up investigation is certainly a necessity to provide more
clarity about this issue.
5.1.4 Relatively high scores on the L and K scales with a fairly low F score
Complications in treatment indications for therapeutic processes should not be underestimated
when high scores on the scales L and K go together with lower score positions on scale F, see the
blue line in figure 26:
Figure 26: High scores on L and K in combination with a (relative) low score on F
Both social desirability scales 1 and 3 are elevated and enforce each other. It presents both a
façade in which negative characteristics are concealed (scale K, faking good) as well as inability to
be in touch with one’s own and others intrapsychic dynamics (scale L). This refers to the
mechanism of “alexithymia” (Taylor, 1984). There is not only the incapability to recognize and
name the own feelings, but one is completely incapable of being in touch with one’s own inner
world as a whole, and often also that of others. When it comes to completing the MMPI
questionnaire, it often implies that the clinical scales can be pushed down, especially the scales
EI.
Notwithstanding the shortcomings of being unable to get in touch with one’s own psychic
dynamics, one can sometimes be capable of reporting inner turmoil. It is perceived in the clinical
image which then culminates in somewhat elevated scores on scale F despite the high scores on
the scales L and K (see the red line in figure 26).
5.1.5 L, F and K scales low
When all of the scores on the three validity scales are low, the diagnostician should seriously
consider the existence of very early personality pathology, such as psychopathic traits and severe
forms of early narcissism (often seen in a V shape) or of subtypes of ASD (usually seen in a roof
shape) or a combination of both disorders.
5.1.6 Scale L high with scales F and K low(er) or scale K high with scales L and F low(er)
See for score patterns in figure 27:
Figure 27: Scale L high or K high
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L F K
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When the score on scale L is high together with lower scores on the scales F and K (red line) there
are for sure the reporting of pathological signs, but there is little insight into the background and
the underlying dynamics, usually it is due to insufficient ability to that end. When only the score
on scale K is high (blue line) one tries to present oneself as normal and as adapted to the
expectations of others as much possible.
5.1.7 Scales Fb and Fp
The relation between the score on scale F and those on the scales Fb and Fp has great clinical
relevance. For obvious reasons the score on the scale Fb is often somewhat higher than the score
on scale F and the score on scale Fp is usually slightly lower than scale F. When this is not the
case (Fb is lower than F) it calls for further investigation to find the cause of this phenomenon.
Mostly it indicates egosyntonie of the psychopathology in the context of an inability for an
adequate self-representation on self-reports. Scores on scale Fb that exceed those on scale F
considerably mirror a great deal of state influences.
5.2 Content scales
Figure 28 depicts a common score profile of the content scales which are commonly found
among clients with psychopathology:
Figure 28: Common and frequent found profile of the content scales
A number of clinical findings are discussed per content scale that are worth noting. This is
followed by a number of possible scoring combinations that are often found by diagnosticians in
their clinical practice.
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ANX FRS OBS DEP HEA BIZ ANG CYN TPA ASP LSE SOD FAM WRK TRT
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5.2.1 The content scales each in their own right
➢ ANX:
The anxiety scale (ANX) increases on average first and fastest in any kind of psychopathology . It
can be considered as the most sensitive scale of the content scales. The (relative) lagging behind
of a score on the ANX scale is more striking than an elevation of this score as such. Often a
relative low score refers therefore to ASD pathology. Severe variaties of early personality
disorders may also apply.
➢ FRS
The fears scale (FRS) contains specific items and in rare cases it is elevated. This involves
externalized and projected fear onto a specific object.
➢ OBS
After the anxiety and depression scales, this scale is the third in sequence to show elevations
within the anxiety- and depression cluster (ANX, FRS, OBS and DEP). The obsession scale is often
prominently visible in the score profile of the content scales, next to the already present
elevations on ANX and DEP, especially with traits within cluster A of the DSM personality
disorders, such as schizoid and schizotypal personality disorders (and extra vulnerability to
develop psychotic symptoms), but also with developmental disorders, primarily ASD and ADHD.
➢ DEP
The depression scale is commonly raised together with the anxiety scale, nevertheless it lags a
fraction behind it. This content scale reacts strongly to experienced intrapsychic dynamics. One
quickly indicates feeling desolate on this scale. The DEP scale is much more sensitive and non-
specific than the clinical scale 2.
➢ HEA
This scale is mainly about the somatic aspects of the elevations on the clinical scales 1 and 3
when one worries about his/her physical health.
➢ BIZ
The bizarre ideation scale (BIZ, bizarre representations and thoughts) focuses on the
representation of one’s perceptions experienced as strange. This scale does not raise easily and is
specific in its nature. The interpretation of this scale always takes place against the background
of and in combination with the clinical scales 6 and in particular 8, with special attention for the
subscales Sc5 and Sc6. Discrepancies between the subscale Sc6 and scale BIZ therefore are
conspicuous and meaningful. For example, the combination of high scores on subscale Sc6 and
lower scores on the content scale BIZ can indicate the existence of dissociative phenomena
rather than psychotic symptoms.
➢ ANG
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When this scale is elevated, it refers to the experienced and reported feelings of anger and
rage. For its interpretation, it is important to initially draw up a theory-driven expectation about
the degree of anger that is characteristic of the supposed dynamic entity. Afterwards the
diagnostician compares this expectation with the actual score on the anger scale, representing
the level of self-reported subjective evaluation of one’s anger. For instance, a client, who mainly
applies internalizing coping mechanisms and thus usually suppresses anxiety, will show a higher
score on the anger scale than expected when frustrations increase to for him unacceptable levels
despite control and defense. In these cases the client already perceives low levels of anger
rapidly as excessive.
➢ CYN
Cynism can be seen as an indirect way of shaping aggression. Aggressive feelings are covered
up by a snappish and discrediting attitude.
➢ ASP
The antisocial practices scale is about factual and specific asocial and antisocial behavior. Raised
scores do not necessarily point to antisocial traits in the personality structure. Indeed it is most
often not the case.
➢ TPA
High scores, on the type A scale, are often found in ADHD and in structural and prolonged
periods of inner turmoil.
➢ LSE
The scale low self-esteem shows in terms of its significance great overlap with the clinical scales 2
and 7. In principle, in all cases of high-level personality organizations and structures the scores
are high. Uncertainty, self-doubt and feelings of inferiority characterize the clinical image.
➢ SOD
Social discomfort scores indicate social insecurity and, with sharp increases, also social anxiety,
possibly in combination with experiencing social awkwardness and ineptness.
High correlations with concepts, dimensions and subtests, such as shyness, social inadequacy and
social introversion, acknowledge the intended essence of this content scale. When the internal
psychic differentiation is less developed and present, the diagnostician expects lower scores on
this content scale.
➢ FAM
The score on the family scale is quickly increased in case of dissatisfaction with all sort of social
and familial relationships, in which one functions or has functioned and from which one (still
continuously) suffers a lot. It involves therefore the current feelings of frustration.
➢ WRK
The work scale also has to do with feelings of dissatisfaction about not being able to function
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well at the workplace. It does not suggest anything about the cause of it. These scores may also
occur in otherwise mentally healthy people, who become suspicious and insecure due to working
in an unsafe working environment
➢ TRT
The meaning of the TRT scale can be confusing. The reason lies in its name (negative treatment
attitude indicator) and to the intention of the construction of this content scale. Clinical evidence
suggests that high scores do not indicate a lack of will to cooperate, rather than a lack of hope for
a positive result of a treatment. The client feels demoralized and only adapts to meet the
expectations of the practitioner and indulge him. In cases in which the TRT scale scores are high,
it is primarily important to address and problematize the expectations of the client as a topic in
the beginning of a psychological treatment. A slightly increased score is normal in mental health
care because of the anxiety that therapy may generate.
Hence, average to low scores reflect a quasi-motivated attitude without much self-criticism.
Indeed one comes across average and low scores more often in forensic and addiction settings.
5.2.2 Relevant combinations of the content scales
Roughly two clusters are to be distinguished within the content scales, namely an internalizing
cluster consisting of two sub-clusters and an aggression cluster.
5.2.2.1 Cluster of internalizing scales
The internalizing cluster is made up of two subclusters, namely that of the ANX, FRS, OBS and
DEP scales and the other one is comprised of the LSE and SOD scales.
5.2.2.1.1 Subcluster scales ANX, FRS, OBS and DEP
Heightened scores on the scales ANX and DEP are common in case of mild to severe forms of
psychopathology, see figure 29. Deviations are to be understood as atypical.
Figure 29: Common score profile first subcluster of the content scales
The diagnostician finds low scores in cases of early personality pathology like oblivious
narcissistic properties and often in developmental disorders too.
5.2.2.1.2 Subcluster scales LSE and SOD
Clients who’s personality functioning is organized on a high level (internalizing, emotional
differentiation; mostly neurotically organized or with extremely high level borderline
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personalities) have considerably elevated scores on both the content scales LSE and SOD. Yet,
already at slightly lower and weaker level of functioning and personality structures, the SOD
scale score decreases relative to the LSE scale, see Figure 30:
Figure 30: A higher LSE score than the SOD score
Lower scores on the scale SOD correspond to (relatively) lower scores on the clinical scale 0 (this
also counts for the NVM/NKPV dimension shyness). The defense mechanisms and the internal
emotional differentiation then are of a less developed, mature quality (more impulsivity and
black and white thinking as the score gets lower). The lower the score on SOD, the greater the
doubt one has about one’s own identity (identity diffusion).
Absolutely atypical of nature therefore is the reverse score pattern, namely a higher score on the
scale SOD combined with a lower score on the scale LSE. Social uncertainty and anxiety do not go
together with its counterpart, namely internal feelings of uncertainty. These dynamics take no
part in the self-image, despite the social inhibition. This indicates emotional deficiencies, see
figure 31:
Figure 31: An average LSE score combined with a higher SOD score
Average to low scores on the scale combination LSE and SOD (both low at the same time)
hypothesize the existence of early personality pathology, such as narcissistic disorders or more
severe pathologies. One totally rejects aggressive feelings and experiencing easily feelings of
offense and insult when receiving criticism.
5.2.2.2 Cluster of the aggression scales
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LSE SOD
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The aggression cluster of the content scales consists of four scales that lay next to each other in
the middle of the score configuration of the content scales profile, namely ANG, CYN, ASP and
TPA. In cases of increased ANG and CYN (direct and indirect aggression respectively), it is
expected that the internalizing content scales will almost always also show elevated or high
scores, if internalizing mechanisms have developed. Preferably, these scores are higher than the
scales of aggression in order to maintain and promote control. A few combinations are possible:
- High scores on the internalizing and aggression scales
Low(er) scores on the aggression scales are to be expected in cases of neurotic structures and
high level borderline personalities. Sometimes the repression is so extreme that the raw scores
on the aggression scales are very low and/or nearly equal to zero. Higher scores therefore
indicate heavy state influences. In such cases, high to very high scores of the aggression cluster
will go hand in hand and simultaneously with a substantial increase on all internalization scales.
Clients with psychotic personality structures and immature personalities, as expected on
theoretical-clinical grounds, consistently demonstrate average aggression levels in combination
with elevated LSE and only average to slightly above average SOD scores.
- Moderate levels of internalizing mechanisms in combination with above average
aggression
Clients, who are prone to develop feelings of anxiety quickly (high EI) in combination with
intermediate to low level borderline characteristics, will demonstrate in their structural nature
higher levels of aggression. Due to deficient internalizing coping mechanisms, they do not
succeed to reduce these feelings, see figure 32:
Figure 32: Low level borderline characteristics with relative high aggression scales
Note that typically for low level personality structures, the score on the SOD scale remains
relatively low in the score profile.
- Low levels of internalizing mechanisms In combination with high aggression
Clients characterized by hypervigilant narcissistic pathology tend to deny aggressive feelings,
thus they obviously tend to present low scores on the aggression scales in self-report
questionnaires. External and long-lasting feelings of indignation and frustrations can temporarily
raise aggressive feelings in combination with some temporary (slightly) increased internalizing
mechanisms, see figure 33:
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Figure 33: Sensitive narcissistic personalities with raised scores on the aggression scales
When the scores on the aggression scales are elevated together and simultaneously with a total
absence of the sensitive internalizing scores, then one does not mentalize and integrate
aggressive feelings at all, with results in unexpected impulsiveness, see figure 34:
Figure 34: High scores on the aggression scales with a lack of internal processing
5.3 The supplementary Es scale
The supplementary scales can be considered as complementary and are partly still experimental
in nature. The following are a few comments about the Ego-strength (Es) scale, because it is
often taken into account in daily clinical practice together with many misunderstandings about
the interpretation of this scale. The ES scale is the only scale within the MMPI, which is not
reversed in a pathological direction. It is asserted by MMPI experts (Butcher among others, in
oral communication to the author in 1992) that low to very low scores on the Es scale refer to
ego-weakness. Extra caution should be required when indicating a psychotherapeutic treatment.
This statement needs a nuance, because the Es scale does not represent a structural personality
characteristic. It is rather the outcome of the fraction between the capacity to tolerate
frustration and psychic burden. In other words, the higher the psychic suffering (denumerator),
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ANX FRS OBS DEP HEA BIZ ANG CYN ASP TPA LSE SOD FAM WRK TRT
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the smaller the fracture, thus the farther the score on the scale will drop, sometimes even to the
point of negative values. Low scores therefore do not have to indicate ego-weakness at all. It may
even appear among people with ego strength, who are immensely under stress. As always and
therefore here too, the mix-up of structure and state can do injustice to the client. Vice versa,
the same applies to clients, who have higher scores because of low state levels superimposed on
weak psychic resources. The nomenclature of this scale therefore is inadequate and can mislead
the clinician.
6 Special score profiles of the MMPI
6.1 Complexities
For an example of a score profile that mirrors great stratification and complexity in the
psychopathological representation, see figure 35:
Figure 35: Score profile representing a stratified and complex psychic representation
The displayed profile in figure 35 indicates the merging of the hypothesized immature
personality (2, 7 together with an average 0) with both narcissistic (relatively lower 1 and 3) and
schizotypical (7 and 8) traits. This complexity does not consist out of the severity of all the
distinguishable components in the score profile as such, but rather out of the sum of the
characteristics that reinforce each other in a negative way. Additionally, the advantage of using
psychodiagnostic instruments lies in the possibility to unravel the clinical presentation/profile,
which is composed of the different building blocks.
6.2 Inconsistencies
Inconsistencies can manifest themselves in all kinds of levels and areas in the diagnostic data, i.e.
between the results of several different instruments or within the outcomes of one instrument.
Below follows a summary of some of the various possibilities of such inconsistencies in de MMPI.
Some were briefly mentioned previously, such as the combination of a high score on the SOD in
combination with a low score on the LSE content scales. This also applies to the lagging behind of
the most sensitive internalizing scales, such as the content scales ANX and DEP, together with the
concurrent reported stress and anger. Self-report and self-representation thus are at odds with
the clinical and theory driven developmental models. It is preferable to recognize and identify
these inconsistencies and to take them seriously, rather than to consider them as uncomfortable
0
10
20
30
40
50
60
70
80
90
L F K 1 2 3 4 5 6 7 8 9 0
45
and unwelcomed complications, when interpretating the questionnaire. It is advisable to avoid
making forced statements in the attempts to make the incomprehensible comprehensible.
Several explanations are possible for inconsistencies that occur. The following are the most
important ones:
- The rarely occurring response tendencies.
- Being so psychicly disorganized that the client is not able to give a coherent self-
representation and thus reports many conflicting and contradictory aspects of one’s own
psychic functioning. The questionnaire is filled in inconsistently, because the client
experiences him/herself in an erratic way.
- Incapability of perceiving and understanding the underlying intention and meaning of the
items. One thus tends to answer factually and concretely. E.g.: “I like dancing very much”
as incorrect or not agreed, in case of, for example, a permanent injury of the legs.
- Alternating between state and personality traits might cause confusion about the
structural nature of the symptoms.
- Long-term influences can cross basic structural and basic traits, such as excessive
impulsivity caused among other things by congenital brain injury (NCB) and complex
PTSS as examples.
- Temporarily or permanent lack of reality testing and assessment
- Disconnection of many domains and layers within the psychic functioning. Behavior or
temporarily used coping strategies, for example, do not match and are sometimes even
incompatible with the basic and structural traits, as well as, with the underlying
personality structure and organization.
- Inability to represent oneself in a coherent manner due to developmental disorders, such
as ASD characteristics.
These explanations sometimes coincide or even go together. In the absence of (alternative)
explanations and hypotheses, it is then necessary to continue searching on the basis of a
hypothetical-deductive method, just as long as the most plausible reason for these
inconsistencies are found.
For the sake of further reflection on the matter, the following is a presentation of possible and
also fairly frequent examples from the clinical practice.
- High L score and lower F score in combination with average scores on the subscales Sc1
and Sc2
The relatively low scores on the subscales Sc1 and Sc2 are noteworthy. One does not report
feelings of alienation within scale 8, even though the configuration of the validity scales
suggest just that. The indirect way of monitoring the dynamics is not in line with the
phenomena that are inquired in a direct manner.
- Low score on scale 0 in combination with low scores on the subscales Pd3 and Ma3 (the
imperturbability subscales)
A scoring combination that often occurs. However, it is incorrect on theoretical grounds. When
scores on the shyness scale are high, the inner inhibition mechanisms would lead to the
adaptation to the wishes, expectations and demands of others. This is compatible with low
scores on Pd3 and Ma3 (T scores < 50) and vice versa. A low 0 score in combination with low
scores on Pd3 and Ma3, are illogical and not do not make sense from the developmental
perspective. These inconsistencies are common in cases of developmental disorders and such
46
can indicate it. For example, it may represent clients, who show repressed behavior on the one
side but are reluctant, distant and do not really care about others on the other side, usually
because of an incapability for that end. Possibly it is done without any awareness. The client
indirectly and unintentionally demonstrates incomprehension of where the concrete content of
the items refer to.
- High scores on the clinical scales 7 and 0 in combination with relatively lower scores on
the 1, 2 and 3 scales
Figure 36 portrays a notorious score profile in the clinical setting, which usually and strikingly
often appears in cases of ASD pathology (Kok en Eurelings-Bontekoe, 2007):
Figure 36: Lagging scores on the scales 1, 2 and 3 together with elevated scores on 7 and 0
Both, the high L validity scale and the relatively low scores on the scales that represent the inner
dynamics, reflect a serious lack of mentalization ability. The sense of inner turmoil, the social
awkwardness and the attempts at rational control are familiar to the client.
7 In conclusion
With the help of a theory-driven interpretation method in a personality assessment, the
diagnostician can determine the strengths and weakest links in a client's psychological structure
and functioning (Jonker & Snellen, 1991; Hörz-Sagstetter et al, 2021). This is of importance for
the clinical practitioner. The diagnostics enable the clinician to adapt and match the therapy to
the psychological level of the client (Gabbard, 2002). The vision, which was obtained, forms a
good foundation to the interventions, which are carried out. With a vision thus obtained the
performed interventions are also conceived of a better foundation. The complaints and
symptoms are perceived in a contextual embedding, which makes it possible to better account
for the clinician’s actions (Snellen & Eurelings-Bontekoe, 2009). It is the fundamental reason for
applying personality assessment. Utilizing personality assessment in daily clinical practice
remains a difficult and a challenging undertaking. Nevertheless, it is worth the effort, because it
enhances the professional abilities of the clinician, which benefits the care given to the client. A
well-executed personality assessment offers the necessary added value and sometimes it offers
indispensable support, but the initial inquisitive observation and the logical and critical
thinking/analysis will always remain the most indispensable tools of the clinician.
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