Journal of Personality Disorders, 15(1), 72–83, 2001

© 2001 The Guilford Press

ADDICTED PATIENTS WITH

PERSONALITY DISORDERS:
TRAITS, SCHEMAS, AND
PRESENTING PROBLEMS
Samuel A. Ball, PhD, and John J. Cecero, PhD

We evaluated the association of Structure Clinical Interview for the

DSM-IV Axis II (SCID-II) severity and personality traits, early maladap-
tive schemas, and presenting symptoms in 41 methadone-maintained
patients meeting criteria for either antisocial, borderline, avoidant, or
depressive personality disorder. Correlational analyses indicated that
the severity of each personality disorder was associated with a unique
profile of presenting problems and underlying traits and schemas. The
evaluation of multiple psychological indicators appears to be a useful
method for case conceptualization and planning interventions within a
promising individual therapy model that focuses both on substance
abuse and psychiatric symptoms and maladaptive schemas and coping
styles.

This study evaluated the association of personality disorder severity with

the personality trait, maladaptive schema, and psychological problem con-
structs that are used to guide the implementation of a recently developed
manual-guided treatment approach. As promising treatments for person-
ality disorders emerge, there is an increased need for a system of assess-
ment that has relevance to treatment decisions. The Diagnostic and Statis-
tical Manual of Mental Disorders, 4th edition (DSM-IV; American
Psychiatric Association, 1994) Axis II categories have not been particularly
useful for treatment planning or for consistently predicting response to
Axis I treatment (see reviews by Sanislow & McGlashan, 1998; Verheul,
Ball, & van den Brink, 1998). van Velzen and Emmelkamp’s (1996) review
suggests that the presence or absence of an Axis II disorder may not be the

Support for this study was provided from a Behavioral Therapy Development grant from the
National Institute on Drug Abuse (R01 DA10012-01) to Samuel A. Ball.
The preliminary data from this study were presented at the June 1998 annual meeting of the
College on Problems of Drug Dependence in Scottsdale, Arizona, and final results were pre-
sented at the 6th International Congress of the International Society for the Study of Person-
ality Disorders in Geneva, Switzerland, September, 1999.
The authors thank William O’Neill for his help with data collection and management.
From the Department of Psychiatry, Yale University School of Medicine (Ball) and the Depart-
ment of Psychology, Fordham University (Cecero).
Address correspondence to Samuel A. Ball, PhD, VA CT Healthcare Center (151D), Building
35 (MIRECC), 950 Campbell Avenue, West Haven, CT 06516; E-mail: alemball@snet.net.

72
ADDICTED PATIENTS WITH PERSONALITY DISORDERS 73

critical factor for predicting Axis I disorder outcome. Rather, it may be the
range of other variables (e.g., traits, ego strength, capacity for therapeutic
alliance, symptoms, and severity) on which personality disordered individ-
uals differ that are the critical dimensions for treatment planning and out-
come.
Koerner, Kohlenberg, and Parker (1996) have proposed an alternative
diagnostic process that provides a detailed assessment of the symptoms,
problems, and theoretically based, individualized mediators of change that
are systematically linked to a behavioral therapy approach. Similarly,
Westen and Arkowitz-Westen (1999) feel that the DSM-IV Axis II should
not be used to diagnose patients in treatment for personality problems.
They suggest that this more traditional categorical approach could be re-
placed or supplemented with a more functional assessment of personality
that develops a case formulation based on the specific cognitive, affective,
interpersonal, and behavior themes or problems of each patient. In fact,
the more promising treatment approaches for borderline (Linehan, 1993)
and avoidant (Alden, 1989) personality disorder focus less on the broad,
heterogeneous Axis II categories and more on specific behavioral targets
(parasuicidal behavior and affect regulation for borderline; social skills
training for avoidant). Other recent personality disorder psychotherapies
focus at the level of personality traits (Paris, 1998), relational patterns
(Benjamin, 1993; Magnavita, 1997), and schemas (Beck et al., 1992;
Young, 1994) as points of intervention for these complex disorders.
In Dual Focus Schema Therapy (Ball, 1998; Ball & Young, 2000), per-
sonality traits are regarded as heritable dispositions that influence the ac-
tions of early caregivers. Repetitive, dysfunctional behaviors on the part of
early caregivers contributes to the development of unconditional, negative
views of self, others, and the world. These early maladaptive schemas can
lead to personality-related problems in one of several ways. First, the expe-
rience of these belief systems can trigger depressive, anxiety, or anger
symptoms. Second, early maladaptive schemas may predispose individu-
als to seek problematic intimate, social, and occupational relationships
that reinforce the strength of the schema. Third, because the experience of
the affect and memories associated with early maladaptive schemas is dis-
tressing, individuals develop maladaptive coping styles, including escape
or avoidance (e.g., through substance use) (Young, 1994). DFST is a man-
ual-guided individual therapy that targets the presenting symptoms (sub-
stance abuse, psychiatric, interpersonal) and their associated traits,
schemas, and coping styles through cognitive, experiential, relational, and
behavioral interventions based on a detailed case conceptualization.
This study provides a preliminary evaluation of our case conceptual-
ization by correlating the severity of the more common DSM-IV personal-
ity disorders found in our sample (antisocial, borderline, avoidant, and
depressive) with the different dimensions used to inform our treatment
approach: (a) personality traits, (b) early maladaptive cognitive schemas
and; (c) presenting problems (psychiatric, interpersonal). We based our
hypotheses on several sources of information (Beck et al., 1990; Costa &
Widiger, 1994; Livesley, 1995; Sperry, 1995). Specifically, we predicted
that antisocial severity would be related to (a) lower Agreeableness and
74 BALL AND CECERO

Conscientiousness and higher Sensation-Seeking traits; (b) Mistrust/

Abuse, Emotional Inhibition, Entitlement, and Insufficient Self-Control
schemas and (c) Hostile, Domineering, Vindictiveness, and Cold present-
ing problems. We predicted that borderline severity would be associated
with (a) higher Neuroticism and lower Agreeableness, Conscientiousness,
and Positive Affect traits; (b) higher ratings on many early maladaptive
schemas, especially Abandonment/Instability, Emotional Deprivation,
Mistrust/Abuse, Defectiveness/Shame, Vulnerability to Harm; and (c)
most types of presenting psychiatric symptom in addition to Domineering
and Intrusive interpersonal problems. We expected avoidant severity to
be related to (a) higher Neuroticism and lower Extraversion, Openness,
and Sensation Seeking; (b) Social Isolation and Defectiveness/Shame
schemas; and (c) Anxiety, Phobic Anxiety, Interpersonal Sensitivity symp-
toms, and Socially Avoidant and Nonassertive presenting problems. Our
predictions for depressive personality disorder severity were more specu-
lative (but see Phillips, Hirschfield, Shea, & Gunderson, 1993) because of
its more recent addition to the appendix of DSM-IV. We expected it to be
related to (a) higher Neuroticism and Conscientiousness and lower Ex-
traversion and Positive Affect; (b) Dependence/Incompetence, Failure to
Achieve, and Defectiveness/Shame schemas; and (c) Depression-related
presenting problems.

METHOD
PARTICIPANTS
Participants were 41 outpatients in methadone maintenance who met di-
agnostic criteria for antisocial, borderline, avoidant, or depressive person-
ality disorder diagnosis. The sample was predominantly Caucasian (85%;
13% African American; 2% Hispanic) men (46%) and women (54%) with a
mean age of 37.4 years (SD = 5.9). Participants were mostly single (46%;
32% separated or divorced; 22% married or cohabitating), 39% lived alone,
and 61% lived with family or friends. A total of 54% of participants re-
ported having no close friends. The sample was predominantly high-school
educated (median = 12 years of school, range 1–16). Although 59% re-
ported having had a skill or profession (5% managerial or professional;
37% skilled; 48% semi- or unskilled labor) and many had periods of ex-
tended employment (longest job held in months: mean = 63.8, SD = 45.5,
range 1–180), only 10% reported full-time employment as being their typi-
cal work pattern in the past 3 years or 30 days and 68% reported no work-
related income in the 30 days before baseline assessment. A total of 31 of
the 41 participants received either unemployment compensation, public
assistance, or Social Security income and over 50% reported relying on
family members for financial support.
All participants met DSM-IV criteria for opioid dependence on agonist
medication. The length of the participant’s current methadone treatment
episode was quite varied (range 1–180 months) with a mean of 23.1
months (SD = 42.1) in treatment. Participants were mostly injection drug
users by history (71%; intranasal, 27%; oral, 2%) and 47% of the sample
reported using heroin in the 30 days before assessment (37% used alcohol,
ADDICTED PATIENTS WITH PERSONALITY DISORDERS 75

34% used cocaine, 27% used tranquilizers, and 6% used cannabis in the
previous 30 days). Although all patients were primarily opioid dependent
by history, several considered these other substances to be their primary
problem in the 30 days before assessment (5%, alcohol; 5%, benzodi-
azepines; 10%, cocaine; 2%, inhalants). The average number of previous
admissions ranged from one to seven with a mean of 1.9 (SD = 1.7). Al-
though six of the 41 participants were on probation and referred to
methadone, criminal justice was not involved in the voluntary consent for
this psychotherapy study and dropping out of the protocol carried no
sanctions with criminal justice or with participation in the patient’s stan-
dard methadone treatment.

ASSESSMENTS
Personality Disorders. The Structured Clinical Interview for DSM-IV Axis II
(SCID-II; First, Spitzer, Gibbon, Williams, & Benjamin, 1994) is a semi-
structured interview used to assess personality disorders. A self-report in-
strument was given first, in which each of the 117 dichotomous items cor-
respond to a DSM-IV personality disorder diagnostic criteria. The
interviewer then queried each of the self-report “yes” responses of those di-
agnoses for which there were a sufficient number of endorsed items to
yield a possible diagnosis. The interviewer had five years experience in
SCID-II interviewing from a previous National Institute on Drug Abuse
(NIDA) funded diagnostic study that focused on distinguishing personality
disorder symptoms from the acute and prolonged effects of substances, in
addition to the behaviors required to maintain a substance abuse lifestyle
(Rounsaville et al., 1998). Videotapes were reviewed in supervision with
the first author.

Personality Traits. The NEO Five Factor Inventory (NEO-FFI; Costa & Mc-
Crae, 1992) is a 60-item questionnaire that asks participants to rate items
on a 5-point scale (1 = strongly agree to 5 = strongly disagree) and yields
scores on the five major domains of personality: Neuroticism, Extraver-
sion, Openness, Agreeableness, and Conscientiousness. The reliability and
validity of this instrument has been extensively evaluated in normal and
clinical samples (Costa & McCrae, 1992) and specifically in substance
abusers (Ball, Tennen, Kranzler, Poling, & Rounsaville, 1997). The Multiple
Affect Adjective Checklist-Revised, Trait Version (MAACL-R; Zuckerman &
Lubin, 1985) is a 132-adjective checklist that provides reliable and valid
state and trait measures of affects and has been used extensively in per-
sonality and clinical research (Lubin, Swearingin, & Zuckerman, 1996).
We only analyzed Positive Affect and Sensation Seeking trait scales be-
cause Anxiety, Depression, and Hostility were adequately covered by an-
other measure (see Brief Symptom Inventory below).

Early Maladaptive Schemas. The Young Schema Questionnaire (YSQ;

Young & Brown, 1990) is a 205 Likert scale, self-report instrument that
measures 15 early maladaptive schemas: Abandonment/Instability, Emo-
tional Deprivation, Mistrust/Abuse, Social Isolation, Defectiveness/Shame,
76 BALL AND CECERO

Failure to Achieve, Dependence/Incompetence, Vulnerability to Harm, En-

meshment, Subjugation, Self- Sacrifice, Emotional Inhibition, Unrelenting
Standards, Entitlement, and Insufficient Self-Control. There is evidence
supporting the reliability and validity of this instrument (Lee, Taylor, &
Dunn, 1999; Schmidt, Joiner, Young, & Telch, 1995).

Presenting Problems. The Brief Symptom Inventory (BSI; Derogatis, 1992)

is a 53-item, self-report inventory of current (i.e., “past 30 days including
today”) psychiatric symptoms that asks participants to rate items on a 5-
point scale of distress. It yields nine primary symptom dimensions (Anxi-
ety, Depression, Hostility, Interpersonal Sensitivity, Obsessive-Compul-
sive, Paranoia, Phobic Anxiety, Psychoticism, and Somatization). The
Inventory of Interpersonal Problems-Circumplex (IIP-CX; Alden, Wiggins, &
Pincus, 1990) is a 64-item, self-report short form derived from the Inven-
tory of Interpersonal Problems (Horowitz, Rosenberg, Baer, Ureño, & Val-
laseñor, 1988) and measures types of interpersonal problems in the past
30 days on a five-point Likert scale of distress based on an interpersonal
circumplex model of personality: Domineering, Vindictive, Intrusive, Cold,
Socially Avoidant, Exploitable, Nonassertive, and Overly Nurturant.

PROCEDURE
All participants were evaluated as part of a NIDA-funded behavioral ther-
apy development project that focused on the development of a treatment
manual for personality disordered substance abusers (Ball, 1998; Ball &
Young, 2000) and its comparison with a 12-Step oriented Drug Counsel-
ing. A total of 78 outpatients in methadone maintenance were evaluated
initially for eligibility for this study, which included the presence of at least
one personality disorder. In addition, patients were eligible if they were
having trouble abstaining from substances and were not acutely psy-
chotic, suicidal, homicidal, or cognitively impaired. All participants volun-
teered for the study because they reported to the methadone clinic admis-
sion or counseling staff that they were interested in receiving individual
therapy for emotional and relationship problems. Three patients were ex-
cluded because of current psychosis and three because of very low reading
ability that would have precluded completion of self-reports. A total of 31
were ineligible on account of not meeting SCID-II criteria for any personal-
ity disorder. There were no differences between participants and ineligible
patients on age, gender, race, or the duration or number of methadone
treatment episodes.

RESULTS
We focused on evaluating the severity of the four most common personality
disorders in this sample. Using the cut-off scores established for the SCID-
II, antisocial, borderline, avoidant, and depressive (appendix diagnosis
under consideration) diagnoses were found in over half of the participants
and there was a high level of multiple diagnoses in this sample (see Table
1). There was no association between age and personality disorder severity
 ADDICTED PATIENTS WITH PERSONALITY DISORDERS 77

TABLE 1. Categorical Frequency and Dimensional Severity of SCID-II

Personality Disorders

Diagnosis Symptom Severity

______________________________ _______________________________________
Axis II Disorder Frequency Percentage (%)a Mean Symptoms SD ␣
Antisocial 29 71 9.7b 4.3b .76
Borderline 23 56 4.4 1.8 .61
Avoidant 23 56 3.3 2.3 .87
Depressive 31 76 5.2 1.7 .74
Note. Average number of personality disorders was 3.3 (SD = 1.4) (range 1–7), which also included paranoid
(12%), schizoid (7%), schizotypal (7%), narcissistic (5%), dependent (17%), obsessive-compulsive (7%), and
passive-aggressive (negativistic) (20%).
a
Sample was chosen based on presence of at least one personality disorder diagnosis.
b
Antisocial severity includes both childhood conduct disorder and adult antisocial symptoms.

and the only gender difference was for males to endorse more antisocial
personality disorder symptoms than females, t(39) = 2.45, p < .02 (see
Table 1).

PERSONALITY TRAITS
Table 2 lists Pearson correlations between personality disorder symptom
severity (summed SCID-II interview counts) and traits as measured by the
NEO-FFI and MAACL-R. Antisocial personality disorder severity was asso-
ciated with very low Agreeableness and high Sensation Seeking. Borderline
severity was not associated with the NEO-FFI or MAACL-R traits assessed.
Avoidant severity was associated with higher Neuroticism and lower Ex-
traversion, Openness to Experience and lower Sensation Seeking and Pos-
itive Affect. Depressive severity was associated with lower Extraversion.

EARLY MALADAPTIVE SCHEMAS

Table 3 lists correlations between personality disorder severity and early
maladaptive schemas. Antisocial personality disorder severity was associ-
ated with Mistrust/Abuse, Vulnerability to Harm, and Emotional Inhibi-
tion schemas; Borderline severity was associated with Abandonment/In-
stability and Mistrust/Abuse. Avoidant severity was related to a

TABLE 2. Correlation of DSM-IV Personality Disorder Severity with Traits from

NEO-FFI and MAACL-R

NEO-Five Factor Inventory Domains MAACL-R Traits

SCID ________________________________________________________________ __________________
Axis II Openness to Conscien- Sensation Positive
Disorder Neuroticism Extraversion Experience Agreeableness tiousness Seeking Affect
Antisocial –.10 –.08 .00 –.76*** –.10 .32* –.13
Borderline .10 –.10 –.11 –.15 –.03 .18 .15
Avoidant .38* –.40* –.51*** .12 –.02 –.41** –.32*
Depressive .27 –.36* –.26 –.05 –.12 –.25 –.17
Note. NEO-FFI, NEO-Five Factor Inventory (Costa & McCrae, 1992); MAACL-R, Multiple Affect Adjective
Checklist–Revised, Trait version (Zuckerman & Lubin, 1985).
*p < .05; **p < .01; ***p < .001, for zero-order correlations (n = 41).
 78 BALL AND CECERO

TABLE 3. Correlation of DSM-IV Personality Disorder Severity with Young’s Early

Maladaptive Schemas

SCID Early Maladaptive Schemas (YSQ)

Axis II
Disorder A/I ED M/A SI D/S F/A D/I VH EM SUB SS EI US ENT IS
Antisocial .06 .09 .34* .20 .19 .09 .02 .39* .12 –.12 –.21 .48** .18 .30 .23
Borderline .35* .02 .36* .03 –.05 –.04 –.08 –.02 .29 .08 .09 .13 .12 –.03 .03
Avoidant .08 –.03 .10 .10 –.06 .31 .11 .12 .23 .41* –.09 .08 –.22 –.25 .02
Depressive .28 .33 .42* .39* .36* .38* .30 .33 .02 .37* –.04 .28 .05 –.09 .23
Note. A/I, Abandonment/Instability; ED, Emotional Deprivation; M/A, Mistrust/Abuse; SI, Social Isolation;
D/S, Defectiveness/Shame; F/A, Failure to Achieve; D/I, Dependence/Incompetence; VH, Vulnerability to
Harm; EM, Enmeshment; SUB, Subjugation; SS, Self-Sacrifice; EI, Emotional Inhibition; US, Unrelenting
Standards; ENT, Entitlement; IS, Insufficient Self-Control; and YSQ, Young Schema Questionnaire (Young &
Brown, 1990).
*p < .05; **p < .01; ***p < .001, for zero-order correlation (n = 34).

Subjugation early maladaptive schema. Depressive severity was associated

with Mistrust/Abuse, Social Isolation, Defectiveness/ Shame, Failure to
Achieve, and Subjugation schemas.

PRESENTING PROBLEMS
Before presenting the association between SCID-II personality disorder
severity and BSI and IIP-CX scores, we will briefly review the significant
addiction- and psychiatric-related problems faced by this severely im-
paired group of chronic patients. At the time of screening for study eligibil-
ity, approximately one-third of the sample self-reported significant symp-
toms of depression, anxiety, violent behavior, suicidal ideation or attempts
in the past 30 days; the majority had experienced these symptoms in their
lifetime. One half of the sample reported engaging in at least one HIV-re-
lated risky behavior in the past 3 months. The majority (85%) reported ex-
periencing emotional abuse as children and a significant number reported
past physical (49%) and sexual (27%) abuse. Regarding their addiction,
participants averaged over 10 years of substance abuse with polydrug
abuse common. Multiple treatments in substance abuse (Mean = 7.5) and
psychiatric (Mean = 5.0) programs and incarceration during adulthood
provided further evidence for considering this a chronic, difficult-to-treat
sample of dual disordered individuals.
The correlations between personality disorder severity and psychiatric
symptoms and interpersonal problems are listed in Table 4 (BSI) and Table
5 (IIP-CX). Antisocial personality disorder severity was associated with
higher IIP-CX Domineering, Vindictive, Cold, and lower Exploitable inter-
personal problems. Antisocial severity also was associated with BSI Phobic
Anxiety, Somatization, Hostility, Paranoia, and Psychotic Ideation symp-
toms in addition to higher frequency of substance use within the past 30
days, r(41) = .39, p < .009 and number of lifetime arrests, r(41) = .38, p <
.016. Borderline personality disorder severity was associated with Socially
Avoidant interpersonal problems and BSI Depression, Anxiety, Somatiza-
tion, Interpersonal Sensitivity, Hostility, and Paranoia. Borderline severity
also was related to a parental history of substance abuse, t(39) = 2.52, p <
 ADDICTED PATIENTS WITH PERSONALITY DISORDERS 79

TABLE 4. Correlation of DSM-IV Personality Disorder Severity with Psychiatric

Symptom Severity.
Brief Symptom Inventory Subscales
SCID
Axis II Phobic Obsessive- Soma- Interpersonal Psychotic
Disorder Depression Anxiety Anxiety Compulsive tization Sensitivity Hostility Paranoia Ideation

Antisocial .18 .27 .47** .23 .41** .29 .61*** .45** .35*
Borderline .36* .33* .31 .16 .38* .42** .40* .43** .22
Avoidant –.02 –.05 .12 .07 .01 .06 .19 .14 –.07
Depressive .21 .10 .23 .02 .04 .21 .12 .17 .19

*p < .05; **p < .01; ***p < .001, for zero-order correlations (n = 41).

.016 and a history of childhood physical, t(39) = 3.01, p < .005, and sexual
abuse, t(39) = 2.77, p < .009. Avoidant severity was related to more Ex-
ploitable interpersonal problems. Depressive severity was associated with
higher Exploitable interpersonal problems and a history of childhood
physical abuse, t(39) = 2.31, p < .026,

DISCUSSION
We presented results of an assessment of personality traits, early mal-
adaptive schemas, and presenting problems (psychiatric and interper-
sonal) in 41 opiate-dependent patients diagnosed with DSM-IV antisocial,
borderline, avoidant, or depressive personality disorders. Many of the cor-
relations between the symptom severity of these disorders and our person-
ality and interpersonal indicators were consistent with the literature
(Costa & Widiger, 1994; Livesley, 1995; Sperry, 1995) and may partly re-
flect overlap with the DSM-IV criteria. For example, antisocial personality
disorder severity was related to lower Agreeableness and Exploitability and
higher Sensation Seeking, Hostility, Domineering, Vindictiveness, and
Cold dimensions. Avoidant severity was related to higher Neuroticism and
Exploitability and lower Extraversion, Openness, Sensation Seeking, and
Positive Affect dimensions.
Of somewhat greater interest were the relations between the personal-
ity disorders and maladaptive schemas that have been hypothesized
(Beck, et al., 1990) but not previously evaluated. As predicted, antisocial
severity was related to Mistrust/Abuse and Emotional Inhibition (in addi-

TABLE 5. Correlation of DSM-IV Personality Disorder Severity with Recent Interpersonal

Problems

Inventory of Interpersonal Problems Scales

SCID
Axis II Socially Overly
Disorder Domineering Vindictive Intrusive Cold Avoidant Exploitable Nonassertive Nurturant
Antisocial .61*** .59*** .03 .35* –.02 –.31* .03 .29
Borderline .23 .18 –.14 .25 .37* .11 .30 .12
Avoidant –.03 .19 .16 .07 .17 .35* .16 .16
Depressive .05 .07 .24 .15 .17 .39* .09 .19
*p < .05; **p < .01; ***p < .001, for Zero order correlations (n = 41).
80 BALL AND CECERO

tion to Vulnerability to Harm) schemas but not Entitlement or Insufficient

Self-Control. Borderline severity was correlated specifically with Abandon-
ment/Instability and Mistrust/Abuse (as predicted), but not with a
broader range of early maladaptive schemas as hypothesized by Young
(1995). Avoidant severity was unrelated to Social Isolation or Defective-
ness/Shame schemas but was associate with higher Subjugation. Depres-
sive personality disorder severity was correlated above .25 with 10 of 15
early maladaptive schemas (five were significant), which was a pattern
closer to what we predicted for Borderline. In addition, an assessment of
early maladaptive schemas provided better differentiation between
avoidant and depressive disorders than any of the other measures in-
cluded.
However, several of the associations predicted from previous research
were not found in our sample of substance-dependent patients. Antisocial
was unrelated to low Conscientiousness. Although borderline severity was
related to multiple psychiatric symptom categories on the BSI, it was not
associated with higher Neuroticism, Anxiety, Depression, Hostility or lower
Agreeableness, Conscientiousness, or Positive Affect. Contrary to predic-
tions, avoidant severity was uncorrelated with symptoms of Anxiety, Pho-
bic Anxiety, Interpersonal Sensitivity or problems of Social Avoidance and
Nonassertiveness. Depressive personality severity was positively associ-
ated with Extraversion and Neuroticism (not signficant), but this disorder
was no more correlated with Depression severity than with any other BSI
subscale. Previous research has found that the five-factor model accounts
for significant variation in personality disorders in clinical and community
samples with Neuroticism serving as a common risk factor for many Axis II
(and Axis I) disorders and Extraversion, Agreeableness, and Conscien-
tiousness domains and facets differentiating specific disorders (Costa &
Widiger, 1994). Our limited number of significant findings may have been
the result of our sample size and strategy. Specifically, our selection of pa-
tients who met diagnostic criteria for one of the four personality disorders
by definition truncated the range (i.e., variability) of scores for the four
severity measures. This, combined with a relatively small clinical sample
with higher range of addiction and psychiatric symptoms, lowered our
power to detect associations between our indicators.
Unlike avoidant and depressive severity, the two cluster B disorders
assessed were related to many psychiatric symptoms. Although this was
predicted for borderline, several unpredicted associations were found for
antisocial severity, including Phobic Anxiety, Somatization, Paranoia, and
Psychotic Ideation (and Vulnerability to Harm schema). These findings
may not be generalizable to a nonsubstance-dependent population. Bor-
derline and antisocial personality disorder are associated with greater psy-
chiatric and substance abuse severity (Verheul et al., 1998) in addicted
populations. Our sample as a whole reported very high levels of lifetime
and current depression, anxiety, violence, suicidality, childhood abuse,
HIV risk, substance abuse, psychosocial impairment, and previous treat-
ment.
We have used the results of these assessments to guide the clinical
case conceptualization and techniques used with patients in our NIDA-
ADDICTED PATIENTS WITH PERSONALITY DISORDERS 81

funded study of Dual Focus Schema Therapy (Ball, 1998; Ball & Young,
2000). In the early phases of our treatment, the different psychiatric symp-
toms and interpersonal problems assessed in this report provide multiple
foci for behavioral interventions. Once the presenting substance abuse,
psychiatric distress, or interpersonal problems have reduced in intensity,
psychotherapeutic work can begin to integrate a focus on the core issues
and patterns (i.e., maladaptive schemas and coping styles). Early and sus-
tained therapeutic attention to current symptoms and conflicts helps re-
duce relapse risk and promotes the necessary cognitive, emotional, and in-
terpersonal stability necessary for later exploratory work. Patient trust
engendered through early resolution of at least some of the major present-
ing complaints also may permit later empathic confrontation of maladap-
tive cognitive and behavioral patterns. Both the presenting symptom-fo-
cused and associated schema-focused aspects of treatment occur with a
knowledge and appreciation of personality traits and disorders that the
therapist shares with the patient early on in treatment. We believe that
sharing a coherent, individualized conceptualization based on the mea-
sures in this report has provided the foundation from which interpreta-
tions or confrontations could be made by the therapist and accepted by
the patient.
We believe that the personality, interpersonal, and schema indicators
evaluated in this report have had much greater relevance for planning in-
terventions and educating patients about their personality and related
problems than have the DSM-IV categories. McCrae et al. (in press) have
suggested that a model combining a profile of normal-range personality
traits with an assessment of personality-related problems would be a more
reliable, valid, and treatment-relevant system for conceptualizing person-
ality disorders and should replace Axis II in future DSM revisions. Al-
though we agree with many in the field who believe that Axis II could be re-
placed by a dimensional model of personality disorder, we believe that it
would cause unnecessary confusion to drop it completely from the treat-
ment planning or research investigation process unless clinicians and sci-
entists become completely familiar with an alternative model. Until then, it
provides an important anchor for communication between clinicians and
patients and between researchers and funding agencies, in addition to
serving as the system against which alternative models can be compared.
For this reason, we chose to map out the validity of our theoretical indica-
tors onto four of the most common Axis II categories found in substance
abuse samples.

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