Addi~'tive Behavior.s, Vol. 4. pp. 401 to 407 © Pergamon Press Ltd 1979. Printed in Great Britain
0306-4603 79 1101-0401502.00/0
MACANDREW ADDICTION SCALE AND OTHER MMPI CHARACTERISTICS ASSOCIATED WITH OBESITY, ANOREXIA AND SMOKING BEHAVIOR GLORIA RAKITA LEON*, RONETTE KOLOTKIN a n d GREGORY KORGESKI University of Minnesota Abstract--Groups of persons with substance abuse problems (obesity, smoking, and anorexia) and a normal control group of persons without habit problems were evaluated on the MacAndrew Scale (MAC) of the MMPI (originally developed to measure proneness to alcoholism). Two Point code types were calculated for those persons for whom complete MMPI information was available. The male smokers demonstrated a mean MAC score close to the addictive range. The female smokers and the in general moderately obese groups as well as the anorexic group showed no significant differences in MAC score in comparison to the normal controls. The smokers and obese subjects showed a tendency toward depression and impulsivity, and the smokers also showed a trend toward somatization. It appears from the present findings as well as those of other investigators that an elevated score on the MacAndrew Scale can be interpreted as an indication of an addiction problem or addiction proneness. However, not all persons with substance abuse patterns have an elevated score on this measure.
The identification of individuals who may be prone to develop various substance abuse problems is an important concern in terms of prevention and early intervention. The possibility that a common addictive personality or behavioral syndrome exists in persons with different types of addiction problems can only be evaluated after the development of reliable and valid measuring instruments. At present, the MacAndrew Scale (MAC) has been demonstrated to be unique in its ability to tap a common personality or behavioral dimension across at least 2 types of addiction problems: alcoholism and opiate drug addiction. Since MacAndrew's publication in 1965 of an MMPI-derived scale that differentiated between male alcoholic out-patients and non-alcoholic psychiatric outpatients, other investigators have confirmed the ability of the MAC scale to accurately identify alcoholic from general psychiatric groups (e.g., Rich & Davis, 1969; Rosenberg, 1972; and Vega, 1971). MacAndrew (1965) found that a cutoff score of 24 successfully classified 81.759/o of the alcoholics and the non-alcoholics. The stability of the MAC scores before and after treatment for alcoholism was demonstrated by Chang et al. (1973), Huber & Danahy (1975), and Rohan, 1972. Further, Hoffman et al. (1974) found no significant difference in the MAC scores of a group of alcoholics compared with their pre-alcoholic college entrance MAC scores obtained an average of 13 yr previously. The MAC scores of the pre-alcoholic co.llege students significantly differentiated them at a 729/o accuracy level from a random sample of college classmate controls. The possibility that the MacAndrew Scale measures a more general characteristic of addiction proneness or an addictive behavior pattern rather than a pattern specific to alcoholism was suggested by the findings of Fowler (1975), Kranitz (1972), and Miller (1977) indicating that heroin and opiate addicts had significantly higher MAC scores than did psychiatric patients, but that the MAC scores of alcoholics and drug addicts were not significantly different from each other. The mean MAC score for the alcoholics was 28.00, for psychiatric outpatients, 19.56 (MacAndrew, 1965~ and for opiate addicts, 27.50 (Fowler, 1975). The study of substance abuse groups was further extended to an evaluation of massively obese persons (i.e., those at least 1009/o above ideal body weight) who can be considered as a group that abuses food. Leon et al. (1979) reported a mean MAC score of 23.58 for massively obese persons prior to undergoing intestinal bypass surgery, and a mean score of 23.87 for the same group 1 yr after surgery. The * Reprint requests should be addressed to: Gloria R. Leon, Department of Psychology, Elliott Hall, 75 East River Road, Minneapolis, MN 55455, U.S.A. 401
402
GLORIA RAKITA LEON, RONETTE KOLOTK1Nand GREGORY KORGESKI
results therefore suggest that persons who are compulsive eaters have personality or behavioral characteristics (as measured by the MAC scale) in common with persons exhibiting other types of addictions or habit problems associated with oral consumption. Using other psychometric measures, Platt (1975) failed to find evidence of an addiction-prone personality syndrome in comparing heroin addict and non-addict offenders. However, Schwartz (1977) reported that the MAC was not sensitive to a general dimension of anti-sociality, although the MAC score was associated with high energy levels, impulsivity, shallow interpersonal relationships, and general psychological maladjustment. It appears that these latter characteristics, rather than general anti-social patterns, are more specific to persons with addiction problems. Similarly, MMPI studies comparing the personality characteristics of undergraduate smokers and non-smokers indicated a greater preference among the smokers for social activities and excitement, and more conflict with authority (Berger, 1971). Level of smoking was significantly correlated with MMPI Scales 1 (Hs), 2 (D), 3 (Hy), and 4 (Pd) (Robbins et al., 1971). The ability of the M A C scale to differentiate persons with several types of addiction problems from other psychiatric groups and from normal controls suggests that this scale has unique qualities that other psychometric measures and other MMPI-derived alcoholism scales do not possess. The potential use of this scale as a screening measure for addiction proneness makes it important to obtain comprehensive information about how persons with other addiction or substance abuse problems score on this measure. Of further interest is the assessment of the relationship between the MAC scores and the general MMPI profile configurations for the groups studied. The purpose of the present research, therefore, was to extend the inquiry about the personality and behavioral characteristics of addicted persons to individuals who can be considered as addicted to other substances, i.e., food and tobacco. Some information also was obtained about a group that abuses food through its non-use or inappropriate use, i.e., persons who manifest anorexia nervosa. The results of this investigation should then provide some indication about the utility of using the MAC scale to screen for addiction proneness across several areas. METHOD
Subjects Group 1 (TOPS Obese) consisted of 56 women who were members of various chapters of TOPS, a self-help club for weight reduction. The subjects were actively involved in losing weight. The mean age of the women was 39.96 yr (range = 14-65), and the mean percentage above ideal body weight was 40.74~o (ranging from 7.21" to 188.50~). Group 2 (Behavior Modification Obese) consisted of 73 women who were members of groups that were taught behavior modification principles for weight reduction. The subjects were evaluated before the weight loss program started. The mean age was 44.94 yr (range = 27-59), and the mean percentage above ideal weight was 64.03~o (ranging from 19.23 to 118.10~. Groups 1 and 2 were evaluated separately due 1~o the possibility of personality differences between persons who chose these quite different treatment programs, as well as differences due to whether the weight reduction had already begun. Group 3 (Smokers) consisted of 83 persons (44 males and 39 females) who were attending smoking cessation groups run by either the American Cancer Society (ACS) (N = 41) or a private clinic (N = 53). The mean age of the males was 35.53yr (range = 16-62) and for females, 32.16 yr (range = 19-57). The mean percentage above ideal weight for the males was 7.02~ (range = -17.65-56.25~o). The mean percentage above ideal weight for the females was -2.17~o (range = -22.50-40.91~o). The persons in this group met the following criteria for addicted smokers: the consumption of 2 packs of cigarettes or more a day, numerous unsuccessful attempts at quitting, a belief * Several of the women were close to their weightgoal at the time they were evaluated.
Addictive characteristics
403
that they smoked to excess, and severe physical discomfort while trying to quit smoking. The ACS and private clinic group programs were fairly similar. Group 4 (Anorexics) consisted of 33 females who were hospitalized for treatment of anorexia nervosa. The age range was from 12 to 25 yr. These persons were included in this study because the refusal to eat and/or eating and vomiting can be considered as a substance abuse. Group 5 (Normal controls) was made up of 118 persons (37 males and 81 females) who were of relatively normal weight, were not heavy smokers or drinkers, and did not have other habit problems such as taking drugs or medications, or gambling. The mean age of the males was 31.83yr (range = 20-58) and of the females, 36.25 (range = 20-62). The mean percentage above ideal weight for the males was 7.64~o (range = -11.39-29.75~o), and for the females, - 2 . 4 4 ~ (range = -20.59-43.94~o). The subjects in this group were obtained through church and PTA groups, as well as University evening classes. Measures
The MacAndrew Scale is a 49 item scale developed from the MMPI. The original scale consisted of 51 items, but the items specifically referring to excessive alcohol use have been dropped by most investigators using this scale (Graham, 1978). Scores on the MMPI validity and clinical scales also were analyzed in those groups in which information was available. Procedure
The data on the subjects in the TOPS Obese, ACS Smokers, and part of the Normal control group was obtained by a research assistant who went to the various groups and solicited the cooperation of those members interested in participating in the study. The subjects were instructed to fill out the MMPI forms at home and were given stamped envelopes to mail the materials to the investigators. The TOPS Obese and ACS Smokers were already involved in their respective programs at the time of evaluation. (The return rates were as follows: TOPS Obese--33~; ACS Smokers--35~o; Normal Controls--71.3~o). The MAC scores were the only information that could be obtained for the Behavior Modification Obese, the private clinic smokers' groups, the anorexic patients, and 69 persons in the control group. The agencies or programs had various constraints on making available to us the complete MMPI profiles. Evaluation of the substance abuse subjects in these latter groups was carried out before the start of their respective treatment programs. RESULTS MacAndrew scale
The MAC score data for the TOPS Obese, Behavior Modification Obese, Female Smokers, Male Smokers, Female Normal controls and Male Normal controls was evaluated by a one-way analysis of variance. A significant Group effect was demonstrated: F (5, 324) = 12.38, P < 0.001. The post-hoc means analysis using the Scheff6 test at a 0.05 level of significance indicated that the mean for the Male Smokers group was significantly different from the other group means and fell within the addictive range according to MacAndrews' criterion (1965). None of the other group means were significantly different from each other. Table 1 presents the MAC score means and standard deviations for the TOPS Obese, Behavior Modification Obese, Female and Male Smokers, and Female and Male Control groups. A relatively greater proportion of the group of smokers in comparison to the other groups reported other habit problems: 20.5~ of the female smokers reported an obesity problem, 13.67/o of the male smokers reported a problem in taking drugs or medications,
404
GLORIA RAKITA LEON, RONETTE KOLOTKIN and GREGORY KORGESKI Table 1. MAC score means and standard deviations for TOPS Obese, behavior modification obese, smokers, and normal controls
TOPS Obese Beh. mod. obese Female smokers Male smokers Female controls Male controls
Mean MAC score
SD
20.304 20.356 21.769 24.864 19.617 21.595
4.647 3.421 4.270 3.849 3.330 3.655
and 18.2~ of the male smokers and 20.5~o of the female smokers reported a variety of other problems. Of the TOPS Obese, 19.6~o reported that they smoked. The number of non-responders to this question by the members of the two obese groups precludes any specific conclusions about other habit problems in obese persons other than the smoking information just reported. The mean MAC score for the anorexic group was 20.1. Table 2 presents the mean MAC scores for this group sub-divided according to age and type of eating problem. Table 2. MAC score means for anorexic sample
All anorexics Adults (18 and over) Adults who binge and vomit Adults who are self-starvers Adolescents (12-17)
N
MAC score
33 24 13
20.1 19.8 20.1
11
19.5
9
20.4
MMPI profiles Complete MMPI information was available for the TOPS Obese (N = 56); ACS Smokers (21 males and 20 females), and 49 persons in the Normal control group (6 males and 43 females). The Scheff6 test (set at the 0.05 level of significance was used to carry out post-hoc comparisons for the group means on each MMPI scale. All of the MMPI mean scale scores were within the normal range. The post-hoc analysis indicated significant group differences on 9 of the 13 MMPI scales and on 8 of these scales, the T-score mean for the female control group was significantly different from combinations of other group means. Table 3 presents the mean scale scores on the MMPI and the means comparisons for the TOPS Obese, ACS Smokers, and Normal control groups. The T-score means (non-K corrected) on Scales 2 (D) and 4 (Pd) were relatively elevated for the TOPS Obese, and male and female smokers groups. The T-score mean on Scale 3 (Hy) was relatively elevated for the male and female smokers groups. These findings indicate a greater degree of dysphoric affect and impulsivity in the obese and the male and female smokers groups, and a greater tendency toward somatization in the smokers groups. The MMPI profiles were evaluated according to the percentage of persons manifesting a particular two-point code type, in either order of the 2 highest scales. A 2-0/0-2 (D-Si/Si-D) code type was evident for the relatively largest proportion of persons in the TOPS Obese group (16.1~o). The code type manifested by the relatively largest proportion of female smokers was the 3-4/4-3(Hy-Pd/Pd-Hy) code type (25~o). The male smokers tied between the 2-3/3-2(D-Hy/Hy-D) and 3-5/5-3(Hy-Mf/Mf-Hy) code type (14.3~o for each combination). The female normal control, findings showed 20.9~o with
Addictive characteristics
405
Table 3. MMPI mean scale scores and scale mean comparisons for TOPS Obese, ACS smokers, and normal control groups Groups 1 TOPS Obese Scale Female
2 3 ACS Smokers Male Female
4 5 Normal controls Male Female
L F K 1 (Hs) 2 (D) 3 (Hy) 4 (Pd) 5 (Mt) 6 (Pa) 7 (Pt) 8 (Sc) 9 (Ma) 0 (Si)
46.67 56.24 52.29 55.86 66.19 64.19 64.33 66.67 59.67 57.81 58.67 54.48 54.19
49.00 51.83 55.50 49.33 50.00 57.00 55.83 63.17 55.00 50.50 52.00 54.17 55.67
46.25 55.04 52.11 53.39 59.14 57.16 58.82 45.18 56.11 55.75 55.64 56.14 57.93
43.50 61.80 53.70 56.00 65.10 66.25 69.80 44.35 61.25 58.90 59.20 55.90 57.85
46.26 48.51 60.40 43.91 48.65 55.02 49.56 44.16 55.23 44.49 45.77 51.16 51.12
Means analysis NS 5/3* 5/1.2"* 5/1,2,3 5/1,2,3; 2/4 5/2.3 5/1,2,3 1,3,5/2,4 NS 5/1,2,3 5/1,2,3 NS NS
Note: T-score means are non-K corrected.
* Group 5 mean significantly different from Group 3 mean. None of other means significantly different from each other. ** Group 5 significantly different from Groups 1 and 2. Groups 1 and 2 not significantly different from each other.
a 3-6/6-3(Hy-Pa/Pa-Hy) code type. The relatively largest proportion of male normal controls exhibited a 3-5/5-3(Hy-Mf/Mf-Hy) code type (33.3~o). Table 4 summarizes the first and second highest proportion of persons in each group receiving a particular 2 point code. It can be seen that Scale 2 (D) appears in both 2 point codes listed for the obese group, in both 2 point codes for the smokers, and in 1 code type for the normals. Scale 4 (Pd) appears in 1 of the code types for the obese, and in 2 code types for the smokers. Scale 3 (Hy) appears in 3 of the Smokers' code types. Correlation coefficients were computed comparing the MAC score with the M M P I scale scores. Statistically significant correlations were found for the K Scale (r = -0.260; P = 0.002), Scale 2 (D) (r = -0.248; P = 0.004), Scale 4 (Pd) (r = 0.166; P = 0.056), Scale 9 (Ma) (r = 0.507; P < 0.001), and Scale 0 (Si) (r = -0.308; P < 0.001). For this sample, relative elevations on the MAC scale were positively associated with a high activity level and impulsivity, and negatively associated with defensiveness, depression, and social introversion. DISCUSSION
The question explored in this investigation was whether the MacAndrew Scale taps a common addictive personality or behavioral syndrome irrespective of the type of habit problem manifested. The importance of this question lies in the potential for identifying addiction-prone individuals and intervening before the habit problem becomes extremely difficult to overcome. The results of this investigation indicate that the group mean score on the MacAndrew Scale for the male smokers was within the range considered as addictive (MacAndrew, 1965). The groups of moderately obese persons and the female smokers did not score Table 4. Proportion of obese, smokers, and normal controls receiving a particular MMPI two point code
Code Types
Obese
Female smokers,
Male smokers
Female normals
Male normals
2-0/0-2 (16.1%) 2-4/4-2 (8.9~o)
3-4/4-3 (25.0%) 2-4/4-2 (15.0~)
2-3/3-2 (14.3%) 3-5/5-3 (14.3~o)
3-6/6-3 (20.9%) 6-0/0-6 (14.0~)
3-5/5-3 (33.3%) 2-0/0-2 (16.7°) 4-9/9-4 (16.7%) 5-9/9-5 (16.7°~o) 5-0/0-5 (16.7°~;)
406
GLORIA RAKITA LEON, RONETTE KOLOTKIN and GREGORY KORGESKI
in the addictive range, nor did the persons in the anorexic group. However, a prior investigation using the MacAndrew Scale with massively obese persons (predominantly women) (Leon et al., 1979) demonstrated MAC scores close to the addictive range (X = 23.58). These latter results therefore suggest a qualitative distinction between persons with a moderate and those with a massive obesity problem. The massively obese, i.e., persons 100 pounds or more above ideal body weight, seem to exhibit personality or behavioral characteristics that are similar to those found in persons with other types of addictions. The MacAndrew Scale appears to be sensitive in identifying groups of persons with other types of severe habit problems. Graham J. R., (personal communication, 1978) recently evaluated a group of 100 non-alcoholic compulsive gamblers and found a mean MAC score of 27.65 for that group. The mean MAC score of a comparison group of 100 alcoholics was 28.06. Therefore, the present investigation as well as the findings of others suggests that although not all groups of persons with habit problems exhibit elevated Mac scores, those persons who score close to the addictive range on the MacAndrew Scale may indeed exhibit some common characteristics. It should be recalled, however, that Schwartz's findings (1977) indicated that the MacAndrew Scale was not simply a measure of a general anti-social behavior pattern or of general deviance. The results of the present study and those of Schwartz point to a positive relationship between MAC score and a high activity level and impulsiveness, although high MAC scorers are not simply persons with 4-9 (Pd-Ma) code types. The overall MMPI findings demonstrated a trend toward depression and impulsiveness in both the smokers and obese groups, as well as a tendency toward somatization in the smokers. The relatively elevated mean scores on Scales 2 (D), 3 (Hy)~ and 4 (Pd) suggests that the particular habit problem is not an isolated behavioral characteristic but is associated with other interpersonal and mood problems. It is important to note, however, that the groups evaluated were persons who identified their habit pattern as a problem that they wanted to change. Whether similar findings w~,uld be demonstrated in persons not in treatment is unknown. The results of this investigation would seem to suggest that males who are heavy smokers and seeking treatment for smoking cessation should participate in intervention programs oriented around dealing with the addictive nature of their problem. The fact that a moderate proportion of the smokers, particularly the males, indicated other habit problems such as taking excessive amounts of drugs or other medications may point to a more general addictive personality or behavioral pattern in tLis group. This generalized addictive characteristic is an issue that might have tc be taken into account in designing and implementing treatment programs. Is there a general characteristic of addiction proneness irrespective of the substance abused? The male smokers' data in the present study taken together with the findings of previous studies suggests a common thread among some but not all of the types of substance abuse problems evaluated. An elevated score on the MacAndrew Scale seems fairly sensitive in identifying individuals (although not all individuals) with addiction problems. It therefore would seem appropriate to include this scale among screening measures for addiction proneness. Acknowledgements--This research was supported in part by a grant from the Roche Psychiatric Service Institute to the first author. The helpful comments of John R. Graham in his review of the manuscript are gratefully acknowledged. Thanks are due to Sheila Grogan and Larry Past for their efforts in the data collection. The cooperation of Ronald K. Kalkhoff, Russ Borud, William Duffy, and William Seals in obtaining information from their respective groups is gratefully acknowledged. REFERENCES Berger, E. M. MMPI item differences between smoker and non-smoker college freshman males. Journal of Consulting and Clinical Psychology, 1971, 36, 446. Chang, A., Caldwell, A. & Moss, T. Stability in personality traits in alcoholics during and after treatment as measured by the MMPI: A one year follow-up study. Proceedings of the 81st Annual Convention of the American Psychological Association, 1973, 8, 387-388,
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Fowler, R. A method for the evaluation of the abuse prone patient. Scientific Exhibit presented at the annual meeting of the American Academy of Family Physicians, Chicago, 1975. Graham, J. R. A review of some important special MMPI scales. In P. McReynolds (Ed.), Advances in Psychological Assessment IV.. San Francisco: Jossey-Bass, 1978. Hoffman, H., Loper, R. G. & Kammeier, M. L. Identifying future alcoholics with M M P I alcoholism scales. Quarterly Journal of Studies on Alcohol, 1974, 35, 490~98. Huber, N. & Danahy, S. Use of the MMPI in predicting completion and evaluating changes in a long term alcoholism treatment program. Journal of Studies on Alcohol, 1975, 36, 1230-1237. Kranitz, L. Alcoholics, heroin addicts and non addicts: Comparisons on the MacAndrew alcoholism scale of the MMPI. Quarterly Journal of Studies on Alcohol, 1972, 33, 807-809. Leon, G. R., Eckert, E. D., Teed, D. & Buchwald, H. Changes in body image and other psychological factors after intestiflal bypass surgery for massive obesity. 1979, Journal of Behavioral Medicine, in press. MacAndrew, C. The differentiation of male alcoholic outpatients from non-alcoholic psychiatric patients by means of the MMPI. Quarterly Journal of Studies on Alcohol, 1965, 26, 238-246. Miller, M. T. Research on the addictive personality. Paper presented at the Twelfth Annual MMPI Symposium, St. Petersburg Beach, Florida, February 1977. Platt, J. J. Addiction proneness and personality in heroin addicts. Journal of Abnormal Psychology, 1975, 84, 303-306. Rich, C. C. & Davis, H. G. Concurrent validity of M M P I alcoholism scales. Journal of Clinical Psychology, 1969, 25, 425-426. Robbins, P. R, Janck, R. H. & Meyersburg, H. A. Psychological factors in smoking, drinking, and drug experimentation. Journal of Clinical Psychology, 1971, 27, 450-452. Rohan, W. P. M M P I changes in hospitalized alcoholics: A second study. Quarterly Journal of Studies on Alcohol, 1972, 33, 65-76. Rosenberg, N. M M P I alcoholism scales. Journal of Clinical Psychology, 1972, 28, 515-522. Schwartz, M. F. The MacAndrew alcoholism scale: A construct validity study. Unpublished doctoral dissertation, Kent State University, 1977. Vega, A. Cross-validation of four MMPI scales for alcoholism. Quarterly Journal of Studies on Alcohol, 1971, 32, 791-797.
0306-4603 79 1101-0401502.00/0
MACANDREW ADDICTION SCALE AND OTHER MMPI CHARACTERISTICS ASSOCIATED WITH OBESITY, ANOREXIA AND SMOKING BEHAVIOR GLORIA RAKITA LEON*, RONETTE KOLOTKIN a n d GREGORY KORGESKI University of Minnesota Abstract--Groups of persons with substance abuse problems (obesity, smoking, and anorexia) and a normal control group of persons without habit problems were evaluated on the MacAndrew Scale (MAC) of the MMPI (originally developed to measure proneness to alcoholism). Two Point code types were calculated for those persons for whom complete MMPI information was available. The male smokers demonstrated a mean MAC score close to the addictive range. The female smokers and the in general moderately obese groups as well as the anorexic group showed no significant differences in MAC score in comparison to the normal controls. The smokers and obese subjects showed a tendency toward depression and impulsivity, and the smokers also showed a trend toward somatization. It appears from the present findings as well as those of other investigators that an elevated score on the MacAndrew Scale can be interpreted as an indication of an addiction problem or addiction proneness. However, not all persons with substance abuse patterns have an elevated score on this measure.
The identification of individuals who may be prone to develop various substance abuse problems is an important concern in terms of prevention and early intervention. The possibility that a common addictive personality or behavioral syndrome exists in persons with different types of addiction problems can only be evaluated after the development of reliable and valid measuring instruments. At present, the MacAndrew Scale (MAC) has been demonstrated to be unique in its ability to tap a common personality or behavioral dimension across at least 2 types of addiction problems: alcoholism and opiate drug addiction. Since MacAndrew's publication in 1965 of an MMPI-derived scale that differentiated between male alcoholic out-patients and non-alcoholic psychiatric outpatients, other investigators have confirmed the ability of the MAC scale to accurately identify alcoholic from general psychiatric groups (e.g., Rich & Davis, 1969; Rosenberg, 1972; and Vega, 1971). MacAndrew (1965) found that a cutoff score of 24 successfully classified 81.759/o of the alcoholics and the non-alcoholics. The stability of the MAC scores before and after treatment for alcoholism was demonstrated by Chang et al. (1973), Huber & Danahy (1975), and Rohan, 1972. Further, Hoffman et al. (1974) found no significant difference in the MAC scores of a group of alcoholics compared with their pre-alcoholic college entrance MAC scores obtained an average of 13 yr previously. The MAC scores of the pre-alcoholic co.llege students significantly differentiated them at a 729/o accuracy level from a random sample of college classmate controls. The possibility that the MacAndrew Scale measures a more general characteristic of addiction proneness or an addictive behavior pattern rather than a pattern specific to alcoholism was suggested by the findings of Fowler (1975), Kranitz (1972), and Miller (1977) indicating that heroin and opiate addicts had significantly higher MAC scores than did psychiatric patients, but that the MAC scores of alcoholics and drug addicts were not significantly different from each other. The mean MAC score for the alcoholics was 28.00, for psychiatric outpatients, 19.56 (MacAndrew, 1965~ and for opiate addicts, 27.50 (Fowler, 1975). The study of substance abuse groups was further extended to an evaluation of massively obese persons (i.e., those at least 1009/o above ideal body weight) who can be considered as a group that abuses food. Leon et al. (1979) reported a mean MAC score of 23.58 for massively obese persons prior to undergoing intestinal bypass surgery, and a mean score of 23.87 for the same group 1 yr after surgery. The * Reprint requests should be addressed to: Gloria R. Leon, Department of Psychology, Elliott Hall, 75 East River Road, Minneapolis, MN 55455, U.S.A. 401
402
GLORIA RAKITA LEON, RONETTE KOLOTK1Nand GREGORY KORGESKI
results therefore suggest that persons who are compulsive eaters have personality or behavioral characteristics (as measured by the MAC scale) in common with persons exhibiting other types of addictions or habit problems associated with oral consumption. Using other psychometric measures, Platt (1975) failed to find evidence of an addiction-prone personality syndrome in comparing heroin addict and non-addict offenders. However, Schwartz (1977) reported that the MAC was not sensitive to a general dimension of anti-sociality, although the MAC score was associated with high energy levels, impulsivity, shallow interpersonal relationships, and general psychological maladjustment. It appears that these latter characteristics, rather than general anti-social patterns, are more specific to persons with addiction problems. Similarly, MMPI studies comparing the personality characteristics of undergraduate smokers and non-smokers indicated a greater preference among the smokers for social activities and excitement, and more conflict with authority (Berger, 1971). Level of smoking was significantly correlated with MMPI Scales 1 (Hs), 2 (D), 3 (Hy), and 4 (Pd) (Robbins et al., 1971). The ability of the M A C scale to differentiate persons with several types of addiction problems from other psychiatric groups and from normal controls suggests that this scale has unique qualities that other psychometric measures and other MMPI-derived alcoholism scales do not possess. The potential use of this scale as a screening measure for addiction proneness makes it important to obtain comprehensive information about how persons with other addiction or substance abuse problems score on this measure. Of further interest is the assessment of the relationship between the MAC scores and the general MMPI profile configurations for the groups studied. The purpose of the present research, therefore, was to extend the inquiry about the personality and behavioral characteristics of addicted persons to individuals who can be considered as addicted to other substances, i.e., food and tobacco. Some information also was obtained about a group that abuses food through its non-use or inappropriate use, i.e., persons who manifest anorexia nervosa. The results of this investigation should then provide some indication about the utility of using the MAC scale to screen for addiction proneness across several areas. METHOD
Subjects Group 1 (TOPS Obese) consisted of 56 women who were members of various chapters of TOPS, a self-help club for weight reduction. The subjects were actively involved in losing weight. The mean age of the women was 39.96 yr (range = 14-65), and the mean percentage above ideal body weight was 40.74~o (ranging from 7.21" to 188.50~). Group 2 (Behavior Modification Obese) consisted of 73 women who were members of groups that were taught behavior modification principles for weight reduction. The subjects were evaluated before the weight loss program started. The mean age was 44.94 yr (range = 27-59), and the mean percentage above ideal weight was 64.03~o (ranging from 19.23 to 118.10~. Groups 1 and 2 were evaluated separately due 1~o the possibility of personality differences between persons who chose these quite different treatment programs, as well as differences due to whether the weight reduction had already begun. Group 3 (Smokers) consisted of 83 persons (44 males and 39 females) who were attending smoking cessation groups run by either the American Cancer Society (ACS) (N = 41) or a private clinic (N = 53). The mean age of the males was 35.53yr (range = 16-62) and for females, 32.16 yr (range = 19-57). The mean percentage above ideal weight for the males was 7.02~ (range = -17.65-56.25~o). The mean percentage above ideal weight for the females was -2.17~o (range = -22.50-40.91~o). The persons in this group met the following criteria for addicted smokers: the consumption of 2 packs of cigarettes or more a day, numerous unsuccessful attempts at quitting, a belief * Several of the women were close to their weightgoal at the time they were evaluated.
Addictive characteristics
403
that they smoked to excess, and severe physical discomfort while trying to quit smoking. The ACS and private clinic group programs were fairly similar. Group 4 (Anorexics) consisted of 33 females who were hospitalized for treatment of anorexia nervosa. The age range was from 12 to 25 yr. These persons were included in this study because the refusal to eat and/or eating and vomiting can be considered as a substance abuse. Group 5 (Normal controls) was made up of 118 persons (37 males and 81 females) who were of relatively normal weight, were not heavy smokers or drinkers, and did not have other habit problems such as taking drugs or medications, or gambling. The mean age of the males was 31.83yr (range = 20-58) and of the females, 36.25 (range = 20-62). The mean percentage above ideal weight for the males was 7.64~o (range = -11.39-29.75~o), and for the females, - 2 . 4 4 ~ (range = -20.59-43.94~o). The subjects in this group were obtained through church and PTA groups, as well as University evening classes. Measures
The MacAndrew Scale is a 49 item scale developed from the MMPI. The original scale consisted of 51 items, but the items specifically referring to excessive alcohol use have been dropped by most investigators using this scale (Graham, 1978). Scores on the MMPI validity and clinical scales also were analyzed in those groups in which information was available. Procedure
The data on the subjects in the TOPS Obese, ACS Smokers, and part of the Normal control group was obtained by a research assistant who went to the various groups and solicited the cooperation of those members interested in participating in the study. The subjects were instructed to fill out the MMPI forms at home and were given stamped envelopes to mail the materials to the investigators. The TOPS Obese and ACS Smokers were already involved in their respective programs at the time of evaluation. (The return rates were as follows: TOPS Obese--33~; ACS Smokers--35~o; Normal Controls--71.3~o). The MAC scores were the only information that could be obtained for the Behavior Modification Obese, the private clinic smokers' groups, the anorexic patients, and 69 persons in the control group. The agencies or programs had various constraints on making available to us the complete MMPI profiles. Evaluation of the substance abuse subjects in these latter groups was carried out before the start of their respective treatment programs. RESULTS MacAndrew scale
The MAC score data for the TOPS Obese, Behavior Modification Obese, Female Smokers, Male Smokers, Female Normal controls and Male Normal controls was evaluated by a one-way analysis of variance. A significant Group effect was demonstrated: F (5, 324) = 12.38, P < 0.001. The post-hoc means analysis using the Scheff6 test at a 0.05 level of significance indicated that the mean for the Male Smokers group was significantly different from the other group means and fell within the addictive range according to MacAndrews' criterion (1965). None of the other group means were significantly different from each other. Table 1 presents the MAC score means and standard deviations for the TOPS Obese, Behavior Modification Obese, Female and Male Smokers, and Female and Male Control groups. A relatively greater proportion of the group of smokers in comparison to the other groups reported other habit problems: 20.5~ of the female smokers reported an obesity problem, 13.67/o of the male smokers reported a problem in taking drugs or medications,
404
GLORIA RAKITA LEON, RONETTE KOLOTKIN and GREGORY KORGESKI Table 1. MAC score means and standard deviations for TOPS Obese, behavior modification obese, smokers, and normal controls
TOPS Obese Beh. mod. obese Female smokers Male smokers Female controls Male controls
Mean MAC score
SD
20.304 20.356 21.769 24.864 19.617 21.595
4.647 3.421 4.270 3.849 3.330 3.655
and 18.2~ of the male smokers and 20.5~o of the female smokers reported a variety of other problems. Of the TOPS Obese, 19.6~o reported that they smoked. The number of non-responders to this question by the members of the two obese groups precludes any specific conclusions about other habit problems in obese persons other than the smoking information just reported. The mean MAC score for the anorexic group was 20.1. Table 2 presents the mean MAC scores for this group sub-divided according to age and type of eating problem. Table 2. MAC score means for anorexic sample
All anorexics Adults (18 and over) Adults who binge and vomit Adults who are self-starvers Adolescents (12-17)
N
MAC score
33 24 13
20.1 19.8 20.1
11
19.5
9
20.4
MMPI profiles Complete MMPI information was available for the TOPS Obese (N = 56); ACS Smokers (21 males and 20 females), and 49 persons in the Normal control group (6 males and 43 females). The Scheff6 test (set at the 0.05 level of significance was used to carry out post-hoc comparisons for the group means on each MMPI scale. All of the MMPI mean scale scores were within the normal range. The post-hoc analysis indicated significant group differences on 9 of the 13 MMPI scales and on 8 of these scales, the T-score mean for the female control group was significantly different from combinations of other group means. Table 3 presents the mean scale scores on the MMPI and the means comparisons for the TOPS Obese, ACS Smokers, and Normal control groups. The T-score means (non-K corrected) on Scales 2 (D) and 4 (Pd) were relatively elevated for the TOPS Obese, and male and female smokers groups. The T-score mean on Scale 3 (Hy) was relatively elevated for the male and female smokers groups. These findings indicate a greater degree of dysphoric affect and impulsivity in the obese and the male and female smokers groups, and a greater tendency toward somatization in the smokers groups. The MMPI profiles were evaluated according to the percentage of persons manifesting a particular two-point code type, in either order of the 2 highest scales. A 2-0/0-2 (D-Si/Si-D) code type was evident for the relatively largest proportion of persons in the TOPS Obese group (16.1~o). The code type manifested by the relatively largest proportion of female smokers was the 3-4/4-3(Hy-Pd/Pd-Hy) code type (25~o). The male smokers tied between the 2-3/3-2(D-Hy/Hy-D) and 3-5/5-3(Hy-Mf/Mf-Hy) code type (14.3~o for each combination). The female normal control, findings showed 20.9~o with
Addictive characteristics
405
Table 3. MMPI mean scale scores and scale mean comparisons for TOPS Obese, ACS smokers, and normal control groups Groups 1 TOPS Obese Scale Female
2 3 ACS Smokers Male Female
4 5 Normal controls Male Female
L F K 1 (Hs) 2 (D) 3 (Hy) 4 (Pd) 5 (Mt) 6 (Pa) 7 (Pt) 8 (Sc) 9 (Ma) 0 (Si)
46.67 56.24 52.29 55.86 66.19 64.19 64.33 66.67 59.67 57.81 58.67 54.48 54.19
49.00 51.83 55.50 49.33 50.00 57.00 55.83 63.17 55.00 50.50 52.00 54.17 55.67
46.25 55.04 52.11 53.39 59.14 57.16 58.82 45.18 56.11 55.75 55.64 56.14 57.93
43.50 61.80 53.70 56.00 65.10 66.25 69.80 44.35 61.25 58.90 59.20 55.90 57.85
46.26 48.51 60.40 43.91 48.65 55.02 49.56 44.16 55.23 44.49 45.77 51.16 51.12
Means analysis NS 5/3* 5/1.2"* 5/1,2,3 5/1,2,3; 2/4 5/2.3 5/1,2,3 1,3,5/2,4 NS 5/1,2,3 5/1,2,3 NS NS
Note: T-score means are non-K corrected.
* Group 5 mean significantly different from Group 3 mean. None of other means significantly different from each other. ** Group 5 significantly different from Groups 1 and 2. Groups 1 and 2 not significantly different from each other.
a 3-6/6-3(Hy-Pa/Pa-Hy) code type. The relatively largest proportion of male normal controls exhibited a 3-5/5-3(Hy-Mf/Mf-Hy) code type (33.3~o). Table 4 summarizes the first and second highest proportion of persons in each group receiving a particular 2 point code. It can be seen that Scale 2 (D) appears in both 2 point codes listed for the obese group, in both 2 point codes for the smokers, and in 1 code type for the normals. Scale 4 (Pd) appears in 1 of the code types for the obese, and in 2 code types for the smokers. Scale 3 (Hy) appears in 3 of the Smokers' code types. Correlation coefficients were computed comparing the MAC score with the M M P I scale scores. Statistically significant correlations were found for the K Scale (r = -0.260; P = 0.002), Scale 2 (D) (r = -0.248; P = 0.004), Scale 4 (Pd) (r = 0.166; P = 0.056), Scale 9 (Ma) (r = 0.507; P < 0.001), and Scale 0 (Si) (r = -0.308; P < 0.001). For this sample, relative elevations on the MAC scale were positively associated with a high activity level and impulsivity, and negatively associated with defensiveness, depression, and social introversion. DISCUSSION
The question explored in this investigation was whether the MacAndrew Scale taps a common addictive personality or behavioral syndrome irrespective of the type of habit problem manifested. The importance of this question lies in the potential for identifying addiction-prone individuals and intervening before the habit problem becomes extremely difficult to overcome. The results of this investigation indicate that the group mean score on the MacAndrew Scale for the male smokers was within the range considered as addictive (MacAndrew, 1965). The groups of moderately obese persons and the female smokers did not score Table 4. Proportion of obese, smokers, and normal controls receiving a particular MMPI two point code
Code Types
Obese
Female smokers,
Male smokers
Female normals
Male normals
2-0/0-2 (16.1%) 2-4/4-2 (8.9~o)
3-4/4-3 (25.0%) 2-4/4-2 (15.0~)
2-3/3-2 (14.3%) 3-5/5-3 (14.3~o)
3-6/6-3 (20.9%) 6-0/0-6 (14.0~)
3-5/5-3 (33.3%) 2-0/0-2 (16.7°) 4-9/9-4 (16.7%) 5-9/9-5 (16.7°~o) 5-0/0-5 (16.7°~;)
406
GLORIA RAKITA LEON, RONETTE KOLOTKIN and GREGORY KORGESKI
in the addictive range, nor did the persons in the anorexic group. However, a prior investigation using the MacAndrew Scale with massively obese persons (predominantly women) (Leon et al., 1979) demonstrated MAC scores close to the addictive range (X = 23.58). These latter results therefore suggest a qualitative distinction between persons with a moderate and those with a massive obesity problem. The massively obese, i.e., persons 100 pounds or more above ideal body weight, seem to exhibit personality or behavioral characteristics that are similar to those found in persons with other types of addictions. The MacAndrew Scale appears to be sensitive in identifying groups of persons with other types of severe habit problems. Graham J. R., (personal communication, 1978) recently evaluated a group of 100 non-alcoholic compulsive gamblers and found a mean MAC score of 27.65 for that group. The mean MAC score of a comparison group of 100 alcoholics was 28.06. Therefore, the present investigation as well as the findings of others suggests that although not all groups of persons with habit problems exhibit elevated Mac scores, those persons who score close to the addictive range on the MacAndrew Scale may indeed exhibit some common characteristics. It should be recalled, however, that Schwartz's findings (1977) indicated that the MacAndrew Scale was not simply a measure of a general anti-social behavior pattern or of general deviance. The results of the present study and those of Schwartz point to a positive relationship between MAC score and a high activity level and impulsiveness, although high MAC scorers are not simply persons with 4-9 (Pd-Ma) code types. The overall MMPI findings demonstrated a trend toward depression and impulsiveness in both the smokers and obese groups, as well as a tendency toward somatization in the smokers. The relatively elevated mean scores on Scales 2 (D), 3 (Hy)~ and 4 (Pd) suggests that the particular habit problem is not an isolated behavioral characteristic but is associated with other interpersonal and mood problems. It is important to note, however, that the groups evaluated were persons who identified their habit pattern as a problem that they wanted to change. Whether similar findings w~,uld be demonstrated in persons not in treatment is unknown. The results of this investigation would seem to suggest that males who are heavy smokers and seeking treatment for smoking cessation should participate in intervention programs oriented around dealing with the addictive nature of their problem. The fact that a moderate proportion of the smokers, particularly the males, indicated other habit problems such as taking excessive amounts of drugs or other medications may point to a more general addictive personality or behavioral pattern in tLis group. This generalized addictive characteristic is an issue that might have tc be taken into account in designing and implementing treatment programs. Is there a general characteristic of addiction proneness irrespective of the substance abused? The male smokers' data in the present study taken together with the findings of previous studies suggests a common thread among some but not all of the types of substance abuse problems evaluated. An elevated score on the MacAndrew Scale seems fairly sensitive in identifying individuals (although not all individuals) with addiction problems. It therefore would seem appropriate to include this scale among screening measures for addiction proneness. Acknowledgements--This research was supported in part by a grant from the Roche Psychiatric Service Institute to the first author. The helpful comments of John R. Graham in his review of the manuscript are gratefully acknowledged. Thanks are due to Sheila Grogan and Larry Past for their efforts in the data collection. The cooperation of Ronald K. Kalkhoff, Russ Borud, William Duffy, and William Seals in obtaining information from their respective groups is gratefully acknowledged. REFERENCES Berger, E. M. MMPI item differences between smoker and non-smoker college freshman males. Journal of Consulting and Clinical Psychology, 1971, 36, 446. Chang, A., Caldwell, A. & Moss, T. Stability in personality traits in alcoholics during and after treatment as measured by the MMPI: A one year follow-up study. Proceedings of the 81st Annual Convention of the American Psychological Association, 1973, 8, 387-388,
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