Content uploaded by Shian-Ling Keng
Author content
All content in this area was uploaded by Shian-Ling Keng on Jan 29, 2018
Content may be subject to copyright.
Send Orders for Reprints to reprin ts@benthamscience.ae
Current Psychiatry Reviews, 2017, 13, 000-000 1
REVIEW ARTICLE
1573-4005/17 $58.00+.00 © 2017 Bentham Science Publishers
Understanding Borderline Personality Disorder Across Sociocultural
Groups: Findings, Issues, and Future Directions
Andrada D. Neacsiua,*, Jeremy W. Eberleb, Shian-Ling Kengc, Caitlin M. Fangd and
M. Zachary Rosenthala,d
aDuke University Medical Center; bUniversity of Washington; cNational University of Singapore; dDuke University
Abstract: Background: In recent years, there have been significant advancements in understanding
the etiology, assessment, and treatment of borderline personality disorder [BPD]. However, the
influence of culture has not been carefully considered. The present review is an attempt to identify
cultural factors that may change the presentation, assessment, and response to treatment among
adults and adolescents with BPD.
Discussion: We discuss the relevance of examining the BPD diagnosis across cultures, define cul-
ture, and review studies on the prevalence of BPD across sociocultural groups.
Conclusion: We provide a comprehensive list of assessments developed to capture BPD and the
cultural adaptations and validations attempted thus far. We also summarize the evidence base for
culturally sensitive treatments for BPD. Finally, we present suggestions for future research and
clinical implications for our findings.
Keywords: Borderline personality disorder, culture, review, prevalence, assessment, treatment.
INTRODUCTION
The role of culture has long been recognized as an impor-
tant consideration in the etiology, maintenance, and treat-
ment of mental health problems, and in recent years a grow-
ing interest in the intersection of culture, psychology, and
psychopathology [1] emerged. Recent findings suggest that
cultural influences affect the development [2] and course of
many mental health problems [1], including mood [3], anxi-
ety [4], eating [5], substance use [6], and personality disor-
ders[PDs] [7]. Although the role of culture has been charac-
terized in some disorders, reviews and recommendations
continue to be needed to advance an understanding of the
influence of culture on other psychiatric problems.
Borderline personality disorder (BPD) is a severe condi-
tion that often includes suicidal behavior, comorbidity with
other psychiatric conditions, poor psychosocial functioning,
and frequent use of costly mental health services [8]. Adults
who meet diagnostic criteria for BPD commonly use inpa-
tient and outpatient mental health services, yet are widely
characterized as being difficult-to-treat, and may benefit
less than others from psychotherapy [9]. Although some
*Address correspondence to this author at the Cognitive Behavioral Research
and Therapy Program, Department of Psychiatry and Behavioral Sciences,
Duke University Medical Center [3026], 2213 Elba St., Rm 123, Durham,
NC, 27710; Tel: [919] 684-6714; Fax: 919-684-6770;
E-mail: andrada.neacsiu@duke.edu
researchers have discussed the importance of culture for
BPD [10, 11], no comprehensive review has examined the
intersection between cultural dimensions and the prevalence
of BPD across the globe, the empirical basis of assessments
used in different countries, and the evidence base for differ-
ent types of treatment for BPD in different cultures. There
have been several reviews focusing more broadly on psy-
chopathology and culture that can be applicable to BPD [12-
14]. Their findings highlight several cultural factors that may
impact personality pathology, diagnosis, and treatment, in-
cluding biases inherent to Western conceptualizations of
dysfunction, child-rearing practices, family-based experi-
ences, religion, societal influences, life events, economics
and racism, and acculturation. While insightful, this work is
broad, a decade old, and primarily focused on theoretical
rather than data driven conclusions.
Given that BPD is a severe and debilitating disorder with
a heterogeneous constellation of problems that are notori-
ously challenging to treat, it is critical, therefore, to conduct
a comprehensive, data-driven examination of the the preva-
lence of the disorder across cultures, the unique ways in
which culture influences BPD presentation and assessment,
and the ways that treatments can be delivered or modified in
a culturally sensitive manner. Furthermore, a critical exami-
nation of the evidence behind cultural adaptations of instru-
ments used to assess for BPD across the globe is needed.
Addressing the influence of cultural factors is particularly
important because most research on participants diagnosed
A R T I C L E H I S T O R Y!
Received: November 13, 2016
Revised: February 05, 2017
Accepted: May 19, 2017
DOI:
10.2174/1573400513666170612122034!
2 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
with BPD has been conducted among individuals from a
narrow sample of cultural backgrounds, usually ethnic ma-
jority (i.e., Caucasian) populations [15] and conclusions
drawn from these samples may be misleading for practicing
clinicians. In this review, we aim to synthesize assessment,
treatment, and epidemiological data from across the world to
highlight future direction in research as well as to identify
implications that are directly relevant to clinical practice.
DEFINITION OF CULTURE
Following the definition of Barnouw [16], we understand
culture as the shared lifestyle and patterns of behavior within
a group of people that are transmitted from one generation to
the next by means of language and imitation. Tseng [17]
brings additional dimension to this definition by highlighting
that[a] cultural groups should be distinguishable from one
another;[b] patterned behavior includes views, beliefs, val-
ues, and attitudes;[c] culture is learned;[d] culture gives
meaning to behaviors that we engage in; and[e] culture is not
immutable, but can change and be influenced by other cul-
tures. Because specific behavioral patterns that may differen-
tiate one culture from another [e.g., traditionalism, collectiv-
ism, masculinity] have received limited attention in BPD
research, we examine the intersection of BPD and culture by
examining the manifestation, prevalence, and treatment of
this disorder within delineated sociocultural groups. Others
[2, 18, 19] have also highlighted the importance of sociocul-
tural groups in understanding the dynamic nature of culture
within an individual, especially as it relates to mental health.
Kitayama [19] suggests that each person actively attempts to
coordinate his or her values, beliefs, and behaviors with dif-
ferent sociocultural groups. While group membership is not
equivalent to culture [17], we build this review on the as-
sumption that pertaining to a specific sociocultural group
implies sharing at least some of the group’s cultural charac-
teristics[e.g., values, beliefs, attitudes, behaviors]. Thus, us-
ing the group level of Sue and Sue’s [20] tripartite frame-
work of personal identity, a model developed to increase
multicultural competency for counselors and clinicians, we
define the following cultural dimensions that separate so-
ciocultural groups: geographic location, gender, sexual ori-
entation, race, ethnicity, religious preference, age, disability,
marital status, and socioeconomic status. In addition, we
extend these grouping variables based on Marsella’s [1]
model of cultural etiology by including urbanization and
migration/immigration in our analysis. We believe that
within each of these groups there are shared lifestyles, chal-
lenges, and patterns of behavior that are transmitted across
generations; thus, each of these groups contains a subculture
that could nuance the presentation of BPD.
To enhance our analysis of BPD and culture, we also
characterize the geographic location grouping based on
Hofstede’s [21] dimensions of culture. According to exten-
sive multinational research, Hofstede, Hofstede, and Minkov
[22] concluded that these cultural dimensions are globally
applicable and reflective of all aspects of life, including fam-
ily, education, employment, and healthcare. These dimen-
sions include individualism versus collectivism, power dis-
tance, masculinity versus femininity, and uncertainty avoid-
ance [21]. The first dimension [individualism-collectivism]
reflects whether society’s members [not an individual] tend
to integrate into groups. Individualistic societies expect that
individuals are independent and self-reliant; collectivistic
societies value strong integration into groups [often fami-
lies]. Power distance refers to expectancies from individuals
and acceptance in a society for unequal power distribution.
High power differential societies teach and value expertise
and obedience; low power differential societies treat all
members as equal. The third dimension [masculinity-
femininity] describes a society’s propensity towards emo-
tional and social roles [feminine society] or assertiveness and
competitiveness [masculine society]. Masculine societies
also tend to have a more obvious split in gender roles,
whereas feminine societies may include more variety in the
responses that can be expected from both male and female
individuals. The last dimension highlights a society’s level
of comfort with uncertainty [or lack of structure]. Novel,
surprising situations are embraced in societies with low
avoidance of uncertainty. High-avoidance societies promote
strict rules and behavioral codes, have harsh punishments for
deviations from these rules, and believe in absolutes.
The present article is an attempt to discuss and integrate
findings on BPD within specific sociocultural groups with
the goal of comparing the presentation and response to
treatment of people who meet criteria for this severe disorder
between groups. We discuss conceptual and methodological
challenges in conducting cross-cultural assessments, review
extant studies on the prevalence and treatment of BPD
around the world, identify cultural considerations that may
affect the manifestation of the disorder, and explore ways to
provide culturally sensitive treatment to this population. Fi-
nally, we present suggestions for future research at the inter-
section of BPD and culture.
PREVALENCE OF BPD ACROSS SOCIOCULTURAL
GROUPS
Diagnostic Systems and Definitions
The word borderline was first used in 1938 when Adolf
Stern described a syndrome bordering on both psychosis and
neurosis [23]. Over the ensuing decades, eight specific prob-
lems associated with this syndrome were empirically identi-
fied, and BPD was added to the DSM-III [24]. The DSM-IV
added a criterion[stress induced dissociation/paranoia] [25],
and the diagnosis was kept the same in the DSM-5 [26]. Cur-
rently, the DSM diagnosis requires that a person meet five
out of nine criteria, including problems with abandonment,
idealization and devaluation in relationships, identity distur-
bance, self-harming behavior, difficulties controlling anger,
affective instability, chronic emptiness, stress-induced disso-
ciation or paranoia, and impulsivity in at least two areas that
are self-damaging.
Starting with the DSM-IV, diagnoses were constructed in
collaboration with the World Health Organization with the
goal of making them compatible with and translatable to [27]
the International Statistical Classification of Diseases and
Related Health Problems [ICD-10] [28]. An ICD-10 diagno-
sis of emotionally unstable personality disorder [EUPD] re-
quires a longstanding abnormal behavioral pattern consisting
of markedly disharmonious attitudes and behaviors involving
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 3
several areas of functioning. The borderline type includes
disturbances in self-image, aims, and internal preferences;
chronic feelings of emptiness; unstable relationships and fear
of abandonment; and self-injurious behaviors.
We present the results of a comprehensive search for
studies on the prevalence and manifestation of BPD in vari-
ous sociocultural groups [geographic location, biological
sex, sexual orientation, age, marital status, race/ethnicity,
religion, immigration, socioeconomic status, and urbanism].
Although there are likely to be variations in attitudes, behav-
iors, and values within each group, sociocultural groups can
shed important light on understanding the dynamic nature of
culture within an individual [19]. An analysis at the level of
values, attitudes, and behaviors is impossible because no
research at that level exists. Therefore, we chose to infer that
those who pertain to a sociodemographic group would have
at least some similar cultural characteristics, and, therefore,
that an analysis of the evidence at a group level could shed
insight into the cross-cultural prevalence and manifestation
of BPD.
SEARCH STRATEGY
We searched PsycINFO for the terms borderline and
personality and restricted results to those published in jour-
nals before June 2013. To examine geography, we parsed the
7,764 results by location using queries composed of search
terms we derived from the names of 241 countries/areas and
28 regions and subregions used by the United Nations Statis-
tics Division [29]. We analyzed results from each query in-
dividually, except when there were over 100 results, in
which case we added terms[e.g., culture, epidemiology,
prevalence] to restrict results. In parsing the results we gave
preference to studies that used probability samples represen-
tative of the country’s general population, and when such
studies were unavailable, we chose to present studies of
other nonclinical samples. When nonclinical studies were
unavailable, we selected clinical studies that had few eligibil-
ity criteria and that used samples selected by probability,
consecutive, or convenience methods, in that order. This
method of synthesizing the literature has the benefit of giv-
ing us a comprehensive view of BPD across the globe. The
inherent limitation is that the quality of the studies included
is variable and outside of the US and Europe studies primar-
ily targeted clinical samples, which weakens our conclusions
about community samples. To mitigate this, the supplemen-
tary tables present summaries of all studies with methodol-
ogy and limitations included.
To examine the other sociocultural groups, we narrowed
the search to borderline personality disorder, added terms
such as gender, transsexual, homosexual, race, ethnicity,
religion, spirituality, immigration, disability, urbanism, age,
marital status/satisfaction, married, and socioeconomic
status, and considered the results of each query individually.
In both search methods, we found additional items by mining
references and corresponding with colleagues. We excluded
single-case reports, conference proceedings, poster abstracts,
and dissertations.
From the abovementioned articles, we extracted the in-
struments used to assess BPD. To identify any additional
instruments, we searched PsycINFO and Google Scholar for
the terms personality disorder and assessment, instrument,
interview, self-report, measurement, and psychometrics. We
then identified the validation studies for each instrument and
summarized this information in Table S1 [see Supporting
Information]. To identify cultural adaptations and transla-
tions of these instruments, we then searched Web of Science
and Google Scholar and examined all of the articles that
were published in a non-U.S. location and that cited each of
the validation studies for all of the instruments. If over 500
articles emerged, we restricted the search to articles that also
included terms such as translation, adaptation, validation, or
psychometrics in their titles or abstracts. For instruments that
were developed outside the United States, we also examined
results to identify English translations and adaptations.
Not all articles were available in English. To interpret
non-English articles, we read any available English ab-
stracts/summaries and used the following procedures to re-
view the full texts. For articles written in Romanian[N = 3],
Spanish[N = 19], French[N = 6], Portuguese[N = 5], Ital-
ian[N = 2], and Mandarin[N = 11], we read the original arti-
cles using our own language skills. For articles written in
Turkish[N = 3], German[N = 7], Russian[N = 2], Polish[N =
3], Dutch[N = 4], Japanese[N = 1], Korean[N = 4], and
Farsi[N = 1], we translated the articles with the aid of online
translation technology[Google Translate] and asked multi-
lingual colleagues and paid translators to confirm using a
standardized form the information that we extracted and any
additional information that would be relevant.
ASSESSMENT OF BPD
Over 45 instruments have been developed that can assess
for BPD specifically or in the context of assessing for PDs.
Of these, 32 have been translated into 33 other languages,
yielding 178 translations and adaptations. Table S1 summa-
rizes the existing instruments and their psychometric proper-
ties, translations, and validations in other languages. The
majority of instruments were translated following standard-
ized procedures, and psychometric properties of the transla-
tions were examined. We found 30 instruments where the
researchers also explicitly stated how they culturally adapted
the instrument[i.e., items were not simply translated, but also
changed to capture similar meanings within the culture]. The
majority of translations were for Spanish[N = 19]; Dutch[N =
18]; German[N = 17]; Mandarin[N = 13]; French[N = 12];
Italian[N = 11]; Portuguese and Norwegian[N = 8 each]; and
Turkish, Korean, and Japanese[N = 7 each]. There were few
translations for Urdu, Swahili, Icelandic, Czech, Cantonese,
Bulgarian, and Arabic[N = 1 each]; Taiwanese and He-
brew[N = 2 each]; Swedish, Serbian, Russian, Romanian,
Farsi, Malay, Hindu, Hebrew, and Afrikaans[N = 3 each];
and Polish, Finnish, and Danish[N = 4 each]. The majority of
the adaptations were found for Spanish, Mandarin, Taiwan-
ese, and Danish languages.
Although cultural adaptations of instruments may be de-
sirable[see [30] for an example of an excellent process for
adapting an instrument], translations have been successfully
used across the globe and have captured BPD in most coun-
tries and groups. The majority of authors used a standardized
translation and back-translation process, involving bilingual
4 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
researchers who could accurately preserve meaning from one
language to another. The most translated self-reports are the
PDQ and TCI[translated into 15 languages], the MCMI
[translated into 11], the BPI[translated into 8], and the
STIPO and PDBQ[translated into 7]. Of these, the PDBQ,
TCI, and MCMI are not specifically designed to measure
BPD, although they are sometimes used for this purpose. The
self-reports with the strongest psychometric properties[MSI-
BPD, BSL] are not among the most translated, highlighting
that researchers may benefit from more information about
the existing assessments in order to translate and adapt the
best[rather than the most transalated] measures for their cul-
tures. By contrast, the interviews with the strongest psycho-
metric properties have been the most frequently translated in
other cultures. We found 20 translations for the IPDE, 17 for
the SCID-II, and 6 each for the DIB, DIPD, and SAP.
With both interviews and self-reports, psychometric
properties need to be assessed within each culture before
using the instrument in research. Twenty-three translations
did not have evidence of validation within the target cul-
ture[but may have presented evidence of validation in other
cultures]. These translations need validation studies[and lin-
guistic adaptations] before being included in further studies.
However, because we did not conduct an exhaustive review
of each translation and limited results to those published
before 2013, it is possible that additional research has ad-
dressed the gaps we identified
Overall, we found that over 150 of the translations had
some validation data within the country where they were
used, which suggests that the prevalence and treatment find-
ings presented below truly reflect BPD samples. Neverthe-
less, some limitations of cross-cultural BPD assessments
are[a] use of instruments with weak psychometric proper-
ties,[b] use of instruments that are not designed to diagnose
BPD,[c] unclear rationale for choosing one instrument versus
another,[d] limited discussion surrounding cultural adapta-
tions, and[e] use of different translations of the same instru-
ment in a culture. Such limitations should be considered in
interpreting the prevalence and treatment data summarized
below.
GEOGRAPHY
Roughly three fourths of the research on BPD has been
done in Northern America and Western and Northern
Europe. A dearth of epidemiological studies on BPD in gen-
eral populations outside these regions precludes a compari-
son of prevalence rates between these and less researched
regions, but a host of multiple- and single-country studies
suggests that BPD can be found across the world.
Multinational Studies
Multisite studies of psychopathology suggest BPD is
globally present. The International Pilot Study of Personality
Disorders[IPSPD], assessed psychiatric inpatients and
outpatients from 14 sites in 11 countries[India, Switzerland,
Netherlands, England, Luxembourg, Germany, Kenya,
United States, Norway, Japan, Austria]. Although the study
was not epidemiological, the researchers diagnosed BPD in
every country except Kenya [31].
Multinational medication trials also suggest an
international presence of BPD. One trial across 59
community and academic centers in 9 countries[Argentina,
Chile, Italy, Peru, Poland, Romania, United States, Turkey,
Venezuela] included 451 outpatients diagnosed with BPD. In
a prior trial [32], 314 outpatients across 52 sites in 9
countries[Belgium, France, Germany, Norway, Portugal,
Spain, Sweden, United Kingdom, United States] were given
BPD diagnoses. These studies do not present the rate of BPD
in each country, but they suggest BPD can be found in
various regions.
Single-country studies
Although the multinational studies suggest that BPD can
be found outside of Northern America and Europe, they
include only subsets of countries and lack information on the
manifestation of BPD outside of these regions. To obtain a
more inclusive and nuanced view of BPD around the world,
we examined studies of BPD at the level of individual
countries. Table S2 details prevalence rates[point, period,
lifetime] broken by geographical region and country.
Northern America
About half of all BPD research has occurred in Northern
America. According to Hofstede [33], the United States and
Canada are marked by low power differential, moderate-to-
low uncertainty avoidance, high individualism, and moder-
ate-to-high masculinity. Therefore, in these societies, people
are expected to take care of themselves, they value competi-
tiveness and achievement, and they challenge power differ-
entials, expecting equal rights for each person. Uncertainty is
embraced more than it is avoided, suggesting that people are
prone to taking risks and open to new ideas.
Most of the research has occurred in the United States.
Studies of nationally [34, 35] and regionally [36, 37] repre-
sentative samples suggest that BPD is present in 0.5-3.9% of
adults and that 5.9% of the population develops BPD at
some point. The difference in rates may be due to the types
of measurements used in the studies [38]. Youths are more
likely to develop BPD than adults. In a random regional
sample of youths[9-19 years], 7.8% met criteria for at least
moderate BPD, and 3.0% met criteria for severe BPD [39].
BPD is often the most prevalent PD in clinical contexts [40],
but rates vary based on the setting, selection criteria [41],
and assessment method [42]. About 30.8-64.0% of psychiat-
ric inpatients [43-45] and 9.3-18.0% of psychiatric outpa-
tients [45, 46] have BPD, and 6.4% of patients in primary
care [47] eventually develop BPD.
Prevalence rates of BPD in the United States are often
cited for Canada as well. To our knowledge, no studies have
assessed the rate of BPD in the general population or in psy-
chiatric inpatients in Canada, but one study [48] found that
22.6% of Canadian adult psychiatric outpatients had BPD. In
another study, 29.3% of inpatients admitted to a forensic
assessment unit were diagnosed with BPD [49].
Western Europe
Western Europe is home to the second largest group of
studies on BPD. Although geographically adjacent, countries
in this region vary on cultural dimensions. Germany and
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 5
Austria; the Netherlands, Luxembourg, and Switzerland; and
Belgium and France are characterized by low, moderate, and
moderate-to-high power differential, respectively. All
countries are characterized by moderate-to-high uncertainty
avoidance and individualism. People in Germany, Austria,
Switzerland, and, to a lesser extent, Belgium endorse a
propensity for masculinity, Luxembourg culture balances
both masculinity and femininity, and people in the
Netherlands and France are characterized by a moderate-to-
low score on this scale, endorsing more feminine societies.
[21, 22, 33] Therefore, the common threads in Western
Europe are that people are expected to take care of
themselves and tend to be fairly risk averse, needing rules
and following established paths and guidelines. In Belgium
and France, power inequality is expected: Each individual
has his or her place in society, and such differences are
respected. In the other countries, there is more striving for
equal power for everyone. The French and the Dutch are
more focused on well-being than they are on competition and
achievement, and emotional expression is expected from
both men and women. Germans, Austrians, and Swiss adults
are similar to Americans in their pursuit of achievement.
Most of the BPD research in Western Europe has has
taken place in Germany. Regionally representative samples
suggest that 0.7% of adults with children[and 4.2% of these
children as adults] in the general population meet criteria for
BPD [50] and that 1.1% of the population develops BPD at
some point [51]. The only other representative sample in this
region was in France, where BPD was found among 14.4%
of high school students [52].
The available data are insufficient to draw conclusions
about prevalence as related to cultural dimensions;
nevertheless, some hypotheses emerge. There was a much
higher prevalence of BPD among youths in France[14.4%]
than among young adults in Germany[4.2%], countries that
differ in their power differential and masculinity. In addition,
the Netherlands, a feminine culture with low uncertainty
avoidance, had some of the lowest rates of BPD among
inpatients and outpatients[12-14%] when compared to
countries that are masculine and highly avoidant of
uncertainty[13-23%], although these data are from studies
that used small convenience samples. Therefore, the
methodology and assessment used are limitations that may
confound these trends.
Northern Europe
Northern Europe has hosted the third greatest number of
studies on BPD. As with those in Western Europe, countries
in Northern Europe vary on some of the cultural dimensions.
All Northern European countries are characterized by low
power differential[i.e., members of society expect to be
equal] and uncertainty avoidance[i.e., risks and new ideas are
welcomed], except for Finland and Norway, which endorsed
moderate avoidance of uncertainty. People in the United
Kingdom reported that their society was in between
collectivism, the tendency for groups that take care of each
other to form, and individualism, the tendency for
individuals to think of themselves as needing to take care
primarily of their own needs. People in all other countries
reported a moderate-to-high preference for individualism.
The United Kingdom and Ireland were identified as
moderate-to-highly masculine societies, suggesting that they
prize competition and achievement. Norway, Finland,
Sweden, and Denmark were identified as primarily feminine
societies, where caring for others and quality of life are
prioritized [33].
Most of the BPD research has been done in the United
Kingdom. Studies of representative samples of Great Britain
found BPD in 0.7% of the general population [53] and in
3.2% of a cohort of children[11 years] [54]. Other studies
with nationally representative samples were conducted in
Norway and Sweden. In Norway, a regionally representative
sample suggests that 0.7% of adults in the general population
have BPD [55]. In Sweden, a random sample of the Isle of
Gotland suggests that BPD occurs in 4.5-5.4% of adults [56].
There is no pattern in cultural dimensions that can account
for these differences.
BPD was found among inpatients and outpatients across
Northern Europe: in 6.3-40.6% of Swedish psychiatric
inpatients and outpatients [57-59], 0.8-2% of inpatients
across all psychiatric hospitals in Denmark [60], 7.4% of all
people who completed suicide in Finland [61], and among
adult female outpatients in Ireland [62]. No hypotheses on
cultural differences can be extracted based on these data.
Australia and New Zealand
According to Hofstede [33], Australia and New Zealand
are individualistic, masculine cultures marked by moderate-
to-low power differential and low avoidance of uncertainty.
Therefore, members of these societies seek achievement,
success, and equality; focus on taking care of their own
needs; follow traditional, established paths; and avoid new
ideas. Most research on BPD in this region has been
conducted in Australia, where a nationally representative
sample suggests that 0.95% of the general population
develops BPD at some point [63]. BPD has also been
diagnosed among inpatients [64] and outpatients [65-70] in
both countries.
Central America
Most of the research on BPD in Central America has
occurred in Mexico, a masculine, collectivistic culture
marked by high power differential and high uncertainty
avoidance [33]. We found no epidemiological research on
BPD in the general population, but BPD has been found
among psychiatric inpatients [71] and outpatients [72], in-
cluding 50.0% of outpatients seeking treatment for PDs [73].
In a study of cross-cultural differences among people in
Nicaragua and Sweden, 8 psychiatric outpatients in
Nicaragua were diagnosed with BPD [74].
South America
Countries in South America are similar in their moderate-
to-high power differential and high avoidance of uncertainty,
meaning that each person does not question his or her place
in society and that traditional, established ideas are followed
and valued. Most countries have a collectivistic society,
where groups and families take care of one another’s needs,
except for Argentina and Brazil, which tend to be balanced
between collectivism and individualism. Venezuela,
Argentina, and Columbia are primarily masculine cultures
driven by achievement, competition, and a need to stand out
6 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
from the crowd. People in Brazil rated their culture as
balanced between masculinity and femininity, while people
in Chile and Peru saw their societies as primarily feminine,
valuing quality of life and the well-being of all above
individual success [33].
We did not find any epidemiological research on BPD in
the general population in South America, but several studies
in clinical and prison contexts suggest that it is present. In
Argentina and Colombia, 6-39% of convenience samples of
outpatients met criteria for BPD [75-77]. There was a
slightly higher prevalence of BPD diagnoses in Peru[27-
31%], which has a feminine culture, than in masculine cul-
tures such as Argentina[10.3-27.3%] [78, 79] and Bra-
zil[22% of women hospitalized for a suicide attempt] [80].
BPD was also found in Brazilian prisons at rates of 19.7-
34.8% [81] and in Chilean, Peruvian, and Venezuelan outpa-
tients [82, 83].
Based on the available data, no other cultural compari-
sons can be made in this region. Additional cultural informa-
tion comes from a study where 20 Argentinian adult patients
diagnosed with DSM-III-R BPD were compared to 20 pa-
tients diagnosed with other PDs [84]. Those with BPD en-
dorsed an average of six BPD criteria, whereas those with
other PDs endorsed an average of two. Corsaro [84] con-
cluded BPD patients in Argentina have unique characteristics
compared to patients with other PDs.
Africa
Hofstede’s [33] research in East and West Africa
highlights that the northern part of the continent consists of
primarily collectivistic cultures marked by moderate-to-high
power differential, moderate uncertainty avoidance, and
moderate-to-low masculinity. South Africa is similar in that
it has moderate power differential and uncertainty avoidance,
but differences come from the fact that White South Africans
form a society that is primarily individualistic and masculine
[21, 22]. There are no data on Black South Africans with
respect to Hofstede’s dimensions.
No epidemiological research on BPD in the general
population was found for Africa, but several studies in
clinical settings suggest it is present. Most research has been
done in South Africa, where in a random sample of medical
records from psychiatric inpatients, BPD was diagnosed at a
rate of 1.33% [85], and where in a sample of patients
admitted to a psychiatric emergency unit for suicidal
behavior, 22.5% were diagnosed with BPD [86]. In this
study, BPD was the only PD associated with prior suicide
attempts. BPD has also been diagnosed in patients with
obsessive-compulsive disorder and trichotillomania,
especially in patients who also reported dissociation [87]. A
study of White psychiatric hospital patients with BPD
showed that patients’ family relationships were unstable and
emotionally intense [88]. Qualitative studies found that BPD
outpatients identified trust, a working relationship, focus,
and “carrying on” as helpful in keeping them in treatment
[89], and use of stringent contingencies for self-harm as
helpful only if self-harm urges were low [90].
In Egypt, BPD has been diagnosed in 13.5% of
outpatients with an anxiety, somatoform, adjustment, or
dissociative disorder [91]. Asaad, et al. [92] also found that
outpatients with BPD and those with depression exhibited
similar sleep profiles, replicating findings from studies done
in the United States [93].
Although the IPSPD did not identify any definite cases of
DSM-III-R BPD in Kenya, 10% of inpatients and outpatients
were noted as definite/probable cases, and 8% of inpatients
and outpatients received definite ICD-10 BPD diagnoses
[94]. Another study indicated that 5.4% of Kenyan inpatients
had BPD. The authors also noted that PDs may be diagnosed
less often in Kenya because a dearth of mental health
resources may result in only highly severe cases seeking
treatment [95].
From the point of view of cultural dimensions, the only
hypothesis that arrises from these data is whether the
prevalence of BPD in inpatient settings is higher in more
feminine cultures such as Kenya than in more masculine
cultures such as South Africa.
Eastern Europe
According to newer research by Hofstede and his group
[21, 22], power differential varies in Eastern European
countries from moderate-to-low in Hungary; to moderate-to-
high in Poland; to high in Romania, Bulgaria, and Russia.
Therefore, whereas in Hungary equality of all members of
society is sought, other countries have a clear hierarchy of
power, where everyone has her place and order is not
questioned. All of these countries are characterized by high
uncertainty avoidance, meaning that their members tend to
follow rules, avoid risks, and reject novel ideas. People in
Russia, Romania, and Bulgaria describe their cultures as
collectivistic and feminine, promoting the well-being of all
above individual success. People in Hungary and Poland
describe individualistic, masculine cultures based on
achievement and a need to stand out [21, 22].
Epidemiological studies on BPD in the general
population of Eastern Europe were not found, but studies
from clinical settings show BPD is present, although the
available data do not suggest any other comparisons in this
region based on cultural dimensions. In psychiatric samples
in Bulgaria, BPD has been found in 3.8% of inpatients, 5.2%
of day center patients, and 1.4% of outpatients. The BPD
symptoms of boredom/emptiness and emotional instability
had the highest specificity, and principal component analysis
revealed three main factors for the BPD diagnosis:
behavioral acting out, identity disturbance and self-harm, and
core identity disturbance [96].
BPD has been diagnosed in outpatient [83], inpatient, and
emergency room settings in Romania [97-99] BPD inpatients
scored higher on neuroticism and lower on extraversion and
agreeableness when compared to nonclinical controls [99]
Grecu et al. [98] studied a sample of adults who had com-
pleted suicide on an inpatient unit. Over 6% retrospectively
met criteria for BPD. In another study [97], the same authors
retroactively diagnosed BPD in 153 people who had com-
pleted suicide and found that impulsivity, anger dysregula-
tion, substance abuse, and depression[frequently induced by
separation/divorce] were factors most often related to sui-
cide. The majority of completers were in their 30s[33.3%] or
40s[50.3%] and worked as farmers[24%] or unskilled labor-
ers[23%] or were unemployed[12%]. Most people completed
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 7
suicide at[58%] or near[28%] home. Hanging[60%] was the
most frequently used method, followed by overdosing[17%],
drowning[8%], and cutting[7%]. Most[88%] had histories of
chaotic family relationships and exposure to abuse, and 10%
grew up in orphanages [97].
BPD has also been found among inpatients in Hungary
[100], among inpatients and outpatients in Poland [83, 101],
and among 47 psychiatric patients from Russia and Cyprus
[102].
Southern Europe
All countries in Southern Europe endorse moderate-to-
high power differential and high avoidance of uncertainty.
Portugal, Greece, Croatia, and Serbia trend toward
collectivism, while Italy and Spain are more individualistic
cultures. Italy and Greece are primarily masculine societies,
while Portugal, Croatia, Serbia, and Spain show moderate-
to-low scores on this dimension, indicating a more feminine
society [21, 22, 33].
The only representative sample in Southern Europe
was collected by examining Spanish primary care databases.
The prevalence rate of BPD was 0.02% [103]. No other
epidemiological studies of BPD could be found.
Nevertheless, BPD has been diagnosed in clinical settings
throughout Southern Europe, with most of the research
taking place in Italy. Among outpatients, a slightly lower
prevalence of BPD can be found in convenience samples in
Spain[a more feminine culture] and Bosnia-Herzegovina[6-
7%] [104, 105] when compared to samples in Italy[a more
masculine culture] and the former Yugoslav Republic of
Macedonia[18-25%] [106, 107]. BPD was also found in
outpatient settings in Croatia, Serbia, and Portugal [108,
109]. Among inpatients, slightly lower rates are found in
Greece, a collectivistic culture[4.9-13.8%] [110, 111], than
in Italy, an individualistic culture[26.8-40.4%] [106, 112].
Eastern Asia
Countries in this region are collectivistic; people put the
interest of social groups above their individual interests.
They also share a moderate-to-high power differential, where
hierarchy is expected and respected. Countries differ on the
other dimensions of culture. China and Hong Kong have low
avoidance of uncertainty, embracing risks and new ideas.
Taiwanese, Japanese, and South Korean cultures are marked
by moderate-to-high avoidance of risks and uncertainty.
With regard to masculinity and femininity, Japan is balanced
between seeking achievement and promoting the well-being
and quality of life of all members of society. China and
Hong Kong tend to be primarily masculine cultures, while
Taiwan and South Korea score low on this dimension,
having feminine cultures [21, 22, 33]. Because of the large
variability in findings in Eastern Asia, no comparisons based
on these dimensions can be made; nevertheless, cultural
differences between this region and Western regions have
been examined by several researchers. Thus, we present
prevalence findings about cultural differences between
Eastern Asia and the Western world.
Despite the absence of BPD from the CCMD, over the
last decade research on BPD has exploded in China [113],
with more and more studies in general and psychiatric popu-
lations. In nonclinical subsamples, studies find the preva-
lence of BPD to range from less than 1% [114] to 1.8% [115]
in college students, to up to 8.4% in high school students
[116], to 0.3% in factory workers [117]. In clinical settings,
rates of BPD range from 1.3%[for outpatients] [117] to
7.1%[for inpatients and outpatients] [118].
Factor analysis of BPD diagnosis and instruments consis-
tently find four main factors: emotion dysregulation, impul-
sivity, cognitive disturbance, and unstable interpersonal rela-
tionships [116, 119] In addition, BPD symptomatology of
high school students is correlated to that of their parents,
suggesting that BPD runs in families in China [116]. Prob-
lems such as reckless driving, promiscuous sex, and sub-
stance abuse, which are included in DSM-IV criteria for
BPD, may not be relevant to patients in China, where per-
sonal cars are rare, sex is taboo, and drugs are rigidly con-
trolled. Huang et al. [120] diagnosed outpatients with BPD,
and retrospective reports of childhood abuse showed that
diagnosis was significantly predicted by sexual abuse, ma-
ternal neglect, maternal physical abuse, and paternal antipa-
thy. That childhood abuse predicted BPD diagnosis is con-
sistent with studies of etiological factors done in the West
and Japan. However, maternal physical abuse predicted BPD
diagnosis as strongly as sexual abuse did, and this has not
been replicated in the West. The authors noted that, while the
rate of physical abuse was in the range of rates found in
North America and Europe, the use of strict disciplinary be-
havior, including physical force, is accepted by many parents
in China and may be used more by mothers, the primary dis-
ciplinarians in the traditional culture. Although sexual abuse
also predicted BPD, the rate of such abuse in patients with
BPD was lower than the rates found in North America. The
authors suggest this may be due to different rates of child-
hood sexual abuse in the general population in China versus
North America.
In Hong Kong, Leung and Leung [121] found that 6.3-
6.6% of high school students met criteria for BPD based on
the MSI-BPD. However, when a stringent simulated diag-
nostic procedure was used in place of diagnostic interviews,
the rate of BPD was 2%. BPD has also been diagnosed
among outpatients [122] and among 18.8% of patients admit-
ted to a hospital after an act of deliberate self-harm [123].
Wong et al. [123] noted similarities in the BPD profiles of
their sample with those of the West in regard to higher rates
in females, high comorbidity with Axis I disorders, and high
rates of childhood abuse, but theorize, similar to Paris [11],
that the lower rate of BPD in their study compared to others
in the West may be due to the protective cultural factors of
traditional Chinese societies, such as norms for group cohe-
sion and the existence of strong family ties.
In Taiwan, Song, et al. [124] found that the prevalence
rate of BPD among college students was 1.0% and that BPD
was comorbid with other PDs. Emotional abuse and physical
neglect correlated with BPD. Additionally, Cheng, Mann,
and Chan [125] studied completed suicides among Han Chi-
nese and two aboriginal ethnic groups and found that 5.3%
of suicide completers met criteria for BPD. Principle compo-
nent analysis of the BPI revealed three factors: general pa-
thology, self-destructive behavior, and fear of closeness
[126].
8 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
We did not find research on BPD in the general
population in Japan, but several studies in clinical settings
suggest BPD is present. The rate of BPD rangea from
7.0%[among inpatients and outpatients] [94] to 41.1%
[among female outpatients] [127]. BPD has also been diag-
nosed in outpatients with major depression [128], panic
disorder [129], and bulimia nervosa [130]. BPD has also
been diagnosed more often in inpatients and outpatients with
anorexia or bulimia and alcoholism than in those with
alcoholism alone [131] or with bulimia alone [132]. Habitual
self-mutilation is potentially related to BPD and has also
been studied in outpatients [133].
Machizawa-Summers [134] found that Japanese female
outpatients with BPD reported more severe forms of
emotional, physical, and sexual abuse than outpatients with
no PDs, consistent with prior studies in North America.
Patients with BPD also rated their parents as more
overprotective and less caring. Logistic regression revealed
that BPD diagnosis was significantly predicted by emotional
abuse and neglect and paternal overprotection. The author
suggests that these findings may be due to, among other
possibilities, greater acceptance of authoritative parenting
and greater tolerance of enmeshed parent-child relationships
in Japan. In a sample of patients who had received treatment
and who retrospectively met BPD criteria, logistic regression
revealed that overinvolvement in family relationships
significantly predicted poor outcomes [135]. The sample’s
global outcomes and suicide rate were consistent with those
found in Western studies. However, these patients were more
likely to live with their families of origin than were BPD
patients in the United States [136].
Several studies have concluded that, while some
differences may exist, the clinical pictures of BPD patients in
Japan and the United States are comparable. For example,
Moriya et al. [137] found lower comorbidity of eating
disorders in their BPD patients compared to those in the
United States, which they suggested may be due to sampling
issues given the treatment of eating disorders by special
programs in the United States. In addition, the authors
attributed lower comorbidity of substance use disorders to
stricter drug control practices in Japan. Japanese patients also
scored lower on DIB statements for drug abuse and drug-
induced psychotic experiences but higher on statements for
derealization and depersonalization. They also reported more
intense, unstable relationships and dependency/masochism
and lower social isolation, which the authors attributed to the
tendency of Japanese patients to live with their parents.
Besides these differences, the authors reported that the
clinical picture of patients with BPD in Japan is “no
different” than that of patients with BPD in the United
States[p. 422].
In addition, Ikuta et al. [127] compared the clinical
charactieristics of BPD patients in Boston[diagnosed using
DIB-R] versus Tokyo[diagnosed using DIB]. Boston patients
had a higher rate of BPD and mean DIB-R total score than
Tokyo patients, but the authors attributed this to different
inclusion criteria for the original samples. Boston patients
also had higher scores for the affect and cognition scales, but
only one of 22 summary statements—nondelusional
paranoia—delineated the groups. Although this difference
remained significant when controlling for age and SES, the
authors attributed it to a disparity in the DIB versions used.
Analyses with these covariates also showed that Boston
patients scored higher on chronic feelings of helplessness/
hopelessness/worthlessness/guilt, which the authors suggest
may be due to lower SES among this population or to
interviewer error, while Tokyo patients scored higher for
manipulative suicide efforts, which the authors suggest may
be due to age differences[on average, the Tokyo patients
were younger] resulting from different inclusion criteria for
the original samples. The authors also note the potential role
of sociocultural factors, such as more religious prohibition of
suicide in the United States and more support for expressed
suicidality among Japanese patients, many of whom, in the
age range of the sample, live with their parents. Still, the
authors conclude that Japan has patients with BPD whose
features are “basically identical” to those of patients in the
United States.
BPD has also been found in nonclinical and clinical set-
tings in Korea. In a three-year longitudinal study, Ha et al.
[138] identified 91 first-year students with BPD among 143
female high school students who were recruited with a pos-
sible BPD diagnosis from over 3,600 first-year high school
students; 48 met criteria for BPD alone. The authors found
that, at baseline, students with BPD scored higher on novelty
seeking and harm avoidance and lower on self-directness
than matched healthy controls. Over the three-year follow-
up, students with BPD increased less in self-directedness
than controls and did not increase in cooperativeness or self-
transcendence, while controls did. Regarding psychiatric
settings, Lyoo, Han, and Cho [139] diagnosed 83 Korean
inpatients and outpatients with BPD. After excluding pa-
tients who had comorbid psychiatric disorders, the authors
measured the brain volumes of 25 patients with BPD and
found that their frontal lobes were significantly smaller than
those of matched healthy controls.
Southeastern Asia
Little research has been conducted on BPD in Southeast-
ern Asia, but BPD has been diagnosed in clinical settings in
Thailand, a collectivistic, feminine society characterized by
moderately high power differential and avoidance of uncer-
tainty [33]. Wongpakaran et al. [140] found that 13.0% of
inpatients and outpatients met criteria for BPD. Furthermore,
two female patients with BPD and comorbid depression were
reported in a study on the treatment of depression with tran-
scranial magnetic stimulation [141].
Southern Asia
Countries in Southern Asia consist of collectivistic
cultures that value a hierarchy where everyone has a place
and order is not questioned[moderate-to-high power
differential]. They vary in aversive uncertainty[moderate-to-
low for India, moderate-to-high for Bangladesh and Iran] and
whether they are predominantly masculine[Bangladesh],
balanced between masculine and feminine[India], or
feminine[Iran] societies [21, 22, 33].
Most of the research on BPD in Southern Asia has come
from India. Prevalence rates of BPD in inpatient and
outpatient settings in India and Bangladesh range from 0.16
to 15% [94, 142, 143]. Among Indian inpatients and
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 9
outpatients who self-injure, Nath et al. [144] found that
28.6% of patients in the younger group[15-24 years] and
13.8% of patients in the older group[45-74 years] met
criteria for BPD.
Some researchers have argued that the profile of BPD
patients in India is similar to that of patients in the United
States. Pinto, Dhavale, Nair, Patil, and Dewan [145]
diagnosed 17.3% of a sample of hospital patients who had
attempted suicide with DSM-IV BPD. BPD patients showed
a high rate of “childhood sexual/physical abuse, comorbid
depression and substance abuse, frequent and severe self-
injurious behavior, and a high risk for suicide”—similar to
the profile of patients with BPD found in the United
States[p. 387]. Pinto et al. [145] state that their results
suggest that BPD is not a Western disorder. No other
comparisons based on cultural dimensions could be made
with the available data.
Western Asia
Countries in Western Asia where we found BPD
research[Turkey, Israel, United Arab Emirates] are fairly
different on Hofstede’s dimensions. Israelis endorse low
power differential, while Turks show moderate and Arabs
show high endorsment of hierarchical structures. All three
cultures have high avoidance of uncertainty and are balanced
or tend to be more feminine cultures, where the quality of
life of all members of society is valued over individual
achievement. The United Arab Emirates and Turkey are
primarily collectivistic, while Israel is individualistic [21, 22,
33]. No comparisons on these dimensions could be made
given the available data on BPD.
Most of the research has taken place in Turkey, where
BPD has been found in both general and psychiatric
populations. Regarding the general population, BPD was
diagnosed in 3.5% of a stratified random sample of women.
Women with a dissociative disorder were significantly more
likely to have BPD than those without one [146]. BPD was
also diagnosed in 8.5% of a random sample of college
students. Most[72.5%] students with BPD were also
diagnosed with a dissociative disorder, and students with
BPD reported significantly more childhood trauma[i.e.,
emotional and sexual abuse, physical neglect] than did those
without BPD [147].
As for psychiatric inpatients, Senol, Dereboy, and Yuksel
[148] retrospectively diagnosed 10.2% of a sample of
Turkish inpatients with BPD, and all but one of the BPD
patients who participated in a 2-to-4 year follow-up study
were diagnosed with BPD again. In addition, Yasan, Danis,
Tamam, Ozmen, and Ozkan [149] diagnosed BPD, the most
prevalent PD in the sample, in 8.3% patients admitted to a
hospital after they attempted suicide by poisoning. In
addition, Coşkunol, Bağdiken, Sorias, and Saygili [150]
found that, in 50 psychiatric inpatients at a univeristy
hospital assessed by the SCID-II, 5[10%] had DSM-III-R
BPD. BPD has also been found among inpatients with other
conditions, such as dissociative disorders [146], including
dissociative identity disorder [151, 152], conversion disorder
[153], alcohol and/or drug dependence [154, 155], and
dermatological conditions [156].
BPD has also been diagnosed in Turkish outpatient
settings [83, 157], including among outpatients with other
conditions, such as major depressive disorder [158], panic
disorder [159], dissociative identity disorder [151], or a
conversion symptom [160] or disorder [161].
Some authors comment on the simiarlity of BPD profiles
in Turkey compared to those in other areas; other researchers
point out behavioral differences. Senol et al. [148] reported
that comorbidity patterns in the retrospectively diagnosed
group and the follow-up group of their study—affective
disorders were the most common Axis I diagnoses, followed
by alcohol and substance use—were consistent with profiles
of BPD in Western countries. However, Yasan et al. [149]
reviewed several differences in the profiles of suicidal
behavior in Eastern and Western countries despite
similarities in the psychopathology associated with such
behavior across cultures. For example, the most common
substance used for poisoning in their study was insecticide;
in Western samples, drugs are more popular. They also state
that conflicts between adolescent girls and elder males in a
region marked by a “patriarchal family pattern with strict
adherence to Islamic lifestyle” may contribute to relatively
higher suicide risk among females in the region as compared
to other areas[p. 469].
BPD has also been found in clinical settings in Israel.
Patients with BPD have served as a control group in Israel in
studies on stressful life events and major depressive
disorders [162] and bipolar disorder [163]. Somer [164] also
reported that in Israel BPD is among the five most
commonly considered alternative diagnoses for dissociative
identity disorder, a diagosis whose validity some Israeli
clinicians question. In Lebanon we found no data specifically
on BPD. Finally, in the United Arab Emirates, BPD has been
diagnosed among 3.8% of adults in primary care [165].
SUMMARY
Geographic location presents people with unique envi-
ronmental resources[e.g., forests] and challenges[e.g., natural
disasters] and determines the natural terrain for interaction
among people[e.g., secluded island vs. well-connected me-
tropolis]. As Triandis [166], stated, “people who share a lan-
guage, a time period, and a geographic region are most likely
to be able to interact, and to develop shared meanings[i.e., to
belong to the same culture]”[p. 64]. Therefore, in the preced-
ing sections, we examined the characteristics and prevalence
of BPD within different geographical regions. We found no
studies of BPD from Melanesia, Polynesia, the Caribbean, or
Central Asia, but BPD was found in every other region. Al-
though epidemiological data on the prevalence of BPD
across the world are sparse, the existence of BPD across the
Americas, Europe, Australia and New Zealand, Africa, and
Eastern, Southern, and Western Asia suggests BPD is pre-
sent around the world.
Some scholars have suggested that BPD, though not a
culture-bound syndrome, may be more prevalent in Western
cultures when compared to non-Western societies [167, 168].
Based on our review, we found that BPD is prevalent across
the globe, with studies suggesting that about 0.7-3.9% of
10 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
adults and 3-14% of children and adolescents can be diag-
nosed with BPD. We did not find any evidence of higher
prevalence in non-Western countries; rather, rates seemed to
be similar in the countries where epidemiological investiga-
tions were conducted, regardless of their geographic loca-
tion[e.g., United States, China, Turkey, Germany, Norway].
Despite the rather low prevalence of BPD in the general
population, we found that across the world adults and ado-
lescents who meet criteria for BPD pose a significant burden
on inpatient and outpatient Psychiatric Services Up to 65%
of psychiatric patients met criteria for BPD, with the highest
rates in the United States, Peru, Italy, Sweden, and Argentina
and the lowest rates in Denmark, South Africa, China, and
India. These findings highlight the need for international
evidence-based treatments that are efficient and effective in
psychiatric settings to serve the needs of this group and to
reduce the existing burden on the mental health services.
Although an East/West distinction could not be made, we
did find trends in the prevalence data based on the cultural
dimensions examined, although these should be interpreted
with caution because they are based on a very small number
of studies that were primarily conducted on convenience
samples. First, we found few studies that examined the
prevalence of BPD in primary care settings[i.e., outside of
psychiatric hospitals and clinics]. The existing studies
showed a trend for a much lower prevalence of BPD in
feminine cultures[e.g., Spain; 0.2%] when compared to mas-
culine cultures[United States, United Arab Emirates; 4-6%].
A similar trend was found when examining samples of adults
who engaged in suicidal behavior prior to the study[e.g.,
attempted or completed suicide, self-harmed, had suicidal
ideation]. In these studies, rates of BPD in feminine cul-
tures[Taiwan, Finland, Turkey; 5-8%] were much lower than
in masculine cultures[South Africa, Brazil, India; 17-29%].
Across the world, countries with predominantly feminine
cultures also tended to have lower rates of BPD among psy-
chiatric inpatients[0.8-6%] than countries with masculine
cultures[1-54%]. Taken together, these trends may suggest
that being part of a feminine culture may be a protective fac-
tor either for the development of BPD or for problematic
behaviors that lead to suicide, primary care visits, or inpa-
tient stays. Feminine societies may foster an environment
where emotional expression is encouraged and, thus, where
more opportunities for validation may exist, which may re-
duce or lead to greater acceptance of BPD pathology.
Second, we also found a trend for higher prevalence of
BPD in outpatient settings in countries that are primarily
individualistic[9-27%] when compared to collectivistic coun-
tries[1-8%; but see exceptions] [120]. It is possible that seek-
ing outpatient help in individualistic cultures is more permit-
ted, while in collectivistic cultures families provide more
support and, therefore, the need for outpatient services may
not be seen. We did not find any patterns in BPD prevalence
rates between countries with low versus high power differen-
tial or with different tolerances of uncertainty.
Our findings are subject to limitations [see Table S2 for a
list for each study]. The first concerns sample representa-
tiveness. Countries with studies that used probability sam-
ples of the general population of the country or a part of the
country include only the United States, Germany, Norway,
Sweden, United Kingdom, Australia, and Turkey. Probabil-
ity samples of nonclinical students have been studied in parts
of France and China[mainland], and probability or consecu-
tive clinical samples or suicides have been studied in all or
part of Denmark, Finland, South Africa, and China[Taiwan].
However, studies in the remaining countries have[a] not
stated the sampling method,[b] used a convenience sample,
or[c] used probability or consecutive sampling at only a sin-
gle site or at a nonprobabilistically determined set of sites.
One study did not state a precise location [102]. For studies
that did not state the sampling method or that used a conven-
ience sample, the representativeness of the sample is un-
known. For studies that used probability or consecutive sam-
pling at one site or a nonprobabilistic set of sites, the sample
may be representative of the populations at the site[s] of the
study, especially if the sample is probabilistic, but it is un-
known whether the sample represents populations beyond
the site[s], which may be idiosyncratic. Prevalence estimates
from clinical sites and prisons, for example, can be distorted
by selection biases[e.g., Berkson’s bias] and may differ
across countries due to differences in treatment seeking, ac-
cess to mental health services, and legal systems rather than
to true differences in the rate of BPD. Second, it is important
that a study describe the number and characteristics of the
subjects it includes/excludes and the reasons for inclu-
sion/exclusion, especially for nonprobabilistic samples.
Additional limitations concern the validity and reliability
of the BPD diagnoses. Some studies did not state the diag-
nostic system [e.g., DSM-IV], others did not state the diag-
nostic method[e.g., IPDE], and one stated neither the system
nor the method [169]. In addition, some studies that stated a
method did not appear to use standardized instruments; in-
stead, they diagnosed BPD via chart review, psychological
autopsy, clinical interview, unstated clinical methods, un-
structured interview, or unstated structured interview. Of the
studies that used standardized diagnostic instruments, some
did not provide evidence of the validity and reliability of the
instrument used. A common case was to present the valida-
tion data for an original instrument when the authors used a
translation of that instrument. Another common problem
included not providing evidence of interrater reliability for
standardized interviews.
We also considered using only an interview or a self-
report[but not both] to diagnose BPD a limitation. Theoreti-
cal and empirical findings from several countries support the
use of multi-method, standardized assessments to diagnose
BPD [170-172]. While most researchers agree that use of a
self-report as a diagnostic tool may lead to a high number of
false positives, relying on interview data alone is also prob-
lematic because it may miss aspects of the patient’s presenta-
tion that informants could offer or that the patient would
disclose on a self-report. It is therefore recommended to start
the assessment of BPD with a questionnaire that has high
sensitivity, to follow this with an interview that has high
specificity [171], and to supplement as needed with standard-
ized assessments of informants.
Other potential limitations are pertinent but beyond our
scope. For example, to determine the impact of geography
per se, one would need to compare “demographically equiva-
lent” samples from different locations [166]. Even when
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 11
comparing BPD across countries using nationally representa-
tive probability samples, if the samples differ based on age,
gender, or another variable, it may be unclear whether any
difference in the prevalence of BPD is due to geography or
the other variable. Furthermore, without being able to ascer-
tain that measurement was done in a similar fashion across
studies, how BPD is assessed and diagnosed may lead to the
differences we hypothesize. Because we do not present data
from only demographically equivalent samples, with stan-
dardized measurements, any comparisons of BPD across
countries based on these data are subject to potential con-
founds of this kind.
More research is needed to better chart the geographical
prevalence of BPD and its interaction with cultural variables
that may influence its manifestation in different locations.
Furthermore, research that examines individuals’ cultural
values as they sync or clash with the predominant views of
their sociocultural groups [173] can also shed light on the
development and maintenance of BPD, as such differences
may lead to chronic invalidation, one of the hypothesized
risk factors for BPD [174].
GENDER AND TRANSSEXUALISM
Despite advancements highlighting that biological sex
carries less weight than gender-role endorsement, most BPD
research has focused on differences between the sexes. BPD
purportedly occurs more often among women than men [38,
175]. Each iteration of the DSM presents such a differential
prevalence; according the DSM-5, the female-to-male ratio is
3:1, a finding of meta-analyses of clinical studies [176]. The
DSM-III also lists gender identity as a type of identity distur-
bance in BPD [177], and some have suggested transsexual-
ism is a “severe manifestation” of such disturbance among
some people with BPD [178].
If BPD truly is more common among women, this differ-
ence may exist because women have[a] more frequent sexual
abuse and higher levels of certain biological features
[autonomic arousal, serotonin responsivity, frontal activity],
which may contribute to greater behavioral inhibition and
internalizing symptoms, and[b] higher levels of neuroticism
and/or differential socialization, which may contribute to
increased impulsive aggression [175]. However, the seem-
ingly greater prevalence of BPD among women may be illu-
sory. Kaplan [179] argued that borderline PD might appear
more prevalent among women because of gender bias in
DSM diagnostic criteria. Indeed, differences in the diagnosis
of PDs can arise via biased sampling; biased diagnostic con-
structs, criteria, and thresholds; biased application of diag-
nostic criteria; and biased assessment instruments [180].
Skodol and Bender [175] argued that diagnostic biases may
exist but that the greater rates of BPD found among females
in clinical settings are due in large part to sampling bias and
that only representative general population samples can re-
veal the true rate of BPD by gender.
In representative samples of the general population, rates
of BPD among females and males do not significantly differ
among adults [34, 35] or adolescents [39] in the United
States, Norway [55], or Australia [63], but findings in other
countries are mixed. In Great Britain, rates of BPD among
boys and girls do not significantly differ [54], but among
adults[16-74 years], more males have BPD[1.0% vs. 0.4%]
[53]. By contrast, more women than men have BPD in
Germany[1.3% vs. 0.9%] [51]. We did not find rates of BPD
by gender for representative general population samples of
other countries. Still, the reviewed studies suggest BPD is
not unequivocally more common in females; although it may
occur more often in females in some locations, in other
locations or in some age groups BPD may occur equally
often or even more often in males.
Even if BPD occurs equally often among males and
females, some evidence suggests it may manifest differently
by gender [181, 182], although little is known about BPD
among men and about gender differences because fewer men
with BPD appear at clinical settings [183] and few
researchers have analyzed gender [184]. First, men with
BPD tend to show more explosive temperaments and greater
novelty seeking than women with BPD, who tend to show
greater harm avoidance [182]. In addition, whereas
adolescent girls with BPD resemble adults with BPD, boys
with BPD are more aggressive, disruptive, and antisocial
[185] when compared to BPD men. Boys[11 years] with
BPD in Great Britain are also more likely to be impulsive
than their female counterparts [54]. Additionally, men with
BPD more often have substance use or intermittent exposive
disorder, and paranoid, passive-aggressive, narcissistic,
sadistic, and antisocial PDs, whereas women with BPD more
often have eating, mood, anxiety, and posttraumatic stress
disorders [182], and somatoform and histrionic PDs [186].
Finally, the men tend to seek substance use rehabilitation,
while the women tend to obtain pharmacological and
psychotherapeutic treatments [182] and in Austria are more
likely to obtain outpatient treatment after inpatient treatment
[187]. In sum, the males tend to be more explosive, novelty
seeking, aggressive, antisocial, disruptive, and impulsive and
to have different co-occuring disorders and treatment-
seeking patterns. These gender differences my be due to
neurobiological differences between men and women [188].
Nevertheless, some researchers have emphasized the
presence of more gender similarities than differences. For
example, Johnson et al. [184] found different rates of PTSD,
eating disorders, subtance disorders, and schizotypal,
narcissistic, and antisocial PDs among men with BPD and
women with BPD in the United States but argued that,
because these differences also exist in other populations,
they are not unique to BPD—although higher rates of other
PDs among men with BPD may reflect exaggerated forms of
typical gender differences in social relatedness.[Tadić et a l.
[189], made a similar argument for a German sample.] The
men and women also reported comparable rates of childhood
abuse, which may be a common risk factor. In Germany,
Banzhaf et al. [183] found gender differences in rates of
narcissistic and antisocial PDs, higher neuroticism among
women with BPD, and higher dissocial behavior among men
with BPD but found no differences in the DSM-IV BPD
criteria met by each gender—although others have, with
women more often showing paranoia/dissociation [186],
identity disturbance [184], and affective instability [189] and
men more often showing intense anger and impulsivity
[189]. Banzhaf et al. [183] also found no gender differences
12 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
in BPD severity or global impairment, consistent with other
studies [190]. Finally, some studies suggest men with BPD
and women with BPD show similar self-harm behaviors,
having no differences in self-cutting [191] and differing out
of 22 self-harm behaviors only on head-banging and losing a
job on purpose, which are more common in men [192];
however, others suggest self-mutilation is more common
over time among women than men [193]. These studies
suggest the gender differences in co-occuring disorders in
BPD populations reflect typical—or for some disorders,
exaggerated—gender differences of other populations.
Additionally, the genders show similar childhood abuse
rates, BPD severity, global impairment, and self-harm
behaviors.
Results on the relationship between transsexualism and
BPD have been mixed. On the one hand, Coid [178] found
that 15% of male and female offenders with DSM-III BPD in
high-security psychiatric hospitals in England had lifetime
transsexualism, a significant association. On the other hand,
Seikowski, Gollek, Harth, and Reinhardt [194] found that
88% of a sample of transsexuals in Germany did not report
problems associated with BPD and that other variables pre-
dicted BPD severity in the remaining 12%; the authors con-
cluded their data “refute the often-assumed increased rela-
tionship between [BPD] and transsexuality”[p. 141]. Singh et
al. [177] also found that no female psychiatric outpatients
with IPDE or DSM-IV BPD surpassed a cutoff for gender
dysphoria. Although transsexualism may be present in some
people with BPD, it is not present in all BPD samples, and
when BPD-related problems are found in transsexuals, these
problems may be explained by other factors.
In sum, despite claims that more women than men have
BPD, epidemiological studies suggest BPD can be equally
prevalent across sexes, more prevalent among men, or more
prevalent among women, depending on the study location
and age group. Males with BPD may show different
personality problems and treatment-seeking patterns than
females with BPD, but both men and women show
comparable childhood abuse rates, BPD severity, global
impairment, and self-harm behaviors. Gender differences in
co-occurring disorders exist, and these may reflect typical, or
for some disorders, exaggerated, differences of other
populations. One study suggests an association between
transsexualism and BPD, but others do not. Future research
should use epidemiological studies of various populations to
further assess the true prevalence of BPD by gender [175]
and the relationship between BPD and transsexualism. Such
studies should also include measures of gender-role en-
dorsement, such as the conformity to masculine and feminine
norms inventories [195, 196], to examine the effects of iden-
tifying with different gender roles and their relationship to
BPD. Longitudinal studies should also be used to further
explore causal pathways for BPD [175] and to assess the role
of gender on the course of comorbid disorders and on the
course, treatment, and remission of BPD [183, 190].
SEXUAL ORIENTATION
We did not find any studies on the prevalence of BPD by
sexual orientation, but studies suggest homosexuality is more
prevalent among people with BPD than among clinical
samples without BPD and the general population. For
example, more psychiatric inpatients with DIB-R and DSM-
III-R BPD reported homosexual or bisexual orientation
[27.2% vs. 15.3%] and same-sex relationships[36.6% vs.
18.1%] than those without BPD[but with other PDs] during a
10-year period [197]. However, the distribution of
homosexuality among people with BPD may differ along
gender lines.
Homosexuality seems particularly more prevalent among
men with versus without BPD. In the United States and
Canada, homosexuality was more prevalent in male
outpatients with DIB-R BPD[16.7%] than in non-BPD male
outpatients with other PDs[1.7%] [198], more prevalent in
consecutive male psychiatric outpatients with DSM-III
BPD[57%] than in male[5%] or female[0%] consecutive
depressed psychiatric outpatients without BPD [199], and
more prevalent in consecutive male psychiatric inpatients
with DIB BPD[53%] than in men in the general
population[4-5.2%] [200-202]. Dulit, Fyer, Miller, Sacks,
and Frances [203] found that consecutive male psychiatric
inpatients with DSM-III BPD[22% homosexual, 26%
bisexual] were less likely to be heterosexual than those
without BPD[44% vs. 78%] and more likely to be
homosexual than men of a similar age range in the general
population were to have rare-to-frequent homosexual
contact[up to 14%] [204]. Although these outpatient and
inpatient studies suggest homosexuality is more common
among men with versus without BPD, none identified the
rate of homosexuality among men who have BPD in the
general population—a rate that would allow a more valid
comparison.
Findings on the prevalence of homosexuality among
women with versus without a BPD diagnosis are mixed. On
the one hand, similar rates of homosexual or bisexual
orientation as that reported by Reich and Zanarini
[197][27.2% homosexual or bisexual] have been found
among consecutive female psychiatric outpatients with IPDE
or DSM-IV BPD[27% homosexual or bisexual; 9% and 18%,
in turn] in Canada [177] and among consecutive female
psychiatric inpatients with DSM-IV BPD[31.1% homosexual
or bisexual; 6.7% and 24.4%, in turn] in Germany, with a
nonsignificant trend for a greater rate of bisexuality among
this group[24.4%] compared to a group of healthy female
controls[6.7%] [205]. Moreover, Singh et al. [177] stated
that the rate of homosexual or bisexual orientation in each of
these studies was higher than the rate for women in the gen-
eral population[1.4%] [206]. In addition, homosexuality was
more prevalent in consecutive female psychiatric inpatients
with DIB BPD[11%] than in women in the general popula-
tion[1-2%] [200, 202, 207], and a sample of female outpa-
tients with MCMI-II and DSM-III-R BPD reported greater
sexual attraction to other women than did women without
PDs [208]. On the other hand, Dulit et al. [203] found no
significant difference in rates of heterosexuality in consecu-
tive female psychiatric inpatients with[73%] versus with-
out[89%] DSM-III BPD and found a rate of homosexuality
among those with BPD similar to the rate of homosexuality
among women in the general population[1-2%] [200]. In
addition, in Schulte-Herbrüggen et al. [205], a larger propor-
tion of the healthy female controls[13.3%] reported homo-
sexual orientation than the female psychiatric inpatients with
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 13
DSM-IV BPD[6.7%], though this difference was not signifi-
cant. Moreover, no significant difference in the rates of ho-
mosexual experiences was found between female internal
medicine outpatients with and without PDQ-4 or MSI
BPD[10.0% vs. 15.0%] [209] or between female psychiatric
inpatients with and without BPD [182]. In light of these dis-
crepant results among female psychiatric inpatients and out-
patients, the relationship between homosexuality and BPD
among women remains unclear.
Findings on the prevalence of homosexuality among men
versus women who meet criteria for BPD are also mixed.
Some studies have found that homosexuality is more com-
mon among psychiatric inpatients with DIB BPD who are
male versus female[53% vs. 11%] [199], that fewer consecu-
tive male than female psychiatric inpatients with DSM-III
BPD are heterosexual[44% vs. 73%], and that more consecu-
tive male than female psychiatric inpatients with DSM-III
BPD are homosexual[22% vs. 3%] [203]. In addition, Stone
et al. [210] found that rates of homosexual or bisexual orien-
tation in consecutive male versus female inpatients with
DSM-III BPD are 16% versus 1%, respectively. However,
one study found no significant difference in the rate of ho-
mosexuality or bisexuality between male and female psychi-
atric inpatients with DIB-R and DSM-III-R BPD[29.8% vs.
26.6%] [197]. Also, no significant gender differences in the
rate of bisexuality emerged between consecutive male and
female psychiatric inpatients with DSM-III or DIB BPD[26%
vs. 11%] [203]; 5% each [199]. Most of these studies, nota-
bly all of inpatient samples, suggest homosexuality is more
common in men versus women with BPD, but two found no
significant differences, leaving the distribution of homosexu-
ality by gender in people with BPD unclear.
Homosexual or bisexual orientation in people with BPD
is associated with childhood sexual abuse and family history
of such orientation, and some have proposed relationships
with impulsivity and identity disturbance. Paris et al. [198]
found reported histories of childhood sexual abuse among
significantly more male outpatients with DIB-R BPD who
reported sexual relationships with men than among those
who did not[100% vs. 37.3%], and Reich and Zanarini [197]
found a trend toward a significant association between a re-
ported history of childhood sexual abuse and homosexual or
bisexual orientation and/or same-sex relationships among
psychiatric inpatients with DIB-R and DSM-III-R BPD. Fur-
thermore, Kalichman et al. [211] found that gay and bisexual
men who had been sexually coerced scored higher on the
borderline personality scale of the SNAP [212] than those
who had not been coerced. Reich and Zanarini [197] found
that a reported family history of homosexual or bisexual ori-
entation was significantly associated with homosexual or
bisexual orientation and/or same-sex relationships among
such patients. Some researchers have suggested that higher
rates of homosexual behavior among people with BPD may
be due to impulsivity paired with identity disturbance [181]
and that a trend for a higher rate of bisexual orientation in
female psychiatric inpatients with DSM-IV BPD may reflect
identity disturbance [205].
Study of the intersection of BPD and sexual orientation
presents several methodological challenges. The varied
prevalence rates of sexual orientations we have seen across
studies may be due to different methods for assessing sexual
orientation[e.g., clinical interview, chart review, DIB] [197],
which can be defined in different ways[e.g., sexual attrac-
tion, self-definition, sexual behavior] [205, 206]. Reich and
Zanarini [197], for example, found that the rate of psychiat-
ric patients with DIB-R and DSM-III-R BPD who reported
same-sex relationships was higher than the rate of such pa-
tients who reported homosexual or bisexual orientation—a
finding clinicians should bear in mind to avoid implicitly
assuming a BPD patient who engages in homosexual behav-
ior also self-identifies as homosexual or bisexual [181]. Dif-
ferent rates may also be due to idiosyncratic samples [177].
BPD may also be misdiagnosed in homosexual or bisex-
ual clients. Eubanks-Carter and Goldfried [213] found that
clinicians tend to diagnose males they perceive as gay or
bisexual with DSM-IV BPD, and Falco [214] writes that les-
bians who are struggling with the process of “coming out”
may also present with impulsivity, anger, intense relation-
ships, and affective instability—effects that overlap with
BPD criteria. In addition, Ritter and Terndrup [215] point out
potential sexual orientation bias in BPD diagnoses based on
DSM-III, which included sexual impulsivity and uncertain
gender identity as criteria.[DSM-III-R included sexual impul-
sivity and uncertain sexual orientation as criteria as well]
[216]. Uncertain sexual orientation was removed from for-
mal BPD criteria in DSM-IV [25]. To differentiate sexual
identity crises from BPD, Gonsiorek [217] recommends that
clients’ histories be carefully examined; those with BPD will
exhibit “a chronic pattern of ‘stable instability,’ poor ego
differentiation, relatively primitive object relations, and split-
ting operations”[p. 14] in multiple domains—features usu-
ally absent in the histories of those experiencing acute sexual
identity crises rather than BPD. Ritter and Terndrup [215]
called for skepticism toward studies that find associations
between homosexuality and BPD in light of the complexity
of assessing sexual orientation.
Taken together, these studies suggest homosexuality is
more prevalent among people—particularly men—with
versus without a BPD diagnosis; findings among women
with versus without a BPD diagnosis and among men versus
women who meet criteria for BPD are varied. Additionally,
homosexual or bisexual orientation among people with a
BPD diagnosis is associated with childhood sexual abuse and
family history of such orientation. However, the results of
such studies should be considered with caution given several
methodological challenges. The intersection of BPD and
sexual orientation needs more research [197, 205], including
studies that use epidemiological samples and evaluate the
impact of same-sex relationships on BPD severity and func-
tioning.
RACE AND ETHNICITY
One study of the general population in the United States
and some studies of psychiatric and forensic samples in the
United States and United Kingdom suggest rates of BPD
differ among racial and ethnic groups; however, other gen-
eral population studies and a U.S. forensic sample suggest
BPD is equally distributed by race and ethnicity. BPD ap-
pears to manifest differently among different racial and eth-
14 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
nic groups; nevertheless, it appears to have construct validity
across them.
To start, results from studies of the U.S. general popula-
tion are conflicting. For example, in a nationally representa-
tive sample, Grant et al. [34] found that, on the Wave 2 Al-
cohol Use Disorder and Associated Disabilities Interview
Schedule, BPD was significantly more prevalent in Native
American men and significantly less prevalent in Asian
women and in Hispanic men and women than in White men
and women. However, analyzing rates of BPD derived from
multiple imputations in a nationally representative sample,
Lenzenweger et al. [35] found no significant differences in
race-ethnicity using the IPDE. In addition, Swartz et al.
[218] found no significant difference between Non-Whites
and Whites in rates of BPD on the DIS/Borderline Index in a
random sample of the Piedmont of North Carolina. Studies
of the general population of the United States are therefore
inconclusive.
Findings from studies of psychiatric and forensic samples
in the United States are also mixed. Although several studies
of psychiatric samples suggest rates of BPD differ along
racial and ethnic lines, a forensic study suggests BPD is
equally prevalent: Trestman, Ford, Zhang, and Wiesbrock
[219] found no significant racial differences or race-by-
gender interactions in the rate of DSM-IV BPD using the
SCID-II in 508 inmates across five adult jails in Connecticut.
In addition, the studies suggesting BPD is differentially
prevalent differ from the epidemiological study that
suggested differential prevalence in that they suggest BPD is
more, rather than less, common in Hispanics than in
Caucasians and in that they further suggest BPD is more
common in Hispanics than in African Americans. These
psychiatric studies also illustrate nuances that may differ
among racial and ethnic groups.
For example, in 554 psychiatric patients from Boston,
New Haven, New York, and Providence, Chavira et al. [220]
diagnosed DSM-IV BPD using the DIPD-IV more often in
Hispanics than in Caucasians and African Americans.
Hispanics endorsed more intense anger, affective instability,
and unstable relationships criteria than Caucasians, and
African Americans endorsed unstable relationships at a
higher rate than Caucasians. The authors suggested that the
higher rate of BPD in Hispanics may be due to acculturative
stress or diagnostic bias and called for more studies on
ethnicity and PDs. Despite the greater rate of BPD among
Hispanics, a subsequent study of 547 treatment-seeking or
recently treated participants from the same sites found
that, versus Whites, Hispanics and African Americans
with DSM-IV BPD on the DIPD-IV were less likely to have
ever received any psychotropic medication, especially
antidepressants, and to have ever been admitted to a
psychiatric hospital. Hispanics and African Americans also
attended fewer medication sessions than Whites [221].
In another study, Castaneda and Franco [222] reviewed
the medical records of 1,583 psychiatric inpatients
discharged from a New York hospital and found no
significant difference in rates of DSM-III BPD across ethnic
groups. However, whereas women had BPD significantly
more often than men, no gender difference emerged among
Hispanics. In addition, Hispanic men had BPD more often
than White and Black men, but no significant differences in
the rates of BPD among women emerged across ethnic
groups. The authors suggested the differences may reflect
actual differences or diagnostic bias.
Moreover, Akhtar, Byrne, and Doghramji [223] pooled
data on BPD among inpatients and outpatients from other
studies and found that patients with BPD tended to be
younger than those without BPD, that more women than men
tended to be diagnosed with BPD, and that, in the seven
studies that addressed race, fewer Black patients were
diagnosed with BPD than were present in control groups
without BPD. Regarding the racial difference, the authors
speculated that Blacks may be underrepresented in clinical
samples due to more frequent admission to the correctional
system. However, the authors stressed the limitations of
pooling data from studies with varying diagnostic criteria,
limited information on socioeconomic status, and
unspecified control groups and argued for a large,
prospective population survey on the prevalence of BPD.
Studies of forensic and psychiatric samples in the United
Kingdom suggest rates of BPD differ by race and ethnicity;
these studies are consistent with the U.S. epidemiological
study that suggested BPD is differentially prevalent in that
they suggest BPD is less common in South Asian men than
in White men, but the studies differ from the epidemiological
study[and the U.S. psychiatric studies] in that they suggest
BPD is less, rather than no more[or more], common in
Blacks than in Whites. For example, in 3,155 patients
compulsorily admitted to secure forensic psychiatric services
from seven regions in England and Wales, Coid, Kahtan,
Gault, and Jarman [224] found that Blacks received BPD
diagnoses less often than Whites. Similarly, in a cross-
sectional study of 3,142 prisoners across all 131 prisons in
these countries, Coid et al. [225] found that Black and South
Asian men were less likely to be diagnosed with DSM-IV
BPD based on the SCID-II than White men. Black women
were also less likely to be diagnosed with BPD than White
women, but this was only true in analyses not adjusted for
various factors. Black women with BPD also were less likely
to have been previously admitted to a psychiatric hospital
than were White women with BPD [226]. Although these
studies suggest BPD is differentially prevalent in the United
Kingdom, studies using samples of the country’s general
population are necessary to draw a more definitive
conclusion.
Some of the above studies that suggest the prevalence of
BPD differs by racial or ethnic group also suggest differ-
ences among the groups in the clinical profiles and treatment
histories of people who have BPD, and two additional stud-
ies reveal between-group differences in factor structure and
self- and other-harm behaviors. Regarding factor structure,
Selby and Joiner [227] gave nine IPDE screening questions
to a representative sample of 1,140 adults from the general
population in south Florida and, using a principal components
analysis, identified four factors[affective dysregulation,
cognitive disturbance, disturbed relatedness, behavioral
dysregulation] common to each ethnic group. Affective
dysregulation was the primary factor for Caucasians, but
cognitive disturbance was that for Hispanics and African
Americans. The authors suggested this may be due to
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 15
differences in the groups’ values and acceptance of emotion;
Hispanics and African Americans may be more open to
emotion than Caucasians. In addition, Hispanics and African
Americans may place a greater value on group cohesion,
which is disrupted by dissociation, feelings of emptiness, or
fears of abandonment [227].
In addition, the same study found that affective and
behavioral dysregulation correlated significantly higher for
Caucasians than for Hispanics and African Americans. The
authors reasoned that emotional expression and suicidality
may be related more strongly in Caucasians and that
Caucasians may exhibit suicidal behavior to express emotion
and may receive positively reinforcing repsonses to such
behavior from others. By contrast, expressing emotion via
suicidal behavior may be less accepted among Hispanics and
African Americans, who may get negative reinforcement
from others. Furthermore, impulsivity did not load on the
same factor for each group. Impulsivity loaded on cognitive
disturbance for Caucasians, on disturbed relatedness for
Hispanics, and on affective dysregulation for African
Americans. This may be due to different interpretations of
the item for impulsivity across groups or to sociocultural
differences [227].
With respect to harm behaviors, a study of 17 African
American and 27 White inpatients and outpatients with
DSM-IV BPD in the United States found that, after
controlling for setting and the presence of mood and
substance use problems, African Americans had and acted on
thoughts about harming themselves significantly less
frequently than Whites, and significantly more African
Americans than Whites had thoughts about harming others.
The authors suggested these differences may be due to
protective factors such as religiosity, family support,
negative community attitudes about suicide, and negative
beliefs about suicide among African Americans and to
outwardly directed righteous anger among African
Americans due to the “double stigma”[p. 93] of not only
having BPD, but also being a racial minority. The authors
also suggested it may be less culturally unacceptable among
African Americans with BPD to express thoughts about
harming others than about harming themselves [228].
Despite these differences in the manifestation of BPD,
the disorder seems to be a valid construct across racial and
ethnic groups. In a study of Hispanic outpatients assessed for
DSM-IV BPD with the S-DIPD-IV, affective instability was
the most frequently occuring problem and had the greatest
negative predictive power, and identity disturbance and
suicidality or self-injury were the least frequently occuring
problems, with suicidality or self-injury having the greatest
positive predictive power [229]—similar results to those
found in a study of a more ethnically diverse sample [230],
supporting BPD’s construct validity across Hispanic and
other cultures.
In short, results on BPD’s prevalence by racial and ethnic
groups are mixed; some studies suggest it is differentially
prevalent, but the rates from such studies show little
consistency across sample types and countries, and some
studies have found no significant group differences. If race
or ethnicity influences BPD’s prevlaence, it is likely only
one of many influential factors. After all, a meta-analysis of
15 studies on PDs and ethnicity conducted in the United
States and United Kingdom found that, although Blacks re-
ceived PD diagnoses significantly less often than Whites did,
country and specific PD, among other factors, may have con-
tributed to the heterogeneity of the studies’ results [231]. The
manifestation of BPD appears to differ across racial and
ethnic groups, and the disorder seems to be a valid construct
across them.
RELIGION
We did not find any studies on the prevalence of BPD
across different religious or spiritual frameworks, but a few
studies suggest a significant interaction between BPD and
religion and spirituality. For example, in a study of 4,800
psychiatric inpatients in the United States, atheists scored
significantly, although only mildly, higher than agnostic
patients and minimally, moderately, and strongly religious
patients on the borderline subscale—reflecting DSM-III
criteria—of the 42-item BPRS. The authors [232] suggested
this may be due to object inconstancy and splitting among
patients with BPD. In addition, Sansone, Kelley, and Forbis
[233] found that greater BPD severity assessed by the PDQ-4
and SHI was associated with lower overall levels of
religious/spiritual well-being over the prior year in a cross-
sectional sample of 308 internal medicine outpatients in the
United States. The authors stated that people with BPD may
“tend to come from homes with less [religion/spirituality]”
[p. 51]. They also proposed that lower levels of religious/
spritual well-being among people with a BPD diagnosis may
be due to “numerous early traumatizing experiences as well
as current re-victimization experiences[‘If there were a
higher force, how could this continue to happen to me?’]”[p.
51] or to genetics. Moreover, Sansone and Wiederman [234]
found that U.S. primary care outpatients who endorsed
having intentionally distanced themselves from God as
punishment on the SHI were more likely to score above
clinical cutoffs on the BPD scale of the PDQ-4 than were
those who did not endorse having done so, but a lack of data
on religiosity in this study makes it unclear whether BPD
severity is associated with religious belief, as one cannot rule
out the possibility that all participants were equally religious.
Some researchers [235] have concluded that religion and
spiritual well-being are not as compromised as general
psychological well-being in people with borderline traits,
although it is unclear what evidence supports this conclusion.
For example, Bennett et al. [235] conclude that “while
overall well being is reported as low, religious and spiritual
well being remains high”[p. 82], but they describe only
findings of lower religious and spiritual well-bieng among
people with borderline traits and claims that treatments with
religious and spritual components may benefit people with
BPD or borderline traits; they present no evidence that
religious and spiritual well-being are not reduced or are less
reduced than general psychological well-being in such
populations.
Studies from the United Kingdom reveal that only some
dimensions of religiosity are positively related to the
borderline personality traits scale[STB] of the Schizotypal
Traits Questionnaire[STQ] [236]. Maltby and Day [237]
found that extrinsic-personal orientation toward religion was
16 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
positively related to STB in men and that religious
experiences were positively related to STB in women, and
Joseph, Smith, and Diduca [238] found that the quest
approach to religion was positively related to STB. However,
Maltby and Day [237], along with Maltby, Garner, Lewis,
and Day [239], who studied college students, found that
intrinisic orientation toward religion was negatively related
to STB in men and that extrinsic-social orientation toward
religion was negatively related to STB in women. In
addition, White, Joseph, and Neil [240] found that positive
attitudes toward Christianity were negatively related to STB.
Reviewing these studies, Koenig, King, and Carson [241]
concluded that people who are religious/spiritually involved
are less likely to have BPD, and the authors called for more
research on the relationship between religion/sprituality and
PDs and on religious/spiritual interventions for PDs.
AGE
With regard to age, evidence suggests that the disorder is
more prevalent in youths, although it continues throughout
the lifespan. For example, in a random regional sample of
U.S. youths[9-19 years], 7.8% met criteria for at least
moderate BPD [39], while among representative samples of
U.S. adults, BPD is diagnosed in 0.5-3.9% of the population
[35-37]. The almost double prevalence rates in adults when
compared to youths have not been found only in the United
States. For example, in a comparison of young and old
Indians, Nath et al. [144] found that 28.6% of patients in the
younger group[15-24 years] and 13.8% of patients in the
older group[45-74 years] met criteria for BPD.
Impulsivity and deliberate self-harm are more common in
younger patients [242-244]. Older patients report poorer
quality of life, worse health, greater pain levels, and more
use of healthcare resources than younger patients [243].
Improvement in BPD severity occurs similarly within all age
groups, although some evidence of decline in functioning for
older adults with BPD could be found [245].
DISABILITY
There have been few examinations of differences in BPD
prevalence and presentation between able and disabled
groups. All research found was conducted in the United
States or Canada. While results are mixed, most of the well-
controlled studies point towards a higher incidence of BPD
in those with physical, cognitive, social, or medical
disability. In an examination of a nationally representative
epidemiological sample that included assessment of BPD,
Grant et al. [34] found that when compared to those without
BPD, respondents who met criteria for BPD scored
significantly higher on a disability self-report, even when
sociodemographic characteristics, medical conditions, and
other psychiatric disorders were controlled for. Women with
a lifetime diagnosis of BPD reported significantly higher
disability than men with a BPD diagnosis. A different
examination of over 1,500 consecutive patients with work-
related chronic musculoskeletal pain disability found that the
prevalence of BPD in this sample was almost 7 times higher
than in the general population [i.e., 27.5% of participants
met criteria for BPD]. While the assessment instrument
used[SCID-II] does not allow a temporal examination of
BPD and work-related disability, it highlights that this group
is at increased risk for BPD [246]. A longitudinal
examination of receiving disability income also shows that
those diagnosed with BPD are 3 times more likely than
adults diagnosed with other PDs to receive social security
disability income over a 10-year span [247]. We could find
only one study where no significant difference was found in
BPD prevalence for chronic pain patients who did or did not
receive medical disability [248]. This study also had a
limited convenience sample[117 chronic pain patients] and
used a self-report[PDQ-4] to diagnose BPD.
In a Canadian sample, when comparing the scores on an
established disability measure with existing norms, adults
with a BPD diagnosis were classified as scoring in the top
20% with regard to reported severity of difficulties with
mobility and self-care. Cognitive disability placed them in
the bottom 10% compared to norms, and social impairment
placed them in the bottom 5%. Interestingly, first-degree
relatives scored consistently higher than BPD subjects but
when compared to controls were also reporting more
physical, cognitive, and social disability. Based on additional
analyses, the authors conclude that problems with inattention
and forgetfulness are more common in BPD when compared
to controls and may lead to difficulties carrying out basic
self-care and occupational activities. The study had a small
sample size[26 BPD adults, 17 first-degree relatives, 31
healthy controls] and used a convenience sample [249].
Nevertheless, it provides preliminary insight into the
potential mechanisms through which disability and BPD
may be related.
Taken together, these studies highlight the importance of
continuing to assess the prevalence of BPD in disabled
samples given that the incidence of disability is higher in
BPD samples when compared to non-BPD samples. It
should be noted that no epidemiological study of disability
that includes BPD rates could be found, which limits the
conclusions we can draw about the prevalence of BPD in
disabled samples. In addition, we could not find any
empirical investigation of BPD prevalence in those who have
learning, developmental, or intellectual disabilities, although
these types of difficulties at least in theory can increase
vulnerability to development and maintenance of BPD. Thus,
additional examination is needed. Furthermore, cross-
national studies of disability and BPD are also needed,
especially given the different approaches to disability that
are taken by individualistic versus collectivistic cultures[i.e.,
supporting independence versus taking over needs] [21, 22].
MARITAL STATUS
Demographic descriptives such as marital status are
reported in the majority of studies where BPD samples are
included and have been the topic of few independent
investigations. Evidence from epidemiological trials suggests
that adults who are single are more likely to meet criteria for
BPD. For example, a BPD diagnosis was twice more likely
to happen in adults who were separated/divorced/widowed
[8.4%] or never married[8.7%] than in those who were mar-
ried or cohabitating with a partner[4.4%] [34]. Although
marriage may seem to be a protective factor for BPD, docu-
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 17
mented problems among those who meet criteria for BPD
who are married show that these individuals are at higher
risk of losing their relationships than their non-BPD counter-
parts. In couples with at least one BPD partner, there are
significantly more conflicts, acts of marital violence, and
breakups, and relationship satisfaction is significantly lower
when compared with couples where neither of the partners
meets criteria for BPD [250, 251]. Women who meet criteria
for BPD also report significantly stronger negative attitudes
towards sexual relationships with partners, feel more sexu-
ally pressured by partners, and have ambivalent feelings
about their sexuality when compared to their non-BPD coun-
terparts [250]. While these studies highlight that additional
nuances can be expected in the presentation of a married
patient with BPD, more causal studies are needed to further
understand the protective and detrimental aspects of relation-
ships within BPD psychopathology.
SOCIOECONOMIC STATUS
Findings have been mixed with regard to the association
between BPD and socioeconomic status[SES]. Three cross-
sectional studies found no differences between patients with
BPD and other psychiatric patients without BPD in terms of
SES [252-254]. Data from a general population studied
longitudinally, however, reflect an association between BPD
and SES [255]; particularly, a one standard deviation
increase in family SES was associated with an approximately
2-unit decrease in BPD severity. Another 6-year prospective
study by Zanarini et al. [256] found that remitted BPD
patients came from significantly higher SES backgrounds
compared to patients with BPD who did not recover. The
study also found that those who did not recover engaged in
significantly fewer forms of psychiatric treatments prior to
their admission, suggesting that unequal access to treatment
may be a reason that underlies the association between SES
and recovery from BPD in this sample. Lastly, a study by De
Genna and Feske [257] that examined the association
between race and BPD in a sample of White and African
American female patients with BPD found that SES
mediated the relationship between race and several
internalizing and externalizing problems associated with
BPD. Specifically, being African American was associated
with having lower SES, which in turn predicted greater
externalizing problems such as anger and aggressive
behaviors. The nature of the mediated relationship among
race, SES, and internalizing problems[e.g., trait shame, guilt]
was not reported in this study.
IMMIGRATION
Immigration has been proposed as a risk factor for BPD.
Paris [11] argued that BPD may emerge in response to psy-
chosocial risk factors such as a lack of sociocultural integra-
tion, which he noted as a phenomenon more prevalent in
modernized Western societies than developing, traditional
societies. He further hypothesized that immigration, specifi-
cally from a developing country to a more modernized soci-
ety such as North America, puts individuals at greater risk
for developing BPD. Other researchers have proposed and
found that a mismatch between personality styles[e.g., allo-
centric vs. idiocentric personality orientation] and prevailing
cultural values[i.e., collectivism vs. individualism] may put
individuals at greater risk for psychological distress [173].
One study in Spain [258] reviewed 11,578 consecutive
psychiatric emergency admissions over a 4-year period and
found that immigrants were less likely to be diagnosed with
BPD than the indigenous group. These studies suggest that,
contrary to Paris [11]’s hypothesis, immigration is not a risk
factor for BPD. Methodological issues such as potential
biases in cross-cultural assessment of BPD and potential
under-representation of immigrants[e.g., certain subgroups
of immigrants are less likely to seek psychiatric help due to
their illegal status], however, limit firm conclusions
regarding the hypothesis [258]. Future research with greater
methodological rigor is needed to establish more
conclusively whether immigration is a risk factor for BPD.
URBANIZATION
There is limited research explicitly examining differences
in BPD prevalence and presentation in rural versus urban
settings. However, one notable exception is work conducted
by Tousignant and Kovess [259], who investigated rural-
urban differences in BPD characteristics among community
alcoholics and problem drinkers in Quebec. This investiga-
tion found that alcoholics who endorsed problems consistent
with BPD were more likely to be from urban areas than al-
coholics without BPD characteristics [259].
Several additional studies have conducted secondary
analyses on urban-rural differences in BPD. These findings
are mixed, with some studies supporting heightened preva-
lence of BPD in urban settings and others finding no consis-
tent relationship. For example, secondary analyses conducted
with a community sample of individuals living in England,
Wales, or Scotland found a trend towards significance for
adults diagnosed with BPD living in urban locations, relative
to[semi-]rural locations [260]. More general findings also
highlight an elevated prevalence of PDs in urban settings
[51].
By contrast, a study investigating sociodemographic
characteristics of PDs in a Swedish community sample found
no significant differences in BPD prevalence between indi-
viduals living in urban versus rural settings [56]. This is con-
sistent with findings indicating no difference in BPD preva-
lence amongst Chinese undergraduates from rural versus
urban settings [261]. Mixed findings concerning the impact
of urban versus rural settings on BPD prevalence and treat-
ment retention [262] highlight the need for more data clarify-
ing these relationships.
SUMMARY
Although BPD has been said to occur more often among
women than men, epidemiological studies from the United
States, Australia, and Norway suggest BPD is equally
prevalent across genders, but future epidemiological research
is needed to resolve mixed results found in other countries.
Males and females with BPD exhibit different types of
personality-related problems and treatment-seeking behaviors
but report comparable child abuse rates, severity of illness,
global impairment, and self-harm behaviors. Future
epidemiological research is also needed to resolve mixed
18 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
findings about the relationship between BPD and
transsexualism. Homosexuality appears more prevalent
among people—particularly men—who meet versus do not
meet criteria for BPD, but findings among women with
versus without a BPD diagnosis and among men versus
women diagnosed with BPD are mixed. Studies from the
United States and United Kingdom suggest BPD may vary
across racial and ethnic groups, but the rates from such
studies show little consistency, and other studies from the
United States suggest BPD is equally prevalent. BPD seems
to manifest differently among such groups even though it
appears to be a valid construct across them. Given theoretical
hypotheses that ethnic minorities may have a disproportion-
ate burden of illness [2], studies should refine their assess-
ment measures to examine whether this claim is true with
regard to BPD. Rates of BPD are higher in youth than in
older adults, with impulsivity and self-harm being more
prevalent in younger groups, and poorer health and increased
negative affect being more frequent in older groups. Fur-
thermore, the incidence of disability is higher in BPD sam-
ples when compared to non-BPD samples, which warrants
additional investigation of this relationship in this high-risk
group.
Adults who are single are more likely to meet criteria for
BPD, although those who are in a relationship and meet cri-
teria for BPD are at higher risk for exacerbated interpersonal
problems. BPD may be associated with lower levels of
religion and spirituality, a set of findings that alligns well
with theoretical arguments that religion may offer a success-
ful coping resource for those with mental illness [2].
Nevertheless, studies from the United Kingdom suggest that
some dimensions of religosity are positively related to BPD.
Finally, immigration has been proposed to be a risk factor for
BPD [2], but findings of lower rates among immigrants
suggest immigration may in fact not be a risk factor,
although research with more methodological rigor is needed.
Findings have been mixed with regard to the association
between BPD, SES, and urban living.
TREATMENTS FOR BPD ACROSS THE GLOBE
Treatment research on BPD has primarily been con-
ducted in the United States and in other westernized cultures.
Various approaches have been developed to treat BPD, in-
cluding cognitive behavioral approaches, pharmacological
approaches, and psychodynamic approaches. We begin the
treatment section by briefly describing the main approaches
to treatment and their empirical support[contextualized geo-
graphically], as well as summarizing available literature on
the role of cultural factors[particularly, sociodemographic
variables] in moderating the effects of these interventions.
COGNITIVE BEHAVIORAL APPROACHES
Cognitive-behavioral therapies[CBTs] identify how prob-
lems with thoughts, emotions, and behaviors contribute to
the development and maintainance of psychopathology.
CBTs take a problem-focused, action-oriented approach to
changing maladaptive thoughts, feelings, and behaviors and
have the most evidence base for the treatment of BPD. For
example, a RCT conducted in the UK highlighted that that
adding CBT to TAU was cost-effective [263] and resulted in
greater improvement in symptom distress, state anxiety, dys-
functional beliefs, and suicidal acts [264].
A particular type of CBT, DBT, is considered the gold
standard for the treatment of BPD because of its empirical
support. DBT was originally developed as a treatment for
chronic suicidal and self-injurious behaviors, which typically
characterize patients with severe BPD [174]. DBT is based
on the conceptualization of dysfunctional behavior as a con-
sequence of an underlying emotional dysregulation, which
involves intense negative affect and an inability to modulate
that affect. DBT integrates elements of traditional CBT with
Zen philosophy and has a simultaneous focus on both accep-
tance and behavior change strategies to help clients improve
their emotion regulation abilities [174, 265].
To date, a total of fourteen controlled trials have been
conducted to examine the efficacy of DBT in treating BPD.
Nine of these trials were conducted in North America. Four
of these trials were conducted in Europe[Germany, Spain,
and the Netherlands], and one trial was conducted in Austra-
lia. Two recent meta-analyses summarize these trials on the
efficacy of DBT [266, 267]. They conclude that DBT is ef-
fective in reducing self-injurious and suicidal behaviors in
BPD [see Table S3]. Panos et al. [267] further found that
DBT was better than TAU in reducing attrition during treat-
ment in several of the studies reviewed. Limitations of these
meta-analyses include a small number of reviewed studies
and use of only published studies. Since these meta-analyses,
more studies evaluating the efficacy of DBT have been pub-
lished. For example, a controlled study by Roepke et al.
[268] based in Germany found that DBT resulted in signifi-
cant improvements in self-esteem and clarity of self-concept
among BPD women. Among various established treatments
for BPD to date, DBT has received the most empirical sup-
port.
Systems Training for Emotional Predictability and Prob-
lem Solving[STEPPS] [269], is a manualized intervention
that combines CBT principles with a systems component
designed to educate significant others about BPD in order to
foster an adaptive social network. The treatment involves
weekly skills training groups with the patient. Several RCTs
and preliminary studies have examined the effectiveness of
STEPPS in treating BPD in the United States [269-271] and
in the Netherlands [Table S3] [272, 273]. Despite methodo-
logical limitations in some of these studies[e.g., small sample
size and lack of a control group in Black et al. [270]’s
study], they provide substantial evidence for the effective-
ness of STEPPS as an adjunctive treatment for BPD in the
United States and in Europe.
Some types of CBT put a bigger emphasis on cognitive
work. For example, Cognitive Therapy[CT] emphasizes the
contribution of thoughts and attributions to psychopathology
and primarily focuses on patients and therapists working
together to identify, challenge, and restructure problematic
ways of thinking in hopes of promoting a more adaptive
worldview [274]. Applied to BPD, the goal of CT is to ad-
dress extreme, negative beliefs that maintain behavioral and
interpersonal difficulties [275]. Two studies have examined
the effectiveness of CT in treating BPD: an open trial con-
ducted in the United States [275] and a RCT conducted in
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 19
France [see Table S3] [276]. Findings from the open trial
indicate CT was effective in reducing BPD-related problems,
depression, hopelessness, and suicidal ideation [275]; how-
ever, results from the RCT revealed no differences between
CT and Rogerian supportive therapy other than improved
treatment retention with CT [276].
Schema-focused therapy[SFT] [277] is based on the sup-
position that children develop stable patterns of think-
ing[schemas] in childhood. Maladaptive early schemas may
persist into adulthood and contribute to dysfunctional behav-
ioral patterns in later life. The goal of SFT is to identify,
challenge, and modify early schemas to promote more adap-
tive affect, cognition, and behavior. The efficacy of SFT as a
treatment of BPD has been investigated by RCTs conducted
in the United States [278] and in the Netherlands [279, 280],
as well as in preliminary investigations in Norway [281][see
Table S3]. Overall, these studies showed that SFT is effec-
tive in improving recovery and reducing clinical dysfunction
in BPD. The findings however need to be considered in light
of certain limitations such as inclusion of only female par-
ticipants in the study [278] and heterogeneous qualifications
among therapists delivering the intervention [279, 280]. In
addition, examination of this treatment in other cultures is
needed.
Schmidt and Davidson’s Manual Assisted Cognitive
Treatment [MACT] [282] is a brief treatment that in-
corporates elements of cognitive therapy, DBT, and
bibliotherapy. There have been two small-scale RCTs
examining the effectiveness of MACT in treating BPD
[see Table S3] [283, 284]. Despite methodological
limitations[e.g., small sample sizes] these preliminary
studies suggest MACT may be useful as an adjunctive
intervention especially in reducing NSSI in BPD. The
efficacy of the treatment has only been established
within the United States, and there is a need to exam-
ine the effects of the treatment in other cultural con-
texts.
All studies on the efficacy of cognitive behaviorally ori-
ented treatments for BPD have been conducted in Western
countries, such as the United States and several European
countries, which limits the generalizability of these findings
to other cultural or national contexts. Of the reviewed stud-
ies, only a few examined the role of cultural[specifically
demographic] factors as potential moderators of the effects
of treatment of interest. Black et al. [270] examined the effi-
cacy of STEPPS in treating BPD and found that men had
greater improvements than women on general distress but
education did not have any impact. Another study on DBT
found that neither age nor employment status moderated the
efficacy of the treatment [285]. Lastly, Davidson et al. [286]
similarly found that age, employment status, and education
did not influence the effects of CBT for patients with BPD.
PSYCHOPHARMACOLOGICAL APPROACHES
There has been substantial research investigating the effi-
cacy of psychopharmacological treatments of BPD. This
body of work has examined several classes of medications,
including antipsychotics, mood stabilizers, antidepressants,
and vitamin supplements. Although no single drug seems
capable of eliminating all symptoms of BPD [287-289], there
is evidence that certain classes of medication may be effec-
tive in treating specific domains of dysfunction common to
BPD. Understanding the impact of these medications may
help clinicians decide whether medication may be a useful
adjunct to treatment, and if so, which medication to choose.
Drawing from multiple reviews and meta-analyses con-
ducted on this topic [289-293], we have identified 29 RCTs
investigating psychopharmacological interventions for BPD.
Eighteen of these investigations were conducted in the
United States, and 11 were conducted in Europe[including
Ireland, Belgium, Germany, Austria, Spain, and the Nether-
lands]. Collectively, these studies suggest that certain first-
and second-generation antipsychotics[e.g., haloperidol, olan-
zapine, ziprasidone, flupenthixol, decanoate, thiothixene,
aripirazole] may be useful in treating anger, aggression, in-
terpersonal dysfunction, impulsivity, and psychotic symp-
toms in BPD[see Table S3]. Certain mood stabilizers[e.g.,
valproate semisodium, selective serotonin reuptake inhibi-
tors] have also been found effective in addressing elements
of dysfunction in BPD, particularly anger, interpersonal dys-
function, impulsivity, and affective instability [293, 294].
Investigations on antidepressants have produced mixed find-
ings, but suggest a potential effect on anger and affective
instability. Finally, omega-3 fatty acid supplements may be
effective in reducing suicidality and self-mutilating behav-
iors in BPD. None of these studies examined the role of cul-
ture as a moderator of the effects of medications for the
treatment of BPD, even though there is substantial evidence
that cultural factors [e.g., ethnicity, race] influence an indi-
vidual's responsiveness to medication.
PSYCHODYNAMIC APPROACHES
Two psychodynamic approaches developed to treat BPD
in the United States have received the greatest attention:
transference-focused psychotherapy [TFP] [295] and men-
talization-based treatment[MBT] [296]. TFP was developed
based on conceptualization of BPD from an object-relations
perspective [297]. The focus of TFP is on the integration of
good and bad representations of self and others and on the
resolution of fixed, primitive internalized object relations.
Primary treatment techniques used include exploration, con-
frontation, and interpretation within the transference rela-
tionship between the patient and the therapist. The treatment
follows the following hierarchy of targets:[1] containment of
suicidal and self-destructive behaviors,[2] therapy-destroying
behaviors, and[3] identification and recapitulation of domi-
nant object relational patterns, as experienced in the transfer-
ence relationship [298].
To date, three randomized controlled trials[RCTs] have
evaluated the effectiveness of TFP in treating BPD in the
United States [299], in Austria and Germany [300], and in
the Netherlands [279]. A summary of the findings of these
studies can be found on Table S3. Taken together, these
studies found that TFP is effective in reducing psychological
and behavioral problems commonly associated with BPD,
such as suicidality, depression, anxiety, and anger, although
the quality of the RCTs conducted on this treatment[e.g., no
adherence indicators for the primary interventions] dampens
20 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
the strength of these conclusions. No differences between
countries were identified.
MBT is a psychodynamic treatment grounded on princi-
ples of attachment and cognitive theory. The goal of MBT is
to increase clients’ capacity for mentalization and to facili-
tate a more complete, integrated sense of mental agency. To
date, two randomized trials[both conducted in the United
Kingdom] have evaluated the effects of MBT in treating
BPD [see Table S3]. These studies found that MBT is supe-
rior to standard psychiatric care or structured clinical man-
agement in lowering severity of psychopathological prob-
lems, number of suicidal and self-injurious acts, and number
of inpatient days, and in improving social and interpersonal
functioning [296, 301]. Limitations of these studies include a
small sample size [296] and potential allegiance effects[i.e.,
evaluation of treatment carried out by the treatment develop-
ers themselves]. No data for this treatment in other countries
were found.
Two time-limited psychodynamic interventions have also
been investigated as potential interventions for BPD: psychic
representation focused psychotherapy [PRFP] [302] and se-
quential brief Adlerian psychodynamic psychotherapy[SB-
APP] [303]. PRFP is a manualized, time-limited psychody-
namic treatment based on classical psychoanalytic principles,
which focuses on distorted psychic representations. SB-APP
is a time-limited psychodynamic therapy focused on Alfred
Adler's theories of personality functioning levels. Prelimi-
nary RCTs conducted on these two interventions[in Spain
and Italy, respectively] have shown promising results in sup-
port of the treatments’ efficacy in reducing problems associ-
ated with BPD [302, 304]. These studies are characterized by
limitations such as small sample sizes and need to be repli-
cated in other countries.
In sum, there is evidence that several psychodynamically-
oriented therapies, particularly TFP and MBT, may be prom-
ising treatments for BPD although additional, higher quality
studies are needed. However, given that these studies are
conducted exclusively in the United States or Europe, the
findings may not be generalizable to non-U.S. or -European
contexts. Also, none of these studies examined cultural vari-
ables[e.g., SES, ethnicity] as factors that could potentially
moderate the effects of the investigated treatment, with the
exception of Bateman and Fonagy [296], who found that
demographic variables[i.e., age, gender, marital status, and
education] generally did not moderate the effects of MBT on
problems associated with BPD.
INTEGRATIVE APPROACHES
There are several BPD interventions that do not fit neatly
into the categories of CBT, pharmacological, or psychody-
namic approaches, but rather combine elements of multiple
disciplines. Two such treatments are cognitive analytic psy-
chotherapy[CAT] [305] and interpersonal psychother-
apy[IPT] [306]. CAT is a time-limited therapy developed in
the United Kingdom and examined in Australia [307] that
incorporates elements of both psychodynamic object rela-
tions theory and cognitive psychology. Findings thus far [see
Table S3] suggest that adjunctive CAT may be beneficial in
reducing self-harming behavior in BPD; however, outcomes
in the CAT group were not significantly different from the
control group. Additionally, these findings were based on a
group of adolescents with BPD features and may not gener-
alize to adults who meet full criteria for BPD. An analysis of
factors associated with successful remission from BPD fol-
lowing CAT that was conducted in the United Kingdom
suggests that CAT may be particularly effective for indi-
viduals with low BPD severity, no history of self-harm, and
no comorbid alcohol abuse [308].
IPT is a manualized, time-limited therapy that combines
psychodynamic therapeutic techniques with CBT elements
such as assigned homework and structured interviews. Al-
though originally intended to treat major depression, an ad-
aptation of IPT has been developed by Markowitz et al. that
is specifically intended as an intervention for BPD[IPD-
BPD] [309]. One RCT of IPT-BPD conducted in Italy found
that combined pharmacotherapy and IPT-BPD produced
more improvement in anxiety, interpersonal relationships,
affective instability, and impulsivity than medication alone
[310]. However, there was no significant reduction in BPD
severity or remission, and exclusion of comorbid disorders
limits the generalizability of findings. In conclusion, evi-
dence suggests that current adjunctive integrative approaches
do not have significant benefits in reducing BPD severity,
over and above control conditions.
DISCUSSION AND FUTURE DIRECTIONS
BPD is a complex and severe psychiatric disorder found
throughout the world that is characterized by a diverse con-
stellation of culturally influenced problems across interper-
sonal, emotional, behavioral, and cognitive areas of function-
ing. Although the DSM-5 emphasizes the importance of cul-
ture when considering the diagnostic criteria of BPD, clini-
cians need guidance in ways to conduct culturally sensitive
assessments of BPD. However, with few exceptions, the
influence of culture has not been carefully considered in the
recent surge of research investigating the etiology, mainte-
nance, and neurobiological underpinnings of BPD. Accord-
ingly, the purpose of this cross-cultural review of BPD was
to identify cultural factors that may influence the assessment
and treatment of adults and adolescents meeting criteria for
this disorder. We found that BPD is present across the globe
and that cultural dimensions may influence prevalence. We
also found a disproportionate burden posed by this disorder
on mental health services considering the prevalence of BPD
in inpatient and outpatient settings when compared to the
prevalence in the general population. This finding suggests
that it is imperative to identify and treat this disorder across
the globe. We identified sociocultural groups in which risk
for BPD is higher[e.g., those who are young, disabled, sin-
gle, or in the LGBTQ community], and cultural variables
that are protective against the development of BPD[e.g., re-
ligious beliefs]. We also provided evidence against hypothe-
ses that BPD is more prevalent in Western countries or that it
is a disorder that primarily affects women. Assessments and
treatments for BPD have been translated and adapted in sev-
eral countries and used with various levels of success. Over-
all, the research provides important insights into BPD as a
global problem and offers clear areas where additional re-
search may be needed or may be most beneficial.
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 21
In the following section, we discuss some of our deci-
sions taken when structuring the data presented in this re-
view. We also present additional theoretical considerations
in the assessment and treatment of BPD that were not cap-
tured by the data-driven review. It is important to highlight
that the following sections should primarily be read as offer-
ing opinions and hypotheses that could influence future di-
rections for research in BPD.
DECISION TO DEFINE CULTURE AS GROUP
MEMBERSHIP
In our review we chose to define culture as group mem-
bership, which is in line with most of the contemporary re-
search in social and clinical psychology where culture is
synonymous with society, nation, or ethnicity [17, 311]. Al-
though this view of culture is widespread, it has many prob-
lems such as leading to stereotyping and promoting use of a
single criterion to understand one’s behavior that could be
irrelevant or not representative [18, 166, 311]. Many re-
searchers argue that culture is better understood as a complex
phenomenon that dynamically emerges in interactions be-
tween people, that consists of shared elements, and that is
transmitted across generations [166]. Unfortunately, the re-
search on BPD and culture does not allow an examination
based on a more complex definition. Therefore, while we are
aware of the limitations and criticism that come with a group
membership definition of culture, operationalizing culture in
this way allowed us to begin the discussion of cultural fac-
tors that may influence presentation, prevalence, and treat-
ment of BPD.
With regard to the particular groups we chose to exam-
ine, there is no consensus in the literature to establish what
grouping variables are most relevant to culture. Most exami-
nations of culture and psychopathology commonly examine
groups defined by ethnicity, race, and gender [2] without
providing specific rationales for their choices. We attempted
to make our review more comprehensive by identifying
frameworks that break cultural identity into membership in
several groups and examining evidence within each of these
groups. The chosen frameworks overlap with conceptualiza-
tions presented by others. For example, Hays [312] presents
a model of cultural identity[ADDRESSING] that includes
membership in groups defined by age, developmental or
acquired disabilities, religion and spiritual orientation, eth-
nicity, SES, sexual orientation, indigenous heritage, national
origin, and gender. This model differs from Sue & Sue’s [20]
by breaking down geographic location into indigenous heri-
tage and nation of origin. The research we summarized does
not permit comparisons or summaries on these dimensions;
nevertheless, it may be an interesting future direction to
parse out within each geographical location differences in
BPD prevalence and treatment based on origin and heritage.
We chose to include Hofstede’s [21] cultural dimensions
to provide additional depth to our analysis. More recently
Hofstede et al. [22] presented two additional dimen-
sions[short- vs. long-term orientation and indulgence vs.
restraint]. Because of limited empirical investigation of these
two additional dimensions, we decided to not include them
in the present analyses. There are also other frameworks that
are fundamentally different from Hofstede’s dimensions. For
example, Tanaka-Matsumi [313] encourages culturally in-
formed research to examine self-orientation, values, family
structure and social support, and individualism and collectiv-
ism orientations. Future research that clarifies definitions of
culture, relevant group membership, and what dimensions of
culture are most appropriate or useful in BPD research could
greatly help this field.
IMPORTANCE OF CONTINUING TO CONDUCT
RESEARCH ON BPD AND CULTURE
A PD is “an enduring pattern of inner experience and
behavior that deviates markedly from the expectations of the
individual’s culture” [26] in a way that causes significant
clinical distress and impairment in social and occupational
functioning. The fact that culture is part of the definition of a
PD highlights the importance of cultural understanding of
distress and impairment when assessing, understanding, and
treating BPD. The marked variation in how personality is
understood across the globe is highlighted by the lack of a
diagnosis for PDs in non-westernized cultures where the
construct of a dysfunctional personality may not fit with the
culture’s conceptualization of the human experience. For
example, in Confucian cultures someone who exhibits prob-
lematic behaviors consistent with a PD is someone who has
not achieved Xiu Yang[a personality quality assurance proc-
ess that aligns one with Confucian ideals] [17]. Thus, from
the perspective of Confucian cultures a personality can only
be disordered momentarily, and individuals have the power
to rehabilitate their own personality through education and
through Xiu Yang [171].
The current research on BPD across sociocultural groups
brings about exciting conclusions and future directions. Nev-
ertheless, the theoretical premises above suggest that simply
translating diagnostic criteria, assessment instruments, and
treatments for PDs in other cultures may lead to erroneous
estimations of prevalence, problematic treatment, and lost
opportunities to understand additional nuances that could
enhance treatment. As applied to BPD, a disorder that can be
lethal, costly, and devastating to families and the economy,
careful consideration of the interplay of culture, assessment,
and treatment of this PD may be crucial. For example, un-
derstanding the societal invalidation of assuming that educa-
tion and Xiu Yang should be enough to “resolve” problems
consistent with BPD can greatly enhance treatments where
recovering from invalidation is targeted and can also help
epidemiological researchers identify under-reporting of this
problem. Furthermore, incorporating the process of Xiu
Yang in treatment could greatly increase its appeal and the
client’s motivation to engage in learning how to change
problematic behaviors.
Additional evidence for the importance of continuing
research and developing more nuanced assessments and
treatments for BPD comes from criticisms highlighting that
the BPD diagnosis lacks cultural sensitivity. Researchers
have argued that there is a sex [314] and a racial [26, 315]
bias embedded in the BPD diagnostic system. Attempts to
implement the DSM in other cultures also highlight differ-
ences in clinical presentations that may be missed by the
current diagnosis [316, 317]. For example, in Argentina,
Leiderman et al. [316] surveyed 116 mental health profes-
22 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
sionals. They found that professionals had difficulty assess-
ing with the DSM and tended to rely on the impulsivity and
affective instability criteria to diagnose BPD. Sharan [318]
commented on the challenges involved in assessing several
features of BPD in India, including labeling occupational
avoidance for housewives; assessing unwillingness to be
with others unless certainly liked in those who do not have
relationships outside of the family; interpreting hitting fam-
ily members, which may be at times culturally appropriate;
and assessing reckless driving in those who do not have a
car. Similarly, in Turkey all participants who were given a
questionnaire about BPD criteria left the item addressing
substance use blank, which the authors explained as likely
coming from fear around legal repercussions [319].
Assessments of other diagnoses across cultures also high-
light that a disorder may manifest differently in different
cultures. For example, in the case of depression, differences
in the subjective experience, description, and expression of
clinical manifestations across different societies, historical
periods, or geographic regions have been consistently found
[320]. An analysis of depression cross-culturally showed that
fatigue and lack of energy were universally important, that
guilt was more predominantly found in Western cultures, and
that somatic complaints have been much more strongly en-
dorsed as a way to communicate depression across cultures
than sad or depressed mood [321]. As with the research ad-
dressing cultural differences in depression, it is appropriate
to consider differences in the subjective experience, descrip-
tion, and expression of BPD criteria across cultures.
In our review of the assessment and understanding of
BPD across the world, we did not find any discussion of how
different BPD diagnostic criteria may manifest in different
sociocultural groups. Below we present hypotheses related to
cultural dimensions that might be useful to consider when
examining or assessing BPD diagnostic criteria across the
globe.
Disturbed Relationships Through a Cultural Lens
The first two criteria in the DSM describe relationship
difficulties involving fear of abandonment and unstable rela-
tionships. Several researchers have identified interpersonal
dysregulation as a core component of the BPD phenotype
and have hypothesized that these difficulties are a marker of
the BPD pathology [322]. Therefore, interpersonal distur-
bance is key; nevertheless, how exactly this disturbance
manifests may be influenced by culture. Fear of being aban-
doned implies an individualistic view of the world where one
can be alone, or abandoned. In collectivistic cultures, where
the self includes the family and the community [171], fear of
being alone may be unusual, and instability in relationships
may manifest in a different way.
For example, in Confucian cultures each person must
strive to be pleasant and easy going, kind hearted, respectful,
forgiving, and accommodating in interpersonal situations
[171]. Therefore, the focus in a relationship is on others
rather than on the self. This view of relationships is less
likely to give rise to idealization and devaluation of others,
but rather can yield difficulties such as Taijinkyofusho, a
Japanese cultural-bound syndrome where people develop a
phobia of not being successful at relationships [17]. Thus,
fear of being abandoned and tumultuous relationships may
manifest differently in Asian cultures.
Disturbed Identity Through a Cultural Lens
The third and eighth criteria in the DSM assess identity
disturbance and chronic feelings of emptiness. The cultural
dimensions proposed by Hofstede [21] are relevant to a sense
of self and can modulate what would lead to identity distress
in different cultures. From the perspective of this model,
distress with one’s identity would emerge from feelings of
guilt and alienation in individualistic cultures; rejection and
social conflict in collectivistic cultures; a sense of failure and
self-blame in high power differential cultures; personal un-
certainty and confusion in low power differential cultures;
guilt, problems with competence, and performance deficits in
masculine cultures; anxiety, feeling misunderstood, or hav-
ing unsatisfied dependent needs in feminine cultures; intel-
lectualizing distress and repressing emotions in cultures that
avoid uncertainty; and confusion and helplessness in cultures
that embrace uncertainty [21]. To date, identity disturbance
within BPD in DSM-5 has been defined from the perspective
of an individualistic, masculine, high power differential, un-
certainty avoidant culture.
It may be important to explore whether a disturbed iden-
tity within cultures with different dimensions would fit the
same definition. For example, for traditional followers of the
teachings of Confucius, a model citizen strives towards Ren
and Yi[benevolence, overall kindness, and willingness to
sacrifice for one’s friends and beliefs]. Achieving Ren and
Yi is highly valued, as are being polite; following norms,
rituals, and behavioral codes; working hard towards one’s
goals; having trustworthiness and dependability; and being
loyal. Confucius followers reflect daily on personal growth
through the process of Xiu Yang [171]. Identity in Confucian
countries cannot be assessed without understanding how
closely the person values Ren, Yi, and the process of Xiu
Yang. Someone who experiences confusion about his or her
identity, but who follows these traditions may be considered
to have normative struggles and to be in the process of Xiu
Yang [171]. In addition, identity involves one’s entire fam-
ily, and the emotion most often associated with violating this
identity is shame. Thus, identity disturbance in these cultures
should include assessments of family shame, and personal
views of the self and of self-improvement.
An additional example comes from Hindu culture. In
India, assessment of identity and of emptiness is difficult due
to challenges in patients’ understandings of questions about
self-image, internal preference, emptiness, and emotional
shallowness [323]. Shweder and Bourne [324] noted that
differences in self-concept in India may come from a holistic
perception where individuals do not conceive of themselves
as having immutable traits, but instead have a self-concept
dynamically altered by interpersonal relationships over time.
Thus, one’s personality is relative and can only be under-
stood in the context of current and past relationships. In this
view, changing the self to fit with those around is normative
and not dysfunctional; identity disturbance may thus occur
when this has not happened and beliefs about the self remain
stable and enduring across relationships and time.
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 23
Similar to problems with the definition of identity, the
problematic nature of emptiness may be culture specific. In
westernized cultures, individuality is sought, and therefore
emptiness is seen as pathological. In Buddhist cultures, emp-
tiness is sought, and its achievement is celebrated [325].
Therefore, what identity disturbance means varies in each
culture, and an assessment of this construct cannot be con-
ducted without understanding how the self[including empti-
ness] is seen in each culture.
Suicide and Self-harm Through a Cultural Lens
Suicide and self-harm are considered maladaptive behav-
iors in Western cultures and are included as markers of psy-
chopathology[BPD, major depressive disorder]. With respect
to BPD, suicidal behaviors are considered core features of
the diagnosis [167]. Nevertheless, in some cultures self-
destructive behaviors may be common. For example, in Ja-
pan not being able to borrow money is a considered a sign of
societal rejection [17] and may lead to ikka-shinju[family
suicide]. Therefore, instead of declaring bankruptcy or be-
coming homeless, activities considered too disgraceful [326],
attempting family suicide in Japan may be a culturally ac-
ceptable way to regulate shame and embarrassment. An addi-
tional example comes from the practice of Sati in South
Asian cultures [327]. In this practice, a woman attempts sui-
cide by burning together with her husband in his funeral pyre
as an act of respect and submission. Similarly, self-
mutilation is normative in non-Western areas of the world
such as the Middle East, Malaysia, and India where religious
rituals require self-harming behaviors. As a result, what is
considered personality psychopathology in a Western culture
may be normative behavior in other cultures [7]. It is there-
fore an important empirical question to identify whether sui-
cidal behavior is maladaptive and should be considered as a
BPD criterion even if it is culturally appropriate.
Assessors should also consider the forms and functions
of self-harming behaviors, which vary widely across cultures
[321]. Durkheim [328] distinguished among four types of
suicide based on their underlying functions. Two types are
likely relevant to the culturally sensitive assessment of suici-
dal behaviors: in Durkheim’s view,[a] egoistic suicide is a
consequence of problematic social relationships that lead to
reduced self-restraint, and[b] anomic suicide is a conse-
quence of alienation and generally follows emotions such as
disillusionment and disappointment. According to him, sui-
cide is a marker of the societal pathology resultant from the
decreased cohesion that emerged when modernization and
urbanization led to the collapse of traditional norms [328].
Religious and political beliefs common to a culture are
also important to assess because they influence the frequency
of suicidal behavior. Several practicing Catholic countries
such as Ireland or Spain have much lower suicide rates than
protestant countries [e.g., Denmark, Sweden] or than Catho-
lic countries where the church has limited influence [Austria,
Czechoslovakia, and Hungary] [321], although this relation-
ship is only correlational. In some countries such as India,
Singapore, or Malaysia, suicide is illegal [329-331]. Thus,
assessing for different ways in which someone may harm
themselves in cultures where suicidal behavior is illegal or
immoral may be important in understanding BPD. For ex-
ample, people may choose a more socially appropriate way
to self-harm such as getting tattoos or piercings, or may re-
sort to more lethal methods for suicide[such as poisoning or
jumping] [329].
Affective Instability Through a Cultural Lens
The BPD diagnosis also includes affective instability and
difficulties with anger, criteria that should also be assessed
within the context of culture. For example, in the People’s
Republic of China all mood disorders are labeled as depres-
sion, and there is confusion about the difference between
major depression and severe depression since both are trans-
lated with the same word [332]. This problem is also appar-
ent in Nigeria where the same word is used to express multi-
ple emotions [333]. Therefore, language differences may
make the assessment of rapid shifts between emotions diffi-
cult. In addition, emotions of guilt and shame may be fre-
quently expressed in some countries[e.g., Japan] but may be
largely absent in other cultures[e.g., Indonesia] [17].
A related consideration in the assessment of emotional
functioning is that negative emotions are expressed through
somatization in many cultures [334]. Affective instability
may also manifest through a variety of culturally specific
ways, such as culture-bound syndromes including
Koro[overpowering fear that one’s genitals are retracting and
will disappear], Dhat[fear of passing semen in urine, result-
ing in impotence], Malgri[anxiety about spirit possession
following disrespect of the water or the land], or Hwa
Byung[fire sickness in women resulting from suppressed
anger at family or husband, which typically involves a tran-
sient but highly dysregulated emotional experience].
Similarly, dysfunctional anger may be expressed via cul-
ture-bound syndromes, such as Amok[indiscriminate mass
homicide attack] or Bilis and Colera[physical illnesses
brought on by suppressed emotions or an uncontrolled anger
outburst]. An assessment of affective and anger problems for
those who may meet criteria for BPD should therefore in-
clude these cultural manifestations as well as a thorough
assessment of physical symptoms associated with dysregu-
lated affect.
Impulsivity Through a Cultural Lens
Impulsivity is another aspect of BPD that can vary phe-
notypically across cultures. For example, problem drinking
occurs less among Jewish, Chinese, and Italian cultures and
more frequently in Irish and Native American communities.
Draguns [321] hypothesizes that in the first group alcohol is
seen as food and is consumed initially at home, in modera-
tion, as part of a ritual. In the latter group, alcohol or other
drugs are considered forms of rebellion and are consumed in
secret, initially behind the family’s back [321]. Therefore,
problem drinking or drug use may be more frequently en-
countered in cultures where substance use is not normative.
Similarly, other impulsive behaviors[e.g., binge eating,
reckless driving] may manifest more frequently in cultures
where the behavior is not normative and must be done in
secret.
24 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
Stress-induced Dissociation/paranoia Through a Cultural
Lens
The last criterion assessed for a BPD diagnosis is stress-
induced dissociation or paranoia. It is unlikely that dissocia-
tion and paranoia are the only stress-induced problems in
BPD. Cross-culturally, any stress-induced alterations in
thoughts and behaviors that make one display florid psycho-
pathology could be conceptualized as being consistent with
this BPD criterion. Therefore, it may be important to con-
sider any culturally patterned reaction to stress [335]. Such
manifestations could be culturally bound syndromes such as
Attaque de Nervios[similar to a stress-induced panic attack],
Shin-byung and Zar[anxiety, dissociation, and somatic com-
plaints thought to be caused by spirit possession], Latah or
Imu[similar to stress-induced psychosis], Pibloktoq[Arctic
hysteria], Susto[fear of getting so startled that the soul leaves
the body], or Frigophobia[excessive fear of catching cold]
[336].
ADDITIONAL HYPOTHESIZED FACTORS THAT
INFLUENCE BPD ACROSS CULTURES
A few additional considerations are important when as-
sessing BPD cross-culturally. For example, Millon [337]
hypothesized that Western culture is exacerbating the devel-
opment and maintenance of BPD by reinforcing alternatives
to traditional values. From this perspective, the departure
from traditional cultural norms, along with the increase in
independence and availability of choice in the modern West-
ern society, may result in increased instability and ambiva-
lence, contributing to higher rates of BPD [337]. Others have
also highlighted the influence of modern culture on the in-
creased rates of BPD [167, 338]. Though there is no consen-
sus on the effects of changing cultural norms on the preva-
lence or incidence of BPD, it may be important when assess-
ing for BPD to consider whether departures from traditional
cultural norms are associated with expression and dysfunc-
tion.
An additional consideration for the assessment of BPD
concerns the influence of culture on the biological underpin-
nings of the disorder. Studies conducted in the United States
and Western Europe found that individuals diagnosed with
BPD may be characterized by hyporeactivity and reduced
volume in the prefrontal cortex and hyperreactivity in the
limbic system [339]. Additional disruptions in limbic-
prefrontal cortex reactivity were also found. These disrup-
tions hold true for both negative affectivity and physical pain
[340]. In Western cultures, these areas of the brain have been
associated with intense emotional reactivity and difficulties
with emotion regulation [340]. It may be important to assess
whether similar biological changes characterize BPD in other
cultures and whether biological disruptions could be used to
assess BPD across cultures.[It is important to highlight that
our recommendation comes from the assumption that differ-
ences between cultures exist.]
Because of the clear importance of culture in the pheno-
typic manifestation of BPD, research examining ways in
which cultural factors may influence the assessment of BPD
diagnostic criteria is needed. Such work has been done with
other psychiatric disorders, including mood and anxiety dis-
orders. For example, evidence suggests that, for non-native
English-speaking individuals, there is a tendency to report
more psychopathology in English than in their native lan-
guage [220]. Studies investigating the ways in which clinical
assessment of BPD is influenced by cultural factors can draw
from existing investigations in other disorders to begin ex-
amining factors that have a high likelihood of influencing
BPD assessment and presentation.
In order to guide future empirical research examining the
role of culture on BPD psychiatric assessment, it may there-
fore be fruitful to turn to the broader literature to identify
hypotheses to test. For example, cultural variables found to
influence neuropsychological assessments include, but are
not limited to, differences in the assumption that an examiner
can ask personal questions, in the perception of the rigid
structure of an interview, in the expectation that participants
will try their best and perform as fast as possible, and in the
patterns of neural activation among brain regions recruited
for various tasks [341]. Such cross-cultural differences are
relevant in the assessment of BPD and should be examined.
Additional hypotheses relevant to BPD assessment can
be generated using research conducted within the field of
organizational psychology. Lanik and Mitchell Gibbons
[342] review the literature on culturally sensitive assess-
ments and provide guidelines for better training of cross-
cultural assessors. First, they describe the theory of protes-
tant relational ideology, which refers to Western beliefs that
affect and relationship matters are not appropriate for the
workplace. Such beliefs in turn influence job assessments
where those who have this ideology encode interpersonal
information and affective cues less frequently than those
who do not. Furthermore, in some Asian cultures relation-
ship building is a required step before directly delving into a
job-related task in an interview. Therefore, beliefs about re-
lationships and affect guide the information that we encode
from the environment in job situations and likely in other
situations as well [342].
Second, thinking styles of both the assessor and the indi-
vidual being assessed also can influence responses to as-
sessments and interpretations of results. Of importance is the
difference between holistic thinkers, who focus on the con-
text as a whole, and analytical thinkers, who tend to focus on
the focal object and to ignore the surroundings. Western cul-
tures are more likely to include analytical thinking, whereas
Eastern cultures are primarily formed of holistic thinkers.
Furthermore, culture affects views about the appropriateness
of verbally expressing one’s thoughts and opinions. For ex-
ample, in Filipino culture, it is normative to defer to others in
a group setting rather than to speak your own individualistic
opinion in the absence of considering the group. In contrast,
in South African it is common for individuals to be expected
to speak up in group settings [342].
Third, how exactly one answers a particular question is
also dependent on cultural norms. According to Lanik [342],
Westerners are more likely to select extreme points on a
scale than those from Eastern cultures. Furthermore, what
the extreme points of each subjective measurement mean to
an individual varies by cultures. Lastly, in collectivistic cul-
tures, taking more time to reach a decision is common be-
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 25
cause the extra time makes room for development of rela-
tionships and trust.
Although a mental health assessment is different from a
job interview, this body of data highlights several hypotheses
whose testing is warranted. First, assumptions that may be
common in one culture may clash with assumptions from a
different culture and could lead to erroneous assessment.
Second, how the individual being assessed understands prob-
lems and examples may be different from how the instru-
ment is structured or what the interviewer is expecting.
Third, much information may remain private without an
open discussion about what is appropriate to disclose.
Fourth, group intervention may be inappropriate in some
cultures[e.g., Filipino] but not others[e.g., South African].
Fifth, self-report ratings are likely more extreme in Western
versus Eastern cultures, and therefore cross-cultural
comparisons may be erroneous. Sixth, the amount of time
the client and the assessor expect an assessment to take
may be different, and some of the information elicited/
communicated may serve a relational rather than an assess-
ment goal.
CULTURALLY SENSITIVE ASSESSMENT
Alarcón [320] describes important considerations about
the process of assessment that help interviewers take the role
of culture into account. When assessing for BPD in a differ-
ent culture, an assessor should understand the setting in
which the individual lives, the health structures, and the sys-
tems that would be relevant to the diagnosis. For example, in
Taiwan people are paid when they are accepted to an inpa-
tient mental health setting, which has important relevance to
the diagnosis and treatment of suicidal behavior in BPD. In
addition to setting, understanding the unique history and
culture of the individual and finding a common ground for
communication is crucial, especially given that the assessor
also has a cultural background. A clinical assessment should
include talking to other people in the individual’s life and
assessing the help-seeking pattern or modality that is com-
mon in his or her life, the history of compliance with mental
health treatment, the perception of BPD severity, the impact
of the clinical condition on the individual’s family and rela-
tionships, the individual’s coping style, and the overall orga-
nization of the clinical report. Specific cultural variables
should include demographics, race, ethnicity, language, re-
ligion, history of disease, context, meaning of the disease,
explanatory model that the person holds for the disease, and
what is actually impacted by the disease.
Assessment instruments and measures commonly used in
the BPD literature could benefit from studies where these
variables are considered and inaccuracies in the assessments
are corrected or guidelines for the interpretation of results are
provided. For example, in the case of depression, one com-
monly used instrument is the Beck Depression Inven-
tory[BDI] [343]. According to a literature review [344], the
BDI was primarily normed with White, middle-class Ameri-
can samples and may be inappropriate for minority samples
because it focuses on cognitive rather than more somatic
problems. The authors give an example of a Vietnamese
translation that had to modify or discard all but four of the
items to accurately capture depression in a sample composed
of displaced Vietnamese living in the United States. Thus,
the authors report that the BDI may not effectively measure
depression in some minority populations [344]. Similar criti-
cism has faced the use of personality measurements in cross-
cultural contexts. For example, the Minnesota Multiphasic
Personality Inventory[MMPI] [345] has been found to have
bias in test language, inappropriate standardization samples,
bias in test-taking skills, bias in administration an interpreta-
tion of data, and a lack of appropriate norms for culturally
diverse samples. Therefore, the MMPI-2 tried to correct such
problems to increase cultural sensitivity, although problems
still remain [346]. Such scrutiny for BPD measures is also
needed.
We conducted a thorough review of the instruments de-
veloped to assess for BPD and their translations and valida-
tions in other languages. We found an impressive number of
assessment options for BPD and many translations and vali-
dations in other languages. Most researchers used standard-
ized procedures to adapt instruments to their cultures, which
strengthens conclusions drawn from research using these
instruments. Nevertheless, some problems also emerged that
may be addressed by future research. First, not all of the in-
struments that are internationally used have strong psycho-
metric properties, and it is unclear what criteria are used to
choose one instrument versus another. We hypothesize that
many researchers translate instruments that are popular
rather than instruments that have the strongest psychometric
properties. Second, in a few cases different groups within the
same culture have different translations of the same instru-
ment. We recommend examining the information in Table
S1 before designing or translating new measurements for
BPD in order to reduce the cross-cultural variability in as-
sessment. We also recommend conducting additional re-
search on how to best adapt some of the translations cultur-
ally, to more clearly identify BPD in non-English speaking
cultures.
CROSS-CULTURAL CONSIDERATIONS FOR BPD
TREATMENTS
Various researchers have discussed theoretical and prac-
tical considerations for adapting treatments cross-culturally.
Nagayama Hall [347] presents a compelling argument about
the difference between evidence-based treatments and cul-
turally sensitive treatments. His discussion is limited to eth-
nic-based cultural differences within the United States but
could be extrapolated to how treatments for BPD are trans-
lated and utilized in other cultures. According to him, the
fact that a treatment is evidence based does not mean it is
effective for individuals from a different culture and there-
fore that it is culturally sensitive. For example, simply in-
cluding ethnic minorities in study samples does not offer
evidence that the treatment is culturally sensitive for these
ethnic minorities because the procedures, assessments, and
expectations are geared to not finding differences for minor-
ity samples. Furthermore, inclusion of minorities yields such
a broad spectrum of ethnicities included that any relevant
information is likely washed out because of the heterogene-
ity of the culturally diverse sample. He proposes guidelines
for adapting treatments in a culturally sensitive fashion, es-
pecially through considering interdependence, spirituality,
26 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
and discrimination, constructs that differentiate ethnic minor-
ity from majority populations.
The construct of interdependence refers to the idea that
ethnic minority cultures generally emphasize the importance
of interpersonal relationships and group identity much more
than European American cultures. Spirituality includes relig-
ion, traditions, and social and political behaviors and is typi-
cally much more complex and often more deeply interwoven
in the lives of minority individuals than in those of European
Americans. Lastly, chronic exposure to discrimination is not
uncommon in ethnic minority samples, but not in European
American samples. Therefore, interventions may be ineffec-
tive[a] if they are targeted solely at the individual[like cogni-
tive restructuring in CBT], because they may clash with en-
vironmental messages that the individual receives and with
the individual’s group identity;[b] if they reject spirituality or
restrict it to religious beliefs and behaviors, because they
may invalidate the experience and expectations of the per-
son; or[c] if they misinterpret discrimination-induced stress.
To increase cultural sensitivity in these contexts, Hall [348]
recommends interpersonal and family therapy, use of envi-
ronmental interventions, and evidence of respect for spiritual
diversity through incorporation of language, metaphors, and
stories from the client’s spiritual background. Beyond these
considerations, geographical and contextual factors, such as
presence of conflict and violence, availability of trained
mental health professionals, availability of basic infrastruc-
ture, translatability of a therapeutic concept to a local lan-
guage, literacy level of the target population, as well as dif-
ferences in treatment-seeking behavior, present additional
challenges that need to be addressed for treatments to be
delivered effectively [349]. Following, we discuss the cultural
sensitivity of the treatments reviewed with an emphasis on
future directions for refining these treatments across cultures.
Cultural Sensitivity of Cognitive Behavioral Treatments
for BPD
Research to date suggests that cognitive behavioral
treatments for BPD [e.g., DBT, STEPPS, CT] are generally
efficacious in treating common behavioral and psychological
problems associated with BPD, but the available evidence is
established only within American and European contexts.
Several considerations may be relevant for adapting cogni-
tive behavioral interventions cross-culturally. To highlight
these considerations, we first outline aspects of cognitive
behavioral interventions that distinguish them from other
treatment approaches. These aspects include understanding
psychological experiences in terms of thoughts, emotions,
and behaviors[along with a focus on modifying irrational or
dysfunctional thoughts]; using homework outside of therapy
sessions; directing session activity; teaching skills[e.g., ex-
posure and behavioral activation] to cope with problems;
focusing on clients’ present and future experiences; and pro-
viding psychoeducation about clients’ disorders [350]. Cer-
tain CBT-based approaches, such as DBT, further incorpo-
rate mindfulness and acceptance strategies as key strategies.
One of the core features of CBT is the understanding of
psychological experiences in terms of thoughts, emotions,
physical sensations, and behaviors, as well as the intercon-
nections among these elements. These aspects of experiences
are considered as meaningfully separated from one another,
and the role of thoughts is given particular precedence in
terms of its impact on emotions [274, 351]. Such an under-
standing of psychological experiences may not be readily
apparent or acknowledged in every culture. For example,
despite the popularity of mindfulness in Western psychother-
apy, the literature from which mindfulness is drawn[various
Buddhist traditions] makes no distinction between thoughts
and emotions [351]. Clients coming from such traditions
thus may not readily understand their experiences in terms of
thoughts and emotions.
Use of homework outside of therapy sessions and direc-
tion of session activity are two other aspects of CBT that
need to be considered in the context of clients’ experiences
and expectations about therapy. For example, use of home-
work outside of therapy sessions is thought to be consistent
with Chinese values related to power hierarchy, work ethic,
achievement orientation, and discipline [352]. The value of
respect for authority figures may also result in a greater ten-
dency among Asian clients to view their therapists as expert
authority figures and to expect their therapists to be proactive
in providing direction, teaching skills, and giving advice
[353].
At a practical level, the process and content of the skills
teaching aspect of CBT may also need to be tailored in ac-
cordance with clients’ cultural backgrounds and needs. For
example, O’Hearn and Pollard [354], in their adaptation of
DBT for deaf individuals, added several modifications to the
standard DBT protocol, such as prolonging the number of
sessions used to teach a DBT skills module, using metaphors
that make sense in American Sign Language, simplifying
and incorporating diagrams into diary cards for clients with
limited English literacy, and creating substitute mnemonics
for skills that can be understood by an average deaf individ-
ual. Hall, et al. [348], in examining the relevance of mind-
fulness-based psychotherapies for Asian clients, proposed an
application of mindfulness practice that emphasizes non-
judgmental awareness of not only one’s inner experi-
ences[which is emphasized in Western mindfulness prac-
tice], but also of others’ reactions. Such an application of
mindfulness, according to the authors, is consistent with
Asian worldviews related to promoting integration or whole-
ness of an individual’s identity with others’ identities.
Another key aspect of CBT concerns a focus on clients’
present and future experiences. The extent to which clients’
preferences or inclinations for focusing on present and future
experiences may vary by culture. Clients may also disclose
information about their present lives in ways that are not
directly perceivable by clinicians. For example, storytelling
is commonly used within traditional Native American cul-
tures to convey ideas, values, and messages [355]. Clients
from these cultures thus may at times convey information
about their present experiences through storytelling. Clini-
cians attuned to this method of communication may therefore
be more readily able to gather information about a client’s
present life through listening to stories shared by the client.
CBT approaches also emphasize psychoeducation to the
client about his or her disorder. Relevant considerations here
include the fact that the diagnosis of BPD may not be widely
known[or known at all] in certain cultures, and that BPD is
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 27
associated with varying degrees of stigmas across communi-
ties. Clinicians should also be sensitive towards different
ways through which a culture understands the etiology of a
psychological disorder [e.g., a predominantly biological or
spiritual understanding], which may differ significantly from
the understanding of the clinicians.
With all of these considerations in mind, given the cur-
rent state of the evidence, CBTs are likely the most promis-
ing treatments to be adapted across cultures. In particular,
DBT, which is a principle-based treatment, allows for room
to apply the principles of the treatment in a culturally sensi-
tive manner. While work is needed to more explicitly define
the form in which different functions of DBT components
may take depending on the cultural background of the popu-
lation targeted, we believe this treatments holds the most
promise to be easily tailored across cultures.
Cultural Sensitivity of Psychopharmacological Treat-
ments for BPD
Findings from psychopharmacological RCTs for BPD
suggest that some drug treatments may be effective for cer-
tain aspects of the BPD psychopathology. Nevertheless, cau-
tion is in order when considering pharmacotherapy for this
particular population. Clients with BPD are notoriously non-
compliant with treatment regimens, may abuse the pre-
scribed drugs or overdose, and may experience unintended
effects of the drugs. With these caveats in mind, carefully
monitored pharmacotherapy may be a useful adjunct to psy-
chotherapy in BPD treatments.
There is substantial evidence that cultural factors [e.g.,
ethnicity, race] influence an individual's responsiveness to
medication. Research has found that certain genetic factors
may result in racial and ethnic differences in the metabolism,
perceived side effects, and clinical effectiveness of medica-
tion [356, 357]. Furthermore, cultural differences in the per-
ception of mental illness and of medication may influence
rates of prescription of medications, magnitude of placebo
effects, and individuals' adherence to pharmacological treat-
ment [358]. Future research on these interventions should
draw upon the growing body of work in ethnopharmacology
in order to determine with more precision which medications
may be most effective both within and across cultural con-
texts.
Despite evidence of variation in response to medication
resulting from cultural factors, there is a latent assumption
that findings drawn from one investigation of a psychophar-
macological intervention can be applied universally to other
contexts and cultures. This is demonstrated by the fact that
many investigations into the efficacy of pharmacological
interventions for BPD did not even mention the country in
which subjects were recruited. The latent assumption of uni-
versality in response to medication may result in misleading
conclusions regarding the efficacy of psychopharmacological
treatments for adults with BPD who have different racial,
ethnic, and cultural backgrounds. Future research on these
interventions should draw upon the growing body of work in
ethnopharmacology in order to determine with more preci-
sion which medications may be most effective both within
and across cultural contexts.
Cultural Sensitivity of Psychodynamic Treatments for
BPD
Research suggests that psychodynamic approaches such
as TFP and MBT may be effective in reducing psychopa-
thology and improving functioning among patients with
BPD, but none of the psychodynamic approaches reviewed
has been evaluated in countries and cultures other than Euro-
pean American cultures to establish cross-cultural effective-
ness. The premise of each treatment[concept of self and oth-
ers as separate] fits well with the westernized view of an
individualistic society; this view however may have to be
adjusted for cultures with a more collectivistic view of the
world. In some cultures, such as Chinese culture, there is an
emphasis on the interests and needs of the group over those
of an individual, in line with traditional Confucius values
involving the need to maintain social harmony and ordered
relationships [359, 360]. Treatments that emphasize devel-
opment of an integrated self-identity, such as TFP, therefore,
may therefore benefit from considering and incorporating a
conceptualization of self that extends beyond an individualis-
tic identity. Similarly, Comas-Diaz and Minrath [361] argued
that psychoanalytic treatment of clients with BPD from eth-
nic minority cultures[within the American context] must
view the goal of helping clients achieve separation and
autonomy with “gradient expectations of cultural norms”[p.
423]. Further, psychotherapeutic techniques such as confron-
tation and interpretation need to be implemented in a manner
sensitive to a client’s cultural contexts, assumptions, and
beliefs. Comaz-Diaz and Minrath [361] highlighted the im-
portance of distinguishing the extent to which transference in
psychotherapy is intrapsychic versus sociocultural and of
recognizing the interplay of the two forces [361]. For exam-
ple, clients may respond to a therapist in a submissive and
compliant manner due to culturally based deference toward
authority figures. However, such interpersonal style may also
be a replication of the client’s experience with social institu-
tions that are oppressive. It is also important that therapists
distinguish pathological defenses from adaptive coping
[361]. For example, in some cultures, carrying a weapon
may be an adaptive, necessary means to protect oneself and
one’s family. However, such a behavior may easily be inter-
preted as a paranoid, aggressive mechanism if a therapist has
not carefully explored the underlying meaning of the behav-
ior [361]. Overall, the authors advocated for a therapeutic
approach that integrates a psychoanalytic orientation within a
sociocultural context, while aiming to strengthen ego func-
tioning, foster the development of more adaptive coping
mechanisms, and solidify a sense of identity as an individual
and as a member of a cultural group.
CONCLUSIONS
There are several broad conclusions that have emerged
from our review. One key conclusion is that the phenotypic
expression of problems associated with BPD is inextricably
linked to the culture in which such problems are expressed.
For example, the form and function of BPD criterion behav-
iors such as self-injury, affective instability, or anger may
vary across cultures. Because the way in which BPD criteria
are experienced and expressed is related to cultural norms, it
28 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
is very important that clinicians remain aware of their as-
sumptions and heuristics about expected BPD problems and
presentations. For example, culturally sensitive assessment
and diagnosis of BPD requires that clinicians actively assess
BPD criteria through the individual’s relevant cultural lens in
order to attempt to prevent Type II[rejecting the hypothesis
that BPD criteria have been met] and I errors[rejecting the
hypothesis that BPD criteria have not been met] in decision
making.
Another key conclusion of this review is that culturally
sensitive assessment of BPD can be informed by findings
from research investigating culturally relevant factors that
may affect the manifestation of the disorder, including age,
gender, race and ethnicity, sexual orientation, marital and
disability status, religion, SES, history of migration, and liv-
ing in urban versus rural settings. Indeed, a review of this
area of research points to the possibility that some of these
factors may be associated with differential expression of
specific BPD problems. It is recommended that future re-
search be conducted to more rigorously examine the ways in
which these factors may influence BPD presentation and
treatment, in order to further assist clinicians with possible
culturally relevant moderators, which may be proxy vari-
ables reflecting psychological and cultural processes needing
to be considered before making firm conclusions about a
diagnosis of BPD.
In addition to considerations related to assessment and
diagnosis, a conclusion of this review is that it is important
that adults and adolescents meeting criteria for BPD be
treated in a culturally sensitive manner when receiving be-
havioral therapies and pharmacotherapies. Empirically sup-
ported interventions such as DBT need to be administered in
a thoughtful and personally tailored manner to reasonably
address the role of culture in the reduction of BPD-related
problems and enhancement of life functioning. For example,
interventions targeting interpersonal functioning in BPD
need to consider the role of culture in the specific ways the
client learns to change how they relate to others. Similarly,
psychotherapies such as DBT that commonly use concepts
such as one’s individual values and goals need to consider
the individual’s cultural identity and sense of self in relation-
ship to the larger cultural group. Finally, cultural differences
in the perception and stigma associated with mental illness
and of psychotropic medication may influence compliance
and effectiveness of pharmacotherapies. More generally, it is
recommended that clinicians be mindful of ways in which
culture may influence processes essential to treatment[e.g .,
therapeutic relationship, compliance with treatment] for BPD
across all clients.
CONSENT FOR PUBLICATION
Not applicable.
CONFLICT OF INTEREST
Drs. Neacsiu and Rosenthal receive fees for trainings on
cognitive behavioral therapy and dialectical behavior ther-
apy, two of the treatments described in this review.
ACKNOWLEDGEMENTS
We would like to thank the following people for helping
with the translation of some of the articles included and with
the organization of our sources: Hadya Abdul Satar, Duru
Altug, Olga Andreyanova, Maria Buczynska, Kerstin Bur-
meister, Nourhan Elsayed, Pablo Gagliesi, Simay Gokbay-
rak, Kim de Jong, Min-Su Kang, Tatyana Kholodkov, Jas-
mine Kim, Eugene Kobiako, Mae Ang Mae Chen, Sergei
Menis, Liza Mordkovich, Sandra M. C. Niethardt, Olga
Rublinetska, Marina Salnikova, Alsu Shakirova, Michael
Sun, Matthew Tkachuck, and Sarah Winnig. We would also
like to thank Megan Ramaiya for her thoughtful comments
on an earlier version of the manuscript. Research reported in
this publication was in part supported by the National Center
for Advancing Translational Sciences of the National Insti-
tutes of Health under Award Number 5KL2TR001115 and
by the National Institute of Mental Health, under award
number 1R01MH095806-01A1. The content is solely the
responsibility of the authors and does not necessarily repre-
sent the official views of the National Institutes of Health.
SUPPLEMENTARY MATERIAL
Supplementary material is available on the publisher’s
web site along with the published article.
REFERENCES
[1] Marsella AJ, Yamada AM. Culture and Psychopathology:
Foundations, Issues, Directions. J Pac Rim Psychol 2010; 4(2):
103-15.
[2] Hwang W-C, Myers HF, Abe-Kim J, Ting JY. A conceptual
paradigm for understanding culture's impact on mental health: The
cultural influences on mental health(CIMH) model. Clin Psychol
Rev 2008; 28(2): 211-27.
[3] Eshun S, Caldwell-Colbert T. Culture and mood disorders. Culture
and mental health: sociocultural influences, theory, and practice
Hoboken: Wiley-Blackwell 2009: 181-95.
[4] Marques L, Robinaugh DJ, LeBlanc NJ, Hinton D. Cross-cultural
variations in the prevalence and presentation of anxiety disorders.
Exp Rev Neurother 2011; 11(2): 313-22.
[5] Miller M, Pumariega A. Culture and eating disorders: A historical
and cross-cultural review. Psychiat-Interpers Biol Process 2001;
64(2): 93-110.
[6] Salous A, Omar H. Substance abuse among adolescents: a cross-
cultural review. Int J Disab Human Develop 2009; 8(2): 155-8.
[7] Ziegenbein M, Calliess IT, Sieberer M, Machleidt W. Personality
disorders in a cross-cultural perspective: Impact of culture and
migration on diagnosis and etiological aspects. Curr Psychia Rev
2008; 4(1): 39-47.
[8] Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M.
Borderline personality disorder. Lancet 2004; 364(9432): 453-61.
[9] Linehan M. Cognitive-behavioral Treatment of Borderline
Personality Disorder: Guilford Press; 1993 1993. 584 p.
[10] Jani S, Johnson RS, Banu S, Shah A. Cross-cultural bias in the
diagnosis of borderline personality disorder. Bull Menninger Clin
2016; 80(2): 146-65.
[11] Paris J. Success and failure in the treatment of patients with
borderline personality disorder. Sante Ment Que 1996; 22(1): 16-
29.
[12] Cooke DJ. Psychopathic personality in different cultures: What do
we know? What do we need to find out? J Personality Disord 1996;
10(1): 23-40.
[13] Lewis-Fernandez R, Kleinman A. Culture, personality, and
psychopathology. $J. Abnorm. Psychol 1994; 103(1): 67-71.
[14] Alarcón RD, Foulks EF, Vakkur M. Personality disorders and
culture: Clinical and conceptual interactions: John Wiley & Sons;
1998.
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 29
[15] Cardemil EV. Cultural adaptations to empirically supported
treatments: A research agenda. The Scientific Review of Mental
Health Practice 2010; 7(2): 8-21.
[16] Barnouw V. Culture and personality. Homewood, Ill.,: Dorsey
Press; 1963. 410 pages p.
[17] Tseng W-S. Handbook of cultural psychiatry. Int Rev Psychiatry.
2001; 14: 71-3.
[18] Adams G, Markus HR. Culture as patterns: An alternative approach
to the problem of reification. Cult Psychol. 2001; 7(3): 283-96.
[19] Kitayama S. Cultural psychology of the self: A renewed look at
independence and interdependence. Psychology at the Turn of the
Millennium. 2002; 2: 305-22.
[20] Sue DW, Sue D. Counseling the culturally diverse: Theory and
practice: John Wiley & Sons; 2012.
[21] Hofstede G. Culture's Consequences: Comparing Values,
Behaviors, Institutions and Organizations Across Nations: SAGE;
2001.
[22] Hofstede G, Hofstede GJ, Minkov M. Cultures and organizations :
software of the mind : intercultural cooperation and its importance
for survival. Revised and expanded 3rd edition. ed. New York:
McGraw-Hill; 2010. xiv, 561 pages p.
[23] Stern A. Borderline group of neuroses. The Psychoanal Quart 1938.
[24] American Psychiatric Association. Task Force on Nomenclature
and Statistics., American Psychiatric Association. Committee on
Nomenclature and Statistics. Diagnostic and statistical manual of
mental disorders. 3d ed. Washington, D.C.: American Psychiatric
Association; 1980. 494 pages p.
[25] American Psychiatric Association., American Psychiatric
Association. Task Force on DSM-IV. Diagnostic and statistical
manual of mental disorders : DSM-IV. 4th ed. Washington, DC:
American Psychiatric Association; 1994. xxvii, 886 pages p.
[26] American Psychiatric Association., American Psychiatric
Association. DSM-5 Task Force. Diagnostic and statistical manual
of mental disorders : DSM-5. 5th ed. Washington, D.C.: American
Psychiatric Association; 2013. xliv, 947 p. p.
[27] Whewell P, Ryman A, Bonanno D, Heather N. Does the ICD 10
classification accurately describe subtypes of borderline personality
disorder?. Br J Med Psychol 2000; 73 Pt 4: 483-94.
[28] Organization WH. The ICD-10 classification of mental and
behavioural disorders: clinical descriptions and diagnostic
guidelines: World Health Organization; 1992.
[29] Division UNS. Standard country or area codes for statistical
use(Series M, No. 49, Revision 4) http: //unstats.un.org/unsd/
methods/m49/m49.htm2013 (
[30] Karno M, Burnam A, Escobar JI, Hough RL, Eaton WW.
Development of the Spanish-language version of the National
Institute of Mental Health Diagnostic Interview Schedule. Arch
Gen Psychiat. 1983; 40(11): 1183-8.
[31] Loranger AW, Sartorius N, Andreoli A, et al. The International
Personality Disorder Examination. The World Health
Organization/Alcohol, Drug Abuse, and Mental Health
Administration international pilot study of personality disorders.
Arch Gen Psychiat 1994; 51(3): 215-24.
[32] Schulz SC, Zanarini MC, Bateman A, et al. Olanzapine for the
treatment of borderline personality disorder: variable dose 12-week
randomised double-blind placebo-controlled study. Br J Psychiat: J
Mental Sci 2008; 193(6): 485-92.
[33] Hofstede G. The cultural relativity of organizational practices and
theories. J Int Business Studies 1983; 14(2): 75-89.
[34] Grant BF, Chou SP, Goldstein RB, et al. Prevalence, correlates,
disability, and comorbidity of DSM-IV borderline personality
disorder: results from the Wave 2 National Epidemiologic Survey
on Alcohol and Related Conditions. J Clin Psychiatry 2008; 69(4):
533.
[35] Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV
personality disorders in the National Comorbidity Survey
Replication. Biol Psychiat 2007; 62(6): 553-64.
[36] Crawford TN, Cohen P, Johnson JG, et al. Self-reported
personality disorder in the children in the community sample:
convergent and prospective validity in late adolescence and
adulthood. J Pers Disord 2005; 19(1): 30-52.
[37] Samuels J, Eaton WW, Bienvenu OJ, Brown CH, Costa PT,
Nestadt G. Prevalence and correlates of personality disorders in a
community sample. Br J Psychiat 2002; 180(6): 536-42.
[38] Tomko RL, Trull TJ, Wood PK, Sher KJ. Characteristics of
borderline personality disorder in a community sample:
comorbidity, treatment utilization, and general functioning. J Pers
Disord 2014; 28(5): 734-50.
[39] Bernstein DP, Cohen P, Velez CN, Schwab-Stone M, Siever LJ,
Shinsato L. Prevalence and stability of the DSM-III-R personality
disorders in a community-based survey of adolescents. Am J
Psychiat 1993; 150: 1237-.
[40] Widiger TA, Weissman MM. Epidemiology of borderline
personality disorder. Psychiatric Services 1991; 42(10): 1015-21.
[41] Widiger TA, Frances AJ. Epidemiology, diagnosis, and
comorbidity of borderline personality disorder. Int Rev Psychiat
1989; 8: 8-24.
[42] Zimmerman M, Mattia JI. Differences between clinical and
research practices in diagnosing borderline personality disorder.
Am J Psychiat 1999; 156(10): 1570-4.
[43] Leontieva L, Gregory R. Characteristics of patients with borderline
personality disorder in a state psychiatric hospital. J Pers Disord
2013; 27(2): 222-32.
[44] Grilo CM, McGlashan TH, Quinlan DM, Walker ML, Greenfeld D,
Edell WS. Frequency of personality disorders in two age cohorts of
psychiatric inpatients. Am J Psychiat 1998; 155(1): 140-2.
[45] Oldham JM, Skodol AE, Kellman HD, et al. Comorbidity of axis I
and axis II disorders. Am J Psychiat 1995; 152(4): 571-8.
[46] Zimmerman M, Rothschild L, Chelminski I. The prevalence of
DSM-IV personality disorders in psychiatric outpatients. Am J
Psychiat 2005; 162(10): 1911-8.
[47] Gross R, Olfson M, Gameroff M, et al. Borderline personality
disorder in primary care. Arch Intern Med 2002; 162(1): 53-60.
[48] Korzekwa MI, Dell PF, Links PS, Thabane L, Webb SP.
Estimating the prevalence of borderline personality disorder in
psychiatric outpatients using a two-phase procedure. Compr
Psychiat 2008; 49(4): 380-6.
[49] Nussbaum D, Rogers R. Screening psychiatric patients for Axis II
disorders. SAGE Publications Sage CA: Los Angeles, CA; 1992.
[50] Barnow S, Arens EA, Sieswerda S, Dinu-Biringer R, Spitzer C,
Lang S. Borderline personality disorder and psychosis: a review.
Curr Psychiat Rep 2010; 12(3): 186-95.
[51] Maier W, Lichtermann D, Klingler T, Heun R, Hallmayer J.
Prevalences of personality disorders(DSM-III-R) in the
community. J Pers Disord 1992; 6(3): 187-96.
[52] Chabrol H, Montovany A, Chouicha K, Callahan S, Mullet E.
Frequency of borderline personality disorder in a sample of French
high school students. Can J Psychiat 2001; 46(9): 847-9.
[53] Coid J, Yang M, Tyrer P, Roberts A, Ullrich S. Prevalence and
correlates of personality disorder in Great Britain. Br J Psychiat
2006; 188(5): 423-31.
[54] Zanarini MC, Horwood J, Wolke D, Waylen A, Fitzmaurice G,
Grant BF. Prevalence of DSM-IV borderline personality disorder in
two community samples: 6,330 English 11-year-olds and 34,653
American adults. J Pers Disord 2011; 25(5): 607-19.
[55] Torgersen S, Kringlen E, Cramer V. The prevalence of personality
disorders in a community sample. Arch Gen Psychiat 2001; 58(6):
590-6.
[56] Ekselius L, Tillfors M, Furmark T, Fredrikson M. Personality
disorders in the general population: DSM-IV and ICD-10 defined
prevalence as related to sociodemographic profile. Personality And
Individual Differences 2001; 30(2): 311-20.
[57] Kullgren G. Personality disorders among psychiatric inpatients.
Nord J Psychiat 1992; 46(1): 27-32.
[58] Ottosson H, Bodlund O, Ekselius L, et al. DSM-IV and ICD-10
personality disorders: a comparison of a self-report
questionnaire(DIP-Q) with a structured interview. Eur Psychiat
1998; 13(5): 246-53.
[59] Bodlund O, Ekselius L, Lindström E. Personality traits and
disorders among psychiatric outpatients and normal subjects on the
basis of the SCID screen questionnaire. Nord J Psychiat 1993;
47(6): 425-33.
[60] Simonsen E, Mellergard M. Trends in the use of the borderline
diagnosis in Denmark from 1975 to 1985. J Pers Disord 1988; 2(2):
102-8.
[61] Henriksson MM, Aro HM, Marttunen MJ, et al. Mental disorders
and comorbidity in suicide. Am J Psychiat 1993; 150: 935-.
[62] O’Neill A, D’Souza A, Carballedo A, Joseph S, Kerskens C, Frodl
T. Magnetic resonance imaging in patients with borderline
personality disorder: a study of volumetric abnormalities. Psychiat
Res Neuroimag 2013; 213(1): 1-10.
30 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
[63] Jackson HJ, Burgess PM. Personality disorders in the community: a
report from the Australian National Survey of Mental Health and
Wellbeing. Soc Psychiat Psychiatr Epidemiol 2000; 35(12): 531-8.
[64] Wong MT, Tye C. Low hospital inpatient readmission rate in
patients with borderline personality disorder: a naturalistic study at
Southern Health, Victoria, Australia. Aust N Z J Psychiat 2005;
39(7): 607-11.
[65] Dewe C, Krawitz R. Component analysis of dialectical behavior
therapy skills training. Aust Psychiat 2007; 15(3): 222-5.
[66] Brassington J, Krawitz R. Australasian dialectical behaviour
therapy pilot outcome study: effectiveness, utility and feasibility.
Aust Psychiat 2006; 14(3): 313-9.
[67] Meares R, Stevenson J. An outcome study of psychotherapy for
patients with borderline personality disorder. Am J Psychiat 1992;
149(3): 358-62.
[68] Korner A, Gerull F, Meares R, Stevenson J. Borderline personality
disorder treated with the conversational model: a replication study.
Compr Psychiat 2006; 47(5): 406-11.
[69] Moor S, Crowe M, Luty S, Carter J, Joyce PR. Effects of
comorbidity and early age of onset in young people with Bipolar
Disorder on self harming behaviour and suicide attempts. J Affect
Disord 2012; 136(3): 1212-5.
[70] Mulder RT, Joyce PR, Luty SE. The relationship of personality
disorders to treatment outcome in depressed outpatients. J Clin
Psychiat 2003; 64(3): 259-64.
[71] Jaime Espinosa J, Blum Grynberg B, Romero Mendoza MP.
Suicidal risk and lethality in patients with borderline personality
disorder(BPD), at a psychiatry hospital. Salud Mental 2009; 32(4):
317-25.
[72] López D, Cuevas P, Gómez A, Mendoza J. Psicoterapia focalizada
en la transferencia para el trastorno límite de la personalidad. Un
estudio con pacientes femeninas. Salud Mental 2004; 27(4).
[73] Cuevas P, Camacho J, Mejía R, et al. Cambios en la psicopatología
del trastorno limítrofe de la personalidad, en los pacientes tratados
con psicoterapia psicodinámica. Salud Mental 2000; 23(6).
[74] Sundbom E, Jacobsson L, Kullgren G, Penayo U. Personality and
defenses: a cross-cultural study of psychiatric patients and healthy
individuals in Nicaragua and Sweden. Psychol Rep 1998;
83(3_suppl): 1331-47.
[75] Monroy GMC, Huertas LDP. Comorbilidad en el Eje I del
Trastorno Límite de la Personalidad. V Xer.97.
[76] Rodríguez M, Guerrero S. Frequency and Phenomenology of Self-
Inflicted Injuries in Colombian Women with Eating Disorders.
Revista Colombiana de Psiquiatría 2005; 34(3): 343-54.
[77] Silva W, Giagante B, Saizar R, et al. Clinical features and
prognosis of nonepileptic seizures in a developing country.
Epilepsia 2001; 42(3): 398-401.
[78] Xamena PR-P, Espert CS-J, Pavlovsky F. Datos operacionales de la
Sala de Internación de Psicopatología de un hospital general a lo
largo de un año. Volumen XVII-Nº 67–Mayo–Junio 2006.182.
[79] Matusevichi M. Modelo de comunidad terapéutica en internaciones
psiquiátricas breves. 2006. Vertex Revista argentina de psiquiatría.
(65).
[80] Gomes FA, O'Brien B, Nakano AMS. Attempted suicide in
reproductive age women. Health Care Women Int 2009; 30(8):
707-19.
[81] Pondé MP, Freire AC, Mendonça MS. The prevalence of mental
disorders in prisoners in the city of Salvador, Bahia, Brazil. J
Forensic Sci 2011; 56(3): 679-82.
[82] Menchaca A, Perez O, Peralta A. Intermittent-continuous eclectic
therapy: A group approach for borderline personality disorder. J
Psychiatr Pract® 2007; 13(4): 281-4.
[83] Zanarini MC, Schulz SC, Detke HC, et al. A dose comparison of
olanzapine for the treatment of borderline personality disorder: a
12-week randomized, double-blind, placebo-controlled study. J
Clin Psychiat 2011; 72(10): 1353-62.
[84] Corsaro B. Caracteristicas de los pacientes borderline en Argentina.
Revista Psicologia Contemporanea 2000; 7(2): 89-91.
[85] Strebel A, Msomi N, Stacey M. A gender and racial
epidemiological profile of public psychiatric hospitals in the
Western Cape. S Afr J Psychol 1999; 29(2): 53-61.
[86] Dirks B. Repetition of parasuicide—ICD‐10 personality disorders
and adversity. Acta Psychiatr Scand 1998; 98(3): 208-13.
[87] Lochner C, Seedat S, Hemmings SM, et al. Dissociative
experiences in obsessive-compulsive disorder and trichotillomania:
Clinical and genetic findings. Compr Psychiat 2004; 45(5): 384-91.
[88] Kirsten DK, Van Lellyveld V, Venter CA. Perceptions that patients
diagnosed with Borderline Personality Disorder have of their
families. S Afr J Psychol 2006; 36(2): 319-39.
[89] Langley G, Klopper H. Trust as a foundation for the therapeutic
intervention for patients with borderline personality disorder. J
Psychiatr Ment Health Nurs 2005; 12(1): 23-32.
[90] Straker G, Waks B. Limit setting in regard to self-damaging acts:
The patient's perspective. Psychotherap Theory Res Pract Train
1997; 34(2): 192.
[91] Okasha A, Omar A, Lotaief F, Ghanem M, El Dawla AS, Okasha
T. Comorbidity of axis I and axis II diagnoses in a sample of
Egyptian patients with neurotic disorders. Compr Psychiat 1996;
37(2): 95-101.
[92] Asaad T, Okasha T, Okasha A. Sleep EEG findings in ICD-10
borderline personality disorder in Egypt. J Affect Disord 2002;
71(1): 11-8.
[93] Akiskal HS, Yerevanian BI, Davis GC, King D, Lemmi H. The
nosologic status of borderline personality: clinical and
polysomnographic study. Am J Psychiat 1985; 142(2): 192-8.
[94] Loranger AW, Janca A, Sartorius N. Assessment and diagnosis of
personality disorders: The ICD-10 international personality
disorder examination(IPDE): Cambridge University Press; 1997.
[95] Thuo J, Ndetei DM, Maru H, Kuria M. The prevalence of
personality disorders in a Kenyan inpatient sample. J Pers Disord
2008; 22(2): 217-20.
[96] Onchev G, Ganev K. Borderline personality disorder in Bulgaria:
period prevalence, syndrome validity, and comorbidity. Eur J
Psychiat 2000; 14(1): 26-31.
[97] Grecu G, Grecu-Gabos M, Grecu-Gabos I. Particularitati ale
tulburarilor de personalitate borderline asociate cu conduite
comportamental-autolitice. Revista Romana de Psihiatrie 2000; 1:
1-12.
[98] Grecu G, Grecu-Gabos M, Grecu-Gabos I. Consideratii asupra
suicidului in spitalul de psihiatrie. Revista Romana de Psihiatrie
2005; 1(2): 1-9.
[99] Năstase V, COZMAN D, Răchieriu C. Comorbiditatea de axă i-
dsm în tulburarea de personalitate borderline–abordare
dimensională. Clujul Medical.460.
[100] Unoka Z, Fogd D, Füzy M, Csukly G. Misreading the facial signs:
specific impairments and error patterns in recognition of facial
emotions with negative valence in borderline personality disorder.
Psychiat Res 2011; 189(3): 419-25.
[101] Rabe-Jablonska J. Jadlowstret psychiczny u doroslych kobiet.
Psychiatr Pol 2003; 37(1): 29-37.
[102] Sokolova E, Burlakova N, Leontiou F. Connection between the
diffuse gender identity phenomenon and the personal cognitive
style. Voprosy Psikhologii 2002(3): 41-+.
[103] Aragonès E, Salvador-Carulla L, López-Muntaner J, Ferrer M,
Piñol JL. Registered prevalence of borderline personality disorder
in primary care databases. Gac Sanit 2013; 27(2): 171-4.
[104] Avdibegović E, Sinanović O. Consequences of domestic violence
on women’s mental health in Bosnia and Herzegovina. Croat Med J
2006; 47(5): 730-41.
[105] Peris L, Szerman N, Ruíz M. Eficacia y seguridad de Gabapentina
en el Trastorno Límite de Personalidad: estudio abierto de seis
meses de duración. Volumen XVIII-Nº 76–Noviembre–Diciembre
2007. 2007; 18(75): 418.
[106] Fossati A, Maffei C, Bagnato M, et al. Patterns of covariation of
DSM-IV personality disorders in a mixed psychiatric sample.
Compr Psychiat 2000; 41(3): 206-15.
[107] Latas M, Starcevic V, Trajkovic G, Bogojevic G. Predictors of
comorbid personality disorders in patients with panic disorder with
agoraphobia. Compr Psychiat 2000; 41(1): 28-34.
[108] Lecic-Tosevski D, Draganic S. The relationship between
personality disorders and dysthymia. Psychiatriki 1997; 8(3): 187-
95.
[109] Podobnik J, Podobnik IF, Grgic N, Marcinko D, Pivac N. The
effect of add-on treatment with quetiapine on measures of
depression, aggression, irritability and suicidal tendencies in
children and adolescents. Psychopharmacology(Berl) 2012; 220(3):
639-41.
[110] Giotakos O. Narrow and broad definition of mixed-handedness in
male psychiatric patients. Percept Mot Skills 2001; 93(3): 631-8.
[111] Peritogiannis V, Stefanou E, Damigos D, Mavreas V. Admission
rates of patients with borderline personality disorder in a
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 31
psychiatric unit in a General Hospital. Int J Psychiat Clin Pract
2008; 12(1): 78-80.
[112] Marinangeli M, Butti G, Scinto A, et al. Patterns of comorbidity
among DSM-III-R personality disorders. Psychopathology 2000;
33(2): 69-74.
[113] Zhong J, Leung F. Diagnosis of borderline personality disorder in
China: Current status and future directions. Curr Psychiat Rep
2009; 11(1): 69-73.
[114] Fu W, Yao S-Q, Yu H-H, et al. The prevalence of the cluster B
personality disorders in university students. Chin Ment Health J
2008; 22(2): 87.
[115] Xiang J, Li W, Shen H. Defense mechanisms in college students
with borderline personality disorder. Chin Ment Health J 2010; 4:
275-8.
[116] Cheng H, Huang Y, Liu B, Liu Z. Familial aggregation of
personality disorder: epidemiological evidence from high school
students 18 years and older in Beijing, China. Compr Psychiat
2010; 51(5): 524-30.
[117] Xiao Z, Yan H, Wang Z, et al. Trauma and dissociation in China.
Am J Psychiat 2006; 163(8): 1388-91.
[118] Yang J, McCrae RR, Costa PT, et al. The cross-cultural
generalizability of Axis-II constructs: an evaluation of two
personality disorder assessment instruments in the People's
Republic of China. J Pers Disord 2000; 14(3): 249-63.
[119] Wang Y, Leung F, Zhong J. The adaptation of McLean screening
instrument for borderline personality disorder among Chinese
college students. Chin J Clin Psychol 2008; 16(3): 258-60.
[120] Huang J, Yang Y, Wu J, Napolitano LA, Xi Y, Cui Y. Childhood
abuse in Chinese patients with borderline personality disorder. J
Pers Disord 2012; 26(2): 238-54.
[121] Leung S-W, Leung F. Construct validity and prevalence rate of
borderline personality disorder among Chinese adolescents. J Pers
Disord 2009; 23(5): 494-513.
[122] Wong H-M, Chow L-Y. Borderline personality disorder
subscale(Chinese version) of the structured clinical interview for
DSM-IV axis II personality disorders: a validation study in
Cantonese-speaking Hong Kong Chinese. East Asian Arch Psychiat
2011; 21(2): 52.
[123] Wong H-M, Leung HC-M, Chow L-Y, Kam W-K, Tang AK-L.
Prevalence of borderline personality disorder and its clinical
correlates in Chinese patients with recent deliberate self-harm. J
Pers Disord 2010; 24(6): 800-11.
[124] Song D, Fu W, Kong M, Sun X. The prevalence of borderline
personality disorder in college students. Chin J Clin Psychol 2009;
17(3): 342-4.
[125] Cheng A, Mann A, Chan K. Personality disorder and suicide. A
case-control study. Br J Psychiat 1997; 170(5): 441-6.
[126] Lee C-Y, Wen J-K, Yeh W-C, Lee Y, Chong M. Reliability and
Validity of the 20-Item Taiwan Version of the Borderline
Personality Inventory. Chang Gung Med J 2009; 32(2): 165-71.
[127] Ikuta N, Zanarini MC, Minakawa K, Miyake Y, Moriya N,
Nishizono-Maher A. Comparison of American and Japanese
outpatients with borderline personality disorder. Compr Psychiat
1994; 35(5): 382-5.
[128] Sato T, Sakado K, Uehara T, Narita T, Hirano S. Personality
disorder comorbidity in early-onset versus late-onset major
depression in Japan. J Nerv Ment Dis 1999; 187(4): 237-42.
[129] Iketani T, Kiriike N, Stein MB, et al. Patterns of axis II
comorbidity in early-onset versus late-onset panic disorder in
Japan. Compr Psychiat 2004; 45(2): 114-20.
[130] Matsunaga H, Kiriike N, Matsui T, et al. Gender differences in
social and interpersonal features and personality disorders among
Japanese patients with obsessive-compulsive disorder. Compr
Psychiat 2000; 41(4): 266-72.
[131] Suzuki K, Higuchi S, Yamada K, Mizutani Y, Kono H. Young
female alcoholics with and without eating disorders: A comparative
study in Japan. Am J Psychiat 1993; 150: 1053-.
[132] Suzuki K, Higuchi S, Yamada K, Komiya H, Takagi S. Bulimia
nervosa with and without alcoholism: A comparative study in
Japan. Int J Eat Disord 1994; 16(2): 137-46.
[133] Matsumoto T, Azekawa T, Yamaguchi A, Asami T, Iseki E.
Habitual self‐mutilation in Japan. Psychiat Clin Neurosci 2004;
58(2): 191-8.
[134] Machizawa‐Summers S. Childhood trauma and parental bonding
among Japanese female patients with borderline personality
disorder. $Int J Psychol 2007; 42(4): 265-73.
[135] Yoshida K, Tonai E, Nagai H, et al. Long-term follow-up study of
borderline patients in Japan: a preliminary study. Compr Psychiat
2006; 47(5): 426-32.
[136] McGlashan TH. The Chestnut Lodge follow-up study: III. Long-
term outcome of borderline personalities. Arch Gen Psychiat 1986;
43(1): 20-30.
[137] Moriya N, Miyake Y, Minakawa K, Ikuta N, Nishizono-Maher A.
Diagnosis and clinical features of borderline personality disorder in
the East and West: A preliminary report. Compr Psychiat 1993;
34(6): 418-23.
[138] Ha KS, Kim SJ, Yune SK, et al. Three‐year follow up of women
with and without borderline personality disorder: development of
Cloninger's character in adolescence. Psychiatry Clin Neurosci
2004; 58(1): 42-7.
[139] Lyoo IK, Han MH, Cho DY. A brain MRI study in subjects with
borderline personality disorder. J Affect Disord 1998; 50(2): 235-
43.
[140] Wongpakaran T, Wongpakaran N, Sirithepthawee U, et al.
Interpersonal problems among psychiatric outpatients and non-
clinical samples. Singapore Med J 2012; 53(7): 481-7.
[141] Krisanaprakornkit T, Paholpak S, Tassaniyom K, Pimpanit V.
Transcranial magnetic stimulation for treatment resistant
depression: six case reports and review. J Med Assoc Thai 2010;
93(5): 580-6.
[142] Fahmida A, Wahab M, Rahman M. Pattern of psychiatric morbidity
among the patients admitted in a private psychiatric clinic.
Bangladesh J. Med. Sci 2009; 8(1&2): 23.
[143] Gupta S, Mattoo SK. Personality disorders: Prevalence and
demography at a psychiatric outpatient in North India. Int J Soc
Psychiatry 2012; 58(2): 146-52.
[144] Nath S, Patra DK, Biswas S, Mallick AK, Bandyopadhyay GK,
Ghosh S. Comparative study of personality disorder associated
with deliberate self harm in two different age groups(15–24 years
and 45–74 years). Ind J Psychiat 2008; 50(3): 177.
[145] Pinto C, Dhavale HS, Nair S, Patil B, Dewan M. Borderline
personality disorder exists in India. J Nerv Ment Dis 2000; 188(6):
386-8.
[146] Şar V, Akyüz G, Doğan O. Prevalence of dissociative disorders
among women in the general population. Psychiat Res 2007;
149(1): 169-76.
[147] Sar V, Akyuz G, Kugu N, Ozturk E, Ertem-Vehid H. Axis I
dissociative disorder comorbidity in borderline personality disorder
and reports of childhood trauma. J Clin Psychiatry 2006; 67(10):
1583-90.
[148] Senol S, Dereboy C, Yüksel N. Borderline disorder in Turkey: a 2-
to 4-year follow-up. Soc Psychiatry Psychiatr Epidemiol 1997;
32(2): 109-12.
[149] Yasan A, Danis R, Tamam L, Ozmen S, Ozkan M. Socio‐Cultural
Features and Sex Profile of the Individuals with Serious Suicide
Attempts in Southeastern Turkey: A One‐Year Survey. Suicide
Life Threat Behav 2008; 38(4): 467-80.
[150] Coşkunol H, Bağdiken İ, Sorias S, Saygılı R. SCID-II(Türkçe
versiyonu) görüşmesinin kişilik bozukluklarındaki güvenirliği.
Türk Psikoloji Dergisi 1994; 9(32): 26-9.
[151] Sar V, Yargic LI, Tutkun H. Structured interview data on 35 cases
of dissociative identity disorder in Turkey. The Am J Psychiat
1996; 153(10): 1329.
[152] Yargiç LI, Şar V, Tutkun H, Alyanak B. Comparison of
dissociative identity disorder with other diagnostic groups using a
structured interview in Turkey. Compr Psychiat 1998; 39(6): 345-
51.
[153] Tezcan E, Atmaca M, Kuloglu M, Gecici O, Buyukbayram A,
Tutkun H. Dissociative disorders in Turkish inpatients with
conversion disorder. Compr Psychiat 2003; 44(4): 324-30.
[154] Evren C, Cınar O, Evren B. Relationship of alexithymia and
dissociation with severity of borderline personality features in male
substance-dependent inpatients. Compr Psychiat 2012; 53(6): 854-
9.
[155] Evren C, Cinar O, Evren B, Celik S. Relationship of self-mutilative
behaviours with severity of borderline personality, childhood
trauma and impulsivity in male substance-dependent inpatients.
Psychiat Res 2012; 200(1): 20-5.
[156] Coşkun BK, Atmaca M, Saral Y, Coskun N. Prevalence of
psychological factors in chronic dermatoses. Int J Psychiatry Clin
Pract 2005; 9(1): 52-4.
32 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
[157] Semiz UB, Basoglu C, Ebrinc S, Cetin M. Nightmare disorder,
dream anxiety, and subjective sleep quality in patients with
borderline personality disorder. Psychiatry Clin Neurosci 2008;
62(1): 48-55.
[158] Güleç MY, Hocaoğlu C. Relationship between personality and
disability in patients with major depressive disorder. Isr J Psychiat
Rel 2010; 48(2): 123-8.
[159] Ozkan M, Altindag A. Comorbid personality disorders in subjects
with panic disorder: do personality disorders increase clinical
severity? Compr Psychiat 2005; 46(1): 20-6.
[160] Sar V, Islam S, Öztürk E. Childhood emotional abuse and
dissociation in patients with conversion symptoms. Psychiatry Clin
Neurosci 2009; 63(5): 670-7.
[161] Şar V, Akyüz G, Kundakçı T, Kızıltan E, Doğan O. Childhood
trauma, dissociation, and psychiatric comorbidity in patients with
conversion disorder. Am J Psychiat 2004; 161(12): 2271-6.
[162] Horesh N, Klomek AB, Apter A. Stressful life events and major
depressive disorders. Psychiat Res 2008; 160(2): 192-9.
[163] Horesh N, Apter A, Zalsman G. Timing, quantity and quality of
stressful life events in childhood and preceding the first episode of
bipolar disorder. J Affect Disord 2011; 134(1): 434-7.
[164] Somer E. Israeli mental health professionals' attitudes towards
dissociative disorders, reported incidence and alternative diagnoses
considered. J Trauma Dissociation 2000; 1(1): 21-44.
[165] El‐Rufaie O, Al‐Sabosy M, Abuzeid M, Ghubash R. Personality
profile among primary care patients: experimenting with the Arabic
IPDE ICD‐10. Acta Psychiatr Scand 2002; 105(1): 37-41.
[166] Triandis HC. Culture and psychology: A history of the study of
their relationship: Guilford Press; 2007.
[167] Paris J, Lis E. Can sociocultural and historical mechanisms
influence the development of borderline personality disorder?
Transcultural Psychiat 2012; 50(1): 140-51.
[168] Alarcón RD, Foulks EF. Cultural factors and personality disorders.
In: Widiger TA, Frances AJ, Pincus HA, Ross R, First MB, Davis
W, editors. DSM-IV Sourcebook 3. Washington DC: American
Psychiatric Association; 1997. p. 975-82.
[169] Marčinko D, Bilić V . Family therapy as addition to individual
therapy and psychopharmacotherapy in late adolescent female
patients suffering from borderline personality disorder with
comorbidity and positive suicidal history. Psychiatr Danub 2010;
22(2): 257-60.
[170] Hopwood CJ, Morey LC, Edelen MO, et al. A comparison of
interview and self-report methods for the assessment of borderline
personality disorder criteria. Psychol Assess 2008; 20(1): 81.
[171] Tang S, Huang Y. Diagnosing personality disorders in China. J Int
Med 1995; 2: 291-7.
[172] Zimmerman M, Mattia JI. Axis I diagnostic comorbidity and
borderline personality disorder. Compr Psychiat 1999; 40(4): 245-
52.
[173] Caldwell-Harris CL, Ayçiçegi A. When personality and culture
clash: The psychological distress of allocentrics in an individualist
culture and idiocentrics in a collectivist culture. Transcult.
Psychiatry 2006; 43(3): 331-61.
[174] Linehan M. Cognitive-behavioral treatment of borderline
personality disorder: Guilford press; 1993.
[175] Skodol AE, Bender DS. Why are women diagnosed borderline
more than men? Psychiatr Q. 2003; 74(4): 349-60.
[176] Widiger TA, Trull TJ. Borderline and narcissistic personality
disorders. Comprehensive handbook of psychopathology: Springer;
1993. p. 371-94.
[177] Singh D, McMain S, Zucker KJ. Gender identity and sexual
orientation in women with borderline personality disorder. J Sex
Med 2011; 8(2): 447-54.
[178] Coid J. The co-morbidity of personality disorder and lifetime
clinical syndromes in dangerous offenders. J Forens Psychiatry
Psychol. 2003; 14(2): 341-66.
[179] Kaplan M. A woman's view of DSM-III. Am. Psychol 1983; 38(7):
786.
[180] Widiger TA. Invited essay: Sex biases in the diagnosis of
personality disorders. J Pers Disord 1998; 12(2): 95-118.
[181] Wiederman MW, Sansone RA. Borderline personality disorder and
sexuality. Fam. Relat 2009; 17(3): 277-82.
[182] Sansone RA, Sansone LA. Gender patterns in borderline
personality disorder. Innov Clin Neurosci 2011; 8(5): 16.
[183] Banzhaf A, Ritter K, Merkl A, Schulte-Herbrüggen O, Lammers C-
H, Roepke S. Gender differences in a clinical sample of patients
with borderline personality disorder. J Pers Disord 2012; 26(3):
368-80.
[184] Johnson DM, Shea MT, Yen S, et al. Gender differences in
borderline personality disorder: Findings from the Collaborative
Longitudinal Personality Disorders Study. Compr Psychiat 2003;
44(4): 284-92.
[185] Bradley R, Zittel Conklin C, Westen D. The borderline personality
diagnosis in adolescents: gender differences and subtypes. J. Child
Psychol. Psychiatry 2005; 46(9): 1006-19.
[186] McCormick B, Blum N, Hansel R, et al. Relationship of sex to
symptom severity, psychiatric comorbidity, and health care
utilization in 163 subjects with borderline personality disorder.
Compr Psychiat 2007; 48(5): 406-12.
[187] Loffler-Stastka H, Voracek M, Leithner K, et al. Predicting
psychotherapy utilization for patients with borderline personality
disorder. Psychotherapy Research. 2003; 13(2): 255-64.
[188] Mancke F, Bertsch K, Herpertz SC. Gender differences in
aggression of borderline personality disorder. Borderline Personal
Disord Emot Dysregul 2015; 2(1): 7.
[189] Tadić A, Wagner S, Hoch J, et al. Gender differences in axis I and
axis II comorbidity in patients with borderline personality disorder.
Psychopathology 2009; 42(4): 257-63.
[190] Zlotnick C, Rothschild L, Zimmerman M. The role of gender in the
clinical presentation of patients with borderline personality
disorder. J Pers Disord 2002; 16(3): 277-82.
[191] Marchetto M. Repetitive skin‐cutting: Parental bonding,
personality and gender. PSYCHOL PSYCHOTHER-T 2006; 79(3):
445-59.
[192] Sansone RA, Lam C, Wiederman MW. Being bullied in childhood:
correlations with borderline personality in adulthood. Compr
Psychiat 2010; 51(5): 458-61.
[193] Zanarini MC, Laudate CS, Frankenburg FR, Reich DB,
Fitzmaurice G. Predictors of self-mutilation in patients with
borderline personality disorder: A 10-year follow-up study. J
Psychiatr Res 2011; 45(6): 823-8.
[194] Seikowski K, Gollek S, Harth W, Reinhardt M. Borderline-
Persönlichkeitsstörung und Transsexualität. Psychiatr Prax 2008;
35(03): 135-41.
[195] Mahalik JR, Locke BD, Ludlow LH, et al. Development of the
Conformity to Masculine Norms Inventory. Psychol Men Masc
2003; 4(1): 3.
[196] Mahalik JR, Morray EB, Coonerty-Femiano A, et al. Development
of the conformity to feminine norms inventory. Sex Roles 2005;
52(7): 417-35.
[197] Reich DB, Zanarini MC. Sexual orientation and relationship choice
in borderline personality disorder over ten years of prospective
follow-up. J Pers Disord 2008; 22(6): 564-72.
[198] Paris J, Zweig-Frank H, Guzder J. Psychological factors associated
with homosexuality in males with borderline personality disorder. J
Pers Disord 1995; 9(1): 56-61.
[199] Zubenko GS, George AW, Soloff PH, Schulz P. Sexual practices
among patients with borderline personality disorder. The Am J
Psychiat 1987.
[200] Gebhard PH. Incidence of overt homosexuality in the United States
and Western Europe. National Institute of Mental Health task force
on homosexuality: Final report and background papers. 1972: 22-9.
[201] Kinsey AC, Pomeroy WB, Martin CE, Sloan S. Sexual behavior in
the human male. 1948.
[202] Zubenko GS, George AW, Soloff PH, Schulz P. Sexual practices
among patients with borderline personality disorder. The Am J
Psychiat 1987; 144(6): 748-52.
[203] Dulit RA, Fyer MR, Miller FT, Sacks MH, Frances AJ. Gender
differences in sexual preference and substance abuse of inpatients
with borderline personality disorder. J Pers Disord 1993; 7(2): 182-
5.
[204] Fay RE, Turner CF, Klassen AD, Gagnon JH. Prevalence and
patterns of same-gender sexual contact among men. Age. 1989;
21(24): 9.3.
[205] Schulte‐Herbrüggen O, Ahlers CJ, Kronsbein JM, et al.
WOMEN'S SEXUAL HEALTH: Impaired Sexual Function in
Patients with Borderline Personality Disorder is Determined by
History of Sexual Abuse. J Sex Med 2009; 6(12): 3356-63.
[206] Laumann EO. The social organization of sexuality: Sexual
practices in the United States: University of Chicago Press; 1994.
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 33
[207] Kinsey A, Pomeroy WB, Martin CE. Sexual Behavior in the
Human Female, by AC Kinsey, WB Wardell, CE Martin and
Others: WB Saunders; 1953.
[208] Hurlbert DF, Apt C, White LC. An empirical examination into the
sexuality of women with borderline personality disorder. J Sex
Marital Ther 1992; 18(3): 231-42.
[209] Sansone RA, Barnes J, Muennich E, Wiederman MW. Borderline
personality symptomatology and sexual impulsivity. Int J
Psychiatry Med 2008; 38(1): 53-60.
[210] Stone MH. The fate of borderline patients: Successful outcome and
psychiatric practice: Guilford Press; 1990.
[211] Kalichman SC, Benotsch E, Rompa D, et al. Unwanted sexual
experiences and sexual risks in gay and bisexual men: Associations
among revictimization, substance use, and psychiatric symptoms. J
Sex Res 2001; 38(1): 1-9.
[212] Clark LA. Schedule for Nonadaptive and Adaptive Personality
Manual for Administration, Scoring, and Interpretation. .
Minneapolis, MN: University of Minnesota Press; 1993.
[213] Eubanks‐Carter C, Goldfried MR. The impact of client sexual
orientation and gender on clinical judgments and diagnosis of
borderline personality disorder. J. Clin. Psychol. 2006; 62(6): 751-
70.
[214] Falco KL. Psychotherapy with lesbian clients: Theory into practice:
Psychology Press; 1991.
[215] Ritter K, Terndrup AI. Handbook of affirmative psychotherapy
with lesbians and gay men: Guilford Press; 2002.
[216] American Psychiatric Association., American Psychiatric
Association. Work Group to Revise DSM-III. Diagnostic and
statistical manual of mental disorders : DSM-III-R. 3rd ed.
Washington, DC: American Psychiatric Association; 1987. xxix,
567 pages p.
[217] Gonsiorek J. Book review of Masters & Johnson. Homosexuality
in. 1981.
[218] Swartz M, Blazer D, George L, Winfield I. Estimating the
prevalence of borderline personality disorder in the community. J
Pers Disord 1990; 4(3): 257-72.
[219] Trestman RL, Ford J, Zhang W, Wiesbrock V. Current and lifetime
psychiatric illness among inmates not identified as acutely mentally
ill at intake in Connecticut's jails. J Am Acad Psychiatry Law 2007;
35(4): 490-500.
[220] Chavira DA, Grilo CM, Shea MT, et al. Ethnicity and four
personality disorders. Compr Psychiat 2003; 44(6): 483-91.
[221] Bender DS, Skodol AE, Dyck IR, et al. Ethnicity and mental health
treatment utilization by patients with personality disorders. J
Consult Clin Psychol 2007; 75(6): 992.
[222] Castaneda R, Franco H. Sex and ethnic distribution of borderline
personality disorder in an inpatient sample. The Am J Psychiat
1985.
[223] Akhtar S, Byrne JP, Doghramji K. The demographic profile of
borderline personality disorder. J Clin Psychiatry 1986.
[224] Coid JW, Kahtan N, Gault S, Jarman B. Ethnic differences in
admissions to secure forensic psychiatry services. Br J Psychiat
2000; 177(3): 241-7.
[225] Coid J, Petruckevitch A, Bebbington P, et al. Ethnic differences in
prisoners. I: Criminality and psychiatric morbidity. Br J Psychiatry
2002; 181(DEC): 473-80.
[226] Coid J, Petruckevitch A, Bebbington P, et al. Ethnic differences in
prisoners 2: Risk factors and psychiatric service use. 2002.
[227] Selby EA, Joiner TE. Ethnic variations in the structure of
borderline personality disorder symptomatology. J Psychiatr Res
2008; 43(2): 115-23.
[228] Newhill CE, Eack SM, Conner KO. Racial differences between
African and white Americans in the presentation of borderline
personality disorder. Race Soc Probl 2009; 1(2): 87-96.
[229] Grilo CM, Becker DF, Anez LM, McGlashan TH. Diagnostic
efficiency of DSM-IV criteria for borderline personality disorder:
an evaluation in Hispanic men and women with substance use
disorders. J Consult Clin Psychol 2004; 72(1): 126.
[230] Grilo CM, McGlashan TH, Morey LC, al. Internal consistency,
intercriterion overlap and diagnostic efficiency of criteria sets for
DSM-IV schizotypal, borderline, avoidant and obsessive-
compulsive personality disorders. Acta Psychiatr Scand 2001;
104(4): 264-72.
[231] McGilloway A, Hall RE, Lee T, Bhui KS. A systematic review of
personality disorder, race and ethnicity: prevalence, aetiology and
treatment. BMC psychiatry. 2010; 10(1): 33.
[232] Snyder S, Goodpaster WA, Pitts Jr WM, Pokorny AD, Gustin QL.
Demography of psychiatric patients with borderline personality
traits. Psychopathology 1985; 18(1): 38-49.
[233] Sansone RA, Kelley AR, Forbis JS. Religion/spirituality status and
borderline personality symptomatology among outpatients in an
internal medicine clinic. Int J Psychiatry Clin Pract 2012; 16(1):
48-52.
[234] Sansone RA, Wiederman MW. Distancing oneself from God:
relationships with borderline personality symptomatology. Ment.
Health Relig. Cult 2013; 16(2): 210-4.
[235] Bennett K, Shepherd J, Janca A. Personality disorders and
spirituality. Curr Opin Psychiatry 2013; 26(1): 79-83.
[236] Claridge G, Broks P. Schizotypy and hemisphere function—I:
Theoretical considerations and the measurement of schizotypy.
$Pers. Individ. Dif 1984; 5(6): 633-48.
[237] Maltby J, Day L. Religious experience, religious orientation and
schizotypy. Ment. Health Relig. Cult 2002; 5(2): 163-74.
[238] Joseph S, Smith D, Diduca D. Religious orientation and its
association with personality, schizotypal traits and manic-
depressive experiences. Ment. Health Relig. Cult 2002; 5(1): 73-81.
[239] Maltby J, Garner I, Lewis CA, Day L. Religious orientation and
schizotypal traits. $Pers. Individ. Dif 2000; 28(1): 143-51.
[240] White J, Joseph S, Neil A. Religiosity, psychoticism, and
schizotypal traits. $Pers. Individ. Dif 1995; 19(6): 847-51.
[241] Koenig H, King D, Carson VB. Handbook of religion and health:
Oup Usa; 2012.
[242] Arens EA, Stopsack M, Spitzer C, et al. Borderline personality
disorder in four different age groups: a cross-sectional study of
community residents in Germany. J Pers Disord 2013; 27(2): 196-
207.
[243] Blum N, Franklin J, Hansel R, et al. Relationship of age to
symptom severity, psychiatric comorbidity and health care
utilization in persons with borderline personality disorder.
Personal. Ment. Health 2008; 2(1): 25-34.
[244] Stepp SD, Pilkonis PA. Age-related differences in individual DSM
criteria for borderline personality disorder. J Pers Disord 2008;
22(4): 427-32.
[245] Tracie Shea M, Edelen MO, Pinto A, et al. Improvement in
borderline personality disorder in relationship to age. Acta
Psychiatr Scand 2009; 119(2): 143-8.
[246] Dersh J, Gatchel RJ, Polatin P, Mayer T. Prevalence of psychiatric
disorders in patients with chronic work-related musculoskeletal
pain disability. J Occup Environ Med 2002; 44(5): 459-68.
[247] Zanarini MC, Jacoby RJ, Frankenburg FR, Reich DB, Fitzmaurice
G. The 10-year course of social security disability income reported
by patients with borderline personality disorder and axis II
comparison subjects. J Pers Disord 2009; 23(4): 346-56.
[248] Sansone RA, Sinclair JD, Wiederman MW. Disability and
borderline personality disorder in chronic pain patients. $Pain Res.
Manag 2010; 15(6): 369-70.
[249] Ruocco AC, Lam J, McMain SF. Subjective cognitive complaints
and functional disability in patients with borderline personality
disorder and their nonaffected first-degree relatives. Can J Psychiat
2014; 59(6): 335-44.
[250] Bouchard S, Sabourin S, Lussier Y, Villeneuve E. Relationship
quality and stability in couples when one partner suffers from
borderline personality disorder. J Marital Fam Ther 2009; 35(4):
446-55.
[251] Whisman MA, Schonbrun YC. Social consequences of borderline
personality disorder symptoms in a population-based survey:
Marital distress, marital violence, and marital disruption. J Pers
Disord 2009; 23(4): 410-5.
[252] Reich RB, Vera SC, Marino MF, Levin A, Yong L, Frankenburg
FR. Reported pathological childhood experiences associated with
the development of borderline personality disorder. Am J Psychiat
1997; 154(8): 11011106.
[253] Zanarini MC, Frankenburg FR, Dubo ED, et al. Axis I comorbidity
of borderline personality disorder. Am J Psychiat 1998; 155(12):
1733-9.
[254] Becker DF, Grilo CM, Edell WS, McGlashan TH. Comorbidity of
borderline personality disorder with other personality disorders in
hospitalized adolescents and adults. Am J Psychiat 2000; 157(12):
2011-6.
[255] Cohen P, Chen H, Gordon K, Johnson J, Brook J, Kasen S.
Socioeconomic background and the developmental course of
34 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
schizotypal and borderline personality disorder symptoms. Dev
Psychopathol 2008; 20(2): 633-50.
[256] Zanarini MC, Frankenburg F, Vujanovic A, Hennen J, Reich D,
Silk K. Axis II comorbidity of borderline personality disorder:
description of 6‐year course and prediction to time‐to‐remission.
Acta Psychiatr Scand 2004; 110(6): 416-20.
[257] De Genna NM, Feske U. Phenomenology of borderline personality
disorder: the role of race and socioeconomic status. J Nerv Ment
Dis 2013; 201(12): 1027.
[258] Pascual J, Malagon A, Corcoles D, et al. Immigrants and borderline
personality disorder at a psychiatric emergency service. Br J
Psychiat 2008; 193(6): 471-6.
[259] Tousignant M, Kovess V. Borderline traits among community
alcoholics and problem-drinkers: Rural-urban differences. Can. J.
Psychiatry1989; 34(8): 796-9.
[260] Coid J, Yang M, Bebbington P, et al. Borderline personality
disorder: health service use and social functioning among a
national household population. $Psychol. Med 2009; 39(10): 1721-
31.
[261] Huang X, Ling H, Yang B, Dou G. Screening of personality
disorders among Chinese college students by Personality
Diagnostic Questionnaire-4+. J Pers Disord 2007; 21(4): 448-54.
[262] Yeaman C, Gambach J, Bach B, Manker J, Diwan S, Corrigan P.
What happens to people receiving inpatient psychiatric services in
mixed rural and urban communities? Administration and Policy in
Mental Health and Mental Health Services Research. 2003; 30(3):
247-53.
[263] Palmer S, Davidson K, Tyrer P, et al. The cost-effectiveness of
cognitive behavior therapy for borderline personality disorder:
results from the BOSCOT trial. J Pers Disord 2006; 20(5): 466-81.
[264] Davidson K, Norrie J, Tyrer P, et al. The effectiveness of cognitive
behavior therapy for borderline personality disorder: results from
the borderline personality disorder study of cognitive
therapy(BOSCOT) trial. J Pers Disord 2006; 20(5): 450-65.
[265] Robins CJ. Dialectical behavior therapy for borderline personality
disorder. Psychiatric Annals 2002; 32(10): 6 08-16.
[266] Kliem S, Kröger C, Kosfelder J. Dialectical behavior therapy for
borderline personality disorder: a meta-analysis using mixed-
effects modeling. American Psychological Association; 2010.
[267] Panos PT, Jackson JW, Hasan O, Panos A. Meta-analysis and
systematic review assessing the efficacy of dialectical behavior
therapy(DBT). Res. Soc. Work Pract 2014; 24(2): 213-23.
[268] Roepke S, Schröder‐Abé M, Schütz A, et al. Dialectic behavioural
therapy has an impact on self‐concept clarity and facets of
self‐esteem in women with borderline personality disorder. Clin
Psychol Psychother 2011; 18(2): 148-58.
[269] Blum N, Pfohl B, John DS, Monahan P, Black DW. STEPPS: a
cognitive-behavioral systems-based group treatment for outpatients
with borderline personality disorder—a preliminary report. Compr
Psychiat 2002; 43(4): 301-10.
[270] Black DW, Blum N, Eichinger L, McCormick B, Allen J, Sieleni
B. STEPPS: Systems Training for Emotional Predictability and
Problem Solving in women offenders with borderline personality
disorder in prison—A pilot study. CNS spectrums 2008; 13(10):
881-6.
[271] Blum N, St. John D, Pfohl B, et al. Systems Training for Emotional
Predictability and Problem Solving(STEPPS) for outpatients with
borderline personality disorder: a randomized controlled trial and
1-year follow-up. Am J Psychiat 2008; 165(4): 468-78.
[272] Schuppert HM, Giesen‐Bloo J, van Gemert TG, et al.
Effectiveness of an emotion regulation group training for
adolescents—a randomized controlled pilot study. Clin Psychol
Psychother 2009; 16(6): 467-78.
[273] Bos EH, van Wel EB, Appelo MT, Verbraak MJ. A randomized
controlled trial of a Dutch version of systems training for emotional
predictability and problem solving for borderline personality
disorder. J Nerv Ment Dis 2010; 198(4): 299-304.
[274] Beck AT, Freeman A, Davis DD. Cognitive therapy of personality
disorders: Guilford Publications; 1990.
[275] Brown GK, Newman CF, Charlesworth SE, Crits-Christoph P,
Beck AT. An open clinical trial of cognitive therapy for borderline
personality disorder. J Pers Disord 2004; 18(3: Special issue): 257-
71.
[276] Cottraux J, Note ID, Boutitie F, et al. Cognitive therapy versus
Rogerian supportive therapy in borderline personality disorder.
Psychother. Psychosom 2009; 78(5): 307-16.
[277] Young JE, Klosko JS, Weishaar ME. Schema therapy: A
practitioner's guide: Guilford Press; 2003.
[278] Farrell JM, Shaw IA, Webber MA. A schema-focused approach to
group psychotherapy for outpatients with borderline personality
disorder: a randomized controlled trial. J Behav Ther Exp
Psychiatry 2009; 40(2): 317-28.
[279] Giesen-Bloo J, Van Dyck R, Spinhoven P, et al. Outpatient
psychotherapy for borderline personality disorder: randomized trial
of schema-focused therapy vs transference-focused psychotherapy.
Arch Gen Psychiat 2006; 63(6): 649-58.
[280] Nadort M, Arntz A, Smit JH, et al. Implementation of outpatient
schema therapy for borderline personality disorder with versus
without crisis support by the therapist outside office hours: A
randomized trial. Behav Res Ther 2009; 47(11): 961-73.
[281] Nordahl HM, Nysæter TE. Schema therapy for patients with
borderline personality disorder: a single case series. J Behav Ther
Exp Psychiat 2005; 36(3): 254-64.
[282] Evans K, Tyrer P, Catalan J, et al. Manual-assisted cognitive-
behaviour therapy(MACT): a randomized controlled trial of a brief
intervention with bibliotherapy in the treatment of recurrent
deliberate self-harm. $Psychol Med 1999; 29(1): 19-25.
[283] Weinberg I, Gunderson JG, Hennen J, Cutter Jr CJ. Manual
assisted cognitive treatment for deliberate self-harm in borderline
personality disorder patients. J Pers Disord 2006; 20(5): 482-92.
[284] Morey LC, Lowmaster SE, Hopwood CJ. A pilot study of manual-
assisted cognitive therapy with a therapeutic assessment
augmentation for borderline personality disorder. Psychiat Res
2010; 178(3): 531-5.
[285] Bohus M, Haaf B, Simms T, et al. Effectiveness of inpatient
dialectical behavioral therapy for borderline personality disorder: a
controlled trial. Behav Res Ther 2004; 42(5): 487-99.
[286] Davidson KM, Tyrer P, Norrie J, Palmer SJ, Tyrer H. Cognitive
therapy v. usual treatment for borderline personality disorder:
prospective 6-year follow-up. Br J Psychiat 2010; 197(6): 456-62.
[287] Dimeff LA, McDavid J, Linehan MM. Pharmacotherapy for
borderline personality disorder: A review of the literature and
recommendations for treatment. J Clin Psychol Med Settings 1999;
6(1): 113-38.
[288] Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M.
Borderline personality disorder. The Lancet. 2004; 364(9432): 453-
61.
[289] Nose M, Cipriani A, Biancosino B, Grassi L, Barbui C. Efficacy of
pharmacotherapy against core traits of borderline personality
disorder: meta-analysis of randomized controlled trials. Int Clin
Psychopharmacol 2006; 21(6): 345-53.
[290] Lieb K, Völlm B, Rücker G, Timmer A, Stoffers JM.
Pharmacotherapy for borderline personality disorder: Cochrane
systematic review of randomised trials. Br J Psychiat 2010; 196(1):
4-12.
[291] Vita A, De Peri L, Sacchetti E. Antipsychotics, antidepressants,
anticonvulsants, and placebo on the symptom dimensions of
borderline personality disorder: a meta-analysis of randomized
controlled and open-label trials. J Clin Psychopharmacol 2011;
31(5): 613-24.
[292] Stoffers J, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K.
Pharmacological interventions for borderline personality disorder.
The Cochrane Library 2010.
[293] Tajima K, García-Albea J, Navas M, Carrasco J.
Psychopharmacological treatment in borderline personality
disorder. Actas Esp Psiquiatr 2008; 36(1): 39-49.
[294] Stein DJ, Simeon D, Frenkel M, Islam MN, Hollander E. An open
trial of valproate in borderline personality disorder. J Clin
Psychiatry 1995.
[295] Clarkin JF, Yeomans FE, Kernberg OF. Psychotherapy for
borderline personality. 1999.
[296] Bateman A, Fonagy P. Effectiveness of partial hospitalization in
the treatment of borderline personality disorder: a randomized
controlled trial. Am J Psychiat 1999; 156(10): 1563-9.
[297] Kernberg OF, Yeomans FE, Clarkin JF, Levy KN. Transference
focused psychotherapy: Overview and update. The International
Journal of Psychoanalysis 2008; 89(3): 601-20.
[298] Clarkin JF, Foelsch PA, Levy KN, Hull JW, Delaney JC, Kernberg
OF. The development of a psychodynamic treatment for patients
with borderline personality disorder: a preliminary study of
behavioral change. J Pers Disord 2001; 15(6): 487-95.
Understanding Borderline Personality Disorder Across Sociocultural Groups Current Psychiatry Reviews, 2017, Vol. 13, No . 3 35
[299] Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating
three treatments for borderline personality disorder: a multiwave
study. Am J Psychiat 2007; 164(6): 922-8.
[300] Doering S, Hörz S, Rentrop M, et al. Transference-focused
psychotherapy v. treatment by community psychotherapists for
borderline personality disorder: randomised controlled trial. Br J
Psychiat 2010; 196(5): 389-95.
[301] Bateman A, Fonagy P. Randomized controlled trial of outpatient
mentalization-based treatment versus structured clinical
management for borderline personality disorder. Am J Psychiat
2009; 166(12): 1355-64.
[302] Reneses B, Figuera D, Salcedo G, et al. P02-444-A Controlled
Randomized Study on the Efficacy of Short-Term Dinamic
Psychotherapy in Borderline Personality Disorders(BPD).
Preliminary Results. Eur Psychiat 2011; 26: 1040.
[303] Ferrero A, Cairo E, Fassina S, Pierò A, Simonelli B. Sequential
Brief Adlerian Psychodynamic Psychotherapy(SB-APP): technical
issues for the treatment of aggressiveness in patients with
Borderline Personality Organisation(BPO). Panminerva Med.
2009; 51(Suppl 3): 39-50.
[304] Amianto F, Ferrero A, Pierò A, et al. Supervised team
management, with or without structured psychotherapy, in heavy
users of a mental health service with borderline personality
disorder: a two-year follow-up preliminary randomized study.
BMC psychiatry 2011; 11(1): 181.
[305] Ryle A, Kerr IB. The Main Features of CAT. Introducing
Cognitive Analytic Therapy: Principles and Practice. 2002: 6-20.
[306] Klerman G, Weissman M, Rounsaville B, Chevron E. Interpersonal
psychotherapy of depression. 1984. Northvale, NJ: Jason Aronson.
1984
[307] Chanen AM, Jackson HJ, McCutcheon LK, et al. Early
intervention for adolescents with borderline personality disorder
using cognitive analytic therapy: randomised controlled trial. Br J
Psychiat 2008; 193(6): 477-84.
[308] Ryle A, Golynkina K. Effectiveness of time‐limited cognitive
analytic therapy of borderline personality disorder: Factors
associated with outcome. Psychol Psychother-T 2000; 73(2): 197-
210.
[309] Markowitz JC, Bleiberg K, Pessin H, Skodol AE. Adapting
interpersonal psychotherapy for borderline personality disorder.
$JMH 2007; 16(1): 103-16.
[310] Bellino S, Rinaldi C, Bogetto F. Adaptation of interpersonal
psychotherapy to borderline personality disorder: a comparison of
combined therapy and single pharmacotherapy. Can J Psychiat
2010; 55(2): 74-81.
[311] Adams G, Markus HR. Toward a conception of culture suitable for
a social psychology of culture. The psychological foundations of
culture 2004: 335-60.
[312] Hays PA. Addressing cultural complexities in practice: A
framework for clinicians and counselors: American Psychological
Association; 2001.
[313] Tanaka-Matsumi J. Abnormal psychology and culture. The
handbook of culture and psychology. 2001: 265-86.
[314] Kerr LK. The" borderline" as the sociocultural origin of borderline
personality disorder-and psychiatry. Ethical Hum Psychol Psychiat
2004; 6(3): 201-5.
[315] Iwamasa GY, Larrabee AL, Merritt RD. Are personality disorder
criteria ethnically biased? A card-sort analysis. Cultur Divers
Ethnic Minor Psychol 2000; 6(3): 284.
[316] Leiderman EA, Buchovsky S, Jiménez M, et al. Diagnóstico y
Tratamiento del Trastorno Borderline de la personalidad: Una
encuesta a profesionales. Vertex, Revista Argentina de Psiquiatría
2004; 15: 280-6.
[317] Corsaro B. El uso del diagnóstico Borderline en Argentina.
Posibles consecuencias. Vertex, Revista Argentina de Psiquiatría
1990; 1: 36-9.
[318] Sharan P. An overview of Indian research in personality disorders.
Ind J Psychiat 2010; 52(Suppl1): S250.
[319] Aydemir Ö, Demet MM, Danacı AE, et al. Borderline kişilik
envanterinin Türkçe’ye uyarlanması, güvenilirlik ve geçerliliği.
Türkiye’de Psikiyatri 2006; 8(1): 6-10.
[320] Alarcón RD. Cultural issues in the coordination of DSM-V and
ICD-11. Contemporary directions in psychopathology: scientific
foundations of the DSM-V and ICD-11. 2010: 97-110.
[321] Draguns JG. Psychopathological and clinical aspects of personal
experience: From selves and values to deficits and symptoms. $J
Cross-Cult. Psychol 2001: 247.
[322] Blais MA, Hilsenroth MJ, Castlebury FD. Content validity of the
DSM-IV borderline and narcissistic personality disorder criteria
sets. Compr Psychiat 1997; 38(1): 31-7.
[323] Sharan P, Kulhara P, Verma S, Mohanty M. Reliability of the ICD-
10 international personality disorder examination(IPDE)(hindi
version): a preliminary study. Ind J Psychiat 2002; 44(4): 362.
[324] Shweder RA, Bourne EJ. Does the concept of the person vary
cross-culturally? In: Shweder RA, editor. Thinking through
cultures: Expeditions in cultural psychology. Boston, MA: Harvard
University Press.; 1984. p. 113-55.
[325] Epstein M. Going to pieces without falling apart: A Buddhist
perspective on wholeness: Harmony; 1999.
[326] Ohara K. ABSTRACTS: CHARACTERISTICS OF SUICIDES IN
JAPAN ESPECIALLY OF PARENT-CHILD DOUBLE SUICIDE.
Am J Psychiat 1963; 120(4): 382-5.
[327] Hawley JS. Sati, the blessing and the curse: The burning of wives
in India: Oxford University Press; 1994.
[328] Durkheim E. Suicide: a study in sociology (1897). Translated by
JA Spaulding and G Simpson(Glencoe, Illinois: The Free Press,
1951). 1951.
[329] Chen Y-Y, Chien-Chang Wu K, Yousuf S, Yip PS. Suicide in Asia:
opportunities and challenges. Epidemiol Rev 2011; 34(1): 129-44.
[330] Maniam T. Suicide and undetermined violent deaths in Malaysia,
1966-1990: Evidence for the misclassification of suicide statistics.
Asia Pac J Public Health 1995; 8(3): 181-5.
[331] Attempt to Commit Suicide,(2008).
[332] Lee S. Cultures in psychiatric nosology: the CCMD-2-R and
international classification of mental disorders. Cult Med
Psychiatry 1996; 20(4): 421-72.
[333] Abusah P. Multicultural influences in case management: Transcult.
Psychiatry Mental Health in Australia. 1993.
[334] Thakker J, Ward T. Culture and classification: The cross-cultural
application of the DSM-IV. Clin Psychol Rev 1998; 18(5): 501-29.
[335] Draguns JG, Tanaka-Matsumi J. Assessment of psychopathology
across and within cultures: issues and findings. Behav Res Ther
2003; 41(7): 755-76.
[336] Tseng W-S. From peculiar psychiatric disorders through culture-
bound syndromes to culture-related specific syndromes. Transcult.
Psychiatry 2006; 43(4): 554-76.
[337] Millon T. A sociocultural conception of the borderline personality
disorder epidemic. Contemporary directions in psychopathology:
Scientific foundations of the DSM-V and ICD-11. 2010: 111-23.
[338] Fabrega H. Cultural challenges to the psychiatric enterprise. Compr
Psychiat 1995; 36(5): 377-83.
[339] O’Neill A, Frodl T. Brain structure and function in borderline
personality disorder. Brain Struct Funct 2012; 217(4): 767-82.
[340] Stein DJ. Borderline personality disorder: toward integration. CNS
spectrums 2009; 14(7): 352-6.
[341] Agranovich AV, Puente AE. Do Russian and American normal
adults perform similarly on neuropsychological tests?: Preliminary
findings on the relationship between culture and test performance.
Arch Clin Neuropsychol 2007; 22(3): 273-82.
[342] Lanik M, Mitchell Gibbons A. Guidelines for cross-cultural
assessor training in multicultural assessment centers. The
Psychologist-Manager Journal 2011; 14(4): 221.
[343] Beck AT, Steer RA, Carbin MG. Psychometric properties of the
Beck Depression Inventory: Twenty-five years of evaluation. Clin
Psychol Rev 1988; 8(1): 77-100.
[344] Braun FK, Fine ES, Greif DC, Devenny JM. Guidelines for
multicultural assessment: An Asian Indian American case study. J
Multicult Counsel Dev 2010; 38(3): 130-41.
[345] Hathaway SR, McKinley JC. A multiphasic personality
schedule(Minnesota): I. Construction of the schedule. JRL 1940;
10(2): 249-54.
[346] Ridley CR, Li LC, Hill CL. Multicultural assessment:
Reexamination, reconceptualization, and practical application.
Couns Psychol 1998; 26(6): 827-910.
[347] Hall GCN. Psychotherapy research with ethnic minorities:
empirical, ethical, and conceptual issues. J Consult Clin Psychol
2001; 69(3): 502.
[348] Hall GC, Hong JJ, Zane NW, Meyer OL. Culturally competent
treatments for Asian Americans: The relevance of mindfulness and
36 Current Psychiatry Reviews, 2017, Vol. 13, No. 3 Neacsiu et al.
acceptance‐based psychotherapies. Clinical Psychology: Science
and Practice 2011; 18(3): 215-31.
[349] Bass JK, Annan J, McIvor Murray S, et al. Controlled trial of
psychotherapy for Congolese survivors of sexual violence. N Engl
J Med 2013; 368(23): 2182-91.
[350] Blagys MD, Hilsenroth MJ. Distinctive activities of cognitive–
behavioral therapy: A review of the comparative psychotherapy
process literature. Clin Psychol Rev 2002; 22(5): 671-706.
[351] Chambers R, Gullone E, Allen NB. Mindful emotion regulation:
An integrative review. Clin Psychol Rev 2009; 29(6): 560-72.
[352] Hodges J, Oei TP. Would Confucius benefit from psychotherapy?
The compatibility of cognitive behaviour therapy and Chinese
values. Behav Res Ther 2007; 45(5): 901-14.
[353] Hwang W-C. The psychotherapy adaptation and modification
framework: Application to Asian Americans. Am Psychol 2006;
61(7): 702.
[354] O’Hearn A, Pollard RQ. Modifying dialectical behavior therapy for
deaf individuals. Cogn Behav Pract 2008; 15(4): 400-14.
[355] Hodge FS, Pasqua A, Marquez CA, Geishirt-Cantrell B. Utilizing
traditional storytelling to promote wellness in American Indian
communities. J Transcult Nurs 2002; 13(1): 6-11.
[356] Chaudhry IB, Neelam K, Duddu V, Husain N. Ethnicity and
psychopharmacology. $J. Psychopharmacol 2008; 22(6): 673-80.
[357] Muñoz C, Hilgenberg C. Ethnopharmacology: Understanding how
ethnicity can affect drug response is essential to providing
culturally competent care. Am J Nurs 2005; 105(8): 40-8.
[358] Burroughs VJ, Maxey RW, Levy RA. Racial and ethnic differences
in response to medicines: towards individualized pharmaceutical
treatment. J Natl Med Assoc 2002; 94(10 Suppl): 1.
[359] Markus HR, Kitayama S. Culture and the self: Implications for
cognition, emotion, and motivation. Psychol Rev 1991; 98(2) : 224-53.
[360] Bond MHE. The Handbook of Chinese Psychology. New York:
Oxford University Press; 1996.
[361] Comas-Diaz L, Minrath M. Psychotherapy with ethnic minority
borderline clients. Psychother Theor Res Pract Train 1985; 22(2S):
418-26.
