Racial Differences Between African and White Americans
in the Presentation of Borderline Personality Disorder
Christina E. Newhill Æ Æ Shaun M. Eack Æ Æ
Kyaien O. Conner
Published online: 21 April 2009
? Springer Science+Business Media, LLC 2009
monly thought of as a disorder of White females. Despite
evidence indicating similar prevalence rates across races
and genders, no study has examined the experience of BPD
among ethnic minorities and how this differs from Whites.
The affective and behavioral symptoms of BPD were
studied in 17 African Americans and 27 White Americans
with the disorder. Results indicated that African Americans
experience greater affective intensity and emotional dys-
regulation, fewer self-harming behaviors, and more
thoughts of interpersonal aggression than Whites. Differ-
ences in affective symptoms were accounted for by group
differences in substance use and receipt of inpatient ser-
vices, whereas differences in behavioral symptomatology
persisted after adjusting for potential confounders. These
findings suggest that not only is BPD not a disorder
exclusive to White females, but that the experience of the
disorder may differ substantially across races. Implications
for future research and directions for developing culturally
relevant treatments are discussed.
Borderline personality disorder (BPD) is com-
African Americans ? Racial differences ?
Emotion dysregulation ? Violence
Borderline personality disorder ?
Borderline personality disorder (BPD) is a complex and
disabling mental illness that is characterized by significant
interpersonal impairment and considerable difficulties with
community adjustment (Skodol et al. 2002). The treatment
and management of individuals with BPD is an ongoing
challenge for the mental/behavioral health care system,
creating ‘‘a substantial burden of illness for society’’
(Hyman 2002, p. 933).
One of the central features, and most problematic
aspects, of BPD is dysregulation of emotion, particularly
negative affects. It is well established that such emotional
instability can lead to repeated self-harming behavior
(Gunderson 2001; Linehan 1993), and findings from the
MacArthur Risk Assessment Study have shown that per-
sons with BPD also commonly engage in significant
interpersonal violence (Newhill et al. unpublished manu-
script). More recent findings have shown that emotion
dysregulation is a significant longitudinal mediator of
violent behavior among individuals with BPD, and may
serve as the primary mechanism that enhances risk for
violence among this population (Newhill et al. under
review). This is important because such violence can result
in repeated hospitalization, incarceration, homelessness,
injury or death, exacting considerable costs economically
and in human suffering (McNeil et al. 2005).
Although the treatment and research literature on BPD is
substantial, the tendency has been to characterize the dis-
order as primarily affecting White females and little-to-no
attention has been paid as to how the disorder manifests
and what differences may exist with persons of color with
BPD or men with BPD. Whatever existing data available,
however, suggest that the occurrence of BPD cuts across
gender and racial groups (Newhill and Vaughn 2009).
C. E. Newhill (&) ? S. M. Eack
School of Social Work, University of Pittsburgh, Pittsburgh,
K. O. Conner
Western Psychiatric Institute and Clinic, University of Pittsburgh
School of Medicine, Pittsburgh, PA, USA
Race Soc Probl (2009) 1:87–96
Emotional Dysregulation and BPD
Emotional dysregulation involves difficulty in regulating
intense negative affect such as anger, anxiety, and dys-
phoria (Koenigsberg et al. 2002; Newhill et al. 2004; Yen
et al. 2002). It is theorized that emotional dysregulation
problems stem from a combination of biological suscepti-
bility and learned responses to affectively laden early
experiences (Linehan 1993), with vulnerable individuals
developing patterns of maladaptive regulatory behaviors
over time. For example, some individuals may engage in
self-harming behavior as a strategy to cope and regulate
overwhelming painful emotions (Kemperman et al. 1997;
M. Linehan, personal communication, 1997; Russ et al.
1992, 1994). An individual with poor emotion regulation is
predisposed to emotional sensitivity, becomes easily
aroused by emotional stimuli, and has great difficulty in
calming and settling down to emotional baseline (Linehan
1993). Clearly, there are conceptual overlaps among the
concepts of emotional dysregulation, behavioral disinhibi-
tion (Gross 1998), impulsive aggression (Critchfield et al.
2004), and labile affect (Schore 2003). For the purpose of
the study reported here, however, we define emotional
dysregulation, as is commonly used in clinical assessment
and intervention, as the overall process of experiencing and
managing emotions, whether or not this leads to behavioral
difficulties (Linehan 1993).
Race and Emotions
A range of cultural factors has been documented in the
study of emotion. Research has documented that different
racial groups tend to differ in expressed emotion (Marsh
et al. 2003) as well as in how emotion is recognized
(Ekman et al. 1987). These racial differences have been
associated with level of affect recognition, ratings of
emotional intensity (Matsumoto et al. 1999), and to situa-
tions perceived as likely to give rise to certain emotions.
These variations may be due to the way in which a situation
or event is assessed, the culturally informed sanctions that
different racial and ethnic groups might exert against
acknowledging and expressing certain emotions, the cul-
tural display or labeling of emotions, as well as the influ-
ence of social structures in society on emotions and
emotional expression (Brekke et al. 2005). These mecha-
nisms that affect emotion regulation need to be further
studied in BPD, particularly among racial, and ethnic
Current emotion literature pays little attention to ethnic
or cultural variations in emotion expression. Emotion
research has historically been concerned with documenting
universals in emotion, not differences. Gross (1998), in his
review of emotion regulation, highlighted the need for
more research in this area by indicating that more attention
needs to be paid to conducting emotion research with
ethnically diverse samples. Lawton and colleagues (1993)
suggest that research into emotions should look to extend
generality, particularly across socioeconomic, racial and
Despite the lack of empirical research, most of the
factors involved in emotion processes have shown some
degree of racial variation. Taking into account factors
related to race and culture may aid in the determination of
the kinds of emotional reactions individuals exhibit and
express. Culture-specific learning experiences with respect
to emotions are manifest in differential patterns of emo-
tional assessment and expression, reflecting the fact that
individuals from different racial or ethnic groups are taught
to express emotions in different ways and with different
intentions and meaning. Wierzbicka (1999) states that we
think differently, feel differently, relate differently, and
function differently precisely because we are members of
different racial and cultural groups. She argues that every
culture contains a set of scripts that guide how individuals
belonging to that culture should feel, how and when they
should express their emotions and how they should react to
Emotions as well as behaviors can be recognized,
acknowledged, and expressed differently among different
racial groups. Using a multi-ethnic sample of 755 com-
munity dwelling older adults to look at differences in
emotion expression by ethnicity, Consedine and Magai
(2002) found significant differences in nine out of the ten
trait emotions studied, as well as in levels of emotion
expressed during conflict. Overall, White Americans
reported more negative affective experiences, and greater
use of ‘‘emotional tactics’’ during conflict than African
Americans. African Americans reported significantly less
guilt than all other racial/ethnic groups. They reported less
sadness, shame, fear, and anger than their White counter-
parts. African Americans also reported the lowest mean
level of emotional conflict tactics, being significantly less
likely to express emotions during conflicts than their White
counterparts. This finding supports other research docu-
menting African Americans general tendency to report
lower levels of a number of negative emotions and higher
levels of some positive emotions.
Race and BPD Symptomatology
The issue of racial differences in BPD symptomatology has
not been examined and research on racial differences in the
experience and expression of emotion has been mixed.
Some racial differences have been found regarding levels
of autonomic arousal among healthy individuals, depend-
ing on the social context presented (Vrana and Rollock
88 Race Soc Probl (2009) 1:87–96
2002), and other equivocal findings exist regarding emo-
tional expressivity of healthy individuals (Gross and John
2003; Davidson 2001; Consedine et al. 2002). In addition,
on average, African Americans exhibit important differ-
ences on some of the primary behavioral manifestations of
BPD. Perhaps, the most significant difference has been
found in census data, indicating that African Americans are
significantly less likely to commit suicide than White
Americans (Mcintosh 1989), perhaps due to differences in
cultural norms (Morrison and Downey 2000). Regarding
violence toward others, Klassen and O’Connor (1989)
found racial differences in rates of violence in a sample of
psychiatric patients, but most other studies have found no
differences on the basis of race (Monahan et al. 2001),
particularly when controlling for socioeconomic status or
level of violence in the individual’s neighborhood (Stead-
man et al. 1998; Swartz et al. 1998).
Clearly, racial differences in the experience and
expression of emotion, and in the presentation of violent
behavior is mixed, and for the most part, inconclusive.
However, such findings do suggest that if the emotional
and behavioral differences that have been tentatively
observed in African American populations as a whole
compared to White Americans do exist, the experience and
symptom presentation of those individuals who develop
BPD may be markedly different across racial groups.
Unfortunately, BPD has largely been considered a pri-
marily White, female disorder (e.g., Akhtar et al. 1986),
and to date, no studies have attended to potential racial
differences in the presentation of BPD. If important racial
differences exist in how BPD is manifested and experi-
enced by the people who suffer from this illness, such
information could be vital to developing specialized, cul-
turally sensitive treatments for this population.
This research was conducted as part of a larger study to
develop a measure of emotional dysregulation for indi-
viduals with Cluster B personality disorders. We only
briefly summarize the methods relevant to this study, as
these have been explained in detail elsewhere (Newhill
et al. 2004).
Participants in this research included 100 individuals with
Cluster B personality disorders from three inpatient units
and five outpatient clinics at a large university hospital
system in an eastern state. Recruitment involved alerting
clinicians about the details of the study and providing each
clinician with a set of recruitment flyers that could be
shared with prospective participants. Potential subjects
who were interested in participating placed a call directly
to the researchers, calls were returned within 24 h and, if
the patient was still interested in participating, an interview
Since this study focuses on racial differences in the
presentation of BPD, we restricted our analysis to only
African American (n = 17) and White (n = 27) individu-
als with BPD. Both the Axis I and personality disorder
diagnoses were based upon either chart review or the
current treating clinician’s report. Participants were pre-
dominantly female (86%), with ages ranging from 19 to 56
(M = 36.39, SD = 8.72). Over half of the participants
were receiving some form of financial assistance, either
through Medicaid (64%) or Social Security (59%). All but
three participants had at least one documented co-morbid
Axis I diagnosis, which predominantly included diagnoses
from the mood and/or anxiety disorders spectrum (59%), as
well as co-morbid substance use diagnoses (18%). Such
psychiatric co-morbidity is reported to be typical for
community samples of BPD patients (Conklin and Westen
2005). While there were no significant racial differences
with respect to participants’ demographics, Medicaid, or
Social Security status, African Americans were dispro-
portionately represented in outpatient settings, U = .44,
v2(1, N = 44) = 8.59, p\.01, and suffered from co-
morbid mood and substance use problems more than
Whites, U = .47, v2(1, N = 44) = 9.85, p\.01.
After recruitment and consent, participants were inter-
viewed using a battery of measures (described below) and a
structured interview addressing violent and suicidal
behavior, by either the first author or a master’s-level
research associate. All the interviews were conducted
either in the inpatient or outpatient unit where the partici-
pant was receiving services or at a site in the community.
Interviews lasted approximately 90 min, after which par-
ticipants were paid $15 for their participation. This study
was approved by the [authors’ university] Institutional
Review Board, and all the participants gave written,
informed consent prior to participation.
Affective and emotional symptoms associated with the
characteristics of BPD were assessed using a variety of
different measures. Emotional dysregulation, a core feature
of BPD (Koenigsberg et al. 2002; Yen et al. 2002), was
Race Soc Probl (2009) 1:87–9689
measured using the General Emotional Dysregulation
Measure (GEDM) (Newhill et al. 2004), a 13-item, reliable
and valid instrument designed to measure emotional dys-
regulation in individuals with Cluster B personality disor-
ders. We have previously shown that the GEDM converges
significantly other measures of emotion measures related to
emotion dysregulation, such as affect intensity and nega-
tive affect (Newhill et al. 2004). Affect intensity, another
core affective feature of individuals with BPD (Linehan
1993), was measured using the Affect Intensity Measure
(AIM) (Larsen 1984; Larsen et al. 1986), a highly reliable
and valid measure of intensity or strength of affect asso-
ciated with certain life events. Larson and colleagues
(1986) have shown ratings on this measure to be associated
with the presence of high and low intensity emotional sit-
uations in both daily life and the laboratory. Finally,
positive and negative mood was assessed using the 20-item
Positive and Negative Affect Scale (PANAS) (Watson
et al. 1988), a reliable and valid measure of stability of
mood experienced over specified periods of time. Watson
and colleagues (1988) have shown that the PANAS con-
verges significantly with other measures of positive and
negative emotion. In our sample, we found the GEDM,
AIM, and the positive, and negative subscales of the
PANAS, all to have adequate internal consistency
(a = .87, .81, .93, .97, respectively).
In addition to affective symptomatology, BPD is associated
with significant behavioral dysregulation manifesting as
problems in interpersonal relationships, self-harm, and
aggressive behavior (American Psychiatric Association
2000; Eronen et al. 1997; Holtzworth-Munroe 2000;
Linehan 1993; Soliman and Reza 2001). We measured
interpersonal problems using the personality disorder sub-
scales from the Inventory of Interpersonal Problems (IIP-
PD; Pilkonis et al. 1996), a reliable and valid measure of
interpersonal difficulties among individuals with person-
ality disorders and other psychiatric populations. Previous
research has shown the IIP-PD to be significantly predic-
tive of a diagnosis of personality disorder (Pilkonis et al.
1996). In our sample, we found the IIP-PD to have good
internal consistency (a = .92).
Finally, a structured interview was used to assess both
the frequency and nature of participants’ suicidal and
aggressive thoughts and behavior. Questions were posed
regarding whether the participant has had thoughts about
harming him/herself, what kinds of thoughts he/she has
had, the frequency of such thoughts and whether he or she
has acted on such thoughts and, if so, specifically what the
actions consisted of (e.g., cutting self or burning self). The
interview also asked whether participants ever had
daydreams or thoughts about physically hurting or injuring
another person, what kinds of thoughts he or she has had,
how often he or she has such thoughts, and whether the
participant has ever acted on their violent thoughts.
Do African Americans and White Americans Differ
in Their Presentation of BPD?
We began our analysis of racial differences in the presen-
tation of BPD by examining the degree to which African
Americans and White Americans with BPD differed in
their presentation of the affective and behavioral symptoms
associated with the disorder. In order to protect the
experiment-wise error rate, omnibus multivariate analyses
of variance (MANOVA) were conducted on score data
whenever possible. Chi-square tests were used for cate-
gorical data. Logarithmic and quadratic transformations
were performed on skewed data, and all the score data were
transformed to a standard metric (M = 50, SD = 10).
As can be seen in Table 1, there were a number of
significant differences between the African American and
White BPD patients in their presentation of affective and
behavioral symptoms. Omnibus MANOVA indicated that
there were significant differences between African Amer-
icans and White Americans in their experience of the
affective symptoms of BPD, F(4, 38) = 3.17, p\.05.
Follow-up univariate tests indicated that, on average,
African Americans tended to experience more positive,
F(1, 41) = 4.18, p\.05, and intense affect, F(1, 41) =
6.49, p\.01, and reported higher levels of emotional
dysregulation, F(1, 41) = 5.48, p\.05. No significant
differences emerged between African Americans and
White Americans in their experience of interpersonal
problems, F(3, 40) = .18, ns. Findings concerning suicidal
and violent behaviors indicated that while African Ameri-
cans and White Americans were equally likely to have self-
harming thoughts, v2(1, N = 44) = .11, ns, African
Americans were more likely to report having violent
thoughts toward others, v2(1, N = 44) = 6.50, p\.05,
whereas White Americans more frequently experienced,
F(1, 40) = 10.62, p\.01, and acted upon self-harming
thoughts, F(1, 35) = 7.60, p\.01. However, among
individuals who had violent thoughts, there were no sig-
nificant racial differences in the frequency of these
thoughts, F(1, 18) = .10, ns, or the frequency with which
they acted upon their thoughts, v2(1, N = 22) = .11, ns.
Such findings indicate that while African American and
White BPD patients share some similarities in their
expression of symptoms of the illness, they also evidence
some significant differences, particularly with regard to the
90Race Soc Probl (2009) 1:87–96
experience of emotion dysregulation, which should be
taken into account in both assessment and in designing
approaches to treatment.
What May Account for Racial Differences
in the Presentation of BPD?
After finding that there were some significant differences
between African Americans and White Americans in their
presentation of the affective and behavioral symptoms of
BPD, we explored the veracity of these findings on a uni-
variate level using analysis of covariance (ANCOVA) and
hierarchical logistic regression, removing shared variance
with the two demographic factors that differed significantly
between races: inpatient versus outpatient setting and the
presence of co-morbid mood and substance use problems.
This was necessary because these factors represent
important potential confounding variables when looking at
differences in BPD symptomatology. For example, it is
reasonable to assume that individuals treated in outpatient
settings might have less frequent self-harming behaviors
than those treated on inpatient units due to the nature of
current civil commitment criteria and, because African
Americans were overrepresented among the outpatient
settings, this could explain why racial differences were
found in the frequency of self-harming behaviors.
As can be seen in Table 2, many of the differences
between African Americans’ and White Americans’ pre-
sentation of the affective symptoms of BPD could be
accounted for by differences in where these individuals
received treatment and whether they experienced substance
use problems. After controlling for treatment setting, there
were no longer significant racial differences in emotion
dysregulation, and differences in affect intensity and
positive affect remained only marginal. This pattern was
generally repeated when controlling for the presence of
co-morbid mood and substance use problems (although
racial differences in affect intensity continued to remain
statistically significant), when simultaneously controlling
for both treatment setting and co-morbid mood/substance
use problems. Such findings suggest that racial differences
in the affect symptoms of BPD may be largely accounted
for by co-morbid substance use problems and, surprisingly,
less intensive treatment.
When examining differences between African Ameri-
cans and White Americans in their presentation of the
behavioral symptoms of BPD, our findings were somewhat
different. Even after controlling for treatment setting and
the presence of co-morbid substance use and mood prob-
lems, African Americans continued to exhibit and act on
self-harming thoughts significantly less than their White
counterparts. Furthermore, African Americans continued to
Table 1 Differences between African and White Americans in affective and behavioral symptoms of borderline personality disorder
Measure African AmericanWhite Test
F(4, 38) = 3.17*
Affect intensity 54.528.44 47.059.97
F(1, 41) = 6.49**
Emotional dysregulation54.469.40 47.59 9.42
F(1, 41) = 5.48*
Negative affect50.4312.04 49.90 8.84
F(1, 41) = .03
Positive affect53.716.46 47.4911.37
F(1, 41) = 4.18*
F(3, 40) = 1.73
F(1, 42) = 4.04?
Aggression 53.6910.17 47.68 9.34
F(1, 42) = .87
F(1, 42) = .22
v2(1, N = 44) = .11
F(1, 40) = 10.62**
Frequency acted onb
Thoughts of cuttingb
F(1, 35) = 7.60**
v2(1, N = 36) = 9.27**
v2(1, N = 44) = 6.50*
v2(1, N = 22) = .105
F(1, 18) = .10
?p\.10, * p\.05, ** p\.01
aPercentages reflect the percentage of participants within each racial group endorsing the item
bAnalyses are presented only for the subset of individuals indicating they experienced selfharming or violent thoughts
Race Soc Probl (2009) 1:87–9691
experience fewer thoughts of self harm after controlling for
treatment setting and co-morbid substance use/mood
problems, although this effect was not significant when
both of these factors were controlled for simultaneously.
Conversely, even when controlling for treatment setting
and co-morbid substance use/mood problems, more Afri-
can Americans continued to report experiencing thoughts
about harming others than White Americans. Such differ-
ences in the presentation of the behavioral symptoms of
BPD, even when controlling for potential confounders,
lend some support to possible important racial differences
in the core behavioral symptoms of the disorder.
This study examined differences in the affective and
behavioral presentation of BPD among 17 African Amer-
ican and 27 White American individuals with the disorder.
Results indicated that there were significant differences in
affective and behavioral symptomatology between African
American and White American individuals, with African
Americans experiencing greater affective intensity and
emotion dysregulation symptoms and thoughts of inter-
personal violence than White Americans. Interestingly,
African Americans also reported experiencing much more
positive affects, and were significantly less likely to report
engaging in self-harming behaviors. Although differences
in affective symptoms were attenuated to non-significant
levels when accounting for substance use problems and
treatment context, which may in themselves reflect a dif-
ference in the presentation of the illness, differences in
behavioral symptomatology remained robust after adjust-
ing for these potential confounders. These findings suggest
that the experience of BPD may differ in important and
significant ways depending on the cultural background of
the individual. A variety of sociocultural factors, including
environmental stressors and stigma, may account for these
The Role of Stress
One possible explanation for the racial differences in the
presentation of BPD found in this study may reside in the
fact that many negative emotions and problematic behav-
iors are responses to stress. For individuals with BPD, the
disorder itself can be a daily stressor, along with the added
ongoing stress of experiencing prejudice, stigma and dis-
crimination based on having a mental health disorder.
Psychological research acknowledges the importance of
the appraisal of potentially harmful environmental events
and individual perceptions of stress (Brown 2004; Lazarus
and Folkman 1984). In order to understand how individuals
respond behaviorally and emotionally, it is important to
understand individuals’ personality characteristics, social
influences, exposure to stress, and perception and inter-
pretation of stressors. In addition, individuals, such as
African Americans, who are exposed to similar social and
economic stressors, and share similar ascribed and social
roles and positions will experience similar types and levels
of stress (Pearlin 1989), which must be considered in
looking at racial differences in emotion dysregulation and
other behaviors characteristic of BPD. Chronic stress in the
everyday lives of African Americans includes a myriad of
hassles, including racial discrimination, oppression, and
financial burden, and strain that may lead to negative
emotional responses (Brown 2004) as well as negative
The Role of Stigma
Individuals with BPD also carry a heavy burden of stigma.
Stigma involves the perception of a negative attribute that
evolves into a global devaluation of the person (Katz
Table 2 Associations between
race and borderline
symptomatology after removing
shared variance with potential
?p\.10, * p\.05,
aEffect sizes are represented by
Pearson’s r for continuous
variables and U for categorical
variables, adjusting for potential
confounders. Positive effect
sizes represent higher scores/
frequencies for African
Measure Between-group effect sizesa
Affect intensity.37** .27?
Positive affect .32*
Frequency acted on-.42**-.41*-.48**
Thoughts of cutting-.51**-.35*
Violent thoughts .38**
92Race Soc Probl (2009) 1:87–96
1981). Even mental health professionals subscribe to the
negative stereotypes of individuals with BPD, and often try
to avoid treating them (Aviram et al. 2006). Individuals
with BPD are likely to encounter two types of stigma:
public stigma and self stigma. Public stigma refers to the
general public’s reaction to individuals with a mental
health diagnosis and the stereotypes, prejudice, and dis-
crimination that follow as a result. Self-stigma occurs when
individuals with a mental health diagnosis accept the
negative views held by the general public, resulting in
diminished self-esteem and lower self-efficacy as a result
(Corrigan and Watson 2002).
Research suggests, however, that not everybody reacts
to stigma by feeling depressed and devalued. Empirical
studies report that rather than internalizing stigma and
feeling bad about oneself, some individuals become righ-
teously angry due to the prejudice and discrimination they
have experienced as a result of their membership in a
stigmatized group (Corrigan and Watson 2002; Deegan
1990). Individuals with mental illness may even vent their
righteous anger directly toward those who have stigmatized
them. Such anger may, at times, involve thoughts of
harming those who have harmed them although the indi-
vidual may not act on such thoughts. Research suggests
that such anger may, in fact, be a healthy response to
stigma, particularly among African Americans, and a
response preferable to blaming or harming oneself. Wright
(1997) suggests that this anger is associated with a col-
lective and affirming response to the experiences of stig-
matization. Therefore, is it possible that some African
Americans with BPD, a group that experiences the double
stigma of being a racial minority as well as having a highly
stigmatized psychiatric diagnosis may exhibit righteous
anger. Righteous anger is, in fact, a coping mechanism
protecting individuals from the detrimental impact of
stigma. These individuals may be protecting their own self-
esteem by turning their anger outward, instead of turning it
inward. This concept needs to be examined and validated
in future research.
What May Account for Racial Differences in the
Symptom Presentation of Individuals with BPD
In this investigation, even after controlling for treatment
setting and the presence of co-morbid substance use and
mood problems, African Americans experienced fewer
thoughts of self-harm and acted upon these thoughts less
than their White counterparts, and they reported experi-
encing more thoughts about harming others than their
White counterparts. This finding supports research that
documents lower rates of suicidal ideation and attempts
among African Americans in clinical as well as non-clin-
ical samples (Garlow et al. 2005). This disparity may be
due to the interplay of suicide risk and protective factors
that are differentially expressed and experienced by dif-
ferent racial and cultural groups.
Among African Americans, religiosity, family support,
and a community-held attitude that suicide is unacceptable
are factors that have been proposed as buffers against
suicide (Gibbs 1997; Greening and Stoppelbein 2002;
Harris and Molock 2000; Marion and Range 2003). Reli-
gious beliefs and devotion have been shown to be highly
protective against suicide among African Americans. Other
cultural attributes that mitigate suicide risk among blacks
are family cohesion and support and a tendency to seek
support from friends and family (Harris and Molock 2000).
Helms and Cook (1999) found that African Americans with
strong religious and social ties were the least likely to have
The Suicide Prevention Resource Center’s Black
American fact sheet suggests that beliefs about suicide can
act as a protective factor. African Americans often view
suicide as a sign of weakness, not assertiveness, and
believe that suicide is a shameful act. Vernellia Randall, a
professor at the Institute on Race, Health Care and the Law,
University of Dayton School of Law (2007), states that
while African Americans have lower suicide rates, they
have higher homicide rates. She suggests that when some
people encounter stress they can no longer handle, they
turn to violence. Suicide occurs when people choose to turn
that violence inwards towards themselves. Homicide, on
the other hand, occurs when people choose to turn the
violence against other people instead. In the black com-
munity, it is not that turning violence outward is accept-
able, rather it may be that turning it inward is more
unacceptable (Randall 2007).
Among African Americans with BPD, it may be more
culturally acceptable to express thoughts of harming others,
than to express thoughts of harming oneself. They may also
be more likely to act upon thoughts of harming others, than
to act upon thoughts of harming themselves. It is not that
the Black community condones an outward expression of
violence; they may be, however, more accepting of that
than an inward expression of violence through self-harm or
suicide. These issues need to be further examined to
explore the true mechanism working within this popula-
tion, and to understand how these different behavioral
symptoms may affect the presentation of BPD. This
research has implications for the development of culturally
relevant treatment of BPD across racially different groups.
Strengths and Limitations
One limitation of this study is the sample size, which
precluded more sophisticated analytic techniques with the
Race Soc Probl (2009) 1:87–96 93
potential of elucidating the relationships among variables
in more detail. Second, the sample was drawn from a range
of mental health settings which limits the generalizability
of the findings to the general population as well as other
settings where individuals with borderline personality may
receive services, such as criminal justice or child welfare
settings. Finally, data on criminal and violence history
were not collected, which could account for behavioral
differences across races, particularly with regard to violent
The primary strength of the study, however, is that it is
the first study to examine racial differences in the affective
and behavioral presentation of BPD and the findings
clearly show that, first, BPD is not a disorder that only
occurs in White females and, second, there are significant
differences in affective and behavioral symptomatology
between African American and White American individ-
uals with BPD which have implications for future research
investigations as well as for developing culturally relevant
treatment of BPD across racially different groups.
Implications for Research and Practice
The BPD is a severe and persistent mental illness that
carries considerable stigma and formidable challenges for
successful community adjustment. Because of the disor-
der’s problematic symptoms, in particular highly dysreg-
ulated emotions, many individuals with BPD engage in
self-harm as well as repeated incidents of interpersonal
violence which may result in negative consequences, such
as hospitalization or incarceration. However, we believe
that significant racial and gender disparities may exist in
terms of receiving appropriate psychiatric care. This sug-
gests a number of potentially fruitful paths for future
First, because of institutional racism and stereotyped
assumptions about race and mental illness, we suspect that
individuals of color with BPD may be more likely to end
up in the criminal justice system rather than a source of
psychiatric health care as a result of their behavior prob-
lems. In contrast, White individuals with BPD, particularly
females, may be more likely to receive care immediately in
the mental health system. As a result, individuals of color
with BPD may less likely to receive appropriate psychiatric
care. This places such individuals at continued high risk for
harm to self or others and has significant implications for
behavioral health resources in our jails and prisons.
A second important area for future investigations is
examining the prevalence of BPD in the criminal justice
system and how the mental health needs of these individ-
uals are and are not being met. Such data can determine the
need for modifying established evidence-based treatments
for provision in a criminal justice environment. Third, we
hope that our research on racial differences in the presen-
tation of BPD can be extended with larger and more
diverse samples that could pinpoint commonalities and
differences more extensively to inform the development of
culturally relevant treatments. For example, such a study
would expand to include subjects representing other racial/
ethnic groups as well as including a more equal represen-
tation of men. Finally, we know very little about the types
of situational contexts that trigger thoughts about and
incidents of violence toward others among individuals with
BPD and how such situations may differ by race and
gender. Such information could guide the construction of
prototype scenarios for use in future treatment develop-
In conclusion, the treatment and management of indi-
viduals with BPD is an ongoing challenge for the mental/
behavioral health care system and such individuals also
commonly receive services from a range of other providers,
creating a significant social service and health care burden
on society. In order to more successfully meet the needs of
this population and support them in recovery, we must have
a better understanding of the specific racial, ethnic, and
cultural differences in symptom presentation and treatment
needs. Relieving the burden of illness on the individuals
suffering from the disorder, their families and society rests
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