Addictive Behaviors, Vol. 23, No. 6, pp.

855868, 1998
Copyright 1998 Elsevier Science Ltd
Pergamon Printed in the USA. All rights reserved
0306-4603/98 $19.00 1 .00
PII S0306-4603(98)00072-0

PREDICTING PERSONALITY PATHOLOGY AMONG ADULT

PATIENTS WITH SUBSTANCE USE DISORDERS: EFFECTS OF
CHILDHOOD MALTREATMENT
DAVID P. BERNSTEIN,* JUDITH A. STEIN,
and LEONARD HANDELSMAN
*Bronx VA Medical Center; Mount Sinai School of Medicine;
University of California at Los Angeles; Duke University School of Medicine

Abstract The purpose of this study was to examine predictive relationships between types
of childhood maltreatment and personality disorders in a substance-abusing population.
Three hundred thirty-nine drug- or alcohol-dependent patients completed a reliable and valid
retrospective measure of childhood trauma, the CTQ, and a self-report inventory that assesses
the entire range of DSM-III-R personality disorders, the PDQ-R. As a preliminary step, fac-
tor analyses were used to group personality disorders into the three DSM-III-R Axis II clus-
ters (Clusters A, B, and C), although some diagnostic subclusters were also found. Structural
equation modeling analyses revealed several significant paths between types of maltreatment
and personality disorder clusters (and subclusters). Physical abuse and physical neglect were
related to a subcluster of psychopathic personality disorders consisting of childhood and
adult antisocial personality traits and sadistic traits. Emotional abuse emerged as a broad risk
factor for personality disorders in Clusters A, B, and C. Emotional neglect was related to the
traits of schizoid personality disorder, which formed its own subcluster. Finally, sexual abuse,
which had been expected to predict borderline personality disorder traits, was unrelated to
any personality disorder cluster. These findings support the view that child maltreatment con-
tributes to the high prevalence of co-morbid personality disorders in addicted populations.
1998 Elsevier Science Ltd

Recent studies have indicated that histories of child abuse and neglect are highly prev-
alent in populations of treatment-seeking drug addicts and alcoholics. A study of 178
drug- and alcohol-dependent patients from the United States and Australia found that
84% reported histories of child abuse and neglect (Cohen & Densen-Gerber, 1982). In
a study of adult and adolescent patients in a chemical dependency rehabilitation pro-
gram, 75% of adult women and up to 90% of adolescent girls reported histories of
child sexual abuse; rates of child sexual abuse reported by adult and adolescent males
were 16% and 42%, respectively (Rohsenow, Corbett, & Devine, 1988). A study of
100 male alcoholic veterans on an inpatient rehabilitation unit found that 33% re-
ported histories of child physical abuse (Schaefer, Sobieraj, & Hollyfield, 1988). In an-
other study of male veterans undergoing inpatient substance abuse treatment, 77% re-
ported exposure to one or more types of severe childhood trauma (Triffelman,
Marmar, Delucci, & Ronfeldt, 1995). Although prevalences varied depending on the
population chosen, the types of trauma investigated, and the methods used to assess
maltreatment (e.g., chart review, structured interview), these studies consistently

Support for this research was provided by Grant P01 DA01070-24 from the National Institute on Drug
Abuse.
The authors thank Wendy Sallin for her secretarial and production assistance, and Harvey Jelley and
Michael Charash for their assistance with literature searches.
Requests for reprints should be sent to David P. Bernstein, Bronx VA Medical Center, Psychiatry Service
116A, 130 West Kingsbridge Road, Bronx, NY 10468.

855
856 D. P. BERNSTEIN et al.

found that childhood abuse and deprivation were common experiences among drug-
and alcohol-dependent patients.
These findings raise a number of important questions. One issue is whether child-
hood trauma plays an etiologic role in the development of addictive disorders, ac-
counting for its high prevalence in addicted populations. Although some studies have
found an association between childhood trauma and substance abuse (Dembo,
Dertke, Borders, Washburn, & Schmeidler, 1988; Hernandez, 1992), others suggest a
more complicated picture (Widom, Ireland, & Glynn, 1995). For example, one longi-
tudinal study found no association between childhood victimization and subsequent
alcohol problems in men, but did report such a relationship in women, even after con-
trolling for parental substance abuse and other variables (Widom et al., 1995). A re-
cent review of the literature concluded that the results of empirical studies on child-
hood trauma and alcoholism have been mixed and that there is insufficient evidence
to draw any definitive conclusions about the etiologic role of maltreatment in alcohol
use disorders (Langeland & Hartgers, 1998).
A second issue is whether childhood trauma contributes to the high prevalence of
co-morbid psychopathology that is often seen in substance-abusing patients (Hessel-
brock, Meyer, & Keener, 1985; Rounsaville et al., 1991). Many factors may account for
the occurrence of psychiatric problems in substance-abusing individuals, including ge-
netic vulnerability, life experiences, and the impact of substance use itself on neurobi-
ologic functioning (Bernstein & Handelsman, 1995). However, the impact of trau-
matic experiences on the psychological functioning of addicts has rarely been studied,
despite increasing evidence that child abuse and neglect are highly prevalent in ad-
dicted populations.
In the present study, we examined the relationship between childhood trauma and
co-morbid personality disorders in drug- or alcohol-dependent patients. Research in-
dicates that many addicted individuals also meet diagnostic criteria for personality dis-
orders, with antisocial and borderline personality disorders being the most prevalent
Axis II disorders in addicted populations (Brooner, Schmidt, Felch, & Bigelow, 1992;
Hesselbrock et al., 1985; Khantzian & Treece, 1985). Moreover, research has also sup-
ported a connection between childhood trauma and personality disorders, especially
borderline and antisocial personality disorders. Several studies have found that psy-
chiatric patients with histories of child sexual abuse are more likely to meet diagnostic
criteria for borderline personality disorder (Herman, Perry, & van der Kolk, 1989;
Paris, Zweig-Frank, & Guzder, 1994; Zanarini, Gunderson, Marino, Schwartz, &
Frankenburg, 1989). Moreover, sexually abused individuals are more likely to engage
in self-destructive behaviors, such as self-mutilation and suicide attempts, that are of-
ten characteristic of borderline patients (Lipschitz et al., under review; van der Kolk,
Perry, & Herman, 1991). There is substantial evidence supporting a link between child
physical abuse and aggression and delinquency (Dodge, Bates, & Pettit, 1990; Mali-
nosky-Rummell & Hansen, 1993). In one of the few longitudinal studies to examine
this issue, Luntz and Widom (1994) found that children who had been physically or
sexually abused were at increased risk for developing antisocial personality disorder
as adults.
Fewer studies have examined the impact of other types of maltreatment, such as
emotional abuse and physical and emotional neglect, on personality disorders. Physi-
cal neglect, and specifically poor parental supervision, has been implicated in the de-
velopment of antisocial personality. For example, in a review of the causes of juvenile
delinquency, Loeber and Dishion (1983) found that inadequate parental caretaking
 Predicting personality pathology 857

was a probable contributory factor to antisocial behavior in youth. A few studies have
found that emotional abuse, including verbal and nonverbal forms of emotional deni-
gration, is related to low self-esteem (Briere & Runtz, 1988; Gross & Keller, 1992), a
central feature of avoidant and dependent personality disorders (Hirschfield, Shea, &
Weise, 1991; Millon, 1991). On the other hand, no empirical studies could be found on
the impact of emotional neglectthe failure of caretakers to meet childrens emo-
tional needs, such as the need for love, nurturance, and supporton personality disor-
ders. However, several psychoanalytic theorists have suggested that emotional depri-
vation plays a critical role in the development of schizoid personality disorder, which
is characterized by an inability to form emotional attachments (Fairbairn, 1952; Gun-
trip, 1969; Winnicott, 1965).
These findings raise the possibility that child abuse and deprivation contribute to
the high prevalence of co-morbid personality disorders in addicted populations. The
purpose of our study was to examine the effects of maltreatment on personality disor-
ders in a group of treatment-seeking drug- or alcohol-dependent patients. Previous
studies of the effects of maltreatment have often focused on only one or two types of
trauma, typically sexual or physical abuse, while failing to control for other traumatic
experiences which may also be present, such as emotional abuse, and physical and
emotional neglect (Briere, 1992). This has made it difficult to disentangle the effects of
specific forms of maltreatment from other co-occurring forms. In this study, we used a
maltreatment inventory, the Childhood Trauma Questionnaire (CTQ; Bernstein &
Fink, 1998), that inquires about a broad range of maltreatment experiences, including
physical, sexual, and emotional abuse, and physical and emotional neglect, and has
also received extensive validation in previous studies, including validation by indepen-
dent corroborative evidence (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997). We
also assessed the full range of DSM-III-R personality disorders using a well-validated
self-report inventory, the Personality Diagnostic Questionnaire-Revised (PDQ-R;
Hyler & Rieder, 1987). Thus, our research design was a truly multivariate one in which
multiple forms of maltreatment and the entire range of personality disorder diagnoses
were represented.

M E T H O D

Participants
A primarily male sample (85.6%) of 378 adult substance users was obtained from
the inpatient detoxification and rehabilitation units at the Veterans Affairs Medical
Center in the Bronx, New York (n 5 252) and an outpatient methadone maintenance
program affiliated with the Mount Sinai Medical Center in New York City (n 5 126).
The combined sample, which ranged from 24 to 68 years (M 5 40.2 years, SD 5 8.8),
consisted of predominantly minority (50.3% African-American, 33.7% Hispanic, and
13.4% White), inner-city addicts from backgrounds of urban poverty. The Mount Si-
nai sample included a higher proportion of female (41%) and Hispanic patients (His-
panic, 50%; African-American, 38.5%; White, 9%) than the Bronx VA sample, which
was largely male (98.4%) and mostly African-American (African-American, 56%;
Hispanic, 26%; White, 15.2%gender: x2 5 102.48, df 5 1, p , .001; ethnicity: x2 5
21.34, df 5 3, p , .001).
All patients were given DSM-III-R diagnoses of drug and/or alcohol dependence by
the admitting psychiatrist. The Mount Sinai sample consisted entirely of heroin-de-
pendent patients maintained on methadone, while the VA sample was composed of
858 D. P. BERNSTEIN et al.

patients with drug (i.e., cocaine or heroin) or alcohol dependence (drug dependence,
56.5%; alcohol dependence, 43.5%). Although patients differed in terms of their pre-
dominant pattern of substance use69.4% of the combined sample were considered
primarily drug dependent while 30.6% were considered primarily alcohol depen-
dentmost patients in the combined sample reported extensive lifetime histories of
polysubstance use with alcohol (90.1%), cocaine (68.3%), cannabis (60%), and heroin
(39.2%) being the most frequently used substances. Among patients who reported us-
ing each respective substance, the mean (SD) years of lifetime regular use was: alco-
hol, 18.9 (11.0) years; cocaine, 7.3 (5.6) years; cannabis, 10.1 (8.0) years; and heroin,
10.1 (7.1) years. Although the two samples differed in terms of gender, ethnicity, and
type of predominant substance use, we chose to combine them in order to have suffi-
cient statistical power for the SEM analyses that are described below.

Instruments
Childhood Trauma Questionnaire. The Childhood Trauma Questionnaire (CTQ;
Bernstein & Fink, 1998) is a brief self-report inventory that assesses five types of mal-
treatment: Emotional, Physical, and Sexual Abuse, and Emotional and Physical Ne-
glect. Items on the CTQ inquire about experiences in childhood and adolescence and
are responded to on a 5-point Likert-type scale with response options ranging from
never true to very often true. Validation of the CTQ has involved over 2,200 individuals
in seven different clinical and community samples, including adult substance abusers
(Bernstein & Fink, 1998). Studies have indicated that self-reports on the CTQ are
highly stable over time (Bernstein et al., 1994), show convergent and discriminant va-
lidity with other trauma measures (Bernstein et al., 1994; Fink, Bernstein, Handels-
man, Foote, & Lovejoy, 1995), and tend to be corroborated when independent evi-
dence is available (Bernstein et al., 1997). In the latter study, the CTQ showed good
sensitivity (.86 to .78) and satisfactory or better specificity (.76 to .61), when adoles-
cent psychiatric patients self-reports on the CTQ were compared to trauma ratings
based on all available data, such as child welfare records and the reports of family
members and referring clinicians and agencies (Bernstein et al., 1997). The original
version of the CTQ consisted of 70 items. Recently, however, we have developed and
validated a screening version of the scale in which each type of maltreatment is repre-
sented by only five items, making it more efficient to administer across a range of set-
tings (Bernstein et al., under review). In the present study, patients were given the
original 70-item version of the CTQ, but only those items from the brief CTQ were
used for scoring purposes. We applied the scoring algorithms from the brief CTQ be-
cause in some respects it is psychometrically superior to the original version; specifi-
cally, some items from the original CTQ loaded highly on more than one of its factors
and were eliminated from the brief version of the scale creating more discriminable
factors (Bernstein et al., under review). The CTQ was administered as part of a bat-
tery of psychological tests approximately 1 week after patients were admitted to the
inpatient or outpatient facilities. As is reported below, not all of the 378 participants
who completed the CTQ also completed the PDQ-R so the analyses are reported for a
subsample of the original participants. Informed consent was obtained under the gen-
eral consent for clinical services obtained from the patients.

Psychiatric scales from the PDQR. The Personality Diagnostic Questionnaire-Revised

(PDQ-R; Hyler & Rieder, 1987) is a self-report inventory that assesses the full range
 Predicting personality pathology 859

of DSM-III-R personality disorders, including the two provisional Axis II diagnoses,

sadistic and self-defeating personality disorders. The PDQ-R has shown good reliabil-
ity and validity in previous studies, including convergent validity with structured inter-
views for personality disorders (Hyler, Skodol, Oldham, Kellman, & Doidge, 1992).
We used the PDQ-R scales that count the number of traits exhibited (i.e., diagnostic
criteria) for each personality disorder rather than dichotomous indicators. We pre-
ferred to use the PDQ-R scales dimensionally, rather than creating dichotomous per-
sonality disorder diagnoses, because studies have shown the self-report measures such
as the PDQ-R tend to overdiagnose personality disorders when the DSM diagnostic
thresholds are applied (Hyler et al., 1992). Three hundred thirty-nine of the patients in
the combined sample had scores on the PDQ-R and were included in the latent vari-
able analysis. A higher proportion of the VA sample completed the PDQ-R (95.6%)
than the Mount Sinai sample (80.8%; x2 5 22.43, df 5 1, p , .001). In the combined
sample, the patients who did not complete the PDQ-R (n 5 39) had slightly lower
mean (SD) scores than patients who completed the PDQ-R (N 5 339) on the CTQ
Physical Abuse scale (9.22 [4.3] vs. 7.7 [3.5]; t 5 2.02, df 5 376, p , .05) but were not
significantly different on any of the other CTQ scales.

Preliminary analyses
Preliminary comparisons indicated the presence of several gender and ethnic group
differences on CTQ and PDQ-R variables. Female patients received significantly
higher mean scores than male patients on the CTQ scales for Sexual Abuse (t 5 4.94,
df 5 237, p , .001) and Emotional Abuse (t 5 2.19, df 5 237, p , .05) and on the
PDQ-R scales for avoidant (t 5 2.63, df 5 237, p , .01), borderline (t 5 2.09, df 5 237,
p , .05), dependent (t 5 2.36, df 5 237, p , .05), and histrionic (t 5 2.71, df 5 237, p ,
.01) personality disorders; male patients received higher scores on the PDQ-R scale
for antisocial personality disorder (adult traits; t 5 3.21, df 5 237, p , .001). Ethnic
group differences were found in scores on the CTQ scales for Emotional Abuse, F(2,
328) 5 3.16, p , .05 (no significant pairwise group differences by Tukey HSD); Emo-
tional Neglect, F(2, 328) 5 9.01, p , .001 (Whites and Hispanics . African-Ameri-
cans); and Physical Neglect, F(2, 328) 5 4.98, p , .01 (Hispanics . African-Ameri-
cans), and in the PDQ-R scales for antisocial personality disorder [childhood traits],
F(2, 328) 5 3.27, p , .05 (Hispanics . African-Americans) and passive-aggressive,
F(2, 328) 5 4.02, p , .05 (Hispanics . African-Americans) personality disorder. How-
ever, these gender and ethnic group differences were ambiguous to interpret because
the vast majority of the female patients in the study (91.8%) were from the Mount Si-
nai methadone maintenance sample and were twice as likely to be Hispanic as the pa-
tients in the VA sample. Thus, in the combined sample, female gender and Hispanic
ethnicity were confounded with each other and also with membership in the Mount Si-
nai group.

Confirmatory factor analysis models. We developed outcome latent variables rep-

resenting the established clusters for the DSM-III-R personality disorders (American
Psychiatric Association, 1987) using the PDQ-R. By using the DSM-III-R Axis II clus-
ters, rather than the individual PDQ-R scales, we reduced the number of potential
paths from types of maltreatment to personality disorder outcomes, thus reducing the
likelihood of capitalizing on chance relationships in the data due to multiple signifi-
cance tests (i.e., experimentwise Type I error). Preliminary confirmatory factor analy-
860 D. P. BERNSTEIN et al.

ses generally supported the a priori DSM-III-R personality disorder configurations.

However, we did find some exceptions which are reported as follows. In Cluster A we
included paranoid and schizotypal personality disorders. In preliminary factor analy-
ses, schizoid symptomatology did not load highly with Cluster A, mainly because
schizoid did not correlate significantly with paranoid traits. Thus, schizoid was in-
cluded in the latent variable analysis as a separate variable. Again, based on the pre-
liminary factor analyses, Cluster B was split into two subclusters. B1 included the
psychopathic personality disorders: antisocial personality disorder (adult traits), anti-
social personality disorder (childhood traits), and sadistic personality disorder. Cluster
B2 included the dramatic personality disorders: borderline, histrionic, and narcissistic
personality disorders; Cluster C included avoidant, dependent, obsessive-compulsive,
passive-aggressive and self-defeating personality disorders. We then developed a con-
firmatory latent variable model in which each of the five types of maltreatment as-
sessed by the CTQ was indicated by five items, and each Axis II cluster was indicated
by its separate personality disorder variables. This model allowed all latent constructs
to intercorrelate freely with no imputation of causality or precedence. This analysis
assessed the adequacy of the proposed factor structure and the relationships among
the latent variables. The latent variable analyses were performed using the EQS struc-
tural equations modeling program (Bentler, 1995).
Fit of these models was assessed with the Satorra-Bentler chi-square statistic and
the Robust Comparative Fit Index (RCFI), which are most appropriate when the data
are multivariately kurtose (Bentler & Dudgeon, 1996). A chi-square value no more
than twice the degrees of freedom in the model generally indicates a plausible, well-
fitting model. The RCFI ranges between 0 and 1 and compares the improvement of fit
of a hypothesized model to a model of complete independence among the measured
variables while adjusting for sample size. To improve model fit, we examined results
of the Lagrange Multiplier Test (LM test; Chou & Bentler, 1990) to see whether there
were any significant and theoretically sound correlated error residuals we could add to
the original CFA.

Path analyses. Once the measurement model was established in the CFA, we then
tested the predictive utility and specificity of the latent abuse factors. The path model
tested the power of the latent constructs to predict the various Axis II clusters. In
these models, the CTQ factors were allowed to correlate among themselves, as were
the residuals of the outcome variables, the latent factors corresponding to the DSM-
III-R Axis II clusters. Nonsignificant predictive paths between predictor and outcome
latent variables were dropped gradually until only significant paths remained.
Based on our review of the empirical and theoretical literature, we formulated sev-
eral hypotheses about the effects of different types of maltreatment on the personal-
ity disorder clusters. First, considerable empirical evidence suggested that physical
abuse would be related to antisocial and aggressive traits, which were represented in
our data set by the psychopathic subcluster of Cluster B (Cluster B1), and that sex-
ual abuse would be related to borderline traits, which were included in the dramatic
subcluster of Cluster B (Cluster B2). Although there was less empirical evidence on
which to base our other hypotheses, we formulated the following more provisional
conjectures about the effects of the other types of maltreatment: physical neglect
would also make an independent contribution to the prediction of antisocial behav-
ior, represented by Cluster B1; emotional abuse would be associated with low self-
esteem, which was represented by the anxious Cluster (Cluster C); and emotional
 Predicting personality pathology 861

neglect would be associated with schizoid traits, which formed their own subcluster of
Cluster A.

R E S U L T S

The mean (SD) scores for the CTQ items and for the CTQ and PDQ-R scales are
presented in Table 1. For descriptive purposes, we determined the frequency of differ-
ent types of self-reported maltreatment histories in the substance-abusing patients by
applying predetermined cut scores to the CTQ data (Bernstein & Fink, 1998). When
the most inclusive cut scores were used (i.e., cut scores that captured even cases of low
severity), the prevalences of child maltreatment were: Physical Abuse, 55.3% (n 5
188), Sexual Abuse, 36.5% (n 5 124), Emotional Abuse, 45.9% (n 5 156), Physical
Neglect, 36.8% (n 5 125), and Emotional Neglect, 47.1% (n 5 160). Some 79.7% of
the sample had a history of any type of maltreatment when the most inclusive cut
scores were used. When more restrictive cut scores were used (i.e., cut scores that cap-
tured only cases of moderate or greater severity), the prevalences of child maltreat-
ment were: Physical Abuse, 32.9% (n 5 188), Sexual Abuse, 25% (n 5 85), Emotional
Abuse, 23.5% (n 5 80), Physical Neglect, 21.5% (n 5 73), and Emotional Neglect,
21.5% (n 5 73). Some 54.1% of the sample had a history of any type of maltreatment,
when the more restrictive cut scores were employed.

Confirmatory factor analysis

Table 1 reports the results of the initial CFA. The CFA model had excellent fit sta-
tistics: S-B x2(657, N 5 339) 5 1069.24; RCFI 5 .91). All fit indexes were greater than
.90, and the chi-square/degrees of freedom ratios were less than 2:1. The Satorra-
Bentler fit statistics were used because the normalized multivariate kurtosis estimate
was 56.23. All factor loadings were significant (p , .001). Means, standard deviations,
and factor loadings of the measured variables are reported in Table 1.
Table 2 reports the correlations among the DSM-III-R Axis II clusters and the five
CTQ factors in the confirmatory factor analysis. All CTQ factors and Axis II outcome
variables were positively correlated, many significantly. One supplementary correla-
tion among the residuals was added to the CFA model as suggested by the LM test: a
reasonable correlation between the residuals of two sexual abuse items (someone
tried to touch me in a sexual way, or tried to make me touch them, and someone
tried to make me do sexual things or watch sexual things).

Path model
Figure 1 depicts significant CTQ predictors of the DSM-III-R personality disorder
clusters. In addition, the standardized factor loadings of the individual scales on their
clusters are reported. All of these factor loadings were substantial as well as significant
(p , .001). This model had an excellent fit: S-B x2(677, N 5 339) 5 1039.42; RCFI 5
.92). Emotional Abuse significantly predicted Cluster A. Physical Abuse and Physical
Neglect predicted Cluster B-1. Cluster B-2 was predicted by Emotional Abuse as was
Cluster C. Emotional Neglect predicted schizoid personality disorder. Although Sex-
ual Abuse did not significantly predict any of the clusters, the Lagrange Multiplier test
reported a significant relationship between Sexual Abuse and one subscale from Clus-
ter C, avoidant personality disorder. However, to avoid capitalizing on possibly
chance relationships in the data, we did not add any specific paths from latent vari-
ables to measured variables in this model.
862 D. P. BERNSTEIN et al.

Table 1. Means, standard deviations, and factor loadings of measured variables in the
confirmatory factor analysis

M(SD) Factor loadinga

I. Emotional Abuse: 9.5 (4.8)

Called names by family 2.2 (1.2) .61
Parents wished was never born 1.6 (1.1) .69
Felt hated by family 1.7 (1.2) .78
Family said hurtful things 2.2 (1.2) .80
Was emotionally abused 2.0 (1.3) .81
II. Physical Abuse: 9.2 (4.3)
Hit hard enough to see doctor 1.4 (0.9) .75
Hit hard enough to leave bruises 1.8 (1.2) .76
Punished with hard objects 3.0 (1.4) .54
Was physically abused 1.7 (1.2) .75
Hit badly enough to be noticed 1.4 (0.9) .71
III. Sexual Abuse: 7.3 (4.5)
Was touched sexually 1.7 (1.2) .82
Hurt if didnt do something sexual 1.3 (0.8) .77
Made to do sexual things 1.5 (1.0) .87
Was molested 1.4 (1.0) .91
Was sexually abused 1.4 (1.0) .91
IV. Emotional Neglect: 10.3 (4.9)
Felt loved (R) 1.9 (1.2) .81
Made to feel important (R) 2.3 (1.2) .69
Was looked out for (R) 2.0 (1.1) .78
Family felt close (R) 2.1 (1.2) .76
Family was source of strength (R) 2.1 (1.2) .83
V. Physical Neglect: 7.6 (3.2)
Not enough to eat 1.5 (0.9) .41
Got taken care of (R) 1.8 (1.2) .67
Parents were drunk or high 1.4 (0.9) .51
Wore dirty clothes 1.4 (0.8) .66
Got taken to doctor (R) 1.5 (0.9) .54
VI. Cluster A:
Paranoid (range 5 07) 4.2 (1.6) .65
Schizotypal (09) 3.6 (1.9) .77
VII. Cluster B1:
Sadistic (07) 1.7 (1.3) .64
Anti-Social (Childhood; 012) 2.7 (2.8) .64
Anti-Social (Adult; 010) 3.5 (2.1) .66
VIII. Cluster B2:
Borderline (08) 4.6 (1.9) .71
Histrionic (08) 2.8 (2.1) .75
Narissistic (09) 3.5 (2.1) .70
IX. Cluster C:
Avoidant (07) 2.0 (1.6) .65
Dependent (08) 2.4 (1.8) .66
Obsessive-Compulsive (08) 2.7 (1.7) .63
Passive-Aggressive (09) 2.8 (1.9) .74
Self-Defeating (08) 3.0 (1.9) .77
X. Schizoid (07) 2.4 (1.4) 1.0

Note. Range of all CTQ items 5 15 (1 5 never true; 2 5 rarely true; 3 5 sometimes true; 4 5 often true; 5 5
very often true). Range of all CTQ scale scores 5 525. R 5 reverse-scored item.
aAll factor loadings significant, p # .001.
 Predicting personality pathology 863

Table 2. Correlations between Childhood Trauma Questionnaire (CTQ) subscales

and personality disorder variables

Emotional Physical Sexual Emotional Physical

Abuse Abuse Abuse Neglect Neglect

Outcome variables
Cluster A .43*** .30*** .28*** .21*** .25***
Cluster B1 .33*** .31*** .19** .26*** .26***
Cluster B2 .31*** .20*** .22*** .13* .10
Cluster C .36*** .20*** .23*** .23*** .17**
Schizoid .25*** .19*** .16** .27*** .25***

*p # .05, **p # .01, ***p # .001.

D I S C U S S I O N

As in previous studies (Cohen & Densen-Gerber, 1982; Rohsenow et al., 1988;

Schaefer et al., 1988; Triffelman et al., 1995), we found very high prevalences of child-
hood trauma in treatment-seeking drug addicts and alcoholics. Nearly 80% of the
sample reported a history of child abuse or neglect when an inclusive threshold was
used to determine caseness, and 54% were considered abused or neglected when a
more conservative threshold was used. Moreover, several significant maltreatment ef-
fects were found when we used SEM to examine the specific interrelationships be-
tween different types of maltreatment and personality disorder clusters. As hypothe-
sized, physical abuse and physical neglect were related to a subcluster of
psychopathic personality disorder traits consisting of childhood and adult antisocial
traits and sadistic traits. Emotional abuse emerged as a broad risk factor for personal-
ity disorders, exhibiting not only the hypothesized associations with anxiety cluster
personality disorders (avoidant, dependent, obsessive-compulsive, passive-aggressive,
self-defeating), but also associations with subclusters characterized by mistrust and ec-
centricity (paranoid and schizotypal) and by impulsivity and affective lability (border-
line, histrionic, and narcissistic). As hypothesized, emotional neglect was related to
the traits of schizoid personality disorder, which formed its own subcluster. Finally,
sexual abuse, which had been expected to predict borderline personality disorder
traits, was unrelated to any personality disorder cluster.
These results have several potentially important implications. First, our factor ana-
lytic finding of a subcluster of psychopathic personality disorder traits, including
child and adult antisocial traits and sadistic traits, is consistent with a large literature
on the prominence of antisocial features in substance-abusing populations (Brooner et
al., 1992; Hesselbrock et al., 1985; Khantzian & Treece, 1985). Most studies have
found that antisocial behavior is nearly ubiquitous among substance abusers, with
25% to 50% of drug addicts and alcoholics meeting criteria sufficient for an antisocial
personality disorder diagnosis. Although other factor analytic studies have supported
the grouping of personality disorders into Clusters A, B, and C (Bagby, Joffe, Parker,
& Schuller, 1993), our partial replication involving separate psychopathic and im-
pulsivity/lability subclusters of Cluster B suggests a potentially important variation in
substance-abusing populations. The finding that these subclusters were associated
with different types of maltreatmentthe psychopathic subcluster with physical
abuse and physical neglect, and the impulsivity/ affective lability subcluster with
emotional abusesupports the discriminant validity of this distinction in substance-
abusing patients.
864 D. P. BERNSTEIN et al.

Fig. 1. Significant regression paths among latent variables in the structural equation model
predicting DSM-III-R personality disorders (N 5 339). Regression coefficients are
standardized (a means p , .05, b means p , .01, c means p , .001). Factor loadings of
manifest indicators on DSM-III-R clusters are all significant, p , .001. Correlations among
predictors and correlations among residuals of outcomes are not depicted for readability.
 Predicting personality pathology 865

Next, our results suggest that the consequences of emotional abuse go beyond low
self-esteeman association reported in previous studies (Briere & Runtz, 1988; Gross
& Keller, 1992)to encompass a broader range of personality disorder traits. Al-
though some authors have defined emotional maltreatment in terms of verbal and
nonverbal denigration (McGee & Wolfe, 1991), others have argued that emotional
maltreatment is fundamental to all forms of childhood victimization (Hart & Brassard,
1991). According to the latter view, experiences such as sexual and physical abuse are
not limited to their overt, physical manifestations, but share in common certain emo-
tional elements such as exploiting, rejecting, and terrorizing victims (Hart & Brassard,
1991). An implication of this perspective is that emotional maltreatment should have
broad consequences for personality formation, impacting not only on the childs sense
of self-worth, but on his or her developing ability to form trusting interpersonal rela-
tionships and modulate affective states. The results of our study are consistent with
the view that emotional abuse is broadly related to personality impairment. In con-
trast, our results suggest that emotional neglect is more specifically related to schizoid
traits such as emotional detachment and aloofnessa finding that is consistent with a
large body of psychoanalytic theory suggesting that extreme emotional deprivation in
childhood contributes to the development of a false self presentation (Fairbairn,
1952; Guntrip, 1969; Winnicott, 1965). It is important to note, however, that the DSM-
III-R operationalization of the schizoid concept is not identical to its formulation in
the psychoanalytic literature; nevertheless, Millon, who was largely responsible for
creating the DSM diagnostic criteria for schizoid personality, has made it clear that
these criteria are derived from psychoanalytic descriptions, albeit in somewhat modi-
fied form (Millon, 1981). In general, these findings underscore the need for further
study of emotional maltreatment, an area that has received comparatively little empir-
ical attention.
The failure to find the predicted relationship between child sexual abuse and bor-
derline personality disorder, which was a component of the dramatic subcluster of
Cluster B, requires explanation. First, significant correlations were found between
child sexual abuse and every personality disorder cluster or subcluster we examined,
including the subcluster containing borderline traits; it was only when other forms of
maltreatment were controlled for in the SEM model that these associations with child
sexual abuse disappeared. Thus, studies that have focused exclusively on child sex-
ual abuse may have drawn mistaken inferences about sexual abuses unique effects,
due to their failure to control for other co-occurring types of trauma (Briere, 1992).
Second, the large literature on the role of child sexual abuse in borderline personality
disorder is based mostly, but not entirely, on samples of women (Paris, 1997), whereas
our sample consisted primarily of men. It is conceivable that gender is a moderating
variable that interacts with maltreatment to produce differential effects in females and
males, although some studies have reported that child sexual abuse is related to bor-
derline personality in men (Paris et al., 1994). Alternatively, it may be that the severity
of sexual abuse in our sample of predominantly male substance abusers was not suffi-
cient to produce the effects on borderline pathology that have been found in studies of
women. Consistent with the latter explanation, Ruggiero (1995) studied 200 male sub-
stance abusers and found that, although many reported histories of child sexual abuse,
only 3% of their sexual abuse histories were classified as severe to extreme. Moreover,
the highest levels of personality disorder traits were found in the small number of men
with severe sexual abuse histories. A final alternative is that our failure to find specific
sexual abuse effects is due to our methodology, which involved the use of dimensional
866 D. P. BERNSTEIN et al.

measures of childhood trauma and broad personality disorder clusters, rather than
more traditional categorical Axis II diagnoses. On the other hand, our approach was
successful in finding a number of other predicted relationships between child maltreat-
ment variables and Axis II psychopathology.
The findings of this study need to be interpreted in light of certain limitations. First,
our assessment of abuse and neglect histories was based on retrospective self-report;
due to the absence of corroborative evidence for these cases, the validity of these self-
reports cannot be established with absolute certainty. On the other hand, the retro-
spective measure we employed, the CTQ, has received extensive validation in previ-
ous studies, including corroboration with external evidence, such as child welfare
records and the reports of contemporary informants, when such data were available
(Bernstein et al., 1997). Second, although we used a well-validated self-report inven-
tory, the PDQ-R, to assess personality disorder traits, it is conceivable that assessment
with a structured interview for personality disorders would have produced different
results. Third, our use of self-report measures to assess both maltreatment and person-
ality disorders raises questions about the influence of shared method variance on our
results. On the other hand, our finding that different types of maltreatment were re-
lated to different personality disorder outcomes mitigates against this possibility.
Next, due to its retrospective nature, our study design was essentially a correlational
one, limiting any inferences that can be made about causality. Longitudinal studies
would be needed to make stronger causal attributions about the effects of childhood
trauma on personality disorders. Finally, our findings are most conservatively general-
ized to populations of substance abusers who seek treatment and should be replicated
in other samples of drug- and alcohol-dependent patients. Replications in community
samples would be necessary to extend these findings to nonreferred populations.
In summary, these findings support the view that child maltreatment contributes to
the high prevalence of personality disorders in addicted populations. Many addicts
and alcoholics grow up in families where child abuse and deprivation are routine. Fa-
milial substance abuse is also frequently a part of this picture. Research indicates that
parental drug and alcohol abuse is a major contributor to childhood victimization
(Magura & Laudet, 1996) and that victimized children may be at increased risk of de-
veloping addictive disorders (Dembo et al., 1988; Hernandez, 1992), although evi-
dence for the latter is mixed (Langeland & Hartgers, 1998). Thus, childhood victimiza-
tion may be a common antecedent of both substance abuse and personality disorders,
contributing to their high degree of co-morbidity. Future studies should attempt a
comprehensive test of this model by comparing the risk of substance abuse and per-
sonality disorders in nonreferred groups of individuals with and without histories of
child maltreatment.

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