Chapter 3 100 4. Discussion This is the first meta-analysis to assess the associations between BPP and lowered emotional awareness in general, and alexithymia in particular. Emotional awareness has been considered an important factor in BPP in clinical theories [12, 16, 95, 107110]. Until recently, empirical findings on this clinical assumption were scarce or mixed at best [63]. However, there has been an increase of empirical studies on this topic, which allowed for this study’s assessment to be more robust. Efforts were made to include all relevant studies in order to minimize the possibility of a restriction of range effect masking relevant associations. To maximize coverage, we included studies using a categorical definition of BPP as well as studies using a dimensional approach. For the same reason, studies with clinical groups as well as those with nonclinical groups were included. Because of the significant conceptual overlap, we included both studies measuring emotional awareness and those measuring alexithymia. Subsequent various analyses were done to investigate possible differential associations. Results demonstrate a moderate relationship between emotional awareness processes and BPP. Studies comparing patients with a clinical diagnosis of BPP to healthy controls even showed a strong association. Although the funnel plot of the main meta-analysis was somewhat skewed to the right, further analyses did not confirm the presence of publication bias. Thus, the meta-analysis shows that it is elemental to further consider the role of disturbed processing in emotional awareness or alexithymia in BPP. Studies measuring emotional awareness did not statistically differ from those measuring alexithymia. Subsequent analyses showed that associations with BPP were significantly stronger for two aspects of alexithymia (difficulties in identifying and describing emotions) than for externally oriented thinking. This finding supports clinical descriptions (e.g., [12]) highlighting that the core difficulties to overcome when diagnosed with BPP are becoming aware of emotions and adequately labeling them. However, the association between BPP and externally oriented thinking might also primarily have been weaker—although still significant—due to the low internal consistency of the externally oriented thinking factor of the TAS-20 [37]. A number of limitations apply to this meta-analysis. An important concern is that the relation between emotional awareness and BPP could be a spurious one, based on the presence of a third variable. As explained in the introduction, BPP is characterized by strong negative affectivity. In studies on alexithymia using the TAS20, the subscales of identifying and describing emotions also show a strong relation to negative affectivity (see also [111]). Hence, negative affectivity might explain the
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