Exploring Relationships between Adult Attachment, Spirituality and Personality Disorder Traits among Individuals in In-patient Treatment for Substance Use Disorders

Gail Horton, Nealys Luna, Tammy Malloy


Both secure attachment style and higher levels of spirituality have been shown to be protective factors in the treatment of substance use disorders. However, very little is known about how either of these factors is related to personality disorder (PD) traits that are commonly co-morbid with substance use disorders. The purpose of this study was to explore the relative importance of spirituality (existential purpose/meaning in life and religious well-being) and attachment dimensions (attachment avoidance and attachment anxiety) as predictors of personality disorder trait levels among individuals receiving treatment for substance use disorders. Results showed that existential purpose and meaning in life was the best predictor of clinical/subclinical levels of borderline and antisocial PD traits and that attachment anxiety was the best predictor of clinical/subclinical levels of avoidant and dependent PD traits. None of the other PD traits was significantly associated with either attachment dimensions or spirituality dimensions.

Full Text:



American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revised). Arlington, VA: American Psychiatric Publishing.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

American Psychiatric Association. (2015). APA_DSM5_The-Personality-Inventory-For-DSM-5-Brief-Form-Adult.pdf. Available at: http://www.psychiatry.org/

Ball, S. A., Nich, C., Rounsaville, B. J., Eagan, D., & Carroll, K. M. (2004). Millon Clinical Multiaxial Inventory-III subtypes of opioid dependence: Validity and matching to behavioral therapies. Journal of Consulting and Clinical Psychology, 72(4), 698-711. http://dx.doi.org/10.1037/0022-006X.72.4.698

Bandelow, B., Schmahl, C., Falkai, P., & Wedekind, D. (2010). Borderline personality disorder: A dysregulation of the endogenous opioid system? Psychological Review, 117(2), 623-636. http://dx.doi.org/10.1037/a0018095

Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61(2), 226-244. http://dx.doi.org/10.1037/0022-3514.61.2.226

Bender, D., Farber, B., & Geller, J. (2001). Cluster B personality traits and attachment. Journal of the Academy of Psychoanalysis, 29(4), 551-563. http://dx.doi.org/10.1521/jaap.29.4.551.21545

Bennett, K. Shepard, J., & Janca, A. (2013). Personality disorders and spirituality. Current Opinions in Psychiatry, 26, 79-83. http://dx.doi.org/10.1097/YCO.0b013e32835b2c17

Brennan, K. A., & Shaver, P. R. (1998). Attachment styles and personality disorders: Their connections to each other and to parental divorce, parental death and perceptions of parental caregiving. Journal of Personality, 66(5), 835-878. http://dx.doi.org/10.1111/1467-6494.00034

Brown, R., Newman, I., & Fraas, J. (2004). Accessing a model’s ability to classify subjects: The importance of considering marginally accurate classifications. Multiple Linear Regression Viewpoints, 30(1), 1-7.

Cacciola, J. S., Alterman, A. I., McKay, J. R., & Rutherford, M. J. (2001). Psychiatric comorbidity in patients with substance use disorders: Do not forget Axis II disorders. Psychiatric Annals, 31(5), 321-331. http://dx.doi.org/10.3928/0048-5713-20010501-10

Calsyn, D. A., Wells, E. A., Fleming, C., & Saxon, A. J. (2000). Changes in Millon Clinical Multiaxial Inventory scores among opiate addicts as a function of retention in methadone maintenance treatment and recent drug use. The American Journal of Drug and Alcohol Abuse, 26(2), 297-309. http://dx.doi.org/10.1081/ADA-100100606

Campesino, M., & Schwartz, G. (2006). Spirituality among Latinas/os: Implications of culture in conceptualization and measurement. Advances in Nursing Science, 29(1), 69-81. http://dx.doi.org/10.1097/00012272-200601000-00007

Canda, E. & Furman, L. (2010). Spiritual diversity in social work: The heart of helping (2nd ed.). New York: Oxford University Press.

Caspers, K. M., Yucuis, R., Troutman, B., & Spinks, R. (2006). Attachment as an organizer of behavior: Implications for substance abuse problems and willingness to seek treatment. Substance Abuse Treatment, Prevention, and Policy, 1(32). http://dx.doi.org/10.1186/1747-597X-1-32

Chen, E. Y., Brown, M. Z., Harned, M. S., & Linehan, M. M. (2009). A comparison of borderline personality disorder with and without eating disorders. Psychiatry Research, 170, 86-90. http://dx.doi.org/10.1016/j.psychres.2009.03.006

Cooper, A. M. (1987). Histrionic, narcissistic, and compulsive personality disorders. In G. L. Tischler (Ed.), Diagnosis and classification in psychiatry: A critical appraisal of DSM-III, (pp. 290-299). New York: Cambridge University Press.

Craig, R. J. (2005). Alternative interpretations for the Histrionic, Narcissistic, and Compulsive personality disorder scales of the MCMI-III. In R. J. Craig (Ed.), New directions in interpreting the Millon Clinical Multiaxial Inventory-III (MCMI-III), (pp. 71-93). Hoboken, NJ: John Wiley and Sons Publishing.

Craig, R. J., & Olson, R. E. (2001). Adjective descriptions of personality disorders: A convergent validity study of the MCMI-III. Journal of Personality Assessment, 77(2), 259-271. http://dx.doi.org/10.1207/S15327752JPA7702_09

Crowell, J., Fraley, C., & Shaver, P. (1999). Measurement of individual differences in adolescent and adult attachment. In J. Cassidy, & P. Shaver (Eds.), Handbook of attachment: theory, research, and clinical applications (pp. 599-634). New York: Guilford Press.

Dalmida, S. G. (2006). Spirituality, mental health, physical health and health-related quality of life in women with HIV/AIDS: Integrating spirituality into mental health care. Issues in Mental Health Nursing, 27(2), 185-198. http://dx.doi.org/10.1080/01612840500436958

Diaz, N., Horton, E. G., & Malloy, T. (2014). Attachment style, spirituality and depressive symptoms among individuals in substance abuse treatment. Journal of Social Service Research, on line publication. http://dx.doi.org/10.1080/01488376.2014.896851

Diaz, N., Horton, E. G., McIlveen, J., Weiner, M., & Nelson, J. (2009). Dysthymia among substance abusers: An exploratory study of individuals and mental health factors. International Journal of Mental Health and Addiction, 7, 357-367. http://dx.doi.org/10.1007/s11469-008-9158-0

Diaz, N., Horton, E. G., McIlveen, J., Weiner, M., & Williams, L. B. (2011). Spirituality, religiosity, and depressive symptoms among individuals in substance abuse treatment. Journal of Religion and Spirituality in Social Work: Social Thought, 30, 71-87. http://dx.doi.org/10.1080/15426432.2011.542729

Diaz, N., Horton, E. G., & Weiner, M. (2012). Dysthymia, major depression, and double depression among individuals receiving substance abuse treatment. Health, 4(12), 1229-1237. http://dx.doi.org/10.4236/health.2012.412181

Doolittle, B. R., & Farrell, M. (2004). The association between spirituality and depression in an urban clinic. Journal of Clinical Psychiatry, 6(3), 114-118. http://dx.doi.org/10.4088/pcc.v06n0302

Ellison, C. W. (1983). Spiritual well-being: Conceptualization and measurement. Journal of Psychology and Theology, 11, 330-340.

Eurelings-Bontekoe, E., Hekman-Van Steeg, J., & Verschuur, M. (2005). The association between personality, attachment, psychological distress, church denomination and the God concept among a non-clinical sample. Mental Health, Religion & Culture, 8(2), 141-154. http://dx.doi.org/10.1080/13674670412331304320

Fernander, A., Wilson, J. F., Staton, M., Leukfeld, C. (2004). An exploratory examination of the Spiritual Well-being scale among incarcerated Black and White male drug users. International Journal of Offender Therapy and Comparative Criminology, 48(4), 403-414. http://dx.doi.org/10.1177/0306624X04263450

Fraley, R. C., Waller, N. G., & Brennan, K. A. (2000). An item-response theory analysis of self-report measures of adult attachment. Journal of Personality and Social Psychology, 78, 350-365. http://dx.doi.org/10.1037/0022-3514.78.2.350

Fry P. S., & Debats, D. L. (2002). Self-efficacy beliefs as predictors of loneliness and psychological distress in older adults. International Journal on Aging and Human Development, 55(3), 233-269. http://dx.doi.org/10.2190/KBVP-L2TE-2ERY-BH26

Gabbard, G. O., Schmahl, C., Siever, L. J., & Iskander, E. J. (2012). Personality disorders. In T. E. Schlaepfer, & C. X. B. Nemerof (Eds.), Neurobiology of psychiatric disorders: Handbook of clinical neurology, 3rd series, (pp. 463-475). Amsterdam, Netherlands: Elsevier Publishers.

Galione, J., & Zimmerman, M. (2010). A comparison of depressed patients with and without borderline personality disorder: Implications for interpreting studies of the validity of the bipolar spectrum. Journal of Personality Disorders, 24(6), 763-772. http://dx.doi.org/10.1521/pedi.2010.24.6.763

Granqvist, P. (2010). Religion as attachment. Archives for the Psychology of Religion, 32(1), 5-24. http://dx.doi.org/10.1163/157361210X487177

Granqvist, P., Mikulincer, M., Gewirtz, V., & Shaver, P. R. (2012). Experimental findings on God as an attachment figure: Normative processes and moderating effects of internal working models. Journal of Personality and Social Psychology, 103(5), 804-818. http://dx.doi.org/10.1037/a0029344

Grant, B. F., Stinson, F. S., Dawson, D., Chou, S. P., & Ruan, W. J. (2005). Co-occurrence of DSM-IV personality disorders in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Comprehensive Psychiatry, 46, 1-5. http://dx.doi.org/10.1016/j.comppsych.2004.07.019

Grant, B. F., Stinson, F. S., Dawson, D., Chou, S. P., Ruan, W. J., & Pickering, R. P. (2004). Co-occurrence of 12 month alcohol and drug disorders in the United States: Results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry, 61, 361-368. http://dx.doi.org/10.1001/archpsyc.61.4.361

Gratz, K. L., Tull, M. T., Baruch, D. E., Bornavalova, M. A., & Lejuez, C. W. (2008). Factors associated with co-occurring borderline personality disorder among inner-city substance users: The role of childhood maltreatment, negative affect intensity/reactivity, and emotional dysregulation. Comprehensive Psychiatry, 49, 603-615. http://dx.doi.org/10.1016/j.comppsych.2008.04.005

Haggery, G. (2009). Attachment and interpersonal distress: Examining the relationship between attachment styles and interpersonal problems in a clinical population. Clinical Psychology and Psychotherapy, 16(1), 1-9. http://dx.doi.org/10.1002/cpp.596

Hill, J., Paice, J. A., Cameron, J. R., & Shott, S. (2005). Spirituality and distress in palliative care consultation. Journal of Palliative Medicine, 8(4), 782-788. http://dx.doi.org/10.1089/jpm.2005.8.782

Horton, E. G., Diaz, N., Weiner, M., & Malloy, T. (2012). Adult attachment style, spirituality, and religiosity among individuals in treatment for substance use disorders. Florida Public Health Review, 9, 121-131.

Horton, E. G., Luna, N., & Malloy, T. (2015). Exploring the relationships between spirituality and personality disorder traits among a sample of in-patients in treatment for substance use disorder. International Journal of Mental Health and Addiction, Online First edition,

Hood, R. W., Jr., Hill, P. C., & Spilka, B. (2009). The psychology of religion: An empirical approach (4th ed.). New York: Guilford Press.

Hughes, P. Turton, P., Hopper, E., McGauley, G. A., & Fonagy, P. (2004). Factors associated with unresolved classification of the Adult Attachment Interview in women who have suffered stillbirth. Development and Psychopathology, 16, 215-230. http://dx.doi.org/10.1017/S0954579404044487

Jahng, S., Trull, T. J., Wood, P. K. Tragesser, S. L., Tomko, R., Grant, J. D., Bucholz, K. K., & Sher, K. J. (2011). Distinguishing general and specific personality disorder features and implications for substance dependence comorbidity. Journal of Abnormal Psychology, 120(3), 656-669. http://dx.doi.org/10.1037/a0023539

Kaskutas, L. A., Turk, N., Bond, J., & Weisner, C. (2003). The role of religion, spirituality, and Alcoholics Anonymous in sustained sobriety. Alcoholism Treatment Quarterly, 21, 1-6. http://dx.doi.org/10.1300/J020v21n01_01

Koenig, H. G. (2008). Concerns about measuring “spirituality” in research. Journal of Nervous and Mental Disease, 196(5), 349-355. http://dx.doi.org/10.1097/NMD.0b013e31816ff796

Lee, H-J, Bagge, C. L., Montgomery, J. V. G., Schumacher, J. A., & Coffey, S. F. (2010). Does co-morbid substance use disorder exacerbate borderline personality features? A comparison of borderline personality disorder individuals with vs. without current substance dependence. Personality Disorders: theory, Research, and Treatment, 1(4), 239-249. http://dx.doi.org/10.1037/a0017647

Levy, K. N., Meehan, K. B., Weber, M., Reynoso, J., & Clarkin, J. F. (2003). Attachment and borderline personality disorder: Implications for psychotherapy. Psychopathology, 38, 64-74. http://dx.doi.org/10.1159/000084813

Marc, W. (2015). Personality disorder and addiction. In G. Dom, & Moggi, F. (Eds.), Co-occurring addictive and psychiatric disorders: A practice-based handbook from a European perspective, (pp. 137-148). New York: Springer-Verlag Publishing.

Mikulincer, M., & Shaver, P. (2007). Attachment in adulthood: Structure, dynamics, and change. New York: Guilford Press.

Millon, T. (1997). Millon Clinical Multiaxial Inventory-III Manual (2nd ed.). Minneapolis, MN: National Computer System.

Millon, T., Millon, C., Davis, R., & Grossman, S. (2009). MCMI-III Manual (4th ed.). Minneapolis, MN: Pearson Education, Inc.

Moggi, F., Giovanoli, A., Buri, C., Moos, B. S., & Moos, R. H. (2010). Patients with substance use and personality disorders: A comparison of patient characteristics, treatment process, and outcomes in Swiss and U.S. substance use disorder programs. The American Journal of Drug and Alcohol Abuse, 36, 66-72. http://dx.doi.org/10.3109/00952990903575806

Nakash-Eisikovits, O., Dutra, L., & Westen, D. (2002). Relationships between attachment patterns and personality pathology in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 41(9), 1111-1123. http://dx.doi.org/10.1097/00004583-200209000-00012

National Institute on Drug Abuse (2015). Trends and statistics. Available at: http://www.drugabuse.gov/related-topics/trends-statistics

Nelson, C. J., Rosenfeld, B., Breitbart, W., & Galietta, M. (2002). Spirituality, religion, and depression in the terminally ill. Psychosomatics, 43(3), 213-220. http://dx.doi.org/10.1176/appi.psy.43.3.213

Newman, I., Brown, R., & Fraas, J. (2004). Comparison of logistic regression, linear probability, and third-degree polynomial models: Which should researchers use? Multiple Linear Regression Viewpoints, 30(1), 1-7.

Oman, D. (2014). Defining religion and spirituality. In R. F. Paloutzian, & C. L. Park (Eds.), Handbook of the psychology of religion and spirituality (2nd ed.) (pp. 23-47). New York: Guilford Press.

Piderman, K. M., Schneekloth, T. D., Pankratz, V. S., Stevens, S. R., & Altchuler, S. I. (2008). Spirituality during alcoholism treatment and continuous abstinence for one year. Journal of Studies on Alcohol, 68, 282-290. http://dx.doi.org/10.2190/pm.38.4.a

Piedmont, R. L., Hassinger, C. J., Rhorer, J., Sherman, E. F., Sherman, N. C., & Williams, J. E. G. (2007). Relations among spirituality and religiosity and Axis 2 functioning in two college samples. Research in the Social Scientific Study of Religion, 18, 53-73. http://dx.doi.org/10.1163/ej.9789004158511.i-301.24

Preti, E., Rottoli, C., Dainese, S., Di Pierro, R., Rancati, F., & Madeddu, F. (2015). Personality structure features associated with early drop out in patients with substance disorders and comorbid personality disorders. International Journal of Mental Health and Addiction, 13, 536-547. http://dx.doi.org/10.1007/s11469-015-9540-7

Riggs, S. A., Sahl, G., Greenwald, E., Atkinson, H., Paulson, A., & Ross, C. A. (2007). Family environment and adult attachment as predictors of psychopathology and personality dysfunction among inpatient abuse survivors. Violence and Victims, 22(5), 576-600. http://dx.doi.org/10.1891/088667007782312159

Sansone, R. A. & Sansone, L. A. (2011). Substance use disorders and borderline personality: Common bedfellows. Innovations in Clinical Neuroscience, 8(9), 10-13.

Saunders, S., Lucas, V., & Kuras, L. (2007). Measuring the discrepancy between current and ideal spiritual and religious functioning in problem drinkers. Psychology of Addictive Behaviors, 21(3), 404-408. http://dx.doi.org/10.1037/0893-164X.21.3.404

Schindler, A. Thomasius, R., Peterson, K., & Sack, P.-M. (2009). Heroin as an attachment substitute? Differences in attachment representations between opioid, ecstasy, and cannabis abusers. Attachment and Human Development, 11(3), 307-330. http://dx.doi.org/10.1080/14616730902815009

Scoot, L. N., Kim, Y., Nolf, K. A., Hallquist, M. N., Wright, A. G. C., Stepp, S. D., Morse, J. Q., & Pilkonis, P. A. (2013). Preoccupied attachment and emotional dysregulation: Specific aspects of borderline personality disorder or general dimensions of personality pathology? Journal of Personality Disorders, 27(4), 473-495. http://dx.doi.org/10.1521/pedi_2013_27_099

Seidlitz, L., Abernethy, A. D., Duberstein, P. R., Evinger, J. S., Chang, T. H., & Lewis, B. (2002). Development of the Spiritual Transcendence Index. Journal of the Scientific Study of Religion, 41, 439-453. http://dx.doi.org/10.1111/1468-5906.00129

Senormanci, O, Senormanci, G., Guclu, O., & Konka, R. (2014). Attachment and family functioning in patients with internet addiction. General Hospital Psychiatry, 36 (2), 203-207. http://dx.doi.org/10.1016/j.genhosppsych.2013.10.012

Shaver, P. R., Schachner, D., Mikulincer, M. (2005). Attachment style, excessive reassurance seeking, relationship processes, and depression. Personality and Social Psychology Bulletin, 31(3), 343-359. http://dx.doi.org/10.1177/0146167204271709

Sonneborn, C., & Bosma, M. (2011). Comorbidity and outcome in dual diagnosis patients – characteristics of 228 inpatients. Mental Health and Substance Use, 5(1), 42-51. http://dx.doi.org/10.1080/17523281.2011.609654

Sorajjakool, S., Aja, V., Chilson, B., Ramirez-Johnson, J., & Earll, A. (2008). Disconnection, depression, and spirituality: A study of the role of spirituality and meaning in the lives of individuals with severe depression. Pastoral Psychology, 56, 521-532. http://dx.doi.org/10.1007/s11089-008-0125-2

Straussner, S. L. A., & Nemenzik, J. M. (2007). Co-occurring substance use and personality disorders: Current thinking on etiology, diagnosis, and treatment. Journal on Social Work Practice in the Addictions, 7(1/2), 5-23. http://dx.doi.org/10.1300/J160v07n01_02

Teplin, D., O'Connell, T., Daiter, J., & Varenbut, M. (2004). A psychometric study of the prevalence of DSM-IV personality disorders among office-based methadone maintenance patients. The American Journal of Drug and Alcohol Abuse, 30(3), 515-524. http://dx.doi.org/10.1081/ADA-200032270

Tull, M. T., & Gratz, K. L. (2012). The impact of borderline personality disorder on residential substance abuse treatment dropout among men. Drug and Alcohol Dependence, 121, 97-102. http://dx.doi.org/10.1016/j.drugalcdep.2011.08.014

Walter, M., Gunderson, J. G., Zararini, M. C., Sanislow, C. A., Grilo, C. M., McGlashan, T. H., ... Skodol, A. E. (2008). Addiction, 104, 97-103. http://dx.doi.org/10.1111/j.1360-0443.2008.02413.x

Westen, D., Nakash, O., Thomas, C., & Bradley, R. (2006). Clinical assessment of attachment patterns and personality disorders in adolescents and adults. Journal of Consulting and Clinical Psychology, 74(6), 1065-1085. http://dx.doi.org/10.1037/0022-006X.74.6.1065

Zikos, E., Gill, K. J., & Charney, D. A. (2010). Personality disorders among alcoholic outpatients: Prevalence and course in treatment. Canadian Journal of Psychiatry, 55(2), 65-73.

DOI: https://doi.org/10.5296/ijsw.v3i1.8384


  • There are currently no refbacks.

International Journal of Social Work  ISSN 2332-7278

Copyright © Macrothink Institute 

To make sure that you can receive messages from us, please add the 'macrothink.org' domains to your e-mail 'safe list'. If you do not receive e-mail in your 'inbox', please check your 'spam' or 'junk' folder.