Psychological research is conducted to help broaden our knowledge and understanding of psychological processes, human behaviors and to possibly help build effective treatments for disorders and diagnostic criteria that accurately diagnose patients. In many different countries and cultures, Borderline Personality Disorder (BPD) has many different diagnostic criteria that define the disorder. Due to the lack of cross-cultural research around BPD cultural differences were not accounted for when considering how BPD symptoms may look in other places around the world. According to the American Psychiatric Association’s DSM-V, BPD would be diagnosed to a patient that shows signs of instability in functioning, affect, mood, and interpersonal relationships and often experience profound impairment in general functioning, marked impulsivity, and high levels of anger and hostility (American Psychiatric Association, 2013) (Skodol, A. E., Gunderson, J. G., Pfohl, B., Widiger, T. A., Livesley, W., & Siever, L. J. (2002). More severe cases of BPD can lead individuals to experience a higher risk of self-injurious and suicidal behaviors (Oldham J., 2001).
In China, the Chinese Classification of Mental Disorders (CCMD) the disorder known as BPD is not included or viewed as a diagnostic category. However, a disorder in the CCMD termed as Impulsive Personality disorder (IPD) overlaps heavily with the diagnostic criteria of the DSM-V BPD diagnosis (Zhong, J., & Leung, F. 2009). With the addition of certain diagnostic criteria, IPD and BPD could be considered the same disorder. CCMD IPD patients and DSM-V BPD patients will only show significant differences in two traits; substantial signs of impulsivity that is not required of a DSM-V patient with BPD and transient psychotic features which is not meant to be present in CCMD IPD patients (Zhong, J., & Leung, F. 2009). Although BPD as a diagnosis is not included in the CCMD there have been many recent studies conducted in China that supports BPD being present in the Chinese population but the lack of foundational research about BPD in China is limited. According to (Leung and Leung, 2009) if prevalence rates for BPD are generalized to China about 13-26 million people may have BPD, with no hope of receiving a proper diagnosis. A recent study conducted found that the prevalence of BPD in psychiatric outpatients was 5.8% with a frequency of 3.5% in males and 7.5% in females supporting that BPD is prevalent in the Chinese population (Wang, Lanlan, et al. 2012).
The main topic of this study is to examine if childhood abuse predicts for BPD in adults with similar strength in both Chinese culture and the United States culture. What is expected from the results is that individuals that were born and raised in China for at least 15 years are diagnosed with BPD less frequently than individuals who are born and raised in the United States at least 15 years due to their collectivistic upbringing and cultural rearing norms impacting their experience of the negative effects of childhood abuse. The topic at hand is significant because there is an extreme lack of cross-cultural research that has been conducted about BPD in China. There is even less research attempting to compare predictors of BPD in China to the United States and if those predictors are valid enough in determining a later BPD diagnosis. BPD can have a lasting effect on an individual’s life, it is crucial that every culture has diagnostic criteria that are consistent and culturally appropriate. With more research seeking to understand cultural variance and the diagnostic criteria for BPD, the accuracy of diagnosis and later treatment of the disorder will begin to improve worldwide. Previous research assessing the diagnostic criteria of BPD and its cultural variance between countries especially in immigrant populations is lacking. With the lack of cross-cultural research into BPD, the disorder becomes complicated by risks of misdiagnosis, mistreatment, and misunderstanding. Symptoms of BPD can manifest differently depending on the environment, which is why future research should be geared towards finding dimensional categories for assessing cross-cultural symptoms of BPD. The gap in research that this study is attempting to fill is if childhood abuse is a cross-cultural predictor of BPD in adults in China and the United States in order for researchers and practitioners to be confident when assessing cross-cultural diagnosis.
Childhood abuse in this study will be defined using the ACE study which states that having experienced abuse whether it be physical, emotional or sexual, or trauma influenced by the environment such as parental substance abuse, violence in the home not directly towards the child, and lastly neglect (Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Marks, J. S. 2019). In many Asian countries, physical discipline does not amount to child maltreatment unless there is an extreme amount of physical strain inflicted on the child. Other forms of childhood abuse that are not necessarily physical such as emotional abuse and forms of neglect and even at times sexual abuse are not viewed as abuse in some Asian countries (Larsen, S., Kim-Goh, M., & Nguyen, T. D. (2008). In American culture physical punishments towards children are not uncommon; however, they are still considered forms of physical abuse (Millard, D. (2000).
Previous research suggests that childhood abuse is a very strong predictor for a later BPD diagnosis in the U.S. with many studies citing that a history of childhood abuse is common among the BPD population possibly suggesting abuse may be an etiological factor. (Huang, J., Napolitano, L. A., Wu, J., Yang, Y., Xi, Y., Li, Y., & Li, K. 2013). In many cases of BPD, these individuals reported high rates of childhood emotional, physical, and sexual abuse and often experiencing some form of neglect as well (Macintosh, H. B., Godbout, N., & Dubash, N. (2015). One study found in 467 psychiatric inpatients who had been diagnosed with BPD as much as 91% of them had some history of childhood abuse (Macintosh et al., (2015). While childhood abuse is a very strong predictor for BPD in the United States these findings can not be generalized to the Chinese population without the proper research supporting the claim due to the vast cultural differences between countries. Some recent surveys and self-report measures were conducted in China suggesting the occurrences of childhood abuse is common among the population (Huang, J., Yang, Y., Wu, J., Napolitano, L. A., Xi, Y., & Cui, Y. (2012). Which led us to hypothesize that if childhood abuse is such a strong predictor for BPD in the U.S. would the same be true for the Chinese population if child abuse is common within the population. However, with little research that exists outside the U.S. comparing the relationship between childhood abuse and BPD, our research will seek to fill that gap in determining if childhood abuse is a culture-specific predictor for BPD.
With a BPD diagnosis, biological factors play a role in its development but research also suggests that environmental factors also play a critical role (Huang et al. 2012). Environmental influencers hinge off of the social and cultural dynamic a person is exposed to in daily life. In many places around the world, the cultural norms and social interactions are not going to be consistent, the need for cross-cultural research is crucial because the development of BPD may manifest differently within various cultures while some identifying characteristics may remain cross-culturally. China tends to encompass more of a collectivistic culture whereas in the United States individualistic culture is more common (Huang, J., et al. 2012). Culturally, China shows more aspects of hierarchical systems and authoritarianism in parent-child relationships than the United States, placing higher importance on interdependence, discipline, and obedience from their children(Jani et al., 2016). The United States, historically showing more individualistic characteristics encourages people to be more autonomous and independent while pursuing individual goals (Jani et al., 2016). Some of the child-rearing practices in China could also be viewed as cruel which in most cases is used in order to obtain the obedience of the child with one study mentioning that this type of parenting style may be correlated with child maltreatment and abuse (Huang, J., et al. 2012). However, if these types of behaviors towards children are not seen as abuse in Asian cultures there may be numerous amounts of people who have suffered from this type of childhood abuse that considers that type of treatment normal and acceptable. In China, particularly due to its cultural norms certain key aspects that would encompass a BPD disorder such as feelings of emptiness and the fear of abandonment are looked down upon, causing many Chinese practitioners to disregard BPD as a disorder entirely (Jani, S., Johnson, R. S., Banu, S., & Shah, A. (2016). Even though the culture of China and the United States is different psychometric measures within the DSM-IV show that the diagnostic criteria can be culturally generalizable to the Chinese population.
The purpose of the paper is to address different culture dynamics which in this case are individualistic and collectivistic culture and how similar predictors of BPD can present themselves in contrasting ways because of cultural differences. Considering the strength of a later BPD diagnosis in the U.S. when accompanied by a history of childhood abuse we hypothesized that if childhood abuse is common in China some occurrences of BPD should be present within the population; although the frequency of BPD diagnosis will be lower than the United States due to the cultural differences.