Cluster B and C Personality Traits, Symptom Correlates,
and Treatment Utilization in Postacute Schizophrenia
Amanda Wickett, PsyD,* William Essman, PhD,† Josephine Beck-Jennings, BA,†
Louanne Davis, PsyD,‡ John McIlvried, PhD,† and Paul H. Lysaker, PhD‡§
Abstract: Unusually high levels of Cluster B and C personality traits
have been observed in schizophrenia. While these have been linked to
poorer function, less clear is the association of these personality traits
with symptoms and service utilization. To examine this issue, 46
participants with schizophrenia or schizoaffective disorder were admin-
istered the Millon Clinical Multiaxial Inventory, Third Edition, and the
Positive and Negative Syndrome Scale, and an inventory was taken of
medical and psychiatric service utilization. Two sets of multiple regres-
and symptoms revealed that emotional discomfort symptoms were
significantly related to level of borderline traits. Higher levels of
positive symptoms were linked with more avoidant traits and fewer
dependent traits. Higher levels of negative symptoms were linked with
greater avoidant traits. Service utilization was predicted by borderline,
antisocial, and avoidant traits. Implications for rehabilitation and treat-
ment are discussed.
Key Words: Schizophrenia, symptoms service utilization,
personality disorder, Cluster B traits, Cluster C traits.
(J Nerv Ment Dis 2006;194: 650–653)
Gurrera et al., 2000; Kentros et al., 1997; Lysaker et al., 2004a)
and influence behavior over the course of illness, potentially
affecting course and outcome (Hulbert et al., 1996; Lysaker et
al., 1999). Two sets of personality traits of particular interest in
schizophrenia are Cluster B and C personality traits, or the traits
associated with borderline, antisocial, narcissistic, histrionic,
avoidant and dependent personality (Smith et al., 1995). Cluster
B personality traits as a whole generally share the qualities of
heightened impulsively, egocentricity, manipulativeness, and in-
dependent, share the qualities of anxiousness, hypersensitivity, and
esearch has suggested that stable personality differences
exist among persons with schizophrenia (Donat et al., 1992;
timidity (American Psychiatric Association, 1994; Kraus and
Reynolds, 2001). Importantly, Cluster B and C traits have
been detected in one third to one half of persons with
schizophrenia (Hogg et al., 1990; Nielsen et al., 1997; Solano
and Chavez, 2000), a rate exceeding that of the general
population (Casey and Tyrer, 1986; 1990; Widiger and Rog-
While research has increasingly suggested that more
broad personality traits such as extraversion and neuroticism
may impact on more traditional symptoms of schizophrenia
(Lysaker et al., 1998; 2003), less clear is how traits linked to
Cluster B and C personality disorders are related to clinical
phenomenon and service utilization. Research has found that
the presence of a Cluster B personality disorder among per-
sons without schizophrenia predicts more affective and somatic
symptoms (Snyder et al., 1986) and greater medical and psychi-
atric service utilization (Bender et al., 2001; Kessler et al., 1994;
Narrow et al., 1993; Olfson and Pincus, 1994; Tirer et al., 2000).
Research has also found that nonpsychotic persons with Cluster
C personality disorders experience more anxiety and depression
than those without Cluster C personality disorders (Modestin et
al., 1997; Rees et al., 1997). Is the same true among persons
with schizophrenia? Put another way, do persons with schizo-
phrenia and Cluster B or C traits show a different pattern of
symptoms and service utilization relative to persons with schizo-
phrenia who do not exhibit Cluster B or C traits? Evidence sup-
porting this includes findings that Cluster B traits are linked to
poorer social function in schizophrenia and that the presence of
Cluster C personality disorder traits in schizophrenia may pre-
dict more negative, emotional discomfort, and cognitive symp-
toms (Benjamin, 1993; Dickerson et al., 1998).
To explore this question, we assessed symptoms, service
utilization, and Cluster B and C personality traits in individuals
with schizophrenia or schizoaffective disorder in a postacute
phase of illness. Of note, we chose to assess Cluster B and C
personality traits using a psychological test, the Millon Clinical
Multiaxial Inventory, Third Edition (MCMI-III, Millon et al.,
1997), rather than a structured interview to be able to better
assess the degree to which traits were present and not merely
their absence or presence. In assessing service utilization, we
tallied medical and psychiatric service usage separately and
divided each into outpatient and inpatient. While this entailed
with one another, we chose to reduce this data to these four
categories to avoid increasing an already large number of anal-
Four County Counseling Center, Logansport, IN; †Department of Psychol-
ogy, University of Indianapolis, Indianapolis, Indiana; ‡Roudebush VA
Medical Center, Indianapolis, Indiana; and §Indiana University School of
Medicine, Department of Psychiatry, Indianapolis, Indiana.
Send reprint requests to Paul H. Lysaker, PhD, Day Hospital 116H, 1481
West 10th St., Roudebush VA Medical Center, Indianapolis, IN 46202.
Copyright © 2006 by Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 194, Number 9, September 2006
yses. Of note in tallying inpatient services, we chose to count the
number of admissions rather than number of days given that
discharge dates and therefore lengths of stay can be affected by
a wide range of extraneous variables, including ward census and
clients signing out against medical advice.
We made the following predictions: higher levels of
Cluster B traits would be associated with higher levels of
symptoms and greater rates of medical and psychiatric service
utilization. We also predicted higher levels of the Cluster C trait
of dependency would be linked with greater levels of symptoms
and service utilization, while higher levels of the Cluster C trait
but lesser amounts of service utilization. While we predicted
links between personality and symptoms in general, we mea-
sured several domains of symptomatology for exploratory pur-
Forty-six male and two female participants with schizo-
phrenia (n ? 32) or schizoaffective disorder (n ? 14) were
recruited from the outpatient Psychiatry Services of a VA
Medical Center. All participants were in a postacute phase of
illness as defined by having no hospitalizations or changes in
medication or housing in the month prior to entering the
study. Excluded from the study were participants with indi-
cations in their chart of active substance abuse or history of
mental retardation. The mean age of the sample was 48.3
(SD ? 7.7) years of age, and the mean educational level was
12.5 (SD ? 1.7) years. The average participant had a lifetime
history of 11.0 (SD ? 12.4) psychiatric hospitalizations, with
the first occurring at a mean age of 24.1 (SD ? 6.7) years.
Twenty-six were Caucasian, 21 were African-American, and
one was Latino. Service utilization could not be determined
for two participants due to death or relocation, and they were
therefore excluded from the sample.
The MCMI-III (Millon et al., 1997) contains a list of
175 statements and asks participants to indicate whether the
statement is generally true or false for them. On the basis of
their responses, participants are given t scores that denote the
relative level of a variety of personality dimensions including
histrionic, narcissistic, borderline, dependency, and avoidant
traits. The authors of the MCMI-III suggest that t scores
greater than 75 indicate clinically significant traits and instru-
ments have reported evidence of satisfactory reliability and
The Positive and Negative Syndrome Scale (PANSS;
Kay et al., 1989) is a 30-item rating scale completed by
clinically trained research staff at the conclusion of a chart
review and semistructured interview. For the purposes of this
study, the factor analytically derived positive, negative, ex-
citement and emotional discomfort components were used
(Bell et al., 1994). Assessment of interrater reliability has
found good to excellent intraclass correlations on all PANSS
scale scores and most items, including the insight and judg-
ment item (Bell et al., 1992).
Following informed consent, participants were adminis-
tered the Structured Clinical Interview for DSM-IV and then
administered the PANSS and MCMI-III. The PANSS was
scored blind to the results of the MCMI-III. Next, participants
were interviewed about their psychiatric and medical treatments
for the prior year. For treatment received outside a VA, both
inpatient and outpatient medical and psychiatric service visits
were tabulated based on verbal report for the 12 prior months.
For care received at a VA Medical Center, electronic medical
records were examined to determine medical and psychiatric,
inpatient, and outpatient service utilization over the prior 12-
month period. Outpatient visits were tabulated according to total
number of visits, and thus, more than one visit could occur per
day for outpatient care (e.g., there could be four visits in a day
if three groups were attended along with medication manage-
ment). Inpatient care was tabulated as the total number of
discrete admissions. Four scores were thus produced: medical
As suggested by Millon et al. (1997), participants were
classified as having significant levels of Cluster B or C person-
ality characteristics if their borderline, narcissistic, histrionic,
antisocial, avoidant, or dependent MCMI-III base rate score
reached or exceeded 75. Furthermore, the likelihood of a per-
sonality disorder diagnosis escalates as base rate scores reach or
exceed 85. This resulted in 27 (59%) out of 46 participants
endorsing Cluster B items at the trait level (base rate score of 75
B items on the MCMI-III at the personality disorder level.
Thirty-eight participants (83%) endorsed Cluster C items at the
trait level, while 14 (30%) endorsed these items at the disorder
level. Univariate analyses comparing participants with and with-
out Cluster B and C characteristics found no differences in age
or education. ANOVA comparing MCMI Cluster B and C traits
for participants with schizophrenia or schizoaffective disorder
revealed no significant differences.
The mean number of inpatient psychiatric admissions for
the sample was .75 (SD ? 1.36), with the minimum being 0
admissions and the maximum being 5. The mean number of
inpatient medical admissions for the sample was .08 (SD ? .27),
with the minimum being 0 admissions and the maximum being
1. The mean number of outpatient psychiatric visits for the
sample was 151.66 (SD ? 149.81), with the minimum being 0
admissions and the maximum being 608. Of these, the majority
were accounted for by group psychotherapy (mean ? 114.10;
SD ? 140.33, with the minimum and maximum being 0 and
550). The mean number of outpatient medical visits for the
sample was .54 (SD ? 1.11), with the minimum being 0 visits
and the maximum being 4.
To determine whether personality traits were related to
symptoms and service utilization, all MCMI base rate scores
were next converted to z scores, and two sets of stepwise
multiple regression analyses were performed. The first exam-
ined whether Cluster B traits including antisocial, narcissistic,
and borderline predicted PANSS positive, negative, excite-
The Journal of Nervous and Mental Disease • Volume 194, Number 9, September 2006Personality Traits in Schizophrenia
© 2006 Lippincott Williams & Wilkins
ment and emotional discomfort scores as well as outpatient
medical, outpatient psychiatric, and inpatient psychiatric vis-
its. Histrionic traits were not included in the analysis as no
participants endorsed significant levels of these traits. These
analyses found that borderline traits were significantly related
to emotional discomfort symptoms (F ?1,44? ? 8.13; p ?
0.01; partial R2? .15; p ? 0.01). An examination of univar-
iate correlations indicated that greater levels of borderline
traits predicted greater emotional discomfort. Narcissistic and
antisocial traits were not significantly related to symptom
scores. Borderline traits were linked to both outpatient med-
ical (F ?1,44? ? 6.33; p ? 0.05; partial R2? .13; p ? 0.05)
and inpatient psychiatric visits (F ?1,44? ? 5.29; p ? 0.05;
partial R2? .11; p ? 0.05), with univariate correlations
revealing that greater levels of this trait linked to greater
service utilization. Antisocial traits were linked with inpatient
medical visits (F ?1,44? ? 4.16; p ? 0.05; partial R2? .09;
p ? 0.05), with univariate correlations revealing that greater
levels of this trait were linked to more service utilization.
In the second set of analyses, links between the Cluster
C traits, dependency and avoidant, with PANSS scores and
service utilization were studied. Obsessive-compulsive disor-
der traits were not included in the analysis, as the convergent
validity of the obsessive-compulsive personality variable on
the MCMI-III has been questioned (Rossi et al., 2003).
Avoidant traits were linked to negative (F ?1,44? ? 5.30; p ?
0.05; partial R2? .11; p ? 0.05) and emotional discomfort
symptoms (F ?1,44? ? 6.19; p ? 0.05; partial R2? .12; p ?
0.05) and to inpatient psychiatric utilization (F ?1,44? ? 5.14;
p ? 0.05; partial R2? .14; p ? 0.05). Univariate correlations
revealed that greater levels of this trait predicted greater symp-
toms but less service utilization. Dependent traits were linked
only to positive symptoms (F ?1,44? ? 5.29; partial R2? .11;
p ? 0.05). Univariate correlations revealing greater dependency
predicted lesser levels of positive symptoms.
Finally, given that there potential that participants might
have both Cluster B and C traits, two stepwise multiple regres-
Cluster B and C traits: PANSS emotional discomfort score and
inpatient psychiatric hospitalizations. These analyses revealed
that emotional discomfort was linked more closely to borderline
traits (partial R2? .15; p ? 0.01), with avoidant traits contrib-
6.27; p ? 0.01). Inpatient psychiatric admissions were most
closely related to avoidant traits (partial R2? .14; p ? 0.01),
with borderline traits contributing at the trend level (partial
R2? .06; p ? 0.07; F ?2,43? ? 5.50; p ? 0.01).
Consistent with other reports, this study found that among
a group of persons with schizophrenia spectrum disorders, more
than one third had significant levels of at least one Cluster B or
C personality trait. Most common were avoidant personality
traits, followed by dependent, borderline, and antisocial. As
predicted, the participants with these Cluster B traits tended to
experience more emotional discomfort and to use more medical
services relative to other participants without elevations in Clus-
ter B traits. Antisocial traits predicted greater medical inpatient
service utilization in the prior year, while borderline traits
predicted more outpatient medical and inpatient psychiatric
services. Greater avoidance was linked to greater emotional
distress and negative symptoms and with lesser inpatient psy-
chiatric service utilization. Contrary to our predictions, no dif-
ferences were found among those with significant Cluster B
traits with regard to positive, negative, or excitement symptoms.
One interpretation of these results is that persons with
schizophrenia and a combination of borderline and avoidant
traits are more depressed and anxious, though not necessarily
more prone to more severe levels of excitement, paranoid,
suspicious, or grandiose symptoms, than those without such
traits. It seems possible intuitively that having both schizo-
phrenia and these traits may put persons at risk for having a
stormier course of illness, one more vulnerable to greater
affective upheaval. Perhaps there is an interaction between
these factors that makes interpersonal connections even more
tenuous, resulting in greater distress. It has been suggested,
for instance, that these traits are reflections of difficulties
discerning the thoughts and affects of others (Semerari et al.,
In press). We speculate that such deficits in combination with
deficits in self-monitoring in schizophrenia may make partic-
ipation in daily life an even more tumultuous experience.
It is interesting that while avoidant and borderline traits
were both linked to greater emotional distress, their relation-
ships to inpatient psychiatric services utilizations were in
opposite directions. While this is what would be expected in
persons without psychosis, with replication this finding may
have clinical implications. In particular, it may be that mal-
adaptive personality traits interact with schizophrenia, result-
ing in two different pathways by which persons cope with
unrest in their life. With instability in affects and relation-
ships, there may be a greater drive to seek psychiatric hos-
pitalizations when overwhelmed, while people with greater
social inhibitions and insecurity may be less likely to seek
hospitalization during these times, withdrawing and possibly
presenting with more negative symptoms. It may thus be
particularly important for practitioners offering services such
as psychotherapy that seek to address coping and emotional
distress to be attuned to the potential presence of avoidant
versus borderline traits and their different implications.
It was also interesting that dependent traits were linked to
research is available in this area, one possibility as suggested
elsewhere (Lysaker et al., 2004b) is that dependency in schizo-
phrenia is an adaptive response to limitations and deficits.
Perhaps the ability to connect closely with and to rely upon
others serves as a protective factor and makes it easier to man-
age unusual beliefs. It is also possible that with higher levels of
positive symptoms, particularly paranoid forms of positive
symptoms, persons resist forming any dependent relationships.
All of these speculations should be taken as fodder for future
research, and it should be noted that there are rival hypothesizes
that cannot be ruled out. It may be, for instance, that utilization
of services affects personality or that both are the result of other
factors not measured here. Since most of those with Cluster B
regarding the overall Cluster B dimension of personality should
Wickett et al.
The Journal of Nervous and Mental Disease • Volume 194, Number 9, September 2006
© 2006 Lippincott Williams & Wilkins
also be made with caution. The data do suggest, however, that Download full-text
Cluster B and C traits are prevalent, and perhaps not evenly
distributed among those with schizophrenia spectrum disorders.
Furthermore, when entered together into regressions to predict
emotional discomfort and inpatient hospitalization, some over-
lap was noted between Clusters B and C, suggesting that they
may not exist entirely independently of one another.
Lastly, there are limitations to this study. First, gener-
alization of findings is limited by sample composition. We
examined a rehabilitation sample composed of persons gen-
erally in their 40s, many of whom were receiving consider-
able amounts of outpatient psychiatric service with both
schizophrenia and schizoaffective disorder. It may be that
personality traits and treatment utilization have a different
relationship among younger persons, persons less open to
treatment or in a different phase of illness, or persons with
schizophrenia versus schizoaffective disorder not referred for
rehabilitation. Symptoms and personality were also assessed
at one point in time, and personality was assessed exclusively
by self-report. Without a control group of persons with other
disorders, it is also unclear whether what was measured here
is unique to schizophrenia or perhaps common to psychiatric
disorders in general. Finally, multiple analyses were con-
ducted, including several that were exploratory in nature, and
while two-tailed tests were conducted despite unidirectional
hypotheses, these have inflated the chances of spurious find-
ings. Ultimately, therefore, replication is needed with larger
samples including females and males in earlier phases of
illness, along with research that measures personality symp-
toms and neurocognition at multiple points in time in a
variety of settings. Such research has the potential to examine
whether changes in personality may precede, proceed from,
or be unrelated to changes in symptom levels and treatment
utilization. It may also be possible to detect associations
among symptoms, service utilization, and personality that
have important implications for treatment and rehabilitation.
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