Addressing Cultural Bias in the Treatment of Personality Disorders

Without consideration of cultural factors, personality disorder assessment remains inaccurate for migrant and ethnically marginalized groups.

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A recent study, published in Transcultural Psychiatry, examined how personality disorders (PDs) are incorrectly diagnosed or completely overlooked within migrant and ethnically marginalized groups. To improve the assessment of PDs, the authors presented a new culturally-informed framework that focuses on the connection between PDs, migratory processes, and cultural factors.

The results shine a light on the limitations of psychiatry to accurately diagnose and provide treatment for migrant populations without a culturally-informed approach that considers broader socio-cultural and political factors. The study was led by Ardalan Najjarkakhaki, a psychologist and researcher affiliated with the Department of Intercultural Psychiatry at the Parnassia Psychiatric Institute. The authors write:

“An approach that places the person in a socio-cultural context can guide clinicians to assess PDs in a more contextually grounded way, rather than locating the patient’s problems entirely within the individual. A contextual perspective on PDs should include an assessment of temperament/ character, developmental history, systemic/family dynamics, migration processes, cultural dimensions, and possible historical trauma.”

White paper boat onto world map with "Help" sign on it.The idea that PDs are misunderstood and misdiagnosed has become engrained in popular awareness among the general public due to increased research around the topic. Past research shows that Borderline PD is often a response to trauma for many individuals. For this reason, those within sexually marginalized groups tend to be over-diagnosed with Borderline PD.

Additionally, research has found that individuals with PDs tend to be treated inappropriately by psychiatrists, and advocates have called for great concern over assessment and diagnostic practices. Although the topic of PDs in migrant groups remains limited, the issue is of great importance as psychology professionals attempt to draft best practice guidelines on migrant and refugee work. Preventing pathologization and overdiagnosis in these groups is essential as mental health and legal professions call for greater access to mental health services for migrant families.

PDs have long been criticized for their conceptualization of behavior in mostly Anglo-American values, such as a hyper-focus on the concept of self and the resistance of psychiatry to integrate cultural context. Although past studies have supported cross-cultural validation of the Five-Factor Model of personality, several researchers reject this claim of the universal applicability of PDs.

There is considerable evidence showing disparate overdiagnosis among racially and ethnically marginalized groups. For example, second-generation immigrants are significantly more likely to meet criteria for borderline PD than native-born Americans; Schizoid PD is diagnosed more often in African-American and Caribbean Black groups compared to European Americans; mixed-race patients are more likely to be assigned a PD diagnosis; Hispanic groups receive a borderline PD diagnosis more often than Caucasian and African American groups.

On the other extreme, past research also shows how racially and ethnically marginalized groups may experience underdiagnosis of PDs. For example, a systematic review of ethnic variations in psychiatric diagnoses found that British Black patients were less likely than white patients to receive a PD diagnosis, suggesting that patients from marginalized groups might be less likely to be offered access to therapy and mental health treatment.

Misdiagnosis of PDs is associated with several risks and impacts on psychological wellbeing. First, overdiagnosis of PDs can contribute to psychiatric stigma, potentially leading clinicians to ignore systemic discrimination and diagnose natural psychological reactions to violence as symptoms. Second, underdiagnosis of PDs may contribute to the economic burden of PDs in the healthcare system and ineffective treatment interventions.

“Refugees, with a history of persecution, imprisonment, and torture, can display hyperarousal, emotional lability, antagonism, paranoid ideation, and dissociation as part of complex trauma, which could resemble the borderline criterion of transient, stress-related paranoid ideations, or severe dissociative symptoms,” the authors write. “Chronic experiences of boredom or worthlessness, stemming from the migrant’s experience of lacking purpose or direction, could resemble the criterion of feelings of chronic emptiness.”

The authors examine the longitudinal development of PD traits in migrant groups in their new framework of culturally-informed diagnosis and how each PD diagnosis overlaps with migratory processes. For example, Borderline PD is characterized by chronic identity disturbances, which may be confused with cultural identity disturbances and fragmented identities migrants inherit through relocation.

A migrant client who struggles with cultural identity disturbances may “display splitting between two contrasting or mutually exclusive self-representations from different cultures, display complex hybrids of various cultural identities, or display shifts between idealization and devaluation of the abandoned culture versus the host culture.”

In their framework of culturally-informed diagnostic practices, the authors argue that five cultural dimensions must be considered to minimize the risk of overdiagnosis of PD among ethnically marginalized groups: 1) collectivism-individualism, 2) interdependent self-concept – independent self-concept, 3) traditional gender roles – non-traditional gender roles, 4) emotional expressiveness-emotional inhibition, and 5) supernatural-material.

Although much can be said about the overlapping areas of culture and personality, the authors highlight these cultural aspects because behaviors stemming from these dimensions are most likely to resemble or mask personality pathology.

Najjarkakhaki and Ghane coin this phenomenon as “culturally masked PD,” understood as when behavioral patterns match aspects of what is culturally accepted or dictated but exceed relevant cultural norms, causing significant impairment to the patients and others as well as impairment in different areas of wellbeing.

Further, this new framework calls for a trauma-informed approach that considers the long-term impacts of historical trauma, particularly the effects of colonization and genocide on indigenous groups who are more often diagnosed with Borderline PD.

“We argue that migration processes could be treated as differential factors to assist the clinician in disentangling migration processes from PD traits. Migration processes can merely resemble personality pathology, activate (latent) vulnerabilities, or aggravate preexisting personality pathology,” the authors write.

The introduction of Najjarkakhaki and Ghane’s new framework culminates in eight clinical implications when administering the semi-structured clinical interview to classify PDs (SCID-5-PD) to contextualize PD assessment.

These implications included a thorough screening of childhood stressors and related maladaptive patterns, assessing patterns of behavior within family systems, considering pre- and post-migratory functioning, assessing loss of resources, weighing cultural dimensions, including historical trauma in conceptualization, and critically assessing one’s own biases as a clinician.

 

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Najjarkakhaki, A. & Ghane, S. (2021) The role of migration processes and cultural factors in the classification of personality disorders. Transcultural Psychiatry. 0(0). 1-15. guidelines: DOI: 10.1177/13634615211036408 (Link)

14 COMMENTS

  1. Therapists who play god have a disordered personality. Rapists and child abusers have a disordered personality. Political monsters have a disordered personality. Greedy capitalists have a disordered personality. Labelling patients stressed out by life with this monstrous biased title?

    Psychiatry has a personality disorder.

    Can’t Mad do something in regards to celebrities, I’m thinking the SNL guy, who spout this nonsense? Some kind of campaign, empathetic and humorous?

    Pete, don’t trust any doctor who will tell you your millions-making personality is disordered! Others will believe the nonsense! Be kind to the world!

  2. So-called “personality disorder” is more correctly seen as SOCIAL DYSFUNCTION. Our dysfunctional society literally breeds “disordered” persons, who are thus seen as having personal, individual “personality disorders”. Such is pseudoscience. Sick societies make sick people sicker. Sick people heal when they can escape the damage of other sick persons in this sick society. Psychiatry is at best a SYMPTOM ITSELF….
    & psychiatry is a MALIGNANT symptom!
    Like a social tumor! Shrinks are TUMORISTS! LOL!….

  3. So, instead of saying that no one should be diagnosed with borderline personality disorder, are we going to say that if a woman is white, middle class, and heteronormative, with no immediately obvious signs of being traumatized….well then, maybe it’s okay? If the person appears to have privilege and the psychiatrist, in the extremely small amount of time he spends with the patient, in which he learns next to nothing about her history, maybe she really is a borderline. Maybe with all of her privilege she’ll be able to withstand the abuse that comes her way from medical professionals and society in general while she tries to survive the devastating impact of being called “a borderline”?
    This is the third or fourth article I’ve read on this website that seems to argue that it’s not the diagnosis itself that’s the problem, but the problem is it’s being “over diagnosed” in a particular segment of the population.
    Seems to me like we’re going in the wrong direction.

    • I agree with you. It is pure “cultural bias” to believe something like “borderline personality disorder” even exists at all. It is clearly skewed against women for starters. And how can you “overdiagnose” something that is not objectively diagnosable by any known standard? It’s like saying that beauty or cowardice or kindness is “overdiagnosed.” If there is no objective standard, there is no meaning to “over-” and “underdiagnosis.” We’re just making shit up, and no one’s “diagnosis” should be invented arbitrarily. But if it IS invented arbitrarily, it’s nonsense to talk about “overdiagnosis!”

      • Thanks, Steve. Obviously, it’s terrible for anyone to be diagnosed with a personality disorder (especially borderline), and particularly anyone who already is oppressed based on ethnicity or other cultural factors. But I worry that an article that talks about overdiagnosis has the effect of, ultimately, validating the diagnoses themselves.
        After all of the information that’s come out about how the DSM was compiled and how unscientific and biased every aspect of Psychiatry really is, it feels like it’s going backwards to speak about overdiagnosis of any so-called mental illness.

      • Steve, have you ever SERIOUSLY asked yourself, or considered the question, – WHAT EXACTLY IS, a “personality”, and where EXACTLY in the genetic code is it coded for? Must be genetic in origin, right?…. At what exact moment in the genesis & development of a personality does the “personality disorder” BEGIN? Or EMERGE? Or *WHAT* *EXACTLY*, IN SCIENTIFIC TERMS, are we talking about here? Would you agree that any “personality”, IN REALITY, only exists as a metaphor? Or CONCEPT?….Try as I might, Steve, I can only come up with bullshit here….see what I mean?….

        • Yes, I most definitely have considered that question in detail. I think you ask an excellent question, and one to which I nor anyone else I know of has a real answer. It could be viewed as a metaphor, certainly. I think it is one of those things that we only observe by seeing the results of it, kind of like magnetic force or gravity – you only know it’s there because of what effects it has on objects within its sphere of influence. That being said, the “mind” is a similarly problematic force. Assuming that the “mind” is simply an effect of the brain leads us to psychiatry or other empty conclusions. It appears there is something that is able to INFLUENCE the brain, to the point of actually altering its STRUCTURE (look at the studies on altered brain structure in meditating Buddhist monks, for instance), yet no one can really say what it is?

          But I’m not one to say something is “bullshit” just because I can’t explain it. That’s not really scientific, either. I am much more inclined to simply say that personality is a pattern of behavior that a person tends to engage in, sort of the interaction between his/her mind and the environment s/he encounters, that some of it appears to be “inherent” and some learned, but that we don’t really know what it is or how it comes to exist, any more than we know what the mind is or how it comes to be. It’s a mystery, and I’m OK with that.

          • “….personality is a PATTERN of behavior that a person tends to engage in,”…. In other words, you’re saying that a “personality” is a pattern? So folks have a “pattern disorder”?…. Aren’t you OBSERVING their behavior, repeatedly, and that how you know it’s a pattern? So is the personality it’s own thing, or is it YOUR OBSERVATION of it? How do psychs train to recognize patterns of behavior? What happens when those behaviors change over time? Couldn’t a person grow up out of a personality disorder? How much is “inherent”? Is it genetically inherent? Or culturally inherent? See where I’m going with this? Steve, this is a great conversation! I’m not giving you shit, but I am exploring this topic here. We need the best rhetoric, to have a chance of making psychiatry become history. The lies that most people believe about psychiatry are the results, partly, of deliberate propaganda campaigns, known as “marketing”, and “advertising”. Isn’t “direct-to-consumer” TV ads a form of propaganda? Yes, of course you can agree with that statement. What I meant as “bullshit”, above, is the WHOLE THING…. Now, when I look at the WHOLE of psychiatry and the “mental health industry”, all I see in industrialized bullshit…..get what I mean here?….I think you do….you’ll get it…. THANKS!, Steve!….

          • Well, of course, I agree 100%, a “personality” can’t have a “disorder,” it is not a thing of the physical universe, it’s a consequence of thought and decisions made by a person. And I’d say that of course, a personality CAN be changed – I see it more or less as an invention a person creates to deal with the decisions they need to make to survive in the physical universe. I like the question of “genetically inherent” or “culturally inherent.” I might also add “spiritually inherent,” because I see it as entirely possible we bring some history with us when we arrive on the planet. But that’s getting deeper than we need to here. The very idea that a “personality” is something that can be “ill” or “disordered” is pretty outrageous, and yes, obviously has to come from someone else judging a person’s “personality” as being good or bad or inadequate. It is observable, but I don’t think anyone but the person him/herself is in a place to judge the quality or usefulness or need for change of the personality. It’s something we own completely ourselves. Criticisms of a set of “personality disorders” is rank prejudice and nothing more.

            So I’m totally with you – psychiatry is utter bullshit, because it starts from a false premise that there is a “right” personality or “right” mind that only THEY can determine, even when they have no idea how they possibly could begin to make such judgments. Such is the hubris of psychiatry!

    • THANK-YOU! KateL, I was dumping the whole load of DSM-5, psychiatry, so-called “mental illnesses”, psych drugs, etc., in the garbage. It’s all bogus. But I wasn’t thinking about it the way you explained it. I totally get what you’re saying. The article here, basically says what you’re suggesting it says. It actually AFFIRMS the existence of “borderline”! Thank-you for pointing it out.

  4. sad to see articles written where the authors seem to have a belief
    in the DSM. Are people “disordered”?
    Well duh, of course. EVERYONE is in some way.
    it’s unbelievable how (and I dislike using words like “shallow”) but yes, unbelievable
    how uneducated, misinformed psychiatry has brought the general population.

    So few have any self thought. Let me show you many “disordered” folks. Everyone
    and his dog qualifies.

    The “cultural awareness” garbage has been used to try and substantiate psychiatry.
    They are USING people who were marginalized generations ago. ALL OVER again.
    Psychiatry and it’s DSM believers are like bloodsuckers.

  5. Iatrogenic brain damage distorts my personality.

    If it did not, I would have nothing to worry about about.

    Maybe someone might say my brain invents an illusion of my personality. But that is still my brain doing so. And its not an illusion. If a personality aint affected by psyche drugs then there is no diminished responsibility to inhebriated people on antipsychotics that make them uninhibited.

    Just wanted to do the counter arguement whilst fixing my washine machine. Not being snooty. Just joshing and seeing an interesting thread. No need to reply.

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