Ethnicity and four personality disorders

"I am secretary, therapist, maid, nurse": a qualitative exploration of lived experiences of caring for a family member with a BPD diagnosis

BACKGROUND

Informal caring is an increasingly common phenomenon. Experiences of mental health caring are not well-researched, and few studies focus on experiences of family carers supporting individuals with a Borderline Personality Disorder (BPD) diagnosis.

AIMS

This research explores lived experiences of people in caring roles for family members diagnosed with BPD.

METHODS

Seventy-two participants who identified as carers to a loved one diagnosed with BPD completed an online qualitative survey. Six of these participants took part in follow-up interviews, and three completed a follow-up survey. Survey responses and interviews were compiled and analysed using reflexive thematic analysis.

RESULTS

Two main themes were developed. "Labour of Love" involved experiences of burden and strain, and "Self as Secondary" incorporated feeling unheard and obliged to censor one's own behaviours.

CONCLUSIONS

Overall, this research broadens awareness of how a mental health diagnosis and a diagnosis of BPD specifically can have a broader, systemic impact on not only the individuals diagnosed, but their families and those providing support to them, and suggests that provision of support by healthcare providers to carers is necessary.

Factor structure and measurement invariance of Schizotypal Personality Questionnaire-Brief Revised (Updated) in India

AIM

Schizotypal Personality Questionnaire-Brief Revised-Updated (SPQ-BRU) is an easy-to-conduct, theoretically consistent, and psychometrically better measure of schizotypal personality. However, its study is limited to developed countries. Thus, in the present study, we tested the factor structure and measurement invariance of SPQ-BRU in India.

METHODS

A sample of 734 college students was selected from two sites (n = 614 from Muzaffarnagar in western Uttar Pradesh and n = 120 from Guhana in Haryana). Confirmatory factor analysis was used to test the good fitness of the different models of SPQ-BRU and the measurement invariance across sex and region.

RESULTS

The first-order nine-factor model was a better-fit model (among a set of first-order and second-order models), whereas the second-order three-factor model was a more parsimonious good-fit model of SPQ-BRU. The nine-factor model was strongly invariant across sex and region. Women had higher social anxiety, ideas of reference, and lower constricted affect than men. Moreover, the Gohana sample was higher on several schizotypal personality facades than the Muzaffarnagar sample.

CONCLUSIONS

The present study supported the cross-cultural validity of schizotypal personality and partially established a reliable and valid SPQ-BRU-Hindi language version.

Race and self-reported paranoia: Increased item endorsement on subscales of the SPQ

There is a dearth of research examining how individual-level and systemic racism may lead to elevated diagnostic and symptom rates of paranoia in Black Americans. The present study employed item response theory methods to investigate item- and subscale-level functioning in the Schizotypal Personality Questionnaire (SPQ) in 388 Black and 450 White participants across the schizophrenia-spectrum (i.e., non-psychiatric controls, individuals with schizophrenia, schizoaffective disorder, or schizotypal personality disorder). It was predicted that (1) Black participants would score significantly higher than Whites on the Suspiciousness and Paranoid Ideation subscale of the SPQ, while controlling for total SPQ severity and relevant demographics and (2) Black participants would endorse these subscale items at a lower latent severity level (i.e., total SPQ score) compared to Whites. Generalized linear modeling showed that Black participants endorsed higher scores on subscales sampling paranoia (e.g., Suspiciousness and Paranoid Ideation), while White participants endorsed higher rates within disorganized/positive symptomatology subscales (e.g., Odd or Eccentric Behavior). IRT analyses showed that Black individuals also endorse items within the Suspiciousness and Paranoid Ideation subscale at lower latent severity levels, leading to inflated subscale scores when compared to their White counterparts. Results indicate prominent race effects on self-reported paranoia as assessed by the SPQ. This study provides foundational data to parse what could be normative endorsements of paranoia versus indicators of clinical risk in Black Americans. Implications and recommendations for paranoia research and assessment are discussed.

Evaluating Measures of Externalizing Personality Pathology Traits in Black and White American Adolescents in a Program for at-Risk Youths

Adolescent personality assessment measures can aid in the identification of traits that are associated with various types of maladjustment. Externalizing personality pathology traits (e.g., antisocial, borderline, and narcissistic personality disorder features) are particularly relevant for many problematic outcomes, yet measures that assess these traits have not been validated extensively in diverse samples. The present study aimed to examine the properties of measures of externalizing personality pathology traits in a sample of White (n = 184) and Black (n = 99) adolescents participating in a residential program for at-risk youth. The fit of the proposed structure for these measures was tested in the sample as a whole and in each racial group separately. Associations between these measures and the count of disciplinary infractions received while in the program were also tested. Measures were found to have less than optimal fit in this sample, especially among Black adolescents. Suggestions for future research and clinical use of these measures are discussed.

The role of migration processes and cultural factors in the classification of personality disorders

Migrants and ethnic minorities are at risk of being under- and overdiagnosed with personality disorders (PDs). A culturally informed approach to the classification of PDs guides clinicians in incorporating migration processes and cultural factors, to arrive at a reliable and valid assessment of personality pathology. In this article, we provide a tentative framework to highlight specific interactions between personality disorders, migration processes, and cultural factors. It is argued that migration processes can merely resemble personality pathology, activate certain (latent) vulnerabilities, and aggravate pre-existing personality pathology. We propose that these migration processes can include manifestations of grief about the loss of pre-migratory psychosocial and economic resources, and the struggle to attain psychosocial and economic resources in the host culture. Moreover, several cultural dimensions are outlined that can either resemble or mask personality pathology. The term "culturally masked personality disorder" is coined, to delineate clinical cases in which cultural factors are overused or misused to rationalize behavioral patterns that are consistently inflexible, distressing, or harmful to the individual and/or significant others, lead to significant impairment, and exceed the relevant cultural norms. Additionally, the role of historical trauma is addressed in the context of potential overdiagnosis of personality disorders in Indigenous persons, and the implications of misdiagnosis in migrants, ethnic minorities, and Indigenous populations are elaborated. Finally, clinical implications are discussed, outlining various diagnostic steps, including an assessment of temperament/character, developmental history, systemic/family dynamics, migration processes, cultural dimensions, and possible historical trauma.

An Empirical Evaluation of the DSM-5 Alternative Model of Personality Disorders in Later Life

Personality disorders (PDs) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are conceptualized as distinct clinical syndromes. However, debate persists about the clinical utility of this categorical model, with many researchers supporting a dimensional model that focuses on pathological personality traits and personality dysfunction. This model was published in Section III of DSM-5 and named the Alternative Model of Personality Disorders (AMPD). This study evaluated the AMPD by examining relationships between traits and dysfunction with traditional categorical PD constructs among older adults. Older adults (N = 202) completed the Personality Inventory for DSM-5, Levels of Personality Functioning Scale-Self-Report, and Coolidge Axis II Inventory. Results indicated that pathological personality traits do not relate to categorical PDs in directions predicted by the AMPD. Personality functioning related to categorical PDs in expected theoretical patterns according to the AMPD but lacked incremental validity above pathological personality traits. An implication of these findings is that the AMPD does not fully resolve the age-related issues with the traditional categorical PD model.

Tracking salience in young people: A psychometric field test of the Aberrant Salience Inventory (ASI)

AIM

To explore the prevalence of Aberrant Salience (AS, an alleged experiential feature of psychosis-proneness) in Italian young people and corroborate the transcultural validity of the Aberrant Salience Inventory (ASI).

METHODS

Young adults attending an Italian university (n = 649) underwent serial evaluations with the ASI together with psychometric proxies for help seeking General Health Questionnaire and attenuated positive and negative symptoms Schizotypal Personality Questionnaire (SPQ). The distribution of ASI scores was explored with latent class analysis (LCA).

RESULTS

Reliability of the Italian version of the ASI (I-ASI) was acceptable for all subscales (ordinal alpha >.70). Concurrent validity was in the expected direction, with higher correlations with measures of attenuated positive symptoms vs negative symptoms of psychosis (Steigers' z test, P < .005 in all comparisons). LCA identified three classes, with 217 (33.4%) participants in the "high aberrant salience" class. Gender and age were not related to class membership. Compared to the baseline class, SPQ scores in the schizotypy range were more likely in the "high aberrant salience" class (OR = 39.1; 95%confidence interval: 5.30-288.1).

CONCLUSION

AS is a relatively common experience among Italian young people. The study also confirmed the validity of field-testing ASI as a tool for the real-world characterization of people with vulnerability to psychosis, such as symptomatic help seekers with clinical high-risk states.

Community and Clinical Epidemiology of Borderline Personality Disorder

Several studies of the prevalence of borderline personality disorder in community and clinical settings have been carried out to date. Although results vary according to sampling method and assessment method, median point prevalence is roughly 1%, with higher or lower rates in certain community subpopulations. In clinical settings, the prevalence is around 10% to 12% in outpatient psychiatric clinics and 20% to 22% among inpatient clinics. Further research is needed to identify the prevalence and correlates of borderline personality disorder in other clinical settings (eg, primary care) and to investigate the impact of demographic variables on borderline personality disorder prevalence.

Ethnic variation in personality disorder: evaluation of 6 years of hospital admissions

Aims and methodThere is limited evidence on ethnic differences in personality disorder prevalence rates. We compared rates of people with personality disorder admitted to hospital in East London from 2007 to 2013.

RESULTS

Of all people admitted to hospital, 9.7% had a personality disorder diagnosis. The admission rate for personality disorder has increased each year. Compared with White subjects, personality disorder was significantly less prevalent among Black and other minority ethnic (BME) groups. Personality disorder was diagnosed in 20% of forensic, 11% of general adult, 8% of adolescent and 2% of old-age in-patients.Clinical implicationsThe increasing number of personality disorder diagnoses year on year indicates the increasing impact of personality disorder on in-patient services. It is important to identify and appropriately manage patients with a personality disorder diagnosis due to the significant strain they place on resources. The reasons for fewer admissions of BME patients may reflect alternative service use, a truly lower prevalence rate or under-detection.Declaration of interestNone.

Cross-cultural bias in the diagnosis of borderline personality disorder

Borderline personality disorder (BPD) is an internationally recognized disorder, although it is slightly varied in its nosology in the International Classification of Diseases, 10th Revision (ICD-10), the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), and the Chinese Classification of Mental Disorders (CCMD). While it is recognized by genetic and neurobiological patterns, instability of affect, impaired interpersonal relationships, and unstable sense of self, its manifestation is extremely varied based on environmental factors, particularly culture. Several studies of the manifestation of BPD between and across countries, particularly in immigrant populations, identify variations in symptom prevalence based on culture. These findings reveal a need for more unified dimensional-based categorization of BPD to reduce cross-cultural bias and improve identification.

Obsessive-compulsive (anankastic) personality disorder: toward the ICD-11 classification

Obsessive-compulsive personality disorder (OCPD) is an early-onset disorder characterized by perfectionism, need for control, and cognitive rigidity. Its nosological status is currently under review. Historically, OCPD has been conceptualized as bearing a close relationship with obsessive-compulsive disorder (OCD). In this article, we discuss the diagnosis of OCPD in anticipation of its review for the ICD-11, from the perspective of clinical utility, global applicability, and research planning. Considering the recent establishment of an obsessive-compulsive and related disorders (OCRD) category in DSM-5, we focus on the relationship between OCPD and the disorders that are currently thought to bear a close relationship with OCD, including DSM-5 OCRD, and other compulsive disorders such as eating disorder and autistic spectrum disorder (that were not included in the DSM-5 OCRD category), as well as with the personality disorders, focusing on nosological determinants such as phenomenology, course of illness, heritability, environmental risk factors, comorbidity, neurocognitive endophenotypes, and treatment response. Based on this analysis, we attempt to draw conclusions as to its optimal placement in diagnostic systems and draw attention to key research questions that could be explored in field trials.

Examination of the factor structure of the Schizotypal Personality Questionnaire among British and Trinidadian adults

Much debate in schizotypal research has centred on the factor structure of the Schizotypal Personality Questionnaire (SPQ), with research variously showing higher-order dimensionality consisting of two to seven dimensions. In addition, cross-cultural support for the stability of those factors remains limited. Here, we examined the factor structure of the SPQ among British and Trinidadian adults. Participants from a White British subsample (n = 351) resident in the UK and from an African Caribbean subsample (n = 284) resident in Trinidad completed the SPQ. The higher-order factor structure of the SPQ was analysed through confirmatory factor analysis, followed by multiple-group analysis for the model of best fit. Between-group differences for sex and ethnicity were investigated using multivariate analysis of variance in relation to the higher-order domains. The model of best-fit was the four-factor structure, which demonstrated measurement invariance across groups. Additionally, these data had an adequate fit for two alternative models: (a) 3-factor and (b) modified 4-factor model. The British subsample had significantly higher scores across all domains than the Trinidadian group, and men scored significantly higher on the disorganised domain than women. The four-factor structure received confirmatory support and, importantly, support for use with populations varying in ethnicity and culture.

Ethnic Differences in Personality Disorder Patterns among Women Veterans Diagnosed with PTSD

Personality Disorders (PDs) impair the ability to function socially and occupationally. PD prevalence rates among veterans who have also been diagnosed with posttraumatic stress disorder (PTSD) range from 45%–79%. This study examined ethnic differences in PDs assessed with the Millon Clinical Multiaxial Inventory-III in 260 non-Hispanic white (64%), Hispanic (27%), and African American (9%), mostly single, women veterans in treatment for PTSD. After adjusting for covariates including number and sexual-nature of trauma, findings revealed the adjusted odds ratio of having a cluster A PD was almost three times higher for African Americans (p = 0.046) then the other two ethnic groups, which may be driven by the paranoid PD scale and potentially reflects an adaptive response to racial discrimination. In cluster designation analysis, the odds were twice as high of having a cluster B PD with childhood trauma (p = 0.046), and a cluster C PD with sexual trauma (p = 0.004), demonstrating the significance of childhood and sexual trauma on long-term chronic personality patterns in women veterans. These results highlight the importance of using instruments with demonstrated diagnostic validity for minority populations.

The convergence of personality disorder diagnoses across different methods among monolingual (Spanish-speaking only) Hispanic patients in substance use treatment

Methods for diagnosing personality disorders (PDs) within clinical settings typically diverge from those used in treatment research. Treatment groups in research studies are routinely diagnosed using semistructured interviews or self-report questionnaires, yet these methods show poor agreement with clinical diagnoses recorded in medical charts or assigned by treating clinicians, reducing the potential for evidence-based practice. Furthermore, existing research has been limited by focusing on primarily White and English-speaking participants. Our study extended prior research by comparing 4 independent methods of PD diagnosis, including self-report questionnaire, semistructured interview, chart diagnoses, and ratings by treating clinicians, within a clinical series of 130 monolingual (Spanish only) Hispanic persons (69% male; M age 37.4), in treatment for substance use. The authors examined the convergence of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) PD diagnoses across these methods. PD diagnoses appeared infrequently within medical charts but were diagnosed at higher levels by independent treating clinicians, self-report questionnaires, and semistructured interviews. Nonetheless, diagnostic concordance between clinical diagnoses and the other methods were poor (κ < .20). Convergence of PD diagnoses across diagnostic methods for Spanish-speaking Hispanic persons are comparable to other groups allaying concerns about cross-cultural application of PD diagnoses. Additionally, the results of this study echo previous research in suggesting that clinicians' PD diagnoses overlap little with self-report questionnaires or semistructured diagnostic interviews and suggest that PDs are underdiagnosed using standard diagnostic approaches. Implications for the clinical application of empirically supported research are discussed.

Socioeconomic-status and mental health in a personality disorder sample: the importance of neighborhood factors

This cross-sectional study examined the associations between neighborhood-level socioeconomic-status (NSES), and psychosocial functioning and personality pathology among 335 adults drawn from the Collaborative Longitudinal Personality Disorders Study. Participants belonged to four personality disorder (PD) diagnostic groups: Avoidant, Borderline, Schizotypal, and Obsessive Compulsive. Global functioning, social adjustment, and PD symptoms were assessed following a minimum two-year period of residential stability. Residence in higherrisk neighborhoods was associated with more PD symptoms and lower levels of functioning and social adjustment. These relationships were consistent after controlling for individual-level socioeconomic-status and ethnicity; however, the positive association between neighborhood-level socio-economic risk and PD symptoms was evident only at higher levels of individual-level socio-economic risk. Our findings identify NSES as a candidate for explaining some of the variability in symptoms and functioning among PD individuals.

Phenomenology of borderline personality disorder: the role of race and socioeconomic status

Little is known about racial differences in borderline personality disorder (BPD) that may influence etiology, phenomenology, and treatment of women with BPD. A total of 83 women with BPD participated in this cross-sectional study: n = 41 white and n = 42 African-American women. Structured interviews were used to assess Axis I and II disorders, and a series of interviews and questionnaires captured internalizing and externalizing symptoms. The white women with BPD reported more severe internalizing symptoms, whereas the African-American women reported more severe externalizing symptoms. Except for the association between race and number of suicide attempts, the relationship between race and internalizing/externalizing symptoms was mediated by socioeconomic status. In conclusion, African-American women with BPD may present with more severe symptoms of lack of anger control and fewer suicidal behaviors than those of white women with BPD, raising the possibility that they are misdiagnosed and receive treatments that are not optimal for BPD.

Borderline personality disorder, exposure to interpersonal trauma, and psychiatric comorbidity in urban primary care patients

OBJECTIVE

Few data are available on interpersonal trauma as a risk factor for borderline personality disorder (BPD) and its psychiatric comorbidity in ethnic minority primary care populations. This study aimed to examine the relation between trauma exposure and BPD in low-income, predominantly Hispanic primary care patients.

METHOD

Logistic regression was used to analyze data from structured clinical interviews and self-report measures (n = 474). BPD was assessed with the McLean screening scale. Trauma exposure was assessed with the Life Events Checklist (LEC); posttraumatic stress disorder (PTSD) was assessed with the Lifetime Composite International Diagnostic Interview, other psychiatric disorders with the SCID-I, and functional impairment with items from the Sheehan Disability Scale and Social Adjustment Scale Self-Report (SAS-SR).

RESULTS

Of the 57 (14%) patients screening positive for BPD, 83% reported a history of interpersonally traumatic events such as sexual and physical assault or abuse. While interpersonal trauma experienced during adulthood was as strongly associated with BPD as interpersonal trauma experienced during childhood, noninterpersonal trauma was associated with BPD only if it had occurred during childhood. The majority (91%) of patients screening positive for BPD met criteria for at least one current DSM-IV Axis I diagnosis and exhibited significant levels of functional impairment.

CONCLUSION

Increased awareness of BPD in minority patients attending primary care clinics, high rates of exposure to interpersonal trauma, and elevated risk for psychiatric comorbidity in this population may enhance physicians' understanding, treatment, and referral of BPD patients.

Prevalence, correlates, disability, and comorbidity of DSM-IV schizotypal personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions

OBJECTIVE

To present nationally representative findings on the prevalence, correlates, and comorbidity of and disability associated with DSM-IV schizotypal personality disorder (SPD).

METHOD

This study used the 2004-2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions, which targeted a nationally representative sample of the adult civilian population of the United States aged 18 years and older and residing in households and group quarters. In Wave 2, attempts were made to conduct face-to-face reinterviews with all respondents to the Wave 1 interview.

RESULTS

Lifetime prevalence of SPD was 3.9%, with significantly greater rates among men (4.2%) than women (3.7%) (p < .01). Odds for SPD were significantly greater among black women, individuals with lower incomes, and those who were separated, divorced, or widowed; odds were significantly lower among Asian men (all p < .01). Schizotypal personality disorder was associated with substantial mental disability in both sexes. Co-occurrence rates of Axis I and other Axis II disorders among respondents with SPD were much higher than rates of co-occurrence of SPD among respondents with other disorders. After adjustment for sociodemographic characteristics and additional comorbidity, associations remained significant in both sexes between SPD and 12-month and lifetime bipolar I disorder, social and specific phobias, and posttraumatic stress disorder, as well as 12-month bipolar II disorder, lifetime generalized anxiety disorder, and borderline and narcissistic personality disorders (all p < .01).

CONCLUSIONS

Common and unique factors may underlie associations of SPD with narcissistic and borderline personality disorders, whereas much of the comorbidity between SPD and most mood and anxiety disorders appears to reflect factors common to these disorders. Some of the associations with SPD were sex specific. Schizotypal personality disorder and dependent, avoidant, and borderline personality disorders were associated with the occurrence of schizophrenia or psychotic episode. Schizotypal personality disorder is a prevalent, fairly stable, highly disabling disorder in the general population. Sex differences in associations of SPD with other specific Axis I and II disorders can inform more focused, hypothesis-driven investigations of factors underlying the comorbid relationships. Schizotypal as well as borderline, dependent, and avoidant personality disorders may be components of the schizophrenia spectrum.

Axis II comorbidity in borderline personality disorder is influenced by sex, age, and clinical severity

Borderline personality disorder (BPD) is a severe psychiatric disorder that has a high clinical heterogeneity and frequent co-occurrence with other personality disorders (PDs). Although several studies have been performed to assess axis II comorbidity in BPD, more research is needed to clarify associated factors. The aim of this study was to determine the prevalence of co-occurrent axis II disorders in a large sample of patients with BPD and to investigate the influence of sex, age, and severity on this comorbidity. Data were collected from 484 patients with BPD through 2 semistructured interviews. We analyzed the frequency of axis II comorbidity and assessed differences regarding sex, age, and severity of BPD. About 74% of patients with BPD had at least 1 co-occurrent axis II disorder. The most common were paranoid, passive-aggressive, avoidant, and dependent PDs. Significant sex differences were found. Women presented more comorbidity with dependent PD, whereas men showed higher rates of comorbidity with antisocial PD. We also observed a significant positive correlation between age and the number of co-occurrent axis II disorders in women with BPD. Another finding was the positive correlation between BPD severity and the number of co-occurrent axis II disorders. These findings suggest that comorbidity with other axis II disorders and sex, age, and severity should be taken into account when developing treatment strategies and determining the prognosis of BPD.

Ethnicity in trauma and psychiatric disorders: findings from the collaborative longitudinal study of personality disorders

The study's aims are to explore ethnic differences in rates of adverse childhood experiences and lifetime traumatic events and in rates of psychiatric disorders for patients exposed to similar traumas. Rates of these events and rates of major depressive disorder, posttraumatic stress, substance use, and borderline personality disorders were compared among 506 non-Hispanic Whites (N-HW), 108 Latina(o)s, and 94 African Americans (AA) participating in the Collaborative Longitudinal Personality Disorder Study. We found that Whites reported higher rates of neglect than African Americans and Latina(o)s, higher rates of verbal/emotional abuse than African Americans, and higher rates of accidents and injuries/feared serious injury than Latina(o)s. African Americans had higher rates of seeing someone injured/killed than Whites. No significant interaction was observed between adverse events and ethnicity for mental disorders.

The prevalence and structure of obsessive-compulsive personality disorder in Hispanic psychiatric outpatients

This study sought to confirm a multi-factor model of Obsessive-compulsive personality disorder (OCPD) in a Hispanic outpatient sample and to explore associations of the OCPD factors with aggression, depression, and suicidal thoughts. One hundred and thirty monolingual, Spanish-speaking participants were recruited from a community mental health center and were assessed by bilingual doctoral-level clinicians. OCPD was highly prevalent (26%) in this sample. Multi-factor models of OCPD were tested and the two factors - perfectionism and interpersonal rigidity - provided the best model fit. Interpersonal rigidity was associated with aggression and anger while perfectionism was associated with depression and suicidal thoughts.

Exploratory factor analysis of borderline personality disorder criteria in monolingual Hispanic outpatients with substance use disorders

This study examined the factor structure of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for borderline personality disorder (BPD) in Hispanic patients. Subjects were 130 monolingual Hispanic adults who had been admitted to a specialty outpatient clinic that provides psychiatric and substance abuse services to Spanish-speaking individuals. All were reliably assessed with the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders. After evaluating internal consistency of the BPD criterion set, an exploratory factor analysis was performed using principal axis factoring. Results suggested a unidimensional structure, and were consistent with similar studies of the DSM-IV criteria for BPD in non-Hispanic samples. These findings have implications for understanding borderline psychopathology in this population, and for the overall validity of the DSM-IV BPD construct.

A systematic review of personality disorder, race and ethnicity: prevalence, aetiology and treatment

BACKGROUND

Although psychoses and ethnicity are well researched, the importance of culture, race and ethnicity has been overlooked in Personality Disorders (PD) research. This study aimed to review the published literature on ethnic variations of prevalence, aetiology and treatment of PD.

METHOD

A systematic review of studies of PD and race, culture and ethnicity including a narrative synthesis of observational data and meta-analyses of prevalence data with tests for heterogeneity.

RESULTS

There were few studies with original data on personality disorder and ethnicity. Studies varied in their classification of ethnic group, and few studies defined a specific type of personality disorder. Overall, meta-analyses revealed significant differences in prevalence between black and white groups (OR 0.476, CIs 0.248 - 0.915, p = 0.026) but no differences between Asian or Hispanic groups compared with white groups. Meta-regression analyses found that heterogeneity was explained by some study characteristics: a lower prevalence of PD was reported among black compared with white patients in UK studies, studies using case-note diagnoses rather than structured diagnostic interviews, studies of borderline PD compared with the other PD, studies in secure and inpatient compared with community settings, and among subjects with co-morbid disorders compared to the rest. The evidence base on aetiology and treatment was small.

CONCLUSION

There is some evidence of ethnic variations in prevalence of personality disorder but methodological characteristics are likely to account for some of the variation. The findings may indicate neglect of PD diagnosis among ethnic groups, or a true lower prevalence amongst black patients. Further studies are required using more precise cultural and ethnic groups.

One-year treatment outcomes of African-American and Hispanic patients with bipolar I or II disorder in STEP-BD

OBJECTIVE

Few studies have compared treatment outcomes of African-American, Hispanic, and non-Hispanic white patients with bipolar disorder. The U.S. Systematic Treatment Enhancement Program for Bipolar Disorder compared one-year outcomes for bipolar I or II disorder from each of these racial-ethnic groups.

METHODS

African Americans (N=155) were retrospectively compared with a matched group of non-Hispanic whites (N=729), and Hispanics (N=152) were compared with a separate matched group of non-Hispanic whites (N=822). Response and recovery outcomes were examined. Survival analysis was used to compare time to treatment response for depression (Montgomery-Asberg Depression Rating Scale) and mania (Young Mania Rating Scale) as well as global assessment of functioning (Global Assessment of Functioning).

RESULTS

For manic and depressive symptoms, time to response and proportion of responders were similar across groups. Over the study year the proportion of days well was similar across groups. A smaller proportion of African Americans met criteria for improved global functioning. Depression response among African Americans with psychotic symptoms was slower than the response among African Americans without psychotic symptoms and among non-Hispanic whites with or without psychotic symptoms. No differences between Hispanics and non-Hispanic whites in response times and recovery were observed.

CONCLUSIONS

Results are consistent with U.S. clinical trials for other psychiatric disorders, which have reported similar outcomes for ratings of primary symptoms. Baseline psychotic symptoms are likely a significant contributor when African Americans with bipolar disorder are slow to recover. These results may be less generalizable to uninsured patients.

Factor structure and diagnostic efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for avoidant personality disorder in Hispanic men and women with substance use disorders

OBJECTIVE

This study examined the internal consistency, factor structure, and diagnostic efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria for avoidant personality disorder (AVPD) and the extent to which these metrics may be affected by sex.

METHOD

Subjects were 130 monolingual Hispanic adults (90 men, 40 women) who had been admitted to a specialty clinic that provides psychiatric and substance abuse services to Spanish-speaking patients. All were reliably assessed with the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders. The AVPD diagnosis was determined by the best-estimate method. After evaluating internal consistency of the AVPD criterion set, an exploratory factor analysis was performed using principal components extraction. Afterward, diagnostic efficiency indices were calculated for all AVPD criteria. Subsequent analyses examined men and women separately.

RESULTS

For the overall group, internal consistency of AVPD criteria was good. Exploratory factor analysis revealed a 1-factor solution (accounting for 70% of the variance), supporting the unidimensionality of the AVPD criterion set. The best inclusion criterion was "reluctance to take risks," whereas "interpersonally inhibited" was the best exclusion criterion and the best predictor overall. When men and women were examined separately, similar results were obtained for both internal consistency and factor structure, with slight variations noted between sexes in the patterning of diagnostic efficiency indices.

CONCLUSIONS

These psychometric findings, which were similar for men and women, support the construct validity of the DSM-IV criteria for AVPD and may also have implications for the treatment of this particular clinical population.

A biosocial developmental model of borderline personality: Elaborating and extending Linehan's theory

Over the past several decades, research has focused increasingly on developmental precursors to psychological disorders that were previously assumed to emerge only in adulthood. This change in focus follows from the recognition that complex transactions between biological vulnerabilities and psychosocial risk factors shape emotional and behavioral development beginning at conception. To date, however, empirical research on the development of borderline personality is extremely limited. Indeed, in the decade since M. M. Linehan initially proposed a biosocial model of the development of borderline personality disorder, there have been few attempts to test the model among at-risk youth. In this review, diverse literatures are reviewed that can inform understanding of the ontogenesis of borderline pathology, and testable hypotheses are proposed to guide future research with at-risk children and adolescents. One probable pathway is identified that leads to borderline personality disorder; it begins with early vulnerability, expressed initially as impulsivity and followed by heightened emotional sensitivity. These vulnerabilities are potentiated across development by environmental risk factors that give rise to more extreme emotional, behavioral, and cognitive dysregulation. (PsycINFO Database Record (c) 2009 APA, all rights reserved).

Borderline Personality Traits and Intimate Partner Aggression: An International Multisite, Cross-Gender Analysis

Although research has consistently shown that men and women use intimate partner aggression (IPA) at approximately equal rates, there is little empirical research on whether the predictors of IPA are the same for men and women. The current study investigated whether borderline personality (BP) differentially predicted the use of IPA for men and women across 67 university sites from around the world. Results showed that BP predicted several forms of IPA and that gender did not moderate the association between IPA and BP. Although the strength of the association between IPA and BP significantly differed across sites, it was in the predicted direction for the overwhelming majority of sites. Implications of these results and suggestions for future research are discussed.

Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions

OBJECTIVES

To present nationally representative findings on prevalence, sociodemographic correlates, disability, and comorbidity of narcissistic personality disorder (NPD) among men and women.

METHOD

Face-to-face interviews with 34,653 adults participating in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions conducted between 2004 and 2005 in the United States.

RESULTS

Prevalence of lifetime NPD was 6.2%, with rates greater for men (7.7%) than for women (4.8%). NPD was significantly more prevalent among black men and women and Hispanic women, younger adults, and separated/divorced/widowed and never married adults. NPD was associated with mental disability among men but not women. High co-occurrence rates of substance use, mood, and anxiety disorders and other personality disorders were observed. With additional comorbidity controlled for, associations with bipolar I disorder, post-traumatic stress disorder, and schizotypal and borderline personality disorders remained significant, but weakened, among men and women. Similar associations were observed between NPD and specific phobia, generalized anxiety disorder, and bipolar II disorder among women and between NPD and alcohol abuse, alcohol dependence, drug dependence, and histrionic and obsessive-compulsive personality disorders among men. Dysthymic disorder was significantly and negatively associated with NPD.

CONCLUSIONS

NPD is a prevalent personality disorder in the general U.S. population and is associated with considerable disability among men, whose rates exceed those of women. NPD may not be as stable as previously recognized or described in the DSM-IV. The results highlight the need for further research from numerous perspectives to identify the unique and common genetic and environmental factors underlying the disorder-specific associations with NPD observed in this study.

Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVES

To present nationally representative findings on prevalence, sociodemographic correlates, disability, and comorbidity of borderline personality disorder (BPD) among men and women.

METHOD

Face-to-face interviews were conducted with 34,653 adults participating in the 2004-2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Personality disorder diagnoses were made using the Wave 2 Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version.

RESULTS

Prevalence of lifetime BPD was 5.9% (99% CI = 5.4 to 6.4). There were no differences in the rates of BPD among men (5.6%, 99% CI = 5.0 to 6.2) and women (6.2%, 99% CI = 5.6 to 6.9). BPD was more prevalent among Native American men, younger and separated/divorced/widowed adults, and those with lower incomes and education and was less prevalent among Hispanic men and women and Asian women. BPD was associated with substantial mental and physical disability, especially among women. High co-occurrence rates of mood and anxiety disorders with BPD were similar. With additional comorbidity controlled for, associations with bipolar disorder and schizotypal and narcissistic personality disorders remained strong and significant (odds ratios > or = 4.3). Associations of BPD with other specific disorders were no longer significant or were considerably weakened.

CONCLUSIONS

BPD is much more prevalent in the general population than previously recognized, is equally prevalent among men and women, and is associated with considerable mental and physical disability, especially among women. Unique and common factors may differentially contribute to disorder-specific comorbidity with BPD, and some of these associations appear to be sex-specific. There is a need for future epidemiologic, clinical, and genetically informed studies to identify unique and common factors that underlie disorder-specific comorbidity with BPD. Important sex differences observed in rates of BPD and associations with BPD can inform more focused, hypothesis-driven investigations of these factors.

Schizotypal personality: neurodevelopmental and psychosocial trajectories

Schizotypal personality research holds the promise of critically important insights into the etiology and ultimate prevention of schizophrenia. This article provides a critical overview of diagnostic, developmental, demographic, psychosocial, genetic, neurodevelopmental, psychophysiological, neurochemical, neurocognitive, brain imaging, and prevention-treatment issues pertaining to this personality disorder. It is argued that genetic and early environmental influences act in concert to alter brain structure/function throughout development, resulting in disturbances to basic cognitive and affective processes that give rise to three building blocks of schizotypy-cognitive-perceptual, interpersonal, and disorganized features. Two clinical subtypes are hypothesized: (a) neurodevelopmental schizotypy, which has its roots in genetic, prenatal, and early postnatal factors, is relatively stable, has genetic affinity to schizophrenia, and may benefit preferentially from pharmacological intervention, and (b) pseudoschizotypy, which is unrelated to schizophrenia, has its roots in psychosocial adversity, shows greater symptom fluctuations, and may be more responsive to psychosocial intervention.

Obsessive compulsive personality disorder and obsessive compulsive disorder: clinical characteristics, diagnostic difficulties, and treatment

BACKGROUND

The overlap between obsessive compulsive personality disorder (OCPD) and obsessive compulsive disorder (OCD) has received increasing recognition and continues to be a source of much debate. With the advent of new research methodologies, researchers have attempted to distinguish whether OCPD and OCD are two distinct phenomena that can co-occur or whether they are similar, overlapping constructs.

METHODS

MEDLINE was used to systematically review the OCPD and OCD literature published between 1991 and 2004.

RESULTS

Using the more stringent DSM-IV criteria, results from OCD clinical samples suggest that the majority of individuals with OCD (75%) do not have OCPD. Similarly, results from personality disorder samples suggest that the majority of individuals with OCPD (80%) do not have OCD.

CONCLUSIONS

While there is evidence that OCD and OCPD are linked, the literature does not support either one as a necessary or sufficient component of the other.

The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications

The Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000) was developed to fill gaps in our understanding of the nature, course, and impact of personality disorders (PDs). Here, we review published findings to date, discuss their implications for current conceptualizations of PDs, and raise questions that warrant future consideration. We have found that PDs are more stable than major depressive disorder, but that meaningful improvements are possible and not uncommon. We have confirmed also that PDs constitute a significant public health problem, with respect to associated functional impairment, extensive treatment utilization, negative prognostic impact on major depressive disorder, and suicide risk. At the same time, we have demonstrated that dimensional models of PDs have clinical validity that categories do not, especially greater temporal stability. Furthermore, dimensional personality traits appear to be the foundation of behaviors described by many PD criteria. Taken together, our results lead us to hypothesize that PDs may be reconceptualized as hybrids of stable personality traits and intermittently expressed symptomatic behaviors.

High prevalence of personality disorders among healthy volunteers for research: implications for control group bias

Individuals who volunteer as control subjects for clinical studies are regularly screened for Axis I diagnoses, but seldom screened for Axis II disorders. This study examined the relative rates of Axis II diagnoses among 341 volunteers passing an initial telephone screen for entry into biological research studies. Axis I and II diagnoses by DSM-IV were assigned by best estimate after structured clinical interview, and subjects were categorized into one of three groups based on their diagnostic profiles: (1) volunteers without lifetime Axis I or II diagnoses ("healthy controls"), (2) personality-disordered volunteers without any history of Axis I pathology, and (3) personality-disordered volunteers with past (but not current) Axis I pathology. The results revealed a high prevalence of personality disorders (44.4%) among these volunteers. Several clinically relevant self-report inventories were used to demonstrate important characterological differences between the three comparison groups. Although inventory results demonstrated multiple differences between all three groups, most scales revealed differences between healthy controls and the two personality-disordered groups (with or without lifetime Axis I diagnoses), suggesting that most of the variance was accounted for by the presence or absence of an Axis II disorder, not a past Axis I disorder. These results suggest that personality-disordered volunteers may bias a control group due to the infrequent screening for Axis II disorders among volunteers for medical and psychiatric research. Implications are discussed for routine Axis II screening of volunteers for research with specific diagnostic instruments.

Borderline personality and eating disorders

Borderline personality disorder (BPD) is an Axis II disorder that is characterized by an intact façade, longstanding self-regulation difficulties and self-harm behavior, and unstable interpersonal relationships and mood. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994), the prevalence of BPD in the general population is around 2%. The symptoms of the disorder appear to be influenced by gender. Despite defined diagnostic criteria, BPD tends to have polymorphic clinical presentations with both multiple psychological and somatic symptoms. The etiology of BPD appears to be related to genetic predisposition, early developmental trauma, and biparental failure, although other contributory factors may be involved. We discuss, through the use of several models, the possible relationships between BPD and eating disorders.