Thursday, August 27, 2015

Personality Disorders – The Common Bizarre Behaviors Part IV: The Role of Culture 

In reality it is often difficult for clinicians to make a differential diagnosis among personality disorders as they share many key features in common. Some of the traits that are common to all personality disorders include:

Difficulty abiding by societal rules and conventions
Lack of empathy
Lack of hallucinations and overt thought disorders (except during brief psychotic episodes)
Lack of individual accountability
Lack of insight into how objectionable their behavior is to others
Lack of perspective
Superficial understanding of themselves
Vulnerability to other mental problems

Diagnosis often becomes an impression of the predominant features of the disorders rather than excluding one set of diagnostic criterion for another. Clinicians may  also make a diagnosis based on what they believe to be the less stigmatizing personality disorder label (Aviram, Brodsky, & Stanley, 2006; Markham, 2003). There are gender differences in the prevalence of types of personality disorders. Antisocial personality disorder is more common among males, while borderline, dependent, and hysterical personality disorders are more common among females. Labeling biases among health professionals may explain some of these gender differences (Ussher, 2013). There is some evidence that clinicians may diagnose people with personality disorders based on the role stereotype of their status group (Landrine, 1989). Age may also complicate the diagnosis of personality disorders as well as introduce bias (Magoteaux & Bonnivier, 2009). And lastly, it seems that personality disorders may manifest in different ways depending on the cultural context of the person manifesting the disorder.

This is important because personality disorders tend to resemble many of the culture-bound syndromes, disorders, and behaviors found in cultures from all around the world. For instance, the culture-bound syndrome taijin kyofusho (which literally means fear of interpersonal relations) typically found in Japan and other parts of Asia, shares many of the features of avoidant and dependent personality disorders. The phenomena of latah, found primarily in Southeast Asia, carries echoes of borderline and histrionic personality disorders, while people who suffer from amok may show symptoms of antisocial and narcissistic personality disorders. It is difficult to fail to see the relationship between obsessive-compulsive personality disorder and the salaryman culture in Japan, just as it is difficult not to notice the schizotypal thinking present in koro. While these are just a few examples from around the world, we can also find similarities with personality disorders in our own Western culture. For example it is hard to miss the flavor of narcissistic and borderline personality disorders among some of the people who practice vampirism. Likewise, we see characteristics of antisocial, narcissistic, paranoid, and schizotypal disorders in the phenomena of school shooters – perhaps a Western version of the Southeast Asian cultural disorder amok.

So how do we understand the influence of culture to personality disorders?  One thing we can try to do is to understand the relative influence of cultural characteristics in the different personality disorders. Alarcon & Foulks have attempted this in their 1995 paper. They list the personality disorders in a rank from the most ‘biologically based’ to the most ‘psychosocialculturally based’. This kind of ranking may make it easier to understand the influence of culture on each type of personality disorder. Alarcon & Foulks (1995, p. 84) also list each personality disorder in this ranking scheme with the characteristics of each disorder:

Schizotypal (Eccentric): Individualism, hyperintellectualization, hyperstimulation leading to excessive fantasy, self-affirmation, insocialbility.

Paranoid (Suspicious): Individualism, distrustfulness, rigidity, sense of oppressiveness, anger, adversarialism / antagonism, distorted sociability.

Schizoid (Asocial):  Individualism, indifference, distorted self-sufficiency, hypostimulation, limited sociability.

Antisocial (Aggressive): Individualism, antagonism, conflict-proness, rigidity, need to prove self, anger, demonstrativeness.

Borderline (Unstable): Ambiguity, unpredictability, inconsistency, need to prove self, distorted sociability.

Obsessive-Compulsive (Conforming): Self-doubts, uncertainty, inconsistency, rigidity, frugalism.

Avoidant (Withdrawn): Inconsistency, sense of personal inferiority, no risk-taking, limited sociability.

Dependent (Submissive): Opaqueness, distorted sociability, unconditional rule following, search for paternalism.

Narcissistic (Egotistic): Individualism / selfishness, self-affirmation, grandiosity, emptiness, hypersociobility.

Histrionic (Gregarious): Social, instability, overstimulation, self-affirmation, demonstrativeness, materialism.

And lastly Alarcon and Foulks include an 11th characterization which, is not strictly a personality disorder:

Passive-Aggressive (Negativistic): Inconsistency, conflict-proness, distorted sociability, punitiveness.

This is an interesting way to understand the different personality disorders as each set of traits in the above descriptions may reflect characteristics of a patient’s cultural group and

“it would be incumbent upon the clinician to sort them out…and assign to them a diagnostic, as well as a therapeutic value. An analysis of the “symptoms” present in the above sets, from the perspective provided by different ethnic and cultural groups…might prove helpful to the clinician in differentiating PDs from non-pathological, culturally determined behavior.” (Alarcon & Foulks, 1995, p.84-85).

And in fact, this kind of an approach (similarly proposed by Paniagua, 2000) can be helpful in examining the ‘pathology’ of all culturally-significant behaviors, not just those that resemble personality disorders.

The connection between various culture bound syndromes and personality disorders deserves further study. While not everything defined as a culture bound syndrome is related to personality disorders, the prevalence of similarities suggests more than a coincidental connection. Personality disorders are indeed a world-wide phenomena. Our lack of understanding the etiology of personality disorders and the difficulty in treating them, suggests that the study of these serious disorders should be a priority for clinical psychology research.


Alarcon, R. D . & Foulks, E. F. (1995). Personality Disorders and Culture: Contemporary Clinical Views (Part B). Cultural Diversity and Mental Health, 1(2), pp. 79-91.

Aviram, R. B., Brodsky, B. S., & Stanley, B. (2006). Borderline Personality Disorder, Stigma, and Treatment Implications. Harvard Review Of Psychiatry (Taylor & Francis Ltd),14(5), 249-256.

Landrine, H. (1989). The politics of personality disorder. Psychology Of Women Quarterly, 13(3), 325-339.

Magoteaux, A. L., & Bonnivier, j. F. (2009). Distinguishing between personality disorders, stereotypes, and eccentricities in older adults. Journal Of Psychosocial Nursing And Mental Health Services, 47(7), 19-24.

Markham, D. (2003). Attitudes towards patients with a diagnosis of 'borderline personality disorder': social rejection and dangerousness. Journal Of Mental Health, 12(6), 595-612.

Paniagua, F. A. (2000). Culture-bound syndromes, cultural variations, and psychopathology. In Handbook of Multicultural Mental Health. Cuéllar, I., & Paniagua, F. A. (Eds). pp. 139-169. San Diego, CA, US: Academic Press.

Ussher, J.M. (2013). Diagnosing difficult women and pathologising femininity: Gender bias in psychiatric nosology. Feminism & Psychology, 23(1), pp. 63-69.

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