Cross-Cultural Manifestations of Borderline Personality Disorder

Western cultures are primarily individualistic, encouraging people to be independent and autonomous and to strive for personal goals. Other cultures are more collectivistic, encouraging interdependent and cooperative behaviors. There is reasonable evidence that the “goodness of fit” between an individual’s personality style and society is associated with self-reported psychological distress.

Personality disorders are considered to be particularly prone to cross­ cultural bias for various reasons. The definition emphasizes that a personality disorder is “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.” Nevertheless, despite culture’s importance, theory and research have significantly underestimated its influence, and personality disorder constructs and diagnoses are significantly influenced by culture.

Several cultural factors may impact personality pathology, diagnosis, and treatment, including biases inherent to Western conceptualizations of dysfunction. For example, the development of criteria and nosology in the West makes it seem like personality disorders are Western clinical entities. On the contrary, many of the behaviors are pan-cultural. 

Borderline personality disorder (BPD) has a wide variety of presentations, is extensively researched, and is associated with significant functional impairments for the individual.

Andrada Delia Neacsiu, Ph.D., Assistant Professor in Psychiatry and Behavioral Sciences at Duke University School of Medicine, and colleagues synthesized international assessment, treatment, and epidemiological data. The researchers found that about half of all BPD research has been conducted in Northern America, followed by 25% in Western and Northern Europe. They noted that epidemiological research into the disorder outside Western cultures is scarce, and comparing prevalence rates between these and less researched regions is impossible. However, there are a host of multiple- and single-country studies that suggest that BPD can be found across the world.

The few studies investigating the presentation of BPD in non-Western cultures have found that the manifestations of BPD vary between cultures, which is not accounted for in the DSM diagnosis. Given that BPD is a severe and debilitating disorder with a heterogeneous constellation of problems that are notoriously challenging to treat, it is critical to conduct a comprehensive examination of the disorder, the unique ways in which culture influences BPD presentation and assessment, and the ways that treatments can be delivered or modified in a culturally sensitive manner.

Assessing psychopathology requires a tailored approach, especially when culture may heavily impact presentation. Viewing culture from an individual’s perspective eschews reliance on stereotypes and prevents inaccurately assuming that a given cultural norm applies equally to all individuals who share that culture. Mental health professionals must have a deep and textured understanding of “cultural competency,” as it has been argued that cultural competence in clinical work will lead to a robust approach and ultimately humanize clients and their context successfully.

Mezzich et al. (1999) identified the impact of culture on psychiatric assessment and diagnosis:

• Culture shapes and directs the content, meaning, and configuration of symptoms.
• Culture provides a matrix for the interpersonal situation of the diagnostic interview.
• Since the clinical encounter is often inter-cultural, the dynamics of cross-cultural work are crucial for understanding and refining diagnostic categories and practices.
• Culture gives overall conceptualizations of the diagnostic systems, which usually become the products of their time and circumstances.

Cross-culturally and racially within the same culture, BPD is not easily identified. In an increasingly diversified world, a concern arises that cultural bias may prevent the appropriate identification of BPD in a cross-cultural clinical setting. 

• The association between personality disorder and migration or ethnicity has not been extensively investigated, but several studies identify racial differences in identifying BPD in Western countries. 
• Black patients are less frequently diagnosed with BPD than White patients in the U.S. and Great Britain.
• Hispanic immigrants are more often diagnosed with BPD than White or Black patients in the U.S.
• Immigrants have lower rates of BPD diagnoses than indigenous populations.

Self Harm

Suicide and self-harm are considered maladaptive behaviors and suggest psychopathology in Western cultures. Concerning BPD, suicidal behaviors are considered core features of the diagnosis. Many people with BPD recurrently harm themselves, usually to provide relief from intolerable distress. However, in some cultures, suicide is acceptable to prevent shame and embarrassment. Therefore, it is crucial that clinicians closely explore the function of self-harming behaviors, as it varies widely across cultures.

A collectivistic or family-oriented culture may prevent individuals from exhibiting the classic impulsive and suicidal behaviors of BPD. Thus, BPD may go misdiagnosed or undiagnosed when failing to account for a patient’s cultural context.

Disturbed Relationships

Relationship difficulties involving fear of abandonment and unstable relationships are key markers of BPD pathology. Fear of being abandoned implies an individualistic view of the world where one can be alone or abandoned. However, in cultures where the self includes the family and the community, fear of being alone may be unusual, and instability in relationships may manifest differently. 

Culture may influence how this disturbance manifests, as tumultuous relationships and the fear of abandonment, a hallmark of Western BPD, may not manifest similarly elsewhere. For example, in collectivistic cultures, the focus of the relationship is on others rather than the self. For example, the Japanese cultural-bound syndrome, Taijinkyofusho, is when individuals fear relationship failure. 

Disturbed Identity

The definition of identity disturbance within BPD diagnostic criteria is based on the Western notion that individuals are unique and function independently. However, a disturbed identity in other cultures may differ from the individualistic perception. For example, in India, one’s personality is relative and can only be understood in the context of current and past relationships. In this view, changing the self to fit with those around is normative and not dysfunctional, and one’s personality is considered dysfunctional only if it does not change and a person’s beliefs about the self remain stable and enduring across relationships and time.

Identity in Confucian countries can only be assessed by understanding how closely the person values Ren (benevolence), Yi (righteousness), and the process of Xiu Yang (to cultivate and nurture your heart). Identity involves one’s entire family, and shame is the emotion most often associated with violating this identity. Thus, identity disturbance in these cultures should include assessments of family shame and personal views of the self and self-improvement.

Impulsivity

Impulsive behavior involving sex or drugs, parasuicidal gestures, and suicidal behavior is not a consistent finding in individuals diagnosed with BPD across cultures. This may be because traditional, cohesive cultures with pervasive community expectations reduce feelings of abandonment or acting out that would predispose individuals with BPD to engage in impulsive acts, possibly by inhibiting emotional expression. Conversely, western societies’ individualism and flexible rules may allow for greater emotional expression that could be linked to problem behaviors.

Affective Instability

Emotional instability and difficulties with anger should be assessed within the context of culture. For example, in Nigeria, the same word is used to express multiple emotions, highlighting that language differences may make evaluating rapid shifts between emotions difficult. In addition, shame and guilt may be frequently expressed in some countries (e.g., Japan) but largely absent in others (e.g., Indonesia). Therefore, exploring physical symptoms associated with dysregulated emotions and considering relevant cultural manifestations is critical when assessing BPD.

Affective instability and anger may also manifest in a variety of culturally specific ways, such as culture-bound syndromes, including:

• Ataque de Nervios: Somatic expression of unpleasant emotions – uncontrollable shouting, crying, trembling, aggression, or fainting spells (Puerto Rico, Caribbean)
• Koro: Overpowering fear that one’s sex organs are retracting and will disappear (Africa, Asia, and Europe)
• HwaByung: Suppressed anger at family or husband, which typically involves a transient but highly dysregulated emotional experience (Korea)
• Dhat: Fear of passing semen in urine, resulting in impotence (India and Southeast Asia)
• Amok: Sudden mass assault against people or things following a period of brooding (Malaysian)
• Muina: Physical illnesses are brought on by suppressed emotions or an uncontrolled anger outburst (Latin America)

Diagnostic interviews must be conducted sensitively to understand how an individual’s symptom presentation is tied to their culture.

• Clinicians should try to assess the patient’s perspective of their cultural practices as more collectivist or individualist to understand protective or risk factors for specific BPD presentations.
• Clinicians should assess appropriate coping mechanisms within the patient’s larger culture and family.
• Clinicians should evaluate changes in behavior due to immigration. In addition, clinicians should evaluate family members to compare acculturative changes that may account for symptoms rather than BPD, if applicable.
• Clinicians should utilize domain-based assessments rather than a criteria-based evaluation method that may not be cross-culturally identifiable.

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