Chapter 3 102 118] were initially included but were removed due to missing data. Regarding the assessment of alexithymia, the Toronto Structured Interview for Alexithymia (TSIA) [41] is considered one of the most valid and reliable instruments for assessing alexithymia. Unfortunately, no studies to date related the TSIA to BPP. Third, although the results show a moderate to strong relationship between BPP and lowered emotional awareness/alexithymia, results cannot be generalized to single individuals with BPP. It must be taken into account that not all patients with BPP are alexithymic [81, 119]. For example, Semerari and colleagues [120] found distinct problems in identifying and describing personal emotions in only one out of four closely examined BPD patients. In our meta-analysis, this is further illustrated by the fact that some studies did not find a significant relationship. Fourth, there is high heterogeneity across studies that our sensitivity analyses could not explain. It is unlikely that the heterogeneity is caused by differences in study quality since the quality of the studies is similar, apart from the differences in study design and measurement of emotional awareness that we previously addressed in the sensitivity analyses. Participants were recruited in similar ways, and mainly selfreport measures for alexithymia or emotional awareness were used. Future research should further test the veracity of the association between BPP and lowered emotional awareness. The mono-method of self-report measures used in almost all included studies in this meta-analysis precludes drawing definite conclusions about found correlations. Causality should be addressed. Some theories assume that lowered emotional awareness and/or alexithymia lead to BPP, yet some presume it to be the other way around. Proper research on these assumptions is warranted, including experimental and longitudinal studies. Another important question for future research is whether low emotional awareness or alexithymia is as specific to other disorders as it is for BPP. Alexithymia is found to be associated with several psychiatric and somatic disorders and is thus not unique to BPP. For example, meta-analyses showed that it is also an important factor in PTSD [121] and parental bonding [122]. A recent systematic review concluded that alexithymia, in particular difficulties in becoming aware of and labeling emotions, is a key factor in eating disorders as well [37]. Further studies would ideally focus on genetic, neurophysiological, social, and cultural antecedents of alexithymia in BPP, on its consequences, and on alexithymia as a transdiagnostic factor in different disorders. Whereas both alexithymic and borderline patients were long considered therapeutically unresponsive and, consequently, difficult to treat [123, 124], therapies nowadays explicitly focus on increasing emotional awareness. Therefore,
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