Ethnic distribution of personality disorder

The prevalence of personality disorder in the UK is between 4% and 33% and ranges from 13% of general practitioner patients to 40–50% of psychiatric in-patients. There are no figures relating to ethnicity. Ethnic minorities are over-represented in psychiatric services and especially in compulsory psychiatric care. Black clients are less likely than White clients to be diagnosed with personality disorder and more likely to be diagnosed with schizophrenia. Ethnic minorities are underrepresented in specialist psychotherapy services and are less likely than White clients to be offered counselling or psychological therapy. ¹

In a cross-sectional survey of in-patient data collected over 2 years (2007–2009), we examined the prevalence of personality disorder with regard to ethnic distribution among 6531 psychiatric in-patients. The survey was conducted in Mersey Care National Health Service Trust, a mental healthcare provider in the north-west of England. Ethnicity was divided into two broad categories: White British, and Black and minority ethnic.

Of the 273 patients (4.2% of sample) diagnosed with personality disorder, 23 (8.4%) were Black and minority ethnic patients and 250 (91.6%) were White British patients. The most common diagnosis was emotionally unstable personality disorder (184 cases).

The results of the survey have led us to further consider why there is underdiagnosis of personality disorder in Black and minority ethnic groups. There is a dearth of research evidence and literature examining personality disorder in those groups and existing evidence refers to studies not representative of the UK population.

National Health Service evidence for mental health in Black and minority ethnic populations states cultural differences exist in the way in which psychological distress is presented, perceived and interpreted, and different cultures develop different responses for coping with psychological stressors. The evidence base on risk and protective factors for mental illness is largely drawn from research on White European or North American populations and hence cannot be generalised to Black and minority ethnic populations. ²

Cultural and racial stereotyping is a common experience in the context of assessment and decisions concerning treatment, and influences the types of services and diagnoses that Black and minority ethnic individuals seek and receive. A Sainsbury Centre for Mental Health report found that there is a cycle of fear fuelled by prejudice, misunderstanding, misconceptions and sometimes racism in mental health services for this group of users. ³

The concept of personality disorder in itself poses problems with diagnostic uncertainty and is perceived as a stigmatising label. Attempting to redress the balance with regard to personality disorder within Black and minority ethnic groups is made more difficult due to the pre-existing attitudes towards mental illness in these communities. Mental illness can be regarded as a non-entity, a stigma or a taboo. However, it is not only the patients that need educating but also the professionals responsible for detection and management of personality disorders.