Culture and Borderline Personality Disorder in India

Culture and ICD-11 personality disorder: Implications for clinical practice across diverse ethnic groups

BACKGROUND

Personality disorder (PD) in ICD-11 is defined primarily by self and interpersonal dysfunction and optionally by other qualifiers. This definition is inseparable from relativism of cultural determinants.

AIMS

This review aimed to synthesize the relevant aspects of the influence of culture on clinical practice and health management for this condition, aligning them to the ICD-11 PD model.

METHOD

In Scopus, we systematically searched for studies that included the text strings: cultur* | personality AND (disorder* OR patholog*) without any restrictions on publication date or language or other exclusion criteria, up to November 2022.

RESULTS

Evidence suggests that cultural variables in ethnic groups (Western and non-Western) such as the individualist/collectivist philosophy, historical/generational trauma, immigration, acculturation, religion, and gender influence the etiology, semiology, epidemiology, evaluation, diagnosis, treatment, and management of health services for ICD-11 PD. We discuss the limitations and propose future lines of research on this topic based on our knowledge and experience. In this review, we provide the scientific community and clinicians with relevant cultural information to guide their practice and propose strategies to manage PD from the ICD-11 model.

CONCLUSIONS

More research is needed using mixed study methodologies on stigma, the experiences of patients, clinicians, and health agencies, to reduce the care gaps and achieve a culturally comprehensive, inclusive, and competent use of this new model.

Dimensional models of personality disorders: Challenges and opportunities

Categorical models of personality disorders have been beneficial throughout psychiatric history, providing a mechanism for organizing and communicating research and treatment. However, the view that individuals with personality disorders are qualitatively distinct from the general population is no longer tenable. This perspective has amassed steady criticism, ranging from inconsequential to irreconcilable. In response, stronger evidence has been accumulated in support of a dimensional perspective that unifies normal and pathological personality on underlying trait continua. Contemporary nosology has largely shifted toward this dimensional perspective, yet broader adoption within public lexicon and routine clinical practice appears slow. This review focuses on challenges and the related opportunities of moving toward dimensional models in personality disorder research and practice. First, we highlight the need for ongoing development of a broader array of measurement methods, ideally facilitating multimethod assessments that reduce biases associated with any single methodology. These efforts should also include measurement across both poles of each trait, intensive longitudinal studies, and more deeply considering social desirability. Second, wider communication and training in dimensional approaches is needed for individuals working in mental health. This will require clear demonstrations of incremental treatment efficacy and structured public health rebates. Third, we should embrace cultural and geographic diversity, and investigate how unifying humanity may reduce the stigma and shame currently generated by arbitrarily labeling an individual's personality as normal or abnormal. This review aims to organize ongoing research efforts toward broader and routine usage of dimensional perspectives within research and clinical spaces.

Contextualizing motherhood in persons with borderline personality vulnerabilities: cultural adaptation of the parent development interview-revised in an Indian context

An understanding of the complex intersection of borderline personality vulnerabilities and motherhood calls for an integrative and culture-sensitive lens in assessment and therapeutic interventions. The aim of the study was to explore constructions of motherhood in an Indian context to inform the adaptation of the Parent Development Interview-Revised (PDI-R) for use with mothers with borderline personality vulnerabilities. A stepwise framework was followed to obtain conceptual, semantic, and operational equivalences for the PDI-R adaptation. Interviews on contextualised aspects of motherhood were conducted with a sample of eight mental health practitioners specializing in borderline personality disorders, women's mental health or child psychology, two cultural psychologists, one gynaecologist and one paediatrician. Six emergent themes were identified through thematic analysis, 'The ideal mother and her search for identity,' 'Mothering the mother and the vicissitudes of care,' 'Not just mine - negotiating boundaries,' 'Mother knows best,' 'Food, feeding and embodied nurturing,' and 'Approaching motherhood in the clinic.' The proposed adaptations to the PDI-R were further reviewed by two experts, a clinical psychologist and a psychiatrist specialised in perinatal services. This was followed by the process of operational equivalence through administration of PDI-R with two mothers with borderline personality vulnerabilities and two mothers from the community. The expert review and the administration informed the final adaptation of the PDI-R. A systematic process of adaptation can support the use of measures like the PDI-R in different cultures. A contextual understanding of constructions of motherhood and borderline personality has potential to support meaningful assessment and targeted parenting interventions.

Irrelevant angry faces impair response inhibition, and the go and stop processes share attentional resources

Response inhibition is a crucial component of executive control, which refers to our ability to suppress responses that are no longer needed or inappropriate. The stop-signal task is a standard tool to assess inhibitory control over actions. Here, we use irrelevant facial expressions (happy, angry, or neutral) as both go and stop-signal to examine competition for shared attentional resources between (a) emotion and inhibition process and (b) go and stop processes. Participants were required to respond to go signals (gender discrimination task: male or female). Occasionally, a stop-signal (face with irrelevant angry, happy, or neutral facial expression) was presented, and participants were required to withhold their motor response. We found that emotion processing (especially angry faces) captures attention away from the task, and the emotionality of the stop signal matters only when the go signal is non-emotional. When the go signal was non-emotional, we found that stop-signal with irrelevant angry facial expressions impaired inhibitory control compared to stop-signal with irrelevant happy and neutral facial expressions. These results indicate that the processing of emotion and inhibition process exploit a shared pool of attentional resources. These results favor an interactive capacity-sharing account of the go and stop processes in models of response inhibition.

Recognizing Emotions through Facial Expressions: A Largescale Experimental Study

Experimental research examining emotional processes is typically based on the observation of images with affective content, including facial expressions. Future studies will benefit from databases with emotion-inducing stimuli in which characteristics of the stimuli potentially influencing results can be controlled. This study presents Portuguese normative data for the identification of seven facial expressions of emotions (plus a neutral face), on the Radboud Faces Database (RaFD). The effect of participants’ gender and models’ sex on emotion recognition was also examined. Participants (N = 1249) were exposed to 312 pictures of white adults displaying emotional and neutral faces with a frontal gaze. Recognition agreement between the displayed and participants’ chosen expressions ranged from 69% (for anger) to 97% (for happiness). Recognition levels were significantly higher among women than among men only for anger and contempt. The emotion recognition was higher either in female models or in male models depending on the emotion. Overall, the results show high recognition levels of the facial expressions presented, indicating that the RaFD provides adequate stimuli for studies examining the recognition of facial expressions of emotion among college students. Participants’ gender had a limited influence on emotion recognition, but the sex of the model requires additional consideration.

Development and validation of a screening instrument for borderline personality disorder (SI-Bord) for use among university students

BACKGROUND

The screening instrument for borderline personality disorder (SI-Bord) consists of a 5-item self-reported questionnaire on the key features of BPD from the DSM-5 using a 5-point Likert scale. This study investigated its validity and reliability in screening for BPD in university students.

METHODS

A cross-sectional study was conducted on a sample of university students in Thailand between November and December 2019. An online assessment gathered demographic data and results from the SI-Bord, the Perceived Stress Scale-10 (PSS-10) and the Patient Health Questionnaire-9 (PHQ-9). Participants whose SI-Bord scores were ≥ 1 were randomly selected to be interviewed and assessed for a BPD diagnosis by four psychiatrists using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) as a reference point. An intraclass correlation coefficient (ICC) of 0.925 (95% CI, 0.805-0.979) ensured inter-rater reliability between the four psychiatrists. The diagnostic sensitivity and specificity of the SI-Bord, as compared to that of the SCID-II, were determined to indicate the cut-off score. The Receiver Operating Characteristics (ROC) was analyzed to evaluate its diagnostic accuracy.

RESULTS

The study included 342 students aged 18-25 years (the mean age was 20.25 ± 1.4 years), 80.4% of whom were female. Among the 68 participants selected for an online interview, 16 were diagnosed with BPD. The cut-off score of the SI-Bord was > 9, as suggested by the Youden index, yielding a sensitivity of 56.3% and a specificity of 92.3%. It had a positive predictive value of 69.2% and negative predictive value of 87.3%. The SI-Bord had adequate discriminative power between cases and non-cases of BPD, with the area under the ROC curve being 0.83. Cronbach's alpha for the SI-Bord was 0.76, indicating acceptable internal consistency. The SI-Bord score was positively correlated to PHQ-9 and PSS-10 scores (r = 0.67 and r = 0.69, p < 0.001, respectively) and negatively correlated to MSPSS (r = - 0.50, p < 0.001). The prevalence of BPD in the sample was 6.4%, according to the cut-off score > 9.

CONCLUSION

The SI-Bord demonstrated good reliability and validity for screening BPD in university students. However, a study in non-Thai and other population groups should be warranted.