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.

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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
and the formation of the self, its indepen-
dence vis-A-vis immediate socioenvironmen-
tal events, and the clarifying role of cultural
norms in the delineation of normality and
psychopathology (Hallowell, 1934; Hamil-
ton, 1971; Dohrenwend & Dohrenwend,
1974; Mezzich & Goode, 1994). However,
because the design of DSM-IV was intended
to maintain or even reduce the number of
axes, emphasis shifted toward the cultural
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
enhancement of the present five-axes model
(Mezzich, Kleinman, Fabrega, & Parron, in
press), and culminated with the proposal of
a Cultural Formulation incorporated in the
new Manual (Mezzich & Goode, 1994; Mez-
zich et al., in press; Alarc6n, in press). This
formulation may facilitate research efforts
centered on issues such as acculturation,
language skills and preferences, the mean-
ing of stress experiences, explanatory mod-
els of illness, perceived levels of adaptive
functioning, care-seeking patterns, and ex-
pectations on illness outcome and quality of
life (Kleinman, 1977; Greenley, 1984; Fa-
brega, 1992, 1994; Nhu, 1976; Hallowell,
1934; Kirmayer, 1989; Flaskerud & Hu, 1992;
Kleinman, 1988). The Cultural Formulation
guidelines include a description of the cul-
tural identity of the patient, the cultural ex-
planations of his/her illness, cultural factors
related to psychosocial environment and
functioning, the cultural elements of the
diagnostician-patient relationship, and an
overall assessment for diagnosis and care.
The diagnosis of PDs has the least amount
of cultural referents among measurement
instruments used for the main nosological
categories (Lopez & Munoz, 1987). A study
by Banks andJuni (1991) on the application
of a Defense Mechanisms Inventory (DMI)
to 229 minority non-college-educated youths
throws some light into aspects of the person-
ality structure that may help to diagnose and
understand eventual personality variations
in clinical populations. The comparison was
made with published normative figures
among White American students. One hun-
dred and fifty-seven respondents were Afri-
can Americans (98 men and 59 women),
ALARC6N AND FOULKS
and 72 were Hispanics (34 men and 38 wom-
en). It was determined that the data for the
two groups could be safely collapsed for
analysis purposes; nevertheless, reliability
was greater for the college population than
for the minority populations. Hispanics and
African Americans adopted a defensive style
which emphasizes "principalization," includ-
ing defenses such as isolation, intellectualiz-
ation, rationalization, and reversal of affect.
In the latter, instead of negative responses
often described as "healthy cultural para-
noia" (Grier & Cobbs, 1968), positive re-
sponses are produced as in reaction forma-
tion, denial, repression, and negation. This
means that minority patients often use a
constellation of defenses that "split off affect
from content," that is, they deal with conflict
by responding in positive or neutral ways to
negative circumstances (Harwood, 1981;
Henry, 1963). Additional studies are re-
quired before this promising finding can be
seen as supporting the elaboration of crite-
ria applicable to PDs.
A major issue for the diagnostician work-
ing across cultures is the requirement of dif-
ferentiating the ideal personality type, the
typical personality, and the atypical person-
ality from the standpoint of cultural func-
tionality. Ideal personality types are most of-
ten revealed when questioning people about
what they are like and how one should raise
children and conduct life. In any society,
"typical personality" and its behavioral cor-
relates may differ considerably from the ide-
al, yet be considered normal and expectable
from the perspective of that society
(Fabrega, 1994). Likewise, the atypical may
be neither ideal nor average in behavior,
and still not be considered abnormal. Such
atypical individuals may be found in the
ranks of mystics, priests, ministers, artists,
and others who transcend customary social
roles, and are considered to make major
overall contributions to their societies. In
these cases, the definitions of personality
disorder, resting on determinations of func-
tionality relative to the culture of origin, may
assume a different dimension when such an
 PERSONALITY DISORDERS AND
individual is displaced to the context of an-
other culture (Fabrega, 1989).
Biological Perspective:A Critique
Cloninger (1987) has discussed basic per-
sonality traits as adaptive capabilities which
all humans possess to varying degrees. It is
the innate variation in the relative quantity
of each trait in interaction with environmen-
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tal demands which, he believes, results in
those enduring qualities that define person-
ality. He suggests that PDs, such as those list-
ed in DSM-III-R (and presumably DSM-IV),
represent the outcomes of extreme strength
or extreme weakness of one or more traits
interacting with the strength and weakness
of others. Cloninger (1987) and Siever et al.
(1990) propose further that genetic factors
may be related to the expression of these
neurotemperamental systems, and the exag-
geration of any of them may relate Axis II
PDs to Axis I disorders. Thus, schizophrenia
would represent a further exaggeration of
the traits which determined the schizotypal
personality, and these disorders would be
seen in genetically related individuals
(Siever et al., 1990; Frangos, Athanassenas,
Tsitourides, & Katsanov, 1985).
Investigating spectrum disorders from a
phenomenological and psychobiological per-
spective, Siever and Davis (1991) suggest
that four major categories of Axis I disorders
can be related systematically to four clusters
of Axis II disorders. They argue that dysfunc-
tion in the cognitive/perceptual dimension
results in odd cluster disorders and, if ex-
treme, schizophrenic disorders. Dysfunction
in the impulsivity/aggression dimension re-
sults in borderline antisocial personality dis-
orders, and if severe, impulse control disor-
ders. Dysfunction in the affective stabilizing
dimension results in dramatic cluster disor-
ders, and if severe, major affective disorders.
Finally, dysfunction in the anxiety/inhibi-
tion dimension results in anxious cluster dis-
orders, and if severe, anxiety disorders.
These models suggest that PDs and even
Axis I disorders may represent the unadap-
CULTURE 81
tive extreme of basic trait expression, al-
though the extent of convergence of normal
and pathological traits remains to be deter-
mined. According to Cloninger (1987), the
optimum of overall flexibility in social adap-
tation might be found in the range of inter-
mediate or nearly average trait values. Vari-
ants at either extreme may excel or have
advantage in certain social roles or cultural
configurations, but are less flexible in their
ability to adapt socially overall. Cloninger
proposes that balanced selection for inter-
mediate adaptive optima may explain the
persistence of the extreme variants in popu-
lations.
While all these contributions represent a
considerable advance, there are still a num-
ber of problems that make their application
questionable for a culturally sensitive and
relevant consideration of PDs in a diagnostic
system. Some of these problems are:
1. Innate variations of acquired adaptive
capabilities and the interaction of each
trait with environmental demands are
time-honored, hardly new theoretical
assumptions (Engel, 1977).
2. The proposed basic predispositions in
active interplay with environmental
stimuli are by no means the final or
even the only ones; they should be
seen rather as related, among other
things, to the instruments utilized in
the specific research design (Escobar,
Karno, & Golding, 1987). Further-
more, their dimensional nature has
not covered yet the numerous inter-
acting possibilities beyond the cor-
relation (already attempted) with the
existing DSM-III-R categories.
3. The ascription of neurotransmitter
systems regulating in a specific man-
ner each of Cloninger's three basic
predispositions is simplistic at best,
and to say that genetic factors may be
related to the expression of these
three neurotemperamental systems is
quite a predictable yet unproven
proposition.
 82
4. The prevalence findings predicted by
Cloninger's model refer in some cases
to specific personality disorders such
as the antisocial, and in others to sev-
eral of the DSM-III-R types, so that
such figures can be construed ambig-
uously.
A cultural view of the diagnostic process
makes it possible to see, through the pa-
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tient's identified "symptoms," some of the
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cultural influences which can help to weigh
the clinical evidence more objectively. It
should not be forgotten that even within
seemingly homogeneous cultural groups
there are subgroups or variations due to cor-
relative cultural differences based on re-
gional, religious, or other sociocultural pa-
rameters. Such is the case among "Anglo"
patients in the South and the Northeast, or
among Mexicans and Puerto Ricans in the
Hispanic community. Nevertheless, some
general rules can be applicable, and can
doubtlessly be enriched by research find-
ings.
Measurement Approaches
The instrumental assessment of personality
is a very relevant area for the estimation of
social and cultural factors, and the diagnos-
tic biases they engender. In his review, Dana
(1984) asserts that PDs have become a typi-
cal psychopathological reaction to the envi-
ronment, and advocates an assessment that
includes awareness of modernization and
acculturation effects. Clear distinctions be-
tween etic and emic measures can reduce
assessor bias, and enhance fairness in de-
scriptions of culturally different persons.
Prejudices induced by ignorance, and but-
tressed by fear of the "unknown" minority
persons, may result in an unrealistic apprais-
al of their aspirations and motivations;
therefore, it is important to apply "modera-
tor variables in the personality assessment of
minority persons," a point also argued by
Neligh (1988) in relation to the Native
American population, and by Escobar, Kar-
ALARC6N AND FoULKS
no, and Golding (1987) about Hispanic pa-
tients.
Choca, Shanley, Peterson, and Vanden-
burg (1990) study the scores of Black and
White male psychiatric inpatients at a VA Hos-
pital on the Millon Clinical Multiaxial Inven-
tory (MCMI). In predicting psychopathology
for the two races, comparisons of MCMI per-
formance indicated significant differences
for all diagnoses except PDs. An analysis of
variance demonstrated that the scores ob-
tained by the Black and White groups were
significantly different in nine of the 20 scales.
Three of these scales (histrionic, narcissistic,
antisocial) show Blacks with a higher score
than Whites. The results also suggested pos-
sible deficiencies in terms of the culture-
fairness of individual items. The authors as-
certain that the expert's assessments against
which inventories are validated or evaluated
could also contain biases: this introduces a
logical circularity that only adds to the com-
plexity of bias investigation. They advocate
the use of factor analysis in bias studies. This
line of research is promising in that it would
ensure specific validation of clinical diag-
noses, and eventually may provide more clear
criteria for the initial assessment.
Along the same lines, McCreary and Padilla
(1977) studied Minnesota Multiphasic Per-
sonality Inventory (MMPI) differences
among Black, Mexican American, and
White male offenders. Cultural factors seem
to be related to the differences between
Mexican Americans and Whites on the L, K,
and Overcontrolled Hostility scales, whereas
differences on the Hy scale seem to reflect
socioeconomic factors. Interestingly enough,
Mexican Americans were classified more of-
ten as "psychiatric" cases, while Whites and
Blacks were placed well into the "sociopathic
range"; nevertheless, Hostility and even the
L and K scales reflect strong personality fac-
tors, as Gynther (1972) found in his own
study using MMPI on Black individuals. The
fact that the McCreary and Padilla study uti-
lized offenders as research participants is
one of several limitations for the generaliza-
tion of its conclusions.
 PERSONALITY DISORDERS AND CULTURE
A comprehensive cross-cultural adapta-
tion of clinical and epidemiological instru-
ments is the main thrust of an article by
Bravo, Canino, Rubio-Stipec, and Woodbury-
Farifia (1991). They worked with the Span-
ish translation of the Diagnostic Interview
Schedule (DIS). A careful adaptation pro-
cess goes beyond mere language translation,
and has to address validity in the semantic,
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technical, content, criterion, and concep-
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tual equivalence dimensions. A number of
symptoms, different from those included
on questionnaires developed for English-
speaking populations, appear when the task
of identifying culturally significant mani-
festations of mental distress is undertaken.
This may prove to be particularly true for
the diagnosis of PDs.
On the basis of an epidemiological com-
parison between Indian and Metis (Native)
and non-Native psychiatric inpatients in the
province of Saskatchewan, Canada, Fritz
(1976) found the Indian and Metis as being
20 and 76%, respectively, more frequently
assigned the diagnoses of personality and
behavior disorders. Indian females were hos-
pitalized 266% more frequently than non-
Indian females, whereas Indian males were
hospitalized for these disorders less fre-
quently than non-Native males. The author
does not discuss the types of PDs or other
basic culturally determined factors that may
have a bearing on these findings. The pat-
tern of passivity, weakness of emotional inte-
gration, and constriction of emotional reac-
tivity found by Boyer, DeVos, and Boyer
(1983) among Apaches may, however, apply
to some extent.
Another problem with diagnostic instru-
ments was identified by Kortmann (1990)
who applied the Self-Reporting Question-
naire (SRQ), developed by the World
Health Organization (WHO) as a "univer-
sally applicable psychiatric case finding in-
strument," to 110 respondents in Ethiopia.
A moderate criterion validity was found, the
author ascribing it to the low sensitivity of
the instrument, which may also explain the
scarcity of PDs among the findings. The
83
study also revealed problems in transcultural
communication, as many of the diagnostic
concepts used in the instrument were "too
Western" to be transposed unchanged to the
Ethiopian culture.
Research Approaches: Bases for a Model
Precise measurements of the cultural com-
ponents of PDs are, thus, highly desirable
but difficult. Perhaps as Abroms (1981)
points out, we should abandon the attempt
to quantify the relative contributions of ge-
notype versus environment (the latter in-
cluding psychological and social factors) to
psychiatric conditions and, rather, assign a
complementary role to each in the diagnosis
and treatment of such conditions. Perhaps,
as Littlewood (1990) and more so Leff
(1990) propose, we should attempt to ex-
plain (or understand) each psychiatric con-
dition vis-a-vis a theoretical bipolar spectrum
ranging from the biological to the sociologi-
cal (or sociocultural), and adding an estima-
tion of the cultural distance between exam-
iners and populations being studied, or
between patient groups being compared.
This is consonant with the postulates of uni-
versality and contextualization advocated by
the "new cross-cultural psychiatry" (Klein-
man, 1977, 1988).
In this sense, the three existing PD clus-
ters, or the ten PD types included in DSM-IV
could, first, be arranged along a spectrum,
and the magnitude of the cultural compo-
nent on each one could be estimated follow-
ing the parameters of DSM-IV's cultural for-
mulation (Mezzich & Goode, 1994; Mezzich
et al., in press). At the same time, the cultur-
ally determined vulnerability to stressors,
and the treatability by social, sociocultural,
or psychosociocultural means could be as-
sessed.
There are several ways to implement this
strategy or parts of it. One could carefully
examine the operational criteria laid out for
each personality disorder and dissect them
on the basis of their possible cultural refer-
ents. Next, indicators from the literature on
 84 ALA RC 6 N AND FOULKS

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

ness, anger, adversarialism/antagonism, dis-

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than "dissecting" individual criteria, and

then proceed with the examination of each
type from the different cultural perspec-
tives.
Let us assume, for example, that as a re-
sult of a literature review of available evi-
dence, the ten established PDs can be
ranked from the "most biologically based" to
the "most psychosocioculturally based" in
the following order:
torted sociability.
SCHIZOID (ASOCIAL): Individualism, indif-
ference, distorted self-sufficiency, hypostim-
ulation, limited sociability.
ANTISOCIAL (AGGRESSIVE): Individualism,
antagonism, conflict-proneness, rigidity,
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
al group from which the patient comes, and
so it would be incumbent upon the clinician
to sort them out [Leff's (1990) assessment
of the "cultural distance"], and assign to
them a diagnostic, as well as a therapeutic
value. An analysis of the "symptoms" present
in the above sets, from the perspectives pro-
vided by different ethnic and cultural
groups, using an instrument such as Weiss'
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Explanatory Model Interview Catalogue
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(EMIC) scale (Weiss, Doongaji, & Sid-
dhartha, 1992; Flaherty, Gaviria, & Pathak,
1988; Channabasavanna, Raguram, Weiss,
Parvathavardhini, & Thriveni, 1993) might
prove helpful to the clinician in differentiat-
ing PDs from nonpathological, culturally de-
termined behavior.
Discussion
PDs pointedly raise questions regarding the
purposes and functions of a diagnostic sys-
tem. The history, wide prevalence, endemi-
city, and patient suffering and maladapta-
tion associated with Axis I disorders have
been invoked as expressions of their "bio-
medical" nature and common characteris-
tics across social groups. Such kinds of disor-
ders would thus seem to constitute "natural"
targets of a diagnostic system. These features
are less clearly evident with respect to PDs.
The latter are more vulnerable to the claim
that they are relative to the societies in which
they are formulated, and that phenomena
such as social labeling and medicalization
are influential in their diagnosis (Moore,
1990; Fabrega, 1994; Lewis-Fernandez &
Kleinman, 1994). Stated succinctly, the PDs
codified in the DSM and other nosological
systems seem to be more culturally bound to
or associated with the rules, standards, and
conventions on adaptive and maladaptive
behaviors found in Western contemporary
societies, and because of this are easy prey to
political misuse.
PDs have the lowest levels of validity and
reliability among all disorders in psychiatric
nomenclatures. This is partly due to the
85
ubiquitous role of social and cultural factors
in the determination of their clinical pro-
files. Almost every author would agree that
cultural factors do shape the personality of
the individual through child-rearing prac-
tices, family-based customs and traditions,
and the experiential development of coping
mechanisms (Leighton, 1981). Unfortu-
nately, the assessment of these factors was
strongly influenced, for many decades, by a
version of "drive theory" that attempted to
explain patterns of culture as an interplay of
intrapsychic agencies (Benedict, 1934;
Whiting & Child, 1953), or unconsciously
operating defense mechanisms (Kardiner,
1945). The difficulties of such approaches
have been pointed out by Battan (1983) and
Clemens (1982), who, in critiquing Lasch's
(1978) The Culture of Narcissism, point out
the tautologies involved in attempts to con-
solidate psychoanalysis and social systems in
the study of contemporary American cul-
ture.
Neoanalytical thinkers concede now the
reinforcing character of cultural factors on
normal and abnormal development of per-
sonality, and assign value to social attitudes
toward psychopathology, competition, and
impersonalization brought about by tech-
nology. Also noted is the pervasive influence
of personality on the causation and experi-
encing of other psychiatric conditions such
as depression and schizophrenia (Rubins,
1975; Opler, 1973). As Lidz points out, "un-
less it is appreciated that humans have dual
endowment-a genetic inheritance that is
born into them, and a cultural heritage into
which they are born, and which they must
assimilate from those who raise them, hu-
man development and maldevelopment can
never be understood correctly" (Lidz, 1979).
In this sense, the dimension of language,
like the role of family and its culture, its
dynamic organization, and the role of pa-
rental figures, acquires not only symbolic
but also pathoplastic and pathogenic rele-
vance.
Leighton (1981) makes a cogent argu-
ment to reject the extremes of cultural de-
 86
terminism, and states that culture should be
thought of as "an important but partial in-
fluence in the day-to-day functioning of a
person." On the basis of his own work with
Eskimo villagers in Alaska and Yoruba vil-
lagers in Nigeria (Leighton, Harding, Mack-
lin, MacMillan, & Leighton, 1963), he sug-
gests that culture may indeed influence the
frequency of affective and personality disor-
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ders, but it "is hard to disentangle it from
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the much more powerful effects of age and
sex, and of situational factors such as pover-
ty." He considers it useful to think of culture
and personality as sets of more or less inde-
pendent variables which interact with each
other in particular ways, in the life of each
particular patient. What happens in PDs is
that "the coping guidelines of culture that
have been passed down from previous gen-
erations often no longer work well, and in
many instances do not work at all." When
employed along with psychological concepts
of personality processes and with social situ-
ational processes, particularly rapid change
and the consequences of sociocultural disin-
tegration, personality as a conceptual tool
becomes more relevant. From this constant
interaction, a number of factors emerge that
can make the individual more vulnerable
than the average person to environmental
stresses (Reading, 1977; Montero & Sloan,
1988; Tolor, 1978).
On the basis of a historicoanthropologi-
cal approach, Nuckolls (1992) argues that
antisocial and histrionic personality disor-
ders represent the extreme expression of
stereotyped family values, perpetuated by
cultural notions (independence vs. depen-
dence) attached to gender. Values were "del-
egated" to women and men in a historical
group process of conflict, ambivalence, and
splitting that first assigned "moralism" to
women and "materialism" to men. Clinical
labeling becomes then a "legitimate" means
for the realization of stereotypes. Many other
authors discuss gender as a culturally charged
concept in the labeling of PDs (Lucchi &
Gaston, 1990; Wu, 1992; Israel, Raskin, Libow,
& Prowder, 1978; Symonds, 1976).
ALARC6N AND FOULKS
From another vantage point, it is clear
that personality and behavior patterns are
markers of a number of social interactions,
as well as of other psychiatric conditions,
particularly affective disorders and psycho-
somatic entities (Wittkower, Cleghorn, Li-
powski, & Murphy, 1969). In this sense, it
becomes extremely important to ascertain,
for instance, similarities and differences be-
tween type A behavior, as described by De-
Gregorio and Carver (1980), Friedman
(1977), and Jenkins (1976), with some of
the DSM-IV types such as obsessive-compul-
sive and negativistic or passive-aggressive.
The complex transactions between such in-
dividuals and the modern Western culture
provide opportunities for both reward and
punishment, with a concomitant impact on
their behavior and emotional health.
Culture affects a number of behaviors
and disorders that may not have found use-
ful labeling in current classifications. Abu-
sive and even homicidal parents as de-
scribed by Bourget and Bradford (1990) is a
case in point. The same can be said of the
plight of battered wives, in which cultural
factors interplay quite closely with person-
ality features such as jealousy, immaturity,
dependency, aggressiveness, and sadomas-
ochism. Prescott (1974) considers this con-
dition as a "failure in adaptation [or] a fail-
ure to acquire adequate social learning."
An example of the connection between
personality, personality disorder, other psy-
chiatric conditions, and culture (which in-
cludes ethnicity as an important compo-
nent) is seen in the work by Zucker and
Gomberg (1986), who challenge some of
the findings of Vaillant's (1983) classical
follow-up study on alcoholics. There is
strong evidence that some personality vari-
ables, including antisocial behavior, are pre-
morbidly present in persons who later be-
come alcoholic. Ethnic differences in the
amount of alcohol consumption relate not
only to norms about child and adult alcohol
use and intoxication, but they also mark a
wide range of individual and interpersonal
differences in educational and occupational
 PERSONALITY DISORDERS AND CULTURE
aspiration, cohesiveness of kinship net-
works, and cultural values about sexuality,
marriage, and other elements of socialized
behavior. Obviously, the process of develop-
ing a PD occurs in a social world, and is
influenced by a biopsychosocial process.
More than 20 years ago, Sheperd and
Sartorius (1974) made a plea for a more
precise delineation of the PDs and their dif-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
ferentiation from normal variants of person-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ality, and advocated research on socio-
cultural and comparative aspects of this
problem, and on its public health implica-
tions. These principles are reviewed by Reid
(1985) in regards to antisocial personality.
He comments on the pathogenic force of a
"chronicle of purported injustices" found in
the autobiography of a patient diagnosed in
his youth as a sociopath. He makes the sug-
gestive point that some persons with antiso-
cial characteristics may be "highly adaptive
to our modern world of stress and prob-
lems," a point also made by Levine and Shai-
ova (1974).
Some authors have elaborated also on
the protective/therapeutic role of culture in
PDs. Brook, Whiteman, Balka, and Ham-
burg (1992) mention the "protective buff-
ers" used by African-American and Puerto
Rican families, and point out their value in
helping to target and time therapeutic inter-
ventions for drug users from both ethnic
groups. Lee and Newton (1981) provide ex-
amples of stress coping mechanisms among
Hawaiians dealing with childbirth and physi-
cal illness; they are strongly dictated by the
cultural notions of "rationalistic animism"
and harmonious psychological-phasic rela-
tionships. Neki (1976) asserts that in the av-
erage Indian population, an enormous pro-
portion of dependence, fostered by the
culture during childhood, is permitted to be
carried forward. This is partly confirmed by
Teja's study (1978) that found PDs less fre-
quently diagnosed among Indian as com-
pared to U.S. patients. Indian individuals
with PDs and inadequacies of various kinds
either cling to the sheltering care of the
joint or extended family, or give up the usual
87
pursuits of life and become wanderers in
search of God and peace. All these findings
are contrasted with the American cultural
emphasis on individuation, independence,
self-reliance, and competence in diverse
roles from adolescence on, family and soci-
ety for the most part not being inclined to
nurture inadequacies of their members. In
Teja's opinion (1978), the Protestant work
ethic has no doubt contributed to this orien-
tation, and to the concomitant subjective
distress and personality problems.
For all the above reasons, it is crucially
important to consider the cultural context
in order to differentiate normal role behav-
ior from the extremes that might indicate a
PD (Denis, 1990; Westermeyer & Wintrob,
1979). Impairments in the cross-cultural
context, may, however, be the result of mal-
adjustment to a majority or dominant cultur-
al perspective, or be related to dysfunction
of the reference group itself. We believe that
traits which are not considered to be unde-
sirable by the patient's reference group,
should not be included on the list of traits
essential to meeting diagnostic criteria for a
PD. Such caution may avoid mislabeling,
and the unnecessary stigmatization of people
from other ethnic groups or social classes.
In conclusion, culture's relationship with
PDs should not be overestimated in etiologi-
cal terms, but rather seen as an explanation
of behavioral patterns, a covariable in the
pathogenesis of PDs and in the pathoplasty
of their symptoms, and/or as a dimension
of the diagnosis and nosology of these disor-
ders. Thus, cultural knowledge by the clini-
cian will play a useful role as preventor of
the medicalization (or rather, pathologiza-
tion) of personality traits (Mezzich &
Goode, 1994; Zuckerman, 1990). In this
sense, a culturally informed public and cul-
turally sophisticated practioners will prevent
the risks of stereotyping and trivialization of
human behavior by helping to delineate dis-
tinctions between personality styles and per-
sonality disorders.
Society as a whole can generate enough
confusion of roles and expectations, uncer-
 88
tainty of structures, rapidly changing values,
and other disruptions to the point that some
authors argue will cause an increase in char-
acterological disorders (Merton, 1964; Beck-
er, 1972). These trends, however, can be
translated into dire predictions disguising
extremist, catastrophizing views (Levine &
Shaiova, 1974). The sobering evidence is
that, for instance, the impact of pathological
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
social network (Paris, 1991). This review also
calls our attention to the need to distinguish
between intraethnic distribution of psycho-
pathology and interethnic variations repre-
sented by the notion of cultural relativism. It
is certainly important to assess both the ben-
efits and risks of multiculturalism as a social
reality across the globe (Hughes, 1993;
Schlesinger, 1992). However, the cultural
enrichment of social groups, brought about
by historical changes, tolerance, and cross-
fertilization (Oetting & Beauvois, 1991) ne-
gates both the extreme culturalistic views of
psychopathology and social behavior, and
the reductionistic impact of the ultrabiologi-
cal approach to the study of personality dis-
orders.
Acknowledgment
The authors wish to acknowledge the expert
technical assistance of Ms. Terry Lawson in
the preparation of this manuscript.
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