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Individual judgements, attitudes and behaviours are likely to be shaped by cultural, moral as well as situational expectations. The threshold for what is acceptable behaviour and what is disordered differs across cultures, between sexes and according to an individual’s situation. This is why many believe that the concept of personality disorder obscures the wider social issues of ethnic and cultural differences, gender inequalities and age variations.

ETHNIC & CULTURAL DIFFERENCES:

Cultural differences exist in the way in which psychological distress is presented, perceived and interpreted. Different cultures develop different responses for coping with psychological stressors. It is a well known fact that ethnic minorities are disproportionately represented in psychiatric services. The diagnosis of personality disorders is no exception. Cultural and racial stereotyping is a common experience in the context of assessment, diagnosis and also decisions concerning treatment. Some studies show that certain types of personality disorders (e.g. anti-social personality disorder) are over-diagnosed in black and other ethnic minorities. There are certain other studies which reveal that there is a risk that diagnosis of personality disorders are overlooked in black and ethnic minorities, which in turn have treatment implications (that ethnic minorities are less likely than white clients to be offered counselling or psychological therapy).

So, ethnic and cultural variations influence the diagnosis of personality disorders in two ways:
1)     By means of variations in the way psychological distress is expressed (as symptoms) within each culture or race.
2)     In the way these expressions are perceived as (signs of) ‘abnormal behaviour’ in the context of a different culture, leading to ‘labelling’ as personality disorders.

GENDER DIFFERENCES:

Gender plays a significant role in determining behaviours and attitudes which may be considered as signs of personality disorder. Huge differences exist between sexes in the prevalence of specific types of personality disorders. For example, Borderline personality disorders have a 3:1 female:male ratio; Anti-social personality disorders have a disproportionate skew towards males. These differences may stem from the innate differences in the pattern of thinking and judgement between men and women. For example, what is considered ‘inappropriately provocative behaviour’ for a woman may be understood very differently for a man. Or the differences may be a result of the widespread gender equalities prevalent in many societies. For example, some writers highlight a pattern of women being driven to behave in ways society considers ‘unacceptable’ because of social pressures such as oppression and sexual abuse. Women are then punished for behaving in ‘unacceptable’ ways. So, the social causes of their behaviour are obscured and hidden as the focus becomes the individual’s unacceptable behaviour (rather than the discrimination and distress which the individual goes through) . Hysteria is the most widely known example: some women responded to the oppression of Victorian society by expressing emotions in ways that were not considered appropriate for a woman. These women were discredited, their experience dismissed, and the broader issue of women’s oppression obscured by describing them as ‘mad’. It is argued that Borderline Personality Disorder is a modern day version of this same pattern.

AGE VARIATIONS:

Age variations exist in the overall prevalence of personality disorders, as well as prevalence of specific types of personality disorders among different age groups. Studies have shown highest rates in the younger age group and lowest rates in the older age group. Certain types of personality disorders like Borderline and Anti-social personality disorders are much more prevalent in the younger age group. Also, more complex types and multiple personality disorders are also more common in the younger age gropu.
Symptomatology and presentation also varies between different age groups. Adolescents and young adults tend to have more ‘externalizing behaviours’ and older people tend to have more ‘internalizing behaviours’. As a general rule, the severity of personality disorders also has a tendency to decrease with age. These variations may be due to poorer coping strategies or immature defence mechanisms in the younger age group. It could also be that ‘social priming’ occurs as age advances, hence people tend to learn more socially acceptable and adaptive behaviours.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist


REFERENCES:
1)     NHS Evidence-Mental Health. Marginalised groups – black and minority ethnic groups. Mentality, 2004
2) XXXXXXX XXXXXXX ‘Women at the Margins: me, Borderline Personality Disorder and Women at the Margins’ Annual Review of Critical Psychiatry
3)     A systematic review of personality disorder, race and ethnicity: prevalence, aetiology and treatment; Mc Gilloway et al; BMC Psychiatry 2010, 10:33
4)     Race, culture, ethnicity and personality disorder: Group Careif position paper; Ascoli et al; WCPRR XXXXXXX 2011: 52-60.
5)     The effect of age on prevalence, type and diagnosis of personality disorder in psychiatric inpatients. Stevenson et al; Int J Geriatr Psychiatry. 2011 Sep;26(9):981-7.

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