Ethnicity and four personality disorders

Ethnicity and Four Personality Disorders

Denise A. Chavira, Carlos M. Grilo, M. Tracie Shea, Shirley Yen, John G. Gunderson,Leslie C. Morey, Andrew E. Skodol, Robert L. Stout, Mary C. Zanarini, and Thomas H. Mcglashan

The current study examined the relationship between

ethnicity and DSM-IV personality disorders. The dis-

tribution of four personality disorders—borderline

(BPD), schizotypal (STPD), avoidant (AVPD), and ob-

sessive-compulsive (OCPD)—along with their criteria

sets, were compared across three ethnic groups (Cau-

casians, African Americans, and Hispanics) using both

a clinician-administered diagnostic interview and a

self-report instrument. Participants were 554 patients

drawn from the Collaborative Longitudinal Personal-

ity Disorders Study (CLPS) who comprised these

three ethnic groups and met personality disorder cri-

teria based on reliably administered semistructured

interviews. Chi-square analyses revealed dispropor-

tionately higher rates of BPD in Hispanic than in Cau-

casian and African American participants and higher

rates of STPD among African Americans when com-

pared to Caucasians. Self-report data reflected similar

patterns. The findings suggest that in treatment-seek-

ing samples, Caucasians, Hispanics, and African

Americans may present with different patterns of per-

sonality pathology. The factors contributing to these

differences warrant further investigation.

© 2003 Elsevier Inc. All rights reserved.

ALTHOUGH RESEARCH investigating therole of culture among axis I disorders has

gained greater impetus during the past two de-cades, among personality disorders, these studiesare scarce. The absence of such data is strikinggiven that culture is intertwined with personality inmany ways. For example, culture influences chil-drearing practices, theoretical worldviews (e.g., in-terdependence v individualism), interpersonal ex-pectations, and self-concept.1-3 Similarly, culturehas the potential to influence pathology inasmuchas it affects: (1) how the individual perceives aproblem; (2) how the individual expresses theproblem; (3) the interaction between the clinicianand the individual; and (4) whether or not andwhen the individual decides to seek treatment.4-9

Notwithstanding data suggesting that personal-ity and culture are related, few studies have as-sessed rates of personality disorders across ethnicgroups in the United States. To date, epidemiolog-ical findings are available for only three DSMpersonality disorders. Data from the Epidemiolog-ical Catchment Area (ECA) study10 indicated sim-ilar rates of histrionic personality disorder amongAfrican Americans and Caucasians.11 In anotherstudy of ECA data, a trend towards higher rates ofborderline personality disorder was reported innon-white individuals belonging to lower socio-economic groups.12 Lastly, similar rates of antiso-cial personality disorder were found among Mex-ican Americans, Puerto Ricans, and non-Hispanicwhites,13,14 and modest yet nonsignificant eleva-tions were reported in African Americans whencompared to Caucasians.10

Paralleling the absence of data at the epidemio-logical level, most clinical studies of personality

disorders do not present ethnicity data. A Medlinesearch found relevant articles for antisocial person-ality disorder and borderline personality disorder.In a study of insanity acquittees, African Ameri-cans were more likely to have schizophrenia, sub-stance abuse, and antisocial personality disorderdiagnoses than Caucasians.15 Among outpatientsdiagnosed with alcohol-use disorders, a similarpattern was reported for antisocial personality dis-order; however, this finding was no longer signif-icant after socioeconomic status was controlled.16

Ethnic differences for borderline personality dis-order have been inconsistent. Akhtar et al.17 re-viewed 17 studies that presented information aboutethnicity and found disproportionately more Afri-can American patients in the “nonborderline”group than in the borderline personality disordergroup. In a different study, where 1,583 inpatientcharts were retrospectively reviewed and 101 pa-tients with borderline personality disorder wereidentified, ethnic group differences in rates of bor-derline personality disorder were not found.18 In-

From the Department of Psychiatry, University of CaliforniaSan Diego, La Jolla, CA; Department of Psychiatry, Yale Uni-versity School of Medicine, New Haven, CT; Department ofPsychiatry and Human Behavior, Brown University, Provi-dence, RI; Harvard Medical School and McLean Hospital,Boston, MA; Texas A & M University, College Station, TX; andColumbia University College of Physicians and Surgeons andNew York State Psychiatric Institute, New York, NY.

Address reprint requests to Denise A. Chavira, Ph.D., Uni-versity of California San Diego, Department of Psychiatry,8950 Villa La Jolla Dr, #2243, La Jolla, CA 92037.

© 2003 Elsevier Inc. All rights reserved.0010-440X/03/4406-0012$30.00/0doi:10.1016/S0010-440X(03)00104-4

Comprehensive Psychiatry, Vol. 44, No. 6 (November/December), 2003: pp 483-491 483

terestingly, differences were observed when genderwas analyzed: more women than men were diag-nosed with borderline personality disorder in Cau-casian and African Americans; however, amongHispanic men (mainly Puerto Rican) and women,there were no differences. Furthermore, Hispanicmen were found to have higher rates of borderlinepersonality disorder than Caucasian and AfricanAmerican men. According to the authors, suchdifferences might be attributed to clinician misdi-agnosis due to language differences and/or misper-ceptions of culturally appropriate behavior. Alter-natively, the stress of immigration might lead toidentity confusion, especially for Hispanic men.

The present study provides empirical data exam-ining the association of ethnicity with personalitydisorders in a clinical sample. Our major aim wasto compare the relative proportion of four person-ality disorder diagnoses among three ethnic groupsin a sample of participants recruited for a longitu-dinal study of personality disorders.21 A secondaryaim was to examine whether specific personalitydisorder criteria accounted for the differences inethnicity distribution found at the diagnostic level.

METHOD

ParticipantsParticipants were recruited for the Collaborative Longitudi-

nal Study of Personality (CLPS),21 a naturalistic longitudinalstudy of four personality disorders. Participants were recruitedfrom clinical facilities affiliated with each of the four recruit-ment sites (Boston, New Haven, New York, and Providence).Individuals who had previously or were currently receivingsome type of psychiatric or psychological services were alsorecruited from postings and media advertisements. A total of668 individuals between the ages of 18 to 45 years participatedin this larger study. The targeted personality disorders wereborderline personality disorder (BPD), schizotypal personalitydisorder (STPD), avoidant personality disorder (AVPD), andobsessive-compulsive personality disorder (OCPD); a compar-ison group of participants with major depressive disorder with-out a personality disorder was also recruited. Forty-three per-cent were outpatients in mental health settings, 12% werepsychiatric inpatients, 5% were from other mental health ormedical settings, and 40% were self-referred.

Participants were screened to assess age eligibility and treat-ment status. Individuals with active psychosis, acute substanceintoxication, withdrawal, or other confusional states, and ahistory of schizophrenia or schizoaffective disorder were ex-cluded. All participants signed written informed consent afterthe research procedures had been fully explained. For the pur-poses of the current study, individuals who formed the compar-ison group in the CLPS study were not included. Also, due tothe small sample sizes of the Asian American (n � 13) and“other” (n � 7) groups, only Caucasians (n � 433), African

Americans (n � 65), and Hispanics (n � 56) were included inthe following analyses.

The sample consisted of 202 (36.5%) men and 352 (63.5%)women. Their mean ages were 34.3 (SD � 7.5) and 32.1 (SD �8.3) years, respectively. The mean age of the entire group was32.9 (SD � 8.1) years. Participants were asked to identify theirethnic group membership by choosing from a list of five cate-gories, including a group classified as “other.”

AssessmentParticipants meeting basic inclusion and exclusion criteria for

study participation were screened for possible personality dis-orders with the Personality Screening Questionnaire (PSQ), aself-report instrument derived from the Personality DiagnosticQuestionnaire-4 (PDQ-4)22 assessing the four targeted person-ality disorders. Earlier versions of the PDQ-4 have been shownto be highly sensitive in screening for personality disorders inboth inpatients and outpatients.23,24 Participants who were pos-itive on the PSQ for one or more of the personality disorderswere referred for further assessment. Participants also com-pleted the Depression Screening Questionnaire to screen for thepresence of DSM-IV defined current major depressive disorder.Participants who screened positive for major depressive disor-der without a personality disorder as defined by the PSQ werereferred as potential controls for diagnostic assessment.

All participants were interviewed by trained and experiencedinterviewers who had either a masters or doctoral degree orcomparable clinical experience. The interviewers administeredthe Structured Clinical Interview for DSM-IV Axis I Disorders(SCID-I)25 and the Diagnostic Interview for DSM-IV Person-ality Disorders (DIPD-4).26 DIPD diagnoses of STPD, BPD,AVPD, or OCPD were supported by at least one of two othercontrasting methods of axis II assessment. Participants com-pleted a 360-item self-report questionnaire measuring both nor-mal and abnormal personality traits, the Schedule for Nonadap-tive and Adaptive Personality (SNAP).27 In addition, availabletreating clinicians were solicited to complete a PersonalityAssessment Form (PAF), which assesses the degree to which asubject meets a prototypic description of each of the fourpersonality disorders on a six-point scale. Participants who metDSM-IV criteria for at least one of the four personality disor-ders on the basis of the DIPD, with convergent support by eitherthe SNAP or an independent clinician’s PAF rating of 4 or more,were eligible for the larger CLPS study. For the purposes of thecurrent report, personality disorder groups were defined byDIPD diagnoses and at least consistent SNAP or PAF ratings onone of the personality disorders. Using this group assignmentstrategy, participants could belong to one or more personalitydisorder groups.

Data AnalysisBecause the personality disorder groups as defined here were

not independent, separate chi-square analyses were conductedfor each of the four study personality disorder diagnoses. Om-nibus tests were used to test whether the proportion of partici-pants in the three ethnic groups differed significantly acrosseach personality disorder group. Significant chi-square testswere followed by post hoc comparisons: (1) Caucasians vHispanics, (2) African Americans v Caucasians, and (3) His-panics v African Americans. Secondary analyses were con-

484 CHAVIRA ET AL

ducted at the criterion level to determine whether specificcriteria were responsible for the differences across ethnicgroups. Additionally, analyses were conducted to verify thatethnicity differences were consistent across structured interviewand self-report (i.e., the SNAP) methods. Lastly, analyses at thediagnostic level were rerun for men and women separately.Logistic regression analyses were used to test for an interactionbetween ethnicity and gender.

RESULTS

Primary Aim: Distribution of Ethnicity AcrossFour Personality Disorder Diagnoses Using aSemistructured Interview (DIPD)

Four separate 2 � 3 chi-square tests were con-ducted. The omnibus chi-square analysis examin-ing the distribution of BPD across ethnic groupswas significant [�2 (2, n � 554) � 12.64, P �.002] (Table 1). There was also a significant dif-ference across groups for STPD [�2 (2, n � 554) �7.06, P � .03]. No significant differences werefound for OCPD [�2 (2, n � 554) � .89, P � .64]or AVPD [�2 (2, n � 554) � .27, P � .87].

Post hoc 2 � 2 chi-square analyses were per-formed contrasting the distribution of BPD andSTPD across pairs of ethnic groups. Hispanics haddisproportionately more BPD diagnoses than Cau-casians [�2 (1, n � 489) � 11.49, P � .001] andAfrican Americans [�2 (1, n � 121) � 6.16, P �.01] (Table 1). For STPD, African Americans haddisproportionately more diagnoses than both Cau-casians [�2 (1, n � 498) � 4.40, P � .05] andHispanics [�2 (1, n � 121) � 4.45, P � .05].

Convergent Support: Distribution of EthnicityAcross Four Personality Disorder DiagnosesUsing Patient Self-Report (SNAP)

Chi-square tests were conducted to verify thatsimilar diagnostic patterns were present using pa-tient’s self-report (the SNAP). Findings were in thesame direction as the DIPD results for both BPDand STPD (Table 1). Paralleling DIPD findings,Hispanics had disproportionately more BPD diag-noses than Caucasians [�2 (1, n � 487) � 4.50,P � .05] and African Americans had dispropor-tionately more STPD diagnoses than Caucasians[�2 (1, n � 487) � 8.87, P � .005]. Also, consis-tent with the DIPD interview, no significant differ-ences were found for OCPD [�2 (2, N � 552) �2.22, P � .33] or AVPD [�2 (2, N � 552) � 3.56,P � .17]. Although DIPD and SNAP findings wereconsistent, it is important to point out that theseassessments were not entirely independent givenour selection procedures.

Secondary Analyses

Distribution of ethnicity across BPD and STPDpersonality disorder criteria. The presence or ab-sence of a specific criterion was assessed across thethree ethnic groups (i.e., Caucasians, AfricanAmericans, and Hispanics). As shown in Table 2,significant chi square tests were found for DIPD-BPD criterion 1 (intense anger), DIPD-BPD crite-rion 2 (affective instability), and DIPD-BPD crite-rion 9 (unstable relationships). Follow-up post hoc

Table 1. Chi Square Tests: Distribution of BPD, STPD, OCPD, and AVPD Across Three Ethnic Groups Using DIPD Structured

Interview and SNAP Self-Report

Caucasian (n � 433) African American (n � 65) Hispanic (n � 56)�2 df Pn (%) n (%) n (%)

BPDDIPD 171 (40)a 26 (40)a 36 (64)b 12.64 2 .002

SNAP 121 (28)b 23 (35)b 24 (43)a 5.97 2 .05

STPDDIPD 70 (16)b 18 (28)a 6 (11)b 7.06 2 .03

SNAP 106 (25)b 28 (43)a 17 (30)ab 9.99 2 .007

OCPDDIPD 197 (45) 29 (45) 29 (52) .89 2 .64SNAP 219 (51) 36 (55) 34 (61) 2.22 2 .33

AVPDDIPD 248 (57) 35 (54) 32 (57) .27 2 .87SNAP 247 (57) 45 (69) 31 (55) 3.56 2 .17

NOTE. Proportions that share the same superscript are not significantly different from each other. Total percentage exceeds 100because of multiple personality disorder diagnoses for each subject. N � 433 for Caucasians who completed the DIPD and N � 431for Caucasians who completed the SNAP.

ETHICITY AND FOUR PERSONALITY DISORDERS 485

2 � 2 chi-square analyses (alpha � .05) revealedthat Hispanics had disproportionately higher en-dorsement rates than Caucasians on criterion 1(intense anger) [�2 (1, n � 489) � 8.99, P � .001],criterion 2 (affective instability) [�2 (1, n � 489) �11.18, P � .001], and criterion 9 (unstable rela-tionships) [�2 (1, n � 489) � 12.51, P � .001].African Americans also had disproportionately

higher rates than Caucasians on criterion 9 [�2 (1,n � 498) � 4.75, P � .05].

The STPD criteria that were differentially dis-tributed across ethnic groups were DIPD-STPDcriteria 1 (excessive social anxiety), DIPD-STPDcriterion 2 (no friends), DIPD-STPD criterion 3(odd beliefs), and DIPD-STPD criterion 5 (para-noia) (Table 3). African Americans had dispropor-

Table 2. BPD Criteria Across Ethnic Groups Using the DIPD (structured interview)

Caucasian African American Hispanic�2 df Pn (%) n (%) n (%)

DIPD-BPD 1 205 (47)b 39 (60)ab 39 (70)a 12.46 2 .002

Intense angerDIPD-BPD 2 234 (54)b 42 (65)ab 44 (79)a 14.50 2 .001

Affective instabilityDIPD-BPD 3 189 (44) 33 (51) 31 (55) 3.50 2 .17

EmptinessDIPD-BPD 4 153 (35) 22 (34) 25 (45) 1.98 2 .37

Confusion over identityDIPD-BPD 5 161 (37) 20 (31) 25 (45) 2.48 2 .29

ParanoiaDIPD-BPD 6 131 (30) 23 (35) 25 (45) 4.82 2 .09

Fears of abandonmentDIPD-BPD 7 127 (29) 14 (22) 18 (32) 2.13 2 .35

Self-injury, suicideDIPD-BPD 8 201 (46) 36 (55) 33 (59) 4.41 2 .11

ImpulsivityDIPD-BPD 9 174 (40)b 36 (55)ab 37 (66)a 16.93 2 .001

Unstable relationships

NOTE. DIPD (N � 554). Proportions that share the same superscript are not significantly different from each other.

Table 3. STPD Criteria Across Ethnic Groups Using the DIPD (structured interview)


DIPD-STPD 1 77 (18)b 20 (31)a 6 (11)b 8.85 2 .01

Social anxietyDIPD-STPD 2 112 (26)b 28 (43)a 18 (32)ab 8.61 2 .01

No friendsDIPD-STPD 3 92 (21)b 23 (35)a 8 (14)b 8.8 2 .01

Odd beliefsDIPD-STPD 4 114 (26) 25 (39) 15 (27) 4.17 2 .12

Unusual perceptionsDIPD-STPD 5 152 (35)b 36 (55)a 22 (39)ab 9.92 2 .01

ParanoiaDIPD-STPD 6 135 (31) 29 (45) 20 (36) 4.78 2 .09

Ideas of referenceDIPD-STPD 7 37 (9) 2 (3) 1 (2) 5.27 2 .07

Odd behaviorDIPD-STPD 8 47 (11) 7 (11) 3 (5) 1.64 2 .44

Odd thinkingDIPD-STPD 9 38 (9) 8 (12) 1 (2) 4.51 2 .11

Constricted affect

NOTE. DIPD (N � 554). Proportions that share the same superscript are not significantly different from each other.

486 CHAVIRA ET AL

tionately higher rates of social anxiety [�2 (1, n �498) � 5.28, P � .05], no close friends [�2 (1, n �498) � 7.45, P � .01], odd beliefs [�2 (1, n �498) � 5.59, P � .05], and paranoia [�2 (1, n �498) � 9.05, P � .01] than Caucasians. AfricanAmericans also had disproportionately higher ratesof social anxiety and odd beliefs compared toHispanics: [�2 (1, n � 121) � 6.03, P � .01] and[X2 (1, n � 121) � 5.96, P � .05], respectively.

Gender: Simple main and moderating effects.To analyze potential gender effects, separate chi-square analyses were performed for men andwomen. As shown in Table 4, significant differ-ences were found for BPD among men and STPDamong women. Post hoc comparisons revealed thatHispanic men had disproportionately more BPDdiagnoses than Caucasian men [�2 (1, n � 186) �11.59, P � .001]. African American women hadmore STPD diagnoses than both Hispanic women[�2 (1, n � 88) � 3.99, P � .05] and Caucasianwomen [�2 (1, n � 313) � 11.28, P � .001]. Nogender effects were found for AVPD or OCPD.Logistic regression analyses were conducted to testfor an interaction between ethnicity and genderpredicting BPD and STPD, with gender, ethnicity,and the interaction term entered simultaneously.Contrast coding was used to examine the effect ofeach group relevant to the average effects of theother groups. All of the gender by ethnicity inter-actions were not significant.

DISCUSSION

Borderline Personality Disorder

In this study, there was a fairly robust relation-ship between ethnicity and BPD using structuredinterview diagnoses. Among individuals present-

ing to a clinical setting with a targeted personalitydisorder diagnosis, Hispanics had disproportion-ately higher rates of BPD than Caucasians andAfrican Americans. A detailed analysis of the cri-teria that were differentially distributed across eth-nic groups revealed that symptoms such as intenseanger, affective instability, and unstable relation-ships were more frequently endorsed for Hispanicsthan for Caucasians.

Explanations for the relationship between eth-nicity and BPD, particularly Hispanic ethnicity, arevaried. According to Miller,28,29 borderline pathol-ogy arises from an individual’s perceived sense ofsocial failure combined with feelings of marginal-ity and powerlessness. For some ethnic minorityindividuals (e.g., Hispanics), the process of accul-turating to a new society can result in identityconfusion, feelings of emptiness, alienation, aban-donment, loss of control, and anxiety. 30,31 Further-more, the acculturation process itself can also dis-rupt the family system and foster intergenerationalconflicts.32 It is plausible that such experiencesmay be a source of greater mood instability, anger,and problematic interpersonal relationships.

The consequences of such transitions and thepotential loss of status may be particularly pro-nounced for Hispanic men, whose identity is tra-ditionally embedded within a cultural frameworkthat emphasizes authority and respect for men.33

Preliminary analyses revealed that Hispanic menhad disproportionately more BPD diagnoses thanother groups; however, the interaction betweenethnicity and gender was not significant. Given thatacculturation status was not directly assessed inthis study, it is unclear to what degree acculturation

Table 4. Ethnic Distribution of Personality Disorders by Gender


Men n � 169 n � 16 n � 17BPD 46 (27)b 5 (31)ab 12 (71)a 13.54 2 .001

STPD 45 (27) 5 (31) 3 (18) .87 2 .65OCPD 88 (52) 5 (31) 5 (29) 5.25 2 .07AVPD 94 (56) 7 (44) 10 (59) .94 2 .62

Women n � 264 n � 49 n � 39BPD 125 (47) 21 (43) 24 (62) 3.41 2 .18STPD 25 (10)b 13 (27)a 3 (8)b 12.36 2 .002

OCPD 108 (41) 24 (49) 24 (62) 6.36 2 .04AVPD 154 (58) 28 (57) 22 (56) .07 2 .97

NOTE. Proportions that share the same superscript are not significantly different from each other.


and acculturative stress account for borderline per-sonality traits.

Another possible explanation for ethnic differ-ences in BPD involves misdiagnosis or diagnosticbias. The argument here is that clinicians who areunfamiliar with the language, behavior, and inter-personal style of certain ethnic groups may per-ceive characteristics that are acceptable and per-haps encouraged in a culture (e.g., novelty seeking,quick temper, extravagance, etc.) as being deviantand pathological from a Western psychiatric stand-point. For example, within Puerto Rican culture,men are permitted to be more emotional thanwomen and to exhibit strong emotions such asanger, aggressiveness, and sexual attraction.34 Inaddition, among some Hispanic groups, symptomssuch as uncontrollable shouting, attacks of crying,trembling, heat in the chest rising into the head,and verbal or physical aggression may represent aculture-bound syndrome known as ataque de nerv-ios.35 Ataques are usually triggered by a stressfulevent relating to the family, including death of aloved one, conflicts with a spouse or children, orwitnessing an accident involving a family member.Using a cultural framework, some manifestationsof ataques de nervios may be perceived as a com-mon expression of distress but from a Westernstandpoint, these characteristics may be seen asoverly dramatic and deviant.36 Alternatively, somestudies suggest that individuals whose first lan-guage is not English report more pathology inEnglish than in their native tongue.37,38 At the veryleast, however, we know that the personality dis-order diagnoses that were derived from the clini-cian-administered structured interview were con-sistent with patient’s self-report, countering theposition that clinician bias alone is accountable forthe relationship between Hispanic ethnicity andBPD.

Schizotypal Personality Disorder

Explanations for more STPD diagnoses amongAfrican Americans relative to Caucasians and His-panics are equally complex. In the current study,African Americans had disproportionately moreSTPD diagnoses than Caucasians and Hispanics onboth the structured interview and self-report instru-ment. Criteria from the DIPD that were differen-tially distributed across ethnic groups were socialanxiety, no close friends, odd beliefs, and paranoia;African Americans had higher rates than Cauca-

sians on each of these criteria, and higher rates ofsocial anxiety and odd beliefs than Hispanics. Af-rican American women appeared to have higherrates of STPD than women from other groups;however, a significant interaction between genderand ethnicity was not present.

To our knowledge, there are no studies examin-ing ethnic differences in prevalence rates of STPD,but a few studies have investigated ethnic differ-ences among traits and disorders that occupy thesame spectrum as STPD (i.e., schizotypal traits andschizophrenia). In a study of schizotypal traits con-ducted in the United Kingdom,39 African Carib-bean participants reported more delusional ideationthan white individuals, but not more generalschizotypal traits (e.g., unusual experiences of per-ception and cognition, cognitive disorganizationand attentional difficulties, and introvertive anhe-donia). Detailed analysis revealed that the delu-sions were mostly persecutory or grandiose in na-ture. According to the authors, this finding mayreflect higher rates of paranoid schizophreniafound in the African Caribbean population40 orAfrican Caribbeans’ discontent with their socialposition in the United Kingdom.

Studies assessing prevalence rates of schizo-phrenia across ethnic groups are numerous, butinconsistent. Higher, lower, and equal rates ofschizophrenia have been reported for ethnic minor-ity groups, namely, African Americans and AfricanCaribbeans, when compared to Caucasians.41-44 In-consistencies have been explained by controllingfor third variables such as socioeconomic status,age, education, and therapist ethnicity, yet somestudies have found that differences continue toexist even after controls are applied.39,45

Explanations for ethnic differences in schizo-phrenia are not well understood. According to theNational Institute of Mental Health Genetics Ini-tiative study, which assessed schizophrenia pedi-grees from African Americans and EuropeanAmericans,46 genetic variations acting togetherwith differential exposure to environmental stres-sors may contribute to differences in prevalencerates. Alternative hypotheses propose that all indi-viduals are equally vulnerable but that exposure toenvironmental risk factors is different. For exam-ple, differential exposure to biological risk factors(e.g., viral infections, pregnancy and birth compli-cations, perinatal brain damage) may increase the

488 CHAVIRA ET AL

rates of schizophrenia in some ethnic groups; todate, studies investigating this relationship arescarce.47 Social stressors such as migration, urbanliving, and low socioeconomic status may alsohave an important influence.10,48,49 It is likely thatthe relationship between ethnicity and schizophre-nia spectrum disorders represents a complex inter-action of multiple genes and environmental trig-gers.

Problems with misdiagnosis and clinical biashave often been discussed with reference to schizo-phrenia. In the current study, African Americanshad higher endorsement rates for criteria such asexcessive social anxiety, absence of close friends,odd beliefs, and paranoia. According to a rater biasexplanation, a clinician’s lack of familiarity withculturally sanctioned behaviors (e.g., communica-tion with ancestral spirits, premonitions, “laying ofhands”) could lead to misdiagnosis. Also, beliefsabout persecution and paranoia may be related todiscriminatory experiences that reflect reality butcould be misinterpreted as delusional. As previ-ously stated, disproportionately higher rates ofSTPD were also present when patient’s self-reportwas used. Ultimately, one might argue that thecurrent diagnostic system, steeped in Euro-Westernnorms, is not sensitive to cultural patterns of be-havior; however, at present such a position requiresfurther investigation.50

Limitations

This study is based on individuals who pre-sented to clinical settings and were diagnosed witha given personality disorder; therefore, it is unclearwhether ethnic minorities who present to a clinicalsetting are representative of the larger population.In fact, given that Hispanics had more BPD diag-noses and African Americans had more STPD di-agnoses, it may be that ethnic minorities whopresent to clinical settings are more severely im-paired than what we would expect to find in epi-demiological studies. The possible stigma associ-ated with mental health care51-54 may lead many

ethnic minorities to seek alternative therapies (e.g.,religious counseling, medical explanations, folkremedies, talking to family members) before psy-chiatric treatment.55,56 Similarly, ethnic minorityindividuals may not present or continue treatmentat facilities that are mainstream focused and/orculturally naive.

This study is limited by the absence of informa-tion regarding specific ethnic group identificationand by the smaller sample sizes in follow-up anal-yses. It is unknown whether the findings concern-ing BPD apply to all Hispanic subgroups (i.e.,Puerto Ricans, Cubans, Mexican Americans).Given the sample size of the Hispanic group, itwould not be possible to conduct meaningful anal-yses if subgroups were created. As previously men-tioned, information regarding acculturation level isnot known therefore we are unable to understandthe degree of variability within ethnic groups.Lastly, analyses addressing the influence of gendermust be interpreted with caution given the smallersample sizes.

Conclusions

This is one of the first studies to provide asnapshot of the relationship between ethnicity andselected personality disorders. The potential impli-cations of the study findings are numerous as arethe directions for future research. For example,findings raise questions regarding the influence ofcultural experiences as pathogenic; more specifi-cally, do certain ethnic groups have culturally ori-ented experiences that create distress and perhapsan increased vulnerability for developing a person-ality disorder. On the other hand, findings may callinto question whether DSM-defined diagnostic cat-egories are culturally informed to the degree that isnecessary to provide a contextual approach to per-sonality disorders. However, future studies need tobe conducted at the community and epidemiolog-ical levels in order to more clearly understand therelationship between ethnicity and personality pa-thology in non–treatment-seeking populations.

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Ethnicity and four personality disorders