The transculturality of borderline personality disorder symptoms

Patients diagnosed with Borderline Personality Disorder exhibit a wide variety of impulsive behaviors, such as substance abuse, excessive money spending, eating compulsions, reckless driving, and difficulty in controlling intense anger, yet the most characteristic symptoms consist of a pattern of self-injurious behaviors when under interpersonal stress. These symptoms fall under externalizing behaviors, while other symptoms, namely fear of abandonment, chronic feelings of emptiness, emotional instability, and social isolation may be considered as internalizing processes (Mulder, 2012). The prevalence of this diagnosis has been increasing in recent decades and is a common disorder in North America and Europe (American Psychiatric Association, 2013). Although it is possible to find this disorder among other societies, its prevalence is yet to be estimated in many. Additionally, it has not been included in the Chinese Classification of Mental Disorders III (Chinese Society of Psychiatry, 2001). The cultural context and social environment may influence the evaluation, expression, repression, and containment of certain symptoms, making the diagnosis difficult in certain cultures (Ronningstam et al., 2018). Several authors argued that the absence of social cohesion, generational discontinuity, poorly defined social roles, and rapid social change found in developed societies are social and cultural factors often related with emotional dysregulation and identity diffusion (Paris & Lis, 2013). In turn, traditional societies, such as Asian, have norms which promote more tenuous change, rigorous role definition, and strong transgenerational identity that may limit the development of impulsive symptoms. Also, other BPD’s diagnostic criteria, such as fear of abandonment, were considered not appropriate in the Chinese cultural context, which values collectivistic identities and enmeshed relationships. Besides, Keng et al. (2019) found that interpersonal difficulties in BPD may be intertwined with behavioral dysregulation in Singaporean individuals. There, family members tend to live close to each other and share traditional values of social harmony, emotion control, and interdependence. Hence emotional dysregulation in the context of interpersonal relationships may manifest themselves in behavioral problems (self-harming), which are invalidated in social environment (Matthews, 2015). Furthermore, social capital can also influence mental health in several ways: the existence of social support allows the individual to feel cared for, cherished and valued, and to belong to a network of mutual obligations; it stimulates social participation and commitment, which results from the adoption of real-life roles; and in close interpersonal contact (Berkman, 2014). In rural settings, social capital may be higher, as members of smaller populations are more likely to form meaningful relationships with the people they contact daily (Giordano et al., 2011). Moreover, the likelihood of responding symptomatically to social change – social sensitivity – may explain the mechanism by which social factors affect the development of BPD (Paris & Lis, 2013). In more traditional cultures, social changes seem to happen in a slower rhythm and individuals with social sensitivity may be withdrawn from impulsive and suicidal behaviors. In Italy, these patients are more likely to present internalizing symptoms of BPD, such as emotional sensitivity, emptiness, and painful interpersonal relationships (Ronningstam et al., 2018). In the case of BPD, religion and spirituality seem to play a less significant role than in other psychiatric disorders, however self-harming behaviors may be discouraged within the Catholic religion. This may be considered, for example, in Italian culture, where Catholicism is dominant, and where young and adult individuals show fewer parasuicidal acts and suicidality. In addition, culture may influence not only the acceptance or rejection of a diagnosis and adherence to treatments, but also the conduct of the clinical encounter. Thus, cultural differences implications in diagnosis accuracy, treatment decisions, prognostic considerations, and clinical outcomes should be made aware. Therefore, while looking at personality disorders we should consider not only the culture in which it developed, but also the culture that observes it, considering that the The transculturality of borderline personality disorder symptoms