Culture and personality disorder: from a fragmented literature to a contextually grounded alternative

Exploring Hikikomori-like idiom of distress a year into the SARS-CoV-2 pandemic in Oman: Factorial validity of the 25-item Hikikomori Questionnaire, prevalence and associated factors

BACKGROUND

Existing literature that examines the Hikikomori-like idiom of distress (HLID) initially labelled this phenomenon as a culture-bound syndrome. However, the increasing number of reports from other parts of the world suggest that HLID could instead be a culture-reactive idiom of distress, originating from biopsychosocial disequilibrium and cultural upheaval. The impact of imposed social withdrawal due to the Coronavirus 2 severe acute respiratory syndrome (SARS-CoV-2) pandemic on the growing prevalence of HLID has not yet been adequately explored. Aims: The first objective is to examine the factorial validity of the 25-item Hikikomori Questionnaire (HQ-25) in Oman. Second, we aimed to investigate the prevalence of HLID following the lifting of SARS-COV-2 restrictions in the Arabian Gulf country of Oman. The third related objective is to examine factors associated with the variation of HLID.

METHODS

This cross-sectional online survey was widely distributed across the diverse socio-demographic population residing in Oman. After the validation of the questionnaire and the factorial validity, the Arabic version of HQ-25 was used to explore the prevalence and factors associated with HLID.

RESULTS

A total of 1529 participants were included in the study (response rate = 76.5%), of whom 44% (n = 673) expressed HLID. We randomly split it into half, one for exploratory factor analysis (EFA) (n = 764) and the other half for confirmatory factor analysis (CFA) (n = 765). From the EFA results, a three-factor model was found for the Omani version of HQ-25, which represented 52.87% of the variance with good internal reliability (Overall Cronbach's: 0.92; Socialisation: 0.92; Isolation: 0.84; Emotional support: 0.73). The CFA results report acceptable goodness-of-fit indices (χ2/df = 17.92, p < .001; CFI = 0.90; TLI = 0.95; RMSEA = 0.04, 95% CI 0.02-0.07; SRMR = 0.05) of the three-factor model of the collected samples. All 1529 data were used in the respondents. The results of the logistic regression showed that married marital status (OR = 1.51, 95% CI: 1.12-2.03, p = 0.007), older age (OR = 0.97, 95% CI: 0.95-0.99, p = 0.008), living in an urban area (OR = 0.71, 95% CI: 0.56-0.91, p = 0.006), unemployed occupational status (OR = 1.72, 95% CI: 1.30-2.88, p < .001), screen time (7+ hours vs. <4 hours: OR = 4.50, 95% CI: 3.16-6.41, p < .001; 4-7 hours vs. <4 hours: OR = 2.10, 95% CI: 1.61-2.70, p < .001), history of mental illness (OR = 3.70, 95% CI: 2.29-5.91, p < .001), and adverse childhood experiences (OR = 2.60, 95% CI: 2.03-3.20, p < .001) were significant risk factors for HLID.

CONCLUSION

The factorial validity of the HQ-25 performed in this study appears to mirror the previously reported 3-factor structures. Some of the associated factors appear to support and, conversely, dissent from the findings of previous studies. These are discussed in terms of the attributions of the SARS-COV-2 pandemic, demographic trends in Oman, and sociocultural factors specific to the region of interest.

Mental Health Literacy about Personality Disorders: A Multicultural Study

Mental health literacy (MHL) refers to lay people's knowledge and beliefs about the diagnosis and treatment of mental illness. The current study aimed at investigating MHL regarding personality disorders (PDs) multiculturally, comparing Turkish and Italian populations. In total, 262 participants responded to an online vignette identification task that required them to label the PDs of seven hypothetical subjects and rate various dimensions of their disorders. Narcissistic (25%), obsessive-compulsive (13%), and paranoid (12%) PDs were the most correctly labeled, while the average accuracy values for other PDs were below 0.04%. Compared to Turkish participants, Italian participants were more accurate in labeling narcissistic PD. Additionally, of the seven PDs, narcissistic PD was associated with the most happiness and success at work. Subjects with borderline and avoidant PDs were the most recognized as having psychological problems (>90%), yet their PDs were among the least correctly identified. Overall, participants from both cultures were generally successful at recognizing the presence of a mental illness, but they rarely labeled it correctly. Only limited cultural differences emerged. The present findings may inform the design of outreach programs to promote MHL regarding PDs, thereby facilitating early recognition of PDs and help-seeking behaviors for affected individuals.

The comorbidity between Borderline Personality Disorder (BPD) and Generalized Anxiety Disorder (GAD): A systematic review and meta-analysis

Borderline personality disorder (BPD) is a psychiatric condition characterized by severe instability in affect, impulse control, and interpersonal functioning. Existing literature has confirmed that BPD is highly comorbid with other psychiatric conditions, including anxiety disorders. Despite this, little research has investigated the nature of the relationship between generalized anxiety disorder (GAD) and BPD. The aim of this systematic review and meta-analysis is to synthesize the literature concerning the prevalence and clinical outcomes of BPD and GAD comorbidity in adults. The following three databases were searched on October 27, 2021: PsycINFO, PubMed, and Embase. Twenty-four studies were included (n = 21 reporting on prevalence of the comorbidity, n = 4 reporting on clinical outcomes associated with the comorbidity), 9 of which were included in a meta-analysis. The meta-analysis showed that the pooled prevalence for current GAD in individuals with BPD was 16.4% (CI 95%: 1.9%; 66.1%) in inpatient samples, and 30.6% (CI 95%: 21.9%; 41.1%) in outpatient or community samples. The pooled lifetime prevalence of GAD in individuals with BPD was 11.3% (CI 95%: 8.9%; 14.3%) in inpatient samples, and 13.7% (CI 95%: 3.4%; 41.4%) in outpatient or community samples. Comorbidity between BPD and GAD was associated with worse outcomes on measures of BPD severity, impulsivity, anger, and hopelessness. In conclusion, this systematic review and meta-analysis indicate that comorbid GAD and BPD is highly prevalent, although the pooled prevalence rates should be interpreted with caution considering the large and overlapping confidence intervals. Further, this comorbidity is associated with worse BPD symptom severity.

Cross-cultural Study of the Personality Inventory for the DSM-5 (PID-5) across the Portuguese and the United Arab Emirates (UAE) Community and Clinical Populations

Aims

The present paper focused on compare the PID-5 mean score levels across two matched community and clinical samples of Portugal and the UAE.

Background

The generalizability and universality of the Alternative Model of Personality Disorders has been thoroughly studied through the Personality Inventory for DSM-5 (PID-5) across countries and languages. However, studies comparing Western and Middle Eastern countries are still limited, in particular those who assess the PID-5 measurement invariance.

Objectives

We examined measurement invariance of the PID-5 scales across matched Emirati and Portuguese clinical and nonclinical groups, as well as compare and contrast the PID-5 mean score levels across both countries and samples.

Methods

The Arabic and the Portuguese versions of the PID-5 was administered to Emirati community participants (N = 300, 80% women and 20% men, M_age = 27.95) which were matched with Portuguese community participants (N = 300, 80.3% women and 19.7% men, M_age = 28.96), as well as clinical participants of the UAE (N = 150, 61.3% women and 38.7% men, M_age = 31.29) and Portugal (N = 150, 52% men and 48% women, M_age = 44.97). We examined measurement invariance through an unrestricted Factor Analysis based program, and mean scores levels were compared and analyzed.

Results

Our findings supported the PID-5 measurement invariance across the Emirati and Portuguese clinical samples pointing to the universality and generalizability of the Alternative Model of Personality Disorders. The Emirati psychiatric sample exhibited somehow higher results than the Portuguese psychiatric participants, albeit the small effect size for most of the PID-5 scales.

Conclusion

Further research is needed to examine the applicability of the PID-5 across non-clinical representative samples of Portugal and the UAE, and other Middle Eastern countries.

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.

The prevalence of personality disorders in the community: a global systematic review and meta-analysis

BACKGROUND

Personality disorders are now internationally recognised as a mental health priority. Nevertheless, there are no systematic reviews examining the global prevalence of personality disorders.

AIMS

To calculate the worldwide prevalence of personality disorders and examine whether rates vary between high-income countries and low- and middle-income countries (LMICs).

METHOD

We systematically searched PsycINFO, MEDLINE, EMBASE and PubMed from January 1980 to May 2018 to identify articles reporting personality disorder prevalence rates in community populations (PROSPERO registration number: CRD42017065094).

RESULTS

A total of 46 studies (from 21 different countries spanning 6 continents) satisfied inclusion criteria. The worldwide pooled prevalence of any personality disorder was 7.8% (95% CI 6.1-9.5). Rates were greater in high-income countries (9.6%, 95% CI 7.9-11.3%) compared with LMICs (4.3%, 95% CI 2.6-6.1%). In univariate meta-regressions, significant heterogeneity was partly attributable to study design (two-stage v. one-stage assessment), county income (high-income countries v. LMICs) and interview administration (clinician v. trained graduate). In multiple meta-regression analysis, study design remained a significant predictor of heterogeneity. Global rates of cluster A, B and C personality disorders were 3.8% (95% CI 3.2, 4.4%), 2.8% (1.6, 3.7%) and 5.0% (4.2, 5.9%).

CONCLUSIONS

Personality disorders are prevalent globally. Nevertheless, pooled prevalence rates should be interpreted with caution due to high levels of heterogeneity. More large-scale studies with standardised methodologies are now needed to increase our understanding of population needs and regional variations.

Frequency of narcissistic personality disorder in a counseling center population in China

BACKGROUND

Narcissistic personality disorder (NPD) has never been applied in Chinese clinical practice, and the distribution of NPD in the clinical population of China is largely unknown. The current study uses two-stage clinic-based screening to investigate the frequency and clinical features of NPD in a Chinese help-seeking sample.

METHODS

A total of 1402 consecutive outpatients ages 18-60 were recruited during their visit to the Shanghai Mental Health Center and screened with the Personality Diagnostic Questionnaire Fourth Edition Plus (PDQ-4+) and Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Axis II (SCID-II). The structured clinical interview was administered to estimate the rate of NPD and the frequency of each disorder criterion.

RESULTS

The frequency estimate of NPD in the total sample was 4.0%. Among the 56 outpatients who met the criteria for NPD, there were more males than females, and many had a better educational background. The SCID-II interviews revealed high frequencies of diagnostic criterion 1 ("exaggerated sense of self-importance. NPD likely overlaps with Histrionic PD, Borderline PD, and Paranoid PD. This two stage screening method can enhance detection of Chinese NPD patients in clinical settings.

CONCLUSIONS

Narcissism pathology is not rare in the Chinese psychiatric community when using the DSM-IV NPD criteria. Existing evidence suggests, at least indirectly, that there are important benefits of NPD diagnosis in psychiatric practice.

Cultural Aspects in Symptomatology, Assessment, and Treatment of Personality Disorders

PURPOSE OF REVIEW

This review discusses cultural trends, challenges, and approaches to assessment and treatment of personality traits and disorders. Specific focus include current developments in the Asian, Italian, Iranian, and Australian societies, as well as the process of acculturation, following moves between cultures with the impact on healthy and disordered personality function.

RECENT FINDINGS

Each culture with its specific history, dimensions, values, and practices influences and gears the individual and family or group in unique ways that affect personality functioning. Similarly, each culture provides means of protection and assimilation as well as norms for acceptance and denunciations of specific behaviors and personality traits. The diagnosis of personality disorders and their treatment need to take into consideration the individual in the context of the culture and society in which they live. Core personality problems, especially emotion dysregulation and interpersonal functioning are specifically influenced by cultural norms and context.

A compromise solution between overlapping and overlooking DSM personality disorders in Chinese psychiatric practice

OBJECTIVE

This study aimed to examine the overlaps between the Diagnostic and Statistical Manual-5 (DSM-5) Personality Disorders (PDs) in a high-risk clinical population and to explore a transitional model for implementing DSM-5 PDs.

METHOD

A sample population of 982 outpatients with at least one diagnosed PD was selected from 3,075 outpatients of the Shanghai Mental Health Center. The diagnostic process comprised of a personality diagnostic questionnaire and a structured clinical interview.

RESULTS

685 (22.3%) patients were diagnosed with at least one of six PDs (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal) under the alternative DSM-5 model for personality disorders proposed in Section III of the DSM-5. Nearly 20.3% of the subjects with PD met criteria for at least two PDs (of the 685 PD patients/6 PD model). Cluster and principal component analyses suggest a transitional model for the 7 specific PD categories (among the 722 PD patients, the overlapping rate was 24.1%) will be more appropriate for PD diagnosis in China.

CONCLUSIONS

Using the simplified PD categories in the alternative DSM-5 model for personality disorders will reduce the overlaps in PD diagnoses in Chinese psychiatric practice, and should be preferred over the DSM-5 PD diagnostic system.

Determinants of Suicidality and of Treatment Modalities in a Community Psychiatry Sample of Asylum Seekers

A high prevalence of mental illness has been reported in asylum seekers. The present cross-sectional study examined suicidal thoughts, treatment modalities (outpatient crisis intervention, inpatient care), and their determinants in asylum seekers (n = 119) and permanent residents (n = 120) attending the same outpatient clinic in Geneva, Switzerland. The most frequent diagnoses were depressive disorders (64.7%) and posttraumatic stress disorder (34.5%) in asylum seekers and psychotic (55.0%) and depressive disorders (33.3%) in permanent residents. The frequency of suicidal thoughts was similar in both groups (>30%). Asylum seekers benefited from outpatient crisis intervention more frequently than residents did (26.9% vs. 5.8%), whereas inpatient care was less frequent (25.2% vs. 44.2%). In asylum seekers, acute suicidal thoughts were associated with increased frequency of outpatient crisis interventions, and, suicidal thoughts, psychosis, or personality disorders were associated with higher rates of hospitalization. Documenting clinical characteristics and service utilization of asylum seekers is a prerequisite to organizing targeted interventions.

Culture and personality disorder: a focus on Indigenous Australians

PURPOSE OF REVIEW

To examine the validity of concept and diagnosis of personality disorder in transcultural settings using Indigenous Australian people as an example.

RECENT FINDINGS

There are significant deficits in comparative research on personality disorders across cultures. There is also a dearth of information regarding Indigenous Australians, and cultural applicability and clinical utility of the diagnosis of personality disorder in this group.

SUMMARY

The concept of culture is generally ignored when making a diagnosis of personality disorder. A valid diagnosis should incorporate what would be considered understandable and adaptive behavior in a person's culture. In Indigenous Australian culture, making diagnosis of a personality disorder is complicated by historical trauma from colonization, disruption of kinship networks, and ongoing effects of poverty and social marginalization.

Pathways to sympathies for violent protest and terrorism

BACKGROUND

Radicalisation is proposed to explain why some individuals begin to support and take part in violent extremism. However, there is little empirical population research to inform prevention, and insufficient attention to the role of psychiatric vulnerabilities.

AIMS

To test the impact of depressive symptoms, adverse life events and political engagement on sympathies for violent protest and terrorism (SVPT).

METHOD

A cross-sectional survey of a representative sample of Pakistani and Bangladeshi men and women from two English cities. Weighted, multivariable, logistic regression yielded population estimates of association (odds ratio (OR) and 95% confidence intervals) against a binary outcome of SVPT derived from a three-group solution following cluster analysis.

RESULTS

Depressive symptoms were associated with a higher risk of SVPT (OR = 2.59, 95% CI 1.59-4.23, P<0.001), but mediated little of the overall effects of life events and political engagement, which were associated with a lower risk of SVPT (death of a close friend: OR = 0.24, 95% CI 0.07-0.74; donating money to a charity: OR = 0.52, 95% CI 0.3-0.9).

CONCLUSIONS

Independent of SVPT associations with depressive symptoms, some expressions of social connectedness (measured as life events and political engagement) are associated with a lower risk of SVPT.