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Brianna J. Turner, Julie Prud’homme, and Nicole Legg
Personality disorders (PDs) affect approximately 9–16 percent of the population, or about one in eight adults (Grant et al., 2004; Lenzenweger, Lane, Loranger, & Kessler, 2007; Torgersen, Kringlen, & Cramer, 2001; Trull, Jahng, Tomko, Wood, & Sher, 2010). Despite their prevalence, PDs are under-researched and their causes remain poorly understood. Diagnostic frameworks caution clinicians to evaluate a person’s characteristic ways of thinking, feeling, and behaving in relation to that person’s culture of origin in order to arrive at an appropriate PD diagnosis (American Psychiatric Association [APA], 2013; World Health Organization [WHO], 2010). Yet, large-scale studies regarding environmental and sociocultural factors and personality pathology are only recently emerging, and minimal guidance is provided on how culture should be accounted for in diagnostic decisions. This chapter provides an overview of how environmental and sociocultural factors contribute to the development, expression, and maintenance of PDs, and considers how cultural considerations could be better reflected in research and clinical practice.
At the outset, we note that current definitions of PDs are rooted in Western biomedical traditions (Fabrega, 1994), and there is ongoing debate regarding the validity and utility of many PD diagnoses as cross-cultural or universal entities (Mulder, 2012; Ryder, Dere, Sun, & Chentsova-Dutton, 2014). Indeed, some authors argue that diagnostic nosologies such as the Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 2013) and the International Statistical Classification of Diseases (ICD; WHO, 2010) must be viewed as cultural products (Alarcón & Foulks, 1995a, 1995b; Chen, Nettles, & Chen, 2009). With this broad perspective in mind, our chapter attempts to synthesize extant research in a manner that acknowledges the role of culture in how we define and understand sociocultural and environmental influences on PDs. Our chapter begins with a review of studies that have sought to quantify the impact of environmental and sociocultural influences on PDs. Next, we consider theoretical models that explain when and how environmental and sociocultural factors influence PD symptoms. We then review empirical evidence regarding specific types of environmental and sociocultural factors associated with PDs, and conclude with recommendations for future research, evolving diagnostic models, and clinical practice.
How Much Do Environmental and Sociocultural Factors Contribute to Personality Disorders?
Logically, the first step in understanding how environmental and sociocultural factors impact PDs is to establish that such factors play a role in their onset and maintenance. In this section, we will review two types of studies that test this premise: behavioral genetic twin and sibling studies, and cross-national and community epidemiological studies. Both types of research inform the scope of environmental and sociocultural contributions to the development, expression, and maintenance of PDs.
Behavioral Genetic Studies
Large-scale heritability studies of PDs have only recently been undertaken, allowing researchers to quantify the relative contributions of genetic versus environmental influences on PDs. A major population-based study of 2794 Norwegian twins estimated that between 20 percent and 55 percent of the variability in PDs is attributable to genetic variation, whereas 59–80 percent of the variability is attributable to environmental influences1 (Kendler et al., 2008; see also Kendler, Myers, Torgersen, Neale, & Reichborn-Kjennerud, 2007; Reichborn-Kjennerud et al., 2007; Torgersen et al., 2008). These ranges roughly align with studies that have estimated environmental contributions to borderline PD (40–58 percent; Amad, Ramoz, Thomas, Jardri, & Gorwood, 2014; Distel et al., 2008; Kendler, Myers, & Reichborn-Kjennerud, 2011) and antisocial PD (50–59 percent; Rhee & Waldman, 2002; Tuvblad & Beaver, 2013). However, in the Norwegian twin study, environmental factors made the smallest contribution to antisocial and borderline PDs, and the largest contribution to schizotypal, paranoid, schizoid, and narcissistic PDs (Kendler et al., 2008). Further, although most environmental contributions were disorder-specific, a structural model identified three common environmental influences that loosely correspond to the clusters of PDs defined in the DSM-IV (Kendler et al., 2008). For instance, all four Cluster B disorders share a common environmental factor that accounts for 25–41 percent of their variance, whereas 35–45 percent of the variance was accounted for by disorder-specific environmental influences (Torgersen et al., 2008). Environmental influences on PDs have also been linked to normative personality traits, such as neuroticism and disinhibition (Kendler et al., 2011). Thus, twin and sibling studies suggest that environmental factors substantially contribute to variance in PDs.
One consistent but surprising finding to arise from behavioral genetic research is that shared environments (i.e., influences that make siblings similar, such as being reared in the same family and community) make only small to negligible contributions to PDs, whereas unique, non-shared environmental influences (i.e., influences that make siblings who are reared together dissimilar) and measurement error explain the majority of variability in PDs (Kendler et al., 2008). On its face, this finding seems to conflict with many psychological theories that emphasize the role of shared family environments in the development of PDs (e.g., Clarkin, Lenzenweger, Yeomans, Levy, & Kernberg, 2007; Fonagy & Bateman, 2008; Smith Benjamin, 2005). However, a few caveats should be considered before concluding that family environments are unimportant for PDs. First, power calculations estimate that large samples, between 725 and 7000 twin pairs, are required to disentangle passive gene–environment correlations and accurately estimate shared environmental influences (see Martin, Eaves, Kearsey, & Davies, 1978). So far, most twin studies of personality pathology fall far short of this requirement (see Carpenter, Tomko, Trull, & Boomsma, 2013). Second, environmental exposures are often measured retrospectively and imprecisely, or are inadequately scaled, which has made estimation of specific shared environmental contributions difficult (Carpenter et al., 2013), and attempts to classify important sources of shared or non-shared contribution have largely been unsuccessful (Neiderhiser, Reiss, & Hetherington, 2007; Plomin, Asbury, & Dunn, 2001). Given that variance due to measurement error is also contained in estimates of non-shared environmental influences, some researchers have suggested that the larger contribution of non-shared relative to shared environments may be due to transient, measurement-occasion variance and difficulty in reliably assessing PDs (Burt, McGue, Carter, & Iacono, 2007; Perry, 1992; Turkheimer, 2000). Contrary to this suggestion, however, recent longitudinal studies have found that non-shared environmental factors explained about 30–50 percent of stable variability in PDs across ten-year intervals (Gjerde et al., 2015; Reichborn-Kjennerud et al., 2015), supporting their prospective importance.
Notable, negligible contributions of shared environments have been identified in behavioral genetic studies of normative personality traits, cognitive abilities, and other psychological disorders, making this pattern a rule rather than an exception in the field of psychology (see Plomin et al., 2001; Turkheimer, 2000). With the previous caveats in mind, our best evidence from recent large-scale twin studies suggests that familial aggregation of PDs occurs primarily due to shared genetic vulnerability for broader personality traits (e.g., neuroticism, rigidity), and that most of the environmental contributions to PDs occur due to processes that differ between siblings (i.e., non-shared influences). In light of these results, researchers have emphasized that environmental contributions to PDs might be best conceptualized by the diathesis–stress, or gene–environment, model, wherein environmental influences have the greatest impact when interacting or co-occurring with temperamental or genetic vulnerabilities (e.g., Jaffee et al., 2005; Tuvblad, Grann, & Lichtenstein, 2006). Future attempts to disentangle the relative contributions of environmental versus genetic factors to personality pathology should attempt to account for such cumulative and interactive effects in their design and analysis.
Cross-National and Demographic Comparisons
Cross-national, national, and representative community studies compare the prevalence of personality pathology across demographic groups to elucidate factors that may place an individual at higher risk for developing or expressing personality pathology. Before considering the results of this research, we note two cautions. First, it is important to remember that personality traits and disorders vary more widely within than between cultures (e.g., McCrae & Terracciano, 2005). Even purportedly large cultural differences, such as individualistic versus collectivistic orientations, have been found to be more modest than initially theorized (Oyserman, Coon, & Kemmelmeier, 2002). Thus, the largest sources of variance in PDs are still expected to be idiographic. Second, there is an important dilemma in epidemiological research concerning how best to balance methodological standardization to ensure comparability of results across samples with the use of culturally-informed, emic designs (see Calliess, Sieberer, Machleidt, & Ziegenbein, 2008; Ryder et al., 2014). Unfortunately, there is no easy way to resolve this dilemma. The prevalence studies reviewed below adopt DSM or ICD definitions of PDs and use well-validated but potentially Western-centric assessment instruments (e.g., the International Personality Disorder Examination [IPDE; Loranger et al., 1994], the Structured Interview for DSM-IV Personality [Pfohl, Blum, & Zimmerman, 1997]).
With respect to cross-national comparisons, national studies demonstrate that PDs can be reliably detected in clinical samples across Western and non-Western countries (Benjet, Borges, & Medina-Mora, 2008; Dereboy, Güzel, Dereboy, Okyay, & Eskin, 2014; Gawda & Czubak, 2017; Loranger et al., 1994; Pedersen & Simonsen, 2014; Rossier & Rigozzi, 2008; Suliman, Stein, Williams, & Seedat, 2008; Yang et al., 2000; Zhong & Leung, 2009); these results counter the idea that PDs are entirely culture-bound syndromes. Differences in the prevalence of PDs between non-Western and Western countries are difficult to ascertain, however, given the wide range of prevalence estimates obtained across methodologies (e.g., clinical versus community samples; screening questionnaires versus interviews; see de Bernier, Kim, & Sen, 2014; Ryder et al., 2014). A recent systematic review of PD prevalence in Asian countries, for instance, found that prevalence estimates in community samples ranged from 1.8–4.4 percent among Chinese adults to 24 percent among Taiwanese and Indian adults without histories of suicide attempts (de Bernier et al., 2014). In clinical samples, estimates ranged from 1–7 percent among psychiatric inpatients and outpatients when PDs were assessed via clinical judgment to 30–50 percent of psychiatric patients and up to 87 percent of suicidal inpatients assessed via structured diagnostic tools (de Bernier et al., 2014). Similar methodological differences have been identified in studies conducted in Western countries (Lyons, Jerskey, & Genderson, 2011), suggesting that firmer conclusions regarding cross-national differences will require consideration of the research methodology used to generate the national prevalence estimates.
To our knowledge, only one major cross-national comparison of PD prevalence has been conducted (Huang et al., 2009).2 The World Mental Health Surveys, conducted in 13 countries (Colombia, Lebanon, Mexico, Nigeria, China, South Africa, the USA, Belgium, France, Germany, Italy, Netherlands, and Spain), found that the prevalence of PDs ranged from around 2–3 percent (Western Europe and Nigeria) to 7–8 percent (Colombia and the USA; Huang et al., 2009). Neither regional nor country-income differences appear to account for the national variation in PD prevalence estimates (Huang et al., 2009). Although there is some evidence to suggest that the prevalence of PDs may vary cross-culturally, it is still unclear what processes might account for these differences.
Representative community surveys can also be used to compare demographic subgroups, elucidating potential environmental or sociocultural contributors to PDs. Community surveys are especially important as they overcome clinical biases that arise due to differential patterns of service use. Representative surveys show that PDs tend to be stratified by gender, age, ethnicity, and socioeconomic status. Specifically, PDs are more common in people who are younger (especially Cluster B disorders), who have lower educational attainment, who have lower annual incomes or are unemployed (especially schizotypal, borderline, and avoidant PDs), who have never married or are divorced, separated, or widowed (especially Cluster A and C disorders), who are living alone (especially Cluster A and C disorders), and who live in urban centers (Coid, Yang, Tyrer, Roberts, & Ullrich, 2006; Dereboy et al., 2014; Grant et al., 2004; Huang et al., 2009; Lenzenweger et al., 2007; Samuels et al., 2002; Torgersen et al., 2001; Trull et al., 2010). Cluster A disorders are also more prevalent among people who experience multiple indices of social deprivation (i.e., high school education or lower, living alone, living in the urban center of a city; see Torgersen, 2012). Whether these demographic factors represent a cause or consequence of personality pathology remains unclear.
Evidence for gender differences in PDs is decidedly mixed. Some studies find higher prevalence of PDs in men versus women (Coid et al., 2006; Huang et al., 2009; Samuels et al., 2002; Suliman et al., 2008; Trull et al., 2010), whereas others find equivalent rates between genders (Lenzenweger et al., 2007; Torgersen et al., 2001). There is some consensus that antisocial, narcissistic, and schizoid PDs are more prevalent in men, whereas histrionic, avoidant, and dependent PDs are more common among women (see Oltmanns & Powers, 2012; Torgersen, 2012 for recent reviews), but results do not always support this pattern. Results are especially inconsistent with respect to the gender distributions of paranoid, borderline, and obsessive-compulsive PDs, with some studies showing higher prevalence of these disorders in women (Grant et al., 2004; Oltmanns, Rodrigues, Weinstein, & Gleason, 2014), others showing no gender difference (Coid et al., 2006; Lenzenweger et al., 2007; Torgersen et al., 2001), and one study finding a higher prevalence of obsessive-compulsive PD in men (Oltmanns et al., 2014). Borderline PD may be over-represented among women in clinical samples, but is more evenly distributed in the general population (Skodol & Bender, 2003). The only PD that has demonstrated consistent gender difference in prevalence is antisocial PD, which is about three to five times more common in men versus women (see Cale & Lilienfeld, 2002). Additional explanations for gender differences will be considered later in this chapter. It is worth noting, however, that gendered patterns in PDs correspond to differences in normative personality traits, with higher sensation seeking, disinhibition, and assertiveness in men, and higher neuroticism and agreeableness in women (see Lynam & Widiger, 2007).
Mixed findings are also apparent when ethnic groups are compared. A recent meta-analysis suggested that white adults are slightly but significantly more likely to be diagnosed with PDs compared to black adults, although this difference may reflect regional differences (UK vs. USA) and be limited to clinical samples and settings (McGilloway, Hall, Lee, & Bhui, 2010). Differences between white adults and both Asian and Hispanic adults were not identified, but relatively few studies could be included in these analyses. In the USA, a nationally representative survey showed that rates of PDs were highest among American Indian/Alaskan Natives, followed by black non-Hispanic, Hispanic, white non-Hispanic, and finally Asian/Native Hawaiian/Other Pacific Islander adults (Trull et al., 2010). In terms of specific disorders, white Americans experienced higher rates of obsessive-compulsive PD, whereas black, Hispanic, and Native Americans experienced higher rates of schizoid and paranoid PDs (Grant et al., 2004). Avoidant and antisocial PDs were more common among Native Americans, and histrionic PD was more common among black Americans, relative to white Americans (Grant et al., 2004). Borderline PD was most common among Native American men, and least common among Asian women (Grant et al., 2008). In a large treatment-seeking sample of American adults, borderline PD was more common among Hispanic patients, and schizotypal PD was more common among black patients, relative to white patients (Chavira et al., 2003).
Apparent differences in PD prevalence must be interpreted in light of systemic differences in the experiences of racial/ethnic groups. For instance, whereas Cluster A PDs are more commonly diagnosed among black Americans (e.g., Chavira et al., 2003; Gibbs et al., 2013), several authors express concern that this difference reflects pathologization and misinterpretation of normative cultural mistrust that arises when black individuals, as well as other minorities, experience pervasive discrimination, prejudice, and trauma (Gibbs et al., 2013; Whaley, 1997). A similar effect might occur for recent immigrants and refugees whose unfamiliarity with the local language, institutions, and norms may evoke apprehension, withdrawal, and a sense of distrust that can be mistaken for paranoid or schizoid PD (Calliess et al., 2008), or who may report problems with identity, feelings of emptiness, and fears of abandonment that could be mistaken for borderline PD (Alarcón & Foulks, 1995a). Likewise, prisoners, older adults, and people with hearing impairments and other disabilities may exhibit habitual fearfulness, mistrust, antagonism, or acquiescence that must be carefully assessed before concluding it reflects personality pathology (Ryder, Sunohara, & Kirmayer, 2015).
Recent studies suggest that socioeconomic status is a better predictor of risk than race/ethnicity (De Genna & Feske, 2013; Iacovino, Jackson, & Oltmanns, 2014), but that race/ethnicity can influence symptom expression. For instance, whereas white Americans with borderline PD reported greater emotional instability, self-injury, and suicidality, Hispanic and black Americans with borderline PD reported more cognitive symptoms such as emptiness, identity instability, and dissociation (Selby & Joiner, 2008). Considering these findings, it is apparent that multiple social factors must be taken into account to accurately understand racial/ethnic and other demographic differences, and that invariance of symptoms should not be assumed.
When and How Do Environmental and Sociocultural Factors Contribute to Personality Disorders?
Numerous theoretical models have sought to explain when and how environmental and sociocultural factors can predispose an individual to, or perpetuate, personality pathology. We first examine theories that focus on familial and interpersonal contributions to PDs, and then examine theories that focus on broader cultural contributions to PDs.
Environmental Theories of PDs
Biosocial Theory. Linehan’s (1993) biosocial theory of borderline PD emphasizes the role of early family environments in the development of PD symptoms, and of later interpersonal contexts in perpetuating symptoms through adolescence and adulthood. According to the biosocial theory, emotion dysregulation is a core feature of borderline PD. This emotion dysregulation arises due to transactions between invalidating environments that ignore, reject, punish, or trivialize emotional experiences or expressions, and biological predispositions to heightened emotional sensitivity, reactivity, and behavioral disinhibition. According to this model, a lack of fit between the child’s emotional sensitivity and caregivers’ responses to emotions creates a vicious cycle that alternately punishes and reinforces intense emotional expressions. Ultimately, a child learns that only extreme emotional reactions are likely to garner a desired response from caregivers, but these same reactions are judged as unwarranted and unacceptable. As a result, the child does not learn how to label, control, or tolerate emotional experiences in a way that is acceptable to others, nor does she or he learn to resolve problems that contribute to overwhelming emotional experiences. Over time, these interactions become transactional, with biological and environmental factors constantly influencing one another to escalate the pattern of extreme emotional expression and invalidating responses. Invalidation of emotional experience and expression continues to perpetuate borderline PD symptoms in adolescence and adulthood, exacerbating problems in emotion labeling and modulation. As such, these individuals are not able to change their behavior to meet the demands of the environment or the environment itself, perpetuating the chronic emotional and behavioral difficulties that characterize borderline PD.
Attachment Theories. According to Bowlby’s (1982) attachment theory, infants must develop secure relationships with a primary caregiver for successful social-emotional development. Early attachment failures or disruptions have cascading consequences for emotional, cognitive, and interpersonal development via internal working models that are based on early experiences with caregivers. One way of understanding how early childhood experiences relate to personality pathology is through the concept of attachment styles (Ainsworth, Blehar, Waters, & Wall, 1978). Children with anxious-ambivalent styles feel extreme distress when their caregivers leave their surroundings and exhibit continued distress and contact-seeking behaviors upon reunion with their caregivers. These children are more vulnerable to experiencing anxiety and frustration (Sroufe, 2005), which may increase risk for avoidant, obsessive-compulsive, dependent, borderline, or histrionic PDs (Meyer & Pilkonis, 2005). Children with anxious-avoidant styles are not overly distressed when caregivers leave their surroundings, and tend to actively ignore or avoid reuniting with the caregiver following separation. As such, these children tend to experience difficulties in empathy, hostility, and anger (Sroufe, 2005), which may increase risk of antisocial, narcissistic, schizoid, or paranoid PDs later in life (Meyer & Pilkonis, 2005). Children with disorganized-disoriented styles engage in contradictory and inconsistent behaviors with their caregivers. This style is associated with dissociation and emotion dysregulation (Sroufe, 2005), which may increase risk for schizotypal and borderline PDs (Meyer & Pilkonis, 2005).
Attachment can also be understood as a process that impacts brain development, self and emotion regulation, adaptive interpersonal skills, and adult personality (Sroufe, 2005), and thus has natural implications for understanding PDs (Levy, 2005). Applying this research to PDs, Gunderson’s (2007) attachment theory of borderline PD argues that early attachment difficulties, especially development of a disorganized-ambivalent style, result in pervasive interpersonal hypersensitivity, which is viewed as a cardinal phenotype of borderline PD. Similarly, Fonagy and Bateman’s (2008) theory posits that early attachment disruptions impair the development of mentalization (i.e., the ability to accurately perceive and understand the mental states of oneself and others), which results in emotion dysregulation, dissociation, and a disorganized sense of self.
Interpersonal Theories. Interpersonal theories of PDs (see Pincus & Hopwood, 2012) originated with the work of Harry Stack Sullivan (1953), who defined personality as recurring patterns of real and imagined interpersonal interactions. According to Stack Sullivan, all interactions are characterized by basic needs for security and self-esteem (later related to communion and agency by Wiggins [1991]), which may be realized or frustrated in each interaction. Frustration of these motives can result in self-dysregulation (e.g., incoherent sense of self, unstable self-esteem, and difficulty differentiating the self from others), affective dysregulation (e.g., difficulty modulating emotional states, tendency to experience too much or too little of some emotions), and interpersonal or “field” dysregulation (e.g., difficulty initiating or maintaining intimacy, lack of empathy; Pincus & Hopwood, 2012). According to interpersonal theories, personality pathology arises when security and self-esteem motives are chronically frustrated due to a child’s temperamental vulnerability and a toxic learning environment, which prevents the child from achieving developmental copy processes that are crucial to healthy interpersonal functioning (Smith Benjamin, 2005). Repeated interpersonal frustration and failure to achieve adaptive copy processes result in parataxic distortions, or mental representations of interactions that do not match objective representations. When parataxic distortions become chronic, they manifest as rigid and extreme patterns of interpersonal and self-protective behaviors that are commonly observed in PDs. Like other theories summarized in this section, interpersonal theories view personality pathology as arising from an interaction between temperamental vulnerability and adverse early environments, which leads to enduring problems of thinking, feeling, and behaving that, over time, become self-reinforcing (see Pincus & Hopwood, 2012).
Psychodynamic Theories. Psychodynamic theories also emphasize caregiver–infant interactions in accounting for the development of PDs. Early caregiving experiences are said to influence children’s object relations, or mental representations of the self and others (Clarkin et al., 2007). Children who experience abusive, unresponsive, neglectful, or intrusive caregivers may develop negative, disorganized, inconsistent, or overvalued models of the self and others, resulting in identity diffusion. Negative caregiving experiences can also result in impairments in ego development, which, in turn, impact judgment, planning, and the development of mature versus immature defense mechanisms. Particularly influential among the psychodynamic theories of PD have been Kernberg’s (1975) and Kohut’s (1977) theories.
Kernberg’s object-relations theory (1975; see also Clarkin et al., 2007) argues that early associations between the self, caregiver, and emotions, called self-object-affect triads, form the basis for later motivational drives. Beginning around age 3, polarized “good” and “bad” representations are gradually integrated to form more complete representations of the self and others. Among individuals who develop PDs, however, normal development is arrested, resulting in a failure to adequately integrate positive and negative triads. Such failures lead to a vulnerable sense of self and an over-reliance on splitting (in which positive and negative images of the self and others cannot be reconciled or simultaneously experienced), projective identification, and dissociation as defense mechanisms later in life. In borderline PD, splitting involves rapid and chaotic shifts between idealized and devalued self-concepts and appraisals of others in response to intense aggressive impulses the ego cannot handle. In narcissistic PD, relationships with others are viewed as a means of gaining external validation and reflection of the idealized self-concept to protect against criticism that could expose the devalued self-concept.
According to Kohut’s theory (1977), children need accurate mirroring of their emotions by caregivers to overcome natural helplessness and develop a sense of mastery. Accurate parental mirroring fosters development of positive identity and emotion regulation abilities. In contrast, when parents provide inadequate or inaccurate mirroring, children develop a pathological fear of losing their sense of self. In narcissistic PD, inadequate or inaccurate mirroring results in a poorly developed self-concept that is highly vulnerable to threat, as shown by the individual’s sensitivity to criticism, pervasive sense of shame, and need for continued mirroring to label, tolerate, and regulate emotion. In borderline PD, insufficient soothing from caregivers results in a pervasive sense of emptiness, lack of organized self-concept, and hypersensitivity to abandonment.
Sociocultural Theories of PDs
Paris’ Integrated Sociocultural-Historical Theory. Paris’ (1997, 2003) integrated sociocultural-historical theory argues that generation-cohort effects and cross-cultural differences in personality pathology support the idea that sociocultural norms affect the distribution, expression, and pathologization of PDs. For instance, the dramatic rise in violent crimes in the USA and UK since the Second World War might suggest that cultural norms have shifted to encourage more impulsive, aggressive, and disruptive behaviors in modern society (Paris, 1997, 2003; Rutter & Smith, 1995), resulting in an increased prevalence of Cluster B disorders (Widiger & Bornstein, 2002). Paris articulates three factors that contribute to sociocultural and historical trends: symptom banks, social cohesion, and social capital (Paris & Lis, 2013). The “symptom bank” describes the ways in which psychological distress is likely to be expressed in a given cultural group or historical period (Shorter, 1997). For instance, whereas somatization and conversion symptoms were prevalent during the nineteenth century, self-injury, repetitive suicidal behaviors, and externalizing behaviors may be increasing in modernized Western societies (Paris, 1997; Rutter & Smith, 1995). Shifts in symptom expression are also mediated via social contagion, which describes direct and indirect transmission of symptomatic expressions, and social sensitivity, which describes how likely a person is to respond symptomatically to distress evoked by social change (Paris & Lis, 2013).
Paris (1997, 2014) additionally argues that recent cultural shifts are increasing the rate and severity of psychological distress due to changes in social capital and social cohesion. Declines in social capital can be traced to declining engagement in traditional social institutions such as marriage, family, religion, and volunteerism, resulting in increasingly less connection, trust, and goodwill among group members. As social capital deteriorates, the buffering role of traditional social structures erodes, increasing risk for psychopathology. Moreover, as traditional roles are less strongly prescribed, many youth experience greater difficulties navigating social role choice and consolidating positive identities. The ever-increasing pace of change, particularly with regard to technological advancements, undermines continuity of norms across generations, as the norms of previous generations are no longer supplied or useful. Moreover, as social cohesion declines and less trust is placed in authority figures, community leaders, and family traditions, there are fewer avenues through which to teach and enforce prosocial behavior. Social networks become less stable, allowing more pathological peer groups to form. Together, these changes promote a kind of “cultural narcissism” that encourages self-promotion, autonomy, instant gratification, and competitive success, exacerbates externalizing behavior, and elevates the prevalence of maladaptive personality traits and Cluster B PDs (Paris, 2014). Changes in symptom banks, social capital, and social cohesion associated with modernization can thus explain why some cultural and demographic groups may be more vulnerable to personality pathology than others.
Gender Role Theory. According to gender role theory, the socially- and culturally-constructed nature of gender role expectations, identities, and behavior strongly influence personality (Spence & Helmreich, 1978; Wood & Eagly, 2012). Gendered role expectations are rooted in biological differences, reinforced by implicit and explicit socialization, and internalized as gender identities (Wood & Eagly, 2012). These gendered roles can be organized according to agentic/instrumental traits and communal/expressive traits (Spence & Helmreich, 1978). Agentic/instrumental traits, including dominance, assertiveness, independence, and competitive success, are commonly encouraged in boys and men. Communal/expressive traits, including selflessness, warmth, emotional sensitivity, and amiability, are commonly encouraged in girls and women. Gender role theory posits that, because of society’s gendered socialization of children, PDs that represent agentic/instrumental traits (i.e., narcissistic and antisocial PDs) should be more common in men, whereas PDs that represent communal/expressive traits (i.e., dependent, histrionic, and borderline PDs) should be more common in women. Additionally, non-conformity to gender role expectations (e.g., women with higher agentic/instrumental traits; men with higher communal/expressive traits) may be viewed as more pathological or atypical in cultures with extreme or rigid gender role expectations. As such, clinicians should carefully evaluate cultural contexts and their own expectations when assessing potentially gendered trait expressions.
The convergence between PD descriptions and gender roles has led some authors to question whether apparent gender differences in PDs reflect true differences in prevalence, or whether diagnostic criteria artificially inflate PD diagnoses or pathologize behavior based on gender stereotypes (Bjorklund, 2006; Kaplan, 1983). At least three scenarios are possible in this regard: according to the clinician/assessment bias hypothesis, men and women with equivalent pathology exhibit similar symptoms but these expressions are interpreted differently by clinicians; according to the criterion bias hypothesis, the criteria for each PD are rooted in definitions of adaptive functioning that more closely align with one gender role than the other, reflecting inherent gender bias; and, finally, according to the cultural relativity hypothesis, men and women express the same underlying pathology differently, but clinicians who are unaware or insensitive to these differences may misdiagnose the underlying problem (Widiger, 1998).
Although the debate regarding the tenability of these hypotheses is far from resolved, research has shed some light on their plausibility. Consistent with the clinician/assessment bias hypothesis, studies have found that although diagnostic criteria and normative personality traits were rated and interpreted similarly by clinicians, a fictional patient was more likely to receive a diagnosis of histrionic PD if described as female, but more likely to be diagnosed with antisocial PD if described as male (Ford & Widiger, 1989; Samuel & Widiger, 2009). However, in more recent studies, a fictional client was no more likely to receive a borderline PD diagnosis compared to a diagnosis of posttraumatic stress, major depressive, or generalized anxiety disorders based on the individual’s noted gender (Cwik, Papen, Lemke, & Margraf, 2016; Woodward, Taft, Gordon, & Meis, 2009). Inconsistent with the criterion bias hypothesis, studies show that clinicians do not rate criteria associated with “feminine” PDs (e.g., histrionic, dependent) as more or less severe, impairing, or abnormal than those associated with “masculine” PDs (e.g., antisocial; Funtowicz & Widiger, 1999; Morey, Warner, & Boggs, 2002), and that these criteria do not show gender bias in their associations with severity or impairment in clinical (Boggs, Morey, Skodol, Shea, & Sanislow, 2005) or non-clinical samples (Jane, Oltmanns, South, & Turkheimer, 2007; Morey et al., 2002). Consistent with the cultural relativity hypothesis, some authors suggest that diagnostic criteria may not adequately capture symptoms of antisocial PD as expressed in women versus men (Cale & Lilienfeld, 2002; Sprague, Javdani, Sadeh, Newman, & Verona, 2012). However, until broader issues related to gender biases are resolved (see Widiger, 1998), the latter hypothesis will remain difficult to test.
Critical Cultural Theory. Critical theorists note that the current diagnostic criteria for PDs are rooted in Western notions of the self that emphasize autonomy, independence, and individual agency, rather than concepts of the self that emphasize interdependence and socially determined behavior (Chen et al., 2009; Fabrega, 1994). Emerging research shows that behaviors that are considered maladaptive in one culture may not be problematic in others. For instance, shyness and withdrawal correlate with poor emotional and social outcomes in Australia and the USA; however, these traits are not associated with impairments and predict good adjustment in China and Korea (Chen & Stevenson, 1995; Kim, Rapee, Ja Oh, & Moon, 2008). Moreover, students living in Boston, Massachusetts (an independent-orientated region) with more of a collectivistic orientation experienced more anxiety and depression than their individualistic-oriented peers, whereas students living in Istanbul (an interdependent-oriented region) with a more individualistic orientation reported more paranoid thinking, narcissism, impulsivity, and antisociality compared to their collectivistic-oriented peers (Caldwell-Harris & Ayçiçegi, 2006). Thus, certain aspects of PDs may be culturally bound, as personality traits may only be problematic when a person’s cultural orientation does not fit with the demands and values of the culture in which he or she is embedded.
At the same time, cultural anthropologists note that some PD concepts, especially psychopathy and antisociality, are recognized across diverse cultural groups, including the Alaskan Inuit and Nigerian Yoruba, and thus may be considered culturally universal (Cooke, 2009; Murphy, 1976). Moreover, the Big Five personality traits have been found to characterize personality constructs and structure in Western and non-Western cultures, using both etic and emic approaches (e.g., Allik, 2005; Rossier & Rigozzi, 2008; Terracciano & McCrae, 2006; Yang & Bond, 1990). Thus, there is some reason to believe that certain personality constructs may be culturally translatable. Nevertheless, cultural context and goodness of fit must be considered in assessing the possible functional implications of these traits.
What Types of Sociocultural or Environmental Influences Increase Risk for Personality Disorders?
Given that such a large percentage of the variance in PDs is attributable to environmental influences (Kendler et al., 2008), the next question to consider is exactly what types of environments increase an individual’s risk for developing or expressing a PD. Before summarizing putative environmental and sociocultural risk factors for PDs, we wish to emphasize that the vast majority of people with these experiences do not go on to develop PDs, and some people with PDs do not experience any of the stressors listed below. In other words, these environmental and sociocultural experiences are neither necessary nor sufficient to cause PDs, but they may elevate risk when they interact with temperamental or genetic vulnerabilities.
Early Childhood Adversity and Developmental Trauma. People with PDs are significantly more likely to report childhood adversity, abuse, and trauma, relative to people without PDs (Afifi et al., 2011; Battle et al., 2004; Björkenstam, Ekselius, Burström, Kosidou, & Björkenstam, 2017; Widom, Czaja, & Paris, 2009). This result has been robustly supported across categorical and dimensional conceptualizations of PDs (see Hengartner, Ajdacic-Gross, Rodgers, Müller, & Rössler, 2013) for a broad range of childhood adversities, from parental separation (Lahti et al., 2012), to physical and sexual abuse (Johnson, Cohen, Brown, Smailes, & Bernstein, 1999; Widom et al., 2009), to war-related trauma (Munjiza, Britvic, Radman, & Crawford, 2017), and using both retrospective and prospective designs (e.g., Cutajar et al., 2010; Johnson et al., 1999; Widom et al., 2009). Childhood abuse or neglect is associated with a four-fold increase in the odds of developing a PD (Johnson et al., 1999), with a dose–response relationship between the total number of adverse events and symptom severity (Bandelow et al., 2005; Björkenstam et al., 2017; Distel et al., 2011).
Some evidence suggests that different types of adversities may be associated with specific PDs. Specifically, sexual abuse is associated with paranoid, schizotypal, borderline, avoidant, dependent, and obsessive-compulsive PDs; physical abuse is associated with antisocial PD; and emotional neglect is associated with histrionic and borderline PDs (Lobbestael, Arntz, & Bernstein, 2010). Further, although childhood emotional neglect has been found to be most strongly associated with avoidant and paranoid PDs, as well as Cluster A PD symptom severity, physical neglect is most strongly associated with schizotypal PD, as well as cluster A symptom severity (Johnson, Smailes, Cohen, Brown, & Bernstein, 2000).
Unsurprisingly, gene–environment interactions play an important role in this relationship. For instance, physical maltreatment was associated with a 2 percent increase in conduct problems among children at low genetic risk, but a 24 percent increase among children at high genetic risk (Jaffee et al., 2005). Whereas genetic influence explained more variance in antisocial behavior among individuals raised in socioeconomically advantaged environments, shared environmental influences explained more variance in antisocial behaviors among individuals raised in disadvantaged environments (Tuvblad et al., 2006). Adopted children of parents with antisocial PD who were exposed to caregiver conflict, divorce, psychopathology, physical maltreatment, or low social status were much more likely to develop conduct problems, relative to genetically-vulnerable but environmentally-unexposed peers (Cadoret, Yates, Troughton, Woodworth, & Stewart, 1995).
The over-representation of early adversity and developmental trauma in PD populations has led some authors to propose that certain PDs could be conceptualized as a type of posttraumatic stress disorder (see Lewis & Grenyer, 2009). However, these proposals remain controversial, as not all individuals with a PD have experienced developmental trauma or adversity (Bandelow et al., 2005; Gunderson & Sabo, 1993). Nonetheless, early childhood adversity is one of the most robust environmental correlates of PDs.
Stressful Life Events. The association between adversity, trauma, and personality pathology is not limited to childhood experiences. Adolescents and adults with PDs experience more daily hassles and stressful events than do their peers without PDs (Stepp, Pilkonis, Yaggi, Morse, & Feske, 2009; Tessner, Mittal, & Walker, 2011). Stressful life events such as divorce and job loss predicted borderline PD features in genetically vulnerable individuals, and traumatic events such as sexual assault predicted elevated borderline PD features even in those who are genetically less vulnerable (Distel et al., 2011). Among Vietnam veterans, traumatic experiences during combat were associated with more antisocial behaviors later in life, even after controlling for childhood adversity (Barrett et al., 1996). This evidence suggests that environmental stressors continue to play a role in PDs through adulthood.
Parenting Styles and Parental Psychopathology. Parenting plays a key role in emotional, behavioral, and cognitive development; thus, it is no surprise it has also been linked to PDs. Early studies based on Baumrind’s parenting style typology (i.e., neglectful, permissive, authoritative, authoritarian) have linked permissive and authoritarian parenting styles to narcissistic traits (Watson, Little, & Biderman, 1992), authoritarian parenting to antisocial traits (Farrington, 1993), and authoritative parenting styles to low psychopathology (Baumrind, 1966). More recent studies of specific parenting behaviors find that personality pathology is negatively associated with parental warmth and monitoring, and positively associated with psychological control, harsh punishment, and rejection (Horton, Bleau, & Drwecki, 2006; Huang et al., 2014; Stravynski, Elie, & Franche, 1989; Wetzel & Robins, 2016). Coercive communication cycles that escalate aggression and emotional arousal via negative reinforcement are theorized to play an especially important role in the development of antisocial traits (Snyder, Schrepferman, & St. Peter, 1997).
Although theoretical models posit that specific parenting profiles might be associated with different types of personality pathology (e.g., authoritarian, overprotective parenting is predicted to elevate risk for dependent PD; rejecting, dismissive parenting is predicted to elevate risk for avoidant PD; see Widiger & Bornstein, 2002), few studies have directly tested these assumptions. One recent longitudinal study showed that low parental warmth was associated with elevated risk of paranoid, schizoid, schizotypal, antisocial, borderline, and avoidant PDs in early to middle adulthood, whereas harsh parental punishment was associated with later paranoid, schizotypal, and borderline PDs (Johnson, Cohen, Chen, Kasen, & Brook, 2006). Poor parental supervision was most strongly associated with borderline and paranoid PDs, and Cluster B symptom severity (Johnson et al., 2000). A dose–response relationship is also evident, with more problematic parenting behaviors linked to greater likelihood of personality pathology (Johnson, Cohen, Chen, et al., 2006). Similar associations with parenting style are also evident when personality pathology is assessed dimensionally (De Clercq, Van Leeuwen, De Fruyt, Van Hiel, & Mervielde, 2008).
Combinations of different parenting profiles might exert even stronger effects on personality pathology than specific parenting behaviors considered in isolation. The combination of low warmth, low supervision, and high rejection/hostility by parents is particularly strongly associated with conduct problems and antisocial behavior (Hoeve et al., 2009), whereas the combination of maternal inconsistency and over-involvement is associated with borderline PD in adolescents (Bezirganian, Cohen, & Brook, 1993).
Parental psychopathology is also associated with elevated risk of personality pathology among children (McLaughlin et al., 2012; Schuppert, Albers, Minderaa, Emmelkamp, & Nauta, 2012). This is not surprising given that parental psychopathology is associated with many of the maladaptive parenting behaviors summarized above (Johnson, Cohen, Kasen, Ehrensaft, & Crawford, 2006). Studies increasingly highlight intergenerational cycles between psychopathology and parenting behaviors that maintain PDs in families (Infurna et al., 2016; Smith & Farrington, 2004).
Peer Relationships. Peer experiences, including rejection, humiliation, and bullying (e.g., Alden, Laposa, Taylor, & Ryder, 2002) and social contagion (e.g., Paris, 1997), are theorized to play a role in PDs, but few studies have tested these proposals. Delinquent peer groups have been consistently linked to antisocial behavior in adolescence and later adulthood (Dishion, Nelson, Winter, & Bullock, 2004; Dishion & Tipsord, 2011), but whether similar effects occur for other PD symptoms is relatively unknown.
Neighborhoods and Communities. Evidence regarding neighborhood- and community-level factors that elevate risk for PDs is sparse. Walsh and colleagues (2013) showed that residing in a high-risk neighborhood (defined by the median household income and the proportion of households or individuals in the area who were receiving public assistance, unemployed, and living below the poverty line) was associated with more severe PD symptoms, particularly for individuals with low socioeconomic status. These results are consistent with previous studies showing that neighborhood deprivation and community solidarity have an important impact on children’s emotional and behavioral problems (Caspi, Taylor, Moffitt, & Plomin, 2000), as well as violent crime and antisocial behavior (Sampson, Raudenbush, & Earls, 1997). These factors merit increased attention in future studies.
Where to From Here? Conclusions, Implications, and Future Directions
Summary and Conclusions
Although research investigating environmental and sociocultural contributions to personality pathology is still relatively new, tentative conclusions may be drawn. Both empirical and theoretical accounts underscore that environmental and sociocultural factors are integral to the development, expression, and maintenance of PDs. Non-shared environmental influences – those that account for differences between siblings – are estimated to account for 50–89 percent of the variance in PD prevalence, whereas shared influences seem to play a lesser role. Community studies highlight an elevated prevalence of PDs among those who are socially disadvantaged, including those who have lower income and educational attainment and who live in more urban and high-risk neighborhoods; however, whether these demographic features are causes, correlates, or consequences of personality pathology requires further investigation. Cross-national and cross-cultural comparisons suggest that, although we should be very cautious in assuming universality with respect to diagnostic entities, basic constructs underlying normative and maladaptive personality may have cross-cultural validity and utility. The expression, meaning, and impact of specific personality traits and behaviors may differ across gender roles, historical periods, and cultural groups. Thus, understanding the implications of personality traits for a person’s social, occupational, and emotional functioning requires interpreting symptoms and traits through an environmental and cultural lens.
Implications for Practice
Applying current diagnostic guidelines for PDs requires grappling with assumptions of cultural universality versus relativity to determine whether behaviors are sufficiently persistent and pathological to merit a PD diagnosis. Clinical errors can result from adopting either assumption dogmatically. Using one’s own culture as a reference or, alternatively, applying broad cultural stereotypes to evaluate a client’s behavior, can lead clinicians to over-pathologize behaviors that are culturally normative or under-pathologize behaviors that are clinically significant. Clinicians should be mindful of their cultural competency and seek consultation, training, and supervision as required. Experiences of immigration and acculturation, gendered expectations for behavior, disabilities, marginalization, and discrimination can all influence symptom presentation and interpretation. Treatment planning should consider cultural issues, including patterns of help-seeking behavior and possible adaptations to treatment. Whereas current psychotherapeutic interventions naturally flow from environmental theories (e.g., Smith Benjamin 2005; Fonagy & Bateman, 2008; Linehan, 1993), sociocultural theories demand a different sort of intervention, and these systemic efforts deserve attention.
Future Directions
A number of future research endeavors can improve our understanding of the environmental and sociocultural factors that influence PDs. As noted above, cross-national comparative studies using similar methodologies may help clarify the prevalence of PDs across different countries, and within different cultural groups in the same country. At the same time, studies that adopt culturally informed assessments of PDs are crucial for understanding how distinct cultures and environments shape PD symptoms, expressions, and definitions. Prospective cohort studies will help to untangle possible generational and historical trends in personality pathology that have rarely been examined. Finally, incorporating clearly operationalized measurements of environmental and sociocultural factors in future PD studies will improve our ability to quantify and understand these effects.
One issue that deserves special consideration is the growing push for dimensional conceptualizations of personality pathology. An alternative dimensional model of PD diagnosis is included in Section III of the DSM-5 (APA, 2013), and similar models are expected to appear in the ICD-11 (WHO, 2010). Although some concerns remain regarding the clinical feasibility and utility of this approach, we believe that the field will increasingly move toward dimensional conceptualizations of personality pathology in the coming years. What would such a shift mean for understanding the role of sociocultural and environmental factors in personality pathology? As described above, many of the specific environmental and sociocultural correlates of PDs have already been validated against corresponding normative or maladaptive traits, and many theoretical models initially arose from dimensional conceptualizations of personality, suggesting excellent potential for translation. In terms of clinical practice, it is noteworthy that aside from borderline, antisocial, and unspecified PD, most categorical PD diagnoses are rarely used in most countries (Tyrer, Crawford, Mulder, & ICD-11 Working Group, 2011), potentially pointing to their limited cross-cultural utility. Given emerging evidence that the Big Five traits can be reliably assessed in diverse cultural contexts, a shift toward dimensional diagnosis of personality pathology based on maladaptive traits could improve the cross-cultural validity of PD nosology and stimulate cross-cultural research. Such a shift would require substantial effort to establish the reliability, validity, and utility of both the dimensional model and its assessment instruments, but we believe the time is right for such work. An alternative or intermediate step might be to reduce PD diagnoses into broader domains (e.g., anxious/dependent, antagonistic/aggressive, withdrawn/isolated, obsessive/rigid, and psychopathic/antisocial; Mulder, 2012); however, this may not adequately address issues of comorbidity that are frequently encountered in clinical practice.
Whether or not the field adopts dimensional models for clinical practice, increasing efforts to establish the cross-cultural structure, reliability, and validity of dimensional assessments of personality pathology is a vital step in advancing knowledge of environmental and sociocultural influences on PDs. Expanding research efforts to investigate the meaning and impact of personality constructs within distinct and intersecting cultural groups is a crucial and needed direction for future research. Moreover, future research should address limitations of previous studies by increasing the use of representative samples, prospective and repeated measurement designs of environmental influences and personality pathology, as well as standardized operationalizations of environmental influences. Cultural influences, which are largely assumed in current designs, would benefit from more explicit and nuanced measurement. Together, these efforts would substantially enhance our understanding of why some people develop PDs and how we can prevent them.
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1Note that measurement error is included in estimates of environmental influence.
2Although Loranger et al. (1994), on behalf of the World Health Organization, sought to validate the reliability and validity of the IPDE across 11 countries, this study used clinical rather than community samples and was not intended to examine the prevalence of PDs cross-nationally.