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FEA TURE

Personality Disorders and Culture:


Contemporary Clinical Views
(Part B)
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

RENATO D. ALARCON, M.D., M.P.H.


This document is copyrighted by the American Psychological Association or one of its allied publishers.

Emory University School of Medicine


Atlanta Veterans Administration Medical Center

EDWARD E FOULKS, M.D., PH.D.


Tulane University Medical School
New Orleans Veterans Administration Medical Center

This article reviews the basic concepts surrounding the clinical relationships
between culture and personality disorders (PDs). PartA of this article, which
appeared in Cultural Diversity and Mental Health, Vol. 1, No. 1, pp 3-
17 (1995), examined the interpretive/explanatory and pathogenic/
pathoplastic roles of culture. Herein, culture's role as a diagnostic/nosological
factor is discussed through the use of measurement instruments and the cul-
turalformulation included in DSM-IV (American PsychiatricAssociation,
1994). In addition to these three roles, some authors would also consider a
therapeutic/protectivefunction for culture in PDs. Following a critique of the
biological perspective, a research model based on the definition of the cultural
profile and the estimation of the cultural distance between clinical examiners
and populations is proposed. It is important to reject both biological reduc-
tionism and the extremes of cultural determinism, in order to better assess the
intraethnic distribution of psychopathology, and interethnic variations repre-
sented by the notion of cultural relativism. 1995 John Wiley & Sons, Inc.
personality disorders * culture · psychopathology · diversity · cultural psychiatry

Culture as a Diagnostic/Nosological Factor in the diagnosis of psychiatric conditions in


general and personality disorders (PDs) in
Some authors have advocated the creation particular. They base their views on the pow-
of a cultural axis as an independent factor erful influence of culture on the concept

Editor's Note: The first part of this article appeared in Cultural Diversity and Mental Health,
Vol. 1, No. 1, pp 3-17 (1995).
Reprint requests should be directed to Dr Renato D. Alarc6n, Psychiatry Service (116A),
Atlanta VAMC, 1670 Clairmont Road, Atlanta, GA 30033.

Cultural Diversity and Mental Health, Vol. 1, No. 2, 79-91 (1995)


© 1995 by John Wiley & Sons, Inc. CCC 1077-341X/95/020079-13
80 ALARC6N AND FOULKS

and the formation of the self, its indepen- and 72 were Hispanics (34 men and 38 wom-
dence vis-A-vis immediate socioenvironmen- en). It was determined that the data for the
tal events, and the clarifying role of cultural two groups could be safely collapsed for
norms in the delineation of normality and analysis purposes; nevertheless, reliability
psychopathology (Hallowell, 1934; Hamil- was greater for the college population than
ton, 1971; Dohrenwend & Dohrenwend, for the minority populations. Hispanics and
1974; Mezzich & Goode, 1994). However, African Americans adopted a defensive style
because the design of DSM-IV was intended which emphasizes "principalization," includ-
to maintain or even reduce the number of ing defenses such as isolation, intellectualiz-
axes, emphasis shifted toward the cultural
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ation, rationalization, and reversal of affect.


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enhancement of the present five-axes model In the latter, instead of negative responses
(Mezzich, Kleinman, Fabrega, & Parron, in often described as "healthy cultural para-
press), and culminated with the proposal of noia" (Grier & Cobbs, 1968), positive re-
a Cultural Formulation incorporated in the sponses are produced as in reaction forma-
new Manual (Mezzich & Goode, 1994; Mez- tion, denial, repression, and negation. This
zich et al., in press; Alarc6n, in press). This means that minority patients often use a
formulation may facilitate research efforts constellation of defenses that "split off affect
centered on issues such as acculturation, from content," that is, they deal with conflict
language skills and preferences, the mean- by responding in positive or neutral ways to
ing of stress experiences, explanatory mod- negative circumstances (Harwood, 1981;
els of illness, perceived levels of adaptive Henry, 1963). Additional studies are re-
functioning, care-seeking patterns, and ex- quired before this promising finding can be
pectations on illness outcome and quality of seen as supporting the elaboration of crite-
life (Kleinman, 1977; Greenley, 1984; Fa- ria applicable to PDs.
brega, 1992, 1994; Nhu, 1976; Hallowell, A major issue for the diagnostician work-
1934; Kirmayer, 1989; Flaskerud & Hu, 1992; ing across cultures is the requirement of dif-
Kleinman, 1988). The Cultural Formulation ferentiating the ideal personality type, the
guidelines include a description of the cul- typical personality, and the atypical person-
tural identity of the patient, the cultural ex- ality from the standpoint of cultural func-
planations of his/her illness, cultural factors tionality. Ideal personality types are most of-
related to psychosocial environment and ten revealed when questioning people about
functioning, the cultural elements of the what they are like and how one should raise
diagnostician-patient relationship, and an children and conduct life. In any society,
overall assessment for diagnosis and care. "typical personality" and its behavioral cor-
The diagnosis of PDs has the least amount relates may differ considerably from the ide-
of cultural referents among measurement al, yet be considered normal and expectable
instruments used for the main nosological from the perspective of that society
categories (Lopez & Munoz, 1987). A study (Fabrega, 1994). Likewise, the atypical may
by Banks andJuni (1991) on the application be neither ideal nor average in behavior,
of a Defense Mechanisms Inventory (DMI) and still not be considered abnormal. Such
to 229 minority non-college-educated youths atypical individuals may be found in the
throws some light into aspects of the person- ranks of mystics, priests, ministers, artists,
ality structure that may help to diagnose and and others who transcend customary social
understand eventual personality variations roles, and are considered to make major
in clinical populations. The comparison was overall contributions to their societies. In
made with published normative figures these cases, the definitions of personality
among White American students. One hun- disorder, resting on determinations of func-
dred and fifty-seven respondents were Afri- tionality relative to the culture of origin, may
can Americans (98 men and 59 women), assume a different dimension when such an
PERSONALITY DISORDERS AND CULTURE 81

individual is displaced to the context of an- tive extreme of basic trait expression, al-
other culture (Fabrega, 1989). though the extent of convergence of normal
and pathological traits remains to be deter-
mined. According to Cloninger (1987), the
Biological Perspective:A Critique
optimum of overall flexibility in social adap-
Cloninger (1987) has discussed basic per- tation might be found in the range of inter-
sonality traits as adaptive capabilities which mediate or nearly average trait values. Vari-
all humans possess to varying degrees. It is ants at either extreme may excel or have
the innate variation in the relative quantity advantage in certain social roles or cultural
of each trait in interaction with environmen- configurations, but are less flexible in their
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

tal demands which, he believes, results in ability to adapt socially overall. Cloninger
those enduring qualities that define person- proposes that balanced selection for inter-
ality. He suggests that PDs, such as those list- mediate adaptive optima may explain the
ed in DSM-III-R (and presumably DSM-IV), persistence of the extreme variants in popu-
represent the outcomes of extreme strength lations.
or extreme weakness of one or more traits While all these contributions represent a
interacting with the strength and weakness considerable advance, there are still a num-
of others. Cloninger (1987) and Siever et al. ber of problems that make their application
(1990) propose further that genetic factors questionable for a culturally sensitive and
may be related to the expression of these relevant consideration of PDs in a diagnostic
neurotemperamental systems, and the exag- system. Some of these problems are:
geration of any of them may relate Axis II
1. Innate variations of acquired adaptive
PDs to Axis I disorders. Thus, schizophrenia
capabilities and the interaction of each
would represent a further exaggeration of
trait with environmental demands are
the traits which determined the schizotypal
time-honored, hardly new theoretical
personality, and these disorders would be
assumptions (Engel, 1977).
seen in genetically related individuals
(Siever et al., 1990; Frangos, Athanassenas, 2. The proposed basic predispositions in
Tsitourides, & Katsanov, 1985). active interplay with environmental
Investigating spectrum disorders from a stimuli are by no means the final or
phenomenological and psychobiological per- even the only ones; they should be
spective, Siever and Davis (1991) suggest seen rather as related, among other
that four major categories of Axis I disorders things, to the instruments utilized in
can be related systematically to four clusters the specific research design (Escobar,
of Axis II disorders. They argue that dysfunc- Karno, & Golding, 1987). Further-
tion in the cognitive/perceptual dimension more, their dimensional nature has
results in odd cluster disorders and, if ex- not covered yet the numerous inter-
treme, schizophrenic disorders. Dysfunction acting possibilities beyond the cor-
in the impulsivity/aggression dimension re- relation (already attempted) with the
sults in borderline antisocial personality dis- existing DSM-III-R categories.
orders, and if severe, impulse control disor- 3. The ascription of neurotransmitter
ders. Dysfunction in the affective stabilizing systems regulating in a specific man-
dimension results in dramatic cluster disor- ner each of Cloninger's three basic
ders, and if severe, major affective disorders. predispositions is simplistic at best,
Finally, dysfunction in the anxiety/inhibi- and to say that genetic factors may be
tion dimension results in anxious cluster dis- related to the expression of these
orders, and if severe, anxiety disorders. three neurotemperamental systems is
These models suggest that PDs and even quite a predictable yet unproven
Axis I disorders may represent the unadap- proposition.
82 ALARC6N AND FoULKS

4. The prevalence findings predicted by no, and Golding (1987) about Hispanic pa-
Cloninger's model refer in some cases tients.
to specific personality disorders such Choca, Shanley, Peterson, and Vanden-
as the antisocial, and in others to sev- burg (1990) study the scores of Black and
eral of the DSM-III-R types, so that White male psychiatric inpatients at a VA Hos-
such figures can be construed ambig- pital on the Millon Clinical Multiaxial Inven-
uously. tory (MCMI). In predicting psychopathology
for the two races, comparisons of MCMI per-
A cultural view of the diagnostic process
formance indicated significant differences
makes it possible to see, through the pa-
for all diagnoses except PDs. An analysis of
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tient's identified "symptoms," some of the


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variance demonstrated that the scores ob-


cultural influences which can help to weigh tained by the Black and White groups were
the clinical evidence more objectively. It significantly different in nine of the 20 scales.
should not be forgotten that even within
Three of these scales (histrionic, narcissistic,
seemingly homogeneous cultural groups antisocial) show Blacks with a higher score
there are subgroups or variations due to cor- than Whites. The results also suggested pos-
relative cultural differences based on re- sible deficiencies in terms of the culture-
gional, religious, or other sociocultural pa- fairness of individual items. The authors as-
rameters. Such is the case among "Anglo" certain that the expert's assessments against
patients in the South and the Northeast, or which inventories are validated or evaluated
among Mexicans and Puerto Ricans in the could also contain biases: this introduces a
Hispanic community. Nevertheless, some logical circularity that only adds to the com-
general rules can be applicable, and can plexity of bias investigation. They advocate
doubtlessly be enriched by research find- the use of factor analysis in bias studies. This
ings. line of research is promising in that it would
ensure specific validation of clinical diag-
noses, and eventually may provide more clear
Measurement Approaches
criteria for the initial assessment.
The instrumental assessment of personality Along the same lines, McCreary and Padilla
is a very relevant area for the estimation of (1977) studied Minnesota Multiphasic Per-
social and cultural factors, and the diagnos- sonality Inventory (MMPI) differences
tic biases they engender. In his review, Dana among Black, Mexican American, and
(1984) asserts that PDs have become a typi- White male offenders. Cultural factors seem
cal psychopathological reaction to the envi- to be related to the differences between
ronment, and advocates an assessment that Mexican Americans and Whites on the L, K,
includes awareness of modernization and and Overcontrolled Hostility scales, whereas
acculturation effects. Clear distinctions be- differences on the Hy scale seem to reflect
tween etic and emic measures can reduce socioeconomic factors. Interestingly enough,
assessor bias, and enhance fairness in de- Mexican Americans were classified more of-
scriptions of culturally different persons. ten as "psychiatric" cases, while Whites and
Prejudices induced by ignorance, and but- Blacks were placed well into the "sociopathic
tressed by fear of the "unknown" minority range"; nevertheless, Hostility and even the
persons, may result in an unrealistic apprais- L and K scales reflect strong personality fac-
al of their aspirations and motivations; tors, as Gynther (1972) found in his own
therefore, it is important to apply "modera- study using MMPI on Black individuals. The
tor variables in the personality assessment of fact that the McCreary and Padilla study uti-
minority persons," a point also argued by lized offenders as research participants is
Neligh (1988) in relation to the Native one of several limitations for the generaliza-
American population, and by Escobar, Kar- tion of its conclusions.
PERSONALITY DISORDERS AND CULTURE 83

A comprehensive cross-cultural adapta- study also revealed problems in transcultural


tion of clinical and epidemiological instru- communication, as many of the diagnostic
ments is the main thrust of an article by concepts used in the instrument were "too
Bravo, Canino, Rubio-Stipec, and Woodbury- Western" to be transposed unchanged to the
Farifia (1991). They worked with the Span- Ethiopian culture.
ish translation of the Diagnostic Interview
Schedule (DIS). A careful adaptation pro- Research Approaches: Bases for a Model
cess goes beyond mere language translation,
and has to address validity in the semantic, Precise measurements of the cultural com-
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technical, content, criterion, and concep- ponents of PDs are, thus, highly desirable
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tual equivalence dimensions. A number of but difficult. Perhaps as Abroms (1981)


symptoms, different from those included points out, we should abandon the attempt
on questionnaires developed for English- to quantify the relative contributions of ge-
speaking populations, appear when the task notype versus environment (the latter in-
of identifying culturally significant mani- cluding psychological and social factors) to
festations of mental distress is undertaken. psychiatric conditions and, rather, assign a
This may prove to be particularly true for complementary role to each in the diagnosis
the diagnosis of PDs. and treatment of such conditions. Perhaps,
On the basis of an epidemiological com- as Littlewood (1990) and more so Leff
parison between Indian and Metis (Native) (1990) propose, we should attempt to ex-
and non-Native psychiatric inpatients in the plain (or understand) each psychiatric con-
province of Saskatchewan, Canada, Fritz dition vis-a-vis a theoretical bipolar spectrum
(1976) found the Indian and Metis as being ranging from the biological to the sociologi-
20 and 76%, respectively, more frequently cal (or sociocultural), and adding an estima-
assigned the diagnoses of personality and tion of the cultural distance between exam-
behavior disorders. Indian females were hos- iners and populations being studied, or
pitalized 266% more frequently than non- between patient groups being compared.
Indian females, whereas Indian males were This is consonant with the postulates of uni-
hospitalized for these disorders less fre- versality and contextualization advocated by
quently than non-Native males. The author the "new cross-cultural psychiatry" (Klein-
does not discuss the types of PDs or other man, 1977, 1988).
basic culturally determined factors that may In this sense, the three existing PD clus-
have a bearing on these findings. The pat- ters, or the ten PD types included in DSM-IV
tern of passivity, weakness of emotional inte- could, first, be arranged along a spectrum,
gration, and constriction of emotional reac- and the magnitude of the cultural compo-
tivity found by Boyer, DeVos, and Boyer nent on each one could be estimated follow-
(1983) among Apaches may, however, apply ing the parameters of DSM-IV's cultural for-
to some extent. mulation (Mezzich & Goode, 1994; Mezzich
Another problem with diagnostic instru- et al., in press). At the same time, the cultur-
ments was identified by Kortmann (1990) ally determined vulnerability to stressors,
who applied the Self-Reporting Question- and the treatability by social, sociocultural,
naire (SRQ), developed by the World or psychosociocultural means could be as-
Health Organization (WHO) as a "univer- sessed.
sally applicable psychiatric case finding in- There are several ways to implement this
strument," to 110 respondents in Ethiopia. strategy or parts of it. One could carefully
A moderate criterion validity was found, the examine the operational criteria laid out for
author ascribing it to the low sensitivity of each personality disorder and dissect them
the instrument, which may also explain the on the basis of their possible cultural refer-
scarcity of PDs among the findings. The ents. Next, indicators from the literature on
84 ALA RC 6 N AND FOULKS

PDs and their place at different points on profiles. This procedure could reveal the fol-
the biosociocultural continuum could be as- lowing:
certained. Once a gradation is obtained,
each type could be assessed from different SCHIZOTYPAL (ECCENTRIC): Individualism,
cultural perspectives (i.e., the clinician's and hyperintellectualization, hyperstimulation
the patient's), trying, if at all possible, to leading to excessive fantasy, self-affirmation,
stress the similarities or commonalities be- insociability.
tween such perspectives. Another approach
could be to globally assign a culturalprofileto PARANOID (SUSPICIOUS): Individualism, dis-
each personality disorder category, rather trustfulness, rigidity, sense of oppressive-
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ness, anger, adversarialism/antagonism, dis-


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than "dissecting" individual criteria, and


then proceed with the examination of each torted sociability.
type from the different cultural perspec-
tives. SCHIZOID (ASOCIAL): Individualism, indif-
Let us assume, for example, that as a re- ference, distorted self-sufficiency, hypostim-
sult of a literature review of available evi- ulation, limited sociability.
dence, the ten established PDs can be
ANTISOCIAL (AGGRESSIVE): Individualism,
ranked from the "most biologically based" to
the "most psychosocioculturally based" in antagonism, conflict-proneness, rigidity,
the following order: need to prove self, anger, demonstrativeness.

1. Schizotypal BORDERLINE (UNSTABLE): Ambiguity, un-


2. Paranoid predictability, inconsistency, need to prove
3. Schizoid self, distorted sociability.
4. Antisocial OBSESSIVE-COMPULSIVE (CONFORMING):
5. Borderline Self-doubts, uncertainty, inconsistency, rigid-
6. Obsessive-compulsive ity, frugalism.
7. Dependent
AVOIDANT (WITHDRAWN): Inconsistency,
8. Avoidant sense of personal inferiority, no risk-taking,
9. Narcissistic limited sociability.
10. Histrionic.
DEPENDENT (SUBMISSIVE): Opaqueness,
This type of categorization resembles distorted sociability, unconditional rule-
that utilized by the Dohrenwends (1969) to following, search for paternalism.
rank "attitudes" of mastery at one pole and
helplessness at the other, in estimating per- NARCISSISTIC (EGOTISTIC): Individualism/
sonal dispositions. A first look at the above selfishness, self-affirmation, grandiosity,
spectrum already suggests that the more emptiness, hypersociability.
biologically based a personality disorder,
the more vulnerable it is to psychosocial HISTRIONIC (GREGARIOUS): Social insta-
stressors. The assignment of a culturalprofile bility, overstimulation, self-affirmation, dem-
to each of the PDs would subsequently take onstrativeness, materialism.
into account conventional social and cultur-
al criteria, a general assessment of the DSM PASSIVE-AGGRESSIVE (NEGATIVISTIC): In-
operational criteria for each category, and consistency, conflict-proneness, distorted
the clinical experience in the study of PDs. sociability, punitiveness.
Millon's (1981) biosocial approach might be Some of the traits included in the above
used to aid in the characterization of such sets may reflect characteristics of the cultur-
PERSONALITYDISORDER SANDCULTURE 85

al group from which the patient comes, and ubiquitous role of social and cultural factors
so it would be incumbent upon the clinician in the determination of their clinical pro-
to sort them out [Leff's (1990) assessment files. Almost every author would agree that
of the "cultural distance"], and assign to cultural factors do shape the personality of
them a diagnostic, as well as a therapeutic the individual through child-rearing prac-
value. An analysis of the "symptoms" present tices, family-based customs and traditions,
in the above sets, from the perspectives pro- and the experiential development of coping
vided by different ethnic and cultural mechanisms (Leighton, 1981). Unfortu-
groups, using an instrument such as Weiss' nately, the assessment of these factors was
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Explanatory Model Interview Catalogue strongly influenced, for many decades, by a


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(EMIC) scale (Weiss, Doongaji, & Sid- version of "drive theory" that attempted to
dhartha, 1992; Flaherty, Gaviria, & Pathak, explain patterns of culture as an interplay of
1988; Channabasavanna, Raguram, Weiss, intrapsychic agencies (Benedict, 1934;
Parvathavardhini, & Thriveni, 1993) might Whiting & Child, 1953), or unconsciously
prove helpful to the clinician in differentiat- operating defense mechanisms (Kardiner,
ing PDs from nonpathological, culturally de- 1945). The difficulties of such approaches
termined behavior. have been pointed out by Battan (1983) and
Clemens (1982), who, in critiquing Lasch's
(1978) The Culture of Narcissism, point out
Discussion the tautologies involved in attempts to con-
solidate psychoanalysis and social systems in
PDs pointedly raise questions regarding the the study of contemporary American cul-
purposes and functions of a diagnostic sys- ture.
tem. The history, wide prevalence, endemi- Neoanalytical thinkers concede now the
city, and patient suffering and maladapta- reinforcing character of cultural factors on
tion associated with Axis I disorders have normal and abnormal development of per-
been invoked as expressions of their "bio- sonality, and assign value to social attitudes
medical" nature and common characteris- toward psychopathology, competition, and
tics across social groups. Such kinds of disor- impersonalization brought about by tech-
ders would thus seem to constitute "natural" nology. Also noted is the pervasive influence
targets of a diagnostic system. These features of personality on the causation and experi-
are less clearly evident with respect to PDs. encing of other psychiatric conditions such
The latter are more vulnerable to the claim as depression and schizophrenia (Rubins,
that they are relative to the societies in which 1975; Opler, 1973). As Lidz points out, "un-
they are formulated, and that phenomena less it is appreciated that humans have dual
such as social labeling and medicalization endowment-a genetic inheritance that is
are influential in their diagnosis (Moore, born into them, and a cultural heritage into
1990; Fabrega, 1994; Lewis-Fernandez & which they are born, and which they must
Kleinman, 1994). Stated succinctly, the PDs assimilate from those who raise them, hu-
codified in the DSM and other nosological man development and maldevelopment can
systems seem to be more culturally bound to never be understood correctly" (Lidz, 1979).
or associated with the rules, standards, and In this sense, the dimension of language,
conventions on adaptive and maladaptive like the role of family and its culture, its
behaviors found in Western contemporary dynamic organization, and the role of pa-
societies, and because of this are easy prey to rental figures, acquires not only symbolic
political misuse. but also pathoplastic and pathogenic rele-
PDs have the lowest levels of validity and vance.
reliability among all disorders in psychiatric Leighton (1981) makes a cogent argu-
nomenclatures. This is partly due to the ment to reject the extremes of cultural de-
86 ALARC6N AND FOULKS

terminism, and states that culture should be From another vantage point, it is clear
thought of as "an important but partial in- that personality and behavior patterns are
fluence in the day-to-day functioning of a markers of a number of social interactions,
person." On the basis of his own work with as well as of other psychiatric conditions,
Eskimo villagers in Alaska and Yoruba vil- particularly affective disorders and psycho-
lagers in Nigeria (Leighton, Harding, Mack- somatic entities (Wittkower, Cleghorn, Li-
lin, MacMillan, & Leighton, 1963), he sug- powski, & Murphy, 1969). In this sense, it
gests that culture may indeed influence the becomes extremely important to ascertain,
frequency of affective and personality disor- for instance, similarities and differences be-
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ders, but it "is hard to disentangle it from tween type A behavior, as described by De-
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the much more powerful effects of age and Gregorio and Carver (1980), Friedman
sex, and of situational factors such as pover- (1977), and Jenkins (1976), with some of
ty." He considers it useful to think of culture the DSM-IV types such as obsessive-compul-
and personality as sets of more or less inde- sive and negativistic or passive-aggressive.
pendent variables which interact with each The complex transactions between such in-
other in particular ways, in the life of each dividuals and the modern Western culture
particular patient. What happens in PDs is provide opportunities for both reward and
that "the coping guidelines of culture that punishment, with a concomitant impact on
have been passed down from previous gen- their behavior and emotional health.
erations often no longer work well, and in Culture affects a number of behaviors
many instances do not work at all." When and disorders that may not have found use-
employed along with psychological concepts ful labeling in current classifications. Abu-
of personality processes and with social situ- sive and even homicidal parents as de-
ational processes, particularly rapid change scribed by Bourget and Bradford (1990) is a
and the consequences of sociocultural disin- case in point. The same can be said of the
tegration, personality as a conceptual tool plight of battered wives, in which cultural
becomes more relevant. From this constant factors interplay quite closely with person-
interaction, a number of factors emerge that ality features such as jealousy, immaturity,
can make the individual more vulnerable dependency, aggressiveness, and sadomas-
than the average person to environmental ochism. Prescott (1974) considers this con-
stresses (Reading, 1977; Montero & Sloan, dition as a "failure in adaptation [or] a fail-
1988; Tolor, 1978). ure to acquire adequate social learning."
On the basis of a historicoanthropologi- An example of the connection between
cal approach, Nuckolls (1992) argues that personality, personality disorder, other psy-
antisocial and histrionic personality disor- chiatric conditions, and culture (which in-
ders represent the extreme expression of cludes ethnicity as an important compo-
stereotyped family values, perpetuated by nent) is seen in the work by Zucker and
cultural notions (independence vs. depen- Gomberg (1986), who challenge some of
dence) attached to gender. Values were "del- the findings of Vaillant's (1983) classical
egated" to women and men in a historical follow-up study on alcoholics. There is
group process of conflict, ambivalence, and strong evidence that some personality vari-
splitting that first assigned "moralism" to ables, including antisocial behavior, are pre-
women and "materialism" to men. Clinical morbidly present in persons who later be-
labeling becomes then a "legitimate" means come alcoholic. Ethnic differences in the
for the realization of stereotypes. Many other amount of alcohol consumption relate not
authors discuss gender as a culturally charged only to norms about child and adult alcohol
concept in the labeling of PDs (Lucchi & use and intoxication, but they also mark a
Gaston, 1990; Wu, 1992; Israel, Raskin, Libow, wide range of individual and interpersonal
& Prowder, 1978; Symonds, 1976). differences in educational and occupational
PERSONALITY DISORDERS AND CULTURE 87

aspiration, cohesiveness of kinship net- pursuits of life and become wanderers in


works, and cultural values about sexuality, search of God and peace. All these findings
marriage, and other elements of socialized are contrasted with the American cultural
behavior. Obviously, the process of develop- emphasis on individuation, independence,
ing a PD occurs in a social world, and is self-reliance, and competence in diverse
influenced by a biopsychosocial process. roles from adolescence on, family and soci-
More than 20 years ago, Sheperd and ety for the most part not being inclined to
Sartorius (1974) made a plea for a more nurture inadequacies of their members. In
precise delineation of the PDs and their dif- Teja's opinion (1978), the Protestant work
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ferentiation from normal variants of person- ethic has no doubt contributed to this orien-
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ality, and advocated research on socio- tation, and to the concomitant subjective
cultural and comparative aspects of this distress and personality problems.
problem, and on its public health implica- For all the above reasons, it is crucially
tions. These principles are reviewed by Reid important to consider the cultural context
(1985) in regards to antisocial personality. in order to differentiate normal role behav-
He comments on the pathogenic force of a ior from the extremes that might indicate a
"chronicle of purported injustices" found in PD (Denis, 1990; Westermeyer & Wintrob,
the autobiography of a patient diagnosed in 1979). Impairments in the cross-cultural
his youth as a sociopath. He makes the sug- context, may, however, be the result of mal-
gestive point that some persons with antiso- adjustment to a majority or dominant cultur-
cial characteristics may be "highly adaptive al perspective, or be related to dysfunction
to our modern world of stress and prob- of the reference group itself. We believe that
lems," a point also made by Levine and Shai- traits which are not considered to be unde-
ova (1974). sirable by the patient's reference group,
Some authors have elaborated also on should not be included on the list of traits
the protective/therapeutic role of culture in essential to meeting diagnostic criteria for a
PDs. Brook, Whiteman, Balka, and Ham- PD. Such caution may avoid mislabeling,
burg (1992) mention the "protective buff- and the unnecessary stigmatization of people
ers" used by African-American and Puerto from other ethnic groups or social classes.
Rican families, and point out their value in In conclusion, culture's relationship with
helping to target and time therapeutic inter- PDs should not be overestimated in etiologi-
ventions for drug users from both ethnic cal terms, but rather seen as an explanation
groups. Lee and Newton (1981) provide ex- of behavioral patterns, a covariable in the
amples of stress coping mechanisms among pathogenesis of PDs and in the pathoplasty
Hawaiians dealing with childbirth and physi- of their symptoms, and/or as a dimension
cal illness; they are strongly dictated by the of the diagnosis and nosology of these disor-
cultural notions of "rationalistic animism" ders. Thus, cultural knowledge by the clini-
and harmonious psychological-phasic rela- cian will play a useful role as preventor of
tionships. Neki (1976) asserts that in the av- the medicalization (or rather, pathologiza-
erage Indian population, an enormous pro- tion) of personality traits (Mezzich &
portion of dependence, fostered by the Goode, 1994; Zuckerman, 1990). In this
culture during childhood, is permitted to be sense, a culturally informed public and cul-
carried forward. This is partly confirmed by turally sophisticated practioners will prevent
Teja's study (1978) that found PDs less fre- the risks of stereotyping and trivialization of
quently diagnosed among Indian as com- human behavior by helping to delineate dis-
pared to U.S. patients. Indian individuals tinctions between personality styles and per-
with PDs and inadequacies of various kinds sonality disorders.
either cling to the sheltering care of the Society as a whole can generate enough
joint or extended family, or give up the usual confusion of roles and expectations, uncer-
88 ALARC6N AND FoULKS

tainty of structures, rapidly changing values, reliabilities. Journal of Personality Assessment,


and other disruptions to the point that some 56, 327-334.
authors argue will cause an increase in char- Battan,J. F. (1983). The "new narcissism" in 20th
acterological disorders (Merton, 1964; Beck- century America: The shadow and substance
er, 1972). These trends, however, can be of social change. Journal of Social History, 17,
translated into dire predictions disguising 199-220.
extremist, catastrophizing views (Levine & Becker, W. C. (1972). Consequences of different
Shaiova, 1974). The sobering evidence is kinds of parental discipline. In D. R. Heise
that, for instance, the impact of pathological (Ed.), Personality and socialization. Chicago:
Rand McNally.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

parenting can be buffered by better rela-


This document is copyrighted by the American Psychological Association or one of its allied publishers.

tions with the other parent and a mediating Benedict, R. (1934). Patterns of culture. Boston:
social network (Paris, 1991). This review also Haughton-Mifflin and Company.
calls our attention to the need to distinguish Bourget, D., & Bradford, G. M. W. (1990). Homi-
cidal parents. CanadianJournal of Psychiatry,
between intraethnic distribution of psycho-
35, 233-238.
pathology and interethnic variations repre-
sented by the notion of cultural relativism. It Boyer, L. B., DeVos, G., & Boyer, R. M. (1983). A
longitudinal study of three Apache brothers
is certainly important to assess both the ben-
as reflected in the Rorschach protocols. Jour-
efits and risks of multiculturalism as a social
nal of Psychoanalytical Anthropology, 6, 125-
reality across the globe (Hughes, 1993; 161.
Schlesinger, 1992). However, the cultural
Bravo, M., Canino, G. J., Rubio-Stipec, M., &
enrichment of social groups, brought about Woodbury-Farina, M. (1991). A cross-
by historical changes, tolerance, and cross- cultural adaptation of a psychiatric epidem-
fertilization (Oetting & Beauvois, 1991) ne- iology instrument: The Diagnostic Interview
gates both the extreme culturalistic views of Schedule's adaptation in Puerto Rico. Cul-
psychopathology and social behavior, and ture, Medicine and Psychiatry, 15, 1-18.
the reductionistic impact of the ultrabiologi- Brook,J. S., Whiteman, M., Balka, E. B., & Ham-
cal approach to the study of personality dis- burg, B. A. (1992). African-American and
orders. Puerto Rican drug use: Personality, familial,
and other environmental risk factors. Genet-
ics, Sociology and Genetic Psychology Mono-
Acknowledgment graphs, 118, 417-438.
Channabasavanna, S. M., Raguram, R., Weiss,
The authors wish to acknowledge the expert M. G., Parvathavardhini, R., & Thriveni, M.
technical assistance of Ms. Terry Lawson in (1993). Ethnography of psychiatric illness-
the preparation of this manuscript. A pilot study. National Institute of Mental
Health and Neuro-SciencesJournal, 11, 1-10.
Choca, J. P., & Shanley, L. A., Peterson, C. A., &
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